Chronic Pain & Opioid Addiction: The Role of Integrated Care

PLEASE NOTE: This is an unedited transcript. Please refer to the video to confirm exact quotes.

SARAH DASH: My name is Sarah Dash and I’m President and CEO of the Alliance for Health Policy. We are really thrilled to be hosting this conversation today. We’ve heard so much, as many of you know, about the opioid epidemic but not as much about the underlying issues around pain and how to manage it, and so we have a fantastic panel today that’s going to explore these issues with us.

Before we get started with the panel, just a couple of words about today’s event. This is the third event in a series on the future of chronic care, and you can follow along on Twitter at hash tag future of healthcare. We are extremely pleased and grateful to have three annual sponsors who have been supporting this series, as well as an earlier series that we did on the future of health insurance, and a series that we will do this fall on the future of the healthcare workforce. And those are Anthem, Ascension, and Health is Primary, and I want to thank them. And we’re going to hear remarks from them in just a couple of minutes. I also want to thank the sponsors of the chronic care series specifically: CAPG, DaVita, Express Scripts, and Genentech.

So, without further ado, we’re just going to hear a couple of words, first beginning with Sherry Dubester, who is Vice President of Behavioral Health and Clinical Programs at Anthem. Sherry.

SHERRY DUBESTER: Thanks very much, Sarah. Well, it’s a pleasure to be here today and I can’t imagine a more timely topic, so I can see from the attendance that there’s a lot of interest and that’s wonderful.

Just a word about Anthem. Anthem Blue Cross is the Blues in 14 states, we’re in 20 Medicaid markets as well, and we insure one in eight Americans, so are very invested in working on the opioid crisis as well as chronic care management, integrated behavioral medical care, and all the issues that I think we’ll hear more about today.

I lead a clinical strategy in behavioral health and I’m a psychiatrist by training, and have been leading our company wide opioid strategy work. The importance of an integrated care approach is so fundamental to the programs that we deliver for our members at Anthem, and for the collaboratives that we are increasingly engaging with, our providers—medical, behavioral—for the care delivery that they’re engaged with as well. And the concept of integrated care really applies, whether you’re thinking about well being, or whether you’re thinking about chronic conditions such as diabetes, certainly as you’re thinking about the opioid crisis and chronic pain.

So what do we mean by integration? And I’m guessing you may hear different definitions today, at the very least, integrated care involves integration of medical and behavioral care and there’s a tremendous amount of exciting work going on in this arena. Anthem is certainly very focused on it, so are many payers, the providers, and a lot of that is actually collaboratives, which is wonderful.

But I want to leave you also with some thoughts about that integration should also pay attention to the social determinants of health. Do the members and the patients that providers care for have a safe place to live? Do they have access to healthy food? Do they have a safe place to move and walk? Do they have transportation to their appointments? Because when it comes to the kind of complex health issues that we’ll be talking about today, our version of holistic health and integrated care probably has to go beyond even the medical/behavioral but also really think about the full whole health concept. So with that, I’ll turn it over to the next speaker, and really look forward to the dialog today. Thank you.

SARAH DASH: Great. Thank you so much, Sherry. And next I would like to introduce Mark Hayes, who is Senior Vice President for Federal Policy and Advocacy at Ascension. Mark.

MARK HAYES: Thank you. Good afternoon everyone. We are just so glad to be a sponsor of the Alliance and of this event. This is such an important topic. In the midst of everything that’s going on in healthcare right now from the healthcare, the larger healthcare debate, around the direction of our healthcare system, to hurricanes, to so many issues, we can’t lose sight of this important one. It is crucial that we crack the code on how to deliver pain management in a better way that isn’t fueling the opioid crisis, so I’m so excited to hear what our speakers have to say today. I’m very glad that you all are here, and we’re very glad to be a sponsor. If you’re not already familiar with Ascension, we are the largest Catholic and nonprofit health system in the United States. We’re in 22 states around the country and on behalf of our caregivers and clinicians, we welcome you, and thank you for being here.

SARAH DASH: Thank you. Finally, I’d like to introduce Kirsten Thistle, who is here joining us from the Health is Primary campaign.

KIRSTEN THISTLE: Thank you. Good afternoon. As Sarah said, I’m Kirsten Thistle and I am, along with my colleague, Ann Saybolt, the campaign director for Health is Primary. First, a quick poll. How many of you guys have actually heard of the Health is Primary Campaign? Not bad. We have been running ads in the Hill and then Roll Call and hoping to raise awareness about our program. It was launched a couple years ago by eight family medicine organizations, most notably the American Academy of Family Physicians, and our goal really has been to focus on raising awareness around the value of primary care in America and how a country with a strong foundation of primary care can deliver better health, better quality at a lower cost.

A big part of what we’ve been talking about is this idea of integration—integrating behavioral health, mental health, nutrition—all of these other clinical services into the primary care setting. We have a long way to go. A big hurdle to clear in order to be successful is to change payment models so that we can move away from the fee for service model and move to value-based payment where we’re looking more holistically at patients.

We’ve been traveling the country and finding case studies of where this is working and, again, we have a long way to go, but I think we’re seeing some bright spots around the country in different models of how this is delivering success for patients. If you go to our website, healthisprimary.org, you can see case studies of specific examples of practices that have been successful and really looking at data-driven metrics of how they’ve succeeded and what that success looks like.

So again, we’re thrilled to be sponsors of the Alliance, and of this really important event. It’s obviously clearly timely and the opioid epidemic, I know, keeps us both up at night because it’s just staggering, the impact that it’s having on this country. So we’re thrilled to hear what the speakers have to say today and look forward to a lively discussion.

SARAH DASH: Great. Thank you so much to all of you, and I’ve moved over here so we can go ahead and get started with the panel.

So we’re really lucky to have an excellent panel here today that represents individuals who are really on the front lines of this epidemic, who are dealing with real patients with real pain, and looking at the evolving guidelines for treating pain, and how that intersects with this national epidemic. So I’m going to go ahead and introduce them now and then we’ll hear their presentations and then do a Q&A and discussion.

All the way to my right is Ben Miller, who is Chief Policy Officer for the Well Being Trust, a national foundation committed to advancing the mental, social, and spiritual health of the nation. And prior to joining the Well Being Trust, Dr. Miller spent eight years as Associate Professor in the Department of Family Medicine at the University of Colorado School of Medicine, and he was also the founding director of the Eugene S. Farley, Jr. Health Policy Center.

Eric Schoomaker, and I should say Dr. Eric Schoomaker, also is a Professor and Vice Chair for Leadership, Centers, and Programs in the Department of Military and Emergency Medicine at the Uniformed Services University. Prior to his retirement, after 32 years of active service, and he is a Lieutenant General Doctor, Lt. Gen. Dr. Schoomaker served as the 42nd U.S. Army Surgeon General and Commanding General of the U.S. Army Medical Command. We are so thrilled to have you here today.

To my left, Dr. William Morris, is a clinician at the Dominican Hospital in Santa Cruz, California where he is Medical Director of the Utilization Management Department. He is also the medical director of the Community Clinic of Janus, the local methadone and suboxone treatment clinic, as well as medical director of the Driftwood Skilled Nursing Facility. And then, after the panel, maybe you can tell us how to be in three places at once.

Finally, Dr. Andrea Gelzer is the Senior Vice President and Corporate Chief Medical Officer for AmeriHealth Caritas. Previously Dr. Gelzer served as the Chief Medical Officer for Boston Medical Center Health Net Plan. She also served multiple roles, including Senior Vice President of Clinical Public Affairs at Cigna Corporation and, for 16 years, worked in private practice in internal medicine, so a wealth of experience and we’re thrilled to have all of you here, and without further ado, I’ll turn it over to Dr. Miller.

DR. BEN MILLER: Thank you Sarah. Good afternoon everyone. Okay. This is not a trick question. How many of you have experienced pain? Alright. Everybody’s hand in this room should go up because at some point in your life everyone in this room has experienced pain. Now, your pain might have varied from ouch, I slammed my hand in the door, or ouch, I had a car accident and now my neck hurts all the time, or it might be something as like, my goodness, it’s Friday morning and I’m sitting here listening to this Miller guy talk. I mean, there’s a lot of different ways to classify pain. My important point here, which I want to make repeatedly here, is that this is all of us. And our inability to design solutions to meet the population need on something as basic as pain is causing us problems.

