 I am JoLinda LeClaire, Director of Drug Prevention Policy for Vermont. I oversee the Governor's Opioid Coordination Council, which Governor Phil Scott established by Executive Order in January 2017. Since then, the Council has focused on its mission to improve Vermont's response to our opioid challenges through prevention, treatment, recovery, and enforcement. This crisis touches everyone in our state. Many Vermonters have family members and loved ones who have become addicted after receiving opioid prescriptions for pain. Others were exposed to opioids and other drugs through friends, dealers, and traffickers. Regardless of how they were exposed, we know we have among us many who now have the chronic isolating and too often deadly disease of addiction. We are making progress. Treatment is available across the state through Vermont's nationally known hub and spoke system of treatment. Recovery centers in our communities are providing effective wraparound support to help people achieve long term recovery. Many communities are building prevention coalitions to provide our children and families the tools they need to be resilient in the face of life's challenges and traumas. Vermont law enforcement has steadily worked to increase community safety and to decrease the supply of illegal drugs. They also work hard to support prevention strategies that will reduce the demand for opioids. There is more we can do and must do to turn the curve on Vermont's opioid challenges. Drug prevention education is a top priority for schools and communities. Increasing intervention opportunities in emergency rooms and other places will help more people enter treatment and recovery. Individuals and families in recovery need support to obtain jobs and rebuild their lives and support for harm reduction through safe and appropriate use and disposal of drugs and syringes will increase safety in homes and communities. Something we all can do to take every opportunity to raise awareness and reduce stigma by talking about addiction to highlight the science of addiction as well as the cultural, social and economic challenges associated with addiction. The producers and hosts of Vermont Cable Access and the Opioid Coordination Council have created an eight-part series entitled, Understanding Vermont's Opioid Crisis, Working Together to Create a More Resilient Community. This is the sixth in the series and it is about wellness, integrative healthcare for pain management and treatment. In this segment, host Pat McDonald explores approaches to pain management and addiction treatment that reduce or replace the need for opioids. This requires education for prescribers and patients and improved screening for patients, strategies that are underway and highlighted by the governor's Opioid Coordination Council. Hi, this is Pat McDonough and I want to thank Joe Linda for the introduction. As Joe Linda mentioned, this show is about the use of non-pharmacological approach to pain management for addiction treatment and recovery and is also about patient education regarding options and risks in pain management. And we have, Ben Kinsley is here with us today, co-host and co-producer, and we have got three very special guests who are highly qualified to talk about this subject. And it's Dr. Josh Clavin, chief medical officer at Blue Cross Blue Shield. Doctor, how are you? Good, welcome. Dr. John Porter on the other side here of the room of medical director of comprehensive pain program. I have to talk later, doctor. And the commissioner, Mark Levine of Vermont Department of Health. So I would like each of you, we ask our guests to talk a little bit about themselves just so our audience has a flavor for who you are, and how your work that you're doing now ties into our discussion tonight. So Dr. Clavin. Sure, I'm been a practicing physician in Vermont for almost 20 years. I've been at the Blue Cross Blue Shield Health Plan for only about three, three and a half years. Before that, I was in Central Vermont area as a primary care physician. I worked as ER doc and hospitalist and I'm an internist and a pediatrician, so I kind of do family medicine. And so I managed many patients with chronic pain as part of my long time job in primary care, and recognized a lot of the barriers that and issues that we're trying to address. So that informs a lot of the work that I'm trying to do at Blue Cross Blue Shield Vermont in partnership with my colleagues to the left and throughout the state. There's I've noticed there's a lot more partnerships these days. And I'd like to talk about that later, it just seems to be working more closely together and better these days. So commissioner. Yes. So I'm an internist as well, practiced general internal medicine, literally up to the day I began my commissioner work. And as a general internist, did a lot of preventive medicine, screening for disease and chronic disease management. And all of those actually feed into the topic we're going to talk about with opioids. But I also did a lot of screening for other substances, you know, more commonly than opioid, such as nicotine, alcohol, marijuana, using a technique called expert, which is screening, brief intervention, referral to treatment. But we didn't really call it that we just kind of did all of that. And we'd like to disseminate that model even further. Currently as health commissioner, obviously, the opioid crisis is a big focus of the Health Department, a big focus of my alcohol and drug abuse program division at the Health Department. And clearly, it's in the media all the time. But more importantly, it's in the lived experience of people in the public. And so everybody in every community has been touched in some way by it, which really elevates the level of importance that assumes for all of them. As part of my role in health commissioner, I'm also a member of the governor's opioid coordinating council. And there are regional coalitions throughout the state. And I sit on the executive council of the Chittenden County, I hope you know, and there's there's just so many activities going on that I'm sure we'll get into as we I said this at the last show we did on enforcement that when Governor Schumlin used his whole state of the state speech, I mean, myself and my little circle of friends, we have no clue where we live. I mean, we're just not we had no idea. And we were wondering, why is he doing this? We found out pretty quickly after that this is huge. And how serious it is. And it's everywhere. And I