Stanford Health Policy Forum: The Problem of Prescription Opioids

Stanford Health Policy Forum: The Problem of Prescription Opioids


All right. Good afternoon,
everybody, and welcome to another edition of the
Stanford Health Policy Forum. My name is Keith Humphreys. I chair the advisory
group for the forum, which also includes Drs. Mary Goldstein Ann Arvin,
Doug Owens, Dan Kessler, and Rob Kocher. We hold these events two
or three times a year to provide education
and initiate dialogue about the most important health
policy issues of the day, and I think you’ll agree
prescription opioids is certainly one of those. All of the events are filmed,
and you can watch them, if you wish, on
our website, which is healthpolicyforum–
that’s one word– healthpolicyforum.stanford.edu. That’s also where you can
find out about future events. Because we are filmed,
two requests of you. Number one, please
turn your cellphones on when you leave today. [LAUGHTER] And number two, remember the
Questions and Answers session, that will be on the internet. So if you have questions,
that’s fantastic, but please don’t ask them about
personal medical situations, because we can’t guarantee your
privacy once this goes online. These events are all
open to the public and free, and the
only reason we can do that is because we
get excellent support from the office of our
dean, Dr. Lloyd Minor, who’s going to open our
presentation today with his thoughts about
this important issue. Dr. Minor. Thank you. Well, thank you, Keith, and
I want to thank all of you for being here today. And in just a moment,
Keith will introduce our very distinguished panel. I think this is a
extraordinarily timely topic. Practically every week, we read
something in the national press or in the medical press
about issues related to prescription opioid usage. And these issues really
reflect a dilemma that we, as physicians, face,
wanting of course always to bring the best care, the best
compassionate care, the best science, to the benefit
of our patients, and yet also needing
to have knowledge about and respect the adverse
effects that can occur, in certain cases, with
prescription opioid usage when that opioid usage leads
to abuse and leads to a whole host
of other problems. That, compounded with the fact
of patients who need opioids are frequently patients who
also need an incredible amount of our time and utilize the
resources of the medical care delivery system in
challenging ways. So how do we reconcile
that with our need to be looking always for
greater opportunities to deliver more efficient and
effective care to patients? So these dilemmas,
these conflicts, frequently converge
around issues that are brought to the
fore with opioid usage. So it’s a very timely topic,
and Keith and colleagues have assembled a very
distinguished panel. I look forward to learning
from them this afternoon, as we all do. And I’ll turn it back
over to Keith, now, to make the introductions. Thanks for being here. [APPLAUSE] Thanks very much, Lloyd. Now at many of
these events, we’ve brought in an outside guest. But today, we happen to
have had the top experts right here at Stanford,
so I’m proud to say this is an all Stanford
Medical School production. And let me introduce our
distinguished guests to you. On your right is
Dr. Anna Lembke. Anna is an assistant professor
of psychiatry here at Stanford. She heads the Addiction
Medicine Fellowship as well as runs the Addiction
Medicine Clinic. She’s an expert on
addiction, including to prescription opioids. And you may have read
a much-debated article, much-discussed article, she
wrote in the New England Journal of Medicine recently,
about why doctors prescribe opioids sometimes,
even when they know they’re going to be misused. In the middle is
Dr. Sean Mackey. Sean holds the Redlich
Chair in Medicine. He’s in the Department
of Anesthesiology, where he runs the
Division of Pain Medicine. There are not many
things going on nationally in pain
management that Sean does not have a leadership role in. He just finished a
year as the president of the American Academy
of Pain Medicine, and he’s now got a leadership
role in the National Pain Strategy– which I should
mention is now online, if you just google
on that– and that is how the government
is going to approach this issue in the coming years. It’s open for public comment,
you can participate in it, and that it even got to this
point is a big credit to Sean. Our interviewer, as usual,
will be Paul Costello. He’s the head of Media
and Communications in the Medical School,
and he took that role after a long and distinguished
career as a spokesperson for many important figures,
including First Lady Rosalynn Carter. The way we’ll run this is
up to about the hour or so, our guests will
talk, and then we’ll open it up for your
comments and questions. And we’ll have roving
microphones at that point. So please welcome our
panel, and let’s get going. [APPLAUSE] Thank you Dean Minor, and
thank you, Keith Humphrey, and welcome. And welcome, everyone, to
the panel discussion today. How many of you have
suffered from serious pain? So a significant number of
people here, really familiar with it. Let me start with a
question for both of you. And Anna, you wrote
a perspective in 2012 in the New England
Journal of Medicine, and you talked about the
epidemic use of opioids in the US and said that many
instances, physicians are fully aware, fully aware,
that their patients were abusing their meds
or diverting them for other non-medical uses. And you talked about
some of the reasons. And some of the reasons were
really fascinating, I thought. Recent changes in medicine’s
philosophy of pain treatment. Cultural trends in America’s
attitudes toward suffering. And financial disincentives
for treating addiction. And Sean, as Keith
mentioned, you were a member of the Institute
of Medicine’s panel on pain that called for a cultural
transformation of attitudes towards pain and its
prevention and management. It’s said that every
year, approximately 100 million Americans,
100 million Americans, suffer from chronic
pain, a condition that costs the nation between
$560 billion and $635 billion annually. And much of the pain,
the report said, could be alleviated or
better treated and managed. So I want to begin
by asking each of you, what is the common
ground that you share? And what are the gaps? What are the divergences? Anna, why don’t
we start with you? OK Well, let me start by
saying that Sean and I have a lot of common ground. But let me emphasize,
for the sake of making this more interesting,
where we might differ. So the Institute of Medicine
report, Relieving Pain in America, came out in 2011. And in 2011, just by way
of an example of many cases that I’ve seen, I
was asked to consult on a patient admitted to this
hospital for low back pain. And the consult question
was specifically, does this patient misuse
her prescription opioids? Is she addicted to them? So in preparation for
seeing the patient, I looked at the prior
medical records. And what I discovered was
that in two prior hospital admissions, my
psychiatric colleagues had been consulted on
the exact same question. Does this patient have
an opioid addiction? And both of them have
answered that yes, she does, that they would recommend that
the patient be tapered down and off of her opioids
for her pain medication, that non-opioid
alternatives be used, and that she be referred
for addiction treatment. And on both of those
prior occasions, neither of those
recommendations was followed. And here I was being asked
again to see the same patient, and she had an obvious history
of prescription opioid use. In the four or five weeks
prior to my seeing her, she had obtained over
1,200 opioid pills from multiple prescribers. She was also concurrently
injecting heroin. And she had a life that was
ravaged by opioid addiction. So it really made me wonder,
why is this happening? Why am I asked the same question
that my colleagues already answered? Why are the doctors continuing
to prescribe opioid medication to a patient who is obviously
abusing them and addicted to them? And when I went to see her,
the answer to that question became more clear. She said to me, Doctor,
I know I’m addicted. But if you don’t
prescribe me medications that I want for pain,
I’m going to sue you for leaving me in pain. So what that really
told me, and what I think it’s really important
for folks to understand, is the cultural transformation
that the Institute of Medicine report was asking for. Th diseasification of pain,
overcoming our opioid phobia, as it was called,
had already happened. We had already been
fully indoctrinated into not just treating pain, but
essentially overtreating pain. And in that same year
that the report came out from the Institute
of Medicine, the CDC released an unprecedented
report stating that there was an opioid
epidemic in this country. And the numbers
certainly verified that. They based that report
primarily on the number of overdose deaths
due to opioids. It’s now the leading
cause of accidental death in this country. More than 16,000 folks per year
die due to opiate overdose. So this whole cultural
transformation that the Institute
of Medicine was saying that we needed to have
had not only happened by 2011, when the report came out, but it
