Mikelle Moore: Hi, I’m Mikelle Moore, Senior Vice President for Community Health at Intermountain Healthcare. Here at Intermountain, we are focused on improving the health of our communities as we work to help people live the healthiest lives possible. For us that means thinking about the biggest health issues facing our communities, so prevention of diabetes, high blood pressure, conditions tied to obesity and health behaviors, as well as working to improve depression, reduce suicide rates and address the issues around us related to prescription opioid misuse.
Today that's where we're going to focus our discussion. You can't really read the paper today without seeing something about the opioid crisis in our community, where it is worse than many other places around the country. And many of these issues, they're complex, difficult to address, but Intermountain has a community health approach to improving it, and that's very much a result of the partnership we have with Dr. David Hasleton. Dr. Hasleton's our Senior Medical Director at Intermountain, and I like to say he's also our medical leader for prescription opioid misuse. Do you mind if I give you that additional title?
David Hasleton, MD: Sounds like a good plan to me.
Mikelle Moore: All right, we're gonna make it official one of these days. I really appreciate you being here, and more importantly I appreciate the work you're doing.
David Hasleton, MD: Oh, glad to be here. Thank you.
Mikelle Moore: Thank you. First, I'd really like for you to help me frame this issue, because we hear about this crisis both in Utah, we're hearing about it nationally all of the time. Could you share what Intermountain is doing to address the issue, and what you've been working so hard on recently?
David Hasleton, MD: Intermountain Healthcare recognized that Utah has a significant problem with opioid misuse, really in the prescription space. We've realized over the last probably two years now that we have a problem amongst our providers giving too many opioid pills. And not that the providers have done this with bad intent. It's all been how we've been trained to do this. So, Intermountain Healthcare has taken it on because we insure so many lives in this state and see so many people in this state, we really figured we could have an impact on this state and improve the health of our communities. So we've tried to reduce the number of opioids appropriately amongst prescriptions that are given to our patients.
Mikelle Moore: Good. How are we doing that?
David Hasleton, MD: Well there are a number of ways. Number one, we really start with focusing on the provider, the physicians and advanced practice clinicians who prescribe. And we educate them on what's an appropriate use or appropriate prescription use for their patients. For example, I've talked to the orthopedic surgeons, talked to the spine surgeons and other specialists who prescribe medication after surgery, and helped them see maybe there's some overprescribing going on, maybe there's a different way we can do this.
In the last couple of, well, about a year, we've had survey data go out to patients who have received prescriptions for opioids after surgery, and the survey data really shows we're using about 50 percent or even less than the total number that's been given on a prescription. For example, if a patient is receiving 100 pills of Percocet after their surgery, they're only taking 40 to 50 pills, therefore there's that much left over that can be diverted or misused in any number of ways.
Mikelle Moore: And I've seen that data as well, and I think there was a follow-up question if I recall, that we asked patients what did they do with those leftover medications. And by far, most of those prescriptions were left in people's medicine cabinets, right?
David Hasleton, MD: Oh, sometimes people really like to hold onto these. But more and more, the community's understanding is that this is a dangerous practice because these medications end up in the wrong hands, and then people run into opioid misuse disorder problems and they become addicted to these medications when they really had the chance not to be.
Mikelle Moore: And, how hard are those conversations, Dr. Hasleton? I mean I can imagine, you're an emergency medicine physician. These are physicians you've related to in your practice, but you're having a different kind of conversation with them when you're talking about their prescribing patterns.
David Hasleton, MD: I'll tell you, these are fun conversations. Some of them really easy…
Mikelle Moore: You have an interesting idea of fun.
David Hasleton, MD: Some have been easy and some have not been quite so easy. So, I see a number of patients in my own practice where they come in requesting medications for whatever ails them, whatever pain they have, and so I understand that from that perspective.
Now, I'm gonna jump back a little bit in time. When I was trained years ago in residency, opioids were thought to be a good medication for various types of pain, and we prescribed lots of them. So now, when I have conversations with physicians, surgeons in particular and others, they really feel like the way they prescribe is the best way to prescribe.
