 Good afternoon and welcome to the third seminar in this year's Health Law Institute Seminary Series. It's my great pleasure to introduce today's speaker, Professor Leo Bolecki. My name is Matthew Erder, I should say. I'm the director of the Health Law Institute here at Dalhousie. Professor Bolecki holds a joint appointment with the Northeastern School of Law in Boston and the Boubet College of Health Sciences at the same university. His expertise is on the use of law to improve health with a focus on drug policy, reducing the spread of infectious diseases like HIV and the role of criminal justice systems and the enforcement of criminal law in shaping public health outcomes. I'm going to keep it brief in terms of an introduction because I think the great turnout today is excited to hear what Professor Bolecki has to say. Professor Bolecki has been working on the opioid epidemic before it was described as such, before it was on newspaper front pages every single day. I think he's been working or researching, writing about this problem since the early 2000s. Sadly many of you are here today because the profile and scope of that problem has deepened quite tragically. So I look forward to hearing Professor Bolecki's presentation from Panacea to Panopticon thinking specifically about prescription drug monitoring programs that a variety of jurisdictions have set up here in Nova Scotia but as well of course in various states in the United States. So without further ado I welcome Professor Bolecki. Thank you so much. So first I wanted to thank Professor Erdman and Professor Herter for inviting me here. It's really a huge pleasure to be here and it's my first time in Halifax and it's lovely and I hope to come back and explore it further. And today I wanted to talk about the implementation of prescription monitoring programs or prescription drug monitoring programs as they're known in the States in the context of the opioid crisis. So to situate the discussion I'm going to start with just a very brief note about public health surveillance in general and some of the benefits and drawbacks and potential side effects of having surveillance systems in place. So prescription monitoring programs represent an example of a public health surveillance system. Then I'm going to talk about the huge explosion in the number and scope of prescription monitoring in the context of the opioid crisis. Then I hope to share with you some empirical insights into this issue. So talking about not just conceptual legal issues but actually using empirical methods to try to explore some of the problems that I'll highlight. And then I'll just mention a few emerging trends that are troubling to kind of, you know, pique your interest especially if you're a student or a researcher to think about how some of the deployment is maybe problematic at least in the United States. And then I'll conclude with a few discussion points about sort of the policy and legal implications. So to start us off I actually wanted to mention that some of the concerns that I'll describe are not purely theoretical as we often do in law. We kind of fall into the trap of sort of creating fact patterns that are purely theoretical. So some of the discussion today will be about privacy and I just wanted to bring up the situation that actually emerged in the last couple of weeks or an incident rather. And that is in the context of actually another public health crisis in the U.S. which is gun violence but in the context of the horrible events that occurred in Las Vegas, the mass shooting there, next day there was leaked information about the shooter from the prescription drug monitoring program. And this incident I think highlights the danger, I mean, so, you know, personal health information is always somewhat vulnerable to being disclosed in an authorized way but prescription drug monitoring programs as I'll talk about create basically a clearing house, a centralized clearing house of prescription information to which a lot of people have access. And so that brings up the danger that this information can be inappropriately accessed and leaked and this incident actually highlights the risks of that. And, you know, also obviously aside from the harm to the individual, also creates a lot of problems for people who might, you know, so the implications, the implication here is, you know, the shooter was prescribed certain drugs that are, you know, anti-depression medication. So what implication is made after that kind of information is disclosed is that, you know, all people with depression are prone to violence as is often talked about, you know, in the U.S. when there's a mass shooting oftentimes people start talking about, oh, well, there's, you know, mental health issues and we need to deal better with people who have mental health issues, leaving aside the point that people who have mental health issues are much more frequently victims of violence and not perpetrators of violence. And so I think, you know, this kind of disclosure actually creates broader societal problems and risks than just the individual who is affected. So to situate the discussion I think it's important to talk a little bit about the complex history of public health surveillance. So in the U.S. as well as many other places, you know, public health surveillance is an essential tool in order to respond in an informed fashion to public health or health problems. We have to know, we have to have information about, you know, the scope of the problem, who is affected, who is most vulnerable, where, you know, where problems are cropping up and occurring in order to target resources. So public health surveillance is a really important, fundamental tool essentially to an appropriate and measured public health response. However, these kinds of surveillance systems have not always been deployed in the most measured or even way and have oftentimes mapped out onto other kinds of surveillance and basically, you know, state repression efforts. So, you know, for example, there used to be public health surveillance or reportable sort of mandates to report certain kinds of patient-provider interactions. So providers were in some states required to report abortions or attempted abortions. There were public health surveillance focused on venereal disease, on HIV, and again, you know, these are not necessarily sinister kinds of interventions and surveillance systems, but the way that they were deployed oftentimes unevenly, oftentimes targeting people of color, oftentimes targeting people who are economically disadvantaged, whereas people who are not, who are more wealthy, for example. So oftentimes, STI surveillance, for example, was only instituted in public hospitals. So only poor people were targeted with surveillance where people who could pay for private care were not. Same thing is true now, for example, of drug testing. So a lot of times, you know, and this is in the States, you know, I do not attempt to speak of the Canadian