we're sitting and then go out and try to be weekend warriors on the sports field and you hurt your knee, injury your back. so it isn't necessarily i can look at what professionals tend to see a higher use of opioids than others. >> commissioner: marina, in your review of the data did you find concentrations in any job description areas. not the departments but particular job description areas? >> in the previous analysis we did not slice it by job code but

we have that ability so we can do a deeper dive. in looking at the population usage of potentially for a simple therapy pilot, we know a lot of our opioid usage or those with musculoskeletal injuries but what cause we don't know and we looked at it by not job code but department and not necessarily the trades. we'll share that with you. the other thing is if it's coming from an active injury and i think paige alluded to this it would be under workmans comp and wouldn't be in our numbers. >> a lot of the questions you ask will come back. >> commissioner: very good. thank you. thank you, paige. we have blue shield, is it?

>> yes, it is blue shield. >> good afternoon. >> commissioner: good afternoon. >> i'm the director of clinical pharmaceutical programs at blue shield. i'm a pharmacist by profession. so you can answer some of the questions. and i want to, today, for having a chance to talk about our narcotic safety initiative. it's a passion project for us, a passion program for us. basically in 2014 we started observing a lot -- >> the clerk: we have a presentation. thank you. >> we starting getting a growing

voice of members telling us the prescription." yesterday opioids were becoming a major concern and being perpetuated. in our efforts what we wanted to do was to evaluate how to reduce overuse for those with non-chronic cancer pain. our goal is to reduce that amount by 50% by the end of 2018 compared to our baseline 2014. nord -- this is quite an aggressive goal. when we first started out we weren't sure if we'd achieve this but what we decided to do at that time was to implement evidenc evidence-based interventions, helping prescribers, prescription members who were on

them to lower and safer doses or maybe to discontinue opioid therapy altogether. also important is to identify and stop fraud, waste and abuse. and to identify problematic use and deploy resources to help members get to more effective treatments and effect state and national policies that really impact the crisis. thank you. our initiative began with the evaluation of what was happening amongst their members and families who were very much impacted by substance use disorder. they were telling us that often times what they were observing is that a prescription was with

what started the cascade of events. and then perpetuated by continuing refills for the prescription opioids. we have recently had data shown that a lot of substance use disorders started with street drugs. now we're seeing more and more that is starting with a prescription that's prescribed by a physician and filled and dispensed by pharmacies. we believe health plans have an important role in helping mitigate the crisis. not just from the perspective of fulfilling a treatment but understanding our option. with the board approval in 2014 we launched our enterprise-wide initiative. what we decided at that time to

do was to launch the impactful interventions we felt would make the most difference. frankly, our approach was to first turn off the tap, so to speak and prevent people from starting prescription opioids if there was other options they could use. and then also to help those people on the other end of the spectrum on the highest doses at the highest risk for imminent harm. you'll see in the presentation over the past three years, our approach has been aligned to those activities. so in 2015 we primarily applied more stringent review of new prescription opioids especially long-acting opioids which have the highest risk of chronic use. we also started looking at te data and found most the opioid is with hydrocodone which is a common opioid ingredient found

in cough and cold medicine. when you ask the question, what type of person is most likely to be impacted by substance use disorder, it's any and all and children are very much affected by cough and cold. teenagers get the cough and cold with the hydrocodone in it and something they can use illicitly at parties and such. in 2016 we narrowed our focus on the analysis and we helped to assess and stratisfy the risk and between last year and this year we completed an analysis of emergency room prescribing of

opioids in the l.a. county area. the good news that we found is that over the last three years, the prescribing has been coming down. more importantly, prescribing as come down primarily for prescriptions written for more than a three-day supply. that's very important because most of people's chronic use is when they get a chronic prescription that can last a long time. in 2017 this year, we increased our focus on what i call the middle group. those are the people who have been chronically using opioids in moderate doses. and what we're really trying to do is work to address as mentioned earlier access to evidence-based substance use disorder programs, alternate pain management and to help members manage pain and reduce risk through pain management programs and other alternate treatments. we're also continuing those

analytic efforts i mentioned earlier. we're partnering with the california health care foundation and harvard university in an analysis and hope to vie publication within the next -- hope to have a publication within the next nine to ten months if not sooner. we're trying to understand the impact of the program or efforts both at a plan level and as well as at a general level, population level. so the good news is for our total book of business at blue shield california medicare and commercial, as of the first quarter we've observed a 32% reduction in the consumption of opioids. it's not just the number of prescriptions. that's one thing but you have to take in consideration all the dosing going on. to fentanyl is much more potent than morphine. for every fentanyl prescription

you can multiply that and that's your consumption. we're looking at it from a consumption standpoint. we're very much pleased to see not only the 32% reduction but the fact that we're tracking to our 50% goal by the end of the next year.

