#PewPerspectives - Week of Nov 27

Following are the stories that I posted on LinkedIn during this week in case you missed them, along with my additional editorial comments in bold. View counts are as of 3:00pm ET on December 11.

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WV cities sue accreditation agency over opioid 'misinformation campaign' (754 views)

West Virginia leads the way in lawsuits against Big Opioid Pharma (manufacturers and distributors). The cities of Charleston, Huntington and Kenova, along with the town of Ceredo, took that up a notch by suing The Joint Commission. "The lawsuit alleges The Joint Commission teamed up with OxyContin-maker Purdue Pharma and issued pain management standards in 2001 that 'grossly misrepresented the addictive qualities of opioids.' The commission 'zealously' enforced the standards through its accreditation programs." That's the same non-profit accreditation organization that I wrote about for DORN Companies in October (2,300 views to-date) given their decision to change those standards ("The game-changer for the opioid epidemic"). In that blogpost, I credited them with the changes - effective January 1 - and encouraged everyone to implement them. However, before changing their perspective, did they contribute (strategically or unwillingly) to the actual genesis of the #opioid epidemic? I guess those WV cities are about to help us figure that out. While I have heard some say that "pointing fingers" isn't helpful, I think accountability is. Especially for public agencies (like these West Virginia cities) that must spend their finite budgets on dealing with the aftermath of the opioid epidemic. If it can be proven that they willfully played a part in opioids being over-prescribed that helped initiate the epidemic, then they should help pay to #CleanUpTheMess.

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Five years later, Colorado sees toll of pot legalization (5,540 views)

An interesting viewpoint at the 5th year anniversary of Colorado legalizing recreational marijuana. According to this op-ed from Colorado Springs, "we remain an embarrassing cautionary tale." Pretty strong language which they back up with indicators such as an overwhelming aroma of marijuana on highways and in residential communities, increasing homelessness, "doubling in the number of drivers involved in fatal crashes who tested positive for marijuana," presence in schools ("drug violations reported by Colorado's K-12 schools have increased 45 percent in the past four years"), #1 in teen use of marijuana in the US. Obviously legalization of recreational use and medical use are two completely different conversations (and repercussions) but this writer obviously has a strong opinion that it was a mistake (or at the very least not managed properly). Should other states considering recreational legalization look closely at the "experiment" conducted by Colorado now that five years of experience is in the books? I will leave that up to you to decide. As evidenced by the number of views and the comments posted (some sided with this op-ed author's viewpoint while others disagreed), understanding the implications of marijuana legalization is top-of-mind for many. Similar to anything else, the benefits must out-weigh the risks to validate the usefulness. An interesting article from Collective Evolution was proposed as a counterargument to the op-ed author which led to my following response that kind of sums it up:

Thanks for sharing this info as we attempt to provide a balanced viewpoint. It's interesting that three of the seven are purely about economics (reasons 2, 4, 5) and two are about public opinion (reasons 6, 7). Reason 1 is about reduced crime rate (which, because it's so complex there is correlation but likely not a direct causal relationship). Reason 3 will ultimately be the most valuable in helping the science become more clear as to the benefits and risks of cannabis use. Obviously, recreational and medicinal use have two completely different associated motivations and value to society - medical use should help people better manage their medical conditions whereas recreational use is solely about the revenue. As always, the marijuana issue is complicated - regardless of which "side" you may be on.

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Asking About Opioids: A Treatment Plan Can Make All The Difference (161 views)

Screening is not enough - engaging to enact change is key. It appears that Christiana Care Health System in Wilmington DE has come up with a way to connect the two. Their "Project Engage" is very interesting. They use screening tools to identify alcohol or opioid/drug addiction to not only address the withdrawal symptoms from discontinuance but immediately connect them with counselors that can address the underlying addiction. They have incorporated standard Q's into routine and ER visits that could identify issues (i.e. screening), and if issues are discovered then "leverage the withdrawal" (intriguing choice of words) to "pair patients with addiction counselors and get them enrolled in community-based drug treatment program before they've even left the hospital." Two thirds of those patients have been directed into drug treatment, and a substantial 60% are still in treatment one month later. In addition, they've lowered readmission rates and the number of people that leave the hospital against medical advice. This is the key quote - "The health system is treating opioid addiction as a disease, with medicine and in-house specialists." Should other healthcare systems be doing something similar? It sure seems like a good approach.

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The Answer is Yes (1,288 views)

I ran across this tweet from David Juurlink MD, PhD, FRCPC (head of the Clinical Pharmacology and Toxicology division at the Sunnybrook Health Sciences Centre in Toronto, Ontario). Self explanatory. But just to be clear of my understanding - the texted question was from a patient or friend of Dr. Juurlink and his answer was "Yes. The answer is yes.". The primary takeaway? Do not put anything into your mouth without knowing in advance the reason and the risks vs. benefits. Ultimately, everyone is responsible for themselves to make the right decisions. #DoYourHomework.

