SMART Policy Podcast
Podcast by the UT SMART Initiative. Host Jeremy Kourvelas speaks with experts from across the recovery ecosystem - representing healthcare, prevention, law enforcement and more - about local, state and federal drug policy to find out what is and isn't working to make this fight against addiction a little easier.
SMART Policy Podcast
If Opioid Prescriptions Are Down, Why Are Overdose Deaths Still So High?
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You're listening to the Smart Policy Podcast, a production of the University of Tennessee's Institute for Public Service. There's no question that over-prescribing of opioids kick-started the opioid crisis. The data is so overwhelming that nearly two dozen major companies have settled lawsuits to the tune of tens of billions of dollars because of that evidence. And we've since then dramatically cut the supply of prescription opioids. So problem solved, right?
SPEAKER_02We've more than tripled our opioid deaths per year since we started these prescription reduction programs. You know, just cutting off the amount of, let's say, hydrocodone that's coming out of the clinic is really working at the wrong end of the stick in terms of reducing opioid deaths.
SPEAKER_00My guest this month is Dr. Clay Jackson, a chronic pain specialist and member of the Tennessee Opioid Abatement Council, which is tasked with overseeing the majority of the state's share of the opioid settlement dollars. In this conversation, we discuss how while tightening regulations and oversight of opioid prescribing have had many positive impacts, they have had unexpected consequences for chronic pain patients as well.
SPEAKER_02I faced a business into that, Jeremy, and I've had multiple patients with stage 4 cancer go into withdrawal because they can't find their opioids. Because guess what? If you're Walgreens and you pay$5.3 billion in fines for over-dispensing opioids, uh you tend to not want the opioid business. That's my perspective.
SPEAKER_00For Dr. Jackson, the ongoing demand for fentanyl, methamphetamine, cocaine, and a host of other substances is evidence of the need to reduce demand for all illicit substances altogether, and that clamping down on prescription opioids is not the only policy worth considering.
SPEAKER_02It's important that we don't fall asleep to the switch and say, oh, prescriptions are down. That's great, everything's gonna work out fine. No, it didn't work out fine. Prescription opioids right now, they're just not driving this wagon. People are gonna find something to hit their dopamine levels when they don't have routine, normal human interaction.
SPEAKER_00We also discussed successes from the opioid settlement funding, how pharmacies face new challenges, economic realities for modern patients, breaking down treatment silos, and we even dive into a little bit of relevant American history. To say I enjoyed this conversation is a massive understatement. Dr. Jackson, thank you for joining me. It was a pleasure speaking with you last time, and it's always a pleasure talking with you. There's been much to do over the past uh uh gosh, I believe at least a year since we had you on the show. In particular, uh the opioid abatement council spent$80 million, which was a pretty significant achievement. Um, but thank you very much for joining me and being on the Smart Policy Podcast today.
SPEAKER_02Jeremy, it's great to be with you guys. I always enjoy our conversations. They always seem to run far afield and uh delightfully to go longer than we anticipated, which uh that's a sign of a of a stimulating intellectual friend um and an interesting topic. So I hope your listeners are edified and uh challenged and and intrigued by what we what we discussed today. Uh you mentioned the opioid abatement council. As you know, I'm I'm one of the 15 members of the council. In fact, the the only representative as I know of from West Tennessee's Grand Division. So we it's exciting work. We're really trying to advance the cause of opioid abatement. What does that mean? Uh if you're not familiar with the phrase, uh, we're trying to mitigate the effects of adverse events of opioids in our society, both from misuse, non-medical use. There are unintended consequences of routine medical use. And we're trying to abate those effects as well. And then certainly the substance use disorders that we see. And this is a multidisciplinary task force that really works from all angles, primary prevention, secondary prevention. So there's education within our school system and other non-governmental entities, such as churches, synagogues, temples, et cetera, community groups to get the word out about opioid abuse. And then there's, you know, secondary prevention, such uh harm prevention, such as uh naloxone, to try to reverse uh the effects of opioids if someone has an acute overdose. There are treatment facilities that are being funded, there are positions being funded, programs in terms of outreach, community outreach, peer support. There's research that's being supported, a broad variety of attempts to get our hands around this problem and to help more Tennesseans survive. Because I'm telling you, um, the last decade or so of what we've been doing has not had the intended uh results that that we wanted. And if it's okay, I'd just probably like to talk about that in terms of my journey from the Chronic Pain Guidelines Commission for opioid prescriptions on the medical side to what we've seen in overdoses. Okay if we get into a bit of that. Yes, please, absolutely. Sure. Um, I'm glad you said so. So, you know, um, I think everybody knows the opioid story, and everybody's heard about the opioid epidemic, uh, opioid crisis, et cetera. Can't turn on television or or click on your smartphone without hearing those phrases and seeing them. So obviously, late 90s, mid-90s to let's say 2010, 2011, what we have is sort of a linear curve of growth in opioid prescriptions in the United States. And you can cut that any number of ways per capita, per state, uh, per pharmacy, per doctor. We just see um uh growth in opioid uh dispensing. Now you'll see figures that you know, we have 5% of the world's population in the US, and we consume 95% of the world's hydrocodone. And it's true, but it's misleading because hydrocodone is really not sold in large quantities in other uh countries. It's other opioids such as Tramadol that are consumed in large quantities. So there is a gap in terms of per capita consumption of opioids in the United States on the prescription side with the rest of the world, both so-called developed and so-called developing. Um, however, that gap's not as wide as some of those sort of first-cut, maybe misleading uh statistics would tell you, such as hydrocodone sales. Suffice to say, with this growth in opioid prescriptions, we saw an absolutely corresponding growth in um opioid overdose admissions to ER, um, opioid overdose deaths, and opioid use disorder or substance abuse disorder admission