. >> to, you know, make improvements, and those partnerships have also been able to help us identify some really unusual outilizization, so what we are starting to see are some really compounded opioi opioids that are questionable in untwebdintended uses, and s we're identifying them, we're going after those pharmacies. we're also, you know, making sure we're employing the right restrictions and levels of protection in place to limit that liability. in 2018, our plan includes continuing to evaluate and expand access to substance use

disorder and alternate pain treatments and also to medical assisted treatments, so buprenorphine, which is also known as sebaxone, that medication is very important for people who are needing to transition off of opioid therapy, and we've improved access to that. vivitrol is another one that is helped to commonly control cravings, and methadone, and naloxone is the one if you get into an acute overdose situation, you can use that one to help reverse the effects of that. so we're really working to make sure that access is available to all of these treatments and to pain management programs. we've also launched a very successful and well attended provider education series, and

we're addressing topics such as opioid tapering, concurrent use with other high risk medications, benzodiazepines, muscle relaxers or sleepers, and also locking down unapproved uses with the compounds. we continue to work on policy strategies that have high likelihood of impact. there are a lot of policy proposals, but quite frankly, a lot of them are just -- you know, that's the existing state today. it's really not impactful. we want to make sure we're driving impactful legislation, and finally, but not last, is we continue to partner and collaborate with key stakeholders. we view this as a plan, this is one area where everybody agrees that we really need to partner together to fight the crisis. so i'm really pleased that i was able to provide a report

today of the very positive results for the hss population. we believe so strongly in the efforts here that we've actually incorporated performance guarantees into your 2017-2018 contract, and we expect to continue to see improvements over time, so with that, i'll open it up for questions. >> are there questions from members of the board? >> yeah, i have one. >> yes. >> when you go to -- suppose somebody breaks their finger or whatever, and they go to a doctor. so is there a set -- something set now where there's how much of this drug that they should give to the patient or how do you control that? >> well, the cdc has published guidelines for how much and how long anybody should be prescribing an opioid, and what we've been doing is really working with providers to get them to be aware of the guide lines and start prescribing in accordance with the guidelines,

so there are a number of ways. education is the easy passive way, and then, the more physical way, the one that has some impact to members is that you employ restrictions on formulary and benefits, so those are usual ways of dealing with how long, how much. i think probably the more important way is really to plant the seeds with the prescriber because once they really understand and are educated, then, you're not impacting just one person, you're impacting everybody that that person -- that prescriber's taking care of, and we've seen that, you know, with some of our case management efforts. as we start to educate the most difficult prescribers, people who have been very entrenched about thinking how you manage pain for people with opioids, once they understand and they know we want to get people to

safer space, they're much more open of doing a different way for managing for pain with other, you know, members. >> and i -- is my impression correct that kind of the typical pattern was that you've had an injury that required these types of medications, you've kind of got a ten day supply, and you might be taking it two or three times a day, something like that, that was kind of the standard, much -- more being said. no matter what it was, you got a ten day supply of whatever -- >> yes, except that it wasn't a ten day supply, it was a 30-day supply. >> 30-day. >> exactly, and you know when you are planning a surgery, most surgeons are just automatically prescribing an opioid -- not every surgery requires an opioid after surgery. you really have to look at the ability for pain tolerance and what the injury or the surgery was, and many nonopioid medications can

effectively manage pain. >> and the cdc guidelines, are they recent, and how recent? >> the cdc guidelines were, i think, updated last year, and maybe again earlier this year. they're very recent. >> okay. thank you. >> so there isn't anything to say that the physician can't prescribe more, though? >> no, and that's one of the things that i personally would like to see -- in other states, they've enacted legislation and policies to limit the number of days that an opioid prescription can be prescribed for a first time. i personally don't think that's a bad thing, but you know, there's a lot of politics involved in that, but short of that, i think all of the health plans have been working on limiting those -- the coverage limits for opioids. and we have to be really careful, you know, especially