context. So drug testing of pregnant women, for example, in many states is mandated for people who are in Medicare, which is the socialized medicine program for people who are economically disadvantaged in the United States. Drug testing for people who receive, for pregnant women who receive private care is not mandated and in fact is very rarely done. So to say that we need these diagnostic tools in order to inform proper care, but yet imposing these surveillance systems only on people who are disadvantaged obviously brings up a lot of equity concerns. So the, you know, the overall framework that I'll come back to in this discussion today is the idea of how introducing a surveillance framework into the provider patient relationship might change that relationship. And so, you know, creating a surveillance system is not, it doesn't just collect information. It also creates a perceived and real sort of intervention into the interaction between a doctor and a patient. So when a doctor is being surveilled through this kind of system and the patient is being surveilled, that can change their behavior. And so in that sense, a surveillance system is both an intervention and a way to collect data. So it's not sort of a neutral, a neutral intervention. And it also brings up the discussion and discourse around dual loyalty, which is the concept of, you know, who is really, who is the boss essentially with, you know, in the doctor-patient relationship. Is it the patient? So theoretically, you know, the duty of the provider is always to the patient. But in fact, there's this concept of dual loyalty. So in a lot of sort of socialized medicine context, that dual loyalty also belongs not just to the patient but to the state. So when a doctor is working for the state. And in the context of non-socialized medicine context, you know, the insurance company or whoever is paying the bills essentially. So who does the provider owe the loyalty to? And so prescription drug monitoring programs really kind of harp on that issue because they reorient how providers are practicing and what their metrics of success may be. So within that larger discussion of public health surveillance, I think it's important to talk about, you know, to situate that discourse or to situate prescription monitoring in that discourse. So prescription monitoring essentially, it's actually, it dates back to the early 1900s. The idea behind prescription monitoring is you want to balance medication access with diversion control. So drugs that are dangerous, that can cause addiction, that can cause, you know, people to experience a lot of negative consequences. There was an effort in the early 1900s to bring some semblance of regulation to opioids, to cocaine, to other kinds of medications that were being prescribed in a very sort of loose, you know, what was perceived as a loose way. In the modern era, so the modern prescription monitoring program really emerges in the 1970s and coincides with two developments. One is the development of electronic tools. So traditionally prescription monitoring had been done on paper. So it was done through, you know, a prescriber would prescribe the drug and use carbon copy forms, one of which would go to the patient, one of which would go to the provider, and in some states actually they were required to file a form with a regulatory agency. So it was a paper-based system, you know, very clunky, obviously not terribly nimble for any kind of data analysis or response. The 1970s and later bring a new era to this effort because you saw, you know, the deployment of electronic tools, computer tools. So instead of filing the information on paper, there started to be systems that would actually allow people to do electronic filing, or if they did paper filing, those paper forms would be then transferred onto computer disks basically or tapes in that era. And just to very quickly mention, there was actually one of the landmark privacy cases in the U.S. jurisprudence, was a Supreme Court case called Whalen v. Rowe in 1977 where both doctors and patients actually challenged the New York State's prescription monitoring program and said this is an intrusion both into medical practice as well as patient privacy and the Supreme Court, which had actually been marching towards providing more privacy protections. This is a Whalen Court actually walked back and said, you know, what this is a rational use of government power and we're going to essentially allow this New York State program to proceed. And that really laid the groundwork to the development of prescription monitoring in the modern era because essentially it gave carte blanche to states to develop these kinds of surveillance efforts without a lot of privacy protections. And also I'll just mention very quickly, those efforts in the 1970s also coincided with basically what was the early days of the war on drugs and this, you know, a lot of drug hysteria basically about heroin and about cocaine and, you know, kind of looking at healthcare providers as pushers of drugs and trying to bring some semblance of regulation to what was perceived to be a system that was out of control. And in many ways the prescription drug monitoring program anchored in what was the landmark legislation of the time to respond to the, to kind of launch the war on drugs, the Control Substances Act, which created a schedule of drugs and is actually a similar framework in Canada. So the statute defined sort of substances of abuse or drugs of abuse in this kind of graded schedule. So there's a schedule one through five based on criteria that are kind of nebulous but essentially, you know, drugs potential for abuse and accepted medical use. And so based on those criteria, drugs are defined in the scheduling framework and the reason why that's significant for the prescription monitoring discussion is that a lot of prescription monitoring systems actually use that schedule to say, you know what, we're going to track those control substances that are defined by the statute in our monitoring efforts. And so because that framework, that scheduling definition was very, very broad, the prescription monitoring efforts would then equally broad because they used it as an anchor as a reference. So up until 1970s, you know, these systems were relatively seldom used. They were in place in a bunch of places. I'll show a slide in a minute. But in the context of the opioid crisis, they became a very central tool. And the reason why they became a central tool and a tool that a lot of states were relying on is because the early phase of the opioid crisis was seen as one driven by prescription medications, same in Canada, but to a much, unfortunately, to a shockingly broader extent. I mean, these numbers in the context of the awful situation in Canada in some provinces, this really pales in comparison to the U.S. situation. And this is why, as Professor Erdman said in an early meeting, we really shouldn't be looking to the U.S. for solutions to