America’s Opioid Crisis – Collaborations & Cutting Edge Tech

In this episode of our series on opioid abuse in America we talk with Rob Valuck, PhD, co-founder and CEO of OpiSafe and Director of the Colorado Consortium for Prescription Drug Abuse Prevention. Rob is a leading proponent of collaborative approaches to addressing the crisis and provides insights into the successes and challenges of this approach based on his experience in Colorado. We also discuss how OpiSafe is using innovative, cutting-edge information technology deliver ever more effective and efficient interventions.

Dr. Levin: Welcome to 4x4 Health sponsored by Datica. Datica, bringing health care to the cloud. Check them out at www.datica.com . I am your host Dr. Dave Levin. America is in the midst of an opioid abuse crisis. Consider some of the statistics reported by the U.S. Department of Health and Human Services or HHS. It’s estimated that in 2017 more than 28,000 deaths were attributed to overdosing on synthetic opioids. Which translates to more than one hundred and thirty deaths every day. Also of great concern is the steady rise in the number of people misusing opioids for the first time. In 2016, two million people misuse prescription opioids for the first time and reflecting the fact that patients often move on to street drugs when they can no longer get legitimate prescriptions. 81,000 people used heroin for the first time. This is a genuine crisis and an all hands on deck moment for health care. In response HHS has proposed a five-point plan that’s designed to lead to better prevention, treatment and recovery services, enhance data collection and research improve pain management. And increased targeting of overdose pursing drugs like naloxone. In this special series of 4x4 Health our guests share their views on the crisis as we look at the current state of diagnosis and treatment. As well as the role technology can play in enabling better care. Today I’m talking with Rob Valuck, co-founder and CEO of OpiSafe, the Denver based company that develops software to address the opioid crisis and improve medication management for pain and addiction. Rob began his career in academia as a professor at the University of Colorado school of pharmacy Public Health and Medicine where he taught and did research for 20 years. In 2013 Rob was named director of the Colorado consortium for prescription drug abuse prevention by then Colorado Gov. John Hickenlooper. The statewide consortium has gained national recognition as a model for the development of collaborative coordinated responses to the opioid crisis. These days Rob and his business partner and chief technology officer Chris Ennis develop systems such as OpiSafe, OpiRescue and treatment G.P.S. to bring comprehensive connected solutions to the most vexing aspects of the problem. From this intro you can see why we asked Rob to be our guest as part of this series. His academic background, practical experience and leadership skills have placed him at the vanguard of innovative and collaborative responses to this crisis. Welcome to 4x4 health Rob.

Dr. Valuck: Hi Dave. Thanks. Pleasure to be here.

Dr. Levin: Before we get into the opioid discussion let’s start with our usual opening question, take a moment and tell us about yourself and your organization.

Dr. Valuck: Sure. My name again is Rob Valuck I basically am a person who is originally a pharmacist by training then I became an academic and wanted to have a larger impact on the problems that I was seeing in my practice and my professional practice. Worked for many years at that university doing research and educating future practitioners, whether that’s pharmacists or doctors or nurses or others about different aspects of these kinds of problems and trying to use data to help you better informed decisions and work forward that way and bring some of those important things into practice. Learned a lot, but had a lot of frustrations with siloed data and siloed practices and wanted to then move to the larger level and try to impact things that a systems or policy level, which led to that work that you mentioned with the governor’s consortium here in Colorado to try to get folks collaborating and working together to solve problems across different agencies and professions and in different kinds of care settings. And then most recently where you run into places where there’s instances where policies still aren’t enough or specific programs aren’t enough looking to just develop answers to certain problems that we’ve got with data that may not exist or a data that may not be integrated. And it led me to a partner with a colleague of mine ,Chris Ennis, to create our company called OpiSafe to try to where other aspects of the market might be failing to create solutions to address those gaps.

Dr. Levin: Well that’s great. And I know we’re going to get much deeper into the work that you and Chris have done. The other thing that’s always interesting to me is sort of people’s personal history of involvement. What drew you to this to the field of pharmacy in general and particularly to your interest in the abuse of opioids and pain management in general?