with -- not -- i think it's easier to do that with new prescriptions, people who have not been on opioids before, but for people who have been, you have to be much more careful because you don't want to create a situation where they decompensate or then, they go to street drugs. >> commissioner ferrigno. >> i know there's some -- a couple years back with the police department, they had the behavioral science unit, and there's people that have some problems with opioids, and there's some pain management medications that you use. is that hard to get approved, or is that... >> if you're referring to seboxone, or buprenorphine is one of those other treatments. it acts somewhat like an opioid, but it doesn't have some of the risks that are associated with it, and they use it to help people detox off of opioids, but more recently,

the way that practice has been evolving is that they're starting to use it as maintenance therapy now, so people who used to be on opioids may, instead, be switched to a seboxone drug and maintained on that over time until they can get their substance abuse disorder under control, and it may be that they never really get it under control, so you may have to maintain for a long period of time. >> i just have one more point. >> yes, please. >> i know that you if go and get your teeth pulled, you get a 30-day supply, and you don't even need it, you can just take ibuprofen. i think people keep this stuff in their medicine cabinets, and kids take it and take it to parties. >> yeah. that's one of the reasons why we have an opioid epidemic. >> yeah, stock piling is one of the things that we addressed, but 30-day supplies, if you're giving people 90 day supplies

through mail service, that's where you can easily stock pile, and that's where we put a stop to that, as have many other plans, as well. >> page, i'm not sure how we're doing that. is this every plan that's coming in next, on you how are we doing that. united health plan. >> good afternoon. >> good afternoon, you can raise that microphone slightly. just -- there you go, but do talk into it. thank you. >> michael terhare. i'm with optimal x under united health care, and i'll be speaking to you about the city plan and the programs that we have in place. i am a registered pharmacist. my role or title is clinical consultant. i've been a retail pharmacist, and i have been

involved with the pbm industry, pharmacy ben fit manager for over 15 years or so. the first slide, we've got a couple of stratistics up there as you've kind of alluded to, you can heavy about this almost every other day. week nav ago, we heard president trump speak about it on national television. last night, on ktvu, there was a little segment about state suing pharma, so we know it's there. and here's some of the metrics str statistics: every 16 minutes, there can be a death due to overdose from these medications. it's very expensive: 78.5 billion. i think this was, if i'm not mistaken, 2013. most of the expenses are because the treatment is so expensive and going up.

and 4.5 million americans, piage already alluded to that number. and here's a big number: the u.s. consumes 80% of the opioids, so... the next slide, what i wanted to do is on the left, we see there's some other statistics. we already covered those. i want to first go over the opioid utilization for the city plan. we've got some data there. this is for january through september 2017. the plan paid $113,000. that was actually down dramatically from the same period 2016. now i attribute that a lot to the programs we have in place. there's a huge awareness out there, too. we're working with physicians, so what we're trying to do is bend the trend

that everybody knows has been going up for -- frankly, it's been two decade does. that's severe the problem is. the prescription count, 1692, year to date, and member utilization, 491. tylenol, hydrocodone, fentanyl, you've heard percocet, vicodin. the good news on the top five, there's no long acting opioids, as that was brought out earlier. that is what's killing people. oxycontin is the top drug in the united states that everybody's taking and having problems with. let's go to the next slide and see what our program does for

the city plan. we have a real wide range of programs here and touch a lot of points. it's a multitiered approach. on the left, i'll talk about -- these programs, what they do is they reduce unnecessary and inappropriate use of these medications, so for instance, we prior off long acting opioids. that's the oxycontins. that's what's really driving this. and what we did was we built in those cdc guidelines, and so somebody's wanting to get one of those, per the guidelines, it makes sense. well maybe you don't need maybe even drug therapy. maybe

