Hello, my name is Karen Farris, and I'm a professor at the University of Michigan College of Pharmacy. And I'm here because of my work with the Institute of Health Care Policy Innovation, where we have pulled together terrific collaborators from across the university to put together this opioid use and misuse MOOC for you. To start our conversation today, I'm going to have everyone introduce themselves. >> Hi, I'm Chad Brummett, I'm an anesthesiologist and a pain physician. And I'm one of the co-directors of the Michigan Opioid Prescribing Engagement Network. >> Hi, I'm Amy Bohnert, I'm a health services researcher and associate professor in the Department of Psychiatry at the University of Michigan. I'm here also representing the Michigan Opioid Collaborative. >> Hi, I'm Rebecca Cunningham, I'm the director of the University of Michigan Injury Prevention Center and a professor in Emergency Medicine and the School of Public Health. >> Hi, I'm John Ayanian, I'm a professor at the University of Michigan in the Medical School, School of Public Health and the Ford School of Public Policy. I'm also the director of the Institute for Healthcare Policy and Innovation. >> So if each of you could tell me what your organization does and/or talk about the research that you're doing as it relates to opioid use and misuse. >> The Michigan Opioid Prescribing Engagement Network or Michigan OPEN has really focused on what's happening in acute care specifically surgery, dentistry, emergency medicine, and trauma. And a differentiating factor of our group as compared to other groups doing work in the same space is we're really looking at patients not receiving opioids before the care, and their care and outcomes following those acute care episodes. Specifically trying to reduce prescribing where we know that prescribing has been an excess for many years for surgery, but also looking to eliminate unnecessary exposures things like dental extraction or minor surgery. And then our last pillar is really around safe opioid disposal, both getting excess medications out of the community and also trying to create a pathway for everyday disposal options. >> So I do research that looks at how treatment practices under real world conditions. So observational research relates to people's risk of opioid overdose in order to think about how healthcare systems can change in order to improve patient outcomes related to opioid use. That also includes some trials, clinical trials of studies to test out interventions that help patients change their behavior in ways to reduce opioid misuse and risk of opioid overdose. In addition to that the Michigan Opioid Collaborative is a project that's through the Department of Psychiatry where we work with all different sorts of treatment providers to improve access to treatment for opioid use disorders around the state. So a lot of the focus on that is to improve the number of people who are prescribing medications to treat opioid use disorders. But of course, there's a lot of other components of addiction treatment that helps support the prescriber and support the patient to improve their outcomes. Counseling and the processes that medical assistants and other people in a clinic do. Nurses often are the ones doing injections for some of the medications that are injection based. So we work with all different types of providers to help improve the entire care process. We've had success with doing that in the upper peninsula and other areas around the state where there's been very limited access. >> So the University of Michigan Injury Prevention Center has many pillars, our pillar around opioid really crosses a full public health approach. So within the area of research, we have multiple projects that are engaged in aspects from prevention through overdose prevention in health settings to community based work with naloxone. We have work in the education space where we're working to educate providers across the state and in partnership with our health department. We have work collating and assessing policies that already exist in making recommendations around the State of Michigan for how the state is best approaching this problem. As well as fundamental work in the surveillance and understanding of the basic numbers that we're dealing with both in here in Michigan and improving the system. We have of surveillance for both non-fatal and fatal overdose, so that we can get information best to local communities. So that they can make decisions about the programs that they're running. >> So the Institute for Healthcare Policy and Innovation is a community of over 600 faculty members at the University of Michigan, from 15 schools and colleges across campus. And our role in addressing the opioid epidemic is in bringing that strong community of faculty and the students that work with them together. To develop more rigorous research in partnership with groups on campus, such as the Injury Prevention Center and the Michigan Opioid Prescribing Engagement Network. [COUGH] We also support the Opioid Solutions Network in partnership with the Injury Prevention Center. This is a network that brings together dozens of faculty from across campus from basic scientists through public health faculty to work on a wide spectrum of solutions to bring different types of expertise to bear. And then finally, IHPI, or Institute for Healthcare Policy and Innovation helps to translate all the important research and policy work going on campus. So they can be used by policy makers, by health system leaders, and by community leaders who are on the frontlines of addressing the opioid epidemic. >> So now we can have open up our conversation. So as most of you as you know, the focus of this MOOC is on non-prescribing practitioners. So that could be MAs that are working in physician offices, it could be nurses, it could be a dental hygienist, pharmacist, so those non-prescribing practitioners. Could you each talk about how your organization fits within this, or why you think this is a positive thing to do for your organization? >> So much of the information that patients receive after an acute care episodes of surgery, dentistry comes from non-prescribing providers. And they play an incredible role in that patients outcomes, both