Travis Rieder, Ph.D., presents at the Johns Hopkins Department of PM&R’s Grand Rounds on August 17, 2021.
So what I'm gonna do today, given you all's expertise is I'm going to focus on kind of one half of that research program that you just heard about. So I spent the last of what you're thinking about pain and opioids, but also addiction and drug overdose. There's obviously a relationship between all of these things, but I'm going to talk a lot about the ethics of opioid prescribing. And so the backdrop of that conversation is that I as an ethicist, right? So bias coming through I as an ethicist, I wish there was a little bit more explicit ethics in the conversation of how should one prescribe opioids, whether and when one should prescribe opioids. And so we get what we get are lots of guidelines like the CDC guidelines like specialty organizations guidelines, but they're very often this kind of general backdrop of opioids are risky. Don't do it too much right? Don't prescribe them too often. Rather than trying to think seriously about um the goal is to be responsible clinician every time you're using a d a license to prescribe a substance that has both benefits and risks your job is to balance the two. And that's the challenge that I'm interested in working through in a more nuanced way than just saying, hey, opioids are risky. Let's not use them too much. So here are some background things um to be super clear, I always over disclosed rather than under disclosed, you can probably guess, but I do receive royalties from the sale of my book in pain and this talk is a summary of, say 30 to 40% of that book. Um and here are the objectives for discussion. Today, I'm going to describe a really rich sort of detailed case study and I have all these details because it's my case study. Uh and so Goal number one is to extract a generalized herbal lesson from that case study which is gonna require going beyond the end of one and incorporating other sorts of evidence. Goal number two is to articulate three principles of responsible opioid prescribing. So this is what I call my kind of emerging or evolving framework, ethical framework for prescribing and goal. Number three is to identify current failures and practice concerning discharging those responsibilities and for some of that, I'm actually hoping to rely on you, if you have thoughts about what you see in practice, I am going to try to leave 10 or 15 minutes for questions and discussion and I'd be really interested to hear you all thoughts. So here's part one of the talk, this is that personal case study um And it starts six years ago, now more than six years ago, May 23, so this is memorial day weekend of that year and I was heading out to do this. That was my intention, avid motorcycle rider, I love going down to Shenandoah, this picture was taken on skyline drive, that's where I was headed. I did not make it there. However, about three blocks from my house, a young guy in a white big panel van blew a stop sign and I had no time to react and he hit me squarely on the left side of my motorcycle. So I got boned just a few blocks from my house. My left foot was crushed between the bumper of the band and the fairing of the motorcycle and this was the result. Um, so you can probably see a decent amount of what's going on in this X ray, There was some damage to do a lot of the lower foot, so 2nd and 3rd metatarsals broke pretty cleanly through. They actually tore up the soft tissue and came through the top of the foot. But the real damage happened with the big toe first metatarsal. Uh, this this sort of explosion, which I'm sure is the technical medical jargon. Um, this sort of explosion blew a hole out through the bottom inside of my foot. And so I had those big armored boots on that you saw in the picture, they couldn't do much against this sort of crush injury. So I hit the pavement stops sliding, My foot was in searing pain, immediately reached down to pull off the armored boots. And when I did, I saw a big kind of, I don't know, baseball to softball sized hole in the bottom of my foot, exposed bone exposed tendon. And so I knew that I was, I had a pretty serious injury, but not being a physician or a nurse or an E. M. T. Myself, I did not know how serious it was. And so for you all who might be interested to know the details and the set up why I needed the paying management structure that I did. Um What what followed was I was in a limb salvage situation, which of course I did not know at the time, the surgeon thought that they were going to have to amputate my foot's, maybe get away with just a transmitted carcel amputation across the top half. But they worked some magic. They were able to salvage the foot. But that meant that instead of just the one amputation surgery, I had a long series of reconstruction surgeries. So the first five surgeries occurred over that first month to five weeks and the first three were orthopedic surgeries to pull the bones together. The fourth was the first attempted plastic surgery to fix that wound on the bottom. Um They thought that they'd be able to use a skin graft on my forearm. Looking back, I'm not sure how they thought that was gonna work. It was it was a weight bearing area, exposed bone, very large wound. So by the time they ended up dividing the tissue and getting it all cleaned up the wound was even bigger during that fourth surgery. So they aborted the skin graft, send me back home with a wound vac which is how I've been doing for the last couple of weeks and contacted one of the local limb salvage units that had a specialty in free flap surgeries. So surgery number five was the big one. Free flap surgery. They took muscle fat and skin from my left thigh to again, medical jargon. I'm sure plugged the hole in my foot. It was enough transplanted tissue. It needed its own blood supply. So they had an artery micro surgically transferred from the thigh to the foot and they thought I might want to feel my foot at some point, be able to sense danger if I stepped on anything hot or sharp. So they also transplanted a nerve from my thigh to my foot. So all of that took a long time was incredibly painful and resulted in lots and lots of opioid medication to be super clear. It was important. I had under medicated experiences during those 1st 4-6 weeks. They were um Just hellish. There's no other way I can describe it under medicated pain. I hit it, I hit what I called a 10 on the pain scale. Exactly one time, it was the night of my, my first night in