If you look at the data you can see, and I don’t need to repeat these facts, a lot of individuals daily suffer from pain. What type of pain is it? Well, I’ll get into that in just a second. But this is a substantial need that is oftentimes going unmet in our society. Some of those reasons really are how we define what pain is, and so you can look at the literature and we could spend probably six hours talking about this, there’s a variety of different ways to classify pain. You can have tissue damage, you can have nerve damage, or you can have, what we call – I love this word – psychogenic. No, it is not something that you take and go to a concert. Psychogenic is really kind of how you believe your pain to be, or what you think about yourself or believe about yourself and how that influences your physical behavior or your pain.

As I just described, most classification systems, however, really kind of quickly gloss over what we mean when we talk about pain. So we can have acute pain, like a bee sting, or we can have more chronic pain which is pain that we live with consistently throughout our lives. Underlying all of this, though, is a need to look at the whole.

In 1977, one of the most seminal articles came out by George Engle on the biopsychosocial model. And I want to mention that in this context because as you hear today, a lot of the solutions that we’ve created to address pain have not necessarily taken into account the whole biopsychosocial continuum of care. They’ve taken on a piece of that. We’re going to focus on the biological, okay, but they haven’t necessarily talked about, well, how are you doing with this and what are the things that we might be able to do at a social level to influence how you are better addressing your pain? And it comes down to this one main true fact, which is why I’m so glad to see integration in the title of today’s talk, we are a fragmented society in a fragmented culture that has treated pieces of health and not necessarily taken into account the whole of health. Pain is one of the best examples of this that I can give you. If I only addressed your physical symptoms how is that really helping you cope with this new change in your life that’s decreasing the quality of your life? These are substantial issues that fragmented care really do force us to kind of say, well, no wonder we have problems like opioid epidemics.

We have seen a dramatic increase in the use of opioids in this country, and it doesn’t take a rocket scientist to figure this out. Why is the U.S. prescribing more opioids for pain than anyone else in the entire world? Well, it takes us back to the reason that we have so many discussions in places like this because healthcare fundamentally is broken, and in our brokenness and our fracturedness we have let people down. So what do we do to solve those problems? Well, we integrate. And we have to integrate by putting the person first. So I have three points that I want to make here with my limited time.

Number one, when we talk about pain, we have to come up with solutions that are actually around the person in the community. I’m going to give you two examples of this. First of all, it’s important that you know your data, know who you’re actually talking about when you stand up on stages like this and you talk about, well, here’s the program that we’re actually advocating for. You need to know the people that you’re trying to serve. You need to know what their needs are and design the program to their needs. An example this is in northeast Colorado. A good friend and colleague, Dr. Jack Westfall, has done a program where he’s actually gone out to folks in the farming community. He’s gone out to folks that just live in rural areas of the state and said, “How can we best address the opioid crisis in northeast Colorado, but most importantly, how can we also talk about your pain and let you know that there is a team of individuals that are here to help you.” These are beer coasters. These are beer coaster, okay? How novel is it to think about taking a message and putting it on a beer coaster that is sitting in your local bar, or that you’re handing out at your local farm feed store and your farmers take home and put their beverage on. You have to take the message to the audience in the places that they are. You can’t expect them to come to you and just say, “Okay. I now have pain,” or “I’m addicted to this substance. What is it that you’re going to do to help me?”

Another example of this is that they’ve got these really wonderful flyers that normalize not only pain but what happens when you might actually become addicted to the medications that you’re taking to manage your pain. You normalize it, and you let people know that there is hope. That beyond just kind of this fact that you’re facing every day that you are in pain and you are suffering, there is a team of people that are here to help you and to listen to you and not judge you. And so there’s little caveats at the bottom of each of these posters that say things like, listen, this is not a moral failing when you take another pill. This is not really a moral failing when you can’t show up at work because you’re in so much pain. This is about how can we now create a solution that targets what you need and what is best for you.

Another example, here—second point here, actually. How do we create programs that are actually in response to the systematic problem? So what we need now are more systematic solutions to address pain and less programs that take on a piece of that. And so, the bumper sticker for this one is that systems are greater than programs. We have to have systematic solutions to talk about pain. You’ll hear a lot of these in just a minute, examples of these.

This slide simply shows you what people have to experience and go through to try and get help for care. Now the example that I’m using here is mental health. So if you’re identified with some type of mental health need you are churning throughout the system, constantly trying to find a place to land. What happens if you’re an individual that experiences pain and someone says, “Well, we don’t do that here. You have to go over there for that.” You stigmatize, you don’t necessarily normalize, and most importantly, folks, people that are suffering have to wait to get help for their suffering. There is something fundamentally wrong about that in our society. Integration allows for us to be in those places where people are addressing their needs in the time that they need them. It might be the fact that you were just told that your back pain is so substantial that you’re not going to be able to go back to work. It might be that someone just said, well, you know what, it’s the combination of your diabetes, your depression, and now your diabetic neuropathy that has led us to this place of not being able to figure out what we’re going to do next. How are you going to cope with that? These are conversations that people have every day and what we’ve done, because of the fragmentation, is that we’ve made it really hard for people to get help for those problems.

One study that came out recently looked specifically at what happens when you provide some type of substance use treatment around opioid use in primary care, hence, the integration. We give people momentary, instantaneous access for that problem and, you can see here, the data are quite clear, that individuals, when given access to mental health services or some type of substance use treatment, they use it. They use it because it’s a timely intervention for their need.

Other examples of this, the state of Virginia, currently through what they call their ARTS waiver, which is Addiction and Recovery Treatment Services, has looked at this systematic continuum of care and said we know that the solutions are much broader than just creating another buprenorphine prescriber for opioid abuse, or just putting another mental health clinician practice. This is a system issue and we need to tackle that. They’ve increased provider training and education and they’ve looked specifically at ways that they can not only have medicine interventions but they can also have counseling to help individuals with that pain. Almost done here.

Quickly on Virginia, though, you can look at the number of prescribers and the number of individuals that are entering into the system because of what the state has done at a policy level to be able to increase the number of folks that can help with pain and substance use.

Last point. In order to ultimately do everything that I’m talking about, we have to have a different culture around payment. We’ve got to be able to create some type of comprehensive payment strategy that supports a continuum of care; not pay for another piece of care, pay for a continuum of care. That’s our team. Right now, the dominant culture in our healthcare system is that we pay for services in discreet categories and there’s not more egregious example of this than how we pay for mental health and physical health. If you incorporate pain here into that equation and you say, I want to be able to provide a team-based approach to you in my primary care practice, in my hospital setting, and yet I tell you that you’re going to have to figure out some type of really creative workaround to pay for that, most people are not going to do it. So we have to have really comprehensive and strategies on addressing payment. Skip to the end here.

Recommendations for payment are really basic. If we want to tackle pain and tackle it in the moment that people actually need that care, we’ve got to have some type of incentive for a team approach to care. This is not about figuring out another code. This is not about paying another provider more. This is about paying for that team to take care of the person. We’ve got to figure out a way to incentivize this and to support the quality and the outcomes that people are actually needing right now. Thank you.

SARAH DASH: Thank you, Ben. So we’ll turn next to Dr. Eric Schoomaker.

DR. ERIC SCHOOMAKER: Thank you. Thank you. It’s a privilege to be here today and I especially appreciate all of you coming out today and seeing so many of you in the audience because I think, to echo what everyone of the folks have said from the dais today, this is a crippling problem for the nation as a whole and it begins with pain. I want to endorse and embrace everything that Ben has said here—can I call you Ben?

DR. MILLER: Yeah, please.

DR. SCHOOMAKER: You can call me Eric. Because fundamentally, to go back to what he started off with, this emanates from pain. We know from the Centers of Disease Control that the problems with opioids in the country today emanate, in the main, from pain, and inaccurately and improperly treated pain. Pain is at the source of this epidemic and I usually, when talking to audiences like, this start off by talking about the example of John Snow, an epidemiologist – father of epidemiology – and an anesthesiologist in London in 1853, who first realized that you can’t solve the problem of a cholera epidemic by just treating cholera victims. You have to go and find the source of the epidemic. And he found the Broad Street pump, realized that it was the common source of water for almost every victim of cholera in London at that time. They had washed a contaminated diaper in a small depression about three feet from the pump, it became contaminated and that was the source of the epidemic. We are in an epidemic of opioid addiction, but the solution is not just to attack opioids, it’s to attack pain.

