Opiate Regulation Policies: Balancing Pain and Addiction

Opiate Regulation Policies: Balancing Pain and Addiction

Good afternoon. We’re going to go
ahead and start, and Commissioner Bharel will
join us when she arrives. My name is Robert
Kinscherff, and I am the current
Senior Fellow in Law and Applied Neuroscience
of a joint program between the Petrie-Flom
Center for Health Law Policy, Biotechnology,
and Bioethics at Harvard Law School. Better? Thank you. The Petrie-Flom Center is
a leading research program that addresses pressing policy,
ethics, and legal issues in the area of health
care and other domains. We are pleased to
be joined today by the Executive Director,
Holly Fernandez Lynch, who is with us at the back. We are also joined by Dr.
Judith Edersheim of the Center for Law, Brain, and Behavior
at Mass General Hospital. The mission of the CLBB is
to understand the implication of rapidly evolving
neurosciences for ethics, law,
and public policy in a variety of different areas. Today’s panel is
one in a series that is put on by the Center for
Law, Brain, and Behavior and the Petrie-Flom Center. And we will be
having another one at the end of this
month that will focus on showing the
documentary film Newtown, and then have a panel to think
about the question, who helps the helpers once an immediate
act or mass act of community violence is over and
we’re sort of managing in with the aftereffects for
individuals for that purpose. We’ve been joined by
Commissioner Bharel. Do you want to take a moment
and catch your breath, and Rita can go first? Or are you ready to
launch into the fray? MONICA BHAREL: I’m
ready whenever you are. ROBERT KINSCHERFF: OK. And I would personally like to
welcome Amanda Pustilnik, who was the inaugural senior fellow
for this joint fellowship in law and applied neuroscience. Professor Pustilnik
is Professor of Law at the University of
Maryland Carey School of Law, where she teaches criminal law,
evidence, and law neuroscience. And her current
research includes work on models of mind in criminal
law and evidentiary issues presented by neuroscience. And so without
further ado, I’m going to have Amanda come
up as moderator and get us really rolling. Thank you. AMANDA PUSTILNIK: Thank
you very much for being here, and in particular,
thank you to our panelists. I’m going to introduce
them briefly, because if I introduce them with
all of their accomplishments, that would take up at least
three times the amount of the full panel time. So we’re very privileged
to have with us today Commissioner Monica
Bharel who is the Commissioner of
the Massachusetts Department of Public Health. And she is in charge of,
among many other things, spearheading the state’s
response to the opioid crisis. Prior to becoming the
state commissioner, she was the Chief Medical
Officer for Boston Health Care for the Homeless, and as
an inveterate underachiever, has served on the faculty of
Harvard Medical School, Boston University Medical School,
and Harvard School of Public Health, and received
her MPH degree through the Commonwealth Fund
Harvard University Fellowship. We’ll be hearing from
Dr. Bharel first. Then it’s our honor to hear
from Dr. David Borsook, who is one of the world’s leading
experts in how pain arises and what can be done about it. He’s a Professor
of Anesthesiology at Boston Children’s Hospital. He’s a core member of the
Faculty of the Center for Law, Brain, and Behavior at
MGH, and the Director of the Pain and Imaging
Neuroscience Group at Boston Children’s Hospital. He also was one of the
first people period to use neuroimaging to
look at what pain is and how the body creates
and process his pain. And then we’ll
move back to policy with Rita Nieves, who is the
Deputy Director of the Boston Public Health Commission. So we’ll be getting
state and city. And also holds a
master’s in public health and a degree in nursing, and
is very much on the front lines of the opioid issues today. I’m going to give you
some very brief framing, not to take time
away from our panel. So you have heard that we
have an opioid epidemic. And we do. We have an opioid epidemic
because we have two epidemics. We have an
overabundance of opioids cheaply available on the market,
both legally and illegally, these opioid painkillers. And on the other hand,
we have an epidemic of undertreated or untreated
chronic pain, chronic pain being the single biggest medical
problem in the United States in terms of both numbers
of doctors visits and associated health
burden from loss of work, loss of quality of life. So how is it that we
both have too many painkillers and too much pain,
and neither is being solved? So we come here at the nexus
of these two epidemics. And the genesis of
the opioid epidemic is related to the
epidemic in pain. So what’s the role
of opioids now? On a typical day in the
US, 650,000 prescriptions for opioids are dispensed. 4,000 people initiate
new use of opioids. Pardon me, 4,000 people
initiate new non-medical use of opioids every day. About 600 people, by contrast,
every day initiate heroin use. So you can see that the
abuse of lawful opioids is multiples of
the heroin problem. And approximately
90 people a day die in the US of an opioid
overdose, approximately 33,000 deaths a year. That used to be almost
entirely prescription opioids. It’s increasingly street
opioids and illegal fentanyl from China. But the prescription component
is very well baked through. And this is a very
unusual epidemic from a legal perspective,
because on the one hand, it shares features with
other drug epidemics that we’re familiar with– crack in the ’80s,
heroin in the ’70s– where there’s unlawful drug
activity that’s causing death and there’s primarily a
criminal justice response. But it also shares
a lot of features with tobacco-related
health problems and tobacco litigations against
manufacturers who have promoted
products possibly being conscious that they
pose an unreasonable risk. And because opioids are
a lawful class of drugs and they can have an important
role in pain treatment, we have opportunities for
regulatory intervention and treatment that may not
have been available in more conventional drug epidemics. And we’ll hear from Dr. Borsook
on the medical aspects of this. And I’ll leave you with one
thought on the manufacturers and how did we
get to this place. There’s a little town called
Kermit, West Virginia. It’s a town of population 400. So what’s that, less than the
1L class at Harvard Law School? In one year, Purdue, the
manufacturer of OxyContin, supplied the pharmacy there,
the 400 people of Kermit, with 500,000 doses of OxyContin. So with that, I’d like to turn
to Commissioner Bharel, who will tell us what
the state is facing and what the state
is doing about it. MONICA BHAREL: Good morning. Where are we? It’s afternoon now. Good afternoon, everyone. Great to be here with you today. And I really
appreciate this chance to be with my esteemed
fellow members on the panel. And Professor
Pustilnik, thank you for setting it up
so effectively. So as we talk today,
I’m going to talk a little bit– there’s so many
different areas we can touch on, and really important, the
legal issues that you just raised. But I’m going to give you an
overview of some of the work we’re doing at the state level. And I want to emphasize
the way that we’re looking at this through
a public health lens, and then we can open it
up and talk a little bit. To frame the issue for you– so some of you may
know a little bit about the work we do at the
Department of Public Health and some of you may not. The Massachusetts
Department of Public Health is the organization
that, really, our mission from our
start and our history has been to protect and promote
the lives of all residents of Massachusetts. And that leads to a broad
array of both regulatory responsibilities as well as
promoting health prevention disease surveillance work. And the Massachusetts
Department of Public Health has an extremely long