had spun wildly out of control. And doctors essentially
found themselves trapped in a situation where
they were forced to prescribe, even when they knew the pills
were doing harm to patients, because they were afraid of
being censured by their peers. They were afraid of being sued
for leaving patients in pain. In fact, there
were many lawsuits in the state of
California alone, in which doctors and
nurses were successfully sued by patients because
they did not adequately address their patients’ pain. So that was my major beef
with the Institute of Medicine report, was essentially that
it had jumped the shark. It was old news. There was some
boilerplate language in the report about
opioid addiction. But really, they missed
the opportunity with that. It was their responsibility to
take, to say, you know what? We kind of have a problem
here, and we really need to do something about it. But can’t you have
a problem and also– can’t you have an opioid
addiction epidemic and also have undertreating of
pain at the same time, Sean? So I think you’re going to
hear more of this tension that Dean Minor mentioned. And by the way, let me just
say, up front, thank you for allowing me to be here. Thanks, Keith. Thank you, Paul. Thank you, Dean Minor,
for allowing me to have the best job in the universe. It’s a great place to be. And then also, I
just want to put right up front, in case
anybody’s wondering, I have no conflicts of interest. I have no industry support. I take no pharma industry
money and haven’t for many, many, many years. And as you’re going to hear,
hopefully through here, let me be very clear. I am not pro-opioid. I am not anti-opioid. I’m pro-patient. That’s really what
it comes down to. The Institute of
Medicine report, as we put out in June
of 2011, for which are former Dean Pizzo
was the co-chair of this, recognized this conundrum that
Dean Minor just very eloquently described. And that is that we do have
this epidemic of opioid misuse, abuse, addiction,
overdose, deaths. No question about it. And Anna just gave a
great example of somebody who’s really got into
problems and just really shouldn’t be
on opioids, and they should have weaned down. But at the other
end of the spectrum, we have this knowledge
that we’ve got an epidemic of chronic pain. 100 million Americans, 37%
of the US adult population, half a trillion dollars a year. Running the
spectrum, by the way, from people who self-manage
their chronic pain to people who are cared for in
comprehensive interdisciplinary pain centers like ours. It is a huge
societal burden, one that affects the person,
their family, and everybody. And how do we address this issue
of substance abuse, misuse, and addiction, and also, on
the other hand, knowledge that opioids do remain one of
the agents that are incredibly beneficial for people at
the end-of-life cancer pain, incredibly beneficial for
treating pain after surgery or acute injuries,
and in some people, the data has pretty
clearly shown that in chronic non-cancer
pain, in some people, improves their quality of
life and physical function? And so how are we
balancing that? I’ll tell you, on the IOM
panel, very specifically, we didn’t attempt to address it. And so I appreciate that Anna
feels that we missed the boat. But the reality is, we didn’t
miss the boat, because Congress gave us a very specific charge
not to get on that boat. So we were given
five bullet points. We were there to address pain. We did want to at least slip
in this problem of opioids, but we knew that if we did
go into detail, that one, it would be stricken out
from the IOM, and two, that there’s so much
hyperbole and drama over this, it would have subsumed the
primary message that we were trying to put out in
the IOM pain report, that it is a public
health problem. That there is this issue of the
disease nature of chronic pain, one that I would submit has
not been well-appreciated in our society, and
one that is, I think, been highly beneficial
to our patients. The fact we do need
comprehensive interdisciplinary care, that that care involves
the spectrum of medications, procedures, psychological
and behavioral approaches, physical therapy
approaches– and yes, somewhere in there,
it can also include opioids for the right person. When and how does pain
shift from acute pain to chronic pain? Part of the problem we have
here is with the language. We grew up on this
concept of acute pain and chronic pain, acute
pain being time-limited, ending at three
months or six months, and then chronic
pain takes over. We learn that it’s artificial. At five months and 30 days,
acute pain, and at six months, it’s now chronic pain–
that doesn’t work. What we’re now learning is that
pain exists across a continuum. Not only does exist
across a continuum, but people may
actually be set up before the injury
to be predisposed to get chronic pain. And so we’re learning that there
are mechanisms in place that set someone up before they
ever come to the operating room table, before they ever
get into that injury, before they’re ever
hurt during war time, to develop chronic
pain afterwards. We’re getting a
better understanding of those mechanisms
and those factors. That’s a lot of what the
research that we’re doing here at Stanford, both in the
perioperative period, but also in the clinic. Can you talk about that
set-up from brain imaging? What are you seeing about
how the brain is set up for that pain? And why one individual
over another individual? So we’ve learned that these
vulnerabilities that set people up, whether it be pain
or a substance abuse disorder– we know that there
are vulnerabilities for that as well. What we’re trying
to figure out is are there shared
vulnerabilities, or are they distinct? We’ve learned that at
least in the perioperative, in the presurgical
environment, they seem to have some
degree of separation. So people who have early
childhood adverse events, people who come in with
high anxiety and depression, where we can see actual
brain changes before they come into surgery
that set them up. People who have this
phenomena of catastrophizing– and Dr. Darnall here is the
queen of catastrophizing. Her research is all
focusing on that and trying to prevent it
and treat it and understand the mechanisms– probably
the biggest predictor for people who go on to have
chronic pain after surgery or after a low back pain injury. Anna, I want to– you and
I had an interesting talk a few weeks ago, and you
gave a historical perspective of opioids. And opioids were widely
used for the Civil War, and then in the late 1890s,
there were so curtailment of them, a cut-down on them. If you could give us a
little history of the ebb and flow of opioids, and why
this sudden growth in the 1990s and 2000s? Why this epidemic? Why this hit now? OK, so can I go
back to something that Sean said, though? Sure. Yeah. So Sean, it was interesting
that you commented that the reason the
IOM report didn’t want to address pain
addiction was because of all the hyperbole associated
with the opioid epidemic, or the overdose deaths. But I guess I would
suggest that there’s been some degree of
hyperbole regarding the pain epidemic that we see in this
country, in that the number, the 100 million or 37%
of Americans in pain has been questioned,
and maybe that’s really an exaggeration of the number
of people struggling with pain. The other thing that really
strikes me is that again, one of the missions of the
Institute of Medicine report was the diseasification of
pain, that pain would be identified as its own illness. And that mission has been
incredibly successful. What is really
fascinating to me, just as a cultural
distinction, is that the diseasification
of addiction has gone nowhere, essentially,
although we’ve been battling that since about the 1750s. So that’s just like a really
fascinating juxtaposition, why really, within two decades,
pain has become a disease, and addiction is
still floundering. I have my own ideas
about why that might be. But did you want
to respond to that? I’ll go back for the history. Yeah, I think, very briefly,
the 37%, the 100 million, it’s a real number. It’s actually consistent
with the same percentage that you see in Western
Europe and Australia. We verified the
numbers many times. I know it sounds like a huge
number, 100 million, 37%. But understand that that
number encompasses people who are like my father,
who self-manage, who played a lot
of sports early on, and got beaten up a
lot in those sports, and just suffers in silence. He won’t even talk
to me about his pain. He just kind of
deals on his own. All the way across the
spectrum, to the people who are in end-of-life cancer pain,
and everything in between. And so it’s much like
the spectrum of diabetes. You have people who have
high blood sugar and impaired glucose tolerance, all the
way to the frank disease of diabetes. And so I think that’s where
people get this question. Like they’re thinking
it’s only high-impact pain that we’re talking about,
and that’s not the case. The date on high-impact
pain, probably somewhere between 20 and 40
million Americans is at play. And with regard to the
diseasification, if you will– I hadn’t heard that
term before with pain– we have been pushing that hard. And I’m sorry. I wish we could get
that same message out about substance abuse
