History of the Opioid Crisis: How We Got Here

[Music] I've been interested in in drug issues actually since the first class I walked into in college where I was suggest I was recommended to take a class called drugs in society taught by a Swiss ethnographer and I walked in I remember it vividly because I just started first time I had been in cafeterias where you could get all you could eat so I stuffed a bunch of fruit in my bag before I left the cafeteria which was promptly squished by the thirteen books I had in the bag to take to the class so all of my books from that class which I still have are soaked in banana the the class talked about drug issues and in particular sort of issues that that really tapped into something in me that got me inspired to work on this topic which I've been involved in for almost 30 years and that that was the restrictions on syringe access that led to the HIV explosions among people who inject drugs so that was really my my intro into this issue but I'm gonna go back even further than that and we'll start with 1890 so this is a an obituary about a young woman 23 years old who was the daughter of a well-known hardware merchant and was found dead in bed she when she was 17 she broke her shoulder and got some morphine to ease the pain and became addicted to the use of morphine her form was almost a skeleton and her she had puncture marks from shoulder to wrist by the points of a syringe for the fatal drug had been injected into her system so if you look at this story it's not frankly so different from the stories we've heard about over the last ten years in the midst of the opioid crisis so this isn't entirely new we've had we've had issues and concerns with opioids for for for some time the beginning of real prohibition and the sort of the drug war as we know it was really in 1914 with the Harrison narcotics act and that act was interestingly it was actually just a tax act it required any dispensing of opium or cocaine both of which were legally termed narcotics so I'm not sure how cocaine is a narcotic but legally it is and these products had you had to purchase a tax bill it's which kind of got you registered in order to dispense these products so that really started to restrict the use of the products and then there was one small phrase in this law which said addiction is not a disease and based on that the courts interpreted it that doctors could not use medications to treat addiction so all of the people who were being maintained by a physician on morphine for for really brought would call today an opioid use disorder or any or other drugs for a substance use disorder had to be stopped and the doctors became criminals and by the mid 20s there was nothing left in terms of treating addiction in the medical community and because addiction had been decided to find is not a disease the treatment of addiction largely almost entirely left the hands left the medical community it was fascinating because it was those a very small phrase actually the phrase was because addiction was not a disease with the exact words we lost the ability to treat addiction for a long long time now in the 1960s there were some fantastic physicians Murray nice winder being one of them who started providing methadone for addiction treatment and I think you've had you've probably heard a little bit about this but of course methadone is is an opioid agonist so it's a I know it's an opioid that's long-acting that happens to work quite well to help people who have an opioid use disorder to not use illicit opioids get their life together and results in a vast number of improvements for people with this disorder the the use of methadone however came under a different purview because addiction was not a disease because you can't use these products based on court decisions to treat an addiction these programs got their own very unique legal situation where methadone became by far in a way the most tightly regulated product in our pharmacopoeia methadone has to be provided through specialized clinics and these clinics are extremely tightly regulated the rules are almost entirely controlled at the federal level and the process of getting a methadone clinic established is very challenged is very challenging not just by the regulatory issues but by the NIMBY issues and the and the people who go to a methadone clinic you know they have to go and stand in line with a bunch of other people who have an opioid use disorder and maybe other substance use disorders so it actually can be challenging to to not use other drugs when you're in a methadone clinic because you're around a lot of other people who use a lot of drugs so it's it can be a really challenging environment sometimes especially for people who really don't want that life anymore so methadone isn't always the the right treatment in that scenario now the issue of overdose which is really at the heart of the opioid crisis that we're eventually going to get to that of course was an issue but nobody traced it overdose is not a reportable disease nobody keeps track of overdose like we keep track of HIV or hepatitis C or hepatitis B or chlamydia gonorrhea or you know 150 other reportable diseases overdose is not a reportable event whether fatal or non-fatal so nobody paid much attention to it the only attention I started paying attention to this to overdose issues in 1995 and I was looking at Drug Enforcement Administration reports annual reports and I was seeing that they were talking about the number of people that died from heroin overdose and they would say there were there were 3,000 deaths from heroin overdose this year there were 4,000 deaths last year what we're doing is working give us more money to do more of what we're doing and then the next year they would say there were there were there were 2,000 deaths from opioid or 3,000 deaths from opiate overdose last this year there were there were 1,500 last year what would we need to do more what we're doing to get the numbers down so give us more money to do more what we're doing and that was it that was the only way that these numbers were used and I always thought can we use these numbers to actually do something different can we use them to actually gauge how well we're doing in different policies and then in 1997 there was there was a tragedy in a part of the country in text in a part of Texas called Plano in Plano Texas is an area of upper middle-class white population so this is where we start to talk about the racism inherent in in the drug war and in frankly in the opioid crisis which is I think a really fascinating issue in this circumstance these were young kids sort of 1718 years old who had been using chiva which was a term for heroin but they just called it Chiba they didn't realize in some ways that it was heroin and they would use it for a while to develop their use disorder that their parents would find out their parents would force them into a treatment program that come out of the treatment program and they do what 99% of people who come out of a treatment program do they would go and get high they would go and get high with their friends and they would do a couple of things that really that really were what I called at the time a textbook heroin overdose they would drink a bunch of alcohol then they would inject some heroin so you've just depleted you've just set yourself in a in a state where you can't really regulate things you can't really control things you've already lost a lot of functioning and then they and then they would inject heroin and not necessarily be able to regulate that and they had no tolerance because they'd been in his treatment program and so they would go out and their friends would when they found them they would panic they wouldn't call emergency because they don't want to get arrested and they don't want police coming to their house and so when they figured eventually they would put the person in a car drive them to an emergency department and drop them off outside the emergency department and speed away and there were about 19 deaths 19 or 20 deaths in in in a year and a half period from Matt but what was different about this because the the truth was there were a lot of deaths all the time from heroin through the decades and nobody cared so what was different in this circumstance these were upper middle class white kids so the press was sympathetic what you saw in newspapers was you know this is a horrible horrible tragedy it's not the kids fault it's not the families fault it's just a terrible tragedy what can we do so I was working at the place called the open society institute at the time and we we managed to get some funding to do a conference on heroin overdose prevention and it was the first international conference and that was in 2000 and at that conference we talked about a few different things we talked about education and in terms of in terms of prevention we talked about educating people who use drugs you know what are the main risk factors that we've identified we knew from the already from the epidemiology that it was periods of abstinence it was using multiple drugs and and and you know