Dr. Valuck: Sure. I came from a very medical background and my father was a physician, was an anesthesiologist by training and was one of the earlier generation of the first what you’d call pain positions back in the 1970s working specifically on pain services in the hospital setting from an anesthesiologist perspective. My brother is a dentist. I saw a lot of what happens with prescribing opioids for people with acute pain in post-surgical pain for dentistry, which is often the first time people are exposed is when they have their wisdom teeth extracted. So I experienced a lot of that. So I came from that kind of setting and myself was following a similar career path. Was a pharmacist by training and was contemplating going into clinical practice as a physician or going to med school or something like that and decided that for me I still enjoyed the pharmacology of it. So I got advanced training in pharmacology and was a clinical pharmacologist doing consulting work for complex cases for people with, it was primarily psychiatric and neuropsychiatric kinds of thing. So I started to see patients with not only chronic pain, but addiction or other behavioral health disorders and did a lot of clinical work in that area for a number of years and just started to see this as a, problem that folks started to see and even in the late 80s we were seeing it then and then into the early 90s that addiction was much more common than the general public or even the health professions were aware and just really watched this thing grow unfortunately into the crisis that it has become and all along the way wanting to try to figure out how on earth can we address this thing. And it started off as just a clinical level and then again it was trying to educate practitioners better and then it was trying to develop better policies and then most recently where things have just failed, not taking no for an answer. If nothing else I think one of my qualities that I am proud of is persistence that if something isn’t working, continuing to try to find out how to solve those problems and most recently with technological answers to some of them.

Dr. Levin: Well certainly to succeed in changing health care you’ve got to be really persistent. And likewise if you’re trying to introduce new technologies into health care I have a feeling we’re going to get a little deeper into that in a few minutes. But before we do though we were really fortunate we’ve had Dr. Morales Apollo from the Hazelton Betty Ford Foundation on an earlier podcast and Marv gave us sort of his overview of the crisis from a clinical perspective and its impact on the community. I was wondering you know it’s almost fair to ask this question, because it’s so complex and broad and deep. But it’s my podcasts and I get to ask the questions anyway and so just take a moment if you would and just share you know again from your perspective what you’re seeing out there. Then we’ll get into your efforts to address it. But when you say this thing, this opioid crisis what does that really mean to you. What do you see happening out there?

Dr. Valuck: Sure. It’s really I think as a society over the last 30 years really, maybe a little bit more but it’s been at least 30 years maybe 35. We have really shifted a huge pendulum swinging from one side to the other from perhaps under treating pain and being weary of things like opioids when they were first really starting to be marketed with drugs like Percodan and Percocet and your original launch of Vicodin, back in the day when we were a little bit more leery of how do we treat pain and should we use these things because they do have some potential for addiction. We knew that then in the early 80s, in the mid 80s we knew that was potentially an issue. But a lot of forces came together. I’ve heard some other folks call it the perfect storm of forces both public and private and market and social forces all coming together. Things that were you know increased focus on treating pain, which I think is well motivated that we do a better job of treating people’s pain. But also you know government programs focusing on different things or incentivizing people to treat pain better with survey scores and tied to better payment. The Joint Commission asking people to address people’s pain and have a plan for it. The American Pain Society at the time doing launching campaigns about recognizing people’s pain. Pharmaceutical marketing not to be understated ever, the power of pharmaceutical marketing in getting awareness built about chronic pain and acute pain and the fact that opioids may be effective for these conditions. Putting all these things together we really swung the pendulum very hard over to the other side to the point where over a about a 20-year period we have just gotten to the point where pain equals opioids, in virtually everybody’s mind. Whether it’s a practitioner or the prescriber themselves, the nurse on the unit and the acute setting or a patient or a family member or virtually anyone. We have just become a society where pain equals opioid and we’ve gotten to the point where we consume the vast majority of the world’s opioids are consumed prescribed dispense consumed in the United States. Virtually all of the Oxycodone in the world is prescribed and consumed here and it has always struck me that if we use 80 percent of the world’s opioids, we don’t have 80 percent of the world’s population and nor do I think we have 80 percent of the world’s pain. So clearly there’s something wrong, something amiss. And I just think it’s been a hard swinging on to the one direction and we’ve become very very reliant on these as the tool for treating pain and undoing that disentangling that that twenty five years of forces is proving to be very challenging and very complex as you can imagine.

