will define and assist with us establishing why or what leads people to potentially be more at risk for transitioning to a chronic pain. The biological factors are often, in chronic pain, poorly correlated with the severity of the pain, and the treatment approaches need to really address all of the different factors, the psychosocial contributors, and the biological injury. And oftentimes, we switch to this chronic illness management model, which is probably more similar when we talk about our patients who have diabetes, high blood pressure, in the world of psychiatry, depression, anxiety, right? These are the things that we can treat and we can manage and we can help make more tolerable and increase the functioning of the individual, and that really needs to, in many ways, be the goal, right? That's kind of been the shift in medicine when it comes to most of our illness treatment modalities. It's, how do we get you living and functioning the way that you should be, we believe, functioning and living? And that's where the chronic illness approach comes in. So we'll review a little bit more about the specifics behind acute pain. Again, we have these nociceptors, these cells that become activated when a tissue injury of some kind occurs, and that causes a whole host of chemicals that are released, and in many ways, that response is very protective. It comes from, okay, there's an injury, so I need to move away from that noxious stimuli, and my body needs to create a variety of different chemical signals so that we can move along to not only getting away from it, but also working on healing the process. And a lot of those chemicals that get activated with prostaglandins, substance P, arachidonigas, all those different things lead to more of a pain, but also, again, they tend to signal in, let's have something come and help the situation. We have different types of nerve fibers. We have the myelinated alpha-delta fibers, and those are the ones that are responsible for rapid transmission. Those are the ones that go very quickly and pull out and show that sharp pain, versus the unmyelinated C fibers, which more of a deep, throbbing, aching pain that kind of lingers a little bit more. When you stub your toe and you get that initial shot of pain, versus the throbbing that continues afterwards. So, lots of different medication options for pain management, and we'll go through a variety of them. We have the opioids, which, interestingly, they block the perception of pain. They block the release of substance P, so we don't necessarily perceive that pain. Part of the challenge that comes with opioids is, whereas some of the other pain medications can help by leading to treating that pain, the opioids, in many ways, just take away our perception of pain, which that's why so many people, unfortunately, can re-injure an area if they are on opioids, because they don't necessarily perceive that they're causing more damage to the area. The NSAIDs, on the other hand, who block COX-1 and COX-2, and some specifically only for COX-2, and they are anti-inflammatory in nature, but they also allow for some healing to occur. They allow for some positive treatment in the actual injury itself. Pain is a unique mechanism that works through NMDA antagonism, and that can also help to, in many ways, block that perception of pain. And then we have the peripheral nerve blocks, which are site-specific treatments that block nerve conduction of pain. So we can see from this list that a majority of these are really about how do we prevent the perception of pain. And of course, that again goes with the idea of functioning, because if we can get you up and moving, if we can get you from lying in bed because your back is spasming to being able to move around, we also know that that will lead to improved health and improvement to the spasming, rather. So lots of non-pharmacologic options, and part of that comes from the fact that really the first three options, the opioids, the NSAIDs, the ketamine, not necessarily fantastic, right? They all have their limitations. We know we will talk a lot about the limitations with opioids. We're learning more and more that the NSAIDs tend to have a reasonable amount of risk associated with them, and they're not as amazing as we originally thought. And we even started to see this way back when with the specific COX-2 inhibitors and the cardiovascular challenges that came with those. But so non-pharmacologic options, really those allow for specific treatment of the area in many ways without necessarily leading to nonspecific whole body disseminated effects of the medications. So heat or cold, both of those tend to be good for both relaxing and providing some analgesia. Spine manipulation, acupuncture, massage, these are all different mechanisms by which we can use physical manipulations to treat the body. And then we have some of the fancier electrical mechanisms, remote electrical neuromodulation, transcutaneous electrical nerve stimulation, also called TENS, and those work in a different mechanism by way of releasing causing almost a little bit more pain per se, but it kind of attenuates the effects over time. Radiofrequency ablation, again, is a way to kind of burn the nerve, basically. And then the behavioral and psychotherapy modalities can also be very helpful, especially since we know that, again, there's those psychological components that come with chronic pain. So I want to talk a little more specifically about some of these treatments, because they're maybe not in our regular repertoire of treatments. TENS, transcutaneous electrical nerve stimulation, basically you put different nerves and attach them to the overlying painful areas, which will send voltage across the area. Again, it's based on the gate theory. It's based on the idea that if we lead to enough activation, we'll inhibit those nociceptive transmissions at the spinal cord. This unfortunately has a variety of different efficacies. The data is sparse, not great quality, but at the same time, I will say that the risk of a TENS unit, significantly lower, right? Basically, we're talking primarily we have the risk of cost and the risk of time. And it also might be something, a lot of these can be used in conjunction with other things. So what's nice is, is that we're going to attack it from a multitude of mechanisms. And if we deuce enough that have a decent amount of evidence, and especially, I'm of the opinion, lower side effect profiles, then we're likely to have more positive results overall. Radiofrequency ablation, again, that's a denervation procedure that involves basically burning the nerve. And it really seems to depend on where the location is for whether or not it's beneficial to the area. Basically, though, you go in, it's a procedure, and you will use an electrode to zap the nerve that you think is responsible. And I think part of that is also part of the challenge, because we may think that one nerve is particularly the area to focus on, and it's not always, our bodies don't always follow the rules. I'm sure we all remember from our Netter's Anatomy text, how Frank Netter had a little bit of a creativity sometimes when it came to anatomy, and the truth is our bodies do too. There is an entire psychotherapy modality that has been developed to help manage pain, chronic pain specifically. It's cognitive behavioral therapy for pain, and it's manualized. It's used often in the VA setting, but can also be used in the private sector. And basically, again, it encourages the patient to adopt an active problem-solving approach to coping with the challenges associated with pain. Basically, we use exercise, we use time-based pacing, which is one that I think a lot of people have a hard time accepting. Basically time-based pacing focuses the idea that we are going to do something, and then as opposed to our normal mechanism, which is we say, I'm going to cut the grass, and we cut the entire lawn, which takes, let's say, five hours, and then maybe we're laid up in bed with back pain for the next two days. The problem with that mechanism is you then have those two days where you're not doing things, so your list of activities builds and builds and builds and builds, and then within that next day, finally you can start doing again, period. You have that same, I have to do this whole huge list of things, and what happens is we end up seeing that pattern occur over and over again. What time-based pacing suggests is that instead of that method, we do a little bit and then take a break. For example, with the cutting grass method, if you cut the grass for 45 minutes, let's say, and then you take a five-minute rest, it's going to allow you to, instead of causing more and more damage to that area and having to be laid up for another two days afterwards, yeah, the whole grass, maybe it's going to take a little bit longer, but then you're not going to be laid up for two days, and you're not going to end up falling behind and repeating that pattern. It's very effective. The biggest challenge with that method is getting buy-in from the patients. I really think that they need to be able to see that that works before they can actually find that it fits within their new paradigm. Relaxation training, that can be tensing your muscles, whole body muscle tension, cognitive restructuring. We can also use visualization techniques so people can visualize a safe space, a happy space, so to speak, where they can focus in on using those other senses, smelling the smells. If somebody says, well, my favorite happy place is going to the beach at sunset, okay, you're going to go over the specifics you're going to talk about and figure out what is the temperature of the sand. Are you wearing shoes? Are you feeling the sand within your toes? What is the smell of the ocean? What is the feel of sunset, the breeze that might be blowing on you? The more specific you can get, the better. Behavioral activation, of course, is also huge because, again, we know that when people are moving, generally a lot of those areas that have chronic pain tend to be more effective, as well as when they're functioning and seeing that positive success, they tend to have a lot more improvement in the pain because they're focusing on what they're doing as opposed to focusing in on the pain the entire time. With chronic pain, as I said before, we do have less clear evidence about what tissue is damaged, which of course makes it a lot harder to treat. This is a common condition. I'm sure that if I were to ask all of you, well, we can use the whole React thing. By a show of hands, how many people treat people with chronic pain? People might not know how to raise their hands on the... Ah, okay. At the bottom, there should be a React button. Yeah, the little heart. Any kind of reaction you would like to put for your experience with treating chronic pain, I suppose. So yeah, definitely seeing some hands up and it is, and it's a common condition. It's frustrating. None of us got into any kind of medicine because we wanted to be stymied by how to treat people. So basically, not only is this common, but it's costly. The estimates back from 2011, and I'm sure those numbers are much higher now, was in the hundreds of billions, and not small hundreds either, and it leads to not only increased costs to the medical system, but also loss of productivity, disability, and chronic pain tends to lead to more of those chronic illnesses that we, of course, want to try and avoid. So I'd like to offer a case, and again, please, I'd love to have plenty of interactivity within this. So we have a 33-year-old female who arrives to your primary care practice as a new patient. She's just moved from another state and is looking to establish care. She describes a long history of chronic pelvic pain that started after a hysterectomy. She's managed with long-acting oxycodone, 30 milligrams daily with oxycodone, and acetaminophen, five milligrams, three times a day, as needed for breakthrough pain for the last five years. What else do you want to know about this patient's medical history? Feel free to just unmute yourselves and throw out some answers of what you would like to know about this individual. What other concerns or treatment that the patient has had? Definitely want to know kind of what, what else has been done to manage this pain? Did someone go straight to the, to the oxycodone route? Michelle Jesse says trauma history. What alternatives has she used? Anything else anybody wants to find out about, about the patient? Again, is she taking the medication as prescribed or has she had to take more of it to get the effects she needs? Sure, absolutely. She's been on the same, it sounds like she's been on the same thing for the last five years. Right, I mean, it's not taken. And, and one of the things that we'll get into later is the fact that we now have a better understanding that any sentient being that you give oxycodone to is going to have a different experience on day zero as they are on day 1,000. That's just the nature of the beast. And so we need to be mindful of that because we want to not just automatically say, oh, that's it, she's addicted. When the reality is, is it could be that it's just not doing the same thing. I would also say that, you know, in that realm of any, any history of trauma, any, any other alternative treatments, we also want to know what other kind of chronic medical conditions do we have? What does the day-to-day look like? What is the activity level? And a big question is, and this is often very common to find out and very useful to find out when we're dealing with somebody with chronic pain is what is your, that's, this is where a lot of times that zero to 10 Likert scale model can be beneficial for us. Because a lot of times, if somebody is not an individual who suffered from chronic pain, right. Then they know a zero, they know a 10 and they can guess a five, but it's not really something that's so helpful for people who don't understand pain. People who suffer from chronic pain start to have more numbers involved. And we can say, well, what is your current level of pain at? What is it at when it's at its best? What is it at when it's worst? And this is most important because this is where we have the opportunity to have a lot more education shared is what is your tolerable level of pain? Because again, the key is when we start to refer to chronic conditions, we're at chronic management types. We're not at the, how do we cure this? And I think that's oftentimes a big challenge that comes in the idea of medicine when for a while, I'm sure all of us thought, and our patients certainly think we're in the business of curing things. And the reality is, is the more we see, yeah, there's a couple of things out there we can cure, but there's an awful lot out there that we can treat and manage effectively, but we don't necessarily cure it. All of these different things are great ways to start to build rapport with this patient, because if you start right away with either, nope, not giving you any oxycodone, period, or even work on the, go with the idea of any kind of suspicion, really, because this is probably somebody who, especially if it's been for the last five years, maybe it's been even longer, we don't know why she got the hysterectomy in the first place. So that's a useful piece of information to find out. We don't know how much this hysterectomy has affected this individual, what perhaps it changed with her goals in life, what she had wanted to do, what she didn't want to do. Lots of different questions to really begin to establish the entire human being, which then, once we understand that and we build that rapport and we have that information, then we can start figuring out, okay, what is our concern? Is it safe? Is it not safe? Do we continue? Do we not? Do we adjust? So she tells us that she's otherwise medically healthy, and she had hysterectomy following 12 months of