I am JoLinda LeClaire, Director of Drug Prevention Policy for Vermont. I oversee the Governor's Opioid Coordination Council, which Governor Phil Scott established by Executive Order in January 2017. Since then, the Council has focused on its mission to improve Vermont's response to our opioid challenges through prevention, treatment, recovery, and enforcement. This crisis touches everyone in our state. Many Vermonters have family members and loved ones who have become addicted after receiving opioid prescriptions for pain. Others were exposed to opioids and other drugs through friends, dealers, and traffickers. Regardless of how they were exposed, we know we have among us many who now have the chronic isolating and too often deadly disease of addiction. We are making progress. Treatment is available across the state through Vermont's nationally known hub and spoke system of treatment. Recovery centers in our communities are providing effective wraparound support to help people achieve long term recovery. Many communities are building prevention coalitions to provide our children and families the tools they need to be resilient in the face of life's challenges and traumas. Vermont law enforcement has steadily worked to increase community safety and to decrease the supply of illegal drugs. They also work hard to support prevention strategies that will reduce the demand for opioids. There is more we can do and must do to turn the curve on Vermont's opioid challenges. Drug prevention education is a top priority for schools and communities. Increasing intervention opportunities in emergency rooms and other places will help more people enter treatment and recovery. Individuals and families in recovery need support to obtain jobs and rebuild their lives and support for harm reduction through safe and appropriate use and disposal of drugs and syringes will increase safety in homes and communities. Something we all can do to take every opportunity to raise awareness and reduce stigma by talking about addiction to highlight the science of addiction as well as the cultural, social and economic challenges associated with addiction. The producers and hosts of Vermont Cable Access and the Opioid Coordination Council have created an eight-part series entitled, Understanding Vermont's Opioid Crisis, Working Together to Create a More Resilient Community. This is the sixth in the series and it is about wellness, integrative healthcare for pain management and treatment. In this segment, host Pat McDonald explores approaches to pain management and addiction treatment that reduce or replace the need for opioids. This requires education for prescribers and patients and improved screening for patients, strategies that are underway and highlighted by the governor's Opioid Coordination Council. Hi, this is Pat McDonough and I want to thank Joe Linda for the introduction. As Joe Linda mentioned, this show is about the use of non-pharmacological approach to pain management for addiction treatment and recovery and is also about patient education regarding options and risks in pain management. And we have, Ben Kinsley is here with us today, co-host and co-producer, and we have got three very special guests who are highly qualified to talk about this subject. And it's Dr. Josh Clavin, chief medical officer at Blue Cross Blue Shield. Doctor, how are you? Good, welcome. Dr. John Porter on the other side here of the room of medical director of comprehensive pain program. I have to talk later, doctor. And the commissioner, Mark Levine of Vermont Department of Health. So I would like each of you, we ask our guests to talk a little bit about themselves just so our audience has a flavor for who you are, and how your work that you're doing now ties into our discussion tonight. So Dr. Clavin. Sure, I'm been a practicing physician in Vermont for almost 20 years. I've been at the Blue Cross Blue Shield Health Plan for only about three, three and a half years. Before that, I was in Central Vermont area as a primary care physician. I worked as ER doc and hospitalist and I'm an internist and a pediatrician, so I kind of do family medicine. And so I managed many patients with chronic pain as part of my long time job in primary care, and recognized a lot of the barriers that and issues that we're trying to address. So that informs a lot of the work that I'm trying to do at Blue Cross Blue Shield Vermont in partnership with my colleagues to the left and throughout the state. There's I've noticed there's a lot more partnerships these days. And I'd like to talk about that later, it just seems to be working more closely together and better these days. So commissioner. Yes. So I'm an internist as well, practiced general internal medicine, literally up to the day I began my commissioner work. And as a general internist, did a lot of preventive medicine, screening for disease and chronic disease management. And all of those actually feed into the topic we're going to talk about with opioids. But I also did a lot of screening for other substances, you know, more commonly than opioid, such as nicotine, alcohol, marijuana, using a technique called expert, which is screening, brief intervention, referral to treatment. But we didn't really call it that we just kind of did all of that. And we'd like to disseminate that model even further. Currently as health commissioner, obviously, the opioid crisis is a big focus of the Health Department, a big focus of my alcohol and drug abuse program division at the Health Department. And clearly, it's in the media all the time. But more importantly, it's in the lived experience of people in the public. And so everybody in every community has been touched in some way by it, which really elevates the level of importance that assumes for all of them. As part of my role in health commissioner, I'm also a member of the governor's opioid coordinating council. And there are regional coalitions throughout the state. And I sit on the executive council of the Chittenden County, I hope you know, and there's there's just so many activities going on that I'm sure we'll get into as we I said this at the last show we did on enforcement that when Governor Schumlin used his whole state of the state speech, I mean, myself and my little circle of friends, we have no clue where we live. I mean, we're just not we had no idea. And we were wondering, why is he doing this? We found out pretty quickly after that this is huge. And how serious it is. And it's everywhere. And I just that was a lesson for me. Because I'm like, What is he doing? So anyway, he was doing the right thing. So Porter. Yes. And I am a family physician. I practice for a number of years in Bennington. And then about 20 years ago came up to work at the University in the family of medicine residency, and subsequently at the University of Vermont. And since December, I have been working to put together the program to that we hope will kind of approach the issue of chronic pain for folks in a way that that finds more success than we have had to this point, using an integrative approach. So that's really fascinating. I'm really looking forward to this discussion. So well, there's so much we can talk about on this subject. But Commissioner, let's start with you. Could you summarize from your perspective, where we are at with the opioid crisis and kind of how we got here? Yeah, maybe I'll do that in the reverse order. Sure. God here. And a lot of times people focus on one big area and say this was the problem. But it's really a multi pronged kind of issue. So the health professions play a big role. Individual predisposition plays a big role. Economics plays a role. Society plays a role. So starting with the health professions, obviously, there was, and to a less degree still is, an epidemic of over prescribing of opioid medications by the prescription route. No one's denying that if you ask people who are immersed themselves in the disorder of opioid use, they'll tell you that four out of five times it began with the prescription drug use. Having said that, it doesn't mean that the prescription that was written for them got them into trouble, although that may have been the fact. Most often it turns out perhaps as much as two thirds of the time, it was by diversion. And that's why in Vermont, we have these campaigns called most dangerous leftover campaigns, because it's the things that are still hanging around the medicine cabinet that either get stolen, borrowed, diverted by, you know, illegal or legal means to susceptible people. And so a big thrust of what we've done in Vermont with new rules about how to prescribe these is making sure people are really tuned into the right quantity, right dosage, and that initial prescription, only enough pills that are needed, as opposed to a 30 day supply for something that might have only needed 48 hours worth of treatment. So that's, you know, clearly part of the way we got into this. There was also the culpability on the part of the pharmaceutical industry, specific companies and distributors who really misled the healthcare professionals into thinking that these drugs had low addictive potential, when in fact they have very strong addictive potential. And then there was some misconception about the utility of these drugs for management of chronic pain. And I know Dr. Porter is going to get into his clinic later on, but at the same time, for a long time, people felt that we were helping people who had chronic pain with something that was useful for them, not harmful. And we didn't have many alternatives in their place. So opioids became the natural default, if you will. And the whole thinking on that has changed needless to say. But having said all that, we don't want to take away from genetic and biological predisposition. We don't want to take away from the fact that there are these so called social determinants of health that really create what we term diseases of despair, like substance use, alcohol use, etc. And this is related to, you know, socioeconomic issues like poverty, education issues, social isolation, things of that sort. And these toxic stresses that young kids grow up with, depending on the environment that they're brought into, where there may be abuse in the household, there may be someone who has a disorder of substance use, there may be someone incarcerated, etc. All of that combines into sort of how we got there in a sense. And originally, there was a lack of really good access to treatment. Now there's really good access to treatment of opioid use disorder. So we've taken care of that aspect of thing. People converted, if you will, from the oral prescription drug route to the intravenous heroin, and now unfortunately much more dangerous fentanyl routes, really through economic concerns. These these are cheaper than getting prescription drugs. They're often easier for people to obtain illegally than the legal route in a clinician's office. And the supply of heroin was abundant. And so required a whole host of new law enforcement strategies to try to grapple with that as well. So all of these factors kind of came into play. The impact on the population of Vermont has been quite substantial. As you were mentioning by the state of the state address from years ago, we currently have about 8 to 9,000 people in treatment. Widely not known but nationally derived figures tell us that at most two or three out of 10 people who have an opioid use disorder are getting treatment. That means there's a whole host of people out there that are actively using drugs and not actually getting treatment. So