The devastating opioid epidemic in the U.S. is a crisis that was created, in part, by healthcare itself as prescriptions for pain-relieving medications rapidly increased in the 2000s. Now, healthcare is at the forefront in trying to fix the problem. At Geisinger, a healthcare system serving more than 1.5 million patients in Pennsylvania and New Jersey, where we work, we are taking a multifaceted approach and seeing a big impact. By combining data-driven assessments, targeted engagement of high prescribers, EHR-based interventions, and pharmacist support in care management, Geisinger has dramatically reduced opioid prescribing. In addition, programs promoting safe medication disposal in the surrounding communities reduced the number of left-over opioids in medicine cabinets, helping to stem opioid abuse in the surrounding communities.
Using our robust data archive system which captures electronic health record, medical and prescription claims, and other information, we create dashboard displays for use by leadership, operational teams, and clinicians to reveal population-level trends and identify patients and clinicians for targeted interventions. For example, in 2012 we launched a controlled-substance monitoring dashboard to better understand use of controlled substances in our system, with a focus on improving pain management. This dashboard, updated in real-time, displays a myriad of types of information on a population and patient level including counts of patients prescribed opioids, those co-prescribed other controlled substances, patient use of naloxone, visits to emergency departments, medication use agreements, location heat maps, and other data to help us identify gaps in care and opportunities for improvement.
Engaging high prescribers
Using the dashboard, we quickly saw that clinicians were prescribing opioids at vastly different rates. In addition to developing programs on pain-management for our broad clinician population, we targeted a focused group of high prescribers. Generally, high prescribing clinicians were unaware of their rates. After alerting them about their pattern, we began regular feedback sessions where the prescriber, practice-site medical director, and a specially trained chronic-pain pharmacist reviewed individual patient cases and provided guidance on dose reduction strategies, risks associated with certain co-prescribed agents such as benzodiazepines, alternative treatment options, clinical support tools, and referral options. The combination of prescribing transparency, education, and one-on-one counseling has helped to dramatically reduce the number of high volume prescribers and cut the prescribing of new opioids by 44% over the past three years.
Concurrent with our work with high volume prescribers, we deployed population-level approaches to modifying prescriber behavior. We transitioned from paper to electronic prescriptions for controlled substances, which reduces the likelihood of prescription tampering, and linked our state prescription drug monitoring program to prescriptions made within our EHR, making it easier for providers to review a patient’s profile for other controlled substances before completing a new opioid order. Additionally, our EHR limits the number of days worth of medication allowed for any new opioid prescription resulting in a reduced number of opioids dispensed per prescription.
Pharmacist-supported pain management
Since 2011, Geisinger pharmacists specializing in pain management have worked closely with patients and the rest of the healthcare team to reduce patients’ dependence on opioids while still managing their pain. In addition to optimizing the medication regimen, pharmacists recommend activities, physical therapy, and behavioral health interventions that can help patients cope with pain and reduce dependence on opioids.
Now deployed in 15 primary care and specialty sites across Geisinger, these pharmacists actively manage pain medications for over 1,500 patients. Within 12 months of enrollment in pharmacist care, patients’ morphine milligram equivalent (MME) dose per day (a measure of how much prescription pain medication a patient takes per day) is on average reduced by half from 50 MME to 25 MME with 33% of patients tapering off opioids completely.
Pain medications are frequently not completely used and are the most common type of drug to result in leftovers. These may then be sold, shared, or sit in medicine cabinets where family members or others may find them. According to the Pennsylvania Youth Survey, which is administered every two years to students from 6th through 12th grade, 39% of young people reporting drug use acquire prescription drugs from a family member in their household. Geisinger has led a community effort to raise awareness of the problem, hosting community hearings, producing public service announcements, engaging students in schools and developing a robust media engagement campaign. Geisinger also leads efforts by local organizations to facilitate proper disposal of medications. Since 2014, Geisinger has collected over 15,000 pounds of medications from the community, largely through “take-back” services at its hospitals, pharmacies and other community locations; an estimated 10% of these medications are controlled substances.
Because of these efforts we have seen a 30% decline in total opioids prescribed over the past two years. Among patients with chronic non-cancer pain, we’ve seen reduced health care utilization, including fewer emergency department visits.
We are now exploring additional approaches to reducing opioid prescribing while effectively managing pain, including using behavioral “nudges” to encourage appropriate prescribing as well as engaging patients through mobile technology to better monitor and manage pain. We encourage every health system to adopt these and other best practice strategies while sharing new approaches to combatting the opioid epidemic.
Sure, everyone wants to be happy. But what kind of happiness do people want? Is it happiness experienced moment-to-moment? Or is it being able to look back and remember a time as happy? Nobel Prize winner Daniel Kahneman described this distinction as “being happy in your life” versus “being happy about your life.” Take a moment to ask yourself, which happiness are you seeking?