the hospital when I was not being given much medication at all. Um and those moments make you want to kill yourself there just unimaginable. So to be super clear that opioids were very important, I was undergoing surgeries on the pace of, you know, 123 a week in between surgeries I was having wound back changes, nurses were coming in and pulling this this phone out of the inside of my foot and it would stick to my foot and it was the stuff of nightmares. I would have to get leaders cauterized if there was getting blood on the bandages. So everything about this was nightmares too painful. The opioids worked really, really well on top of the opioids. After the fifth surgery I got gabapentin prescribed for for nerve pain from that transplanted nerve. And over the course of this time in and out of hospitals there was a continuous escalation of my therapy. There were multiple handoffs. I was in three different hospitals for five different surgeries, lots of different teams. And eventually after 10 days in the final hospital after surgery number five, I get sent home and my only pain management instructions at that time are don't get behind the pain. Um so I'm taking OxyContin twice a day. The extended release oxyCODONE on taking gabapentin tin every six hours. I'm told I can take the immediate release oxyCODONE every four hours for breakthrough pain. I'm watching the clock. I'm being a very compliant patient not getting behind the pain. And they also told me to keep an eye out for tolerance. Had obviously been upping my dose for weeks now. Um and they said that's going to continue to happen. And so if I start to sense that I'm getting behind the pain because the meds are running out of their effectiveness. I need to let my prescriber know so they can increase the dose. And so I did that as well and continue to increase the prescribing dose. Um to shorten a long story too, only moderately long after about two months from the accident, several weeks home from the hospital, I finally go back to see my original trauma surgeon who's going to take. New X rays. We're gonna talk about whether I expect I'll ever walk again. Very important stuff, but he's the one having not seen me for a while asked me all the routine questions during checkup asks you know, what's your pain level, Like what are you doing for it? I'm there with my partner Saudia who helps me keep track of my life during this very traumatic time and we kind of do the math together. And so we add up, you know, the 40 mg OxyContin and the 15 mg oxy code on five or six times a day plus the gabapentin. And so we kind of do the math and tell them and he's the 1st 12 months after the injury to kind of suddenly turned serious, stop what he's doing and say Travis, that's too much, you're too far out from the injury, The dose is too high, it's time for you to get off the meds And that is the first warning anyone gave us about um dependence, physical dependence. The risk of coming withdrawal about the risk of addiction despite this is 2015. We're in the midst of a raging opioid epidemic. Nobody talked to me about the risk of addiction. Now of course you might presume I know that there's a risk of addiction with opioids which I did vaguely but nobody told me, hey you might want to be concerned about being on them longer than you have to be about taking a higher dose than you need. So this is the moment where I realized when you get off the pills but that trauma doc who says you have to get off also said kind of not my job. And so we asked him how how to get off here so we can't stop. Cold turkey, you'll go into withdrawal so you need to go to your prescriber and get a plan. So that's what I did turns out my prescriber was a plastic surgeon and he was not very concerned. We saw him the next day. Um he was not very concerned about my still being on this dose. He's the one who's been prescribing. It was just so sure you know if you think you're you're ready let's let's go ahead and tape rio. And we asked him how to taper and he clearly didn't have a good answer. He kind of thought for a minute and said let's drop 25% of everything each week for the next four weeks. So take all of your meds, the gabapentin OxyContin ir oxyCODONE on, divided into four and tomorrow drop a quarter next week drop another quarter and so on you'll be off and clear in a month. And so that's what I did and that's what started the story. That really changed everything. Um So the key takeaway because I know you all are busy and so maybe some of you will leave for the end of the talk. The thing I don't want you to leave without knowing is that that was terrible advice. I was two months in on pretty significantly pretty significant doses of opioids. So you might be interested to know the numbers so much much later when I learned about things like mm es I would run the calculation do the math. So I was on 170 to 200 es a day of opioids plus gallop entin. Um And what that tapering strategy did is it was aggressive enough that if I were sensitive to dependence and withdrawal I would go into withdrawal. 25% is a huge dose reduction. Um But also because it's 25% instead of cold turkey. Uh It guaranteed that I would extend it out for four weeks if I stayed on that schedule. And so that's what happened. I went into withdrawal. It got worse every day and it stayed that way for 29 days. So that's what I I gave this talk on. I gave this ted talk a couple of years ago and the reason I did this is because I can't I can't give this talk all the time. And so I started getting more and more invitations to tell doctors what withdrawal is like because it became clear that not all doctors understood that opioid withdrawal is not merely uncomfortable. So they wanted someone like me who has a PhD who doctors would respect to come in and tell them how absolutely miserable withdrawal is. Um but kind of doing that in a full throated way and reliving it is not super fun. And so in 2017 I decided I would do it on the ted stage and then there's a high definition open access recording for anyone to use for educational purposes or whatnot. Um So I put this up, I'm not going to click this button, that would be very strange. Sit here and have you watched my ted talk? But I put this up so that you know that if you Kind of want to hear the full throated version or if you want to share with any colleagues 14 minutes, they can get a picture of what opioid withdrawal feels like from the inside. What I'm gonna do here instead is I'm gonna give you kind of