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Scott Webb (Host): We've all heard about the global opioid epidemic, but many of us may not know how and why opioids became such a public health issue or what the alternatives are to opioids for pain relief. I'm joined today by Dr. Kevin Walker. He's a Pain Medicine Specialist with PRISMA Health, and he's here today to help us understand opioids, when they are appropriate and how addictive they can be. This is Flourish, a podcast brought to you by PRISMA Health. I'm Scott Webb. Doctor, thanks so much for your time today. We're talking about opioids and the opioid addiction level across the country. And it's been in the news a lot. I know there's a lot of misinformation, so it's great to have an expert on to kind of clear things up for us. So, we'll start here. What should everyone know about opioid medications?

Kevin Walker, MD (Guest): Yeah, opioids are very commonly discussed in our media platforms today and opioids have been around a long time. But the most important thing for our patients to know, opioids are not dissimilar to other medications. What I mean by that, is every medication that we're prescribed, give and take, have risks and have benefits.

So, patients really need to understand what they're taking it for, why they're taking it, what are the risks in taking it and what some side effects they should expect from these medications and ways to minimize those side effects that can happen.

Host: Yeah, and it is great as a patient, to have all the information. You know, my son just had surgery on his thumb and I was very interested to know what would be prescribed for an 18 year old. And they definitely made it clear that they try to avoid opioids as much as possible. So, what are some of the examples of commonly prescribed opioid medications?

Dr. Walker: Yes. So, commonly people will have heard of a medication like Lortab or Norco, which is a hydrocodone based product. Other common ones are oxycodone based products. Most people have also heard of morphine, which can be prescribed as an injectable medication when you're in the hospital or even pills. Oxycontin was an oxycodone based product that has been in the media quite a bit over the last couple of years.

And one of the newer ones, even though it's not a new medication, but we hear a lot about it, especially in the midst of this opioid epidemic, is a medication called fentanyl, which is a synthetic opioid that is being abused on the street in a powdered form. But it's a common medicine that was used in operating rooms as an injectable medication. But those are ones we see and use on a regular basis in healthcare.

Host: Yeah and I'm sure that those are the ones that we've all heard about. We've read about, seen in the news, as you say, just can't get away from conversations about opioids and the epidemic really. So, under what circumstances, injury, procedures, chronic condition would a patient typically receive opioid medications?

Dr. Walker: It's really common, and you actually alluded to in a point where if you've had surgery, it's not uncommon to be given a short term. And what I mean by that, a couple of days of a prescription of an opioid, so you can recover from your surgery. We are starting to study this extensively to see, do all patients need it. And the good news is the answer is no, but we've got to learn more about that. Not uncommonly in traumatic events, say you're in a bad car wreck. And all of a sudden you broke your femur and it's sticking out part of your leg, you probably deserve a little bit of pain medication until you can get some good treatments for that.

Not uncommonly, in our patients who have cancer, especially metastatic cancer. They can have significant pain when the cancer metastasized to other places, whether it's in the bone or a different organ or something like that. So, those are the most common and the most studied environments where opioids are used.

Host: And you've mentioned that the importance of making sure that patients understand what they're taking, what the side effects could be. So, before being prescribed or taking a pain medication, what are some of the questions we should ask our doctors?

Dr. Walker: So, I educate every patient. The first question you should always ask is why, and that's why of anything. Why am I taking this medication? Why do I need this procedure? Why do I need to do whatever it is you're asking me to do? Because if they understand the why, their compliance is going to be better and it's going to be a better treatment plan for them. They clearly need to understand, are there side effects? What are the risks? How do I mitigate those risks? What can I do to protect myself, to make myself healthier and not cause any other harm?

Host: So, what are some of the effective alternatives? I know, I mentioned my son had surgery on his thumb and really the doctor said a couple of Tylenol will do the trick in many cases for many folks, but in general, what are some of the effective alternatives to taking opioid painkillers?

Dr. Walker: So, one of the most important things to determine the best alternative is, what's your diagnosis. We'll use your son, as an example, had thumb surgery. Clearly you got an obvious diagnosis, right? So, it's going to be muscular, inflammatory pain; well medications like Tylenol, medications like Advil will work really well as anti-inflammatory type medications.

