Our next speaker is going to speak about pain and narcotic addiction in neurosurgery. It's my pleasure to introduce Dr. Ellen Ayer. She is the co-director for functional neurosurgery at Henry Ford Health System, which I was 11 years at Henry Ford, which is a wonderful place to work. She has a faculty appointment at Wayne State University. She completed her BA from Northwestern and went on to earn her MD and PhD in neuroscience at the University of Cincinnati. She completed her neurosurgical residency at the University of Cincinnati and then went on to complete specialty fellowship training in epilepsy and functional neurosurgery at UCSF. At Ford, she is responsible. Her focus is neurosurgical treatment of movement disorders, epilepsy, and pain. She is very involved in research, and she is treasurer for the AANS-CNS Joint Section on Women in Neurosurgery. It's my pleasure to introduce Dr. Ellen Ayer. Thank you. Thank you all so much for having me, and as was just mentioned, you know, the opioid crisis is something that, these are my disclosures, it's on television all the time, right? We're seeing this as an issue to be discussed, and what I want to focus on is what we can do as a practitioner community to try and attack this head on. Despite looking at everything that's on the news, I'm still struck every time I recognize exactly how many prescriptions are out there. There are 260 million opioid prescriptions filled every year. That's enough for one bottle for every adult in the United States. So we are still at a point where many, many prescriptions are out there. And it has resulted in a growing toll for the community. About 2008, drug overdose overtook the death toll for relative to motor vehicle accidents. So this has been largely around opioid prescriptions, as you can see on the right-hand side, but as there has been a dip in opioid prescriptions, we are seeing an increase in heroin-related deaths from individuals who have probably gotten hooked from prescription drugs from the outset. And the government has taken notice, and they've really been hitting this hard, even more so just recently here. So big things have now happened. Just in this last year, the DOJ, DEA were able to convince a major pharmaceutical company to pull their extended-release opioid from the market. And they're taking additional steps. They've proposed cutting Schedule 1 and Schedule 2 production, so actually limiting how much the pharmaceutical companies can produce, reducing it by 20 percent, and have established an opioid fraud and abuse detection unit. This has really, this unit has been focused on opioid-related healthcare fraud. It is using big data to identify and prosecute individuals that are contributing to the prescription opioid epidemic. So there is this big news release back in July talking about 400 people-plus that had been charged with healthcare fraud. More than a quarter of those were because of opioid deaths. So I think most of us in this room, all of us in this room, I think have, feel a very strong responsibility towards our care of our patients and the opioid-appropriate prescribing. We're now getting additional, you know, incentives to try and stay on top of it. As I looked at all of this data, I thought, you know, it was kind of easy for me to say, wasn't me, I didn't do it, it was that guy. We got rid of him, right, it was that one. I'm not part of this as a problem. I'm giving what the patients need. So I was really struck looking at this issue in my own practice and some data that I'd like to share with you from colleagues at University of Michigan I think really highlights this. If I look at my own practice and what I expect for post-operative complication rates, on a high end I might say, you know, what, 2% maybe, operative complication rate is a pretty, you know, it's a good, generous. But I think we need to start looking at the additional post-operative complication, which is new persistent opioid use. On average, and this is mostly from general surgery procedures, the average is about 6 to 7% of patients become new persistent opioid users after surgery. That's to me three times the complication rate of what we otherwise expect from surgery. And I think a lot of this has happened quite innocently when they looked at prescriptions following lap coli at U of M. This is the number of opioids or prescribments marked there about how many Norco these are equated to. So the vast majority, 77% of prescriptions fall into this category, right? So the average 77% of prescriptions fell into that 30 to 60 Norco range, okay, and those are actually in morphine equivalents. However, what did people actually use? Well, the average use was either 10 Norco or 7 Oxy, so 50 oral morphine equivalents. The median use was 30. So look at the mismatch between the prescriptions we've been giving and what was actually being taken. And the vast majority of people are not disposing of these excess opioids. And it's been a very easy thing for all of us to do, right? We don't want to get those additional phone calls for refills. At University of Michigan, just for the simple procedure, they said, okay, you're going to reduce to only this many prescriptions or this many pills after a lap coli for an opioid naive person didn't actually result in an increase in the number of phone calls. So there are little things that we can do by just keeping track of what it is that we are prescribing. In neurosurgery, as you all know, though, most of our patients or