What Becoming a Patient Taught Me About America's Problem with Opioids | November 30, 2021

February 08, 2022

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Travis N. Rieder, PhD, is the Assistant Director for Education Initiatives, Director of the Master of Bioethics degree program and Research Scholar at the Berman Institute of Bioethics. He is also a Faculty Affiliate at the Center for Public Health Advocacy within the Johns Hopkins Bloomberg School of Public Health. A philosopher by training, bioethicist by profession, and communicator by passion, Dr. Rieder is also author of In Pain: A Bioethicist’s Personal Struggle with Opioids.

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00:46So let me
00:46go ahead and get started as
00:48folks are joining good afternoon.
00:49I'm David Fiellin,
00:50I'm director of the Yale Program
00:53in addiction medicine and I want
00:55to welcome you to today's talk in
00:57our finding solutions to the opioid
01:00crisis speaker series in collaboration
01:02with the Sandgaard Foundation.
01:04We're joined today by Dr. Travis Rieder,
01:06who will speak on the topic,
01:08but becoming a patient taught me
01:10about America's problem with opioids.
01:12Before we get started,
01:14we just want to review.
01:15A few housekeeping items on
01:17the following slides.
01:20So as a reminder, you can learn
01:23more about the program in addiction
01:25medicine and the finding solutions to
01:28the opioid crisis speaker series by
01:30visiting addiction medicine.yale.edu.
01:32Following our program in the Sandgaard
01:35Foundation on Twitter at
01:38@YaleADM and at @SandgaardFnd.
01:40And by joining our program listserv,
01:43please just email emma.biegacki@yale.edu
01:45to be added.
01:48If you'll be live tweeting
01:50about today's talk,
01:51be sure to tag us and include
01:53event hashtags at finding solutions
01:55and at band together.
02:00Second, as a reminder,
02:01coming up in this series on December 7th
02:04will be welcoming Doctor Edward Coupet
02:07and Doctor Don Stader, 2 emergency
02:09Medicine Physicians who will be
02:11speaking on emergency department based
02:13treatment and harm reduction efforts.
02:15For opioid use disorder this talk
02:17will provide information on national
02:19efforts supporting Ed initiated
02:21buprenorphine and the Colorado not
02:24naloxone project with which the
02:26Sandgaard founded is involved to
02:28participate in today's session.
02:31Use the chat box to share comments and
02:34observations with your fellow attendees
02:35and post your questions in the Q&A box.
02:41Finally, CME is available for today's event.
02:44To receive credit, please text the
02:46code and read to the number in read.
02:49This information will be provided in the
02:51chat at the beginning of the session.
02:55Now I'd like to introduce Kyle Henderson,
02:57executive director of
02:59the Sandgaard Foundation,
03:00to say a few words and cheer about
03:03the mission work of the foundation.
03:05Thank you David and thank you
03:07everyone for joining us today,
03:08especially Travis.
03:09Very excited to hear from you.
03:12The Sandgaard Foundation was
03:13founded just three years ago,
03:15but its story starts about 25 years ago.
03:18So Thomas Sandgaard founded Zynex Medical,
03:21which is a publicly traded medical device
03:24company that helps with pain management.
03:26So it actually gets people off of.
03:30So addictive painkilling
03:31drugs like Oxycontin.
03:33So through that mission and the
03:36share loss of life that we both
03:38seen through the opioid epidemic,
03:40he was inspired to start the foundation.
03:42The Sandgaard foundation,
03:43so our exclusive mission is fighting
03:46the opioid epidemic and we're honored
03:49to work with groups like the Yale
03:51University Program in Addiction Medicine.
03:54And some other wonderful groups like
03:57the Voices Project where we've helped
03:59to distribute over 500,000 units
04:00of maloone since January 1st.
04:03We're also involved in films and concerts,
04:06but all aligned with this mission,
04:09so again, it's been a wonderful hosting.
04:11These events with Yale and we
04:12couldn't do it without them.
04:14We've had some wonderful speakers
04:16and you can watch some of our
04:18previous videos by reaching out.
04:19We can get you those details,
04:20but we're we're honored to
04:22have Travis with us today,
04:23and we can all dive into this.
04:26This narrative.
04:26Further and hopefully we can all
04:28learn something from each other.
04:30Then again,
04:30thank you Travis and thank you
04:31all for having us.
04:34Thank you Kyle.
04:35So now I'd like to introduce our
04:37speaker today, Doctor Travis Rieder,
04:38who is an assistant professor and
04:40director of the Masters of Bioethics
04:43degree program and a research
04:44scholar at the Berman Institute for
04:46Bioethics at Johns Hopkins University.
04:48He's also a faculty affiliate affiliate
04:50at the Center for Public Health Advocacy
04:53and holds secondary appointments
04:55in the Department of Philosophy
04:57and Health Policy and Management.
04:59Doctor writers work falls into
05:02two distinct research programs,
05:03only one of which I think he's
05:05going to speak about today.
05:06The first concerns ethics and policy
05:09questions about sustainability,
05:10planetary limitations, and climate change.
05:14A second concerns Americas overdose
05:17epidemic and policy issues surrounding
05:20prescription and illicit opioids.
05:22Dr Writer has written on
05:24physician responsibility for safe,
05:25safely prescribing and tapering opioids,
05:28as well as ethical considerations
05:30in pain management is author of
05:32the book in Pain,
05:33a bioethicist personal struggle with opioids.
05:36That was published in 2019.
05:39Doctor writer also sits on the National
05:41Institute on Drug Abuse National
05:43Advisory Council on drug abuse.
05:45And so it's with pleasure that
05:47we introduce Kyle to you today.
05:49I'm sorry Travis to you today, Travis.
05:51Go ahead.
05:53Thank you, David.
05:54Thank you for that introduction.
05:56Thanks Kyle for you and your
05:58institute support and the whole
06:00team who brought me here today.
06:01Go ahead and share my screen here.
06:04There we are.
06:06So here's plan for today.
06:09I'm a bioethicist by profession,
06:12so my my day job is when you think
06:14of as doing medical ethics and
06:16public health ethics working with
06:19science and health policy and by
06:21what this is love case studies,
06:24we need something to hang onto
06:27to try to help figure out.
06:30How to reason?
06:31Through difficult ethical
06:32and policy dilemmas?
06:34But I always tell my students there
06:36is a challenge with case studies.
06:37They can be cartoons,
06:38they can be very shallow and then they
06:40actually don't tell us very much at all.
06:42And in the worst case they can backfire.
06:44So we want really rich case studies.
06:47What that means is part of my
06:48job is storytelling and I'm
06:50going to do some of that today.
06:51Fortunately slash unfortunately,
06:53as you'll hear,
06:54I have a really good case study where
06:57I have a lot of rich detail because
06:59that case study is mine and so the first,
07:02third or so at the talk is
07:03going to be giving you.
07:05This rich,
07:05detailed case study and then we're
07:07going to spiral out from there,
07:09and so we're going to start with
07:11this case study and Part 2 of the
07:13talk is going to be trying to draw
07:16some generalizable lessons from my
07:18potentially idiosyncratic experience.
07:20You know,
07:20wouldn't want to try to draw a
07:22generalizable lessons from an F1,
07:24and so provide some data,
07:26provide some background,
07:26and figure out where I might
07:28have actually discovered some
07:29cracks in the healthcare system.
07:31So that's Part 2 and then Part 3 as well.
07:34I mean, ethicist.
07:36So if you're a hammer,
07:37you see everything as a nail,
07:39so I want to think about an
07:41actual moral framework that
07:42could help people doing some of
07:44the work that I'm talking about.
07:46And so there are a lot of ways that
07:48we can think about the work that needs
07:49to be done when it comes to opioids,
07:51and I'm only going to have
07:53time here to focus on one,
07:54so I will talk about prescribers
07:56in that third section.
07:57Of course you can extrapolate from
07:59that if you are a patient or if you're
08:01a pharmacist or if you're another
08:03clinician who works with prescribers.
08:04But I'm going to try to think about
08:06what it means to be a responsible.
08:07Prescriber of drugs like opioids,
08:11so that is the preview.
08:13Importantly,
08:14I have nothing to disclose in terms of
08:17financial interests that would conflict me.
08:19So let us begin.
08:20So here's part one part one
08:23is the personal case study,
08:25and as you might gather from the picture,
08:26it has to do with the motorcycle.
08:29And the story is feeling older and
08:31older as I give versions of this talk.
08:33May 23rd,
08:342015.
08:35This was the Saturday of Memorial Day
08:39weekend. And it was going
08:41to be a gorgeous day.
08:42And so the goal was to take my motorcycle
08:45out and meet up with my buddy Nathan.
08:47And we were going to go down
08:49into the beautiful hills of
08:51Shenandoah Valley to Skyline Drive.
08:53So this was the goal.
08:54This was from an earlier trip of the
08:56same route and Skyline Drive is gorgeous.
08:59If you've never done it,
09:00it's really fun on a motorcycle.
09:02So this repeat was the goal.
09:05It's not what happened, however.
09:07On May 23rd, 2015.
09:09I made it about three
09:11blocks away from my house.
09:14Still in my neighborhood
09:15and early in the morning,
09:17young kid hadn't had his coffee
09:20yet blew a stop sign and pulled
09:22out as I drove by and T boned me
09:25on the left side of my motorcycle.
09:28So with the orthopedic trauma
09:30surgeon would hypothesize later
09:32kind of given my description.
09:34Not everything happened very fast,
09:36but it looked like my left foot got just,
09:39you know.
09:40Momentarily,
09:41just for a split second crushed
09:43between the bumper of the van and
09:45the fairing of the motorcycle.
09:48And so this was the result.
09:51Now,
09:51just in case not everyone in the
09:53audience is a you know radiologist.
09:56I will say that's not what an X ray
09:58of a foot is supposed to look like.
10:00If you look at the second and
10:03third metatarsals here you can see
10:05they broke pretty cleanly through.
10:07They actually started to come
10:08out through the top of my foot,
10:10but the real damage was the great toe
10:13first metatarsal just shattered and
10:15all of these bone shards became shrapnel.
10:18Just blew a hole out the inside of my foot.
10:21And so by the time I stop
10:23sliding on the ground,
10:25I was in blinding pain
10:26trying to rip off my boot,
10:28get the boot off my sock had torn
10:31and I could see inside my foot.
10:33It kind of folded in half and
10:35I could see tendon and bone and
10:38bone Shard and that was when I
10:40knew I was in a bit of trouble.
10:43So that's how May 23rd started.
10:48What was going to unfold
10:50over the next several weeks?
10:51Was my initial trauma team had
10:54to decide discover whether or
10:57not my foot was salvageable.
10:59So I was in a limb salvage situation.
11:01The immediate threat was amputation.
11:03My surgeon hoped that they could
11:05get away with a transmetatarsal
11:07amputation or transmit,
11:09which means I get to keep the bottom of
11:12the the back half of my foot and the heel.
11:15But there was some threat with
11:16all the soft tissue damage.
11:17If it couldn't vascular eyes
11:18if it started to die.
11:19So I would I would actually
11:21lose all of my foot.
11:22So that was the threat.
11:22Of course,
11:23that was a very scary thing to hear
11:25for someone who who powers before
11:28days before was perfectly healthy.
11:31So we tried our best to look
11:34down the road at Reconstruction.
11:37Now I've started to actually start
11:40doing talks in person again,
11:41so after a year and a half of zoom I
11:43got really accustomed to this where
11:44I can keep you in suspense longer,
11:47but it seems unfair.
11:49But yeah,
11:49when I'm up on stage you can see me
11:50strutting around like I own the place.
