Selected Podcast
The Opioid Epidemic from an Emergency Medicine Physician's Perspective
The nation’s opioid epidemic is regularly in the news but now you can hear about it from an Emergency Medicine physician's perspective. Dr. Pete Mikkelsen, Medical Director of the Emergency Department at Pullman Regional Hospital, provides useful information on the crisis.
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Learn more about Pete Mikklesen, MD
Pete Mikkelsen, MD, Emergency Medicine
Pete Mikklesen, MD, joined Pullman Regional Hospital in 2003. He has been Medical Director of the Emergency Department since 2011. His professional interests are compassionate emergency medical care and healthcare leadership.Learn more about Pete Mikklesen, MD
Transcription:
Prakash Chandran (Host): The opioid epidemic in America has claimed hundreds of thousands of lives over the last two decades. Chances are, you can think of someone you know who's been touched by this type of addiction. Today we'll talk about how opioid use became so pervasive and what we can do to help those who are struggling. Here with us to discuss is Dr. Pete Mikkelsen, the Medical Director of Emergency Services at Pullman Regional Hospital. Dr. Mikkelsen, thanks so much for being here today.
Dr. Pete Mikkelsen, MD (Guest): Oh, it's my pleasure. Thank you.
Prakash: First of all, can you explain what exactly an opioid is, and tell us what initially caused the epidemic.
Dr. Mikkelsen: Sure. I think a lot of people have an idea of what opioids are, but basically they're pain medications that are derived from the opium poppyseeds, and some of them are still natural, and some of them are synthetic opioids. And they act in a certain way on the body, but primarily people take them to help with pain, and they do cause some euphoria or some feeling of well-being as well.
Some common examples that you may have heard of are morphine or Dilaudid for injectable opioids, and then some medications that people take are Hydrocodone or Vicodin, Lortab, Percocet, things like that. And additional opioids are all the way to heroin and Fentanyl.
Prakash: There seem to be quite a few of them, so why did doctors prescribe so many opioids?
Dr. Mikkelsen: I can speak primarily to the opioid epidemic and a little bit of the history, at least in the United States. I'm almost twenty years into my career in medicine, and so I've been able to see this sort of evolve. And it really started back in 1980, a letter to the editor in the New England Journal of Medicine, that really minimized the risk of addiction from doses of opioids. And what they were really talking about were pain medications that you receive for a painful condition, and they looked at people and whether or not they became addicted to them, and they found out that it was relatively rare.
So if you were in the hospital, and you got a couple doses of say morphine after a surgery, you were relatively unlikely to develop an opioid addiction. However, what happened with that letter is that it was used to promote using opioids for chronic pain. And as a lot of people have seen in the press lately, that big pharmaceutical companies promoted the use of long-acting opioids to treat chronic pain, and that led to a lot of difficulties with addiction.
Somewhere around in the 2000's, then there was a strong effort to evaluate patients' pain, whether it was acute pain or chronic pain, and they even called it the fifth vital sign. Pain is a subjective measure, it really isn't a vital sign such as your blood pressure or heart rate, but it was measured as that. And so because we were asking people about their level of pain, it was implied that we would then do something about it, and a lot of people feel that further promoted the use of opioids, and prescription opioids specifically.
Then we saw a major increase in the opioids prescriptions around that time, from 2000 to say 2012, and even ongoing today, about a fivefold increase during that time which is unfortunate because it led to a lot of addiction, a lot of overdoses, and to the crisis that we're experiencing today.
Prakash: So what is emergency medicine doing to combat this problem?
Dr. Mikkelsen: I think going back even to combat it, I think emergency medicine is almost a little bit like the canary in the coal mine for a lot of the emerging drug problems in the country. And we began seeing overdoses and people withdrawing from their opioids or narcotics quite a while ago, and there started to be some action taken by emergency medicine in the state of Washington, and also across the country, trying to educate the population about the role of emergency physicians and the emergency department in managing chronic pain, and trying to limit that and have that pain managed through primary care offices or pain specialists, and really trying to limit the number of prescriptions that emergency- that patients receive for narcotics from the emergency department, or opioids.
There still is certainly a role for prescribing opioids for acute injuries and acute problems, but the management of chronic pain out of the emergency department is really something we try to avoid. In many states we have what's called a prescription monitoring program where we're able to see any prescriptions filled by our patients for controlled substances, so many of those are opioids in addition to other substances, and that helps us understand if patients are going to multiple providers, maybe not going the usual channels to achieve their pain management.
Prakash: And for those who may have an addicted friend or family member, what can they do to help?