to inpatient facilities. And so you've got people that have lost control of use of the substance, you've got people that are overdosing and not dying, and you've got people that are overdosing and dying. All of these things we're tracking exactly with the rise of prescriptions. Enter people like myself in the early 2010s to you know, concerned citizens, uh administrators, governmental officials, legislators, uh, healthcare professionals saying, hey, we we got to do something about this. And uh the first thing we probably need to do is is reduce the amount of opioids that are going out through the clinic doors. The the licit, the licit, the legal prescriptions, we need to reduce these. And so uh we need to educate doctors, nurse practitioners of PAs, we need to educate patients, we need to provide non-opioid prescriptions, non-pharmacologic approaches to pain. Uh, we just need to reduce opioid prescriptions. And if we do that, then overdose deaths will go down. That's kind of what we thought would happen. Um, probably if you remember your uh freshman to statistics class, your professor probably said something like, Correlation is not causality. Just because two things are associated doesn't mean they're causing one is causing the other. Well, we all knew that sitting around the room in 2012 in a Tennessee Chronic Pain Guidelines Committee, but we said, hey, we we got to do something. So we did. And over the last 10 to 12 years, we've seen a gradual fall in the annual rates of ovioid prescriptions in our state. Uh, I think that's laudable. I think it is good. I think it needed to happen. Uh, I think it needed to happen in a smooth, orderly way, you know, low teens percentage, you know, 10 to 15% maybe per annum, rather than a huge drop-off, because we didn't want, first of all, chronic pain patients to suffer unnecessarily. And we also did not want to create um a black market for opioids. Right. Because if you take them all uh out of the clinics suddenly or a huge drop-off, then that would drive illicit demand. And we we don't want to do that. And and we discussed that. Well, we got what we wanted in terms of a gradual decrease in opioid prescription in tendency. You know, hallelujah, that's that's that's great. But unfortunately, we didn't see a concomitant reduction in opioid deaths or uh opioid overdoses. In fact, what we saw was a growth in overdose deaths. Basically, it if you look back at 2012 when we started, we saw approximately 1,100 opioid deaths. 2013 that grew to 1200, 2014, 1300, 2015, 1500, 2016, uh, 1600. And this just kept rising as prescriptions kept falling. And then in around 2016 to 18, we saw heroin and fentanyl enter the scene, and overdose deaths actually started growing not arithmetically, but growing geometrically, to the point that in the pandemic hit, people weren't able to access good substance abuse disorder treatments, medication-assisted treatments such as methadone or buprenorphine, uh, you know, the different brands of those products, but they weren't able to get to their clinics uh in in a uh an orderly fashion. And so in 2021, we're up to 3,800 opioid deaths a year. Remember, we started 1100. We've more than tripled our opioid deaths per year since we started these sort of prescription reduction programs. Uh, we leveled off a little bit in 2022. Um, and and those are the latest uh tabulated data that I have. 3,800 uh deaths again from opioids. And and so as we cut prescriptions down, we didn't see opioid deaths go down. And if you look at the overdose deaths by drug type, opioids still have the lion's share of deaths, but it's heroin and fentanyl that are driving it, uh, primarily fentanyl. Heroin deaths have actually fallen the last two years, and pain reliever deaths are absolutely flat. So, right now, what we're seeing uh 2022, the last year, we see about 3,000 opioid deaths. And, you know, the fast majority of those are fentanyl. Only 500 of those deaths are from pain relievers. And so basically five to one, you got basically 2,500 uh deaths from fentanyl, and you got about 500 from pain relievers. So what that shows you is, you know, just cutting off the amount of, let's say, hydrocodone or oxycodone that's coming out of a clinic is really working at the wrong end of the stick in terms of reducing opioid deaths. Opioid deaths, we're going to reduce them. It has to be focused on uh demand uh reduction, educating people that street drugs, illicit drugs are not safe. We need to educate people that they need to have Narcan available. And we need to educate people that one and done is a thing that you, you know, in the old days, if you tried a drug of abuse, you might survive, you might not, but your odds were much better than they are today, where some of the fentanyl analogs can kill you even with a very minimal exposure. And so you may think you're buying an illicit um oxycodone pill, but it may be pressed fentanyl. You just don't know. You may think you're buying crack cocaine, but it may have been mixed with fentanyl and you could die. So we need to educate people regarding the dangers of fentanyl as an illicit substance. And then, you know, interdiction is an important part of the of the supply chain disruption. But I have to tell you, uh, fentanyl is so potent that very small amounts can be turned into large amounts of money and can unfortunately supply many people with illicit substances that suffer from substance use disorder. And so, you know, unless you're interrupting networks of people, interdiction is a difficult strategy. If you're looking to stop a substance coming in, you know, that would the US Postal Service, UPS, FedEx, ports, shipping, we'd have to really change the way our country works. Imagine TSA at every element of entry of product in this in this country. I don't think we have enough drug-stiffing dogs. It's interrupting networks, maybe possible. Interdicting per substance is an extremely difficult challenge given that you don't need a lot of fentanyl to go a long way.
SPEAKER_00It's rather jarring to hear that prescription overdose deaths have remained flat in comparison. It's certainly the bleeding edge of the problem is fentanyl and other illicit opioids. But wow, I mean, with so many prescribing changes in place, with so many so-called pill mills getting shut down, and Tennessee has had a really robust law in shutting down uh pain clinics that had uh more dubious practices. Um there have been guilty pleas and felony charges and the like. But with all of this in mind, that it's still taking up a decent chunk of overall overdose fatalities is really rather revealing. And I and I think it's interesting that you pointed to a demand side of the equation in terms of how we might consider abating this. Prevention certainly covers this broadly, but um if we have changed prescribing norms to make it much harder to, let's, for lack of a better term, recklessly prescribe opioids, if we have better prescribing guidelines and practices now, uh, what else can we do?
