Fred, your talk was was really great. What would you say is your take-home point at the end? Unfortunately, we lost a lot of it, but even following the slides and that data, what's the main take-home point? Sure, so University of Michigan as a whole with the Opioid Prescribing Engagement Network has done a lot of work looking at what factors are really related to persistent use or patients who are first exposed to an opioid after surgery and how many of those keep using them beyond 90 days. And what they found and what we found in our studies is really that it isn't related to the type of surgery or what you might consider injury or surgery severity, but instead it's consistently linked to specific patient factors and prescribing factors. And so, you know, unfortunately the audio wasn't working, but the biggest take-home points were consistently patients that got a bigger initial dose or dose within the perioperative period were at much higher risk of continuing to use opioids beyond 90 days. And then patient factors that again and again came up were medical comorbidities, tobacco use, and then especially mental health disorders such as depression, anxiety, prior substance abuse, and some pre-existing pain conditions. You know, I think all, I mean, I think we've seen that across the board and that's what all the literature has basically shown, not only within orthopedics, but within general surgery and even within the hand literature. You know, one thing I've noticed anecdotally, and I'm curious if everybody else feels this way, that really, and you made this point in your slide, the less you prescribe, the less you prescribe. So I don't give refills at all. And in the last year, I've given one refill and I stopped giving refills. And I found that when I tell patients that they never asked for it. And I find that the less, no matter what I prescribe, patients really only take about half of it as a rule, obviously we're outliers. And so I've sort of slowly decreased where I was prescribing 60 and patients would take 30, and then I prescribed 30 and they would take 15. And now I rarely prescribe more than 15 pills, regardless of the operation and patients are still not taking all of them. And I'm curious if everybody else can comment on that as well. So I will say that's, I guess, one point that was made that didn't come across without the audio is that, you know, that paper where they looked at laparoscopic cholecystectomy, they really said that that sets a mental reference point and it kind of tells the patients, here's what you can expect to take given how big the prescription is. And as you saw, just based on the slides, you know, they went from prescribing 50 pills where patients took six of them to prescribing 15 and they took even less and refills went down even. And I think that's being borne out in the literature as people are developing prescribing protocols. And I think, you know, what it's going to take is developing one prescribing protocol and then looking at it again and saying, is that enough? And then going down again and seeing how that affects refill rates and persistence. You know, I think there are so many misconceptions about this, you know, somehow patients think narcotics in some form are therapeutic. In other words, if they're not, you know, taking narcotics, they're not going to get better as fast or something. But it, I think it takes a long time, not a long time, it takes a certain amount of time to set those expectations. As you said in your talk, Holly, it takes a couple extra minutes and I think we have to incorporate that into the discussion. The other thing I think is important from Bert's work, and I'd be interested in hearing what other folks have to say, is as we sort of go through our practice, you know, year upon year, you get a little bit better about seeing those people who try to identify those people who are going to be problems, right? Those people who say they, you know, from the outset that they have a high pain tolerance or something. It's dealing with those people. It's fine identifying and then we go to then what? I'd be interested in seeing what people's strategies are in terms of when, you know, when you see those people that you know are going to be a problem. Do you take any, do anything differently or any particular special precautions there? I don't. I just tell them how it is. Well, we now have, we have a written contract now with all our patients and I think a lot of the benefit of this new law is just our ability to educate them and say this is now a national epidemic and here's the law. So there, we're going to be, you know, strictly monitoring your narcotic usage and knowing that in advance, I think a lot of patients are reluctant to ask for refills. I've seen our refill rate drop precipitously since the law went into effect and my experience is similar to Holly's. I rarely am writing refills and it was so routine a year ago that it really has amazed me how quickly people are now getting off narcotics. We were having a discussion before this meeting started about some of the problems that we've used as alternatives and I think we intended to get into that, you know, one of them being regional blocks and polymodal therapy. You know, and I think, you know, we've kind of gotten back into a corner where we're using regional