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Melanie Cole (Host): Improving the way opioids are prescribed through clinical practice guidelines can ensure the patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse or abuse or overdose from these drugs. My guest is Dr. Robert Good. He's the Chief Medical Officer of Carle Medical Management and Health Alliance Medical Plan. Dr. Good, what's been the parameters or guidelines for the prescription of opioids in the past, and what's different now? How has it changed?

Dr. Robert Good, DO (Guest): Well I think the problem started multiple years ago, when the US government in conjunction with the VA system decided that people shouldn't have pain at all, and through that process started propagating the thought that we ought to be pain-free, and we even started what we called the fifth vital sign, and the expectation was to achieve zero pain. That really resulted in a mess, and that mess was associated with increased addiction, and people still with chronic pain.

Melanie: How are you looking at it different now, doc?

Dr. Good: Well I think that one, we got messed up with the goal, and once the person has a chronic condition, the expectation isn't so much about relieving all of pain, it's about maximizing normal function. Let's get people back to their normal activities and improve their own ability to self-manage their discomfort. Yeah, we wanted to reduce- subjectively we want to reduce the pain intensity, but we want folks to be able to be functional, and be able to get back to their work, their jobs, et cetera.

Melanie: So at this point, what's involved in opioid selection, dosage, duration, follow-up, or discontinuation? I mean how are you assessing the risk or addressing the harms of opioid use with certain patients?

Dr. Good: Well I think there's a couple of things are important that we follow. One, there needs to be a specific diagnosis. Oftentimes people have been placed on narcotics and there hasn't been a very specific workup as to the nature and the type of their pain, a real true assessment of their functional status. You know, how does a person cope with their situation in their life? What are the other factors that are surrounding that pain, whether it's social, or historical, or psychological? It's just really truly analyzing the person as a whole and trying to understand what's the cause of the pain, so it can be more focused in its treatment. I think that there's been a lot of work done about, 'Well how much is too much? What should be our limits?' And so the CDC, about two years ago, came out with a very nice 54-page paper with guidelines wrapped around it, about what do we do to treat chronic pain? And what they basically found was when morphine milligram equivalents get greater than ninety milligrams, there's really no benefit to the patient, and so alternative means of treating pain need to be discussed and worked with the patient.

Melanie: What best practices are you employing, and how do you evaluate the impact of these programs on outcomes? What strategies are you employing?

Dr. Good: Well one, when a person has chronic discomfort, one is getting a true diagnosis. That's extremely important. That is the best practice. And two, is if they are already on a narcotic, to understand what their morphine equivalents are. So for instance, we sometimes don't realize the strength of fentanyl or hydrocodone. Let's just say a 50-year-old male that's been placed on a fentanyl patch of 50 micrograms, that's equivalent to 120 milligrams of morphine. Hydrocodone, maybe they're taking it four times a day, or even three times a day, 30 milligrams. Well now that's 90, that's a one-to-one ratio to morphine. So that's 210 milligrams of morphine per day equivalent, that's over two times what the CDC recommends. Sometimes we just don't appreciate the strength of some of these products. There's multiple calculators out there to help physicians do that. I think the other thing is making sure that when a person is on a chronic opioid, or has some need for that, and we try to minimize that need, that they understand the risk that they're taking with their own lives. So an agreement between the physician and the patient should be developed, it's a two-way agreement, but it's really about informed consent for products that decrease life expectancy. So chronic opioid therapy decreases one's life, and so they need to understand that this product is something that is not life-long beneficial to them, and if they're going to be involved with it, there needs to be a very prescribed monitoring technique, and that's also outlined in these types of agreements.

Melanie: So while you were talking about the current and projected, the morphine equivalence, do you think that patient perception of pain management - and you mentioned this in the beginning of the segment as well - plays a role in this patient understanding of what it is they're doing to their own bodies by accepting this type of pain management?

Dr. Good: Correct. So one is that one can become dependent upon doses of opioids to the point of addiction in which judgment may be impaired. There's a lot of things that happen within the brain and the receptors for pain management that start to not really benefit the patient over time, and I think that there needs to be an attempt at understanding that, and alternatives to help control the discomfort so they can become more functional. So whether that's therapy, or whether that's specific injection therapy into say a low back or a joint, or whether that's the use of non-steroidal anti-inflammatory drugs in a more aggressive way, whether that might be acupuncture or other types of pain treatment. We need to consider all of that to help the patient reduce their dependence on opioids.

Melanie: Really so important, everything that you're saying. Where do you see this going in the next ten years? There's so much written about it in the media, but we hear about it as this addiction epidemic, but we don't necessarily hear about it from the best practice point of view of clinicians and this stewardship. So where do you see it going?

Dr. Good: Well I think over time, physicians are not as likely to start somebody on opioids over a long period of time. Studies show that after about three weeks in a post-operative setting, after about three weeks of narcotic use, you've kind of maximized what an opioid will do as far as pain relief. So the surgeons and physicians are becoming much more sensitive to utilizing alternatives to stay away from higher doses of narcotics. Over time, I believe that will result in fewer people being kind of sensitized to the opioids and be on higher doses that they really are having a hard time controlling. There's also a variety of mechanisms to slowly reduce use of opioids, and so those have been documented, and we can provide that information for the patient and for the physician that's prescribing them. I think physicians need to be just really aware that chronic use of opioids decreases life expectancy. When we start opioids, we need to be looking at the red flags; the items that are likely that somebody may overdose, and as you are aware, the number of people who die every day in America has significantly increased to the point we're starting to affect our overall average life expectancy in our nation. So people with a history of substance abuse, or if they've had opioid overdoses in the past, or if they're on high doses, or if they're combining sedatives like Valium or Xanax with the narcotics, or if they just keep escalating the amount of narcotics they're taking and they're not really getting any pain relief; those are all red flags that we should be very cautious in prescribing opioids to that type of patient, and looking for alternatives.

Melanie: Is there a standardized set of questions? Things that physicians should be looking? As you mentioned those red flags, Dr. Good, are there something that is pretty well nationwide set out by the CDC so that people can determine that risk?

Dr. Good: Yeah, I mean that the CDC reviews that in their paper, but I think it's good medical care that obtains a complete history for everybody that has any serious condition so that there's a full understanding of what their past medical history has been and looking at the physical exam. Does the physical exam- is it consistent with what you're seeing in the function of the patient? So you know, there's always- what the patient tells you, make your observation of what the patient's doing, and there's also the function that the patient is able to undergo, and does that all match in your assessment? We ought to be doing drug screening, urinary drug screening in folks who are on chronic opioids, because oftentimes they may be combining illegal substances with substances that we prescribe, and that makes that extremely dangerous. People also ought to be looking at our state registry, from the Illinois or the Indiana Pharmacy Registry, so we know are there other prescribers for the same medications that you are prescribing? So those are things you can do to kind of be cautious and safe with the patient. But at the end of the day, all of that is to protect the patient, and it's those types of standards as the best practice standard around opioid therapy.

Melanie: Good points all. Dr. Good, thank you so much for being with us today. You're listening to Expert Insights with Carle Foundation Hospital. For a listing of Carle providers, or to view Carle's sponsored educational activities, please visit www.CarleConnect.com. That's www.CarleConnect.com We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for listening.