the opioid crisis because we've done a really horrible job at managing this crisis. So the early days of the prescription opioid, the opioid crisis were characterized by a pretty steady substantial rise in overdoses related to prescription medications. So that was the first phase. And then we saw basically a leveling off, this line is prescription drugs, a leveling off in the prescription-related overdoses and a essentially almost simultaneous stratospheric rise in heroin-related overdoses. And then the third phase of the crisis really started around 2014, 2013, 2014 when you started to see what had been a pretty low number of fentanyl related to overdoses where that number is just absolutely skyrocketed. And this is why I think I have some reservations about using the word epidemic to describe this because it's not technically an epidemic. This is not a contagion. But the dynamic of this crisis as it has evolved in the United States is absolutely mind-boggling and has just developed so quickly. And we really haven't seen this level of deaths since the AIDS epidemic. And it actually has surpassed those numbers as of 2015. So I talk about this to situate the discussion but also to point out that, in fact, prescription drug deaths were the driver of the crisis for a period of time, up until about 2010, 2011, and now it's really heroin and fentanyl. So we've entered a new phase. And it's not like prescription-related deaths have absolutely plummeted, but they have plateaued to a certain extent. And in many ways, a lot of these data are also difficult to disentangle because sometimes what people think are prescription drugs, if they buy on the streets, are fentanyl. And so oftentimes it's hard to distinguish whether you take Oxycon that's on the street that looks like Oxycon or it's an illegally manufactured drug. So in some ways, these data also aggregate a lot of illicit medications that were not pharmaceutically manufactured into that prescription drug category. In other words, this number of prescription-related deaths is probably actually lower and that's going to be hard to track. So the narrative, in the context of this dynamic crisis, the narrative about its causes and its solutions really focused on supply-side problems. And what I mean by that is that people, policymakers, as well as a lot of public health folks and folks who work in healthcare have basically singularly attributed the crisis to an oversupply of prescription medications. So the narrative goes that we were extremely overly liberal in providing prescription medications and we got people hooked and these doctors were pushing medications on people or were giving the standard story in the media, for example, is that you had a high school athlete who had a sprained ankle and they got a bunch of Oxycontins and then they kind of slid off the rails and started using heroin. And that narrative also implicates a lot of the race and class issues as well. So instead of, as in the past, there was a lot of judgment about the moral failings of people who use drugs in this context, in the context of this crisis, the tables have kind of flipped and we oftentimes characterize the crisis as iatrogenic in the sense that the healthcare system actually hooked people on drugs and there were kind of blameless victims and that we need to be doing more. So in fact, there was certainly overprescribing in the sense that opioids became kind of a catch-all. So people presenting with a variety of complex problems in the U.S. and I think to a certain degree in Canada, the easy answer became, well, you can take this and it'll make you feel better, no matter what's wrong with you. Opioids make you feel better, whether you have physical pain, emotional pain, stress, other kinds of things that may be bothering you. Opioids are kind of a catch-all salve that essentially make those problems go away. And so to the extent that U.S. and Canada to a certain extent have a lot of structural problems, have a lot of problems with the healthcare system in a way that we treat a lot of complex issues, having those drugs close at hand and easy to prescribe was the thing that I believe drove this kind of overprescribing issue. So people often talk about, well, opioids shouldn't be the first intervention that you're reached to. If someone presents with complex pain issues, you should first deploy interdisciplinary physical therapy and acupuncture and all these other things. Well, okay, that may or may not be true. Actually, the evidence behind those interventions is not very solid. But even if that is true, how do you pay for that? How do you get access to that? Who has time to navigate the system to reach for those other interdisciplinary interventions? So the architecture of the healthcare system really is configured to favor easy and quick fixes of which opioids certainly are. But that's not actually how the problem was framed. The problem was framed as, you know, we're just using too many of these drugs. We need to use fewer of them and then the problem will be solved. Along those lines, a lot of discussion was focused on people who are doctor shopping, so going to a bunch of different providers and getting drugs from different sources and selling them or diverting them or misusing them in other ways. And also, you know, just purely sort of rogue and venal providers who are just, you know, essentially flooding communities with opioids and that certainly occurred to a small extent. And then finally, you know, the role of the pharmaceutical industry and insurance industry and sort of the relationship, the cozy relationship between pharma and its regulators and how the pharmaceutical industry basically misrepresented a lot of these drugs as being low risk when in fact the risk was quite a bit higher. Now, given that narrative, given the narrative of, you know, supply-focused root causes of the crisis and that narrative really gives rise to the idea that if you could only clamp down on a supply, that would actually help fix the issue. That gave rise to the imperative to make sure that we had tools in place to help sort of regulate prescribing in a much more tight way. And prescription drug monitoring programs or prescription monitoring programs become a central element or a central feature of that effort. Now, the way that prescription monitoring programs were discussed was basically that they could do a bunch of stuff. They could do all of these different things, and I list them here. So a lot of it was focused on, you know, sort of surveilling and regulating access. So catching bad prescribers, rogue prescribers, catching doctor shoppers and also deterring people from engaging in those practices. Also there was a discussion of kind of the clinical value of prescription monitoring. So not just surveillance, but also knowing that a patient is getting one drug from one provider and another drug from another provider can inform clinical decision making theoretically, right? So if you only know what