blocks almost out of necessity now and probably all of us have seen some complications from the, from these blocks and Jim had made the point, you know, who takes ownership when these complications occur? Is it the person administering the block or is it the surgeon or the hospital facility? And that's been an ongoing dilemma that I don't think we've necessarily solved, but I think the education that's come out of this new healthcare law has really benefited our ability to monitor our patients and counsel them about how they should be managing pain and how quickly they can get off their medications. Paul, how do you think we should manage that as orthopedists? Because we're the ones seeing them back in the office and they say they've got some buzzing in the bottom of their foot and it won't go away. What's, how should we approach that and try to give them the best care? What are our options with regard to you and your anesthesia colleagues, do you think? Yeah, I think getting them in for evaluation with a, with a pain physician is probably a good idea if this is something that's not going away. In my talk, I talked about the closed claim data and it, I think Dr. Anderson had mentioned this in his talk that over time, although they saw a higher incidence of neuropathic pain that immediately after the block and has been reported over time, it seemed that the long-term complications were pretty consistent with what we know from the closed claim database. So I think getting, first of all, give it a little bit of time. If a, something like an EMG is required, it's not going to show a deficit right away. You've got to give it a couple of weeks, but getting that patient in for evaluation, if there is an ongoing problem with a neuropathic type of pain, then you're going to want to start desensitization therapy, topicals, these types of things. So I, we were talking before our broadcast started, the, some of the difference in practice patterns around the country. And I've always had a little bit of a bias that people doing acute pain should have some capacity to absorb those patients if they do have a problem. And you know, something else I wanted to mention, I really appreciated Holly's talk. I had a chance to listen to it and she said something interesting that I was hoping she could comment on a little bit. I think you said you prescribe ibuprofen and Tylenol. And I think that has a strong implication to the patients whenever they get a prescription from a physician. Maybe you could speak to that a little bit. Sure. So I, I didn't use to do that. I used to recommend that patients take it, but when I came to HSS, that's actually Scott's protocol to prescribe the ibuprofen. So I started doing that and then prescribing acetaminophen. And I just, I found that patients then take that medication and that accompanied with my direct instructions that, or, you know, information that the average person takes pain medication for two days after surgery, that, and you don't have to take opioids. You can take Tylenol as prescribed. I don't know what to say. It's made such a tremendous difference in my practice. I honestly, for triple arthrodesis, I prescribed 15 pills and I don't get refills and I've had one patient refill since I've started at HSS in March. It's just been a dramatic change. And I think it's been a few things. I think it's been the conversation I have, but I also think that prescribing acetaminophen and ibuprofen, it's like prescribing a narcotic. If patients have the prescriptions, they think they're supposed to take it and they take it. What about, can I touch on that a little bit, Holly and everybody else? You know, there's this dogma in orthopedics about NSAIDs and anything to do with the bone, whether it's a fracture or a fusion or anything. And we have this sort of, we teach our trainees this sort of black and white, no NSAIDs and that sort of thing, which I think is, my opinion is that's pretty rigid, you know, giving people Toradol at the end of the case or even judicious amounts of NSAIDs. I'd be interested to see what everybody's threshold is for that. I don't think anybody, well, I shouldn't say that. I don't think, Holly, would you be okay with your triple arthrodesis patient taking Motrin three times a day for six weeks, which is not what you're talking about. I mean, I think that most acute pain, the definition of acute pain is a week, really a week of pain. And honestly, ask your patients how long they have pain. And most patients, the majority of patients have pain for two to three days after the block wears off. And so we prescribe the ibuprofen. And again, this comes from all the HSS data that preceded me, that preceded my time there, where they, correct me if I'm wrong, Scott, prescribed three days of ibuprofen. And that's it. The only time I don't prescribe ibuprofen is when the patient has a contraindication, some sort of bleeding disorder, a common anticoagulant. And maybe if it's like the fourth non-union and I'm sort of the last hurrah. But there are no human studies that have shown any bone healing issues. And if you look at the European data, they routinely use ibuprofen postoperatively and their non-union rates are, are they much different than ours? I don't, I don't think so. Now I have not looked at my own data, so maybe my non-union rate is higher. So