Dr. Mikkelsen: Sure. This is a very difficult problem in the country, and locally as well. 30,000 Americans die every year from opioid overdose. In fact, in 2016 it peaked at 42,000 Americans died from opioid overdose, and the majority of those are from prescription opioids. And I think most people know somebody or have a family member who's been affected by this. Many more people are affected by opioid abuse certainly than actually overdose, so this is affecting a lot of American lives.
It's one thing that we've started to look at over the last few years, say if we see somebody in the emergency department and we're concerned that they may be misusing opioids, then we really need to start looking at that as a disease and not as a problem for us. Starting to move people towards treatment options to help them overcome their disease.
And so there's the treatment aspect of seeking treatment for opioid use disorder, and the other part is the being prepared for potential overdose. And so a lot of experts are now recommending that family members and friends of folks with opioid use disorder or opioid addiction have access to a reversal agent such as Narcan or Naloxone, and this is a medication that if you discover someone who's overdosed, you can basically treat that patient, and there are many lay people that have the ability to do this in addition to our police force here in Pullman and certainly emergency medical providers, EMS, first responders.
The Narcan or the overdose kits require a prescription in Washington state, however in Idaho, it's an over-the-counter medication. You can request it from a pharmacy and receive it there.
Prakash: You mentioned the potential signs of overuse to look out for, and this is certainly something that emergency physicians as yourself might be able to spot, but for a friend and family member, how can they identify that? What are the signs that they should look for?
Dr. Mikkelsen: For overuse or addiction, there are lots of signs of addiction. Basically if it's affecting your life, if the use of opioids has a negative effect on your life, then that's a problem. But I think what you're asking more is about the acute overdose, if somebody takes too much, and what you'll see is all the way to the end where they stop breathing. There are lots of videos on this, YouTube videos and things, where you can see actually- visualize somebody who's overdosed on opioids.
And typically what ends up happening is that the medication depresses the respiratory drive, or your drive to breathe, and that leads to a cascade of events that can eventually lead to death. So as a lay person, you want to see somebody who if you see them, they're not responsive, you sort of try to move them to see if they respond to you, they don't. Especially if they're salivating, if they have real small pupils, that could be an opioid overdose. A lot of times there are signs, there may be pill bottles around, or needles, or other signs of injecting opioids on the arms or other places on the body as well. That's an opportunity to really save somebody's life by providing the Narcan in addition to calling 911.
Prakash: Well Dr. Mikkelsen, thanks so much for your time. This has been extremely helpful. For more information, please visit www.PullmanRegional.org. That's www.PullmanRegional.org. This is The Health Podcast from Pullman Regional. I'm Prakash Chandran, thank you so much for listening.
Prakash Chandran (Host): The opioid epidemic in America has claimed hundreds of thousands of lives over the last two decades. Chances are, you can think of someone you know who's been touched by this type of addiction. Today we'll talk about how opioid use became so pervasive and what we can do to help those who are struggling. Here with us to discuss is Dr. Pete Mikkelsen, the Medical Director of Emergency Services at Pullman Regional Hospital. Dr. Mikkelsen, thanks so much for being here today.
Dr. Pete Mikkelsen, MD (Guest): Oh, it's my pleasure. Thank you.
Prakash: First of all, can you explain what exactly an opioid is, and tell us what initially caused the epidemic.
Dr. Mikkelsen: Sure. I think a lot of people have an idea of what opioids are, but basically they're pain medications that are derived from the opium poppyseeds, and some of them are still natural, and some of them are synthetic opioids. And they act in a certain way on the body, but primarily people take them to help with pain, and they do cause some euphoria or some feeling of well-being as well.
Some common examples that you may have heard of are morphine or Dilaudid for injectable opioids, and then some medications that people take are Hydrocodone or Vicodin, Lortab, Percocet, things like that. And additional opioids are all the way to heroin and Fentanyl.
Prakash: There seem to be quite a few of them, so why did doctors prescribe so many opioids?
Dr. Mikkelsen: I can speak primarily to the opioid epidemic and a little bit of the history, at least in the United States. I'm almost twenty years into my career in medicine, and so I've been able to see this sort of evolve. And it really started back in 1980, a letter to the editor in the New England Journal of Medicine, that really minimized the risk of addiction from doses of opioids. And what they were really talking about were pain medications that you receive for a painful condition, and they looked at people and whether or not they became addicted to them, and they found out that it was relatively rare.
So if you were in the hospital, and you got a couple doses of say morphine after a surgery, you were relatively unlikely to develop an opioid addiction. However, what happened with that letter is that it was used to promote using opioids for chronic pain. And as a lot of people have seen in the press lately, that big pharmaceutical companies promoted the use of long-acting opioids to treat chronic pain, and that led to a lot of difficulties with addiction.