This might seem like a needless delineation; after all, a time experienced as happy is often also remembered as happy. An evening spent with good friends over good food and wine will be experienced and remembered happily. Similarly, an interesting project staffed with one’s favorite colleagues will be fun to work on and look back on.
But the two don’t always go hand in hand. A weekend spent relaxing in front of the TV will be experienced as happy in the moment, but that time won’t be memorable and may even usher feelings of guilt in hindsight. A day at the zoo with one’s young children may involve many frustrating moments, but a singular moment of delight will make that day a happy memory. A week of late nights stuck at the office, while not fun exactly, will make one feel satisfied in hindsight, if it results in a major achievement.
While happiness scholars have long grappled with which form of happiness should be measured and pursued, nobody has simply asked people which version of happiness they seek. But if we want to find ways to be happy, it may help to understand what type of happiness we truly want.
In a series of studies, recently published in The Journal of Positive Psychology, we directly asked thousands of people (ages 18 to 81) about their preference between experienced and remembered happiness. We found that people’s preferences differed according to the length of time they were considering — and according to their culture. For Westerners, the happiness most people said they wanted for the next day was different from the happiness they said they wanted for their lifetime, even though one’s days add up to one’s life. We found this interesting; if people make decisions by the hour, they may end up with a different version of happiness than what they say they want for their life.
In one study, we asked 1,145 Americans to choose between experienced happiness (“where you experience happiness on a moment-to-moment basis”) and remembered happiness (“where afterwards you will reflect back and feel happy”) for either a longer timeframe (i.e., their life overall or next year) or a shorter timeframe (i.e., their next day or hour). The majority of participants chose experienced happiness over remembered happiness when choosing for their life (79%) or their next year (65%). By contrast, there was a roughly even split of participants who chose experienced happiness and remembered happiness when choosing what they wanted for their next hour (49%) or day (48%). This pattern of results was not affected by individuals’ overall happiness, impulsivity, age, household income, marital status, or parental status.
After participants made their choices, we asked them to write a short paragraph explaining why. We found that those who favored experienced happiness mostly expressed a belief in carpe diem: a philosophy that one should seize the present moment because the future is uncertain and life is short. On the other hand, participants’ explanations for choosing remembered happiness ranged from a desire for a longer lasting happiness, to a nostalgic treasuring of memories, to the motivation to achieve in order to feel productive and proud.
So people became more philosophical when asked to consider longer time periods like their life overall, and they reported wanting more happiness experienced in the moment. But when they thought about the next day or hour, it was as though a Puritan work ethic emerged — more people seemed to be willing to forfeit those moments of happiness, to put the work in now to be able to look back later and feel happy. This willingness is necessary, of course, during certain periods of life. But defaulting to it too often may lead to missing out on experiencing happiness. Those unseized moments add up, and together they may go against what many believe constitutes a happy life.
We conducted a few more studies to test the robustness of our results. In one study, we gave people different definitions of remembered happiness to see if a particular portrayal was driving the result. In another, we varied how soon the hour was that they were considering (“one hour today” vs. “one hour toward the end of your life”) to see if imminence and perhaps impatience played a role in people’s preferences. In both cases, these treatments didn’t change the pattern we saw: when choosing for their life, most people chose experienced happiness over remembered happiness; but when choosing for an hour, half chose remembered happiness.
Last, we wanted to test whether the pattern we saw among all of our American participants generalized to other cultures. We presented the same choice between experienced and remembered happiness, for either their next hour or for their life, to approximately 400 people in other Western countries (England and the Netherlands) and 400 in Eastern countries (China and Japan).
Like Americans, when choosing for their life, the majority of Europeans (65%) chose experienced happiness over remembered happiness; but when choosing for their next hour, the Puritan work ethic appeared even more strongly with a majority (62%) choosing remembered happiness over experienced happiness.
In contrast, Easterners’ preferred happiness persisted across timeframes. The majority of Easterners chose experienced happiness over remembered happiness regardless of whether choosing for their life (81%) or their next hour (84%). Why this consistency? We believe that participants in China and Japan were more clear in their preference for experienced happiness due to the long religious history in Eastern cultures of teaching the value of mindfulness and appreciating each present moment.
Our studies asked thousands of individuals which of two types of happiness—experienced or remembered—they preferred. We found that the answer depends on whether people are considering the short pieces of their life or their life overall, and where they’re from. Though the pursuit of happiness is so fundamental as to be called an inalienable right, the particular form of happiness individuals pursue is surprisingly malleable.
It’s important to note that while this research helps us understand people’s beliefs about which happiness is preferable, it does not prescribe which form of happiness would be better to pursue. But these results reveal that Westerners planning their lives by the day or the hour will likely achieve a different version of happiness than what they themselves believe makes a happy life. We’re all too busy, and we’re driven to turn down opportunities to constantly feel happy. But if you believe you want a life of happiness experienced in the moment, think twice before preventing yourself from achieving it.