just that was a lesson for me. Because I'm like, What is he doing? So anyway, he was doing the right thing. So Porter. Yes. And I am a family physician. I practice for a number of years in Bennington. And then about 20 years ago came up to work at the University in the family of medicine residency, and subsequently at the University of Vermont. And since December, I have been working to put together the program to that we hope will kind of approach the issue of chronic pain for folks in a way that that finds more success than we have had to this point, using an integrative approach. So that's really fascinating. I'm really looking forward to this discussion. So well, there's so much we can talk about on this subject. But Commissioner, let's start with you. Could you summarize from your perspective, where we are at with the opioid crisis and kind of how we got here? Yeah, maybe I'll do that in the reverse order. Sure. God here. And a lot of times people focus on one big area and say this was the problem. But it's really a multi pronged kind of issue. So the health professions play a big role. Individual predisposition plays a big role. Economics plays a role. Society plays a role. So starting with the health professions, obviously, there was, and to a less degree still is, an epidemic of over prescribing of opioid medications by the prescription route. No one's denying that if you ask people who are immersed themselves in the disorder of opioid use, they'll tell you that four out of five times it began with the prescription drug use. Having said that, it doesn't mean that the prescription that was written for them got them into trouble, although that may have been the fact. Most often it turns out perhaps as much as two thirds of the time, it was by diversion. And that's why in Vermont, we have these campaigns called most dangerous leftover campaigns, because it's the things that are still hanging around the medicine cabinet that either get stolen, borrowed, diverted by, you know, illegal or legal means to susceptible people. And so a big thrust of what we've done in Vermont with new rules about how to prescribe these is making sure people are really tuned into the right quantity, right dosage, and that initial prescription, only enough pills that are needed, as opposed to a 30 day supply for something that might have only needed 48 hours worth of treatment. So that's, you know, clearly part of the way we got into this. There was also the culpability on the part of the pharmaceutical industry, specific companies and distributors who really misled the healthcare professionals into thinking that these drugs had low addictive potential, when in fact they have very strong addictive potential. And then there was some misconception about the utility of these drugs for management of chronic pain. And I know Dr. Porter is going to get into his clinic later on, but at the same time, for a long time, people felt that we were helping people who had chronic pain with something that was useful for them, not harmful. And we didn't have many alternatives in their place. So opioids became the natural default, if you will. And the whole thinking on that has changed needless to say. But having said all that, we don't want to take away from genetic and biological predisposition. We don't want to take away from the fact that there are these so called social determinants of health that really create what we term diseases of despair, like substance use, alcohol use, etc. And this is related to, you know, socioeconomic issues like poverty, education issues, social isolation, things of that sort. And these toxic stresses that young kids grow up with, depending on the environment that they're brought into, where there may be abuse in the household, there may be someone who has a disorder of substance use, there may be someone incarcerated, etc. All of that combines into sort of how we got there in a sense. And originally, there was a lack of really good access to treatment. Now there's really good access to treatment of opioid use disorder. So we've taken care of that aspect of thing. People converted, if you will, from the oral prescription drug route to the intravenous heroin, and now unfortunately much more dangerous fentanyl routes, really through economic concerns. These these are cheaper than getting prescription drugs. They're often easier for people to obtain illegally than the legal route in a clinician's office. And the supply of heroin was abundant. And so required a whole host of new law enforcement strategies to try to grapple with that as well. So all of these factors kind of came into play. The impact on the population of Vermont has been quite substantial. As you were mentioning by the state of the state address from years ago, we currently have about 8 to 9,000 people in treatment. Widely not known but nationally derived figures tell us that at most two or three out of 10 people who have an opioid use disorder are getting treatment. That means there's a whole host of people out there that are actively using drugs and not actually getting treatment. So if you look at the universe in Vermont, we could have as many as 20 or 30,000 individuals in the state total who have this problem. And it has this huge impact on everyone as I alluded to earlier. So that's why community coalitions develop, etc. Its impact can also be measured in just mortality. There are two Vermonters a week on average who are dying of an unintentional overdose. That's about 100 a year. There's also this huge impact on kids. And when I have my colleagues in the Department of Children and Families show me their statistics. It turns out that in the last two years, 50% of children age is zero to five that are in the custody of the state of the Department of Children and Families were attributed to opiate use issues in their family. And that's about 500 kids a year. I'm very involved in prevent child abuse from on them on the board. And our numbers have gone up, but it's not from abuse. It's from neglect. Because when you're on the opioids, you just sort of can't care for your kids. So that's why the numbers are going up. And we had them down for quite a while. And now they're right back up again. Especially in the zero to five year old, which is a real tragedy. So enough on the impact. I hope that answered you. That was very thorough. Very thorough answer. Thank you. It's it's amazing, all the aspects of, you know, just regular day life in Vermont that this impacts. I don't