if you look at the universe in Vermont, we could have as many as 20 or 30,000 individuals in the state total who have this problem. And it has this huge impact on everyone as I alluded to earlier. So that's why community coalitions develop, etc. Its impact can also be measured in just mortality. There are two Vermonters a week on average who are dying of an unintentional overdose. That's about 100 a year. There's also this huge impact on kids. And when I have my colleagues in the Department of Children and Families show me their statistics. It turns out that in the last two years, 50% of children age is zero to five that are in the custody of the state of the Department of Children and Families were attributed to opiate use issues in their family. And that's about 500 kids a year. I'm very involved in prevent child abuse from on them on the board. And our numbers have gone up, but it's not from abuse. It's from neglect. Because when you're on the opioids, you just sort of can't care for your kids. So that's why the numbers are going up. And we had them down for quite a while. And now they're right back up again. Especially in the zero to five year old, which is a real tragedy. So enough on the impact. I hope that answered you. That was very thorough. Very thorough answer. Thank you. It's it's amazing, all the aspects of, you know, just regular day life in Vermont that this impacts. I don't know, Dr. Porter, if you have anything to add to that in terms of the treatment and and diagnosing of the issue? Yeah, well, I would, I think that was a very comprehensive response and thoughtful response on Dr. Levine's part. You know, I think we in the allopathic medical field have something to kind of carry here as far as as wishing that we had perhaps done better critical thinking and design systems that responded better to individual conditions.   If you don't, we feel neglected. That's right. You don't do that. But I do think it's it's an opportunity for us to look at how we're practicing and how we can really kind of move towards a more patient centered approach. And so that's what we're all working on. That's great. Dr. Plavin, I just want to ask a little bit different question about Blue Cross Blue Shield, where you work. How has that been impacted by the opioid crisis? I went on your website and there's I think there's a lot of policy changes, medical changes. You've really been active and somebody in Blue Cross up at the State House trying to swerve some things around and being responsive. So the so Blue Cross has been engaged with the opioid epidemic writ large since 2002, when it was the heroin epidemic. So we have been intervening over time and raising awareness, provider outreach and education, early intervention and end recovery. And so we had supported Bess O'Brien's films that you're familiar with. Here today, The Hungry Heart and the tours. Yeah, the tours throughout the the the state, which were very engaging. We also supported the Voices Project, which is the voice of youth and ended up being a play. It was videotaped and available. And a book as well called Listen and a CD called Listen. And then more recently, we worked with Vermont PBS to read, to have further community dialogues and we re-televised, if you will, here today and Hungry Heart with Bess as well. So that's on the raising awareness side. In regards to the the current kind of partnerships, we had actually been planning on starting to address this institutionally at the same time when at that at that time, the commissioner was Dr. Chen, reached out to us and said, hey, we're actually putting together a statewide task force. We'd like this to be multi-payer and have everyone engaged. And we said, sure, that sounds like a great idea. So we met with him and other payers and then eventually got involved in the statewide opioid task force. And in the end, what we did was we operationalized the guidelines that were agreed upon. So having guidelines and rules are one thing, enforcing them and making them real is another. And so what we have found is that we when we have put hard stops in the pharmacies for someone who is opioid naive, never had a medication before, maybe just had a procedure and was given a prescription for 30 tabs. Well, the new rule in the system says no more than seven days, no more than so much mild equivalence of medication, and it will stop it right there before it's dispensed. What we found is that that actually has further decreased. We've seen an overall decrease in opioid use. That has further decreased that by about 20% by actually operationalizing the rule within your systems. And so that took some doing, but we continue to improve on those. We have new policies around long-acting opioids. We are having meetings about next steps as what we want to do as a state and how can we help to operationalize those decisions because patients are also at high risk of overdose, whether on high doses, when they are have a co-prescription of sedating medications. So we're very concerned about that. And we do a lot of monitoring and outreach to providers. How many physicians do you have a Blue Cross for the Shield who maybe are monitoring all of these interactions of drugs? So we have two pharmacists and basically three physicians. And not full time. And so, yeah, I make a lot of the calls myself. And then the other thing is mental health, the interplay of mental health diagnoses and both chronic pain and then opioid abuse and the untreated underlying issues. Exactly. And so that's something we also consider a risk factor and work with our... So you deal directly with your clients, your customers. Do you call them and talk and have people follow up with the patient? We work through the provider. There are some federal rules around. So we work with provider as much as possible. And we certainly don't want to get, never want to get in the way of the physician, you know, patient relationship. And so we want to augment that. That's important. Well, we think Blue Cross Blue Shield is a wonderful community partner. So thank you very much. Maybe you had some questions. Yeah. So there's, you mentioned the role that you're playing working with state and in some cases federal officials and programs trying to address this crisis. And there's three critical pieces, in my understanding, to that, to that relationship. And it's ensuring patients receive the right care in the right setting, providing states with sufficient resources to address the epidemic and addressing the fraud and abuse that's harming people who need help. That one, we can probably expand on a little bit more. Yeah. You know, and so, so right time, right place, there, we actually have a very robust case management program nurses and social workers and mental health and licensed alcohol and drug counselors who work with our members who are struggling within recovery. And also for all sorts of other chronic conditions. It's unique because we're actually a provider-payer partnership with the Barbara Retreat. And so we're completely integrated between mental health and medical. And, and so we have lots of different programs to support patients in recovery. One of the things we found was that when patients are first identified with opioid misuse disorder, and they're started on MAT or medication assisted treatment at a hub, sometimes there's a gap between the hub, the central kind of stabilization facility, and what's called the Spoke, which is the community provider who takes on their care once they're stable. Sometimes people fall through the cracks. So what we've done is actually put in a case manager in the middle to make sure and ensure that members get kind of from the hub to the Spoke, if you will. And we were the first payer to actually contract with all the hubs, pay them at a bundled rate, break down a bunch of barriers around finance, which include things like people who are initially on medication assisted treatment are often given daily or weekly dosing. And we were, we realized that the way that the benefit structure was designed was not to the benefit of the patient. And so we prorated the quote unquote copay, whatever the portion of the patient might need and need to pay so that they weren't kind of stuck with that every time they filled the prescription, among other things. We do support SBIRT actively and do support training and expansion of that throughout the state. That's the early intervention, early diagnosis and harm reduction model for for substance misuse in general, I would say. And we're expanding that model as well. And lifestyle misuse. Yeah, exactly. Exercise diet. Oh, please, let's not talk about that. And then on the on the other side, we're working with Dr. Porter and also another site and the proper retreat, actually, to stand up what we like to think of centers of excellence. So just like we have a hub and spoke model for opioid misuse and medications treatment for chronic pain, we don't have a system to adequately manage our patients. And we in primary care often, if you will, left holding the bill, if you will, and not adequately trained to manage complex pain syndromes like this, what we have historically done is send patients off for consults to interventional pain clinics. They might get an injection. It might help temporarily. But in fact, much of that interventional care is not actually that helpful for patients. And what we firmly believe is that there needs to be kind of a middle man center of excellence or hub and a series of these throughout the state to support patients and verminers as well as the medical system and Dr. Porter's is would be the first one that's up and running. Right. The second one that we're retreat, but we envision probably six to eight of these throughout the state. So kind of like a parallel structure to a parallel structure for chronic pain. Great lead into Dr. Porter, because we'd like you to talk about the comprehensive pain program. CPP, I got it. CPP. Yeah, and I think we can go back and maybe along the lines of what Dr. Plavin was saying, kind of take a systems look at how we have been doing this. So you can imagine a patient who has been dealing with pain for many months or years on a perhaps an opiate who may have a co-occurring mental health challenge, depression, anxiety whose vocational plans may have been disrupted, whose family system has likely been disrupted.  And they present to the office with with this array of suffering around their chronic pain and leave, you know, probably experience a very transactional event, right? I'm here. Here's what's happening. My pain is five out of 10 or eight out of 10. And so they may well leave feeling like they weren't well served, frustrated, they don't feel much better. They may be having side effects from their medication regime. Well, somebody brought up the underlying, I think you've talked about the underlying factors. A lot of pain, I think, is underlying factors which could trigger pain, correct? Is that? I think we're learning a lot psychological about about how the nervous system seems to behave in folks who have chronic pain.  