I should definitely go back and look at the difference and see sort of pre-ibuprofen and post-ibuprofen and see if there's a difference. I don't think you'll be able to prove it either. So there's so many factors that go into union versus not. We all try to limit anything we can avoid or do to decrease those non-unions, but I don't think it's the end stage. Now to answer the question about the protocol we use, we use three days of ibuprofen in combination with the narcotic and even try to do Tylenol if we can, but it's, you know, six to 800 milligrams, three times a day for three days. So, so you're right. It's just at the beginning, but even at that, I think Jim, to your point, we so overdo that, that probably we're making the narcotic problem worse. It's like ankle fractures and things that heal all the time. We're telling those patients now that they, again, say that I think it's a disservice to our patients. No doubt about it. And even, even just a single dose of, of Toradol intraoperative, or at the end of the case, seems to make a huge difference. I mean, you know, five years ago, the kidney stones were getting, maybe seven or eight years ago, we're getting narcotics. Now, I mean, Toradol is for an incredibly painful condition. So I think we need to sort of pay attention to that. John, your thoughts about that? Yeah, I agree. We had in our preoperative literature that we did not want the patients to use anti-inflammatories because of the theoretical downside to reducing bone healing in the early phase of inflammation. So the first three days, theoretically, may be the most critical if that's when the inflammatory cascade begins. But we have no data to support that. And we're really trying to choose between the lesser of all evils, because narcotics are probably way worse than any detrimental consequence to an anti-inflammatory. Blocks are not a complete benign procedure. And there are certainly a number of patients that can get some component of neuropathic pain. But we're doing more and more large surgeries that are very, very painful. And we're now in a situation where many of these cannot be done on an inpatient basis, so we're sending them home. So we really have no great alternatives that are completely risk-free or are going to solve all problems. But I think anti-inflammatories, in my practice, have not reduced my healing rate. And they certainly have improved my ability to get people out of narcotics. So now we routinely use them. One comment, just to piggyback, John, on what you said about sending patients home. I've also found that when patients are admitted to the hospital, they take many more narcotics. And part of that is, again, the dogma about pain. And there's no level of pain that's acceptable. And I think that, unfortunately, for nurses taking care of inpatients, they feel obligated to offer the patient pain medication every four to six hours. And so I found that even for the same procedure, when the patient's at it as an outpatient, the patient takes less pain medication. Yeah, and I think that goes along with patient counseling. When the patients weren't hearing the message that no pain is acceptable or good, that's a very difficult situation to manage. And now I think we probably all are much better at saying pain is normal. It will get better. And you just got to get through it and get over the hump. And a seven-day supply, I think, is adequate for the majority of our patients. I think, too, it takes some counseling and talking with the team. As a resident, I'm still first line for a lot of these calls where it's not uncommon to get a page from PACU or somewhere like that saying patients in 10 out of 10 pain. And you walk over and you actually see them. And you have to wake them up to assess their 10 out of 10 pain. And so I think it also takes some coaching in saying it's not just a number that's being recorded, but kind of assessing the situation. I had the same problem, Burt, with the nurses, too, because they'll constantly tell the patients, stay ahead of the pain. So they're giving constantly to take the pain medicine. And I can't tell you how many times the patients come back in two weeks and said, the nurses told me to stay ahead of the pain. So I took pain medicine. But I don't think I ever really needed it. So it's also a cultural thing. We have to educate everybody else, too. And that's hard because you don't have the time to reach out to everybody and tell them all this. But we have to make an effort to do that, I don't know, through meetings, friend services, or whatnot. I want to digress for just two seconds to make sure we've got, it's great, we've still got 62 or 63 people listening. Just to reiterate that, A, to apologize for the problem we've had streaming this, number one, not for lack of effort. And number two, that the talks, which are all really great, about an hour and 15 minutes worth of several talks will be available on the PRC website. And if there's any problems, please get hold of AOFAS. But I want to make sure we're clear about that. I want to continue our discussion, but I want to digress for a brief moment just to let everybody know we were going to do that. I want to switch gears here a little bit, because I think there are a lot of interesting topics to talk about. One of them is for each of you. There's a lot of