Yale Psychiatry Grand Rounds: "Reclaiming Psychiatry's Place in Treating Pain and Addiction: A Clinician-Educator's Story"

November 22, 2024

"Reclaiming Psychiatry's Place in Treating Pain and Addiction: A Clinician-Educator's Story"

Ellen Edens, MD, MPE,

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00:00Absolutely an honor, so thank
00:02you all for being here.
00:03Today, I'm gonna be talking
00:04about something that is a
00:05passion of mine.
00:07Thank you.
00:08Which is
00:11we good?
00:15Trying to convince you that
00:17chronic pain management
00:19is actually something psychiatrists
00:20can and should be doing.
00:22And so that's what we're
00:23gonna be talking about today.
00:26I'm gonna tell this story
00:27through my lens as a
00:28clinician educator,
00:31and so let's get started.
00:32Let me see. There we
00:33go. I do have some
00:34disclosures. I'm I am on
00:35the advisory board of Aspire
00:37three sixty five, and I'm
00:38gonna be talking about off
00:39label uses of medications today.
00:42I always like to start
00:43my talk out with my
00:44gratitudes
00:45because why wait, honestly?
00:48And so the first person
00:50is kind of right back
00:51at you with Doctor. Petrakis.
00:53Here we are,
00:55training for the Closer to
00:56Free bike ride in honor
00:57of doctor Mike Cerniak this
00:59summer.
01:00This is doctor Petrakis, myself,
01:03and Jean Vining, who's Bob
01:04Malison's wife.
01:06And it was just an
01:06incredible experience, but doctor Petrakis
01:09is
01:10a friend
01:11and a one of a
01:11kind mentor, so,
01:14she's just a gift to
01:15me. My second gratitude is
01:17I turned fifty this year.
01:19Fifty. I'm not sure
01:22I am not sure if
01:23when you get too old
01:25to
01:26be excited about having your
01:27parents as cheerleaders,
01:29but my parents happen to
01:31be here in the audience.
01:32And I just want a
01:33huge
01:37a huge shout out to
01:38them. My father is a
01:40professor in the department of
01:41orthopedics at University of Tennessee
01:43Health Science Center. Here I
01:44am as a senior in
01:46high school visiting him in
01:47surgery.
01:48He started the first foot
01:50and ankle fellowship in orthopedics.
01:52So he is a foot
01:53and ankle doctor, and we
01:54had a skeleton always growing
01:56up, and it was always
01:57missing its feet because the
01:59feet were in his white
02:00coat. So he always had
02:02a prop whenever he needed
02:04to educate or teach someone.
02:06But he's the reason I'm
02:07a doctor, and he's the
02:08reason that that I wanted
02:09to be a medical educator.
02:10So huge gratitudes
02:12for my dad.
02:13But not to be outdone,
02:15my mother is after I
02:17finished college, she went back
02:19and got her master's of
02:20divinity and then her doctorate
02:21in ministry,
02:23and she became the first
02:25female pastor at the church
02:26that we both grew up
02:27in. It was a Baptist
02:29church, and that was kind
02:30of unheard of. She has
02:32all of her life been
02:33charting uncharted territory and is
02:35a role model for me.
02:36Here, she's
02:38baptizing
02:38my youngest daughter, Natalie.
02:41So that was this last
02:42September.
02:45This talk would not happen
02:46without my team, the clinical
02:48team, and I just really
02:49want a huge shout out
02:50to doctor Will Becker.
02:52We've been doing this from
02:54the beginning.
02:55Many of these slides are
02:56his. A lot of this
02:57research is stuff that's he
02:58has led,
03:00and he helps me kind
03:01of run through my thoughts
03:02here. So huge shout out
03:04to Will Becker, who's a
03:05colleague and friend. Of course,
03:07the rest of the team,
03:08doctor Edmond, is doing some
03:09really amazing research herself. We've
03:11got APRNs, clinical nurse practitioners,
03:14pharmacists,
03:14people are missing PAs, etcetera.
03:16We have a very interprofessional
03:18team.
03:19Thank you.
03:22And then this is my
03:23last one, and I'll move
03:24on.
03:25This is a huge win
03:26for us in the field.
03:27In September, this came out
03:29in NPR
03:30that there was,
03:31some signal that opioid overdose
03:33deaths were plummeting.
03:35And so that was published
03:36in September and on NPR.
03:38And then just last week,
03:39the CDC really confirmed that
03:42with a second four months
03:43of the year, and nationally,
03:45we've seen a sixteen point
03:47six percent drop in overdose
03:48deaths,
03:50this year.
03:51This is not the end.
03:53We can't really,
03:55let up at this point.
03:56We still probably are gonna
03:57reach a hundred thousand overdose
03:59deaths this year, but this
04:00is huge, huge progress and
04:02something I think we should
04:03be celebrating.
04:05Strong work for everybody who
04:06stepped up, to help make
04:08this change.
04:10Alright. Here are my objectives.
04:11I wanna talk about, psychiatry's
04:13unique skill set. This is
04:15something I'm very convinced of
04:16and why interprofessional
04:18training in this field is
04:19essential for psychiatrists.
04:21We're also gonna talk about
04:22a framework for managing opioid
04:24prescribing in this context of
04:25long term opioid therapy for
04:27chronic pain. And then at
04:29the end, we'll talk about
04:30a debate that's going on
04:32around really the clumsiness
04:34of the DSM-five opioid use
04:35disorder criteria
04:37for people when they are
04:37prescribed long term opioid therapy.
04:40But erase all of that,
04:41there really is one thing
04:43I want as a take
04:44home message.
04:45I hope you don't leave
04:46after this, but it's really
04:47the one thing I want
04:48everybody
04:49to to get to get,
04:51and that is that chronic
04:52pain is a condition of
04:54the central nervous system
04:56that has negative
04:58cognitive,
05:00behavioral, and emotional consequences.
05:02Let's say it one more
05:03time.
05:04Chronic pain is a condition
05:06of the central nervous system
05:07that has negative cognitive, behavioral,
05:10and emotional consequences.
05:12And so as such, I'm
05:14quite
05:15convinced
05:16that chronic pain is a
05:17neuropsychiatric
05:18condition and one that we
05:19need to be trained in.
05:22Just to tell you my
05:23context and how I got
05:24started,
05:26this was two thousand and
05:27eleven. I I was very
05:29clear from the beginning, I
05:30wanna come on faculty, I'll
05:32do as many fellowships as
05:33is needed in order to
05:35find a spot for me
05:36and I did,
05:37but at one point, it
05:38was late twenty ten, Doctor.
05:40Petrarcus said there is a
05:41job that's coming open and
05:43we'd welcome you to apply,
05:44see if you might be
05:45a good fit, but, Ellen,
05:46it's in chronic pain. What
05:48do you know about chronic
05:49pain?
05:50And I said, well, doctor
05:52Declan Berry gave me a
05:53lecture during fellowship,
05:55and I had the good
05:57sense to go and actually
05:58visit one of the groups
05:59that he was leading at
06:00the Abt Foundation because, of
06:02course, he was doing,
06:03some really
06:05innovative work in this field,
06:07but short of that, I
06:08had no training.
06:10Just to let you know
06:11kind of the clinical context
06:12and why she might have
06:13come to an addiction psychiatry
06:15trained
06:15person for this position or
06:17to apply,
06:19in two thousand ten, you
06:20have the Susan Oakey,
06:22article coming out in the
06:24New England Journal
06:25of Medicine that says a
06:26flood of opioids, a rising
06:27tide of deaths. You can
06:29see this just
06:30exponential rise in overdose deaths,
06:32and we're always are also
06:33seeing that it is,
06:35running parallel to a rise
06:37in opioid prescribing. Ten, twenty
06:38eleven. The next slide is
06:39the CDC confirming this a
06:41year later, that not only
06:41were opioid prescriptions going up,
06:42overdose deaths were going up,
06:42but also opioid treatment admissions
06:44were going up.
06:53So this myth that if
06:55you had chronic pain, you
06:57would not develop an opioid
06:58use disorder
06:59was clearly false. And so
07:01that is why I think
07:03she was looking for an
07:04addiction specialist to come and
07:05work in this space. But
07:07I would argue
07:09that chronic pain and mental
07:10health, the recognition of their
07:13overlap
07:14well predated any opioid crisis.
07:16And this is not a
07:18feat, something that only addiction
07:19specialists need to know about.
07:21But in truth,
07:24prevalence of mental health conditions
07:26in chronic pain for people
07:27who have chronic pain. Anxiety
07:29and depression is very high.
07:30PTSD
07:31and trauma is also high,
07:33as is ADHD and substance
07:35use disorders. And we know
07:36that the presence of these
07:37psychiatric conditions
07:38worsen chronic pain outcomes.