the summary version and the more academic version, I've been studying this for several years now. So um what I would come to learn is that withdrawal from most drugs actually tends to be um something like the opposite of the drug's effects. Right? So a lot of people talk about opioid withdrawal is like, I was a bad case of the flu, I think. Well you imagine the worst case the flu you've ever had multiply that by 1000 and that's like a pretty good start of your baseline, you know, terrible illness, but you should also think about, you know, what do opioids do for you? So you can experience what I think about what it's like to experience their deprivation. So they're analgesics, right? So the opposite is hyper all jesus, so everything your body catches on fire, your joints, your muscles, your bones, they all catch on fire, but whatever you've been under, whatever you've been medicating is now under medicated. And so you're hyper logistic with reference to some damage and so my foot was just feeling like it was exploding all over again. So part of withdrawal is just really, really terrible pain and sensitivity to pain, especially you don't even want to be touched. Um opioids are euphoric, right? That's why they're addictive. Um So the opposite of this is is what dysphoria, it's it's feeling really terrible, it can be depression, it can be anxiety. So for me it was just crushing depression and this was really one of the very worst symptoms because I didn't understand what depression was like, and so I thought, you know, the I thought that I understood that the world is just not worth living in anymore. And it was just my brain misfiring. Um but also what opioids are sedatives, right? And so um there was this weird sort of hyperactivity that came with withdrawal. And so you've seen in the movies, you read in the books, the kind of jitteriness, the shakiness, the trimmers of withdrawal. That comes from this like weird sense of hyperactivity, your muscles need to twitch, they need to do something and that's like awful enough when it's baseline for hours and days and then weeks at a time. But it also keeps you from sleeping. And so if you come insomniac. And so since I've done this talk, and since I've written my book, I get emails from hundreds and hundreds of patients very often in the midst of withdrawal, which is a terrible time to hear from someone that they just want to talk to someone who understands. And the number one thing they all complain about is the insomnia because they've been awake for three days straight. So all those miserable symptoms don't get a reprieve, right? So that's a picture of the symptoms of withdrawal and then there's this other like dirty trick of nature of withdrawal, which is that if you do what sounds like a sensible sort of taper where you take a set percentage dose reduction from the start, like a 25% of your starting dose and then you reduce it over several weeks at the beginning, It's a 25% dose reduction. But the second time you do it, your brain has started to adapt to the new environment. And so now to make the Matthews, you're supposed to run 100 mg. You went from 175. Now for the second dose drop your in 75 you kind of started to reestablish homeostasis. You go 75 to 50. It's a 33% does drop, not a 25% does drop. So this like dirty joke of nature is that the withdrawal symptoms get worse as the percentage dose dose reduction goes up. And so you tend to get worse as you get closer to finishing the taper. So folks who work in addiction medicine are very familiar with this because they've seen people over and over make it all the way through a taper of buprenorphine or methadone and then at the very end relapse because the withdrawal is so nightmarish that the closer you get to the end because you eventually have to go from From something to nothing. You eventually have to do a 100% does drop. So, um here's a really nice graphic representation of what withdrawal feels like the first time I talked about my experiences in the journal Health Affairs and the artists put together this very accurate rendition of what it feels like to be squeezed in advice steadily over weeks. And the reason I did it for the full 29 days is because I could not find anyone to help me through this process. And what I want you to think about is the fact that I'm well connected. I'm professional, I'm educated. My partner is also a PhD. She has a PhD in immunology. We are well connected folks. I'm a professor at johns Hopkins and a bunch of things happened. One even we couldn't get anyone to listen to us or take it seriously or want to deal with me, shaky withdrawal, sometimes crying. Um that desperation immediately led people to turn me away clinicians, doctors offices and two. I was ashamed for reasons that I wouldn't think about or articulate until much later. I was ashamed about not being able to get off these medications that we have so clearly stigmatized in society. And so I never tried to exploit my connections at johns Hopkins at least not until much later in the story. So To go through the whole 29 days and the end of the story is not a pretty one. It's not a heroes overcoming of obstacles. It's that in the last week the withdrawal has gotten at his absolute peak. I'm on day four without any sleep at all. I've spent nights on the bathroom floor. Um you know, from the, from the nausea and the vomiting and I'm scared enough because I started thinking about suicide as a totally rational option because I thought this is my life Now I'm scared enough by that. My partner is scared enough by that that we decided that I'll go back on the medication. This is what my prescribing doctor has wanted me to do for four weeks. He was very scared by the severity of the withdrawal symptoms. He eagerly prescribed me a new bottle of oxy code on. Um We asked for it to be in five mg tabs so that I could kind of titrate back up and not go on more than I needed to. But that was our suggestion and not his. And um that night I fully intended to go back on the medication and here's the thing. I 100% believed that if I went back on the medication I would never come off of it again. I believe that with all my heart and I was planning to go back on it anyway because it meant surviving. And I thought that continuing withdrawal with withdrawal meant not surviving. Mm hmm. And the reason the story ends here is because I got really lucky because that night I actually went to bed for the first time in four weeks and I put the bottle of pills on my