Mikelle Moore: Hi, I'm Mikelle Moore, Senior Vice President of Community Health for Intermountain Healthcare. Today I have Dr. Ware Branch with me. I'm excited because we're going to be talking about some of Intermountain's work to reduce the impact of our prescription opioid problems here in Utah, and influence the way we practice across the country. Dr. Branch has been a friend for a number of years, and a key partner in this work. I'd love for you to introduce yourself Ware, and tell people a little bit about you.

Dr. Ware Branch: Thanks Mikelle. I'm Ware Branch, and I'm the Medical Director of Women and Newborns Clinical Program for Intermountain Healthcare.

Mikelle Moore: Great. About a year ago now, Intermountain ... Well, let me back up. Even prior to a year ago, about four years ago now, we started noticing the rise in prescription opioid related deaths in Utah, and set an objective of working with our community to try to prevent opioid deaths, and also reduce prescribing that could be harmful and lead to misuse. Then about a year ago, Intermountain set a goal to reduce our prescribing for acute conditions by 40%. As we formed that goal, we talked with clinical leaders like yourself about it. And frankly, set a goal not knowing how we would get there.

I'd love to have you reflect on what it felt like when we were setting that goal, and whether you thought it was possible at that time to reduce prescribing for deliveries, let's say, in your work.

Dr. Ware Branch: I remember when the leadership came to us and said, "We've got this goal because we're concerned about opioid use disorder, and the impact of opioid use disorder on such things as" in my world, maternal morbidity, and maternal mortality. When the leadership presented that we would like to reduce utilization use by 40% I thought, "That's a challenge." It's especially a challenge if we were going to do it quickly. I thought that would be something of a difficult task.

Nonetheless, we took on the task and approached our regional and facility leadership. Especially with regard to delivery opioid prescriptions. That is, birth of child, and opioid prescriptions. We approached our facility leadership including operations folk, and physicians and sort of challenged them with the idea that we should reign this in. That's how we started. We have regular meetings where in we can talk about such things, and get feedback from them in real time. We took that approach. Eventually we settled on how many tablets one should get at the time of discharge after having had a child for cesarean, and for vaginal birth, and have incorporated that into the electronic medical record options.

That was our approach. Does that help answer the question?

Mikelle Moore: Yeah, that helps a lot.

Dr. Ware Branch: Yeah.

Mikelle Moore: How are you doing? What are the results? Here we are about 10 months into the year, about the time of a pregnancy ironically.

Dr. Ware Branch: Yeah.

Mikelle Moore: How are we doing so far within the clinical program?

Dr. Ware Branch: Well, first let me give credit to the operations folks, and to the physicians. Because, I think they saw the problem, they were willing to participate, and they took up the gauntlet as it were. The discussion I think is filtered down to the locales, where in the opioids are prescribed, and we've had a good response. We are down by at least 30%, and for postpartum patients, down by approaching 40%, as is the goal within the system. We're doing quite well I think, without causing any disruption in care. I mean, it's sort of the right thing to do, and we are handling that part reasonably well. We have our challenges here or there, but I think we're doing very well.

Mikelle Moore: You raise an issue. I get asked this often when I talk about our work in this area. Have we had patients express concern about the amount of medication they're being prescribed?

Dr. Ware Branch: I can't speak for every physician.

Mikelle Moore: Sure.

Dr. Ware Branch: But, I am not aware of pushback I guess, in common parlance, that's been inappropriate or damaging. I don't know of any such case.

Mikelle Moore: Do you think that if we're prescribing 40% less now than we were a year ago, is that ... Are we at the right place, or do you still see some of your colleagues prescribing beyond the recommendations, and are there still outliers, if you will, that you're working to address?

Dr. Ware Branch: That's a good question. First and foremost, we never intended to be so prescriptive about this, that there wasn't room for good clinical judgment.

Mikelle Moore: Go ahead.