disorders, because I’m a firm believer that addiction
medicine, substance use disorders, is a disease. And we need to do a better job
in getting that message out, too. Thanks, Sean. So just to address
your question before, then, throughout
history, opioids have been used to
effectively treat pain. And prescription
opioids– for example, heroin, which was, in the early
1900s, sold over the counter right next to Bayer
aspirin– we have a long history of this kind
of pendulum swing of using opioids, doctors
prescribing them for their patients
for pain, and then it leading to some kind of
misuse or opioid epidemic. And then the government
and other forces cracking down to rein that in. And we’re in a similar cycle
now with prescription opioids. I think I want to make
sure that I do communicate that the whole mission of
treating pain and doing a better job caring for patients
with pain that started in about the early 1980s in this country
was really in response to kind of a groundswell among
health care providers recognizing that we
really weren’t doing a good job treating pain,
especially in the case of death and dying. So this whole pain
movement and trying to get people to more
liberally prescribe opioids came from a
really good place, and it really needed to happen. There were people
in excruciating pain at the end of life who
weren’t getting any relief, because physicians
were terrified of turning them into
addicts– which, of course, made no sense. They didn’t even have
the time to get there. But again, you know, like
everything in medicine, which tends to fluctuate
through wide extremes, that mission of getting folks
to more aggressively prescribe opioids has now– the pendulum
has swung the other way, and now we find ourselves
facing this opioid epidemic. But Anna, haven’t we been
a culture that has said, suck it up. Pain is good for you. Pain builds character. And that’s essentially what
the IOM was trying to get at, is that there’s this
cultural notion that pain is character-building. And you when I had
that discussion before. And you came back with
an interesting retort, that that’s not really
the culture of today. Right. So if you look
historically, actually, across many different
cultures, you will see that both psychological
and physical suffering, historically, have thought
to play some positive role in human experience,
whether it’s kind of a spiritual
transformation, or even 100 years ago
in the medical field, patients being in
pain perioperatively was thought to be good. It invigorated
their immune system. Pain was thought to
accelerate healing. So there was some
positive benefit of folks experiencing pain. In contemporary culture,
that has completely shifted. We do not see any virtue
in anybody being in pain. We really see no
value in suffering spiritually for many folks. We feel like leaving
someone in pain is not only causing them
suffering in the moment, but actually might
potentially lead to some kind of psychic
scar, which might lead to some kind of future pain. The perfect example of this is
post-traumatic stress disorder. You know, if someone experiences
a psychological or physical painful experience, than they
could have a psychic wound and then continue to
experience pain going forward. That’s essentially
a Freudian concept, that somehow in early
development, if there’s some kind of emotional
trauma, it can lead to trauma later in life. So I think that’s one of the big
ideas of contemporary culture that has fed into the
problem of prescription opioid use, this idea that
there is no place for pain, there is no amount of
suffering that is acceptable, that essentially, we all have
to be pain-free all the time. My favorite example
of this is actually on the schoolyard today. We’re so terrified that our kids
will be bullied in any shape or form that now the
predominant form of bullying is to accuse another
kid of being a bully. Sean, take us into the
clinic, if you will, and tell us about the
patients that you see, and the variety of conditions
that they come to you. The desperation, perhaps. Yeah, and give me an opportunity
to respond to that, also. So at the Stanford
Pain Management Center, we’re a major tertiary and
quaternary referral center. What we’ve built here over
the last several years is this really beautiful,
innovative place where we all come together
in a team-based environment, with pain medicine physicians
across all walks of training, from anesthesiologists,
PM&R, neurology, psychiatry, internal medicine, and we’ve
built with pain psychology, with physical therapy, with
dietary, with biofeedback, and we do it in a co-located,
coordinated care model. And we invite other
departments and other groups to come in and work with us. Anna comes in and we
see patients together in a team-oriented approach. And it’s beautiful, and
it’s where the data supports that you get the best care. And I think we do it better
than any place on the planet. The type of patients we see–
it runs the entire gamut. Everybody from the
39-year-old guy who sprained his back in touch
football over the weekend and has an acute disc
herniation, to the person who’s at end of life. Maybe exampled by
Sandra Hyde, who is a young woman
who has given me permission to talk
about her, who had a foot injury in a motor
vehicle accident 10 years ago. Burning, terrible nerve pain. Terrible condition called
complex regional pain syndrome that spread over her entire
foot, and its spread, now, to her upper extremities. It’s taken over her life. But she still works. She works at Walt Disney
World and flies out to see us. And so she came to us
with a large amount of depression and anxiety. We got pain psychology
involved to work with her, physical therapy. We apply different medications. Turned out we never
treated her with opioids. We used nerve pain medications. And it is this
team-based approach that we called for the
Institute of Medicine, that we just called for again
in the National Pain Strategy, that hopefully we will have
an opportunity to comment on, that we think is going to lead
this cultural transformation as we move forward. And just addressing
what Anna said, I appreciate the
perspective that society doesn’t want to have any pain. I’ll tell you, that’s not what
my patients are asking for, generally. They’re not saying, hey, can
you take away all my pain? I can’t handle any pain. For the most part, what they
want is control of their lives back. They want to be able to get
back to doing the things that they were doing that they
can no longer do because pain has robbed them of that. And if I ask them, which is it
that you would prefer to have? Do you want to go back to work? Do you want to spend time
with your family and friends? But are you willing to
do that if you’re still experiencing pain? They’re all going to say yes. So I think it’s somewhat of a
false argument that our society as a whole cannot
deal with any pain. I think this problem that
we got into– in part, I agree with what Anna
said, but I actually have some disagreement
with this. I think it was a perfect
storm and a convergence, in part back in the ’90s,
where there was this greater awareness of pain. Coinciding with that
is the realities back in the ’90s
and early 2000s. We had very few
tools to treat pain. Opioids were probably
the most common. At the same time,
we did unfortunately have some reports that came
out from some physicians saying it’s safe
to prescribe these, and people are not
going to get addicted. At the same time,
we had legislators that were telling
us, hey, you need to pay more attention to this. It is a moral imperative
to treat pain. There were the lawsuits
that were mentioned. There was the pressures. And at the same time,
increasing production pressures on our primary
care doctors, where they’re now having to
see patients, what, five to seven minutes? And so they’re reaching for
the main, the simplest tool that they have
available to them, and a percentage of people
actually do get into trouble. And that was the problem. The good side out
of all of this is that we did an incredible job
in raising public awareness about this problem of pain in
our society, a problem that is growing every year with
the aging of our population, the fact we’re keeping people
alive when they have cancer. Now our treatments for
cancer, by the way, lead them to have chronic pain. That we’re keeping
men and women alive in Iraq and Afghanistan
because of the body armor and the treatments,
but they’re coming back with chronic pain problems. And so we’ve got
this terrible issue. And once again, we need to
have a rational approach to how we’re going to address
the issues that Anna very eloquently described,
but the fact that hey, we got these people out
there that are suffering and can’t work. Well, you mentioned new tools,
and the old tools are opioids. What are the new tools? And how rapidly
are the new tools coming into place,
that opioids will be perhaps the second or
third treatment approach, rather than the first? Yeah. So the tools, if
you think about– you could pick a metaphor. Tires on a car, legs on a table. There’s four or five
of these pillars, which there’s a variety
of different medications. At this point, we probably
have 30, 40, 50 or so different types of medications that