there's another modality to try. okay. that doesn't work. try it -- let's try a medication, but maybe not an opioid. many atlas v.a. health care system in april came out with a controlled study that said -- compared opioids versus nonopioids, and back pain and rheumatoid arthritis, so it's about the same. it makes sense. if you've really got to go further, let's use a short acting opioid to start out with before you get to the long acting. that is he that's a very important piece we have in here. other things we have is we limit the fentanyl patch because that is appropriate. there is appropriate times to use this, and that's the key here: the appropriate times to use these medications, but have the safeguards in place so you

start-up above, before you get into the very powerful long acting drugs. in addition, a long-acting one, we've put a limit on the daily dose, per cdc guidelines. now in some cases, cancer, etcetera, thatt makes sense: okay. you need more than that? no problem. the other thing we do, we've got it in there for not only the long-acting one per day, but we're going to add up all the opioids, and if that hits a certain ceiling, we're going to reach out to the doctor and make sure that's appropriate. over on the right side, these programs are mainly we monitor the claims and then identify situations where we can make an impact. so for instance, the high utilizer narcotic program,

here, we look at 30-days of claims, and if we see a member's getting way too many narcotics, numerous pharmacies, numerous physicians, that's a real big red flag. we're going to reach out to those physicians, and they appreciate that, too. they don't know sometimes that the member is going to other physicians. now, if we see a pattern there, we can even lock in the member to one pharmacy, which makes sense. that pharmacist will have nice monitoring for that member. i'm happy to report, also good news on this front, with your plan, the last four quarters, i haven't seen any members that have hit this flag, so good news on that. we can identify prescribers that are out liers, so if

they're prescribing way up here, higher doses, longer lasting medication, we reach out to them. we also -- for high claim cost memo members, somebody that's spending a lot of money on these narcotics, we'll go ahead and get case management involved with them and see how we can help out. we've got edits in place where sometimes these medications are interacting with other medications, that it should not happen for more than a month or so. we're going to go ahead and then reach out to that physician. we also have a program here, fraught waste abuse. we can look at programs here and say boy, there's a lot of claims coming in from this doctor, and this pharmacist with this doctor, and these people here, it looks like drug trafficking, so we go ahead and turn that over to the authorities. over on the right side of this slide, we see some -- if somebody needs treatment, we've

got a benefit for it. we also don't prior off naloxone. we brought that up earlier. if somebody needs to be saved, overdosed. and then, we also have an 800 number for substance treatment. in anybo anybody can call that: the member, friend, family, they'll help them out. so that's what we have in the city plan, some really good, positive results. paragra now, we are always continuing to update our criteria and our programs based off of cdc and other evidence-based guidelines. the accounting now, knowing that this is an important subject, we'll keep you up to date on our updates both as the city plan utilization.

i'm sure there's some literature out there, but i will say anecdotally, i do see this: in other words, somebody that's got a job all day, driving a truck, and i'm on the same account. mike is on that. we're going to see more back pain, and use of those, but the key is, do you have the right programs in place so they use the right ones first? i'll go ahead and turn it over now to michelle, and she'll talk about the retiree program. >> okay. thank you. are there questions -- any other questions? okay. please. go right ahead. >> good afternoon. michelle la 1 sics. so what you'll hear from me is very similar themes to what you have heard from the previous

speakers, but when you're dealing with a retiree population, as page mentioned, sometimes, the utilization is higher. there is more cancer. sometimes, you do have some members in hospice, and it's appropriate for them to receive that. when i talk about some of these programs, similar to the other plans, as well, you know hospice is cancer, those are very appropriate, so we do exclude those, but you will see that more in a retiree population. so on the right-hand side, we have for your retiree proposition, your utilization, we have about 3600 retirees that have had at least one opioid medication year to date. that is about 24 a% of your population. if you recall what page said, in the teens, is it about 14 or 15%. it is more of the retiree population, just because of their age and their illnesses and their disease burden. and then, if you look at that, what does that translate into

in prescriptions? it's about over 13,000 prescriptions year to date, and that equates to -- let's see... i'm sorry. for -- in terms of the percentage, but what i wanted to get at that you talked about long acting and short acting, so what we're finding is about 14% of those prescriptions it for long acting opioids, and then, you'll see at the bottom, the table there, they're mostly short acting, so your population is retirees is also using more short acting than they are using long acting. and so next, i will go into the different programs that we have in place for your retiree population. very similarly, we do prior authorization and quantity limits to make sure that opioids are being used appropriately and safely. if you look at your top