know, Dr. Porter, if you have anything to add to that in terms of the treatment and and diagnosing of the issue? Yeah, well, I would, I think that was a very comprehensive response and thoughtful response on Dr. Levine's part. You know, I think we in the allopathic medical field have something to kind of carry here as far as as wishing that we had perhaps done better critical thinking and design systems that responded better to individual conditions. So when somebody comes into the office with a complaint of chronic pain, you know, I think given the way our systems have been set up historically, typically you give a pill. If it's a strep throat, you give a pill. If you don't, we feel neglected. That's right. You don't do that. But I do think it's it's an opportunity for us to look at how we're practicing and how we can really kind of move towards a more patient centered approach. And so that's what we're all working on. That's great. Dr. Plavin, I just want to ask a little bit different question about Blue Cross Blue Shield, where you work. How has that been impacted by the opioid crisis? I went on your website and there's I think there's a lot of policy changes, medical changes. You've really been active and somebody in Blue Cross up at the State House trying to swerve some things around and being responsive. So the so Blue Cross has been engaged with the opioid epidemic writ large since 2002, when it was the heroin epidemic. So we have been intervening over time and raising awareness, provider outreach and education, early intervention and end recovery. And so we had supported Bess O'Brien's films that you're familiar with. Here today, The Hungry Heart and the tours. Yeah, the tours throughout the the the state, which were very engaging. We also supported the Voices Project, which is the voice of youth and ended up being a play. It was videotaped and available. And a book as well called Listen and a CD called Listen. And then more recently, we worked with Vermont PBS to read, to have further community dialogues and we re-televised, if you will, here today and Hungry Heart with Bess as well. So that's on the raising awareness side. In regards to the the current kind of partnerships, we had actually been planning on starting to address this institutionally at the same time when at that at that time, the commissioner was Dr. Chen, reached out to us and said, hey, we're actually putting together a statewide task force. We'd like this to be multi-payer and have everyone engaged. And we said, sure, that sounds like a great idea. So we met with him and other payers and then eventually got involved in the statewide opioid task force. And in the end, what we did was we operationalized the guidelines that were agreed upon. So having guidelines and rules are one thing, enforcing them and making them real is another. And so what we have found is that we when we have put hard stops in the pharmacies for someone who is opioid naive, never had a medication before, maybe just had a procedure and was given a prescription for 30 tabs. Well, the new rule in the system says no more than seven days, no more than so much mild equivalence of medication, and it will stop it right there before it's dispensed. What we found is that that actually has further decreased. We've seen an overall decrease in opioid use. That has further decreased that by about 20% by actually operationalizing the rule within your systems. And so that took some doing, but we continue to improve on those. We have new policies around long-acting opioids. We are having meetings about next steps as what we want to do as a state and how can we help to operationalize those decisions because patients are also at high risk of overdose, whether on high doses, when they are have a co-prescription of sedating medications. So we're very concerned about that. And we do a lot of monitoring and outreach to providers. How many physicians do you have a Blue Cross for the Shield who maybe are monitoring all of these interactions of drugs? So we have two pharmacists and basically three physicians. And not full time. And so, yeah, I make a lot of the calls myself. And then the other thing is mental health, the interplay of mental health diagnoses and both chronic pain and then opioid abuse and the untreated underlying issues. Exactly. And so that's something we also consider a risk factor and work with our... So you deal directly with your clients, your customers. Do you call them and talk and have people follow up with the patient? We work through the provider. There are some federal rules around. So we work with provider as much as possible. And we certainly don't want to get, never want to get in the way of the physician, you know, patient relationship. And so we want to augment that. That's important. Well, we think Blue Cross Blue Shield is a wonderful community partner. So thank you very much. Maybe you had some questions. Yeah. So there's, you mentioned the role that you're playing working with state and in some cases federal officials and programs trying to address this crisis. And there's three critical pieces, in my understanding, to that, to that relationship. And it's ensuring patients receive the right care in the right setting, providing states with sufficient resources to address the epidemic and addressing the fraud and abuse that's harming people who need help. That one, we can probably expand on a little bit more. Yeah. You know, and so, so right time, right place, there, we actually have a very robust case management program nurses and social workers and mental health and licensed alcohol and drug counselors who work with our members who are struggling within recovery. And also for all sorts of other chronic conditions. It's unique because we're actually a provider-payer partnership with the Barbara Retreat. And so we're completely integrated between mental health and medical. And, and so we have lots of different programs to support patients in recovery. One of the things we found was that when patients are first identified with opioid misuse disorder, and they're started on MAT or medication assisted treatment at a hub, sometimes there's a gap between the hub, the central kind of stabilization facility, and what's called the Spoke, which is the community provider who takes on their care once they're stable. Sometimes people fall through the cracks. So what we've done is actually put in a case manager in the middle to make sure and ensure that members get kind of from the hub to the