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Opinion: Surgeons give patients too many opioids. A few simple steps could curb excess prescribing

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Opinion: Surgeons give patients too many opioids. A few simple steps could curb excess prescribing

America’s opioid epidemic is as bad as it has ever been. Although the sharp increase in opioid overdose deaths over the last decade is largely attributed to the rise in fentanyl distributed through drug cartels, a startling number can be traced to prescriptions. In fact, the Centers for Disease Control and Prevention estimates that 45 people died each day in 2021 from a prescription opioid overdose — about one-fifth of all opioid-related deaths.

Some efforts to curb opioid prescribing have shown promise, including prescription drug monitoring programs, promotion of alternative analgesics, provider education and informing prescribing physicians when their patients die from opioid overdoses. But there is one medical specialty for which opioids are still a crucial part of most patients’ treatment plan: surgery. Nearly every patient discharged after surgery leaves the hospital in significant pain, which is why surgeons prescribe more opioids than almost any other specialty.

Most patients, however, do not use all the opioids they are prescribed after an operation. That leaves excess pills in circulation and helps fuel the epidemic. If we could get surgeons to prescribe only the number of pills patients need for their own use, this could greatly reduce the number of excess pills available for diversion and misuse, among patients, their families and members of their communities. This, in turn, could reduce addiction and overdoses.

Minimizing how often a surgery patient ends up with extra opioids would not solve the crisis, but it’s part of the solution — and it’s achievable.

Changing prescribers’ behavior is hard. They get set in their ways, moored by a strong belief that what they are doing is best for their patients. Moreover, they strenuously resist attempts to constrain their freedom to decide what is best. Our research team looked to behavioral science for ways to nudge providers to prescribe in accordance with best practices, while leaving them with full autonomy to choose what they think would be best.

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Conventional strategies for curbing excessive opioid prescribing assume that surgeons are rational actors who, whenever they are informed about patient needs and incentivized to attend to them, will act to maximize the welfare of patients. If that were the case, simply educating doctors about the dangers of overprescribing might be sufficient.

However, numerous studies from experimental psychology and behavioral economics have shown that people are highly selective in the information they focus on and more socially minded than traditional models of rational self-interest would predict.

Such insights from behavioral science provide promising avenues for curtailing excessive opioid prescribing by surgeons. For instance, one group of researchers found that setting the default opioid quantity in the electronic health record system to match the amount patients actually use substantially reduces the amount of opioids prescribed. Apparently, busy surgeons tended to go with the flow when prescribing — presumably because the default number of pills became a salient reference point, was easiest to enter and suggested a norm of correct behavior.

Surgeons, like other humans, are social animals who are strongly motivated to adhere to the norms of good behavior endorsed by their peers. We capitalized on this for our recent study, a randomized trial to test two simple interventions across 19 hospitals in Northern California for a year.

In one version, the emails informed surgeons that they had prescribed more pills than other surgeons in their health system had been prescribing for the same procedure. This message highlighted “descriptive” norms of actual behavior. In a second, simpler version, whenever a surgeon prescribed opioid amounts that exceeded recommended quantities for the procedure they had performed, we sent the doctor an email notification informing them. This intervention highlighted “injunctive” norms of ideal behavior.

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Surprisingly, both social norm interventions had the exact same impact on prescribing. Subsequent patients were about 25% less likely to receive an opioid prescription that exceeded the recommended amount. This resulted in about 42,000 fewer pills in the community for the 26,000 patients who were part of the intervention group.

Imagine how many fewer pills would be prescribed if this were scaled up nationwide, given that there are more than 50 million inpatient surgical procedures performed each year in the U.S. Surely this would lead to millions, if not tens of millions, fewer opioid pills circulating in the U.S. each year.

Inexpensive solutions grounded in evidence on human behavior can be powerful tools in our campaign against opioid addiction. Sometimes just a light touch — a tweak to the default settings in the electronic health system or an automated email to surgeons — can have an outsize effect on prescribing decisions with life-or-death consequences.