SPEAKER_02Well, let's just talk about some of the measures that we have. I mean, public chapter 1039 uh basically says that your initial prescription of opioids should be for basically 72 hours. And so that stopped a lot of the 30-day dental prescriptions for painful tooth. Right. It stopped a lot of I sprained my ankle, I went to the ER, I got two weeks worth of oxycodone or hydrocodone or hydromorphone, you know, delauded. A lot of that's been stopped. You know, you can go back and you can write seven days, you can write 14 days, you know, 30 days, etc. But you have to put wine, you got to put informed consent. And there are additional steps to protect the patient and to make sure that, you know, someone is, I guess someone could do all those steps and not think about it, but it makes it harder to mindlessly just write, you know, a bunch of pills for somebody. So I think that's been an important step in keeping lots of loose pills from lying around. We know, for instance, that for teenagers who try opus for the first time, the number one source is not the corner drug dealer. The number one source is a medicine cabinet of a friend or relative. And they get this medicine for free. Uh, they don't buy it, they don't trade money or sex or drugs for drugs. They, you know, they they trade a smile for drugs. They go to grandma's cabinet, they go to their aunt's cabinet and they find it. Uh, their uncle's cabinet, they they find it and they use it. Uh a non-medical use of opioids tend to start from friend or family members. Well, published chapter 1039 cuts down on that sum. There have been some unintended consequences in that PC one uh 1039 has led some people to just stop prescribing in for patients in appropriate medical ways. You know, shortly after 1039 came out, we we had pain medicine clinics that on day four post-op would have patients rolling in in wheelchairs from you know orthopedic surgeries, et cetera, saying my my my orthopedists won't give me any more pain medicine. I they sent me here on day four of an acute operation recovery period, you know, that's that's not really appropriate management. That's not really what the authors of 1039 imagined, and and certainly it's not what the pain medicine docs can can accommodate and not what they're truly trained to do, um, which is manage complex cases over time. So, you know, those unintended consequences have uh affected patients. I I think the key message, uh, you know, Jeremy, and maybe maybe you and I take two different messages out of the data. If I'm looking at all these mitigation strategies for reducing prescriptions, and I see that there's 500 overdose deaths a year from prescription medication or pain relievers, and that's remained constant over time while other sources have grown, including stimulants such as methamphetamine, including stimulants such as cocaine, including illicit opioids like heroin and fentanyl, then, you know, kind of my message or take home out of that is, you know, maybe there's a subset of people that misuse prescription drugs and reducing the supply of prescription drugs hasn't affected that very much. But perhaps we could work on demand in terms of, hey, if you got an extra 12 hydrocodone, throw them away, flush them down the toilet, put them in the burn barrel, you know, do something to get rid of these opioids so that they're not lying around. Because it may not be Dr. Jones or Ms. Smith, the nurse practitioner, who prescribe it's a problem at this point. It's that, you know, obviously, if we prescribe no opioids, then people wouldn't be dying of opioid pain relivers. They die of Tylenol and aspirin, but that's a different story. They die of ibuprofen, that's a different story. But, you know, obviously zero input re you know means zero adverse events. But I don't think we want zero opioids. Uh, I don't think we want uh stage four cancer patients not receiving opioid prescriptions. Well, that'll never happen. I, you know, you're you're that's a straw man argument. It's uh these are public policy events and and and laws that uh are meant to keep people from over-prescribing. It has nothing to do with can't cancer patients, and cancer patients get all the medicine they want. Um, you know, this is a family podcast. I'm gonna keep it clean, but um, I call falsehood uh balderdash, if I could. I I could use some stronger language, but um I face the business into that, Jeremy. And I've had multiple patients with stage four cancer that have a pristine record of opioid use, no adverse events, no non-medical abuse, no adherent behaviors. I've had multiple patients of that type go into withdrawal because they can't find their opioids. Because guess what? If you're Walgreens and you pay$5.3 billion in fines for over dispensing opioids, uh you tend to not want the opioid business. That's my perspective. I had a small town pharmacist not involved in all the opioid penalties and part of the opioid abatement uh legislation and litigation, excuse me, and all that. And this this small town pharmacist told me I'm not taking new pain patients that are on opioids. Well, why? Are you you are you are you prejudiced? Are you bigoted? I mean, what's the deal? You you are a pharmacist, you have a sign that says you sell medicine. What's what's the deal? Uh I can't get it. I can't get it from the suppliers. I can't get enough from my suppliers to meet the needs of the patients that already have. So I can't take new patients because I don't want to have to tell them no. Because uh, oh, by the way, you know, we don't fill these prescriptions ahead of time. We fill them on the day they're due, 30 days after the last fill. And so it's kind of a crapshoot whether the pharmacy has it or not. And so we get into this roulette game of of calling pharmacies around the city to see if uh if the patient can get a supply.
SPEAKER_00So the the national opioid settlements, which uh are often talked about now as as is definitely a good thing and no denial there, quite a lot of money coming in has had uh an unintended chilling effect on even just the legal operations of uh opioid prescription?
SPEAKER_02I'd make that argument, not even on the prescribing side, but on the dispensing side and the supply side. Uh, you know, you take intermediaries like McKesson that had to pay large amounts of money, you know, they're under regular increased regulatory oversight. Um, and and I don't argue that that should not be the case. Right. But business people make business decisions. And if you tell me that moving forward, my business practice is gonna be under increased regulation. And uh if you show me through negative feedback and consequences that I have to change my behavior, then I'm gonna change my behavior, yeah. Yeah, they change the behavior and they tend to overcorrect. So, you know, physicians, nurse practice, and PAs, guess what? They're prescribing less opioids. Hooray! Get out the party hat and the party favors. Let's blow the kazoo. We're glad about that that they're writing less per capita. We needed to correct, but you've got a lot of people that overcorrected and just said, you know, there are a lot of primary care practices that prescribe zero opioids, period. End of story. That's it, that's all. I'm not sure that's what we wanted to happen. You know, in 2012, when when I kind of started this public policy thing with the Chronic Pain Guidelines Committee in Tennessee, if a pharmacy didn't have your PERCAC or your Lore Tab, well, you they hand you your paper prescription back and you go down the street and you find a different pharmacy. We did away with that. Uh prescriptions are supposed to be electronic. Why? Makes it easier to track. Supposedly less errors. And and I'm not going to argue that data. I'm I'm going to assume that there are less errors. But the the unintended consequence of that electronic prescription is the DEA ruled you can't. Move those so if your corner Walgreens doesn't have it and you need to go to your CVS, you know, two miles away, or Super X drugs, or mom and pop family diner and pharmacy, or you know, Jones pharmacy, you can't take that electronic prescription and move it. So you got to call the pay, you got to call the doctor back. You got to get a new prescription. Okay, how long is that gonna take? You know, how many of you listening can call your doctor and get an answer in an hour, right? This is not your blood pressure medicine that can be filled a week ahead. This medicine can't be filled until it's due. So we're day of, all right. What about work? What about child care? What about transportation? If you're middle class, you're upper class, I guess you're upper class, somebody's shopping for you. I don't know. But if you're middle class, this is an inconvenience. This is a call into work to say, hey, I'm sorry, I uh I got an issue with my medical care. I'll be in four hours later than I thought. Because you're going around town and and trying to get back to your doctor's office to see. But for my patients that are of low income status, let's say we've got a family that's got three generations living in a house. They got two cars but four jobs, and they've got daycare issues to deal with, and they're working at jobs where leave for medical uh circumstances is not necessarily great. Um, I know there's FMLA. Don't give me blowback, but that's that's paperwork. Um, you got to get to somebody, you got to get that signed. We're talking about an afternoon here. If you're working at your average big box retailer at a low uh income position, these folks they just don't have the resources to be off work chasing medication.
SPEAKER_00No, and it could even cause troubles with your employer. Uh they they might say, Hey, you're you you've missed too many days. Yeah.
