Opioids In Workers’ Compensation Opioids in WC...GEOGRAPHIC VARIATION IN OPIOID PRESCRIBING 32...

2018 Annual Meeting

& Educational Conference

Opioids In Workers’ Compensation:

Research From WCRI

John W. Ruser, Ph.D.

NCSI 2018 Annual Meeting

June 12, 2018

AGENDA • Introduce WCRI

• Opioid dispensing to injured workers

• How does opioid prescribing vary across geographic areas?

• How has it changed over time and why?

• What measures are stakeholders taking to control opioid

prescribing?

• Impact of opioid prescriptions on duration of temporary

disability

2

ABOUT WCRI • Independent, not-for-profit research organization founded in

1983

• Diverse membership and funding support

• Including larger self-insured and insured employers

• Research focuses on WC benefit delivery systems

• Not pricing

• Resource for public officials & stakeholders

3

WCRI APPROACH • Mission

“Be a catalyst for improving WC systems by providing the public

with high-quality, credible information on important public policy

issues.”

• Don’t make policy recommendations nor take positions on

issues

• Provide just the facts by means of peer-reviewed studies

4

OPIOID DISPENSING TO INJURED WORKERS:

COMPARISONS ACROSS 26 STATES

FINDINGS BASED ON

SEVERAL WCRI STUDIES • Interstate Variations in Use of Opioids, 4th Edition

• Longer-Term Dispensing of Opioids, 4th Edition

• Impact Of Kentucky Opioid Reforms

6

DATA FOR INTERSTATE

COMPARISONS • Injuries from 2010 to 2013 with Rx observed over an average

24-month period postinjury

• Nonsurgical claims with more than 7 days of lost time with Rx

paid under workers’ compensation

• Large samples from 26 states

• Sample represents 36–69 percent of claims across study states

7

MAJOR FINDINGS • Frequency and amount of opioids per claim decreased in most

states over the study period

• Reflect measures taken by many stakeholders

• More than 2 out of 3 injured workers with pain medications

received opioids in majority of states

• Amount of opioids per claim continued to be higher in LA, PA;

also higher in NY despite large decrease

• Opioids were frequently dispensed together with other sedating

drugs

• Few injured workers with longer-term opioids received

guideline recommended services

8

DECLINES IN OPIOID PRESCRIBING

CDC: OPIOID PRESCRIBING

DECREASED IN SEVERAL COUNTIES

FROM 2010 TO 2015

10

Source: Guy et al. (2017). Vital Signs: Changes In Opioid Prescribing In The United States, 2006–2015

Increased

Stable

Decreased

Insufficient Data

Change In Morphine Milligram Equivalents Prescribed Per Capita (2010–2015)

-16

2

-18

-16

-14

-12

-10

-8

-6

-4

-2

0

2

4

KY

*

NY

*

MD

*

NV

*

TN

*

LA

*

NJ*

VA

*

IN*

FL

*

AR

*

PA

*

NC

*

CT

*

CA

*

KS

MA

WI

GA

IL MI

TX

MN

IA SC

MO

FEWER INJURED WORKERS WITH PAIN

MEDICATIONS RECEIVED OPIOIDS IN

LATEST STUDY PERIOD

11

2013/15: Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2012, To September 30, 2013, Prescriptions Filled Through March 31, 2015; Similar Notation Used For 2010/12 Source: Interstate Variations In Use Of Opioids, 4th Edition (2017)

% P

oin

t C

ha

ng

e In

% C

laim

s W

ith

Pa

in M

ed

ica

tio

ns

Th

at

Ha

d O

pio

ids

, 2

01

0/1

2 T

o 2

01

3/1

5

* Statistically Significant At 10% Level

SIGNIFICANT REDUCTIONS IN

AMOUNT OF OPIOIDS PER CLAIM

SEEN IN MOST STATES

12

Source: Interstate Variations In Use Of Opioids, 4th Edition (2017)

-1,500

-1,000

-500

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

MO IA WI

IN

NJ*

AR

MN

*

KS

* IL

FL

*

TN

*

VA

NV

*

CT

*

MI*

GA

*

TX

*

NC

*

SC

CA

*

KY

*

MA

*

MD

*

PA

*

NY

*

LA

Average MEA per Claim, 2010/2012 Difference between 2010/2012 and 2013/2015 Claims