Spoke, if you will. And we were the first payer to actually contract with all the hubs, pay them at a bundled rate, break down a bunch of barriers around finance, which include things like people who are initially on medication assisted treatment are often given daily or weekly dosing. And we were, we realized that the way that the benefit structure was designed was not to the benefit of the patient. And so we prorated the quote unquote copay, whatever the portion of the patient might need and need to pay so that they weren't kind of stuck with that every time they filled the prescription, among other things. We do support SBIRT actively and do support training and expansion of that throughout the state. That's the early intervention, early diagnosis and harm reduction model for for substance misuse in general, I would say. And we're expanding that model as well. And lifestyle misuse. Yeah, exactly. Exercise diet. Oh, please, let's not talk about that. And then on the on the other side, we're working with Dr. Porter and also another site and the proper retreat, actually, to stand up what we like to think of centers of excellence. So just like we have a hub and spoke model for opioid misuse and medications treatment for chronic pain, we don't have a system to adequately manage our patients. And we in primary care often, if you will, left holding the bill, if you will, and not adequately trained to manage complex pain syndromes like this, what we have historically done is send patients off for consults to interventional pain clinics. They might get an injection. It might help temporarily. But in fact, much of that interventional care is not actually that helpful for patients. And what we firmly believe is that there needs to be kind of a middle man center of excellence or hub and a series of these throughout the state to support patients and verminers as well as the medical system and Dr. Porter's is would be the first one that's up and running. Right. The second one that we're retreat, but we envision probably six to eight of these throughout the state. So kind of like a parallel structure to a parallel structure for chronic pain. Great lead into Dr. Porter, because we'd like you to talk about the comprehensive pain program. CPP, I got it. CPP. Yeah, and I think we can go back and maybe along the lines of what Dr. Plavin was saying, kind of take a systems look at how we have been doing this. So you can imagine a patient who has been dealing with pain for many months or years on a perhaps an opiate who may have a co-occurring mental health challenge, depression, anxiety whose vocational plans may have been disrupted, whose family system has likely been disrupted. And, you know, in our traditional setting, having that person call and make an appointment for a follow-up visit, you know, which in a primary care setting often turns out to be a 15 minute visit. And they present to the office with with this array of suffering around their chronic pain and leave, you know, probably experience a very transactional event, right? I'm here. Here's what's happening. My pain is five out of 10 or eight out of 10. And so they may well leave feeling like they weren't well served, frustrated, they don't feel much better. They may be having side effects from their medication regime. Well, somebody brought up the underlying, I think you've talked about the underlying factors. A lot of pain, I think, is underlying factors which could trigger pain, correct? Is that? I think we're learning a lot psychological about about how the nervous system seems to behave in folks who have chronic pain. And there's it's not as simple as, you know, I have pain in my back and the tissue may be normal in writing respects, but there's pain there. So where's it coming from? And so we're looking at how to approach it in different ways. But if I go back to that scenario with the patient coming in with their chronic pain to a primary care setting and you go to the other side of the desk or the exam table, you have the clinician, you know, who has this patient with many needs and challenges, trying to take care of that in a 15 minute visit. That ends up being frustrating and draining for the clinician. And so I think one of the questions for us is with this condition, how can we really try to develop a system that is patient centered, that uses a broader toolbox of options than than we've had just with our traditional approach. So what is your playing? Can't say a pain clinic going to be doing that's up in September. It's a new building at the university? There's an area that's being renovated about 9000 square feet. It's on Tilly Drive. And the intention is first of all to take care of the cohort of folks who have been seen at the pain clinic before the CPP came into being and offer them access to this. And then we'll open it up to the faculty practices and primary care internal medicine and family medicine and then beyond that within the system. And for many folks who go through that, as we put this program together, this will be a 12 week so called episode of care with a weekly time for patients to come. Nice. And during that time each week, they'll get some education about what's happening with their body in this process. They'll have a chance to do some movement. They'll have access to other modalities be introduced. Do you have like massages there and other things there at the facility? So this facility will have physical therapy, occupational therapy, yoga therapy, massage therapy, acupuncture, and then some mental health approaches that are designed to help folks up kind of gain some new skills. That's great. So I think going back here, you know, the idea is for folks who have been in pain. And I think we use the word chronic pain. For me, the more accurate word is suffering, right? There's pain centrally, but there's suffering all around that that often leaves people isolated. And so the intention is to help folks articulate meaningful goals for themselves about what they would like to be doing. And it may not, as opposed to the old days, when it would be, I want to increase the range of motion on my shoulder to 90 degrees, right, which would be a traditional kind of medical approach. It may be I want to get on the floor with my grandchild and play, you know, or I want to be able to get out to the store or, but using those goals and then working with staffs who, who a staff who has expertise in these various modalities, helping people. Don't you think people have