Dr. Levin: Well the factors that you say align really nicely with what the doctor Apollo pointed out as well. Including that that in the United States we consume the vast majority of oxycodone, but clearly don’t have the vast majority of the population. The other things that we talked about were the emergence of fentanyl as a sort of super super super potent form. That’s had some additional challenges to it. And then as you said this emphasis on pain management. And when I was working in that world, I was part of promoting these programs around pain as the fifth vital sign if you will. And as you said I think this is all really well intended. And there is a balancing here that needs to occur. Because pain is real and effective pain management is very important in healing people and treating illness. But clearly causing addiction along the ways is not a desirable outcome. You really focus a lot of your effort in two areas that I think are really fascinating. So one is around collaborative efforts. And the other is the role of new technology and I don’t mean to imply you’re not doing other things as well. But these are the areas that that I’d like us to start to drill in. So let’s start first with the statewide collaborative. Tell us a little bit about that and frankly why a collaborative. Why is this needed?

Dr. Valuck: Yes. Well about seven or eight years ago our governor at the time this was Governor Hickenlooper saw some of the data that we were seeing. Things like the overdose death rate going up. It wasn’t at its peak yet, but climbing and the nonmedical use rate as reported by The National Survey on Drug Use and Health at the time in 2010 and 2011 had Colorado at number two in the country in self-reported nonmedical use. And a number of these statistical measures got the attention of the governor here and he asked some of his staff you know go around the state and see what’s going on and try to from the ground up. See what the problem looks like and what we should do about it. And as a result there were some strategic planning, sessions that were called and stakeholders that were engaged you know it was a very much a grassroots kind of bottom up effort to gather people and talk about this problem and throughout the course of several months, eight or nine months a strategic plan was created to try to address the problem from several different perspectives and the encouraging thing all along was that it was very collaborative. All of the state agencies, health professions associations, folks from the Prevention world and the medical treatment world, public health world, the addiction treatment world folks from law enforcement and education and housing were all involved in this strategic planning and created what at the time I thought was a very thoughtful and robust strategic plan for addressing the issue from a variety of perspectives. And at the end of some of those sessions there was an important conversation about how do you keep this moving and where do you, how is this or how do you hand a strategic plan to if you will. And it was very easy to say it’s a public health problem. Give it to the state public health department. That’s very credible or it’s a behavioral health addiction issue. Give it to the single state authority for addiction and behavioral health, which is our office of behavioral health and human services. Or you could make a lesser argument that we just need regulate those overprescribing doctors better, so give it to regulatory. That didn’t apply or create a new Office of Government or different ways to try to do this and we decided here that we already had a small task force that had been working for a few years and I was a member of that task force and made a suggestion. Why don’t we give it to the 510C3 and therefore everybody owns it. But nobody really owns it on their own. And we could try this as a statewide effort and a collaborative to work together to try to solve the problem and work it that way. And we gave it a go. And the governor asked me if I would give it a try and so I was sort of all and told and didn’t really have any position to tell the governor no. I didn’t think politically would be very smart for my career. So I said sure I’ll try it for a year. And lo and behold this is in the middle of 2013. We’re still going strong. We’ve got a staff of about 15 people that work to support 10 different work groups focusing on different aspects of the problem. Everything from public awareness to provide education to safe disposal treatment and recovery and heroin response coordination and all different kinds of things. But it’s a living breathing collaborative that reaches out all across Colorado to engage communities and engage all the stakeholders. And rather than just meet for a summit and then dissipate and go back to your individual work, it keeps this process going. And just a little bit of infrastructure without becoming another behemoth of an organization. Because at the state level 12 people is not a lot of FTE for a state with five and a half million people and you know relatively large geography and that kind of thing that Colorado represents. But we decided to try it and it’s been strangely I did not expect it to go as well as it did. But it’s going very well and all of our agencies collaborates and some after us Federal funding coming. We get together and talk about who’s applying for the funding, What’s the most appropriate use of those dollars. Where might other dollars be coming in that we don’t need to duplicate, all that sort of stuff. And now in the last couple of years our state legislature has asked us, we’ve gained enough recognition that they ask us to advise on an interim committee for opioids and other substance use disorders. What sorts of state legislation should be passed or what kind of funding would be needed from the state and has asked us to advise them and we’ve managed to pass over the last three and a half, four years now. Just going on 4, 17 pieces of legislation to address the opioid crisis in a variety of ways and some very specific initiatives. It’s been a very interesting but very fulfilling collaborative is now worth six hundred people around Colorado, [unclear] every month or every other month work group meetings and annual meeting and all of that just to continue to be able to talk with each other just for that purpose of collaborating and coordinating. I think really really effective.