So where's it coming from? And so we're looking at how to approach it in different ways. But if I go back to that scenario with the patient coming in with their chronic pain to a primary care setting and you go to the other side of the desk or the exam table, you have the clinician, you know, who has this patient with many needs and challenges, trying to take care of that in a 15 minute visit. That ends up being frustrating and draining for the clinician. And so I think one of the questions for us is with this condition, how can we really try to develop a system that is patient centered, that uses a broader toolbox of options than than we've had just with our traditional approach. So what is your playing? Can't say a pain clinic going to be doing that's up in September. It's a new building at the university? There's an area that's being renovated about 9000 square feet. It's on Tilly Drive. And the intention is first of all to take care of the cohort of folks who have been seen at the pain clinic before the CPP came into being and offer them access to this. And then we'll open it up to the faculty practices and primary care internal medicine and family medicine and then beyond that within the system. And for many folks who go through that, as we put this program together, this will be a 12 week so called episode of care with a weekly time for patients to come. Nice. And during that time each week, they'll get some education about what's happening with their body in this process. They'll have a chance to do some movement. They'll have access to other modalities be introduced. Do you have like massages there and other things there at the facility? So this facility will have physical therapy, occupational therapy, yoga therapy, massage therapy, acupuncture, and then some mental health approaches that are designed to help folks up kind of gain some new skills. That's great. So I think going back here, you know, the idea is for folks who have been in pain. And I think we use the word chronic pain. For me, the more accurate word is suffering, right? There's pain centrally, but there's suffering all around that that often leaves people isolated. And so the intention is to help folks articulate meaningful goals for themselves about what they would like to be doing. And it may not, as opposed to the old days, when it would be, I want to increase the range of motion on my shoulder to 90 degrees, right, which would be a traditional kind of medical approach. It may be I want to get on the floor with my grandchild and play, you know, or I want to be able to get out to the store or, but using those goals and then working with staffs who, who a staff who has expertise in these various modalities, helping people. Don't you think people have a, um, they think zero is good. I've had this discussion on the show before, and they, every time you go into the doctor's office, they say zero to 10. Yes. Where is your pain? Well, if somebody presents zero to you, you think I should have zero. Yes. I remember growing up and they said, you just had surgery. Of course, you're going to be in pain. And they gave you aspirin or something and it didn't go, it didn't go to zero. Maybe it went to four. Yeah. It does that. I think that doesn't help. Well, I think that doesn't help the doctor. It's a very real point. And at the same time, um, you know, to tell somebody who's had chronic pain that you're never going to be pain-free is, is tough. And yet I do think that's part of the work. Yeah. Because we know in this, in this area of endeavor, if, if folks make 30 or 40% improvement in terms of comfort level, in terms of functional level, that's a home run right now. So I also think we've given folks some signals that, you know, we just got the right formulation or the right medicine, we can do this, right? But people really deserve it. We should have started it at two. Yeah. And even, even that pain chart that we use, you know, is so one-dimensional, right? Exactly. Because there's a lot more to, and I don't never know how to fit it in. But I always think that maybe it's helpful to the doctors to hear from the patient better, worse. And it was four last week and six this week. That would help. That's zero. I think it's a shorthand that has some effort, some use for sure. But I think again, in terms of that broader sense of how are we doing here with life, how, what skills are we able to provide with you or access to modalities that you didn't know would help and they seem to be helping. That's a cultural change. You know, and when it was introduced as the fifth vital sign, right? And the regulators caught on to it. And Jacob actually required some documentation there of that did not help. Because again, it was addressed in too simplistic fashion. And it's a more complex issue and is focused on your experience of suffering, which I think would like better than pain, and your goals for your function. And so I think it's not just us that have to change, but the entire culture to some degree. Right. Just to piggyback onto that. It was as another component of how we got into the epidemic, the overreliance on this as a quality measure that almost forced clinicians into prescribing more and more. But it all stems back to, I think the word is expectations. Yeah. So perhaps we as prescribers may have had unrealistic expectations of how to manage the pain. But those coming in with pain and suffering, you know, with our high tech healthcare system, everyone expects that the expectation is I will go from 10 to zero and the condition I have, I don't have to live with that the rest of my life because it'll be taken care of. And we're learning that actually we can help you live with that in very productive ways. If you work with us in the settings that you've heard described. There's so much, if there's so much going on, you have to worry about drug interaction. And I mean, there's so much stuff you have to worry about. And I don't think Dr. Porter can chime in on this. The promise of this clinic is not that every person who's been on opioids chronically for their life is going to be suddenly off of opioids or that the approach is even going to be to drastically reduce their opioids and make them uncomfortable. It's to really augment the system built around them to help them cope with their pain and suffering, which may perhaps allow a reduction in dose of the opioids. I actually look at the true promise of the centers as are being described for the people who haven't yet become chronic opioid need patients. They have pain and need help managing it. Their physicians need a hub as was described that they can be referred to to really help a holistic integrated approach around that pain and then never get into the slippery slope of requiring more and more opioid to manage the pain. There's still a lot of these pharmaceutical companies said that it wasn't addictive when they first introduced it. That was they sort of told a little there was a little fib and that's why numerous states have a lot of lawsuits now because of that. Well, there's a national class action lawsuit around there is. Yeah, right. But I do see the promise as being in the more opioid naive population that they never get there. And then people who maybe were thinking that just taking a drug will help everything that's wrong with them have a different kind of approach that can be productive for them. I think that's a very important delineation. And I've talked to a lot of audiences and there are people people who have chronic pain who are on chronic opioids who are stable have no reason to think that anyone's going to take quote unquote take it away from you. If it's helping your function and you are you are stable, there's no reason to do so. Now, when we've looked at these types of clinics which do exist throughout the United States, somewhat spotterly, the overall in the whole population that they see about there's about a 20% 30% reduction in total opioid prescriptions. But that doesn't mean any individual patient will be will have a reduced dose. It's their choice as they choose to find alternative means of treatment. So how do people come to your clinic? Does my doctor say you should go to the CPP that's this will be on referral and again, initially will be from the faculty practices up at UVM. But it will be on referral and it will be a referral service. We'll take folks in work with them, communicate with the medical home. And then the other there are two other important parts to the to the program. One is that at the end of that 90 day or 12 week period, we don't want people just to kind of fall off the edge of the table. So we'd like them to continue to maintain and build the skills that they have with the work they've done in those first in that first foundational event. And the other part we're working on is a track for folks who are in primary support roles could be a partner, spouse, might be an older child. I could talk about that. My husband had back surgery in November. So that's me. He's going to a pain clinic next week. So there you go. But again, in the sense that this is a this is a three dimensional problem and challenge for family systems. Because I think that's because sometimes pain, you can't see pain sometimes. And I think it's good for the caretaker to understand what's really going on. And and to have a sense of what the patient is learning and also probably to get some porous in a cohort experience, right? Because it's it is its own it is its own challenge. The other just going back to the cultural change issue in in our traditional way of kind of working with chronic pain, it has been transactional. It has been one in which the patients options are limited, right? And so what we would like to do is to increase patient self-efficacy at kind of picking out things that work for them and their agency in terms of engaging the medical system. And I think that's probably and we will have to see if this is borne out. But there's a reason to think that's a powerful way to help people move forward with with a condition that's chronic. That's excellent. That's great. Ben, did you have a Well, so this is something that we talked about briefly. I think Dr. Porter, you had mentioned earlier about the new facility that you're opening at UVM is psychological counseling being embedded in opioid treatment as you know, that's part of the root cause of of addiction. Kind of to piggyback on top of that, I'm curious to know how integrated the mental health and treatment addiction treatment services are and how much crossover there is between addiction as well as other mental health issues. So that's going to be have to be have to be required foundational prerequisite for these centers that it is there's a medical component and a strong foundation in psychological mental health component. And and so your clinic is going to have that as a foundation, the clinic at the Barbara retreat in fact is coming out of mental health and in fact are bringing in medical to them. And and I think we all agree that that's that's one of the most important things. Is that true in almost all cases that there's some hidden I don't want to say hidden, but there's some psychological issues there. Is that so we would in a broad in a broad sense since we study this at Blue Cross through our claims and what not in the chronic disease population in which this is a chronic disease approximately and it varies 20 percent of the population has a co-occurring mental health diagnosis. Those with co-occurring mental health diagnoses have a 40 percent higher utilization and cost on the medical side. So if you don't treat the mental health and don't get them access to services, you're never going to manage the chronic condition. And we know that on a one on one basis with patients, but at a population level, we need to actually build systems to address it. And if people don't fall into a frank mental health diagnosis, right, there are still issues that relate to their being in day to day life and skills that can be helpful in terms of helping them navigate