This week I talk to Dr. Michael Ashburn about how the opioid crisis impacts the clinical practice of pain physicians, the importance of collaboration between the academic, legislative and enforcement communities, about how policy changes over time have contributed to the current opioid situation in our country. If you’ve ever wondered how you as a practitioner can get involved beyond your clinical work to help combat the opioid epidemic, you won’t want to miss this episode.
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Justin: [01:12 ] Hey, it’s Justin Harvey here. I’m pleased to introduce to you our guest this week, Dr. Michael Ashburn. Michael is a professor of anesthesiology and critical care at the hospital of the University of Pennsylvania as well as the director of Penn Pain Medicine Center and a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania. His list of accomplishments and expertise is quite immense and I think that in trying to summarize it, I’m not even going to do it justice, but briefly, he was a Robert Wood Johnson health policy fellow with Senator Orrin Hatch back in the 90s he’s worked with the DEA, the FBI, the Doj, and the FDA to name a few on policies addressing opioid addiction and other issues. It’s hard to imagine a person more qualified to discuss the current landscape of policy around opioid addiction and how it impacts the clinical practice of anesthesiologists and pain physicians. In addition, my wife Sarah has worked with him in the pain clinic and said that he’s an absolutely delightful person as well. So Dr. Michael Ashburn, thank you for joining us today on the anesthesia success podcast. Happy to be here. So Michael, you’ve done a lot of work on many sides of this issue of what we’re now calling the opioid crisis from policy involvement to providing advice for enforcement and oversight agencies to being a clinical practitioner as well. So tell us a little bit about the current scope of your work as it exists today in that space.
Dr. Ashburn: [02:28] I’m a professor in the Department of anesthesiology and I direct the pain medicine center at the University of Pennsylvania. my work is divided between providing direct patient care to patients. About 40% of my time is just me seeing patients. I spend a fair amount of time supervising residents and fellows and providing patient care and collaboration with residents and fellows. And then I have some time blocked out for my administrative issues as well as academic pursuits.
Justin: [03:05 ] Great. And I’m curious in the context of supervising residents, working with them clinically, but also I’m sure trying to, you know, give them some career perspective as to the, the track that they’re going to be proceeding upon. Do you ever talk to them about the current environment with regards to, you know, legislation and practice and enforcement with regards to opioids and, and how that is going to potentially impact their career or future clinical flexibility perhaps?
Dr. Ashburn: [03:31] we certainly do have those discussions. not in any structured way. For the most part, when a NCG resident spends time with a pain specialist or in their core rotation, we get a grand total of two months of their time. And our focus at that time is to give them exposure to the clinical practice of pain. And so frequently we’re focused on the clinical aspects of what we do. Now. It doesn’t take very long in clinical practice to be able to glide over to a policy discussion that’s precipitated by a particular scenario in the clinic. One may be patient who presents, who’s on high doses of opioids, who, our recommendation is is that they’d be tapered or a patient who presents, who meets the diagnostic criteria of an opiod use disorder. And then the resident participates and observes a discussion between me and the patient with regard to the need for treatment for opioid use disorder and the availability or lack there of, of treatment options for those individuals. And, and so subsequent to the patient or actually can talk about as a policy.
Justin: [04:45 ] It makes sense. so you’ve obviously been very involved in helping to liaise between the medical community and there’s a legislative and regulatory community for quite a long time. when did you first become interested in that type of dynamic?
Dr. Ashburn: [04:58] I probably got an interested in policy in the early to mid nineties. at that time I was a mid level at the University of Utah and President Clinton was the president. And the first episode on healthcare reform was very much underway and there was a rapid change in the environment of healthcare from a fee for service environment to one of what was the first iteration of managed care, consider which included considerable consolidation within the healthcare field and strict limits on who would pay for what. And at that time, there was significant concern over the impact on how we would be able to provide pink hair and anesthesia care and surgical services. At that time, I recognize that I would be in a much better position as an to understand the policy issues. And I went back and got a master’s in public health while I continued to work for the University of Utah.
Dr. Ashburn: [06:05] I was coming onto my seven or eighth year of faculty in, was do a sabbatical and chose to do a Robert Wood Johnson Pelosi or Robert Wood Johnson health policy fellowship in Washington DC. I prepare for it. met with the whole book as many people as I could possibly meet with in the Utah area. Worked hard at making sure I submitted an application that I thought was as robust as it could be and then went to Washington DC and interviewed for the position, ultimately was awarded one of the slots. And the, that was a very obviously very intentional on my part. I initially anticipated going into a health policy related role when I return, but actually that did not occur for a variety of different reasons and, but ultimately the fellowship and the experiences and again, during the fellowship has impacted my academic career and it certainly is impacted by my participation to help my willingness and confidence in participate in health policy dialogue going forward.