Dr. Levin: Yeah. There’s just so much in what you said, I would just point out a couple of things. One is the diversity of the work and the membership reflects I think the both the diversity of the origins of the crisis and the potential responses to it. The other thing I really like here is you’ve taken an academic approach but this is a very practical application of that. How do we go if you will from an academic discussion or the bench to the bedside to actually make a difference in people’s lives and in the community. So I applaud you for that. This is probably a tough question, because you’re doing so many different things. But pull out one example, give us a little bit more concrete example of something the collaborative has done together that you’re particularly proud of or you think particularly effective. Hopefully both.

Dr. Valuck: Sure so I’ll be brief but there’s two of them I’d like to highlight. One was the first thing we saw were data suggesting that most people who end up with a problem and a problem could be chronic opioid therapy or something that should have been acute or it could be addiction or an overdose or unfortunately an overdose deaths or someone who if they’re fortunate got into treatment, any of those things. Most people about three quarters of them start off with leftover medicines in the medicine cabinet. And mostly it’s a family member or friend. Seventy percent is leftovers from a family member or friends medicine cabinet. 17 percent is their own leftovers. So we figure to look for 87 percent of this problem is the medicine cabinet problem we call it, then we need to address that immediately. The first piece of the lowest hanging fruit. So we went to our legislature about three months after we reformed and said look we need funding to create a statewide permanent disposal program where we put medication drop boxes in pharmacies and or law enforcement departments depending on the area of the state where they may or may not have a pharmacy in every town to have the option for people to get the medicines out of their medicine cabinet and do some public awareness about that. So we took that on early. We were the first state that I’m aware of to fund this at the state level. We now have these drop boxes in all counties in Colorado and we collect more pounds per capita than anyone in our region for medication take back. So we took that very aggressively and put something on the ground immediately to start addressing that part of the problem. On the back end we decided well we have like many states probably most. We have a treatment gap for you know definitely not having enough access to addiction treatment. As a recent as three or four years ago the surgeon general said the treatment gaps in United States four years ago was 90 percent. Nine out of 10 people needing treatment not able to get it for whatever reason. So we aggressively have been working to expand access to treatment. And we took it upon ourselves to go out and train as many doctors as possible to provide addiction treatment, including primary care docs to get them aware of what they can do to start providing medication assisted treatment or at least starting people on addiction treatment and facilitating connections to behavioral health and other services and in the last two and a half years, we started, two and a half years ago there were 279 doctors who had their DEA ex waiver it’s called so they could prescribe buprenorphine or Suboxone in their clinics. Not many of them were even using that, maybe a hundred doctors were using this credential. And in two and a half years we have trained another 13 hundred doctors in Colorado and in virtually all of the states. So that now we have almost 1,500 actually providers and we’ve gone from middle of the pack 23rd to 3rd in the country in a number of these trained providers per capita. So we’ve really ramped up capacity to try to provide addiction treatment. Now we’re still seeing a lot of challenges getting them to actually prescribe, connecting them to behavioral health services and trying to assure adequate reimbursement and coverage by Medicaid and all sorts of issues. But that’s on the back end of being very trying to be very aggressive to get more capacity immediately and our treatment gap has gone from 90 percent to 69 percent in two years.

Dr. Levin: That’s really remarkable. And I can see why you wanted to talk about both of these initiatives and one of the things that struck me is you started with an evidence base. So it’s fine to sit around and speculate about the origins or something or what’s driving it. But you had some real data that helped you pick some areas to focus, took some broad activities but then it also sounds like you’ve measured the impact. So whether it’s the number of pounds per capita that’s recapture or the access to treatment metrics. These are all the hallmarks of a well conceived and well executed quality improvement projects. So good for you. And my guess is there are many more examples like this that we just don’t have time to get into today. Any last thoughts about this idea of collaboration and the roles of collaborative before we turn to technology?