people, I think, in the audience who are engaged with opioid reduction in their hospitals and either part of committees or thinking about starting committees. Can you provide any information about your protocols or online resources that are helpful or best practices? You've all had a great deal of experience navigating this through your medical centers. Any tips to sort of shortcut, so to speak, to cut to the chase in terms of get where you need to be? It would be, I think, really valuable for our audience. We will typically prescribe a seven-day course of narcotic, either Norco or Percocet 5s. We rarely prescribe 10 anymore. It used to be routine. We tell everybody to go on 800 of ibuprofen three times a day. We usually will give them a prescription for Flexeril for a few days if we're doing any soft tissue procedures, and then Tylenol to use as needed. So we're kind of attacking it from multiple different modalities. I don't tell patients to get blocks anymore. I used to say, you need to get a block or we're not going to be able to do the surgery and send you home. Now I offer it to them as an option. I think making sure that your patients make an informed decision as to whether they want a block or not is probably the right way to go because blocks are not completely risk-free. And I usually tell them that. I share my data from our study showing that somewhere around 1% of blocks aren't going to wear off completely. And there's a component of neuropathic pain that may persist well after the block is worn off. The majority of those do improve, but I let patients know that there's some risk with that block, just like I have the informed consent discussion about the surgery. And I let them make that decision. I don't push it. The anesthesia doesn't push it, but it's offered to them. And that pretty much is our protocol. If they need a refill, we usually have a script kept in our office file and the refill will instantly go down from either Percocet to a Norco, something with less morphine equivalents. And they're told that you'll get one refill, but we do not go past one refill. And that's... Oh, excuse me, John. Go ahead. That's been our protocol and it's been very effective. I want to hear what Holly and Scott have to say too, but I want to digress for two seconds. When you said Flexeril, because I listened when Paul talked about magnesium and spasm. And I think of Achilles tendon repairs and things we do, tendon transfers. Do you have an opinion about magnesium versus Flexeril, Paul, in your work? And again, I want to hear what Holly and Scott have to say, but I'll forget about it if I don't regress on that. Yeah, that's a great question. We've introduced that as part of a few protocols for various perioperative care pathways. And magnesium has good evidence for it. It's a good muscle relaxant and the formulation really matters. The best evidence is for magnesium glycinate, which is not on most hospital formularies. It's available as a supplement, but it has no cognitive issues like Flexeril. Some people are very sensitive to Flexeril. It has no compounding effect with other meds and it's a laxative. So it's a great first line for muscle spasm. I use it routinely for anything with a spasmodic component to it. If it doesn't work, you can always escalate care, but it's a great entry point. And we've had very good, great success with it. I'm sorry to interrupt Holly and Scott. Your thoughts on resources and your approach to this for our audience? Well, you know, again, just to give a little perspective. So I've operated in four different foreign countries and none of those patients have ever been prescribed a narcotic. In doing large operations in Vietnam, they take Tylenol if they have it. If you look at the European literature and you look at the data that we collected from the Dutch Orthopedic Financial Society, we give almost three times as many narcotics. It's the same patients. People are people. And so there's no reason why somebody, honestly John, like even needs a seven day supply after a funding correction. They really don't. And I just beg everybody, ask your patients what they actually take and document it. You will learn so much. Tell your patients how many days it's going to take to get better, how many days they're going to need to be on narcotics. Don't say seven days, say two to three. And then ask every patient that comes back and I guarantee you will say, oh my gosh, I'm over prescribing. Because I used to, I used to give, I created a whole algorithm. I believe it was 2015 and 2016 for foot and ankle when I was at Mass General. And I have since halved that. And it's all been just asking patients what they take. So again, I give ibuprofen and Tylenol prescriptions. I give oxycodone because I get a little nervous about the Percocet and having the Tylenol in both. And I'd rather have the patients take the Tylenol and the Advil around the clock and then use the oxycodone for breakthrough pain as opposed to the other way around. I give an anti-emetic, typically Zofran. I give Colace and maybe Aspirin once a day. So I don't do any muscle relaxants or anything like that. I'm not, I don't know, I don't, I just haven't thrown up a lot of experience with that. And it's been really, I would say over the last year to two years, it's been really life-altering. I don't give, I