I want to also reinforce something that Ben said. We now know something we didn’t know maybe 30 years ago, that acute pain and chronic pain are two different states. Chronic pain is not a symptom of another problem, it is a brain disease. When we’ve had pain for a period of weeks to months and we go through a process called “chronification,” and when we do that, the pain is not sighted in tissue disruption and no susceptive nerve injury, it’s sighted in the brain. And it interacts between the emotional basis of the brain, the limbic system, sources of memory and it’s as idiosyncratic and fingerprinted across different patients as much as fingerprints are different across patients. And so every patient, as Ben said, has to be treated in a patient-centric way that addresses the individual needs of that patient. Their memories of pain, their experience with pain, their sources of pain and the like.

I’m going to talk about changing this culture of how we approach pain, and I use that term deliberately because all of the major studies that have been done, whether it was done by the military that we are a part of, or by the Institute of Medicine, now the National Academy of Medicine, have highlighted the fact that we have to change the culture of how we approach pain. This is just an image to kind of blend together the complexity of where pain comes from in our soldiers and our veterans to include the psychological and emotional impacts of being separated from family, their loss of friends, the exposure to, what I think is, the signature weapon of these wars, which is blast. I don’t endorse a signature wound, but certainly the signature weapon and then how we’ve been approaching this in the form of complementary approaches. I’m obliged to say I have these disclosures and disclaimers. The second point is pretty important. We only embrace, and through the help of the Congress, are compelled within the DOD only to adopt standards of practice that have evidence behind them that have FDA approval and the like, and so nothing I’m going to talk about today is smoking mirrors; I’m talking today about good evidence based practices. And I don’t know who speaks for the DOD in my university, but I’m certainly not that person. These are all my personal thoughts.

Okay. We knew that you wouldn’t have any difficult identifying the fact that combat wounds and injuries in combat, which by the way, exceed the number of wounds, it’s always illnesses and injuries that get our soldiers, sailors, airmen, Marines and Coast Guardsmen, are the source of much of the pain that they experience, but I wanted you also to be aware, ignore the complexity of this slide. Look not at the lyrics but at the melody, and the melody here is over the course of a decade or more from actual data drawn from ambulatory visits, you can see while the prevalence and incidence of cardiovascular disease, kidney disease and others remain pretty static, the incidence of musculoskeletal complaints and of mental health disorders rose dramatically starting about mid odds. And those musculoskeletal complaints are not because of combat wounds necessarily, although they’re related, they’re because we are stressing a force, unlike we ever have before, light infantrymen in the Marines or the Army, and Air Force targeter, are carrying on average 120 pounds and often operating above 8,000 or 10,000 feet and that are doing this on multiple rotations and so they get injuries. Sports injuries are still the most common problem that we face, and so we’re not unlike any other force. This is just to emphasize something that also Ben brought up, and that is, this is a study in the VA but it’s been duplicated with tens of thousands of patients since then, that if you look at the prevalence of pain in intersection with post traumatic stress disorder and traumatic brain injury of concussive form, mild traumatic brain injury, what you find is, chronic pain rarely exists alone. It exists in a comorbid state with psychological problems and with TBI. The fact is, it’s a minority of the cases in which you have pain alone, or even post traumatic stress disorder or concussion alone. So we’re taking care of a very complex group of patients with very complex biopsychosocial problems.

We established a task for in around 2008, 2009 that published a comprehensive pain management strategy. We realized that we were faced with an unprecedented pressure to manage chronic pain and came up with, through objective studies of both the literature and our system, of the need for a holistic multi disciplinary and multi modal approach to that that use state of the art evidence based practices that focused on optimal quality of care and function of our people, patients – both our family members and our soldiers – for managing that. About a year later, the Institute of Medicine, now the National Academy of Medicine, launched a similar study that looked at the whole nation, not just the military’s problem, and came up with a very similar set of recommendations. And among them was, we don’t need to abandon opioids. I’m not an anti-opioid person. If I’m in a major traffic accident, or if I break my leg, or if I’m an IAD explosion, I’m not going to shout: “Give me acupuncture.” I’m going to ask for morphine and I want it there. The same for any major trauma. What we’re saying is, this is not the panacea that it’s been cast to be.

This is a very important slide because it shows the intersection and interaction among the federal medical partners in this. On the top you’re going to see different organizations and on the bottom you’re going to see products, in the middle is the time line. It began actually with the VA, and I can’t speak for the VA, but the VA has been one of the leaders here. The VA saw this problem early, they attacked it early, they established a step care model that is multi modal, multi disciplinary, team based in its approach, and incremental in its application, and published those. Our task force resulted in a product as well. The Institute of Medicine then followed with the report I just talked about. At the same time, the National Institutes of Health had organized an Interagency Pain Research Coordinating Council, known as the IPRCC, with federal members from the services as well as the NIH and about that time, the secretary of HHS came to this coordinating committee and said, look, since you’re already working on research efforts, you come up with a national pain strategy that’s going to apply the principles that we’re outlining in the Institute of Medicine. And the results of that, as I’ll show you in just a second, were the national pain strategy. At the same time, the National Center for Complementary and Alternative Medicine, the NCCAM, now known as the National Center for Complementary and Integrative Health, this isn’t about creating an alternative universe, this is about integrating complementary practices into conventional practices, and it’s not just about medical treatments, it’s about maintaining and promoting health and well being. So many of these complementary practices need to be integrated at the self care level. They then established, through the leadership of Dr. Josie Briggs, the Director, an effort to use the platforms of the VA and the DOD to advance research in evidence based approaches of complementary practices in chronic pain. We’ve looked at this in the military health system, we now have the publication of the national pain strategy out of the IPRCC and others, which resulted in the Presidential Memorandum to start looking carefully at opioids and other approaches to pain management, the CARA Act and, of course, the CDC opioid guidelines. But I want to stress again that this isn’t about just regulating opioids, and it certainly isn’t about swinging the pendulum back to a state in which we don’t manage pain with opioids; it’s rather to look at the whole person and the whole package.

If we have one thing that we would recommend, it’s that we adopt, across the country, a pain assessment tool that gets us away from the thing that every one of you – Ben had you all raise your hands if you had pain – if you’ve had pain, you know if you go to a clinic or a hospital or see a doctor or anybody, the first thing, the last thing, and everything in between is the question: Are you in pain and what number is it? Well, that has no utility. In an 11-step analog model from zero to 10 has no utility if it’s not linked to function, if it’s not linked to functional impairment. And so we have adopted, with the help of the VA, a common language. We’ve adopted the Defense and Veteran’s Pain Rating Scale. You’ll see the familiar 11-step analog scale with the faces, but you’ll also see that every one of those steps is described in terms of a functional decay, so you can’t be at 10-level pain sitting eating your lunch and watching TV. You’ve got to have a major disruption in function and, very important on the flip side of this card, begins to look at the major interference that pain causes sleep, activity, mood, and stress. Is your pain causing you stress? Is it interfering with your sleep and the like? This causes a whole different dialog to occur between the providing team and the patient because you can find patients who have stable 4-, 5-, 6-level pain but are now getting sleep, now eating, are not interfering with their activity. That’s a success. Whereas driving toward pain of zero is only accomplished by putting people to sleep and having them, you know, inactive and non conversant on the carpet.

So those are my thoughts. Thank you very much.

SARAH DASH: Great. Thank you very much. And before we move on to our next two presentations which I very much want to hear, I just want to ask a little bit of a clarifying question and maybe either Dr. Miller or Dr. Schoomaker can kind of jump in here, but you both made the distinction between acute pain and chronic pain. Are there distinctions in the medical literature between the different types of pain? Is there more acute pain than chronic pain? We’ve also, you know, I think, out there, probably heard the term “chronic non cancer pain,” cancer pain is perhaps different. Can you kind of just spell that out for us a little bit more and then if Dr. Schoomaker, if you could kind of tell us a little bit more about the scale on the standardized pain assessment, does that cover all those kinds of pain? Is that kind of a way to address people’s pain whether it’s in the moment, acute, or a more chronic kind of issue?

DR. MILLER: Okay. We’ll make it really, really simple because this is the way I think. When you think about the differences between acute and chronic you can consider time. This is a really easy variable. Is this something that is an instantaneous pain that’s probably going to go away within a short time frame, or is this something that’s going to continue and you’re going to be stuck with or you’re going to have for an extended period of time? I mean, it’s the basic definitions of acute versus chronic. Typically, when we think about acute pain it could be something like I’m recovering from a surgery. It could be something like, okay, I mentioned earlier, I got stung by a bee. Or, when we go to chronic pain, this is something like I might have had an accident where now my back is forever in this shape and this is the pain that I experience. Chronic pain, and for many people, actually something that they learn to live with and they can function with but is something that they have. It’s like a ringing in the ear, or it’s like something that you might also have been diagnosed with that you have for the rest of your life, you have to figure out a way to cope with that. That’s typically the way that we distinguish those two, and I welcome your distinctions there, too.