a lot of them are not opioid naive. We are dealing with a different situation. And it is a cycle of patients that have pain, anxiety, sleeping problems, not coping. None of these do well when it comes to gaining good pain control. And so they're presenting to us in a complicated situation. If they're on opioids, a lot of their mu receptors are probably already saturated. And they can even get to the point of having an opioid-induced hyperalgesia. I actually had this not that long ago where a patient was screaming, screaming in pain postoperatively, and they gave another injection to help with the pain, and it only got worse. We required overnight stay in it for an outpatient procedure for the patient to get a ketamine drip. When we are operating on a patient who has a predisposition or has already been taking opioids, for every 10 morphine equivalents per day, preoperatively, that a patient is taking, you should expect almost one morphine equivalent per hour needed over normal, your average opioid naive patient. So if that patient comes in and is taking Norco 10s three times a day, that's basically an extra 2.5 milligrams of morphine every hour addition that you should expect that patient to need following surgery. And then we're also dealing with this other problem, right? Surgery and the Jedi mind trick. We get patients who are sent to us who have been taking opioids for their back pain or something, and the physician who's been prescribing the medication says, opioids aren't the solution. Surgery's the solution. Right? You're going to go, you're going to get the surgery, and it's going to be a miraculous thing, and you won't need your opioids anymore. Unfortunately, not so much true. So if we look at postoperative opioids in chronic users, patients who were taking opioids prior to surgery are far less likely to be off of them a year later. 60% of patients who were taking preoperative opioids have persisted in using opioids after surgery. And this is associated with an increase in complications and healthcare costs. Patients, and this is, again, data from general surgery where we're seeing an increase in hospitalization costs, an increase in complication rate, and rate of readmissions. So this is, you know, a real issue that is going to come back at us from the point of cost control as well as patient safety. So what is it that we can do to try and address this? Well, certainly we can prescribe fewer opioids to naive patients. We can wean long-term users off of medications when appropriate. And we need to learn about effective alternatives. They are out there, but we haven't been quite so familiar with them. They haven't been an at-hand toolbox in caring for patients. So I want to present to you a little bit the toolkit that I think of and what is out there at our disposal to help us be clear about what a patient's preoperative position is relative to opioids and how we can best help them. So I want to touch on a couple of things that are out there, including prescription drug monitoring programs, opioid conversion tools, encouraging disposal, and then knowing your state board guidelines. So prescription drug monitoring programs have become fairly universal. In Missouri, actually, they do have them, but it's only in certain areas, from what I understand. They have not gotten to a statewide, and in D.C. they're still getting theirs fully outrunning. But pretty much every state has their own. And it's a central database of all Schedule II medication prescriptions for any particular patient. What's nice, I know, in Michigan, where I am, we have the ability, when we log in, to actually check other regional states. So I can tell if somebody has gotten a prescription from Indiana or Ohio. And the best development that I see coming forward is that this is getting integrated into the electronic medical record. So very soon, at our institution, I know, we'll be able to get it through Epic, which is what we use. And really being able to check this to know what the patient is taking and what has been prescribed can be very helpful. It's often quite enlightening. Our system, it says what the equivalents are and how much of it is sedative medications versus opioids or whatever. And it'll give you a summary number and you're like, wow, I didn't look at what the patient told me they were taking and translate it into, wow, how much medication they really are taking. So I think it's very helpful. But not all systems have that. And so opioid calculators are very helpful. And these are just a couple that you can find and you can download onto your smartphone. The New York City opioid calculator is very helpful. I like the one, FM-ANSA, on the right just because it allows for including different types of medications. You may have a patient taking a fentanyl patch in addition to oral medications and it'll translate all of that so that you can see how many oral morphine equivalents per day a patient is taking. And then disposal. I share with you this website that the DEA offers. I will tell you there are a lot of patients who won't go to this because they don't want to think about the DEA or the government, you know, handing over excess medications to the government who's now looking at you. But there are sites all over. In our institution, we have recently gotten disposal bins in every single one of our pharmacies. So we now include teaching on our after-visit summary and direct patients on our after-visit summary to what the locations are that