irregular painful menstrual cycles that would last for at least 10 days. She has struggled with depression off and on since the age of 15, but states these seem to be unrelated and well-managed with escitalopram 20 milligrams that she's been taking since the age of 22. So what questions might we have about her depressive symptoms? Anyone have anything that they'd like to know more about with the depression? We're all really thinking. Yes, and admittedly it is early. So something we might want to know about is how's her sleep at the moment, right? Because we know that depression can impact sleep. We also know that pain can impact sleep. So it might be one of those questions of, hey, do you find yourself always taking a five milligram oxycodone and acetaminophen before you go to bed? Does that help you with your sleep? Do you sleep through the night? Are you waking up repeatedly because you need to shift? Or what else is going on with your sleep? Because that will give us a good gauge of, again, are we using the pain medicine to treat pain? Or are we using the pain medicine to do something else? We also have what life events could have triggered the depression. And then someone else says, I see depression as secondary to the pain. I'd love to hear more about the depression being secondary to the pain. Are we thinking that the pain caused the depression or are we thinking that the depression might be unrelated entirely? Hi, I'm Donna. And I'm the one that made the comment. I have seen super happy, go lucky, fun people who come across an injury or something that puts them into a chronic pain situation and seeing their personality change to where they're more of a depressed or not as engaged person. And so that's why I think that in this case, that it might be secondary to the pain is what my thoughts were. Is that if she had a full life, had the hysterectomy, now is in chronic pain, most likely, most young people are happy, go lucky people. They'll have a lot of trauma in their lives early on. Now, she could have had trauma like the other person mentioned. Monica mentioned that she could have, something could have triggered depression, but I don't want to rule out the fact that maybe nothing happened and it's secondary to the pain because I think that's a real viable situation. Absolutely. Absolutely. And I love that idea because again, we're at that age where, you know, she's going from this idea of she's invincible to all of a sudden, oh, now I have to be mindful of my body. Can I jump in? I'm sorry. I'm a clinical health psychologist and I'm going to contrast that just a hair. Most, when you look at the epidemiology of most development of mood disorders and anxiety disorders, the age of onset is late teens, early twenties for the first episode. So while some people may be happy, go lucky, that is actually the initiation of depression and other types of psychiatric disorders, a lot of psychiatric disorders. So I think this, I don't think that that assessment is wrong per se, but it would require a comprehensive assessment of her symptoms, family history, and other factors to really differentiate that. Absolutely. Absolutely. And I think this is, this is why it's so important to have that differential, right? Because we also know that she says she started to have depressive symptoms since 15, but she only apparently had, it seems based on what she told us that her, her pelvic pain and even the issues with the irregular menses, which, okay, maybe it wasn't, you know, she had the hysterectomy and she was 28, roughly, maybe it was 27, but maybe even 26. Suffice to say that's 11 years earlier or later than the depression that she says she's had developed. And even still about four or five years after she ended up getting started on treatment. But we can see either of those cases, we can see the happy, go lucky person who all of a sudden was hit with, I'm no longer immortal. And in fact, now I feel like I am prematurely aged versus the person who, if they have depression and they have other things that have led to depression, is that possible? That, that was what kind of took a situation where normally we might be able to fix the problem and the pain would be gone versus now we have someone who is, has developed a chronic pain. We talked before about, you know, we already wanted to know what medication trials had been on, has the patient been on? And that might be good by the way, for not just the pain aspect, but we are armed with a number of medications that can treat both depressive symptoms and chronic pain. So has she tried any of those before? Were those effective? Esotelopram, not necessarily known for its pain relieving factors compared to a lot of the more noradrenergic of the antidepressants. Also, what therapies has she tried that could be both physical or pain management based and psychological therapies, behavioral therapies, right? There's pelvic floor therapy. Has she ever tried that? Is that something that might work for her? So lots of good questions that we see are coming up for this individual, even as we get more information. One of the things we also don't know, by the way, is, is her pain well managed? Is she still having pain? If so, how much? Again, what are her goals? So let's talk about some of the causes of psychiatric comorbidities and chronic pain. A lot of people have co-occurring depression and chronic pain. A lot of people also, we see the trauma, we see personality disorders, which can include borderline personality disorder as one of them. And in a sense, we know that with a lot of people who suffer from borderline personality disorder, part of it is, is that disconnect between neutral stimuli versus negative stimuli, or rather that inappropriate connection. And so if you often have that negative mindset or that feeling of I'm alone, I'm isolated and I see everybody else and they're all different than me, that can worsen your perception of your pain. Anxiety disorders, absolutely. And we see that that's a huge range, right? Anywhere from 16.5% all the way up to 50%. And substance use disorders, it's a little bit more of a narrow window. It's interesting to note though, by the way, that the substance use disorders don't necessarily have a direct and huge correlation with the comorbidity and chronic pain. That being said, there are also a lot of variables involved in trying to figure out what is a substance use disorder that has led to, or that has led to chronic pain versus a chronic pain situation, or perhaps even the prescribing has led to a substance use disorder. Iatrogenic causes of substance use disorders are unfortunately huge and chronic pain, I'm sure we can imagine, is not a low on the list of causes for that. So two to three times higher of co-occurring psychiatric disorders in chronic pain patients compared to the general population. And we know that in this population, in general, we're seeing that treating the psychiatric conditions is so paramount because it leads to better and more positive management of the other medical conditions. We know that our insurance company accountants have done the math and they've seen that depression that's untreated, the costs of other medical management, cardiovascular treatments, so on and so forth, are as much as four times higher. So for all reasons, we're seeing that there's so much importance to treating all over the person and especially managing those psychiatric conditions because they will lead to improvement in the perception of the chronic pain and how they're functioning. Among patients with major depressive disorder, the reported chronic pain is so much higher and that includes both disabling and non-disabling pain. And again, we see that that takes away from the person's ability to function, the person's ability to work and be a productive member of society, which then of course, unfortunately, worsens the depressive disorder because if all you're doing is sitting and stewing over all of those negative thoughts and the pain is increasing, then we see the vicious spiral and that vicious cycle. That low quality of life, that's probably, again, the most key thing because if you take someone, let's use both of the examples that were mentioned earlier. We have the happy-go-lucky individual who all of a sudden has this smack in the face of this terrible chronic pain that occurs. All of a sudden, I could do everything a year ago and now I can't do anything. That kind of absolute mindset, which it's hard to not fall into, especially in the beginning. Conversely, the person who has that negative mindset of everything is going poorly, everything, nothing is working well, and all of a sudden, yeah, now I'm seeing I was right. See, now I have this pain and now everything, I'm just proving over and over again that, yeah, and now everything, I'm just proving over and over again that, yeah, I am just not, that idea of not being good enough, that idea of lacking of the self-worth is huge. We see panic and anxiety in relation to these conditions as well. This idea of, I want to go do something. I would love to go to my kid's baseball game, but I'm going to be sitting on the bleachers and the bleachers are very hard and there's no back support, and then I'm going to end up feeling pain. Yeah, I'm going to go to my kid's baseball game, but then I'm going to end up being laid up for the next several days. I have to decide, am I going to be in pain or am I going to miss out? That constant missing out can hugely impact someone's ability to reach functional success. A lot of times we see anxiety disorders that can occur before pain onset, whereas the depressive disorders can occur after the pain onset, and so that's one of the important things to take note of. Within an addiction, there are a huge, it's any anywhere between three and 40 percent, and part of the challenge is because this kind of is a big question of what is considered to be addiction. Is the person who ends up struggling with addiction, is the person who ends up a big question of what is considered to be addiction? Is the person who ends up starting to use more than prescribed because maybe they've become intolerant, maybe they haven't had the opportunity to have an adjustment to their dosing, is that addiction if they use more than prescribed because they weren't prescribed enough? Or conversely, what if they move to a new area, or what if their doctor retired? We see such a stark difference between where people were prescribing opioids, and that of course goes to that 80s and 90s history of oxycodone and oxycontin versus how we're treating now. We now have states that have different variable recommendations on what is the appropriate morphine milligram equivalents for treating pain, and so if you had a doctor who then retired and you get a new doctor, all of a sudden you're coming to them and they're going to say you're on this much of the opioids, you're on this many morphine equivalent dose milligrams, I gotta cut you down. Is that addiction? What if they end up seeking a new doctor because they say well I can't do this? All of these different areas we can unfortunately create a lot of addiction. We also are going to be tasked with dealing with the individuals who are suffering and struggling with I want to be on less, I don't like that I'm not functioning, but I'm in too much pain, and maybe they haven't been offered or don't know about some of the other opportunities, some of the other ways that we can help, and a lot of times there's that fear of pain. I think that fear of pain can be such a strong driver for people. They will continue to take medicine that prevents them from functioning if it means that they won't have pain because they know that when they have pain they are miserable, and misery tends to lead to a lot of other negative things as we've said. So basically the numbers again not so high in any area less than a quarter of a percent, less than a fifth of a percent of patients on chronic opioid analgesics for pain management have no previous or current history of abuse or addiction. And anywhere from 11, around 11.5 percent, the numbers were pretty variable though, end up developing those aberrant drug using behaviors. We're going to talk a little bit more about kind of the different tools that we can measure the different, as we call them, aberrant behaviors, sometimes also called red flags when we're looking into different things and using our tools. And it seems that if we really look and get a good history on the patient themselves to really select out those that are at highest risk of developing an addiction, we do seem to see a lot lower rate of a developing of addiction. So the CDC has come out with 12 recommendations for managing pain and evaluating whether or not opioids are appropriate. And it's important to note that in all of these recommendations they have different classifications of the strength and the validity of the evidence provided. So we have also the generalizability. Where do we have this information from? Can we use this for everyone or is this really specific to a small subset of individuals that are dealing with pain or chronic pain? Any questions so far? Any questions that have come up? Okay. So recommendation one, clinicians should maximize use of non-pharmacologic and non-opioid pharmacologic therapies as appropriate for the specific condition. Patient only consider opioid therapy for acute pain if benefits are anticipated to outweigh the risks. Okay. Recommendation two, patients should use non-pharmacologic and non-opioid if benefits are anticipated to outweigh the risks. Okay. And before prescribing, we want to know and go over what are the risks of opioid therapy? What are the potential benefits we're going to find? It makes sense that this is the first question to be asking. It makes sense this is the first recommendation. We really want to see, like we've said, what's going on here? What do we know? And we see that our data has shifted. Again, even with acute pain, there are a lot of doctors who are not prescribing opioids at all for acute pain conditions. And we're even seeing a shift in some of the practices pre-surgically. So for example, there has been some of a movement to move from the idea of nothing by mouth before surgery to the idea that maybe having a small amount of an easily digestible, like clears, before surgery might lead to better tolerance of the surgery, might lead to the decreased need and use for opioids in the treatment. And we also have seen that there is the, at least in Florida, and I think this could be everywhere, but please correct me if I'm wrong. There's that three-day acute checkbox on the prescription, so to speak. If you're going to prescribe pain medications that are opioids, you have that three-day box versus an exception to the three-day rule versus chronic. And that helps to categorize whether or not the individual, how they're being prescribed pain medicines. We want to have the conversation with the patient about this. We want to really get into those risks and benefits. It's the same idea, and this is very time-consuming, so this is a challenge. Am I correct? We have a number of primary care people, right? Can someone tell me, on average, how much time do you get when you're meeting with a patient? Anyone want to share their time for, and going, well, we won't even get to the 50,000 things that you need to check on in the multiple systems and the multiple screening tests. How long do you get with your patients? Check on in the multiple systems and the multiple screening tests. How long do you get with your patients? 