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Melanie Cole (Host): The crisis of addiction to opioids has become a national epidemic. According to the CDC, it is now comparable to deaths from motor vehicle crashes involving persons under the age of 65, and here to discuss this current state of the epidemic is Dr. Robert Healy. He's the Chief Medical Quality Officer at Carle Foundation Hospital. Dr. Healy, explain a little bit about the current state of the opioid issue. What are we seeing right now?

Dr. Robert Healy, MD (Guest): Well we're seeing a lot of deaths. We're seeing a lot of people overdosing on opioids. Our emergency room, like others in the area, are seeing an increase year on year of the number of people coming in who have overdosed. We're seeing a lot more provider awareness of the issue, and a lot more need for education for our providers as we prescribe opioids to people, because they are good medications to use in certain circumstances, but to try and figure out when they might not be the best medication to use, and especially people who are on long-term opioid therapy that we feel need to come off of the medicine, we are looking for educating our providers on how to do that.

Melanie: Well I would think that would seem to be one of the bigger challenges, is for you providers to decide when you're talking about pain management, and you're trying to decide the best forum. What goes through your head? What are you trying to decide for that patient, and are there certain criteria that you will use as you look at a patient and say, "Okay, this is what I can use with this patient, or this is what I cannot use"?

Dr. Healy: Yeah, that's a great question. We've developed a clinical guideline through our best practice committee at Carle, and we're in the process of refining that, and educating our providers about it, and our staff. But you're right, we have to look- first of all, opioids aren't the first choice for pain management, and we have to assess people- first of all, find out exactly what's causing their pain. And you'd think that that would be an easy thing to do, but sometimes it's not. People having chronic pain in a certain region, but the imaging doesn't show what could be causing it, or the tests that we do don't show what could be causing it, but we try to first find out what is the cause of the pain, then that could help direct our therapy. We try to do non-medical therapy first, so physical therapy, therapy with ice and heat, and therapy with exercise and weight loss can be effective, but some people are going to need more than that, so then we start talking about a lot of the different medications that could be used, and different classes that could be used short of using opioids. But there are a number of people who will need the opioid therapy, and a number of them will need it chronically because the pain is not going to go away. So we really look to see, first of all that we make sure that our providers are looking for the non-opioid therapy first, and then if they're considering opioid therapy, assessing the patient. There are some evidence-based tools out there. Opioid Risk Tool, or ORT is one of them that we're going to use, and that can help to assess whether a patient is a high risk for abuse potential or addiction, and if so, we'll have that conversation with the patient and we might not use opioid therapy in that patient.

Melanie: Well that's exactly what I was going for as you're talking about ORT, the quantifiable interview questions that you would use to determine risk, whether somebody would be more at risk if you're going to have to resort to opioids. In this country today, Dr. Healy, do you think that doctors are now much more hesitant to prescribe, and if they're using some of these interview questions about alcohol, or issues maybe back when the person was in their twenties? Do you think that this is now making you all a little more hesitant?

Dr. Healy: We have seen evidence. Nationally there's been evidence, and also we've looked locally through our own Health Alliance Medical Plans population, and in the last couple years there's been a 20% decrease in the amount of opioids written for. Now that could be good, but it might not be, and what I mean by that is sometimes being human, physicians will look at a problem, and sometimes the pendulum swings the other way, so we're less likely to give opioids where we were more free to do that in the past. And the trick is that for certain patients, they still are appropriate, so finding out who those patients are, and for certain patients they're not appropriate, and using less is a good thing.

Melanie: So now on to the addiction itself, if you do prescribe opiates for somebody for pain management, how is a clinician to monitor that pain and that patient and get a sense if there is addiction starting to happen?