they can dispose of any excess medications relative to any prescription. So I think part of the important thing here is really understanding the state rules of where you practice because it is quite variable. And I have on here the Federation of State Medical Boards website. If you just go to fsmb.org, you'll be able to get to their summary page and also directly to your own state board regulations. The state rules are variable. But they generally address the duration of a prescription, what CME requirements might be there, what your responsibility is to use the PDMP for your state, and what documentation requirements there are. Now, they're variable. They've kind of been generated out of a couple of key documents that have been put out there. One is the CDC guidelines. CDC guidelines establish a duration parameter for prescription of opioids for acute pain. Three days or less is often sufficient. And more than seven days is rarely needed. You as a clinician need to evaluate the benefits and risks one to four weeks after initiation and repeat that evaluation every three months. If you are not seeing an improvement in function, and I really underline function, this is not about pain control score, then you should be tapering and discontinuing the medications. It's often one thing that we have been, you know, pushed to the back of our mind is, are we actually improving the patient's function? I think the article that came out very recently in the New England Journal showing that patients who were prescribed Tylenol versus opioids at a year had absolutely no difference in their pain control and actually the patients who were taking the Tylenol were doing better. So we, if we're not actually achieving improved function with opioids, we're not getting the results that we're looking for. So for a patient who is taking more than 50 morphine equivalents per day, you really need to reassess the benefits and risks when increasing above that and review the PDMP again every three months. You really need to justify titrating anything above 90 morphine equivalents per day. And the CDC guidelines also really encourage that you should have a urine drug screen at initiation and at least every year. But spot urine checks are also encouraged. Avoid benzo and opioid combination. I know in the spine cases they do. This is a tough one. How many patients have gotten a spine fusion and are getting Valium and Percocet for their pain and for their muscle spasms? We've been changing our utilization of Valium quite a bit and moving to non-benzo muscle relaxants. The second group that has placed their recommendations that you will see in your own state guidelines is the American Medical Association Opioid Task Force. And while they had similar recommendations, they feel that it's a requirement that all physicians and prescribers should be registered and use their state PDMP. They push for co-prescription of Naloxone to patients that are at high risk of overdose. I will tell you this has been a big conversation in our institution because who really feels comfortable prescribing Naloxone and who do we give it to? In our neurosurgery department, we haven't gotten to that point, but we're working with our pain management colleagues to identify which patients that might be the best thing to do. And again, the AMA recommends safe storage and disposal of opioids in all medications. So what are the things that we can do? How can we be the champions of appropriate opioid prescriptions? And keep in mind, I'm not up here to tell you you should not be using any opioids or not be prescribing any opioids. I have a heavy, heavy pain practice. I'm a functional neurosurgeon, so in addition to treating Parkinson's disease and epilepsy, I do a lot of spinal cord stimulators, a lot of pain procedures blocks, whatever, for patients with chronic pain. So I am working with this population all the time, and there are times patients need opioids. It's just what needs to happen. But I'm really moving towards incorporating a multimodal aspect to the pain management, both pre-, intra-, and post-op. Preoperatively, I will counsel patients who are taking more than 60 morphine equivalents today. I share with them how much more difficult their pain control is going to be afterwards given their baseline opioid requirements. And in a number of situations, I will wean their opioids prior to surgery, particularly if they're undergoing a bigger surgery where I know, you know, if I have to do a spine fusion, those are patients where I know their pain control is going to be very difficult. I will really work to wean their opioids prior to surgery. Generally, try and do this by about 25% each week, starting with the long-acting medications first and then the short-acting. And our goal is to decrease narcotics by about half prior to surgery. So for elective procedures, try and be a little aggressive about this. Preoperatively, looking more and more at multimodal analgesia. In my practice, I have a fair number of patients who are taking gabapentin or Lyrica. And I may increase that dose prior to surgery. Even for a patient who has not taken any of this, not has been gabapentin-naive, a single dose in the pre-op area before going to surgery can significantly decrease their opioid requirements after surgery. So it's a very simple thing that can be done in our anesthesia practice at Henry Ford has moved to doing this. Should also be considering whether or not the patient has taken a TCA or an