nightstand and I put a glass of water on the nightstand correction. Saudi did those things because I couldn't walk. Um and I fell asleep before I took any of the pills. I fell asleep. I slept for six hours, which was more than I had slept in weeks and when I woke up, I certainly did not feel good, but I could immediately tell that the symptoms have abated. I was hungry for the first time in weeks and I knew that I could finish the process and that's the only reason that I'm here with this version of the story. Um you know, telling it to you all instead of whatever lies down the path of going back on a substance that I fully committed to just staying on forever. So here's the first question that I thought of um in the immediate aftermath of withdrawal, I didn't want to think about it all. I just wanted to get distance from this trauma. Um it was by far the worst thing that had ever happened in my life and think about that. I just had my foot blown apart on a motorcycle, but the withdrawal is the defining feature of my care and so I wanted to just get away from it and then I slowly started sharing, sharing with close family, sharing with some friends and colleagues and people who ask questions like, you know, you're a bioethicist, you work at johns Hopkins, maybe you could do something about this. So I slowly got curious, my researchers brain started kicking in as I got further from the event itself. So the first question that occurred to me was whose job was I and what I would eventually come to think of is I would come to think that there's this job that is something like routine dependence care and that's what I was trying to figure out whose job it was. And the reason is um I would have thought that I was my prescribing physicians responsibility, right? So they're gonna know how to do this because they put me on the pills. And my prescribing physician was very quickly out of his depth. And so he said, look, you're you're a complex case now, you you need a specialist, you need to go to pain medicine, my pain management. Doctors from the hospital who had put me on this really aggressive regimen, never even would speak to me. They delivered through nurses the message that they're an inpatient um uh in an inpatient group that prescribes opiate medication, but they don't deal with tapering or withdrawal management. We would eventually find an independent pain management group, not in the hospital. And they actually said the same thing um that they could evaluate me for more opioids if that's what I needed, but that they did not manage withdrawal or tapering. So I asked them well who does that and they said, well addiction medicine does that. And this struck me as really strange because it had never occurred to me that what I was dealing with had any relationship to addiction because I was sick, I was sick from this process, I was violently ill but I didn't crave the drugs. I had a household of them for a while and I wasn't thinking about taking any of them was never taking them in any way other than prescribed. So even before I started studying this for a living, something didn't click with the idea that addiction medicine was was where I needed to be. But I called them anyway because I needed help and they very quickly kind of agreed with me. I told my story and they say I'll never forget. Here's a quote from one of the very nice gals turns out she was at a methadone clinic. I didn't know anything. I just called looked up addiction called them. It's a very nice gal at a methadone clinic, probably the receptionist, he's talking about the phone collects my story and says oh honey you are not our job and that sounds a little cruel but she was being very sweet. She said look we have a waiting list and we're dealing with people who are if we don't get them into treatment, they might go take heroin laced with fentaNYL and die tomorrow. You you just got prescribed pills that are making you sick like aren't you someone else's job. And I said well sure who's said, I don't know your prescriber and this is what tore me apart. There was some massive chasm in the health care system that nobody seemed to think that I was their responsibility and yet it's not like I was some idiosyncratic case. We have trauma cases every day. We have major surgeries every day across the country. People were being put on opioids. And it seemed that I despite being in a very privileged position having access of a kind that very few people have having been at three world class hospitals in the Washington D. C. Baltimore area. Despite all that nobody saw me as their job. Alright, so here's lesson number one, this was the first thing that I published on in the journal Health Affairs. It's a very very simple point and it is that if we use opioids, someone has to be able and willing to taper them, it has to be somebody's job. My first job was that if you're a physician who prescribes opioids or a PhD or an M. P. Then you need to take responsibility for tapering. And I very quickly realized that wouldn't always be the right structure for an institutional solution. So I started working with surgical hospitals and the surgeons were never going to be the ones to actually manage tapering and withdrawal. So I saw from the idea it has to be someone's job and it has to be clear to everyone, even if it's not the prescribers. But here's the thing I entered the story in the middle right. I had this very intense experience where I noticed this gap in the health care system. But I was already in a case where it was clear that I needed opioids for a pretty long time. So some of the answers, some of the questions were already answered. Um and so I was trying to articulate this, this kind of nuanced idea that if you are put on opioids has to be someone's job to get you off of them, but that's not actually super helpful as an ethics framework because when I started giving talks to clinicians and doing grand rounds and that sort of thing, a lot of the stuff that people want to know is like, so should we just not use opioids that, you know, the CDC is saying that they're not great for chronic pain patients and we're getting these papers that say they're really dangerous and we never had good evidence for them in the first part. Should we just not use them? So they're all these should questions like, what should we do about opioids that is asking a much broader question, then I was trying to answer. So what I'm gonna do now is I'm going to step back and show what I tried to do over the coming year to fit in this kind of more nuanced picture into a broader framework that answers some of these questions. So here's the background. 