Dr. Valuck: I think the take homes for me are despite skepticism that this may not work with totally volunteer efforts again now almost seven years that we’ve been at this. If people are aligned and we follow a model called collective impact, if people are aligned and believe they have a common agenda that everybody was participating in forming the agenda and that’s how we did it. Which was good news supported by a small amount of backbone ongoing support, which is what we are. The consortium is just this backbone support that you can really solve or at least address in a meaningful way complex social problems. And then just to bring everybody together and we’re always on the quest for, first call for me was to the medical society in our state that if we’re going to solve this, organized medicine needs to be part of the solution obviously. But then so was the case with prevention or treatment or recovery or law enforcement. And once everybody came together and we have stayed together that way, the power of that collaboration is really remarkable. So I just encourage people, drive everyone to the table, listen to all of that input, everybody’s got something they can do. And you know that’s what I would say everybody grab a shovel and we all grab a shovel and take one scoop of dirt we can move that mountain if we all do a little bit.

Dr. Levin: I couldn’t agree more and listening to you describe the experience I was reminded of my experiences. The one that really jumps out for me was IHI for healthcare improvement which in some ways mirrors the model you described. And it was largely volunteer. It’s pretty diverse. They provided that kind of backbone and some best practices. There was a lot of sharing. They were real big on the idea of steal shamelessly and share senselessly. And those and that camaraderie and that sort of sharing can be extremely powerful. And you’re right, it sometimes requires less resources than you might expect. If you’re just joined us you’re listening to 4x4 health, we’re talking about the opioid abuse crisis with Rob Valuck, CEO of OpiSafe. Rob I’d like to turn now to technology because I know that’s another area of interest of yours in a lot of activity. So take a few minutes and tell us just broadly what you’re seeing in terms of particularly new information technology that’s emerging to address the crisis and then I expect we will sort of go ramble down this road see where it takes us.

Dr. Valuck: Sure. I think that you know we’ve tried for many years, I think we’ve had some successes at dealing with the crisis from the standpoint of better programs, better education for practitioners, certain pieces of legislation have been helpful. Some funding in key areas for treatment expansion. But yet even all of those pieces as helpful as they are can still be kind of siloed if we’re funding things from a behavioral health angle or a public health angle or a department of justice angle, you’re still targeting typically one base of the problem and not that those things aren’t helpful. But it then shows that there’s going to be a need. We have found to overcome the continued frustrations of things like how do you get people to collaborate, If we go out and want to train more primary care doctors for example to provide better pain management or consider treating patients with addictions and we’re talking to primary care doctors, how on earth do we do that. There’s a lot of challenges. For example, people working in different organizations. In Colorado vast geographies from urban, suburban, rural and frontier geographies. People working with different kinds of electronic health record systems that Lord knows there is a multiplicity of technologies out there for electronic health records and the potential is wonderful, but it’s also creates its own problems with the multiplicity problem. There is information exchanges and different ways of trying to do that. Some of the new technologies that have evolved legislatively and now are tools that are available for practitioners like prescription drug monitoring programs, which are essentially state databases, 49 of the 50 states have these. Where pharmacies report in all of the prescriptions that they fill for controlled substances. So I as a doctor or a pharmacist could check this database and see if somebody is going to five other doctors or six other pharmacies. They call it shopping around of doctor shopping or pharmacy shopping and I can find out if that’s happening and maybe not fill that and become the sixth pharmacy to fill this prescription for this patient. That’s a tool or there’s lots of new emerging tools for people to better measure their pain. Apps to measure their opinion or apps to help them with doing biofeedback or different kinds of music therapy, distraction therapy. All kinds of alternative approaches to treating pain. All sorts of promising technologies for decision support or using artificial intelligence to detect patterns of what might be going on and do research in terms of how to address where problems are happening and what’s working and what’s not working. And so there’s a lot of different pieces that I described these as individual spokes that are out there, lots of spokes. But there are precious few wheels that are integrating various spokes to provide really comprehensive solutions and we all know it. We would go farther on four wheels than a whole pile of spokes. With that concept in mind is how I see the market is finding the next opportunity to provide better support for patients and doctors is to bring things together. Try to make it easier for them rather than harder. Because all of these tools are good. And yet each one of them is a potential complicating factor for a patient or to a doctor if there’s multiple tools out there pretty quickly, clinicians will say that’s wonderful but I don’t know how to use 27 tools at a time. I can barely use just my electronic health record and see my patient 13 minutes and accomplish what I need to accomplish. So it’s a wonderful environment with a lot of innovation, but it’s also a challenging environment because of the realities of all of the different multiplicity of systems and the constraints that are placed upon providers and in patients to try to accomplish what they want to.