07:41We also have all probably
07:42all had the experience of
07:44sitting with somebody who has
07:45refractory depression who says I
07:47can't get better when I'm
07:48in this much pain. Right?
07:50So there it's a bidirectional,
07:52interaction, and this is just
07:54a a large study that
07:55came out this summer in
07:56pain,
07:57from the National Health Interview
07:59Survey of thirty two thousand
08:00adults. And what basically, what
08:02it shows is if you
08:03have chronic pain, and this
08:04is high impact chronic pain,
08:05you're having a lot of
08:06difficulty doing errands. I mean,
08:08simple things is doing errands
08:09on your own, participating in
08:09social activities. Your, work is
08:09limited due to your health
08:10problems. It's even worse if
08:12you have anxiety and depression,
08:13but it's much worse if
08:15you have both co occurring
08:22chronic, high impact chronic pain
08:24and, anxiety and depression.
08:27And so at this point,
08:28the question became for me
08:30back in two thousand and
08:31eleven,
08:32why did I know so
08:33little and what did I
08:34need to know to work
08:36in this space? I'm not
08:37going to spend much time
08:38talking about the why did
08:39I know so little? I
08:40think it has something to
08:41do with
08:43psychiatrists don't diagnose
08:44chronic pain conditions.
08:46And because we don't diagnose
08:48it, we don't really see
08:49it as ours, and we
08:50don't have ownership of it.
08:52But it doesn't mean that
08:53we don't have not only
08:55a right, but a responsibility
08:57to actually work within this
08:59space.
09:00But the next question was,
09:01what did I need to
09:02know? And over the last
09:04ten years, this I've come
09:05to think of it as
09:06in two buckets.
09:07So this is the way
09:08I think about it. We
09:09have to have a little
09:10bit of knowledge. That's true.
09:11And I think this has
09:12to happen in psychiatry residencies.
09:15And then we need a
09:15collaborative approach. If we're not
09:17gonna be the quarterbacks of
09:18the chronic pain care team,
09:20then we've got to know
09:21how to reach out. How
09:21do we collaborate? How do
09:23we provide a consultative role,
09:25in this field?
09:26So let's move on to
09:28a little bit of knowledge.
09:29I'm gonna tell you all
09:30this now, hopefully in the
09:31next twenty minutes.
09:33So what is chronic pain
09:34as distinct from acute pain?
09:37According to the ICD eleven,
09:38it is pain that lasts
09:39more than three months. That's
09:41it. That's really all it
09:42is. It is pain that
09:43lasts more than three months.
09:44It lasts beyond the normal
09:45time for healing. It's not
09:47acute pain, which is adaptive.
09:49So really, we think of
09:50it as a fire alarm
09:52going off when there is
09:53no fire.
09:54That's a signal and it's
09:56stressful,
09:57but it is not acute
09:58pain. It's not signaling impending
10:00tissue damage anymore. It is
10:02both a physical
10:05and a psychological phenomenon.
10:07Kind of get, a little
10:09bit more granular and explain
10:10it just to kind of
10:11juxtapose it. I think what
10:13chronic pain is, let's talk
10:14about acute pain.
10:15So you can see here,
10:17light touch is depicted by
10:18the feather here, and pain
10:21signals are traveling along the
10:22a beta fibers to the
10:23dorsal horn of the spinal
10:25cord. They're in black.
10:26Temperature and light touch are
10:28traveling sorry. Temperature and sharp
10:30touch are traveling via the
10:32c fibers
10:33also to the dorsal horn
10:35of the the spinal cord
10:36where then it synapses with
10:38the central nervous system and
10:40goes on up to the
10:41brain where it's perceived,
10:43modulated,
10:43and then there's actually inhibitory
10:46descending,
10:47pathways from the medulla
10:49back down.
10:51So that's how acute pain
10:52works.
10:54Pro tip, we think this
10:55is where tricyclics and SNRIs
10:57work is really in that
10:58inhibitory descending pathway, and you
11:01can think of pain intensity
11:02as the sum of the
11:04ascending stimulus minus the descending
11:06inhibit inhibition.
11:09So let's think about two
11:10models of chronic pain. One
11:11is chronic inflammatory pain. This
11:13might be your rheumatoid arthritis.
11:15This is where you have
11:16pro inflammatory chemokines that are
11:18really sending off signals to
11:20the c fibers,
11:21and then of course that
11:22becomes a tonic noxious impulse,
11:24so people are kind of
11:26chronically experiencing
11:27this pain.
11:28But another model that I
11:30think will be very familiar
11:31to us psychiatrists is one
11:32of neuronal plasticity
11:34that leads to central sensitization.
11:36And this is really where
11:37your c fibers, your a
11:39beta fibers, your, your peripheral
11:40fibers have sustained an injury.
11:42And then in kind of
11:44the healing process,
11:45there's,
11:47regeneration
11:48and, activated macrophages and glial
11:51cells are recruited and you
11:53really get a dysregulation
11:54of these, peripheral pain fibers
11:57that then,
11:58really change the what's happening
12:00in the dorsal horn of
12:01the spinal cord,
12:04and end up with, kind
12:05of chronic pain syndrome going
12:08up to the brain.
12:10All right. So that's two
12:12models.
12:13Let's talk about options for
12:14treating pain.
12:16When I think about pain
12:17treatments, I think about them
12:19in two buckets. The first
12:20one is non medication treatments,
12:22and the second is medication
12:24treatments. Let's talk about non
12:26medication treatments. And I'm gonna
12:27demonstrate this to y'all by
12:28the way, in a video
12:29in just a second. You'll
12:30see me talk to a
12:31patient about this. But the
12:32first thing is active treatments.
12:34So these are things the
12:35patient does, and this is
12:36first line.
12:37The second,
12:39category I think of is
12:40passive treatments
12:42that these are things that
12:43are done to the patient,
12:44but they don't include medications
12:46for the most part. I
12:46mean, I have a steroid
12:47injection, but a lot of
12:48times there's trigger point injections.
12:50We have,
12:51tens units, nerve block surgeries.
12:53I probably should have mentioned
12:54chiropractic and acupuncture first.
12:57And then when you go
12:58to your medication treatments, I
12:59think about it as non
13:00opioid analgesics. And if you
13:02look at these, we've got
13:03our NSAIDs, our antidepressants, our
13:04anti epileptics,
13:06muscle relaxants.
13:07Diazepam
13:08is often prescribed,
13:10as a muscle relaxant, by
13:12the way.
13:13And I think that's maybe
13:14where psychiatrists could actually be
13:15involved in that particular piece
13:17is in deprescribing,
13:18if anything, and then your
13:20topicals.
13:21And then, of course, there
13:22are opioid analgesics,
13:23both long and short acting.
13:25So if you look at
13:26this list and then I
13:27highlight everything that psychiatrists either
13:29know something about
13:31or,
13:31actively
13:32prescribe or do, you can
13:34see that there's a lot
13:35of yellow up on this
13:37screen.
13:38Right? And there's not much
13:39more, by the way. This
13:40is, this is really it.
13:41This is what we got
13:42for chronic pain.
13:44I'm sure there's some other
13:45things. Hopefully we're going to
13:46get more treatments, but this
13:48is it. And a large
13:49proportion
13:50is squarely in our,
13:52field.
13:54So how does all of
13:55this fit together? What I
13:56would say is, let's talk
13:58about what is our role
13:59and what is not, and
13:59I think this has to
14:00be very clearly explained to
14:02trainees if we're going to
14:03get traction as to why
14:04this is important. Again, we
14:05don't diagnose pain conditions, generally.
14:07We don't order diagnostic tests,
14:09generally, and we don't generally
14:11serve as the team quarterback,
14:13which we're used to doing.
14:14So that requires a little
14:15bit of a frame shift,
14:16I think. But we definitely
14:18can act as a consultant.
14:20We can diagnose and treat
14:21co occurring mental health conditions,
14:22including opioid use disorder. We
14:24can educate patients about multimodal
14:26treatment and I'll show you
14:27I'll demonstrate that in just
14:28a bit. You'll explain the
14:30inner interplay between mood, stress,
14:32anxiety, addiction and chronic pain.
14:34Primary care doctors don't have
14:35a lot of time to
14:36explain this, Right? We do.
14:38This would be a wonderful,
14:40wonderful
14:40benefit
14:41to our patients if we
14:42were able to do this.
14:44And of course we can
14:44deliver, oversee, and recommend evidence
14:46based treatments,
14:47in this area.
14:51As far as a functional
14:52pain assessment, I'm also going
14:54to demonstrate this in just
14:56a second.
14:58We, again, we're not diagnosing.
14:59So I don't it's not
15:00when you see me, you'll
15:01see that all of these
15:02questions
15:04feel very comfortable, I think,
15:06for psychiatrists. Psychologists often lead
15:08the field in pain assessments,
15:10health psychologists do, and so
15:11I'm gonna demonstrate a functional
15:13pain assessment. I thought,
15:17what I'm gonna do is
15:18first set the stage. This
15:19is miss Davis. We're gonna
15:20have two cases that are
15:21fairly similar. I presented this
15:23at the American Psychiatric Association
15:25meeting in May.