history and was really the start of the American public
health movement in the country, starting with the
predecessor of both Rita and myself, Paul Revere,
who was the first president of the Boston Board of
Health back in the 1800s. So as we think about
our broad work, one of the ways we work within
the current opiate epidemic is that the state authority
for opiate services, substance use services, the
Bureau of Substance Abuse Services, sits in the
Department of Public Health. So that becomes a
primary role of us. As I think about
the opioid epidemic, you heard a little
bit about my past. For 20 years in my clinical
work, much of it which was at Boston Health Care
for the Homeless Program, I worked with individuals
suffering from substance use disorder and saw
the ways in which the system worked, and
oftentimes didn’t work, for them. So I bring my clinical
experience to a real desire to improve the way
that individuals cared for with this
medical disease interact with our system. And as I think about
it, I think about it as an opportunity to elevate
the work of the Department of Public Health to what my
goals for our department are, which is for us to
be a national leader in innovative, outcomes-focused
public health based on a data-driven approach
with a focus on quality, public health, and
health care services and an emphasis on the social
determinants and eradication of health disparities. And when we look at
it from this angle– I’ll now put the information
on the opioids in this view. So many of you have probably
seen this information. As we work to make sure that
information and data is more available, we now put
out quarterly reports on what we have available
related to opioid deaths in Massachusetts. So I show this to you– I’ll point out a
couple of things. As you’ll see,
since the year 2000, there’s been over
a 450% increase in the number of opioid-related
deaths in Massachusetts. And if you note, you’ll see
between 2013 and 2014 on, there’s a steep rise in
the number of deaths. And a really
important contributor to that you’ll see
on the bottom is the now presence in our
market of illicit fentanyl. And so fentanyl is
really contributing to this vast increase
in the number of deaths. And as you see, we’re putting
out more and more data. The areas in red there are
areas that we’re predicting– and we validated this tool to
do predictive modeling for cases that aren’t closed yet– to know whether or not they will
likely be related to opioids. And that’s why we’re able to put
out this data more effectively. So as you can see, based
on this information, Governor Baker listed
addressing the opioid epidemic as one of our number one
public health issues. We break the data down
in many different ways to try to really
understand the root causes of this complex
health and social issue so that we can address
it appropriately. And I have multiple examples. I’ve chosen a few to show you. So if you look here, you’ll
see a map of Massachusetts. And this shows not only just the
raw numbers of opioid overdose deaths, but the rates. And I point this out to you
because when you look at rates, you’ll see it’s not
just a problem anymore, opioid overdoses,
of urban centers, as we’ve seen with, as you
heard alluded to earlier, prior substance use epidemics. This is one that, of course, the
high numbers are in the cities. But it’s really a problem
throughout the state. And that’s also another
thing that’s unique. So we have fentanyl in
the picture right now, and we also have the incredible
burden across the state. Look, for example,
at the Berkshires and in the Cape area,
which you may have heard. It’s really disseminated
throughout the state across socioeconomic lines. All communities are affected
and impacted by this. As we think about
this opioid epidemic and how to respond to it, I
want to walk you through what we’re doing at the state level. The governor put together
an opioid working group two years ago when he
first came to office. And having worked in this
area for a long time, I can tell you that one of the
most important things to me about this group was
it was cross-sectoral. So it wasn’t just
medical individuals. It wasn’t just public
health individuals. It was people from the medical
community, from public health, from criminal justice,
from education, individuals suffering from chronic pain,
as well as community members, people in recovery, so on. So we were looking at the
current opioid epidemic from many different angles to
see how we can approach it. And we came up with
65 recommendations and a 19-step action plan. I won’t go through
them all with you. They’re available
at the Department of Public Health website. But I just want to give you a
flavor of some of the things we’re addressing that I thought
might be of interest to you. First, in the area
of prevention, I want to talk about
prevention in two ways. So when you have a
public health model, you have to talk about
primary prevention, right? So there was this question
about prescription painkillers. And we know that with this
current opioid epidemic, more than ever
before, individuals are beginning
their substance use disorder with pain medicines. And whether it’s
theirs or something that they receive
from someone else, that’s a hallmark of this event,
this epidemic that we’re in. And we know from the data
we’ve looked at that 80% of individuals who die from an
opioid overdose– more than 80, really– started with a
prescription painkiller. So that really changes
the focus of how we look at primary prevention
and how we educate around that. The other big
issue that came out as we went and spoke to
individuals across the state was the issue of stigma. And many of you have
heard about stigma related to behavioral
health issues, particularly mental health. But we’re really seeing that
stigma about what substance use disorders are and
how individuals come into the state of addiction
was extremely stigmatizing for individuals
and their families and was keeping them from
getting the care they needed. So we started this campaign. It’s still going on. If you have a chance to join,
hashtag #StateWithoutStigMA. And it’s really about getting
people at the community level to understand substance use
disorder for the medical disease that it is– you might
hear a little bit more about that later– and how it needs to be treated
as a medical disease, not as a moral decision or a choice. And part of this
campaign includes, you’ll see the four
individuals up top, brave individuals
who themselves are in recovery, who talk
about their interactions with the system. And the hashtag
#StateWithoutStigMA is a social media campaign
to try and educate individuals, primary education. The other area that
we really wanted to focus on on prevention
is with the prescribers. So you heard a suggestion
of that earlier. So as a prescriber
myself, how do we make sure that prescribers have
the tools that they need to, of course, be able to treat pain
management when appropriate, but to balance that with the
potential for opioid misuse? And I must say, one of the
most powerful groups that advocated to us and
also to the governor was a group of medical students
from all four medical schools in Massachusetts who
came to us and said, we don’t feel like
we’re trained enough and we get the
education we need to be able to make those decisions
between adequately treating pain and being able to
diagnose opioid misuse. And we’re not getting
trained in that. So what we developed with the
Massachusetts Medical Society in all four medical schools–
the deans were primarily involved in this, and we led
it through the Department of Public Health. And what we came up with
is 10 core competencies– we published it in Academic
Medicine just recently– that we all agreed on would be
taught to every medical student who graduates, so that
they have the education– you might hear about
the pain opioid balance a little bit later on today– so that they start to have
the tools that they need. We then went from medical