just don't give refills. I tell patients, you will not get a refill from me. And I've had one patient call for one. And typically what happens is when people call, I just had a conversation with a patient on Sunday who had surgery on Thursday. And she said, you know, I'm really having a lot of pain and I only have two pain pills left. And I talked her through it. And the reality was she wasn't taking Tylenol or Ibuprofen. And once she started taking that, I said, call me back if you have any issues. Let's give it like three or four hours. She was done, she was good. And so sometimes it takes a little more time. I answer all my own calls because I find that having somebody who doesn't know the patient, the easiest thing to do is. Holly? I think we lost her. I think we lost the video. Holly, I don't know. You might have to log back in. The technology folder guys are busy tonight. It sounds like maybe we can get back in. I wanna get some thoughts on people's threshold. I think I heard a little bit about what your opinion is, John, about your threshold for, are you back, Holly? And here's a threshold for blocks. So it's a sort of a two part question I have. One is who gets a block? Who do you recommend should have a block or who not? And then the second part of that question that Paul, you can help us with is advantages and disadvantages of single shot popliteal block versus catheter, who does better? What kind of things are you thinking about? Yeah, I would say that the majority of my large bony work gets a block. I have that conversation telling them what's involved and what the risks are. And I would say the majority of them accept that and get a block. Well, there are specific procedures where I tell them they don't need a block. And it's usually single incision surgery, soft tissue type procedures, simple surgeries like hardware removal, things like that. I talk to them, yeah. Talk to them. Bi-malarial fractures? Bi-malarial fractures usually are getting blocks. Yes, get a block? I'm sorry, I didn't hear you. Yes. Yeah. Bi-males are usually getting blocks. Uni-males, I usually tell them I can get them by without a block. So I'll do a, if I can use a local anesthetic to numb all their surgical fields, then I usually will tell them they can get by without a block. But I would venture to guess that 75% of my patients are getting blocks. Forefoot surgery? Isolated. Forefoot surgery? Forefoot surgery, no. Usually not. What's everybody else think? So my protocol, it's interesting to hear what Holly said too is any surgery where they're not gonna be putting weight on it, I'm gonna give them a popliteal block or the anesthesiologist. And I do see problems, but I can't say it's that many. We did a study actually maybe two years ago where we looked up all the complications after ankle block and a popliteal block. Again, there would be more probably ankle block complications, but not really knowing. The truth is the complications we report are pretty low for both. I think we have anesthesiologists that are really well-versed in it. They give adjuvants in their block too, which make them last like a day or longer. So they're drawn to the table. And that actually has obviated in my experience the need for any catheter because at the end of the day, I think the long-acting blocks work just as well as the catheter. But anyhow, one thing I meant to bring up before is we did this study, which was really hard to get published, but we had all the surgeons report all the complications that they had over, I think it was about a year period with either one of those blocks. And then in a blinded way, we had myself and one of the anesthesiologists kind of put the blame, if you will, on whose complication it was, whether anesthesia or orthopedics. And usually the orthopedics said it was the anesthesia's problem and the anesthesiologist said it was the orthopedics problem. So it goes back exactly what you were saying before. I'm digressing a bit, but like who manages these and how we deal with it, because it's really hard, the truth is, to tell what the problems are. But what it sounds like is we're using blocks. I'm using blocks at least more than the rest of you. And I have not seen that big of a problem. Yeah, that's really interesting about the adjuvants. And that kind of gets to what Jim had asked about single shot versus catheter. One of the big problems we've had over the last year has been just a lack of consistent supply of local anesthetics. It seems like every month we have a different shortage that we're dealing with. And so it's led to some creative solutions in addition to adjuvants. But the big problem that I see with catheters is no matter how well I think I'm educating patients about it, there is a letdown effect. And so we do a pretty dense local anesthetic for the initial block, the popliteal block. And then inevitably, 12, 18 hours later, that wears off. And they think their catheter is not working. And we'll look at it, interrogate it with ultrasound and so on. But we go to a weaker solution. And that's because patients go home with that. You don't wanna run a potentially toxic dose. You want them to be in an environment where they're monitored while they have that dense block on board. So that's the big disadvantage I see about blocks. We follow all of our own catheters at Michigan