15:28There is a part in
15:29this video where she asks
15:31me how talk therapy will
15:33help her chronic pain, and
15:34I don't answer her. And
15:36the reason I didn't answer
15:37her is because we were
15:37gonna do that later in
15:38the workshop. So for our
15:40purposes, I'm gonna do it
15:41after this video is over.
15:42You're gonna have I'm gonna
15:43demonstrate how that's done, but
15:45just FYI. So miss Davis
15:47is a forty four year
15:47old female with major depression.
15:49She's coming into your office.
15:50She's on, you know, pretty
15:51high dose sertraline.
15:52That has helped some. Her,
15:54depression has
15:57it it it has gone
15:58down. It has improved, but
16:00not not remitted.
16:01She's very focused on her
16:03chronic pain. I'll always be
16:04in pain, so I'll always
16:05be depressed.
16:06She got started on opioids
16:07in the context of a
16:08cancer diagnosis and has remained
16:10on them, And her opioid
16:11prescriber is beginning to initiate
16:13a taper, and she's very
16:14anxious. And so you decide
16:15to find out more about
16:16her experience of chronic pain.
16:19And here we go.
16:22Hopefully, this will work.
16:24So tell me about your
16:25pain.
16:26So I have pain all
16:28over. The worst is in
16:29my chest when I get
16:30muscle spasms, but I have
16:32pain in my back and
16:33my neck. Even my legs
16:34ache all the time.
16:36Is there any burning or
16:37shooting pain?
16:39No.
16:40What about numbness or tingling?
16:42Not really.
16:43And what have you tried
16:44that makes the pain better?
16:46Well, the oxycodone makes it
16:48so that I can at
16:48least get grocery shopping done,
16:50but that's about it.
16:52Anything else?
16:54I have a good friend
16:55who calls me. That helps.
16:57And sometimes I get outside.
16:59I can't really go very
17:00far, though, but it does
17:02help.
17:04What what things make it
17:05worse?
17:07Standing for too long, typically,
17:09sitting for too long, and
17:11walking more than ten minutes.
17:14Tell me about a typical
17:15day.
17:17So I can't really sleep
17:18at all.
17:19I usually wake up around
17:21five in the morning,
17:22and I have some coffee
17:24breakfast before work.
17:25When I get home, I'm
17:27just exhausted.
17:28I usually just sit on
17:30the couch and watch television
17:31until bedtime.
17:32I go to bed around
17:33nine PM.
17:35On weekends,
17:36I just rest. I go
17:37to church on Sunday, but
17:38that's about it. Sometimes my
17:40daughter comes to visit.
17:41Oh, miss Davis, it's clear
17:43pain is really
17:45impacting your life in many
17:46ways.
17:47I'd like to ask now
17:48about specific areas that pain
17:50affects you. That'd be okay?
17:54Does pain impact your ability
17:55to do physical activity?
17:58Yes. I used to run
17:59and hike before my diagnosis.
18:02Now I can barely walk
18:03around the block.
18:05That's tough.
18:06Are you able to take
18:07care of your daily tasks
18:08such as dressing yourself, cooking,
18:10or preparing meals, or cleaning
18:11your house?
18:13Yeah. I do okay. Some
18:15nights, I'm so tired, though.
18:16All I can do is
18:17microwave a dinner, but I
18:19get along.
18:20And how does pain impact
18:22social relationships?
18:25I try and keep in
18:25touch with people, but I'm
18:27usually too tired.
18:29And who wants to be
18:29around someone like me anyway?
18:31I'm not really that bad
18:32anymore.
18:34And you mentioned that sleep
18:35is really hard for you
18:36and that you experience pain
18:37as the reason for sleepiness.
18:39Correct?
18:41Yeah.
18:42What about your mood? What
18:44connection do you see between
18:45your mood and pain?
18:47I feel like pain just
18:48makes me so grumpy. I'm
18:50just not really that fun
18:52anymore.
18:54Some people also know that
18:55when they're in a better
18:56mood or a worse mood,
18:58that impacts how much pain
18:59they experience.
19:00Do you ever notice that
19:02connection where your mood impacts
19:03your pain?
19:05Well, I like having my
19:07daughter around. That helps.
19:10And how would you describe
19:11your overall quality of life?
19:14Pretty pathetic.
19:16I don't really do anything
19:17but work and go to
19:18church once a week.
19:20Miss Davis, it's clear that
19:21pain is really impacting your
19:23overall health and life,
19:25and that's really hard. So
19:27how are you coping with
19:28all of this?
19:30I mean, I read the
19:31bible and pray, and like
19:33I said, my good friend
19:34and my daughter help.
19:36Let me ask you. If
19:37your pain were better managed,
19:39what would you be doing
19:41that you're not doing now?
19:43I mean, I'd love to
19:45complete a five k.
19:47Even walking, it would be
19:48good.
19:49We have a fun one
19:51in the fall that I
19:52haven't been able to join
19:53for, like, several years now,
19:55but that won't really happen.
19:56I can't even walk ten
19:57minutes now, and I like
19:59to sleep better.
20:01But those are some great
20:03goals, miss Davis, that I
20:04think we can work together
20:05to help you achieve.
20:08So now that I've heard
20:09about your pain experience and
20:11what your goals of pain
20:12care are, I'd like to
20:13explore some things that you've
20:14tried for your chronic pain.
20:16Have you ever tried physical
20:18therapy or pool therapy?
20:20No. But getting into a
20:22pool sounds really nice.
20:24What about paced or gentle
20:26exercise like yoga?
20:28What do you mean by
20:29paced? That's a great question.
20:31So by paced, I mean,
20:33where you exercise to just
20:35under the limit of where
20:36pain gets intense.
20:37So for instance, if you
20:38walk ten minutes and hurt
20:40bad, as you mentioned,
20:41then you would stop walking
20:43and take a quick break
20:44every eight minutes instead. And
20:46then once you've recovered, you'd
20:47keep going.
20:49Oh, I see. Okay.
20:52Have you ever seen a
20:53physiatrist or physical medicine and
20:54rehab specialist?
20:56This is a medical specialty
20:57that focuses on the musculoskeletal
20:59system and maximizing function.
21:02No. I've never even heard
21:04of them, but that sounds
21:06interesting.
21:07What about injections, such as
21:09steroid injections into joints or
21:11Botox to relax muscles?
21:13Oh, no. That sounds very
21:15interesting about Botox, but I
21:17don't really like needles.
21:19Have you ever seen a
21:20chiropractor?
21:22Yes. That helped a little
21:24at first, but then it
21:25stopped working.
21:27Ever received acupuncture?
21:29That sounds weird to me.
21:32What about massage?
21:35I've had a massage before.
21:37That does seem to help,
21:39but I can't afford it.
21:41Have you ever tried a
21:42TENS unit?
21:44That hurts. It made my
21:46pain a lot worse.
21:48Does applying heat or ice
21:49help?
21:51Sometimes a heating pad would
21:52help.
21:53Have you ever received talk
21:55or skill based therapy that
21:57specifically,
21:58targets your chronic pain?
22:00No. How will talk therapy
22:03help my pain? I haven't
22:04done that.
22:05Okay. I'd like to come
22:07back to your question about
22:08how this type of therapy
22:09might be useful.
22:10But for now, I'm gonna
22:11turn to medication treatments.
22:14Do you use any ibuprofen,
22:16naproxen,
22:17or other NSAIDs or Tylenol?
22:22Sometimes I take an Advil,
22:23but I don't know why.
22:24It doesn't really help much.
22:26I know they put Tylenol
22:28on Percocets,
22:29but for some reason, my
22:30doctor is only prescribing oxycodone
22:32without the Tylenol.
22:35K. And I know you're
22:36on sertraline.
22:37I'm gonna ask about other
22:38medications in that class that
22:40can really help with pain.
22:41Have you ever tried amitriptyline,
22:44nortriptyline,
22:45or what about venlafaxine
22:47or duloxetine?
22:49No. None of those sound
22:50familiar.
22:52What about gabapentin
22:53or pregabalin?
22:55Yeah. I hate that stuff.
22:58Okay.
22:59Have you ever used muscle
23:00relaxants like baclofen or cyclobenzaprine
23:03before?
23:04Those make me feel really
23:05goofy.
23:07I don't really like to
23:08take those much, but sometimes
23:09I do when the spasms
23:10get really bad.
23:12And last but not least,
23:13what about topicals,
23:15like lidocaine patch or capsaicin
23:17cream or a diclofenac gel?
23:20I used a lidocaine patch
23:21for a while, but it
23:22didn't really do anything.