So, alternating those two medicines is a great way to approach it. So, you're not taking too much of one. It can really help with the pain, so on and so forth. If you have broken bones again, anti-inflammatories can help stabilizing the bones. Back pain is mostly muscular in most cases. So, using some medications to loosen up muscles, stretching those muscles, yoga, Tai-Chi, things of that nature can make us healthier.

Then there are other specific scenarios where patients have nerve pain say from diabetes and they end up with neuropathy. There are medication called membrane stabilizers can calm those nerves down. There are even certain subsets of anti-depressant called SNRIs that can help with pain transmission as well. So, they're all alternatives, but typically they have to be linked to the correct diagnosis. So, I typically educate my colleagues. We got to get to the diagnosis first so we can give the appropriate treatment.

Host: Yeah, and that education is so key and good to know that you do that. And I mentioned in my intro there, about misinformation, but we could also say misconceptions. And what are some of the misconceptions about opioid use, both abuse and addiction?

Dr. Walker: One of the first ones I typically talk to people about is people say, well, the opioids treat my pain and I try to educate patients, opioids are just a perception blocker. They don't treat the pathology as I describe it. So, again, it goes back to my statement earlier about we got to get the correct diagnosis so we can treat the problem, so, you don't have the symptom of pain. But one of the other big misconceptions in our midst of our opioid overdose pandemic issues that we're having is individuals think that I'm immune to that problem. That I grew up in a good family or whatever the case may be. So, I won't become dependent on these medications.

I won't start abusing these medications. And I hate to tell patients or tell anybody for that matter, nobody's immune to abuse of these medications, and everybody will become chemically dependent on these medications if you take them long enough and that's not an addiction thing, that's just your body becomes somewhat of immune dependent on the medication. And no one is immune to that. And we have to be really careful. And that's why it's critically important that patients know that going into the scenario, so they watch out for some warning signs and some concerns there.

Host: Yeah. So, let's do that. Let's talk about the warning signs. When would a person know that they are developing that dependency on the opioids?

Dr. Walker: So, as I work with a lot of our addiction colleagues, you know, what we see is patients' intention. And what I mean by that is what they're focused on when it goes from their normal life experiences, whether it's family, job, enjoyment, activities, and it starts going to about less of those to more of like, I need more medicine.

I need more medicine to the point where the only thing they're focused on is if I don't have my medicine, I can't. That's when things start getting out of control and it's really hard for that individual to recognize it. It's often more of a family member saying, wait, you know, my husband or my spouse, my wife, whatever the case may be, listen you, you really haven't you know, gone for a walk lately where you used to do that everyday, what's going on. And they're like, well, I can't go without my medicine. And those kinds of phrases should start putting up red flags in people's heads to say are you okay? Are you having issues? So, those patients can get some help.

Host: Yeah. And if we can't, as you say, sort of identify that dependency ourselves, family members, friends, things like that. And I wonder maybe during the pandemic, it's been difficult because there's been so much distancing and people haven't been around each other. And I wonder if maybe there's even been a rise in a way, or, you know, more dependency and not being diagnosed by those family members or friends simply because people just haven't been around each other.

Dr. Walker: Absolutely. I mean, Tele-health is a wonderful tool that we have learned how to utilize in a much better way in the midst of this COVID pandemic, but sometimes a face to face, you know, holding a hand, putting a hand on somebody's shoulder can go a long way of getting patients to tell you something they're really concerned or really struggling with where you may not see it through a video screen.

So, absolutely. And with this, we're all more stressed out. We're more worried. We're isolated, we're more depressed. There's a lot of psychological ramifications of this pandemic, which only makes chemical dependency and addiction significantly worse.

Host: Definitely, I think you're so right. And when we talk about these painkillers that we've had, I think we've all been there where we've been prescribed something and because we were perhaps worried about becoming dependent, we didn't end up taking them all because we didn't need them. And so we've got a bunch of, you know, half used pill bottles in our medicine cabinet. How should we store or dispose of painkillers?