Zachary Wagner is a health economist at USC and Rand. Craig R. Fox is a professor of psychology and medicine at UCLA and chair of the Behavioral Decision Making Area at the UCLA Anderson School of Management.

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How California's weather — weird, wonderful, catastrophic — shapes the state and its people

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How California's weather — weird, wonderful, catastrophic — shapes the state and its people

Book Review

The California Sky Watcher: Understanding Weather Patterns and What Comes Next

By William A. Selby
Heyday Books: 384 pages, $30
If you buy books linked on our site, The Times may earn a commission from Bookshop.org, whose fees support independent bookstores.

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The winter before last, my wife and I were driving back to L.A. from Mammoth when our car began veering across the lane markers as dust devils rose from the desert floor. We were in an Antelope Valley windstorm.

A barely visible 18-wheeler about 100 yards ahead of us suddenly toppled over. By the time we had crept through the storm, we had counted at least a dozen more semis lying on the shoulder like tipped cows.

What had caused such violent winds? Did we miss any warning signs? Was such strange weather in fact remarkably common?

William A. Selby’s comprehensive account of California’s varied meteorological phenomena, multitudinous microclimates and seasonal extremes, “The California Sky Watcher: Understanding Weather Patterns and What Comes Next,” solves many such mysteries of the climate that creates — and is created by — the state’s landscape and civilization.

Raised in Santa Ana, Selby is a retired Santa Monica College professor who has conducted research for the National Weather Service. His latest book, complete with helpful, dizzying and sobering diagrams and photographs, could easily serve as the text for a college earth science course. It takes a thoroughly empirical approach to California’s four seasons and their manifestation across its myriad topographies.

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Selby demands a lot of his readers from the get-go: In the introduction, he offers a primer on the fundamental physics of atmospheric science, suggesting that most of what follows won’t make much sense without it. Some readers might be unpleasantly reminded of the days when they were graded on their ability (or inability) to grasp such concepts. But those who muscle through the book’s occasional pedantry — often regarding the negotiations between air masses and geographic formations — will gain a better appreciation of the epic forces contributing to California’s alternately eerie, chaotic and idyllic weather. And those most familiar with the state’s unique climate will be more likely to share Selby’s fascinations.

The science here is most compelling when Selby spins thermal columns, updrafts, trade winds and cloud formations into a history of California’s cities and often manmade geography. He tracks an annual winter cyclone pattern from the North Pacific all the way down to Orange County to tell the story of the 1938 flood, the consequences of which are still evident today. Up to 30 inches of rain in less than a week led to more than 100 deaths and a host of flood control measures, an overreaction that paved river channels and obliterated L.A.’s riverside habitats (and didn’t even fix the flooding problem). To this day, we’re still spending money to remove that concrete and restore lost riparian ecosystems.

Selby aims not only to explain the science of the state’s weather but also to demonstrate its ubiquitous influence on our history and society. His examples range from quotidian comedy to bizarre criminality.

He laments, for example, how San Francisco’s summertime fog and swirling winds resulted in four decades of disastrously entertaining Giants baseball, defined by freezing fans and fly balls thrown unexpectedly off course. The franchise relocated from wind-whipped Candlestick Point to a basin shielded by hills in 2000 — and finally started winning championships.

The state’s weather has also influenced its industry, including the less legitimate sectors. In Northern California’s Emerald Triangle, known for its marijuana farms, clandestine cannabis growers have taken advantage of heavy rainfall and dense forests to illegally reroute water courses. The notion might seem comical at first, but these rogues have poisoned natural ecosystems with chemicals and even murdered civilians and bandits perceived as threats.

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Selby thus relates the state’s weather to its people — who may act in accordance with or, more interestingly, in defiance of it — offering respite from the book’s drier passages.