a, um, they think zero is good. I've had this discussion on the show before, and they, every time you go into the doctor's office, they say zero to 10. Yes. Where is your pain? Well, if somebody presents zero to you, you think I should have zero. Yes. I remember growing up and they said, you just had surgery. Of course, you're going to be in pain. And they gave you aspirin or something and it didn't go, it didn't go to zero. Maybe it went to four. Yeah. It does that. I think that doesn't help. Well, I think that doesn't help the doctor. It's a very real point. And at the same time, um, you know, to tell somebody who's had chronic pain that you're never going to be pain-free is, is tough. And yet I do think that's part of the work. Yeah. Because we know in this, in this area of endeavor, if, if folks make 30 or 40% improvement in terms of comfort level, in terms of functional level, that's a home run right now. So I also think we've given folks some signals that, you know, we just got the right formulation or the right medicine, we can do this, right? But people really deserve it. We should have started it at two. Yeah. And even, even that pain chart that we use, you know, is so one-dimensional, right? Exactly. Because there's a lot more to, and I don't never know how to fit it in. But I always think that maybe it's helpful to the doctors to hear from the patient better, worse. And it was four last week and six this week. That would help. That's zero. I think it's a shorthand that has some effort, some use for sure. But I think again, in terms of that broader sense of how are we doing here with life, how, what skills are we able to provide with you or access to modalities that you didn't know would help and they seem to be helping. That's a cultural change. You know, and when it was introduced as the fifth vital sign, right? And the regulators caught on to it. And Jacob actually required some documentation there of that did not help. Because again, it was addressed in too simplistic fashion. And it's a more complex issue and is focused on your experience of suffering, which I think would like better than pain, and your goals for your function. And so I think it's not just us that have to change, but the entire culture to some degree. Right. Just to piggyback onto that. It was as another component of how we got into the epidemic, the overreliance on this as a quality measure that almost forced clinicians into prescribing more and more. But it all stems back to, I think the word is expectations. Yeah. So perhaps we as prescribers may have had unrealistic expectations of how to manage the pain. But those coming in with pain and suffering, you know, with our high tech healthcare system, everyone expects that the expectation is I will go from 10 to zero and the condition I have, I don't have to live with that the rest of my life because it'll be taken care of. And we're learning that actually we can help you live with that in very productive ways. If you work with us in the settings that you've heard described. There's so much, if there's so much going on, you have to worry about drug interaction. And I mean, there's so much stuff you have to worry about. And I don't think Dr. Porter can chime in on this. The promise of this clinic is not that every person who's been on opioids chronically for their life is going to be suddenly off of opioids or that the approach is even going to be to drastically reduce their opioids and make them uncomfortable. It's to really augment the system built around them to help them cope with their pain and suffering, which may perhaps allow a reduction in dose of the opioids. I actually look at the true promise of the centers as are being described for the people who haven't yet become chronic opioid need patients. They have pain and need help managing it. Their physicians need a hub as was described that they can be referred to to really help a holistic integrated approach around that pain and then never get into the slippery slope of requiring more and more opioid to manage the pain. There's still a lot of these pharmaceutical companies said that it wasn't addictive when they first introduced it. That was they sort of told a little there was a little fib and that's why numerous states have a lot of lawsuits now because of that. Well, there's a national class action lawsuit around there is. Yeah, right. But I do see the promise as being in the more opioid naive population that they never get there. And then people who maybe were thinking that just taking a drug will help everything that's wrong with them have a different kind of approach that can be productive for them. I think that's a very important delineation. And I've talked to a lot of audiences and there are people people who have chronic pain who are on chronic opioids who are stable have no reason to think that anyone's going to take quote unquote take it away from you. If it's helping your function and you are you are stable, there's no reason to do so. Now, when we've looked at these types of clinics which do exist throughout the United States, somewhat spotterly, the overall in the whole population that they see about there's about a 20% 30% reduction in total opioid prescriptions. But that doesn't mean any individual patient will be will have a reduced dose. It's their choice as they choose to find alternative means of treatment. So how do people come to your clinic? Does my doctor say you should go to the CPP that's this will be on referral and again, initially will be from the faculty practices up at UVM. But it will be on referral and it will be a referral service. We'll take folks in work with them, communicate with the medical home. And then the other there are two other important parts to the to the program. One is that at the end of that 90 day or 12 week period, we don't want people just to kind of fall off the edge of the table. So we'd like them to continue to maintain and build the skills that they have with the work they've done in those first in that first foundational event. And the other part we're working on is a track for folks who are in primary support roles could be a partner, spouse, might be an older child. I could talk about that. My husband had back surgery in November. So that's me. He's going to a pain clinic next week. So there you go. But again, in the sense that this is a this is a three dimensional problem and challenge for family systems. Because I think that's because sometimes pain, you can't see pain sometimes. And I