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Melanie Cole (Host):  Welcome. This is Expert Insights with the Carle Foundation Hospital. I’m Melanie Cole and today we’re discussing the CDC Guidelines and new revisions on opioid prescriptions. Joining me is Dr. Elise Wessol. She an Addiction Medicine Physician with the Carle Foundation Hospital. Dr. Wessol, I’m so glad to have you join us today. First, let’s talk about some statistics on opioid prescriptions and overdose deaths in Illinois. Tell us what you’re seeing. What’s been happening?

Elise Wessol, DO (Guest):  Over 50% of people who use opioids are taken from a friend or relative. So, the majority of people who initially use opioids start getting it from a family member or a friend who have a prescription for opioids. As far as the overdose death rate in Illinois alone; 2017 data they reached a high of 2000 and 600 of those were from prescription opioids. And then of course, the rest were from heroine or synthetic opioids such as fentanyl. The majority of overdose deaths have to do with the rise of fentanyl and heroine supplies or people not knowing what they’re getting or buying from the street which has to do with the fentanyl supply in the nation.

Host:  So, previously, physicians were using that for pain management and as you said, people got it from friends and then maybe if they couldn’t get it anymore, they turned to other substances. The CDC has some revised guidelines. Tell us a little bit about that and why they felt the necessity.

Dr. Wessol:  Originally, the CDC put out guidelines for prescribing opioids for chronic non-cancer pain. Due to this trend of prescription opioids driving the opioid epidemic; the pendulum swung too far and physicians had been cutting off patients who were on chronic opioids which in turn leads people to experience opioid withdrawal which is not fully managed by the physician cutting off the opioids. In turn, they turned to street sources for opioids. Whether that’s seeking out opioid pills which can be prescribed or counterfeit or even heroine to relieve their suffering from their pain or from opioid withdrawal. Therefore, the CDC put out another set of guidelines to kind of curb this behavior or this response to the opioid crisis and physicians or providers cutting people off of their opioids.

So, they do have a recommendation that says physicians should avoid increasing opioid pain medications to greater than 90 morphine milliequivalents per day. That doesn’t mean that if a patient is on greater than that, that they should be cut off or their prescription should be lowered to meet that morphine milliequivalent. It means that they should consider other alternative pain modalities as well as seeing if their opioid prescription is effective. We know that high opioid morphine milliequivalents can cause opioid hyperalgesia and that lowering the dose can actually improve pain.

Host:  So, for other providers, and they hear this term stewardship; tell us about what that really means, and you mentioned multimodal approach, maybe using other things either in addition to or instead of or adjuvant therapies, anti-inflammatories, steroids, any of these things that can also help. Tell us what stewardship really looks like.

Dr. Wessol:  So, the multimodal pain management includes nonopioid therapies including NSAIDs, acetaminophen, injections, topicals; but it also includes a biopsychosocial assessment. It is known that people with a high ACE score or Adverse Childhood Experience score or high pain catastrophizing score have higher rates of pain and low tolerance for discomfort. You need to take into account the entire patient picture, not just their pain in how to manage their pain. Which is why the psychosocial evaluation is very important.

If a patient is being weaned off opioids; there needs to be psychosocial and behavioral support. That could be counseling, it could be assessing for comorbid depression, anxiety and treating that as well. And then it also means not cutting off opioids from a patient which will likely lead to worse outcomes than a patient who is getting a higher dose of opioid pain medications and are at risk for respiratory depression and overdose, but if they are cut off; then these people are in a lot of distress and feel like they have no place else to look but the streets.

It is within the physician’s scope of practice to manage pain but to do that responsibly.

Host:  So, you’re an Addiction Medicine Specialist. Tell us a little bit about the opioid use disorder treatment and Dr. Wessol, access to treatment because access to naloxone is somewhat limited in some communities. There are FDA approved forms, Narcan availability, harm reduction practices. Tell us a little bit about the treatment availability and access to that type of treatment.

Dr. Wessol:  Nationally, treatment access is a problem. So, there’s not enough people who treat addiction and it doesn’t just come from Addiction Specialists. Primary care providers can treat addiction. There are psychiatric providers who treat addiction. But because the opioid epidemic was caused by all physicians, all physicians need to take responsibility to now help reverse this opioid epidemic. It can’t just fall on Addiction Specialists because the need is much greater than there are Addiction Specialists out there.

