 a large health care proglomerate on Opana ER. Opana ER, as you may remember, is the supposedly abused deterrent opioid allergy disease at the heart of the HIV epidemic in Indiana, in which the FDA has recommended being removed from the market. In the process of identifying individuals in this health care system, on Opana ER, she came across this particular case and she called me for advice. This was the case of a 28-year-old man with severe chronic pain, but no identifiable organic pathology to explain this pain. And he's an embedded medication with a single prescriber in this large integrated health care system. 40 milligrams of Opana twice a day, 30 milligrams of xylotin once a day, 16 milligrams of oxycodone once a day, 20 milligrams of valumine once a day, 65 milligrams of phenobarbital once a day, 30 milligrams of temazepam once a day, and eight milligrams of xanax once a day. This is equal to more than 470 more phenomilograms of one's daily. Not only is this individual at risk for imminent accidental overdose due to the deadly combination of benturidazepine, other sedatives, and opioids, but he's obviously at risk for a very serious hiatrogenic addiction. All of those of you in medicine have seen cases like this look through. But what I personally find studying is that we are still seeing cases like this in 2017. In 2011, the CDC declared that we were in the midst of a prescription opioid epidemic. Since then, major interventions at the local, state, and federal level have been made, and we are still seeing this kind of egregious overprescribing in otherwise healthy young people with no organic pathology. This is real, I did not make this up. I asked my colleague, do you know this doctor who's prescribing these medications? What kind of person is this doctor? Said, you know, she's a family medicine doctor, she's a wonderful person, she's very caring, she's very conscientious. She inherited this patient from a physician who retired, and it was simply just easier for her to continue on with this regimen. This is really what I want to talk about today. Why is it that a conscientious, smart, well-intentioned physician would continue to prescribe medications in this way? If we take a deeper look, and that's what I hope to do in the next little bit of time that we have together, what I really want to do is examine on a psychodynamic level the interaction between a compassionate doctor and a drug seeking patient, and then bring our lens way out and look at on a meta-level, what are the cultural and systemic forces that are also driving prescribing? Because I do feel that in order to solve this problem, we must first deeply understand it. Because I do think that the prescription drug epidemic is really the canary in the coal mine for what's wrong with our healthcare system, that opioids have in fact become the solution not to patients' problems, but to doctors' problems. So let's begin by looking at what motivates the compassionate doctor. The compassionate doctor is by nature a pleaser. These are individuals who figure out early what level to press to make it through the complex maze of schooling to get to the very top to get into medical school. They're people who know how to make systems work. They're also natural caretakers and dare I say even natural co-dependence. But they're also people who are responding to a higher calling. They're people who could choose to do business for any manner of profession, but they choose medicine because they want to save lives and alleviate suffering. As they go through their medical training, they're socialized to empathize with patients, to walk in their shoes. They are not socialized to second-guess their patients or to react when their patients might be manipulating them. And finally, doctors are motivated by mutually affectionate relationships. I know what gets me up in the morning, even with all the bureaucracy, the prior authorizations, the pharmacies, the regulations, is that mutually affectionate encounter that I've had with my patients when I can truly realize my identity as a healer and the patient can express gratitude because they feel that I have helped them. I think that moment is beautifully captured by the philosopher and theologian, Martin Buber, when he talks about the I and the I moment. Man wishes to be confirmed with his being by now. He wishes to have a presence in the being of the other. Secretly and bashfully, he watches for a yes, which allows him to be in which he can come to him only from one human person to another. I really believe that when the doctor-patient relationship is functioning the way it should, that is what we experience with our patients. It's as gratifying for patients as it is for us, their physicians, so wonderful moment. Let's switch gears around and talk a little bit about the patients. I believe the majority of patients who have become addicted to prescription opioids became addicted to the process of genuinely seeking help for a medical condition. But over time, their brain gets hijacked by this molecule and they begin engaging in behavior that they otherwise would not engage in. I talked today at noon at the ecumenical center a little bit about this, but the way to understand this is to recognize that pleasure and pain work like a balance in your brain reward system. When you have a pleasurable stimulus like taking a viking, it tips your balance to the pleasure side, when you have a painful stimulus, it tips your balance to the pain side. But one of the rules governing this balance is that it wants to remain leveled. So any pleasurable experience, the brain will compensate through a process called neuroadaptation, and it will do that to bring the balance level. So what happens when individuals are taking opioids for days, two weeks, two months, two years, is that there's an enormous process of adaptation that goes on on the other side of the balance that tips that balance to the pain side of things, such that that individual needs to continue to take that opioid, not to get high, but just to feel normal and bring their balance level again. In other words, their reward threshold has been changed. The brain has changed through this process of neuroadaptation. The opioid no longer works as effectively as it did for pain, and at some point they're just treating the withdrawal from their last dose, just trying to feel normal. I think it's very helpful to understand this in your science in order to appreciate what drive kind of manipulative behavior our patients engage in when they try to get a specific type of drug from us. I'm gonna talk now about some of the behaviors that patients use to get a certain type of prescription from their doctor. I use these descriptors not to denigrate patients because I had a great deal of compassion for patients who become addicted, but to create a sort of a memorable montage of the kinds of behaviors that are happening now