DR. SCHOOMAKER: I agree with what Ben said. Just to answer quickly the last part: does the scale apply to acute and chronic? Absolutely. I mean, this is a pain management scale that allows you to address whatever and however long the duration of the pain has been. It just emphasizes, as I said before, how disruptive is this in your life, and what do I need to marshal in the way of resources to address it.

We all know that pain is, at the end of the day, not an objective state. There is no thermometer or measure you can place in any human being to tell their level of pain. It’s entirely subjective. You want to know the proof of that? I’ll give you a drug which completely eliminates your memory and you will not be in pain. Every time you go for a colonoscopy or a major procedure, we give you a set of drugs, benzodiazepines, like Versed, that completely obliterate your memory and for all intents and purposes, with a little bit of pain adjunctive drug, you don’t remember any of that and you’re not in pain. Taking care of some of the most severe Alzheimer patients that I’ve ever had who have had major injuries, it’s very hard to tell they’re in pain because they don’t remember they’re in pain. So pain is subjective. Acute pain is largely around tissue disruption: a burn, a severe traumatic event, a kidney stone, childbirth—these are all acute events that are accompanied by the body’s attempt to alert us. I mean, we have this great machine that is designed to tell us when we’ve had an invasion of a part of our body that you don’t want anybody in there. You’re going to get an infection or you’re going to have a major obstruction. But once that’s been there for any length of time, the brain begins to remodel this whole event. In the most extreme form of that are groups of patients whose pain is entirely psychogenic. We can’t find a single bit of evidence that there’s any tissue disruption whatsoever. They’re very difficult patients to manage because we know that they’re in pain. They have a form of pain that’s emanating from the brain, and yet there is nothing they can put their hands on, or the like, and they’re surrounded by people who will do anything, in the way of drugs or procedures, to try to eliminate that pain, often to their detriment.

So does that explain some of the distinction?

SARAH DASH: I think so. At least to me, and hopefully to our audience. Thank you. Well, and without further ado, we’d like next to hear from Dr. William Morris, from Santa Cruz, to tell us a little bit more how this actually works in the real life system perspective. Thanks.

DR. WILLIAM MORRIS: There’s the sense of the pain of life. So I’d like people to raise their hand, if they feel comfortable, how many people here have been touched themselves, or family members or friends with the pain that comes with addiction, either alcohol, tobacco, drugs? I mean, when I give talks, it’s a large percentage of people that raise their hands and I want us to keep that in mind as we talk about how we design these programs that are integrated and when we talk about parity between addiction services and mental health services with what we traditionally think of as medical care or physical healthcare.

So let me tell you a little bit about my setting. I have to look up my statistics here. I work with Sutter Health, a nonprofit healthcare system that serves over 3 million patients in 24 counties in northern California. We have 6,000 physicians, 24 acute care hospitals, 2.5 million patients received ambulatory care from our providers. Palo Alto Medical Foundation, or PAMF, is a subset of Sutter Health. It serves about 1 million patients in central and southern San Francisco Bay area, and I practice even in a smaller subset of that in Santa Cruz, California about an hour south of San Francisco. So, you know, this is sort of the big picture coming down to the small picture and I want to share with you today what we’ve done on dealing with both chronic opioids and chronic pain.

In 2013, we really felt we needed to deal with the issue of these chronic pain and chronic opioids in our patients because it was causing our providers a lot of pain. You know, how do you deal with these patients? They’re really frustrating. They take a lot of time. We don’t feel like we’re delivering good care to them. And so we developed a committee and we came up with really this challenge, is that, you know, opioid therapy really doesn’t have good data, that it supports, that it works for chronic pain over the long term. I mean, it may help some patients, and you know, you talk to providers at a local level and they all have patients who they say, yes, you know, they’re doing well on chronic opioid therapy. They’re stable. They’re not having signs of loss of control of opioids. We don’t want to cut this off, and patients are horrified that that might happen, you know, because there are practices and groups that say, “We don’t give opioids for chronic pain anymore.” And so patients are stuck and they get into trouble. So how can we safely utilize chronic opiate therapy for patients in chronic pain for whom which opioids are effective, at the same time, how can we recognize and manage those patients for whom chronic opiate therapy has really failed? And I want to emphasize here, we’ve really tried to use the language around opioids failed the patients. Sort of the background behind that is the healthcare system has failed the patient because that’s what we’ve given them for the last two decades is more and more opioids. And I was part of that. I work in palliative care so I take care a lot of patients at the end of life and when patients would come to see me we’d give them more opiates if the opiates weren’t working. And I started seeing more and more patients, or my colleagues would come to me and say, “Dr. Morris, I have this patient who’s not dying, so they don’t really qualify for palliative care, but they’re in a lot of pain and they’re on lots of opioids and it’s not working. What do we do?” So we started to feel the need to try to deal with it.

So what we did was, we got actually some money from California Healthcare Foundation and they allowed us to form a committee that worked on a couple of tasks. But the first thing we did was we looked at safe monitoring of chronic opioid therapy in patients for whom it’s effective. It just happened that the acronym DEA fell out and we said we would do three things, very simple things to try to keep these patients as safe as we can rather than overlay a lot of demands on patients. And one is documentation of chronic opioid therapy status in our electronic health record, so when patients try to prescribe or get prescriptions for opioids from another doctor that pops up. We can do that in our electronic health record. To educate patients not only about the lack of evidence for chronic opioid therapy, but the risks as well as how to be safe when you’re on chronic opioid therapy, things to avoid, like lots of alcohol, sleeping pills, how to safely store your medicine. And then, more recently in the last year, we started to really advocate the use of Narcan, I mean, a nasal spray that counteracts the effect of opioids. So it’s sort of like an epipen if you’re on chronic opioid therapy. Hopefully you never need to use it, like you hopefully never need to use an epipen if you’re allergic to bee stings, but you have it when it’s there. You can’t go out and get it when you’re not breathing anymore, you’ve got to have it at home.

And then, lastly, we all encourage our primary care providers to have a sit down with an opiate agreement. Sit down, talk about treatment goals and expectations, which really emphasize more than just pain relief but functional improvement. Are you getting better? We don’t really do a lot of benefits to patients if we take their pain scores, as already has been mentioned, down to 3 out of 10 but they’re lying on the couch all day. So we have to emphasize both of those things.

So we were able to get, as well, form a coalition in our county called Safe Rx Santa Cruz, and we focused that coalition around the whole concept of opioid failure. When I was in medical school, I had a cardiology attending and he was trying to teach us about heart murmurs and we must have all been sort of nodding off because all of a sudden he said, “Bill. Why did you walk by my Aunt Betty the other day?” And I sort of stammered and said, “I don’t know your Aunt Betty.” And he said, “Of course you don’t know my Aunt Betty. You were never introduced to her.” So he went on to introduce us to heart murmurs and we feel, in the same way, we have to introduce our primary care providers to what opioid failure looks like. So we came up with three questions. The first is, we ask: Are serious opioid related adverse effects occurring? And that might be respiratory failure – that’s pretty serious. Are they life threatening? That’s serious. Are they unable to be managed? Like sometimes patients get horrible constipation and we can’t really manage it, and so that, for those patients, opiates have failed. Alright. So let’s say serious opiate adverse events haven’t happened. The second question we ask is: Are significantly opioid-related aberrant behaviors occurring? By that I mean, are patients taking the opiates likes they should? And this harder to wrap sort of our heads around because it’s a little more vague. Now sometimes, and we’ve created this graphic to help our primary care providers, sometimes they’re very clear. On the top in the red: Is this an acute risk of danger? Are they drinking a lot of alcohol and taking their opioids at the same time? Are they selling their prescriptions on the street? Do they have a clear addiction? Have they lost control of their opioids and continue to use despite harm? And, are they basically taking this medicine without a clear diagnosis? I mean, it happens more and more that we’re seeing patients are here without pain, without a clear, let’s say, x-ray evidence of a back problem and yet they’re on high doses of opiates and they’ve been on it for years. And then we allow the other yellow to the primary care doctors to sort out, with the ones in the yellow category, about how many of those are needed before we say an opioid failure has occurred.