schools to dental schools to the nurse practitioner
programs, the PA programs, the community health
centers have all adopted these to make a
uniform way that we educate. So over 8,500
individuals who graduate from Massachusetts
programs as prescribers now get this education. And we are also expanding
that to residents and people already in practice. So just to give you a flavor
of the kinds of things we’re talking about, we are
expecting that individuals will get trained in
how to evaluate pain, how to screen for a patient’s
risk of substance use disorder, how to understand both
pharmacological and non-pharmacological options
for pain management, as well as understanding
substance use treatment options and being able to use
evidence-based patient engagement and pain
management opportunities. And then finally,
to really address the stigma and the social
determinants of health that surround individuals
who are suffering from substance use disorder. So these core competencies
are now taught throughout for all prescribers. In the area of
intervention, I want to bring a couple of
things to your attention. One is the new prescription
monitoring program, which I hope many of you have heard of. It’s a database of all
prescriptions prescribed by prescribers, not
only in Massachusetts but now we can
access information from 28 different states. And it will soon be all of them. So the prescriber has,
again, enhanced tools while they’re sitting
with a patient to add in addition to the
subjective complaint of pain this other information
that they can use as a tool when prescribing. Another intervention
area is naloxone. So unlike other epidemics,
or say chronic alcoholism or crack cocaine, we have
an immediate antidote that if someone is dying in
front of you with an overdose, if you give them naloxone
it reverses that. So it’s really, really
important that we– all of us in communities. People ask me all
the time, what’s the one thing I could do? I would say, make sure in your
communities where you are that this access to naloxone–
many people know it as one of the brand names Narcan– so that when somebody is
acutely overdosing and at risk of becoming one of
those statistics, they can then get naloxone. We have three different programs
for that in Massachusetts and have been a leader in
developing those nationally. Maybe you’ve seen these. This is about make
the right call. It’s really for individuals to
understand our Good Samaritan laws, because what we
found was individuals were helping somebody
with naloxone but they weren’t staying
with the individual. They were worried about their
own legal ramifications, because they either
had something on them or they were with them. So this is an education tool
about the Good Samaritan law. And then to close, in the area
of treatment and recovery, I want to just
tell you that part of the problem with
our treatment system is we don’t have
enough access to beds, so we’re increasing
the access to beds. We’ve worked with the
Division of Insurance to develop guidelines,
because now it’s mandatory to cover the
first 14 days of treatment. We’ve also strengthened
our own commitment to residential recovery by
increasing the rates there. So all attempts to make sure
that the full spectrum of care is available for individuals. And I hope you’ve
heard of the STEP law that the governor signed last
March, Substance Use Treatment, Education, and Prevention Law. This was really a
first in the nation and has been followed by
many other states, some of the prototypes of this. And just to point out
a couple of pieces– there’s always this
balance of how much. I told you about the
medical school intervention, which was all voluntary,
the schools coming together voluntarily to put together and
adopt these core competencies. And this is what we’ve done
in the regulatory angle. So you, I hope, know
there’s a seven-day limit now on first-time opioids. Patients can do a voluntary
non-opioid director. Just like you’d
say, I don’t want resuscitation or intubation. It’s a similar concept. There must be now training done
and screening in all schools– so looking at
primary prevention, and different ways to screen
and pick up individuals. I told you about the naloxone. And then requiring
evaluations in the ED. So this is all part of a
program of trying to make sure that individuals, number
one, understand the risks before they start using. If they’re in
their early stages, we pick them up with
screenings early on. We make sure that
prescribers understand the risks and benefits
of opioid medications. It’s really a
re-learning for us. We have learned things
through the ’90s and such with the promotion of
opioids for pain management. And then as part
of that, putting the regulatory framework
in to limit the amount– so just the sheer number of
opioids out in the community has decreased. I’ll end by telling
you that all of this is done in a framework of
precision public health. Precision public health is
much like precision medicine, where you really target,
in this case, a population. Understand the risks,
and then target your public health
programming and resources to where they’re most needed. And that’s based on, again,
understanding baseline data. So for the first time
ever in Massachusetts, we’re taking information from
all of these different silos and bringing them together
to help us answer questions. Again, on our website you
can find a lot of our results from this. I want to point out
just a couple for you. One that I thought
you’d be interested in– again, for the first
time, we’ve put together information we have at the
Department of Public Health– birth, death rates,
opioid use services, all at an aggregate level– and for the first time put
it together with DOC data. And this graph tells you
all you need to know. If you’re in practice, you
kind of have a sense for this. But this is really proof to show
that, shockingly, when somebody is released from a DOC
facility, their risk of death from opioids is 56 times higher
than the general population. So it’s information,
precision public health data, like this that is
helping us engage with our criminal
justice colleagues in a very different way,
because we have this information to back up our discussions and
start to talk to them about how we can think about an
individual before they’re released so that we can
have a smooth transition into the community. And then finally, as
we look at our PMP, I’d just point your
direction to the part in red. We now mandate use of the PMP
every time someone prescribes opioid, and we mandate
it the first time they prescribe benzodiazepines. And there’s reasons
and data behind this. For example, we found that
if an individual patient has three or more providers
or pharmacies, then their risk of death
from a fatal overdose goes up sevenfold. So we want clinicians
to have that information as part of their judgment
when they’re prescribing. And second, with
benzodiazepines, if an individual is getting an
opioid and a benzodiazepine– like say Valium, for example– their risk of death
goes up fourfold. So we’re trying to use the data
and the information we have to help us put out
intelligent regulations and change health policy
according to the data we have. And finally, I’ll
leave you with this. If you get a chance
to go to this website, this is a localization
view of our data. So you can go to any town
or city in Massachusetts and look over time what the
opioid death rates have been and what the percentage
of individuals using prescription drugs
versus heroin, fentanyl, and other illicits. So I leave you
with that resource. And then I’ll pass it back over. Thank you. [APPLAUSE] AMANDA PUSTILNIK: Really
impressive efforts that the state is making. We’re going to hear
now from Dr. Borsook. We will be taking questions
and talking about some unifying things at the end. DAVID BORSOOK: So
thanks for inviting me. I should probably request
immunity before starting this, but the clinician is put