medications here, you'll see acetaminophen that's in the percocet and rvicodin. make sure that we have appropriate quantity limits, and also prior authorizations. certain opioid medications are only approved for use for cancer pain, so we want to make sure that we are evaluating that and making sure that they're being used appropriately. and then, also, in terms of -- you heard this throughout -- is -- we call it the morphine equivalent dose, as people have talked about there is different opioids have different potencies, so we want to get to where we can evaluate what's the total number of dosage of opioids a person is getting, so we calculate everything down to a morphine equivalent, what you really want to do is take the

whole picture of the patient and what they're taking, and make sure that it's appropriate. and if it seems that it's not appropriate, we're going to reach out to that fizz and talk to them and make sure they get an attestation from them, a medical necessity, to make sure that it is appropriate to be used in those situations. and then, in terms of case management, as well, we want to bring in all of the providers as a community to help -- help retirees when we may detect that there may be a problem, so we're not just going to immediately, you know, shutdown. we can put restrictions in place when we detect a problem, but first, what we're going to do is we're going to retroactively look at the claim, see if we can detect a prab based on the number of pharmacy and examine pursuers and the dose they're getting, and then, we're going to have a conversation with their providers, and all of their providers that are prescribing these medications to get to a better place with that retiree, and then, if we need to, we can

implement restrictions in terms of the quantity or we can also reject, you know, not cover. and all of this in the background of medicare part d has to be within the framework of the cms guidelines, so cms also has these programs in place, so many of your medicare part d programs will have these medication management type programs in place, as well. we can go to the next slide. and then, we also have another program, in terms of outreaching to providers, in terms of sending out targeting communications. again, when we detect that they are getting an abundance of opioid medication, multiple providers, multiple, you know, pharmacies, outreaching to those providers, making sure they have a full profile and comprehensive view of that

retire rea retiree and what they're taking, and helping them identify there might be a problem or issue here by outreach. we are, as michael mentioned, going to have a program when we detect fraud waste and abuse, so when we detect that, we will send that off to the dea and supporting them, as well as the oid, so we're supporting all of those -- those avenues. and then, lastly, as mentioned, so we talked about making sure that there's appropriate utilization, safe utilization, and then, if there's fraud waste and abuse, trying to cut that off, but we also want to make sure that people are getting access to the treatment that they need, and if they need help from medication assisted therapy for a dependence, that we have removed what barriers we can for them to access those medications, as well as naloxone are inform for an ove

that's all i did. questions. >> questions from the board? all right. how long have you been engaged in this, for both the act of cityplan, and what you're doing? specifically, how long have you structured these types of interventions? >> these interventions have been in place -- i can tell you the prior authorization and quantity limits have always been in place. i've been kind of in the background of the retiree plans since you moved to a medicare part d, and so we have always had prior authorizations and quantity limits in the case management, but we always adjust them each year to make sure that we're staying in tune with new developments. i think more recently, you know, the morphine equivalent dose in those kind of guidelines are more recent, and i think you've heard from multiple folks here that that is kind of the new trend to make sure that we're not just targeting

>> thank you for allowing us to describe our opioid program in california. i'll show the first stage and i wouldn't take a lot of time because paige spoke of this but united states consumes 99% of the world's vicodin and norco, hydrocodone. 99%. that's more than another astounding fact and paige and the others have talked about the rest. so our initiative was really to insure that we provide safe and appropriate care to our appreciates across north america and we give our patients and physicians the tools and support they need for consistent opioid prescribing, monitoring and

documentation. we didn't say oh, that bad patient is a drug addict. the doctor writes the prescription. the pendulum can swish -- switch the other way. it is appropriate to write for the medications for certain types of things and when you do that you need to follow the patient, make sure they're getting better and you're doing it in a safe manner so that's how we focussed it. our next slide talks about how we focussed on the initiative. so we looked and saw and said whole who proscribes most of the medications and it's people like me in family medicine and they're our number one prescribers. i think you heard from previous speakers about emergency room physicians being high prescribers and those are our number two and lo and behold,

it's othrthopedics who are numb three and you ask why more retirees get more opioids. they have problems with their joints and get neese knees replaced and that's often where they get them after surgery. we'll continue to work on our lower proscribing lines. as we pay attention to people from the city we look at our 4 million members. i'm the executive sponsor for the opioid initiative and we have folks from physician education who then work with almost 21 of our hospitals and medical centers and 200 offices so that everybody's speaking the same language.