setting the expectations for what to expect in terms of how long will my pain lasts? How long should I be on opioids, should I even take opioids, and if I'm not going to take opioids what are my alternatives? And I think these are all things that can be in reinforced. Our group has made patient education materials that can also be distributed. And again, this is a role where the non-prescribing providers can ensure that those patients receive those materials. And the last piece is it relates to disposal is really reinforcing the importance of disposal because this is something that I think resonates with anybody in our society. Everyone can relate to having excess opioids and the challenges of getting rid of those. And our non-prescribed providers can certainly play an important role in reinforcing the importance of safe storage and safe disposal. >> So in my role as a primary care physician here at the Michigan Medicine Health System, we have a team based approach to care where every day we're working with nurses, social workers, medical assistance, care managers. And while none of them are actually prescribing the opioids that our patients receive, their closely involved in the care of those patients and the management of their day-to-day needs. So when patients call for refills, when they come in for office visits because of pain related concerns, when they're seeking treatment for an addiction disorder. For example, our social workers and care managers are directly involved in interacting with community resources and programs outside the hospital that we're partnering with to refer our patients for care of their opioid dependence or addiction. And so they're very important members of the care team, and I think it's great that we're reaching out to provide this education. So that they can understand the broader dimensions of the opioid epidemic and what's being done to address it. To really reduce and hopefully eliminate the impact of excess use of opioids in our society. >> So the Injury Prevention Center, and first of all, so we're one of ten centers funded by the CDC across the country. And these materials, focusing with a public health practitioner approach. Are going to be incredibly valuable to public health practitioners in communities on the ground that are trying to get a handle on what's going on and really need the basic background information, all level set. So I think that's one really important piece. And our work across campus, across the multiple schools and types of faculty that are getting engaged in this type of research that may not be providers themselves but are researchers and using a public health approach. They need the basic facts and information that this type of module education will provide. And also this is a possibility to have availability for this information to communities outside of even our local communities here that our center is touch. But be available to a broad base of practitioners, which is also quite important. From an emergency medicine perspective, I can't agree more with John. That our nurses and our social workers need basic information that was not available during their initial training on this epidemic as they approach it with their patients every day, and so do all the power professionals around us. >> Yeah, to build and what all three of you have said from your clinical experience in particular. There's so much stigma around opioid use disorders. And increasingly our patients in the context of all that's going on to try and address the opioid epidemic. The patients who are on long-term opioid therapy for pain even without any opioid misuse or opioid use disorders say that they're experiencing stigma from clinical provider teams too. And as you said most of the clinical care, most of the interactions are actually not with the prescribers, with all the other members of the team. So I think getting all on the same page of the fact that opioid use disorders are a medical problem. And not someone who's choosing to behave in a way that causes problems for other people, treating people with compassion. Understanding what are the best treatment options that for most patients, medications for opioid use disorders are going to lead to better outcomes around their opioid use, around avoiding death from overdose. And being able to communicate effectively with patients that help bring them into treatment. Help improve their outcomes rather than pushing people away because they feel like they're being judged is really important. >> Why do you think that this is an important topic that the U of M addresses? >> So the University of Michigan with the 19 schools across campus has a vast amount of resources to bring to bear as a major research university in this state. And in the ability to get that information out to the communities because there's a lot of misinformation about opioid problem says Dr. Bohnert was saying. And we need our communities to have best practices. And we're really well positioned to help both generate those best practices with outstanding research, as well as to translate them through IHPI and other avenues to the communities that need them. There are the misperception so many people across the power professionals and the public health practitioners that are engaged with this, want to do the right thing. And we need our resources directed towards the parts of the evidence that are most likely to effect change here. And so that's one of the reasons I think University of Michigan is best poised. The other part, I would say is that Michigan has the ability to reach across so many of our communities. Through multiple facets of our schools through the school of social work through the school of nursing through the school of medicine and public health. So we're looking to be good partners with other universities across the state in our communities. >> I agree, University of Michigan in addition to being a top research university is one of the nation's leading health systems and delivering care to patients from across our region. And also a major site of training for health professionals in a whole range of different fields, pharmacists, nurses, social workers, public health professionals, as Rebecca was describing. So we really