Telling a physician that he or she is not prescribing the right way, it oftentimes is not taken the best. Instead, what we try to do is educate them on the survey data, we educate them on best practices, and help them to see, for example in spine surgery, one doctor prescribes 30 pills to his patients post-op, and others prescribe over 100. There's a wide range in how the prescription is done, and so when the providers get together and look at their data in aggregate, they start realizing, “Well maybe I have room to move, maybe I have room to improve on this, because he's only prescribing 30 and having good results.”
When we show data to physicians and advanced practice clinicians, they jump onboard to say, how can I do better?
Mikelle Moore: That really is part of the Intermountain approach to continuous improvement-
David Hasleton, MD: Collaboration.
Mikelle Moore: Right. Working together to figure it out.
David Hasleton, MD: Yeah. And that's why I say this is fun. That's the part that's been fun.
Mikelle Moore: I can see that. Tell me, one of the things we heard as we launched this initiative was real concern, particularly from physicians who are managing patients with a lot of chronic pain wondering: How is our approach different? Because what we've just described is our approach to acute prescribing. What's the approach for chronic pain?
David Hasleton, MD: Chronic pain is more difficult and more complex, certainly. We've had concerns from those providers who provide medication for patients with chronic pain, and we've addressed it in two different ways. Number one, you need to keep prescribing the amount of pain medications you feel is best. We don't have a lot of data out there to suggest differently. Number two, look at your prescribing to see if there's any way you can do something different to improve their lives from a functional status. We’ve also asked them to be careful and not prescribe benzodiazepines along with narcotics, because we know those both medications will suppress the drive to breathe and have more significant bad outcomes.
Mikelle Moore: Are benzodiazepines typically prescribed for anxiety?
David Hasleton, MD: Sometimes sleep disorders. There are numerous behavioral health issues it will be prescribed for as well.
Mikelle Moore: So, sometimes it could be prescribed by a different provider than the one managing the pain, right?
David Hasleton, MD: Correct.
Mikelle Moore: Okay. Let's talk for a minute about addiction or opioid use disorder. What is it? I mean, really what's happening when someone becomes addicted, or we indicate they have opioid use disorder?
David Hasleton, MD: Yeah, opioid use disorder is the term we use these days and maybe in times past the word addiction was used. I think there's a better way to say it now, or at least to frame what people are going through. Because many times they got to this position without their choice. They were taking medication for post-op situations or pain. They became used to the medication and needed more and more and their body became used to it. The chemistry in their brain changes and therefore they need more and more escalating doses to achieve the same level of pain control. That’s what put them in a situation to come to us at times and say, “How do I change this; how do I get off of this; what can you do for me?”
Mikelle Moore: What do we tell someone to do, who we now understand has opioid use disorder? How are our providers at Intermountain right now working to address the disorder?
David Hasleton, MD: Yeah, good question. We can turn off the supply to some degree of acute pain pills in the community, but that only does so much to help. We really have to get on the back end and say, “How do we help those who do have this disorder?”
We've been increasing the number of providers who will provide what's called medication-assisted treatment, and we oftentimes use Buprenorphine in this. The number of providers who understand has also increased, along with public awareness campaigns that emphasize if you have an opioid use disorder that there are ways to treat it. People have alternatives to just continuing down the pathway with pills. We can successfully get you off this, and get you back into a regular life that you can enjoy.
We’ve also partnered with our community health benefit partners out there, including mental health benefit partners, our SelectHealth partner, and a lot of providers to make this work.
Mikelle Moore: Can you describe what typical medication-assisted treatment looks like? What does that entail for someone?
David Hasleton, MD: For somebody who's taken a lot of narcotics in their life and have become used to them, they have a pre-interview with a provider to see if they're a good candidate. They have to be motivated, there has to be a good social support system, and some other motivating factors.