2015, I'm entering this conversation um by the way, as a total Newbie. So I work in, you know ethics and health policy around this stuff now. 2015, I was working on climate change ethics. I didn't know anything about this space. So I basically took two years after the accident to catch up um to learn some of the epidemiology of the overdose epidemic, to learn about addiction independence um and prescribing patterns clinical practice. So here's the backdrop that I think is super important. This data only goes up to 2018, but that's actually good enough for our purposes. Although as as you all, I'm sure know the drug overdose crisis has gotten worse and worse exacerbated now by COVID. But what this does is it shows that in the United States Over the last 20-30 years we have had an evolution of a drug overdose and addiction epidemic that has had multiple phases. And I use this map instead of more simplified one because I want to show you a particular picture. So the top kind of purplish blue lavender line here, this is natural and semi synthetic opioids. So these are commonly prescribed opioids and this is the age adjusted drug overdose death rate involving these different types of opioids. So what this is showing is that from 1999 To its peak in 2011 speak at that time the overdose death rate from commonly prescribed opioids, Basically quadrupled, it increased almost 400%. And if you look at what happened in clinical practice during that time, most of you know this already um the volume of opioid prescribing over this time did that exact same thing. It increased by about 400%. So it's a 1-1 map right here. And so this is the line That led Thomas Frieden, then director of the CDC to say in the late 2000s, the emerging prescription opioid epidemic is doctor driven. So it can be solved in part by doctors actions. That was the rallying cry from the CDC as early as about 2000 and 8 to 2000 and 10. And that would eventually lead in 2016 to the official issuing of the of the initial CDC guidelines. But obviously by then we were doing lots of other things to try to curb this emerging prescription epidemic. Okay, what I want to point out is that as the country started to get very concerned by this aggressively upward sloping line. Mhm. Whoops. They started trying to curb prescribing. And so those of you have been practicing for a while have seen these different phases. You go from pain as the fifth vital sign always check on pain. Opioids are safe and effective. They should be prescribed. That's starting in 1998, Um And then by the late 2000 you're starting to get the first inclination of we're gonna follow Thomas Frieden and and say you know doctors, your job is to stop killing your patients with opioids. And so as that change is happening between 2000 and 10, the volume of prescription opioids peaks. So right at the same time That overdose death rates are peaking, the volume peaks and the volume starts to go down. And now by 2021 we're at about I haven't seen the most recent data, but we had decreased by over 25% from the peak. So that volume has continued to go down. But what I want to point out is that when we started to decrease opioid prescribing while that addressed the particular problem that we saw which was opioid, prescription opioid overdose deaths, it didn't actually solve overdose deaths. Right? This broader thing, the overdose crisis just changed. So heroin has started to become more available to kind of fill this addiction demand. And so heroin starts to spike up as demand for prescriptions gets less. And then when heroin become so profitable, D. A. Starts cracking down on it, drug dealers get really smart and so they wanted to be more profitable, more potent. And so they start lacing it with fentaNYL. So now we go to the dark blue line at the bottom hadn't increased very much in decades. Suddenly fentaNYL takes off. That's the most represented by the synthetic opioids other than methadone. So the the overdose epidemiology completely shifts over the last 10 years and the reason I'm showing you this is because I am in the hospital in 2015. And what's happening here is there's a bit of a sea change, right? Some of my prescribers, some of my physicians have been trained during the decade of pain where you're supposed to take pain really aggressively prescribed opioids are safe and effective when taken as needed. I obviously need them. And some of my clinicians were young. They're out of residency during the time when we're already freaked out about opioids and they're largely learning in medical school, residency and fellowship don't use opioids, especially not very much. And people are worried about taking addiction independence patients into their practice because they don't want that on their chart. So there's a sea change happening. And that's what I discover myself in the middle of. So what I want to point out this diagram here is very cartoonish and I apologize for that. But I think it's helpful anyways. I'm gonna put it up here despite thinking, I look a little dumb when I do it. I want you to think about your attitude toward opioids just to point out that either end of the spectrum is really problematic. So you could be a complete restrictionist about opioids, You could say that they're just not good drugs, they're super dangerous. We shouldn't use them. Uh, and then just don't give them any one. And so you probably know some clinicians or you've heard stories about clinicians across the country just hang up a sign in their office. They say we don't prescribe opioids here Or you could be, you know, hey, drugs for everyone, opioids are safe and effective for nearly every pain. It's the pill for nearly every pain is the one to start with. The one to stay with. That was an OxyContin brand slogan. Um just give give pills out like candy. And what I want to point out is that these are both really bad solutions. So we have really focused on recently in the last several years called a decade. We've really been focused on how drugs for everyone hurt people. Pain is the fifth vital sign. Opioids are safe and effective. We prescribed too liberally and it got us in a ton of trouble. So everyone's on board drugs for everyone is bad. But without recognizing that restriction is um is also really bad. Why? Because go back towards my very first thing I said in this talk when you have your foot