SPEAKER_02Yeah. And I I've got elders that are relying on Uber to take them to the doctor or to take them to the pharmacy. And so these guys now, you know, family can't take them. They're out 30 bucks for the Uber uh in a metro area. And then now they got to pay again because they they got to go to the pharmacy again. And the pharmacy won't tell you that they have your medication in stock because they don't know that you're calling if you're a mule for a gang. So they don't know if somebody's gonna drive a car through the back door. So these pharmacists fear for their lives, they fear for their safety, and so they don't want to put a sign out front that says, hey, we got perk set in, everybody's got a prescription, come in. Right. You know, there's just some real tip of the spear outcomes for patients that sometimes we don't anticipate are gonna happen when we're saying, hey, this will be a good thing if, you know, it's a good thing that there was a legal settlement that acknowledged that and that those funds were earmarked, not for potholes, not for campaign funds, not for, you know, um the the brother-in-law's concrete business. But those funds were earmarked to help patients who struggle with substance use disorder, uh, prescription drug abuse, et cetera, for education to keep it from ever happening. That's awesome. I think that's wonderful. Absolutely. But we're stupid if we don't take into account that this does have sort of mission creep, that there are downstream effects that we might not anticipate. I'm telling you, my patients deal with it. It's it's a daily thing for me. Every business day I deal with this. Every weekend I deal with this. During the day, I write opioid prescriptions. You know what I do at night? Try to help patients find it. Because some of the pharmacies I send it to don't have it. And so now they're calling me in the after-hours clinic and on call and said, Hey, Dr. Jackson, can you help me find the medication? I'm not talking with a high school footballer who tweaked an ankle with a grade one sprain in 1977 and now he's on 80 milligrams of oxycontin four times a day. That's not the patient I'm talking about. And, you know, that's a 2002 story, right? That is not a 2024 story in large degree because of the changes that we've made. I'm talking about patients that are on four percocet a day who have metastatic pancreatic cancer. I'm angry about that. I'm angry that we don't have a better system to serve those patients and that we don't have enough nuance and understanding and complexity and uh nimbleness to create a system and an ecology of care. And I'm frustrated that it's it's difficult for us to do that. And you know, we're gonna get better, we're gonna keep working, but that's one of the things that I want to keep sounding alarm about and making everyone aware, you know, legislators, policymakers, patients, patient advocacy groups, clinicians, uh administrators, help people be aware that there are these unintended consequences that we have to look out for.
SPEAKER_00Of course, in the background of all this is the threat of withdrawal. You you mentioned this uh directly. This has been a risk factor for the re-entry population, it's been a risk factor for people entering into early recovery. Um in those contexts, medications for opioid use disorder, you know, that you mentioned this as well, buprenorphine methadone, et cetera, are often cited as potential bridges for this. And we even see when diversion happens of something like a buprenorphine. It's done say in one particular example I've heard from law enforcement is uh a dealer says he hasn't gotten his new shipment of heroin yet. So uh he's got some spare diverted buprenorphine here. This will tie you over until med shipment comes through, that kind of thing. But it's still when the diversion occurs, it's being used for its intended purpose to stave off withdrawal. Does this work in the context of chronic pain patients? Uh and even barring that, I imagine if not, there are similar barriers from the pharmacy side of things in terms of just simple supply?
SPEAKER_02Supply can be an issue. You know, the challenge with with bipenorphin is let's say you're using suboxone, which has a naloxone component. If someone had medication within a defined period and you give them Suboxone, if they've got opioids in their system, you could precipitate withdrawal because it's a personal agonist. And this gets into some pharmacokinetics that that may be it's kind of getting down the weeds, but it's not always smooth. Um, also in the early 2010s when we started the Chronic Pain Guidelines Commissions, the Department of Mental Health and Substance Abuse Services, Tennessee Department of Health and the Tennessee Board of Medical Examiners, they they sort of felt that they wanted um a pretty good division between medication-assisted therapy and chronic pain clinics. When the idea came for registration of chronic pain clinics, the thought was we already have an issue with so-called pill mills, and we need to get illicit practitioners out of the space and make sure that the people that are that are practicing are good medical clinicians that are doing good medical practice. Well, at the same time, there was a perception that there were some methadone clinics or buprenorphin clinics that might not have had high standards of care either. And so the idea was we didn't want the same person in the same shopping center, you know, saying to the ankle sprain folks, hey, uh, come get your octoccontin here. And then uh, you know, six months later, when they're trying to get off of it, well, okay, come get your buprenorphine here. It's just$300 cash per visit. You can see where the conflict of interest might come for somebody to actually create a market for medication uh assisted therapy. And at that time, it required a DEAX to run medication assisted therapy or MAT. And so there were a limited number of clinicians who could provide these services. And so there was a high demand, and people could demand, you know, relatively high fees and cash fees to see an MAT clinician because there was a limited supply. Those rules have since changed. But the old firewall that Tennessee had between MAT and chronic pain is kind of still there, to be honest with you. And so for me as a clinician, although I have a DEAX, um, I got to be pretty careful about documentation uh when I start providing somebody, say, buprenorphine for opioid use disorder, if I'm already boarded in pain medicine and I'm providing pain care, I'm boarded in palliative care and I'm providing palliative care for a patient with opioids, because there is that stigma of mixing the two worlds. Uh, where if you're a chronic pain clinician or a palliative physician who's providing pain for oncologic patients, it may be there's just a reluctance to dip over and do the anti-withdrawal treatments.
SPEAKER_00So just at baseline, if you were to increase using uh medications through opioid use disorder to bridge that gap in an emergency situation, say, there is potentially the threat of legal ramifications, if only an intense scrutiny, and that other clinicians would have that in the back of their mind in general.