So, one, anybody with opioid use disorder, opioid addiction or who are prescribed chronic opioids need to have a prescription for Narcan. People’s family members should have a prescription for Narcan. Narcan is covered by insurance and pharmacies carry that everywhere and Narcan again, is the reversal agent of opioid overdose or respiratory depression. So, it is within reason to prescribe any patient with prescription for opioids or with an opioid addiction to have Narcan.

So, as far as medication assisted treatment for opioid use disorder, opioid addiction; there are three available FDA approved treatments. Methadone maintenance which can only be provided through federally qualified opioid treatment programs. So, those are your methadone clinics and those are limited around the central Illinois area. There is another medication called naltrexone or extended release naltrexone which is Vivitrol which is an opioid antagonist which is given once a month and then there’s buprenorphine brand name Suboxone which is better known which is a partial opioid agonist and far and wide, we use Suboxone and Vivitrol. So, Vivitrol does not require any special training or DEA licenses. Vivitrol can be given at any primary care clinic. Buprenorphine or Suboxone does require eight hour training for physicians and then 24 hour training for nurse practitioners or physician assistants.

And so, that training can be done by anybody again. So, it’s not just limited to Addiction Specialists. So, we know that medication assisted treatment works. It reduces overdose death rates and increases abstinence and sobriety from opioids. So, there’ many, many articles about it and how it is the gold standard for treating opioid addiction.

One thing I would like to mention is that people think that treating opioid addiction with methadone maintenance or Suboxone is trading one addiction for another. That is not the case. So, people who are addicted to opioids or heroine; they spend all their time and energy seeking out the product whether that’s heroine or prescription opioids and then to be able to function because they want to prevent withdrawals. Opioid withdrawal is a very negatively reinforcing influence on a person’s behavior. So, they will do anything they can not to feel opioid withdrawal. So, over time, an opioid addicted person doesn’t even get the full effect of the opioid. They just want to feel normal and not feel sick.

You are prescribing Suboxone for this patient. They are getting an FDA approved medication that they are getting their withdrawal treated. They also don’t have the risk of opioid withdrawal because buprenorphine has a ceiling effect on respiratory depression. So, no matter how much a person takes of buprenorphine; they won’t go into respiratory depression unless it’s combined with other sedating medications like alcohol, benzodiazepines or gabapentin for example.

So, if a patient is in treatment with medication assisted treatment; they are getting their medication daily. They aren’t going around seeking ways to get money to purchase their opioid and they are able to be a functional human being again. So, it’s really remarkable what medication assisted treatment can do for a patient’s live and that’s why I do what I do. Because not only do they get better, but their lives get better than they have ever been before. So, that is a belief, so, trading one addiction for another that is held by people who really don’t understand what medication assisted treatment is all about or what addiction is all about. So, I just wanted to make that known.

Now, we do, in our practice, meet people where they are at. Whether that means abstinence only or decreasing use or like we talked about, harm reduction. So, harm reduction entails having people use drugs in the safest way possible for lack of a better term. That means access to clean needles, a needle exchange service, education on infectious diseases like hep C and HIV and how those are transferred and how to decrease their risk. So, it you don’t educate people who continue to use on these harm reduction practices; they will show up in the hospital with chronic infectious diseases like hep C or HIV, abscesses, endocarditis which can result in major healthcare costs and hospital admissions and so, while yes, we want them to engage in addiction treatment; this is the next best thing.

Host:  Well thank you for making sure to clear that up. Because that is a widely held misconception. As we wrap up, Dr. Wessol, do you feel, in your opinion that these medication assisted treatments should be more widely available as an important public health advancement? You’ve mentioned a few of the barriers to getting this type of medication and some myths. Wrap it up for us with what you want to see happening and what you see happening and how it all will come together.

Dr. Wessol:  Yes. So, one of the largest used models for treatment for addiction is the Hub and Spoke model. So the Hub is the addiction centers like Carle Addiction Recovery Center. The Spokes are primary care clinics or psychiatric clinics for example. So, we one, the addiction treatment centers would always be available for help with treatment management, what to do in certain situations and the people being managed for addiction are going to their primary care providers for it. So, that will one, overall decrease the burden of addiction in rural areas where there’s no other access to addiction treatment besides their primary care providers and yes, addiction medicine hasn’t always been taught in medical schools and so, there is this lack of understanding and fear about how to treat addiction within a lot of primary care centers.

But really, it’s as easy as prescribing a medication and treating it as a chronic disease because it is. But knowing that you have addiction specialists to call on if you feel like something is beyond your comfort level or scope of practice. So, ideally, addiction treatment would be available at all primary care centers.

Host:  Thank you so much for joining us and sharing your expertise on this really important topic for other providers Dr. Wessol. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at www.carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.