and then there are other factors such as the route of administration injections riskier than other routes of administration and the interventions that we had were kind of limited the main interventions that we that we had main intervention that we had was was education and then potentially working with emergency medical services trying to establish policies that so that paramedics ambulances wouldn't call police immediately so that so that you could feel comfortable calling an ambulance and getting medical care instead of getting police response so those were some of the initial things and then there was a man named Dan big in Chicago with the Chicago recovery alliance who was providing naloxone to people who use drugs in order to reverse overdose now we've all heard a lot about in Locke's own and the media and naloxone is an antagonist to opioids and the idea of providing it to people who use drugs was pretty revolutionary it was over-the-counter in Italy since the early 90s so Italy figured that out a while ago there were a couple people right around the time that Dan started doing this in 1996 there were a couple people in in Europe in the Jersey Islands and in Berlin who had started on a low-level handing out in a lock zone to people who use drugs this was very underground this was you know you're providing a prescription drug without a prescription to people who may use it on themselves or may use it on somebody else so there's lots of potential violations there but that was one of the ideas and then the other the other major idea that we had around around preventing overdose was safe consumption sites or safe injection facilities there's about a dozen different terms for this but this is places where people can go to to safely use drugs usually to inject drugs the most the most famous one in this region would be the insight program in the downtown east side of Vancouver which opened in the early 2000s and has dramatically lowered overdose mortality in the region while also increasing increasing treatment uptake and decreasing HIV hepatitis C risks and infections and managing a lot of other medical sequel I of substance use so that of course was and still is not yet an option in the United States and then the final intervention that was discussed was at the time was heroin treatment programs so was programs where people can go in and inject heroin in a controlled setting and at that point in time there had been a few programs tested in Switzerland and and a couple of other countries in the Swiss program was the most famous at the time where people they people who failed other for whom other treatments failed such as methadone and various other treatments they were they were eligible to enroll in a program where they could go in to a site and inject heroin as many times a day as they needed and what what they found was that people would initially that go in they did inject heroin like four or five times a day and while they were in the program the number of times they injected heroin would decrease to once or twice a day and there as their lives got in order and as they started to trust that this service was going to be there for them and they didn't have to stress about when they were going to get their next fix and the programs were extraordinarily effective that has also remained a barrier in the United States until today so that gets us up to up to our current crisis what we've seen over the last twenty years is a really substantial increase in opioid overdose death so overall we had probably around four thousand deaths in the 98 year in the 1990s it was increasing in the 90s but then it really started to pick up in the 2000s and what we saw in the first ten years of the 2000s was really just prescription opioid deaths increasing we didn't see an increase in heroin deaths we didn't see an increase in fentanyl deaths so there wasn't a lot of transitioning to fentanyl or her - heroin fentanyl wasn't really an issue until 2015 2014-15 so we'll get to that later but heroin you know we didn't see this big transition to heroin in part because there were so many prescription opioids available though the line for the increase in prescription opioid deaths mirrored very well the line for the increase in prescription opioid prescribing the first recognition was in 2007 that there was a problem by the CDC that was the first formal recognition there were researchers in the late 1990s who recognized this as an issue in New England with oxycontin exposure however officially on a national scale it was first recognized in 2007 and we first started seeing interventions to try to address it in 2010 what I will refer to as opioid stewardship interventions so how did we get here and there's five main things that led to this prescription opioid crisis the first one is the economy as we always say it's the economy stupid the second would is the emergence of HMOs in the era of the Clinton era health care reform the third was the war on pain within the medical community the fourth was welfare reform in the Clinton era the elimination of welfare where everybody went to work right I'm not quite everybody and then finally of course a necessary and essential component was the pharmaceutical industry so what was the economy so the economy as we all know in following the 1980s shifts from a manufacturing to a service economy what we saw was that swathes of the United States were left behind they didn't they their their capacity to build the the the new economy that was pushed in the Reagan era just didn't exist and they ended up with with parts of the country particularly Appalachia being the the south sort of the southeast of the country being and and the and Michigan Ohio Regents being some of the areas that were hit the hardest by this new economy the shift away from manufacturing and what's interesting is when you look at this map and when you look at a map of opioid overdose mortality there's a lot of parallels there because those areas were they were left behind by the economy and if you think about in San Francisco if you think about certain like a neighborhood in San Francisco that where people that live there might feel left behind by the economy without any without economic prospects what I think about is people who live in Singh or single room occupancy hotel units people who live in who live in marginal housing their economic prospects are extraordinarily limited and they're and that's that's the kind of community of sort of marginally housed people that's a kind of a community that is often affected by a drug crisis in particularly an opioid crisis when you're left behind and you feel like there is very little you have economic trauma and personal trauma to contend with in your life you're very it's it's a it's a point where you're very susceptible to you as a community are very susceptible to to a drug crisis in particular an opioid crisis the next so the so these regions of the country looked a lot like marginal housing marginally housed people in in in urban centers except for one thing they're almost all white which sets us up for another racial issue in this opioid crisis which is that it probably couldn't have happened if the pharmaceutical companies hadn't specifically targeted these populations with opioid prescribing specifically targeted the physicians in these regions of the country if the pharmaceutical companies had instead for example targeted physicians working in urban centers of the country they wouldn't have been able to do it because they would have been increasing prescribing of opioids to african-american populations which wouldn't have been acceptable like over prescribing to a white population was alright welfare reform so everyone who was on welfare went back to work except for most of them who transitioned to disability and that's kind of the simple story there what we saw in let's say if we go back to a community in Appalachia where people mined and as they age in their mining they get back injuries and they can't mined and now they can't access welfare they end up going to their doctor to access disability however there are two things you have to do to access disability for a physician to provide disability the first is you have to have a diagnosis so your diagnosis is chronic pain the second is you have to be treated for your diagnosis and we're gonna get to a moment why opioids ended up being the treatment of choice the first reason was the simultaneous 90s health care reform which is that HMOs came to cover a huge proportion of the country from not really existing at all to really taking over much of health care and the HMOs said where you don't want to pay for this complex pain management it's too expensive there used to be really comprehensive pain management clinics in centers all over the country they cease to exist with it with the emergence of HMOs and the emergence of opioids of the opioid access that we'll talk about so so this physician now in Kentucky who has the patient on disability that they want to get on disability for their back pain because they can't mine and there's no other job in town then the patients in an