SPEAKER_02There's reality, and then there's the fear of reality, Jeremy. You know how this works. I mean, you don't have to punish too many people to get everybody's attention. Right. And and doctors, like every other human group, you know, we we have fear dynamics just like everybody else. You know, when I when I get a letter from the United States government, I'm not usually assuming positive intent. Uh you know, it's just oh great, the IRS is sending me another check. You know, that's not what we think. If if if somebody shows at my door and says, you know, we're from extricate government agency, I usually don't think they're there to offer me an education or an award. I think, oh man, what what's what's going on here? You know, right. Doctors don't, we just don't like to deal with uh with regulatory agencies. And there's there's fear there that uh, you know, and around the opioid crisis, we've given clinicians a lot of information that says you better watch what you're doing. It's important. First of all, always do what's right for the patient. But in general, I would say that people are very fearful about treating somebody to keep them out of withdrawal because they feel like a specialist should be doing that. And, you know, oh, by the way, if it's 11 o'clock at night, finding that specialist is gonna be very difficult because there's an undersupply. And then we just don't have good information about who can see patients and and and who can see somebody at 11 p.m. You know, honestly, that's gonna get dumped on the ER. Um, and ER doc's gonna have to deal with it. And um, it's just not gonna be a good outcome for the patient. So, you know, let's let's we're we're far down the tree here. How do you prevent this? Well, you prevent it by making sure pharmacies have adequate supply from their suppliers of the medications that are needed. You make sure that doctors and nurse practice and PAs are prescribing medicine properly when it's supposed to be prescribed for legitimate medical use with a good history physical exam and monitoring. Um, the Office of General Counsel does a good job in trying to make sure that if we have complaints about somebody that it that that's looked into, investigated, and if things are good, then then they're good. If they're not, uh the person gets feedback. And that could be instructive or educational, it could be punitive, depending on the the the gravity of the of the deviation from standard of care. You know, we're working on it. You do it by making sure that that patients are on the ball and and and don't wait until the last day to call the office and say, hey, I need a prescription. And and so giving people education about it, uh managing things appropriately, you know, hopefully we can get better. I think the biggest piece that could happen here, and I I've a year ago I heard a rumor they're going to do it. If the DEA would release the hold on electronic prescriptions being movable, at least within a system, let's say that I prescribe to a Walgreens at first and and Adams or whatever. I'm making up names here, and they don't have it. If they could transfer it to another Walgreens electronically, that would save a bunch of trouble because at the pharmacy desk, you take the physician out of it again, at the pharmacy desk, oh, we don't have it, but our our colleague across town has it immediately right then. The patient could go and they don't have to go home and wait on the doctor's office because then you get into ride share issues, work issues, all that kind of stuff. That would that would really, really help. I I think that's the pain point right now. And if the DA would do that, um, I think things would would change. I've actually heard that they were gonna do that, but uh every time I look it up to see if that change would happen, I can't find it. So if the DA would relax that rule, I think that would help a great deal.
SPEAKER_00Do you think pharmacy benefit managers are playing any role in this?
SPEAKER_02You know, I think PBMs, they need to decide what they stock and what their who their suppliers could be. And um there are a lot of people that think that PBMs may be next in line for scrutiny in terms of the role played during the opioid crisis. So I those guys, I I don't look for them to wake up tomorrow morning and say, hey, what can I do to help chronic pain patients achieve and or cancer patients achieve a sustainable supply of opioids? I I don't think that need is on their radar. And I think that they would see it as a threat and a risk to their business model to be concerned about a legitimate supply of opioids. That's a shot in the dark from me. I'm not buddies with any PBMs. I don't know any of them. I haven't talked to any one of them in a while. So, but that's just my supposition that they would be, they'd have some of the same concerns that clinicians have had for the last 20 years about prescribing. They would have some of the same concerns about uh procuring. Okay, I think that's an interesting point still. I I will I will I will tell you that PBMs, these sort of um love letters that they send to people, hey, we noticed that your patient is on this opioid. Um, can you tell us about that and justify to us why they have this? And you know, it's intended to be an educational opportunity. And occasionally I do get information that is helpful, but every piece of paperwork that you send to a clinical office, you know, old, old data here, but they estimated that it takes about 17 bucks to produce a piece of paper coming back out of a clinician's office. By the time you pay all the people, you pay the clinician time to generate it and all this. That may have gone down with more electronic and automation AI stuff. But when you send somebody a letter that says, hey, we're watching you, they get more than the message of, hey, here's a great educational opportunity. Um, I didn't know my patient was on a muscle relaxer and an opioid. I forgot about that. Or I didn't know that, you know, Jones across town wrote uh this uh benzodiazepane for them. I I didn't know that. And sometimes uh clinicians can respond just by saying, I'm gonna write less opioids because I want less papers on my desk. I want less attention. And there can be those that just kind of see it as big brother, you know. I I don't I don't want anybody paying attention to what I'm doing, so I'm just gonna write less opioids. That's that's kind of a concern that I have.
SPEAKER_00I think that's a really valid concern, though. I'm I this is uh a time of flux and a lot of changes are are occurring uh at the federal and state level. That not to mention, and and we certainly don't have to go down this road, but there's been a lot of talk again of of healthcare in general at many different levels. We mentioned PBMs, but there's financing comes into play, uh medication access and things like this. Uh, when government is brought into any sector, there is always the threat of politicization of that sector. Uh so even with just in general to bring that up and if only to say, looming in the background is is the concern that my practice that I went so long to school for, et cetera, et cetera, is now you know on the ballot. Uh that that that is always a probably a concern for a substantial number of uh clinicians of any kind, I'd imagine.
SPEAKER_02Listen, we we have to make rules, and rules have to come from somewhere, and we have to follow those rules. I'm not an absolute libertarian when it comes to medical practice. I mean, you know, I I don't want to go back to, you know, Dr. Johnson's snake oil cure for hand, foot, and mouth disease, treat man or beast. You know, 1890 was not a good time in this country. Uh, cocaine was being sold over the counter, morphine has been sold over the counter for kids' cough.
SPEAKER_01Right.
SPEAKER_02We don't need that. Uh here in Tennessee, you know, with the masking gill company, uh, people that were killed because um there was a cough syrup that was given that was sweetened with a substance that's very much like antifreeze and it poisoned kids. And oh, by the way, uh it was it was used, and there were more African-American children that were killed than Caucasian children because initial market research that showed that African-American children preferred a sweeter product, and so deliberately it was it was sweetened, and so you know that's where you kind of get the FDA with teeth. We were on the business end of that uh as Tennesseans, you know, that was that was a company that had roots here. So I don't want to go back to that. I want rules, I I want to follow rules, I I want a regulated society with respect to medical care, but I want smart rules, right? I want um, and that's that's not a shameless plug for your guy, your guys' entity, but I want smart rules. I want people to look at this, I want us to look at unintended consequences. I want a feedback loop that causes us to change rules if they're not working. I like it that Tennessee has sunset laws, uh, and that you know, legislation dies after a certain amount of time, and you know, that you don't get these dumb things like, you know, there's all these uh state laws of you know, you can't chew gum and eat ice cream or something.
SPEAKER_00Somebody had a lot of giraffe or a street light or something. Exactly.