23:24And then anything else that
23:26you've tried for pain that
23:27I haven't asked about?
23:29No.
23:33Okay.
23:34So I told you that
23:35I would demonstrate how how
23:37when she asked, how would
23:38talk therapy impact my my
23:40pain? And I've learned from
23:41my health psychology colleagues that
23:43sometimes it's better to talk
23:44about skills based therapy,
23:46but what happens over time
23:47with chronic pain is people
23:49start to have thoughts like,
23:50I'm no good. My life
23:52will never be the same.
23:53And then they begin to
23:55stop going places and doing
23:57things. And over time,
23:59pain is absolutely,
24:00the pain is central. And
24:02so what I talk to
24:03patients about is, you know,
24:04pain has really taken control
24:06of your life. And sometimes
24:08if you meet with somebody
24:09or we talk and we
24:10really examine what's going on,
24:12what those triggers are, what
24:14your behaviors are around your
24:15pain,
24:16sometimes we can figure out,
24:18we can tweak some things
24:19that will ultimately put you
24:21back in control.
24:22That is the goal of
24:23talk or skills based therapy
24:25is to find small wins
24:27that ultimately give our patients
24:28more agency.
24:30And many times they'll buy
24:31into that because they don't
24:32really have anything else to
24:34lose. And if we're able
24:35to talk to our patients
24:37about the benefit of skills
24:38based therapy, it would be
24:40huge for our patients.
24:43Okay. The other thing I
24:44think we as psychiatrists can
24:46do is pitch a multimodal
24:47treatment plan.
24:49The main thing here is
24:50people will often say, oh,
24:51I did physical therapy and
24:53it hurt and made things
24:54worse. And so our job
24:56is to really try and
24:57convince patients, okay, you know,
24:59we're not gonna force them
25:00to do something that they
25:01don't wanna do, but what
25:02might be the benefit of
25:04bringing back things that didn't
25:05work in the past? And
25:07so I'm gonna just
25:09demonstrate how I talk to
25:10patients about,
25:12putting together a multimodal care
25:14plan.
25:16Thanks for going through all
25:17of that, miss Davis.
25:19I have a few ideas
25:20already about what might be
25:21helpful for you.
25:22Might I tell you about
25:24how we think about best
25:25practice pain care and how
25:27we're gonna help you find
25:28the right treatments that work
25:29for you?
25:31Oh, yeah.
25:32Yes.
25:34So we now know that
25:35chronic pain isn't just about
25:37the site of injury.
25:38Tissue there has healed.
25:40But what's happened is that
25:42nerve cells all along that
25:44pain pathway to your spinal
25:45cord and up to your
25:46brain and back down again
25:48have changed. And those are
25:50keeping that pain signal going
25:52even when there's no acute
25:53injury or danger anymore.
25:55We sometimes like in chronic
25:57pain to a fire alarm
25:58going off when there isn't
25:59actually a fire.
26:01Over the past few decades,
26:02we've learned a lot about
26:03chronic pain. So for instance,
26:05it's clearer now that chronic
26:06pain is more complex than
26:07we ever imagined.
26:09And while perhaps one day,
26:10we'll have a cure for
26:11it, right now, we only
26:13have a certain number of
26:14treatments that we know work.
26:16I call this our ingredient
26:17list for chronic pain treatments.
26:20And the highest quality care,
26:22which is what we want
26:23you to get,
26:24is like finding the right
26:26recipe for you from that
26:27list of ingredients.
26:29So let's use an example,
26:31like baking a blueberry pie.
26:33Blueberries are delicious, and I
26:35can eat them by the
26:36handful. But by themselves, they're
26:38just not gonna make a
26:38blueberry pie. Right? Rather, you
26:40need lots of ingredients, sugar,
26:42flour, salt, butter,
26:44maybe some lemon juice or
26:46eggs. And bear with me.
26:47You know, you can't have
26:48all of these ingredients on
26:50different days. You can't have
26:51flour on Monday and eggs
26:52on Tuesday.
26:54Rather, you really have to
26:55mix them all together and
26:56put them in the oven
26:57and bake them into something
26:58new.
26:59Well, that's how we think
27:00about pain care now. While
27:02opioids may seem to be
27:04working for you, we probably
27:06can't get the best overall
27:07effect without adding more ingredients.
27:10So maybe we add some
27:11ingredients that you've never used,
27:13things that I asked about
27:14that you didn't hear hadn't
27:15heard about before.
27:17But maybe we also add
27:18back in things that you've
27:19already tried.
27:20And by themselves, maybe they
27:22don't reduce your pain noticeably.
27:24But what if, for instance,
27:25Tylenol can reduce your pain
27:27from an eight, say a
27:28seven point six? And then
27:30getting in the pool, which
27:31you seemed interested in, might
27:33reduce that score to a
27:34seven point two.
27:36Maybe some stretching or yoga
27:38could get you down to
27:39a six point eight,
27:41and adding some pleasurable activities
27:43or coping skills might reduce
27:44it all the way down
27:45to a six.
27:46And then, of course, the
27:47opioids may reduce you to
27:49a five. And suddenly, things
27:51that didn't seem like they
27:52were working on their own
27:53when put altogether
27:55can actually make a pretty
27:56great recipe.
27:57What are your thoughts about
27:58that?
28:00I mean, I guess that
28:01makes sense.
28:02So what's next then?
28:05Well, of those things that
28:06I mentioned, what are you
28:07most interested in?
28:10I guess the pool therapy
28:12is most interesting to me
28:13and maybe restarting with a
28:15chiropractor
28:16and getting out my heating
28:17pad.
28:19Also, you have told me
28:20that I'm at the highest
28:22dose of my antidepressant,
28:23so maybe it's time to
28:24think about something different.
28:27And I'd be open to
28:28seeing the what was it
28:29called again? The rehab
28:31person, maybe?
28:33Miss Davis, I think that
28:34sounds like a wonderful start.
28:36So now let's talk about
28:37your options for an antidepressant.
28:41Okay. So in about thirty
28:43minutes, I have taught you
28:45chronic pain one zero one
28:46for psychiatrists.
28:49And that's really kind of
28:50the nuts and bolts that
28:51we have our trainees learn
28:53or we hope and I'm
28:53gonna go into a little
28:54bit more of our goals
28:55and our objectives in our
28:56clinic, but that's kind of
28:58the basics that I've distilled
28:59over the last decade.
29:01The other thing that I
29:02said we really needed to
29:03have as psychiatrists was a
29:05collaborative or interprofessional approach. Now
29:07if you're a primary care
29:08doc or if you're in
29:09private practice, obviously, you're not
29:11gonna be able to do
29:12a lot of care coordination
29:13other than maybe saying, you
29:15know, they expressed interest. Go
29:16and talk to your primary
29:17care doctor. You can call
29:18the primary care doctor just
29:19to make sure that y'all
29:20are working synergistically together or
29:22the pain team. But now
29:24I am gonna talk about
29:25a pretty innovative clinic that
29:27we have developed over at
29:28the VA that's now been
29:30disseminated nationally.
29:32And,
29:33we're we're looking at taking
29:35it outside of the VA
29:36as well.
29:37This is the chronic pain
29:39management clinic, opioid safety, also
29:41known as the or formerly
29:42known as the opioid assessment
29:43clinic. We just changed our
29:44name two months ago, I
29:45think. But we were the
29:47ORC up until just recently.
29:49We were started in two
29:50thousand twelve. As I've already
29:51mentioned, pain at the VA
29:53was moving or opioid prescribing
29:54was moving from anesthesiology
29:56down to primary care. Primary
29:57care doctors were saying, oh
29:59my gosh, what do we
30:00do? We need help. We
30:01had this huge systems redesign
30:03meeting.
30:04Doctor Declan, sorry, doctor Will
30:06Becker was, coming over. He
30:08had a career development award.
30:10He's an internist. He's got
30:12addiction training.
30:13And, we kind of put
30:15our heads together and we
30:16we started the opioid reassessment
30:18clinic. From the beginning, it
30:20was multidisciplinary.
30:21We have both internal medicine
30:23psychiatry, health psychology, and our
30:24nurse practitioner was psych trained.
30:26We've added well, I'll show
30:28you who all we've added.
30:29Again, we all had addiction
30:30or psychiatry training, and we
30:32took over opioid prescribing. So
30:33this was not a one
30:35time consultation, which was key.
30:37Right? We took over opioid
30:38prescribing to figure out the
30:39plan. So this is how
30:40the ORC or the opioid
30:41safety clinic
30:43works. Primary care doctors put
30:45in a referral, and then,
30:47it's reviewed. The appointment is
30:50scheduled and a structured chart
30:51review is done before the
30:52patient comes. I really wanna
30:54note number six.
30:56This initial visit is
30:58co led by a psychologist
31:00and a prescriber.