15 to 20 minutes. Okay, that seems long. And what about not a provider but I get about 10 minutes with my provider What about um, what about new emails? How long do you guys get for a new evaluation? Okay, so basically what we're saying is we don't get along for follow-ups for sure. And I'm going to guess that that 45 minutes is maybe not most of your averages because I've given it again, other, other presentations to other people in primary care specialties before. And, you know, I've been told, well, we get like 30 minutes for a new and that's it. And so you can, I'm sure you can imagine because you're not imagining, you're experiencing, you meet with someone and you say to them, all right, let's talk about what we can do for this. And then we end up having to spend the entire time on that, right? So what are the risks and benefits? What are we going to talk about? Are we going to talk about the risk of addiction right away? Are we going to, are we going to use that as our, as our scare tactic? Well, and how much of a scare tactic versus a potential reality is it? We know that the data just showed that it's variable. We don't know for sure we need to find out more information, but at the same time we want to be able to say, yeah, this is a risk. And another thing, and a question that we really don't mention enough is starting a medication of any kind is a trial, right? If you have somebody who comes in with hypertension and you're going to treat their high blood pressure and you start them on one medicine, let's say you start them on hydrochlorothiazide and you don't see satisfactory reductions in the blood pressure, the reality is, is that you're either going to stop the hydrochlorothiazide or you're going to add another agent. You're very rarely going to say, oh, well, let's just keep going with it and see what happens. The same is true for diabetes. You're not going to just give them one agent and say, well, let's see how the metformin does. And when the metformin continues to not satisfactorily reduce their A1C, you're not going to say, well, all right, let's just keep going with it and see what happens. And the same is true with opioids. It's a trial. If you're going to prescribe a pain medicine of any kind, it's a trial. If it works, great. If it doesn't work, then do we have to shift gears? It's not necessarily just let's do more and more and more and more. And when we put it in that paradigm, all of a sudden, yeah, it makes a little more sense. And the conversation gets easier because you're setting the stage from the beginning of if this works, this is one conversation. If this doesn't work, it has nothing to do with you as a person. It has to do with the idea of this isn't working. Let's shift to use something else to work. It's setting those expectations up front. And it's really building that necessary conversation and rapport that you want to have with these individuals because unfortunately, they're so used to people just saying, no, I don't give any opioids. That's it. End of conversation. Or here you go. And again, that's really hard to do. And I realize it's really hard to do in that 10 minute block where you might have, again, other systems to go over. You want to really stress the idea that this is a multimodal approach. And I think if you do that from the onset, you're really going to, again, set the stage. You're going to say, you know what, here, I'm here, I'm going to prescribe you medication to treat the pain. I'm also going to prescribe you medication to treat all of your other conditions because we need you feeling like you are in top form. I'm also going to mention that you need to be taking, or you need to be engaged in physical therapy, regular exercise, different pelvic floor therapy, occupational therapy, whatever the kind of therapies that are physical based therapies are that are going to help to also treat the area. They're also going to work on how do I move differently? How do I strengthen? In the case of back pain, I'll use back pain because it's a really common one. Core strengthening, right? Core strengthening is huge. And we know that people with strong cores often are less likely to have back injuries because they don't have all of the excess challenge of the back muscles having to deal with a lot of things that generally the core muscles should be responsible for. We might also recommend, again, psychiatric care, wanting to make sure that we're covering all of those different conditions. And we also want to make sure they understand right from the get-go, I believe you, you're in pain. I believe you're in pain. And at the end of the day, if it turns out that maybe they just have depression, maybe it's just a somatic symptom of a psychiatric condition, we still validate, we still let them know, yes, this is real. And we are going to treat it with this modality. We're going to use these kinds of tools to help treat it. A lot of times when people say, oh, it's just in my head, they automatically think you don't believe them. They think it's not real. They think you're questioning it. When in reality, you're not, you're just saying, you know what, I hear exactly what you're saying. The pain you're describing is likely more emotional in nature. And this is what we're going to do to treat it. This is how we're going to attack this pain. And again, knowing if this doesn't work, we will try something else because that's the key thing. People want to know they have a plan, they have a method, they have a way that they can get help. Recommendation two, with slightly better evidence, by the way, non-opioid therapies are preferred for subacute and chronic pain. Yeah, we've kind of been saying that. That's, you know, so far, not super helpful from the CDC. We know that. We know that we don't just throw opioids at everything and say, good luck. Okay. Only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. Again. Great. We kind of said that same thing in recommendation one, and we know that because again, we're going to treat this like any other condition. We're going to treat the treatment like any other treatment. Let's look at the risks. Let's look at the benefits and let's see which is better for you and which fits your needs. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh the risks. Okay. So far, so good. We really kind of hammered that home. The CDC has been very helpful thus far. First two recommendations. Yep. We're good. We got them. So at the same time, again, we're going to be specific, right? And sometimes people need that. Sometimes they don't, right? We, I'm sure we've all experienced patients who they want the numbers. They want to know what the statistics are. What is the data? What is the prognosis? What is the likelihood that this is going to treat my condition versus I'm going to end up still having a problem? And again, we see that with diabetes, right? People might ask us, well, okay, so I'm going to do all these things. What is the chances that I'm still going to end up with kidney disease later on in life? And other people say, I don't want to know the numbers. I don't want to know the specifics because I'll do what you say. And I accept the idea that statistics are great for populations when on the individual level, either I have it or I don't, right? That person with diabetes who's well-controlled with their diabetes, either they have kidney disease or they don't. The specifics, you may not want to burden the person with all of the available data at the same time. Maybe it's the second visit. Maybe it's the third visit. Maybe they're saying, you know what, I know we're doing all this stuff. And I know that we're trying the other treatment, the opioids, but you know what? It's not working. Or I know we tried NSAIDs first because you said NSAIDs were better for me. And I've tried that and I've tried physical therapy. What else can I do? Because this isn't working for me. And again, if we take this as the idea at that point of saying to the individual, you know what, we're going to attack this from multiple layers and multiple levels and we're in this together because that's the big piece for a lot of this is people feel like they are alone, like they're isolated and they're the only ones who have to deal with this chronic pain. And I would say not just when they're younger, but as they age as well. I don't know at any point in time where most people are happy to say, you know, yeah, everything hurts all the time, but I wake up in the morning. Yeah, that's a great attitude if you can have that. But I don't know that that's necessarily the most common approach. I think a lot of people, the pain gets to you. The pain can be frustrating. It can be overwhelming. And so they want to know, what else can we do? Dr. Dell? Yes. I'm going to transfer the host over to Ms. Joudy. So screen sharing may stop and she will have to give you permission to share again. Okay. All right. So. Oh, it didn't. So you can continue. Awesome. All right. Cool. Okay. Recommendation three is when starting opioid therapy for acute, subacute or chronic pain, clinicians should prescribe immediate release opioids instead of extended release and long acting opioids. What's interesting about this one I find is this goes against oftentimes our normal brain. Right. A lot of us have the idea of, well, we're going to have a brain tumor, we're going to have the idea of, well, the extended release formulation of whatever I'm giving will likely work better because it'll have improved compliance. It'll have improved efficacy. Somebody who only has to take a medicine once a day is more likely to take the medicine than someone who takes a medicine twice a day or three times a day or so on and so forth. That's been the mentality and that remains to be the mentality in most situations. I mean, I would assume, and please correct me if I'm wrong, if you have a choice between prescribing somebody a Z-Pak that they can take for five days and then not have to worry about again, or taking a penicillin or a cephalosporin that they have to take four times a day or for 10 days, I assume that if they're equal efficacy in that particular infection, we're going with the short acting or the short duration with the once a day dosing. Is that a fair estimate for people? Yeah. So all of a sudden now we're saying, hey, wait a minute, go with the short acting instead. Okay. Anybody want to kind of envision why we would want to go with the short acting instead of the long acting in this case? maybe not inadvertently reinforce the benefits of the medication if they're shorter acting than their the perceived benefits could be lower which not as ideal from a clinical standpoint but i'm just wondering if that's one of the reasons okay so so the possibility that maybe they'll be more mindful of when they're taking it and they won't necessarily uh just and it sounds like part of what you're saying also is they'll know why they're taking it and what they're taking it for as opposed to right many people wake up in the morning they take their morning medicine they don't think about what each one individually is doing they just look handful of bills all right any other any other thoughts it looks like we have some in the chats um uh chat says also so you continue to get the feedback on the pain level to encourage other behavioral changes sure sure we wanna we want them to see hey i can't go and lift all these things or move things around it or um can't go for a 15 mile run when i haven't been running ever um not that anybody's i think going for a 15 mile run if they haven't been running ever but suffice it to say that's one of the challenges as we were saying with the opioids where they mask the pain right they work differently than a pain reliever they're analgesic and when we think about what that term means in its basic latin right it's get rid of mask not perceive that's not healing so part of it is also right we know that the extended release long-acting opioids they can pretty much all be misused i know they have the some of the newer formulations that have other deterrents in them i'm going to tell you from the addiction psychiatrist standpoint patients are very savvy they are very intelligent and if you ever want to get an idea of what people are figuring out take a little trip on arrowhead or blue light and just look at some of the posts google some of the results of how do i get this out of it i'll give you a perfect example i was looking at one point and there were whole chat a whole discussion on how to boil off the naloxone in buprenorphine naloxone to be able to get it to be just buprenorphine so yeah we can try and we should try and we should put deterrence in there and at the same time you know we have the old ad the old piece of what happened with oxycontin where it was this totally safe mechanism and within a very short period of time people figured out if i just crush it up and sniff it i get the whole dose of oxycontin all at once so they do carry additional risks the other pieces is that the dosing is very different and so starting somebody on a longer acting dose of a lot or a higher dose of a long-acting opioid may be too much and that may cause other issues there's also incomplete incomplete crossover when you go from an instant release formulation to an extended risk formulation or even when you switch between one opioid and another and so the challenge of transitioning those is really best done when you can do it as as straightforward as possible and as easy as possible because you don't want to of course put them in a situation where they're where they've overdosed that can be you know really challenging and it's also a question of what's your what's your comfort what's your scope if you're not comfortable with prescribing something or handling a certain condition yeah you need to know who to go to but if you don't have that person reaching out to you you don't have that ability to get that warm handoff or that support from someone who is able to to say be a be a resource for your particular practice who can say all right this is how you're going to handle this is what we're going to do and yeah those things are those people are becoming more and more realizing that there's value to that but it's still hard to adopt and there's other challenges which are outside the scope of this particular discussion where that's not necessarily a model that is easily implemented but it doesn't mean that it's a it's reasonable for you to go and jump into something that you're completely uncomfortable with uh quite frankly it would be like me deciding that i'm going to handle prescribing insulin uh it's outside my scope and i can cause major major damage if i just go and give it a shot recommendation four when opioids are initiated for opioid naive patients with acute subacute or chronic pain prescribe the lowest effective dose yeah not only does that make sense but again we want to reduce the risks associated with them never mind the addiction standpoint never mind the overdose standpoint how many people have been on opioids and say okay this makes me sleepy this makes me constipated i can't think clearly i can't i've had plenty of people who say that it affects their ability to have sex so all these different factors these are not necessarily medications that help people function right they may get rid of the pain but do they improve your functioning and so let's use the lowest possible dose and see what we can get because we really want to make sure that we don't overdo it and if opioids are continued clinicians should use caution yeah evaluate individual risks and benefits and avoid increasing above levels likely to yield diminishing results and benefits relative to risk of patients a lot of these i'm sure for for all of us they read like every other type of prescription that we would write every other type of medicine if you don't think it's a bacterial infection that's going to be benefited by this antibiotic don't use it consider the risks of this medication before you just jump to it right we know that the likelihood of treating a sinusitis for example is bacterial versus viral not super likely and we don't that as many as 25% of people that take an antibiotic end up with a gi issue usually diarrhea so this is a similar idea do we