HMO the only thing the HMO will pay for for paint to treat this is opioids so order to get the patient on disability the physician has to prescribe them opioids so that brings us to the war on pain and this was really initially led by oncologists so it was our cancer doctors who didn't want patients to suffer at the end of life and that of course is a laudable goal and was a major issue at that time in the 1970s in the nineteen and even into the 1980s when a couple of opioids started to emerge what we had access to for pain management in terms of opioids was really limited we had we had percocet or acetaminophen with with codeine with oxycodone and we had vicodin or acetaminophen with hydrocodone so both of those that was most of what we had those most of the good opioid products that we had for oral consumption and those products are limited by the acetaminophen by liver toxicity from from the Satyam in affarin or the tylenol so you can only take so much you can only get you know 30 40 milligrams of of an opioid in your system a day without really starting to put your liver at risk the other things we had you know we had we had a we had methadone we had some methadone and we had a little bit of morphine but they were really terrible formulations that were that did not work very well we're not well tolerated and then what we really had after that was IV morphine so basically when you had a patient who had metastatic breast cancer and had terrible bone pain everywhere they would suffer on percocet or vicodin until they were near the end of life they'd go on a morphine drip and that would be the end so we didn't have this ability to manage people for years with terribly painful diseases we needed good mono formulated opioids that didn't contain acetaminophen and we needed industry to provide these for us but industry I happen to sit next a project called the project on death in America in the 1990s and and I had the opportunity to witness some of these conversations and the debate that went on between the oncologists and palliative care doctor advocates for more opioids and Industry and they and what I heard was from the perspective of the physicians and that was that the industry wouldn't produce these products just for end-of-life pain it's not it wasn't a big enough market they wanted all pain so the docs said can we do it for all pain is that good is it safe and they used this one article it's not really an article it's a letter to the editor it's about that was ten lines long from that was in the New England Journal of Medicine in in the 1980s 1982 I believe and this article they pulled out and and started providing this article to to industry to justify to say okay we can prescribe opioids for all pain this was a letter to the editor so it's not a peer-reviewed article it doesn't have that kind of rigor it's some just some numbers that somebody put together they said they looked at about eleven thousand patients who had gotten at least one narcotic and they only found four cases of well documented addiction among patients who had had no history of addiction before that and the addiction was only considered major I'm not sure what a major addiction is as opposed to a minor addiction in one instance and so they concluded from that extraordinary rigorous study that that the development of addiction is rare in medical patients with no history of addiction so thus came oxycontin this article actually ended up being one of the most extraordinarily heavily cited letters to the editor in all of history as you can see this is the number of citations as you can see it really starts to pick up the early 90s but then in 1996 its skyrockets that's oxycontin time and this is a letter to the editor that that's cited in journals journal articles 30 times a year this is insane this is really really impressive and so what we get to see is opioid prescribing going through the roof and so we see opioid prescribing go up and up and up and up and up until 2010 in 2010 we have prescription drug monitoring programs we have people starting to think about opioid prescribing we start to see opioid prescribing level off and start to slowly decline these data only go through 2016 but you can see the decline picks up pace a little bit and it picks up pace more than that after 2016 so let's take another look here so this chart is going to take you from 1990 through 2014 the top line is the top solid line is opioid overdose deaths the lines underneath are various different opioids the one that I've highlighted in red is heroin overdose deaths as you can see and we discussed before they were flat until 2010 and then started to increase so summarizing what we've gone through we had a shift from a manufacturing to a service economy that left swaths of the nation behind and without economic hopes for economic prosperity and then in the night in the in the late 80s early 1990 and and 1990s we had dilaudid emerge which is hydromorphone oral form of hydromorphone and oxycontin which is the long-acting oxycodone that we've all heard so much about through the years we had the the regulatory body for hospitals and medical systems declare that pain is the fifth vital sign so this is part this came with the war on pain so if we don't treat pain if somebody reports their pain is more than three on a scale of one to ten so if I ask you what's your pain right now and you say you say oh you know I just bit a chip so I'm kind of feeling a for if I don't do something about that in the medical visit then it's the equivalent of you coming in and we check your blood pressure and your 220 over 180 and I don't do anything about it so legally it's the same thing as as what we actually have as objective vital signs now we all know I hope if you've ever been pinched by somebody else or you pinched yourself you realize that pain is a subjective experience it has a lot to do with the source of it you know there's it's it's a cognitive process pain is not the pain that we feel that we experience is not actually physical pain it's how our the cortex of our brain processes the signal so it's not the same thing as a blood pressure it's not the same thing as a heart rate those things are we can really objectively measure the pain scale that I put up there before was in in in a study so they suggested that they could get some reliability from this pain scale when they spent extensive effort explaining to people what each number met how many people in this room when they go and there they go to a clinic and the clinic asks what's your pain on a scale of one to ten how many of the how many of you have had that clinician say so one means this this this a two means this and gone through all 10 numbers and really tried to explain what it all means none of you because that's completely absurd and impossible so they took this research tool and implemented it and pretended that it's an objective measure and said we all have to do it and if we don't respond when somebody comes in and says yeah while they're laughing and chatting away yeah my pain 215 on a scale of one to ten and you know we don't we don't put immense effort into that and provide a treatment for it then we are in legal jeopardy so that kind of set things up and then we had state law and board state state laws and medical boards liberalized opioid prescribing so doctors weren't allowed to prescribe opioids as much as before as much as they were after this this was of course pushed by the pharmaceutical industry that was trying to produce all these products as we said we had hm own enrollment skyrocket and start to start to really cover most of the country and so at this point what we have is a situation where we've got some good mono formulated opioids we're told we have to treat pain we have our we have patients who are economically left behind we no longer have legal restrictions on providing the the therapy the insurance won't cover anything else and then welfare reform comes around and our we have to get patients on disability so now think about it you've got that patient comes in they've got a back injury from mining there's no other job they can get you got a you their pain is an eight eight out of ten all the time you got to treat their pain insurance won't pay for anything else so and to get them on disability you have to treat their disease so you've got multiple you've got a regulatory mandate to provide opioids basically you've got a regulatory mandate from from from your regulators in terms of treating pain you've got a a mandate in terms of getting them on disability you got to provide them opioids the insurance payer won't won't cover anything else so you got to provide them out opioids and pretty soon once you provide them opioids the only thing they're gonna want is opioids so we kind of set this up pretty well didn't we and then the FDA approved a couple of other opioids in the years that came this only goes through 2014 I'm actually on like a committee now for the FDA that that reviews opioid drug submissions and it's it's a fascinating experience after seeing what's happened through the years 2007 the CDC recognizes something's going on 