think it's good for the caretaker to understand what's really going on. And and to have a sense of what the patient is learning and also probably to get some porous in a cohort experience, right? Because it's it is its own it is its own challenge. The other just going back to the cultural change issue in in our traditional way of kind of working with chronic pain, it has been transactional. It has been one in which the patients options are limited, right? And so what we would like to do is to increase patient self-efficacy at kind of picking out things that work for them and their agency in terms of engaging the medical system. And I think that's probably and we will have to see if this is borne out. But there's a reason to think that's a powerful way to help people move forward with with a condition that's chronic. That's excellent. That's great. Ben, did you have a Well, so this is something that we talked about briefly. I think Dr. Porter, you had mentioned earlier about the new facility that you're opening at UVM is psychological counseling being embedded in opioid treatment as you know, that's part of the root cause of of addiction. Kind of to piggyback on top of that, I'm curious to know how integrated the mental health and treatment addiction treatment services are and how much crossover there is between addiction as well as other mental health issues. So that's going to be have to be have to be required foundational prerequisite for these centers that it is there's a medical component and a strong foundation in psychological mental health component. And and so your clinic is going to have that as a foundation, the clinic at the Barbara retreat in fact is coming out of mental health and in fact are bringing in medical to them. And and I think we all agree that that's that's one of the most important things. Is that true in almost all cases that there's some hidden I don't want to say hidden, but there's some psychological issues there. Is that so we would in a broad in a broad sense since we study this at Blue Cross through our claims and what not in the chronic disease population in which this is a chronic disease approximately and it varies 20 percent of the population has a co-occurring mental health diagnosis. Those with co-occurring mental health diagnoses have a 40 percent higher utilization and cost on the medical side. So if you don't treat the mental health and don't get them access to services, you're never going to manage the chronic condition. And we know that on a one on one basis with patients, but at a population level, we need to actually build systems to address it. And if people don't fall into a frank mental health diagnosis, right, there are still issues that relate to their being in day to day life and skills that can be helpful in terms of helping them navigate effectively. And things that are chronic pain led to that is true mental health and stress, whether it's Frank Depression or the 90 or one. Ben, in your original question, I think you were also looking at the overlap of mental health and substance use. Yes. Yeah, I like the feeling. And so that one, we don't have a hard and firm number, but numbers as high as 70 percent for coexistence of mental health disorders and substance use disorder. And we can and need to do a better job of addressing both concurrently. The emphasis is clearly always on trying to leave the addiction problem first and work on that. But really concurrently, the mental health aspects need to be taken care of. Obviously, for someone who has come in asking for treatment for their opioid use disorder, the fact of the matter is state of the art treatment is medication assisted treatment with either methadone or buprenorphine predominantly, occasionally now checks on. And so that's going to be a given no matter what. But in the hub and spoke system layered alongside that for the person who wants it, it's not forced on anybody. Are all kinds of support services in terms of case management, in terms of counseling. And certainly the recovery process is replete with peer recovery counselors, licensed alcohol and drug abuse counselors who want to continue to play a big role for that individual, whether they're remaining on MAT or not at that point in their recovery, because the coexistence is so great and the need for that kind of support is so great. Yeah, it's pretty stark if there's a 70% coexistence. I didn't hear that before. And one of the reasons I asked that question is because, you know, we understand that a lot of now understand that many cases of opioid addiction are resulting from a medical issue. They're either prescribed or got access to opiates. But I think there's also a perception before we came to that realization that people turn to addiction for issues related to depression or whatnot that are kind of outside the medical diagnosis piece of it. And I don't know how great of an issue that still is compared to the medical piece of it and the opiate piece of it, but there's certainly a number of factors at play. Absolutely. So I have a list of treatments or types of treatments that I put them in questions and you all came back and said, well, this is the, so all I thought to do is just to list them and maybe some one of you can explain them as we go through that because I was getting a little confused. So first is the integrative treatment and maybe you could be the best person to explain. What is integrative treatment? It's what we've been talking about, I think. Yeah, and for me, an integrative approach is one that combines an allopathic approach with other therapies. And what is allopathic? It's an MD. Oh, okay. Yeah, or it could be an osteopathic approach. Oh, okay. But with other therapies and with mental health kind of programs and services. So the intention is to bring a broader array of options and treatments. Which is different from the whole person care or the same. Because we had a question about that. It's another way of saying the same thing. Because we're going to put up the wellness wheel from UVM because I think that really just kind of captures all of the components of the whole person. So because I think in the past, so often anything that wasn't allopathic, meaning the doctor who provided prescription whatever, was regarded as alternative or complementary. And that meant any other person who saw the patient, they may have practiced chiropractic, they may have practiced acupuncture, they may have done some far Eastern modality. It was all lumped in that. And