So, and finally, we ask the question, if there’s no adverse effects, no aberrant behaviors, we ask the question: Are treatment goals being achieved? And note we ask this third, we don’t ask this first. We say is there enough analgesia and is their functional improved enough? And if the answer is no, opioids have basically failed, even if they don’t have adverse effects or aberrant behaviors. And I agree, we need a standardized tool. Our tool we use, it’s this PEG instrument, and I think it was developed to the VA? But it basically talks P for your Pain score; E – how much does that pain affect your enjoyment of life; and then, G stands for how much does that pain impact your General activity? And we use that to quantify, and the patients are on high doses of opiates and their PEG scores are real high, it’s like why do we keep giving you this medicine again that’s not working?

So, what do we do now that we have this definition? Well, we thought, in addition to educating the primary care providers about this, we thought it was too much to ask the primary care providers who are already overloaded with too much to do to add onto this to their tasks. And so what we did was we started this opiate assessment service. And the opiate assessment service asked the question: Have opiates failed this patient, when they’re challenging, hard, difficult patients referred to us from the primary care providers? The very difficult ones we talk about in an opiate assessment board once a month and we really debate back and forth what’s going on, how could we help this patient. And what happened to them when they were sent to us? Well, we got about – the first year we did this in 2016, one-third of the patients were male, two-thirds were female. The average age of the patients that were sent to us were in their late 50’s, and they had been on opiates for over, on an average, 20 years. So this is how long we’ve been giving opioids for chronic pain. And the average dose they were taking, we call this morphine equivalent, if we convert to morphine, was 120 milligrams. Now, for those of you who don’t know, the CDC says that when you get above 90 you’ve really got to be worried about this patient and you’ve really got to be sure that they’re being helped.

So what happened to them? Well, 13 percent we thought really didn’t represent opioid failure. Two referrals, who weren’t even on opiates, I don’t know why they got sent to us, but if you take the others, okay, 26 percent have weaned off their opiates in the last year, which really surprised me. I thought that this would be a much lower number, but to me, this shows me that patients are ready for a change. Even though they’re scared, they’re ready for the healthcare system to guide them as to what to do. The ones who weren’t able to wean we switched to buprenorphine, and for those of you who don’t know about buprenorphine, it comes in different names, but it’s what’s called a partial opioid agonist, and it is thought to be safer, it prevents withdrawal, it’s not a bad analgesic if you talk to anesthesiologists, and so we’ll utilize this for patients who can’t get weaned but want to get off of opiates. Thirty percent, unfortunately, went back onto their opioids, but fortunately at a lower dose, so it’s not a cure all. It does not work for everybody. Interestingly, about 17 percent of the patients were lost to our follow up, and looking at their records, it really looks like these patients represent serious problems with opiate addiction or psychiatric comorbidities, and we’re going to have to figure out how to deal with those.

I’ve included this in my slides, not to read today, but it’s been so encouraging to get some of the feedback about patients who we converted to buprenorphine. I’d like to highlight this one, because this is actually very consistent with Dr. Miller’s friend’s beer coaster, saying get your life back. This young women suffered with chronic back pain for years, on chronic opioids, switched to suboxone, and she told us: “I have my life back for the first time.”

So, what do we have? This is what PAMF Center now, in Santa Cruz, really envisions as their comprehensive approach to chronic pain. The primary care doctors assess pain ideology, make referrals as appropriate. They appropriately select patients for whom which a chronic opioid trial might be indicated and I agree with Dr. Schoomaker, we should not take opioids off the table for chronic pain, we just have to reduce how often we use it, and we need to assess and safely monitor these patients and refer when or deal with opioid failure—recognize it and deal with it. We have an educational and coping services, not formally, but it is made up of our behavioral health division. We have shared medical appointments that talk about the risks and benefits of opioids. We have healing with pain shared medical appointments that talk about mindfulness, exercise, nutrition, sleep and all these factors as managing their chronic pain. And we have just recently started some chronic opioid support groups.

Ideally, all patients should have functional restoration, alternative therapy, pain clinic services access but in reality this is limited by insurance for the most part. But crucial, crucial, crucial – and we’ve already said this today – is that addiction services and integrated behavioral health services are very important. These patients come with a lot of baggage, a lot of life trauma, a lot of life pain and we really have to have these services as well. And we’ve made a lot of progress with parity over the last decade. We can’t reverse that parity because if we do we’re going to lose this generation and there’s been experts that talk about this as a lost generation. The only way we’re going to deal with this lost generation of patients on chronic opioid therapy for whom which it’s failed is to integrate our healthcare system and deliver these services. Thank you.

SARAH DASH: Thank you. And last, but certainly not least, Dr. Andrea Gelzer from AmeriHealth Caritas. We’re excited to hear from your perspective as a healthcare insurer.

DR. ANDREA GELZER: Thank you Sarah. Good afternoon. I’m honored to be here today with these great experts on this panel and share with you some of our thoughts and thinking on innovative models for chronic pain management.

AmeriHealth Caritas started out as Mercy Health Plan with 300 members in West Philly in the 1980s, and if you know West Philly, it’s a very diverse, very poor, very challenging neighborhood and heroin abuse is one of the biggest issues that we see there.

AmeriHealth caritas has a presence in 17 states now in the District of Columbia, and touches live about 5.8 million individuals of whom about almost 2 million are in managed Medicaid. So when we’re talking about Medicaid, I think it’s very important that we level set. We’re talking about a population with very complex psychosocial and health needs, and they’re not just poor, non-working adults, and the barriers to care they face are significant. And to coin a phrase that ACAP has started to talk about, Medicaid is Us. They’re moms, they’re babies, they’re children, individuals with chronic disabilities and other vulnerable populations – low income seniors. They have housing instability, they have food insecurity, they’re more likely to have complex conditions that require pain relief and they’re likely to have behavioral health comorbidities and substance misuse disorders. In fact, Medicaid is the primary payer for medication addiction treatment.

So, as you’ve heard from the panel, chronic pain is a multifactorial issue, so it requires a multifaceted approach to address it, so at AmeriHealth Caritas, we’re trying to take that multifaceted approach. So we’re implementing, first of all, pharmacy guidelines that align with the CDC limits and opioid recommendations and we’re monitoring and we’re calling out over prescribing, so we’re monitoring physician behavior and prescription behavior and clinically appropriate utilization. We’re doing academic detailing to practices now to tell them about other alternatives. We’re educating providers. We’re merging behavioral health support with physical treatment for chronic pain as well as addiction and, at the same time, we’re providing medication assisted treatment. So the suboxone or buprenorphine and naltrexone – those are the two that are normally used, and we’ve taken all our prior auth requirements away as we’ve been allowed by each state, because each state has to approve all of your prior authorization requirements.

We’re also offering and beginning to offer even non pharmacological treatments, alternative therapies, that may not be on a state’s Medicaid benefit schedule, like acupuncture, of course, PT and OT and there’s been a resurgence in looking at chiropractic care as an alternative. We’re making access to naloxone possible and developing specialized programs that improve access to multidisciplinary pain centers, and we need more of those. They’re few and far between.

We’ve taken a holistic approach to care management for more than 30 years and that approach to integrated care management is vital to address chronic pain, as you’ve heard from the panelists already. All of our care managers use motivational interviewing techniques, and we use evidence-based assessments. So when a new member comes onto the plan, when somebody is referred to care management, the nurse does an intake assessment and they screen now, they screen for behavioral health issues, they screen for substance abuse issues. If the person screens positive for substance abuse we try to get behavioral health referrals right in place and also referrals to other treatment centers as indicated.

Medicaid is mostly still moms and babies, and they make up the largest segment of all of our Medicaid populations, so this is a busy slide but it shows you, for each of our plans, we have 2014, 2015, 2016 with ’16 on top. Neonatal abstinence syndrome is rising in each of our markets and, in fact, our enterprise wise rates have nearly doubled from 2014 to 2016. So we’ve put special emphasis on developing specialized programs for maternity, and we’re making prenatal care for women at risk a priority. Pregnant women taking opioids for chronic pain, or those who may be addicted to opioids, they really need help pursuing treatment and gaining access to social services that may be necessary to stabilize their physical and mental environments and they have to do that before they can actually deal with their addiction, and they’re afraid to talk about it, too, because they’re afraid their kids are going to get taken away, or they’re going to be referred to some kind of – anyway, they’re afraid to talk about it. There’s no one size fits all approach to drug treatment. In the Medicaid managed care arena, we try to ensure that women’s family obligations and circumstances are also considered when the care manager tries to develop a treatment plan.