Dr. Walker: Great. Great question. And this is something we've been researching for the last five years. We're starting to recognize what people might actually need after their fill in the blank type of surgery. So, we're starting to prescribe significantly less, because we found on average people only used about 15% of what they were prescribed.

So, let's say you were given a hundred pills. You use 15 of them. You still have 85 of them lying around and that's probably not a good thing. So, number one is we have drastically reduced the number of pills we're dispensing at discharge after our surgery, for instance, but to your question, how they should be stored? People that do use these medications chronically, they need to be in a protected place. I recommend people get a lockbox, a safe, very few people should have access to that. And they should be trusted people because unfortunately there's people out there that want these medicines and if they know you have them, they're going to take them from you. Now, the other thing is when you have leftover pills and you don't need them, there are ways of disposing them. One of the things we've done in our system here is we develop these dropbox systems near our pharmacy. So, patients can come and safely just, we tell them to scratch out their name on their prescription bottle and just put the prescription bottle with the pills in there.

And we destroy them. We basically incinerate the medications every so often. Typically in communities, the DEA and DHECK programs, which is one of our legislative bodies in our state, they do these drug take-back programs where you can show up and they typically do a big, you know, tractor trailer in a parking lot, and people come and you just give them the pill bottles.

We destroy them and we incinerate those medications. But I tell people if you're really worried, concerned, there's a couple things you can do that are safe. We used to say never flush medicines. What we found with the DEA and working with our regulatory and governmental body saying it's probably safer for us to flush these things versus just letting them get out on the street.

So, I tell people any opioid based medication you're worried about, you can flush them. The other simple thing I tell people to do, if you happen to have a cat, take some of that cat litter. Put the pills in the cat litter and pour some water over it. It turns it into a giant block. You can actually throw it into the trash can, cause it actually deactivates the chemicals in the medications.

So, those are some real, simple, safe ways to do it. Not uncommonly now our pharmacy colleagues are actually giving patients these types of bags, which is similar to the cat litter, where you can dispose of the medications as well. So, it's always great just to ask your healthcare provider, ask your pharmacist, ask anybody that will answer the question for you. Cause there are definitely ways of disposing your medications safely now because we know it's critically important.

Host: Yes, so critical, and we don't want people throwing them in the garbage, because as you say, if people knew or suspected that you had those things, they may be going through your garbage, and I know locally here where I live, our police department has a dropbox and I'm sure that's probably the case for many.

Dr. Walker: Absolutely. And our police departments here do the same. We have found some patients are uncomfortable going to the police departments, which is totally understandable. So, that's why we actually put them in our pharmacies. But yes, our police department has been very active in supporting in this topic and they're willing to help us.

And honestly, they actually help us with some of the disposal when we take them to get them incinerated. So, they're very forward thinking on this, very helpful, and we appreciate all their help in this.

Host: Yeah, definitely. This has been so educational today. You are just a wealth of information. And you get it out so quickly. I love it. Doctor, as we wrap up here, what are your takeaways when it comes to opioids and the addictions, misconceptions, everything else? What are your takeaways today?

Dr. Walker: So, number one, I want everyone to know that addiction is real. It's a medical condition. It's a brain disease. It affects all of us, no matter where you come from, what your ethnic background, what your socioeconomic status is, you are not protected against it. So, please be aware of this. Opioids have a place in medicine. It should not be as ubiquitous as the term I typically uses maybe the way we thought years ago, but they need to be used and used effectively and correctly. And that's where our goals are, is a we're very focused on making sure the patients get the appropriate treatments, but not inappropriate treatments.

Host: Yeah and as you say, opioids may still be appropriate. Right? But they may not always be appropriate. So, education is key, understanding the why, as you mentioned earlier, so again, really great having you on today and you stay well.

Dr. Walker: Thank you, Scott, you have a great day.

Host: That's Dr. Kevin Walker. He's a Pain Medicine Specialist with PRISMA Health and for more information and other podcasts, just like this one, head over to Prismahealth.org. This has been Flourish, a podcast brought to you by PRISMA Health. I'm Scott Webb. Stay well.