Transcription:
The Opioid-Pain Nexus: Current Opioid Use and Safety

Dr. Michael Smith (Host): And so our topic today is opioid use and pain management. My guest is Dr. Dan Millspaugh. Dr. Millspaugh is the Director of the Comprehensive Pain Management Program at Children's Mercy, and also the Director of the Opioid Stewardship Program at Children’s Mercy as well. Dr. Millspaugh, welcome to the show.

Dr. Daniel Millspaugh, MD (Guest): Well thank you, Michael. Good morning.

Dr. Smith: Let's start off with this. Obviously opioid abuse, opioid concerns are definitely all over the media, all over medical practice. So let's just start first with- as an expert, Dr. Millspaugh, what's your take on the current opioid related public health emergency?

Dr. Millspaugh: Well- and I'm glad you stated it that way, because usually people will say 'crisis' or 'epidemic,' but public health emergency is in fact the right terminology, and it's a very valid concern, and all of the attention is warranted. Although I will say it doesn't capture a lot of the nuances of this problem, and I think there's a fear that- an overly simplified fear of it that may end up leading to potential solutions that don't fully address the concern.

And actually I'm reminded of an H.L. Mencken quote which goes something like this: "For every complex problem, there's an answer that's clear, simple, and wrong." And I think we've got to be really careful that we don't fall into that trap, that we overcorrect and therefore have a pendulum swing back so far that we don't use these very powerful tools to their best advantage because we have a new fear of them, a new opioid phobia, if you will.

Having said that, there are some big concerns, and the U.S. is unique in that certainly until most recently we've used about 80% of the world's opioids, which is obviously something that is eye-catching and doesn't really correlate with an increase in pain intensity in the U.S. When you look at other developed countries, they have pain intensities that are- or incidents that are very similar to ours but don't use the same amount of opioids.

And a lot of this stems back to a social movement that was driven by compassion back in the nineties and early 2000's, and even codified as pain in vital signs, and a lot of scoring of pain propagated by the American Pain Society, and then codified by Pain Standards and the Joint Commission, first of which were in 2001. So that had the effect of making a lot of expectation shaping possible so that we viewed pain as something that really ideally should not be present, and that we should use any means necessary, even our most powerful tools to eliminate that in all aspects of pain, not just in cancer pain, or palliative care, or post-surgical pain, but in more typical pains that a lot of us have.

Say for example back pain, which roughly 70% of the American population will have at some point in their life, and using opioids for that condition is frankly misguided and isn't likely to actually help with the problem, but it does put more opioids out into the public and increases the supply.

And if you were to say what the correlation is between prescribing and the rash of increased opioid or drug poisoning deaths, it would be essentially that. That we have- with our prescribing patterns, that are born out of reasonable compassion for patients that are suffering pain, we've increased the supply of opioids in the general population, some of which get diverted, and misused, and that is at least part of the problem. So it's not causative per se, but it is correlative and it is faciliatory.

And if you look a little bit deeper at the stats around drug death, the most recent stats were from 2016 where about 64,000 people died of drug overdose. That's not all opioids though. Increases in cocaine and methamphetamine deaths are also going up, so this is not really an opioid problem exclusively. Fentanyl and heroin deaths are going up, and of course there's been a lot of attention to the essentially poor quality control around holistic drugs where heroin is laced with fentanyl and potent opioid analogs that are problematic. And now prescription opioid deaths are roughly level or potentially up a little bit too, but not as much as heroin and fentanyl, and opioid prescribing is actually going down as those deaths from other drugs continue to go up.

So I think we have to be careful not to overly simplify this. Moreover those deaths are often associated with a great deal of polypharmacy, as we would call it. There's many other drugs involved, often four, five, or six additional drugs in an overdose. Like Diazepam, like Valium, for example, or Ativan, or Xanax, or alcohol, and a number of other things; cocaine, methamphetamine, marijuana often used in addition to the opioid.

So it's more complex, there's more nuance to it than is often presented in the popular media, and if you look at the context of opioid use, in the medical context there's actually a really good study in general pediatrics from this year that showed that the accumulative incidents of long-term opioid therapy over a three year period is only about three in 1,000 for all-comers, all prescriptions of a 1.2 million prescription database.

Now embedded in that data is also information about what increases the risk of misuse or long-term use of opioids, which is a little bit conflated with long-term pain problems. So things like depression, anxiety, other substance use disorders like alcohol use disorder, or even things like ADHD increase the risk or susceptibility to addiction. There's a number of genetic factors in what we would call epigenetic factors. Stress in life, so adverse childhood events, or experiences over time, toxic stress, adolescence in and of itself, and then again a big overlap between mental health conditions and substance use disorder.

And even when you look at long-term opioid therapy in adults for chronic non-cancer pain, the really strictly diagnosed opioid use disorder is probably less than 10%. There may be some other behaviors upwards of a quarter of those patients, but at least 75% even at the most conservative estimates that are having an opioid use disorder. So I think we have to be really careful and not be- not develop a stance of being anti-opioid nor pro-opioid, but rather pro-patients. This is about our patients. How do we treat our patients? What are the proper indications for these medications which are very- I would say very strong, and what's the right amount to give somebody after their dental work if at all? Or after surgery, or after a broken femur, for example. How much should people get? Is there way to do it without opioids? And I think that kind of creativity, it's something that we're really spearheading here at Children's Mercy here. How do we evaluate our prescribing pattern, and how do we take that knowledge that we have and try to help our patients in a better way and try to streamline that process and be more tailored? And even more patient focus.