SPEAKER_021832, you know, and somebody had a you know got drunk and made a law or whatever, and it's there forever. I like it that Tennessee sunsets its laws and we have to look look back at them, make sure they're doing what we wanted them to do in order to keep them. Easy to keep a good law if you vote it back in. Uh, but it keeps things from just kind of being out there in perpetuity. I I like that rule, I think it's good. I love it that Tennessee is a sunshine state in terms of our meetings have to be public, you know, backroom deals. That's not the way Tennessee does business. Uh the opioid commission, it's all it's all public record, and I think that's good because you can go back and look and see every dumb and smart thing that was said, and if you agree with it or disagree with it, and it's all publicly available. You don't have to be an insider to be an insider. Everybody's an insider in Tennessee. All our meetings have public comment. I think that's a good thing. But I'm just saying that it's important that we don't fall asleep with the switch and say, Oh, prescriptions are down. That's great, everything's gonna work out fine. No, it didn't work out fine. Our our deaths have gone up as prescriptions have gone down. Nobody saw fitmill coming, except the Jalisco boys uh that were trafficking it, except the the Chinese companies that were making it. I I'm not sure that most people predicted a resurgence in heroin in in the eastern United States. It happened. Honestly, if if you think that making Dr. Smith write 10 less floor tabs this week than he wrote last week, uh that last month, if you think that's gonna stop the opioid crisis and opioid overdose this, you're you're well Jesus had a statement about straining out of that and swallowing a camel. Uh you you just got the proportionality of it wrong. Prescription opioids right now, they're just not driving this wagon.
SPEAKER_00Uh, you mentioned stimulants earlier. Uh uh we've heard many times that uh methamphetamine and other amphetamine type stimulants, including and then there's cocaine in general, uh, are significantly on the rise in quantities and volumes that really are unprecedented. Prescription opioids are not going to have anything to do with that at all.
SPEAKER_02Well, polysubstance abuse happens. You know, people go to parties and do the MM thing. You know, there's certainly I I talk and so yeah, it very few overdose deaths are a single substance. And so it is included. So some of these data are a little hard to parse because if somebody had three different things in their system, what's the death attributed to? Does it go to all three buckets, etc.? You did mention cocaine and other stimulants. Let's let's just talk about it for a moment. But you know, in Tennessee, these are 2022 data, but in 2022, the number of overdose deaths of all type, you know, you're looking around 3,800. Okay, what's opioids out of that? Uh opioids are 3,000. So a lot of of overdose deaths are attributable to opioids. Now, fentanyl out of that is going to be around 2300 or so, uh, 2,500. You're getting pain relievers is 500, so that's prescription drugs. Now let's let's let's slip down to to overdose deaths and stimulants. You've got stimulant deaths, 2,000. Now, wait a minute. I thought you told me that that opioid deaths were 3,000 and you told me stimulants were 2,000 and you said the total was 3,800. This is where we get into polysubstance abuse. And so some deaths may be counted, so-called counted twice, because if somebody had, let's say, methamphetamine and uh oxycoda on their system, then that's an opioid death and that's a methamphet, that's a stimulant death. But um, with respect to stimulants, the other stimulants have really risen sort of geometrically, they've been on an exponential rise. Uh, and that's primarily methamphetamine um and derivatives. And then cocaine deaths have sort of been an arithmetic rise. They're kind of a a slow percentage, and it's not it's not exponential, it's just it's growth. And it's grown from say 250 or so for cocaine in 2018 up to about uh six or seven hundred in 2022. So it's substantial growth, but not exponential growth. Whereas meth has been an exponential growth. Meth has made a huge comeback uh in in Tennessee over the last four to five five years. So, you know, opioids are not all the story, uh, but prescript of the opioid story uh prescription opioids much, much more um concerning than uh uh prescription opioids, excuse me, much less concerning than the illicits uh such as such as fentanyl and its its its derivatives.
SPEAKER_00Absolutely. Uh I know for sure. I I certainly don't mean to discount uh the phenomenon of polysubstance use, which really is much the norm. Uh at the same time, you mentioned that exponential rise in methamphetamine. Uh we at Smart did an analysis finding that in Tennessee specifically. While deaths involving stimulants, the majority of those also involve opioids, the deaths involving just stimulants alone, again, primarily meth, are increasing at a faster rate than the combination. In other words, uh people are dying at a slightly faster rate of just stimulants themselves than those who are uh than the rate of increase of those who are dying of stimulants plus illicit uh opioids. With that, I mean there there are a number of uh findings as to why this might be the case. Riskier use, higher doses, the potency and supply have increased dramatically, and that's just providing more opportunity for cardiovascular events and things like that. But all this to say simply that it comes back to a demand issue again, uh regardless of if they're taking oxycodone, fentanyl, methamphetamine, cocaine, wh whatever it may be, uh xylosine, it it at the end of the day, uh there is an inherent demand uh for a substance, especially in what they call the fourth wave, where it's shifting combinations uh might include an opioid, might include a stimulant. It we recently had on Sam Canone's The Writer of Dreamland and The Least of Us, and uh we we spoke about uh the need for community uh development, for municipal recovery, not just recovery of the individual. What do you think is going on, or rather, what effect could we play at the cultural societal level to help reduce demand in general, regardless of substance in question?