effectively. And things that are chronic pain led to that is true mental health and stress, whether it's Frank Depression or the 90 or one. Ben, in your original question, I think you were also looking at the overlap of mental health and substance use. Yes. Yeah, I like the feeling. And so that one, we don't have a hard and firm number, but numbers as high as 70 percent for coexistence of mental health disorders and substance use disorder. And we can and need to do a better job of addressing both concurrently. The emphasis is clearly always on trying to leave the addiction problem first and work on that. But really concurrently, the mental health aspects need to be taken care of. Obviously, for someone who has come in asking for treatment for their opioid use disorder, the fact of the matter is state of the art treatment is medication assisted treatment with either methadone or buprenorphine predominantly, occasionally now checks on. And so that's going to be a given no matter what. But in the hub and spoke system layered alongside that for the person who wants it, it's not forced on anybody. Are all kinds of support services in terms of case management, in terms of counseling. And certainly the recovery process is replete with peer recovery counselors, licensed alcohol and drug abuse counselors who want to continue to play a big role for that individual, whether they're remaining on MAT or not at that point in their recovery, because the coexistence is so great and the need for that kind of support is so great. Yeah, it's pretty stark if there's a 70% coexistence. I didn't hear that before. And one of the reasons I asked that question is because, you know, we understand that a lot of now understand that many cases of opioid addiction are resulting from a medical issue. They're either prescribed or got access to opiates. But I think there's also a perception before we came to that realization that people turn to addiction for issues related to depression or whatnot that are kind of outside the medical diagnosis piece of it. And I don't know how great of an issue that still is compared to the medical piece of it and the opiate piece of it, but there's certainly a number of factors at play. Absolutely. So I have a list of treatments or types of treatments that I put them in questions and you all came back and said, well, this is the, so all I thought to do is just to list them and maybe some one of you can explain them as we go through that because I was getting a little confused. So first is the integrative treatment and maybe you could be the best person to explain. What is integrative treatment? It's what we've been talking about, I think. Yeah, and for me, an integrative approach is one that combines an allopathic approach with other therapies. And what is allopathic? It's an MD. Oh, okay. Yeah, or it could be an osteopathic approach. Oh, okay. But with other therapies and with mental health kind of programs and services. So the intention is to bring a broader array of options and treatments. Which is different from the whole person care or the same. Because we had a question about that. It's another way of saying the same thing. Because we're going to put up the wellness wheel from UVM because I think that really just kind of captures all of the components of the whole person. So because I think in the past, so often anything that wasn't allopathic, meaning the doctor who provided prescription whatever, was regarded as alternative or complementary. And that meant any other person who saw the patient, they may have practiced chiropractic, they may have practiced acupuncture, they may have done some far Eastern modality. It was all lumped in that. And it really wasn't a very expressive way of describing what we really want, which is try to find the modality that's appropriate for the person and that will help them get better and become more productive in their life again. It's sort of good to see these modalities being risen up a little bit in recognition of their importance. And that's why she used the word integrative is so much more powerful because it's really, it's not that what the allopathic canon does do, didn't count anymore. And likewise in the opposite direction, if acupuncture was the best, it didn't discount that either. They all can become a component of getting the person to a state of wellness that's greater than where they entered. But integrative is in fact care that is coordinated with the patient at the center. And so yes, one could get chiropractic and acupuncture and go see Dr. Porter all separately. But better, one should get all those services in what I like to call a transdisciplinary model. So it's not just multidisciplinary that we're all sitting in the same room, but we're actually sharing our expertise, coordinating it to find out what actually works for that patient to improve their function and achieve their goals. And better answers can come out of that synergy. Right? Absolutely. Because it's been really the chaotic model up until now. A lot of us think we're sort of in charge and have to find our own paths.  And then if that didn't work, well, I'm gonna try acupuncture because I heard it might work. And it's very chaotic, it's not very coordinated at all. And in the end, the person probably is getting very frustrated because they're independently doing one thing at a time in search of something that maybe we could find in a more coordinated and compassionate way through a clinic like you've heard described. I have a great example of this. I had a back injury a couple years ago with a lower spine injury. And I was seeing my primary care. And then independently I went to see a chiropractor who then referred me to a pain management specialist. And so I was seeing all three of these clinicians at the same time. But fortunately, they had some working relationship with each other already and they were able to kind of have some communication but I can see the value of having all that under one roof. And it was the combination of several different things that ultimately came to a resolution but I can definitely see how that is preferable. So there's two more. One is evidence-based treatment which I think is based on facts and assumptions and results, right? Is that what evidence-based treatment means? Do you want to? No, you guys can start. I don't want to jump in at once. This is a bad one, right? No, it's a good one. It's a great one. But you're referring to evidence-based treatment in a chronic pain person. So bringing other modalities to the table. So what is evidence-based treatment? To be very frank, we have some very strong levels of evidence for some modalities and some gaps in evidence for the others. And I'm saying gaps because it doesn't mean they've been proven to not be helpful. They just don't have the research background, the body of research behind them to show that they could be helpful. And then we have things that I think we could call we're learning from experience. Some already existing clinics at UVM actually that try to deal with more of the mind and body interface and have proven successful in many ways and are gaining their evidence space. And we'd hate to not pay attention to that because they may not have the ultimate randomized controlled trial like a drug for treating cholesterol. Right, cool. Yeah, and I think this is an area where there truly is no template for how to go about this. This will be an area where we learn a lot. We're really curious to see how these disciplines come together and what configurations give us the best outcomes for patients. Is it because the number of patients aren't there to weigh into monitor or like some of the modalities might like acupuncture, I'm not signing up. So I would not be in that study. Is there not enough people who have had acupuncture that could give you the answer? Plenty of had acupuncture but the studies or the funding is not there. It's not there. So our study industry is heavily financed by pharma. Pharma, yes. And so some of these interventions don't have an infrastructure to support their study. And yes, evidence-based classically is randomized controlled trials over large populations. But there is an emerging understanding that we need to actually expand the pool of pragmatic research, look at effectiveness research and focus on outcomes. And so in our relationship with the centers of excellence, our focus is really gonna be on the outcomes and the improvements for those patients regardless of what services are provided. So our intent is to kind of, if you will, pay for it through a bundle and not through a per event payment. Oh, I see, right. Which allows flexibility for Dr. Porter and others to apply the treatments that work for those patients in front of them. It's very exciting, isn't it? And to put this in perspective, if you look at the use of opioids on a chronic basis to treat pain, you will find that the CDC in its guide came out and said there is not an evidence-based to support this being a first-line modality of treatment. Opioids? Opioids. Oh, you would think it was the end-all bill. No, for chronic pain. Oh, really? Not to treat you after your back surgery, but to treat you with a back pain for the next couple of days. Then they gave you the Narcam to go with it. Right, so we're dealing with something that was already widespread, but it was all that people had to turn to quite often. So it was turned to, but it doesn't enjoy the evidence-based we would have wanted it to enjoy. And now we have emerging modalities that are not prescription-written, but that are other modalities of pain management that are needing to have further research to really validate. And they hold a lot of promise of causing much less harm. Yeah, I would think much less costly, some of these modalities. And if you look at insurance, obviously many insurances pay for prescriptions, depending on one's plan, but when it comes to some of these integrative modalities we've been discussing, some are paid for, some aren't paid for, some are paid for by one payer versus another. In the state government, at the Agency of Human Services, we're working with the Centers for Medicare and Medicaid Innovation, CMMI, because they're interested in more comprehensive approaches to the opioid crisis, but also comprehensive approaches to pain management. And they're the first to admit that the current Medicare and Medicaid systems don't pay for things in a way that would encourage their use. And so they're trying to look at ways to enhance the payment for those things, since there's so many large numbers of people dependent on those two insurance pathways, and we're trying to work with them in the same way. Interesting, that's good. Cool stuff. Oh, it's exciting. In some ways you're creating your own evidence-based treatment. And you're, you know, you're- Well, we're certainly looking at outcomes and seeing what helps people move forward. Right, yeah. That's very cool. So we've talked a lot about treatment, different ways to treat, people who are struggling with substance abuse. What are some of the main drivers that would push a patient into relapse while they're in treatment or after treatment? Well, we have unified ourselves here today in regarding substance use disorders as chronic disease, just like diabetes, heart failure, you name it. Right. So our definition of chronic disease is one that the patient will always continue to have, even though we try interventions to try to improve their function and improve suffering, but at the same time, a chronic disease is subject to relapse and remissions. So