we can use for pain, many that we steal from other fields. So we steal a whole bunch
of meds from the psychiatry field– the tricyclic
antidepressants, the SNRIs. We steal from the neurologists
their antiseizure meds, the cardiologists, their meds. They often work
better for pain then the original reason
they were FDA-approved. We have some great tools
with pain psychology that has been shown
to give people better control of
their life back and address this intersection of
the emotional negativity that’s impacting on pain. Physical therapy
approaches– the science in that is growing
by leaps and bounds. Complementary
alternative medicine approaches– we have
procedures and surgeries. And then what’s
growing more and more is this recognition that
we need to teach patients how to better
self-manage their pain. And they need to be
more empowered to take control of it. And what is that process
of self-managing your pain? What that means is
that what we focus on, very much so, is to try to
identify specific goals. We get people to put
together action plans. And you know, if we
could reduce your pain, what would you be doing
differently tomorrow? What is that you can’t do? And we help them
work towards that. We give them education. We give them skills. So what’s fascinating to
me about what you just said there, Sean, is that
pain doctors are essentially becoming psychiatrists, right? What do they provide? They provide behavioral
interventions, these psychiatric and
mood-stabilizing medications. And so again, I think that’s
really important for us to notice, that if you have
the label of a pain doctor and you’re treating a physical
problem that’s in the body, then great. Insurance companies
will pay for it. Drug companies will
provide drugs for it. But if you’re over here and
you’re a mental health care provider, and you’re trying
to bill an insurance company for a behavioral intervention? Forget it. They’re not going to pay for it. And you get no
support, and especially if that mental health
problem is addiction. That’s a really fascinating
and troublesome problem with contemporary medicine. Well, you mentioned a
specific drug, Suboxone. A few weeks ago you
talked about Suboxone, and that is treatment to
help people get off opioids. And you said that
there’s a catch-22, and that when people
are getting opioids, they get reimbursements from
their health care plans, their insurance plans. But for the drugs that will
help them get off opioids, there is no reimbursement. Right. So the Affordable Care Act, one
of the things the Affordable Care Act says was that you
can no longer discriminate against patients for
preexisting conditions, and you have to treat
mental health conditions, including addiction, on parity
with other physical disorders. But the way that insurance
companies are getting out of having to actually
provide parity is they’re basically making
it so incredibly difficult to prescribe the medications
likes Suboxone that will help take care of these people,
that what you have, de facto, is continued
exclusion of these people from health care. And Suboxone is an opioid. It’s a partial
agonist-antagonist so it fits the lock, but you
can’t totally turn the key. It’s essential for helping
people with these disorders. The data accumulated
over decades has shown that it’s saved lives. If I want to write a
prescription for oxycodone, I have absolutely no trouble
getting the insurance company to pay for it and the
pharmacy to fill it. If I want to write a
prescription for suboxone to treat an opioid
addiction, I’ve got about four pages
of paperwork and about literally three
hours on the phone arguing for why that
patient needs that drug. Again, it’s this total hypocrisy
within contemporary medicine. One of the consistent
criticisms about opioid abuse is who prescribes them, and
the bulk of prescriptions are coming from primary care
physicians, in many cases. And I wonder, Sean, if you
think that physicians are asking their patients enough questions,
especially questions like, are you on diazepines,
benzodiazepines, at the same time? Are physicians who are
giving out prescriptions, are they asking their patients
enough critical questions before they prescribe opiates? No. [LAUGHTER] And so what should
be done about that? Well, we need to all work
better to help the primary care physician. This was called for
in the IOM report. If you look in the National
Pain Strategy that was just released for public
commentary, clearly we talk about how primary care is
playing a central role here, and how pain
medicine physicians, how other specialists, need
to work together to help them. So you know, what do we need
to be doing to help them with the prescribing? One is education. The sad truth is that the
average medical student gets seven hours
of pain medicine education in this country. Vets, by the way, get 40
hours of pain, which is great if you’ve got a dog in pain. Not so good if you’ve
got a loved one. So we need to do better– That’s seven more
hours and 40 more hours than they get for
addiction treatment. Just had to put that in there. [LAUGHTER] There you go. We clearly need to elevate that. We need to do a better
job with the education. We need to help them learn how
to better prescribe and monitor patients who are on opioids. Because we gave them– “we.” Pharmaceutical
companies, others, gave them the tools back
in the ’90s and 2000s, but actually didn’t tell
them how to use the tool. And that’s where we
ran into problems. You were co-chair. You recently released
a report as co-chair of the National Strategy. And the National Strategy was
to release an action plan based upon the IOM report on pain. What are the aspects of that? And is education a
key part of that? Education about the
problem of opioids. Yes, so National
Pain Strategy is this country’s
first strategic plan to address pain in
the country, ever. It is a follow-up to the
Institute of Medicine, which was a blueprint,
a high-level blueprint. This one is actually
putting goals into play across the areas of education,
across reimbursement and service delivery, to
incentivize appropriately for the care of people
in pain, and also to call for more team-based
care and mental health reimbursement. To address public awareness. To address
professional education, to better educate our providers. To collect better data– the
data that we have right now related to pain, and
also to substance abuse, is just terrible. And then also to break
down the barriers that we have with disparities,
and how pain care is not fairly distributed across our country. Is there any evidence that
long-term use of opioids are effective once acute pain
is– you know, the acute pain, is there any evidence that
after the acute period, that opioids are effective
for long-term pain? One has to, first of
all, define long term. But let’s just leave that kind
of open and loose, if you will, for the time being. The two things to
point out– one, there is data that supports
a small but statistically significant improvement in
pain and physical function with the use of opioids. There are also studies
that don’t show benefit. They don’t beat placebo. Two, the other thing
to keep in mind is that for all of the pain
treatments that we have out there, I’m
hard-pressed to point to any of them that show
long-term benefit in patients with chronic pain. Part of it is we just
don’t have the studies that look at them over a period
of one year or five years. So in essence, we are holding
opioids to a different standard than we would any of the
other treatments that we use. At some level, I think we should
hold them to a higher standard, because they do come
with increased risks. But I just wanted to put
some appropriate framing, so you don’t think,
well, put them on all these other treatments,
because these other treatments have got much better data. The reality is, they don’t. I think, though, it’s currently
important to emphasize that there are no strong data
to support the use of opioids for chronic pain. And the reason it’s really
important for the public to understand that is because
in the 1980s and 1990s, a different message was
communicated to health care providers. Basically, was an adulteration
of a small case report that came out in 1986, and
that was just sort of parlayed into this
message that, you know, opioids work for chronic pain. If you don’t get relief
on a certain dose, just keep going up. There was even a quote
that less than 1% of folks will actually become
addicted to opioids. That wasn’t even
based on an article. That was based on a letter to
the editor in The New England Journal. It wasn’t much more than tweet
as when someone commented. So I think it’s important for
us to really emphasize now, so that people understand
that the message that they got originally wasn’t actually
true, and that we don’t really know if opioids help
for chronic pain. And that, in fact, they can
cause enormous side effects that people weren’t really aware
of– one of the side effects being that you can get addicted. And– sorry. And there is actually data. Terry [? Nickels ?]
just presented something within the last year. Did a nice metaanalysis
and showed, once again, a statistically
significant, but not a large effect size,
for reductions in pain and also improvements
in physical function. So the data is out there. The problem that we’re all faced