31:02For the first seven years,
31:03this was not the case.
31:05I would lead the initial
31:06ones or some other prescriber.
31:08Usually at the time, we
31:09were pretty, we were small
31:10back then. And then the
31:12psychologist, the health psychologist would
31:14meet with them and follow-up.
31:16It was a trainee. It
31:17was a psychology post doc
31:18around two thousand nineteen, two
31:20thousand twenty that said we
31:21can do this better than,
31:22you know, we can do
31:23it better than this, Ellen,
31:24and really led us through
31:26an entire year quality improvement
31:28project. This was her idea
31:30to really get buy in
31:31because she's basically saying, Ellen,
31:32you're gonna have to share.
31:34And we did we did
31:36this. We figured it out,
31:37and I will never ever
31:38go back. And I think
31:39seeing these co led visits
31:41and psychology is right there.
31:42In fact, they start the
31:44interview.
31:45There is never a sense
31:46that psychology
31:47or that skills based therapy
31:48or that medic you know,
31:50that medications are somehow supreme
31:51over anything else from the
31:52get go. Our patients are
31:53seeing that this is a
31:54team based approach,
31:56and that's just been really
31:57incredible. And I still keep
31:59in touch with the postdoc
32:00who did this, because I
32:01think it changed our clinic.
32:03After that, we talk with
32:04the team, we come up
32:05with a plan, and then,
32:07we do have follow ups.
32:08And our patients do get
32:09health psychology
32:10as well as med management
32:11in our clinic, and we
32:12do care coordination as well,
32:14which we can do at
32:14the VA being the largest
32:16national health care system in
32:17the country.
32:19Alright. Really, I taught I
32:21keep mentioning interprofessionalism.
32:23I will say Rome was
32:24not built in a day.
32:26We started out pretty interprofessional,
32:28but over the years, we
32:29have expanded and expanded and
32:30expanded. We now have clinical
32:31pharmacists.
32:32We have a physician assistant
32:34who works up in our
32:34Newington site. So we have
32:36two clinics going on at
32:37one time. We have a
32:39peer specialist, somebody who's lived
32:40with opioids, with chronic pain,
32:42who's been on opioids, who
32:43switched to buprenorphine so they
32:45can talk to other Veterans.
32:46And just this year, we've
32:47also added chiropractic care and
32:49physical therapy.
32:52I wanna tell you about
32:53the flow of our clinic
32:54by using the case of
32:55miss Morris. So miss Morris
32:56has chronic chest, neck, and
32:58back pain. She's fifty nine
32:59years old. She's on a
33:00hundred and eighty milligrams oxycodone
33:02daily. That's a high dose.
33:03Anything above ninety morphine equivalents,
33:06and this is two hundred
33:06and seventy morphine equivalents. So
33:08very high dose. She had
33:09she also, like miss Davis,
33:11was put on it for
33:11breast cancer, and this is
33:13a comes from an actual
33:15case of
33:16de identified everything, but, this
33:18is a veteran. So she
33:19has breast cancer in remission,
33:21bilateral mastectomy, and continues to
33:23have a lot of muscle
33:24spasms as well as neck
33:24and back pain. She also
33:26has depression and anxiety and
33:27PTSD that's all been untreated.
33:30From an opioid state safety
33:31standpoint there's no evidence of
33:33loss of control on initial,
33:34when we initially see her,
33:37we look at the state
33:38PMP, we don't see any
33:39early refills or anything like
33:40that and she doesn't report
33:41anything either. No history of
33:42substance use, current alcohol, nicotine
33:44or cannabis use, but she
33:45does have sleep apnea which
33:47increases the risk given that
33:48high dose opioid.
33:50She's actually quite functional. She
33:51gardens, she socializes, she even
33:53practices yoga. I mean, we
33:55don't have that many veterans
33:56who are gung ho on
33:57yoga. So that's pretty cool.
33:59I mean, she's pretty active.
34:00Non medication treatment, she's open.
34:03She, besides her own self
34:05management, her active treatment.
34:10She's open to pain, focused,
34:13psychotherapies and a referral for
34:15mental health treatment. Sorry. For
34:16medication treatments, she's exquisitely sensitive.
34:19She can tolerate
34:20a low dose of Venlafaxine
34:21but otherwise really can't tolerate
34:23NSAIDs, gabapentinoids.
34:25The only muscle relaxant she
34:26can tolerate is diazepam and
34:28she did have a prescription
34:29for that in the past.
34:30As far as opioids, she
34:32is terrified coming into our
34:33clinic. She's not happy about
34:35being there. She lost her
34:36out her non VA prescriber,
34:38which is why she was
34:38referred to us.
34:41And she's very anxious about
34:43tapering. Why fix what isn't
34:45broken?
34:46She's experienced withdrawal before,
34:49which is heightens her anxiety
34:51about all of this. She
34:52knows how horrible opioid withdrawal
34:54is, but it wasn't because
34:55she overused. It was really
34:57that a refill arrived late,
34:58and she's very opposed to
35:00switching a buprenorphine, which isn't
35:02entirely uncommon in our clinic.
35:04So this is the framework
35:05and this is what we
35:06teach all of our students.
35:08First, whenever a patient comes
35:09in, we we're wondering, is
35:11this opioid use disorder? And
35:13if it is,
35:15then we refer them to
35:17methadone or to I'm naltrexone,
35:18or we start buprenorphine. In
35:20our clinic, we go ahead
35:21and get that done.
35:23If it is not opioid
35:25use disorder
35:26or we are not clear,
35:27we are not sure, then
35:28we move to the bottom
35:29part of this frame. And
35:31that's where we move to
35:32a risk benefit analysis. Do
35:34the benefits outweigh the harm?
35:35And if no, the harms
35:36outweigh the benefits,
35:37then we offer the patient
35:39a patient centered tapering. And
35:40that means we are going
35:42to add multimodal treatment. We're
35:43gonna be at your side.
35:44We are not gonna let
35:45you go, but we are
35:46gonna move in the direction
35:47of safety,
35:48or we will offer pay
35:49people, an optional rotation of
35:51buprenorphine.
35:52If the benefit is outweighing
35:54the harm,
35:56meaning, you know, we think
35:57that there's substantial benefit, but
35:59the dose is high, we
36:00think equal benefit and less
36:02harm could be achieved at
36:03a lower dose. So we
36:04offer that patient a patient
36:05centered tapering,
36:06protocol or option, including an
36:08optional rotation to buprenorphine.
36:10If the benefit seems to
36:12be present and the dose
36:13is low, we sometimes will
36:15just monitor and reassess. But
36:17I'll tell you, we almost
36:17always offer that person the
36:19option of switching to buprenorphine
36:20as well.
36:21Alright. So why would we
36:22use buprenorphine in these these
36:24patients? Well, first of all,
36:25there's a potential for a
36:26quick taper off of full
36:27agonist. So people are often
36:29on high doses and they
36:29say it's not really working
36:31well. What else do you
36:31have? I need to go
36:32up. I've developed tolerance. How
36:34is switching coming down gonna
36:36help me? And so they're
36:37happy to switch to something
36:38else and immediately we can
36:40get them off of a
36:41full opioid, a full agonist
36:42opioid. It will rapidly re
36:44relieve withdrawal symptoms if that's
36:46present. These days, we really
36:47use the low dose protocol
36:49where we start buprenorphine super
36:50low. We keep them on
36:51the high dose opioids. And
36:53then once we get to,
36:53like, day five and a
36:54reasonable dose of buprenorphine, we
36:56just stop the stop the,
36:58oxycodone or the full agonist.
36:59Most people, many people don't
37:01experience any withdrawal. They feel
37:02a little funny in the
37:03transition, but that's kind of
37:04what they'll describe.
37:06It's quite well tolerated. This
37:08addresses the neurobiologic
37:09adaptation that occurs when anybody's
37:12been on long term opioids
37:13for many years as these
37:14patients have. Observational data suggests
37:16chronic pain efficacy, there's demonstrated
37:19improved function and effectiveness, and
37:20discontinuing full agonist, this is
37:22mostly from the OUD literature,
37:24and then the two thousand
37:25and twenty two VADOD guidelines
37:27recommend it. And I will
37:28say this is something that
37:29I'm happy about. I really
37:31advocated for this when I
37:32was part of this group.
37:34We got it was controversial,
37:37because the there was concern
37:38that buprenorphine would it would,
37:39like, open up the floodgates.
37:41But we thought that we
37:42were very clear
37:43that for people who already
37:45are receiving daily opioids,
37:48consider a switch to Buprenorphine,
37:50that that would be preferred
37:51basically simply because of the
37:52safety, not because of effectiveness,
37:55there weren't there aren't any
37:56trials comparing a partial agonist
37:57and a full agonist necessarily
37:59head to head. So it
38:00was a week four,
38:02recommendation,
38:03but because the safety data
38:05on buprenorphine
38:06is so strong,
38:08the committee or or the
38:09work group ultimately thought that
38:10this was an important recommendation
38:12to include.