need to use it how high should we go before we say you know this isn't working this isn't working how high should we go before we say you know this isn't working and we try something else in general i'm a big believer of start low and go slow right especially because these medicines sometimes they take a little time to take effect and sometimes you have to play that catch up to the pain which obviously we want to try and avoid once we have good control of the pain but while we're trying to get control of the pain there's some catch-up that occurs and so you want to try and be mindful of how can we manage this and more specific numbers when it comes to the risks and benefits there are minimal benefits seen when going above 15 morphine milligram equivalents a day but the risks are exponential in growth the rate of misuse overdose death false injury endocrinologic abnormalities all increase with doses seemingly as low as 20 morphine milligram equivalents per day and the risk of overdose is nearly two to time nine times higher nine times higher with doses greater than 100 morphine milligram equivalents compared to those that are less than 20 so what this really tells us is that that threshold for how much we're giving pretty low and the benefits that we see pretty low at the same time we do have to consider those individuals who we didn't have this data when they were starting on opioids and so now they've been on chronic opioid therapy for decades and they're on 100 200 higher i mean i've seen people who are on 700 morphine milligram equivalents per day which sounds absurd and and it is and yet they were walking around they were well they were having they had a lot of pain so they weren't easily walking but they were breathing and they were conscious and they were certainly upset when we had conversations about trying to adjust their dosage this is where we get into again that conversation with them this is exactly what we're what i was just talking about where we have people already on opioids do we continue it how do we have that conversation how do we work with everybody how do we make time to work as a team because again it's one thing to say all right i want you to go to physical therapy i want you to go to pelvic floor therapy i want you to go to psychotherapy i want you to see the psychiatrist i want you to you know make sure you're exercising get a physical trainer what have you and i'm going to give you opioids but are we talking to each other are we saying what known what benefits are we noticing are we making sure that the patient is dosing their opioid effectively for example the benefits of pre medicating before exercise or physical therapy versus medicating afterwards are we getting into another situation where instead of getting ahead of the pain we're falling behind the pain which unfortunately can lead to higher utilization of the opioid therapy and how do we have that conversation and how do we start with what do we do to start tapering that dose if we're seeing no benefit what's really important is that again we need to be sensitive to the fact that these are people who are going to be wary they're going to be fearful of having pain they're going to be terrified that you're going to that when you stop their opioid they're going to end up not being able to do anything even less than they're doing now and they're going to be in massive pain so have that conversation together be able to say you know what this is no life-threatening issue we're going to work together slowly on adjusting that dose we are going to try and figure out okay let's do this as a team and i think when we have that team approach it really works very well you have patients who are able to say you know what i'm okay with going down by two milligrams or i'll take a half of a five uh milligram of oxycodone acetaminophen rather than a whole one and then you might say okay and then you see them again at the next visit and they say how'd you do oh you know what i didn't really notice a difference that's fantastic that's the goal because that shows them i can take less and i can succeed and i can function and i won't feel any different that's great less medicine always a good thing generally speaking look for the functional improvements focus on that focus on are you doing what you want to be doing are you getting up are you working are you spending time with your loved ones are you socializing are you having fun right these are all necessary aspects of life and these are the things that get taken away when somebody struggles with uh chronic pain so there is limited evidence on how fast one should go with the taper i think the key is they are more likely to be successful if you go at their speed with you in conjunction i've had plenty of people that you know in in other uh controlled substance situations you know as an addiction psychiatrist i work a lot with people who are coming off of benzodiazepines and we often see that they tolerate when they're in charge we can do it fast right i can send them to an inpatient detox and they'll be off of those benzodiazepines in a week or less but they're going to be back on them pretty quickly too on the other hand if i let them drive if i say you know what try and cut one of your clonazepam doses in half let's go from three milligrams a day one milligram three times a day to two and a half milligrams a day total and and i tell them you know what if we're working coming off of it you figure out what works for you i don't care if you do the the cut in the morning dose the afternoon dose the evening dose whatever works best for you and all of a sudden they have all of this control they have all of this freedom and they have all of this okay we're a team i'm driving you're helping me navigate and and that works for people oftentimes i'll tell people i'm like gps right i have a way that i am pretty confident we will have success it doesn't mean my way is the only way and so having that shared decision making often leads to significant benefits and significant tolerance and success another thing that i sometimes will do is i will tell somebody let's try an informal decrease which again they have that fear of what if i don't have enough what if i'm not successful and so i might say i'll give you enough to take one milligram three times a day but try and take reduce that by the half and i cannot tell you how many times they come back the next the next month the next you know however they come however they come and they have this smile on their face and they say i have seven tablets left and i say that's amazing and we cheer the heck out of it and then oftentimes i'll say are you ready to make it a formal decrease and that shift of going from the formal or the informal to the formal they have success and then they come back again and they're like all right i did it i'm ready to try decreasing again and that's such a positive set people up to know that they might have some withdrawal symptoms and if they do be ready to slow down with them because the more discomfort they have the less likely they will succeed in any kind of decrease or any kind of taper they are very likely to give up go to a different doctor switch entirely and just run if they have negative effects so the more we can help them to be successful the more we can tolerate their their speed the more they will be successful and they will have positive results it doesn't matter how long they take by the way less is less number six when opioids are needed for acute pain clinicians superscribe no greater quantity than needed for expected duration of pain severe enough to require opioids okay that makes good sense um the funny thing is and the unfortunate thing is right we also have been in this model of let me give them enough that they won't bother me i don't want to get a call at six o'clock in the morning or at you know 2 a.m on a saturday night from a patient that oh i have so much pain so i'm going to give them a month's supply supply that was a common practice but we're seeing more and more that's not necessary we're seeing a lot of times people are prescribed way too many opioids and they save them why do they save them because we never prescribe them which is kind of an odd thing to say but right that's what happens so we all get that prescription and we fill it and if there's a refill on it of course we fill that and we end up taking one or two of the pills but we save them in the medicine cabinet because i'm not going to be able to reach my doctor at 2 a.m on a saturday night so i'm going to make sure i have my medicine just in case that just in case is a problem that just in case is how people get access to these pain medicines people who shouldn't be on the pain medicine i'm not talking about the person who has chronic kidney stones who says you know what i know that when i have a kidney stone i need one or two maybe even days worth of opioids and to go to the emergency room at three o'clock in the morning on a friday not likely to be successful i am more likely to be able to do this okay then it's a different conversation and we'll talk about what that conversation is but to just have just in case it can be a big problem most people again four to seven days so i'm gonna i'm gonna suggest maybe we take like a five minute ten minute uh five minute break uh so everybody can kind of get get some water get some coffee what have you sure that sounds like a great idea um so it's 8 27 so we can be back at 8 31 or so or 8 32 sure i don't know how to do math sorry so yeah thank you see you in a second all right It is now 832 if you want to get started again okay, I got a chance to look through the the chat and I saw a couple of a couple of questions one of them was back that Was about dental procedures and and I think that Just like with other kinds of pain dental procedures. We've really kind of People really are afraid of pain and I think in general Unfortunately, we are as a society very commonly afraid of dentists and dental procedures And so I think again it kind of comes in that same realm I can tell you that I've worked with a number of people who have gotten all sorts of dental procedures done teeth pulled Root canals bridges all sorts of different things and Many of them when they're in recovery from opioids will say Nope, I'm not taking anything. I'm just gonna do a Tylenol ibuprofen and The reality is is that most of them are like, yeah it's fine to which I'm always a little bit shocked because I just have this image of you know people having painful dental procedures and That fear and so I think it really does fit within again It's still that same four to seven day modality and a lot of people when they're using any kind of opiates They're not finishing them. And so we see the question of Where are people getting these opioids? Where are they coming from and a lot of them Are either getting them directly through their health care provider. This is a this is a large percentage but the other ones notice Given by bought from or took from a friend or relative They were going to visit grandma and grandma had some some Percocet in the in the medicine cabinet and now she has less and And that's a lot of how people are getting the medicine these two pieces are huge and so some of the things that I will often suggest is Again if you're gonna store Opioids store them safely. They have to be in a safe. They have to be somewhere where you are not going to have to worry that someone is going to get them who shouldn't have them and I will say from the prescribing standpoint I'm a big believer in especially with electronic prescribing now, obviously we want to do electronic prescribing As often as possible because I think that that helps to decrease the risk of prescriptions getting confused getting misread getting this written getting Numbers getting changed or modified and yeah, we have some rules in place that are Protecting us from that now, but at the same time Look at your prescription pads. Where do you keep them and Do they have the DEA number written on them a Lot of prescription pads They default with having the prescription. No the DEA number written on them. You don't have to do that That is not a requirement. You can write it in but when you need to prescription for metformin does not require your DEA number and If you're doing that, then it also decreases the the concern surrounding people Getting a hold of your prescription pads and The value that those prescription pads have when someone realizes I don't have the information I need Remember your license your NPI number. Those are public record your DEA number I always think my DEA number like my Social Security number. I'm not giving it unless I really need to You Recommendation seven evaluate the benefits and risks with a patient within one to four weeks of starting opioid therapy and Continue to regularly reevaluate that with patients No different than if we had a patient again I I love using the diabetes example because I think it just fits so beautifully within our chronic care model Both the positives and the pitfalls, right when we start somebody on a new medicine for diabetes We want to make sure is that working for you? Is that decreasing your your daily blood sugar is it decreasing your a1c? Are you still having spikes and and troughs which may look like your a1c is great But I'm sure you've seen plenty of patients who now that they have those Monitors that you can kind of They sit on your skin and so you can take it from your phone at any point in time and scan and get your blood Sugar, right? I have a feeling that a lot of us are potentially seeing yeah, the a1c is better, but sometimes the blood sugar is 200 or 300 or reads just high and Sometimes the blood sugar is down to 60 because you have a patient who's struggling with that at the moment. Well You know his blood sugar is still all over the place a1c is dropping it's getting better but the in-betweens are still the problem and so we want to make sure that we're really talking to these people and Getting to know is your medicine working? What are you doing with the the improved functioning? What does that mean for you set up those goals and say and and they should be smart goals, by the way Let's talk a little bit about what smart goals are Is anybody familiar with that and not smart like smart the acronym? Anybody have any experience with smart goals? Specific measurable achievable Reasonable time-based Exactly exactly and and and that's wonderful because again people will say I want to be able to do more I want to have less pain. I want to function better. That's Fantastic. What does that mean? And how do we know if you got there and when we put that into terms that are more measurable and we can then say is it working or is it not and Then you add them you add to them you shift them you say All right. Now that I'm doing this goal and I see that I've achieved it. I want to increase to the next goal When you do that with patients you're able to get a good sense of what are we doing with this medicine? The the counter your point that I would say I use when I'm dealing with people who are suffering with anxiety I can I can make sure you have no anxiety. I can get you drooling on your couch watching TV But what's the goal then? What are we doing? Is that really what we want to be functioning? Usually in in appropriate situations the answer is no, I don't want to do that. So we want to make sure that we are giving that opportunity for people to say I Know I'm doing better because or I know I'm not doing better yet because and so I need blah blah blah Recommendation eight before starting and periodically during continuation of opioid therapy Clinicians should evaluate risk for opioid related harms and discuss risks with patients That is a huge piece, right So one of the things I treat people and we'll talk more about this in a bit with buprenorphine For opioid use disorder and oftentimes Not