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Amid Opioid Crisis, States Start Embracing Alternative Medicine (762 views)

Progress - in this example, Oregon. It's up to Payers to encourage and pay for treatments they've historically considered "alternative", for Patients to fully engage in their own healthcare choices, and for Providers to think "outside the box" in treatment of chronic pain. Maintaining the status quo is unacceptable. Treatments mentioned in this article include walking, acupuncture, massage, yoga, physical therapy, chiropractic care, peer-group support, behavioral health services, and pool membership. Beyond CareOregon, Workers' Compensation is also starting to advocate and reimburse for those same kinds of treatment options. "Despite the dearth of conclusive research, Shah is convinced that opioids aren’t the right choice for the majority of chronic pain sufferers." I agree. But unless payers are willing to pay for these (and more) "alternative" treatment, opioids remain the "easiest" option.

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Semisynthetic-opioid testing may expand with DOT on board (296 views)

IMPORTANT: For any employer that must comply with U.S. Department of Transportation regulations (safety-sensitive employees in DOT-regulated industries), a new rule is going into effect on January 1, 2018. 49 CFR Part 40 increases the scope of drug testing panels to now include the following semi-synthetic opioids - hydrocodone, hydromorphone, oxymorphone and oxycodone. "This is a direct effort to enhance safety, prevent opioid abuse and combat the nation’s growing opioid epidemic." Indeed. Read the DOT press release and the full rules. And for a more expansive overview to provide context, read this Business Insurance article. The good news is that the National Safety Council reported 57% of employers are doing drug testing with 59% of those (or 33% overall) already testing for semi-synthetic opioids. The bad news is the ones that aren't (for a variety of reasons that I have discovered in speaking with many across the country). When it comes to drivers or people that support the drivers, impairment (from whatever agent) should not be allowed. So this change is good news -- BUT YOU HAVE 30 DAYS TO GET IT IN PLACE. Are you ready?

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There will be plenty of jobs in the future: You just won’t be able to do them (91 views)

Important information to digest and implement. Pretending like robotics and artificial intelligence and self-driving cars won't be hugely disruptive to jobs (and the people that do them) in the not-too-distant future is NOT an option. Preparing for the future -- whether it looks as bleak as 400-800M people unemployed worldwide as estimated by the McKinsey Global Institute report or something less -- is now required. No doubt there will be an impact to Workers' Compensation and the workplace as this transition occurs (is occurring). In the not-so-distant past an employee or employer could envision themselves doing the exact same tasks they now do into the foreseeable future. If you want to be relevant in the near (and certainly long-term) future, you need to assume that what you do and how you do it may change (or no longer be needed). Do your job, but keep your eye on the horizon.

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Violating Trust: Ethical Conundrums in Workers' Compensation (1,193 views)

If you are a #WorkComp professional, you need to add this to your calendar on January 5 @ Noon ET. The subject matter is "Violating Trust: Ethical Conundrums in Workers' Compensation." I have total faith that Bob Wilson and David Langham will be excellent hosts with not-the-usual questions. Their attorney guests for this 2nd edition are outstanding (to borrow a phrase). Both Stuart Colburn (defense) and Robert Rassp (applicant) have deep and wide experience in Work Comp. They also happen to be friends and colleagues, so their arguments are cogent but collegial (and humorous). I've gotten to know Bob over the past year, but I've known Stuart since 2012 when he became my inspiration to become The RxProfessor after hearing him passionately speak about the #opioid issue at an event in Austin. Taking into account the experience of all four of these gentlemen, I can guarantee that you will learn something by attending. I just registered. I suggest you do too. Don't miss it!

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More than 60% of opioid overdose victims are taking the pills to treat a chronic pain condition, study finds (199 views)

"More than 60 percent of people killed by opioid overdoses were driven to the addictive pills by a chronic pain condition, according to a major report." Mentally chew on that for awhile. This recent study by Columbia University of the prescription drug history for 13K Medicaid victims of overdoses uncovered some interesting findings:

• Two thirds were diagnosed with chronic pain
• Significant portion also diagnosed with depression & anxiety
• One third had their pain diagnosed within 12 months of their death
• Less than 20% had been identified to have substance use disorder
• In the year before their death more than half had filled a Rx for opioid or benzodiazepine, and many received both

These numbers could be UNDER estimated because it just covers the years 2001-2007, before the epidemic reached it's peak. The good news is that prescribing behavior is changing, payers and patients are more open to non-pharma alternatives for treating pain, and we're having an honest discussion about the move towards a #BioPsychoSocial treatment model. The bad news is we're not there yet so the focus remains on finding ways to #CleanUpTheMess. The point for me ... We need to find out what individualized treatment works for an individual with chronic pain. Sometimes that includes opioids BUT only after non-opioid and non-pharma treatment have been tried and failed AND the opioids yield higher function level for the individual AND the benefits outweigh the risks. Whatever the choice, it needs to be driven by evidence based medicine AND by what works for that person. If opioids are the choice then proper due diligence needs to be taken to ensure they don't end up as one of these statistics (death or abuse).