blown open when you hit an eight or 10 on the pain scale, morphine, HYDROmorphone fentaNYL. These things are absolute lifesaving, oxyCODONE when you're going home and you need something to pill. Absolutely lifesaving. So we have to be somewhere in the middle. And this is why I laugh at myself from my very cartoonish diagram here because I recognize that that doesn't give you any concrete advice yet. Let me try to get there. But what I want to do is I basically want to admit that where I started this talk by focusing on if you prescribe you need to be able to to d prescribe. That was somewhere in the middle because this is the backdrop in America of trying to stabilize between two radical ends of a pendulum swinging and trying to recognize that opioids are not evil demon drugs and they're also not God's gift to medicine. They are like every other pharma co therapy which is to say they have benefits and risks and those benefits and risks different differ by patient population, require a lot of expertise to use effectively. And so the ethical framework for prescribing these medications is not going to be so different from the ethical framework for prescribing anything else except the drug profiles a little bit different. This is a drug that like some others but not the like some but not others causes dependence and has a risk for addiction, right? That's the sort of thing that's going to be taken into account. So what does it look like to try to aim at the middle of the spectrum? This is the last thing that I want to leave you with. I want to articulate what I think of as a kind of tripartite principle for responsible prescribing. I'm my thinking on this is evolving all the time. So I've been giving a version of this talk for about a year now where I've gotten to this point and my guess is I'm going to keep learning from audiences and from my research and it's gonna get more nuance. But here's here's what I've got so far. So the summary version is uh to responsibly prescribe opioids, you have to initiate appropriately, you have to manage appropriately and you have to discontinue appropriately. So think about this as stages or components of prescribing, and I'll take just a minute to articulate why we need to think about each individually. So appropriate, initiation is what gets all the play, should you use opioids? And if so when this is what everybody is researching, this is what all the articles in the new England Journal and Jama and they get written up instead, this is what almost all of them focus on. And so here's a really classic problem and this is why it's not so different from other drugs at this stage, even like antibiotics, right? Because there is a benefit and there's a risk. So this drug has a risk benefit profile, we need to understand it. And so the first point to recognize is just that we don't overweight one of them because of the cultural moment. So here's the first danger of thinking about risk benefit profiles. If we live in a moment where everyone is talking about the risk of opioids and downplaying downplaying the benefits, you might end up in a position where you think we almost never should use opioids and if someone who has benefited from opioid therapy, I want to say I have yet to meet someone who needed opioids and who then afterwards weren't convinced that we really need access to them in certain cases. Um, so that's the first problem of weighing the benefits and risks. But there's a huge component to this that gets left out, which is that clinicians are human and humans have biases. So we now have a really well established literature that when we do this risk benefit balancing act, we tend to do it, not always taking into account only the clinically relevant properties of the patient. So for instance, black patients, hispanic patients and women are all systematically uh prescribe fewer opioids than men and in particular white men. Right? So they're really obvious racist and sexist origin stories for this, right? We have an entire literature and history of medicine about how women are hysterical. And so hysteria is a way of delegitimizing women's testimony of pain. So there's a philosophical term here called epidemic injustice. That's super important because when a woman comes in and complains of pain and especially to a male clinician, I'm not saying that every male clinician is sexist. What I'm saying is against the backdrop of implicit bias, it's too easy to discount the testimony of a woman. Same thing happens with race against a racist background amid a racist war on drugs where black black patients and black citizens are more aggressively targeted for drug enforcement, it's too easy for a clinician to look at a patient and see black as code for more likely to be abusing the drug or drug seeking. And so there are all sorts of studies and literature now that show that these populations have their pain testimony taken less seriously and when they're paying testimony is taken less seriously, that leads to systematically fewer opioids prescribed. Now it may be that in some cases fewer opioids is the right thing to do, but doing it on the basis of non clinically relevant things, it's never the right thing to do that makes it racist or sexist. Right? That's the equity point. So what's the balance here? The balance is that you're not just having to balance benefit versus risk, You're having to do it in a just way. So like this is the blind scales of justice. Right, okay. The appropriate management parts. This one should be kind of easy. But I think for some time medicine just kind of thought that opioids were simple drugs in the same way that you don't need a ton of expertise as a provider to prescribe antibiotics when somebody comes in with signs of a bacterial infection, we kind of thought that you could prescribe and forget opioid, someone comes in with pain and because they're safe and effective, um you could just give them opioids. And so what we know now is that this risk of physical dependence, this risk of addiction uh and use disorder means that we're gonna need regular check ins and for folks who are doing long term management of opioid therapy, this might need to include partnerships so that you get things like behavioral health assessments need to adopt screenings for the developing use disorder but also physical dependence, right? Not everybody is gonna have trouble with the pills. It's going to have an addiction where they suffer from the cravings and they use despite negative consequence. But