Dr. Ware Branch: We allow for good clinical judgment, period. There are patients who may need more in the way of postpartum pain management, including opioids, compared to the majority of patients. In trying to answer your question about whether a 40% reduction is proper, and clinically appropriate for postpartum patients, I think time will tell. When we looked at the challenge, we also looked at the literature. We tried to figure out what kind of prescriptions were being filled nationally based on what's been published. We think we're clearly in the right ballpark with the numbers that we have recommended for post vaginal birth, and post cesarean section patients. But, we're going to follow up on it. We're going to try to figure out if we're doing the right thing, getting feedback from our regional and facility representatives.

Mikelle Moore: Is that literature changing rapidly? Given this crisis is so broad nationally.

Dr. Ware Branch: Mm-hmm (affirmative).

Mikelle Moore: Are you seeing the research updated on that very regularly?

Dr. Ware Branch: Well, certainly there's been quite a host of articles published about opioid use disorder and pregnancy. Because, it's a national issue, it's an issue that the media has taken hold of as well, and unquestionably it's associated with part of the United States high maternal mortality rate.

Mikelle Moore: Mm-hmm (affirmative).

Dr. Ware Branch: We need to be on it about tackling this, and we are.

Mikelle Moore: How are physicians managing pain in ways beyond prescribing opioids? Or, has that not changed as much as just the quantity that we're prescribing?

Dr. Ware Branch: That's a great question as well. A lot of pain management is about spending time to set expectations. The notion that we should be managing pain in a way that there's no pain is now widely recognized, at least in post surgical patients as being inappropriate. The idea, the ideal situation I should say, is that the physicians would be speaking to the patients who've had, let's say a cesarean section, and explaining to them about how we're trying to manage pain so as to take a healthy approach. It will be that they will have some post operative pain, much like you or I might have some post operative pain if we were to undergo, in my example, a hip replacement.

Mikelle Moore: Recovering from childbirth is painful, right?

Dr. Ware Branch: Yep, mm-hmm (affirmative).

Mikelle Moore: I went through that as well.

Dr. Ware Branch: Well, we want to be sure that it's managed appropriately, and expectations are properly set. We've discussed that at meetings. I can't speak for every physicians approach of course, but I think we in obstetrics are doing a better job of that on a national level given the attention this topic has gotten.

Mikelle Moore: Yeah, I'm sure you are, it's good. Tell me, is the postpartum time period a time period when a woman is more at risk for becoming vulnerable to opioid use disorder?

Dr. Ware Branch: I can't give you a scientifically founded answer. It is a, I believe the general consensus across the country though is that yes. Because of what's been called prenatal mood and anxiety disorders, postpartum issues such as postpartum depression. There may be ... That may set up things such that opioid use disorder is a bit more likely. That's very difficult to prove, but it's sensible for us in trying to keep our patient population as healthy as possible. It's sensible for us to be thinking along those lines. To be considering that the postpartum time might be one where an opioid use disorder slightly more likely to develop. We should think about it that way, in trying to take the best care of our patients.

Mikelle Moore: Yeah, making us more aware-

Dr. Ware Branch: Yes.

Mikelle Moore: ... And even more diligent. Good. I would imagine that given the prevalence now of opioid use disorder in our community, that you also are caring for pregnant women who are opioid dependent. How are we changing the way that we're managing women through childbirth in those scenarios?

Dr. Ware Branch: Patients that are identified as having opioid use disorder, opioid dependent patients, represent one subset of patients that we need to be concerned about. It's been a struggle I think in many venues, for us to do that part well given lack of appropriately designated resources, and given lack of care personnel who are particularly interested in managing this.

We have though, been working with physicians in our community who have an interest in opioid use disorder, and managing opioid dependency. In the Intermountain system we've been talking to behavioral health, and have a gameplay afoot for that. We've been utilizing other resources in the community, including a couple of physicians who are MFM's. That is Maternal Fetal Medicine Specialists, interested in opioid use disorder, who see patients in a couple of clinics around the area.