SPEAKER_02Well, um, I'm glad you mentioned Sam's work. I I love it. Um as Stephen Lloyd, our opioid commission leader, says, you know, Sam's just a great storyteller. And and I'd say, you know, commercial for Sam, if if somebody just really wants to read one nonfiction book and get a handle on what opioids have done in America and what's happened with substance use disorder, I think Dreamland is is as good a description as you can find. There's a cottage industry of these books, so you can find a lot of different ones out there, but I think Dreamland towers uh above with its uh just the the quality of its prose, the depth of insight, uh, and the breadth of coverage. Uh Sam's just a uniquely gifted storyteller, and I'm delighted you guys had him on. I I think his book points out that again, I don't want to overuse the word, but there's an ecology of care and there's an ecology of health, and there's an ecology of addiction and an ecology of illness. One of the things we know, especially in chronic pain, but it's true also in malignity-related pain and palliative care as well. People with an internal locus of control versus people with an external locus of control, that's a huge divide when it comes to facing chronic illness of any type. What do we mean by internal locus of control? People who feel they have personal agency to make a change in their environment for the good, those folks tend to do pretty well. And by the way, a lot of times they end up taking less opioids uh for chronic pain. Whereas people with an external locus of control, these are people that life happens to. They have more of a passive approach, more of a sort of waiting on the next shoe to drop, the next thing to happen, the next hit to come. And um, a lot of times these patients can be very challenging uh in a chronic pain scenario or chronic illness uh scenario, because a lot of times they don't feel that changes that they make can make a difference in their outcomes. Um, with respect to the surroundings that people have, and Sam touches on this, you mentioned the idea of development of community. Of course, that comes from uh I'll probably paraphrase it a butcher a little bit, but um, but Johan Hari uh famously stated that uh sobriety is not the opposite of addiction. The opposite of addiction is community. And substance use disorder, basically addictions of all types, um, take community away from people and replace it with compulsivity. So compulsive use of a substance or behavior sort of perpetuates a shame-based operation that keeps people from being accountable and relatable to those around them that are in their support network. And uh you get, you know, this is true with gambling, it's true with alcohol, it's true with uh stimulants, it's true with opioids, it's it's true with pornography, it's true with uh sexual addictions, and it's it's it's true with eating disorders, be they eating too little, such as anorexia, or eating too much and obesity and and uh overeating, people become ashamed about their behaviors and they get down a trail where they kind of feel like they can't get back, and so they lose a community. And so part of the restoration of what needs to happen in America is not just regulation, it's not just top-down fiat change. And and I'm for good policy, I don't misunderstand me. But good policy ain't gonna do it alone. We have to have grassroots efforts to restore community. Um, we we got to have a good place uh for kids to meet mentors, we got to have a good place uh for mothers to have good support with respect to child care. We we've got to have a good place um for elders to be cared for, and people need meaning and purpose. And without that community, whether it comes through a civic organization, Kwanas, Rotary, Lions, whether it comes through religious uh groups, Church of Synagogue, Temple, the philanthropic groups, there are a number of areas that it can come from. It could be your quilting club. There's a whole concept of bowling alone and a work about how Americans don't belong anymore. Certainly in my realm, I've seen that professional organizations. I was the board president for a professional organization that actually in the 2010s uh folded. And we had at one time we had uh over 4,000 members, but our membership dwindled and and we actually had to stop, you know, just fold up shop. We couldn't uh undergo operations anymore. Why? In part because uh this generation of clinicians wasn't so keen on belonging to a professional association, didn't want to go to meetings, so much more comfortable doing things online. You know, we we called it pajama CME, where continued medical education occurred not in a hotel conference room with your peers and learning at the water cooler together, but you know, everybody's you know, clicking online credits. And I suppose that's great in that good content can be delivered to somebody in Jackson Hole, Wyoming, but good community can't. Uh we we need analog interactions. And so this idea that you know culture isn't shifting in a way of increasing connection and belonging, and we have to be intentional about that. And if we're not, I think those have dire consequences uh for those that have genetics that are predisposed to substance use disorder. Stephen likes to say that addiction is genetics, trauma, and opportunity. And so we can't change people's genetics at this stage of the game. We can try to reduce trauma, early childhood events, et cetera, but we know some level of trauma is going to happen. Well, opportunities for substance abuse are certainly there. We need to substitute those opportunities uh for opportunities for growth and opportunities for community in order that people that have struggled in the past can recover and stay recovered, but also that some people might not ever go down the uh use disorder path because they might have strong enough community networks that they don't abuse or misuse substances in the first place.
SPEAKER_00I'm glad you mentioned associations, the or rather I should say the decline in community connections. I'm glad you mentioned that because it it's it's funny. I've been reading Alexis de Tocqueville's uh Democracy in America, which just this last year, or just this year, uh became one of our state books. In it, uh especially in the first half of it, he outlined several facets of our democracy, what makes us strong. And mind you, he's writing in 1835.
SPEAKER_02And I think it's it's a it's it's a terrifying book when you compare it to today's exactly and contemporary political landscape. It's terrifying to know what Alexis saw and uh what he predicted. And uh it's it's very frightening.
SPEAKER_00Yeah, well, he he pointed out our inherent systemic fragilities. Uh, just the structure of our government, the structure of our society, uh on top of the geography we inhabit, lead to a lot of just inherent threats. I mean, it's a very fragile skyscraper. And he outlined several reasons why we are keeping the thing functioning. At his time, we had only been around for 50 years. Uh-huh. But several times, again and again and again in many different contexts, be it talking about the health of our news industry, the health of our education system, uh, even the health of our churches and our in our local communities, he points to localized civic engagement, an intense focus at the local level. Uh and that everywhere you go, there's a famous quote he he addresses how everywhere you go, there's going to be some kind of association that Americans belong to. Uh-uh, that if there's an issue, we're going to make an association for it. And we're seeing that uh disappear as you just described. And I th it almost seems inevitable that we would be suffering from so many deaths of despair, uh, primarily overdoses uh in this context. It's it's just on my mind as you were just as you were talking through that.
SPEAKER_02Well, in my clinic, you know, it's just taking on primary care and you know, we're we're panning back now from from opiate use disorder into you know compulsive destructive behaviors and and lack of community. You know, in my clinic, a lot of people that make substantive health changes, the people who start exercising right, they start eating right, they've got a support network that's driving that. They're doing it for someone else. If they were doing it for themselves, you know, they would have already done it. There are a few road of Damascus experiences. Of course, I'm alluding to the famous story of conversion of the of St. Paul, where he was traveling to do one set of work, uh, which was basically basically ethnicide, um, and he becomes uh a great saint and changes his whole life in one moment. Well, those kinds of experiences are pretty rare for humans. Most people need a network or a web of people around them to effect positive change. Even for Saul, who became Paul, he although he had this phenomenal instantaneous conversion experience that was revelatory and life-changing for him, there was a network of people around him immediately, other followers of Jesus who helped him along a new path. Well, the idea is for us, if we're going to affect positive change in our lives, you know, we may wake up one morning and say, I'm tired of being overweight, or I'm tired of having high cholesterol, I'm tired of having high blood pressure, I'm uh I'm tired of you know, depending on opioids, I'm tired of, you know, whatever that positive change needs to be, we have a much greater chance of success if we will be part of a network of support that can facilitate that change and move towards that change. This myth of rugged American individualism is just that. It's it's a myth. And I mean that you know some myths are true, and and most myths contain some truth, but I do mean that in a negative quality. It it is misguided to think that we are sort of billiard balls that just bounce off one another and there's no effect on each other, that we're just complete independent moral agents, complete independent health agents that do exactly what we want to do. You know, the yellow flag with the rattlesnake, don't tread on me, etc. Listen, we're just social creatures. We're born for community, we're created for fellowship, we're created for community. When we don't have that, we don't behave, act, or feel at optimal capacity. It's true in every walk of human life. Um, so that's we're just not born to be desert mystics. Right. Um, that's not the normal human ecology. We're not we're not made to be isolated, we're made to be in community with one another. And when we don't do that, then some people are gonna return to refined carbohydrates, some people are gonna return, they're gonna turn to refined fentanyl. You know, people are gonna find something to hit their dopamine levels when they don't have routine, normal human interaction. And so I think to to to the to the idea that we can facilitate those types of communities, it's a long play, it's a long play, but if you know, if I were king of the world today, uh, you know, with a benevolent tyrant or despot, you know, I'm laughing, don't put me on CNN. Um I had control, you know, I want to reduce childhood trauma, I want to reduce adverse childhood events, and I would want to facilitate organic community uh among humans. If you could do those two things and promote it, you can't dictate it by public policy, but if you could promote it with public policy, then some of these issues that we're talking about, they wouldn't be solved, but at least the current would be drifting in the right direction. You'd be you'd be going with the current rather than against it. Guys, I mean, one of the reasons that prescription reduction failed as an opioid mitigation strategy in our state was that we were swimming upstream against a stiff current. And that current was the death of despair thing. And and obviously in deaths of despair, we're uh we're referencing a pretty famous book. If you're listening, you don't have it, Annie Case and uh and Angus Deaton, uh Deaths of Despair, the Future of Capitalism. It's uh, I think revelatory read uh and and is in the in the strain of Tocaville, Neil Postman, Robert Bella, all these sort of classic sociological researchers and writers that have informed uh our republic for 200 years. And I and I think Casey and Deakin stand up well to that tradition. If you don't have desk despair, please get it. I think it uh will will open your eyes.