you yourself are doing as a provider, that limits the scope of your knowledge about the patient and can harm healthcare practice. So if your patient is getting benzodiazepines from one provider and you're prescribing high dose opioids, it's helpful to actually know that and be able to moderate your prescribing practices in a way that minimizes patient risk. So there's a care coordination function. There's also the idea that prescription monitoring can inform patient communication in terms of, oh, well, I see that you have gone to a bunch of different providers. Why is that? What is going on in your life? There also can be sort of a treatment referral function. And so all of these positive sort of clinical practice decision support elements have been something that both regulators and healthcare providers have highlighted in an effort to encourage healthcare providers to use these systems more. They say, well, you can use it for all of these different clinical support functions. And then also there's obviously kind of a public health surveillance benefit, which is, for example, if you see in the prescription monitoring system that a community is being flooded with prescription opioids, that might inform your prevention efforts like you might want to do outreach to make sure that people are aware of overdose risk and distributing the lock zone or figure out what's going on in that community. Why is so many people being prescribed opioids? Let's think about the structural issues that might be in play. So prescription monitoring, as I mentioned, really exploded on the scene with the rise of the opioid crisis. So you see around somewhere from 2000 to 2012, just 2013, a huge explosion in a number of these systems in the U.S. So these are states and District of Columbia. All of the states now have one. Now these systems are very limited in the sense that they don't really collect much contextual information about the patient. They basically just collect patient demographics, what drugs they're prescribing, what dosages, and where those drugs are being dispensed. And I think that's an important issue that I'll come back to. Now the way that the systems are being used, so I just mentioned all of the kind of theoretical uses, but the practical uses, the way that it's actually being implemented, is several. So one is that a lot of these systems are continuously running algorithms to sort of identify outliers, both among patients and providers. So there's a surveillance, kind of a big data surveillance function where the systems are designed to identify what are deemed dangerous practices both by providers and by patients. So the data are then used to focus on providers in terms of, so like in Massachusetts, for example, the system will automatically generate a letter to provider if they're seen as an outlier and saying, you're in the top 10% of prescribers, not sure what's going on, but this is problematic. And also they generate alerts if there's a patient who is deemed a doctor-shopper, they will issue alerts to providers saying, you have a doctor-shopper in your practice, do something about it, not sure what. And then in terms of the patients, this information is also used to kind of go after patients who are deemed to be engaging in problematic practices. In terms of the actual dynamics of how the systems work, again, there is a supporting policy environment that actually now mandates providers to check the system every time. And I think that may be in place here in Nova Scotia as well. So in Massachusetts, for every new patient, you're supposed to look up the patient on the prescription monitoring program. And if you prescribe any schedule two or schedule three substances which are deemed the most risky, you're supposed to consult the system every time. And then pharmacists also consult the system as well. Importantly, even though there's a training for law enforcement on accessing data in the PMP that's mandated, there's no training for providers beyond how to log on to the system. So there's no information or guidance for healthcare providers on using the system as a decision support tool. So all of those things that I mentioned in terms of care coordination, starting conversation with your patients, getting people linked up to substance use treatment based on system information, there's no guidance, training, or any kind of effort. This is like an assumption that providers will use this information to inform their clinical decision making, but there's no concerted effort to develop those kinds of practices. So there's been a lot of criticism of PMPs and I want to kind of situate my discussion in those critiques. So the mainstream critiques of PMPs are basically that they're clunky, they're hard to use, that they are not interlinked between states. So oftentimes a person, and I think that may be true of provinces as well, I'm not sure, but a patient has a medical, basically this limited medical record in one state, but then if they go to another state, you can't see what else is going on. You can only see what happened within that jurisdiction of that state. They're also not, healthcare providers are not compensated in any way for spending the time. So if you're going to mandate people to look their patients up on this electronic prescription monitoring program, they're going to spend maybe one or two minutes doing that. But within a context of the very high pressure U.S. healthcare market, they only have, let's say, 12 minutes. And if they're going to spend 12 minutes, two minutes of that 12 minutes looking the patient up and they can't bill for that activity, it really creates an unfunded mandate that a lot of providers really resist. And then finally that information about the patient's drug treatment data and their prescription data are not integrated. So a patient could go to a methadone clinic and get prescribed methadone. That information is not going to show up in the prescription monitoring program because there's this federal law that basically creates a firewall between the two and a lot of people have argued that that shouldn't be lifted. So there's been some additional critiques for that are not mainstream, so myself and some others. That basically boils down to, okay, you're collecting this information, but how is it going to be used? And that's kind of rooted in this whole literature of decision support science. Healthcare providers can use different aids, including technical aids, to support their decision making. But that has to be really kind of, you know, this kind of techie talk, but it has to be a user-centered approach. You have to ask the users what information they need, how they're going to use that information. PDMPs were not designed with that idea. They were designed from this kind of surveillance framework and many times they were designed by law enforcement agencies. Another major critique is that how does having the system in place affect what people do? And that goes back to this idea that