even if they're just physically dependent, that means there will be withdrawal to deal with. And withdrawal management is not easy. There's also this component of informed consent, right? It blows my mind. Then nobody ever talked to me about my opioid therapy at the very beginning, my early days in the hospital is unconscious, highly medicated, traumatized thought I was losing my foot. It wasn't a great time. But for two months I was on escalating opioid therapy. And none of the rotating cast of characters ever thought that it might be their job to talk to me about the long term challenges of my pain management. Okay, so last one, this is obviously near and dear to my heart. I want to wrap up because you have questions um appropriate discontinuation. So if you prescribe opioids, someone has to know how to de prescribe opioids for that patient. And so here is a handsome fella. David, your link who's a toxicologist up in Canada. You know, you're kind of social media pin pals and he uses my story in education talks and when he does, he uses this great quote that I have now stolen from him, which is don't fly a plane if you don't know how to land. Right. This is the problem he has seen in his years of training medical students and residents and fellows. It's the idea that you can train people to prescribe opioids and never have them know how to get that patient off of opioids to do comfortable safe tapers to manage their pain while at the same time managing a discontinuation process that gets them off this medication. My job here is not to teach you how to taper. Um it's not super hard in routine cases. I I could, but that is not one of the, the learning objectives for this talk. So I'll just show up there are resources like this online. So I was involved in the creation of this one for the atom alliance, which was a CMS contracted project. But very soon I will have a new one if anybody wants to reach out to me because I helped the Maryland State Department of Health put together a new tapering guide which took a lot of advice from the HHS and put it in a nice, you know, one pager front and back, which I think is really, really good and um I want to be super widely distributed. So if this is the sort of information that you'd like to have on hand, I should have the Maryland state Department of Health one very soon and would be happy to share. So that is the summary of my tripartite responsible prescribing principle. Um Here's the very simple lesson of today. Opioids are complex. I think you all probably already know that what I want to add is that makes the ethics of using them complex as well. And I just wanted us to insert a little bit of nuance into this conversation. Hopefully we have done that. So I will stop there. Thank you for your attention. Um I don't know Pablo if you're gonna take Q. And A. Or how to move forward but I will stop for my partner. We thank you so much for the for the presentation. I think it's a very enlightened and very appropriate. I'm not an expert on this in this space, I'm just and a doctor but but I thought it was it was great. I just want to open the the channel for questions and answers. So if people have questions please ah speak up or you can write them in the child if you prefer. I have a quick question so I'm a psychologist and the department um While pain is not my area of expertise, I certainly work with a lot of people that have pain. Um And you mentioned behavioral medicine as part of that role. Um What do you see as psychologies role in that you know certainly we're not going to prescribe and we're also not going to help take people off of the medication from that perspective. But um do you have any more nuanced information about what we as psychologists can do to support this? Yeah. Absolutely. I mean so they're kind of two components to the question, right, Because there's uh there's a huge aspect of just pain psychology which I think is really important. But then there's also this particular piece about tapering withdrawal management long term care because what I didn't have time to get into today is I addressed this very narrow problem which is routine dependence care but we now have an entire population of patients who have been on opioids for years or decades because of our aggressive prescribing practices in the past. And so there are patients on 1000 2000 morphine milligram equivalents. They worked up to that over 20 some years and if they are to try and deep prescribed from that, which is a huge push to get them on lower doses. We actually don't know how long their withdrawal is gonna last. We have reports of it lasting for years. The tapering process going on for years and there's obviously a huge role for psychology and helping to manage somebody's process of of long term drawn out suffering of that sort. So you may well already know this person but one of my favorite people working in this space is Beth Darnell who's a pain psychologist out at stanford and um she has done a lot of really cool work on both. Um what psychologists can do about pain, but also the role they play in helping patients to taper and when tapering is appropriate or not. Um I will just say so that I don't drone on too long. Two separate experts of different kinds met me kind of years after this when I was very willing to talk about it in a somewhat dispassionate way and they learned my story and then got close enough to me to say something that should have been really obvious, which is Travis, you became incredibly depressed during tapering, You blame it on the kind of depression, you know from the side effect of the process. Um you know, you eventually entertained thoughts of things like suicides. Did you ever just think that that might be kind of a response to the fact that you've been through trauma that you'd never processed because you've been heavily medicated from the moment that I had a 1.5 year old baby girl at home that I thought it was never going to be a good father to again right there is all this going on. So I have I have since come to embrace the idea that I was perhaps a little um too narrow in the sort of like pharmacological focus on the suffering that came from the tapering and that there's a real role for therapy. There's a real role for talk therapy for for having professionals help people guide through kind of coming off a medication that might have helped them cope and More ways than one. Thank you other questions. I just want to say maybe it finds a comment and maybe a little bit of