Dr. Levin: I think that’s really true and I’ll share the example that I’m pretty familiar with which is these PDMPs’, the statewide prescription database as you describe it. And you know it’s to me this is one of these classic stories in healthcare, I try to improve health care with technology. So on paper this sounds like a great idea. I mean who could be against the idea of well I want a complete picture of what’s been prescribed to this patient so that I can render better care and I can have more informed conversations with the patient and all of that. I mean this is, sort of mom and apple pie everybody can recognize this would be a good thing to do. But boy when you go to implement it in the real world you’re right into a whole bunch of challenges about well how do you actually gather this information and what exactly when should a clinician check and how do you do that. And one of the key pieces is the workflow and the integration and their workflow. And you sort of touched on this. You know if this is yet another system to log in to, check, lookup, cross reference you know blah blah blah. The typical clinician just doesn’t have the time to do that. It’s not reasonable to ask and so we can build these wonderful codified databases, but if they don’t fit into a sensible workflow for the end users they’re probably not going to have much impact. And to me this is the classic triad of people process and technology. And to make these things work, you almost always have to address all of them. My guess is you would agree with the mini rant that I just went on here.

Dr. Valuck: Absolutely 100 percent.

Dr. Levin: So take us a little deeper now on some of the specific things that you and Chris have been cooking up at OpiSafe.

Dr. Valuck: Sure. We are experiencing some of these frustrations. You know working with doctors and pharmacies and treatment providers and then seeing some of the policy responses that we’ve seen and some of the best practice even if we do have evidence to say we think these things ought to be done and those things over there should not be done and we ought to monitor X, Y and Z and we ought to risk stratify patients and tailor our monitoring accordingly and all of the things that for example the CDC guidelines for prescribing opioids for chronic pain that came out about three years ago, generated a lot of how should I put it, Discussion, debate in the medical community. Perhaps even stronger terms than that. But certainly it has prodded folks into thinking about well if I’m going to provide more comprehensive and more you know better tailored care for patients, I’m going to need to use some tools to do that. And we’ve focused, our first efforts in OpiSafe was to give doctors basically an easier way to do the things that they’re being asked to do. Sometimes being legislated to do that we know these are difficult. And so our goal was a simple click of a button and everything that they need to be doing is being done. Largely automated, so that basically it’s kind of guidelines in a box that might be the CDC guidelines. It might be a state. It might be a health system has their own guidelines. Large hospital system something they have their own. But we have found that they largely look similar. Most of the guidelines do and they ask doctors to do a course a bunch of different things. And we thought nonstarter. We have built systems to you know like I said obese is to basically a single sign on for a doctor, a single click of a button in their H.R to launch our system. Which then pulls data from a variety of different sources from the PDMP at the state level. So the doctor does not have to log into that system. From a toxicology lab if you’re in drug screening as required or chem lab testing is required, pulling in the lab results. Data from patients directly. Many of the things we’d like to know we have to ask patients. So we need to directly ask them about their pain, about their function, their behavioral health screenings like depression or anxiety or sleep disorders. Those things are typically comorbid with pain and then maybe things like quality of life or productivity, all these relevant things that you need to ask of patients and then put them all together, analyze them, display for the doctor sort of a cross-sectional view of what’s going on right at this minute with this patient and tell me if there are any problems, take me right to them. Because just that process that I described is usually several minutes to several hours of work mostly assigned to emails or other staff to try to compile all this information for a clinician and then they have got only a couple of minutes to talk about this and make a decision on where to go next. And we try to automate as much of all that as possible and the safety net for a doctor to say if I’m going to prescribe an opioid, I know I’m doing what I need to. I know I’m following what I need to follow and if there’s any issues they will surface to me and I don’t have to go looking for them. Because we basically automate our monitoring and offer alerts to physicians when the patient starts to experience a problem rather than them having to be actively remembering I have to check x and y and z. So this system is proven very valuable and we’ve gotten a lot of uptake for pain management positions, addiction treating physicians and now larger health systems to try to do the things they either are being mandated to do or would like to do and do it in a very efficient way to seamlessly integrated into workflow and actually as a time saver rather than a time out or into their work.