38:14Alright. So we have two
38:15studies of this clinic that
38:17I'm gonna, show you. This
38:18is the first one. Both
38:19were published in two thousand
38:21and eighteen, but this is
38:22of the first two years
38:23of our clinic. And the
38:24first question we were asking
38:25is, were we recruiting the
38:26right people? Were we targeting
38:27the right people?
38:29This retrospective chart review of
38:30eighty seven patients. You can
38:32see that the majority have
38:33substance use disorders. The majority
38:35have other psychiatric disorders.
38:37The majority had a current
38:38opioid misuse,
38:40significant safety concerns, And about
38:42a third were saying it's
38:44not even working. Right.
38:46So we concluded that we
38:47were actually treating, we were
38:50reaching and treating our target
38:52audience
38:53because we are all addiction
38:54trained. Almost a quarter of
38:56these patients were diagnosed with
38:58a new substance use disorder.
38:59So we really were able
39:00to, you know, just a
39:01new set of eyes looking
39:02for these, conditions.
39:04These patients had opioid, alcohol,
39:06cannabis, cocaine, and tobacco
39:08use disorder.
39:09Of the nine with opioid
39:10use disorder, three transition to
39:12methadone and six to buprenorphine.
39:14We overall were able to
39:15decrease their morphine equivalent daily
39:17dose by thirty three,
39:19milligrams.
39:20Patient satisfaction was pretty high,
39:22I think, given that nobody
39:24wants to come to our
39:25clinic. Right? They're terrified to
39:26come to our clinic. And
39:28so the fact that by
39:29the end, they felt, you
39:30know, the satisfaction was this
39:32high, I think patients feel
39:33pretty supported
39:34and are ultimately fairly satisfied
39:37with the care that they
39:38receive.
39:39Fifty percent of our primary
39:41care doctors were referring to
39:42us, which was great. And
39:43then in that first two
39:44years, we had thirty one
39:45trainees. And so this is
39:46really what I wanna highlight
39:47next.
39:48The majority were coming for
39:50their addiction rotation experience.
39:52And so this really led
39:53me to think because here
39:55I was the associate fellowship
39:56director now for addiction psychiatry,
39:58like what okay. If my
39:59fellows if these fellows are
40:00gonna be coming through, what
40:02is it that they need
40:02to be learning? I mean,
40:03they can see patients, but
40:04I needed clinical goals and
40:06objectives.
40:07And so,
40:09I reached out to John
40:09and Candela at the School
40:10of Teaching and Learning. Imbal
40:12Gaffney was a fellow at
40:13the time, and,
40:14we put together a focus
40:15group of,
40:17fellowship
40:18directors
40:19from five geographically
40:21varied programs
40:22to ask this very question
40:23like what it did should
40:24we be training in this
40:25area? And if so, what
40:26should we learn? And I
40:28think there was definite consensus
40:30from this qualitative,
40:32study that curriculum was needed.
40:34And then there were three
40:35major barriers that were identified.
40:36And one was that there
40:37were lack of clear goals
40:38and objectives.
40:40Some was just, you know,
40:42is this our mission? Like,
40:43people are dying. Should we
40:44be like is it is
40:45it mission creep in a
40:46way to go into chronic
40:47pain?
40:48And then there was also
40:49some resource barriers. I don't
40:51wanna send my addiction psychiatry
40:52fellows
40:53into an interventional pain clinic
40:54where they're just prescribed and
40:56this is again, you know,
40:57back in twenty fourteen where
40:58they're prescribing high dose opioids
40:59and they're doing a lot
41:00of interventions. Like, that's not
41:01gonna be a great site
41:02of training. So that was
41:03not everybody had the kind
41:04of clinic that we had.
41:06So from that, needing real
41:08recognizing that we needed clear
41:09goals and objectives, we decided
41:11to develop them. They've been
41:13tweaked over the, ten years
41:15since,
41:16but this is generally what
41:17we think all of our
41:18trainees should know by the
41:19time they finish their rotation
41:20with us. First of all,
41:21we want them to know
41:22how to do the pain
41:23assessment that I really just
41:24demonstrated for you. We want
41:26them to be able to
41:27analyze the risk benefit,
41:29ratio
41:30and,
41:32really think through that in
41:33order to develop a treatment
41:35plan. We want them to
41:36think about a multimodal treatment
41:37plan and we want them
41:39to be able to consult,
41:40interprofessionally.
41:41We also, you know, we're
41:43gonna be monitoring. Psychiatrists can
41:45order your own drug screens.
41:47We can check PMP, even
41:48if we're not prescribing the
41:50medication. We can help in
41:51some of these ways, even
41:52if we're not overseeing the
41:54opioids.
41:56And last but not least,
41:57we want our trainees
41:59to be able to talk
42:00to patients about the difference
42:02between acute and chronic pain.
42:03Why non pharmacologic management is
42:05so important? Why non opioid
42:08management is so important? And
42:10ultimately, why, what is the
42:12rationale for optimizing mental health
42:13treatment when somebody also has
42:13chronic pain? Mental health treatment
42:15when somebody also has chronic
42:16pain? This is all of
42:16the trainees that we've had
42:17since twenty twenty when we
42:18really started collecting good data.
42:19Huge shout out to Sarah
42:21Edmond and Kelly Coleman for
42:23keeping this data.
42:28But you can see since
42:29twenty twenty, we've had two
42:31hundred sixteen trainees.
42:33It looks like a predominance
42:34of physicians, which it is,
42:36but our physician trainees off
42:37often are just coming in
42:39for much shorter periods of
42:42of time, like a one
42:42or two week just kind
42:42of observation,
42:43whereas a lot of our
42:44non physician trainees are staying
42:45for months.
42:46Our health psychologists are often
42:48with us for an entire
42:49year.
42:50So if you break the
42:51physicians down, you'll see here
42:53that,
42:54forty percent
42:55are
42:56psychiatrists.
42:57And I just want to
42:58note that we have psychiatry
42:59residents from the PGY one,
43:01two, three, and four year,
43:04and Julio Nunez is here,
43:05and he's our inaugural PGY
43:07three outpatient placement, and he's
43:09in the OR, sorry, the
43:10opioid safety clinic for the
43:12entire year. And Marcus Moreno
43:13is our fourth year who's
43:14also in our clinic. And
43:16it's just been invaluable having
43:17them.
43:18We gained so much more
43:19from trainees, but I think
43:20it's it's an awesome, educational
43:23experience for them. Our addiction
43:24psychiatry fellows,
43:26all rotate through,
43:27as well as our CL
43:29fellows. Addiction psychiatry for one
43:30to two months and CL
43:32fellows for three months each.
43:33And so that's been just
43:34a real gift to our
43:35clinic.
43:37Alright. Moving back, we did
43:38another study. This is,
43:41study two. Again, remember how
43:43we give that constrained choice.
43:44You can either tape her
43:45down or you can switch
43:46to bup. We wondered how
43:48that went. Like, what were
43:50what was how was that
43:51being received? And so this
43:53is also a retrospective chart
43:54review
43:55of seventy one patients that
43:57we had given this choice.
43:58And when given the choice
44:00of either a taper down
44:01or switch to buprenorphine,
44:03two thirds chose to switch
44:05to buprenorphine.
44:06So people liked this option.
44:08I don't know if they
44:09liked it, but they chose
44:09it. So something was driving
44:11that. Overall, we were able
44:13to decrease these, the morphine
44:14equivalent daily dose by thirty
44:16milligrams
44:17and,
44:18almost half engaged in non
44:20pharmacologic
44:21pain care. That's pretty cool
44:22and I think speaks to
44:23the interprofessional clinic that we
44:25have.
44:26Just to go as a
44:27comparison, we did have thirty
44:28nine, people who were referred
44:30to us, but did not
44:31ever engage. Either they declined
44:32or didn't show or something
44:34happened. And you can see
44:35that very few were tapered,
44:37very few received buprenorphine if
44:39they weren't referred to our
44:40clinic.
44:41Alright. So let's go back
44:42to miss Morris and continue
44:44working through because now I'm
44:45gonna kinda switch to this
44:47new space of long term
44:48opioid therapy
44:49and what what happens,
44:51when people are having real
44:53difficulty in tapering.
44:54So again, just to remind
44:56you, Ms. Morris is on
44:58a high dose.
44:59She has untreated mental health,
45:02sleep apnea, but otherwise, you
45:04know, no loss of control.
45:05She's functioning okay.
45:07She's exquisitely sensitive to medication,
45:09so there's probably some room
45:11for non medication treatments and
45:12medication treatments, and she really
45:14wants her opioids.