creating a surveillance system not only collects data but also changes practice because people perceive others looking in and trying to track what they're doing and then responding in ways that they may not like. So, you know, providers, for example, if they have a person who's a doctor shopper in their practice and they get a red flag, how do they respond to that red flag? I think it's also important to mention, you know, again, kind of in the context of the earlier point I made about equity, that these systems can affect people differently. So people who are especially vulnerable include, for example, people who are going through gender reassignment surgery or gender reassignment process. And this is because, bizarrely, PMPs actually track testosterone and estrogen because they're deemed as, you know, substances that are vulnerable to abuse because of anabolic steroid use. And so PDMPs, I think, in Canada as well, in the U.S., for sure, track your prescription of testosterone. You know, this is what happens when you have a broad-based drug scheduling framework that is very, very inclusive of substances that need to be controlled and then you anchor your monitoring efforts on that kind of broad statutory framework. Also, people who are especially vulnerable I think are people who have negative experience, who are more vulnerable to negative experiences in the healthcare system. So people with lower socioeconomic status, racial and ethnic minorities, people who have traditionally had sort of experiences of what they've been rebuked or discriminated against in the healthcare system, might experience this kind of surveillance in a different way. They might deem themselves at more risk of being, for example, surveilled by law enforcement when they go and get their prescription drugs and those drugs are tracked by this state-level system. So there's actually been very little empirical work to try to understand how these systems function in real life. So a lot of the work has really focused on this kind of more policy-level approach. So what I mean by that is you classify states as having or not having a prescription monitoring program and then you look at what the health outcomes are and you try to see if it makes a difference. Do states with prescription monitoring programs have, for example, lower prescription rates or lower prescription overdose rates? And so the evidence on that is actually mixed and is extremely, without getting into the weeds of sort of the epi stuff, it's extremely hard to disentangle these kinds of policy interventions from other policy interventions because oftentimes PDMP or PMP legislation was passed as a package of a bunch of stuff. So there were often prescription controls imposed and other kinds of interventions and so a lot of the literature that's been published actually does a very poor job of disentangling those co-interventions and saying, well, it's the PMP that made a difference and not those other things. So even in the context of defining the success of PMPs, for example, as lowering the number of people who are prescribed medication, they actually have been found to affect that. So a lot of articles, probably about half a dozen articles, have now shown that implementing or having a PMP law is correlated with having lower prescription rates in your state. But first of all, they haven't properly controlled for confounders and also the question arises of, okay, well, if you've lowered prescription rates, kind of going back to that graph of the opioid crisis, what happens to the overdose rates overall? Because the problem is that you're seeing a lot of people transitioning from the prescription drug market into the black market. And so to the extent that kind of constricting that supply of opioid prescriptions, if in fact PMPs do that, that might be contributing to people actually entering the black market, which is public health disaster. It's not a benefit. So I'll just briefly, I'm kind of running out of time, but I'll briefly mention two studies that I did with a couple of colleagues on sort of the empirical implementation, to use empirical tools to track the implementation of PMPs, how they actually work on the ground. So this first study is an ethnographic study with a group of prescribers, pharmacists, regulators in law enforcement, and drug users. And I'll just kind of, to give voice to the participants, I'll just kind of put these up, these quotations. So this sort of hypothetical critique that I mentioned earlier, where prescribers could be seeing PMPs as a tool of surveillance in a way that's probably affecting their medical practice that's negative and sparking or spurring the kind of defensive practices that are actually detrimental to the patient. The providers we talked a lot about how the surveillance system is affecting their thinking and their risk perception of being dinged for certain kinds of practices. So what this boils down to is essentially the fact that having problematic patients in your practice, having patients who are on high doses of opioids or having patients that might be engaging in doctor shopping or drug seeking behavior, is a liability for a provider. So as a provider, you don't want to have those patients in your practice because those patients will be flagged by the system, and then you're going to have health to pay for the fact that you have this patient in your practice. So what is the response of a provider to that kind of liability? The response, the easy way out is to say to the patient, you know what, don't come back. I don't want you in my practice. So when a provider does that, they've just shed themselves of liability, but what they've created is on the individual level and on the public health level, they've just created a disaster because that patient is likely not just going to say, oh, well, I guess I'd better stop using opioids now. They're probably going to say, well, I could go to a different provider, but they'll probably look me up on the PDMP and find the same information, and I'll be rebuked by that provider as well, or worse, they'll call the cops on me. So the response is probably from the patient's perspective is that I'm going to go out and look for black market supplies of opioids, which are readily available and, in fact, cheaper and easier to get. And we don't want that to happen. We want to make sure that we engage patients in care, provide wraparound services rather than cutting them out. And when we talk to healthcare, when we talk to drug users, sorry, they oftentimes talked about the prescription drug monitoring as, well, this person uses the word, you know, it's a tool of oppression. So they saw it as a wedge between their provider and patient relationship. They saw it as a way to track, for government to track them and to go after them for certain things. And so, you know, the natural response from a person who has substance use issues and maybe is misusing opioids is then to go to a marketplace where they're not