2010 we start to see the policy and practice changes that I that I've discussed a little bit and we'll discuss some more and that's when we start to see prescription opioid deaths level off they still went up and they just continued to go up which I can't entirely understand but what we really see is a shift to heroin we start to see people really shifting to heroin at this point we're gonna get into that so what happened to the doctor oxycontin this is always worth a discussion I think the manufacturers of oxycontin got in a lot of trouble for paying off Doc's for for promoting oxycontin in ways that it was not actually that were not actually true for lying and things like that they paid a I believe it was a four hundred million dollar fine which was almost a month's revenue one of the things they did they had they had seven poster children for oxycontin in videos that they sent around to to doctors to try to get doctors to prescribe everybody oxycontin and these seven poster children for oxycontin were followed up somebody followed up with them in 2014 to figure out what happened two of them were still using oxycontin and felt they were really benefiting from it one of them had really struggled with addiction following oxycontin and was no no and was no longer using it one had died from a opioid overdose and two had died from complications other complications of opioid use disorder so you have three that there was one additional person who was still using it or who felt that it had helped but it stopped after a little while so three out of seven benefited from the oxycontin four out of seven suffered significantly related to the to their oxycontin use they also had a song a jingle that went out with their materials which was and I couldn't actually find a recording of the jingle which I searched long and hard I'm sure it's been kind of disappeared everywhere on the on the vast interweb but the the jingle was get in the swing of oxycontin so you know you look at I've looked at this add oxycontin maker criticized for new it gets you high campaign and this is of course not real it is a sight it is satirical but it's not so far off I think from where they were at okay so we've made it through the prescription opioid crisis now we're entering the area the era of opioid stewardship and and and and and what happens then so the CDC also happened to sit on the board of the center of the CDC that that's focused on responding to the opioid crisis and at a recent at a board meeting last year they presented this model about how to deal with this issue so we've got this population of people with untreated pain some of its physical some of its psychological you know somebody said to me once a colleague of mine a mentor of mine said you know opioids are offense are a wonderful solve for the for the for the physical and and environmental trauma of a sorry assault for a life full of personal environmental trauma it's a dissociative effects of opioids that can really make it easier to deal with the pain of life and you know we can't ignore that that's something real and once people once somebody has experienced that and and has relied on that to take that away it can be really problematic so we've got this population people with untreated pain so some of them are going to end up in alternative treatment so non opioid treatment some are gonna end up prescribed opioids and some are gonna end up misusing non prescribed opioids this model is vastly oversimplified but I still think it's useful then you've got this proportion of people using prescribed opioids that are going to transition to what they refer to as misuse of prescribed opioids and then potentially misuse of non prescribed opioids some of these people are going to end up in treatment and some will will end up in recovery some are going to end up dying from an opioid overdose so that's their basic model like I said oversimplified but I do think it covers a lot there's four populations that I'm concerned about as we try to reduce opioid prescribing one is the people who have untreated pain 2 is the people using prescribed opioids and the other two groups of the people misusing prescribed opioids and those misusing non prescribed opioids these are the four groups basically the four groups who are using opioids already I'm I'm concerned about them a lot of my researchers research focuses on them because they're the people that have the potential to suffer or suffer adverse consequences from our efforts to reduce opioid supply that's a complex comment because some people really benefit from from reducing opioids so the truth is that line from the population with untreated pain to the population and alternative treatment is really tiny most people can't get this alternative treatment so we managed to a couple years a few years back set up a comprehensive non medication pain management clinic integrative pain management clinic connected to the Tom Waddell clinic in the Tenderloin that clinic is fantastic the patients who go through that clinic thrive I've had many of them in my research studies and they're the ones who say like that clinic far and away manage my pain better than anything I've ever encountered but what they and they can get all those services if they go to 15 different places if they go out to Laguna Honda for 10-minute physical therapy visits every couple of weeks which they can only do for a couple of months before their physical therapy expires like there's all this stuff that they could do but it's piecemeal it's a tons of different places they have to travel all over the city they have to figure out how to pay for things and and it's crazy you know when you're homeless or marginally housed getting around the city is a big deal I mean for me it's a big deal if a physical therapist is more than 10 minutes from my home I'm not going to go so and I have the resources to do it so I can't I can't expect a lot of my patients who don't have these resources to be able to engage in these treatment options even if I can get them available and get them paid for and then the other side of it is the treatment they're gonna end soon so this integrative pain management clinic is paid for out of city funds and is really one of the most fantastic things we've done in responding to the opioid crisis and responding to opioid stewardship the reality however for most people is that that line for untreated pain to get into alternate to manage it with alternative treatments is really really small except for those of us who have a lot of resources so the CDC came up with these guidelines sorry and then the the population that make it into treatment is really small we have a we do better in San Francisco than a lot of other places but around the country that probably that population is really smaller you've probably heard that you know you know a lot of the country you still can't access methadone and you still can't access pupae an orphan you can't access the medications we use to treat opioid use disorder and and then you know if you can access them they're just not provided in a way that you'd actually want to access them I don't know I don't think my dad with type 2 diabetes would have put up with a methadone clinic to get his insulin so you know so it's a even though he never got over his doughnut habit he got treated with respect by his doctors and and provided the care he needed to live and I live 15 years longer than his dad even though his sugars never got under control so we can do the same thing for somebody who has an opioid use disorder but in much of the country we do not so then we have the CDC opioid prescribing guidelines I actually sat on this committee that made those guidelines as well I'm I've done a lot of this work and I'm usually a dissenting voice in much of it so this these guidelines are about shrinking that line they're about shrinking the line from the population with untreated pain to the population using prescription opioids these guidelines are really focused on opioid naive patients they're intended for to try to get doctors to stop starting people on it stop using opioids as a first-line therapy starting people on opioids and titrating up to really high levels for chronic pain that is probably not a best treated with opioids I actually agree with that I don't think that's a bad thing however they've been used we you know many of we knew this was going to happen they've been used by by insurance companies and by clinical systems and by regulators to say you have to get everyone off of opioids so all these people that have been on opioids for 15 years you have to stop their opioids because it's not appropriate or you have to reduce them to this level you know there are on 400 milligrams you got to get them below 50 milligrams and you have to do that today so that's how they're being used so what's gonna happen in this model if we have the same number of people flowing through this model what's gonna happen is that these lines are going to get bigger we're gonna see more people misusing non prescription opioids and more people who were misusing prescription opioids that can't access them