So that's what our opioid stewardship program is primarily about, and of course there's a compliance element to it with how we actually meet Joint Commission requirements and relevant statute regulations. But in large part, our opioid stewardship program is about how do we manage opioid prescribing responsibly? So that's a long-winded answer.

Dr. Smith: Right. I know, that was great though, and you said a couple things that I want to go back and review a little bit with you. First off, the idea that there should be no pain. I was a medical student in the mid-nineties, and I remember being taught that, that pain causes worsening outcomes, et cetera. How do you actually feel about that, and is that- if that's the mentality, no pain, is that leading maybe to some regulatory and agency responses that are appropriate?

Dr. Millspaugh: Yes, I think you're absolutely right, and certainly I was taught that exact viewpoint too, which is pain is something to be avoided, not the least of which is because of the physiologic perturbation that can occur from that, but the stress response associated with pain is the patient's healing.

The other aspect of it is the suffering component, and so that's where the motivation primarily came from, and then that was only justified by the known physiologic responses to it. So we actually in our country have two parallel crises, if you will. The pain crisis, the pain epidemic, and I use those terms knowing they're incorrect, but it's what tends to be used in our society for big problems related to medicine. So we have a lot of people that have chronic pain. We also have a lot of people who misuse substances, particularly opioids, and those two problems don't co-exist well because we do have an appropriate desire to diminish pain as much as reasonably possible. And I think that nuance about what's reasonably possible and how to balance the risk and benefit of the tools we have to reduce pain against the real risk of having severe pain, and we have trouble balancing those things, and I think the overly simplified view of it is we should have no pain. And if you think about the unattended consequence of measuring pain continuously or frequently asking people, "Is your pain on a zero to ten scale six, seven, eight? What is it?" And the implied correct answer is zero. Just asking about it in that way, one, promotes people to focus on it. It makes it higher in their salient. So their salient in that work starts to trigger pretty substantially when they're asked something about pain.

"Well I wasn't in pain until you asked me about it, and now of course I am." And really trying to objectify something which is inherently subjective, so I refer to that as pseudo objectification of this phenomenon. By measuring it, it leads people to believe that, one, there's more science behind it than there is, and two, that it's more objective than it actually is, and that the right answer should be zero. So we push in a way that actually leads us to take more risk than we might otherwise take, and the back pain is a great example of that, which is if 70% of adults have back pain, I think it's unrealistic to expect that people won't have back pain, and to think that we need to do everything possible to get rid of every possible incidence of back pain is in fact misguided and I think driving some of this problem, and actually driving our 80% growth utilization of opioids. This is something of a unique American phenomenon where we don't have very much tolerance for discontent or lack of comfort, and that's as Americans, that's just something that we seem to focus on. "I can't be uncomfortable. Something must be done about this." And that actually gets to another nuance of this which is the interplay between external locus of control and internal locus of control, and internal locus of control, and the way our medical system is organized is, "Doctor, what are you going to do for me?" Instead of, "How do I partner with you in a way that helps you do the best for you as a patient? And what can I do to support you in that journey?"

If we know that a lot of things like back pain, for example, are treated just as well by increased physical activity, and physical therapy, and some cognitive behavioral strategies that we stress or we focus on changing the way we view it from a non-catastrophic to a normal part of existence, those people do as well as many of the other medications we can throw at it. So that's a change. That's an expectation change about what we're shooting for. So I think our expectations are in the process of being changed right now, but it's hard.

Dr. Smith: Well let me ask you this, Dr. Millspaugh. You had said something earlier as well. The perception. The perception, right? In the media with lay people is that opioid prescriptions are going up, we're prescribing it more, and more, and more, but you actually said something that was interesting, that it's actually decreasing. Are you worried that the perception though is going to lead to some- again, some regulatory- further regulatory restrictions on opioid use?

Dr. Millspaugh: Yes, I certainly do, and it actually as already. Fortunately actually towards the end of the month, I'll be heading off to Jefferson city to talk to our leaders in government there to try to make sure we have this nuanced understanding of it so we don't over-shoot. Because we already are restricting the amount that can be prescribed, the duration it can be prescribed, and some of that may be appropriate, but I think when you come up with these relatively rigid regulations, and we remove the clinical decision making power from the providers, and invest it into regulatory governmental or non-governmental agencies, we leave some of our decision making power on the table to our own detriment and the detriment of our patients, but we also allow for these overly restrictive, and rigid, and black and white rule making processes to carry on in a way that may actually lead to the next crisis twenty years from now. So this came out of a well-meaning regulatory process, and we adopted it so thoroughly that now we have consequences of that, and I worry that we will restrict the use of these medications so severely that we will have the next problem fifteen, twenty years down the line.

Dr. Smith: Yeah, well Dr. Millspaugh, we're going to have to leave it there. Dr. Millspaugh is the Director of the Comprehensive Pain Management Program and also the Stewardship Program at Children's Mercy, Kansas City. Dr. Millspaugh, obviously you're doing very important work and I want to thank you for coming on the show. You're listening to Pediatrics in Practice with Children's Mercy, Kansas City. For more information, you can go to www.ChildrensMercy.org. That's www.ChildrensMercy.org. I'm Dr. Mike Smith, thanks for listening.