in a very awkward position with all of this. And I hope the take-home
message is the problem really is not having a national agenda
to look at and get other drugs. There are hundreds of them on
the pharmaceutical counters. The FDA sometimes
doesn’t pass laws to take on other medications
that may be less problematic. And so the physician and the
patient is in a quandary. I mean, I hope you
take home two points. And one is the relative
status of pain and addiction. And the second I’ve
just mentioned, that there’s really no good
treatment for chronic pain. And I’ll give you at least
one slide to look at. And I think it’s
a bit of a copout to push some of our
treatment processes into domains that have no
therapeutic benefit in terms of trials. And of course, it may be
better for the patient, but we are kidding ourselves
that they’re actually getting a treatment
that may be helpful. So to me, the issue is
this relative statuses. If the Ebola virus
was still going on, we would still be sweating it. More patients would be dying. It’s much easier to
understand a dead patient than a patient with
chronic pain who has this silent process
that is affecting them in a tremendous way, and sort
of the suffering in silence. And if you look at what
this country in particular, but also I suppose
France and others, really did for the Ebola virus
was they took on the challenge and they solved it,
and they got rid of it. And there’s a new status. In pain, that has not been
the case, for whatever reason. It can be political. It can be public policy. Sorry. It can be pharmaceutical
interests. It can be all sorts of things. But when you’re sitting
in a chair as a clinician, as I’m sure you guys have seen,
and a patient comes to you and they’re in chronic
pain and they’ve tried 520 different treatments,
not once but maybe twice, what are you going to do? And if you’re a
pain specialist, you may have a few more
tricks up your sleeve. But the average clinician
out there doesn’t. And we had this seminar series
at the NIH consortium on pain, and I happened to chair
one of the sessions related to how do primary care
physicians deal with this. And they really don’t have
any really good [INAUDIBLE] material. And just parenthetically
related to your issue, I taught the Harvard pain
course for a few years. It was one hour, one hour for
the biggest and most dynamic– or one of the biggest
disease entities out there. So this has been
pointed out, that there is this addiction problem. And we know that there
is a pain problem. And the numbers from the initial
Institute of Medicine Report were 100 million people in
the country had chronic pain. And then a much, I think,
more refined report out of NCCIH, National
Institutes of Health, was 25 million or
so had severe pain. So 25 million of us now– and
25 million or more of us later– have chronic pain. And it’s a severe problem. So when you look at
the total numbers of chronic pain, either 25 or
100 million, and its cost– who knows how they
work out these costs. Maybe someone can
educate me on it. But the total cost to
the US is $635 billion, as defined in the
Institute of Medicine. And the opioid epidemic
is around 78 billion. And so it’s very much harder
to say pain is a big problem, because it’s silent
and it doesn’t hit you. It’s similar to if I
have a heart attack now, there’s all sorts of
bells and whistles. An ambulance arrives and
all that kind of thing. But if I have chronic heart
failure, let him get on with it and find his own way. So when you look at the other
domain in terms of suicide– and I’ve been lucky
enough to write a paper on pain and suicide
with Nora Volkow and I at NIDA– the suicide rates in
chronic pain are very high. And we probably don’t
capture them well, because it’s Joe who
walked along the river and jumped off the
bridge because of it or some other kind of thing. But if you look at the
reported prevalence, 5% to 14% of even 25 million. If that’s true,
that’s a real problem. And then if you
look at the issues– and this is actually from down
below here, from this paper by Ilgen. It’s from the VA. I just wanted to make the point
that things that you may not think are bad in pain-related
domains like migraines being up there in terms of
suicide diseases or pain diseases. And so it’s out there. And somehow, we haven’t captured
this as a national issue of, let’s deal with important
things, including addiction. And Igor Elman and I
tried to put together this concept of brain
mechanisms go awry in both pain and addiction. And just to give you
some practical examples, if I was a methadone addict
and I received good treatment and I’m off my methadone and
then you test me for my pain sensitivity years later,
I’m much more sensitive to pain than anyone else. And so when I have
surgery and I’m complaining that Dr. X
is not giving me drugs, it’s because your
brain has changed. And conversely, pain
comes out of nowhere. It is a silent brain
matter at some level. So if I’m depressed and I have
major depressive disorder, 62% of us will have a chronic
generalized pain syndrome– from nowhere, never
having pain before. So our brains can be morphed
into an altered state based on circuitry that exists. And of course,
analgesics attack it. And opioids are well known
to be part of the system, and when given for a long
time, produce a problem. So I just wanted to give you– so you’ll just end me whenever
you’re ready to end me. So I just want to give
you a couple of things on how we look at brain changes,
because I want to give you an example of looking
at the group of patients you mentioned, Joe or Jill
getting a Percocet at a party or whatever. So we can look at the
brain both functionally in terms of its chemistry,
functionally meaning altered brain and connections. And so when these actually get
into a distressed or altered state, the telephone call
from London to Washington no longer works– in other words,
brain area A to B. When my brain is pushed for
wanting and liking in a way that I can’t help
it, when there’s certain parts of my brain where
these connections disappear– and so what is shown
here on this slide is what we call resting
state networks, which are low-frequency networks
that can capture your brain state in health and disease. And it’s been shown across
many diseases to be altered. And then people talk
about gray matter loss in various diseases,
including chronic pain. And don’t think about
it as a neuronal loss, but loss of a tree in the summer
when there are lots of leaves and it’s much more
dense and volumetric, and a tree in the
winter, where it’s gone. And so I’m giving
you actual data, just to show that it exists. But you don’t have
to look at the data. You just need to take
the concepts away. So we took a bunch of very
well looked at patients at McLean Hospital,
where they went through all their addiction profiles. None of them had a
pre-opioid addiction profile. They were all what we called– and there must be
a better term– white-collared opioid addicts,
in the sense that they all had jobs, et cetera. And there are three
major brain changes that were observed in this. And one is gray matter
volume loss in the amygdala. And this is a
quantitative process. So that happens in other
parts of the brain. You can look at it in patients
who come out after surgery and are put on opioids. Their brains are changed
in a similar way. The white matter tracks–
these connections are altered in these patients. And not only
altered, they’re are altered in a way where the
white matter tracks shown in red here are much less robust. Those connections, again,
between London and Washington are not working. And then lastly, in terms
of function– and these are just data sets, but
take the issue away– that the circuits for reward
or wanting are, I want more. I want more, is what the
brain is saying in terms of how these brain systems are. They’re much more
sensitized to that. And so the clinician’s dilemma
are listed in points one through four, and
you can read them. And it’s very difficult.