45:15So if we look at
45:16this frame,
45:17given all of this, we
45:18did not think she had
45:19opioid use disorder. We said,
45:21no, she doesn't, or it's
45:22unclear, but we did not
45:24give her an opioid use
45:25disorder diagnosis. I think most
45:26people would agree with that.
45:28So we moved down to
45:29this bottom frame.
45:31Now
45:32to say, well, do the
45:33benefits outweigh the harms? Like,
45:34that's a hard thing to
45:36kind of consider. And so
45:37what we give to our
45:38medical students and our trainees
45:40are some questions to help
45:41guide this. And these are
45:43the questions that we work
45:43through. So first, is it
45:44opioid use disorder? I already
45:46said no. No. What's the
45:47dose? It's high. What's her
45:49functional status? Well, it's okay,
45:52but she has some anxiety.
45:53She has untreated PTSD.
45:55What's the harm? Obviously, she
45:57has sleep apnea. She's on
45:58high dose opioids. So harms
46:00are really gonna mount over
46:01time. She has this depression
46:03and anxiety.
46:04As far as adjuvant treatment,
46:05she's very active. She's on
46:06Venlafaxine
46:07low dose. She's not on
46:09any other adjuvants at this
46:10time and her preference is
46:12strong
46:13for not changing.
46:14K. So we work through
46:15those things, and then ultimately,
46:17we use that information
46:19to decide where we think
46:20she falls.
46:22What we ultimately decided is
46:24that given the high dose,
46:25given the opioid,
46:26the obstructive sleep apnea, given
46:28the untreated mental health, we
46:30felt like the harms were
46:30really outweighing the benefit.
46:32But guess what? If you
46:33decided that the benefit was
46:35outweighing harm, but the high
46:36dose was high, you still
46:37do the same thing. So
46:39it's okay,
46:40to to, you know, kind
46:42of think about these things,
46:44with her. So that's what
46:45we did. We offered her
46:46a patient centered tapering, including
46:48an optional rotation of buprenorphine,
46:49which she promptly declined. She
46:51was very clear she was
46:52not gonna switch to buprenorphine.
46:53So what we did was
46:55we gave her the choice
46:55then, do you wanna stop
46:56your immediate release or your
46:58slow release?
46:59She wanted that immediate release.
47:01We took her from a
47:02hundred and eighty milligrams to
47:02a hundred and sixty milligrams,
47:04so that was an eleven
47:05percent drop. And it was
47:06tough. It was really tough.
47:08Lots of calls, frequently crying.
47:10I can't function. I'm not
47:11doing anything. You've gotta give
47:12me some Valium for this.
47:14Really can't tolerate other muscle
47:16relaxants.
47:17We saw her back at
47:18we, you know, kind of
47:18coached her through that. Got
47:19her back to month one.
47:20She was very angry. She
47:21felt like she wasn't being
47:22considered her unique case. And
47:25her plan was really, at
47:26that point was just we're
47:27gonna hold the line. Like,
47:28no point in reducing this
47:30any further. This isn't going
47:31super well.
47:32The next month, she came
47:33back still in a lot
47:34of pain, still not functioning,
47:35still on the couch, very
47:37frustrated.
47:38She's gonna, you know, has
47:39has gotten in touch with
47:40patient advocate, which is what
47:42we have we it's a
47:43service we have at the
47:44VA. She was gonna call
47:45her congressperson,
47:47Rosa DeLauro. She was gonna
47:49call the hospital director.
47:50So we said we'll continue
47:51to stall. Like, this is
47:52this is tough. And she
47:53took a ten percent reduction
47:54and we were happy with
47:55that. So, again, we will
47:57stall. We will but we
47:58ultimately wanna keep moving in
47:59the direction of of safety.
48:02So before the the next
48:04follow-up, the third follow-up, she
48:05called and she said, I've
48:06dropped my medications in the
48:07sink. What am I gonna
48:09do? She's very tearful, very
48:10anxious. We offered her buprenorphine
48:12to get her through to
48:12the next appointment,
48:14but she declined. And we
48:15told her we don't refill
48:16early.
48:18So she did come back.
48:19She did get her oxycodone
48:21again for another month, and
48:22at this point we kept
48:23it the same again, but
48:24we said at month four
48:25we're gonna reduce again. Like,
48:27it's time after four months
48:28to take a and we
48:29can go real slow. We'll
48:30take a very low dose,
48:31but that's what we're gonna
48:32do.
48:33And that is what we
48:34did. We decreased seven and
48:35a half percent from one
48:37sixty to one fifty, and
48:38she was very upset by
48:39this. About twenty days later
48:41or so, she called. She
48:43had thrown her medication away
48:44in frustration. She does not
48:45like being controlled. She's super
48:47tearful and scared, and she
48:49was offered buprenorphine as her
48:50only option at that point.
48:53So at this point, this
48:55is where we get into
48:56this bind.
48:57Is this opioid use disorder
48:59or is this something different?
49:01We've prescribed her these medications.
49:03We're kind of,
49:04if you will, forcing a
49:06taper and she's not doing
49:08well. What is this? What's
49:09going on? We have a
49:10lot of patients like this,
49:11right? For two decades we've
49:12put patients on
49:14opioids and so this is
49:15kind of what we're dealing
49:16with in a lot of
49:17people who were prescribed opioids.
49:19Well, one way to kind
49:21of think through this is
49:22to go through the DSM
49:23five criteria.
49:25These are the eleven criteria.
49:27As most of you know,
49:29when prescribed under a doctor's
49:30supervision, you cannot count tolerance
49:32and withdrawal.
49:34And I have learned,
49:35that this wasn't excluded because
49:38of evidence,
49:39this was excluded really because
49:41a champion on the work
49:42group really felt like it
49:43was important that we not
49:46call tolerance and withdrawal
49:48as an opioid use disorder.
49:50Two thousand thirteen when the
49:51DSM five came out, remember
49:53two thousand twelve if it
49:55was really the height of
49:56opioid prescribing. Right? Millions and
49:58millions of scripts were being,
50:00you know, prescribed,
50:02and now we have the
50:03DSM
50:04five coming out. And if
50:05we count tolerance and withdrawal,
50:07we're gonna have a huge
50:08abundance of opioid use disorder.
50:10The prevalence is gonna increase.
50:12Another thing that I've really
50:14learned is that withdrawal and
50:15tolerance
50:16are very,
50:18well validated criteria for substance
50:20use disorders.
50:21And yet,
50:22in large part pushed by
50:24pharmaceutical
50:24companies, they really started to
50:26make a pitch that tolerance
50:28and withdrawal, when they
50:30occur in the context of
50:32prescription,
50:34it's normal.
50:35Well,
50:36what does that mean? Is
50:38it really normal just because
50:39it's coming from a particular
50:41setting or not? But this
50:43is what we were told.
50:45If it's being prescribed to
50:47you and you develop tolerance
50:48and withdrawal,
50:49that can't count because it's
50:50expected because it's quote unquote
50:52normal. And I think that's
50:54really what we have to
50:55rethink here.
50:56Alright. So if we go
50:57through the rest of them,
50:58is she using more than
50:59intended? Yeah. Who knows? I
51:01mean, she says she threw
51:02them away, so I believe
51:03my patience.
51:06Unsuccessful effort to cut down.
51:08Yes. It's unsuccessful, but it's
51:10my effort to cut down.
51:11Right? I'm kind of imposing
51:12this upon her.
51:14Great deal of time. More
51:15time now that we're kind
51:16of taking it away. She's
51:17calling. She's tearful, all of
51:19this.
51:20Cravings,
51:20maybe.
51:22You know, she's not necessarily
51:24endorsing that, but she certainly
51:26is, you know, counting the
51:27hours to the next dose.
51:29She really denies any negative
51:30consequences of it use and
51:32this continuing despite,
51:34physical or psychological
51:36harm, again,
51:37on my benefit risk ratio,
51:40I'm definitely seeing that she's
51:41continuing despite
51:43significant harm.
51:44She doesn't think about it
51:45in the same way. And
51:46so one of the things
51:47that we are increasingly thinking
51:49about is that this is
51:50is this is an issue
51:51of incentive salience. Right? That
51:53opioid has really taken center
51:56stage in huge prominence
51:58and importance in people who've
52:00been receiving long term opioid
52:01therapy.
52:02That's not a criteria for
52:04a substance use disorder, but
52:05it does seem, you know,
52:06it's very glaring in this
52:07case. And so all of
52:09this we get to, I
52:10am mindful of time, maybe.
52:12Maybe she has an opioid
52:13use disorder. And so what
52:14are we gonna do?
52:16The truth is is I
52:17could give her an opioid
52:18use disorder if I wanted
52:19to, but
52:21it's hard. It's hard. She
52:23doesn't want that that diagnosis.