with is these types of data are assessing populations. They’re not assessing
individual patients. The key that we have
here is to figure out for which patient an opioid will
actually provide sustained pain relief and improvements
in physical function, and for which patients
will they not. And for which patients that
if you give them an opioid, they’re going to run into
the problems, just like Anna opened up with in the
beginning of this talk. You mentioned previously
depression, anxiety, the emotional triggers. And can you talk
a bit about, more, the emotional triggers to
pain and how they interact? So pain, by its
very definition, is an unpleasant sensory
and emotional experience. It is part and parcel–
the emotional context is part and parcel of pain. And it turns out this
emotional context shares the same circuitry in our
brain, the same wiring, as things such as anxiety and
depressive symptoms and stress, and this concept
of catastrophizing. And so for many of you–
I saw some hands go up that you have chronic pain. And I bet if I asked if you
had any loved ones that have, many more hands would go p. And if you, yourself,
or your loved ones say, hey, I’m feeling
particularly stressed today, I didn’t get a
good night’s sleep, I’m angry with my spouse or
my boss, your pain will go up. You were wired to
have that happen. It is built into all of us. And so that’s a large part of
what we try to treat people, is helping them
to recognize that, to help them learn how
to take control of that. So that will both
reduce their pain, but more importantly,
get them engaged in more of a rehab approach. You mentioned a term,
Anna, that I had not heard before when we
met– opioid refugees. What are opioid refugees? So opioid refugees
is a term that’s being used to
describe patients who have been on opioids
for many years, prescribed by a doctor for a
diagnosed pain condition, who now in the wake of the highly
publicized prescription opioid epidemic can
no longer obtain those opioids from
their doctors, because their doctors are so
terrified now that they’ll be accused of
being drug dealers, that they essentially
have cut these people off. So these people literally are
wandering around like refugees, trying to find a
doctor to continue to prescribe their
opioid pain medications, and encountering a lot
of problems in doing so. So again, it speaks
to that pendulum swing that we see so often in
medicine, where we overdo it either in one
direction or another, having great difficulty
finding that happy medium. I guess also along the
lines of a opioid refugees, I think it does speak
to the complexity the doctor-patient dynamic
that occurs around this issue. You know, doctors essentially
self-identify as being healers. Most of us go into the
business because we want to alleviate suffering. We tend to believe our patients. We’re trained to do so. But in the very
difficult dynamic of the patient who’s
drug-seeking and likely deceiving us in order to
get pain medication, what we experience is
a lot of anxiety that we may not even be
consciously aware of. And in the face of
that anxiety, we regress and engage in
primitive defense mechanisms like denial, where we
sort of tell ourselves the problem isn’t really
happening, and continue to write the prescription. And the other form
of primitive defense is essentially the
narcissistic rage. So we experience
narcissistic injury because we realize
that we’re not actually engaging
in healing, which is our core professional identity. And then we become
rageful at these patients and essentially kick
them out of our offices and say, I don’t ever
want to see you again. What needs to happen
is a frame shift, so that doctors conceptualized
that people who are misusing and addicted to
prescription drugs have a chronic illness,
a relapsing and remitting chronic illness, that
we call addiction. And instead of kicking these
patients out of their office, they need to put prescription
drug misuse, overuse, or addiction on
their problem list and find ways to help
patients treat it, so that we can avoid this
problem of opioid refugees. In your New England
Journal Perspective, you also mentioned
something that I found pretty
fascinating, is that as the ratings for
physicians increase, the fear of not prescribing
opioids increases also. What’s the correlation there? Right. So you know, again,
that gets back to the fundamentals of the
doctor-patient relationship. So what I was taught,
and what most of us were taught, in medical school
is that the relationship is defined as follows. It is my job to try
to heal the patient. It is the patient’s
chart to try to recover. And what we have
is gratitude within an intimate relationship. Today that is
fundamentally different, although we try to
deny like it’s not. Essentially I, as a
physician, am a provider of goods and services. My patient is a customer. And this is not a relationship. It’s a business transaction. In the place of gratitude,
I have patient satisfaction surveys. And they’re not just
patient satisfaction surveys that I will see. They will go out to the public,
as Stanford is now doing. Or maybe the patient
will go on Yelp end and criticize me there. And in fact my 11-year-old
son was surfing the internet the other day, looking
for I don’t know what. And he said, Mom, is this you? And I went in and I
saw, and there it was. One out of four stars. “The
worst doctor I’ve ever seen.” So you know, talk about
a narcissistic injury. That’s pretty–
that’s pretty bad. She’s an incredible doctor. He’s so good. He, actually– you know, I’m
really hard on him today, because you know,
I’m like, you know, I’ve got to be hard on him
and I know he can take it. But I have to say, I do want to
say that Sean’s pain clinic was really at the forefront of
recognizing the opioid abuse problem and doing
something about it, like having addiction medicine
specialists come and also evaluate patients. So I’m being hard on
him today, but in truth, like all of Sean’s career,
he’s really a maverick, and he’s ahead of the curve
with all of these things. Thank you. Talk about why it’s
important to be a maverick. [LAUGHTER] Why is it important in the
field of pain to be a maverick? Well, I think that being here
at Stanford, that kind of comes part and parcel, doesn’t it? I mean, we’re not playing
in the junior varsity. This is the Olympic level. It’s either go big or go home. That’s healthy
narcissism right there. We all have it. [LAUGHTER] You know? I mean, I got to
tell you, all we think about every day
is just how are we going to do it better? You know, there’s a
clear sense of where things are going to go in
society, from a medical care standpoint. We’re working to innovate,
to push the envelope. The area on patient
satisfaction, just kind of bringing back
to that, clearly a hot topic issue. CMS is changing reimbursement
from whether patients are happy. There’s a lot of concern as
to whether we’re unintendingly creating a situation
which physicians are prescribing opioids
just to keep people happy. It’s been a concern in
the emergency department. It’s a concern in the primary
care and in the pain clinics. So you asked about
being a maverick. What did we do? Well, let me be very clear. I got the data from
Press Ganey, who’s the major company that surveys
all the patient satisfaction. And it was either 4
or 12 million patients in the country. And guess which is
the lowest specialty in patient satisfaction
across the entire country. Pain management. Pain management. And it turns out it’s
not that much lower. It’s only a few
percentage points. But it’s significant. And we’re all fighting over
these few percentage points. So what did we do? We developed our own open
source, open platform model to capture patient satisfaction. And so what we can do is we can
capture patient satisfaction after they leave the
clinic, and we also have an open source
platform for capturing all the patient characteristics. It’s called CHOIR–
Collaborative Health Outcomes Information Registry–
where we deeply capture physical, psychological,
and social functioning. And so now what we can
do is we can predict, before somebody ever
comes into the clinic, who’s going to give us poor
patient satisfaction scores. And so– Don’t see those people. No, I’m kidding. No, see, that’s the thing. That’s the obvious thing. People say, well, get
rid of the haters. No! No, don’t get rid of the haters. These people have unmet needs. Yes. So what we do is we hired care
coordinators, care managers, who are actually going to be
tied in with those people, to now hold their hand and
address their unmet needs. And we’re testing the theory
right now that we can actually change that satisfaction
by giving them better care. So that’s how–
that’s just one way that we’re trying to
push the envelope here. And we’re giving it
all away for free. I wondered if each
of you would just think for a minute about
what is the greatest hope and optimism that there
is for your patients out there? Sean, when you talk to your
patients about recovery, and recovering from
pain, and treating pain today and tomorrow
and in the future, what do you tell them
are the greatest advances to look forward to? We all want a day
when we can, I think, fulfill what President
Obama described in his State of the