Medicine. They get a call daily from a physician to evaluate how they're doing. And inevitably, post-op day one, they're disappointed with their catheter. After that, they tend to do really well. For whatever reason, I don't know if they acclimate to it or what, but later that day when we call them back, they're doing much better. But that's the big disadvantage to the catheters is I see it as that transition period. And it really requires educating patients. And then, yeah, the other challenge is with the, just the supply of local anesthetics. It seems like we never know what we're gonna have. Who is your perfect patient, Paul, for a popliteal catheter versus a popliteal block? Does such a thing exist? I mean, is there somebody that you would talk to your anesthesia colleagues or foot and ankle colleagues and they would all agree this is the person who should have pretty strong consideration for a catheter? Does that exist, do you think? Yeah, I don't think it's a surgical procedure so much as the patient and their expectations and the way they're put together and what their tolerance is. Also, do they have problems with other analgesics? Someone who has a history of GI bleed really can't take NSAIDs, maybe has hepatic issues and acetaminophen is not gonna be good for them. But there's really not a simple answer to that from a surgical standpoint. In my opinion, to me, it's more about the patient. What, I'm gonna switch subjects a little bit that affects us all as we sort of wrap up here over the next 10 minutes or so. What about the patients who come in on narcotics or on Suboxone? You mentioned in your talk that I enjoyed all your talks and I know you spoke in your talk, Paul, about the high-risk patients for chronic opioid use, including people who I think, if I remember the slide correctly, are on Suboxone. What guidance do you have for us, number one? And number two, I'd be interested in hearing from everybody in the panel how you approach that at your institution. And I guess there's two scenarios, A and B. One is the trauma patient who needs to have an op, or with an unstable injury that needs to have an operation. The other is a more elective situation. I'll start on that one, Jim, since we see a lot of patients with that. Since 2011, the national trend overall is a decrease in prescription of short-acting opioids. This is from a epidemiological study in the internal medicine literature a couple months ago. But Suboxone, or buprenorphine prescribing, is up 75%. So we're seeing a lot more patients on buprenorphine. The real challenge is, whenever you encounter one of these patients, find out why they're on it. Is it for off-label use of chronic pain management or is it for substance use disorder? And if it's for substance use disorder, I would be very cautious about taking the patient off of that medication in anticipation of an elective surgery. We used to think that was the right thing to do because it would free up the opioid receptor and then allow them to have better acute pain management. But more recent data shows that these patients have a very high relapse rate, upwards of 85% within one month if they're taken off their buprenorphine. So that's a very challenging patient. And that's someone where I would consider a catheter or a escalation of care because that new receptor is occupied. And opioids still do have a role in acute pain management. I think we all agree that it should be viewed as the adjunct and not the mainstay of pain therapy, but it does have a role. And those receptors are gonna be balanced. So thinking carefully about the multimodal plan for that population, I think is really important. What do we do in New York or Grand Rapids for those patients? I mean, I have anybody who's on Suboxone or has a substance use disorder. I always wanna touch base with their prescriber. So I learned this on the, I was on the MGH Opioid Task Force Steering Committee. And we developed all these guidelines that for Mass General in multiple disciplines. And the recommendations we came up with were that you should speak to the chronic pain doctor, the person who's prescribing, and make sure that you're both on the same page. And as you said, Paul, keep the patient on their baseline pain meds, and then you're gonna give them additional pain meds. But you have to anticipate that they're gonna require more than the average patient. And I would have a contract with them, have a very frank discussion, make sure you get family members involved, and make sure there's a plan for dispensing the medication at home. There's a plan for opioid disposal afterwards. I touch base with the patient every day, actually after surgery to make sure, or with the family and make sure that the patient's okay, and isn't relapsing. And I found that this has been fairly effective, although the reality is that for all I know, somebody has relapsed, and I just haven't been aware of it. Yeah, and Holly, to add to that, more recently we have almost a requirement in special surgery that anybody who's on chronic pain medicine should go through what's called our, well, I say chronic pain, but anybody who's on pain medicines before surgery should go through what's called our chronic pain service. So we'll actually even cancel elective cases if the day of the surgery, the patient gets there, they've