And I just want to give you two examples. In Philadelphia, we’ve partnered with like-minded organizations on this and since 2013 we’ve had a partnership with the Maternity Care Coalition and referred pregnant women to them who have substance use issues, and what they do is pair them with what they call an advocate, and that advocate follows them through the pregnancy and attends addiction services meetings, as well as behavioral health meetings or OBGYN appointments, as well. And it’s really important, even in Philadelphia, where you’ve got lots of academic institutions, the OBGYN’s really don’t know where to send these women, so we have had to – the state of Pennsylvania, actually, has set up centers of excellence and is pretty forward looking on this topic. But we’ve had to educate the OBGYN’s that look, here’s a place, here’s a place at Jefferson, or here’s a place at Crozer, or here’s a place at Penn where you can send your pregnant women. The other one is a Safe Start program, we’ve started another program at Crozer Keystone in Philly, and we call it the Pearl program and it really pairs at risk women, again, with a peer support specialist, so it’s someone who’s actually gone through this before. They follow the woman, like the advocate, through the pregnancy, go to all those meetings, and we’ve also committed to staffing that peer support specialist for up to two years following the pregnancy, because once they deliver, those babies are at tremendous risk.

There are some challenges affecting the delivery of integrated services for chronic pain. We know that multidisciplinary centers are few and far between, and if you’re a pregnant opioid user, it’s even tougher. The 42 CFR Part 2 Regs also really perpetuate a fragmented system. They really need to be looked at because there isn’t enough information sharing between the physical and behavioral health sides, and then behavior change. Members not interested in recovery can be very difficult to reach and engage, so we’ve learned that one of the most impactful ways to tackle this problem is really an old fashioned solution, you know, really shoe leather, getting your feet out on the street. So we meet people where they are, we give them support, guidance, resources, and we do that with an army of community health workers. And nowhere is the success of this approach more evident than in Medicaid managed care. This is what we do on a daily basis.

And before I finish, and forgive me for editorializing a little bit here, but there’s been a report that’s been going around about Medicaid managed care or Medicaid expansion and it’s really quite shocking to me that some individuals are suggesting that Medicaid expansion has fueled this crisis. The notion that expansion of Medicaid is somehow to blame for the scourge of opioid abuse across this country just doesn’t make sense to me. And I mean, I showed you our neonatal abstinence numbers from 2014 to 2016. They aren’t the Medicaid expansion population. It’s all going up, folks. Opioid addiction is a great equalizer. Opioids have no favorite gender, race, age, or socioeconomic status. Everybody – everybody in this room is at risk for falling victim to the opioid crisis. When prescription opioids lead to addiction the problem is with our healthcare system, not the fact that more disadvantaged Americans are finally getting access to that system. Thank you.

SARAH DASH: Thank you. Wow, well, let me do my own audience poll. How many people learned something new about pain today and opioids Great. Well, we’re now at the Q&A discussion portion of our event, so and you have a couple ways that you can ask questions. You can write it on a green card and a member of our staff will bring your question up to me, or if you can see there’s two mics, one on either side of the room, a little lopsided, that you can stand and ask your question. I want to, while everybody is getting their thoughts together, kind of open a question to the panel. I mean, it seems like, just from the standpoint of the physician, you know, I think one of the things that’s remarkable to me about a lot of your comments is that utter lack of blame and finger pointing for any one sort of entity in the system that you were really emphasizing the need for a system and yet, you know, it seems that physicians, you know, have they been caught in the crosshairs here. You mentioned, Dr. Morris, kind of that pain is the fifth vital sign, the pressure to treat pain and yet now, you know, of course, very well reasoned prescribing guidelines for opioids, so what are the practical tools that physicians and other healthcare professionals can use now in the absence of a fully integrated system or the gold standard? Are there those tools that are available to them and, if not, what’s it going to take to get there? I only ask easy questions.

DR. MILLER: I’ll give you an easy answer. I’m kidding. There are no easy answers here. I’ll give you one example of ways that we can begin to normalize the discussion and actually it was reflected down at that end of the table in a couple of different ways. One, we have to make it less scary for people to talk about what they’re going through. I mean, when was the last time you all went to see a provider? Sometimes in the hustle and bustle of healthcare, we feel like we’re being rushed through a process and we’re not necessarily being talked with we’re being talked to. There’s some small things that we can do at a clinical level to normalize talking about pain. I’m going to give you one example, and you may or may not have recognized this. We used to have these things that were used in practice called pain contracts. Are you familiar with these? They’re like, if you don’t do this, or you do that, we will take away your pain medication and you will be in pain. And it was a pejorative, top-down, paternalistic approach to really managing pain. Now what we do, and I heard this reflected really nicely, is we have agreements. We talk about how can we give you functionality in your life? How can we increase the ability for you to go out and do the things that you once enjoyed? We’ve changed it being something we penalized you for to something that we’re working with you around. That’s a small shift in the culture of talking about pain. It’s also a really small shift that happens at an individual practice level. I’m the guy that wants to change the system, don’t get me wrong, but there are basic things that we can do just within our language, within the practice culture, to normalize talking about pain.

DR. SCHOOMAKER: I guess my response to your question, Sarah, is that I’m reminded of what Einstein said. Einstein said, “You can’t solve a problem by applying the same thinking that got you into the problem in the first place.” And what you’re asking us to do is to apply thinking that got us into the problem in the first place. I acknowledge, we all acknowledge, that systems change on the scale that we really require is going to take a lot of people and it’s going to take a lot of policy and it’s going to take a lot of coordination.

One of the reasons I put the pain rating scale up there as sort of in an 8-minute presentation, a take away from you is we think, just like the PEG scale that was raised by Bill, and you’re right, it was developed in the VA, it’s very similar. We call it the DVPRS light. It’s simpler to use. Our scale just gives us more granularity about what aspect of disruption of your life can we deal with: sleep, activity, stress, mood, and that sort of thing. But we’re on the same path. So we gave you what we think is a tool that will at least begin the dialog and the dialog and getting the patient engaged in the dialog is critical.

I think, for the purposes of a discussion like this, we really need to start separating opioid addiction from the pain. We’ve got problems, and I think every one of us has talked about the problems that we’ve gotten into because of this, and they have to be addressed. Just like in a cholera epidemic you’ve got to treat the victim of the cholera, but at the same time we’ve got to apply thinking as to how to stay away from exacerbating the problem or growing the problem any bigger. And I personally think that one way is we’ve got to quit thinking about drugs. Drugs are not the solution.

How many of you see an ad on TV every time you watch a football game, baseball game, a golf tournament, on opioid induced constipation? Can you believe it? We’re now using a drug to counter another drug, and frankly, I think Pharma would like to keep us in the drug dialog. We need to get out of the drug dialog. There are many ways we can manage pain that don’t interfere with function.

Let me raise another thing that was, I think, raised by Andrea sort of indirectly. Why do we have a Mu and Kappa and other receptors that are sensitive to opioids in our body? Nature didn’t put a Mu receptor in our brain in order for us to eventually find an opium poppy and start making heroin and morphine. It’s there for a function and that function is because we manufacture endogenous opioids. It’s what gives the runner’s high, but it has a lot of other social impacts. Mothers ignore their children when they’re on opioids. Mother rats ignore their pups when they’re on opioids. Males become aggressive in the cage when they’re on opioids. So we have a series of mechanisms in our body that are designed for stress environments in which we get pain that help us to survive that stress environment. It helps us lift the car off the child who’s just been run over. It helps a soldier in combat who has a wound run out and save a buddy or take the objective. But it has social implications that are severe and these social implications, as Dan Carr says, of the American Academy of Pain Management, if those were the first that were discovered we’d be looking at opioids in a much different way than we do today.

So we’ve got to separate the problem that creates opioids problems: pain, chronic pain especially – from the opioid treatment, and we’ve got to start thinking very comprehensively about non drug approaches to manage this. Thanks.

SARAH DASH: I know we have someone waiting patiently at the mic, but this does flow into a couple of questions we’ve gotten on cards about those non drug approaches and I think all of you mentioned the words multi modal, you mentioned what some alternative or complementary approaches might be. Dr. Gelzer, you mentioned some of the things that your plans are covering as part of covered services like acupuncture, so, we actually got a couple of questions about how we utilize those complementary approaches. Is this something that is covered by insurance and I’d like to ask kind of the evidence question going back to Dr. Schoomaker’s presentation about what do we know about these so far and what do we need to know.