and have happened over the last three decades. Again, it's through this process of neuroadaptation and pleasure pain and balance that can change an individual's moral compass because of the intense physiologic drive to get more medication just to feel normal. First of all, there's the filibustering technique. These are patients who wait the last 10 seconds of the appointment to ask for a refill because they know that refilling will take about 10 seconds and then saying no, will take another 30 minutes and for a busy clinician that's 30 minutes they don't have. Flattering is a common technique, telling the doctor how wonderful they are, how much better than their other doctor. When I was early in my career, I used to love to hear that and now I dread it. Because I know a few, but I'm going to be on the chopping block next. Demonstrating these are patients who often will undress in my office. I've even had patients driving on the ground. They want to show me all the ways in which their bodies are crying out for pain. In fact, I want patients say to me, I'm on fire and you have to hose. Teaming up is a common strategy. These are patients who often come in with a significant other, often their mother. The mother is crying, the patient is writhing. It's really hard to say no to a next one. There's the city mouse and the country mouse. The city mouse is the patient who walks into the ED and says, I'm in pain, I'm allergic to every analgesic except for IV dilated push with a Benadryl chaser. And then there are the opioid naive individuals or at least they appear that way. I've never, I don't know, I've never taken any pain medicine, I've heard of something oopsy oxy. Since I am a natural codependent, I volunteer oxy content. That's it, doctor, thank you so much. Losing meds is a common strategy. Either the prescription or the medication is themselves. Water seems to be a common thing here. They fell into the toilet, they went through the rim cycle, they dropped from the bottom of my fishing boat. Calling weekends and evenings very common at large integrated health care centers where we have shift work and a teaching hospital. These are patients who will call in the evening for a weekend so they know their rate of a doctor is not around. Seeing a mirror image, this is my personal Achilles heel. These are patients for other health care providers, other nurses, other doctors. They'll drop the names of similar people that we know of or schools that we went to in common. Very hard for me to imagine. I might be manipulated by someone that I have so strongly identified with. Doctor shopping is a term I'm sure you all know. These are people going around to multiple prescribers to get the pain for a similar prescription. And then of course pulling probably one of the most effective techniques. At my hospital this takes the particular form of saying I'm going to call patient relations if you don't give me what I want. Patient relations is a group of non-medical people who take complaints from patients and then you call us the physicians to task when we have received complaints from patients. So now we have some sense of what drives the compassion of the doctor and what drives the drug seeking patient. But they are not working in vacuum. Let's take a moment and widen our lens and look at the broader context in which the compassionate doctor and the drug seeking patient meet. I would say to you that there are four invisible forces driving over prescribing, of which we are only on some level aware most of the time. The first is what I call the toiletization of medicine. Medicine has undergone a vast transformation in the last three decades. There has been a huge migration of doctors working in physician-owned practices who have migrated now into large integrated health care centers. The majority of physicians today are salary employees. This has had an enormous impact on the way that we practice medicine. We are driven by what I call the P-paradigm, the pressure to palliate pain, the pressure to prescribe pills and perform procedures because that's what insurance companies will pay for. The pressure to protect privacy. So even if personal, across the hall is prescribing the medication that I'm trying to get the station off without permission, I can't communicate that. And finally the incredible pressure to please patients. Patients have become customers. We have become waiters. The throughput of body parts is important for full patient health. There are many physicians in this country who are staying upwards of 40 patients per day at five minutes per patient. A couple of years ago, my then 11-year-old son decided that he would Google my name on the internet. And one of the first things he found was this patient rating site, this doctor rating site. And here was a rating of me, written by Corey, and I'll just read you what Corey had to say about me. It's right down here. First of all, he gave me one out of four stars and he said, really wish I had seen this site's reviews before making an appointment with this physician. She provides the kind of care that will make you wish you had never sought help in the first place. Wrong diagnosis, wrong medication. In some cases, this can be terrible. Seek help from someone else. My son said, mom, is that you? I did have a moment where I thought about lying. I was going to say, no, that's the other doctor left you to work at Stanford. But then I realized that would make me a bad parent as well as a bad doctor. So I admitted sheepishly that that indeed was me and I kind of slumped out of the room. This is a non-trivial factor in the way that doctor is prescribed it today. These patient satisfaction surveys are not only potentially publicly shaming, but they're also done by the large and great healthcare centers and doctors are not meeting the kind of rating standards that their institution thinks they should have. Again, they get called to task. It can even impact their salary and promotion. But are there evidence, is there evidence showing that patient satisfaction scores improve health outcomes? I share with you this study in the Archives of Internal Medicine in 2012 that basically shows that high patient satisfaction scores are associated with greater inpatient use, higher overall health care and prescription drug expenditures and higher quality, even when controlled for comorbidities. So there is not a whole lot of evidence there that patient satisfaction surveys that when they're high, they correlate with health outcomes. I personally believe there is a place for these to ask about things like wait time or parking, but I'm not convinced that patient satisfaction surveys will lead to better health outcomes and there's even a very distinct possibility that they make health outcomes worse. Now the good news here is that my son did come out 10 minutes late and say, don't worry, mom, I could give you four out of four