being surveilled in the same way and that is the black market. And that's, again, not something that is a desirable outcome. So I'll just mention quickly, a second study that we did was a social listening analysis and this is a new method, at least to me, where you scrub the web for certain information related to a topic. So in this case, we looked at the postings on Reddit as an online forum related to prescription drug monitoring or prescription monitoring programs and we conducted a sentiment analysis. So basically, kind of, it's like the word on the street except that it's the word on the web. Like, what are people saying? So mentions of P&Ps went up drastically probably in concert with the overall rise in the scope and the number of these programs and I'll just mention this quickly, that the sentiments were generally positive. They were mixed, actually, between positive and negatives among providers. So the dark blue, sorry, the light blue is prescribers and dispensers of drugs. Again, commenting on Reddit about prescription monitoring and they were overwhelmingly negative among patients and family members, which was interesting. I mean, this quote to me is interesting because this is a provider speaking and they're saying, you know what, these systems are really great because I basically tracked a patient and I figured out that they were engaging in inappropriate practices and they basically walked out. They said, you got me and walked out. So this provider is using this as a positive light, again, because it helps them to say, okay, I'm not then going to prescribe drugs to this patient and I'm not going to engage them in my practice, but from a health care and public health perspective, this is actually not a good outcome because they let someone walk out who probably needed a lot of help. So I think this actually is probably a good concluding point, which is that PMPs are not in themselves a benefit. PMPs are a potential tool to improve care coordination, to engage patients in better wraparound services and they're a tool to improve the public health response to the opioid crisis, but how those tools are used has not been discussed enough and this is, again, I'm focusing on the US. In Canada actually we just had a meeting where I heard a lot of heartening comments about how the thinking about PMPs is different and so I just definitely want to say that that is integrating the prescription monitoring information with contextual data about what the patient is experiencing and using that holistically and using it in a context of the fact that prescription is not the only source of drug access, there's also black mark, we function in the context of a wide availability of drugs on a black market and so the way that we deploy supply reduction interventions has to be informed by that reality. There needs to be a lot more thinking about, okay, well, if you find certain information in prescription monitoring program database, how do you use that information to improve patient outcomes and to improve public health outcomes? That discussion, at least in the US, has been had. And then I think there's a lot of work that needs to be done in terms of communication to make sure that providers, for example, do not think that they're expected to fire problematic patients so that perception may or may not be based on reality so medical boards may not actually come after you if you have problematic patients in your practice and if providers see it that way, that's what makes the difference. And the same thing is true of patients. If patients think that the prescription monitoring programs and databases are being used to track them for law enforcement to come after them and that affects them in a way where they actually are pushed out of the healthcare practice, of the healthcare setting, of the volume of services, we should change that perception and make sure that people do not perceive that we don't use the system in that way and that people do not perceive that the system is being used in that way. So I had a couple of other things I'll just mention super quickly. There's jurisprudence in the US that actually makes the situation worse. So there are just two cases, one in Oregon, one in Utah that basically extinguished privacy protections on the state level. So the federal government and the states went to court and the federal government won and said we don't need a warrant to access P&P information for law enforcement purposes. We just need an administrative subpoena which is basically the Drug Enforcement Administration saying we want this information because we want it, don't ask us why, give it to us now. This quote definitely raises eyebrows, at least for me. So one of the judges basically said that people have no expectation of privacy in their prescribing data. This is a federal appeals court kind of strange. So basically we went from having 13 states having a warrant requirement which is in itself interesting that not all states have that, very few. But we went to no states having a warrant requirement for law enforcement access. Another emerging situation is that P&P information is now being bundled with criminal justice data. So when you look a patient up on the system, you see if the patient has been convicted of a drug crime or in the case of Wisconsin, if they've been accused of a drug crime and not even convicted. And that raises a lot of questions about if these systems are a healthcare decision support tool, what kind of healthcare decision is that supposed to inform? If the person has been convicted of a drug crime, especially in the context of what we know about how drug laws are being unevenly deployed towards certain groups of the population. So what does that say about what these systems are designed to do, really? I'll probably just conclude on this conceptual note that I think designing surveillance systems to really protect confidentiality and privacy and preserve the doctor-patient or the provider-patient relationship is actually good for public health. They're not opposing imperatives, but they're actually synergistic imperatives because unless you design these systems to really be respectful and maintain people's confidentiality and to preserve the provider-patient relationship, you're actually doing more harm than good from a public health perspective. I'll just leave this here kind of a sad note, but I think it's really important as we deploy policy interventions in the context of the opioid crisis to do it in a way that actually is based on sound evidence and it does not produce more harm than good, and that has not been necessarily the case in the U.S. As you saw, the crisis has really worsened, partly because a lot of the interventions that were deployed were not well-calibrated to accomplish their aims. That's it. Thank you so much. Thank you. So we have about until 20 after the hour for questions. I'll try to keep a list if you just want to raise your hands. Let me just call me Leo, please. I