Justin: [07:11 ] It makes sense. So I’d love to know what does a day in the life of a Robert Wood Johnson fellow look like in DC? Uh,
Dr. Ashburn: [07:18] well, it’s changed. The program has changed fundamentally now, but it still exist. but this is a fellowship that is, at the time I went through is run through the Institute of Medicine, which is of course now has a new name. but it’s a very prestigious program. And the first three months is fulltime education. they have a wonderful, process at that time where there’s only six fellows a year. And we would go and meet with the WHO’s who of helped health policy. We would meet with a variety, different senate offices, a variety of different offices at the house. We’d go to the White House. We went to the FDA, we went to the surgeon general’s office, we met with the dod, we met with all, many of the think tanks had exist in Washington, are interested in public health. And we met for an hour and a half usually with one person.
Dr. Ashburn: [08:11] Like we met with the secretary of Health at the time. we met with the secretary of HHS at the time and spend an hour and a half listening to what they had to say and asking questions. And that was a wonderful opportunity to understand what people were thinking on both sides of an issue. get a very clear understanding of how the process of development of policy worked and understanding him. After three months, the fellows then would apply for an interview to get a position on somebody staff. And in my case I took a position, with the judiciary committee, the chair of the judiciary committee at the time with Senator Hatch from Utah. I did that very intentionally because I intended to go back to the University of Utah and I intended, I felt like having that connection at the Washington level would be very synergistic. When I returned to Utah and at the time there was a fair amount of legislative work that was going on within the judiciary. Senator Hatch also had a very long history of work on health related issues and was also a member of the help committee, health education, labor and Pensions Committee, even though he was chair of judiciary is also on the help committee. And so I had an opportunity to work on a number of different bills both within judiciary, within help committee related to health policy.
Justin: [09:37 ] Great. So something you alluded to earlier and I also recently read an article where you quote in the Philly Mag and a couple of years ago talking about, opioid policy and how it’s evolved over time. was that in the 90s and with President Clinton, there was a concern at that time when the paradigm is shifting to more of a managed care model, that there was a concern that people who needed help with pain treatment weren’t going to be able to get it potentially. And so the, the access to opioids, was the, the, the thinking at that time was to make sure that people can get what they need rather than trying to, the paradigm being like, let’s protect them from the harmful effects primarily. and obviously in the last 20 years we’ve seen that shift. So can you talk a little bit about kind of how that landscape existed in the 90s and how it’s potentially, if in your opinion it has, if it’s contributed to where we find ourselves today?
Dr. Ashburn: [10:27] Well, one of the challenges that we ran into in the 90s was that, the fragmentation, the, the diva, the impact of managed care in the consolidation, the market prevented, programs or were considered to be interdisciplinary pain programs from existing. When I started my pink career, we actually had an inpatient suite to within which we could admit patients who had complex pain problems and they would stay with us for three to four weeks and that might be overkill. But the concept of an innovative program, they had a pain psychologist, physical and occupational therapists that were dedicated to taking care of people who have complex pain problems and pain specialist in rehab physicians all working on patients with a focus on allowing them to get the maximum pain relief, but also to allow them to improve physical function. You know, focus on returning to work allowed us to provide that service. Then managed care programs carved out psychological health and psychiatric care and so payment for the pain psychology services were eliminated. Then physical therapy and occupational services was carved out to a particular vendor.
Dr. Ashburn: [11:45] So we devolve from integrated interdisciplinary care to physician care and in addition to that, there are well known differences in reimbursement that contribute to problems. And that goes towards the cognitive behavioral programs such as evaluation management services, meeting a patient, talking to them, providing them with medications, prescribing physical therapy and other non interventional modalities. There’s not valued by society as much as us doing an injection. And so there’s a known and perhaps unconscious bias by physicians to do what generates more revenue for them. And so many physicians will focus on what they can do well and what they get reimbursed well by society to do. And so all of that led to focus on interventions and many pain physicians left interventional care and move towards our left interdisciplinary care. I moved towards doing injections.