SNRI, specifically nortriptyline, dezepramine, duloxetine, or venlafaxine. These are very useful, and a lot of patients haven't tried them. I'm always surprised at how many have not. For localized peripheral neuropathic pain, topical lidocaine can also be very helpful. Now, skipping here from pre- to post-operative management, I don't think most of us are actually managing the intra-op. But having the conversation with the anesthesia team about intraoperative management, we have, as part of our own systems opioid task force, have really tried to overhaul our approach to intraoperative and emphasizing more local preoperative blocks and ketamine intraoperatively to try and reduce opioid use during the procedure itself. Post-operatively, we're generally prescribing acetaminophen if we can, given their liver issues, around the clock. It is often synergistic, additive certainly, but can be synergistic in the use of opioids and has been shown to reduce the opioid use overall. In somebody who's been using higher doses of opioids, obviously, we're sort of breaking out Tylenol acetaminophen from the opioids rather than the combined because of the wanting to keep the acetaminophen to less than 3,000 milligrams per day. If you can prescribe NSAIDs, if they're not contraindicated, they can result in a substantial reduction in pain, and many randomized controlled trials have not shown a difference in post-operative bleeding with the use of these. And we can go into the arguments about whether or not it affects spine fusion as well, but for a patient who is opioid naive, Tramadol can be a fantastic alternative for a patient. It's a weaker mu-opioid binder, but it also has SNRI effects. So we're hitting the pain control in two separate ways. A lot of patients look at it as being less potent, but if they're opioid naive, it's still going to be pretty good. And it has a lower risk of addiction, constipation, and a very small risk of respiratory depression. We've gone to having a very low threshold of putting patients who have high pre-op opioid use on telemetry in surgery, or after surgery, because it is a, that is a group of patients. You may think that it's going to be the opioid naive patients, oh I'm afraid I'm going to give them a dose and it's just going to knock them out. I'm sure some of you have experienced this, the opioid tolerant patient who is in pain, in pain, in pain. We're giving them more and more and they are wide awake, they are screaming, they are yelling for more pain control. And they will go from being absolutely wide awake with great vitals to out. Respiratorily depressed, drop their blood pressure, that line is very narrow. They are not coming up to a point and dropping, and then, you know, slowly decompensating. They are just falling off a cliff. So these are patients, particularly if they have a history of sleep apnea, we have gotten a much lower threshold to put them on telemetry. And also, more aggressive about working with our pain team inpatient for patients who are on more than 60 morphine equivalents per day prior to surgery, particularly for the big surgeries, like a big spine fusion where we know that they're going to be looking at increased opioid use postoperatively. I start this process talking to patients about expectations early before surgery, obviously for our elective cases. And establishing expectations. You're on opioids, so an example, implant spinal cord stimulation devices. So you are taking this now. I will expect, I will increase your opioid prescription to this after surgery. We'll make some adjustments as needed. But by one to two weeks after surgery, I expect that you are going to be back to your preoperative dosing. And since you will be getting, we believe, the benefit of spinal cord stimulation, that will then, after about two weeks, be the point to which we start looking at further reducing your preoperative opioid medications. So that is a conversation that I have pretty routinely. And since I do enough of these cases, I have a pretty good handle on how likely it is that a patient's going to fit that path. But having that conversation makes it so much easier, so much easier, and really reduces the number of phone calls that we get after surgery. Because the patients know, okay, this is normal. I'm supposed to have this increased pain. I'm not going to be at zero pain. I'm getting something to help with it now. But about two weeks from now, I'm going to be doing better. For patients who are still on prescription pain medications 90 days after surgery, work on developing a plan with, it says here, PCP. But whoever it is that's been prescribing their preoperative opioids, and encourage them to taper off. Because particularly if they're not having increased function at that point, as I mentioned before, opioids are not helping. You don't just want to send them back. Now, I have the benefit in my practice that a lot of the referring physicians, because of the type of work that I do, are people that I work with all the time. So we kind of have a paradigm in which we work. You know, I have the pain, referring pain physicians for the spinal cord stimulator, the epilepsy patients, whatever. We've had that conversation. If you have high referring physicians, having that conversation for what that expectation should be for a patient of theirs that's going to undergo surgery, for which they've been prescribing opioids, is very helpful. And reduces a lot of the back and forth of, well, they said you were