a diabetic person may be adhering completely to the regimen that you have them on, but they may have done some different things in terms of their level of activity or their diet or the content of their diet that throw their blood sugars off. That would be a relapse in their diabetes, in a sense, and to get to remission, they would have to return to the lifestyle pattern that they had previously and you'd want to explore with them, well, what factors made you kind of go off the wagon here? Why are you eating so much more or exercising so much less and you'd get it to aspects of their life that help determine that and you try to help them repair those? So they may always be in a state of like going for psychological help forever. Right, so someone who had the susceptibility and turned to opioids for one reason or another, but has remained stable for a period of time, will always have that potential. And especially earlier in their course, because we've learned from brain chemistry studies that it takes many months, perhaps as many as nine to 12 months, even when you're on medication-assisted treatment for your brain to kind of get back to the way it was before you developed this problem in the first place. So it physically changes your brain? It really does. So we only have two and a half minutes left. I would just like to wrap it up by what's next? What is your vision of what's the next step here? When you're on the opioid coordination council, they're probably looking ahead. The hub and spoke to me, we're really getting a lot of attention for that model and will that be expanded? What's next? We want it all fixed, quick, right? We're talking next year, right? Yeah, and so, and that's why the opioid coordination council has 23 recommendations, which we're fleshing out and refining better, but 23. But one big one is what we've been talking about today. It's not getting, allowing people to get into this predicament- Well, prevention is what we've always thought about. And powder prevention is having this kind of structure in place so that we can manage pain in a much better way than we may have in the past. So that's one aspect. The hub and spoke is obviously for everybody who has the need for medication assistance, the treatment. The hub, what's in the hub? What does that hub look like? It's sort of like your pain clinic, everything's there? Yes, it is actually a one-stop shopping, if you will. And then they send you to a spoke because specialized? Okay, so the hub is really the complex pain management center if you will, or addiction management center, where you can be inducted into the use of these medications that are so helpful and helping you, but they also provide a lot of this comprehensive support around you, whether it be counseling or case management needs, et cetera. Only, because of federal prescribing regulations, hubs are the only place you can have a methadone prescribed. And so methadone often requires a daily visit, and then the hub is set up to... We have a methadone clinic and a Brufenorfin clinic here in Berlin in my town. That was on the committee that created it. So anyone a methadone will be at the hub for sure. Many people, though, can actually have their opioid use disorder treated as if it were another chronic medical condition in a primary care setting. We call that the spoke. So it's actually transforming the treatment of substance use problems into a chronic disease model, primary care manageable model. Most of those patients will be on buprenorphine, and buprenorphine can be prescribed monthly, and patients will not have to visit that spoke daily. Does they even give it to take home now? Yes. Some forms, if they know you're going to respond. And that is what happens. And there's also access to all the other services that are kind of built into a bundle, as we term it, of care. So that works very well. And it really takes that disease and destigmatizes it. Because when you're sitting in your primary care doctor's office, we don't know if you're there for cold or diabetes or to get buprenorphine. We've actually run out of time. When we had our buprenorphine system here, I was surprised who came to me and said, my son, my daughter. It is people that are well-known in the community, professionals. I was very amazed. They said, we want this. And they're highly functional, folks in recovery are living full lives. Living with a chronic condition. You have your hands full, gentlemen. I really thank you all very much. I've learned a lot, which is always good. As I told you, this is a video. This is series number six in a series of eight videos that we're doing to help Vermonus understand about the opioid crisis. I hope that you will go to the Opiate Coordination Council's website. They'll be done in the next month and June. And you'll have all of the information you ever wanted to know about opioids. Thank you all very much. See you next week. Thank you.


Next Cloud users stay in contact with each other through talk. You can use it for chat, one-on-one and group calls, but also for webinars and presentations. In our previous release, we introduced Recording of Calls. Once the recording is done, you will get notified. The recording is a file shared with you, and if you want, you can share the recording to other participants. The second major feature we introduced was breakout rooms. You can let talk split the room for you, do it manually, or let people choose by themselves. In the breakout sessions, you can discuss and brainstorm, while the moderators can move between rooms. At the end of the discussion, a moderator simply removes the rooms, and everyone is back in the main room. So let's discuss the results of our breakout discussion. I would like to record this session. Now, when I stop the recording, or simply at the end of the call, I get the recording shared with me. Talk notifies me that the recording is shared with me. I can, with one click, share it in the room if I want, but there's more. We demoed our smart picker earlier to easily add a link to a location or a task from deck. We brought the smart picker also to talk, and it can do everything it can do in text and collectives. But you might be wondering, where are my GIFs? Some of you prefer them pronounced as GIFs, but we have them either way. As you can see, talk gained some key features. For our Hub 5 release, we looked again at these features, and how to improve them further. First, when you record a call, you will get a transcript. This is created by an AI, but not by sending your data to a third-party service. It all happens on your server, so no data leaks. A second AI improvement we introduced is translating messages, and again, it happens on your server. With other translation or transcription technologies, you have to send the text and video to a web service, losing control over your data, not with Next Cloud Talk. We are the first to bring chat translation and transcribing of calls all on your server. But there is much more new in talk. Now let's look at the chat and calls more closely. You can now set a custom avatar for a group chat, maybe just an emoji or an image of your choice. By the way, notice that you can now see people typing and convention groups. Isn't that nice? Ah, it seems we have a call. Let's join. We can now also pick a nice background. So let's be on the beach for this call. During editing of documents, you now have the media controls available. That wraps it up. Hub 5 is another big step forward. Next Cloud Talk has all the basics of a powerful chat and video conferencing tool, from breakout rooms to cutting-edge features like AI-based translation. But all this happens on your server. We look forward to hearing your thoughts on Hub 5 and talk.


The title of our sermon this morning is Are You in the Faith? Are you in the faith? This is part three and we are in 2 Corinthians chapter 13 verses 5 through 10. And we've been looking at this text now for a couple of weeks. We come to this third and final week on this text, unpacking this text together. And so far in this text, 2 Corinthians chapter 13 verses 5 through 10, we have focused on the first point of the text, which is Paul's pastoral imperative, his pastoral command to them in verse 5. Examine yourselves as to whether you are in the faith. Test yourselves. Do you not know yourselves that Jesus Christ is in you unless indeed you are disqualified? Now for context, Paul has made two prior visits to the church at Corinth. He's now preparing for a third visit to the church at Corinth. One of the preparation that Paul is now making through this letter involves the Corinthians themselves getting their spiritual house in order. Continued sin in the church, ongoing influence in Corinth of false teachers there, has Paul extremely concerned about their spiritual condition. He is extremely concerned about the condition, the state of this church. As we've also discussed, their sin, the influence of these false teachers has also had a negative impact on the relationship of the church to the apostle Paul himself. Their relationship has become estranged and that is a terrible circumstance to find themselves in. They need the preaching of God's word through the apostle Paul. It's for their good through the efforts of a blistering negative ad campaign, you could say, against the character and ministry of the apostle Paul. His enemies in Corinth have succeeded in planning doubts and ultimately in separating friends.  They look at him with doubt. They look at him with distrust. Paul finds himself in a very unenviable position of having to defend himself and defend his ministry among them. They're putting Paul to the test. You see, they're putting Paul to the test. Look at verse three. They're now seeking a proof that Christ is speaking through him, a proof that he's a genuine apostle, a proof that he actually speaks for the Lord Jesus Christ. Now they ought to know that. Paul spent 18 months with them on his first visit to Corinth. He came again on a second visit. Paul has written now the letters that we know of. This is the fourth letter of those, the second canonical letter. They ought to know better. They ought to know. They know the apostle Paul. But Paul patiently, lovingly, endures their suspicion. He patiently endures their doubt, their criticisms. And he essentially says to them, listen, if you want proof that I'm truly an apostle of the Lord Jesus Christ, then look no further than yourselves. Look no further than yourselves. Verse five, yourselves examine, don't put me to the test, yourselves examine, test yourselves. Do you not see that Jesus Christ is in you? You Paul would say are our living epistle written in our hearts, known and read by all men. Clearly he would say to them, you are an epistle of the Lord Jesus Christ. And who is it? Who is it that ministered that word to you through which you believe, right? Who did the Lord work through to write that living epistle? Paul would say that we are ministers of that living epistle. So then in verse six, I trust Paul says that you will see that we are not disqualified either. Then from the pastoral imperative, given to us in verse five, Paul moves now to a pastor's prayer in verse seven and Paul once again in verse seven wearing his heart on his sleeve. Look at verse seven with me. Now Paul says, I pray to God that you do no evil, not that we should appear approved, but that you should do what is honorable, even though we may seem disqualified. For we can do nothing against the truth, but for the truth, for we are glad when we are weak and you are strong. And this