Union address, this call for precision medicine. So right now, the sad
truth is that despite doing this for 15 or more years,
for a given patient, a given condition, I’m right about
40%, 50% of the time. And that’s actually
pretty good in our field, and in other medical fields,
it’s about the same percentage. And so it’s this very laborious,
frustrating for the patient, frustrating for
us, trial and error process to put a person through
all these different treatments until we find something that
works for them, that ultimately improves their quality of
life, physical function, reduces the pain. We want to get to
the point where we develop this true model
of precision medicine, where for a given person, for a
given painful condition, we can say with a high
degree of likelihood it’s going to be this
set of treatments that’s going to get your life back. That’s what we’re
working on here. That’s what we’ve been
developing the tools through our outcomes platform,
through the basic science research that’s done
here at Stanford, through the translational
and clinical research. And that’s what I describe to
patients that gives me hope, is where this is
all going to end. On top of that, when I
think about the other side of this coin, recognize that the
vast majority of these patients got there through an
injury or through surgery. And so the key is how
can we prevent this? This is a public health problem. This is a public health problem. We need, ultimately,
a vaccine for pain. Now, we’re a long way
from getting there, but we need to be able to
identify those people who are going to be
vulnerable to getting chronic pain after surgery
or after an injury, and we need either
“vaccinate” them. I don’t know if
that’s a shot, or it is what Dr. Darnall
is working on, which is a psychobehavioral
intervention to give to people before surgery
that we think is actually going to reduce the likelihood. So it’s the treatment,
the personalized medicine, after it’s already occurred. It is the prevention
before it occurs. And you can frame this in the
concept of it’s a public health problem, with primary,
secondary, and tertiary prevention. Anna, what about the public
health crisis in opioids? Yeah. I mean, so what I
would hope for– and I agree with much
of what Sean said. But what I would
actually hope for is that fewer patients
medicalize their suffering. That fewer patients
seek out doctors to try to help what ails them. That patients
begin to understand that sometimes engaging
with the health care system is not the way to
manage their pain, whether it’s physical
or psychological. And I totally concur
with Sean, that with the patient
population that I see, we have people getting surgery
after surgery after surgery. They become
professional patients, and they end up worse off
every single time for doing so. And so I would love to
see people step back from the patient role
and find other venues, whether they’re spiritual
or psychological, but not adopting
the patient role. Because I fear that
for them, it ends up in a worse place than
where they started. Anna’s describing this
concept of self-management, and [? agree ?]. And this was part and
parcel of the IOM report. Also a main key part of
the National Pain Strategy. And just again, propping
up here, Stanford. We have some of the best
self-management approaches here with Kate Lorig. She’s like the goddess
of self-management, for decades and decades. And so we’re working
to integrate this into our clinical center,
to try to teach people more of these
self-management approaches. What we need to do is bring
the type of model programs that she developed that
exist outside of health care and integrate them into the
health care environment. Yeah, and what I
would say, the lessons that we can take from
folks in recovery from addictive disorders is
that really, the real transition toward wellness, in my
clinical experience, folks who are really in
recovery are folks who are no longer blaming
others for their problems or looking for some other
person to solve their problems. So I think for a
subset of folks– this is not all patients,
but for a subset of folks– continually looking
to doctors to fix them is the very source of
they’re never getting better. Thank you very much. I asked both Anna and Sean
before if they were friends, and they said they
were very good friends. [LAUGHTER] Thank you for joining us
today for great conversation. And we’re going to
open for questions. [APPLAUSE] You haven’t talked
about opioids– you haven’t talked about
opioids and the use of them as anesthetics, and then turning
people onto those things, and making like in max
Michael Jackson’s case, making them into people who
want to keep on getting it, even though they are
not really in pain. What about that? [INAUDIBLE] Oh, you’re talking
about the intravenous– Patches. Oh, patches. So if I understood the
question, a fentanyl patch, one has to keep
in mind that these medications that we’re talking
about today all fit into one class. They’re called opioids. There’s different flavors
of them, if you will. And there’s different
delivery systems. You can take them orally. You can get them intravenously. You can get them
intramuscularly, rectally, and then also transcutaneously. It’s a patch you put on. The idea of the patch is
just a drug delivery system. It just gives a continuous
dose of the medication over three days. And again, it’s a tool. It’s a tool like any other tool,
one that can provide benefit and one that can be
incredibly misused, such as the Michael
Jackson case. Sorry, I have a couple. I mean, you can choose which
ones– how you want to answer. So one of them was just
figuring out the access to these non-pharmacological and
this amazing team-based care, because I know there’s
constraints within the system to even have access to that. So just wondering
what your thoughts were on that, because it’s going
to take a while, obviously, for us to get that place. The second being the
role of naloxone. That wasn’t brought up, and
I think it could actually be a tool that could
be used to help people think about
the risks of opioids and getting on that train. And then lastly,
you mentioned tools. And I think, Sean, you
had a great point about, like, it’s a tool. We didn’t really teach
people how to use them. And I think it can be– I’ve
spoken with Jodie Trafton, and she’s like, if
it’s used effectively, it can be quite powerful. And I’m just
wondering– obviously not everyone’s going to
have that training on how to use it in that way. So I’m just wondering,
should people even be allowed to use
it if they’re not going to be used in that way? And using Anna’s
example, should we require them, like
buprenorphine prescribers, to go through tons of
training, extra training, in order to prescribe it, and
have the same limits on it as there aren’t on suboxone? So three questions there. So with regard to
access, we’re wide open. We take all insurances. We recognize that
we have a problem throughout the entire
country, and what we need to do is
provide the type of team-based comprehensive
care for everybody across this country, and to
break down these barriers. That’s part of what the National
Pain Strategy calls for. And in part, in the
reimbursement and service delivery, is to
change the incentives so that we can provide
those types of services. The reality is, right
now I lose money in all the psychology,
the acupuncture, the physical therapy, the
dietary, the biofeedback, and we rob from
Peter to pay Paul. And I’m blessed by having
a chair, a department, that supports the model of delivering
the best care possible. In many other situations,
they can’t do that. But we hope to
change that culture. Two– Do you have a
self-management– I guess could there be a platform,
like having on the internet those self-management
strategies? Can you make it just
accessible for everyone? We’re developing that right now. And I also invite you to
look at Kate Lorig’s work. She’s just amazing. But we’re actually, right now,
building that into our system. With naloxone? Yeah, I’ll talk about
naloxone in a second. The other very
fascinating phenomenon that’s developed in recent
years is 12-step recovery groups for chronic pain patients. So if you look those up,
I think you’ll find them. They’re really,
really interesting. First of all, recognition that
some chronic pain patients and folks with addiction are
a very similar population, and that on some level,
not in a conscious way but in an unconscious
way, folks become addicted to their chronic pain. It becomes their
illness identity. And in order for them to
really get into recovery, an addiction model works. So I do refer some patients
to 12-step recovery for pain. So naloxone is essentially an
opioid receptor antagonist. It will go into the
body and if there’s any opioid agonist
that’s on the receptor, it will essentially knock that
out and fit in the interceptor. And it’s currently–
you can prescribe it in the state of California
and other states throughout the country in order
to avoid an opioid overdose. So there are now also Good
Samaritan laws in place. I can prescribe
naloxone not just to the patient to whom
I’m prescribing an opioid, but to a family
member or a friend who may be present and witness
an opioid overdose. So one of the arguments,
now, is should we, as a matter of