going to prescribe. And they said you were going to do this. And now you're telling me I can't get this anymore. I also emphasize to patients the issues of opioid-induced analgesia. Patients don't think of this as even a possibility. What do you mean giving me more opioids can make my pain worse? Sharing that with them helps. Share the risks. Certainly telling a man that long-term opioid use can lead to hypogonadism. It's kind of a helpful, that makes it, they file that one away, I'm just saying. Women, you know, will tend to, well, I'm already at risk of osteoporosis, if I keep taking this, this is going to be even worse. Okay, I'm going to think about that. And then discuss whether or not it's a situation where naloxone prescribing would be helpful. Do know that the AANS and CNS are out there advocating for us on this. We're all aware that there are so many cases, particularly in neurosurgery, that just don't fit these guidelines from CDC and the states and AMA, right? There are just patients that this is not, seven days is not going to help. And I know that in Michigan, it's becoming a hard and fast rule that no prescription can be longer than a seven-day prescription. And you cannot predate a prescription. So you can't see a patient and then give them the prescription, you know, three weeks and just, you know, forward date. Apparently, they are going to let us prescribe or write multiple prescriptions all on the same date, but say do not fill until. So a little bit of a help on that. But, you know, the AANS and CNS and in particular our pain section have been working very, very strongly to push back against some of these things and at least be able to get some parameters for groups of patients in which a seven-day limit to a narcotic prescription can be bypassed. Another great thing that I'm looking forward to getting enacted in various states is allowing for partial prescriptions. A lot of patients, you know, you give them a prescription because you think this is what they're going to need, but they might not need at all. And, you know, the patient's just nervous about getting, having something. What if you told them they, you know, you're going to prescribe 30 Percocet? You can pick up 10. You can pick up those 10 for a lower cost. And, therefore, if you never need anything more, you've saved money and you don't have extra pills laying around. However, if you need the extra, you can just go back to the pharmacy and get the rest of the prescription. And it's not a big rigmarole. So that is an initiative that I have been fighting for very strongly. Again, encouraging multimodal treatments and encouraging addiction treatment. I have not spent that much time focusing on the addiction aspect of this. But, obviously, it's something we should be aware of. And if we have patients where we're getting a lot of very strong anger and emotional responses to these conversations, we need to think about directing them to addiction care services. So take-home messages. We need to reduce opioids. It actually improves outcomes. It does not mean that patients need to live with their pain. But we need to be aware of what those alternatives are and be comfortable with prescribing them. So I like to think of sparing opioid use. So setting expectations is absolutely critical. Use a pain contract. Anytime you think a patient is going to be getting an opioid prescription for more than 30 days, and definitely, if anybody, for more than three months. A pain contract, very helpful. Advise, be in contact with PCP and pain clinic and anybody else who might be prescribing these medications as needed. Reduce the prescriptions. And then encourage disposal. I would like to certainly acknowledge my close colleague, Dr. Schwab, who is also at Henry Ford, who has worked with me a lot on this in our entire opioid task force. We have taken kind of a behemoth of a system across five hospitals and set a goal to reduce our opioid pills by 40% over the next year. You can imagine the magnitude of trying to do that. But we've already made a lot of progress. And that's really because of the individuals listed on this slide. Any questions? I'm sorry, you mentioned the NSAIDs and other studies for spine patients like this. I don't know if I mentioned this. So, it's been inconsistent. And so, it kind of depends on a little bit of the spine surgeon's philosophy. There are people out there, probably still most people out there who say, oh, heck no. I'm not giving NSAIDs to anybody who has had a spine surgery. I've certainly become a lot more aggressive about using them in non-fusion surgeries and letting them do it earlier. The data is just kind of, it's mixed and everybody feels so strongly about, am I going to get a fusion here that you're just never going to, unless there's a definitive study that comes out about it, where I think we're kind of stuck with surgeon preference on that. When you decrease the, the patient comes in with a lot of opioids and you decrease them before surgery, how long do they have to be at that lower dose for that to be effective to help them post-op? Honestly, even just a couple weeks. I mean, if you can go one week to the next week, reducing them by 25%, you've already made a big dent. If you can get them to 50% two weeks before surgery, you've made an even better dent. So, I would say we're probably doing it, getting them down over about two weeks and then probably, you know, they've been on that lower level for a week or so before surgery. But