Somewhere around in the 2000's, then there was a strong effort to evaluate patients' pain, whether it was acute pain or chronic pain, and they even called it the fifth vital sign. Pain is a subjective measure, it really isn't a vital sign such as your blood pressure or heart rate, but it was measured as that. And so because we were asking people about their level of pain, it was implied that we would then do something about it, and a lot of people feel that further promoted the use of opioids, and prescription opioids specifically.
Then we saw a major increase in the opioids prescriptions around that time, from 2000 to say 2012, and even ongoing today, about a fivefold increase during that time which is unfortunate because it led to a lot of addiction, a lot of overdoses, and to the crisis that we're experiencing today.
Prakash: So what is emergency medicine doing to combat this problem?
Dr. Mikkelsen: I think going back even to combat it, I think emergency medicine is almost a little bit like the canary in the coal mine for a lot of the emerging drug problems in the country. And we began seeing overdoses and people withdrawing from their opioids or narcotics quite a while ago, and there started to be some action taken by emergency medicine in the state of Washington, and also across the country, trying to educate the population about the role of emergency physicians and the emergency department in managing chronic pain, and trying to limit that and have that pain managed through primary care offices or pain specialists, and really trying to limit the number of prescriptions that emergency- that patients receive for narcotics from the emergency department, or opioids.
There still is certainly a role for prescribing opioids for acute injuries and acute problems, but the management of chronic pain out of the emergency department is really something we try to avoid. In many states we have what's called a prescription monitoring program where we're able to see any prescriptions filled by our patients for controlled substances, so many of those are opioids in addition to other substances, and that helps us understand if patients are going to multiple providers, maybe not going the usual channels to achieve their pain management.
Prakash: And for those who may have an addicted friend or family member, what can they do to help?
Dr. Mikkelsen: Sure. This is a very difficult problem in the country, and locally as well. 30,000 Americans die every year from opioid overdose. In fact, in 2016 it peaked at 42,000 Americans died from opioid overdose, and the majority of those are from prescription opioids. And I think most people know somebody or have a family member who's been affected by this. Many more people are affected by opioid abuse certainly than actually overdose, so this is affecting a lot of American lives.
It's one thing that we've started to look at over the last few years, say if we see somebody in the emergency department and we're concerned that they may be misusing opioids, then we really need to start looking at that as a disease and not as a problem for us. Starting to move people towards treatment options to help them overcome their disease.
And so there's the treatment aspect of seeking treatment for opioid use disorder, and the other part is the being prepared for potential overdose. And so a lot of experts are now recommending that family members and friends of folks with opioid use disorder or opioid addiction have access to a reversal agent such as Narcan or Naloxone, and this is a medication that if you discover someone who's overdosed, you can basically treat that patient, and there are many lay people that have the ability to do this in addition to our police force here in Pullman and certainly emergency medical providers, EMS, first responders.
The Narcan or the overdose kits require a prescription in Washington state, however in Idaho, it's an over-the-counter medication. You can request it from a pharmacy and receive it there.
Prakash: You mentioned the potential signs of overuse to look out for, and this is certainly something that emergency physicians as yourself might be able to spot, but for a friend and family member, how can they identify that? What are the signs that they should look for?
Dr. Mikkelsen: For overuse or addiction, there are lots of signs of addiction. Basically if it's affecting your life, if the use of opioids has a negative effect on your life, then that's a problem. But I think what you're asking more is about the acute overdose, if somebody takes too much, and what you'll see is all the way to the end where they stop breathing. There are lots of videos on this, YouTube videos and things, where you can see actually- visualize somebody who's overdosed on opioids.
And typically what ends up happening is that the medication depresses the respiratory drive, or your drive to breathe, and that leads to a cascade of events that can eventually lead to death. So as a lay person, you want to see somebody who if you see them, they're not responsive, you sort of try to move them to see if they respond to you, they don't. Especially if they're salivating, if they have real small pupils, that could be an opioid overdose. A lot of times there are signs, there may be pill bottles around, or needles, or other signs of injecting opioids on the arms or other places on the body as well. That's an opportunity to really save somebody's life by providing the Narcan in addition to calling 911.
Prakash: Well Dr. Mikkelsen, thanks so much for your time. This has been extremely helpful. For more information, please visit www.PullmanRegional.org. That's www.PullmanRegional.org. This is The Health Podcast from Pullman Regional. I'm Prakash Chandran, thank you so much for listening.