whether in primary care we are all doing the same thing that was important to do that. so we used a four-pronged approach concentrated on patient education and options for our patients. physician and prescriber education. when i say physician i include nurse practitioners and pas and anybody who prescribes and patient safety and the last is community safety. heard from the last speaker 60% of people who end up on heroin find the drug in grandma's medicine cabinet or mine because i had knee surgery and i need to find a safe way to dispose that. let me talk about what we did for our physician education and support and ms. breslin talked about restrictions for physician on the equities of opioids.

reflecting back 10 or 12 years ago, there were mandates from the medical board to take cme programs. we were taught to treat pain at any cost and a lot of that education was funded by pharma who said most of these drugs are no problems. you can give it. nobody will get addicted and nobody will die and now you know what the statistics are. there's no blame. we had a decade of education that taught us something different and it's going to take us time to re-educate our physicians and patients. so i never learned anything about this in medical school or residency. fortunately for us we have electronic medical records -- did you want to ask a question. >> commissioner: how are you keeping big pharma out of it now? how can we be sure they're not behind this -- >> commissioner: well, they're in our audience. >> we're happy to have them here

but we try to make sure we have evidence-based education so people like myself and others are looking at the education and making sure that's how we give it to our physicians. we don't allow pharmaceutical reps to be in our campuses and that's how we keep pharma out of our place. we put in tools and medical records to prompt them to ask the patient, if it's only going to hurt for three days, write ten pills. there's no reason to write it for 200 as it used to be in the old days. it tells you to monitor or go to

and you need to know whether they're take them because they may not be taking them. somebody else may be taking them or they might be selling them. the trainings we did had to be customized for our physician and getting the people to do the training and involved in the training and get their attention. rather than making it mandatory involving them in their training made a lot of sense. my internal medicine colleague said we want six of the training and two hours of it was communication. how do you have that tough conversation with the patient. i've seen the patients that had their car accident in 1982 and have had six doctors and they've been on these medications forever. all of a sudden i have to tell them, hey, this is not safe for you and you take a sleeping pill and muscle relaxant you may stop breathing. they'll look at me like what's wrong with you. our physicians felt they needed

the communication tools. our e.r. doctors you can't find in the same room at the same time and we designed a three-hour virtual and that's what they took and other colleagues wanted a one-our version and i'm happy to report though we didn't make it mandatory over 99% of our physicians took it and did pay them for it so making sure the time was given was critical for us. and we all have lots of tough prnts and we hahprnts and we hp patients and we can come up with a plan that's going to work for my patient so making sure we

have that was important. so after the education was done, we really needed to have some awareness. did i know how many patients i had on opioids and what doses were they on? we produced a list for each physician to give them the names of their patients, what opioids they were on and what doses they were on. had you seen them this year? are they on a sleeping pill or muscle relaxant did you do a urine drug screen and sent it to their chief as well to look at it with you and in a collegial fashion we discussed that to see how you're doing in that area. we have authorities colleagues to pick up a phone. someone will say did you mean to

write for 200 tablets of percocet and that awareness and check and balance has helped us. for patients we worked on it's informed consent. i don't think we've done a great job explaining to patients these medications generally do not work well for non-cancer pain. and if we're going to use it for accidents and surgeries, using it for a limited time makes sense and there needs to be an end point for this treatment. it's not just something you'll take for 10 and 15 and 20 years. making sure you have the time to discuss that and even watching online and printout an agreement letter if it's going to be appropriate for long-term therapy is fantastic. 20% of patients said don't give me this stuff it sounds dangerous. that was very good.

again, our pharmacists were great in educating patients and if they were to be on medicines they had at least two visits a year which is what the california medical board recommends. patients on high doses, the cdc talks about 19 morphine milligram equivalent. that increases your risk for death and overdose. and looking at the patients indications and can we taper then because they can go through withdrawal. you can't suddenly turn off their pills because then they're off to heroin. if you don't give them alternatives you're in trouble because one in three patients

today has chronic pain of some sort and if you aren't going to give them this make sure they have access to therapy or tai chi or yoga and if you don't give those alternatives they're in a hard spot. >> short of cancer, why do so many people have chronic pain issues? is there a big increase? >> we have all sorts of things. i look fairly okay but i played lots of sports and i have almost no cartilage in my knees. it hurts every day but i don't need opioids. i keep exercising or i've modified my exercise. i don't play too much tennis but maybe i'll bake -- bike or swim or play only an hour.