it does not take that much. So, I have a couple of comments. Do you use Expira in your surgeries? So, I wish my, one of our chief residents was here because she has been arguing with the hospital about this. It's a money thing. So, this is the longer acting injection of anesthetic, right? And the problem is, is that it's very, very expensive. So, in some procedures, what we're actually trying to do, and I don't know, I'm sure there are probably some other people out there who are working on similar initiatives to say in a certain group of individuals, can we do it and just do a direct comparison in our hospital of whether or not we're actually long-term saving money by spending that money up front. We even had this battle with IV Tylenol for a while. The price of IV Tylenol went way up. And so, the hospital really was like, you know, you can't use this except in certain situations. But we're finally getting to the point of being able to show that that extra expense of a couple hundred dollars at the time of surgery does make a difference in terms of overall length of stay and expenditure. And so, my other comment is, what do you do for the patient that's postoperatively screaming and yelling in pain? You've given them a fair amount of narcotic. Vital signs are absolutely stable. They have no increased blood pressure. They have, their heart rate is fine. You walk out of the room, they look like they're sleeping, but the nurse is calling you, and this is a big problem in my ICU, this patient's in pain. You have to do something. You have to do something. And it gets to the point where you're not pleasing the nurse because she wants that patient to have zero pain. Or to just be quiet. And it's like, you know, I'm going to stop, this patient's going to stop breathing soon. Right. What do you do? That's education, education, education. That is, and that's, I think, for us, has become one of the benefits of there being a system-wide initiative is that we are now working on educating. And sharing how those patients in particular are going to be at your highest risk of having an overdose situation. And having a, you know, a nurse alert or whatever you, pre-code call, whatever you call it at your institution. So, education is absolutely critical. That also goes at that moment for me to having the conversation with the patient and with the provider team in the hospital. So, with patients say, you know, I'm not looking for you to be in pain, I'm not telling you, you just have to sit and live with this pain. I'm telling you that that next dose of opioids is probably not going to be the solution. And so, we need to start adding or looking at other medications. And please be a little bit patient with us. And we also aren't going to get you to zero pain. Zero pain is just not an attainable or an appropriate goal. We want it to be manageable. We want you to be up and moving. And what are the other things that we can do to make your pain manageable? So, if we have that as a conversation that now changes the discussion between the patient and the nursing team or other providers as well. Yeah. What are the chances that you get your patients to be 50% less narcotics before surgery? And I just have one comment about the treatment patients. Like, is it by muscle relaxants? Because I know I can give them and save as much as I can. But in my experience, I found it very helpful. We use muscle relaxants a lot, absolutely. My main point about the muscle relaxants, we have gone away from using as much volume as we were previously, just to reduce our co-benzo opioid prescribing. But absolutely, and there are patients, I would put that on the top of the list. I would, I think probably a lot of people do to say you're getting around the clock for the first 24, 48 hours of it. It's not going to be as needed. You're just going to get it. So, I've gone to a lot more of that. The conversation about reducing the medications ahead of time, obviously, if you're the one who's doing the prescribing, you have a little bit more control over whether or not they're actually reducing their medication. But I really try to focus that conversation around expectations postoperatively. And that you're probably really, really, really going to be miserable if we don't, after surgery, if we don't do this now. It can be a hard sell sometimes. But I think, and this is one of the things I'm now kind of working on in my, in our system, is how do we have those conversations with patients in a way that really allows for buy-in with the patient, because that's what you need. But I really do emphasize if we don't do this now, it's going to be so much worse later. Yeah. Communication. Having that conversation with the physician who has been prescribing ahead of time. So, particularly if somebody's been on a high amount of opioids, I would just talk to that individual and say, you know, I'm concerned about how their pain control is going to be after surgery if we don't do something about this now. Can we come up with a plan together to reduce their preoperative opioids? And then let's go ahead and talk about what it's going to, what our plan is afterwards. I will continue to prescribe for the 90 days, or whatever it is that you feel comfortable with after surgery. And then we need to transition back. I will, you know, oftentimes I'm like, I will work on my end during that 90 days, even if I'm doing the prescribing, to be weaning down during that time. Can we agree with the plan on