a question Travis. I mean again, burying lining, I really appreciate that you are sharing your personal story and then you put the science behind um and I think that you highlighted the chaos the chasm that you just described was this idea of a bunch of people put you into the medication, but nobody's really taking you out and and when you go to the infusion clinics, they don't want to deal with people who were sent from doctors type of thing. Do you think it is? So um do you think it's are we making any difference with this? Um this request, a significant education and health systems uh you know, because here you are speaking to a bunch of physicians, many of the people in this group prescribe or manage pain and so on. But at the zone, but but it's important for all of us to understand that the discontinuation aspect ah and and we understand that I think the most probably management pain psychologists in the departments of folks have an understanding that the pain is a very complex situation. But I wonder how systematic, you know, those pain clinics of spain large groups engage with the patients to deliver this continuation. I mean, I'm afraid the honest answer is it's it's still really quite bad in most of the country. Um, so yeah, I called this a chasm in kind of recognition of the needs of care. And I've been, I've been speaking to clinicians for four years now on a regular basis from all over north America and I have yet to go to a place that's like, oh, well, we figured that out. Like, you know, it's there's always at least a small element of oh yeah, I get that. I can see right. Like even if I'm doing a pretty good job, like, oh, I've been tapering since. Like I recognize that that's a systematic or an institutional gap. I will say that there are there are small um, highlights. Right? So Hopkins itself now has a sort of tapering clinic that's not what it's called. Some of you probably know what it is, right? But it's, it's largely for pre surgical folks who are on pretty high doses of opioids, but it's the sort of place where someone like me only typically more complex cases could go and get really expert care at tapering opioids to lower and safer dose for surgery or for coming off chronically high doses after a surgery fixes the pain. So Hopkins itself has a really great resource now, I imagine that we're getting some more of those across the country, it's still really the exception though. And when I work with health systems, which I've done a few different times, they all find it very hard to think about cost management with this, right? Like what's the I. C D 10 code for withdrawal management? Like we've got to get paid for this, right? And like the surgical center I worked with is like our surgeons are not going to spend time every week talking to people about their withdrawal management. So their solution was to train up a group of mps right? Which I think is a fine institutional solution if you can make it work and make it clear that that's whose job it is. So I'm afraid more questions than answers so far, yep. Hi, I'm su kim the pain physician in our department and then thank you for sharing your story and then it's very similar to what we experience in our life and what we learned and what we what we read and if you read the book, dope sick and that yeah, many years ago and that was the one that really enlightened me um to learn about how this all started initially the constant. I mean, I am sorry that you had to go through that struggle, but the reality is that you know that when the fifth vital sign came along and entire acute hospital systems were judged and evaluated by the pain scores and without the proper pain management. Actually the first question that you get after discharge is like how well was remanded? Where was your pain managed during the hospitals day and they put the entire acute care physicians working in the hospital to be so worried about the pain scores and I think the word um it's not where it all started, but that's where um that's the area, that's the reason probably why you got so much of opioid to begin with. Unfortunately, um you mentioned about the institutional gap, the people who are doing inpatient pain are totally different from the people who are doing the outpatient pain management and while the entire government is chasing us too, um decrease the prescription of opioid and outpatient matter, they're really they have been reinforcing prescribing more and more opioid and an impatient and we are being really bombarded with those patients who are coming out and seeking more medication because of the many of them, because of the physical dependence, not because of their mental dependence. More. So. And yet also you pointed out that that really doesn't make any financial benefit or two surgeons or chronic pain practitioners. And it almost felt like you guys started it, can you just please take care of it at least a surgeon's, why are you coming to us and you know, asking us to clean up the matter. It's not that we don't know how to do it, but we're also really busy with our own practices and we don't have the capacity to handle all those cases. So I mean all in all, I mean this is a really um important and critical topic that probably can discuss on and on and give it for many, many hours. But even when I brought that up and when we had the discussion, I actually attended a meeting with the patrol terrorists who was the past president of the A. M. A. And they're all aware of these issues and yet they couldn't figure out the way to handle this properly. So I'm glad that Hopkins is managing it really well by running those clinics and which I'm also aware of. But still we have really long way to go to tackle it and then um more of a broader scope. I agree. I have nothing else to say something. Pretty long way to go. Yeah, thank you sir for those comments. And and and Travis again, thank you so much for your presentation. I think we are at the top of the hour. So I want to make sure people feel okay to, to live with this. I I appreciate the presentation and very important topic for us. So if folks have more questions, you, they know how to find you were part of the same system. Yes. Apparently were part of the same system. I'm happy to, to be in contact with anyone. If you have questions. Follow up thoughts, I want to give me advice any of it. Happy to receive emails. So thank you all for hanging out. Great, thank you. Thank you all.
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