-9% -6%

4% 2%

-21% -16% -26% -27%

-9%

-22% -24%

-4%

-29% -26% -37%

-24% -22% -15% -15% -28%

-34%

-23%

-37%

-11%

-35%

-6%

Ave

rag

e M

orp

hin

e E

qu

iva

len

t A

mo

un

t (M

EA

) P

er

Cla

im W

ith

Op

ioid

s, 2

01

0/1

2 T

o 2

01

3/1

5

* Statistically Significant At 10% Level

% PAIN RX FOR NON-OPIOID ANALGESICS INCREASED IN MOST STATES

13

-15%

-10%

-5%

0%

5%

10%

15%

NY KY CA FL CT VA MN TX PA OK GA NJ TN ARMDMA IA IN KS NC MI LA MO WI IL SC

Ch

an

ge I

n %

Pain

Med

icati

on

R

x:

2010/1

2 T

o 2

013/1

5

Hydrocodone-acetaminophen Non-opioid pain medications

FEDERAL AND STATE POLICIES

ADDRESSING OPIOIDS PRESCRIBING

AND DISPENSING • Federal

• CDC Guideline for Prescribing Opioids for Chronic Pain

• Up-scheduling of Hydrocodone Combination Products

• State

• Prescription drug monitoring programs (PDMP)

• Drug formularies

• Limits on prescribing and dispensing of opioids

• Treatment guidelines addressing opioids

• Other policies addressing opioid prescribing

14

SEVERAL REFORMS COINCIDED WITH

REDUCTIONS IN OPIOIDS FILLED OVER

THE STUDY PERIOD

15

CME: Continuing Medical Education; ppt: Percentage Points

KY NY MD MI TN MA TX

Change In % Claims With

Pain Meds. That Had

Opioids

-16 ppt -9 ppt -6 ppt 0 ppt -5 ppt -1 ppt 0 ppt

Change In Average Amount

Of Opioids Per Claim -34% -35% -37% -37% -24% -23% -22%

PDMP Use

Chronic Opioid Guidelines

Drug Formulary

Quantity Limits

Provider Education CME

Pain Clinic Regulations

• Mandatory use of PDMP (KASPER) use (July 2012)

• Mandatory prescribing, dispensing, and reporting standards

(September 2012)

• Regulation of pain clinics

KASPER: Kentucky All Schedule Prescription Electronic Reporting

IMPACT OF KY REFORMS

SCOPE OF KY HOUSE BILL (HB) 1

16

Source: Kentucky House Bill 1 Impact Evaluation (2015)

IMMEDIATE INCREASE IN KASPER

QUERIES BY PRESCRIBERS AFTER

MANDATE

17

Prescriber Use Mandate Went Into Effect

0%

10%

20%

30%

40%

50%

60%

70%

2011 2013

% C

laim

s W

ith

Pain

Med

icati

on

s

Th

at

Receiv

ed

Op

ioid

s

KY OPIOID REFORMS IMMEDIATELY

DECREASED OPIOIDS DISPENSED TO

KY INJURED WORKERS

18

Claims With Injuries Occurring In Calendar Years 2011 (pre-reform) And 2013 (post-reform), Opioid Rx Filled For One Year Following The Date Of Injury. Kentucky HB 1 Went Into Effect On July 2012. Case-Mix Adjusted Measures Are Reported. Source: Impact Of Kentucky Opioid Reforms (2017)

MO, 1%

IN, -3%

IL, 0%

KY, -10%

MEA: Morphine Equivalent Amount

AVERAGE AMOUNT OF OPIOIDS

RECEIVED BY KENTUCKY WORKERS

DECREASED POST-HB 1

19

0

200

400

600

800

1,000

1,200

1,400

1,600

2011 2013

Avera

ge M

EA

Per

Cla

im W

ith

O

pio

ids (

mg

)

KY, -16%

IL, -9%

IN, -7%

MO, -9%

STATE POLICIES ADDRESSING

OPIOIDS PRESCRIBING AND

DISPENSING Prescription drug monitoring programs (PDMP)