also we pray that you may be made complete. That may seem obvious at the first, but I think it's a point worth laboring for that Paul prays for the church. Paul prays for the church. He faithfully, tirelessly, preaches the word of God to them. He faithfully, tirelessly labors in ministry among them, working for their joy, working for their spiritual well-being. He pleads with them. He weeps with them. He confronts them. He instructs them. He corrects them. He encourages them. He agonizes over the condition of their heart. He weeps over the condition of their heart. He weeps over the state of their soul. He writes this letter. He's written many letters. He labors for them. And all of that planting, all of that sowing, all of that watering, all of that fertilizing is nothing if the Lord isn't the one who gives the increase, right? The Lord must give the increase. Imagine for a moment, the hardworking and diligent farmer. Hardworking and diligent farmer is up early. He labors late by the sweat of his brow until the sun goes down. He can't see anymore to labor. He does the backbreaking work of tilling up the soil, pulling up weeds, throwing out the rocks, furrowing the fields. He walks through the fields casting the seed in the soil. He covers it carefully with earth, cares for the seed. He does all that he can to sow well, does all that he can to sow diligently, right? He tends the field. He drives out the vermin. He scares off the birds that would come in and swoop in and take the seed. He does all that he can in hope and expectation of a harvest. But unless the rains come, he has no crop. John Owen would say that to labor in the Lord's field without prayer is to sow seed at random which will not succeed merely by our sowing. We don't do this in our own strength. We don't do this in our own power. All of our best efforts will come to precisely nothing if the Lord doesn't work in and through them, right? Then we labor and we should be laboring. You find here no excuse for lack of labor. Paul doesn't pray so that he doesn't have to work. Paul works and labors among them and then prays for God to bless his work, right? We're not going to succeed merely by our sowing. We need the Lord to give the increase, right? We can set the kindling on the pile. We need God to rain down fire from heaven upon it, amen? We need to work, but we need to trust the Lord for the results. The genuine, for the genuine disciple of the Lord Jesus Christ who puts his hand to the plow and sows the seed of the gospel. If the Spirit of God doesn't rain down on that work, there's no profit in it. There's no profit in it. All our work, all our labor will not succeed merely by our sowing. It is God who gives the increase. Prayer is no substitute for the work that God has called us to do, but that work is fruitless if we're not relying upon God in faith to work through it, right? So Paul, what does Paul do then? Paul prays. He prays. We need to pray. Right, brothers and sisters? We need to pray. Labor for your brothers and sisters in the church and then pray that God would bless them. When you think about prayer, all the blessings of prayer, it's difficult to be at odds with someone you're praying diligently for, right? Difficult to be hostile toward them or prejudiced against them when you're praying diligently for them. So the Lord uses prayer to knit us together, to cultivate love among us. The Lord uses prayer to make our work fruitful in our ministry efforts as a part of this church. He uses prayer to bless us. We need to pray, right? We need to pray. Paul prays to God for them. Paul's closing the letter. He's bringing it to a close. He's giving them final instruction. He's giving them final warning, giving them final encouragement. And he says, listen, what I'm laboring for, I'm praying for. What I'm laboring for, I'm relying upon God for. So what does Paul pray for? Notice two things from our text. First, he prays for their obedience. Second, he prays for their sanctification. He's laboring for their obedience. He wants them to obey, obey the Lord Christ, right? He's laboring for their obedience. He's laboring for their sanctification.  The two must go together. Our labor is in faith, our labor is in faith. Now notice first, he prays for their obedience and he refers to their obedience in verse seven in two ways, both negatively and positively in verse seven. Look at verse seven. Now I pray to God that you do no evil. That's obedience stated negatively. Don't do evil, right? I pray to God you do no evil. Look also at the end of verse seven, but rather that you should do what is honorable. That's obedience stated positively. Do no kakos in the Greek, evil, but do what is kalos in the Greek, good. There's a bit of a word play there. Do no evil, do rather what is good. He begins by do no evil, okay? Do no evil. Now he references the evil that he was concerned to find among them in chapter 12 verse 20. He's concerned to find among them contentions, jealousies, outbursts of wrath, selfish ambitions, backbidings, whisperings, conceits, tumults. He writes further in verse 21 that he's fearful or concerned of finding among them those who are not repentant of uncleanness, fornication and lewdness. He has in mind a specific experience with the church at Corinth. We have our own sins to be concerned with, don't we? And many of these on this list would also apply to us today. We don't want to find evil in our midst. Do no evil, Paul prays, but rather do what is good, obedience stated positively. The grammar suggests here that Paul wants to find them in an ongoing pattern of doing good. I want you to find, I want to find you doing good, right? Do no evil, but be found doing what is good. The same word used here of good for good is used of a good tree in Luke 6 that brings forth good fruit or in Galatians 6 where we're not to grow weary in doing good. Titus expresses what Paul is praying for here in Titus chapter 3 verse 8 where Titus says, This is a faithful saying. These things I want you to affirm constantly that those who have believed in God should be careful to maintain good works. We are saved by grace through faith. That not of ourselves. It is a gift of God, not of works that anyone should boast. But we are saved to good works that God has prepared beforehand that we should walk in them, right? In Titus, if there's God should be careful to maintain good works, then what should we be talking about doing as a church? We should be talking about obeying the Lord in good works, right? If he wants us to affirm one another of these things constantly, how often should we do that? All the time. Constantly. Right? So I'm not sure it perturbs me the problem that people have today with preaching obedience in the Lord's church. We are to obey the Lord Jesus Christ. How are we to obey him? We're to be diligent, steadfast, abounding in good works, the work of the Lord. What is our responsibility in the church? Good works. Right? Let's take a hint here from Hebrews chapter 10, verse 23, where the writer says, let us hold fast the confession of our hope without wavering, for he who promised is faithful. And let us consider one another in order to stir up love and good works. Not forsaking the assembling of ourselves together as it's a matter of some, but exhorting one another and so much the more as you see the day approaching. Let me ask you, church, let me ask you, have you become complacent in that responsibility? We have a responsibility to serve the Lord. There are good works that the Lord has called us to. They're good, callous, you're useful, beneficial, beautiful, right? They're good works. Our responsibility is to maintain, be careful to maintain good works. Our responsibility in the church is to stir one another up to love and to good works. Not forsaking assembling of ourselves together, but rather assembling together and exhorting one another, stirring one another up to love and good works. Have you become complacent in that responsibility? Do no evil, be found doing what is good. The Lord is going to return. Let us let him find us so doing when he comes. Then Paul adds a qualification to his prayer for their obedience. As we look at this qualification together, consider how important their obedience was to Paul. Consider how important their obedience was to him. What was Paul willing to sacrifice for their obedience? Listen to verse seven.  Not that we should appear approved, but that you should do what is honorable even though we may seem disqualified. In verse six, back in verse six, Paul was hopeful that when the Corinthians examined themselves, the true Christians in Corinth would come to the conclusion from a healthy self-examination that Paul also was genuine, right? That was the point of the self-examination in verse five. But that hope, that desire, the part of the apostle Paul wasn't self-serving. It wasn't self-serving. Paul says essentially here, I'm not praying for you to obey so that we can look good, so that our reputation can be established, right? And Paul says, I'm praying for you to obey even if it means we don't look good. Do you see that in verse seven? In other words, Paul is saying I have no self-interest here. I'm not out for my own reputation. I'm not out for my own name, not out for my own fame. My concern is your spiritual well-being. My concern is your obedience. For the sake of the Lord Christ, for the sake of His church, Paul says, I pray to God, do no evil, do what is good. My concern is your spiritual well-being, your obedience. You have to remember the context here, right? When we think about Paul's reputation being on the line, Paul was being viciously attacked in Corinth by many who wanted to tear down his reputation. And listen, isn't it true? Nobody wants their name dragged through the mud. Nobody wants their name dragged through the mud. It's not easy having your character slandered. It's not easy having your character disparaged or trashed. Some of the most godlessly cruel people are professing Christians who should know better. It might have been understandable under the circumstances for Paul to have lashed out against the injustice of it all, wouldn't it? It was critical. It was critical that Paul had a good reputation among them. Paul wanted the Corinthians to hear him, to heed the message that he was preaching. They needed to listen to him. They needed to trust him. But as important as Paul's reputation was, as important as Paul's good name was, he would much rather have them faithful and obedient to the Lord than his own reputation intact, right? Their obedience more important than his own reputation. Paul surmised that even if he would have to carry on as disqualified in their site, even if he would have to give false teachers the victory over him that they so desperately wanted, even if he had to be humiliated, disparaged, defamed, slandered, or shamed, Paul says it would be worth it if it meant seeing the Corinthians obedient to the faith. I don't care what other men say about me, Paul says. I don't care what other people think. Paul himself was content with being thought of as weak or dishonored or foolish. It's a very small thing, Paul had said, that I should be judged by you or by any human court. That kind of treatment is to be expected for a bond slave of the Lord Jesus Christ, isn't it? All those who desire to live godly in this present age will suffer persecution. And Paul says, I'm not here to serve myself. I'm not here to serve my reputation. Not here to serve my bank account. I'm not here to serve my foolish pride. I only care about what the Lord thinks and I want your obedience to him. Now that's the heart of a faithful minister. It's the heart of a faithful brother, a heart of a faithful sister. Someone who would come to you when you're in sin, who would care not or care less for how they're perceived in your sight than for your own spiritual good.  