Dr. Levin: Well there’s so much in there again starting with evidence-based approaches better designed really layering this in the workflow. And you know it’s the goal of health care is for technology to be an enabler of what we set out to do in the first place. I think unfortunately too often we don’t do a great job of that. But what you’re describing to me sounds very much like the sorts of best practices that lead to real adoption and use and in turn to actual improvement in the real world. You’ve mentioned that what kind of evidence do you have of that adoption and positive impact of these tools.

Dr. Valuck: Yeah we’ve got, we started out in Colorado about three and a half years ago in again very small start-up kind of environment for us, went very quickly from a you know dozens of doctors to hundreds of doctors. Now we’re up at about 10,000 prescribers across the country about 5,000 of which are in Colorado about 50/50 and about 5,000 or in other states. We’re actively connected to the PDMP programs in all the states, all 49 that have them and we connect with almost 20 now independent laboratory partners. We’re agnostic to any sort of single vendor partnering relationship. We want to be a kind of connective tissue solution where we’re not solely trying to tell a practice who they must partner with. We also connect with various electronic health record systems. Now it’s 13 electronic health record systems that we connect with. The [unclear] solution and can provide those solutions and partner that way. So it’s you know it’s exciting we’re bringing on larger health systems that customers now. They are using us across their hospitals, emergency departments, addiction and pain clinics and out into primary care clinics out into the community as these systems integrate and they reach out. But we love it because our solution even if you’re not part of one of these big health systems, it can afford to perhaps invest more even a solo practitioner out in rural Colorado can subscribe to our system. Probably connect to their EHR that has 3 percent or more market share than we do. Connect with them and then be able to take advantage of these same solutions and they don’t have to be a big giant player to take advantage of the technology. We think it should be accessible for any physician. One solo practitioner all the way up to the physician in the largest health system in the state or country.

Dr. Levin: Very good. One of the things that we can use technology for today is also to manage allocation of precious or scarce resources. And I think typically we think about that in terms of either we’ve got limited supplies of something or if its services, are there ways that we can distribute the services more effectively or more efficient. The use of technologies like telehealth to minimize the barriers of time and space to deliver care. Unless my memory’s playing tricks on me you share with me a story a while ago that’s a window into resource allocation but a little bit different than what we might typically think about. And again if I have this correctly, this was really about the distribution of law enforcement resources and that you were looking at some geographic data that was helpful to law enforcement and planning about how they would allocate their precious resources. Do you recall this story? Is this my memory playing tricks on me?

Dr. Valuck: No. Your memory is very good.

Dr. Levin: No. My memory is not very good Rob, but in this case it sounds like maybe I am correct.