20

20 STATES ADOPTED COMPREHENSIVE

PDMP PRESCRIBER USE MANDATES AS

OF 12/2016

21

Source: NAMSDL And Sherry L. Green & Associates, LLC. Key State Requirements For Mandatory Use Of PDMPs By Prescribers (http://www.namsdl.org/library/6757CFE2-E9D2-2C3E-3EED217690E6ABA3)

CA

NC OK AZ TN

IN

GA MS

CT

DE

PA

States With Limited PDMP Prescriber Use Mandates

States With Comprehensive PDMP Prescriber Use Mandates

NV

NM

CO

ND MN

WA

AR

LA

VA KY

OH

NY

RI

WV

VT

NJ

AK

ME

MD

NH

SC

UT

WI

States Without Prescriber Use Mandates

MA

MORE PDMP QUERIES BY

PRESCRIBERS CORRELATED WITH

DECEASES IN OPIOID DISPENSING

22

a Source For X-Axis: The Pew Charitable Trusts (2016). Prescription Drug Monitoring Programs: Evidence-Based Practices To Optimize Prescriber Use

b Source For Y-Axis: Interstate Variations In Use Of Opioids, 4th Edition (2017)

WI

MD

CT

TX

CA

IL

MA

IA

KS

MN

SC

VA FL

NJ

AR

LA

NC IN

MI

TN

NY

KY

-18

-16

-14

-12

-10

-8

-6

-4

-2

0

2

4

0 50 100 150 200 250

% O

f C

laim

s W

ith

Pa

in M

ed

ica

tio

ns

T

ha

t H

ad

Op

ioid

s,

Ch

an

ge

Fro

m

20

10

/12

To

20

13

/15

b

Queries Per DEA-Registered Prescriber In 2014a



DISPENSING • Prescription drug monitoring programs (PDMP)

Drug formularies




23

16 STATES IMPLEMENTED OR PASSED

LEGISLATION TO IMPLEMENT A DRUG

FORMULARY

24

Formulary or preferred

drug list in place

Legislation passed

to implement a

formulary

CA

OK AZ TN

DE

NV

TX

MT ND

WA

AR

OH

NY WY

KY

IN

• Ohio’s Bureau of Workers’ Compensation reported that their

formulary resulted in

25% decrease in opioid Rx

• 74% decrease in muscle relaxant Rx

• TDI Study on Impact of Texas Closed Formulary

• Formulary resulted in decrease in non-formulary (‘N’) drugs

Non-formulary opioids decreased 60%, all opioids decreased 10%

• ‘N’ opioids largely long-acting

Sources: Fiscal Year 2014 Report. 2015. Ohio Bureau of Workers’ Compensation; Impact Of TX

Pharmacy Closed Formulary: A Preliminary Report Based On 12-Month Injuries With 24-Month Services

& Legacy Status. 2015. TX Department Of Insurance, Workers’ Compensation Research & Evaluation

Group.

EXAMPLES OF IMPACT

OF DRUG FORMULARY

25





Limits on prescribing and dispensing of opioids



26

STATE POLICIES LIMITING

PRESCRIBING AND DISPENSING OF

OPIOIDS • FL: banned physician dispensing of CII, CIII opioids (Jul. 2011)

• KY: physician dispensing of opioids limited to 48-hour supply

(Sep. 2012)

• TN: restricts dispensing of opioids and benzodiazepines to a

30-day supply (Oct. 2013)

• MA: landmark legislation limiting first fills to 7-day supply with

exceptions for chronic pain and cancer patients (Mar. 2016)

• Several other states adopted similar first fill limits (AZ, CT, IN,

ME, NH, NJ, NY, PA, RI, VT)

27






Treatment guidelines addressing opioids


28

• Workers’ compensation jurisdictions with treatment guidelines

for chronic pain, include CA, CO, CT, LA, MA, MN, NY, OK, and

WA

• Evidence-based guidelines also developed at the national level

• ODG

• ACOEM

• CDC chronic pain guidelines

• FSMB model policy guidelines

INCREASING NUMBER OF STATES

ADOPTED TREATMENT GUIDELINES

FOR CHRONIC PAIN

29

Random urine drug testing

Psychological and psychiatric evaluations and treatment

Active physical therapy

• Maximum daily dose exceed with caution

• Check state prescription drug monitoring program (PDMP)

database

• Co-prescribing of other drugs

• Interdisciplinary and multidisciplinary care

• Alternative care

TREATMENT GUIDELINES FOR

MANAGEMENT OF LONG-TERM

OPIOID USE FOR CHRONIC PAIN

30

GAP OBSERVED BETWEEN

PRACTICE AND TREATMENT

GUIDELINE RECOMMENDATIONS

Nonsurgical Claims With > 7 Days Of Lost Time That Were Identified As Receiving Opioids On A Longer-Term Basis, Injury Year 2012, Prescriptions Filled Through March 2014, Average 24 Months Of Experience; Source: Longer-Term Dispensing Of Opioids, 4th Edition (2017)