52:25The other thing is,
52:27you know, we we really
52:30are required to kind of
52:31make a distinction between chronic
52:32pain and opioid use disorder,
52:35Not because there is a
52:36distinction,
52:37but because diagnostic codes, US
52:40regulations and clinical practice require
52:42that we differentiate
52:44when something isn't black and
52:45white. And yet we've got
52:47to decide if it's black
52:48or if it's white.
52:50Also different formulations
52:51are available for different diagnoses.
52:54So Miss Morris has been
52:55on a high dose of
52:55opioid, she is going to
52:56need a high dose buprenorphine.
52:58Absolutely.
52:59But there is no high
53:00dose buprenorphine formulation that's FDA
53:02approved for chronic pain. There
53:03are only low dose formulations
53:05for chronic pain and that
53:06is not gonna be enough
53:07for her. So I am
53:08already know if I'm gonna
53:09get her on to buprenorphine,
53:10I'm gonna have to use
53:11off label buprenorphine.
53:12Right? She's just not gonna
53:14tolerate a low dose of
53:14buprenorphine.
53:16And many
53:17plate practice settings
53:19won't treat one or the
53:20other. I'm a pain clinic.
53:21I don't do opiate addiction.
53:23I'm in substance clinic. I
53:25don't do pain. And so
53:27miss Morris would never walk
53:28into a substance use specialty
53:29care That's not where she
53:31sees herself being. It's not
53:32the diagnosis that she feels
53:34is right. And so why
53:35are we having to force
53:36people into these,
53:38categories?
53:41All right.
53:42Ultimately,
53:43I believe it's largely because
53:45of stigma. And I will
53:46say, you know, if you
53:47look at our regulations in
53:48this country, we have very,
53:50very weak evidence for opioids
53:52when prescribed for chronic pain,
53:54and yet we have very
53:55limited
53:57regulations around it. You know,
53:57it's just a schedule two
53:58medication, so it's treated like
54:00every other schedule two medication.
54:02When used for opioid use
54:03disorder, which has very high
54:05strength of evidence and saves
54:07lives,
54:07you're not going to find
54:08any more regulated medications in
54:10the country. Right? This is
54:11an ethical issue,
54:13and it's it's a problem
54:15in how we see,
54:16patients who have opioid use
54:18disorder versus chronic pain.
54:20Alright. So we knew that
54:21this was gonna continue to
54:23be a problem, and I'm
54:23gonna just wrap up quickly.
54:25In twenty nineteen there was
54:26a state of the art
54:27conference
54:28where we worked strategies to
54:29improve opioid safety, and it
54:31was clear that there was
54:32going to be deprescribing of
54:33opioids across the country, and
54:34this was going to continue
54:35to be an issue.
54:36And so we have definitional
54:38problems that I've already explained,
54:39and there really wasn't consensus
54:41on how to handle these
54:42problems.
54:43And so we needed an
54:44approach to work towards consensus.
54:46I wasn't,
54:48familiar with Delphi methodology, but
54:50I've learned since. It really
54:51is you get experts and
54:53then kind of in an
54:54iterative fashion,
54:55you begin to develop consensus
54:57over time. So you ask
54:58questions and it's,
55:00a way to to,
55:01you know, kind of answer
55:02a question.
55:04Alright. So this was the
55:06paper that was published and
55:07this is really being, spearheaded
55:08by my colleague Sarah Edmond
55:10and, of course, Will Becker
55:11and Anne Black who's also
55:12in our department.
55:14And I'm gonna go through
55:15this,
55:16the the Delphi study and
55:17its results. So seventy participants
55:20from this SOTA con conference
55:21were asked, do you think
55:22a new diagnostic entity is
55:24needed on top of long
55:25term opioid therapy for pain
55:27that is related to but
55:27distinct from DSM five opioid
55:29use disorder?
55:30Fifty one percent, fifty one
55:32people responded.
55:33Seventy five percent said, yes,
55:34we need a new diagnosis.
55:35The current system isn't working
55:37for us. And twenty five
55:38percent of us, and I
55:39was in this group, full
55:40disclosure, said no, we don't
55:41need a new diagnosis.
55:45And here were the arguments
55:46for the really these are
55:48unique patients. They're a different
55:49clinical pathway. It will address
55:51the problems that have been
55:52created by DSM five opioid
55:53use disorder exclusions
55:55with tolerance and withdrawal. It'll
55:57facilitate treatment and research with
55:58it, which I think is
55:59a huge
56:00reason to trial to do
56:02this, and it would reduce
56:03stigma and mitigate unite unique
56:05social consequences for people on
56:06long term opioid therapy.
56:09Those of us who thought
56:10we shouldn't create a new
56:11diagnosis
56:12really said it's neurobiologically
56:14indistinct.
56:15I mean, these, you know,
56:16the brain doesn't know where
56:17it's getting its opioids from.
56:19That d s n five
56:20allows for a continuum, and
56:22so it would be better
56:23to rethink the DSM five
56:25criteria
56:26rather than to go outside
56:27of it and create or
56:28it might be included ultimately,
56:30but to create a new
56:31diagnosis.
56:32And really thought that we
56:33would it would worsen stigma
56:34for patients with opioid use
56:35disorder. We've worked so hard
56:37to decrease stigma
56:38for patients with opioid use
56:39disorder and this has, we've
56:41had some gains and now
56:42if all of a sudden
56:43a group of people can
56:44opt out of that diagnosis,
56:46we just wondered to what
56:47extent that would reinforce stigma
56:49for people who have more
56:49moderate to severe opioid use
56:51disorder.
56:52This was published,
56:54in Addiction in January.
56:58As you can see, people
56:59who are in favor of
57:00it were really coming from
57:01medicine, addiction medicine. They were
57:02internists or a pain psychologist,
57:04and those the the authors,
57:07we were addictions, you know,
57:08we were psychiatry or addiction
57:10trained. Right? So I'm wondering
57:11if it's we're seeing things
57:13somewhat differently. Not that it
57:15may it may or may
57:16not be different, but it
57:17that was just a curiosity
57:18to me. Talking about what
57:19we've cut the conclusions that
57:21the group has come from
57:22come to in round two
57:23and three as far as
57:24building a consensus for new
57:25criteria,
57:26to what extent you agree
57:27that each of the following
57:28features should be included. There
57:30have been nineteen proposed criteria.
57:31There's been a post hoc
57:32group, work group that recommended
57:34the finalist, and this is
57:35what is being proposed. So
57:37that the harms outweigh the
57:38benefits of long term opioid
57:39therapy. Somebody is displaying difficulty
57:41tapering,
57:42and there is absence of
57:44a pattern of loss of
57:45control.
57:45And I think that this
57:46is going to be demonstrated
57:48very objectively, like there's no
57:50early refills, they're not using
57:52multiple doctors, they're not tampering
57:54with the formulations.
57:55And so if there's no
57:56evidence of loss of control
57:57then that then this would
57:58be the diagnosis.
58:00And doctor Becker and doctor
58:01Edmond have received funding to
58:03really study this over the
58:04next couple of years, and
58:05I think that's a huge
58:06win for our field.
58:08It's gonna be called prescription
58:10opioid dependent syndrome.
58:12I'm gonna skip this, slide,
58:14but I do really think,
58:15you know, we'll see. We'll
58:16see if it is something
58:18different or if it's not
58:19something different, but I think
58:20kind of our our settings
58:21really,
58:23are determining that. So alright.
58:26Last slide, and then I'm
58:27done.
58:27To conclude,
58:28psychiatrists are essential teammates in
58:31treating chronic pain and we
58:32should receive training. And if
58:33there's any take home message,
58:33that's it. I think our
58:34residents need to be receiving
58:35training and I'm really happy
58:36that so many residents and
58:37fellows come through our
58:39clinic.
58:40That's
58:41the best part of my
58:42job anyway.
58:46There is a false regulatory
58:48and clinical line between chronic
58:49pain and long term opioid
58:51therapy. So I really think
58:53it's time for psychiatrists
58:55to step up and to
58:57advocate for changes in buprenorphine
58:59prescribing when the benefits don't
59:00outweigh the harm.
59:02More flexibility in buprenorphine prescribing.
59:04We need to advocate, like,
59:06with FDA.
59:07We we've gotta figure out
59:08the the regulations. We need
59:10some formulations
59:11that that, maybe manage pain
59:14too. And we need to
59:15eliminate this black and white
59:16thinking. We need to move,
59:18to a risk benefit approach.
59:20And, ultimately, I do think
59:22we need to to rethink
59:23the DSM five opioid use
59:25disorder criteria. I mean, I
59:26think both groups
59:27would agree that it's clumsy
59:29and it's not working and
59:30it's problematic.
59:31And so with doctor Becker
59:33and doctor Edmonds' research, I
59:34think we will have some
59:35data and they will compare
59:36it to the DSM five,
59:38and we will see what
59:39comes from that. So stay
59:41tuned.
59:42That, I'm done.