11:52And then you know.
11:54That spoiler alerts I I got to keep my foot.
11:58It's not a it's not a fancy prosthetic,
12:01it's a very,
12:02very incredible series of surgeries that.
12:07Proved to me that my medical teams
12:09I would end up having teams of three
12:11different hospitals were sophistically
12:13very sophisticated in terms of their their
12:15the practice of medicine were incredibly
12:18good and so the initial 5 surgeries that
12:21I had were the LEM salvage surgeries.
12:24I would have another six months or so later.
12:27After all of the swelling had gone down,
12:29and it could reshape the foot so
12:30that I could get into regular shoes
12:32and work on my gates, etc.
12:34But the first five were am I
12:36going to get to keep my foots?
12:38And what's most important about this
12:40is I had been afraid of amputation.
12:44Because I felt like such a scary loss
12:47for someone who had never considered it.
12:49But what I hadn't known and and what
12:51I wouldn't really have the kind of
12:53wherewithal to even think through or realize,
12:56is that reconstruction carries its own risks,
12:58because instead of having one or
13:01maybe two initial big surgeries
13:03and then immediately work through
13:05a starting the work of recovery,
13:07I was going to go down this long road
13:09of multiple surgeries spread out over
13:12many weeks until they figured out what
13:14to do with this major wound in my foot,
13:16which kept getting bigger as tissue
13:17died and surgery surgeons would cut
13:19away the necrotic tissue every time.
13:21They went in.
13:23I would either be in the hospital or
13:24or take home a affordable wound vacs.
13:26This negative pressure device to
13:28fill the wound and so every few
13:31days I'm having surgery and having
13:33new newly acute post surgical pain.
13:35But even between that I have nurses
13:37coming every day or every other
13:39day to change the wound VAC.
13:40So basically pulling sponge out
13:42of a hole in my body.
13:45It's it's the stuff of nightmares.
13:47Every once in awhile I would start bleeding
13:49and they'd have to go in and cauterize.
13:51Try to find what what's
13:53bleeding and fix that.
13:55All of that is to say,
13:56not just to horrify you.
14:00It's to say that the process became
14:02one very stretched out of very severe,
14:05ongoing, newly acute pain.
14:06The sort of pain that does tend to
14:09respond well to opioids and feels
14:11like it constantly needs opioids.
14:13Always flirting with six out of 10.
14:15Seven out of 10 one night in the hospital,
14:17a 10 out of 10 on the pain scale.
14:19When I got behind the pain,
14:21that's the sort of life that I
14:23had over the course of weeks.
14:25And so. I go through this period
14:30of continued surgeries surgery.
14:33#5 is the big one if you've never thought.
14:36I know this is a largely clinical audience,
14:38but if you've never thought about
14:40the fact that sometimes you have
14:41large holes in your body after trauma
14:42and you figure out to close it,
14:44that's a problem, right?
14:45So I didn't know how they were going to
14:47close this wound where you can no longer,
14:49you know,
14:49pull the skin and and suture it
14:51and it turns out the solution
14:53to that was a free flap surgery.
14:55So I had a surgical team.
14:56Several surgical teams rotate
14:58through for a long surgery.
15:00And take muscle,
15:01fat,
15:01skin and artery for blood supply
15:03and a nerve so that I could
15:06eventually develop sensation.
15:07Take all of that from my thigh and use it to.
15:11I'm pretty sure this is the medical jargon.
15:13Plug the hole in my foot and make
15:16my foot out of part of my thigh
15:18which was pretty incredible.
15:21After surgery number 55 days in the ICU
15:24with yet another new trauma site on my thigh,
15:27the new surgical site.
15:30More post surgical pain.
15:32A big escalation in constantly
15:36escalating painkillers.
15:37Now,
15:37in addition to the Ivy and oral opioid
15:40medication that I've been on and
15:42been escalating for several weeks,
15:44they now had gabapentin.
15:45I've got some some unresolved
15:47nerve nerve pain,
15:48probably where they clip that
15:49nerve out of my thigh.
15:50The gabapentin seemed to do the job,
15:53so that was an addition.
15:55And ten days after surgery,
15:57#5I finally get to go home.
16:00And when I get to go home,
16:02I'm given exactly 1 instruction and
16:05that is instruction regarding my pain,
16:08and that instruction is don't
16:09get behind the pain.
16:11So I am a very good patient and I go
16:15home and every 12 hours I take my oxy contin.
16:18The extended release oxycodone.
16:20Every four hours.
16:22I take my oxycodone IR.
16:24Every six hours,
16:25I think it was I take my gabapentin.
16:28And I watched the clock.
16:30Beautifully take my pills.
16:32They do Peter out pretty regularly.
16:34I start to have more pain sooner,
16:37especially in those early days.
16:39After getting home,
16:39I call the prescriber and he'd say,
16:41yeah, you're developing tolerance.
16:42Fill up the dose IR oxycodone 1015 to 20.
16:47Oxycontin 15 to 20 etc.
16:50And that's how we live for another
16:52month after these weeks and
16:54five surgeries in the hospital.
16:58So.
17:01I. Go back to my orthopedic trauma
17:04surgeon two months after the accident.
17:06I haven't seen him in a long time.
17:07His job was to pull all these bone
17:09charts together right as he put it to me,
17:11rebuild the the pole of the tent
17:13to hold up everything else.
17:16Hadn't seen him in a while.
17:17This is my first check in.
17:18He's going to take new X rays,
17:20see how the bones are healing,
17:21maybe talk about with
17:22our going to walk again.
17:23He's super impressed with
17:24how the free flap is ceiling.
17:26Asking me about my pain when
17:28I'm doing for it.
17:28My partner Saudi and I kind of doing
17:32the math on Oxycontin oxycodone.
17:34Go pentin and we give him the plan.
17:38What we've been doing very
17:39dutifully and he stops.
17:41All of a sudden very distressed and
17:44says Travis it's it's been too long.
17:46It's that's way too much.
17:48You need to be off the medication by now.
17:53And that was the 1st that anyone
17:57said anything to me about problematic
18:00long term use of opioids about risks,
18:04about a need to get off of them
18:05sooner rather than later.
18:06Two months after the accident,
18:08he was the first person to make
18:10any of those comments.
18:11So given the audience,
18:11some of you might want to know
18:13how much I was on.
18:13I would not do this math until
18:15much much later when I learned
18:16about Emmys and me conversions.
18:18So it turns out I was on about 170 to
18:21200 Emmys morphine milligram equivalents.
18:24Of oxycodone, plus the gabapentin.
18:27That was my daily use.
18:29Depending on how bad the pain was,
18:31if I had PT and took an extra
18:33dose of oxy etc.
18:34And I had been opioid naive 2 months prior.
18:37So my trauma surgeon was very concerned.
18:41He said I need to get off the
18:42opioids and I said, OK, I'm ready.
18:44How do I do it?
18:46And he said, well, look,
18:46you can't just stop cold Turkey.
18:48You go into withdrawal.
18:49You've been on this stuff for two months.
18:51But also in here. I'm paraphrasing.
18:53Also not my job like I didn't do this.
18:56I didn't prescribe all these pills,
18:58so who's who's your prescriber?
19:00And the answer was the plastic surgeon.
19:03So the next day we went to
19:05the plastic surgeon.
19:07The plastic surgeon had been
19:09really comfortable prescribing
19:10all of these pills right?
19:12He's the one who had had been
19:14constantly updating the prescriptions,
19:16so I've been taking home ever more bottles.
19:20And we go to him and tell him how
19:22concerned the orthopedic surgeon was,
19:24and he's just not that concerned.
19:25To be honest.
19:26He's like, well,
19:27look great if you think you're ready
19:28to get off. I mean always a good idea.
19:31So we ask how to do it and we should
19:34have known we were in a little bit
19:35of trouble when he did the thing
19:37where he he looked for the answer.
19:39In his eyelids you know the thing was
19:40like.
19:43And then he gave us a plan and the plan was
19:46we're going to take all of these pills,
19:49Oxycontin, IR, oxycodone and
19:51gabapentin and divide them into four.
19:54And starting tomorrow,
19:55starting the day after we see him,
19:57we're going to drop 1/4 of everything
19:59once a week to drop 25% that week.
20:02Week later dropped the next quarter,
20:04and so on, and we'd be off the
20:06meds in four weeks and I know that
20:09these talks sometimes wrong run
20:11longer than folks have time for,
20:13and so in case anyone is going to
20:15step out in the next few minutes
20:17and not get to the punchline,
20:18let me just say this part early.
20:21That was really bad advice.
20:25The the tapering regimen of 25% per week,
20:29especially without trialing it on the
20:32patient first to see how sensitive
20:34they are to dependence and withdrawal,
20:37is very aggressive and.
20:40Yeah, I sometimes tell Med students
20:43like if you want to torture somebody.
20:45This is like a really good plan actually.
20:46Get them dependent on opioids
20:48and then give them this regiment.
20:51And why do I say that this sounds
20:53very dramatic and it's because, well,
20:55sure like you could hurt somebody,
20:57maybe even worse by just taking
20:58their meds away.
20:59So you send them into really
21:01severe acute withdrawal.
21:02But the thing about a 25% every
21:04week for four weeks plan is that the
21:0725% in many patients is going to be
21:10enough to immediately send them into.
21:12Acute, moderate or severe withdrawal.
21:15But it's also gonna take four
21:18weeks to get through it.
21:20And so that's what happened to me.
21:23This this is not a like button.
21:25Don't worry,
21:25I'm not going to press this and
21:26make you listen to my Ted talk.
21:27That would be a very awkward
21:28way to give a talk.
21:29Instead I put this up to to signal that.
21:34Some years ago when I first told my story,
21:38I would regularly get invitations to
21:39come and like tell the withdrawal story.
21:42Can you just come and tell our
21:44clinicians what withdrawal is like?
21:45And I did. I did that a lot.
21:49It's hard, it's hard every time,
21:51and so I eventually decided I need.
21:53I need to have a way that this is
21:55accessible and I can feel like I'm
21:57doing meaningful work for trainees
21:59and not have to do this all the time.
22:01And so when Ted approached me,
22:03the Institute,
22:04not the person and asked if I would
22:07do this Ted talk. I said yes.
22:09Great high def.
22:10High quality audio, Open Access,
22:13free to everyone,
22:13and then I can stop doing this
22:15talk all the time.
22:16So 14 minutes if you want to
22:18hear the kind of dramatic.
22:19Version of of my story and where
22:22it goes from here you're welcome
22:24to use that and use it in training
22:26what I'm going to do,
22:27kind of protectively is give you a
22:29little bit more like the objective version.
22:31What I've learned as a researcher
22:32about my experience and
22:33what withdrawals like that's what you're
22:34going to do for the next few minutes,
22:36and then we will move on.
22:39So in in 2017 I finally got around to
22:41and and decided to publish a little bit
22:44of my experience with opioid withdrawal
22:47and the journal Health Affairs,
22:49so I did a little bit of narrative and
22:51then did some kind of policy analysis.
22:53You know, here's a problem for prescribers.
22:57The graphic artists that put put the full
23:00page image together to go with my story
23:02came up with this image and I thought,
23:05oh oh man.
23:06Somebody really understood it like, yeah,
23:09that's that's what withdrawals like.
23:12And So what I thought was so accurate
23:14about this is that especially especially
23:17extended withdrawal is like a vice
23:20that you know can close forever
23:23and never goes backwards.
23:24And you just assume that at some
23:27point it crushes you and you die.
23:29You don't really know how long it's going
23:32to take or how it's going to happen.