Median Of States

Studied

Range

Among States

Studied

% Of Claims With Opioids That Had Opioids On A Longer-Term Basis

6% 3%–18%

Of These, % That Received Recommended Services

Drug Testing 40% 22%–59%

Psychological Evaluation 7% 3%–30%

Psychological Treatment 3% 1%–12%

Active Physical Therapy 87% 73%–91%

31 31

GEOGRAPHIC VARIATION IN OPIOID

PRESCRIBING

32

CDC: OPIOIDS PRESCRIBED VARIED

SUBSTANTIALLY ACROSS THE

COUNTRY

33

Source: Guy et al. (2017). Vital Signs: Changes In Opioid Prescribing In The United States, 2006–2015

Morphine Milligram Equivalents Prescribed Per Capita (2015)

AT LEAST 2 IN 3 INJURED WORKERS

WITH PAIN MEDICATIONS RECEIVED

OPIOIDS IN MOST STATES

34


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

NJ IL MD KY CT MI NY CA PA FL TN MO IN GA MA IA VA KS TX NV WI NC MN SC LA AR

% O

f C

laim

s W

ith

Pain

M

ed

icati

on

s T

hat

Had

Op

ioid

s,

20

13

/15

1 Opioid Prescription 2 Or More Opioid Prescriptions

52%

85%

OPIOID DRUGS COMMONLY PRESCRIBED

TO INJURED WORKERS, PAID UNDER

WORKERS’ COMPENSATION


% Of Pain Medication Rx That Were For …

Federal Schedule

Median State

26-State Range

Hydrocodone-APAP (Vicodin®) II* 29% 9%–45%

Tramadol (Ultram®) IV 15% 9%–25%

Oxycodone (Percocet®, OxyContin®) II 9% 1%–30%

All Other Opioids (Morphine, Fentanyl, Buprenorphine, etc.)

II & III 3% 2%–6%

Non-Opioid Pain Medications – 42% 32%–57%

35

* The Drug Enforcement Agency rescheduled hydrocodone-combination products from Schedule III to

Schedule II, effective October 2014.

35

AMOUNT OF OPIOIDS PER CLAIM

CONTINUES TO BE HIGHER IN LA,

FOLLOWED BY PA AND NY

36


0

1,000

2,000

3,000

4,000

MO IA NJ KS MN WI TN MI IN NV FL AR CT IL KY GA MD VA TX CA NC SC MA NY PA LA

Ave

rag

e M

orp

hin

e E

qu

iva

len

t A

mo

un

t

Pe

r C

laim

Wit

h O

pio

ids

, 2

01

3/1

5

SMALL PROPORTION OF

CLAIMS HAVE LARGE

AMOUNT OF OPIOIDS

37


16,863 LA

10,950 NY

12,450 PA

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

p0 p5 p10 p15 p20 p25 p30 p35 p40 p45 p50 p55 p60 p65 p70 p75 p80 p85 p90 p95

ME

A P

er

Cla

im W

ith

Op

ioid

s,

20

13

/15

HIGHER AMOUNT COULD BE DRIVEN

BY LONGER DURATION OR

STRONGER DOSES MEA per claim = Number of Rx *

Quantity *

Strength *

Morphine conversion factor (CF)

Rx Fill Date Drug

Name

Morphine

CF

Narcotic

Strength

Qty. MEA

01/01/2012 Vicodin® 1 5mg 40 200

01/10/2012 Percocet® 1.5 10mg 60 900

1100

38 38

LARGER VARIATIONS IN DURATION OF OPIOIDS,

SMALLER VARIATIONS IN AVERAGE DAILY DOSE

OF OPIOIDS


39

Based On Claims With Opioids That Had Days Supply Populated For All Opioid Rx

Median Of States Studied

Range

Among States

Studied

Average Duration Of Opioids Dispensed (days)