His greatest gift to readers is to reveal the climate as an indomitable equalizer. He consults great wordsmiths such as Joan Didion, Joni Mitchell and Annie Dillard to convey the fear and awe that California weather inspires. Patience and perseverance through the book’s atmospheric science pays off: When Selby concludes, “Earth’s natural rhythms, cycles, and systems will always rule our lives in the long run,” we know just how true this is. And a sky watcher should wax philosophical every once in a while.

In the book’s final chapter, on climate change, Selby juxtaposes early settlers’ primitive or nonexistent means of forecasting the weather with today’s mind-blowing technologies. He notes that although more and more Californians live on disaster-prone terrain, the number of lives lost to weather-related disasters has dropped, thanks partly to the availability of such information. If I’ve ever taken my weather app for granted, I won’t do so again anytime soon.

William A. Selby

Now about that windstorm. A relatively stable air mass blows from southwest to northeast over the Transverse Ranges north of L.A. That air rushes down the northern side of the mountains as if on a roller coaster, reaching such velocity that it drops below its level of equilibrium and blasts across the desert floor. To compensate for this sudden change, the winds loop back toward the mountains and mix with the remaining stable air mass, creating oscillations that animate dust storms.

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As dramatic and frightening as it was to experience, it’s an annual occurrence that wreaks regular havoc across the desert. Fortunately, we made it back safely to L.A. and a windless, 62-degree day in the middle of February. Behold, the Golden State.

Daniel Vitale is a writer in Los Angeles and the author of the novel “Orphans of Canland.”

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Pete Theisinger, who led Mars rover missions for JPL, dies at 78

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Pete Theisinger, who led Mars rover missions for JPL, dies at 78

Pete Theisinger, the longtime employee of NASA’s Jet Propulsion Laboratory who led the Spirit, Opportunity and Curiosity rover missions to Mars, died June 26 after a long illness. He was 78.

During a career at JPL that spanned more than half a century, Theisinger worked on missions to six planets. With JPL colleague Richard Cook, he was named one of Time Magazine’s 100 Most Influential People in 2013 for his work on Curiosity, and he was honored in 2017 with a lifetime achievement award from the Smithsonian’s National Air and Space Museum in Washington, D.C.

Born in Fresno in 1945, Theisinger was from an early age a “consummate engineer,” his family said in a statement. He earned a bachelor’s degree in physics from Caltech and planned on going to graduate school.

A summer job at JPL changed that trajectory. He would stay at the La Cañada Flintridge facility for the rest of his career, save for a three-year stint as a JPL contractor.

As an engineer, Theisinger worked on the 1967 Mariner mission to Venus, the 1971 Mariner orbiter mission to Mars, the 1977 Voyager mission to the solar system’s outer planets and the 1989 Galileo mission to Jupiter.

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He was perhaps best known for his role shepherding Mars rover missions. The twin rovers Spirit and Opportunity launched in 2004 for what were intended to be 90-day missions on the Red Planet.

Both robots far exceeded their initial goals. Spirit lasted six years before getting stuck in a sand trap and sending its final communications in 2010. Opportunity roved the planet until 2018, when communications ceased after a massive dust storm. NASA declared the mission over in 2019.

“His integrity and sense of honesty emanated from JPL all the way to NASA headquarters,” said Rob Manning, JPL’s former chief engineer. “They trusted Pete not to pull the wool over their eyes, to do the right thing and be honest.”

Mere days before Spirit’s scheduled landing on Mars, the engineering team discovered a critical design flaw that could cause the robot to crash upon landing, said Manning, at the time a lead system engineer for the mission.

Manning and colleagues presented Theisinger with a fix that would radically restructure their carefully planned landing. With barely 12 hours to go before touchdown, Theisinger called a meeting and said that as long as the team agreed on the plan unanimously, he would back them up.

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The plan worked. Spirit landed safely, and so did its twin rover three weeks later.

“He stood fast. He didn’t panic. He didn’t let us panic. He made us make the case and took full responsibility for the decision,” Manning said.