23:34Felt like a pretty impressive graphic,
23:37so here's here's a quick
23:40overview of opioid withdrawal.
23:43In general,
23:44withdrawal from a drug is very often.
23:48Accompanied by symptoms that are something
23:50like the opposite of the drugs effects.
23:52So what's happening in withdrawal is your
23:54brain is trying to reestablish homeostasis.
23:57Your brains are really good learning
23:59machine and so with with opioids,
24:01your opioid system has become accustomed
24:03to these exogenous opioids like so
24:05why do we have an opioid system?
24:07Well, we have endogenous opioids,
24:08right?
24:09Endorphins are so named because
24:11they are endogenous morphine,
24:12so we have an opioid system because
24:15our body makes some and then
24:17you pump it full of exogenous.
24:19Opioids and it tries to not freak
24:21out every time you you flood it with
24:24opioids and so that is the mechanism for
24:27tolerance and dependence formation your
24:30brain is trying to learn and stabilize.
24:31So now it's stabilized on a higher dose.
24:33Look tolerances protective.
24:34It's protecting you in the
24:36best case scenario,
24:37from overdosing so I would not want
24:41to take anything like the doses.
24:42I was on two months in now as an opioid
24:45naive person because my respiratory
24:48system I'm no longer tolerant.
24:50To the respiratory depression,
24:52right that I was at the time and so.
24:57What's happening in this is as you
25:00try to reestablish homeostasis.
25:02You are missing out on the good things
25:03that the drug was providing and sometimes
25:05being harmed in sort of opposite ways.
25:06And So what do opioids do?
25:08Well?
25:08Obviously their annual cheese, right?
25:10So the opposite of analgesics.
25:12Hyperalgesia.
25:13The first thing that happens?
25:16Well,
25:16that happened for me in withdrawal,
25:18was everything hurt immediately,
25:20so not only whatever you were
25:23medicating just catches on fire,
25:25but everything hurts your skin and your
25:28muscles and your bones and your joints,
25:30and it is the most miserable deep.
25:32And thorough pain that I've ever experienced.
25:37You know,
25:37some people say that withdrawal is like the
25:40flu because it has like the sniffles,
25:42and and obviously nausea. 2 right?
25:43So one of the things opioids do
25:45is they constipate you so you
25:47take away the Constipation and
25:49you get diarrhea and vomiting.
25:51You tend to get sweats and your internal
25:54thermostat kind of goes haywire side
25:56lay out in the summer sun and get chills
25:58but also sweat a few seconds later.
26:01So it's a really miserable experience.
26:02But the.
26:03The flu thing is weird, right? Because?
26:06It's like the worst case of flu
26:07you can imagine times 1000 and then
26:10these other symptoms keep stacking,
26:12so I've never felt pain the way
26:14that I did in withdrawal.
26:16What are some of the other
26:19experiences that you get from
26:20opioids while they're depressants?
26:22Right there said it is,
26:24and so one weird thing that happens
26:27is you get sort of hyperactive,
26:30not in any kind of productive sense,
26:32but you get like your muscles feel.
26:36Energize like there's electricity
26:37coursing through them,
26:38and you get restless in your arms and legs
26:40wanna kick and so that like jitteriness,
26:42that you see in movies sometimes about
26:44someone going through heroin withdrawal
26:46or whatever they like kick the bucket
26:48the the the story is that kick the bucket.
26:52Or kick the habit.
26:53Sorry,
26:54so it's wrong euphemism kick.
26:56The habit is like you have to kick through,
26:58right?
26:59'cause your legs are restless.
27:00It's the old story about
27:01that work that language.
27:05So that jitteriness also
27:07means you can't rest right,
27:09because every time you try to relax,
27:12you're you're wide awake and
27:14your muscles are kicking.
27:15So then you become insomniac and all that
27:17misery you're experiencing the pain and
27:18the flu like symptoms of nausea and vomiting.
27:21Diarrhea, like all of this happening,
27:2220 or 22 or 24 hours a day.
27:26But opioids also do another thing, right?
27:29They're euphoric, which is why
27:31they're the so called drug abuse.
27:34Not great language, but the idea meaning
27:36that they have addiction liability,
27:38'cause they give you a reward and so.
27:43The opposite of euphoria is what it's
27:46it's dysphoria described in some way,
27:48and so for me that was just
27:49crushing depression.
27:53The other.
27:54Really awful feature of opioids is that.
27:58The withdrawal from opioids
28:00gets worse with the increase in
28:04the percentage dose reduction.
28:07So what I mean by this is it's not a.
28:08It's not a raw volume decrease
28:11so that very sensible sounding
28:12like decreased 25% per week that
28:14you know even if it was too much.
28:17You maybe say like well,
28:1810% per week you know and you
28:20do it the same every week.
28:22The problem is that's 10% or 25% of the
28:25starting dose continued throughout,
28:27so let's just think about some math.
28:29So make it easy.
28:30Let's say you're on 100 milligrams
28:32of morphine.
28:32If you do that, 25% / 4 weeks,
28:34what happens is the first week
28:36is a 25% dose reduction.
28:37It's a lot.
28:38You'll probably go into
28:39withdrawal and it sucks,
28:40but the second week is,
28:42your brain has started to become
28:44accustomed to the new reality
28:45of 75 milligrams of morphine.
28:47So if I had known about withdrawal timelines,
28:50what I might have guessed is that
28:52at the end of week one I was
28:53getting close to coming out of it.
28:55The severity was going to start
28:57tampering down just reestablishing
28:59homeostasis.
29:00But then you drop the next dose,
29:01and so if you were back at the
29:03point where 75 is now the new
29:05normal we now 25 from 75 is at 33%
29:08dose reduction and a week later 25
29:10from 50 is a 50% dose reduction.
29:12And of course at some point you have
29:15to go from something to nothing.
29:17So the cruel joke of tapering is
29:19that it gets worse as you go on.
29:22And so I imagine folks in the
29:24audience some have worked in
29:26addiction medicine have have
29:28watched patients go through tapers.
29:30And find it harder and harder.
29:32It's not just the exhaustion,
29:34it's not just that it's been going
29:35on is that it gets harder and
29:37eventually you have to go from
29:39something to nothing and so that
29:41relapse at the end or they going
29:43back on a higher dose at the end is
29:45the most predictable thing in the
29:46world because it gets ever more miserable.
29:50The end of my story I'm going to come back
29:52to details later to try to learn lessons,
29:54but the end of my story is it
29:56gets worse for four weeks,
29:58and in that four week, 4th week.
30:01I've been calling everyone Saudi
30:03has been calling everyone.
30:04Nobody would help us.
30:06None of our prescribers very
30:07early on in the first week.
30:09As soon as the withdrawal got severe
30:11everyone kind of washed their hands at me.
30:13Nobody would take me on.
30:14Very common refrain was I don't
30:16deal with withdrawal maintenance.
30:17I don't deal with tapering.
30:20And so we just stuck it out.
30:23Because I had this belief that I
30:24I had endured so much suffering
30:26by the time I was a few days in
30:29that if I ever rescued myself by
30:30going back on the medication,
30:32I just never come off.
30:33That was, I knew this.
30:35I eventually said this out loud.
30:36This audio so that she knew
30:38that I believed this.
30:39But in the 4th week I was on my third
30:43night without any sleep at all.
30:44I was very very sick I I spent
30:49the whole night and on the
30:50bathroom floor trying to vomit.
30:52I hadn't eaten in days,
30:53so nothing was happening.
30:55It was just painful.
30:56It was just tearing my muscles on
30:58the inside and I spent the whole
31:00night that way not having slept
31:03and I was incredibly depressed
31:05and I believed about myself that
31:08I was just hopelessly broken.
31:10And so I started thinking about
31:12like 1 1/2 year old baby girl.
31:14How terrifying this will be
31:15if she remembers it.
31:16If if she has to live with me long
31:18enough to watch this as she grows up.
31:20Start thinking about my partner
31:22having to do all the work of raising
31:24a kid and caring for a husband
31:26while working full time and I said,
31:30yeah,
31:30I think it's probably time for
31:32me to check out.
31:33I'm not doing anyone any good,
31:34so I started thinking about with
31:36the withdrawal doesn't kill me soon.
31:37How do I?
31:38How do I do the job myself?
31:40And that was the moment
31:42that was scary enough.
31:43That I told Saddi when she woke up
31:46and we were both afraid and so we
31:49decided to go back on the medication.
31:52So deep into the 4th week,
31:54she got her new refill from the prescriber.
31:56He was very happy to give it to us
31:58because he would been worried about
32:00me and and and didn't know what to do.
32:03And so I sat my shiny new bottle
32:05of oxy code on on the night stand,
32:07and my plan was to take a pill
32:10every hour until it was enough
32:12to knock me out and I got some
32:13real sleep and that would be my
32:15new starting dose that was.
32:16That was the plan.
32:18But it's really stubborn,
32:19so I was going to make myself suffer just
32:20a little bit more before I rescued myself,
32:22because,
32:22like I have to try to
32:24fall asleep unmedicated
32:25for at least four hours.
32:26So I laid down to to just
32:29suffer for four more hours.
32:31And then I fell asleep. It was day 29.
32:35And the clock was running out on
32:39the withdrawal timeline and so.
32:42I woke up the next morning
32:44after about 6 hours of sleep,
32:46which is more than I had
32:48gotten in four weeks.
32:49And I certainly still felt very
32:50sick still in a lot of pain,
32:52but I everything had dialed back.
32:54I had rested and I knew that
32:56I could make it at that point.
33:03OK.
33:06First days after all this happened,
33:09I didn't want to think about it.
33:11I didn't want to talk about it,
33:13I just wanted to eat and like
33:16actually enjoy being alive.
33:18But I'm a researcher.
33:20I'm a professor.
33:21And it really bugged me.
33:25At first we started telling our closest
33:29family and friends what had happened.
33:32And people would say, well,
33:33Gee Travis, you're a bioethicist.
33:35Do you think you might have
33:37something to say about this?
33:39And my first instinct was no,
33:41because I was an in of 1, right?
33:43This was a case study, not a study,
33:47and I just thought, well,
33:49look, I must have just gotten
33:52incredibly unlucky, right?
33:57But I just kept being bothered by
34:00that because nobody should get
34:02as unlucky as I did, right like.
34:06I'm sorry, just click the screen.
34:10I was worked on at three world class
34:13hospitals in the DC Baltimore area where
34:16they put my foot together with my thigh.
34:19And nobody could or would help me.
34:23And then I think about well I'm
34:26I'm well educated. I have a PhD.
34:27I'm a professor at Johns Hopkins.
34:29My partner has a PhD.
34:30She's a scientist.
34:31She has spent her lunch every day Googling,
34:34searching, pub Med trying to think,
34:36figure out withdrawal mitigation by herself.
34:39She would lob ideas at doctors
34:41and they would say no, no, no,
34:42you don't know what you're talking about.
34:45How is it that we couldn't find help
34:48with all of our privilege and resources?
34:51And so the thing I kept thinking
34:52about is if I couldn't find help,
34:54what's happening to everyone else.
34:57So this was the initial hypothesis that
35:00I came up with in those early months.
35:02Nobody owns routine withdrawal care,
35:06so when I first started withdrawing,
35:10my first step was the prescriber.
35:12We called the plastic surgeon
35:13and we're like what's going on?
35:15Usually Sodhi was making all the calls.
35:17I was busy throwing up or something
35:19and she said he's really sick.
35:20He's miserable,
35:21and then the days would go on and it would
35:24get kind of scary and so very early on.