44 25–104

Average Morphine Equivalent Daily Dose (MED) Of Opioids (milligrams)

36 32–42

39

METRICS OF HIGHER RISK

OPIOID DISPENSING • Dispensing of opioids on a chronic basis

• Dispensing of opioids at doses exceeding guideline

recommended maximum daily doses

• Concomitant dispensing of opioids with other sedating drugs

40

7–29% OF WORKERS WITH OPIOIDS HAD

CHRONIC OPIOID USE; SOME WORKERS

HAD HIGH-DOSE CHRONIC OPIOID USE


41

Based On Claims With Opioids That Had Days Of Supply Populated For All Opioid Rx

Median Of States

Studied

Range

Among States

Studied

Receiving 60 days or more of opioids in any 90-day period

13% 7%–29%

More than 50 MED of opioids for 60 days

or more in any 90-day period 1.7% 0.6%–4.0%

More than 90 MED of opioids for 60 days

or more in any 90-day period 0.5% 0.2%–1.2%

41

RECEIPT OF OPIOIDS WITH OTHER

SEDATING DRUGS IS ASSOCIATED WITH

HIGHER RISK OF OVERDOSE DEATHS • CDC guideline cautions prescribers about the dangers of prescribing

opioids with central nervous system depressants

• A 2017 WA study found higher risk of opioid overdose deaths when

WA Medicaid enrollees received opioids with other sedatives

• Example:

42

Source: Garg, Fulton-Kehoe, & Franklin (2017): Patterns Of Opioid Use And Risk Of Opioid Overdose Death Among Medicaid Patients

Risk Of Opioid-Related Death Among WA Medicaid

Enrollees With ≥ 1 Opioid Rx Who Concomitantly

Received

Adjusted Hazard Ratio (95% confidence interval)

None 1.0 (base)

Benzodiazepines Only 7.5 (5.5–10.0)

Benzodiazepines And Skeletal Muscle Relaxants 12.6

(8.9–17.9)

Skeletal Muscle Relaxants Only 2.8

(1.8–4.2)

5%

0%

1%

2%

3%

4%

5%

6%

AR IA WI MA CT TN MDMOMN NJ MI NC KS IN NV NY VA KY SC FL TX GA IL CA PA LA

OPIOIDS ARE FREQUENTLY

DISPENSED TOGETHER WITH OTHER

SEDATING DRUGS IN MOST STATES

43


0%

9%

0%

2%

4%

6%

8%

10%

TX KS FL TN MO GA AR CA KY IA NJ NY IN IL MD MN NC PA NV VA MI SC CT LA WI MA

28%

48%

0%

10%

20%

30%

40%

50%

60%

NJ MO WI MA IA NY MI IN MN IL KS TN PA CT AR VA KY SC TX NC NV MD CA GA FL LA

30%

51%

0%

10%

20%

30%

40%

50%

60%

NJ MO WI IA NY KS TN IN MI MA IL AR KY VA CT TX PA MN SC NC MD CA NV GA FL LA

% Of Claims With Opioid That Concomitantly Received…

Benzodiazepines (Valium®, Xanax®) Muscle Relaxants (Flexeril®, Soma®)

Sedatives (Ambien®) Any Sedating Drug

MA: HIGHER RATE OF CONCOMITANT

DISPENSING OF SEDATING DRUGS AMONG

MA WORKERS WITH CHRONIC OPIOID USE

44


Among MA

Claims

With

Opioids

Among MA

Claims With

Chronic

Opioids

% That Received Opioid Simultaneously With …

Benzodiazepines (Valium®, Xanax®) 9% 23%

Muscle Relaxants (Flexeril®, Soma®) 31% 55%

Sedatives (Ambien®) 1% 3%

Any Sedating Drug 36% 65%

IL: WORKERS WITH PHYSICIAN- AND

PHARMACY-DISPENSED OPIOIDS HAD HIGHER

RATE OF OPIOIDS & MUSCLE RELAXANTS

45


% Of IL Claims With

Opioids, By

Dispensing Point

% Of IL Claims With Opioids

That Concomitantly

Received Muscle Relaxants,

By Dispensing Point

Pharmacy-Dispensed

Opioids Only 61% 29%

Physician-Dispensed

Opioids Only 28% 34%

Both Physician- And

Pharmacy-Dispensed

Opioids

10% 52%

Similar patterns were seen in other states with frequent physician

dispensing of opioids and muscle relaxants: CA, CT, FL, GA, MD, and

PA

RECAP OF MAJOR FINDINGS • Frequency and amount of opioids per claim decreased in most