DR. SCHOOMAKER: We can recommend plenty of literature about this. The current modalities in a complementary world that have most of the evidence behind them are acupuncture, Yoga – Yoga and acupuncture and others have been recommended by the America College of Physicians, the Internist Guild to approach low back pain, acute, sub acute, and chronic. So, acupuncture, Yoga, Mindfulness Meditation, chiropractic, music therapy, medical massage, Tai Chi, and probably by extension, Qigong, which are good movement therapies for cervical pain, and did I look any of them? I think those are probably, right now, the most accepted and has the greatest body of evidence in randomized clinical trials in other settings for their use.

DR. GELZER: I would just add that acupuncture – there’s an evidence basis for acupuncture for low back pain and what other indication—and I’m blocking on it—we would cover it for those two indications.

DR. SCHOOMAKER: Post operative pain.

DR. GELZER: Pardon me?

DR. SCHOOMAKER: Post operative pain.

DR. GELZER: Okay, because otherwise there is not on an evidence basis and so all of our clinical policy determinations are based on evidence. So we’re adding that benefit in markets, as a value add. In other words, and using that as an opportunity to get people into programs in order to get that kind of therapy where they sign a contract and have a relationship with their provider to try to really address the chronic pain problem.

SARAH DASH: Thank you. And I think you have some materials and citations in your reading list that address some of that question as well. Alright, thank you for your patience.

ANDREW KESSLER: Thanks. Andrew Kessler. I represent a variety of substance abuse treatment providers in Washington, and Dr. Gelzer, the question is directed to you, but anyone please feel free to answer. On your last slide it almost seemed like a bit of something you wanted to just hit at the last minute, but you mentioned 42 CFR 2, which is rather complex and we don’t have time to explain what that is, but it’s confidentiality between practitioners concerning substance abuse treatment, and you mentioned there needs to be reforms, and while I agree that it can be a frustrating regulation for practitioners to deal with when you’re talking about integrated care, it is also one of the sole protections that consumers have from the criminal justice system, and we all know about the nexus between addiction and the criminal justice system, and the advances and the strides we’ve made, but odds are good, not automatic, but odds are good if you have a patient who is abusing opioids, they are running afoul of the law one way or another, whether they’re purchasing them on the black market, through false prescriptions, what have you, what do you see as the role of the practitioner in terms of making sure that not only the patient is healthy but also safe, because this is the only disease that has to interact with the criminal justice system.

DR. GELZER: You’re absolutely right. It’s a double-edged, triple-edged sword, and I mean, I think more and more the American College of Physicians, the American Academy of Family Practice are saying, look at this. Look at substance abuse, not in the criminal justice system, but look at it. It’s a chronic disease. It’s a chronic ailment that folks have, so there should be protections. That said, I think it’s up to the providers to communicate, to figure out how they’re going to communicate. So if you have to get permissions signed you get the permissions signed, and unfortunately, in this day and age, the encounters are so quick and so, you know, they’re just very quick. I think we need to bundle payments somehow so that people are responsible for the outcomes.

SARAH DASH: Thank you. I’m going to follow up on what you just said, Dr. Gelzer, about bundling payments and ask a really fun question that came in on a card: If you were able to design and implement an alternative payment model through CMMI for the treatment of chronic pain, what would that look like. So go.

DR. SCHOOMAKER: Can we pull up the slides that I had hidden – in your slide deck that I had, I’d recommend the following – I’m sorry. If you would look at your slide deck, or in the hidden slides for mine, I just want to draw your attention to an effort we made with the help of the Samueli Institute, Joan Walters in the audience, and she was a major part of that. Do you want to raise your hand, Joan, just so they know who you are.

So if you look at this page, on page 10, this diagram here in the hidden slides.

SARAH DASH: It’s in your packets.

DR. SCHOOMAKER: You’ll see that after about a year and a half of working across the civilian, DOD, and the VA, and the VA and the DOD are two separate Cabinet agencies, as you know, we concluded using a methodology from the Institute of Healthcare Improvement, an approach to developing just what you’re talking about, and we identified four different domains that had to be approached. One is the Integrative Care domain. You have to design a system that integrates care using the many modalities we’ve talked about here, including conventional care. You have to empower and engage the patient to promote self efficacy because much of what we’re talking about really has to begin with patient self care. You know, mindfulness meditation, Yoga, many of these approaches, biofeedback, they all emanate from self care protocols. You have to design, within the healthcare system, operations that support that. This can be a peripheral. And this is a huge problem for us even in the military. You know, the military healthcare benefit program, TRICARE, does not pay for a majority of these modalities outside the gate. We can do more inside of our military hospitals than we can through our healthcare system outside the gate. And so patients like my wife, who is a chronic low back pain sufferer for the last 25, 30 years, when we’ve gone to communities that we don’t have a facility that provides acupuncture or Yoga or other things, we have to buy it out in the community out of our own pocket. And then last, but not least, and really not least, is we have to have a sustainable business model. If you look at care programs, like Allina Health up in Minnesota that has 11 or 12 different hospitals and clinics connected, they have an integrated approach to pain and problems, but they have to all run this as a loss leader. They lose, you know, several million dollars a year by doing things that paradoxically and ironically are helpful for patients. Length of stays drop. Use of opioids and other drugs drops. Patient satisfaction improves. Function improves, and yet, the system, as we’ve talked about up here, does not pay for that. So, you’ve got to develop a sustainable business model.

DR. MILLER: I would just briefly add that fee for service, and you all understand this, perpetuates the hyper specialization of American healthcare. And so when we start talking about how do we take care of a person and surround them with a team that can meet their needs, there are really one of two really great alternative payment models that exist out there, and the one that I trend toward is more of a global budget type of approach. If you give practices flexibility to create teams for their community they’re going to rise to the challenge, but if we continue to put them under this oppressive fee for service regime it’s very difficult to create novel and innovative solutions that actually are in response to the person. And one basic example of this is that if you wanted to bring, like what was mentioned by Dr. Gelzer, a mental health clinician onto your team and practice, you’re going to have to figure out how to pay for that. But if I give you a budget that takes into account – your community – that takes into account some of the risks that you’re going to assume for addressing these wide range of needs, and you leverage those dollars, you hire your own. They become a member of your team and then, seamlessly, you all work together to meet the needs of that person.

SARAH DASH: Let me ask a follow up. And Dr. Morris, you know, you really described how you started a program and really got a lot of input from the physicians and kind of changed practice within your system, can you describe what was the importance of payment to that and how long did it take? I mean, it seems like you were doing more than just emulating practices. There was a culture change there, as well, so can you talk about—

DR. MORRIS: Well, it’s still in the process. I think this is small, it has a relatively small pilot program within our bigger Sutter Health network, but hopefully it will expand. I mean, obviously, there’s politics and there’s money and people are trying to get – there’s limited resources. But I think what’s helped us the most is having support of leadership to say, sort of like try this. And I didn’t tell you the mistakes we made, you know, so you make mistakes and then you say, okay, we learned from that, let’s try going along with this, and it takes, I feel, leadership and leadership is limited. I mean, I think we sometimes express this surprise, oh, my gosh, you know, we got into this trouble with chronic opioids, pharmaceutical companies really encouraged us to use them, I mean, what’s the bottom line for pharmaceutical companies? They’re for profit. They want to make money. I think we have to sort of accept that and work from that and say, look, we have a capitalistic society, let’s work towards systems that will work within that system, realizing that, you know, the bottom line is you have to make a profit or you’re not going to have any sort of mission. You know, we talk about that even in Catholic healthcare hospitals. You know, no margin, no mission. You’ve got to be able to pay the bills in order to do the services so it takes some creative thinking, leadership support, willing to fail, and then get up and try it a different way, I think. But certainly, within a policy standpoint, the flexibility to do that. You know, sometimes leadership in our healthcare organizations won’t even try if they’re guaranteed that they’re going to lose money from it at the beginning.

SARAH DASH: Thank you. Any other thoughts?

DR. GELZER: I’m just going back to the CMMI question and I mean, there are progressive systems out there and I think that, as you said, you’ve got to have a positive bottom line, so if CMMI is going to give a grant to somebody there are going to be people that will try to get that grant, right? So I think chronic pain bundles are a great place to look.

SARAH DASH: Great. Thank you. We have a question at the mic.