have a question as we're related to the fentanyl crisis. What would Mr. Jaylons of government officials of the structural system who is really bringing these drugs into the country out of the street drugs? And what about the structural surveillance instead of the individual surveillance? And does this coincide with the population of the country? And who is monitoring and tracking street drugs being brought into the country by those powerful and clean government officials and drug cartels that are connected to them? So the control substances regime, the statutes related to control substances, set up a pretty, that was set up in the 70s, creates a really sort of robust or supposedly robust system for tracking drugs that are brought in both on the legal side and the legal side and creates a whole, there's a whole huge effort of interdiction. So the Postal Service and the police and the Coast Guard and all these different agencies, I'm not, again, I'm not familiar, intimately familiar with the Canadian sort of architecture of how that works, but there's a bunch of agencies that collaborate on controlling the flow of drugs into the country. And as you alluded to, there are definitely problems with that. There is corruption. There is probably, you know, the Postal Service probably is under resource to actually track what's coming in. You know, there's obviously a huge volume of products coming in in general. And so it's hard to have that trade be functional and also create the kind of controls that would be necessary to monitor, closely monitor the drugs are not entering through, you know, container ships and mail and so forth. But I think it's also worth noting that, you know, from just kind of economics perspective, I just wrote a paper on this actually. So, you know, classical economics dictates that basically as long as there's demand for a product, the black market will find a way to bring that product in or create or manufacture it domestically. So, you can't talk about, you know, drug control efforts from the interdiction side without also addressing the fact that there's, you know, a major supply for illegal illicit opioids in Canada. And until you address that demand, the supply will always come. And that's just the function of the market system because there's money to be made and it will find a way. And even in the most restrictive countries, which, you know, Canada is not, but places like Iran and Singapore that have the death penalty for drug trafficking, there's still major drug problems. So, well, not in the case of Singapore, but certainly in the case of Iran. So I guess what I'm saying is their interdiction issue is important, but you have to be careful about focusing on the interdiction without focusing on the demand and also talking about the root causes of that demand. You know, why are people seeking out these drugs on the black market? Social scrubbing or whatever. To determine what extent the development of people programs is driven by it. And the second question relating to that, you know, the suggestion that the opiates are the origin of the epidemic. There's a lot of other thoughts around that. There's some 3D modeling of what else is happening that we graphed in September, the 9-11 crisis and the culture of fear that came from that and the economic crisis. So there's a lot else happening in the population that's putting the population at a point of looking for some self-medication of anxiety and hope in the life. And so to what extent is our narrative focused on the opiates at the demand for EP programs, which ultimately, you know, you're suggesting maybe it's actually counter-trial to achieve. Great, great question. So the first question is to what extent the public has demanded these programs. I think that's a, you know, there's a complex relationship between sort of public and policymakers and, you know, folks in government who are regulators. And I think to a major extent, the reason why P&Ps became so popular on a policy level and you saw that graph where, you know, there's just a huge explosion in the number and scope of these programs. The prescription, the conversation about overprescribing presents a simplistic answer to very complex problems and policymaking oftentimes zeroes in on easy fixes. So P&P, I think to a large extent, as well as other efforts to limit prescribing, you know, such as, you know, in certain states in U.S. now the prescription of opioids is mandated to be limited to three days, at least the initial prescription. So there's a, you know, there's a mandate of healthcare practice that limits the initial prescription to three days. And then if you need to refill that prescription, you have to go to a doctor again to fill the prescription. You can do it by phone. So these kinds of interventions create a mirage of simple answers to very complex problems. And I think that P&Ps, to a large extent, are an example of that. You know, they, if the problem is deemed to be overprescribing and these rogue providers, which are actually a tiny slice of the, you know, opioid access, but the narrative is very attractive. And I think we basically became seduced by that narrative instead of focusing on, as you alluded to, what is actually, what are the root causes of the rise in opioid prescribing and opioid use? And in fact, in the U.S., I don't know what the data look like here, you do see, for example, real income or real purchasing power and other economic factors essentially go hand in hand with the rise in opioid use. So like, you know, people have fewer, people have less purchasing power, there's a lot of economic anxiety, there's a huge rise in income inequality and other kinds of structural factors that are extremely difficult to talk about and to fix, but unless you talk about them, you're not really talking about what's driving the crisis. You know, the reason why my belief, why the crisis is morphed in a way that's essentially unmoored it from being, you know, focused on a prescription supply and certainly being problematic, but it's just exploded is because we've applied all of these interventions that have basically made it harder for people to get access to prescription supplies and have moved the population to the black market without addressing demand and that demand is based on, you know, having access to quality health care, having access to quality mental health services, having access to substance use services, as well as having a decent and functional safety net and addressing people's economic and other kinds of concerns. You know, it's a complicated conversation, very, very difficult to talk about what are the policy fixes to those problems. Much easier to talk about, you know, let's impose a policy solution that is, you know, discreet and simple and call it a day, but unfortunately that promises to address the crisis very little. Yeah, sir. Hi, how are you doing? Good. Good. I just wanted to address, as you say, it's very complicated to look at specific one that