Dr. Valuck: You’re right. Even a blind squirrel finds an acorn once in a while right. But in this case yes we have a different solution called OpiRescue that is facing on the side of consumers or law enforcement who typically don’t have a lot of resources about things like addiction treatment or naloxone. What is a drug overdose look like and how would I respond to one. EMS, Paramedics and health care practitioners generally know that. But law enforcement do not and lay people certainly do not. And we thought that’s a problem. And rather than just sort of fly blind on what’s going on with law enforcement or with lay people and just sort of allocate resources blindly. We decided we will build a solution that is amenable to those groups and provide it to those groups so that we can both give them resources, such as educational information on what an overdose looks like and how to respond to it. But also has a built-in data collection tool for if a reversal was performed or witnessed report it to us that. If you saw one or you did one so we can know where the overdoses was happening and what the response to them was through some basic you know 10 or 12 questions whether you’re a sheriff’s deputy or a police officer or whether you’re a layperson and we collect those data through this app called OpiRescue And that data has proven very valuable. In the last two and a half years in Colorado we’ve collected nearly a thousand reversal reports through this app and we know the app is not in everybody’s phone and we would love it to be, but it isn’t. And so our penetration suggests that this is a high number of reversal reports coming in and those we’re able to share with local law enforcement, state public health state level law enforcement and we have used that to say, if there’s a lot of reversals happening in county A or county B we will send more naloxone there or we will send more resources there in terms of treatment or other sort of capacity building resources and use that to drive some of the decisions that have been made both legislatively, programmatically and then in terms of health care response. So we’re very proud of that. That’s been a solution that Colorado, Wyoming, Nebraska and Delaware have all adopted at the state level to measure this kind of activity direct resources and then be able to provide these tools to folks that might need them. Whether it’s law enforcement or a layperson. And most recently we’re super excited that we’ve plugged another solution into that basically into both of our systems it sits in between and this is called treatment G.P.S. where we collect and merge data from about, now it’s almost nine different databases that we access that are publicly available, but not often combined on who provides treatment for counseling or who provides methadone treatment or Suboxone treatment or who prescribes Vivitrol these different medications for treatment or who provides detox kinds of services or inpatient services and patients or others have to try to navigate that and it’s very difficult. Well we’ve built this locator called treatment G.P.S. and from our systems a patient can simply look in and say, oh where is the closest place to me for this kind of treatment and has a map and they can click and call that provider raked in from their phone and get much more quick access to treatment and not have to think about where do I look it up. How do I navigate treatment. Just look at my phone, one click and I’m connected to the closest treatment provider to me. We’re finding that to be already just we’ve only launched it since the first of this year and in four and a half months that experience has really seen this thing grow. People want this and need this and we think it’s a good way to connect folks from whether they’re on the back end may have experienced an overdose and are desperately in need of treatment or somebody who is upfront like a physician or a patient, thinking maybe this chronic opioid therapy is not going so well. Maybe we need some help and maybe somebody who use is problematic and we need to get them into treatment, how do we make these referrals. Not even knowing where the resources are or if I’m in the emergency room how do I have somebody follow up with a provider in the community when they leave the emergency setting. I don’t know where to send them. This enables people to make those connections and match up the need with the existing supply. You know different ways to use technology to help connect people who are already there.

Dr. Levin: Well it’s quite a suite of functionality that you’ve covered there. I won’t do it justice here in my summary. But we’ve got tools for clinicians to help with their own education with more real time information about the patient in front of them. Decision support as they consider treatment options or adjustment therapy. We’ve got the rescue information that’s, it’s like almost like a forward deployed sensory system that’s telling us what’s going on out there. What are the real parameters and boundaries of the activity. How is that shifting and then the last piece which is kind of a navigator to help clinicians and lay people find the appropriate resources to help them address whatever the particular issues they’re addressing. Well like I said I’m sure I didn’t do all of that justice. But that’s kind of what I heard [in listening to the description.

Dr. Valuck: That was really good. I should have you write that down for us.

Dr. Levin: Well you can take recording whenever you like. You know Rob I am struck. This has been a terrific conversation and I am struck that I was correct in my opening biography of you that you’ve been at this for a while and you’ve got some diverse points of view and diverse experience. And so my last question for you is really based on all of this, what is your most sage advice when it comes to the opioid abuse crisis.

Dr. Valuck: I think I would leave it as the you know starting with that notion of collaborating so you can learn from and share experiences with everyone no matter where they come from. And then really for technologists out there, it’s a very exciting opportunity as complicated as it is, its a very exciting opportunity to identify where are the pain points that physicians or patients or loved ones that are navigating the system or treatment providers that we even if we do have treatment providers and people don’t know about them. We have a capacity problem and simultaneously we have an efficiency problem that we’re not using the capacity we do have. But to look at these things and just point at those things that are gaps and build solutions to address them. But do it in a way that’s cognizant of like you said the all the triad so that we can be aware of how do we connect, how do we seamlessly integrate with different systems. How do we work together across these systems. Because you know anything that works in isolation is practically doomed to fail. And those that are you know inter collaborating and are interoperable are going to have a chance.

Dr. Levin: Well that’s truly sage advice in several different dimensions. So thank you for that. We’ve been discussing the opioid abuse crisis with Rob Valuck, CEO of OP Safe. Rob thanks for joining us today.

Dr. Valuck: Thanks very much Dave, its been a treat.

Dr. Levin: You’ve been listening to 4x4 Health sponsored by Datica. Datica, Bringing health care to the cloud. Check them out at www.datica.com. I hope you’ll join us next time for another 4x4 discussion with health care innovators. Until then I’m your host Dr. Dave Levin. Thanks for listening.