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Mindfulness training shows promise for maintaining weight loss (109 views)

So #mindfulness might not just be good for managing pain but also for losing weight (and keeping it off, even more importantly). Obesity certainly complicates the management of pain (which is why learning to eat more nutritiously is part of #CleanUpTheMess) so this is a good combination. But overall the concept is that Mind Over Matter works. Using the most powerful computer in the world - our brain - to mitigate difficult circumstances MUST be part of the overall package to wellness. If you still think mindfulness is a bunch of "warm and fuzzy hooey", think again. Literally.

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Salem Decides to Destigmatize (334 views)

If you have 7 minutes, please watch this video about Salem MA deciding to destigmatize addiction, ensuring it's looked at as a disease and not a moral failing. Not only is it a great outreach for awareness (the video and what's happening on the street) but it includes a friend of mine. Ed Moriarty, Jr. shares the story of his son's addiction to heroin and being 23+ months clean, but also the challenges (pain, disruption) in accepting what was occurring and then helping in recovery. One point especially resonated with me - "You will be a better person" after overcoming (or helping someone overcome) addiction as they are "healthier, more humble, more giving, and more forgiving." Ed happened to share the same story with me in Asheville NC earlier this year at an event we spoke at together. While we've corresponded and talked on the phone, that dinner was our first opportunity to be together in-person. And his story - of love for and pride in his son - made all of our past conversations make even more sense. Ed and his son are an example of success, and there are many others like it. But there are an equal or greater number of stories that did not result in success. Which is what drives Ed, and myself, and others, to #CleanUpTheMess. If you have an influential position in your local community, could what Salem is doing be something you could also do? It would be nice to see something similar in the other 19,353 "incorporated places" (i.e. cities and towns) in the U.S.

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Using "Addiction" Properly (381 views)

Dependence <> Addiction. Please read "Understanding the Difference between Physical Dependence and Addiction" that was recently published by The National Center on Addiction and Substance Abuse. It is important to distinguish between the two terms because "addiction" is a word loaded with #stigma. FDA Commissioner Dr. Scott Gottlieb gets it. Robyn Oster, the author of this article gets it. I get it too. I described the difference in my January 9 blogpost "Using 'Addiction' Properly" and why #WordsMatter as we #CleanUpTheMess. It remains my opinion that "the vast majority of the patients (aka injured workers) were not addicted." When talking about this subject, it's important we all use the appropriate terms because using the wrong ones could create an obstacle to #recovery. Take 10 minutes and read both articles and adjust (if necessary) the lexicon you use in discussing the #opioid epidemic.

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Surgeons and the opioid crisis—prescription guidelines needed (609 views)

I agree with this op-ed from a Canadian plastic and reconstructive surgeon - there need to be #opioid guidance (guidelines?) for surgeons. Often the potency of analgesia post-surgery is determined by the individual surgeon based on their personal experience/training. Sometimes it's determined by hospital policies. Sometimes it's determined by patient expectations for pain relief. Sometimes little strategic thought has been given to the potency or duration of #opioids or what kind of step therapy will be involved to transition them from drugs to activity. I've heard of some pilot programs around the country by individual surgeons and hospital systems - this one at the University of Michigan appears to hold some promise. This Medscape article outlines the dangers of prescribing the wrong 1st pills. But providing some evidence-based guidance on post-surgical analgesia (potentially including #opioids) directly to surgeons remains a gap. And where a gap exists, more problems can arise that contribute to the epidemic. This article from Kaiser Health News discusses more outcomes from Michigan regarding gallbladder surgery. "Despite getting less medication, patients didn’t report higher levels of pain, and they were no more likely than the previously studied patients to ask for prescription refills ... After surgery, patients are getting prescribed more opioids than necessary and doctors can reduce the amount without experiencing negative side effects." If people can get the same (or better) treatment for pain, in this case gallbladder surgery, with less potential negative side effects, then that sure sounds like a "win" to me.

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Beyond Opioids (145 views)

Thanks to Bruce Shutan for including me in his article for the December 2017 edition of "The Self-Insurer" magazine that was just published today (November 27). He did such a great job that it became the feature article on the front page, "Beyond Opioids." It is a wide-ranging discussion about the problem but also some solutions. The best quote that Bruce created is on the first page as an overview - "A comprehensive and holistic approach that integrates employee assistance programs (EAPs) with clinical resources, coupled with the right plan design and cultures of health and safety, can make a significant positive difference." For the digital online version, scroll to page 4 for the start of the article. If we don't consider what is "beyond opioids" then we have no business saying "no" to opioids.

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Due Diligence (248 views)

We need to add a 0 and make it 100% screening. While % of abuse may be low (Dr. Thomas Kosten said avg is 28%), with 8.5M Americans abusing Rx drugs and 259M prescriptions in 2012 (per WebMD), NOT screening is NOT right. It's largely the lack of due diligence (by prescribers and patients) that made this epidemic grow. Putting due diligence back into the process (e.g. would you really want an ACL repair surgery done if an MRI hadn't confirmed a tear?) will help provide the right treatment at the right time.

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In addition, I published three blogposts:

• "#PewPerspectives - Week of Nov 13" on November 27
• "Un-Learning Chronic Pain" on November 28
• "Compassion > Empathy > Sympathy" on December 1

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"It's Never the Wrong Time to do the Right Thing" - Martin Luther King, Jr.

#CleanUpTheMess