35:26We assumed our prescriber
35:27was going to fix this and he,
35:30to his credit very early on said look.
35:32I'm out of my depth.
35:34I'm sorry.
35:37I give him a lot of credit for that,
35:40but when when he was out of his
35:41depth he didn't know how to fix
35:43it and So what he said was, well,
35:45look, Travis should go back on the
35:48meds until he can find someone who's
35:50qualified to actually taper him.
35:52Say who's that and he said I don't know.
35:54Probably pain management, OK?
35:56So then we start looking to pain management.
35:59And the craziest part of this whole story.
36:02And a lot of it's wild is we called
36:05the inpatient pain service at the 3rd
36:07hospital that did the free flap surgery.
36:10They're the ones who really
36:11escalated all my pain care.
36:12And to be fair,
36:14I felt like they saved my life
36:16after that fifth surgery.
36:18I thought the pain was gonna kill me
36:20outright and they got it under control.
36:22Absolutely adored them for that.
36:26But we tried to get ahold of them
36:28and they would not talk to us.
36:29So eventually after two days maybe of
36:31calling the hospital trying to find
36:33someone who would connect us with them,
36:35we got ahold of a nurse and the nurse said,
36:38look, if you're willing to hold,
36:40I'm going to put you on hold.
36:40I'm going to find the attending.
36:43And ask him to come to the
36:46phone to advise you.
36:48She came back after a while and said.
36:51The attending asked me to tell you that
36:54they are an inpatient pain service.
36:57They prescribe opioids.
36:58They do not handle tapering.
37:00They do not manage withdrawal.
37:03Which made my head explode and
37:06so we started thinking about.
37:08Well there must be pain management
37:09teams that aren't inpatient,
37:10and so we found an independent
37:12pain management team in the DMV
37:14area and called them.
37:16And despite not being inpatient any hospital,
37:19they said something remarkably similar.
37:20They said, look, you know,
37:22if he is in need of more opioids,
37:24if he is run out and he needs
37:25to be evaluated to see whether
37:27there's still appropriate,
37:28he can come in and we can start therapy,
37:31but we don't handle tapering and withdrawal.
37:34And I was actually on the phone,
37:36which was pretty rare.
37:37I was actually on the phone for
37:38this call and I said so who's job?
37:41Am I?
37:41And it was a receptionist that we were
37:44speaking to and she said I don't know.
37:46Addiction medicine.
37:50So this was a really interesting
37:52moment because all the way up until
37:54here a couple weeks into withdrawing.
37:57It never occurred to me that when I
37:59was struggling with had anything to
38:01do with addiction, I was just sick.
38:03I had not yet learned it,
38:05but I had internalized this idea
38:07that addiction comes with cravings
38:09and a sense of compulsion,
38:11and you continue to use
38:13despite negative consequences.
38:15I had a house full of pills
38:16that I was choosing not to use,
38:18like addiction did not seem like my problem,
38:20but also I would talk with
38:22anyone who would help me.
38:24And so we started calling addiction clinics
38:25and we had no idea what we're doing,
38:27so we're just.
38:29On Google.
38:30Found different places that were kind of
38:32labeled as a rehab clinic in various ways,
38:34and so I had one conversation
38:37with a very sweet woman.
38:39And I I didn't know anything about
38:41this world yet, but it turns out
38:43I had called a methadone clinic,
38:45and that was not going to
38:47be the best Ave for me.
38:48But I just didn't know anything
38:50and I I called her.
38:52And she said she listened
38:53my story very patiently.
38:54And then she said.
38:56Oh honey, you're not our problem.
38:59She said it very gently.
39:02But I was just crying at this point
39:05and I said who's problem am I?
39:08She said,
39:08look.
39:09We're dealing with people who
39:11might overdose tomorrow from
39:12a contaminated drug supply.
39:14You're just sick because you're
39:16choosing not to take your pills like.
39:18Surely you're pretty.
39:20You're prescribers problem like
39:22they prescribe the drugs isn't it
39:25their job to get you off them?
39:27I thought yeah sure seemed that way.
39:31OK. So that bothered me for a long time.
39:34As a matter of fact,
39:35that was a big part of my initial research.
39:37In this space was kind of going through
39:39and discovering that a lot of people,
39:41when hearing my story and hearing
39:42about my kind of analysis of the
39:44health care system intuitively saw.
39:46Like, yeah, I know that's a big problem.
39:49Withdrawal management just isn't
39:50part of anyone's primary job.
39:52And so then I started to try to analyze
39:55this further and it took me a long time.
39:58Like some of you might have come to this
39:59very quickly, giving your background.
40:01But I was you heard my introduction.
40:03I was working on like climate change ethics,
40:04right? I had no background in this stuff
40:06so I had to learn some neuroscience.
40:07Learn some addiction medicine,
40:08learn some pain medicine and
40:10see what people were doing.
40:11Learn some public health and here's
40:14the next thing that I hypothesized.
40:17Is that what a lot of people are missing?
40:19Is that dependence does not equal addiction,
40:21and that conflation of dependence
40:23with addiction is causing a lot of the
40:26problem with who sees what as whose job,
40:28but also is influencing a lot of
40:30stigma because addiction is deeply,
40:32deeply stigmatized a problem on its own.
40:34But then that stigma bleeds
40:36into dependence and pain care,
40:37which is a big part of what's of
40:39the problem in pain medicine now,
40:41so.
40:43I am guessing that more people in
40:45this audience than in most already
40:46understand the the distinction
40:48between dependence and addiction,
40:49and and so for the next few minutes.
40:51If this is pedantic,
40:53I apologize,
40:53but I've been very surprised at the
40:55number of people I speak to who don't
40:57know this and so just indulge me and
40:59then and then we'll be through it.
41:01Alright,
41:01so we got to distinguish dependence
41:04and addiction,
41:05and so we can think about dependence
41:07as physical dependence to make
41:08it super clear and addiction.
41:09And here are the properties
41:11that accompany both right?
41:13So physical dependence is what happens
41:15when you have withdrawal following
41:17abrupt discontinuation or tapering.
41:19Tapering this too fast, right?
41:22So this is just how brains work.
41:25I remember we talked about the exogenous
41:27opioids flooding the central nervous system,
41:29your brains, a learning machine.
41:30It tries to to rebalance.
41:32You take it away.
41:33It doesn't rebalance again
41:35quickly enough and you suffer.
41:36Really importantly.
41:38This occurs in 100% of individuals on
41:42high doses long-term around the clock.
41:45This is just how brains work.
41:47Having this not happen would be the anomaly,
41:50right?
41:50Your brain isn't appropriately learning
41:52when you run when you're destabilizing it.
41:56With addiction,
41:57we're talking about a behavioral problem.
42:01And the behavioral problem is
42:04identified very often through cravings.
42:07Really importantly.
42:08Some models of addiction say this
42:10is actually the most essential
42:12component of addiction.
42:14It's characterized by continued use,
42:16despite negative consequences.
42:19And one thing that we really have
42:21to come to grips with is that
42:23it occurs in a vast minority
42:24of those exposed to a drug.
42:26We don't know exactly how many.
42:28If you look at meta reviews,
42:29they're kind of all over the place,
42:30but somewhere between 1% like 11% in
42:34several studies identify 6% in particular,
42:36so that seems like as good in numbers in it,
42:40but small compared to 100, right?
42:42The number of people who exposed to a
42:44drug that has addiction liability that
42:47would go on to develop an addiction.
42:49Is not nothing, so I'm not minimizing
42:51it from a public health perspective.
42:536% or even 1% percent is super
42:55problematic in a country with
42:57hundreds of millions of people,
42:59but for an individual patient,
43:00this is very unlikely.
43:02In in, in the general case.
43:05Alright,
43:06so if you still are a little bit
43:07suspicious of the distinction,
43:08let's show that they can come completely
43:10apart in all the different ways.
43:14A bunch of medications cause
43:15dependence, but no addiction.
43:16So in particular a bunch of
43:17psych meds have this property.
43:18They're also others like some heart
43:20medication, but ones that are really
43:22easy to get your mind around are
43:24some depression and anxiety meds.
43:26SSRI's for instance.
43:27So if you've ever been on or prescribed
43:28SSR eyes, you know this very well.
43:30They are physical dependence forming,
43:33which is to say if you abruptly
43:34discontinued them, taper them too fast,
43:37they will cause pretty miserable withdraw.
43:40But they are not addictive drugs,
43:41which is why they are.
43:44They have no street value, right?
43:46Nobody is like there's no black
43:48market for SSR eyes because
43:50they're not only non euphoric,
43:52they're kind of anti euphoric right?
43:54This is not feeding your reward system.
43:56The side effects of SSR eyes are
43:58front loaded and the good effects
44:01happen when you hit the level
44:02of kind of stable dependence.
44:04So the way SSRI's work actually
44:06make it hard to initiate patients
44:08on them and you'll hear doctors or
44:10sometimes hear the doctor perhaps
44:12saying to your patient like.
44:14You've got to give this three
44:15weeks or four weeks or six weeks
44:17or whatever to really understand
44:18whether it's gonna work for you.
44:20That's because they are
44:21precisely not addictive.
44:22They are not rewarding in the way that
44:26instant euphoria or quick onset euphoria is.
44:29We also have behaviors that
44:30can lead to addiction,
44:31but do not cause physical dependence
44:33because there's no substance involved,
44:35and so I think gambling is the most
44:37obvious case because it's really hard
44:39to find people who actually don't
44:40think gambling addiction is real.
44:42But for people who have more
44:44promiscuous definitions of addiction,
44:45this is all over the place.
44:46It's food and sugar, it's sex.
44:48It's smart, smart screens.
44:49You know we can be addicted to a
44:52lot of behaviors that do not cause
44:54physical dependence if you don't have
44:55an exogenous source of a substance,
44:58destabilizing the central nervous system.
45:01But of course,
45:02there's some substances that will cause
45:05dependence and can lead to addiction,
45:08and it turns out that opioids are
45:09pretty brutal in this respect,
45:11so other drugs fall into this category
45:13but aren't as bad in in one way or another,
45:15and so cocaine, for instance,
45:17has much more mild dependence
45:21than than opioids,
45:23for instance.
45:24So most reports of cocaine withdrawal
45:27are not nearly as severe or desperate
45:30in terms of physical symptomology
45:32but it's incredibly euphoric,
45:34so cocaine is an incredibly addictive
45:36drug in terms of the the speed of
45:38onset and the high of the euphoria.
45:40Opioids are this real 1/2 punch.
45:43They're incredibly intense,
45:44euphoric experiences,
45:45especially when snorted, smoked, or injected.
45:48When you get around first pass
45:50metabolism from from taking the pills.
45:52But also,
45:53the withdrawal is miserable,
45:54and so in these drugs you have a
45:56real 1/2 punch of the euphoria
45:58gives that gives you positive
46:00reinforcement and then the escape from
46:03withdrawal is a negative reinforcer,
46:04and so escaping withdrawal is a very
46:08reasonable explanation for taking more drugs.
46:11And it can continue to feed habitual
46:13use that will then contribute to
46:15the development of cravings for
46:17the euphoric aspects like these two
46:20components can definitely go together.
46:21That does not mean the physical
46:23dependence is the same as addiction.
46:25There are two components that helping
46:27to both live in some drugs OK,
46:29Unfortunately this this problem
46:31with dependence and addiction
46:33and the potential conflation.
46:35It actually gets harder.
46:38Because what I discovered in my one case
46:41was an oversight in what I now think
46:44of as routine withdrawal management.