it really wasn't a very expressive way of describing what we really want, which is try to find the modality that's appropriate for the person and that will help them get better and become more productive in their life again. It's sort of good to see these modalities being risen up a little bit in recognition of their importance. And that's why she used the word integrative is so much more powerful because it's really, it's not that what the allopathic canon does do, didn't count anymore. And likewise in the opposite direction, if acupuncture was the best, it didn't discount that either. They all can become a component of getting the person to a state of wellness that's greater than where they entered. But integrative is in fact care that is coordinated with the patient at the center. And so yes, one could get chiropractic and acupuncture and go see Dr. Porter all separately. But better, one should get all those services in what I like to call a transdisciplinary model. So it's not just multidisciplinary that we're all sitting in the same room, but we're actually sharing our expertise, coordinating it to find out what actually works for that patient to improve their function and achieve their goals. And better answers can come out of that synergy. Right? Absolutely. Because it's been really the chaotic model up until now. A lot of us think we're sort of in charge and have to find our own paths. If I didn't relieve your pain, or the prescription I wrote didn't relieve your pain, you'd say, all right, I'm just gonna go see so-and-so, who's a chiropractor. And then if that didn't work, well, I'm gonna try acupuncture because I heard it might work. And it's very chaotic, it's not very coordinated at all. And in the end, the person probably is getting very frustrated because they're independently doing one thing at a time in search of something that maybe we could find in a more coordinated and compassionate way through a clinic like you've heard described. I have a great example of this. I had a back injury a couple years ago with a lower spine injury. And I was seeing my primary care. And then independently I went to see a chiropractor who then referred me to a pain management specialist. And so I was seeing all three of these clinicians at the same time. But fortunately, they had some working relationship with each other already and they were able to kind of have some communication but I can see the value of having all that under one roof. And it was the combination of several different things that ultimately came to a resolution but I can definitely see how that is preferable. So there's two more. One is evidence-based treatment which I think is based on facts and assumptions and results, right? Is that what evidence-based treatment means? Do you want to? No, you guys can start. I don't want to jump in at once. This is a bad one, right? No, it's a good one. It's a great one. But you're referring to evidence-based treatment in a chronic pain person. So bringing other modalities to the table. So what is evidence-based treatment? To be very frank, we have some very strong levels of evidence for some modalities and some gaps in evidence for the others. And I'm saying gaps because it doesn't mean they've been proven to not be helpful. They just don't have the research background, the body of research behind them to show that they could be helpful. And then we have things that I think we could call we're learning from experience. Some already existing clinics at UVM actually that try to deal with more of the mind and body interface and have proven successful in many ways and are gaining their evidence space. And we'd hate to not pay attention to that because they may not have the ultimate randomized controlled trial like a drug for treating cholesterol. Right, cool. Yeah, and I think this is an area where there truly is no template for how to go about this. This will be an area where we learn a lot. We're really curious to see how these disciplines come together and what configurations give us the best outcomes for patients. Is it because the number of patients aren't there to weigh into monitor or like some of the modalities might like acupuncture, I'm not signing up. So I would not be in that study. Is there not enough people who have had acupuncture that could give you the answer? Plenty of had acupuncture but the studies or the funding is not there. It's not there. So our study industry is heavily financed by pharma. Pharma, yes. And so some of these interventions don't have an infrastructure to support their study. And yes, evidence-based classically is randomized controlled trials over large populations. But there is an emerging understanding that we need to actually expand the pool of pragmatic research, look at effectiveness research and focus on outcomes. And so in our relationship with the centers of excellence, our focus is really gonna be on the outcomes and the improvements for those patients regardless of what services are provided. So our intent is to kind of, if you will, pay for it through a bundle and not through a per event payment. Oh, I see, right. Which allows flexibility for Dr. Porter and others to apply the treatments that work for those patients in front of them. It's very exciting, isn't it? And to put this in perspective, if you look at the use of opioids on a chronic basis to treat pain, you will find that the CDC in its guide came out and said there is not an evidence-based to support this being a first-line modality of treatment. Opioids? Opioids. Oh, you would think it was the end-all bill. No, for chronic pain. Oh, really? Not to treat you after your back surgery, but to treat you with a back pain for the next couple of days. Then they gave you the Narcam to go with it. Right, so we're dealing with something that was already widespread, but it was all that people had to turn to quite often. So it was turned to, but it doesn't enjoy the evidence-based we would have wanted it to enjoy. And now we have emerging modalities that are not prescription-written, but that are other modalities of pain management that are needing to have further research to really validate. And they hold a lot of promise of causing much less harm. Yeah, I would think much less costly, some of these modalities. And if you look at insurance, obviously many insurances pay for prescriptions, depending on one's plan, but when it comes to some of these integrative modalities we've been discussing, some are paid for, some aren't paid