Before they get to the provider to start their Buprenorphine, they actually have to go through mild withdrawals. Otherwise, if a patient who just took narcotics, or an opioid, was given Buprenorphine, it would put them into withdrawals. The initial visit is to see if they're a good candidate, but when they come in to take the Buprenorphine, they're in a mild state of panic and withdrawal. Once the Buprenorphine kicks in and starts working, they start to feel better, but that can take a few days. So, we really try to tell them, “About a week into this you're gonna start to feel normal again, but you have to give it some time and be patient.”
Mikelle Moore: I know right now at Intermountain we have public awareness information up in most hospitals, and from what I've understood that's something a lot of our physicians asked for, in terms of support.
David Hasleton, MD: It is.
Mikelle Moore: Can you talk a little bit about that? Why does that help, and can it do more?
David Hasleton, MD: Yeah, many providers have been asking for this for quite a while. Some really have wanted to reduce their opioid use in patients, but there's so much backlash from the community, from patients in particular, because they didn't know any different. They felt like if their provider was not giving them certain opioids, it was bad medical care.
Now there's support from Intermountain Healthcare and other community partners, with signs that say best practice is actually reducing or not using certain opioids at all. That’s a huge benefit for providers, and they feel like somebody's got their back
Mikelle Moore: I hope it's making a difference. Is there any negative reaction when people see that kind of signage up in our facilities, that you're aware of?
David Hasleton, MD: There has been a little bit. Not much, but a little bit. Just on the side that talks about the dangers. Some signs say, “If you take an opioid, really bad things will happen to you — and then people think in their minds ‘if I take one it's gonna ruin my life,’ which is not necessarily the case.”
The intent is to not cut off opioids completely, which some people think that we're doing, but to really use it appropriately.
Mikelle Moore: Yeah, I can see how we can unintentionally make people feel guilty, even, for using pain medication appropriately.
David Hasleton, MD: Yeah, there's a subsegment of the population that will not take opioids at all because they feel like it's a very bad thing to do.
Mikelle Moore: For me that raises an idea we talk a lot about when we're discussing these types of community health issues around stigma. There's still some stigma in our communities around talking about issues like depression or suicide. Opioid misuse is really similar. As we talk more in conversations like this, I think we're helping to reduce that stigma.
David Hasleton, MD: We definitely are, yes.
Mikelle Moore: Right? And we don't want to create new stigma for people who take opioids responsibly and appropriately, right?
David Hasleton, MD: We worry about that. Yeah.
Mikelle Moore: Okay. I think it's important that we have the right discussions.
David Hasleton, MD: And the signage we put in our hospitals and in our clinics needs to reflect that, certainly, and not create guilt or feelings that if you take any opioid at all it's gonna be a bad thing. It is good in certain situations.
Mikelle Moore: Yeah, that makes sense to me. So, we've talked about several of the goals that we have at Intermountain to reduce prescription opioid misuse. How are we doing so far?
David Hasleton, MD: Great question. We're doing fairly well. We sit just below 30 percent, maybe around 28-29 percent total toward the goal, and our goal is 40 percent.
Mikelle Moore: And that's 40 percent reduction from the number of pills we prescribed a year ago, right?
David Hasleton, MD: That's correct, yes, in 2017. Our 2018 goal is to prescribe 40 percent less. We have more work to do, and we're working hard to make that happen.
Mikelle Moore: We're just a little past half the year. That seems like really great progress, particularly when you think about how that goal was set. When we started talking about this as a goal it was right about a year ago. Did you know how we were gonna meet that 40 percent goal?
David Hasleton, MD: Well, we didn't know right away, but we had a passion for it. And I think that drive and that passion for helping our communities — to improve their health, to improve their lives, and improve the families out there — we knew that would drive us forward to have the right answers. Thus far, we’ve made a lot of good choices, but we have a ways to go.
Mikelle Moore: Do you think that, I would guess that we could have just as easily said, “How about we reduce our opioid prescribing by 30%?”
David Hasleton, MD: Oh, we could've, and we're already there.