46:47Everyone who's prescribed opioids in the
46:49case of post trauma that where it's gonna,
46:51you know, reconstructive surgeries
46:52at over on for weeks.
46:54Big painful surgeries.
46:55They're not reconstructive,
46:57but are, you know,
46:58hard to recover from knee replacements
47:00are the ones I always think about.
47:02After watching my mom go through
47:04them incredibly painful surgeries
47:06and really important to do physical
47:08therapy and recovery,
47:09which is of course painful.
47:10And so knee replacements get rated
47:12pretty highly in terms of the amount
47:14of opioids that it's reasonable to use
47:15these sorts of surgeries mean taking opioids.
47:18Pretty regularly for a pretty extended
47:20period of time here extended period
47:21of time only requires more than a few
47:23days to for them to start developing
47:25some dependence and potentially
47:27face the challenge of withdrawal,
47:29but it's all still routine.
47:32Uhm?
47:34My view is that when we're
47:37prescribing opioids pretty regularly
47:38for trauma reconstructions,
47:40major surgeries,
47:41there just has to be a structural
47:44solution to routine management
47:45of withdrawal from people who've
47:47been opioids for two weeks.
47:48Four weeks, 8 weeks, 12 weeks.
47:51But some patients are on for
47:53a lot longer than that.
47:54So this is from the from stat
47:57online magazine and this is a
48:00profile of Stephen Cortez who's
48:03just a real incredible guy.
48:05Good doc and has become very
48:08compelled to investigate what have
48:10now become called legacy patients.
48:13And so here's this,
48:14might be hard for me to read,
48:16so I'll read it to you.
48:17So here's a relevant piece of a paragraph.
48:19So Cartaz Kertes grew concerned by the
48:23medical community's efforts to regain
48:25control. Over prescribing patterns.
48:27After years of LAX distribution.
48:30Limiting prescriptions for new
48:31patients at clear benefits,
48:32he thought,
48:33but he wondered about the results of
48:35reductions among quotes legacy patients.
48:38Their outcomes weren't being tracked.
48:40So what this is getting at is,
48:41well,
48:42we started to worry about our use
48:44of opioids being very profligate
48:45and late 90s early 2000s.
48:47So we started cracking down on it.
48:48Makes really good sense,
48:49not some people home with whole
48:51bottles of Vicodin for routine wisdom,
48:53tooth extraction,
48:53and to collect data on all sorts
48:55of minor surgeries and reduce use.
48:57When possible, we'll get to that.
49:00But some of the response to the
49:02policies of trying to crack down
49:04on opioids was well.
49:05Now we have this generation
49:07of patients who have been
49:09on opioids for years or
49:11decades and remember tolerance.
49:13They sometimes chased the analgesia
49:15up to really incredible numbers.
49:18So tolerances protective so they
49:19could be on doses like 1000 morphine,
49:22milligram equivalents or I had met
49:24a patient on more than 2000 morphine
49:26milligram equivalents numbers that
49:28most folks don't see outside of,
49:30say end of life.
49:32Palliative care so these folks are now
49:35long term patients on really massive
49:38doses have been on for years or decades,
49:41and the dependence for them is something
49:43that we just don't know very much about.
49:45But we've done some studies and Steven is
49:48working on this now trying to track outcomes.
49:50Stanford Pain psychologist Beth Darnall
49:52has been trying to figure out what it
49:54looks like when you give people really
49:56patient centered withdrawal support.
49:57If they're able to taper,
49:58the results are super heterogeneous.
50:00Some people can,
50:01some people can't.
50:02Very few get very low at all,
50:04so these patients are really confusing
50:07for trying to reduce prescribing.
50:10So now we have this piece.
50:12Lead author Debbie Dell who is the
50:15lead author of the 2016 CDC guidelines
50:18and so they say explicitly look
50:20efforts to implement prescribing
50:23recommendations to reduce opioid
50:25related harms are laudable.
50:27But unfortunately some policies
50:28and practices purportedly derived
50:30from the guidelines have in fact
50:32been inconsistent with and often
50:34go beyond its recommendations.
50:35A consensus panel has highlighted
50:37these inconsistencies,
50:38which include inflexible application
50:40of recommended dosage and duration
50:43thresholds and policies that encourage
50:45hard limits and abrupt tapering of
50:48drug dosages resulting in sudden
50:50opioid discontinuation or dismissal of
50:52patients from a physicians practice.
50:55What are some of the outcomes
50:57that folks like?
50:58Doctor Curt Cortez are following.
51:00We have reports of patient
51:03suicides as they're experiencing
51:04withdrawal and unmitigated pain.
51:06We have reports of patients going
51:08to the black market even if they
51:11were previously stable on their
51:13prescription doses.
51:13So this is a very serious problem.
51:15I'm not going to spend a ton
51:16of time talking about this now.
51:18Happy to talk about it during Q&A.
51:20This is a paper I published last summer.
51:22Where I I made an argument that is
51:25not super popular among physicians,
51:28but I'm a year into getting feedback
51:30and re thinking and rethinking.
51:31And I stand by it.
51:33And what I argue in this paper is
51:37that is ethically impermissible.
51:39Two non consensually taper stable
51:42high dose chronic opioid therapy
51:44patients and stable is doing a lot
51:46of work there because there are
51:48times when I think a physician has
51:51to take control of prescribing,
51:53but we have this patient population that
51:55can be severely harmed by destabilizing them,
51:58putting them into withdrawal,
52:00and so I go through very carefully
52:02a case in this paper and say,
52:05I think these are harm expanding
52:07policies if we try to require.
52:09All patients to get to a lower dose,
52:11even if they are safe and
52:14stable on their current dose,
52:16and they might not be if we push them into
52:18withdrawal or under medicated pain.
52:22OK, so here's the general lesson from
52:25this second part, and don't worry,
52:27the third part is going to go faster.
52:29The lesson is that dependence happens,
52:31and so it has to be
52:33somebody's job to treat it.
52:34And it turns out there are different
52:35ways in which dependent shows up.
52:36There's routine dependence that happen
52:38under trauma patients and reconstruction
52:40patients and major surgery patients.
52:42This also happens in cancer patients,
52:44sickle cell patients,
52:45and it's going to be a little bit different.
52:47So with cancer patients,
52:48when the cancer is survivable,
52:50we want to treat their pain
52:52very empathetically.
52:52But we also need to remember
52:54that hopefully they're going to
52:56survive and live a long life.
52:57And if we don't take care with prescribing.
53:00We can turn them into these legacy
53:02patients who find it very hard to ever
53:04get off medication and that might
53:06not be doing them a lot of good.
53:07So there are a lot of these patients
53:10populations that can develop
53:12pretty profound dependencies,
53:14and they all need somebody whose
53:16job it is to treat them.
53:18And it's not always addiction medicine.
53:21OK. So I'm an ethicist.
53:24I want to think in terms of some kind
53:26of concrete methodology or framework,
53:28so here goes.
53:31I think most of you have
53:33probably seen this graph.
53:34Oh shoot, I forgot to update again.
53:36We now have this CDC graph.
53:37We now have it up through 2019.
53:40We have the data through 2020 now,
53:41but I haven't seen it
53:43broken down by opioid type,
53:44but you'll get the relevant
53:46part of this graph, which is.
53:48So this is the overdose.
53:50Death rates involving opioids
53:53between 1999 and 2018.
53:54The general trends here continue for
53:56the next few years, but get worse.
53:58But the most relevant part is this top
54:02line that is kind of lavender ish.
54:04That is the overdose death
54:06rate from prescription opioids
54:08commonly prescribed opioids,
54:10and that number seems to kick off.
54:15What we now think of as
54:16the drug overdose crisis.
54:18So over the course of a
54:19little more than a decade,
54:21you have this huge increase and
54:24this looks like about a 400%
54:27increase between 1999 and 2010.
54:29What's really important to recognize
54:31is that during that same period,
54:33the volume of prescription opioids
54:36prescribed was about 400% what it was before,
54:40so that the increase rather was 400% so.
54:43The overdose death rate from commonly
54:46prescribed opioids increases lockstep
54:49with the volume of opioids prescribed.
54:52As we start to understand
54:53this in the late 2000s,
54:55there is the totally predictable backlash,
54:58and so we first get the
54:59language of the opioid crisis,
55:00then director of the CDC,
55:02Tom Frieden says look,
55:03the prescription opioid
55:04epidemic is doctor driven.
55:06It can be solved in part by doctors actions,
55:09and So what we get is we slowly
55:11get a decrease in the volume
55:14of opioids prescribed starting
55:16in the 2010 to 2012 range,
55:18and what you can see on this graph
55:20is it actually does start to work.
55:22In that narrow sense that I'm
55:24talking about of overdose deaths
55:26from prescription opioids,
55:28they do actually start to tick
55:29down as we tick down the volume.
55:32But does this all the overdose
55:34epidemic not even close?
55:35What happens instead,
55:36is there has started to be a
55:38transition to heroin already,
55:40and there's a really interesting
55:41story about heroin became really
55:43endemic across the country,
55:44and so as people are cut off
55:47from their opioids,
55:49and as the black market
55:51prescription opioid supply dries up,
55:53there is an incentivized transition to
55:55even cheaper, more accessible heroin,
55:57and so phase two with the CDC equals
56:00phase two of the opioid epidemic is heroin.
56:03And totally,
56:05predictably,
56:06once heroin is the real kind of
56:10driver of the drug overdose crisis,
56:12law enforcement cracks down on
56:14heroin and we have something
56:15called the iron law prohibition,
56:17which says when law enforcement
56:18cracks down on a substance,
56:20that substance is predictably going
56:21to become smaller and more potent,
56:24IE more easy to transmit,
56:26easier to transmit,
56:27and so,
56:28heroin starts getting cut with
56:30fentanyl and its chemical analogs,
56:31which is about 50 times more potent
56:33than heroin.
56:34Some of its analogs are way more potent,
56:36so we have carfentanyl's,
56:37the most potent one that I
56:39know of, which is about 10,000 times more
56:42potent than morphine commonly used as a
56:45sedative for large mammals like elephants.
56:48So fentanyl gets into the drug supply
56:51and overdoses from synthetic opioids
56:53like fentanyl and its analogs start
56:55shooting up and become the main driver
56:58of the opioid crisis, all right.
57:00Why is this walkthrough important?
57:01It's gonna be important for a couple reasons.
57:02The most important one is.
57:05Historically, we have this kind
57:08of cartoon view about opioids.
57:10Where if you think about her attitude
57:12about opioids arranged on a spectrum,
57:14we just bounce back and forth between one
57:18pole, which is just absolute restriction.
57:20ISM or prohibition even and so
57:22right now across the country,
57:24there are clinics you know hanging up
57:26signs saying we don't prescribe opioids.
57:29And when that happens, well,
57:31predictably, pain patients suffer,
57:34it becomes hard.
57:36We sometimes start taking opioids
57:38away from reasonable uses.
57:39When this happened the last time,
57:41so history lessons happened before in the
57:4420th century cancer patients end of life.
57:46Life patients started suffering
57:47and so then there was a backlash,
57:50a pain advocacy movement that
57:51made all the sense in the world.
57:53It ended up getting intertwined
57:55with pharmaceutical company money
57:56and we get two drugs for everyone.
57:58This is what started happening in the 1990s.
58:00Early 2000s opioids are the
58:02pill for every pain.
58:03The one to start with the
58:05one to stay with right?
58:07Both of these polls are,
58:09I think, indefensible.
58:12Also,
58:12restriction ISM says that
58:14opioids aren't helpful,
58:15ever, but we know they are.