course, be prescribing naloxone when we prescribe
any kind of opioid as just simply a
way of communicating to patients that these are
a potentially lethal drug? And also, for really
practical reasons, if they do overdose–
because most of the opioid overdoses in this
country, I want to emphasize, are not suicide attempts,
and also not necessarily taking more than prescribed. Sometimes even at
therapeutic doses, because of certain
tolerance that develops to the
analgesic effects but not the respiratory
suppressant effects, people can die of
an opioid overdose. Especially if, for example,
they go to another provider who doesn’t know about
the opioids, and they get a benzodiazepine
prescription, like Valium. Or if they drink more alcohol
than they should, all of those are also respiratory
suppressants. So people can die accidentally. And that’s why naloxone
is a great idea. Your third question,
should we be more restrictive around
any opioid prescription? I think we should, at the
very least, be consistent. I mean, if we’re going to be
restrictive about prescribing suboxone, we should be
restrictive about prescribing any opioid. And it should be
well thought out. And I certainly do
think that anybody who prescribes a
controlled substance, including opioids, should be
mandated to access prescription drug monitoring programs, which
are DEA databases that allow doctors to see all
of the prescriptions for controlled substances
that patients have obtained in the last 12 months in
the state of California, or whatever state you’re in. And now there is some movement
in the federal government to actually tie DEA license
registration to education about how to access the
prescription drug monitoring programs, as well as ideas for
how to incentivize doctors, to get them to use it, or
even mandate that they use it. So all of these ideas are
in play, this recognition that if educating doctors
about this problem isn’t going to fix
the problem, we need to either pay them
to do it or punish them when they don’t do it. Yeah, so just to
follow up, because I think there’s a couple areas
of agreement and there’s one of strong disagreement. The naloxone, by the way,
Health and Human Services just released a report
in which they’re going to throw $100
million, I think it was, at this problem, of which
one of the key points in this is going to be the broader
use of naloxone for treatment. Another major part
of this is going to be pushing more
evidence-based guidelines for the use of it. With regard to
restricting opioids, I think if you apply the same
restrictions to all opioids as you did to
suboxone, we’re going to have a huge problem
on our hands in society. Patients will just
absolutely be up in arms. And we need to be aware of
unintended consequences. We do need to better
clearly educate. And also, maybe better choose
the medications that we use, if we’re going to use opioids. I used to talk, back
in the early 2000s, about the benefits of
methadone, by way of example. Because it’s a medication
that is dirt cheap, and so it helps
break down barriers for those who are of low
socioeconomic status. Long half-life, and it’s a
good analgesic medication. I stopped writing that as
much and recommending it for our primary care doctors
well over 10 years ago, because it’s a tricky drug. It turns out it counts
for about 2% to 3% of all opioid sales
in this country, but it also accounts for
about 30% of the deaths. And why? Well, part of it
is because there are states out there, state
programs, workers’ comp programs, that want methadone
pushed as a front-line agent. Why? Because it’s cheaper. And so we’ve been pushing,
both through the academy that I fortunately– I’m
happy to be an ex-president. It’s always better to
be an ex-president. But we were pushing for it
not to be a front-line agent because of how tricky it is. And I think that’s one
area where we could make a big difference in society. I want to just tag
on to that, Sean, your description of methadone. It is true that methadone causes
the majority of overdose deaths in this country. But it’s really
important to realize that in most of those cases,
the methadone was prescribed in pill form by pain doctors
for the treatment of pain, not in methadone
maintenance clinics for the treatment of addiction. So I think that’s
important to note. The wide availability
of methadone for folks who have opioid
addiction and get it at a methadone clinic,
should be perpetuated. But I agree that
prescribing of methadone by pain doctors in pill
form needs to be limited. I’m not sure I
agree with the point about it coming all
from pain physicians. A lot of this, again, is coming
from– it’s primary care. It’s emergency department. If you look at the date on
where the actual greatest volume of the
opioid prescribing, it’s generally there. And those are the groups that
we have to work together. We don’t want to beat
these people down. Keith and I have had
multiple conversations, and I actually credit
him with this thought. You know, you can segregate docs
into three broad categories. You got the docs that
are doing a great job and are prescribing
appropriately and monitoring. Leave them alone. Give them the tools
to do the job better. You’ve got a smaller group of
docs that are doing a bad job but they think they’re
doing a good job, and they just need education. So give them the
education that they need. And then you’ve got
a sliver of docs that are really just misbehaving. They are doing the wrong
things for the wrong reasons, and that’s where you need
to break out the police. You need to slap them on the
wrist, take away their license. But that group is really
a very small aspect of this overall problem. And so we don’t want to have
one approach to fit all three of these categories. We want to be able to
provide the tools for those who need it, to be able to get
out of the way for the people doing a good job, and then
police those who need policing. Hi. You spoke briefly
about the difficulty in measuring outcomes for
success related to treatment. It strikes me that there’s
been a lot of advances in both developing
different kinds of opioids and then developing
different delivery systems. But our pain scale is a
1-to-10, self-reported measure. I’m wondering if you have any
thoughts on how that affects this area of research,
or whether what might be beneficial, or attempt
to kind of develop a more sensitive way to measure pain. So we’re doing that right now. We’ve built that. It’s called CHOIR. And what we built was
a way of capturing physical, psychological,
and social functioning for every person that
comes into our clinic. And again, we’re giving
it away for free. You raise the problems with
the almighty pain score. The pain score is terrible
for monitoring outcomes in people with chronic pain. Works real well in acute pain. I haven’t asked,
by way of example, I haven’t asked a
patient in my clinic a pain score in maybe a decade. I don’t find it
particularly useful. We’ll ask them, what
are you able to do? What’s your physical
functioning like? How is pain interfering with
your social, vocational, and recreational activities? Those are the things that
are meaningful for patients, and that’s what we need
to more broadly capture. By the way, not just
in pain clinics. This isn’t a problem
just related to us. This is a problem that primary
care has with chronic disease management. We’ve got great ways
of measuring diabetes, with the hemoglobin A1c, with
blood sugars, hypertension with blood pressure. But chronic disease
management, which is becoming the
bulk of the problem, we need these
patient-reported outcomes and to use that track our
treatment effectiveness. That’s where the field is going. I’d like to just interject
for the sake of defending primary care physicians
everywhere, that primary care physicians, it turns out, aren’t
the main doctors supplying prescription opioids. There was an interesting
study recently in the Journal of Pain that said
the number one type of doctor who prescribes the most
opioids is actually orthopedic surgeons. So I think that’s
relevant, because what it shows you is it’s exactly
those doctors who don’t have the benefit of
seeing the outcomes of their prescribing
patterns who are more liable to this problem
than primary care doctors, who unless there’s some kind of
insurance change or extenuating circumstance, are going to
see their patients over months to years. I feel like primary
care doctors, more than any other
type of physician, are aware of the prescription
drug problem and the necessity for doing something about it,
in terms of their prescribing practices. Yeah, and I would agree
that the primary care docs, we don’t need defend them. I’m huge fans of them. We work very closely. And we recognize that surgical
groups are the ones also who are prescribing a lot of that. What are we doing
here at Stanford? Jen Hah is one in our group
who’s working with the surgeons to provide motivational
interviewing approach and educational approaches to
the surgeons and the patients. The challenge that we have
right now is the surgeons are often brought to write
a prescription for 30 days after surgery, of an opioid. The patient may take one
of them and throw up, say I’m not taking
that again, it goes up on the medicine cabinet. Or they may end up taking them