And it’s very difficult, because it’s hard to
say, sorry, I don’t have anything else for you. It’s also hard to say that in
the context of really knowing, well, opioids have
worked for some. We don’t really know that. The data’s not out there. And so when you look at
the Hippocratic oath– and sort of a sentence
out of it in modern format is defined above. I like this description
about a patient’s journey by Dr. Ling out
on the West Coast as being one of the
leaders in the field, because I think it’s so hard to
understand how people suffer. I mean, I had chronic pain
on my left arm for awhile. And I can tell you that it
was as if the physicians I met did not speak English. There was a language
communication problem in terms of trying to
make this understood. And so at the bottom,
this is where we are, is that frontline clinician
of not knowing what to do. And here’s part of the problem. These are most of the pain
treatment modalities, at least from a pharmacological
point of view. And at the top, you’ll see NNT
and NNH, number needed to treat and number needed to harm. And if you look at the
number needed to treat, they’re not that different. But if you look
at the tricyclics compared with the opioids,
it’s not such a big difference. And so this is an issue that
needs to be taken into account. But at the end of the day, it’s
as if it doesn’t matter what you throw at these patients. But there is data to suggest
that opioids actually can make your pain worse. And the best example
of it is in migranes. If they put in opioids, they go
into a chronic migraine state. And it probably is
true for others. We really don’t have
data in the pain field. And it’s not just
the pain field. It’s differentiating a pain
brain versus a patient’s brain who’s preordained to
the addiction domain. And we just don’t have it. And so the drug data I’m rushing
through this, because I’m being asked to move out of here. And so there have been
mitigation strategies. I just circled the one,
because although it looked like an interesting one
to start with, in fact there’s data to show that
this kind of approach is not very helpful. So again, to the
relative state, there is this issue of the
number of prescriptions. The actual problem in terms
of number of prescriptions for chronic long-term
opioid therapy and misuse are about the same. And so know what
are the resolutions? Well, I think one
of the resolutions is to lobby the government
and pharmaceuticals to do something more dynamic. So basically, if we have
an antibiotic for pain that has specificity
and sensitivity or an antibiotic
equivalent, we wouldn’t use opioids in the clinic. And to me, that somehow is
not in much of the discussion. So thanks for your attention. [APPLAUSE] AMANDA PUSTILNIK: I want
to ask one question, which is the commissioner mentioned
the percentage of deaths and adverse incidents
involving fentanyl. So you were talking about
prescription opioids. Will you just speak for
one minute about fentanyl? DAVID BORSOOK: So there is
this problem of transition from one opioid to another. So for example, what is being
called equivalent units for, say, morphine and methadone
becomes very different if you’ve been on morphine
and then take methadone. And so there are
a couple of papers out in the methadone
field of overdose, with much lower doses of
methadone in patients who had already been on another opioid. And they’ve died in hospitals,
never mind on the street. And so when I saw your
data, it sort of struck me that it’s not the fentanyl dose
that’s normally equivalent. People are probably
misreading it. And it may be an opportunity
to educate addicts that in fact they don’t need as much. AMANDA PUSTILNIK:
Thank you very much. ROBERT KINSCHERFF: So we
appreciate that some of you will need to do a hard stop
at 1:00 to go to classes. We are going to continue
with the deputy commissioner, and we do have some time
after 1:00 for those of you who are able to stay
to have a conversation with the panelists. AMANDA PUSTILNIK: Deputy
Commissioner Nieves will now talk to us about
what Boston is doing and how Boston is
partnering with public and private entities to
address some of these issues. RITA NIEVES: Good
afternoon, everybody. It’s a pleasure to be
here with you today. You’re doing a great job
with time management, so I’d better step it up and
try to cover everything quickly. My name is Rita Nieves. I’m the Deputy Director at
the Boston Public Health Commission, which is the
city health department. And up until a year
ago, I was in the role of director of the Addictions
Prevention Treatment and Recovery Support Services
Bureau within the Boston Public Health Commission. Dr. Borsook asked me
earlier if I like my job. And I said, well, for
the last 20 years, I’ve been working in
addictions services. So I must like
some of it, right? And in my new role, I get
to more indirectly work with issues of addiction. But like I said, for the last
20 years that’s all I did. And today, I wanted to give you
a quick overview of what we’re doing locally and what
we’re seeing locally in the city of Boston when it
comes to prescription drugs and opioid. And quickly, the
Recovery Services Bureau within the Boston
Public Health Commission is one of six
bureaus that we have. We have traditional functions
of a public health department, and we’ve run recovery services
for more than 50, 60 years. So we’ve been in this
business for a long time. And we’ve also been
in the business of providing direct care. So not only do we do
surveillance, we do prevention, but we’ve also been a
direct provider of services. And so know this is
the role the bureau, to coordinate both substance
abuse prevention, treatment, and recovery support services
activities throughout the city. And we do this in
collaboration with, obviously, the Department of Public Health,
who is also the funder of many of the programs and the
services that we provide, both on the prevention
and treatment. These are some of the
services that we provide, just so you have an idea. Our continuum
includes a site that is called PAATHS, Providing
Access to Addictions Treatment, Hope, and Support, which
functions as a treatment on-demand site where anybody
can come in and request to be placed in substance
abuse treatment, or they can request information
about how to get services. We run one of the oldest needle
exchange sites in the state. The name is AHOPE. And the model changed
a few years back, so we’re also a site
for overdose prevention and Narcan distribution
in the city. And we also function
as a drop-in center where people may come in. Everybody who comes to the
program for the most part are active users, and
when they’re ready and if they want
services, we can also help them be placed into treatment. And then we have treatment
and recovery support services. We have two outpatient programs. We have family residential
for women and children. We have transitional and
stabilization support program. We also run a recovery
program for men coming out of jail and prison
that’s called Wyman Reentry. And lastly, we have prevention
and risk reduction services. We’re one of the sites that DPH
funds to do overdose prevention in the city. So we do trainings for active
users, providers, family members, friends–
anyone who wants to understand how
to help someone who’s having an overdose. And we also train
them on how to use Narcan and distribute Narcan. We also have a
mobile sharps team. This epidemic has brought a big
issue with needles showing up everywhere. And when I say everywhere,
I mean everywhere. So about three years
ago, Mayor Walsh gave us new funding
so we could start a team whose job is to go around
the city picking up needles. They pick up needles
from needle kiosks that we have installed in
different places in the city. And while they do that, they
get to identify hotspots, places where we know
active using is going on, and it allows the team to
also connect with people who are on the street
and who are totally disconnected from any services. So it’s multipurpose. And we recently
added a outreach team that covers Melnea
Cass and Mass Avenue area, where I’m sure
you’ve read in the paper we call it Recovery Road. Other people call
it something else. And I won’t mention
the name, because it’s a very stigmatizing name. But it’s an area with a high
concentration of services. And we ended up moving
our two shelters that came out of Long Island. So the outreach team
walks the streets, engages people, responds to
overdoses, distributes Narcan. And they do all kinds of tasks
as they do that that work. So I just wanted to quickly
sure some Boston-specific data that pretty much mirrors
what’s happening in the state. And these are treatment