that? Again, I have a little bit of an advantage in the work that I do is that I have, you know, a variety of prescribing physicians that are, and referring physicians where we have sort of a rhythm to it. And I absolutely will prescribe what is additionally needed. If that physician is going to keep a patient on long-term background, it's kind of like, I will prescribe the over and above. They will stay on their background prescription, and then go back to that physician. Most of the physicians that I'm working with are looking to wean it afterwards. It's a conversation. And I think that is the most appreciated part of the process, is whoever was prescribing it before. Because they otherwise feel like they're getting left out to dry, too. Like, it's unsatisfying on both ends of that if you haven't had that conversation and be on the same page. Another comment, and just I think what has led to part of this huge problem is patient satisfaction surveys. And I remember, you know, that meant so much when you'd sit down in the department, and the chairman would say, you know, well, your satisfaction surveys weren't really good because you didn't, you know, patients are writing that you're not adequately treating their pain. How do you think that this is going to affect our practice now as we are trying to pull away from making these patients happy with their narcotics? Absolutely. I get that. So we've, as our opioid task force, we've gone out to basically most of the departments in Henry Ford. Like, particularly amongst the surgeon groups. Like, number one comment after we are done giving the grand rounds is, but if I don't give them medications, my presbyopia score is going to go down. Right? And that is a real concern. Because press Ganey scores are still affecting our reimbursement. Right? So that is actually changing our reimbursement with CMS. So CMS is kind of asking for a couple of things, right? They don't want us prescribing as much, but they also don't want, they want you to keep your patients happy. So I don't know that I have the perfect answer for this now. I actually am running a subcommittee in our health system on communications around this issue. Because I do think that most of it comes down to that. It's going to be very helpful for larger systems where if you can get everybody on the same page, then the, you know, the physicians generally are having the same conversations with the patient. And you're not getting contradictory responses or contradictory education to the patient. So that, I do think, will be helpful. But that's why, even if it's somebody outside of your system, having a conversation with them so that you're on the same page and the patient is not playing one physician off the other will be helpful. I am experiencing with the increased highlight on this in the news that patients are coming into the office with a slightly different set of expectations than they used to. And I've really only seen that in probably the last year or two. So it's becoming a little bit easier to have that conversation. I do think we have to recognize the anxiety that comes with that fear of being in pain and it not being treated. For most people, it is an anxiety worry about that. So addressing that up front and saying it's not that we're looking for you to be in pain, but we have oversold for the last two decades how effective opioids are in controlling that pain. We're pulling back on them not because we're trying to let people be in pain, but because we found out that we are causing more harm and not getting better pain control. So we are now going to talk about other things that we can do to make sure that you get good pain control. So that's kind of the way in which I'm having those conversations. And, you know, I'm hoping by next year to have a little bit more hard data on how that has affected because we're rolling out some of these. Because you want your patients to like you. It is a real issue. If they have not internalized, if they are not taking that on is something that's important to them. The compliance issue is going to be, you know, they're not going to be compliant. And you have to worry about then people looking for other sources of opioids in particular. The other part of that is we do have to be more conscious about patients that unfortunately because of years of over-prescribing have become dependent. And it's now an addiction situation. So knowing who the resources are in your area to refer them to is important. I don't know, one last one, sorry. Do you routinely do your drug screening on your preoperative patients? I have not, but that's particularly because of my own practice, which is that I oftentimes if I have a patient coming to me who are already on opioids, they're already on a contract where they're getting screened and it's in the record. So if I have a concern about that, then yes. I have also found that printing out the PDMP report for that particular patient prior to surgery and actually sitting down with them, you know, at the time of surgery or beforehand and saying, so this is what you're taking right now. And I got to tell you, it's a lot. I don't know that I can give you any more of this. We need to talk about what else we're going to do. It's another health strategy. All right. Thank you so much, Dr. Ware. Excellent presentation. Thank you.

pain management

narcotic addiction

neurosurgery

opioid crisis

opioid prescriptions

heroin-related deaths

government actions

multimodal approach