been seen to be on a history of narcotics, and we haven't referred them to the service. And it's a service of anesthesiologists and pain management specialists that will then see the consultation, pre-op with the patient, and then help manage those, and do a lot of things that you were just talking about. Because the challenge I have is I don't even have time to do all that. And there's no way I can reach out to another chronic pain medicine and have a behavior consultant follow up. But this service, in theory, should do that. And that's probably not as good in reality as it sounds, but it's a starting point. And then I don't know what everybody else has, but we're required to document that we've checked the narcotic surveillance program for all of our patients, so we do that routinely and document that in the chart. And that's a good tip as to what people are taking and doing. Yeah, who staffs that, I'll call it chronic pain services, are there pain psychologists there, too, or is it predominantly? I don't think they're psychologists. I don't know, Holly, if you know, too, but they're on. I mean, at HSS, they're anesthesiologists. The hardest provider to find, in my experience, has been a chronic pain psychologist. And there was one in Boston that I knew of, and I have yet to find somebody in New York. I don't know, Scott, we can talk about this offline, but those people are hard to find, as far as I know. But what about in your institutions, everyone else? Do you have a psychologist? Anybody have any experience with cannabinoid use for post-op pain management? It's a hot topic in Michigan, and it seems to be popping up more and more in my office. Paul, do you have any experience with medical marijuana, cannabinoids? Yeah, we're seeing a lot of it. It's, jury's still out, say it is not great. It's like discussing religion and politics with some patients. They have very strong beliefs about it. It works for them, or whatever, but data is really poor. It actually seems that some of the CBD oils may have a role for neuropathic pain. But out of the, you know, smoking a marijuana cigarette, some, you know, one out of those 64 endocannabinoids that may have some pain relief, it's probably not a great strategy. Certainly for musculoskeletal pain, there's really no evidence for it. Maybe a role for neuropathic pain. But yeah, you're right. We get this question all the time, and now it's just created a lot of challenges with our pain contracts as well, now that it's recreational in Michigan. Huge challenge. Go ahead, John. My understanding is that medical marijuana use increases your risk of opioid usage. Has that been your experience? Yeah, we, you know, it was, people who really advocate for medical marijuana say that it would decrease use of opioids, but we've seen the exact opposite at pain clinics. And it's, whether it amplifies the pain or what, the jury's still out, but definitely we're seeing a lot of co-prescribing, co-use of opioids in marijuana. Very, very common. Well, don't you think, and Bert's work, I think, shows too that it's the same person who may, you know, want to use marijuana is also the same personality type, comorbidities or whatever, who is prone to more chronic opioid use. I mean, that seemed to be where it came back to it. So maybe that's the common origin of both those things rather than cause effect. I don't know. Dr. Hilliard, what are your thoughts on gabapentin? And, you know, it just recently became a controlled substance, at least in Michigan, I think in Kentucky also, but I know a lot of prescribers still use it as adjunct therapy. What are your thoughts on that? Yeah, I think it has a role. You know, I talked in my lecture a little bit about the ortho-hip and knee protocol we put together and the rationale for having low-dose gabapentinoid as part of that protocol. So anytime a scalpel divides skin, you're dividing the dermal plexus. There is a small component of neuropathic pain. And so I definitely think it has a role. Clearly it's opioid sparing. You just have to be careful with it. I don't know that it's really, you know, it's classified as a controlled substance in the state of Michigan, but it's not on the DEA schedule as a controlled substance. That's something that states have adopted. So unfortunately that's introduced a lot of challenges. I prescribe a lot of gabapentin. But yeah, thinking carefully about the surgical type and what type of pain a patient is having, I think is important when making that decision. So if someone has a, example I use in my lecture, below knee amputation where you're dividing two of the largest peripheral nerves of the body, huge neuropathic components of pain. So you want to get on the neuropathic agents. For something like a ankle arthrodesis, it's not common to have a large component of neuropathic pain there per se. So that's where you're going to want to emphasize more anti-inflammatories. I guess to answer your question, Bert, I think there is a role for gabapentin, but it doesn't always have to be a high dose or long term. I wanted to get back to one of those as we wrap up here. Holly asked a question about other pain psychologists around here. And Paul, you can speak to this, but I think your clinic does have a probably overworked pain psychologist that works as part of your team. Am I right about that? We