admissions by drug type. The red line that
you see at the top are prescription abuse
drugs related admissions. When people come into a licensed
treatment program by DPH, they’re asked the question, what
is your primary drug of choice? And then they also
ask them, what’s your secondary, tertiary? So out of that
information, we’re able by city and
by program to be able to determine who’s coming
into the programs and for what other drugs of choice. So the point in this
slide is the red line, like I said, are other possible
prescription abuse drugs. The blue one– and that
includes other opioids. The blue one is
non-heroin opioids. And the point is
that they’re both going down, in Boston at least. I think the state has seen
something more or less that mirrors that. And you’ll see, as I continue
to show you a few more slides, these are the prescription
drugs overdose mortality data for Boston. And there are
three periods here. From 2007 to 2009, the blue
color; 2010 to 2012 is the red, and 2013 to 2015
is the green bar. And as you can see,
the prescription drugs overdose mortality has gone
up in Boston in general from the 2010-2012
period to the 2013-2015. As you can see
here, 7.8 to 15.5. By gender, also has gone up
both for females and males. As you can see, the male
jumped from 10.5 to 21.6. And it’s also going up along
race and ethnic groups. Now, this is a prescription
drug overdose mortality. But now, these numbers– same colors, same grouping,
same domains of gender, race, ethnicity,
overall Boston– as you can see,
without the fentanyl, they seem somehow
stable, especially among whites and males. Boston actually went
down from 7.1 to 6.8. And again, that’s
excluding fentanyl. Now, look at what’s
happening when we look at fentanyl overdose mortality. It’s gone up both in
Boston dramatically, as you can see, from 0.7 to 8.7. And among whites, a big jump. And among males,
and also big jumps. So the commissioner
made reference to this. We’re very concerned
about the contributions that it’s primarily
illicit that we suspect is really contributing
to this increased mortality overall. And again, the amount of,
within the prescription drugs, mortality– how much
we suspect fentanyl is having an impact on. And this is very
clear, how you can see that the blue line is total
prescription drug overdose mortality going up. Between 2013 to 2015,
a sharp increase. But then when you look
at the green line, which is without fentanyl–
just other prescription drugs, no fentanyl included– going down in the
other direction. And then when you look at the
red line in the last two years, that includes all
the overdose deaths. That includes fentanyl going
in the other direction. We are very concerned about
this phenomenon, to the point that we have been looking
at the 2015 data for Boston and seen some drug
overdose deaths associated with stimulants now
with fentanyl in it. So starting to think about
what our conversation with our clients who are using
stimulants should look like, and is there a role now to be
distributing Narcan to people who are using cocaine– that are buying
cocaine on the streets, thinking that they’re
buying cocaine, and having both fatal
and non-fatal overdoses because they’re buying
stuff that has fentanyl. And this is data from our EMS. EMS is part of our city
health department agency. And this is what
we’re dealing with. We get weekly reports from
EMS on their transports. NRIs are narcotic-related
illnesses. And since 2010, you
can see the blue line– that’s the total
amount of transports they’re responding
to that have to do with a narcotic-related issue. And the red are the
times that they have to administer, also going up. The yellows are referred
to the medical examiner. These are people that,
when they respond, the person already is
deceased for the most part. So a couple of things
that I wanted to mention, so you know what
we’ve been doing. Stuff we’re doing
around youth prevention. Stuff we’re doing around
overdose prevention, Narcan administration. Some environmental strategies. Some partnerships
with first responders. And also, some work around
expanding access to treatment. Among the use prevention
strategies we’re using, we started to use a
life skills training. It’s an evidence-based
curriculum for ninth graders. It’s a partnership with
Boston Public Schools. And it has two focuses– one, increasing the perception
of harm related to prescription drug misuse among
students; and one focus around positive
parenting materials that includes tools for
parents to engage children in conversations about
alcohol and drug use. We are in the process
of doing a need assessment around
substance abuse prevention strategies in the city. It’s never been
done, and we wanted to be able to do an assessment
that we could look at what’s our baseline, and
then help us plan very focused strategies
around how we implement some strategies for
prevention of prescription drugs among young people. We have done a ton of training
around overdose prevention. Every week, we train
multiple individuals. These are some of the
things that we cover– how to recognize an overdose,
factors that increase risk for overdose, and how to refer
people to recovery services. We have a video. That’s our YouTube link. And we also have expanded
training for multiple groups. The commissioner
mentioned people who are incarcerated come out
and have a huge amount of risk if they start using again. So we do work with
jails shelters, detoxes. We train mental health
providers, medical providers. We’re doing work
with the business community and public places. We’ve done work with family
and friends for a long time, and also working with public
safety and law enforcement personnel. We have installed drug
kiosks in 12 police stations throughout the
cities to encourage safe disposal of potential
dangerous prescription drugs, and they’re used very
frequently by people. We have done some strategies
to hopefully decrease deaths that we’re seeing in public
bathrooms throughout the city. And that’s the campaign
that we have implemented, training business owners on how
to minimize the opportunities for that to happen. And what to do and
how to train them on overdose prevention
and Narcan use. And by now, all first responders
are carrying Narcan, which was a major accomplishment. It took years for us
to accomplish that, both EMS, fire, and police. And we created this
site so we could really have a low threshold site
where people could just come in and ask for services,
whenever and however they wanted. And we linked it to 311. So now, if anybody
needs anything, they could just call 311 and
we can refer them to PAATHS, and someone can help
them get into treatment. These are some of the ongoing
challenges, as you can see. My time is up. Thank you. [APPLAUSE] AMANDA PUSTILNIK: Thank you
very much, deputy commissioner. Such an informative
presentation. ROBERT KINSCHERFF: Amanda? AMANDA PUSTILNIK: Unfortunately
Commissioner Bharel had to leave. ROBERT KINSCHERFF:
This is being recorded, so you can’t be heard unless
you’re by a microphone. AMANDA PUSTILNIK: OK. ROBERT KINSCHERFF: So what I
was going to suggest to folks– if our panelists
would come up here, and we’ll interact with
folks in the audience who can stay for a bit. When you speak, because
we’re being recorded, you see the little
black plastic boxes along the rim of the table? Just punch the
button at the front as you speak, and the microphone
will be able to pick you up. And Amanda? Take it away. AMANDA PUSTILNIK: Sir? AUDIENCE: So this is a
question for Dr. Borsook. I understand the
perspective of we don’t adequately have mechanisms
for treating chronic pain. But why is the prevalence
of chronic pain so much higher in the
US than anywhere else in rates of disability and
things like that, or at least the data seem to suggest that– certainly, prescriptions of
opioids are hundreds of times higher in the US than they
are elsewhere in the world. DAVID BORSOOK: I
think the first point is that the rates are actually
equivalent in Western society in terms of chronic pain. I don’t remember the tonnage
of opioids imported to the US, but I know in the ’90s it was
like 100 tons or something compared with the UK, where
there was two tons or something or a minuscule amount. And I went through this
transition from no opioid use to using it. What happened was
opioids were used for cancer pain patients and
end-of-life, and it made sense. And then this
chronic pain process was part of new pain treatment
processes at institutions. And opioids looked good. And in fact, I think
we were hoodwinked. And I was part of that group
that, when you put someone on chronic pain on