was alluded to in a few of the readings that were assigned to this first lecture in the CMHA, and that was a case of which there was a little problem, which allegedly provided free textbooks to all Native medical students that said, I'm sorry, I don't have a 1% risk of addiction. Right. Now, this seems like a very ostensibly grained issue with Canadian medicine, maybe American as well, but this is a specific instance, and I'm not really sure between the Royal College and the medical schools and all the regulators where would we even start with such a measure? Yeah, no. I think, you know, it's... I find myself in a weird position being an ardent critic of the pharmaceutical industry and regulatory capture of defending pharmaceutical companies, which is actually not true. I'm not defending them. There's certainly egregious practices and regulatory capture is real, and the fact that pharmaceutical companies are oftentimes indoctrinating healthcare providers without an alternative view being presented. So there's now actually a really hopeful practice of academic detailing. I don't know if you've heard of that, but basically it's the idea that you can go to providers and present public health evidence instead of just presenting the, you know, pharmaceutical funded evidence. You know, we want to make sure that healthcare providers are receiving, you know, balanced view, and oftentimes the speakers has generally been biased. The speaker providing information to healthcare providers has been biased. We certainly want to minimize that and maximize evidence-based practice. And decision support tools can actually play a good role in that because in designing them and in figuring out what information should go into decision support tools, you can have a filter that filters out biased information. So I think, you know, all of that said, it's also true that blaming pharmaceutical companies and evil pharma, again, is a simplistic response. I'm not saying that's what you're doing, but actually a lot of my colleagues in the States have now seized on this idea that it's, you know, it's pharma companies. Let's sue the hell out of pharma companies and everything will be fixed. That's not the case. From a public health perspective, you know, impact litigation in this area against pharma companies is not going to make a difference. The crisis is no longer being driven even by pharmaceutical drugs. So the idea that you can, you know, sue pharma and everything will be well is highly flawed. And I think that we need to regulate pharma better. We need to make sure health, you know, medical education and education of other healthcare providers is balanced and is rooted in a lot of structural competency, not just cultural competencies. So making sure that patients receive structurally informed and trauma-informed care. But that is... Yeah, so, yeah, I mean, all those things are important and regulating pharma is important, but ultimately it's only one small piece of the puzzle. Yeah. Just to take one piece of the sort of larger, you know, maybe root causes or systemic issues to the supply or I guess the need of the man. As Canada gets ready to enter into this regulatory space, have you seen any statistical warping or correlation in states that decriminalize marijuana and that impact on the sort of opioid demand? Yes, yes. So actually, when I talked about... Sorry? Yeah. Well, specifically with the state, you know, the state dynamics. So as you all probably know, the states have experimented with various modes of marijuana legalization or regulation and that presents a lot of opportunity for research. So those of you who are interested in policy research, you know, U.S. is a... Canada is a certain extent too, but U.S., you know, the diversity of policy approaches in the U.S. always presents a lot of opportunity for natural experiments. And so when you look at marijuana legalization or medical marijuana regulation, that is one of the factors in research that comes out as being protective against rising opioid overdose rates. So states that have allowed medical marijuana earlier saw their opioid overdose rates rise at much lower levels or slower levels than states that did not. Now there are some, you know, possible contributing or confounding factors, but all the research that has been published so far, that policy element is one of the things that always comes out as significant. So, you know, at the very least it gives promise to the idea that people might be able to substitute opioid use with marijuana use. And in the U.S. there's very few places where marijuana is actually approved for chronic pain, for example. So that's something that definitely warrants further exploration. It's a real quick question. We have one last question. Along the same veins in regards to using prescription monitoring for overdose prevention, any context or past experience with publicly funded block zone programs based on information able to be gathered from monitoring programs to be able to implement that type of overdose prevention? Great question. So as I mentioned, prescription monitoring programs can be a tool to inform clinical care and harm reduction. So it certainly makes sense for someone who's prescribed high doses of opioids as well as benzodiazepines or maybe co-using alcohol. That person should definitely be co-prescribed in the lock zone. Similarly, if you see on the prescription monitoring program a community where opioid rate, opioid use rates are really high, that community should be targeted for overdose education and the locks on distribution programs. So there's definitely opportunities where you can use prescription monitoring data to inform harm reduction or harm minimization efforts. Unfortunately, it's very rarely used in that way and I think that's something that we need to seize on and maximize and lift up. Great thing. So I want to thank Professor Blotsky, but before I do, just a quick plug for our next seminar, excuse me. So our next and last seminar is on December 1st and another Friday and the title of that presentation is the use of research in veterans health policy making, making matter and it will be given by the Vice President of Research here at Downhouse University, Alice Aiken. So please join us on December 1st. Now I'd like to thank Professor Blotsky for his insightful talk. I think it's a really powerful example of the theme of this year's health law institution, seminar series which is one of interdisciplinarity. The field of health laws and interdisciplinarity field which our associate director Professor Joanna Erdman has really been curating and developing. I think this is a powerful example through Professor Blotsky's case study, close observation of prescription drug monitoring programs in the United States to really run an epidemiology not just with law but of law of how those programs are working in practice and the trade-offs that are embedded might be improved in the future. So thank you very much Professor Blotsky.