stars. Twice. In other words, opioids have become a proxy for the morbid and dying doctor-patient relationship in our modern health care delivery system. I think perhaps it's no accident that oxycontin sounds very much like oxytocin, the attachment hormone. I do believe that now we are giving opioids as a way to create an attachment in a system in which we are no longer giving the opportunity to build a true attachment with our patients and it works very well short term. Patients go home and describe feeling as if they're rat filing or blanket. The problem is it's a disaster long term. The second invisible force driving this opioid epidemic, in particular opioid overprescribing, is the way in which the pharmaceutical industry, particularly makers of opioid analgesics like Purdue, have co-opted big medicine. I show a trojan horse here because I want to emphasize that the pharmaceutical industry was absolutely ingenious in the way that they did this. Yes, there's direct consumer TV advertising. Yes, there's the pen and the hat for the dinners that go to doctors, but that's not how they really conquered opioid prescribing. They conquered opioid prescribing by convincing doctors that it was supported by the evidence when in fact there was no such evidence to support it. They infiltrated the watchdog organizations inside medicine from the Joint Commission to the Federation of State Medical Boards to pain societies to the FDA. And what they succeeded in doing was perpetrating full myths about opioid prescribing, myth number one that opioids work for chronic pain. Opioids are fantastic treatment for acute pain. Opioids are invaluable at the very end in life to ease the transition to death. There is no evidence that when taking daily, opioids are effective treatment for chronic pain, and a burgeoning database showing that there are many ill effects of chronic opioids, and not just addiction. There's opioid-induced hydrogeasia whereby because of this change there's no reward in pain threshold. People's pain, it's worse. There's debilitating constipation, cognitive problem, depression, hormonal problems, and the risk goes on. The other central myth perpetrated by the pharmaceutical industry is that no dose is too hot. So if your patient initially responds to opioids and then comes in and says it's not working anymore, just keep going up and up on a dose. And that is how we got to the point today when we have hundreds of thousands become very high dose pills. Now the only way they're able to survive those doses is because they built up tolerance over time. But it's absolutely disastrous on many levels for them because now their brain is completely changed due to that chronic headache from their exposure. The third myth was that less than 1% can get addicted as long as the prescription is being written for a bona fide medical condition. So this was the idea that somehow the prescription had improved this halo effect. And as long as the doctor was writing it, a patient couldn't get addicted. We now know that's not true. Data coming out at about 25% of individuals on daily chronic opioid therapy over 90 more than a milligram per ounce a day will misuse those opioids, misuses the first step toward addiction. And then finally this fourth myth, pseudo addiction. If you have a patient who displays all of the apes of someone who's gotten addicted, they're not really addicted. They're pseudo addicted. They're in pain. Just give them more opulence. The third invisible force driving over prescribed is what I call a medicalization of poverty. Over the last three decades, not only has there been this mass migration into integrated healthcare, a toiletization of medicine, but doctors are increasingly being asked to care for their psychosocial, socioeconomic, and psychospherical problems of their patients without being given the necessary tools and resources to do so. In that situation, doctors feel overwhelmed by their patients' problems, multi-generational trauma, unemployment, homelessness. And in the face of that feeling of being overwhelmed, they say to themselves, at least I can do this, this over here. The medicalization of poverty is not just incentivized from the doctor on this thing, it's also incentivized from the patient in this thing. And we do have data that the poor are treated differently. People receiving medication are prescribed painkillers at twice the rate of non-medicated patients and died from prescription overdoses at six times the rate. And when I say that the patients are also incentivized to adopt the sick role, what I mean is by increasing numbers of patients for whom their identity as a person has become their identity as a patient. These are what I call professional patients. Patients who literally cannot get well because their paycheck depends on their disability. The amount of money that they can earn by being a sick and disabled person is much more than they can earn a low-paying, low-wage job and disability has essentially become our social safety net. Furthermore, addiction is not itself recognized as a disability or even a disease. In other words, opioids have become a poor substitute for a social safety net. People who are unemployed, low income socially alienated are encouraged to become patients as a way to pay the bills. And then finally another invisible force over-prescribing our cultural narratives around pain. Today in medicine we actually believe that pain in any form is dangerous. We believe that people who experience pain that it can actually leave a kind of psychic scar that sets them up with nature of pain. This can be in the form of post-traumatic stress disorder. It can be in the form of a centralized pain syndrome. But I think it's worth noting that we didn't always have this view of pain in medicine. In fact, 150 years ago doctors believed that pain was salutary. They believed that what doesn't kill you makes you stronger. There are these spiritual benefits. They believed that it used to be the in-response. It used to be cardiovascular system. Whatever you may think about this current cultural narrative I think it's important to recognize that it's a very hard concept. And it has meant that doctors have to do to eliminate all pain that they set their patient up for future pain. Other narratives that we've been explaining are that people are fragile. The body cannot heal itself. Doctors, especially aided by technology, have superhuman ability to heal. And that evicts them what is their right to be complicit. In other words, opioids have become a way to find meaning and identity. How Marx and religion heal pain of the masses here at the point in our history and in fact, opium has become a way to heal. So now I've talked about what motivates the compassionate doctor. What motivates the drug-saving patient. Where does, and the system in which they work in, so where does that mean the compassionate doctor? Basically, we would