Someone who loves you in that way. That's a faithful brother, a faithful sister. Listen, we're all called to ministry in the Lord's church. If you're professing to be a Christian, then you are called to labor for the Lord's people in the Lord's church to minister to them. And this is a faithful example of that. Paul laboring among the people of God even to his own hurt, if that's what it took. And it did. He's got the scars on his back to prove it. There's a parallel to this kind of selfless love expressed by Paul and that's found in Romans chapter 9. Turn there with me quickly. In Romans chapter 9, back a few pages in your New Testament, Paul wears his heart on his sleeve. And there's this parallel in Romans chapter 9 to the same kind of selfless, self-sacrificing love that Paul expresses in our texts. It's found in Romans chapter 9 beginning in verse 1, where Paul says here, he says, I tell the truth in Christ. I'm not lying. My conscience also bearing me witness in the Holy Spirit. Paul effectively here is swearing an oath, right? He is deadly serious about what he's going to say. In other words, this is not exaggeration. This is not hyperbole. He knows that what he's about to say is almost unbelievable. Someone might say, listen, you don't know what you're saying, Paul says, I know exactly what I'm saying. I tell the truth in Christ. I'm not lying. My conscience also bearing me witness in the Holy Spirit that I have great sorrow and continual grief in my heart. Why? Because I could wish that I myself were accursed from Christ for my brethren, my countrymen according to the flesh, who are Israelites, to whom pertain the adoption, the glory, the covenants, the giving of the law, the service of God and the promises of whom are the fathers and from whom according to the flesh, Christ came who is over all the eternally blessed God. Amen. In other words, what Paul is saying here, I would accept separation from the Lord Jesus Christ and the torments of hell if it meant that my countrymen could be reconciled to God and eternally saved. That's Paul's love for those that he's ministering to. Paul's love for his own countrymen according to the flesh. That's an expression of love that we see in his heart in 2 Corinthians chapter 13, verse seven, verse eight, verse nine. How important was their obedience to Paul? How important? Paul told the church in Rome in Romans chapter one, verse five, that through him through Paul or through the Lord Jesus Christ, Paul has received grace and apostleship for obedience to the faith among all nations for his name, among whom you also are the called of Jesus Christ. Paul loved these people and it was an expression of love that he called them to obedience and it was an expression of love that he labored so diligently among them and now it's an expression of love that he pours out his heart to God in prayer for them. So husbands, did you say that about your wife? That I want her saved, soundly, safe on the day of judgment. If it were that she could be saved by it, I would gladly accept hell for her. Do you love her that way? Do you love her sacrificially that way? Wives, would you say that about your husband? Parents, certainly you would say that about your kids, wouldn't you? Like wanting your kids to be saved so desperately, Lord, if it were possible, I would gladly go to hell in their place. Do you have any part of that kind of self-sacrificing love in your heart for the people here in this church? Is there some semblance of that? Are the people here for this church? Do you love the Lord's church in that way? Are you committed to the Lord's church with that kind of self-sacrificing love, the kind of love that says, I will very gladly spend and be spent for your souls. It's so easy, so easy to be self-willed, self-interested, self-indulgent, self-absorbed. What does it look like? What does it look like, brother? What does it look like, sister, when you deny yourself for the sake of the Lord Jesus Christ and serve His people?  Paul is willing to sacrifice his reputation, Paul is willing to sacrifice his life, Paul is willing to sacrifice even his salvation, if that would help. The Lord Jesus Christ sacrifices life, and often to our shame, we're not willing to sacrifice our own time, right? It's shameful, the lack of love, the hard-hearted self-indulgence. We can't show up to worship Him with the people of God. Are you willing to sacrifice some convenience? Isn't it worth it? The people of God are here on the Lord's Day. We need to be here with the people of God worshiping the Lord with them. The people of God are here on Sunday night, and the people of God are here on Sunday night worshiping the Lord. The people of God are praying together. The people of God are singing hymns together. The people of God are hearing the Word of God preach to them on Sunday night. The people of God are here during the week, living amongst one another, sharing time together in small groups. The people of God are here praying together. The people of God are here exhorting one another. The people of God are here loving one another. The people of God are here, don't be hard-hearted. Stop forsaking the assembly. Think seriously about your love for the Lord and your love for the people here. If the Lord's work and if the Lord's people are an unwanted intrusion into your life, work or time, and examine your heart before Him. In 2 Corinthians chapter 13, Paul is laboring in love for them. And it's not a light matter to Paul that he would say, I'd rather have your obedience than my good reputation. Do you see? I pray to God that you do no evil, not that we should appear approved, but that you should do what is honorable, even if we may appear disqualified. For, he says, we can do nothing against the truth, but for the truth. We can do nothing against the truth, but for the truth. Even if it might be more expedient for me, Paul says, even if it might be better for my reputation or more profitable for me to appear approved, we can do nothing that would undermine the work of truth, the work of the truth in you, the work of the gospel in your life, the work of the spirit in your life, the work of the Word of God in your life. Paul is saying, I am bound to labor for the effective working of the Word of God in you, even though I may appear to be disqualified myself, right? I can't go against the truth. Paul's object, Paul's aim, Paul's ambition is to see the truth of God at work in them, and Paul's not going to sacrifice that even for his own reputation. I'm not going to labor, I'm not going to work against the truth, but for the truth. He says, I can do nothing against the working of God's truth for your benefit, even if it's to my own hurt. I can only labor for the effective working of God's truth for your benefit. Four, verse nine, we are glad when we are weak and you are strong. Paul was content, even rejoiced in his own weakness. He said in chapter 12, verse nine, he says, most gladly I will rather boast in my infirmities that the power of Christ may rest upon me. Therefore I take pleasure in infirmities, in reproaches, in needs, in persecutions, in distresses for Christ's sake for when I am weak, then I am strong. Paul understood that when he acknowledged and embraced his own weakness, relied by faith upon the grace of God at work in him, he became a conduit or became a pipeline, an instrument of God's power. And that's what Paul took joy in. Paul wanted to be an instrument of God's power. God working in and through him. And so Paul acknowledged and embraced then his own weakness and relied upon God by faith. This prayer is an evidence of that, relying upon God by faith. Paul knew that he would find no joy, no fruitfulness in his own strength. And so Paul owned his own weakness. He would find strength, fruitfulness, hope and therefore for joy in God's strength. So Paul says in verse nine, I'm happy to appear weak if you're strong. I'm happy, I'm content to appear weak if you're strong. Paul knew that if they were strong, that was evidence that God was at work in power through him and Paul would be content with that. Strong here in verse nine is a reference to running strong, right? Strong in the faith, strong in the power of his might. It's a reference to faithful obedience. If you are running strong, Paul says, I'll be glad to be seen as weak. Paul is praying to God again for their obedience. Secondly, Paul prays for their obedience. Do no evil, but rather do that which is good. Secondly, Paul prays for their sanctification. He prays for their sanctification at the end of verse nine. He says, this also we pray that you may be made complete. That word there for made complete is a word used to mean perfect or whole, made perfect. Brought through a building process of putting things in order to the point of having them complete, the point of completion. It was used medically of setting a broken bone or setting something that was out of joint, taking something that was out of joint and putting it back into joint. Restoring it from uselessness to usefulness, right?  God appointed us that we would glorify him. We were made in his image designed by God to reflect his image to bring glory to him. Apart from that purpose for your creation, you are disjointed.   Paul prays that through their salvation and now through a process of sanctification that they would be made whole. They would be restored. They would be made complete, made perfect. This word appears only here in the New Testament but there are passages in the Bible that help us understand what Paul is referring to here. Turn with me to Colossians chapter one. Colossians chapter one. There's a good example here in Colossians chapter one of exactly what Paul is speaking about. If you look at Colossians chapter one, look first at verse three and what do we find Paul doing for them in verse three? Praying, right? Praying. Paul is not self-sufficient. Paul knows where his strength comes from. Paul knows where the fruitfulness is going to come from. Paul is praying, giving thanks to God for what God has done for them through the gospel. Look at verse three. He says, we give thanks to God, the God and Father of our Lord Jesus Christ, praying always for you since we heard of your faith in Christ Jesus and of your love for all the saints. A drop down to verse nine and notice in verse nine what Paul specifically prays for. Verse nine. For this reason, we also, since the day we heard it, do not cease to pray for you and to ask that you may be filled with the knowledge of his will in all wisdom and spiritual understanding. Verse 10, that you may walk worthy of the Lord, fully pleasing him. What is that? That's obedience. Being fruitful in what? Every good work and increasing in the knowledge of God. Strengthen with all might according to his glorious power for all patients and long suffering with joy. Giving thanks to the Father who has qualified us to be partakers of the inheritance of the saints in the light. That's what Paul is praying for. They would be made complete, filled with knowledge, walking worthy of the Lord, fruitful in every good work, strengthened with all might and giving thanks. And what follows this text is a tremendous passage for Christology, right? The person and work of the Lord Jesus Christ. Then as we