58:17They're really good analgesics for
58:19some forms of severe acute pain
58:22and probably good tools for some
58:24forms of intractable chronic pain
58:26that has proven intractable even
58:30in the face of other modalities.
58:31Sorry, that was methyl,
58:32but I'm not going to weigh in here on that,
58:34but there are probably chronic pain
58:36patients who need a very carefully
58:38monitored opioid therapy too,
58:39but what we know is generally
58:41that there's uses for opioids.
58:42Trism doesn't make sense,
58:43but that doesn't mean the
58:44drugs for everyone makes sense,
58:46so here's the most unhelpful
58:47graphic you've ever seen.
58:49We need to be somewhere in the middle, right?
58:51And I know that's really unhelpful,
58:52said in that way,
58:53so I'm going to try to give
58:54you some concrete guidance.
58:55What does it look like to have a
58:58more nuanced view on responsible
59:01opioid prescribing?
59:02I think we have to break it
59:04out into three components,
59:05so I'm going to spend just a
59:07couple minutes talking about each.
59:09We do need to talk about
59:11appropriate initiation.
59:12When do you use opioids responsibly?
59:15But we also need to talk about
59:17managing them over the long term.
59:19And discontinuing them.
59:21And one of my main points by breaking
59:23it out at these three is how we
59:26always talk about the first one and
59:27act like the other two don't exist.
59:29So let's do talk about the first one.
59:31Show that it's pretty hard in and of itself,
59:34right? But then make sure that we
59:35get the other ones in there too.
59:37So appropriate initiation.
59:38The thing that makes us really hard
59:41is I just said opioids are good,
59:42sometimes right? They're not evil drugs.
59:45They have value.
59:46Which is to say they provide a
59:48benefit of severe pain relief.
59:49But of course, there's a risk of opioid
59:51exposure at risk of tolerance dependence.
59:53Other things that we haven't
59:54talked about like increased falls,
59:55especially in the elderly.
59:57But of course the prominent one.
59:58Addiction and overdose.
60:00OK, when we're in the face of a
01:00:04heightened sense of those risks.
01:00:06We sometimes act like that's
01:00:08the only component and overlook
01:00:10that there's any benefit at all,
01:00:13and so I think in a moment where
01:00:16the majority of the talk about
01:00:18opioids is negative,
01:00:19we're already going to have a harder
01:00:21time doing this balancing job than we should,
01:00:23because we're not going to
01:00:25remember all the time.
01:00:27I had a really dear friend
01:00:29and colleague say to me.
01:00:30On two different occasions,
01:00:32a clinician that I would rather my
01:00:35patients be in pain than to ever be.
01:00:38The person who is part of the causal chain
01:00:41that led them to addiction and overdose.
01:00:44And I get it.
01:00:46But it's also untenable.
01:00:49Because clinicians cause
01:00:51risk of harm all the time,
01:00:54that's what surgery is.
01:00:56We risk infection every
01:00:57time we cut somebody open.
01:00:58There's a chance of a devastating
01:01:00outcome with most of medicine and all.
01:01:02Pharmacology has side effects,
01:01:04so acting like no benefit could
01:01:07outweigh even a tiny risk is
01:01:10not good moral mathematics.
01:01:12It's made harder because we
01:01:13can't just do the balancing act.
01:01:15We have to do it fairly.
01:01:16We have to do it in a just way,
01:01:18and so I think most people
01:01:20here probably know.
01:01:20That's really hard to do with pain medicine,
01:01:22'cause it's a backdrop.
01:01:24It's against a backdrop of racism and sexism,
01:01:26and we have lots of good data that
01:01:28say that clinicians are more likely
01:01:30to prescribe opioids to white people
01:01:33than to black people or Hispanic people.
01:01:35They are more likely to prescribe
01:01:37opioids than men rather than women,
01:01:39and this is unsurprising because it goes
01:01:41against long racist and misogynistic tropes.
01:01:44It goes along with these tropes,
01:01:45right?
01:01:46So the language of hysteria is applied
01:01:48to women who complain too loudly.
01:01:51Of pain, right?
01:01:52They're just being hysterical,
01:01:53so they don't need it as badly,
01:01:56and the language of drug seeker
01:01:58gets applied to minorities more
01:02:00often than to white people.
01:02:01So doing the balancing is hard enough
01:02:04and we have to do it in a just way,
01:02:06which means keeping in mind a
01:02:09background of biases and stereotypes
01:02:11constantly so appropriate.
01:02:13Initiation is already hard enough.
01:02:15When do you use opioids and in what amount?
01:02:17We just need a ton of data.
01:02:18Also, we're getting better at that,
01:02:20but the ethics?
01:02:22Doesn't get easier.
01:02:24We also have to do more
01:02:25appropriate initiation,
01:02:26gets all the play,
01:02:27all the studies come out showing
01:02:29look it turns out you can do most routine
01:02:31wisdom teeth extraction with ibuprofen.
01:02:33Acetaminophen with no clinical
01:02:34difference in pain reports. That's great.
01:02:37Keep collecting the data we need it
01:02:39for all the surgeries Hopkins does
01:02:41some of some of this data collecting
01:02:43and recommending Michigan open
01:02:44the opioid prescribing engagement
01:02:46network does a really fantastic
01:02:47job of disseminating this stuff.
01:02:49Keep doing it.
01:02:50We need more as long as we're prescribing
01:02:52opioids for more than a few days.
01:02:54Some of the time.
01:02:56Gotta manage it right,
01:02:58and so I think a big part of
01:03:00the problem is that.
01:03:00When we decided we decided as
01:03:03generous right when medicine and
01:03:05medical education made the decision
01:03:08that pain didn't require a ton of
01:03:11expertise and medical students
01:03:12didn't get a lot of formal training.
01:03:15They sent the message that opioids or
01:03:18something like antibiotics like you use them,
01:03:20you know,
01:03:21use antibiotics for bacterial and
01:03:22viral infections and everyone who
01:03:23practices medicine really should
01:03:24be able to do this and write the
01:03:26prescription in your job is done
01:03:27and make sure that they take you
01:03:29know the right number of pills.
01:03:31But opioids are not like antibiotics.
01:03:33In a lot of ways,
01:03:34but one of them is that the risk
01:03:36profile changes over the time
01:03:37and so you have to be regularly
01:03:39checking in with patients in.
01:03:41This can involve things like
01:03:43behavioral health assessments
01:03:44if they're still on opioids,
01:03:45do they need a pain specialist or
01:03:47do they need to potentially have
01:03:50an in some form of intervention?
01:03:51Since the addiction medicine
01:03:54to prevent problematic use,
01:03:56so we need these screening tools
01:03:57not only for science and misuse
01:03:59in developing use,
01:04:00sort of but also for physical dependence.
01:04:02Because that's not cost less right?
01:04:04And a big part of this management job
01:04:08is treating opioid prescribing as if
01:04:10it requires actual informed consent
01:04:12and not just handing over a prescription.
01:04:15These are pretty complicated
01:04:16drugs to take and use,
01:04:17and to understand the risk,
01:04:18benefit profile of and if
01:04:20you want an example of that,
01:04:22I'm a professor and my wife,
01:04:23the scientist.
01:04:25And it never dawned on us to think carefully
01:04:28about the pain regiment that I was put on.
01:04:31Shame on us maybe,
01:04:32but I don't think so.
01:04:33I think by and large patients
01:04:36trust their doctors to help
01:04:38them make those decisions.
01:04:40Obviously,
01:04:40appropriate discontinuation is
01:04:41pretty near and dear to my heart.
01:04:46This is David Juurlink.
01:04:47He's he's kind of a a social media buddy.
01:04:50Over recent years when I gave my Ted talk,
01:04:53he started using it.
01:04:55When he educates residents
01:04:56and fellows and Med students,
01:04:58and so we got to know each other a
01:05:00bit and and so now I've shamelessly
01:05:02stolen from him a really great line
01:05:03and maybe I should have just given
01:05:05this line instead of the whole talk.
01:05:07But he says don't fly a plane
01:05:09if you don't know how to land.
01:05:11And that's the encapsulation of the
01:05:14discontinuation requirement, right?
01:05:15If opioids are prescribed for
01:05:18more than a couple of days,
01:05:20somebody who's going to be involved in
01:05:22the care of that patient needs to know
01:05:24how to get the patient off of them.
01:05:25Three weeks in five weeks in eight weeks in,
01:05:28or that there's going to have to
01:05:30be some transition at some point if
01:05:32it develops into problematic use,
01:05:33there has to be a plan and a
01:05:37structural mechanism in place to make
01:05:39sure that people who are prescribed
01:05:41opioids have a path.
01:05:41Off now notice that one part of
01:05:43this is just routine tapering and
01:05:44I'm not going to walk you through
01:05:46this 'cause today it's not my job
01:05:47to actually teach you how to taper.
01:05:50Although relevantly I could,
01:05:51even if not as an MD,
01:05:53I could teach you how to taper
01:05:54because it's not rocket science.
01:05:56And so here is the front and back
01:05:58of a bookmark that I consulted
01:06:00with the Atom alliance,
01:06:02who were contractors for CMSA
01:06:04few years ago and I've worked
01:06:07on a couple more since then.
01:06:09They all have similar sorts of parts,
01:06:11but for routine.
01:06:13Opioid withdrawal management.
01:06:15You you don't need a ton of education,
01:06:20you need some time.
01:06:21You need to think through several of the
01:06:24steps here about slow individualized
01:06:26rates about counseling your patient,
01:06:28and you need to commit to walk with
01:06:30them and then in some complicated cases
01:06:33there are pharma pharmaceutical options
01:06:35that can help manage withdrawal symptoms.
01:06:37And then of course,
01:06:38those come with all sorts
01:06:39of cautions and caveats,
01:06:40just not my job to teach you that today,
01:06:43but these tools now exist and they're
01:06:45pretty easy to use for routine maintenance.
01:06:47Have routine withdrawal management.
01:06:50We could have a workforce of people who
01:06:53know how to get patients off of three
01:06:56weeks of opioids or five weeks of opioids.
01:06:59OK,
01:07:00so there is my tripartite
01:07:03responsible prescribing principle.
01:07:05Here is what I want to leave you with.
01:07:11Remember that it doesn't solve the
01:07:13drug overdose crisis I just gave you
01:07:15what I think are a ton of reasons for
01:07:18making sure that the health care system,
01:07:20medicine individual clinicians do
01:07:22better by patients who are prescribed
01:07:25opioids that they are responsibly
01:07:27prescribed in particular ways.
01:07:28But look again at this graph and
01:07:31realize that of the 100,000 plus people
01:07:35who died from drug overdose in 2020,
01:07:37the majority of them are now from.
01:07:39Fentanyl miss analogues from illicit drugs.
01:07:42The minority now involve
01:07:44pharmaceutical opioids,
01:07:45and those are very often
01:07:47polypharmacy We have to do better
01:07:50at responsibly prescribing opioids,
01:07:52but we also have to not pretend that that is
01:07:55going to solve the drug overdose epidemic.
01:07:58That is the message I'm going to
01:08:00leave you with today.
01:08:01Thank you very much for sticking with me.
01:08:04I believe we have a pretty good
01:08:05chunk of time for Q&A and discussion,
01:08:07so David Emma turn over to you and
01:08:09I will stop sharing my screen.
01:08:12Travis, thank you so much. Just a wonderful.
01:08:19Dissection of the many
01:08:20problems that that we face,
01:08:22and we've covered a lot of ground,
01:08:23really appreciate it.
01:08:25There are some questions and comments in
01:08:28the chat that I I'll try to curate for you.