Theisinger’s next challenge was Curiosity, the largest and most sophisticated rover NASA had yet sent to Mars. Five times heavier than its twin predecessors, Curiosity required an innovative landing apparatus that had to unfold perfectly over seven carefully choreographed minutes. At the end of the famed “Seven Minutes of Terror,” Theisinger was among those who burst into cheers at JPL when the rover landed safely on Aug. 5, 2012. He retired from JPL in March 2017.

Theisinger is survived by his wife, Dona; four children, William, Peter Jeffrey, Tracy and Kelly; and granddaughter Sienna.

“He raised the IQ in whatever room he was in. Not just because he was brilliant and had a diverse set of interests,” his family said in a statement. “Rather, he made everyone around him smarter because they wanted to be better in front of him.”

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Q&A: Noma chef René Redzepi wants to make insects delicious. In 'Omnivore,' he explains why

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Q&A: Noma chef René Redzepi wants to make insects delicious. In 'Omnivore,' he explains why

Earning three Michelin stars and having your restaurant named the best in the world five times might be enough for most chefs, but René Redzepi has set his sights on something bigger: changing the way we eat.

The fare we take for granted today is at risk on multiple fronts. Climate change threatens all kinds of crops, including the most popular food in the world. Mass production by agribusinesses is marring the environment, while monoculture farming practices are giving deadly pathogens a biological edge. Underlying all these challenges is the persistent pressure to feed an ever-growing global population.

None of this was on Redzepi’s mind when he followed his best friend to culinary school at age 15. He quickly found his purpose, cooking in multiple Michelin-starred restaurants before opening Noma in his native Copenhagen 2003.

In the 21 years since, one thing has become abundantly clear.

“There’s something happening with our environment,” Redzepi said, “and how we produce and grow our food has a huge impact.”

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Matt Goulding, left, and René Redzepi created “Omnivore,” a documentary series on Apple TV+.

(Courtesy of Apple TV+)

That’s the starting point for “Omnivore,” which debuts on AppleTV+ on Friday. Created with his “old pal” Matt Goulding, a food writer and three-time James Beard Award winner, the documentary series raises big questions about the future of food by going deep on eight ingredients: chiles, bluefin tuna, salt, bananas, pork, rice, coffee and corn.

Redzepi and Goulding spoke with The Times about their new show and what they learned about sustainability while making it.

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How did “Omnivore” come about?

René Redzepi: Noma was exploding, and I was being offered all sorts of opportunities. I never had the desire to be on TV unless we were informing the world about how magical and important and delicious food is in a way that would be more like “Planet Earth” than a cooking show or travel show.

It was always on the back burner. Then COVID happens.

Matt Goulding: When René called, it all fell into place. His voice always had that kind of David Attenborough echo to it.

Of course we want to make food delicious and enjoyable, but we also want to understand what it means — not just political or cultural but also the natural world, the biological. All of those elements felt like they could be connected through the vessel of the ingredient.

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How did you pick the ingredients?

MG: We thought about this like a recipe. What are some of the fundamental ingredients you would put at the heart of a recipe — the protein or the carb — and what are the seasonings? That’s why we have an episode on chile peppers. They don’t have an essential role in our survival, but they have an essential role in explaining the human psyche.

RR: For me, we need wheat to stay alive, but we need chile to feel alive.

You highlight traditional milpa farmers in the Yucatan and organic rice growers in India. If techniques like theirs were widely adopted, would we be able to feed everyone?

RR: We need large-scale agriculture to be inspired by traditional ways that have been used for thousands of years. At the same time, you need those ancient ways to adopt some technology that can actually help things move forward.

MG: It’s a question at the heart of the series, and the episode on corn is where we address this most directly. It’s built around the idea of a tale of two corns. One is a giant monoculture Iowa farm, and the other is the milpa, this polyculture system that was the way corn was grown during its rise in Mesoamerica.

What attracted us to the milpa was not just this romantic ideal of ancient wisdom. When you look at studies, you’ll find that polycultures can produce more calories per acre than a monoculture can.