states over the study period

• More than 2 out of 3 injured workers with pain medications

received opioids in majority of states

• Amount of opioids per claim continued to be higher in LA, PA;

also higher in NY despite large decrease

• Opioids were frequently dispensed together with other sedating

drugs

• Few injured workers with longer-term opioids received

guideline recommended services

46

THE IMPACT OF OPIOID PRESCRIPTIONS ON

DURATION OF TEMPORARY DISABILITY

MOTIVATION • Impact of opioids on injured workers is not well understood

• Does it improve ability to return to work or does it delay return to

work?

• Does it have therapeutic value?

• Is there a different impact of short-term versus longer-term

prescribing?

48

STUDY GOAL IS TO EXAMINE

CAUSAL EFFECT OF OPIOID USE • Prior studies, as they admit, did not establish a causal impact

of opioids on injured workers

• Estimating effect of opioid use is challenging since cases with

opioids are different from cases without

• Unobserved injury severity

• Unobserved personal characteristics

• Study uses statistical approaches that address concerns about

differences in unobserved injury severity and worker

characteristics

49

THIS STUDY EXAMINES CAUSAL

IMPACT OF OPIOID PRESCRIPTIONS

ON TD DURATION • What is the effect of opioid use on duration of temporary

disability benefits?

• What is the effect of longer-term opioid prescribing on duration

of temporary disability benefits?

50

DATA • Workers with primarily low back pain cases in 2009–2013

• Cases with more than seven days of lost time

• Measures at 24 months’ after an injury

• 28 states

51

MAJOR FINDINGS • Longer-term opioids lead to substantially longer duration of

temporary disability

• Controlling for injury severity

• Shorter-term opioid use has little or no effect on duration of

disability

• Local prescribing patterns matter: Workers receive more

prescriptions for opioids in areas where prescribing is more

prevalent

52

LONGER-TERM

OPIOIDS DEFINITION • Claim has opioid prescriptions in the first 3 months postinjury

and 3+ opioid prescriptions in 7 through 12 months postinjury

53

IMPACT OF LONGER

DURATION OPIOIDS

54

*** Statistically Significant At 1% Level. Regression Controls Include Worker, Injury, And Employer Characteristics, And State Dummies. Longer-Term Prescribing Defined As Having Prescriptions Within The First Three Months After An Injury And Three Or More Visits To Fill Opioid Prescriptions Between The 7th And 12th Months After An Injury.

Estimates For Duration Of Temporary Disability Benefits

Change In Duration Of TD Due To Opioid Use

Longer-Term Opioid Prescribing 251%***

Compared To No Opioids, TD Duration More Than Triples When

Opioids Prescribed On Longer-Term Basis

LITTLE IMPACT OF “ANY OPIOIDS”

USE ON DURATION OF DISABILITY

55

Estimates For Duration Of Temporary Disability Benefits

Change In Duration Of TD Due To Opioid Use

Any opioids within 24 months after an injury 5%

LOCAL PRESCRIBING PATTERNS

ARE STRONG PREDICTORS OF

OPIOID USE • Opioid prescribing rate varies across areas within states; of

claims with low back injuries in our sample, % with opioids:

• 62% in Philadelphia

• 71% in Harrisburg

56

Based On OLS Estimates For Any Opioids Specifications. All Estimates Shown Are Statistically

Significant At 1% Level. Regression Controls Include Worker, Injury, And Employer Characteristics,

And State Dummies.

Change In Individual Opioid Prescriptions Due To 10 ppt Increase In

Local Prescribing

Any Opioid Use

10 ppt increase in rate of “any opioids” within local area 3.4 ppt

THANK YOU! • For comments/questions about the findings:

John Ruser

[email protected] (617) 661-9274 • The research I discussed today is available for purchase on our

website at www.wcrinet.org

• For information about membership, visit

https://www.wcrinet.org/membership

• We invite you to follow us on social media

57

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