surprisingly there are people who have co-occurring pain. One of the things that I ask every time as a psychiatrist even Tell me about your bowel habits. Tell me about are you are you having a bowel movement on a daily basis? What is it? What is our bowel health and regimen look like? that's a very common issue for people across the board and We know that GI issues can cause so many other issues I also ask people again about what has your sex life, right? We know that opioids can reduce testosterone So we want to make sure that is that an issue What are the different risks that we're seeing from a from an everyday standpoint Never mind the addiction risk. Never mind the overdose risk. I want to know how are the harms? What damage are we doing versus what benefit are we doing and then getting into that kind of overdose risk? Component. I want to work with them on How are we reducing our risk and it's not just for them if they have small children at home if they have Large children at home who have friends who come over who use the bathroom again the medicine cabinet What do we have available to us in case somebody uses something? I am a firm believer that The opioids should be locked up in the medicine get in in the safe and the naloxone should be on everybody's coffee table If you I tell people, you know, I'll give you as many as you want you use it. I'll write more In Florida and I believe in Georgia as well. There's a standing order Most states have a standing order where you don't even need a prescription I think and I think it's different depending on where you are. If you don't have a prescription I believe insurance doesn't cover it, but I could be wrong on that but suffice it to say there are so many easy ways to get naloxone and Third party prescribing is allowed So I don't even mind if my naloxone is getting diverted to someone else because I am a firm believer Make it available everywhere to everyone because it's much better to have it and never need it then need it and not have it and That's where we come again with that overdose risk and really doing what we can to prevent that risk To be clear. I don't look at naloxone as a parachute or something that oh, well now people can you know use opioids? Happy-go-lucky and if it happens, I'll just you know, reverse it with naloxone a That's not comfortable at all for anyone and be that's the same argument They had with seatbelts in the 70s being in cars and being mandatory People still drive all sorts of different ways But we know that they're dying less from auto crashes. We know that that's been well surpassed by Opioid overdoses and The reality is It's not like you can do whatever you want just because you have naloxone. And so having it is simply a good safety belt backup Protection emergency medication, whatever we want to call it I'm a big believer in having it available You Pretty much went over all this the the big thing that I would say is really the assess the mental health is a huge aspect Has there been a change to their depression? Has there been a change in their anxiety? Are they having more traumatic? Intrusive thoughts be it through nightmares flashbacks just kind of Thinking about it more and more have they ended up having, you know, maybe they have a different substance use disorder And so have they been using? Substances have they been using? other substances Have they been trying to? Have they been trying to Use cannabis, for example to try and reduce the risk or mitigate their pain Is that working? Is it just making them? Not be able to think clearly or not functioning as well. I Yeah, I was just gonna say we have a comment question Do you consider past addictive issues family history of addictive behaviors on the same level of other risks? Or does it take a heavier weight to prescribe or not? it's a great question and We're gonna get more into detail with that But the the short answer is is yes, all of that should be taken into account We'll talk more about the specifics of that in a little bit I'm gonna assess their changing medical status as well have they Have they been more functional and therefore they've been doing extra and the exercise and so have they maybe lost some weight if they Overweight maybe their blood pressure needs to be re-evaluated. Maybe they're not moving as well They're not functioning as well. And so they've had an increase in their weight. So we need to check. How's their blood pressure? How's their diabetes? are they pre-diabetic now, of course, are they pregnant is always an important question to ask and Just looking at the differences and how these people change We don't want every single visit to focus solely on the chronic pain and that's hard to do because a lot of times since that is something that tends to be all-encompassing I'm guessing it takes a lot of time from the visit and We want to try and be mindful of the other factors again that influence that Another thing is Do they need closer monitoring? Maybe they were originally seeing you monthly and it turned out you know what they seem to be struggling with this They seem to be having more and more of a hard time. They need more support. What can we do to get them more visits? Maybe it's not with you because you might have a day that's filled with If you're doing 10 minute visits That might be a really full day where you have a very full practice and you can't necessarily fit someone in for more and more on the other hand Maybe shorter check-ins more frequently actually saves you time in the long run over that course of the month Maybe that's a way to really get sure okay We're gonna see each other twice a month Once we'll be focused on the pain and one will be focused on the other active issues that are going on Clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program data This is a big one I love Being able to check prescription monitoring program I also will tell you that in the in the system for Florida every every system is different I've noticed because the one that I have for Massachusetts was different and is different than Florida Check more than just your state if you can I'm a big fan of people travel people go to do different places Being in Florida, we got plenty of snowbirds When I was up in Massachusetts, we had plenty of people who could easily drive to other states I know that where you are. It's you know a Probably a relatively long drive to go to another state But it's not impossible and I bet you're probably working with people who do travel You want to know what are they getting and where are they getting it the prescription monitoring data? Each data point is valuable It's important to also remember that just one outlier doesn't necessarily equate to oh my god, this is this is terrible in there and they're clearly You know struggling with major addiction now But you want to be mindful and you want to rack up and continue to monitor for any aberrant behaviors Some of the things that we look for is not just okay When did they last fill in the prescriber that did it you want to check the pharmacy? Which pharmacy are they going to are they going to the same one every time? Are they moving around and going to different pharmacies? If so, why I will tell you that like when I'm prescribing stimulants for patients now Because of the shortages. Yeah, they're going to sometimes different pharmacies because they can't find it anywhere But you also want to look at when are they filling versus how much right so if you give Let's say you see the patient monthly and you give them 30-day supply Odds are you're seeing them on the same day of the week So you've given them a 30-day supply, but you're seeing them in 28 days and then you're writing a new script They can fill it generally two days early. You have another 30-day supply by the end of the year They have almost an extra month or half a month's worth That adds up that's again having that excess opioid Available and you want to be mindful of that. You want to be mindful of are they filling it a little early? Are they doing? every 26 days What how are we doing? And what are we doing? And where are we making it work versus where are we not? Recommendation 10 clinicians should consider the benefits and risks of Toxicology testing to assess for prescribed medications as well as other prescribed and non-prescribed controlled substances. I Am a big fan of urine drug screens across the board now I admit again, I'm in a different position because of What I do When I check the prescription monitoring program if I see with somebody with aberrant behaviors, well great. That's hard data to suggest Yes, this is somebody with an opioid use disorder For example, and I can now talk to them about treatment and helping them to get treatment for this illness for this condition So yeah I'm sure that many of you probably I'm guessing check the prescription monitoring program kind of like fingers crossed They really hope that I don't have anything that's a barren because I don't want to have to figure out how to have that conversation in my 10 minutes with the patient and Right. We don't want to do that Again I'm in a different boat in some ways at the same time though Hopefully after by the end of this you'll feel a little bit more comfortable that You're kind of in the same boat as well because you will now have opportunities and options of how do I help this person if? That's what happens. It no longer needs to be a sorry. You're screwed. I can't help you anymore It can be a all right. We need to shift gears because there's clearly an issue here Let's talk about what we can do again. It's that going back to that have alternatives have options available Urine drug screens same thing. I often tell people I want to know what's going on because you tell me Not because of what your urine tells me at the same time some people have a difficulty Telling people where they're struggling and saying yeah, this is what's going on Often that comes from the fear of being terminated as a patient. Nobody wants to be fired If you have in your discussions, and if you have that set up all along if you're struggling we're gonna talk about it We're gonna shift gears. It's not a punishment. It's a this is what you need so we're gonna work with you with what you need where you need it all of a sudden it shifts from being a Conversation of I'm trying to catch you. I'm playing detective or cop Versus I'm your doctor. I'm gonna help you. I want to help you figure out what's going on I Want us to know what we can do to help and how we can do that and this is serves as a conversation piece another thing that and If you do treat people who suffer from addiction Which I would encourage It's a good concrete measure of success when they first come to you and they first Are struggling and they end up having a urine drug screen that shows things all over the place Lots and lots of positives that are potentially inappropriate positives You get that urine drug screen consistently and as they're succeeding in their recovery you have more and more opportunities to say wow Look at how much black and white data we have to say you have been doing well For this period of time and it creates this positive opportunity for people to feel Heard to people for people to be able to say. Oh, I am doing well It's just like the other smart goals It gives them an opportunity to see that success and I think anytime we can see success. It's a win This is kind of what I already said, so it's just to look at for later But again, it's a key thing with a lot of this rapport is Huge having that opportunity building that conversation being able to say, you know I'm gonna hear a drug screen on you not because I don't trust you a because At least in my case and Maybe in your case as well I'm required to if the DEA ever comes knocking on the door and says, let me see your charts I have to show yeah, I get urine drug screens I check people to make sure that they're taking what they're prescribed and they're not taking what they're not prescribed and At the same time Letting people know. Yeah, sometimes it's really hard to have the conversation But you know what? We're also not playing baseball here. So I don't have a three strikes and you're out policy I have a if you're struggling We need to shift and figure out what we can do to help you because you deserve to get help If We normalize and destigmatize these things if we're always getting urine drug screens on people who are on Controlled substances and we're always having those conversations Then it's not a stigmatizing or a new conversation at the worst time when we have to have it Right. It's not the well, of course I'm getting your injections on you all along because look at what I saw you're positive for cocaine That's not helpful that doesn't really help them to feel heard respected Supported and that's really what we want to do We want to be able to support these people and help them and say what's going on Tell me about what's got what happened. Tell me about why you used cocaine Tell me what we were hoping to get Tell me what we can do to help you in a way that you're not having to do this thing That is potentially very dangerous, especially nowadays. We know that a lot of the stimulants a lot of cocaine is contaminated with fentanyl, so lots and lots of challenges there. So we need to figure out what can we do to help, and having that conversation is a huge piece to this. Recommendation 11, caution when prescribing opioid pain medication and benzodiazepines concurrently. We've seen a lot of overdoses that people have taken opioids, and they've had something else that's a CNS depressant in their system, the risks are definitely present, and we often are very quick to prescribe benzodiazepines because, just like the opioids, they work as a band-aid for a little while, until they don't, until we end up seeing that the person is struggling now with benzos as well, and we want to be mindful of what are we using them for, how are we using them, and what are the risks that we're adding to the scenario, because, for example, respiratory depression. There's a risk with opioids. There's also a risk with benzodiazepines. There's a greater risk when you combine the two, and being mindful of that, being able to have that discussion up front, and again, why are they taking benzodiazepines? What do they feel they need it for? Is this a one-off where they're flying overseas, and they feel like they need to take something just to get through the flight, versus, are they taking something every night because they need to sleep? What's preventing them from sleeping? What's really going on that they need this? When we are able to figure out what the actual problem is, we can potentially treat it a lot more effectively. Stopping the benzodiazepine, we want to be mindful of that as well. We don't want to just go ahead and say, nope, nope, period, never using benzos, and opioids together. We even saw that in, I believe, it was 2010, buprenorphine and opioids got a boxed warning, do not prescribe concurrently with benzodiazepines, and a year later, they rephrased that warning to say, instead of it being a boxed warning, it was all of a sudden a, we don't recommend combining these two, but the benzodiazepines shouldn't be a reason to not prescribe opioids to treat opioid use disorder. That was such a huge difference, because the reality is that, again, if we have that conversation, and you're getting benzodiazepines from some other source, I don't have a way to impact that, other than being able to say, let's have that discussion, let's figure out what's going on, let's see what we can do to help, because without them on board, I can't do it, and we know that when we were denying people treatment for opioid use disorder, for example, because they were taking benzodiazepines, it wasn't like they weren't using opioids, they were just using opioids that weren't prescribed, or opioids that had no supervision