EMILY JONES: Hi. I’m Emily Jones from the National Institute on Drug Abuse at NIH. Quick note on the reimbursement issue, I believe the Medicare Chronic Care Management, the CCM billing codes, can be used for consultation with pain specialists or with other types of specialists that will help primary care providers better manage pain. But the real question I’m up here to ask – first of all, thank you for a wonderful event, wonderful panel, and lunch – how can we improve the safety of things like co-prescribing naloxone, you know, for every fetal overdose there are 30 nonfatal overdoses, and not all of these are people – you know, some of these are people who are pain patients with a prescription for opioids, so how do we make sure that more patients have naloxone for overdose rescue in their home, and then also, this co-prescribing with benzodiazepines, this seems like a real easy kind of a textbook low hanging fruit, and so yes, there’s clinical decision support within the EHR but how else do we kind of improve the safety, just basic levels of safety for pain patients?

DR. MORRIS: I’ll tell you what’s even more discouraging is people who have a nonfatal overdose, there’s data that supports that six months they’re back on their same dose of the same medicines, prescription opioids and benzos, that they were on before and when I am called into the hospital to consult on these patients who have just overdosed, all throughout the chart it says: probably from their opioids. And I say we have to get this patient off opioids. Opioids have failed, or benzos, but usually they’re on both. The doctors say, well, then what do we do? You know, how do we treat their pain? And because we really have depended on drugs for so long we don’t really have, you know, another alternatives and doctors just are trying to relieve the suffering and the pain of these patients. And the patients say – I’ve had patients say, “I’ll die without my opioids.” And so it’s sort of hard to face that and say, “I’m not going to give you opiates.” We try to cut them down, we try to wean it, but I tell you, one of the most scary things, I think, for patients that they have to face is to go off both their opioids and their benzodiazepines. They don’t like it. And, they give us a lot of negative feedback on our quality satisfaction scores which, you know, a leadership looks at and says, hey, Bill, you didn’t get very good quality satisfaction scores. So, you know, okay, I’ll give all the opioids I want. You know – no, I don’t do that, but that’s the problem. So changing what drives quality. I think that a trigger on the electronic health record saying your patients are on both in California, our drug reporting, our cure system, tells us when – gives us an alert when patients are both on opiates and benzos, or multiple opioids, so those are helpful things to do. But then when the rubber hits the road and you have to really try to wean people off of benzos along with their opiates, it’s very hard.

DR. GELZER: I think that I mentioned academic detailing, and so more and more we’re going to be doing that, and more and more our state regulators are expecting us to do that, so we make naloxone available for all of our membership, but who’s going to go get naloxone? I mean, the doctors have to – the academic detailing is to tell the doctor, look, if you have someone who you know is on opioids, tell them – give them a prescription and tell them to go – that’s the most effective way to get them to go.

DR. MORRIS: But they don’t have to get the pharmacies to stock it, which is a problem in our area. Pharmacies haven’t been stocking Narcan. We have to really work with them to get them to keep it in stock.

DR. GELZER: And there are three national quality forums in May just to prove the three Pharmacy Quality Alliance Opioid measures, so people are beginning to look at it. I don’t think one of them is benzodiazepines, but that should be coming. You’re absolutely right.

SARAH DASH: Thank you. I have a quick follow up question about the quality measures since we had a question come in on one of the cards, and then I’m going to ask a final wrap up question, but for those of you in the audience, we just have a few minutes left, about five minutes left in the briefing, so start pulling out your blue evaluation forms, if you would, and before you leave we would appreciate it if you would fill that out.

Let me ask about quality measures because we had a question come in and we talked about kind of the quality measures around treating pain and, Dr. Gelzer, you just mentioned a couple of new ones that have been approved. How do quality measures need to change, if at all, to help facilitate some of the advances that you have been talking about in integrated care?

DR. GELZER: Well, we need to have quality measures that actually measure the outcomes we’re looking to see, and they haven’t really existed. I mean, there are quality measures for diabetes and asthma, but the behavioral health ones are, you know, depression and the substance abuse ones are just coming. The Medicaid innovation project that CMS has been running is actually one of the areas of focus with substance abuse, and so they have now a whole menu of substance abuse metrics that are going to be available for states to pick and choose from. So I think it’s really important that, I mean, what gets measured gets better, so it’s important that we get the measures out there so people start paying attention.

DR. SCHOOMAKER: What we’ve been doing in working with a number of other folks—Northwestern University and the like—is to leverage the NIH’s effort to develop a system called PROMs, which is Patient Reported Outcomes Measurement System. They put about $100 million in a decade into developing this. We’ve adapted it to chronic pain, or pain, and we call it PASTOR. It’s well described. If you go to the website for the Defense and Veterans Center for Integrated Pain Management, the DVCIPM.org, you’ll see a demonstration of PASTOR. And what it provides is what was just described. It’s an outcome focused approach that can be individuated for patients. We use it both in research and clinical use and it focuses on all of the elements that we’ve been talking about that the current system that’s mainly a fee for care system, the widget billing system, that rewards for prescriptions and procedures and the like rather than for the outcome improvement for the pain. It gets around that by looking more comprehensively at how we would evaluate the impact of pain management. So I recommend that you look at P-A-S-T-O-R, PASTOR.

SARAH DASH: Thank you. So just one final question and the questioner notes that the opioid epidemic requires thoughtful and deliberative action that’s going to take some time, but that obviously this is an immediate crisis that demands immediate action. So the question is: What are some immediate next steps that you would recommend, and if you could address for government, for federal, state and/or local government, for payers, insurers, and if you would, also for private funders like entrepreneurs or philanthropists, is there a role there. So just in the few minutes remaining, I know that’s a mouthful, but if you could kind of share your thoughts on what an immediate next step or two might look like.

DR. MILLER: I’ll give you the best summation I can give you. Simply decreasing the amount of opioids that are on the market is not going to solve any of these problems. We’ve got to upstream and we’ve got to address how people have pain, why they have pain, and do something much more systematically to address that pain or else, downstream, we’re always going to be putting Band-Aids on gaping wounds, and that is simply not a good solution. That is how we do a lot of public policy; that’s not how we should address this epidemic. The number one thing that I would suggest, and this is a really basic one, is that we have to look at how our policies inadvertently perpetuate fragmentation in how we take care of people. If the policy somehow limits what a person can get in that moment that they need it the most, it’s probably a policy worth pursuing and changing.

DR. SCHOOMAKER: Yeah. We’re in a sinking lifeboat and while you’re trying to bail out the lifeboat, meaning treat opioid addiction through a variety of things, we’ve got to plug the leaks in the lifeboat and the leaks are pain. We need to institute the national pain strategy in totality, and we have to change the culture of our management of pain, and this is a real – this is a big bite – a mouthful. We want to start by using, universally, some form of a DVPRS, or way of rating pain that engages the patient in meaningful dialog and gets away from a simple approach that just says, we can wipe pain out of your life using drugs or a combination of them, and we think that’ll get the dialog going.

DR. MORRIS: I’m embarrassed to say that our opiate assessment service has a four-month wait to get into. That’s the demand that’s there, so we’ve sort of – our next phase that we’ve decided to do, instead of waiting for the patients coming in to see the opiate assessment service to decide whether they have opiate failure, we’re sort of, I think, following the mode of early days of HIV. We’re going to the people and we’re trying to educate the community. This is what opioid failure looks like. Do you have opiate failure if you’re on chronic opioids? And we’re trying to translate those three questions for patients to ask, and patients can ask those questions, and most of the time they know. And then we’re going to try to empower them to say: you need to go to your doctor and demand that something be done other than continue to give you opioids. So whether that means help me wean in a gradual slow process, because usually weaning happens too quickly so it fails; or, if they’re too scared to wean, you need to get me buprenorphine, so I can switch to buprenorphine and stabilize and be safer until we can gradually wean the buprenorphine. We don’t have enough buprenorphine providers in our community, or suboxone providers in our community, to deal with that demand but we’re trying to ramp that up. So we’re trying to increase suboxone providers and taking it to the people to get them to demand of their healthcare providers, because we’re sort of afraid that if we let the healthcare system deal with it on their own time it’ll take too long.

DR. GELZER: So, maybe the Joint Commission has something to do with where we are today with the pain as the fifth vital sign and making sure pain was addressed years and years ago, so maybe the Joint Commission should tell hospitals – mandate that they have multidisciplinary pain clinics. So mandate that there’s a place for these people to go, so you don’t have that four months long wait and that we have places to send our members. I think that would be helpful.

SARAH DASH: Thank you. Well, a lot of really fascinating discussion today. Please thank the panel with me. We really appreciate you all being here.

If you would, just tell us on your blue evaluation form what other topics you’d like to hear about in the future, we would appreciate it. And be well, have a great weekend. Thanks everybody.