anymore shifting to non prescription opioids and what are the non prescription opioids out there they're heroin and they're fentanyl and that shift matters not just because they have to go on the street and use illicit opioids but also because those opioids are de-facto we know from some data I'll show you later we know that you're more likely to overdose even if you know what you're using your likelihood of overdose is higher if you're using compared to a baseline of you of injecting a prescription opioid so you're misusing a prescription opioid you're injecting it your risk if your miss you if you're injecting heroin of overdose is twice that and if you're injecting fentanyl is four times that of heroin so this is even if you know what you're using so what we see is those lines are gonna get bigger and these lines are going to get bigger which is of course what we've seen in the in the graphs that I showed before we've seen the heroin more mortality escalate and then the fentanyl mortality escalate as fentanyl became available so these goals of opioid stewardship the goal the goals are really to reduce the supply of opioids reduce the diversion of opioids improve the safety of opioids and with all of that hopefully reduce the harms of opioids so there's the and there the focus is really been on reducing the supply I would argue that reducing our argue that you know the the biggest issue is probably diversion and I define diversion a little bit differently I don't like the word because it's really a legal word so I'll call it sharing your opioids are providing your opioids to somebody else and I define that a little bit differently I'd like to ask a question for y'all in the audience have have any of you ever provided a predication prescribed to you to somebody else like shared your amoxicillin with somebody else or something like that I have anyone else okay so some people have not shared a prescription medication with anyone else I I'm actually surprised by that because it's you know it's it's pretty common you get you're you know you get prescribed I have some 600 milligram ibuprofen in my in my cupboard that I would not flinch to offer to my spouse the so you know the idea that that any sharing of opioids is bad is I don't entirely you know it it's it's it's just a reality and I don't think it's necessarily always a terrible thing what I would define as the problem is sharing of opioids with somebody who is opioid naive or have opioid unknown status so in other words providing opioid like selling opioids to somebody driving through your neighborhood in a car that's a problem because then you then what we're doing is we're expanding the population of people who have an opioid who may suffer from an opioid use disorder so that's really the issue and if everyone took the opioids that they were prescribed or only provided or only they and other people who already used opioids use them then we wouldn't have seen the huge expansion in people with opioid use disorder that we witnessed it things would have gotten better because people would have been using prescribed opioids instead of heroin or fentanyl but instead what we ended up with was the reality was that a lot of the opioids that were prescribed ended up in the hands of people that were opioid naive and subsequently developed the opioid use disorder that fundamentally was that the problem in the failure of this grand natural experiment of prescribing tons and tons and tons of opioids some of the efforts to achieve opioid stewardship however are really problematic the Medical Board of California started a couple of years ago sending out letters so what they did was they looked up in the controlled substance monitoring program the cures database of all the controlled substances anyone is prescribed in in or dispensed in in California they looked up those data and match them to opioid overdose death data and then if so if you have a patient that died from an opioid overdose and there's evidence that you prescribed them opioids you got a letter from the Medical Board threatened saying that you were Oh actually what medical board did first was they called the family of the decedent and requested that the family filed a complaint against you whether or not the family wanted to file a complaint they proceeded to issue a letter saying you are under investigation for this prescribing and the and you had to prescribe you had to provide all medical records within three weeks or pay thousands of dollars in fines a day after that what this led to was was a lot of patients a lot of a lot of providers stopping prescribing altogether and in fact stopping plans to prescribe buprenorphine to treat opioid use disorder as well explain a little bit why or why this scenario occurred so one of the things that that my group does is we do training for providers we train providers in how to provide academic detailing and how to train other providers in opioid prescribing and managing patients with opioid use disorder and so we do this all around California there was a clinic system in San Diego that was that all of its providers were getting waiver to provide buprenorphine they were all they were mandate that everyone do that so that so that they could provide that service to all their patients and that they get some a few of their providers got these letters from the Medical Board and they aborted that plan because providing this service would mean that they would be treating people with opioid use disorder who are by definition more likely to die from an overdose which would result in more attention from the Medical Board more letters like this which would cost the health system money because a letter like this runs $30,000 in legal fees just to respond to it so the system abandoned plants to treat to actually contribute to managing the crisis so there are some really terrible things that have happened from from some of these programs so go into the patients that I worry about so patients who are in pain this I this is our pain wheel it's sort of interventions that you can use to manage chronic pain when which includes opioids but there's there's a right there's an array of interventions there's a couple new ones that have emerged that I don't have on here but it kind of gives you an idea that there's a lot you can do and different interventions help for different types of pain myself I suffer from a mid thoracic pain when I sleep at night the way that I manage it is I do I do yoga twists I use yoga yoga is good for mid thoracic pain you know Pilates tends to be good for lower back pain you have different interventions that are better for different types of pain we don't have a ton of data on this but we have some experience what you do is you try a bunch of different things if you have a resources to do it you try a bunch of different things and you find the thing that helps you manage the pain and opioids are not the first line or the second line or frankly the third line for most of these pain disorders so but making these therapies these interventions available means getting insurance companies to start paying for them and that's more expensive than paying for opioids it's really hard to get insurance companies to pay for things that cost more another reason that insurance companies are some sometimes reluctant to pay for these types of interventions was because in the 90s they pulled back on paying for these things because there was more propensity for fraud in these interventions than in medications for example if you go if you were to go see a therapist who checked three boxes that they did these three things for you maybe they didn't spend that much time maybe they only spent ten seconds doing three of the things and and they got paid a lot of money for that and whereas if you are prescribed the medication the insurance company can pretty much know with pretty good sure pretty good certainty that you got what they paid for so so there's there's a less of a fraud issue with the medication or you know less of a concern for a fraud issue with medication than there is for these other therapies so it's hard to get insurance companies to pay for these and that also you know one of the things that we've had some success with is getting them to is to lift some of the prior authorization requirements for some of the non opioid medication therapies so that's we've we've had some success in that domain all right so let's go to a case here so I'm concerned about patients with opioid use disorders so if so a patient is transferred for your syrup to your service his HIV he has generalized body pain he's been treated with a fentanyl patch morphine high dose morphine and high dose oxycodone he's also on to benzodiazepines and three one antipsychotic and two antidepressants he's also in a methadone program for opioid use disorder he injects heroin and he wanted a new provider because the provider wouldn't give him hydromorphone dilaudid he's never heard of you tox and but his viral load is always six always suppressed so he's so he meets the criteria of being a successful and excellent patient in HIV clinic so what would you do