combine those three important missions of a university, research education, and patient care. And we can bring the expertise from all three of those domains to bear on this important problem. And I think that makes each one of them stronger than they would be on their own. >> Anything else to add? >> Yeah, I would add that historically prior to the increase in opioid overdose death. The majority of the problem and also majority of the research and clinical care around opioid use disorders and opioid misuse occurred in a lot of our Coastal large cities, right? Boston and Baltimore and San Francisco, but those places saw some increases. But a lot of what we're calling the opioid epidemic and what the start of it was, was prescription opioid use problems. So I think places like Michigan that have all of these academic and research strengths and have the breath of a university like Michigan. We have experience with the problems and what opioid use disorders look like in the parts of the country that probably represent a lot of what was the increase in problem. But that have historically been not as well research, not as studied or understood that think we can really help educate both within people are Michigan, but outside more broadly in the country. >> Well, one thing we've learned through our research is that the opioid epidemic is affecting all segments of society, urban and rural, rich and poor, different racial and ethnic groups. And so we need to have a comprehensive approach, it's not any one community or segments of society, that's especially affected. It's really spread to all parts of our communities. And so we need a comprehensive solution to the to this broad problem. >> Yeah, very true, and I think just building on what Dr. Cunningham said. This is a university that where people like to collaborate and want to work together, we're around this table now talking today. But we actually worked together closely already, and it has led to collaboration across campus. All the way from geneticists and the school of public health probing genetics of new chronic use and opioid misuse, to work at the medical school to even now engaging our school of music theater and dance to think about how to better reach kids. And I think that that is a unique feature or institution and something I'm proud of. >> Excellent, so we've all talked about some great things that are going on here at the University of Michigan. Can I ask a few of you to put this in context for what's going on around the country or maybe even around the world if you're aware of that? >> So thinking nationally, there's been a lot of investment at a federal level in trying to increase more research on opioid use disorders. So, for example, there's the HEAL Initiative at NIH which has started a large multi-state study of looking at how to implement programs to reduce opioid overdose. But also through the substance abuse mental health services administration. There's been a lot of effort across the US funding going to states to try and improve access to treatment for opioid use disorders and specifically for opioid use disorders. And then both at the state level and nationally a lot of policies that are being reconsidered and efforts to try and improve access. So for example right now, nationally, there's some conversation around removing the requirement that prescribers have weaver in order to prescribe medications for opioid use disorders. That I think could potentially change the nature of how we train people in addiction and treating addiction and potentially make it less specialized just to prescribers but more general training of whole clinical teams. >> I think I would add a little bit of a tangent from Dr. Bohnert, is the lessons that we learn as the nation and our state and our university comes together on this opioid epidemic. And how we address them are ones that will have deep impacts into public health and addiction for decades to come. Many of us worked on the cocaine epidemic and the crack epidemic in the 90s. And there were lessons that we learned from that, that we pulled forward. The ways that we train and these modules train our paraprofessionals as well as the other training that's going on around providers. On things as stigma as best ways to do surveillance, as approaches to addition, as working in really interdisciplinary teams across as really important and with public health on the ground to improve our communities. Those are lessons that we will hopefully use together that will address this particular opioid crisis. But will serve us for public health and for addiction quite well as we move through the rest of the century and address whatever the next drug will be. And there will be another drug, and there will be another public health crisis down the road that will engage all of these sectors, and those lessons will be really critical. >> And from a policy perspective at the national level, I would also add the importance of ensuring coverage and access to care. So that people can get the treatment they need if they have an opioid use disorder. And if they have chronic pain that they can also get the appropriate treatment to manage their chronic pain, which is a important root element of the opioid epidemic that we're addressing now. In that context of the Affordable Care Act has extended coverage to over 20 million Americans. A large portion of that coverage is come through Medicaid expansion in 36 States and the District of Columbia across the country. And we've learned from governors across the political spectrum how important coverage and access to care is for addressing the opioid epidemic. And governors both Republican and in Democratic have been strong advocates of making sure that, that insurance coverage and community based services are available with a partnership with the federal government. And the funding that comes through Medicaid and other federal programs. To make sure people are getting appropriate care, both for managing their pain as well as opioid disorders when that's an important part of their care. >> Thank you all so much for coming and sharing your perspectives on this important topic. I also want to thank each of you for opening up our MOOC, and hope that you continue to enjoy it.