opioids initially, you may have a good response. And if you look at the Cochrane
data for numbers needed to treat, the real problem
in data that’s come out, some of which I just flash
through, related to how long they are on it for
and their dosing. And just to get a total
dose out of everyone’s mind, anyone in this room can be
put on opioids up to 16 grams or more a day. That’s not the problem. So it’s just how you advance it. And that was a record
for me for a cancer pain patient at Mass General. So the total dose theme
is an interesting concept that hasn’t been worked out,
because if you can give someone 1,000 milligrams a day
and they’re not an addict and they’re pain-free,
few people will argue with that if that works. As clinicians, we
don’t know that. And so it’s like
almost every drug we use that’s been through
pharmaceutical control, placebo– sorry, randomized trials–
the average response is 30%. And what’s beginning
to happen is that people are beginning
to look at responders versus non-responders. So you can get, for Drug A, a
group that responds almost 100% and a group that don’t respond,
and somewhere in between. So how do I know
you’re a responder? And the same theme applies
to the opioid process, where it may be that a certain
percentage of the population make good clinical candidates. We don’t know that. AUDIENCE: This is a
question for Ms. Nieves. One of the big
challenges that sadly you didn’t have time to go into
but is of great interest is the challenges
posed by persons with co-occurring mental health
and substance use disorders. Can you say something
about that and what the city is looking to do? RITA NIEVES: Big,
big challenge for us. I’ll speak about what we know
about females in particular. We implemented a study that
was funded in 2000 by SAMHSA. It was called a co-occuring
study for women. And we were looking at how
to integrate mental health, substance abuse, and
trauma into substance abuse treatment for women. And we found in the study–
it lasted about five years– that up to 80% of the women
that were coming into treatment, both outpatient and residential,
had a history of trauma and had some other
co-occuring mental condition. And sadly, know when clients
were sent our programs– we have people here from one
of our transitional programs in the Boston Public
Health Commission– they were pretty young
individuals, many of them also we co-occurring
conditions come in. And the system is
not equipped to treat both issues at the same,
clearly not under one roof. And people end up having to
be referred to other providers in other systems of care. So that alone is
the first barrier, because there are not
that many places where you can send a person that
is dealing with an addiction and also having mental
illness and having someone who could
treat the whole person in an efficient way. So there are lots of
barriers to care for people with co-occuring conditions. And I think it’s one
of the reasons why we end up seeing
a lot of clients leave treatment early,
and then obviously, being labeled as not being
ready, not being compliant, and not being serious
about their treatment, because their underlying
condition is, really, they’re experiencing lots of symptoms
that treatment programs are not equipped to deal with. And as a result,
again, people are labeled in all kinds of ways. And there’s also
a lot of stigma. If you get to have somebody
seen by a mental health provider and they’re put on some
psychotropic medication, there’s a lot of
stigma attached to why do you had to take all
those fine medications and bring them into
treatment, and are you really benefiting from that as
opposed to just trying to get high on something else? So it’s a major issue. And I think the field
is slowly beginning to recognize it, and
also try to incorporate strategies to respond to
the needs of the clients. AUDIENCE: This
question is for Rita. You showed a lot of
trends that basically looked at mortality rates,
et cetera, by sex, gender, and by race. Have you looked at that by age? My question is really about
specifically on young people. Are you seeing similar trends? Is the problem
greater or smaller? RITA NIEVES: It’s bigger
among the 25 to 44 age group. But we have seen
slight increases in younger people, which
they used to not show up in any significant
way in our data. But we have people
between 18 and 24 that are being really
affected by this as well. And traditionally, they were
not so present in the data. AUDIENCE: And then
my follow-up question is really related to
prevention in schools. Are you confident that
what we’re currently doing is effective or do you think
there’s an opportunity there to [INAUDIBLE]? RITA NIEVES: We are
just getting started. I mean, the Boston
Public Schools– that whole system is
an area that we always wanted to have the opportunity
to work in a significant way. With funding from
the state, we’re beginning to implement
those strategies. But that is such a prime
location for us to be at and to really collaborate. We’re actually hoping that
we get some funding from GE to do some serious work
there in the near future. But we’re not doing nearly
enough to get the kids early on and then intervene
with those that are already experimenting with
both alcohol and other drugs. AUDIENCE: First, I wanted to
echo what you said about– I’m at the Boston Public Health
Commission Transitions Program. I wanted to echo
what you said about the co-occurring disorders. We’ve seen it. I’m an intern, but I’ve
seen it multiple times already in the short
time I’ve been there. And it’s been really, really
difficult, so thank you for bringing that to light. My question is for Dr.
Borsook, and for Rita. I’m curious about the
role that insurance comes into play
as far as funding alternative treatment options. My understanding of it is that
alternative treatments are not accessible, especially
when we’re talking about people of differing SES– socioeconomic status– and
access to treatment as far as from a financial perspective. And so I’m curious what
your thoughts are on that. DAVID BORSOOK: Well,
my basic thought is whatever works should be
given, whether it’s throwing you into the Charles River. But I think if you
want to approach things from a mechanistic
or outcome basis, there is a bit of a challenge. And some people seek
alternative medicine and it does well for them. In general, most of those
processes cause no harm, so it’s a safe place to be. But you raise a huge
point, that basically, unless you have insurance,
you won’t get it. And if you do have
insurance, you may get it. And I think it’s
like everything else. If data comes through that shows
that things work– like CBT is actually one of the few
psychological approaches where there’s good data,
and it’s being applied and we’re seeing good results. So I think that’s
part of the issue. I must say, I see
it at Children’s, trying to get referrals
for psychologists to treat patients. And it’s almost impossible
to find psychologists. And I think a lot
of it has to do with your underlying theme
of, if there’s no money, there’s no treatment– or there’s no good treatment,
or no easy opportunity in terms of access. AUDIENCE: I just
wanted to circle back to the topic of stigma,
and what you think are some suggestions that
you could make about people in their everyday
lives kind of working towards ending the stigma. From a student’s perspective,
we’re planning a forum in May. We have a lot of
interest in this topic. But I’m not sure
that people really know the action steps that
they can start taking. RITA NIEVES: I think starting
from holding yourself accountable and your peers on
how you talk about this issue and how you talk
about people that are dealing with this issue. Words matter. And I mentioned
before that we have lots of services in the Mass
Avenue, Melnea Cass area close to Boston Medical
Center, and we had to start our own campaign
against the people that were calling it the Methadone Mile. And there was
actually a business in that stretch that put a very
nasty sign in their window that was very stigmatizing about
the people that were walking in front of their business. So starting with the
words we’re using to refer to people
who are addicted, and starting from
your own circles. Often, most people that
are in a group like this know somebody who’s addicted
to something or is struggling. And we have a role in making
sure that we’re respectful and that we show some compassion
and some understanding about people who happen to be
struggling with an addiction. I’ve never met anybody who chose
to be addicted to anything, you know? I don’t know if anybody has, but
I never met anybody who said, I want to be right
now on the corner of Mass Avenue and Melnea