Mikelle Moore: Are those physicians also providing medication assisted therapy?

Dr. Ware Branch: Yes, so there are really two sort of medication assisted therapies for patients who have opioid use disorder. One is the use of a drug called Methadone, and there are several Methadone clinics in Utah. Patients can be, if they're willing, they can go to such clinics and get Methadone to use instead of other opioids such as heroin, or Fentanyl, or tablets that they've gotten prescriptions for. The other is Suboxone, and that medication is prescribed by individuals who are licensed to do so, including the Maternal Fetal Medicine people that I've spoken about-

Mikelle Moore: Okay, oh good.

Dr. Ware Branch: ... And members of our behavioral health community.

Mikelle Moore: Mm-hmm (affirmative), and that's been another goal that we've had as a system, is to increase the number of patients who have access to medication assisted therapy.

Dr. Ware Branch: Mm-hmm (affirmative).

Mikelle Moore: I appreciate that MFM team is a part of helping create that access for patients. That's good.

Dr. Ware Branch: It's a bit of a challenge to be sure.

Mikelle Moore: I'm sure it is.

Dr. Ware Branch: I think it's worth mentioning that such things are a challenge so that listeners will know we need them to chime in and say, "Rise to the occasion folks."

Mikelle Moore: Mm-hmm (affirmative). What makes it challenging?

Dr. Ware Branch: Well one reason we've struggled to get physicians and other providers interested in the management of opioid use disorder, is that the patients, or at least some of them can be a bit more difficult and time consuming. Or, on occasion, very time consuming patients for which to care. That represents a challenge that can be waring on a given provider, especially if that provider is doing this with little other help. That's a challenge.

Another challenge is that spending quite a bit of time with a small subset of patients is not necessarily highly compensated, relative to doing just general obstetrics for example.

Mikelle Moore: Right.

Dr. Ware Branch: Or, general Maternal Fetal Medicine. We in the system have to recognize that, and take appropriate measures to deal with that kind of problem.

Mikelle Moore: Yeah, I can see that. As we shift from more of a fee for service based model to a value based approach to care, do you think that there's ways that we can really make that happen differently within obstetric care?

Dr. Ware Branch: Well, yes. I think so. This is probably not the place to elaborate exhaustively on that point, but I think so. I would also offer up that we have to.

Mikelle Moore: I agree, we have to. We have to. I'm curious about what's next for your team? You're achieving a really impressive reduction in the number of acute prescribed opioids within your clinical program. Where do you see this going next? What's the next improvement that warrants your focus for improving this aspect of obstetric care?

Dr. Ware Branch: I think the most important thing in the intermediate term, is to stay the course, and to make sure that our operationalization of this is working. I'm talking about electronic medical record pieces, and I'm talking about physicians and other care providers sticking with the mission, sticking with the goals. That's its own challenge, and one we should take on.

Perhaps somewhat more importantly, we have the challenge of setting up appropriate care provision for opioid use disorder patients. We've discussed this, and we've discussed a couple of the challenges. We need to drive that forward, and make sure it's not only in place, but it's intact and running well.

Then lastly, we need to spend a lot of time on patient education.

Mikelle Moore: Mm-hmm (affirmative).

Dr. Ware Branch: The public needs to know that the proper management of opioids is part and parcel of good healthcare. That's its own challenge. We need to get out there, and get the message into the public sector.

Mikelle Moore: I agree, and look forward to doing that with you. I want to close by just talking a little bit about what this means to you personally. I would imagine that leading this out a year ago when you thought, you weren't sure that we could go about this change this rapidly, that it was daunting for you. Do you think it's ... Well, what connected you to the work personally?

Dr. Ware Branch: I've got to give credit to my Operations Lead, Gene Malar, because she has helped me understand anxiety and mood disorders associated with pregnancy, and the importance of them. Not only locally, but nationally.