01:08:32One attendee, indicated asked
01:08:33you to speak to the issue of
01:08:36abandonment and pain management and
01:08:38the consequences of involuntarily
01:08:40tapering long term stable patients.
01:08:42This was sort of early on in your talk
01:08:45and I think you you covered that that,
01:08:47but I didn't know if there
01:08:48was any more you wanted to add
01:08:49to to what you already said.
01:08:52Sure, I can add a few things now,
01:08:54so just have abandonment.
01:08:55Yeah, yeah. I also just realized
01:08:57by opening the Q&A that we have
01:08:59at least one expert in the room,
01:09:01so not to make myself too
01:09:03self-conscious here, but.
01:09:05Steven joined just at the right
01:09:07time to see his slide 20 good.
01:09:12So here is. Here is the most important
01:09:14thing I want to say and then we could be
01:09:17steered and other people could weigh in
01:09:19and and make the question more precise.
01:09:23It is incredibly hard for me to think.
01:09:27That uhm. Patient abandonments?
01:09:31Is ever gonna make things
01:09:34better rather than worse?
01:09:36Right, and so I wanted to be very
01:09:38careful when I said that because
01:09:41I recognized that very often,
01:09:43firing a patient from a practice
01:09:45or clinic or saying I no longer
01:09:47take this sort of patient.
01:09:48So you have 30 days to find a new prescriber,
01:09:50I recognize that that's actually not
01:09:52usually for the patients benefit.
01:09:54It's usually for the prescribers benefit.
01:09:55It's because that practice
01:09:57makes them very uncomfortable,
01:09:59and they're worried about the
01:10:00DEA knocking on their door.
01:10:02They're worrying about getting
01:10:03a letter from the Department of
01:10:04Justice and I and I get that.
01:10:06So what I want to say is,
01:10:08if we're thinking about it
01:10:10in terms of ethical medicine,
01:10:12like how do we actually do
01:10:14right by our patients?
01:10:15I'm very hard pressed to think of a place,
01:10:18think of a time where a patient who's
01:10:21actually on opioids is best served by being
01:10:24fired or by being dropped from the practice.
01:10:28Now note I say when they're
01:10:29actually on opioids,
01:10:30so if you have definitive
01:10:31evidence that they're diverting,
01:10:32that's different,
01:10:33right?
01:10:33So if their urine comes back with no
01:10:35opioids present when you're not worried
01:10:37about them going into unmitigated withdrawal,
01:10:39but what we do when we fire
01:10:41people from the practices?
01:10:43We make sure that they now no longer
01:10:45have access to healthcare, right?
01:10:48Like we,
01:10:48we don't say well like oh,
01:10:51you need a different sort
01:10:52of service that I provide.
01:10:53So let's get you into addiction medicine.
01:10:55The act of just abandonment only says
01:10:57I was your health care provider and
01:10:59now you don't have access to even that.
01:11:01Now we think about how stigmatized so
01:11:03much of this population is and how
01:11:05hard it is to prescribe these high
01:11:07doses hard in the kind of sense of
01:11:09legal fears and that sort of thing.
01:11:11The idea that they're going to easily
01:11:12find somebody to take them on if they're on.
01:11:14800 or something like that is
01:11:16just is foolish.
01:11:18Nobody actually believes that if they
01:11:19dump a bunch of their patients that
01:11:21they're all going to find somebody
01:11:22else willing to take them on.
01:11:23Everyone else has the same fears
01:11:25that they do, right?
01:11:27So?
01:11:28The strongest way to put this that
01:11:31still recognizes that that I'm
01:11:32talking about what patients are owed,
01:11:34and not the reasons of physicians,
01:11:36are actually acting is, I think,
01:11:38the vast majority of the time
01:11:41firing patients for.
01:11:42Not wanting to prescribe for them if they
01:11:45threaten violence to you or whatever,
01:11:46that's a different category.
01:11:47Just 'cause I don't want to prescribe
01:11:49anymore is moral malpractice.
01:11:51It's not a thing we should get to do.
01:11:57Thank you, the next question
01:11:59comes from Sandra Fall,
01:12:00who tells a poignant story.
01:12:01Unfortunately, of her son,
01:12:03who passed away in 2016,
01:12:05but highlights what I think you alluded to,
01:12:09which is that the health
01:12:11care system is broken.
01:12:13There's likely a need for some
01:12:17place in that health care system
01:12:19that has the sophistication to
01:12:21deal with both dependence and
01:12:24addiction at the same time.
01:12:27Because what happens is.
01:12:29Side A says we don't do that.
01:12:31You have to go to side B.
01:12:33Side B says we don't do that.
01:12:34You have to go to side and so I
01:12:37guess I'm asking for a visioning
01:12:39thing and you know there are such
01:12:41interdisciplinary clinics and if
01:12:43you could describe what you think
01:12:45the appropriate response from the
01:12:46health care system might look like.
01:12:50Yeah great great hard question.
01:12:53So at different levels of complexity we
01:12:56probably need different things, right?
01:12:58So the lowest hanging fruit that
01:13:00is probably the biggest reason.
01:13:02I still do these talks right?
01:13:03'cause 'cause know when
01:13:04I'm talking to you all?
01:13:06I'm not very often getting
01:13:08institutions to change right?
01:13:09So I'm largely talking to clinicians
01:13:11and sometimes they can change their
01:13:12practice and so one thing that we can
01:13:14do is a whole bunch of people that have
01:13:16individual patients can take on this,
01:13:18like pretty significant moral
01:13:19burden that I realize is.
01:13:21Is significant given the way things
01:13:23are structured in our health care
01:13:25system and they can make sure
01:13:27that they are better prepared to
01:13:28treat patients of a certain type,
01:13:30and so,
01:13:30especially for folks who are
01:13:32family medicine docs or general
01:13:33practitioners who see folks in a pretty
01:13:35stable way have a relationship and
01:13:37existing relationship with patients.
01:13:39I just want all of them to understand
01:13:41physical dependence and be able to treat it.
01:13:43Like I think that should just
01:13:45be a new standard.
01:13:47Now to be fair to them,
01:13:48we also need to make sure it's reimbursed,
01:13:50right?
01:13:50Like what is the ICD 10 code that
01:13:52they're going to put in when they're
01:13:53spending all these time with patients?
01:13:55So that's the structural
01:13:56stuff we have to get back to,
01:13:57but I want everyone when
01:13:59I teach medical students,
01:14:00I say I want you to know how to do
01:14:03this and be willing to do this as
01:14:05part of your mission to be a good doctor.
01:14:08But now we're gonna have a lot
01:14:10more complicated cases, right?
01:14:11We probably don't actually want a
01:14:12lot of general practitioners to be
01:14:14taking on the most complicated cases,
01:14:16unless they're willing to train up
01:14:17and spend a lot of time doing it,
01:14:19and so one sort of model that I've seen.
01:14:24So at Hopkins just a few years ago,
01:14:25we opened up hurry up.
01:14:28Clinic so it's a parriott prescribing
01:14:30clinic and so they do a lot of
01:14:33tapering for surgery patients and so
01:14:34they get different sorts of patients.
01:14:37And I've had folks you know,
01:14:38I have colleagues who who work
01:14:40there who help stand it up.
01:14:43You know, they said to me like,
01:14:44well, look if you'd come to us,
01:14:46you know and we had had this
01:14:47existing at the time.
01:14:48Like we certainly could help you.
01:14:49'cause these are people who are
01:14:50very well educated on this,
01:14:51but I also would have been like
01:14:52a bad use of their resources.
01:14:53'cause remember, I was a pretty routine case,
01:14:56but I really needed was someone who
01:14:58knew some basic pharmacology and you
01:15:00could do a slow individualized taper
01:15:02and hold my hand through it, right?
01:15:05But some of these much more complex
01:15:07patients patients are coming in on,
01:15:09you know,
01:15:09120 milligrams of methadone and
01:15:11who need a major surgery like they
01:15:12need a plan for how they're going
01:15:14to get the pain management that
01:15:16they need in
01:15:16surgery and staying on methadone
01:15:18and not risking relapse.
01:15:20And that's a complicated case that
01:15:21just needs a ton of attention.
01:15:23And then so that's a methadone
01:15:25case that could be pain management.
01:15:26Or it could be addiction medicine,
01:15:29but we also just have a bunch of
01:15:31patients who are much more like
01:15:32the legacy patient population
01:15:34who come on at 600 or 800M S.
01:15:35They need surgery.
01:15:36They need to make sure that
01:15:37their pain is managed.
01:15:38Post surgical post surgically,
01:15:40and so sometimes they'll want to
01:15:42actually try to go through a taper
01:15:44before surgery to make their pain
01:15:46management after surgery more successful,
01:15:48and so these are really complicated
01:15:50cases when you have a kind of front
01:15:52end view of some of the challenges
01:15:54that they're going to require.
01:15:56So that's two models I don't want
01:15:58to talk for 20 minutes every with
01:16:00every question but one other thing
01:16:02that we should just recognize is.
01:16:04I've I've consulted for some
01:16:07surgical centers before,
01:16:08and one of the immediate things
01:16:10I heard from them is.
01:16:12You're not gonna get a sports surgery
01:16:15center to have all the clinicians
01:16:17ready to like do in depth tapering.
01:16:19After all their reconstructions.
01:16:20And you know, joint replacements.
01:16:21What I hear when I hear this is,
01:16:24like, you know, the docs.
01:16:25We pay 400 grand a year are not going
01:16:27to be on the phone with you all
01:16:29their patients every week, right?
01:16:30And I actually think that's fine
01:16:31as long as there's an alternative
01:16:33plan in place and it took me awhile
01:16:35to come to this 'cause part of
01:16:37me wanted to say like.
01:16:38If you're in charge of the patient
01:16:40under some description and then it
01:16:41really falls on you like you have
01:16:43to at least know how to do this.
01:16:45If it comes to that,
01:16:46and I've given up on that said,
01:16:47you know what structural solutions
01:16:49are totally fine if you're a.
01:16:50If you're a surgery center and you
01:16:52want to train up a team of NPS or PA's,
01:16:54whose job it is to follow patients may
01:16:57after major surgery and and do all of this,
01:16:59I actually think there's a
01:17:01totally reasonable solution,
01:17:02but it has to be an intentional
01:17:04structural commitment.
01:17:06I agree, I think one of the
01:17:07things you highlight there is
01:17:09the issue of workforce, right?
01:17:10So this assumes that that we don't
01:17:12have to do remedial education for
01:17:14the 300,000 practicing primary
01:17:16care physicians and others who on
01:17:18whom this this might fall and so
01:17:20not not all of them have the same
01:17:23understanding of these issues.
01:17:24I think unfortunately,
01:17:25that as you as you do.
01:17:28John Kimberly says one another
01:17:30issue is that different patients
01:17:32respond differently to opioids and
01:17:35current policies and practices
01:17:37seem to assume that everyone
01:17:39responds in the same way and I
01:17:41think you highlighted some of this,
01:17:42but you know there are so many
01:17:45nuances and and different situations.
01:17:48And do we run the risk of making
01:17:51this two algorithmic?
01:17:53Absolutely, so I'm.
01:17:58I'm a broken record for the most part.
01:18:00I really often think that my
01:18:02major value add is just being
01:18:03able to communicate like a human,
01:18:05but the the like one word summary
01:18:07of all of my work in this area
01:18:11is nuanced exclamation point,
01:18:12and so the problem with algorithms
01:18:14is that they are by design,
01:18:16not nuanced, right?
01:18:17So if you if you have a set of
01:18:19rules that you apply to everybody,
01:18:21well then you lose this
01:18:22really important value.