Cass asking for money because I need a fix. And I think looking at language
and the narrative we’re using is a good place to start. And it’s a good place
to start education and increasing awareness. AMANDA PUSTILNIK:
It’s a little ironic that these patients
can go to their doctor to get the prescription but
they can’t go to their doctor to get the treatment, because
for other drug-related public health problems, we’ve taken a
moral slash criminal approach rather than fully the
public health approach that so many public
health actors ask for. So this epidemic, in a way,
may present an opportunity to say, well, these people
became medically addicted. It is more consistent,
then, to treat them in a medical narrative rather
than the shame and morality narrative of salvation and sin. Ma’am? AUDIENCE: Yes. My question has to do with
the use of medical marijuana in terms of treating
chronic pain, and both for somebody who
is already addicted perhaps, or I know somebody who
is approaching addiction in their course of
cancer treatment because of the pain
associated with it. DAVID BORSOOK: So
numerous drug companies are looking at
marijuana equivalents. And there’s no question
that cannabinoid receptors are all where pain receptors
and the pain system is. There’s no good
data, but my sense is that it’s a better
deal than opioids. I’ve experienced
the problem of, I don’t know what to do sir
or madam, and they’ve said, well, I’m going
to try marijuana. And obviously, the federal
law proscribes most of us from prescribing. And so I think there is
this issue of alternatives that are much less problematic. There’ve been a few
papers in the field, especially from a
group at Hopkins, where they’ve looked at
very low dose of drugs that we would think
are in the bad domain– the marijuana’s, et cetera. And in fact, in their trials,
at least as I recall them, the outcomes were better than
antidepressants, et cetera, et cetera. So I think there is this
theme brewing, both from NIH and from patient demand, that
these alternatives are not bad. I think the other thing,
just conceptually, if I have a brain or an
addicted brain state, you’re not going to
change it, or you’re unlikely to change
it, in a minute. I mean, there were these
going under anesthesia. And we’ve seen it
for pain patients who have not responded, and
go on ketamine for a week, and similarly for
opioid addicts. And I think they are all
thematic of rapid brain changes. So there’ve been a
couple of reports of ECT making pain brains
better, or individuals, better. But I think you
raise a good point. And I’m not sure
whether my thought is rational in this society,
but there are all these drugs that don’t make it because
one or two patients had severe outcomes. And that’s not good, of course. But it’s a business
decision and not a decision for the betterment of society. So the question really
is, can we push forward other therapies
which may be better than the opioids and maybe
many of the other drugs, and sort of put them out as
orphan type drugs which the FDA actually has a format for? But something needs
to give where– we’re paying an enormous
cost for lack of knowledge. We’re paying an enormous
cost for just letting opioids be out there and
not knowing what to do with them, at least in the
clinic if you’re treating pain. And thematically,
what has happened is that if you come to a pain
clinic now, most pain clinics– certainly, the
academic institutions– may put you on opioids
with your primary, and then they throw you back
to your primary physician, who is probably the least
adept at handling that problem, although they can
now connect with the pain. So the best example
is a colleague of mine who I helped train. He’s now at UC-Davis. And he would say
something like, I will help you manage this process. And they had a very
good team effort. That doesn’t happen
everywhere, where there are experts working
with primary clinicians on a day-to-day,
patient-by-patient basis. And I think that’s
the unfortunate thing. So if I’m out in the
middle of Nebraska or wherever you want to
call it, it’s much harder. I think some of the
data-driven processes that are beginning to occur in
epidemiological studies and some of the
scientific things are beginning to help
coalesce towards a much more rational process. Because a lot of the stuff
that’s gone on recently, including the CDC
recommendations and including the
NIH recommendations, are not totally based,
at least for pain, on a rational scientific basis. And I think it’s a
good start, and I’m sure two government officials
will be here in a minute. But I think that’s the problem. We really are ignorant. I mean, if you said, from
an addiction point of view, just get rid of
opioids in the clinic, would it stop the opioid
addiction problem? No. AMANDA PUSTILNIK: We have
time for one more question. We could talk to
these people all day, but I have to be
respectful of their time and let them go at some point. In the back, Christine? CHRISTINE HUTCHINSON-JONES: Hi. So I’m Christine. I’m the Administrative Director
at the Petrie-Flom Center. And I’d like to build
on actually the last two questions. So talking about stigma,
we talk a lot about stigma around addiction and
mental health issues. And then Dr. Borsook,
you were just talking about how you feel
like a lot of responses to pain aren’t necessarily very rational
or scientifically driven. I wonder how much
the issue of stigma comes into play around chronic
pain and it gets cast– I’m thinking, for
instance, of the fact that I know there’s been
discussion in the press about whether or not fibromyalgia
is a real thing. So issues like that– you’ve made a very good
case that chronic pain is very under-treated
and under-discussed, and I just wonder how much
stigma might play into that. DAVID BORSOOK: Well,
I was at the Deaconess training in neurology residency
when the HIV process broke. And the stigma around
that was enormous. And then science and
marketing came together, and they’re in a good place. We’re in a good
place as society. I think one of the problems
with pain is the following. Where is it where
chronic pain gets stuck? So for patients, 60%
you can treat them. They get better. They’re functionally
in a better place. But for a large group, it
doesn’t matter what you do. It’s like taking epoxy glues
and putting them together. You can swirl it around, and
at some point it gets stuck. And that’s part of the problem. The second part is, I don’t
see anything wrong with you. What’s your problem? And then, oh, I know a whole
lot of migraine patients or whatever, patients
who are doing OK. So it’s this sort of labeling
of subgroups of patients. It’s also this labeling
of, why aren’t you at work? Well, I don’t know if any of you
have or have had chronic pain, but it’s very difficult. There
are two themes that actually happen for me in my training. And I’m embarrassed to tell you
about it, but I will anyway. One was the so-called
battered woman syndrome, rape and what have you, and how it
leads to long-term effects. We’re seeing it now in kids
who have just chronic pain syndromes and they may get
better before their 20s, and then they have
all sorts of problems later, whether it’s
suicide or depression. I mean, it’s well
documented stuff. So the changed brain
syndrome is a problem. We’ve had kids
who’ve got better. They have no pain. And you look at their brains
and they’re not normal. So they are just
waiting for their brains to be put on fire
in some domain. This transition between
anxiety, depression, and pain– they’re very similar circuits. And so I think the
stigma issue is huge. The pain community by and
large has done a good job until this opioid epidemic. And I think it’s hurt everyone,
because clinicians are scared. Patients are also scared,
for the most part. And so the
stigmatization of this has changed the practice
in pain clinics. They don’t take responsibility
for patients in terms of long-term treatments. And so it is a problem. I don’t know if you
wanted to add anything? RITA NIEVES: No. ROBERT KINSCHERFF: So on behalf
of the Petrie-Flom Center and the Center for Law,
Brain, and Behavior, let’s thank our panelists. [APPLAUSE] Thank you very much.

One comment

  1. Authoritarians really don't care if a bunch of decadent spoiled rich kids kill themselves with drugs. In fact, the enemies of the United States want that. Meanwhile is it such a surprise that eliminating the authoritarian Taliban meant that all that opium could be grown again, regardless whether it shipped through corrupt Russia, China, or American hands?

    Really from a NatSec perspective: this is a self-cleaning oven. YOLO!

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