do. We're very fortunate. We have three, actually, pain psychologists. And what they've done is trained a lot of our social workers to do some of that work. So cognitive behavioral therapy and so on. The big challenge is it's not reimbursed by a lot of insurance payers. They don't cover that service. And we've been really fortunate. They've put on some group courses that are available to large groups of people. So engaging social work at your institution, a lot of them are trained in behavioral health and can do a lot of that work as well. Are there other, again, I apologize to our attendees. We've got a lot of great information on the slides that are gonna be available to you. I wanted to sort of finish or at least sort of wrap up with one other topic that's related to this, not a broad topic, but the subject of diversion. One of Paul's colleagues in anesthesia was giving a talk at a regional high school about three months ago and asked the kids if they could find opioids in their house. How easy would it be? Could they find opioids in their household within 10 minutes if they were asked to do that? And 75% of the kids raised their hand they could find them in the medicine cabinet. So to me, it punctuates the importance of everything we've been talking about, not just taking care of our patients well, but not overprescribing and having this huge volume that some of you have highlighted in your work, this huge volume of unused narcotics that end up back on the street or lots of other places. So it's really, really important work. Does anybody else have any other thoughts or things they wanted to add before we wrap up? I wanna be respectful of people's time. And again, I wanna apologize from a technical standpoint. This was not for lack of preparedness, but it sounds like the IT goblins won tonight. So, but please do look at the presentation that has been prepared. It's about an hour and 15 minutes and it's really, really has a lot of valuable information. Anybody else have any parting thoughts or things you'd like to emphasize? You know, I would just say I'm happy to share any of my material. I give a handout to patients telling them how to get rid of their extra narcotics in a safe way. I have a patient handout that I give to everybody describing what to expect after pain. And I think if we can share all these materials and make them available, you know, you can modify it to what works in your practice, but sort of seeing what other people are doing is really important. So I think if everybody shares their protocols, it'll really help. Holly, could we use the PRC for that or a subset of that? Would that be an appropriate form, do you think? Yeah, I think that's a great idea. Yeah, and that's it too. One of my slides, I put kind of our protocol at HSS, how we prescribe given different levels of surgery and, you know, what other agents that we're using too and how many pills. And that document by itself has been helpful for us because if patients ever have any questions about, you know, why we're giving what we give, well, we have it actually documented, but other people can use it as a guide. It's on the slides actually, so you can see it. And for the record, I don't use that protocol because I think it's too much. Yeah, she uses less, which is a good thing. I'm trying to bring you guys to my side. It's way less than what we used to give in part. I know. There's so many unused pills out there. In that Rothman study, there was like 200,000 pills or something out there. So, but in our recent study, you know, we were giving out 30 pills on average. I think people consumed maybe 20. So that's still too much. You're right. Yeah. Yeah, I think part of it... Go ahead, excuse me, John. Yeah, there's still so much work that needs to be done in this field because I think we're still learning for every action there's a reaction. As this supply of prescription medicine goes down, we have no idea what the reaction out on the street is because there's so many more powerful drugs out there that are readily available at every high school and street corner. But I think this whole process has been very educational for the public. And I think it's really brought awareness to it. And I'm real excited to see that these conversations are now happening because I think we really backed ourselves into a corner and now we're finding a way to get out of it. So I think this has been a great symposium, Jim. And I think everybody on this panel has done a great job highlighting some of the issues and some of the progress that we've made. Yeah, no, I think it's great stuff. I think we've made a lot of headway and have a long ways to go, I think. But I certainly appreciate the time and trouble you have all taken to prepare this. And again, I can't emphasize enough how great the material is on the slide presentation that we weren't able to see tonight, but it'll be available and easily interpretable on the PRC, I think. So unless anyone has any other comments, I'll be respectful of folks' time and we'll wrap things up here. And again, our apologies to our audience. Thank you very much. And thanks to all the faculty this evening.

opioid prescribing

post-surgical pain

persistent opioid use

patient factors

prescribing factors

individualizing pain management

non-opioid pain medications

patient education