hold the opioid as a cause for the compassionate doctor's identity as a healer. But over-prescribing opioids refers to making the compassionate doctor a drug dealer. And that generates anxiety. And what do we do as healthcare providers when we experience anxiety? We do what everybody else does and we enlist our primitive defense mechanisms. So just to recap on what primitive defense mechanisms are, this is a Freudian concept, the psychoanalyst concept, that basically says that these are the kinds of mechanisms that we employ when we are experiencing an intolerable motion. And we do it unconsciously and as a result that emotions subside. Primitive defense mechanisms are different from coping strategies. Coping strategies are things that we do consciously to manage uncomfortable emotions in the world. So I feel anxiety. I am with the primitive defense mechanism. My anxiety dissipates and all as well. I have no idea that I just do that. That's the whole idea of the unconscious element. So what are the primitive defense mechanisms that a compassionate doctor enlist when encountering a drug seeking a patient? Denial. By far the most primitive this is not actually happening. This patient is not actually struggling with a problem with the drugs that I have prescribed. I have been guilty of doing this many, many times. Projection. Projection is where I take an uncomfortable emotion and I project it onto another human being and that way I don't have to tolerate it or identify it. So I am feeling rage toward this drug seeking patient. Instead I project my rage onto them and I say this patient is a borderline. Instead of owning my rage myself and identifying it. Splitting this is where I divide my patients into my good patients many times. I wasn't even where I was doing it. I would look at my schedule in the morning and say oh this is Joan. She comes, she only takes 5 minutes. She brings me a box of chocolate. She's so nice. Such a good patient. Oh Mr. Smech, gosh what a pain in the rear. There's nothing really medically wrong with that guy anyway. I wish he weren't in my practice. Really. This is how we sort our patients. And then of course passive aggression. So the most common manifestation of passive aggression is actually procrastination. So these are the patients that I just somehow forget to call back. Right? Or we're rounding the hospital and somehow I only spent about 30 seconds with that patient. Whereas I might leave her for a good 20 minutes with another patient. Or this is the patient who I know is struggling that she'll probably come back next week but instead I say I'll come back in 3 months she'll be fine. Alright. So what happens when the compassionate doctor and the drug-saving patient get a room? So this is a dramatization and let's see what happens. This is great. We have to battery the diabetes don't play with pensions. I put in a funnel for nutrition. And we're great. So I will see you next time. Okay. Thank you so much. I just love working with you. You're so much better than I was. Time to explain everything. I feel that one of those surveys on the front desk of your relationship and your relationship I just glowed about you. You? Just one more thing before I go. Could you re-film my answer for them? I don't know. I don't know. I think it's probably because of all the extra cooking and cleaning I had to do for the kids to come down. Yeah. I'm not sure that's a good idea. I think I just gave you an overview of that last month and then I tried to check the computer. No. I don't think so. I'm really sorry and you're super busy. It's just that my pain has been so bad. Yeah. I hear you about the pain. It's just that you're really high doses and I'm up a lot on the doses and I'm just starting to think maybe I need to refer to pain specialist and then maybe it's kind of more than I can treat it. Nobody understands my pain. My husband doesn't understand. My kids don't understand. I know you were the one person who understood it. I know you were the one person who understood it. I'll give you an understanding of how unbearable this pain is. Well, the doctor of pain. Oh, I think I'm not trying to work. I'm going to refill this time. But this is it. This is the last time. Please just take it and subscribe. I will, doctor. I will. I promise I will. I understand. It's just that it's like family in town It's just that it's a little It's just that you're broke out like that. I know you're broke out like that. You've always been great. I'm still I'm still Yeah, no. Okay, so really nice to see you and Okay, so not the best example of doctoring. How many people have done something like this? Got some great hands. How many people did it last week? I'm serious. I teach this stuff and yet I still do this because the people in the room is enormous and that's really what I want to show with this video for all the algorithms and all the CNA courses and all the guidelines when you're in the room with the patient, all bets can be on. But obviously this is a kerfuffle that perpetuates the problem. What happens and you saw all kinds of primitive defense mechanisms, denial, splitting, you saw her manipulate, flattering with filibustering. But what happens when those primitive defense mechanisms are part of the doctrine along the work? For example, if the doctor were to check the prescription drug monitoring database, which is a database available in every state in the United States for Missouri which can show us all the prescriptions the patient has received for controlled substance in the past 12 months in that state. What if the doctor then discovers that, oh my goodness, this patient has been going around to multiple doctors, then effectively that doctor is en masse as a defecto drug dealer and that results in a narcissistic injury. And a narcissistic injury is incredibly powerful but I want to emphasize that you do not have to be a pathological narcissist to experience a narcissistic injury. We are all potentially vulnerable because there is this thing called healthy narcissism. What does that mean? That we could all have some degree of healthy narcissism around the things in which we invest our energy and creativity. Whether it's trying to be a good parent or a good third-watcher or a good doctor. Would we invest ourselves in activity and have a degree of competence or a sense of competence in activity and then we have that sense of competence injured or threatened by a very minor thing that can consciously experience an incredible narcissistic injury and by the way, it can be something as simple as saying hello to somebody who doesn't say hello to that. And how do most of us react to a narcissistic injury? Narcissistic rage and retaliation is the most common reaction to a narcissistic injury. So let's see what happens in a Groundhog Day kind of take two. Just one more thing before I go. Could you read from my answer? I know I'm on a couple of days