Justin: [12:49 ] Interesting. And you see in your opinion or I guess in your experience the, the catalytic moment where there was this integrated system that it sounds like you were saying was handling the pain treatment more holistically and perhaps more effectively the with the introduction of managed care there was I I’m imagining and incentive, a direct desire by the insurance companies to say we can’t really verify whether or not the social worker at the holistic pain center is really earning what we’re paying them and therefore we’re going to not pay for that social worker anymore or whatever the behavioral health component of that is and therefore it sounds like you’re sort of being dictated to by an insurance company. Potentially what, how to best treat pain, which previously you had been doing holistically and now there’s more of a, you had been pushed towards more interventional clinical model. Okay.
Dr. Ashburn: [13:38] Well it’s nice to, I mean that that is the argument that was frequently done, but I don’t know that the insurance companies were being, we’d like to clarify what they’re saying is you’re dictating what I can do. In fact, what they were doing in their mind was denying payment for certain types of things or mandating that that care be provided by specific providers rather than in, and I think it’s important for us to recognize what the limits are of the healthcare industry or what, what they were trying to do. They were trying to manage cost in, in an environment where healthcare costs were rapidly increasing year over year in an unsustainable way with the tools that they had. Not trying to justify what they’re doing, but just at least trying to recognize the environment the health insurance companies were in. At the same time, we had a fundamental misalignment of how physicians and other providers will reimbursed.
Dr. Ashburn: [14:38] So these were the times where we were just in usually talking about the concept of adding value, what value is some measure of outcomes with cost and trying to figure out in an innovative way how we can, how we can pay for doing the right thing rather than just for doing something. And in this time of transition, the efforts of controlling costs ran up against some of us who felt that we were trying to add value in this integrative process. All right. When I returned from Robert Wood Johnson Fellowship in Utah, we actually were successful at negotiating global payment rates for our program in Utah. And so we went to different health insurance companies. We, we provided them with data on what we were doing and why we believe that it added value and we, negotiated specific contracts where they would pay a global fee for comprehensive care. And that allowed that individual program in that small market to survive and thrive for a number of years. we were, have not been able to replicate that here in Philadelphia by the way, but in Utah we were able to do that.
Justin: [16:00 ] Excellent. And thanks for the additional clarity and perspective there. so as that, that paradigm shift was happening in the healthcare industry at large, do you, do you see that dynamic, the shift to managed care and the, you know, difference in reimbursement and what hospital, what insurer insurers will pay for? How has that contributed to, you know, where, where we find ourselves today, which there’s this article in the New York Times last year, you may remember calling Kensington, one of the neighborhoods here in Philly, the Walmart of heroin and Philly is pretty renowned for, you know, the, the opioid crisis here as being sort of exhibit a, of a lot of the hardship that our nation is experiencing. I think that’s an excellent some
Dr. Ashburn: [16:42] question. I think that like everything in life, I think the underpinnings of what happened with regard to the opioid epidemic that we’ve been experiencing for the last decade or so is multifactorial and not easy to understand. And I think that there are probably many things that came to bear to cause the crisis and not just one thing. I think your point is well taken is that the devolution, the loss of integrated pain programs caused us to devolve to performing procedures and prescribing medications, which are the two modalities that physicians are comfortable at and medications include chronic opioids. And so there was already an uptick on prescribing opioids. Now in the pain field. The the reasons for that I think are also a multifactorial. First of all, we started to learn more and how to properly treat people with advanced cancer in many pain specialists who took care non cancer.
Dr. Ashburn: [17:49] We’re also the Goto people within their institution on how to take care of complex cancer patients and so we were learning at the same time how to properly administer extended release medications and combination and short acting medications properly treat cancer pain. Then we made a terrible mistake and the mistake was we translated our experience to cancer to non cancer. We assume that if those principles work for somebody who was dying of cancer, they need might be applicable to people who had pain from other sources. In hindsight that was fundamentally wrong in many people moved from an era where we were not offering opioids for the treatment of chronic non cancer pain is starting to offer it and then really starting to offer it. Combined with that shift in that thought process was of course aggressive marketing by the pharmaceutical industry to get us to do it even more.
Dr. Ashburn: [18:48] But I think it’s disingenuous for physicians to completely blame marketing because that decreases agency by or, or dismisses agency by the individual physicians. At the end of the day, it, regardless of the marketing, it’s individual physicians who are making the decision to prescribe or not prescribe. We clearly are influenced by what the pharmaceutical industry puts at us. But in the 90s, up until the early two thousands there concern or the understanding of the influences of marketing on physician practice was naively missing. As we became more aware of that institutions, including the University of Utah and very much included in the University of Pennsylvania, implemented pretty strong guardrails with regard to our interactions with industry. some institutions that did that more aggressively in earlier and they benefited from that and others have done it late. And so, and then on the other hand, there are other, in addition to that, there are other thought leaders, other policy makers at believed that there are other broader issues that have contributed significantly to the opioid crisis.