in this circumstance this is a tough one right so I so in this circumstance you in this particular circumstance you know maybe this patient hasn't they switch providers so they haven't been in clinic in a while and so they haven't been prescribed opioids in a while so they come in I don't prescribe them any opioids and I try to get them to switch to buprenorphine you can imagine it's a long haul so in a K in in a case like this it takes me about three years to get somebody to switch to get somebody transitioned to buprenorphine to manage their opioid use disorder which tends to manage pain especially this generalized body pain lower back pain a lot better than full agonist opioids you all have heard about people northen it's partial agonist it doesn't fully activate the opioid receptors but has a lot of activity and opioid copper receptors and it is frankly better for pain than high-dose full agonist opioids it's not gonna work for everybody nothing works for everybody anyone who tells you that is full of it but it does work for a lot of people and this is a perfect example of somebody for whom it works so a patient like this I I have taken care of and and gotten transitioned to buprenorphine and had them be do extremely well and be extremely successful however in that three-year period I woke up at two o'clock in the morning every other night thinking that they probably overdosed on heroin because I'm not prescribing them all these opioids and it's my fault and the reality the reality was with with patients like this that with a patient like this is it was that they that you know they did start using a lot more heroin and it was a rough period of time so it's a it's a really scary transition I never know if I'm doing the right thing and you know if they if this patient had come to me directly hadn't been that was still being prescribed the opioids and came to me two weeks later after firing their provider I would probably keep prescribing them opioids for some period of time try to work on their medication regimen but I try to do in a collaborative way and I would slowly try to get to the same point that that that I would otherwise achieve but it's a it's tough it's not an easy situation this isn't a safe medication regimen there's probably this there's so many opioids here it's hard to imagine some of them aren't ending up in other people's hands and it's you know but the goal is to keep somebody like this engaged in care and to treat the actual diseases that they have which includes an opioid use disorder without killing them with the treatment that you're giving them so it's a it's a it's a tricky situation we're doing some research on patients in the in the San Francisco Health Network which is the safety net clinics of San Francisco and one of our studies we have some preliminary data from this is a study where we we recruited patients from the clinics who had been prescribed opioids for chronic pain and some of these patients had been continued on opioids some had had their opioids increased over the last five years some had been decreased some have been some of their opioids had been discontinued all together we interviewed them we so we looked at their charts when one said the one side of the research team looked at their charts and charted all their opioid prescriptions and various other things from their medical charts the other side of the team met with the patients and did a historical reconstruction where they reconstructed their illicit substance use over the last five years through this really fancy way where you tie periods of time with events in somebody's life and things like that so then we merged these datasets and we look to see if being disc if having your opioid dose has changed was associated with increased illicit use what we found was that increasing or decreasing your opioid dose was not associated with any change in illicit use of opioids however discontinued discontinuing opioids was was associated with a 2.5 increased likelihood of more illicit opioid use of new or more illicit opioid use in that population we had I think about 60 people who had never used illicit opiates before who initiated illicit opioid use after losing access to their prescribed opioids and you know just to reiterate the reason this matters is because even if you know what you're using if you're using heroin it's riskier then even if you even if you're injecting your prescribed opioids if you're using heroin it's riskier than then injecting your prescribed opioids and if you're using fentanyl it's way riskier and what we've seen in San Francisco is almost is that probably about a 60 percent 60 70 percent of the heroin in San Francisco has been replaced with fentanyl it is different than what we're seeing on the East Coast we don't have the fentanyl fentanyl contaminated heroin like they have on the on the East Coast our heroines black tar and our fentanyl is a white powder so you can tell which is which so you if you buy fentanyl you know you're injecting fentanyl in general so it's a little it's not whereas on the East Coast you have no idea what you're what you're using so so you the more the overdose mortality is way higher on the East Coast because they don't know what's in the drugs I'm gonna jump a little bit because you've had these these talks on buprenorphine and medication treatment for opioid use disorder this slide just m3 emphasizes that transitioning patients from from around a thousand milligrams of morphine a agonist full agonist opioids for chronic pain to sublingual buprenorphine have pain scores so it worked pretty well and then you know just going back to my dad who his diabetes was never well controlled but he had he had an ACE inhibitor for for kidney protection he had aspirin he had a stat he had a statin for cholesterol in all these things at all this ancillary treatment for his diabetes to lower mortality and he lived 15 years longer than his dad who didn't have any of that and likewise even if we can't get somebody treated for an opioid use disorder or substance use disorder can screen them for disease for infections we can vaccinate them we can do aggressive management at cardiac risk factors especially if they're cocaine or methamphetamine user we can treat other we treat tobacco and alcohol use disorders we can educate them and provide them with safe injection equipment and naloxone and we can extend their lives through that kind of a process going on another I'm gonna almost going to wrap up here so we can take some questions another patient here this is a patient that I that I would say I came in with personal and environmental trauma so a 46 year old woman chronic lower back pain treated with escalating opioids for 20 years I'm currently on high-dose morphine and I had a little bit of ativan lives in public housing she's been threatened with eviction she's been incarcerated twice she's lost two kids to CPS she doesn't go to physical therapy because it takes 45 minutes to get there and she has no space in her housing to do any exercises her urine toxicology always has morphine but it also has cocaine she's never had an overdose but the clinic policy is we don't prescribe opioids to someone who's positive for cocaine so what do we do with this patient you know in many settings now we have to stop prescribing opioids is patient and you have to just kind of out you just do a quick taper you taper them off now I would argue that this patient is not just using opioids to treat their chronic pain their chronic physical pain but is also using opioids to cope with the fact that their life kind of sucks and they're not happy and it's hard to make it from day to day and opioids are giving them their make it's making it easier to make it through to tomorrow is it the right way to make it easier to make it through tomorrow maybe not but they've been doing it for 20 they've been doing it this way for 20 years so changing it it's going to be really hard and also because changing because using opioids chronically changes your body and how your body handles things so taking the opioids away is really really hard if you have to take the opioids away I think you know you have to you have to art you have to argue to do it in a really slow fashion you have to somehow get paid the patient on board and get the patient engaged with this process and you have to try to address the other issues that they have you know they're being threatened with eviction all the time they you know it's it's possible they sell a little bit of their morphine and that's how they pay their rent so they're gonna lose their housing and become another homeless person statistic if you just take their opioids away that doesn't i don't i never justify selling opioids so that somebody prescribing opioids so that somebody can sell them and keep and pay their rent I don't I don't medic I don't think that's a valid reason to prescribe an opioid but I do need to recognize that when I take the opioids away my patients may lose their housing and you know that's that's a big hit on their health and it's a big hit on on you know quality of life so you know I have to recognize