or oversight, or really a lot more safety risks than just us being in charge of being able to say, okay, here's what we're prescribing, this is what we're going to figure out, and then we have the conversation again. Should we take you off of the benzodiazepines? Should we taper it? Can we get away with less? Can we get away with none? What can we do to treat whatever you were trying to treat with the benzodiazepines to be more effective and more helpful overall? Recommendation 12, clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medication for opioid use disorder, is not recommended for opioid use disorder because of increased risks of resuming drug use, overdose, and overdose death. I think this is the highest level of evidence that we've seen for any of these, and the reason is, is because we have really good data for this. We know that we need to be treating opioid use disorder effectively. We need to use medications that are FDA approved to treat opioid use disorder. All of these places that claim to do just abstinence only, we're just going to, we'll get you off of everything, and then you'll go out and you'll be, as they put it, clean and free. That whole piece just reeks of stigma. That whole piece just reeks of stigma, and we really need to do what we can to adjust and to shift and help people to be successful. Part of the problem is, is for so long the medical system has been unable or unwilling to help the population struggling with substance use disorders, that they have had to go to each other to get help, and they fear the medical system. They are suspicious of the medical system, and so as we can, as we need to, we need to recreate that trust and rebuild that opportunity to have a conversation of, this is what's going on. This is what we're going to do to help. This is why we need to use this, and not just, good luck Chuck, because that doesn't help, and that doesn't last, and we know that when people stop using, they lose their tolerance very quickly, and oftentimes when they are first released into freedom, so to speak, from some of these programs, they relapse very quickly, right away, and they don't know that they shouldn't use the dose that they were using before they went into treatment, so they end up overdosing and dying, and anytime someone has died, of course, that's a lost opportunity to help that individual, and so much pain that can be avoided for them, for their families, for all involved. So, let's talk about the risk-benefit framework. We want to be judging the treatment, and this is very true. This is a very common thing where there's a difficulty, because in many places, right, we are very quick to say, oh, your metformin isn't working for your diabetes. Let's figure out what we can do to help with the diabetes. We don't say, generally, well, you've failed the metformin, you failed the metformin, so let's see what's wrong with you that the metformin didn't work. On the other hand, we do that with people who are struggling with substances, especially opioid. We say, well, you failed opioid treatment, you screwed up, so now we have to figure out how to help you, because you can't do it without, right? Lots of judgment, lots of negativity in that, and of course, it turns people off. It makes people not want to be in treatment. If we instead say, the opioid failed you, it didn't work for you, let's see how we can help you, and let's talk about what we're doing, because right now, it seems that the risks are outweighing the benefits. The harms are overlapping and overshadowing the potential positives. When we assess pain, we certainly want to be doing comorbid condition and psychosocial evaluation. We want to look and see how's their medical health, how's their mental health, what's their social life like, substance use histories, and I will encourage, and I encourage this as much as I can, if you take a substance use history in the social history section, it kind of implies that we think there's social use of drugs, which there is, but we're not really concerned about that one. So tobacco use, for example, that really belongs in the medical history, because they're social smokers, they have social issues from their smoking, drinking, same, drug use, same. I'm a big believer in putting that in the medical history area, not in the social history, because it's not for social purposes. Evaluating vitamin deficiencies is a huge area, because maybe they have other things going on. Maybe they have some neuropathy and there's a B12 issue. Physical conditioning and core strength is a huge thing to look at, as we've said, and doing a thorough history and physical assess the pain, assess the function, figure out what's going on, where is the pain, where is it worse, where is it best, when is it worse, when is it best, what things aggravate it, what things make it better, what are you using currently to treat your pain, and what have you tried in the past to treat your pain? And not just what have you tried, but a great question is, what did it do to you? Why are you not taking it now? Did it work, but it had a terrible side effect? If so, what was that side effect? Maybe it didn't work, but you were not at a dose that was reasonably high enough to say it didn't work, or maybe you didn't take it long enough, or maybe all sorts of maybe, so find out that information, because it might mean that something that you think is off the table as a trial may not actually be off the table as a trial. Of course, where is it affecting you? And this final one, which is huge, what are their expectations? Do they think that treating your pain means that the pain is at a zero, or do they believe that they can tolerate a four, and when it becomes an eight, that's when they have to stay in bed, that's when they can't do anything, and so their goal is to be ideally at a four, but not higher than a six. That might give you a good idea of what are they going for, and then we know what that means for them. We have a lot of different assessment components. Again, we have the subjective pain assessments, the socio-psychobiological assessments, what is their quality of life, what is their belief on what their suffering is, how's their sleep, how's their functioning, mental health and substance use assessments, depression, anxiety, PTSD, current and past alcohol and drug use, and remember that includes tobacco, alcohol, cannabis, all of the things, even as they become more normalized in society, we still want to know what's going on with their use. We still want to find out what are they using, how are they using, what are their goals? Again, somebody who's using marijuana with the sole purpose of sleep is different than somebody who's taking hits off of their 90% THC vape oil pen throughout the day. That's a different story. 90% THC vape oil pen throughout the day, that's a different purpose. So we have different scales that we can use. We have a numeric rating scale, visual analog scale, and the faces scale. Those are all the different micro scales where you know, it's the zero to ten. Sometimes it's the smiley face at zero versus the sad, crying, upset face at ten. These really only assess what is your pain. Now they are useful when you compare their pain from one visit to the next. If they tell you today my pain is a six, and the next time they see you, oh, my pain is a five. That's great. What's working? What's helped it decrease? Then there's also some more involved testing and assessments that can be utilized. Unfortunately, some of which are probably impractical for routine use in a primary care setting because they're just long and they're a little too comprehensive. But you can assess things like the pain scale, the enjoyment, or the pain enjoyment general activity scale. That is something that's a little bit more bite-size for people. The socio-psychobiological assessment, again, you're going to look at what is their quality of life How is their sleep? What does good health look like for them? What does it mean to have good sleep hygiene? What is bad sleep hygiene like? How do we make those changes? How do we improve? How does sleep relate to pain in the first place? There's a lot of education involved with this and again, it's one of those things where figuring out how do I get all this into a 10-minute session? Yeah, it might be over the course of multiple visits where you kind of start to focus on one particular area and say, this is what we're going to talk about today. This is what we're going to focus on so that you can get some help. But this is also the real main thing as to why we need a multimodal approach because we want everybody to be able to be all hands on deck to help this individual because some people have more time than others with the patients and we want to utilize that and others will have more experience or confidence in certain areas. For example, somebody who does therapy may have more, they're likely rather to have more ability to assess how they're doing therapeutically and what therapeutic things need to change versus somebody who is assessing their medications. What do they do to cope with their pain? Are they still fighting the idea of having chronic pain? That's a huge piece. If they're saying I still shouldn't have any pain, I don't want to have any pain and I don't think it's acceptable unless it's gone, that's something we need to work on because that may prevent them from having the functioning that they would like to have. What are the environmental stresses going on? Is it always worse at the end of the day? Is it always worse when you get home from work and it's been a rough day at the office and you come home and the kids are all all over the place in that bewitching hour where everybody is just wild and and then your pain gets worse? Noting that not only has value to be able to work on that time frame, but also provides and serves as more evidence for that person to have buy-in to say, oh, you know what? I do see that my emotional and social environment does impact my pain experience because again, that's a hard thing sometimes for people to be able to process through. So there's also assessment again of mental health and substance use, depression, anxiety, PTSD, assessing for personality disorders, which we said were huge co-occurrence with chronic pain, past or present substance use disorders. Yes, we want to go through all of them as well as the family history because this is all going to help us have a good assessment of what are our risk factors? What is going to make us say, you know what? I think maybe we should try not to use opioids or we should try to not use a controlled substance because the reality is it is making it much more difficult and the risk is a lot higher than the potential benefits. So this is an example of the PEG scale. We have what number best describes your pain on average in the past week? What number best describes how during the past week pain has interfered with your enjoyment of life? And what number best describes how during the past week pain has interfered with your general activity? What's great is this is fast, it's efficient, so it can be done in a quick office setting and then it gives you what to discuss. They might say, you know what? My pain on average has been a nine, but guess what? I've been able to enjoy a lot of things in my days, so I feel that that's also a nine. How's my general activity been? Well, my general activity's been lower than I would like. It's a five. Okay. How do those compare and how do those affect and impact each other? How is it that if your pain is so high, your enjoyment is still able to be maintained, but your activity is not? Or you might find that it's what we would think is more of the obvious, which is my pain is high, my enjoyment is low, my general activity is low. There's room to discuss and see what's working, what isn't, and how do we make a change? Maybe we see, you know what? When I'm more active, I'm enjoying things more and my pain might start as higher, but then it decreases. Then we want to stratify as best we can the risk of opioid misuse. This may be a hard one to see, but we really want to assess where does this person fit in the risk? Because everybody has a risk. I think we know that and I think we know that clearly. There's always a risk, but what are the potential factors that impact that? Openly discuss that with a patient. I don't think it's a problem to say to someone, you know, you have a strong family history of misusing of opioid use disorder, and we know that chronic pain is a risk factor for developing it. We know that prescribing opioids, which may not be beneficial, are a risk factor. Let's try something else first to decrease the risk of developing more difficulties along the way. We're going to monitor closely. Maybe we have more frequent visits. Maybe we have more urine drug testing to help. Number four. Woo! We got American Deli. So maybe we need to have a frequent callback for a pill count. Maybe we need to do smaller prescriptions more frequently. Maybe we need to have a family member or a friend or a support system who can help manage the medication because we need it, but there's a high risk, so we want to be mindful of what we're doing. So there are a number of different tools available to assess opioid use and opioid misuse risks. So we have the SOAP, the ORT, the STAR, the CISAP, the PDEQ, and there's no gold standard. There's no rigorous testing to say this one is the best choice. This one is the one that's key. A lot of this is figuring out where do they fall on the risk and matching them to the right treatment for where their needs are. And you might need to adjust. Maybe you think somebody is a low risk and it turns out that you find more and more out about their family history and they turn out to have a much higher risk. So you shift gears. So you say, you know what? Or maybe they're ending up having a lot faster of an increase than you feel comfortable with. So, okay. I think we need to see each other more often to make sure and see what else is going on. Maybe we need to double check and see what are the other specialists involved and what do they say? What does the physical therapist say? What does the psychotherapist say? So on and so forth. Where is the depression at? Options, self-management, which would be, you know, doing everything just your own exercise, your own stretching, your own this, your own that. We have the medication component. We have the exercise and other interventions, physical modalities. Again, CBT, behavioral interventions, complementary and alternative therapies, interventional therapies, interdisciplinary rehabilitation. All these are different options that are available and they all have different subsets of what we can do to help. So now we kind of find ourselves in that opioid use disorder section where we're trying to figure out do they have an opioid use disorder? Do they have chronic pain? Do they have both? Where do they fall in the mix? And you can see that unfortunately, it is really difficult to differentiate between chronic pain and opioid use disorder. Are they using larger amounts or over a longer period of time than was intended? That could be. They may have not wanted to get up to the dose they were. Persistent desire or unsuccessful efforts to cut down or control use. Yeah. Every time they try and not take that third dose they end up having a lot of pain and they sleep terribly and then they end up taking more the next day. Lots of time spent to get it. I'm sure you guys have scheduled for every 10 minute visits. And at the same time, I'm sure that sometimes visits last longer than expected and so you might have a full waiting room. So when we consider that these are individuals who are probably waiting a long time to see the doctor and then a long time to get to the pharmacy to get their medicine, there's a lot of time involved in this. Even if it's being done, in a completely