SPEAKER_00So if I might summarize that, uh again, attempting humor here. If I could react to say you mentioned the Gadsden flag, don't tread on me, if I could counter that with another snake-based flag, uh Benjamin Franklin's join or die. Does that about uh similar as what we're saying?
SPEAKER_02How how how beautiful? I mean, isn't that our country? Don't tread on me, join or die. I mean, it we I think both snakes have something to offer us, and and and both movements, both thoughts, both philosophies have something to offer. We do need to be independent actors, but you know, we do need to act on the environment, we do need to be motivated, we do need to take individual responsibility, but we also need social connection. Uh Jeremy, that's brilliant. Uh, you can consider that ideal idea completely stolen. Um, I am now making the PowerPoint in my head uh because that is uh that that is next level insightful. And and I only wish I'd thought of that. Um, I will give you proper credit sometimes if I think about it, but that that message is going far and wide if I ever have a chance to speak in front of people about this again, because that's a brilliant analogy of where we are. Join or die. We need each other, and and and and that's very important if we're gonna succeed.
SPEAKER_00Well, thank you, Doc. I uh in general, I um if there's anything I might ask, uh what potential policy topics or or policy windows should we be considering looking forward?
SPEAKER_02Let me go with federal. I've already called it out. I would love to see the DEA. Um if it's already been done, advertise it because I can't find it. But let's let's get electronic prescriptions for controlled substances such that they can be moved just like a paper prescription. So if the pharmacy doesn't have it, they can move it to a different pharmacy. That's easy. We could do that tomorrow if enough people would write the DEA, if they would let their congresswoman, their congressman know about it. If I come up with one more good idea, my wife may um want me to move out to the farm instead of getting the house. I'm not sure I can run that petition, but I wish somebody would take that up and and and you know, a public advocacy asks the DEA to make it possible to move electronic prescriptions between pharmacies so that supply issues don't hurt patients. That's number one. Number two, I think we need to keep the lines of communication open between specifically state regulatory agencies, such as departments of health, boards of nursing, boards of pharmacy, boards of uh medicine, and departments of mental health and substance abuse services keep those lines of communication open so that prescribers and clinicians in the treatment spaces, chronic pain, palliative care, uh, pain medicine, uh, substitution disorder, so that they have a name or a face in their departments that they can relate to, so that policy is not just some draconian top-down issue, but that we get feedback from the community. I think we've done a pretty good job of that in Tennessee. And that's one of the reasons I'm being I'm very proud of Tennessee for that. We haven't had all the outcomes we're looking for, but I tell you that I do feel engaged as a clinician in the process. I feel like I have a voice. And I feel like that any clinician can have a voice in Tennessee. I think we need to make sure that that's the case uh for clinicians around the country. Because honestly, I'm greedy. I want to exploit every good idea that we have. If somebody in Utah comes up with a good idea, I want to use that in Tennessee. And those kinds of human connections, water cooler communication, can be extremely helpful in in driving that. You know, Johns Hopkins has a good website around uh opial abatement. There, there are others that have information shared. So shared information, I think, is is key. And so policies that promote that are important. Finally, uh, this is a this is a dream of mine, and and this is sort of my holy grail is you know, I used to work ER, I did a lot of overnight shifts um because at that my life didn't have the seniority to do the day shifts. And so if somebody in Oneida, Tennessee is working in ER and they can pull up in real time what treatment beds are available, what 24-7 resources are available to get a patient to care when they need it right now. They don't have to look up insurance, they don't have to look up how many beds they have, whether they have an open bed, all that kind of stuff. If we can just smooth that out and make that digital and you know, they can hover over a county, find the services that they need on a on a website. Um, to me, that's that's great. That the pain points for patients and for clinicians are that we have great systems, but they're inside those, and you don't know. We've got great isolated islands of care, but people don't know what's available. And we can't get people to the right places because we don't know where it is. And so a coordinated effort uh to match need with resource, I think is is a role that government can play. I think it is a role that opioid abatement dollars can play. And and we're working on this, but we don't we don't have it fleshed out. I'd love to see that happen uh so that you know your Oneida ER physician or or PA or MP can get a patient to care at 3 a.m. They can get them to a counselor at 3 a.m. They can get them to a price intervention team. I I call it the the Friday afternoon test. If you can get somebody to Monday, if you can get them through the off hours, if you can, if you can, at midnight test, if you can get them to care at point of meet, meets point of service, I think we can, I think we can move the needle. I think we can save some lives. And uh I think we can abate consequences until we can change some of the ecology we're talking about and and 20 years from now reap a benefit because we have healthier citizens. In the meantime, while we're in crisis, while it's a red alert, let's coordinate rather than just having isolated excellence that isn't integrated.
SPEAKER_00Thank you very much, Dr. Jackson. I think those are really, really excellent ideas. All right. Well, it's it is always a true, true pleasure uh speaking with you. And thank you again for joining me here on the show.
SPEAKER_02Appreciate it, man. Uh appreciate all the great work that you guys are doing at Smart. And please, please, uh just continue to spread the word because we as Tennesseans and folks around the country need to know uh best practices, and that's that's your guide's sweet spot. Greatly appreciate what you're doing for the health of Tennesseans and others.
SPEAKER_00For more episodes on in-depth discussions on Tennessee policies related to substance use disorder by a range of local experts. Please subscribe to us wherever you get podcasts and visit our website at smart.tennessee.edu. I'm Jeremy Corvillas. Thank you for listening. See you next month.