Mikelle Moore: Right. So, do you have any worry about the goal that we set, being as bold as it is?
David Hasleton, MD: It has taken a lot of effort. But if it is the right thing to do, we will do the right thing no matter how hard it is to do it.
Mikelle Moore: Why did you agree to get involved in this? I mean, this isn't necessarily what you were trained to be a part of.
David Hasleton, MD: No. I agreed to be involved because I see this in my practice. I see the harm it has caused. I see the pain its caused to families. I've seen opioid overdose deaths. And I've dealt with the families on the back end. I’ve sat and cried with them and held their hands; I've seen the difficulties. When I look at this from a personal perspective, I want to get involved and help. I want to make a difference for patients, communities, and providers, to improve their satisfaction and their ability to come to work and say, how can I treat my patients better? What can I do to improve the overall health in this community?
Mikelle Moore: When you say that, for me it really connects to what we all came to Intermountain to be a part of, or why we came to the profession of healthcare. I really applaud you for making this journey. I know it's been hard work.
David Hasleton, MD: It's a fun journey, and it's worth every bit of effort. If we can help even one person, one family, and one provider, then we've done good.
Mikelle Moore: I agree. So let's explore that for a minute. If someone wonders whether a family member or a loved one or a coworker may be misusing prescription opioids, what would be the signs?
David Hasleton, MD: That's a good question. If a coworker comes to me and asks, “What are the signs I should look for if my family member, my partner, my child is overusing or misusing opioids?” I would look for signs of disconnectedness, meaning that person disconnects from the family or the typical relationship, they're missing work, or they seem to fall asleep far too often when they shouldn't be (the middle of the day for example, or during meals). Some people literally fall asleep over their plate at the dinner table. And their behavior is strange and odd. Those are the questions that should be asked when you see those behaviors. Then you want to know, “Is there something going on in their life that would indicate an opioid use disorder?”
Mikelle Moore: Okay. I have people approach me all the time who have some connection to this in their lives and I know you do as well. What can we do in our communities to create safety? I know we've been distributing Naloxone kits. Can you talk a little about that and how it helps?
David Hasleton, MD: Yes. To improve the safety in our community, for those who are appropriately using opioids, Naloxone is a great way. It's one way, but it's a great way. There are other ways, certainly. We’ve talked about the public education, provider education, but Naloxone has been a significant benefit. It gives families and patients peace of mind to know that if something does adversely happen, there's a way to reverse that quickly to save their life.
Our pharmacists have been given the leeway to give this medication, this Naloxone kit, to a family and/or patient when they receive an opioid at the time of the prescription pickup. They don't need a physician to write a prescription for it. They'll actually use my name on this, and then I get a report every so often that shows me how many patients and who received this medication. It is a huge satisfier for patients to know, “I'm safer because Intermountain Healthcare cares about this and our pharmacists care about this.” At the point of contact with that pharmacist, they educate the patient. They tell them about narcotics, opioid use disorder, and the signs of overuse, as well as how to use Naloxone. This is all part of who Intermountain Healthcare is and the care that we have for our community.
Mikelle Moore: I've been trained on it as well, and Naloxone is not very scary to use. It’s a lot like the training that many of us received to perform CPR. A couple decades ago, that was really the routine new thing. Similarly, this seems to be moving toward becoming a part of our routine way of protecting our community.
David Hasleton, MD: Naloxone can be given as a nasal spray. The kits we have are a simple shot, and it's a reversal for the opioids. So, if somebody is falling asleep, well more than falling asleep, if they're not breathing and they were taking opioids, Naloxone is the way to save their life.
Mikelle Moore: Dr. Hasleton, thank you so much for joining me in discussing this topic today. You are making a tremendous impact on our community, and helping us improve outcomes related to prescription opioid misuse. Thank you.
David Hasleton, MD: My pleasure to be here, and thanks for having me.
Mikelle Moore: For more information, please check out our website, or for more specific information about prescription opioid misuse, go to our partner's website.