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Monocultures work on a one-dimensional plane — they just use surface area. With polyculture, you’re using using a three-dimensional space to create more food. There’s the crawling vines of the beans, the cover crop of the squash grown below, and the shade being produced by the cornstalks.

The peril of climate change is seen most acutely in the episode about rice. Farmers are so dependent on monsoons, and they’re not behaving as they were in the past.

MG: This single ingredient represents about 20% of the human diet. Figuring out how to continue to grow rice amid this incredible change in our climate is one of the most confounding problems of the 21st century.

Organic farmer Jayakrishnan Thazhathuveetil sows Kuruva rice seeds in Kerala, India.

Organic farmer Jayakrishnan Thazhathuveetil sows Kuruva rice seeds in Kerala, India, in the documentary series “Omnivore” on Apple TV +.

(Courtesy of Apple TV+)

We found JK, a southern Indian rice farmer who was just trying to grow rice for his community. He discovered that all these incredible varieties of rice that he grew up with were disappearing, so he took it upon himself to look for them. Maybe one of them will adapt better to the changing climate.

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RR: Perhaps if we ate more different things, that would also be something that could help. Could we eat more seaweed? Could we eat more mushrooms? Could we eat more legumes? What about bugs? These things have the potential to be mini-staples.

Could we eat more seaweed? Could we eat more mushrooms? Could we eat more legumes? What about bugs?

— René Redzepi, founder and head chef of Noma

Throughout the series, you show how much humans have literally changed the landscape in pursuit of a good bite to eat. Is this necessarily bad?

MG: Food has always been at the sharp end of the globalization spear. It’s been driving a globalized world since the Age of Discovery, looking for spices, trading salts along the Silk Road.

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Sushi chef Takashi Saito guides a knife into a large chunk of bluefin tuna over a cutting board

Master sushi chef Takashi Saito prepares bluefin tuna at his Tokyo restaurant in a scene from the documentary series “Omnivore” on Apple TV+.

(Apple TV+)

Bluefin tuna is a very potent example. What had been a trash fish for the better part of the 20th century could suddenly transform into one of the most sought-after ingredients through the innovation of this one individual at Japan Airlines.

Is this necessarily bad? I don’t think it has to be. There are good ways to do it and there are bad ways to do it. It’s a tough thing to draw a line in the sand.

You seem to have a love/hate relationship with global markets. They make it possible for premium coffee growers in Rwanda to be paid fairly for their labor-intensive work, but they also allow the United Fruit Company to take over big chunks of Latin America to grow bananas.

MG: The United Fruit Company is the classic example of a system that controls all means of production so you can maximize efficiency and profit and get a product around the world. The only thing they didn’t factor in is that you can’t control nature in the long run. This is what we’re seeing with Panama disease and bananas.

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That a banana costs one-fifth of the cost of an apple grown right down the road from you is one of the most confounding things about our food system. But the true cost of that banana — to the workforce, the consumer, and the planet — is definitely much greater.

RR: If we can just make people aware that this is how food works, and make you think about what sort of systems you tap into, that will be powerful. Most people probably have no clue.

MG: When we eat, when we drink, we are voting for some world we want to live in. It’s an incredibly empowering thing to be able to do three times a day.

Did you learn anything while making “Omnivore” that changed the way you do things at Noma?

RR: When we go into Noma 3.0 next year, we will cease to operate as a 12-months-of-the-year restaurant and focus a lot of our attention and skills and team on tackling bigger questions in the food space. One of the projects I’m looking into is this thing that we call Future Staples of Food, which was inspired by a lot of the research we’ve done. I mentioned some of them before — the seaweeds, the mushrooms, legumes, and so on.

What about insects?

RR: For sure. It’s definitely a superfood. It’s unbelievable the amount of calories and nutrition you get. It’s mind-blowing.

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But to change habits and have more things in our diet, we need to make them utterly delicious so that people choose them. Deliciousness is the change factor.

This interview has been edited for length and clarity.

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