legitimate way. They probably won't have cravings, at least not in the same way that we perceive cravings for in relation to opioid use disorder. So that one probably doesn't fit. But failing to fulfill major role obligations? Absolutely. That can be an issue. And is it the chronic pain or is it the treatment of the chronic pain or is it both? And giving up on things, not being able to stop using. Use despite knowledge of harm. Again, significant constipation. That is an issue. Significant difficulties knowing that even though parts of their body are being impacted in a negative way, they still use. When we switched to DSM-5, we did acknowledge that tolerance and withdrawal alone are not enough to diagnose an opioid use disorder. Because anyone who is prescribed an opioid on day one is going to have a different experience with that same opioid on day 782. So we have a second case. We have BM as a 66-year-old male who has been prescribed oxycodone 10 milligrams POQID for chronic back pain. He confides in you that he's been having worsening back pain lately and will often take the oxycodone more than prescribed. He's been averaging about 50 to 60 milligrams in total a day. What more information would you like to know about? You want to have anything they want to find out more about what's going on. We have any new activity added any new emotions felt. What does the pain feel like what causes the pain to worsen. Was there a good pain assessment. Or is he getting the additional doses. Any updated imaging absolutely. So so and I think it's wonderful that we're looking at this from the approach of rather than just saying oh he just wants to get high. We really want to evaluate what's changed what's new in this scenario and what can we do to do something different. So then what are you going to do next. Are you going to are you going to increase his dose. Are you going to do because the other thing is while you're doing the testing to figure out what's going on. We still have to figure out what are we going to do at that moment. We have someone say more treatment options. How long have you been on the original dosages. What helps when the pain worsens ice heater massage. Absolutely we want to get a better sense of what what we add what can we change and and what's great about that is it gives an opportunity to say hold on a minute before we just go and increase the opioids. Let's see what's going on that's going to that's a wonderful way again I think for the patient to feel heard because oftentimes yes people want an answer they want to know what's going on. They want help. And at the same time telling them we have a plan we're going to figure out what's going on and here's what we're going to do to help you in the meantime while we figure that out is such a valid and valuable thing it's validating for the person makes them feel heard. So we talked about the overlaps before and how a lot of this is an issue. The fear of pain can definitely impact people's use. Maybe they don't have the actual pain but they're worried that they're going to have pain so they're dosing ahead of time. Maybe it's a situation where they know they need to be available for their family and they haven't been or they need to be available and alive at their work and they haven't been the rates of aberrant drug taking behaviors astronomical when it comes to the overlap of chronic pain and use it using opioids opioid use disorders are highly prevalent among people with chronic opioid therapy about 62 percent. At the same time there is this idea of pseudo addiction which is where people need more because of tolerance because of a lack of efficacy of the opioid and then they have this look that there's drug seeking when really they're just needing more treatment and again it doesn't necessarily mean they need more opioids they just might need more treatment. So we have a continuation BAM comes back a few weeks later out of the oxycodone early he shared that he's been having to continue is continue to take more than prescribed is sporadically he's taking even more. He noted that he feels it helps him calm down when he's stressed about his finances or relationships. It also helps him to sleep. Do we think that he meets criteria for opioid use disorder I can go back to the slide by the way that has the criteria if we would like. We have someone who says, what are your feelings about the stay ahead of the pain philosophy? Well, I think that that's important. I think we do want to make sure, because playing catch up with the management of pain often leads to higher use overall. At the same time, staying ahead of the pain doesn't necessarily mean extra opioids. It could mean maybe before we go for an exercise session, we make sure to take a dose of acetaminophen or an NSAID before we start our exercise, making sure that we're pre-medicating in that way. Or it could be using, again, pacing ourselves, not just doing it all at once, making sure that we're taking rests in the middle, making sure that we're managing accordingly to expect and anticipate how we're going to not have the pain get worse. So what do we think? Do we think that this gentleman meets criteria for opioid use disorder? And how are we going to manage things from here? What are we going to do? it would seem that he might be using the opioids for more than just pain management. We have someone who says, I would talk to him about his financial stressors and trouble sleeping and see what else there is that's driving the behavior. Right, because clearly we're seeing more of a reliance and this has become a coping strategy for more than just what it's intended for, which of course increases the risk and makes some of those criteria a little bit more clear cut. So what are we gonna do to manage him? How are we gonna treat it? We're gonna find out what else he can do. We're gonna find out more information on the psychosocial stressors and we're not necessarily gonna treat psychosocial stressors psychosocial stressors with opioids. Someone says, does he need to develop some coping methods? Someone else is concerned that the dosage is increasing and he is using it for other stressors in life. Absolutely, and absolutely it's a concern. And I think sometimes this is in part, and I can't help but wanna blame the advertising a little bit, right? We used to have this commercial, right? I don't remember which one it was for, but it was depression hurts, blah, blah, blah can help. And I think the reality is when we talk about pain and we call these medicines, these opioids, painkillers, and then we address and suggest the idea that there are other kinds of pain out there, then we've now linked pain and painkillers to pain of any kind. So yeah, if I'm depressed, I can take oxycodone and that will help. And the bigger problem is that unfortunately in the beginning it does help. It does help people feel more relaxed. It does help people to not deal with their issues. It doesn't help in the longterm, that's for sure. So I see the question of, is he already involved with somebody to help with his behavioral health and his mental health? Absolutely, we wanna try and figure out all of those things. So the management, treatment is again, multimodal and many of the earlier principles still remain, but the opioid medication choice is likely to differ. We can say that it is unlawful to prescribe an opioid to someone for the treatment of opioid use disorder. That's part of the Harrison Narcotics Act. So we can't do that. But buprenorphine is an exception. And this does not mean that we cannot prescribe an opioid to someone that we're treating their pain who also happens to have an opioid use disorder. You just can't double dip with most opioids. Buprenorphine is the exception to this. So the opioid receptors that we have, I'm not gonna go over this in significant detail, but I wanted this to be up there so you guys could see that there's a lot of different receptors and they do different things. And this mu opioid receptor seems to be one of the major areas where we have concern because of, of course, that euphoria that's associated with it. But unfortunately it also has a lot of the analgesic and beneficial effects. So buprenorphine was approved by the FDA in 2002 as a schedule three medication for the treatment of opioid use disorder. And they originally came out with the data 2000 waiver which allowed this medication and other schedule three, four or five narcotic medications that were FDA approved to treat opioid use disorder to be prescribed. Again, that circumvents the Harrison Narcotics Act that was pivotal when it came to increasing access to treatment. Because up until then, the only way people get treatment with medication for their opioid use disorder was to go to an opioid treatment program and be dosed methadone daily. Not every area has a methadone program. The opioid treatment programs are not necessarily all that common, especially in smaller towns, smaller cities, and quite frankly, areas that tend to have more opioid use disorder patients tend to not have the opioid treatment programs as readily available. So is it reasonable for somebody to drive 200 miles round trip to get medication every single day? No, it's not. So buprenorphine opened up that door a little bit more. And then we have additional legislation that was passed in 2016. And since then, to further increase access, we have the allowance of mid-levels to prescribe it and the increase in the number of patients that people can prescribe buprenorphine to. And then when the Omnibus was signed into earlier this year, it eliminated the necessity for the Data 2000 Waiver in general. The idea was that, okay, people will end up starting to prescribe buprenorphine more readily. Buprenorphine works as a partial agonist at the opioid mu receptor. It has decreased risks of euphoria and respiratory depression because of that partial agonist effect. And it is nearly impossible to overdose by itself. All of the overdose reported with buprenorphine involved had other CNS depressants as well at super therapeutic levels. So it's a risk to combine with other CNS depressants, but by itself, because of that partial agonist effect, it is very difficult to have anything terrible happen. It's got a decently long half-life. And if you're just treating the withdrawal and the cravings, you can dose it once a day. If you're treating it for pain though, you do need to dose more frequently because the pain management effects are on the beginning end of the dosing. It's available in multiple formulations, mostly sublingual, buccal, and long-lasting injectable. Transdermal is not FDA approved for opioid use disorders. So that's important to remember that you cannot use it, that formulation, but the other ones you can use. It has extensive first pass metabolism. So oral is not an option. And buprenorphine itself has a terrible taste. So that's important to remember because it really is hard for people to take the medicine sometimes. It's frequently combined with naloxone to deter diversion and misuse. I'm a firm believer that give the combo, unless it's the long-lasting injectable, which doesn't come in the combo because you don't need that. So acute pain management and buprenorphine maintain patients. Initially, you can try non-opioid analgesics. You can continue on the same dose of buprenorphine, but add non-opioid analgesics. You can increase your buprenorphine dose with more frequent, small supplemental doses of sublingual buprenorphine. If somebody's having a procedure, you can increase the dose and that will help manage the pain. Or you can stop the buprenorphine and initiate a phylogenous therapy dose to effect when necessary for that short period of time. Have the conversation. If you're stopping it, how long? When are you going back? If you're increasing it, how long? When are you going back? Perioperative management. I would say, can we take another three minute break? Cause I got several office phone calls. I just want to make sure there's no emergencies and I'll be back shortly. I do apologize for that. Okay. I apologize. My apologies. Just wanted to make sure everything was okay. We didn't get a couple of patients calling back to back. So in that postoperative management period, one of the big things is that the patient is going to fear mistreatment and the provider is going to fear being deceived, which creates a, not a positive balance because both are at odds. And there is a lack of consensus in the field of, you know, how do we manage this? There's some data out there that suggests that buprenorphine can be used in the entire surgical setting. And there's evidence that in, for example, in pregnant women who are undergoing like C-section, for example, they are able to continue buprenorphine and adjust that. And it lowers the dose of morphine required or morphine equivalents required, which obviously that's a good thing. We want them to be on as little as possible. At the same time, there's not necessarily a lot of comfort from all the specialties involved and everybody needs to feel more comfortable. A lot of the times people who suffer with opioid use disorder generally do have a lower threshold for pain tolerance. And so they often do require higher doses of pain medicines. So it's very, very difficult to strike that balance. And I think having that report, having that conversation from the outset and having the expectations clearly on the table. One of the pre-op options is to make sure that everybody's on the same page, maybe seeing, okay, well, who's going to be holding onto the medicine? Who's going to be making sure? How are we going to measure and manage to make sure that you don't struggle with the use of the pain medicine? If the patient's already on the buprenorphine partial agonist or another partial agonist, you take the last dose 24 hours prior to the surgery and utilize short acting opioids as needed afterwards. And again, remember, lower threshold for pain. We also, when patients are on medications for opioid use disorder, they often have an opioid debt. So for example, somebody who's on daily methadone maintenance for their opioid use disorder, if they go inpatient and they have a procedure that requires pain management, if their normal dose of methadone daily is 100 milligrams, they need 100 milligrams just to get that level of normal. So anything, the pain management part must be above and beyond the 100 milligrams. And a lot of times we tend to forget that because obviously we're already giving a dose that makes us somewhat uncomfortable. And so the reality is, is that we must be treating the opioid debt and then the opioids in addition for the pain management component. So this is just another table to kind of figure out our options again. Are we going to continue with a full agonist and then transition to partial? What do we do about risk of relapse? How do we manage that? Where are we keeping the medication? Is a patient gonna hold the medicine? Does the patient have a loved one or a support system that can hold the medicine? Are we using extended release or are we using immediate short release? And then if we're continuing with the partial agonist, are we doing more frequent dosing? Do we increase the dose? What are we doing and what is the discussion? Also specifying the timeline, giving somebody an understanding of this is what I expect it to be. I expect you to need a higher dose of buprenorphine for four days and then to go back to the standard dose that you're on, okay, that has been laid out. That expectation is clear. Naltrexone is a full mu opioid antagonist and it was developed in 63. And FDA approved to treat opioid and alcohol use disorder. It's been around for a long time as an oral medication. And the problem with the oral medication was really the compliance with it. People would just, it wouldn't work in the bottle. So the long acting injection, which came out in 2010 allows for more