things even if it's not gonna change my practice I have to recognize that and maybe we can do something to try to you know solidify their housing find them less expensive housing or something like that before we before we you know pull the rug out from under them it's a really really hard situation confessions of an opium eater a great book if any if anyone has is really interested in this issue I stood at a distance aloof from the uproar of life or as Lenny Bruce puts it I'll die young but it's like kissing God so you know how to reduce opioids when somebody's on opioids and they shouldn't be on opioid so you don't think they should be on a lower dose this is to me right now this is the golden egg of mandate of opioid stewardship we're trying to figure this out there are no guidelines the guideline is you have to have patient engagement but it's really hard to get a patient to say yeah I want to reduce my opioids when they do they reduce their opioids and their pain is so much better and they do fantastically usually not always but usually so you know if you have a patient that wants to do this and they're engaged and you work with them closely and you do it carefully and thoughtfully it can it can really improve their life but if you force it on them it's disastrous people drop out of care people overdose people absolute you have suicide you know we have really bad situations so you know fundamentally I think about this crisis at least the prescription end of it as you know if you think this is iatrogenic academic meaning caused by the medical system then it's like leaving a pair of scissors and a gnat in a pelvis at surgery we have as a medical community an extremely strong ethical requirement to take care of patients that we have harmed with our practices and we harmed a lot of patients by over prescribing opioids and taking care of them doesn't mean just taking the opioids away it means actually taking care of the diseases that we created by over prescribing opioids yeah so I think of two different approaches to opioid stewardship one is really aggressive which is basically the same way we expanded opioid prescribing it's where providers are scared and they want to stop prescribing because they don't want to get the attention of the Medical Board they reduce or they have regulations that say you know your patient on a thousand milligrams has to be under 50 you know honestly if you have a patient on a thousand milligrams you get them down to 600 that's a huge success but the insurance company nobody recognizes that it's a success because they have to be under some magical number so you know changing how we how we deal with that abandoning patients aborting plans to provide addiction care these are this is the aggressive way to manage our over prescribing issue the cautious way you know is really relying on evidence getting patients engaged expanding our non medication options and really trying to struggling to maintain patients in care and and using our opioid use disorder medications vastly I'm gonna stop there I think we have about 18 minutes for questions yeah no it's it's it's absolutely a reality you know I've had patients who they I've patients that I've inherited that are prescribed you know methadone and oxycodone and their urine is only ever positive for heroin cocaine and methamphetamine so they're getting prescribed these medications and they're selling them to buy drugs in the street that can get them more high you know in a situation like that I can't really prescribe those medications I can try to get them onto an opioid use disorder medication you know I can get them onto buprenorphine or methadone program or some other some other intervention but I can't keep prescribing those medications you know and then usually those patients call me curse words and storm out of my exam room which which is hard because I want to keep patients engaged but I don't win all the time I think in in in this situation if you're if you're winning fifty percent of the time you're doing a great job this is really really really challenging what's the difference between medical use and non-medical use some that's how I'm going to interpret your question so medical use is using it to manage some I'll use quote marks legitimate pain issue non-medical uses is using it to get high or have fun in some way and but there's there's a blend between those because sometimes you know for most patients who have an opioid use disorder they're not getting very high they're mostly getting right they're mostly fixed you know that's why it's called fixing because their body has a has it has a strong dependency on opioids but and then you know some of that is some of that getting high is coping with a life is coping with or escaping from a life that is really hard I'm gonna make an analogy teach my dad again you know he never got his donut habit under control I'm not going to claim that it that eating Donuts was a was a medical requirement but it was something his body really wanted to really demanded that he do because that's what you know having type 2 diabetes part of what I having type 2 diabetes is is a craving for for for sugar because your body's not processing it right and it you know it provided him with some feeling of satisfaction and you know as he aged and struggled with various things that he could get that satisfaction of a donut it's not medical it's be better if he didn't do it but we can manage we can manage things and we can help him you know extend his life through other interventions yeah well it was I'm not gonna claim that HMOs are a problem in terms of in terms of health in terms of health care but the emergence of HMOs in the 1990s helped to it was part of the problem and it helped to set the stage and for a couple of reasons main thing being that opioids emerged at the same time and opioids you know at a thousand bucks a year were a lot cheaper than these fifteen thousand dollars a year comprehensive pain management clinics and H the thing HMOs changed in health care is they stopped paying for more expensive stuff and they went for cheaper things and they also tend of the non medication options that were costly and more difficult to regulate I you know hopefully healthcare can be part of the solution I mean the health the health care the insurers have what they've done is they've they've set rules so now you can only prescribe patients you know under you so that what they did before was they said the only thing you can use to treat pain is opioids and now what they're doing is saying you can't use opioids or if you're using opioids you can only use a little bit or if you have somebody on high dose opioids you have to get them below 90 or 60 or 50 milligrams and you have to do that like basically immediately and your and as a doctor you're gonna have to do prior authorizations every month and put hours of your time every into trying to get this patient their medication even if you're trying to taper them down and we're not gonna and if you get them from a thousand milligrams to 500 milligrams we don't care because that's not under our magic number of 50 and so they so they've that they're trying they're trying to be part of the solution but they're not doing it in a nuanced way it's it's hard and I understand you know it's hard when you're looking at these numbers and you're gonna look at a metric I in a whole patient population especially if you're a huge payer you're gonna look at a metric and a whole patient population you can't really look at the subtlety you can't look at it and you can't necessarily see the trend in their opioid prescriptions and say oh they've gone from you know 800 to 750 to 722 710 they're doing great I'm not going to bother the provider I'm just gonna let them refill their 700 milligrams this month you know they can't see that they can't see that level of subtlety they're just using these across-the-board metrics that are misinterpreting the CDC guidelines so again trying to be part of the solution and causing some problems along the way but but we hopefully we you know we've made like I said we've made some adjustments like getting some medications that used to be prior authorization only covered without without that step for those who don't know the prior authorization step is something that providers have to do that that is time-consuming it's basically a way of rationing access to to a product yeah well methadone clinics work really well there's you know as as you've heard before there's three options for three main options for medications to treat opioid use disorder there's naltrexone buprenorphine and methadone very few patients want an El track zone some some do and some do well on it but it's you know probably a couple percent of the population P burn orphan excuse me is my preferred because I can prescribe it as a general provider and patients can can get it pick it up at the pharmacy and be treated just like anyone else with any other disease methadone is very restricted it's in clinic settings sometimes patients do better on methadone and we've had a hard time figuring out who does better on methadone versus who