follow the passage down, follow it with me at verse 24. Paul says this regarding that prayer in relationship to his own work in verse 24. He says, I now rejoice in my sufferings for you, his labor for them, his work for them, the persecution, the difficulty, the adversity that he suffered on their behalf. And he says, I rejoice in that and fill up in my flesh what is lacking in the afflictions of Christ for the sake of his body, which is the church. Not that what Paul was doing for them was in any way atoning for their sin. The Lord Jesus Christ did that entirely and that work is done. But there is work for the people of God that remains for the church. And the Lord intends to do that work through his people. And Paul says, I'm filling up what is lacking in those afflictions of Christ for the sake of his body. I'm going to labor for the church of which verse 25, I became a minister according to the stewardship from God, which was given to me for you to fulfill the word of God. Paul was given a stewardship. Listen brother and sister, you're given a stewardship. I'm given a stewardship. We've been given a stewardship to minister to the people of God in this church and to minister to people out there with the gospel. We also have a stewardship. That's been revealed to us in his word. The mystery, he says in verse 26, which has been hidden from ages and from generations, but now has been revealed to his saints. To them, God willed to make known what are the riches of the glory of this mystery among the Gentiles, which is Christ in you, the hope of glory. Him, we preach, warning every man, teaching every man in all wisdom that we may present every man perfect, complete, whole, sanctified, restored, right? In Christ Jesus. He's praying here and laboring here for the sanctification of God's people. He will labor, preaching Christ, warning every man, teaching every man in all wisdom until all of them are perfect in Christ Jesus. That's our responsibility.  They're perfect. But for all the rest of us here who are not perfect, we have a responsibility to one another, don't we? And my responsibility doesn't end, frankly, when I walk down the stairs. It continues until you're made perfect and your labor of love to me should continue until I'm made perfect. And listen, I'm a long way off. So it's gonna take a lot of work for a long time, if the Lord tarries. Paul says in verse 29, to this end, I also labor, striving according to his working, which works in me mightily. I love that connection. That is Philippians chapter two. Work out your salvation with fear and trembling. Why? Because it's God who is working in you, both the willing to do according to his good pleasure. Paul is praying. Paul knows that the fruitfulness, the blessings come from God himself. Paul knows that that work is going to be done by the spirit of God. But then Paul says it's to this end that I labor, striving according to what Paul? According to his working, which works in me mightily. That's a cause for joy, right? In the life of a believer. To know that when you do the work of God, to know that when you preach the word of God, when you're preaching the Lord Jesus Christ, God in power is working through that word. God in power works in you mightily. To this end, then Paul says I'm going to labor and I'm going to strive. I guess if we don't believe it, we just won't do it. But Paul believes it. And Paul is going to rely upon God and Paul is going to be engaged in that labor for the love of the Lord Jesus Christ and for the love of his people. Look with me at Philippians, Philippians chapter one. Look at another example. Routinely in the New Testament, we see Paul praying for the church. We see Paul praying for the church, relying upon God to do that work in them through his labor, through the preaching of the word of God, through the work that God has called us to do. In other words, God doesn't do that work in absence or in exclusion from our prayers. God does that work through our prayer. God doesn't do that work circumventing his people. God does that work through his people. We are a means through which God accomplishes the work of building up his church. We have a responsibility to join him in that work, right? And to be faithful and to labor and to strive according to his work in and through it. Philippians chapter one, look at verse three. Paul says I thank my God upon every remembrance of you. Paul is praying. Always in every prayer of mine, making requests for you all with joy. Paul is pleading with God to bless these people. For your fellowship in the gospel from the first day until now, Paul has not stopped praying for them, not stopped laboring on their behalf. Being confident, verse six of this very thing, that he who has begun a good work in you will complete it until the day of Jesus Christ. Paul could say, right? Listen, I believe that God who began a good work is going to complete it. And so what does all that have to do with me? I can sit back, I can relax. I don't have to worry about that. God is faithful. If he started that work, he's going to complete it. Paul doesn't think that way. What does Paul think? God has begun a work. God is going to complete it. And so I'm going to jump in there and work for him. I'm going to be a part of that work that God is doing. And I want to be a means through which God completes that work.  He says in verse seven, just as it is right for me to think of this of you all because I have you in my heart, I love you, right? And this is an expression of his love for them. In as much as both in my chains and in the defense and confirmation of the gospel, you all are partakers with me of grace. For God is my witness how greatly I long for you all with the affection of Jesus Christ. And this I pray, do you have any of this heart for the people of God? For this church, for your brothers and sisters, do you love them? Do you love the Lord Jesus Christ this way? Do you love the Lord's people this way? He says this I pray, verse nine, that your love may abound still more and more in knowledge and all discernment. That you may approve the things that are excellent. That you may be sincere and without offense until the day of Christ being filled with the fruits of righteousness which are by Christ Jesus to the glory and praise of God. He's praying for them, praying for their spiritual well-being, pouring out his heart in prayer for them because he loves them, he loves the Lord, he loves the Lord's church, laboring among them because he loves the Lord and he loves the Lord's church. Brothers and sisters, we should live every day in light of that day, right? Approving the things that are excellent, sincere and without offense until the day of Christ living every day in light of that day. If you're not a Christian, if you're not a Christian, if you've never turned from your sin to put your faith in Jesus Christ, then I pray you live every day now in light of that day. That day is going to come in great terror rather than filled with the fruits of righteousness which are by Christ Jesus to the glory and praise of God. If you do not turn from your sin, you do not trust Him alone for salvation, then you will be filled with the fruits of your own unrighteousness in that day. Your condemnation will be to the glory and praise of God. Turn from your sin and trust Him. The Lord offers freely in grace salvation from your sin, salvation from the wrath of God. Turn from your sin. Will you just continue to reject the Savior who offers you that salvation? There's no mystery to this. That mystery's been revealed. You can turn to Him now and forsake your sin and flee to Christ. Paul is praying to that end for those dear people among whom he has ministered, pleading with God to work in Him and through Him mightily for their benefit. So then, Paul having prayed for them, Paul begins to draw this letter, 2 Corinthians now, to a close in verse 10 where Paul says, Therefore I write these things being absent, lest being present I should use sharpness according to the authority which the Lord has given me for edification and not for destruction. Verse 10 in many ways really is a summary of the letter as a whole. These things that he references in verse 10 is referring to the 13 chapters of this letter. These things, this letter, 2 Corinthians, I've written to you being absent, lest being present I should use sharpness. He says, I'm preparing to visit with you. I'm coming for a third visit. And as much as I'm preparing for this visit, Paul says, I want you to prepare for this visit as well. And so I'm writing this letter to you ahead of my visit to give you an opportunity to consider your ways, to consider your sin, and to repent. Paul says, I'd rather not use sharpness. The word means severity. I'd rather not be severe. It's a reference to church discipline, right? We remember, we've discussed the severe letter where Paul rebuked the Corinthians for their unrepentant sin, specifically for not dealing effectively as they should with the false teachers who were gaining a foothold in Corinth. And Paul wrote them a severe letter. This is a reference to church discipline. It's the reference to the authority that's been given Paul as an apostle of the Lord Jesus Christ, an authority that is intended by God for their edification, for their building up, and not for their tearing down, not for their destruction. That's what his authority is to be used for, for their good, for their building up. Paul says, if I come again, as he says in chapter 12, I will not spare. Those who are unrepentant, I will not spare. I'll use sharpness, I'll use severity if I have to. I pray that won't be the case. Paul says, I write these things being absent lest being present, I should use sharpness. And essentially, it's better that I send this letter ahead of my visit so that you can prepare. What will you do? He's asking them, right? What will you do? What are you going to do? I'm pleading with you. I'm pleading with God on your behalf, praying for you. Do no evil. Be found doing good. I want you to be complete. I want you to be made whole in the Lord Jesus Christ. How would the Corinthians respond? That'll be a subject of another sermon. Listen, brothers and sisters, that's our prayer for you. That's our prayer for you. Our prayer to God for you among many things is that you would do no evil. Our prayer for you is that you would rather do that which is honorable, do that which is good. We desire in the Lord that you would be made complete. Be found doing good, brother. Be found doing good, sister. Don't be found in hard-hearted rebellion. Don't be found in cool or even cold-hearted complacency. Don't be found lukewarm, such that you would be vomited out of the Lord's mouth. Don't be found running in the course of this world. Don't be found running in the course of your own self-interest, self-absorbed, preoccupied with your own ambition. Beloved, we have labor to do in this church. We have good work that we have been called to. We have a gospel, the everlasting gospel to preach. There's a good work to be done, be obedient, be zealous, be fervent, be steadfast and abounding in the work of God. Amen. And all praise, honor, and glory to the one who completes that good work in us. Let's pray. As you pray, I'd ask you to go before the Lord and consider your own labor on His behalf, consider the state of your own heart, state of your own soul, and confess sin, repent of sin, trusting Him and pray to the Lord by His Spirit would apply this text to your heart and mind. And then we'll pray together before we're dismissed. Let's pray.