01:18:23So you think about my chart about attitudes,
01:18:25right? Restriction ISM drugs for everybody.
01:18:26You have to be somewhere in the middle.
01:18:28Like we can do this with a lot
01:18:30of what's going on with pain
01:18:31care and opioid management in the
01:18:34country that we just actually need.
01:18:36Physicians who are competent,
01:18:38you know, educated in the relevant way,
01:18:41incentivized in the right direction
01:18:42so that we're not asking everyone to
01:18:44do a bunch of unpaid work, right?
01:18:46So the structure has to reward
01:18:47them in the right ways and then
01:18:49willing to take this on and do good,
01:18:52responsible, individualized pain care.
01:18:54And that individualized is just
01:18:57built into the need for nuans.
01:18:59Everybody is different and everybody
01:19:02is different in the kind of brute
01:19:05biological way that I think the
01:19:06question questioner was asking, right?
01:19:08But also everybody, just.
01:19:11It evolves in different ways
01:19:13with opioid medication,
01:19:14so one of the things a lot of
01:19:16scientists and clinicians have
01:19:17told me when they heard or read
01:19:18my story is that on their view I
01:19:20must have been very sensitive to
01:19:22dependence and withdrawal,
01:19:24and so if there's a bell curve in nature,
01:19:26you know kind of out here and that
01:19:28I have no other data points.
01:19:30So I take their word for it that I
01:19:31was probably out here and most people
01:19:32are in the fatter part of the curve,
01:19:33which means there are other people
01:19:35on the other end of the bell curve
01:19:37who would have just not had nearly
01:19:38as much of a problem and.
01:19:40Hard to hard to manage all of
01:19:41that with an algorithm, right?
01:19:43Because I know that if I'd been
01:19:44on this other end,
01:19:45sorry I'm still using my
01:19:47imaginary bell curve.
01:19:47If I had been one of those people who
01:19:49didn't have any problems, here's the thing.
01:19:50I can tell you for sure.
01:19:51I would have wanted to get off
01:19:53opioids as fast as possible, like no.
01:19:55No need to stretch it out.
01:19:57If I'm not, you know,
01:19:58just in absolute agony when you go faster.
01:20:01And so yeah, that takes individualization.
01:20:03It takes somebody who's actually paying
01:20:05attention to the way the individual
01:20:06patient in front of them is changing.
01:20:09Yeah, so we can you know hop onto
01:20:12the bandwagon of precision medicine
01:20:15and phenotyping and all of those
01:20:17presumably are in the future from
01:20:19our from our research and elsewhere,
01:20:22Dr Cortez says I've recently read
01:20:24several guidances and doctor guidance
01:20:26documents on an opioid taper that
01:20:29emphasized try to get patient,
01:20:31buy in in quotes, but they definitely
01:20:33avoid the concept of quote UN quote,
01:20:36informed consent for taper.
01:20:38If we have mixed.
01:20:39Evidence on the harms and benefits
01:20:41of taper in the otherwise stable
01:20:43long term recipient.
01:20:45Should we call for informed
01:20:47consent in such a situation?
01:20:50Such a characteristically good question.
01:20:53I'm glad we have a bioethicist on board.
01:20:58I mean, I'm gain to run this
01:21:01like I'm game to try this out.
01:21:03I haven't thought about it long
01:21:05enough to have firm views on it,
01:21:06but you know my the paper in which
01:21:08I make the kind of strong argument.
01:21:09I should note this Steven was providing
01:21:12great feedback on that paper,
01:21:13and he's got one with some colleagues
01:21:15that argues a very friendly position.
01:21:20In that paper I say specifically
01:21:22non consensual dose reduction is
01:21:24the problem and so it does sound
01:21:26like I'm basically smuggling in a
01:21:28need for informed consent, right?
01:21:30What bothers me about that?
01:21:32Try to get patient.
01:21:33Buying in is it sounds like if you
01:21:35try and fail then you're good to go.
01:21:37So it sounds like the the
01:21:39algorithm is try to get patient,
01:21:41buy in if that unreasonable
01:21:42patient is not willing to budge.
01:21:43OK, now you do it,
01:21:45but you checked off the box.
01:21:46Try to get patient by end and
01:21:48that seems really problematic.
01:21:49And so I have not spoken with Doctor,
01:21:53Dell or any of the other coauthors
01:21:55about this in particular,
01:21:57but you know she lead authored
01:21:59that piece in the New England
01:22:00Journal that I highlighted,
01:22:01and then she also was part of the
01:22:04team that either advised or or.
01:22:07Reviewed the HHS tapering document
01:22:09so there's official HHS guidance on
01:22:12tapering chronic opioid therapy patients.
01:22:15In my reading of those documents.
01:22:18Is that it leaves completely
01:22:20open my conclusion,
01:22:22which is that if you
01:22:23don't get patient buy in,
01:22:24you stop not continue right?
01:22:27So if the instruction is try
01:22:28to get patient buy in,
01:22:29you can have two versions of that.
01:22:31Try to get patient.
01:22:32Buy in if you don't well
01:22:33then move forward anyway,
01:22:34'cause you're the doctor or try
01:22:36to get patient buying buy in.
01:22:38And if you don't well then
01:22:39you're stuck for the time being.
01:22:41Continue with motivational interviewing,
01:22:43continuing letting them know that you're
01:22:45there for them when they're ready, right?
01:22:48And that's the path that I think is correct.
01:22:51So the specific question was well
01:22:53then should we use informed consent?
01:22:55I mean, maybe that's what we try.
01:22:56Maybe that's what we should try next,
01:22:57say, like look.
01:22:59We don't usually require informed
01:23:01consent for not prescribing,
01:23:03which is one of the reasons doctors get
01:23:04really prickly when I make this argument,
01:23:06they're like look,
01:23:06I have the DEA license for a reason.
01:23:08'cause I'm the gatekeeper for
01:23:10Society of these dangerous drugs,
01:23:12and so it's my decision whether or not to
01:23:14prescribe if I think it's too dangerous,
01:23:16you don't.
01:23:17You aren't owed my prescription.
01:23:20But I think we have.
01:23:22We have gotten ourselves into enough trouble
01:23:24that the situation doesn't hold in this case,
01:23:26so it might be that no one is owed
01:23:28a risky initial prescription, right?
01:23:31So if in your clinical
01:23:33and professional judgment,
01:23:34the risks outweigh the benefits,
01:23:35were initiating opioid therapy,
01:23:36I think your your general assumption
01:23:38there about gatekeeping is right on.
01:23:40The patient is not owed your prescription.
01:23:42You're not a checkout clerk,
01:23:46right?
01:23:48But we got these patients dependence
01:23:51and we did it through the practice of
01:23:53institutionalized and accepted medicine.
01:23:54I'm saying we I didn't.
01:23:55I'm not a clinician.
01:23:56I don't have prescribing authority,
01:23:57but society like we all endorse
01:23:59this pain is the 5th vital sign.
01:24:01You know,
01:24:02like this is opioids or the the
01:24:05the treatment for moderate to
01:24:07severe acute and chronic pain right?
01:24:10And so I think we've gotten our
01:24:12patients into a position where
01:24:14they are now entitled to a say in
01:24:17how we exit from that position.
01:24:19And that's why we can actually utilize
01:24:21the language of informed consent.
01:24:23So Steven, I think I'm on board.
01:24:25Let's try to let's try to do informed
01:24:28consent for for discontinuation this time.
01:24:33You open up a whole bunch of questions
01:24:35in my mind about this notion of
01:24:37gatekeeper in societies decisions,
01:24:39but that's unlikely for another talk.
01:24:43Uh. Judy, asking about the role
01:24:46and that the DEA may be playing in
01:24:49some of these doctors decisions,
01:24:51especially to to follow the CDC guidelines.
01:24:54Do you want to speak to?
01:24:56Governmental structures in general,
01:24:58and perhaps the DEA in particular.
01:25:03I I said probably about as much as I'm.
01:25:05I'm really comfortable saying I'll give it
01:25:08just a little bit of a flavor which is.
01:25:12I'm enough of a public health
01:25:13person so kind of you think about
01:25:15my institutional affiliation in
01:25:16the way of organized my career.
01:25:18I'm I'm a bioethicist affiliated with
01:25:19the Bloomberg School of Public Health
01:25:21and a lot of my work on opioids is
01:25:23not just with clinicians who the
01:25:25prescribing is with epidemiologists
01:25:26who track the overdoses right.
01:25:28It's it's trying to address this
01:25:30from a structural intervention level
01:25:32and not just a clinical level.
01:25:35And I'm pretty skeptical that
01:25:37the DEA is doing a good job,
01:25:39even in the illicit case, right?
01:25:42Uh, I'm pretty skeptical that our
01:25:45attitudes about drugs are helping us.
01:25:48Even when it's in the black market,
01:25:52which all of that is to say less cryptically.
01:25:55The fact that we criminally
01:25:57prosecute people for using drugs
01:26:00seems morally indefensible to me.
01:26:03What that entails is in the clinical context,
01:26:06I want I want I really don't
01:26:09want there to be.
01:26:10A DEA involvement or Department
01:26:12of Justice involvement.
01:26:13Now to be clear,
01:26:16we've had a history of some pill mills,
01:26:19right?
01:26:19So there are stories that are important
01:26:22to keep in mind that there is a law
01:26:25enforcement requirement in rare cases
01:26:27of like genuinely bad actors, right?
01:26:29So there's a book in American pain that's
01:26:31super interesting from several years ago.
01:26:33Now about the Florida pill.
01:26:34Mills Charlotte Bismuth came out
01:26:37with a book recently this year.
01:26:39She was the.
01:26:41Prosecutor for the 1st.
01:26:43I want to get this right
01:26:44and I didn't prepare for it,
01:26:45but I think she was the prosecutor
01:26:47for the first homicide case for a
01:26:50Doctor Who was running a pill mill.
01:26:53So she wrote a book called Bad
01:26:55Medicine this year,
01:26:56and I think those are important
01:26:56to keep in mind that,
01:26:57like law enforcement clearly has a role.
01:27:00What I think is really problematic is law
01:27:02enforcement trying to do public health.
01:27:04And it's even worse when they
01:27:06try to do medicine.
01:27:07And so for the most part,
01:27:10yes,
01:27:10I want doctors to make clinical judgments,
01:27:12not judgments based on whether or not
01:27:14they think the Department of Justice
01:27:15is going to track them as an outlier.
01:27:19So Travis, thank you so much for all of
01:27:22your time and effort and your ability
01:27:25to speak so cogently on these issues.
01:27:27I think we have one last slide
01:27:30just to promote our next session.
01:27:33And there was one unanswered question that
01:27:35related to the role of buprenorphine,
01:27:38but I will refer individuals to
01:27:40your book in pain where you sort of
01:27:44discuss the options for tapering.
01:27:47So if there's one more slide
01:27:49I can speak to it if not.
01:27:51So just a reminder to learn more
01:27:54about the finding some solutions
01:27:56to the opioid crisis speaker
01:27:58series by logging in at visiting
01:28:00addiction medicine at yale.edu.
01:28:02I believe you will be able to
01:28:05access the recordings at that site.
01:28:08You can also follow us on Twitter
01:28:10and follow the Sandgaard Foundation
01:28:12on Twitter and you can join our
01:28:15listserv by emailing Emma Biegacki.
01:28:17So thanks everybody and thank you Travis
01:28:19again for a wonderful discussion.
01:28:21And thank you Kyle
01:28:22very much. Thanks for having me
01:28:24take care. Thank you,
01:28:26thank you thanks everyone.