Dr. Ashburn: [20:05] And that includes income disparity. the recession that occurred in two in the 2006 to 2008, the disenfranchisement of a poor and low middle class folks, the loss of the middle class and the spiraling out of, of, essentially into despair of a large group of individuals that that contributed to opioid use, inability to get work and find meaning in their lives. And all of those things combined have contributed to the crisis that we have. So I think there’s multiple different contributors to this. And I think ultimately the fix is not going to be medical fix only. But I think that the ultimate fix to despair and these other issues related to the human condition of these folks who’ve been disenfranchised will include addressing income inequality. And the huge distribution of wealth where the top 0.1% and the top 1%, are, are, contain a significant amount of wealth and the amount of individuals who don’t have opportunities to lead a meaningful life in America is growing. Interesting.
Justin: [21:28 ] That makes perfect sense. And I’m, I’m sort of chuckling out man, and saying, you know, one factor, one outcome, obviously a big complex problem like the opioid epidemic is going to be multifactorial as you mentioned. So in your opinion, I’m curious, does the, does the current, legislative efforts that we’re seeing appropriately acknowledge the multifactorial nature of this problem or do, do you think it’s maybe more a targeted and not acknowledging and perhaps only looking at, you know, the medical community and, you know, opioid prescribers specifically rather than the broad scope of all the inputs that have caused this problem?
Dr. Ashburn: [22:08] Well, obviously I think it’s the ladder. On the same token, much of the legislation that occurred over the last couple of years have been remarkable in making significant contributions. the, the amount of funding that the INS that society does towards addressing people who have addiction disorders, particularly opioid use disorder are quite small. I’ve been quite small then the amount of resources of Improv to bear to properly screen offer treatment, engage in treatment. Meaningful treatment for addiction disorders has been relatively modest. Physicians had significant knowledge gaps with regard to how to properly diagnose and treat substance use disorders. We have significant limitations on our understanding of how to diagnose and treat pain and we still have knowledge gaps with regard to how to properly use opioids to treat pain. there’s been good data with regard to the concept of opioid stewardship with which is a term that stolen from antibiotic stewardship where physicians have a responsibility to be good stewards and how they prescribe opioids to treat pain.
Dr. Ashburn: [23:22] we don’t do a good job at, instructing patients on how to properly store opioids and we don’t do a good enough job on how to instructing them on the importance of getting rid of the opioids that they have leftover so they don’t become available for nonmedical use by others, others within their, their circle of friends and family. Now the things that broader things with regard to addressing poverty, aggressing despair, are much bigger and more difficult and quite frankly also politically contentious in this environment. You know, that you mentioned Kensington is a big area, a large number of the core, most difficult to treat people who have addiction, including heroin addiction is, are going to be people who are homeless. Those individuals won’t be made better only by getting them into buprenorphine treatment. Rather, they’re going to need help with finding stable housing and then they’re going to need hope.
Dr. Ashburn: [24:30] And what I mean by that is they’re going to need someone to work very hard with them to make sure that they get proper mental health care because many of these people have, coexisting mental health disorders as well as their addiction. And then for those who can, they need to be brought out of there, get their addiction and their mental health treated, and then have help in reengaging in what we would term as normal life. I eat working, finding hope, finding meaning though. That’s, that’s a heavy lift and it’s a much bigger lift than me offering buprenorphine medication assisted treatment. Right.
Justin: [25:07 ] It makes perfect sense. So I know you’ve done some work locally here. and I, I’m, I’d love to hear a little bit about how you’ve worked with, for example, the mayor’s office and if there’s other physicians out there listening who are saying, what can I do at a sort of a grassroots level to help influence in my community at the most local level? What, what’s a way to take the first step?
Dr. Ashburn: [25:26] Well, when I came to the University of Pennsylvania in 2007, of course, had no links with anyone because I came from Utah to come to a new community that had no links or ties with, and so that might be the best kind of the example. In that case, I immediately started getting involved in the home front. And what I mean by that is as I learned about what I could do within my own community, First University of Pennsylvania community to try to improve the process of care, particularly PaintCare and then palliative care. I joined my local societies, Philadelphia Medical Society, Pennsylvania Medical Society, Pennsylvania Society of anesthesiologists, and then kept raising my hand when the opportunities existed. And I actually was proactive and looking for opportunities to join. So I ended up joining the board of the Pennsylvania Society of anesthesiologists because I reached out to the individuals and it come to find out they did not have any at that time did they not have any academic pain doctors and their board of directors.