Mikelle Moore: Mm-hmm (affirmative).

Dr. Ware Branch: The other reality is, I am a member of several professional organizations, and at those annual meetings we talk about the relatively higher maternal mortality rate in the United States, and a sizeable proportion of that is attributable to opioid overdose and misuse.

If you're serious about your field, you better care about this.

Mikelle Moore: Mm-hmm (affirmative).

Dr. Ware Branch: Otherwise, you might want to get a different job.

Mikelle Moore: Right, right. I love what I hear you saying. It's really, opioid prescribing isn't something separate we need to address only because of the downstream issues. It's really affecting outcomes within the clinical arena that you see most core to your work. It's quite-

Dr. Ware Branch: Yes, I mean to make it that much more dramatic from a financial standpoint. A given hospital system, like ours, ends up with a fair number of neonates that have neonatal abstinence syndrome. That is, they are withdrawing from narcotics or opioids. The management, the care of those babies, and the management of those babies is a very, very, very expensive healthcare problem per annum in the United States and locally.

Mikelle Moore: ... Mm-hmm (affirmative). Do you have a sense for whether that's increasing or decreasing right now?

Dr. Ware Branch: I can't tell you the answer to that. We need to follow that though.

Mikelle Moore: Mm-hmm (affirmative), we do.

Dr. Ware Branch: Yeah, yeah.

Mikelle Moore: We do. Well, and we had some good news in the paper actually today, about the decrease in opioid deaths in 2017 compared to 2016.

Dr. Ware Branch: Here in Utah.

Mikelle Moore: Here in Utah.

Dr. Ware Branch: Yeah, here in Utah.

Mikelle Moore: Here in Utah. We're one of only four states in the country that's seen a decrease in that timeframe. Yet, I'm not sure it's a reason to celebrate. We still have a lot more work to do, and could see things trend the other direction. But I want to close with just one last question. Do you think we should have set a goal around reducing deaths, which 20% would have been a pretty lofty goal.

Dr. Ware Branch: Oh, yeah.

Mikelle Moore: Or, was this the right goal to set when you think about it from the clinical program perspective, to reduce prescribing?

Dr. Ware Branch: Well I think first out of the chute, this was a very practical goal.

Mikelle Moore: Mm-hmm (affirmative).

Dr. Ware Branch: I appreciate practicality. The ultimate goal is better outcomes for the patients of course. Using a hard end point like maternal mortality makes a certain amount of sense, 'cause it's quite obviously measurable. But, remember that the complexities of opioid use disorder and other similar problems in the population goes well beyond just mortality, and into family, and how children do over time, and divorce rates. Oh my gosh, it gets to be pretty thick.

Mikelle Moore: Mm-hmm (affirmative).

Dr. Ware Branch: Which one of those, or maybe all of those, should be considered in how we follow our progress?

Mikelle Moore: Right. Yeah, outcomes are not just mortality.

Dr. Ware Branch: Yeah.

Mikelle Moore: There's a lot of morbidity that's not even health on its surface. It's softer care-

Dr. Ware Branch: That's ... And, difficult to measure.

Mikelle Moore: ... Difficult to measure [crosstalk 00:20:57].

Dr. Ware Branch: But, should be part of what we think about taking on as challenges, yeah.

Mikelle Moore: I agree, I agree. I think that brings us to a good close. I think as we do this work to improve health in the community, we need to tackle big problems like this. Prescription opioid misuse is one piece, but now we begin to think about the social determinants, and the broader viewpoint on health, and thinking about this epidemic and its reaches in those ways is going to be important as we go forward. Thank you very much Dr. Branch, for your time today.

Dr. Ware Branch: You're most welcome. I'm glad you're interested in this.

Mikelle Moore: It's always a pleasure, and congratulations on the good work that you've done so far, and look forward to the continued good work of your team.