earlier but my family was in town this week. Oh my gosh, my fibromyalgia is really good. Okay, I'm not too comfortable with that but I'll tell you what, I just got access to a brand new database that allows me to look at all the prescriptions that you've received for the last 12 months in the city health organ. So let me just look your name up on that and you know, that will kind of help me be able to make a decision about whether or not it makes sense to do more treatments, okay? Is that something that you can do after I'm gone? I really kind of need to... I think it's worth it to take the time now. Oh, wow. I'm surprised. I'm going to see a couple of other doctors to get more opioids and there's some benzodiazepines. Yeah, I can explain that. Okay, the Dr. Smith? I mean, who's the Dr. Smith there? Oh, Dr. Smith is my opiate. I've been going there for years. I had several people I had to see this week. Of course, you're the person I count on. Okay. And who is this Dr. Williams here and who does this job? I mean, it seems like a lot of pints going on in terms of describing the condition that involves pain. So this pain medicine is obviously something that I need to learn to manage the condition. I don't know why I feel like I have to defend myself about this. Okay, well, I'm sorry but I'm not going to be able to prescribe opioids anymore for you. I mean, you're obviously addicted and I'm not going to... I mean, it's not like a drug addiction or for an alcoholic or something. This is a medical condition. I'm getting pain medication for a medical condition. I'm not going to be able to help me out with this. This is the only medicine that's been helped with my pain. I'm sorry, but it is clear, you know, I had no idea that this was going to happen. I'm describing it so well. I can't speak any more. A person who's supposed to help take care of someone with a medical condition? I'm not going to have it. I have my medication. Thank you. Pendulum, swing in the other direction also not in this care, right? We have a whole cohort of what are being called opioid refugees, patients who grew a doctor's prescription and came up with a very easy dependent and I think it's opioids. Suddenly being turned out of these clinics nowhere to go, some of them turning to heroin as replaced with many of them dying. So, and what I always, every time I watch this, what I find very tragic is when the patient says, aren't you somebody who's supposed to help a person with a medical condition? Because she has a real medical condition and she also helped a prescription drug. So, by the way, my kids have seen this video more times than they can count. I'd like to walk around and how to say I had no idea. I didn't know that one. That moment of the nursing was the kind of injury really. All right. So the question becomes, how can we do better? How can we bridge the gap between enabling and retaliation? Obviously, we can engage in mindful prescribing. That means being aware of how complex that dynamic is between a doctor and a patient in the room and all of the unconscious forces that can drive that dynamic. I think that engaging in mindful prescribing can really help if you have a group that you can work with to discuss certain patients so that you can make sure that you have an retaliatory condemning and denigrating of patients which really isn't a place that we enjoy it a lot. You'll include that ourselves. It certainly doesn't lead to good care. As per the CGC guidelines we can initiate fewer prescriptions not just opiates but also other addictive medications and delays of pains, stimulants but really this is the easy part of initiating fewer prescriptions. The hard part is what we do with medication commute are prescribed and controlled medication to for any myriad of reasons including your belief that they may benefit from it that it's very, very necessary to closely monitor and use what I call contingency management approach also commonly referred to in behavior economics as tit for tat. Tit for tat is not something we learn in medical school. We sort of see ourselves as our own medication that patients are at risk to misuse what we're convicted to. We have to have contingency management strategies to say if they misuse those medications we don't take them out of our clinic but we do have a response immensely with the transgression for example instead of giving you a whole month's work I'm going to give you two weeks' work as they come back in two weeks and see how you're doing that. I'm going to demonstrate how there are behavior that aren't yet fully addicted if I use tit for tat in my model I can steer them back on to for good course and they can continue to benefit from that medication. But we can't effectively play tit for tat with our patients unless we're using objective monitoring data points which include checking your prescription drug monitoring data. The evidence is currently I believe you're feasible that when doctors check the prescription drug monitoring database they engage in more judicious prescribing not just by potentially withholding opioids to patients who may be misuse but also giving opioids to patients who might actually benefit from them and that these data are really convincing that in states where they have in fact mandating checking the prescription drug monitoring database prior to prescribing at a certain interval there's been a decrease in produced deaths a decrease in doctor shopping etc. In fact it is actually less than 30% of prescribers have access have gained access to the prescription drug monitoring database and a much smaller percentage check it on a regular basis. We also I believe need prescribing clinics. What do I mean by this? I mean that we have as a nation looked at what we can do to help people who have become addicted to opioids 21st Century Cures Act has rolled out a huge initiative to try to make medication-assisted treatments such as buprenorphine, gloxodon and methadone more available to people who become addicted but what about all of those people in between who do not meet criteria for addiction but are on dangerously high daily doses of opioids what do we do with those people? We need to be prescribing clinics that can help those people get down to a safer dose or off completely including non-opioid interventions for pain. I really think that all of our institutions need to create a sex clinic that they call the prescribing clinic where they can send these individuals for the kind of supportive care in my experience many chronic patients on chronic high dose opioids need months to years to get off of their opioids or even to lower the dose from a neurobiological point of view that makes complete sense when you think about this process of neuroadaptation the pleasure of being balanced why should that be able to reverse itself overnight nonetheless common paper strategies tell us 10% per week get the patient off in two months patients will not succeed if you do this if they have been on opioids for years to decades they will become demoralized frustrated we need to be prescribing clinics we provide tremendous amount of support for those individuals who don't need criteria for addiction who are not candidates from epidermal but nonetheless need to come down off their doses we encounter addiction in our patients instead of retaliating we need to think of addiction as a chronic relapsing and remitting disease and I urge you to do this if you believe it is one I know very educated enlightened thoughts of people who have studied this and do not believe addiction is a disease I don't care we have to treat it like a disease in this day and age because the biologizing problem is how we solve them the disease model enhances compassion and reduces stigma which is as important for healthcare providers so in the house of medicine this was a study a study by the following at all looking at outcomes adherence to treatment recurrence and relapse rates of in patients with addiction treating in the house of medicine compared to type 2 diabetes for example and what they found was when we treat addiction like a disease in the house of medicine it has very similar rates of recurrence remission and adherence as other chronic diseases with the behavioral component that's what diabetes type 2 essentially is it's a chronic illness with the behavioral slash diet component that over time leads to these changes in the body just like addiction how can we do better at the systems level we need to build an infrastructure to treat addiction co-located in the house of medicine right now we have fee-for-service silos where people with resources can go but we really don't have any place in the house of medicine at least not consistently across the board we need to create an infrastructure such that patients can walk into any emergency room any doctor's office any maternity warden in this country can say I have addiction will you help me and now we have some buyer resounding yes and your insurance company will pay for it in other words we have to enforce parity it is involved in the land that ensures companies are supposed to pay for addiction and mental health treatment on par with other medical conditions it doesn't happen there are all kinds of carve-outs and loopholes it needs to happen and we need a chronic care model which reasserts the privacy of the doctor-patient relationship as vital to healing our current assembly line approach to medical care works great for name of placements it works great for about a moment it doesn't work for chronic relapsing of any disorders like addiction or for that matter chronic pain we need to build a separate infrastructure that accommodates for these types of illnesses and appreciates the primacy of that relationship through time to have those hard conversations and we can train doctors from the first day of medical school to detect and intervene for substance use problems I'm glad to say that across the country we are seeing medical schools now implement addiction curriculum where they are never willing to deal with death before this is perhaps the only silver line at a tragic epidemic I'm going to leave you with this quote by Reinhold Niebuhr a philosopher, again theologian he said, ultimately, eagle is done not so much by evil people but by good people who do not know themselves and cannot probe deeply if you're interested in these videos for your own teaching purposes they're available at the CME course but also on YouTube I often get asked why didn't you do a video showing how you should have done it basically I ran out of time, energy and money but that would be a great thing to do and that one of you wanted to take that on that would be wonderful but also throughout my medical career I've made a lot more of my mistakes than my successes and I don't think we do enough sharing of our mistakes additional references can be found in my book thank you so much for listening I'd be happy to take your questions I would like to mention to the audience that we have microphones on either side and because we are recording this we ask that you do approach a microphone identify yourself to ask a question and keep your questions brief thank you I was wondering if we could put together a clinical safety study using best practice alerts and the medical record for the faculty practice what's been your experience with faculty and Stanford with medical alerts in the electronic medical records this particular issue ah this particular issue hmm I don't think that would be correct but also truthful um so Stevenford as an institution has been very slow to recognize um the need for or services for patients struggling with substance abuse problems they've come a long way in the past five years or so I mean again sadly are instigated by the opioid epidemic but as a tertiary care hospital they don't see addiction as their priority focus um that may be changing as they're moving more toward a Kaiser model population based model where people can buy a kind of Kaiser-like insurance through Stanford and they're capitating for the year in which case the bottom line for Stanford will be those patients staying well and using a few of these sources I'm not sure I'm really answering your question but um I guess your question was sort of um how is Stanford back with me responding overall to the opioid crisis so I guess it's my um roundabout way of saying um they are responding and there has been some movement but slower than at other institutions and slower than at others but certainly recognition Stanford solution to almost everything is great data and technology um rather than population politics hi thank you for the presentation it's great um I'm Dr. Mary Flores I'm a computerist and my question was you mentioned that some groups like watchdog groups in JCO were infiltrated by pharmaceutical companies can you talk about how we can not let that happen again yeah so I think you know the joint commission in particular um has culpability that they've never owned during the knowledge so the joint commission essentially made pain a bit vital sign and then went around to various hospitals and said um you know ask for patients without pain is going to be um such a thing you have to do they're over for you to do that well we're going to give you these learning tools and the learning tools that they gave them were in fact videotapes and other paraphernalia that they had gotten up for free from Purdue Pharma which gave them so many hospitals that they could meet the information I'm involved in organization called Physicians for Responsible I'm doing prescribing and we wrote a letter to the joint commission asking them to acknowledge the role that they played and um role but I do think it means to be a much clearer vision between uh pharmaceutical industry and medical device companies and those various watched organizations inside of Madison it's very hard to accomplish that though because our legislators are largely in the pocket of the lobbyists who represent pharmaceutical industries so it's really an uphill battle I'm a general intern person I want to thank you also that was exactly the question I was going to ask because sitting in the middle of all of these things I wondered why they would come out this is the reason we have those little we have those little plaques of smiley faces and what the tenant seems to be and the push you know we seem to be taking care of our patients from many years and decades all of a sudden but we're not able to control pain I just was wondering where this had happened and what she said about about in the pocket I recall something something about Mabong a member of Fedgera for many years there were actually articles in the in the New England Journal talking about the ramifications people who were helping having who were having heart attacks and strokes that was sold by a company and as I understand there there were some lobbyists involved and nobody actually actually tackled the company for many years and finally the efforts were so overwhelming I think in fact all now work as salary employees in these large integrated healthcare centers means that we can very easily engage in a kind of group thing which can be very destructive I think that's sort of what happened there's also potential for good if you come up with safe algorithms that are really at its base it's not just all bad there's potential to standardize care and have everybody practicing in a protocolized way that's actually helpful but when we all start going down the same dark road that's what it can really get through Thank you this is the second time I've heard you today I enjoyed the presentations my name is Jenny Forbes I'm a licensed professional counselor in the 25 years that I've worked in this business what scans out the most to me is that very often when you have patients who have chronic physical pain there is a lot of emotional pain and very often patients with fibromyalgia and things like that have experienced some sort of trauma in their life that is not yet resolved right now I'm working for an insurance company case manager and the number of opioid vendors that you know benzodiazepine, mussel, Houston cocktail mussel relaxers the amounts of prescriptions for that are just unbelievable please please please if you have a patient that you're treating for chronic pain make psychotherapy a part of that treatment there are modalities these days to help with chronic pain increase mindfulness learning meditation techniques and things like that so we talk about integrative medicine and the mind and the body are not separate things so instead of panning them genics refer them to therapist that's a much better much more effective long-term strategy for managing the illness that they have now there are patients who do be opioids for legitimate chronic pain illnesses things like that but I think also helping them to balance would be I absolutely agree not only about alternatives for chronic pain or the way to go, prior to 1980 that was the standard care of a multimodal approach in my body techniques, psychotherapy physical therapy the problem is that there are many places where there's no access to that treatment so I think that's important to acknowledge that from a citizen's level we probably all have patients who we would love to benefit psychotherapy insurance companies who have paid for it, they won't pay enough for it and we just can't find one. Thank you again doctor for the presentation, good evening everybody my name is Anthony Blomo I'm actually a counsellor and a program director for Bingden Cemetery Services very known as Mars around San Antonio we're one out of 10 different method on treatment centers so some of the things that you're speaking about definitely getting home with quite a few of my patients when our patients actually come into our treatment centers they're usually coming off of an aeromania or some type of a pain management resume that went into the draws to where they were discharged by their primary physician or prescriber for pain management went into things like morphine or hydrocodone, oxy some patients chewing fentanyl patches I mean a lot of different things when our patients come to us one of the things that our doctor and she has also found a practice doctor makes it a habit is that the PMP is run on every single patient that costs a patient at their base and that it is done periodically so that way we can reach out to those prescribing physicians by coordinating consents with our patients and let them know that in order to maintain treatment with us they have to be discharged from that pain management setting so they cannot receive addiction services at the same time that they're receiving pain management so it's like one or the other and that's one of the state ranks that we have to abide by I'm just wondering as far as your feeling on it are you thinking of making is that all physicians either making that a standard or if there's going to be some oversight to where that is periodically for patients to in order to reduce the likelihood of doctor shopping so the whole idea of demanding prescription drug monitoring checking there are some states have done that already as I mentioned Kentucky is one of them and seeing huge decreases in doctor shopping prescription overdose deaths the problem is that they really are very cumbersome in many states they're hard to use they take a lot of time except for day-to-day so although I asked for checking prescription drug monitoring as the standard of care what we all have to do of the day-to-day in most states we also need interoperability so we need all of the different states to be able to talk to each other hopefully that's what we're going to do thank you good evening enjoy your presentation thank you my name is Darlene Knight I'm a nurse I work mainly in case management this time part of what took me out of Deadside Nursing full-time with some of the frustrations in your book one of the things I want to ask you about is this notion that pain is what the patient says it is is there any other way that you think would be possible to gauge besides the 1 through 10 I always say 10 is maybe his head is coming out yes I bet it's frustrating would that be something possible something besides going past that notion that it's what you say there is no pain so pain is whatever the patient says it is however I don't think using a miracle scale is helpful because one person's stubbed toe is a one another person's stubbed toe is a 10 and conversely the other way around but part of what we have to get away from is continually asking the patients if they're in pain we've really read a whole generation of people who are constantly taking their internal pain