Dr. Ashburn: [26:37] So they asked me to be on the board of directors and then I recognize Pennsylvania did not have a prescription drug monitoring program and there was actually no effort to develop one at the time. And so through the Pennsylvania Society of anesthesiologists, we created the Pennsylvania Pink coalition and we essentially brought together a wide group of advocacy groups to talk about the need to have a prescription drug monitoring program and advocated for that legislation. That led to me meeting with people in the house and the Senate at the state level, developing relationship with the secretary of drug and alcohol programs and then ultimately helping, behind the scenes work on good policy on developing that bill, which passed but it took several years for it to pass. When the bill was passed, I became a member of the advisory board for that group and then subsequently became active at the state level, a number of different committees. And that came through raising my hand, offering to help and then following through on those commitments. And generally the old adage that if you’re not there, then, you know, the first part of being successful is actually being present is true. Though I did not do anything that was transformative other than be present and try to advocate for reasonable policy. I have not been terribly involved on the politics side, although my children are, uh, but I have been successful through Republican and Democrat, governments and advocating for reasonable healthcare related policy issues.
Justin: [28:28 ] Got It. If I’m an anesthesia resident and I’m thinking about pain, and I’m looking at the legislative environment and thinking, oh my gosh, maybe I should just do anesthesia or something with less sort of baggage in today’s, you know, political discourse, how might you encourage somebody in that
Dr. Ashburn: [28:45] situation? Why don’t think the political baggage that exist in pain is any different than it was before? And in fact, with innovations in information technology, electronic health records record, and large datasets, we’re actually at a very fun and exciting time. we’re doing a number of different projects that I actually find to be very exciting looking at large data sets that are collected through our electronic health record to understand the impact of the, the care decisions that we make on large populations and how we can try to do a better job and for existence. For example, there’s been a signal that the combined use of opioids with benzodiazepines increased the risk of harm. We’ve, I’ve been involved in some clinical trials and some invest some Qei trials that have clearly demonstrated that that harm exist. We’ve looked at uh, the use of those medications, the time of surgery and also identified that there, that that combined use as harmful and hopefully the information that we’re gaining fund that effort is actually changing practice. With regard to opioids, our practice is most certainly changed based on learn active learning from 2007 until now. And I would like to think that we can continue to learn until I retire. That won’t change. And so I actually don’t feel threatened by the government government changes in the environment, the regulatory environment because physician should be proactive and doing the best thing for their patients and we should actually be part of the solution and we shouldn’t feel threatened by people who are trying to encourage us to do the right thing.
Justin: [30:29 ] Makes perfect sense. Doctor Ashburn, I appreciate your time today. In closing, I just want to have one final question. You’re, you are a very, very accomplished physician advocate on many fronts. I’m curious to know one thing that you look back on in your career and say, this is something that I’m proud of, a moment where the investment of all my time and all my energy was worth it and was impactful. It could be a patient story, it could be a policy, a event or something like that.
Dr. Ashburn: [30:57] I think that’s an excellent question. I would say actually most recently, well, I think that from my personal career, the most, the most beneficial thing that I’ve done was my decision. Seven years of my career to go back and get an NPH. Is that precipitated? the bill, my ability to effectively compete for the Robert Wood Johnson health policy fellowship and my interest in active participation in health policy I think has had some impact both of my career. And I would like to think that my efforts have helped improve the care that other people have had. most recently the one could see my impact on opioid policy within the state of Pennsylvania related to my advocacy for the PDMP. In hindsight, one could say that that was an easy bill to pass and now very much bread and butter at the time there was active opposition to creating the PDMP in Pennsylvania. But my efforts on participating in that dialogue and debate allow for us to develop the, the ongoing task force has developed a number of state Prac clinical practice guidelines on how to try to improve the care that’s being offered to folks with pain that allowed us to write the core curriculum for all medical students in Pennsylvania and the partnership that we’ve had, which has been very, very productive with, with secretary of health, Rachel Levine and others on developing really sound policy related to pain and addiction.
Justin: [32:28 ] Excellent. Well, Dr. Michael Ashburn, thank you very much for joining us today on the anesthesia success podcast.
Show produced By: Justin Harvey Show Music: Great Scott: Don’t Hold Back