for, some are paid for by one payer versus another. In the state government, at the Agency of Human Services, we're working with the Centers for Medicare and Medicaid Innovation, CMMI, because they're interested in more comprehensive approaches to the opioid crisis, but also comprehensive approaches to pain management. And they're the first to admit that the current Medicare and Medicaid systems don't pay for things in a way that would encourage their use. And so they're trying to look at ways to enhance the payment for those things, since there's so many large numbers of people dependent on those two insurance pathways, and we're trying to work with them in the same way. Interesting, that's good. Cool stuff. Oh, it's exciting. In some ways you're creating your own evidence-based treatment. And you're, you know, you're- Well, we're certainly looking at outcomes and seeing what helps people move forward. Right, yeah. That's very cool. So we've talked a lot about treatment, different ways to treat, people who are struggling with substance abuse. What are some of the main drivers that would push a patient into relapse while they're in treatment or after treatment? Well, we have unified ourselves here today in regarding substance use disorders as chronic disease, just like diabetes, heart failure, you name it. Right. So our definition of chronic disease is one that the patient will always continue to have, even though we try interventions to try to improve their function and improve suffering, but at the same time, a chronic disease is subject to relapse and remissions. So a diabetic person may be adhering completely to the regimen that you have them on, but they may have done some different things in terms of their level of activity or their diet or the content of their diet that throw their blood sugars off. That would be a relapse in their diabetes, in a sense, and to get to remission, they would have to return to the lifestyle pattern that they had previously and you'd want to explore with them, well, what factors made you kind of go off the wagon here? Why are you eating so much more or exercising so much less and you'd get it to aspects of their life that help determine that and you try to help them repair those? So they may always be in a state of like going for psychological help forever. Right, so someone who had the susceptibility and turned to opioids for one reason or another, but has remained stable for a period of time, will always have that potential. And especially earlier in their course, because we've learned from brain chemistry studies that it takes many months, perhaps as many as nine to 12 months, even when you're on medication-assisted treatment for your brain to kind of get back to the way it was before you developed this problem in the first place. So it physically changes your brain? It really does. So we only have two and a half minutes left. I would just like to wrap it up by what's next? What is your vision of what's the next step here? When you're on the opioid coordination council, they're probably looking ahead. The hub and spoke to me, we're really getting a lot of attention for that model and will that be expanded? What's next? We want it all fixed, quick, right? We're talking next year, right? Yeah, and so, and that's why the opioid coordination council has 23 recommendations, which we're fleshing out and refining better, but 23. But one big one is what we've been talking about today. It's not getting, allowing people to get into this predicament- Well, prevention is what we've always thought about. And powder prevention is having this kind of structure in place so that we can manage pain in a much better way than we may have in the past. So that's one aspect. The hub and spoke is obviously for everybody who has the need for medication assistance, the treatment. The hub, what's in the hub? What does that hub look like? It's sort of like your pain clinic, everything's there? Yes, it is actually a one-stop shopping, if you will. And then they send you to a spoke because specialized? Okay, so the hub is really the complex pain management center if you will, or addiction management center, where you can be inducted into the use of these medications that are so helpful and helping you, but they also provide a lot of this comprehensive support around you, whether it be counseling or case management needs, et cetera. Only, because of federal prescribing regulations, hubs are the only place you can have a methadone prescribed. And so methadone often requires a daily visit, and then the hub is set up to... We have a methadone clinic and a Brufenorfin clinic here in Berlin in my town. That was on the committee that created it. So anyone a methadone will be at the hub for sure. Many people, though, can actually have their opioid use disorder treated as if it were another chronic medical condition in a primary care setting. We call that the spoke. So it's actually transforming the treatment of substance use problems into a chronic disease model, primary care manageable model. Most of those patients will be on buprenorphine, and buprenorphine can be prescribed monthly, and patients will not have to visit that spoke daily. Does they even give it to take home now? Yes. Some forms, if they know you're going to respond. And that is what happens. And there's also access to all the other services that are kind of built into a bundle, as we term it, of care. So that works very well. And it really takes that disease and destigmatizes it. Because when you're sitting in your primary care doctor's office, we don't know if you're there for cold or diabetes or to get buprenorphine. We've actually run out of time. When we had our buprenorphine system here, I was surprised who came to me and said, my son, my daughter. It is people that are well-known in the community, professionals. I was very amazed. They said, we want this. And they're highly functional, folks in recovery are living full lives. Living with a chronic condition. You have your hands full, gentlemen. I really thank you all very much. I've learned a lot, which is always good. As I told you, this is a video. This is series number six in a series of eight videos that we're doing to help Vermonus understand about the opioid crisis. I hope that you will go to the Opiate Coordination Council's website. They'll be done in the next month and June. And you'll have all of the information you ever wanted to know about opioids. Thank you all very much. See you next week. Thank you.