>> like i'm a yogi now, is it a practice where people with knee injuries were prescribed stuff forever? >> one study talked about pain for non-cancer addictions that got extrapolated for any kind of pain and they were giving it out for almost anything. there was an article that came out in the literature this week that talked about giving an ibuprofen working better than an opioid. they come to e.r. and paid $100 and the doctor gives them a motrin or ibuprofen and they say i got this at home. we went way on one side in prescribing to one side but not

eliminate for cancer patients and post-surgery. again on the patient safety, these issues are brought up giving smaller quantities. making sure patients are on multiple meds. making sure people who need nal naloxone get it and you want to make sure these are the people who are going to be taking that. then we talked about the alternatives to opioids. and then community protection is really important. i'll give you -- >> something to add to the patient safety is physical therapy. >> yes. >> i said it but i forgot to add it on the slide. >> i don't think there's enough emphasis on it. >> no, we have good access to fisc fiscal -- physical therapy and that works. again, decreasing the amount of

opioids out there makes sense. it's unfortunate, i've had a knee procedure myself and told my surgeon i can't take these. they give me nausea. i'll use ice and motrin and next thing you know, 30 vicodin were in my bag and i said why'd you do that and he said you might have pain over the weekend and may not be able to get hold of me. i said, i know how to get hold of you. i didn't take any of those some having some place to dispose them off. fortunately our pharmacies now have the bins to put them away. >> commissioner: i thank you for that. >> lots of places have them, police stations, fire stations. that is really great to take those back. we already talked about the urine drug screens. well, we talked about a lot things. the other thing is engage community partners. in santa clara county and others

we reached out to all the emergency rooms. because if we're doing something in kaiser permanente what's to stop our patient going to another hospital. having the coverings how we'll handle patients in the e.r. were critical for us. these initiatives started two years ago because you asked how many years did you start back. this is i believe, october of 2013 or early part of 2014 and since then we have seen a 42% reduction in opioids, totally and 30% of patients on high doses. the cdc calls the 19-morphine milligram equivalence and today 85% of our patients have an opioid agreement letter and over 75% have had a urine drug screen to look for diversion.

our emergency room initiative started last year. we have seen a 44% reduction in opioids compared to last year. this year that's an article in the new england journal of medicine talking about high-intensity prescribers in the emergency room. they define those as people getting prescriptions one of four patients leaving the emergency room in this hospital room were getting those and our number was 12 and now it's 6. 6 out of 100 now will get a pain medication. and again a very appropriate amount because they can always be followed up by their primary care physician so there's no reason to give 30 pills. 10 or 12 is fine. that's again great.

and two slides you shared with us we are happy to say for the opioid recipient overview our kp members have the lowest number of recipients per thousand for opioid prescriptions. the next one has the supply overview. again, our kp patients have the lowest both in the active and early retirees and medicare eligible ones. so we talked a little bit about why was this successful. why was this program successful? i think there were a few things that stood out. one was strong leadership support from the top and down through every medical center and every medical office that we have. having a clear and consistent message whether you're a physician, nurse, pharmacist, administrator and having the

interdisciplinary option to consult on tough patient was great and having locking coaching and support was fantastic. having that physician, specific data, i've never seen a list of all my patients on opioids. now when i see it every month i know what progress i'm making and if i need some help. then i think the collaboration with our number -- pharmacy is fantastic. they can call us we have some chronic pain pharmacists who can taper patients because that's tough and with my practice maybe two or three patients is all i can manage because it generates phone calls and e-mails and it's hard for a primary care doctor to do that. so if you have someone else helping you with that it makes it easier. that's all i have to present to you. i'd be happy to take any questions that you