Dr. Healy: One thing we look for is whether the medication is effective or not, and something we might not have done as well in the past but we're making a more concerted effort to do it now, is to assess the patient's functioning, and we do it through a process called the PEG score. So we'll look at the physical activity, the enjoyment people are getting out of life, and whether they're able to do goals that have been set up for them with the patient and the provider talking about what the goal of therapy is. And we assess people ideally a month after they start the medication, or within a month after they start the medication, and then every three months, and we want to see a good response to the therapy. I think - this is my opinion - but in the past, I think people would start on medication, it helped a little bit, and we just left patients on the medication for long-term. What we realize is that these medications don't work in everybody, and so a subset of patients will start the medication, we'll assess the effectiveness, it's not very effective, so we try to rapidly wean them off the medication before they're on it long-term.

Melanie: what have you seen that the HHS or NIH are doing about it, and what are you doing at Carle Foundation Hospital to assess the situation?

Dr. Healy: So we are- first we've looked to the experts. So the CDC especially has put out a lot of good information about the proper way to prescribe, and monitor, and wean these medications if appropriate. So we've looked to the CDC, we've looked to some of our professional groups like the American College of Physicians, and the American Association for Pain Physicians, and looked at what their recommendations are, and then we've made them- we've Carle-ized them is the term we use. So we said, "How do we apply these best practices from the experts to our patients here at Carle?" So we've looked to our electronic medical record, like a lot of places we use Epic, and we're developing registries of patients who are on narcotic therapy so that a primary care doctor knows in their panel who is on chronic narcotic therapy, and then we're able to measure whether our physicians and advanced practice advisors are following our guidelines, which is to see someone every three months to assess them before starting on the medication with the ORT for instance, and to follow them with the PEG score to see if they're responding to the medication.

Melanie: So what else do you want physicians to know about prescribing opiates, and when they should be used judiciously, and stewardship of opioid, and kind of wrap it up for us. Give your best advice, what you are doing there at Carle Foundation Hospital, and what you want other physicians to know.

Dr. Healy: I think like all chronic disease issues, we need to be aware of what the latest best evidence is, and I'll mention a website that has a lot of great information about that. It's called www.ScopeOfPain.org. I think it's www.ScopeOfPain.org, I'll say the other thing in case it's this, or www.ScopeOfPain.com. And that is a two-hour session online where you go through some scenarios about starting opiate therapy, about continuing opiate therapy, or about stopping opiate therapy. That's very effective, and that sums up the external evidence very well. Plus at Carle, we have our internal clinical guideline, which we're educating especially our primary care doctors, but everyone about, and that is if you're going to start the medication, make sure it's appropriate, make sure you've tried other modalities besides opioids. If opioids are indeed what the best clinical scenario suggests, then assessing a patient to see if they're at risk for addiction or for abuse, and then following patients closely. First every couple weeks, every month, but chronically every three months, to go over how the medication is doing, how the patient is doing in their environment, and whether they're still getting benefit from the medication, and if not, talking about waning. Also in that subset of patients, in spite of our best effort to find out, there's a subset- well so evidence of addiction. The best thing to do there is to know what that is, meaning if patients are losing their medication frequently and asking for more, if patients need the same amount of medication- or excuse me, patients need much more medication to get the same amount of benefit from it, those are some warning signs that there might be addiction going on. And then sitting down with the patients and talking about that in detail, and getting ahold of our colleagues in the addiction specialties that could help us to either address that addiction with the patient, or wane the patient slowly from the medication, or refer them to an area and a specialty where they can help us. I think it's important to look at guidelines, and look at the evidence, but of course it comes down to sitting in the office face-to-face with the person who might need this therapy, and we need to realize that there are patients that will benefit from this therapy if we use them the right way. I think the other critical piece to protect ourselves is to document well what we're doing; our thought process, our idea of why someone is on the medication, our idea of what their risk for addiction is. I think that will help protect us and the patient later on.

Melanie: Thank you so much, Dr. Healy, for being with us today. It's such important information for clinicians to hear. You're listening to Expert Insights with Carle Foundation Hospital. For a listing of Carle providers and to view Carle's sponsored educational activities, please visit www.CarleConnect.com. That's www.CarleConnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole.