>> GOOD MORNING, EVERYONE. I'M JOHN KUZIAK, THE ACTING DEPUTY DIRECTOR AT NIH'S NIDCR AND I WOULD LIKE TO WELCOME YOU TO FELLOWSHIP GRAND ROUNDS, THOSE HERE AND THOSE WATCHING ON VIDEO. WE ARE DELIGHTED TODAY TO HAVE DEBRA HOURY TO TALK TO US ABOUT AMERICA'S OPIOID PROBLEM AND HW DENTISTS AS WELL AS MEDICAL PRACTITIONERS CAN HELP ALLEVIATE THIS PROBLEM. BEFORE I INTRODUCE HER I WOULD LIKE TO SAY WHY OPIOIDS AND MORE BROADLY RESEARCH ON PAIN AND PAIN MANAGEMENT ARE OF INTEREST AT N.I.D.C.R. OPIOIDS ARE AN IMPORTANT TOPICS BECAUSE DENTISTS ARE ONE OF THE MAJOR PRESCRIBERS OF IMMEDIATE-RELEASE OPIOIDS AND SECONDLY ORAL-FACIAL PAIN IS ONE OF THE MORE COMMON PAIN CONDITIONS AFFLICTING PEOPLE IN THE UNITED STATES. I JUST WANT TO MENTION A FEW OPIOID-RELATED ACTIVITIES THAT N.I.D.C.R. IS A PART OF. FIRST, OUR INSTITUTE'S NATIONAL DENTIST PRACTICED-BASED RESEARCH NETWORK HAS RECENTLY CONDUCTED A NATIONAL SURVEY OF DENTISTS TO HELP BETTER UNDERSTAND THEIR KNOWLEDGE, THEIR TRAINING AND THEIR OPIOID-PRESCRIBING PRACTICES. THE SURVEY RESULTS THAT WE WILL USE WE HOPE WILL INFORM THE DEVELOPMENT OF EDUCATIONAL FOR PATIENTS AS THEY DEVELOP THEIR PRESCRIBING PRACTICES, AS WELL AS MIS-USE SCREENING. ALSO OUR EXTRA MURAL RESEARCH SCREENING IS STUDYING MECHANISMS OF ORAL-FACIAL PAIN WITH THE IDEA OF DEVELOPING NEW TARGETS THAT ARE NON-ADDICTIVE FOR TREATING CHRONIC PAIN CONDITIONS. IN TERMS OF OUR INVOLVEMENT IN THE LARGER PAIN RESEARCH COMMUNITY, WE WERE ONE OF THE FOUNDING MEMBERS OF THE N.I.H. PAIN CONSORTIUM TOGETHER WITH THE NEUROLOGY INSTITUTE N.I.N.D.S. DR. MARTHA SUMMERMAN IS ON THE EXECUTIVE COMMITTEE OF THE N.I.H. PAIN CONSORTIUM . THOSE IN THE AUDIENCE MAY BE INTERESTED IN THE CENTERS OF EXCELLENCE PAIN PROGRAM. DEVELOPING RESOURCES FOR DENTAL, MEDICAL, NURSING, PHARMACY AND OTHER HEALTH PROFESSIONAL SCHOOLS THAT IS ONLINE AND SHARABLE AMONG THE HEALTH COMMUNITY. DR. SUMMERMAN IS ALSO A MEMBER OF THE INTER-AGENCY PAIN RESEARCH COORDINATING COMMITTEE AT THE I.P.R.C.C. IT IS A FEDERAL ADVISORY COMMITTEE TO ENHANCE PAIN RESEARCH AND PROMOTE COLLABORATION ACROSS THE GOVERNMENT AND ONE OF THE IMPORTANT EFFORTS OF THE I.P.R.C.C. IS THE NATIONAL PAIN STRATEGY, WHICH FOCUSES ON HOW TO IMPROVE PAIN MANAGEMENT AND REDUCE RELIANCE ON PRESCRIPTION MEDICINES. IN THIS REGARD BETTER PAIN CARE PROVIDED THROUGH IMPLEMENTATION OF THE N.P.S. IS PART OF AN ESSENTIAL ELEMENT OF A GOVERNMENT'S INITIATIVES, INCLUDING THE C.D.C. GUIDELINE TO REDUCE OPIOID USE, MISUSE AND OVERDOSE. ANOTHER EFFORT THAT IS ONGOING AND I BELIEVE WILL HAVE RESULTS FAIRLY SOON IS THE FEDERAL PAIN RESEARCH STRATEGY. WHICH INCLUDES A SET OF RESEARCH RECOMMENDATIONS AND A PLAN TO COORDINATE AN ADVANCE FEDERAL PAIN RESEARCH ACROSS THE GOVERNMENT. WITH A FOCUS ON SORT OF THE FULL SPECTRUM OF PAIN, FROM ACUTE PAIN, PREVENTION OF ACUTE PAIN AND PAIN MANAGEMENT TO THE TRANSITION FROM ACUTE TO CHRONIC PAIN AND ALSO CHRONIC PAIN MANAGEMENT. SO AT THIS POINT I WAS GOING TO TURN THE PODIUM OVER TO JANICE LEE WHO IS THE CLINICAL DIRECTOR AT N.I.D.C.R. UNFORTUNATELY AT 10:00 LAST NIGHT I RECEIVED AN EMAIL SAYING SHE HAD MISSED A FLIGHT CONNECTION AND WASN'T GOING TO MAKE IT, SHE HAS A FLIGHT DUE IN AT 10:00 THIS MORNING AND I DON'T THINK SHE WILL MAKE IT FOR THE INTRODUCTION AS SHE WAS GOING TO DO THE INTRODUCING OF DEBRA THIS MORNING. SO THAT REMAINS MY PURVIEW. BUT SHE WANTED ME TO MENTION ONE THING, A BRIEF MENTION OF THE GRAND ROUNDS, WHICH WAS ESTABLISHED IN 2014 AS AN EDUCATIONAL FORUM IN WHICH LEADING SCIENTISTS AND CLINICIANS ADDRESS ADVANCES IN CLINICAL TRANSLATIONAL BASIC RESEARCH IN AREAS RELATED TO DENTAL ORAL, CRANIAL COMPLEX AND BONE METABOLISM. TO EDUCATE AND INSPIRE OUR TRAINEES, STAFF AND OUR INVESTIGATORS. SO INSTEAD OF GOING TO JANICE I WILL JUST CONTINUE AND INTRODUCE DR. DEBRA HOURY, DIRECTOR OF CDC'S NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL. INCLUDING PREVENTION OF PRESCRIPTION DRUG OVERDOSE. SHE RECEIVED HER MEDICAL DIRECTOR MPH FROM TULANE UNIVERSITY AND PRIOR TO JOINING THE C.D.C. DR. HOURY WAS VICE CHAIR AT EMERY UNIVERSITY SCHOOL OF MEDICINE AS WELL AS SOCIO PROFESSOR IN BEHAVIORAL SCIENCE, HEALTH EDUCATION IN ROWLANDS SCHOOL OF HEALTH. FOCUS IS ON VIOLENCE AND INJURY PREVENTION. SHE HAS AUTHORED MORE THAN 100 PAPERS AND BOOK CHAPTERS IN THESE AREAS AND RECEIVED NUMEROUS AWARDS AND RECOGNITION OF HER WORK IN PREVENTION OF VIOLENCE AND INJURY PREVENTION. AND ATTENDING PHYSICIAN IN THE EMERGENCY DEPARTMENT AT EMORY UNIVERSITY AND MEMORIAL HOSPITAL, SO PLEASE JOIN ME IN WELCOMING DR. DEBRA HOURY. >> GOOD MORNING, EVERYBODY, IT'S REALLY A PLEASURE TO BE HERE. I'VE WORKED WITH FOLKS AT N.I.H. BUT NOT REALLY N.I.D.C.R. DR. LEE AND I ACTUALLY MET A COUPLE YEARS AGO AS PART AS EXECUTIVE LEADERSHIP IN ACADEMIC MEDICINE, BEFORE I CAME TO CDC HOW WE CAN LOOK AT THINGS LIKE INTIMATE PARTNER VIOLENCE AND ORAL TRAUMA AND WITH THE OPIOID CRISIS SHE ASKED IF I WOULD TALK. I WORK WORLD OTHER ORGANIZATIONS AT N.I.H. I HAVE HAD THE OPPORTUNITY TO WORK WITH LINDA PORTER ON NATIONAL PAIN STRATEGY AND HAS BEEN INSTRUMENTAL IN REVIEWING OUR C.D.C. GUIDELINE AND WITH TRAUMATIC BRAIN INJURY I'VE APPRECIATED SO I WELCOME THIS OPPORTUNITY. I THINK FOR ME THE OPIOID EPIDEMIC IS PERSONAL, I'VE BEEN A PRACTICING E.R. DOC FOR OVER 15 YEARS AND I STILL SEE PATIENTS AND I HAVE SEEN IT EVOLVE THE PAST 15 YEARS. YOU WANT TO TAKE CARE OF THEIR PAIN AND DO THE RIGHT THING. I'VE SEEN PATIENTS STRUGGLING WITH ADDICTION AND HAVE BEEN FORCEFUL WHAT THEY MAY NEED FROM ME AT THAT TIME AND HELPING THEM NAVIGATE A COMPLICATED SYSTEM. I HAVE REVERSED WITH NALOXONE AND I'VE ALSO NOT BEEN SUCCESSFUL AND HAD TO TELL FAMILY MEMBERS THEY HAVE LOST A LOVED ONE. WHEN I CAME TO CDC I WAS ABLE TO TAKE A STEP BACK AND LOOK AT DATA AND WHAT WE CAN DO AT STATE HEALTH DEPARTMENTS AND LOOK AT IT AT THE MACRO LEVEL BUT AS I WAS TELLING FELLOWS IT'S IMPORTANT TO KEEP THAT GRASP ON THE GROUND, THOSE FACES AND STORIES BECAUSE THAT'S WHAT SHOULD DRIVE WHAT WE DO, SO THAT'S THE LENS THAT I'M COMING FROM. SO JUST TAKING A STEP BACK I WANTED TO PAINT THE PICTURE OF THE OPIOID PROBLEM IN OUR COUNTRY TODAY. INSTEAD OF STARTING TODAY, WE WILL START BACK IN THE LATE 90'S. I WANT YOU TO LOOK AT THIS MAP. YOU WILL SEE THE SCALE ISN'T GOING TO CHANGE. JUST SIT BACK AND LOOK AT THE PICTURE, I THINK THE PICTURE CAN SAY A LOT MORE THAN I CAN. OVER 15 YEARS THE SCALE DIDN'T CHANGE BUT THE EPIDEMIC HAS SPREAD ACROSS OUR UNITED STATES AND IMPACTED MANY COMMUNITIES. PEOPLE WILL SAY MAYBE WE SHOULD FOCUS ON SPECIFIC STATES THAT HAVE HIGH RATES. I SAY WE NEED TO TAKE A NATIONAL APPROACH BECAUSE IF YOU LOOK AT STATES LIKE NEW HAMPSHIRE, A COUPLE YEARS AGO THEY WERE NUMBER 20 FOR OVERDOSE, AND THEN THEY BECAME NUMBER FIVE. IT COULD CHANGE ON A DAILY BASIS. OUR STATES DON'T REALLY HAVE TRE BORDERS. WHERE PATIENTS SEEK MEDICAL CARE COULD BE IN DIFFERENT STATES, IT'S A BLENDED POPULATION AND WE NEED TO TAKE A REAL CONCERTED EFFORT TO THIS ISSUE. SO THE FIRST SIGNS, AND THIS IS HOW CDC FIRST GOT INVOLVED, WAY BEFORE I GOT TO CDC. WE FIRST START LOOKING AT SOME OF THE CDC WONDER DATA. BACK IN THE 90'S OPIOIDS WERE STARTING TO CONTRIBUTE TO DRUG POISONING OVERDOSES AND THIS IS ONE OF THE THINGS CDC WAS TRACKING. THEN IT STARTED BECOMING NUMBER TWO REASON FOR DEATH BEHIND MOTOR INJURIES. INITIALLY IT WAS HEROIN OR COCAINE BUT BY THE LATE 90'S WE STARTED SEEING A CHANGE. AND THAT'S WHEN WE STARTED HEARING FROM STATES, PEOPLE ON THE GROUND, LIKE A MAINE MEDICAL EXAMINER NOTICED MANY OF THE DECEDENTS HAD A PRESCRIPTION. OPIOIDS CONTRIBUTING TO THE DEATHS VERSUS HEROIN IN THE LATE 90'S. THAT'S WHEN WE STARTED TO SEE A CHANGE AND WHAT WAS HAPPENING WITH THE DEMOGRAPHICKS. WE STARTED PULLING DATA FROM DIFFERENT SOURCES FROM NATIONAL VITAL STATISTICS AND SAMHSA. IT WAS LINKED WHEN IT CAME TO OPIOID SALES, A CLOSE ASSOCIATION BETWEEN OPIOID ANALGESIC DEATHS. WE FOUND OPIOID ANALGESICS WERE BEGINNING TO CAUSE AND REALLY THE SIGNIFICANT CONTRIBUTOR TO DRUG OVERDOSE DEATHS. FAST FORWARD TO NOW. WHEN YOU LOOK AT THE AMOUNT OF PRESCRIPTIONS DISPENSED SINCE 1999 HAS QUADRUPLED TO WHERE WE ARE TODAY. ABOUT 250 MILLION PRESCRIPTIONS ARE WRITTEN EACH YEAR IN THE U.S. ENOUGH FOR EVERY SINGLE ADULT TO HAVE THEIR OWN BOTTLE OF PILLS. AND THE CONSUMPTION IN THE U.S. FOR OPIOIDS IS OVER 80%. I THINK WE ARE WELL AWARE WE DON'T CONTRIBUTE TO 80% OF THE WORLD'S POPULATION. SO WHAT IS HAPPENING IN OUR COUNTRY? AND THE DEATHS. WHEN YOU THINK ABOUT THE DEATH TOLL. 165,000 DEATHS SINCE 1999 FROM PRESCRIPTION OPIOIDS. AND IF YOU ADD ILLICIT LIKE HEROIN AND FENTANYL, OVER 78 PEOPLE DIE EACH DAY IN THE U.S. FROM AN OPIOID. AS I MENTION, YOU CAN REALLY SEE HOW THERE'S AN ASSOCIATION WITH PRESCRIPTIONS. THE TOP LINE IS OPIOID SALES AND THE BOTTOM LINE IS OPIOID DEATHS, AND YOU COULD SEE THE SLOPES REALLY PARALLEL EACH OTHER. I LIKE THIS SLIDE BECAUSE YOU COULD SEE THE GOLD IS LOOKING AT PAIN RELIEVERS SOLD BY RATES AND THEN THE DARKER COLORED STATES ARE INCREASED DEATH RATES. YOU COULD SEE IN THE MAJORITY OF WHERE YOU HAVE THE BIG GOLD CIRCLES ARE INCREASED SALES YOU ALSO TEND TO HAVE INCREASED OVERDOSES. AND THIS CAN'T JUST BE EXPLAINED BY HEALTH STATUS BY STATES, IF YOU LOOK AT STATES LIKE ALABAMA, THREE TIMES THE PRESCRIBING RATES OF HAWAII. THERE'S A LOT OF STATE VARIATION, YOU SEE THE STATE VARIATION IN OPIOID-RELATED DEATHS. SO I READ THE PAPERS, I'M SURE YOU ALL DO. YOU START TO SEE A LOT MORE ABOUT HEROIN AND FENTANYL NOW AND HOW IS THAT TIED IN WITH THIS EPIDEMIC. WE RELEASED VITAL SIGNS LAST YEAR AT THE C.D.C. FOCUSING ON HEROIN, THE MAJORITY OF PEOPLE WHO TAKE OPIOIDS DON'T GO ONTO USE HEROIN, RIGHT? BUT IF YOU LOOK AT PEOPLE USING HEROIN, THE MAJORITY STARTED WITH A PRESCRIPTION OPIOID. SO THREE OUT OF FOUR WHO USED HEROIN IN THE PAST YEAR MISUSED OPIOIDS FIRST. WE GO TO AN EPI-AID. WE DID ONE IN OHIO. WE FOUND OF PEOPLE WHO DIED OF A FENTANYL OVERDOSE, 62% HAD AN OPIOID PRESCRIPTION AT SOME POINT IN THE PAST SEVEN YEARS AND ONE IN FIVE HAD A CURRENT OPIOID PRESCRIPTION WHEN THEY DIED OF A FENTANYL OVERDOSE. THERE IS A CORRELATION, THEY ARE RELATED. THERE IS A CONCERN, PRESCRIPTION OPIOID, ARE THEY DRIVING PEOPLE TO HEROIN AND FENTANYL. THERE WAS A NICE PAPER DONE BY WILSON NIDA AND CHRIS JONES THAT SHOW MOST OF THESE CHANGES WERE HAPPENING WAY BEFORE ANY OF THESE PRESCRIPTION OPIOID REGULATIONS WERE GOING INTO PLACE. A LOT OF THESE CHANGES ARE THOUGHT TO BE DUE TO THE WIDE SPREAD AVAILABILITY OF ILLICIT DRUGS. I DON'T KNOW IF YOU READ THE BOOK "DREAM LAND" BUT IT'S A GREAT BOOK THAT TALKS ABOUT THE EPIDEMIC AND DRUG SALES AND AGGRESSIVE MARKETING HAPPEN WITH ILLICIT DRUGS. I'VE EVEN HEARD HEROIN IS ABOUT $10 NOW. IF YOU LOOK VERSUS THE COST OF PRESCRIPTION OPIOIDS, THAT'S A BIG CONTRIBUTOR TO THIS. THERE WAS A STUDY BY DEBBIE DELAMAR THAT SHOWED UP IN STATE THAT DID HAVE MANDATORY PRESCRIPTION CHECKS THERE WERE DECREASES IN OPIOID DEATHS. IT WASN'T SIGNIFICANTLY ASSOCIATED TOWARD HEROIN DEATH BUT THERE WAS A TREND TOWARD IT. WE ARE SEEING IT CAN MAKE A DIFFERENCE. AND GOING TO WHAT I WAS SAYING, WE HAVE SEEN THE RISE IN PRESCRIPTION OPIOIDS AND NOW WE ARE REALLY SEEING THE RISE OF HEROIN AND FENTANYL OVERDOSE. PART IS, THEY ARE SO DEADLY. IF YOU LOOK AT FENTANYL, IT'S ABOUT 100 TIMES AS POTENT AS A REGULAR PRESCRIPTION OPIOID LIKE VICODIN, SO WHEN PEOPLE ARE INJECTING IT A LOT OF TIMES WITH HEROIN THEY AREN'T SEEKING FENTANYL, WE ARE SEEING MORE IN THE EAST BECAUSE IT'S MIX WORLD THE WHITE POWDER HEROIN, VERSUS OUT WEST WHERE IT'S THE BLACK TAR HEROIN, THAT'S WHY WE ARE SEEING MORE OVERDOSES IN THE EAST BECAUSE OF THE TYPE OF HEROIN. IF THEY GET THAT REALLY POTENT FENTANYL IN THERE, THAT COULD RESULT IN A FATAL OVERDOSE. WHAT WE ARE SEEING, BECAUSE IT'S SO POTENT THE USUAL DOSE OF NALOXONE TO REVERSE IT DOESN'T WORK. IT'S TAKING 2-4 DOSES TO REVERSE IT. SO COMMUNITIES ARE REALLY IMPACTED IF THEIR E.M.S. OR FAMILY MEMBER ONLY HAS THAT ONE DOSE OF NALOXONE OR NARCAN AT HOME, THAT MAY NOT BE ENOUGH. ONE WAY WE CAN CHANGE IS FOCUSING ON NOT HAVING PEOPLE GET ADDICTED TO PRESCRIPTION OPIOIDS IN THE FIRST PLACE AND THEY WOULDN'T BE GOING ONTO HEROIN AND FENTANYL. THIS STUDY CAME OUT IN THE JOURNAL OF MED LAST MONTH. IT HIT HOME FOR ME. IT LOOKED AT PEOPLE WHO WERE HIGH PRESCRIBERS, VERSUS LOW PRESCRIBERS IN THE SAME PHYSICIAN PRACTICE. IT'S ONE THING IF YOU ARE LOOKING NATIONALLY. I LOOK BACK AT MY COLLEAGUES AND I KNOW SOME PRESCRIBE MORE THAN OTHERS. IT SHOWS PEOPLE WHO WENT TO HIGH INTENSITY PRESCRIBER, THOSE PATIENTS WERE MORE LIKELY TO BE ON OPIOIDS LONG-TERM BECAUSE OF THE INITIATION OF A PRESCRIPTION. ONE THING I THINK WE WILL GET TO WHEN WE GET TO THE GUIDELINE, OUR GOAL ISN'T TO GIVE OPIOIDS TO PEOPLE WHO HAVE PAIN. WE NEED TO MANAGE PAIN BUT WE NEED TO MANAGE IT APPROPRIATELY AND NOT GIVE PEOPLE A LONGER COURSE OF PAIN MEDICATION SINCE NECESSARY AND OPIOIDS MAY NOT ALWAYS BE THE RIGHT MEDICATION DEPENDING ON THE TYPE OF PAIN AS WELL. WE HAVEN'T DONE AS MUCH WITH DENTAL PRACTITIONERS BUT I'M LOOKING FORWARD TO THE CONVERSATION TO SEE HOW WE CAN PARTNER MORE BUT I DID PULL DATA SPECIFICALLY ON DENTAL PRACTITIONERS. OVERALL THEY PRESCRIBED ABOUT 6% OF ALL OPIOIDS AND THE NUMBERS ARE DECREASING. I THINK WHEN YOU LOOK AT POPULATIONS THAT HAVE THE HIGHEST RATES OF PRESCRIPTIONS FROM DENTISTS, 30% 10-19 COME FROM DENTISTS. WHEN I DID THE OPIOID-PRESCRIBING, WE HAD PARENTS TALK ABOUT AFTER A DENTAL PROCEDURE OR ATHLETIC INJURY, THAT WAS THE INITIATION. AGAIN, THERE'S APPROPRIATE USE FOR OPIOIDS BUT DENTAL EXTRACTION PROBABLY WON'T REQUIRE THAT 14 DAYS OR A REFILL. SO JUST BEING COGNIZANT OF THAT. THERE WAS A JAMA RESEARCH LETTER LOOKING AT HOW MANY PATIENTS WERE GETTING OPIOIDS AFTER AN EXTRACTION, ABOUT 42% WERE GETTING OPIOIDS AFTER A DENTAL EXTRACTION. FOR THEM, I'M NOT THE DENTAL PRACTITIONER, SO I CAN'T SAY IF IT IS APPROPRIATE OR NOT BUT THEY WERE SAYING THESE ARE HIGH DOSES OR TOO LONG OF A COURSE. AND OTHER MEDICATIONS MAY HAVE BEEN BETTER SUITED FOR SOME OF THESE. WE ARE NOW HAVING A LOT MORE PRESCRIPTION DRUG MONITORING PROGRAMS FOR STATES REAL-TIME AND MORE ACCESSIBLE. THERE WAS ONE THAT LOOKED IN SOUTH CAROLINA AT PATIENTS SEEING THE DENTAL PRACTICES. ABOUT 21% OF PATIENTS THAT HAD GOTTEN AN OPIOID FROM A DENTIST HAD A PRESCRIPTION WITHIN 30 DAYS FROM ANOTHER PHYSICIAN. SOMEONE MIGHT HAVE A CHRONIC MEDICAL CONDITION, COMES IN FOR A TOOTH EXTRACTION, MAKES SENSE BUT THIS MAY BE A RED FLAG OF AN OPIOID MISUSE DISORDER THAT MIGHT NEED REFERRAL FOR ADDICTION TREATMENT. I THINK IT'S GOOD CLINICAL PRACTICE TO KNOW WHAT OUR PATIENTS ARE ON, I WOULDN'T WANT TO GIVE SOMEBODY TOO MUCH OF A MEDICATION OR SOMETHING WITH SIDE EFFECTS OR INTERACT. I THINK CHECKING PRESCRIPTION DRUG MONITORING PROGRAM IS HELPFUL AND GIVES MORE INFORMATION. I THINK THIS STUDY IS IMPORTANT TOO. THERE'S A LOT OF PATIENTS WE NEED TO BE CHECKING SO WE KNOW WHAT PRESCRIPTIONS THEY ARE ON. SO TAKING A STEP BACK I WANT TO TELL YOU ABOUT SOME OF THE WORK C.D.C. IS DOING IN THE FIELD. WE HAVE REALLY TRIED TO WORK SYNERGISTICALLY, SHE IS HERE. WITH ALL THE DIFFERENT FEDERAL AGENCIES. OUR ROLE HAS FOCUSED ON PRIMARY PREVENTION AND LOOKING AT SOME OF THE THINGS C.D.C. DOES BEST, LIKE SURVEILLANCE PROTECTION. WE ARE LOOKING AT HOW WE CAN IMPROVE DATA QUALITY AND TRACK TRENDS AS IT HAPPENS ACROSS THE UNITED STATES AND IDENTIFYING DIFFERENT HOTSPOTS. WE ARE ALSO WORKING DIRECTLY WITH STATE HEALTH DEPARTMENTS TO LOOK HOW CAN WE HAVE POPULATION LEVEL APPROACHES TO THE OPIOID EPIDEMIC AND LOOKING AT PUBLIC HEALTH AND GIVING HEALTH CARE PROVIDERS TOOLS. THAT'S THE GUIDELINE WHICH I WILL TALK ABOUT IN A MINUTE. SO ONE OF THE THINGS WE DID, WE CAN ASK TO GO TO DIFFERENT STATES TO DO INVESTIGATIONS, WE HAVE DONE IT FOR SUICIDE CLUSTERS AND LATELY FOR INCREASES IN OPIOID OVERDOSE DEATHS. WE REQUESTED TO GO TO OHIO AND WE FOUND THE MAJORITY OF THESE DEATHS WERE DUE TO FENTANYL AND WE WANTED TO SAY HOW CAN WE USE DIFFERENT DATA SOURCES OUT THERE. AFTER THE FACT ISN'T SO HELPFUL. HOW CAN WE HELP PREDICT WHERE WE NEED TO GO IN COMMUNITIES. SO WE PULLED DATA FROM CORONERS, WE DID INTERVIEWS WITH PEOPLE WHO OVERDOSED BUT REVERSED WITH FAMILY MEMBERS WHO WITNESSED OVERDOSE TO TRY TO GET A SENSE, DO PEOPLE KNOW THIS WAS FENTANYL? WHAT WAS LEADING UP TO IT, HOW COULD IT HAVE BEEN PREVENTED. AND ONE OF THE INTERESTING THINGS AS WE LOOKED AT LAW ENFORCEMENT DATA AND SEIZURES. AND THE DARK BLUE LINE IS LAW ENFORCEMENT FOR FENTANYL AND THE OTHER IS FENTANYL-INVOLVED OVERDOSES. SO WE REALIZE YOU CAN START USING LAW ENFORCEMENT DATA FOR SEIZURE TO GET A SENSE FOR WHAT COMMUNITIES WILL START HAVING FENTANYL RELATED OVERDOSES, TOP STATES OHIO, PENNSYLVANIA, RHODE ISLAND FOR SEIZURES, THEY HAVE THE HIGHEST NUMBER OF FENTANYL OVERDOSES RIGHT NOW. YOU CAN USE LAW ENFORCEMENT DATA TO TRACK AND TARGET MORE AWARENESS AROUND FENTANYL. MANY FOLKS MAY NOT REALIZE FENTANYL IS IN THEIR COMMUNITY AND WHAT TO LOOK FOR AND HAVE MORE NALOXONE ON HAND AND HAVE E.M.S. BE PREPARED. PRESCRIPTION DRUG MONITORING PROGRAMS ARE ALSO VERY HELPFUL. I GET THE PUSH BACK, I'M A DOC. I'VE BEEN LOCKED OUT BEFORE. BUT THERE'S BEEN A LOT OF IMPROVEMENTS IN PRESCRIPTION DRUG MONITORING PROGRAMS. IN GEORGIA THEY RECENTLY ADOPTED A NEW P.D.M.P., IT IS MUCH MORE USER FRIENDLY AND I'M ABLE TO INTEGRATE IT IN CLINICAL PRACTICE. THEY COULD ENHANCE IT AND MAKE IT MORE USER FRIENDLY. IT SHOULD BE A CLINICAL TOOL THAT'S USEFUL. WE ARE WORKING WITH STATES. OHIO HAS BEEN ABLE TO GET THEIR COBRA PHARMACIES TO INTEGRATE IT AND KENTUCKY HAS A CALCULATOR ON THEIR P.D.M.P. TO DO RED FLAGS IF YOU ARE GOING OVER 100 M.M.E.'S. WE WANT THESE TO BE HELPFUL. I THINK THAT'S WHERE P.D.M.P.'S COULD BE HELPFUL. IF YOU HAVE A PATIENT THAT'S BEEN GETTING PRESCRIPTIONS FROM MULTIPLE PROVIDERS REFER THEM FOR TREATMENT, OR HAVE THE DISCUSSION AROUND ADDICTION, IT COULD BE VERY HELPFUL, I THINK TO IDENTIFY PATIENTS. HAVING THAT OBJECTIVE DATA I THINK WILL HELP REDUCE STIGMA. AGAIN IN THE EMERGENCY DEPARTMENT WE WOULD HAVE PEOPLE AND YOU MIGHT SAY THEY WERE A SEEKER, MANY TIMES THEY WEREN'T. THEY COULD JUST BE IN PAIN AND ANXIOUS AND HAVING OBJECTIVE DATA HELPS YOU WITH THAT. SO OVER THE PAST TWO YEARS, WE HAVE BEEN ABLE TO EXPAND OUR STATE WORK, WE ARE NOW FUNDING 44 STATES PLUS WASHINGTON D.C. TO DO OPIOID PREVENTION WORK. WE HAD MULTIPLE PROGRAMS. I ALWAYS CALL IT OUR OPIOID WORK, I'VE LEARNED THERE'S MANY ACRONYMS FOR EVERYTHING, I JUST SAY IT'S OUR OPIOID PORTFOLIO. WITHIN OUR STATE HEALTH DEPARTMENT WORK WE ASKED OUR STATES TO DO TWO THINGS. ONE THEY MUST ENHANCE THEIR PRESCRIPTION DRUG MONITORING PROGRAM. TO BE ELIGIBLE YOU ALREADY HAD TO HAVE ONE. SO 44 STATES WERE ELIGIBLE TO APPLY. WE ARE FUNDING 42 THROUGH THIS AND 12 THROUGH THE OTHER. SO WE HAVE THE SUCCESS STORIES LIKE OHIO AND KENTUCKY WITH WHAT THEY ARE DOING. THE SECOND THING IS LOOK AT SYSTEM LEVEL INTERVENTION. WORKMAN'S COMP PROGRAM. DO THEY HAVE GOOD EVIDENCE-BASED CLINICAL CARE OR QUALITY METRICS. MAKING SURE SYSTEM LEVEL INTERVENTIONS. THE OPTIONAL MODULES WERE EVALUATING POLICY SUCH AS NALOXONE. THAT'S SOMETHING A LOT OF PEOPLE ARE INTERESTED IN, WHAT IS THE EFFECTIVENESS OF NALOXONE FOR LAY PROVIDERS, OR HOW IS IT HELPING WITH RESPONSE TIMES? AND RAPID RESPONSE. I THINK KNOWING SOME COMMUNITIES WILL HAVE MICRO EPIDEMICS LIKE WHAT WE SAW IN SCOTT COUNTY, INDIANA AND GETTING RESOURCES AS SOON AS YOU CAN. AND WE HAVE ALSO SEEN MANY WANT TO DO PRESCRIBING INFORMATION OR CAMPAIGNS. THE OTHER PROGRAM WE STOOD UP LITERALLY THE LAST SIX MONTHS WITH FY-16 FUNDING WAS ENHANCED STATE SURVEILLANCE. WE ARE DOING OUR BEST TO HAVE MORE TIMELY DATA BUT TAKING A PUBLIC HEALTH LENS, MORE TALT -- MORTALITY IS THE TIP OF THE ICEBERG. WE WANT TO LOOK AT HOSPITAL VISITS. LOOK FOR HOTSPOTS AND OTHER EMERGING TRENDS IN DRUG OVERDOS DEATHS. AND WE THINK THIS WILL REALLY HELP STATES BE ABLE TO COMBAT THIS EPIDEMIC MORE QUICKLY. SO THE GUIDELINE. THIS WAS DEVELOPED ONE YEAR AGO ON MARCH 15th WAS WHEN WE PUBLISHED IT. IT WAS MEANT AROUND INITIATION OF OPIOIDS. WE REALIZE THERE ARE MANY PATIENTS ALREADY ON CHRONIC OPIOIDS AND WE PUT LANGUAGE TO HELP GUIDE PHYSICIANS BUT THIS IS REALLY ABOUT THE PATIENT YOU ARE NOW SEING IN YOUR PRIMARY CARE PRACTICE AND WHETHER OR NOT TO INITIATE OPIOIDS. IT WAS MEANT FOR PATIENTS OVER THE AGE OF 18 OR ADULT PATIENTS WITH CHRONIC PAIN. THAT WAS ANY CONDITION EXPECTED TO LAST THREE MONTHS OR LONGER AND FOCUS ON OUTPATIENT SETTING. WHEN WE LOOK AT WHO WAS PRESCRIBING OPIOIDS, PERCENTAGE WISE, A PAIN MEDICINE PHYSICIAN MIGHT PRESCRIBE A HIGHER PERCENTAGE FOR HIS PATIENTS. IF YOU LOOK NATIONALLY, PRIMARY CARE PROVIDERS ARE PRESCRIBING HALF OF ALL THE OPIOIDS OUT THERE. WE WANT TO FOCUS IT OUTSIDE OF PALLIATIVE, END-OF-LIFE CARE AND ACTIVE CANCER. IT WAS A RIGOROUS PROCESS WHICH TOOK PLACE OVER 18 MONTHS, WHICH WAS A QUICK PROCESS. I'M USED TO THE E.R. WE BASE IT ON AN A.H.R.Q. REVIEW AND THEN USE 130 ADDITIONAL UPDATED RANDOMIZED TRIALS, DRAFTED A GUIDELINE, CONSULTED WITH A CORE EXPERT GROUP. THEN STAKEHOLDER MEDICAL SOCIETIES FOR REVIEW, RE-REVISED IT. OPENED IT FOR PUBLIC ENGAGEMENT AND THEN A 30-DAY PUBLIC COMMENT, RE-REVISED IT AND THEN PRESENTED IT TO OUR BOARD OF SCIENTIFIC COUNSELORS AND THEN REVISED IT. WHAT WE FOUND IS OVERALL THERE'S A LACK OF EVIDENCE THAT OPIOIDS CONTROL PAIN EFFECTIVELY LONG TERM. THAT WAS VERY MUCH UNCHANGED FROM THE ORIGINAL SYSTEMATIC REVIEW THAT THERE ISN'T A LOT OF EVIDENCE FOR LONG-TERM USE OF OPIOIDS. WE ALSO SAW THAT RISK OF SERIOUS HARM INCREASES WITH OPIOID DOSE. I THOUGHT THIS WAS SOMETHING I STARTED THINKING WITH MY OWN CLINICAL PRACTICE. I USED TO SIGN WHAT CAME OUT OF THE COMPUTER. WHATEVER WAS THE DEFAULT AND I DIDN'T THINK HOW MANY DAYS IT WAS SET FOR, OR WHAT THE STRENGTH WAS. IT WAS WHATEVER THE DEFAULT SETTING WAS FOR A PAIN MEDICATION, I DIDN'T LOOK IF IT WAS A 5 OR 7.5 OR A 3 OR 7 DAY. I SIGNED WHAT MY RESIDENT GAVE ME. I SEE EYEBROWS RAISING. I GUARANTY IF YOU ARE IN A BUSY SETTING YOU WILL ASSIGN WHAT'S COMING OUT OR WHAT THE HOSPITAL SET. WE STARTED THINKING OF THE LOWEST DOSE POSSIBLE. AND WE DID GIVE GUIDANCE IN THERE, IF YOU ARE AT 50. THAT'S WHEN YOU SHOULD HAVE CAUTION, IF YOU ARE AT 90 OR HIGHER, THEN YOU SHOULD CONSIDER CONSULTING A PAIN SPECIALIST OR CO-PRESCRIBING NALOXONE. WE UNDERSTAND EVERYBODY IS UNIQUE AND DIFFERENT, FOR SOME PEOPLE 50 WOULD BE TOO HIGH. FOR SOME 10 COULD BE TOO HIGH. IT'S JUST A MATTER OF WHAT IS RIGHT FOR THAT PERSON, SO WE WANTED TO USE WHAT WE HAD FROM THE EVIDENCE AND GIVE GENERAL GUIDANCE. AND THE THREE TENETS THAT CAME OUT WERE FIRST DO NO HARM. OPIOIDS WERE NOT RECOMMENDED AS THE FIRST-LINE TREATMENT FOR CHRONIC PAIN. I THINK WHEN YOU GO BACK TO PAIN PHYSIOLOGY IT MAKES SENSE. YOU WANT TO TREAT THE ROOT. ARE YOU TREATING THE PAIN RESPONSE, FOR A LONGER TERM CONDITION YOU NEED TO LOOK AT WHAT'S UNDER THAT PAIN PHYSIOLOGY. WE RECOMMENDED NON PHARMACOLOGICAL AND NON OPIOIDS. IT'S NOT A FAIL FIRST. IF YOU ADD OPIOIDS IT SHOULD BE WITH OTHER MODES OF THERAPY AND WHEN USE IT HAD SHOULD BE THE LOWEST DOSAGE. WITH ANY MEDICATION THAT HAS RISKS, AS YOU WOULD WITH ANY MEDICATION FOR RISK, REEVALUATE THE PATIENT. ARE THEY IMPROVING. IT SEEMS COMMON SENSE WHEN YOU THINK ABOUT IT BUT WHEN I WENT THROUGH MEDICAL SCHOOL WE DIDN'T HAVE THOSE CONVERSATIONS ABOUT OPIOIDS AND WHAT IT MEANT AND RISKS P AND BENEFITS BUT NOW I TALK TO PATIENTS ABOUT THE RISKS AND BENEFITS AND IF ITS THE RIGHT MEDICATION FOR THEM. WE DIDN'T FOCUS ON ACUTE PAIN BUT I WANTED TO PULL THE ONE RECOMMENDATION WE HAD, THE NATIONAL SAFETY COUNCIL IS WORKING WITH AMERICAN ACADEMY OF FAMILY PRACTITIONERS AND COLLEGE OF PHYSICIANS AROUND ACUTE PAIN GUIDELINE AND WE DID MENTION THAT MORE THAN 7 DAYS RARELY NEEDED AND MORE LIKE 3 DAYS WOULD BE OFTEN SUFFICIENT. THIS IS FOR WHAT YOU COULD SEE IN A PRIMARY CARE SETTING. WE THINK IT'S IMPORTANT, AS I MENTIONED, WITH THE NEW ENGLAND JOURNAL STUDIES, INITIATION OF OPIOIDS AND LENGTH OF TIME YOU ARE ON AN OPIOID COULD PUT YOU AT RISK FOR NEEDING THOSE OPIOIDS LONGER TERM. BEING COGNIZANT FOR THE LENGTH OF TIME YOU GIVE AN OPIATE FOR. WE DIDN'T WANT THIS TO SIT ON THE SHELF AND BE ANOTHER GOVERNMENT DOCUMENT. WE WERE TRYING TO FIND WAYS TO MAKE IT MORE USER FRIENDLY. I KEPT THINKING I KNOW WHAT I DID WITH GUIDELINES, I DIDN'T USE, OR IF I DID IT HAD TO BE EASY AND EASY TO REMEMBER. FOCUSING ON CLINICAL TRAINING, WE HAVE BEEN WORKING ON A CURRICULUM FOR NURSING SCHOOLS. HOW CAN WE IMPLEMENT IN DIFFERENT HEALTH CARE SYSTEMS. SOMETHING I TALKED TO DR. PORTER ABOUT THIS MORNING, HOW CAN WE LOOK AT THINGS LIKE INCREASED COVERAGE FOR COUNSELING AROUND OPIOID USE OR INCREASED COVERAGE FOR NON OPIOIDS AND NON PHARM TREATMENTS. SOME EDUCATION AVAILABLE ON OUR WEBSITE. SEVEN DIFFERENT MODULES ALL FOR FREE, CONTINUING EDUCATION ON OPIOID PRESCRIBING, HOW TO TAPER, HOW TO REFER FOR M.A.T., THINGS LIKE THAT. WE ALSO HAVE A MOBILE APP THAT CAME OUT IN DECEMBER, IT HAS MOTIVATIONAL INTERVIEWING, CALCULATOR ON M.M.E. AND EACH OF THE GUIDELINE RECOMMENDATIONS LINKS YOU TO DIFFERENT RESOURCES. IT HAS A CHECKLIST THAT WE DEVELOPED WITH DR. GUWANDI. IF YOU DO 2-3 THINGS WHAT DO YOU NEED TO MAKE SURE YOU ARE DOING WITH A PATIENT. I REMEMBER WHEN I WAS TALKING WITH MY STAFF I SAID I MAY NEED A REFRESHER WHAT ARE NON OPIOID MEDICATIONS AND DIFFERENT USES FOR THEM. WHAT ARE THINGS THE PRACTICING CLINICIAN NEEDS. MATERIALS ON NON OPIOID AND HOW DO YOU ASSESS YOUR PAIN, HOW DO YOU HAVE THOSE CONVERSATIONS. WITHIN HEALTH SYSTEMS WE TRY TO LOOK AT QUALITY IMPROVEMENT METRICS TO LOOK AT WITHIN THEIR PRACTICE HOW MANY ARE ON OPIOIDS AND BENZOS TOGETHER BECAUSE THAT PUTS YOU AT HIGHER RISK. WHAT PERCENTAGE ON THESE HIGH M.M.E.'S LOOKING AT ELECTRONIC RECORDS AND WHAT ARE PROMPTS YOU CAN INTEGRATE INTO CLINICAL ORDERING. BECAUSE IF ITS NOT EASY TO DO, IT'S NOT GOING TO GET DONE. WE DIDN'T HAVE ANY RESOURCES ON OUR WEBSITE. I'M EMBARRASSED TO SAY, FOR DENTAL PRACTITIONERS BUT THE AMERICAN DENTAL ASSOCIATION HAS WEBINARS AND SAMHSA HAD A PROGRAM AND ITS VERY CONSISTENT WITH OUR GUIDELINE. I THINK THE BOTTOM LINE FOR DENTAL PRACTITIONERS WHAT I'VE BEEN SAYING THIS MORNING, INAPPROPRIATE PRESCRIBING IS ONE OF THE THINGS THAT DROVE THIS OPIOID EPIDEMIC TO WHERE WE ARE AT. IT'S NOT DOCTOR BLAMING. WE DID WHAT WE THOUGHT WAS RIGHT FOR THE PATIENT AND WE DIDN'T HAVE THE EVIDENCE AT THE TIME THESE COULD BE ADDICTIVE. I THINK IT'S IMPORTANT TO STAY EDUCATED ON THIS AND FIND OUT HOW CAN WE TREAT PAIN FOR PATIENTS. HOW CAN WE MAKE SURE WE ARE GIVING PATIENTS THE MOST EFFECTIVE DOSES, SO CONTINUING EDUCATION IS IMPORTANT. AFTER HAVING GONE THUE THE PROCESS TO GET THAT GUIDELINE PUBLISHED I WANT PEOPLE TO USE IT. A LOT OF THESE KEY IT TENETS. START LOW. CRUCIAL TO PARTICIPATE IN YOUR STATE'S DRUG MONITORING PROGRAM. CHECKING BEFORE INITIATING LONGER-TERM PRESCRIPTIONS OR EVEN THAT FIRST PRESCRIPTION. AND EDUCATING PATIENTS. THOSE STORIES OF THE PATIENTS I SEE, AND HAVING THOSE CONVERSATIONS WITH THEM ABOUT WHAT ARE THE RISKS AND BENEFITS, WHAT IS THEIR EXPECTED OUTCOME. I THINK IT GOES BACK TO WHAT WE LEARNED IN OUR CLINICAL TRAINING ABOUT THOSE CONVERSATIONS. WHAT IS IT WE WANT TO DO. WE DON'T WANT TO DO ANY HARM BUT WE ALSO WANT TO DO BEST WE CAN TO HELP THOSE PATIENTS IN FRONT OF US. SO WITH THAT, I WILL OPEN IT UP FOR QUESTIONS. THANK YOU. [APPLAUSE] >> SO IN ASKING QUESTIONS PLEASE GO TO THE MICROPHONE. >> I GREW UP IN MEDICINE IN THE 60'S AND 70'S AND WE DIDN'T USE MANY PRESCRIPTION DRUGS. AND THEN A LOT OF HOSPITALS NOW YOU GET PENALIZED IN YOUR SALARY IF THE PATIENTS SAY YOU DIDN'T TREAT THEIR PAIN RIGHT. YOU CAN'T REFUSE AS WELL. NOBODY TALKS ABOUT THAT, IT WAS INCIDENTAL, I DON'T KNOW IF IT WAS CAUSAL TO THAT SAME UP TAKE. BEFORE YOU HAD THE CD 10, CD9 CLASSIFIED MOST OF THESE AS ACCIDENTAL POISONINGS. THE ERROR REPORT WHICH CAUSES HUGE CHANGE IN WHAT WE HAD TO DO DECLARED 7,000 WERE KILLED BY PRESCRIBING. THOSE WERE ALL ACCIDENTAL POISONING, DUE TO NARCOTICS, PRINCIPALLY AND THERE'S A PAPER FROM UTAH, BUT THAT NEVER GOT FEEDBACK. WE DIDN'T REALLY DO BAD PRESCRIBING BACK THEN. I WONDER WHY WE AREN'T GETTING TO PLACES MAKING THE PAIN SCORES AND FEEDBACK GETS INTO PHYSICIANS SALARIES THAT ARE MAKING THEM DO IT. IS THERE ANY WAY TO DO THAT? >> IT'S INTERESTING, BECAUSE AGAIN I'VE BEEN ON BOTH SIDES. I'VE SEEN SOME OF THOSE SCORES YOU GET AS A PHYSICIAN. A LOT OF IT IS PERCEPTION. WHEN WE LOOKED WHAT THE FORMULA FOR HOW MUCH IT WOULD IMPACT YOUR SALARY, I THINK IT WAS LESS THAN 0.1%. BUT THERE'S A PERCEPTION, I'M GETING THIS SCORE, DRIVING PATIENT SATISFACTION, I WILL GET PENALIZED AND I DID SEE WHAT OUR GROUP SCORE OR MY SCORE WOULD BE. WE TRY TO DO A LOT OF EDUCATION. I THINK IT'S SOMETHING WE HAVE DONE A PRETTY GOOD JOB WITH A LOT OF OUR INTERAGENCY WORK. WE HAVE TALKED TO C.M.S. ABOUT THIS AND I BELIEVE THEY OPENED IT FOR COMMENT. WE DO WANT TO MAKE SURE PAIN IS GETTING ASSESSED BUT THAT PHYSICIANS AREN'T PENALIZED FOR IT. WE TALKED ABOUT THE SAME THING ABOUT, I THINK ONE OF THE COMMENTS I HAD HEARD IS WE DON'T ASK WAS YOUR PAIN TREATED, WERE YOU TREATED WITH ANTIBIOTICS FOR THE COLD YOU CAME IN WITH. TRYING TO REFRAME. WERE THE RISKS AND BENEFITS DISCUSSED WITH YOU, WERE APPROPRIATE TREATMENTS DISCUSSED WITH YOU. GOING BACK TO THAT PATIENT-PHYSICIAN DIALOGUE VERSUS WHAT WERE THE ACTIONS. I THINK THERE'S INCREASED ATTENTION ON PRESS GAINEY SCORES, HOW IT FEEDS INTO REIMBURSEMENT, AND PART OF THAT COMES DOWN TO EDUCATION AROUND HOSPITAL SYSTEMS AND AMERICAN HOSPITAL ASSOCIATION HAS BEEN A GREAT PARTNER FOR US AROUND THE GUIDELINE AND I THINK THEY HAVE DONE A LOT OF MESSAGING. TALKING TO HEALTH CARE ADMINISTRATORS HOW THEY USE THAT DATA. I THINK THE PHYSICIANS GET IT, IT'S MAKING SURE THE WHOLE SYSTEM IS SUPPORTIVE OF IT. >> THAT WAS A REALLY INTERESTING TALK. I WAS PARTICULARLY STRUCK BY THE HEAT MAP OF THE U.S. AND WHY THERE WAS INCREDIBLE HETEROGENEITY. VERMONT. NEW HAMPSHIRE. IS THAT A STATE PROBLEM OR MICRO THINGS THAT I DON'T UNDERSTAND? >> I THINK A LOT OF IT, OBVIOUSLY WITH ALMOST ANYTHING IT WILL BE MULTIFACTORIAL. WITH SOME OF IT YOU WILL SEE LOSS OF JOBS. OR INFLUX OF PAIN CLINICS IN SOME AREAS. NOT ENOUGH ACCESS TO M.A.T. SO I THINK YOU HAVE ALL THESE THINGS AND IT LEADS TO THE PERFECT STORM. AND THEN IT ALSO DEPENDS ON SINCE THESE ARE OVERDOSE DEATHS, WHAT IS IN THE MARKET AT THAT TIME. IF YOU ARE SEEING MORE FENTANYL OR MORE HEROIN, THAT WILL BE MORE DEADLY. BUT AS I MENTIONED WITH NEW HAMPSHIRE, GOING FROM NUMBER 20 TO NUMBER 5 IN A YEAR GOES TO SHOW IT'S NOT JUST A STATE ISSUE T COULD HAPPEN ANYWHERE IN THE U.S. I'VE DONE MANY SITE VISITS, WHEN I WENT TO WEST VIRGINIA AND SPENT TIME AT THE CHRONIC PAIN CLINIC FOR ADDICTION, I WAS SURPRISED HOW MANY HAD STARTED WITH A PRESCRIPTION FROM A PHYSICIAN, THEY WERE DOING MANUAL LABOR FOR BACK PAIN AS PART OF THEIR JOB. WENT TO GET TRAINED AND DIDN'T HAVE ACCESS TO PHYSICAL THERAPY AND M.A.T. WHEN THEY NEEDED IT. >> HI, EXCELLENT LECTURE. ANN BERGER FROM PALLIATIVE CARE. I GREW UP IN THE PALLIATIVE CARE WORLD, CHRONIC PAIN. TREAT CHRONIC PAIN. THE WHOLE THING. AND I THINK THIS IS EXCELLENT. I THINK CLEARLY WE HAVE GONE OVER WHAT WE SHOULD HAVE GONE OVER. BUT I THINK, FIRST OF ALL, DO WE KNOW THE DATA OF THE DEATHS, WHAT THE DIAGNOSIS OF THE PATIENTS WERE. BECAUSE I'M PARTICULARLY CONCERNED AS A PALLIATIVE CARE PERSON, YES I THINK CANCER PAIN IS PROBABLY STILL BEING TREATED AND END-OF-LIFE IS HOPEFULLY STILL BEING TREATED BUT THEN THERE ARE THOSE GROUPS OF PALLIATIVE CARE SUCH AS SICKLE CELL, SOME OF THE NEUROLOGIC THINGS AND THOSE PATIENTS ABSOLUTELY CAN'T GET OPIATES ANY MORE. THAT'S PARTICULARLY DIFFICULT FOR ME TO SEE. WERE THEY SOME OF THE DEATHS. I THINK WE DON'T TOTALLY UNDERSTAND THE INTERSECTION BETWEEN GETTING PRESCRIPTIONS AND THEN THE ADDICTION BUT WE AGAIN HAVE GONE ALL THE WAY OVERBOARD. AND I ABSOLUTELY BELIEVE THAT WITH THE INTEGRATIVE COMPLEMENTARY MODALITIES, HYPNOSIS, BIO FEEDBACK, ACUPUNCTURE, THEY MUST BE FUNDED THROUGH INSURANCE BECAUSE WE NEED TO BE GIVING SOMETHING. COUNSELING. THE WHOLE NINE YARDS, OTHERWISE THERE WILL BE A LOT OF PEOPLE IN CHRONIC PAIN THAT HAVE ILLNESSES THAT I WOULD CONSIDER PALLIATIVE CARE ILLNESSES. >> THANK YOU. I THINK ONE OF THE THINGS I LEARNED WHEN I WAS TALKING WITH OUR WORK GROUP MEMBERS THAT WERE PAIN PHYSICIANS, AGAIN I'M E.R., I'M NOT SEEING THE LONG-TERM PATIENTS, THEY HAD PATIENTS ON HIGH DOSE OPIOIDS AND STARTED TAPERING TEM DOWN, AND THE PATIENTS WERE DOING BETTER, BETTER QUALITY OF LIFE, BUT THEY DIDN'T DO IT WITHOUT MAKING SURE THEY HAD GOOD PHYSICAL THERAPY AND OTHER TYPES OF ADJUNCTIVE MEDICINE TO SUPPORT IT. I AM HEARING MORE PHYSICIANS BEING RELUCTANT TO PRESCRIBE OPIOIDS. OUR HOPE THIS WOULD GIVE PHYSICIANS MORE UNDERSTANDING OF WHEN TO GIVE OPIOIDS AND HOW TO ASSESS A PATIENT AROUND FUNCTIONALITY. I DO THINK FOR A LOT OF THE MORE COMPLEX PATIENTS, HOPEFULLY THEY ARE BEING MANAGED WELL IN A PAIN MANAGEMENT SETTING BUT I THINK THE ISSUE IS ACCESS. THAT'S ONE OF THE THINGS DR. PORTER AND I WERE TALKING ABOUT WITH A NATIONAL PAIN STRATEGY, THERE'S STILL CAPS ON PHYSICAL THERAPY, THERE'S NOT GOOD COVERAGE FOR A LOT OF THESE THERAPIES. >> [OFF MIC] >> I LOOK FORWARD TO CONTINUING A DIALOGUE, I THINK ON HOW WE, AT CDC AND NIH COULD SUPPORT THE PUBLIC, FIND THAT BALANCE. IT'S A DIFFICULT BALANCE. IF YOU SAY WE HAVE GONE TOO FAR ONE WAY, IT'S FINDING THAT BALANCE TO WHERE, EVALUATING EACH PATIENT AS AN INDIVIDUAL AND FIGURING OUT WHAT THOSE RISKS AND BENEFITS ARE. >> DR. HOURY THAT WAS A GREAT TALK AND I THINK CDC HAS DONE A SUPERB JOB WITH THESE GUIDELINES. I WANTED TO ASK YOU HOW MUCH ROLE DO YOU THINK IS THE STIGMA ASSOCIATED WITH ADDICTION. AND WHETHER PART OF THE PROBLEM IS OUR FAILURE TO DEVELOP APPROACHES THAT ACKNOWLEDGE AND TREAT THE CO MORBIDITY OF CHRONIC PAIN AND ADDICTION. >> I THINK THE SURGEON GENERAL HAD HIS REPORT THAT CAME OUT RECENTLY THAT REALLY SPOKE TO THAT. THERE HAD BEEN STIGMA AROUND ADDICTION AND I THINK WE NEED TO FOCUS ON IT AS A CHRONIC DISEASE AND REMOVE THE STIGMA AND GET PEOPLE THE HELP THEY NEED. THERE'S NOT ENOUGH M.A.T. OR ADDICTION SPECIALISTS AS WELL. IT'S A DIFFICULT PLACE WE ARE AT IN THIS COUNTRY. WE HAVE PEOPLE WHO NEED MORE ADDICTION SERVICES AND TREATMENT, BUT ON THE OTHER HAND I DON'T WANT MORE PEOPLE GETTING ADDICTED IN THE FIRST PLACE. IF WE ARE ONLY FOCUSED OVER HERE, WE WILL KEEP GROWING IT OVER HERE AND WE WILL HAVE ANOTHER IMBALANCE. I THINK THE CONVERSATION IN THIS COUNTRY HAS CHANGED TO WHERE WE HAVE REALIZED WE ARE -- I MEAN IT'S UNPRECEDENTED WHEN YOU LOOK AT THE NUMBER OF DEATHS AND HOW MANY PEOPLE ARE IMPACTED AND I GUARANTY EVERYBODY IN HERE KNOWS SOMEBODY IMPACTED BY OPIOID ABUSE. I THINK THE CONVERSATIONIS CHANGING. BUT I THINK WE HAVE TO LOOK AT OURSELVES TOO, I THINK BACK EARLY IN MY PRACTICE HOW I VIEW PATIENTS WITH ADDICTION ISSUES AND HOW I LOOK AT THEM NOW AND I THINK WE NEED TO SHOW MORE COMPASSION WHEN WE ARE DOING IT. >> THANK YOU, DR. HOURY FOR THE TALK AND FOR TALKING TO SOME OF THE FELLOWS. FROM A DENTAL PERSPECTIVE, IN MY OPINION, WITH WHERE THE MAJORITY OF PATIENTS THAT MAY HAVE PROBLEMS WITH OPIOID IS THE LACK OF ACCESS TO DENTAL CARE. THE HURDLE TO GET MEDICAL CARE OR ACCESS TO EMERGENCY CARE IS QUITE A BIT LOWER AND THE MAJORITY OF PATIENTS IN THE UNITED STATES THAT ARE SEEKING DENTAL CARE IS OUT OF POCKET. THIS PATIENT GROUPS, AT LEAST IN MY EXPERIENCE, THEY ACCESS THE EMERGENCY CARE NETWORK TO BOTH TREAT THEIR DENTAL DISEASE -- >> WHICH WE DON'T DO. >> AND THEY ARE TOLD TO GO TO THE DENTIST, WHICH THEY DON'T HAVE MONEY TO PAY FOR. I THINK THAT CONVERSATION REALLY REQUIRES A LARGER CONVERSATION ABOUT DENTAL CARE, BASIC DENTAL KARICKHOFF RAJ IN THE UNITED STATES. -- -- DENTAL COVERAGE IN THE UNITED STATES. >> THANK YOU. >> THANK YOU FOR THE GREAT TALK. YOU MENTIONED MAJORITY OF THE PEOPLE WHO GET THE OPIOID PRESCRIPTION DO NOT END UP WITH THE ADDICTION. AS WE NOW HAVE MORE AND MORE PEOPLE, COULD WE LOOK AT WHO WOULD BE MORE SUSCEPTIBLE TO ADDICTION AND CAN YOU ELABORATE ON WHAT YOU ARE LEADING OR HOW COULD THAT BE BEST UTILIZED IN GENERAL CARE. >> SURE. I'M NOT DOING THAT MUCH IN CDC BUT I'M BETTING THERE'S RESEARCH FUNDED AT N.I.H. SOMEWHERE THAT'S REALLY LOOKING AT THAT SUSCEPTIBILITY. I THINK WE HAVE TO REALIZE THAT GENES COULD PREDICT BUT EACH INDIVIDUAL AND HOW THEY EXPRESS IT WILL BE AGAIN INDIVIDUAL. I THINK YOU CAN USE IT TO INFORM CLINICAL CARE BUT I WOULDN'T USE THAT TO BE THE SOLE BASIS WHETHER YOU GIVE SOMEONE AN OPIOID. EACH PATIENT IS UNIQUE. IT'S JUST MORE INFORMATION TO GUIDE YOUR CLINICAL DECISION MAKING. >> YOU HAVE TO RECOGNIZE WHERE THE SOURCE AND HE IS A BIO INFORMATICYST. >> THANK YOU FOR COMING AND JOHN, THANK YOU FOR JUMPING IN. I'M A PRACTICING ORAL MAXILO SURGEON. THERE'S STILL A LONG EFFORT TO KEEP THE DIALOGUE GOING. ARE YOU SEEING ANY CHANGES IN THE AGE IN WHICH OPIOID, THE OPIOIDS ARE BEING PRESCRIBED BECAUSE AS AN ORAL MAXILO SURGEON WE ARE SEEING MANY TEENAGERS GETTING WISDOM TEETH OUT IN THEIR TEEN YEARS. >> I THINK THE UNFORTUNATE THING WE ARE SEEING IN THE U.S. THAT WE REPORT ON WHEN WE LOOKED AT HEROIN, IT WAS GOING UP IN ALMOST ALL AGE GROUPS BECAUSE OF, I THINK, THE INCREASED EXPOSURE TO OPIOIDS WITH SOME OF THE DENTAL DATA WE HAVE SEEN, INCREASED PRESCRIPTIONS AMONG YOUNGER FOLKS COMING FROM BOTH, I BELIEVE, PROBABLY ORTHOPEDICS FROM ATHLETIC INJURIES AND FROM DENTISTS. IT'S HARD TO KNOW AGAIN WHAT IS THAT TIPPING POINT FOR WHEN PEOPLE MIGHT GET ADDICTED OR OVERDOSE. I THINK IN GENERAL, JUST TRYING TO WEIGH THOSE RISKS AND BENEFITS IN FRONT OF EACH PATIENT IN FRONT OF YOU, IS IT APPROPRIATE MEDICATION AND APPROPRIATE LENGTH OF TIME. I HAD A PARENT WHO HAD A PICTURE OF HIS DAUGHTER WHO DIDN'T MAKE IT TO GRADUATION, THAT WAS HER SENIOR PICTURE, BECAUSE SHE OVERDOSED FROM OPIOIDS FROM SHOULDER SURGERY. I THINK EVERYTHING WE DO HAS LONG-TERM IMPACT FOR BETTER OR WORSE SO WE REALLY HAVE TO DO WHAT WE THINK IS RIGHT. >> I WAS INTERESTED IN THE TALK HAS THE PHARMACEUTICAL INDUSTRY BEEN INCLUDED THIS THIS AND CAN YOU COMMENT ON THEIR GUIDELINES AND PRODUCTION? >> [CHUCKLES] I THINK WE ARE AT TIME. I THINK THERE'S BEEN SOME INTERESTING STUDIES OUT THERE. INCLUDING ONE BY CALEB ALEXANDER THAT SHOWED THAT WHEN YOU LOOKED AT THE PUBLIC COMMENTS IN RESPONSE TO GUIDELINE THE MAJORITY OF THE NEGATIVE ONE'S CAME FROM GROUPS THAT WERE FUNDED BY PHARMACEUTICAL COMPANIES OR POTENTIAL CONFLICTS OF INTEREST. AGAIN, I'M AN E.R. DOC SO I'M USED TO HAVING PEOPLE TELL ME ALL THE TIME, I BELIEVE IN LISTENING TO WHAT EVERYBODY HAS TO SAY. WE DID GET INPUT FROM PHARMACEUTICAL COMPANIES AS PART OF OUR PUBLIC COMMENT PROCESS. WE WEIGHED EVERY COMMENT CAREFULLY. THERE WAS GOOD INFORMATION ABOUT DOSAGES OR LENGTH, OR EVEN MANUFACTURING AND WE ARE HOPE TO WORKING WITH ANY PARTNER, INCLUDING PHARMACEUTICAL COMPANIES. PARTICULARLY, I THINK ONE OF THE THINGS THEY CAN LOOK AT IS NON-OPIOID ALTERNATIVES. I'LL LEAVE IT AT THAT. >> JUST A QUICK ONE, I'M CURIOUS WHAT PERCENTAGE, OR IF WE KNOW THE RESEARCH ON PATIENTS THAT ARE EXPERIENCING MORTALITY ASSOCIATED WITH MULTIPLE DOCS GIVING OP YATES. IF THAT'S A SIGNIFICANT PART OF THE PROBLEM, WHERE IS THE CONVERSATION AT FOR FEDERAL PHARMACY DATABASE, SO EVERY PRESCRIPTION MEDICATION COULD BE EASILY ACCESSED BY THE TREATING PHYSICIANS. I WILL LEAVE IT AT THAT. >> THAT'S A GREAT QUESTION. OFFHAND I DON'T KNOW WHAT THE SPECIFIC DATA IS. I KNOW WHEN PATIENTS ARE SEEING MORE THAN ONE DOCTOR AND GETTING PRESCRIPTIONS FROM MORE THAN ONE DOCTOR THEY ARE AT INCREASED RISK FOR OVERDOSE. THERE ARE PRESCRIPTION DRUG MONITORING PROGRAMS IN MANY STATES AND MANY ARE ON THE PLATFORM WHERE YOU CAN PULL THE STATE DATA FROM NEIGHBORING STATES. I THINK WHEN YOU LOOK AT IT, MAJORITY OF -- I THINK I SAW 90% COME FROM WITHIN YOUR STATE, 5% FROM A NEIGHBORING STATE AND THE REMAINDER OF THAT FROM ACROSS THE COUNTRY. AGAIN IT WILL MATTER IF YOU ARE CLOSE TO YOUR STATE BORDER OR NOT. BUT I THINK JUST USING THE STATE SYSTEM FIRST, IS A GOOD FIRST STEP. >> [OFF MIC] WHAT IS THE TRIGGERING EFFECT FOR ADDICTION OR TRIGGERING DOSE FOR ADDICTION AND THEN HAVE A FEDERAL DATABASE, THAT WOULD TRIGGER WARNINGS THAT THE PATIENT MAY BE HITTING THOSE THRESHOLDS. >> AS FAR AS TRIGGERING WARNINGS, RHODE ISLAND HAS A PILOT PROGRAM, NOT FROM THEIR P.D.M.P. BUT THEY HAVE PATIENT NAVIGATORS THAT HELP THEM ACCESS ADDICTION SERVICES AND TREATMENT. I THINK LOOKING AT P.D.M.P.'S OR DATABASES IS ONE THING BUT ALSO LOOKING AT POINT OF ENTRY INTO HEALTH CARE SYSTEMS IS ANOTHER TIME. IN MY MIND THAT'S ALWAYS THE TEACHABLE MOMENT TOO. >> OKAY, IF THERE ARE NO FURTHER QUESTIONS, THEN, THANK YOU VERY MUCH, DEBRA. VERY NICE TALK. [APPLAUSE] .