temperature like their pain scale score has become like their birth date it's a number they ingest what's particularly frustrating a patient with one person in front of a physician who was there for a few minutes versus the person I see for 13 hours the rest of the day well that's the split I'm in the middle because I'm not, I can't prescribe I have to you know go through with the orders when a patient's telling you I'm 10 while you're there and it's nurses are in the middle residents and medical students are in the middle what I tell patients with chronic pain is that dialing into your pain for an acute pain is very important to do but once you have chronic pain that constant dialing in is actually not helpful you might want to check in every once in a while if you have an increased pain but what we need you to do is to divert your brain's blood flow to different areas of the brain to distract yourself from your chronic pain on some level conversations that we have to have making this distinction between acute pain so it's one thing to see a six year old kid coming into your sick cell clinic and doing drug seeking behavior as soon as he sees the white coat and it's every week somebody comes into your cancer clinic and they tell you some story about their from the state a thousand miles away and they left their thousand milligrams of morphine in a rail car and that kind of stuff we have to sort through that and we have to create systemic responses to that and I really appreciate the comments that you made about the systemic changes that we need to make particularly the comments about everybody going to a salaried situation but they're in a salaried situation in the private group and I think we really need to make a public if we're going to put people in a salaried situation we need to make a public system that deals with this problem in fact more than medical problems but the question I want to ask you about is in this state still most of the medical care is covered through a private third party financial intermediary and we have vast areas in this state where the addiction problems are three times what they are in urban areas in rural areas and you can't get any insurance company to go out there and offer insurance even under a federally mandated exchange it doesn't happen so how are we going to address this problem where people that live out farmers get their fingers cut off doing things on the tractor and stuff like that where that problem is how are we going to address that there's a lot of trade even in prescription medications that have come across the border that never had anything to do with any prescribing position so thank you there's a lot there when you said I just want to start by validating I think the toughest patients who seem to be drug seeking and have a real serious medical vulnerability that is painful and how to tease that apart is really tough in terms of rural communities basically you have two large problems that you mentioned one is that they don't have access to providers the second is that even if they did insurance companies they won't pay for it there has been a trend for suing large insurance carriers and think this are winning these suits because people are dying because they're not getting the care that we need at the same time though what does addiction treatment look like what is the standard of care so all of that is an important thing that we need to work on this is talking with the resident of mine, Holly he's doing telepsychiatry telehealth is an important potential for prevention for these rural communities but I just think obviously improving access to addiction treatment and getting paid for is really fundamental yes was there a question on the other side of the room sorry thank you Dr. Lemke, I'm married at this the CEO of the ecumenical center we appreciate you being in San Antonio two weeks ago Patrick Kennedy visited our city and we learned that he, along with Governor Christie from New Jersey have been appointed from the administration to serve on the opioid crisis council my question for you is have they consulted you now you know it's been interesting I've testified before Congress three times, maybe four on this issue Patrick Kennedy was in attendance my book has been read by a number of governors across the state who reached out to me so it's been my real privilege to be able to you know lend my perspective at the national level the opioid commission as you know just came out of the report detailing all the ways in which they feel the economy to respond to the opioid epidemic and I thought it was basically a good generic document saying what has been said before but none of us needs to be said again you know Trump was advised to put the opioid epidemic a national emergency he did in fact make that declaration but could not then take any of the necessary steps to implement the declaration would then give us access to for example staffer funding to do the antibiotic hopefully he will do that shortly you know the Affordable Care Act is problematic in many ways but one of the things the Affordable Care Act did do was in its Medicaid expansion and in making addiction treatment and non-health treatment and the central health benefit it did extend access to millions of people and I forget who didn't have before so unless our current administration comes up with something better than that I'm not in favor of doing away with what we have now it's been much better than the last five years and it was prior to that Dr. Lunky thank you for visiting our one-house city and for doing such an insightful talk I really appreciate it my name is Jessica Breen and I'm another Indian Medical Education Company and I'm also a PhD student studying Medical Anthropology and my question to you is the biomedical model is the western model is the dominant framework and I agree with the previous respond earlier who said that she doesn't believe in Cartesian dualism my quality is one my question to you is in what role do you think integrated medicine can play to contribute towards somehow ameliorating this crisis that we're in the middle of it and how do you define integrated medicine yourself thank you well the phenomenon that I have noticed in the last 10 to 15 years is that more and more people sub means with education are leaving traditional western medicine and seeking out what alternative therapies and I believe that that trend will continue as long as western medicine is not providing a kind of feeling that we can seek and of course I believe that we are at a place of time unless we very closely examine that and face it I think we're going to use a lot of speakers to the way that we currently and there, thank you so much to all of you as you exit you may notice that there are some books for sale and Dr. Lemke will be available here for a short period of time anyway to sign copies of the books that you wish to purchase one