does better on people in orphan you know sometimes people do better on methadone if for example they they part of their disease is like needing some degree of kind of sedation from their medications because you don't get any sedation from buprenorphine buprenorphine kind of wakes you up you know you can get your stuff done if you're using buprenorphine if you're using methadone sometimes you know people who can't control their heroin use without getting a really high dose they you know they can be sedated a little bit and it's it can be hard to look at somebody like that one time and say wow methadone is doing it great for them you might look at them and say methadone is just making them sedated and sleepy and they're not getting anything done that's horrible it's terrible you know what a terrible medication but if you one things you learn as you could one of the things I've learned going through medical practice is you have to look at how someone is compared to how they work and when you have somebody whose life is a complete disaster they can't get housing they can't get anything done they're getting arrest it every other week they have you know their friends and family have all deserted them their you know their life is a real train wreck and they get into a methadone program and then they're able to get into housing a housing unit and then they're able you know they're able to you know find some legal sources of income there they're you know they're able to make it to their doctor's appointments are able to get their diseases under control they're able to get in touch with their with their kids that they haven't seen in 20 years like you know that's a sh a huge improvement you know just like my you know to go back to my dad you know he improved a lot even though his diabetes never got greatly controlled but the so you know it's hard to look at people once and judge whether or not the interventions working but when you follow them over time we know from we know from the data and we know from firsthand experience that that that people really do benefit from methadone so in methadone clinics are taking it as orally as a solution there's no injectable opioid treatment available in the United States there is in Canada and in probably I don't know how many other countries probably at least a dozen other countries in Canada for example you can you can inject morphine you can inject dilaudid hydromorphone you they have they have some heroin injection so they they have I believe they have heroin injection I'm not certain they have they have those access to those interventions I have some patients that one that I'm thinking of in particular that I you know I really wish I could offer him injectable hydromorphone which is dilaudid which is kind of the closest thing we have to heroin that's a pharmaceutical opioid I think he would do really wonderfully on that because he has not thrived in any other interventions but and in those situations they inject themselves so so your question was that early on I I said today in the talk I said addiction was not a disease I was quoting the Harrison narcotics Act where the legislators said that addiction is not a disease that wasn't physicians it wasn't the medical system legislators said it and the court said okay addiction is not a disease so doctors can't treat it that was really the beginning of the mess that we made of treating substance use disorders in the 20th century I so within the medical community yes we consider addiction a disease and in the last in the last thirty years we've seen the emergence of addiction medicine as a field in in medicine it used to be the only people who really had any who treated substance use disorders at all were psychiatrists and they and they didn't use medications because they didn't really use much for medications because they you know they're not really allowed to use many of the medications and what we've seen in the last thirty years is we've seen addiction medicine emerge among family doctors and internal medicine providers who have will come from a different perspective so I as I've expressed several times I think about an opioid use disorder and substance use disorders very much like I think about type 2 diabetes so you have you have a genetic predisposition and there's a genetic predisposition for an opioid use disorder and you have lifestyle factors or exposures so you know my dad was I'm gonna get died he's someday but I'm trying to delay it with lifestyle factors you know so you know your diet and exercise and if you have you know if you know it and when it we measure diabetes with an a1c which is a percentage of red blood cells that have sugar stuck to it and if you have a a 1c that's a little abnormal you probably get that under control with some diet and exercise and you might be able to avoid medications if you're anyone sees through the roof you really got to start medications so I think about it as you know if you have a mild substance use disorder you might be able to get that under control without medications if it's through the roof and I don't offer you at least offer you medications then I don't consider that reasonable practice so this concept of managing addiction as a medical disease it's you know it's it started reimbursing in the 60s when methadone became available and it's really taken off in the last 20 years and part of that take off part of that advancement frankly has been because the opioid crisis affected huge swathes of white America and so people cared about it and if you look back at the history I didn't go through really the history of these drug crises but you know a drug crisis it when it's it's very rare that that it's affected that it's been like this one has been generally it's been about you know the the Chinese and opium or the african-americans and crack you know generally it's about a minority group or Mexicans and Marin cannabis it's about a minority group and racism and going after a group in order to push them down and using criminal justice to to attack it what we've seen in this circumstance is using the healthcare system to address the opioid crisis and I you know I hate to I hate to use the word opportunity but it we do have an opportunity right now with this huge tragedy to try to build a system where we respond to substance use like we respond to other chronic diseases and with public health tools and medical tools so yeah there's been a lot of progress so we have we have good medications to treat opioid use disorder we have good medications for tobacco use disorder we have some good medications for alcohol use disorder you know things are imperfect but we're getting there we we don't have medications yet for stimulant use disorders that's a big element of my own research is looking for those medications for methamphetamine cocaine we've had some we've had some successes but we've got a long way to go for in that domain so yeah I think we've made we've made huge steps there's still a lot of stigma and there's still a lot you know and that stigma is is driven in part by the legal issues you know if donuts were illegal might I would have really struggled a lot more yeah so it's you know it's it's fascinating sometimes when a patient comes in you can feel that you can feel a pressure to to address you know you I think doctor Steiger who spoke here he would he gives fantastic talks on this you know about a patient who sent to him because they're on a little bit of hydrocodone a vicodin and the doctor doesn't want to prescribe them that anymore and and they patient comes to him and you know the patient's he he'll talk to them and say you know and the patient will say yeah you know I mean I that doesn't matter it but you know I drink a lot and I wish I didn't drink so much and so he'll actually he'll ignore the hydrocodone and let it go and he'll address the alcohol use and starting using medications we have approved medications and we have a lot of off-label options for alcohol use disorder but most people with an alcohol use disorder they don't know they there's medications that can help they're not even aware of that I mean it's startling the number of patients that I see in in inpatient settings who have no idea that there's you know a dozen medications that we can pull out of our quiver that might help them and we gotta try multiple medications you know like high blood pressure sometimes you know a patient doesn't respond to the first three medications you try and you find the right one it's the same thing with a substance use disorder we might not have the right medication but we got a bunch that we can try sometimes adherence can be a bigger issue I have to wrap this up I want to say thank you all I appreciate the questions it was great I'm happy to stay here if there's any more questions after this but thanks for being here tonight and for I hope you didn't miss too much of the game [Applause] [Music] you

Channel: University of California Television (UCTV)

Views: 61,509

Rating: 4.6571426 out of 5

Keywords: OxyContin, Opioid, overdose, pain

Id: W3XGddlrPew

Length: 83min 35sec (5015 seconds)

Published: Tue Aug 13 2019