and getting into real problems. But it’s not just a 30-day
supply for everybody. We need to tailor it. And we need to help
patients understand how to take these
medications after a surgery or procedure and then what
to do with them when they’re done taking them, and
that is to bring them back in a safe manner to have them
appropriately disposed of. If opioids are not effective
for long-term pain control, what is the
recommendation, then, for long-term pain control? And what’s a reasonable amount
of time for a physician– say, a primary care
physician who’s seen a patient over years. What’s a reasonable amount
of time for that physician to continue prescribing opioids
for chronic pain in a patient? One year? Two years? Three years? Is that just way too long
to have somebody on opioids to control their pain? Well, you know, I
think it’s always going to be an individualized
cost-benefit analysis. As Sean pointed out,
there are some people who can take opioids for
a long period of time and still seem to get
benefit from them. It would be wrong to
simply discontinue opioids for that one individual
because of the larger public health crisis. However, what we are seeing
now in a primary care context, which is
actually fascinating, is patients have been on
long-term opioids, who’ve had some small incremental
improvement in their function but are running into trouble
because of the opioids– not necessarily trouble
because they’re addicted, but trouble because
of side effects– endocrine abnormalities, lower
testosterone, increased pain in areas where they
didn’t have pain before, a phenomenon we call
opioid-induced hyperalgesia, increased cardiac
risk, increased fracture risk, severe,
debilitating constipation. So the cost-benefit
analysis is such that you taper these
patients off slowly– and that’s an important
point right there, doing it slowly in
a supported manner, not just cutting them off. And what we’re finding is
that these patients actually feel better. I mean, it’s amazing when
I talk to primary care docs how surprised they
are to discover that, and how surprised
their patients are. They can think more clearly. They sleep better. They can go to the
bathroom better. Again, it’s not every case. But I think, again, it’s that
pendulum swing, this awareness that you don’t just continue
these things indefinitely. There are costs to
chronic opioids. So unless the benefits really,
clearly outweigh the costs, you want to be
thoughtful about it. This is brought up, I think,
in the initial discussion with the patient
about prescribing opioids, and changing
the narrative such that the patient understands
that we’re going to do a trial, and I mean trial with a
capital T, of an opioid. Which means that it may only
be for a short period of time to help get them engaged
with all the other therapies and treatments that we
want to engage them in, but it’s not going to be a
permanent or very long-term solution. [INAUDIBLE] answered
very well, and that was what were the side effects
of long-term opioid use, besides the possibility
of addiction, and you gave a list there of
quite a few bad side effects. Yeah. Thank you. Would you comment on
the value of cannabis as an alternative to opioids. Right. So the question was
the value of cannabis as an alternative to opioids. There was a fascinating
paper that just came out that basically looked at opioid
prescribing and consumption in states where
cannabis is legal, and found that those
states had fewer problems with prescription opioids. You know, the inference
being, essentially, that maybe having cannabis
be legal is a good thing, because you’ve increased
access, and then people aren’t– and truly, cannabis
doesn’t have the accidental overdose risk that opioids do. However, there are problems
with consuming cannabis daily, including
cognitive dysfunction, again endocrine dysfunction,
motivational issues, not to mention the risk of
developing tolerance, where it doesn’t work anymore. Withdrawal, or when
you stop taking it, you have physiological and
psychological problems, as well as the problem of addiction. So any drug, whether it’s
prescribed by a doctor or not, that you put into your body,
you want to be careful about. We’ll take one more question. Actually, thank you. I wanted to give a quick
plug for the power of yoga. I personally cured my
chronic low back pain after I tried a number
of different tactics. And the reason it’s
effective it because it addresses the physical
and psychological mindfulness components
of pain, and helped me stop being a patient. So I was wondering
if you guys feel like physicians can
give prescriptions, so to say, for yoga more often. Yes. Well, I’ll tell you, physicians
will get prescriptions for yoga when insurance companies
reimburse for yoga. And probably not before. We’ll take one
more question here. Yes, I just want
to stay thank you for bringing this
hugely important topic, because I personally
have been afflicted. I lost my 26-year-old
son in July to a one-time use
of a prescription of opioid oxycodone and Norco. And I think what I’m trying
to do is to understand, being an activist
role, and now helping to educate our communities
and our schools. I’m seeing so many
of our young kids that are becoming addicted to
these because they don’t want to lose the spot on their
team because they got injured at basketball or football. And I’m just trying
to understand how and what it is that
maybe you would recommend, or what are you doing to
help educate at that level? Because these are our future. This is our future generation,
and we’re losing them so fast. Absolutely agreed. One of the things
that I think, has been missing in the discussion
and in the narrative at a national level is that
this is a public health problem. And as such, we need to treat
it as a public health problem. We focus much of the attention
on the physician-patient interaction, but we can’t
lose sight of the fact that a number of people are
having overdose deaths who were never prescribed
these medications but got them from
Grandma’s medicine cabinet. We need to educate everyone,
from the very young to the very old, that just
because they’re prescribed medications doesn’t
make them safe. And we need to teach people
how to appropriately dispose of these medications and
help them to understand– I think it was Keith
who introduced me to the term of, you
know, your medications are your medications. And Keith, I may
be misquoting you. But it’s a powerful message. And we need that public
awareness aspect of this. And I think that’s part
of what’s been missing. It worked very effectively
in reducing smoking, applying peer pressure and getting
the message out there. Yeah, I would– first of all,
I’m very sorry for your loss. I would certainly
concur with Sean that a big problem is
that young people today assume that anything
that’s in pill form, even if it’s Ecstasy, is safer
than anything not in pill form. So we really have to
disabuse them of that notion. But I think a deeper cultural
problem is that we really have very little to offer
young people, as a society, in the way of meaning
and purpose and identity. And so many of them
are clinging to things like their athletic prowess. And that goes on into
professional sports organizations. I’ve treated many of
these individuals, and that’s everything
that they are. Or their friends,
you know, being popular with their friends. I mean, I really think
this is like a deeper spiritual, societal
issue, in terms of helping young people
finding meaning and purpose and not turning toward pills. Again, I don’t know the
circumstances of your son, so I don’t mean to project
on that [INAUDIBLE]. Just more generally, I see
this as, among young people, a kind of a spiritual
impoverishment that we really need
to do something about. And again, I don’t
think the answer’s going to come from
the medical community. Thank you for coming. And thank you. [APPLAUSE]

5 comments

  1. Been on pain medications for 9 years!

    My life is very active, I can work full time and I live a very good life.

    Before? I wanted to die from the pain!

    Don’t take my live away please:(

  2. So I got through this grueling debate of fear mongering and anti-Opiate activist, especially that Anna Lempke!

    She can go to hell.

    And for the mother, I’m sorry your son wanted to party with prescription pain meds, I’m sorry he’s gone.

    But you would torture over 2 million chronic pain patients because your personal vendettas with oxycodone?

    So where were you when you kid overdosed? No talks from you about how not to abuse pain meds or any medications for that matter?

    Yeah my dad gave me those talks, why didn’t you?

    I’m sorry your son mad a bad choice, but because you failed as a mother doesn’t mean I have to and 2 million other have to be in agony.

    I was just thinking that although this video is 2015, this was the day pain patients rights died.

    Fuck all three of the people for doing this to us!!!

    I hope all you get hurt some how and can’t get what you need to live your life.

    KARMA.

  3. You sicken me and ALL of those COMPLICIT in this GENOCIDE will be held accountable for these most egregious and reprehensible CRIMES AGAINST HUMANITY!
    #Nuremburg

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