consistent dosing if somebody is able to take it and willing to take it. And that can be very effective for managing opioid use disorder. Interestingly, low dose Naltrexone between one and five milligrams orally daily can help to improve pain. It's actually an effective pain management option because it seems to modulate the neuroinflammatory processes involving inflammatory cells and leads to some analgesia and anti-inflammatory effects. And this is apparently the reason why I think it is is because it's below the threshold for opioid antagonism. Suffice it to say it's working, it's got some decent results and it's a way to avoid an opioid. So we can also stratify what the pain is to know where we expect it to be and know that it might shift, but also know that it's not necessarily going to shift. If they're on Naltrexone, if it's the oral, you do need to stop it at least three days before the surgery. And if it's the extended, at least four weeks before. And if it's a major pain or an emergency, there are always other things that can be done. So if somebody is now on Naltrexone, the deterrent shouldn't be that, what if at some point they ever need surgery or they ever have an emergency? I always tell people, you should carry a medication list with you, have it dated in your wallet, because if there's an emergency situation, generally EMS will try and find out who you are. So they'll check, see if you have ID, see if you have a wallet. And if they see a dated piece of paper that says, these are the medications, that's likely to help you to be successful with then managing how we control the pain. Because if they're on extended release Naltrexone and it's an emergency, no, they're not going to necessarily give morphine because that's not necessarily going to help, but they might be able to offer alternatives and minus the might, they will be able to offer alternatives that will help with the pain management. Methadone is a full mute opioid agonist. It does have a risk of respiratory depression, especially because it's so long acting that you have to go up slowly on the dose because it can overlap on itself and you can risk overdose. And it is used either for pain management or treatment of opioid use disorder. It's very important to know that differentiation because you cannot prescribe methadone for the treatment of opioid use disorder. It's a violation of Harrison Narcotics Act and bad things happen as I'm told. It does prolong the QTC. In my experience, psychiatrists are, because we don't have many numbers, so we do really get worked up about the QTC. I think in other specialties, I've been told that they are mindful of it, but less nervous about it compared to psychiatrists because again, we just, we only get a couple of numbers. But really, unless it's a dose greater than 100, it tends to not be a major issue with prolongation of the QTC either. So other things that you might wanna do, you might wanna get a pain specialist involved. Maybe this is, you're feeling this is beyond your comfort, beyond your scope. So again, you're gonna get more in the team, a more of an approach. And this is more of just what I said before about the opioid debt. Very important to remember that because it won't be enough otherwise. And then you'll feel you're being misled and the patient will feel unheard and leads to bad things like AMA. And the other thing is that you might have a patient who refuses any kind of pain medicine. And it's important to know that severe pain is also a risk of relapse. So sometimes it's about figuring out, okay, well, we have to do something to help you because this is not a good plan either. And we've come together to figure out how are we gonna do that for you? So I wanted to make sure I left a bunch of time for questions because I know that this was a lot of that. So please ask questions. I'll go to the slide that has the, there's just a lot about ORN. And then we have a slide with the accreditation information for CMEs, which are always nice and CEUs. And I believe there's a course evaluation and claiming credit. So I'll leave that slide up for everybody to see while we talk about any questions that you might have. No one has any questions? Unless they're typing, not yet. Did I miss the recommendation and current best practices for stacking non-opioid meds for pain? So we can use a variety of different options, and we can certainly talk a little bit more about that. When... We can oftentimes use other non-opioid medications. So, for example, we can use acetaminophen and an NSAID, and you can either stagger them or even take them together. You can add... Some of the antiepileptics have pain, especially nerve pain control associated with them. There are... There are obviously risks with all of these. There's also antidepressants that have pain management benefits. So one of the big things, once you're stacking, is to be aware of the overlap of activities. So, for example, if you're using something that is like... Let's say you're using amitriptyline to help with pain, and you're using... ...topiramate. The reality is that topiramate might be a little sedating. We know that amitriptyline can tend to be rather sedating. So you want to be mindful of whether or not you're impacting the patient's functioning again, right? So we know that if you're having too much sedation or if you're having too much cognitive clouding, another thing we want to make sure of is some of the medications, there are also risks of misuse with them. So, for example, gabapentin. Gabapentin can be very helpful when it comes to neuropathic pain, but it can also be misused. And so we want to be mindful of that. We also want to bear in mind that some of these medications have mood effects. Sometimes we can get bonus benefits from that. So, for example, using duloxetine or amitriptyline with somebody with depression, that's great. That can be very helpful as well as managing the pain. Duloxetine may not be as helpful for anxiety, though. Conversely, topiramate can be beneficial for neuropathic pain in some cases, but it also might cause cognitive effects. So we want to be mindful of that aspect. So there is overlap aspects that we want to be mindful of. Does that kind of help out with – I can be more specific if we would like, but does that help as far as with the non-opioid stacking events? Yes, thank you. Perfect. Our next question is, with elderly chronic pain patients, what alternatives or non-opioid treatments have you found most effective? A lot of times it depends on the individual because in Florida, for example, we have a lot of elderly folks, and I will tell you that I see a variety of – even though they're chronologically similar ages, they are physiologically – there are some that are a much younger 70 and others that are a much older 70. So depending on where they're at and what their current level of functioning is, is going to impact what I'm going to do for them. I'll use the example again of amitriptyline. Hypotension and orthostasis are a risk with it. So if I have somebody who's frail, who I'm worried they're going to take it and then they're going to get up in the middle of the night to go to the restroom and they're going to fall, I'm going to be really careful to maybe either not use that entirely or to be able to dose it in such a way that it's not adding to that level of risk. If I have somebody who is very spry, healthy, young, 71, I'm less concerned. I also want to be mindful of how did we get there? What did we try before? So again, I've had – duloxetine is supposed to have a lot of benefit for pain management, neuropathic pain. I haven't had a lot of great success with that one with patients. So that's not necessarily going to be one of my first go-tos. I think a lot of times it really is very dependent on what we're dealing with and also other co-occurring conditions. It's important to remember that while a lot of the antiepileptics can assist with mood and anxiety in addition to pain management, some of them can actually be destabilizing to mood. So you want to be mindful. You also want to make sure that you're not going for a secondary benefit that may not be an evidence-based one. So hopefully that kind of clears up a little bit of that with the elderly patients. Mostly we want to be mindful more of the anticholinergic effects, risks of falls, hypotension, cognition. We really want to be careful about that. We have another comment question. I'm seeing more patients detoxing from Kratom. Also, what do you feel about CHC CBD products for pain? Kratom is a very interesting compound because it works both as a partial opioid agonist and at, I believe, higher doses it also has stimulant effects. A lot of times I see people when they're using it and either they're not realizing that it can be problematic. Kava is another one in that category where it can feel like, oh, this is helpful, but it turns out that it's actually rather problematic. So generally it can be concerning to have those, how do we figure out how to work with that? I will tell you I generally discourage the use of Kava or Kratom and getting into the THC CBD products. I think we have a lot more research we need to do. From what I've seen, a lot of the data that comes that we have available to discuss about the benefits of the cannabinoid products are based off of much lower THC concentrations and really a different kind of marijuana entirely. So what I would say is I think that we should still research the heck out of it because I'm sure there's really good stuff in there. There's hundreds of psychoactive compounds and different medication potential components, but I just think we need a lot more research. So I do have people who use it and people who use it who say they get benefit, but being that I'm in a situation where I'm working with people who also struggled with it, I do have that piece in mind. So yeah, I would say at this point I'm still a fan of really more research and also more regulation. They've tested a lot of the products that are found in dispensaries and found that because they're not regulated by the FDA, they're considered to be supplements, they don't always have what they say more often than not, and so it does make it more challenging. But I think that high research potential. Okay, I like this question. For patients admitted to the hospital with a history of severe opioid use disorder but unclear ability to continue suboxone or methadone upon outpatient, e.g. due to lack of ability to get to a clinic or pay for meds, et cetera, do you think it's appropriate to start these medications in the hospital? It's a great question. Yes. Yes, I do. So when I was in my fellowship, one of the places that I was at was actually at Brigham and Women's, and they happened to have a consult liaison addiction psychiatrist, and one of the things that he was able to start within the hospital's practice is he's able to initiate people on the medical floors who are either struggling with opioids or found to be struggling with opioids, and they're able to start them on medications like buprenorphine in the hospital. They would try and do their best to help people to find either to get an appointment, to leave with a setup, here's your follow-up appointment. So they had obviously a lot of staff to be able to help, and they had social workers who were able to make those phone calls because that can certainly be time-consuming and challenging. That being said, if the choice is they go back to using fentanyl, let's say, versus they at least have a month's supply of buprenorphine to figure out what they can do and how they can get into treatment, and the reality is that it's saving lives. So I'm a big fan and a big believer that it's not the ideal situation. Of course, we want people to have closed-loop follow-up, but at the same time, we want to give them an opportunity to at least have a chance for more success. Another piece of that that comes in is every state has funding for people who are uninsured, or they say underinsured, still unclear what underinsured means necessarily, but to be able to get treatment for opioid use disorder free of charge, which includes therapy, medication, visits. So there is funding available in every state. That's been one of the wonderful things that was added. I believe it was started by President Obama, and it's been one of those nice really nonpartisan things where just each presidential year, the funding, I believe, has been increased. So what's nice is that they are trying to really make this available to people. As far as concerns about diversion, the reality is yes, I get concerned with diversion. If I were to give a patient a prescription for a month's supply of buprenorphine, what are they going to do with it? At the same time, we know that the data says the risk of being misused in a way that is for the purposes of euphoria, for example, are significantly lower risk, and the reality is if I had a choice between buprenorphine flooding the streets and nonpharmaceutical fentanyl flooding the streets, we know one of them is really killing everybody. So I'm not a fan of diversion. I want to be very clear about that, but I'm also way not a fan of people dying because I can't help someone if they're not missing next to me. So, and yeah, I think that these are patients who, again, they're so used to being looked down upon, negatively treated, that unfortunately the bar for treating them well is really low, and of course we want to raise that bar. We want to get them to feel better, but it's wonderful to see the transition of somebody who is suffering and struggling and then bring them to a place where they can feel heard and respected and treated and have a functional life that they've been looking for. It's really such a wonderful opportunity to provide them with what they deserve, and we see a lot of success, and even if it's just a little bit more functional improvement, that's a win. Looks like we are out of questions, Dr. Daum. So thank you so much for your presentation today. It was wonderful. I will pass it to Santarius to see if he has any closing comments about the evaluation or about the ORN or anything like that. As far as the evaluation, could you display the slide one more time, Dr. Daum? Absolutely, absolutely. There we go. And we also have the links in the chat. Yeah, so as far as receiving your credit, you just follow these instructions, and at the end you'll be able to download your certificate. And the ORN, we can provide trainings such as these for your organization for free. Just go onto our website. Could you go to the slide before that displayed the website? That one, right? It's with the contact information, with the website and the email. Is that displaying or no? Yes, it is. So you can go onto our website and submit a technical assistance request. We will be able to provide training such as these for your organization for free. The only catch is our grant is up for renewal, so all trainings must be completed by or prior to the September 29th, 2024 date to ensure that the ORN has sufficient funds to provide these trainings for you guys. And that's all I have. Okay, well, Dr. Daum, will you be able to provide, or I guess the ORN can provide these slides that we can send out to everyone? So they'll be on the ORN's website through the repository. And the presentation and the slides will be on the Opioid Response Network website. Yes. Great. I can send a link out to that to all of you guys. And other than that, I hope you all have a great day. And again, thank you so much, Dr. Daum. This was a great presentation. Thank you very much for having me. And take care, everybody. Thank you. Bye.

acute pain

chronic pain

pain management

pharmacological treatments

non-pharmacological treatments

psychosocial contributors

biological injury

nociception

nerve fibers

opioids

NSAIDs

ketamine

cognitive-behavioral therapy

psychiatric comorbidities

individualized treatment