The Iceberg Cometh
Dr. Passik is Director, Clinical Addiction Research and Education, Millenium Laboratories Clinical Education, San Diego, California. He has over 25 years’ experience in clinical practice as a pain psychologist specializing in addiction medicine. He is also a longtime member of the PAINWeek faculty and delivered the conference Keynote Address at PAINWeek 2013. We sat down with him at PAINWeek 2014 in Las Vegas to discuss some of the lessons learned during and following the Decade of Pain Control and Research and implications for the appropriate engagement of opioid therapy in chronic noncancer pain management. Following is an edited transcript of his remarks.
The pendulum of opinion in opioid prescribing for chronic noncancer pain
The opioid pendulum has been swinging back and forth since opium was first extracted from the poppy: is this something that helps people, or is it the devil incarnate? And in our debates about the subject, it seems we just go from one extraordinarily polarized view to the other. In recent times, of course, there really has been a movement to try to treat pain more aggressively and use all the tools that we had at our disposal, including opioids, and we became much focused on the sort of liberation of opioids. For a while we were saying the clinicians treating pain needed total access and we needed to focus on eradicating pain to the detriment of how we deal with addiction. Yes, it was kind of one-sided intellectually. Now I think we’ve gone squarely in the other direction. Now, it seems the movement has been to push the pendulum back to where it was in the 1940s when even terminally ill cancer patients were thought to be susceptible to addiction. We’ve lost sight of the fact that it takes the drug in a vulnerable person at a vulnerable time to create a person who abuses, not the drug itself. Most of our solutions, unfortunately, have been extraordinarily one-sided, and so right now we have two public health crises, terribly treated chronic pain and prescription drug abuse and susceptibility to addiction.
Finding the center
I’ve been arguing for the better part of 25 years that in order to catch the pendulum in the middle, and to do that at the front lines of clinical practice, we need, in the words of Doug Gourlay, more “talented amateurs in addiction medicine.” Anyone who prescribes or is part of a team that prescribes controlled substances needs to be a talented amateur; they need to understand how to assess someone’s risk, they need to know strategies to contain the risk, and most importantly, they need to know when they’re in over their head and need not just a talented amateur but a full professional to come in and be part of the team. I don’t think we’ve created that generation of practitioners yet. And as a result, there’s a lot of bewilderment or worse about the drugs.
There are other factors that are causing us to miss the center of the swing. There are a lot of tools available to providers now. There are prescription monitoring programs, there are lot more pain psychologists, there’s a lot more awareness that people need to be assessed, there are risk stratification tools, there’s chromatographic urine drug testing that can be available in 24 hours, there’s pharmacogenetic testing that can help prescribers pick an opioid that’s likely to be safer. But in my view, we’re not getting better outcomes because we still haven’t dealt with problems in the healthcare system. We can have all the tools in the world but if we don’t give providers more time, more education, more reimbursement for the cognitive exercise that’s involved in doing the assessment, planning the treatment and not just doing it in a one-size-fits-all way for everybody, then we can’t really get the pendulum caught in the middle. A talented amateur in addiction medicine in a supportive setting will know how to do that assessment and know which patients are going to need which tools and what frequency and provide that sort of personalized and individualized [treatment] for each and every patient. Many years ago I wrote a paper about the fours As--analgesia, adverse effects, activities of daily living by which I meant a functional level, and aberrant drug related behavior, meaning the addiction related outcomes. To me, a good outcome in opioid therapy involves a good outcome in all four domains, not just your pain score going down.
Responding to opiophobia
Opiophobia has been around for thousands of years. It’s alive and well again. I think we were a little bit naïve when we first started talking about abolishing opiophobia because we made it sound like there was no risk at all. That was a bad move, and it exposed a lot of people to harm potentially because their individual risks with opioids were not assessed. Instead, we needed to say that these are drugs with risks and benefits that people need to understand. We could have educated patients and invited them to be more vocal about their own histories so that they could say I want risk management. I want my pain treated but if I lose control of these drugs that’s not going to help me either. I need to work and support my family, not die of an overdose. There’s all kinds of way in which patients could have been enfranchised if we hadn’t trivialized the risk.
Now that we’re overstating the idea that everybody is vulnerable, that opioids need to be kept away from people, the potential for the undertreatment of pain is emerging anew. I think a lot of people are going to be left out in the cold who need opioids and who would have taken them responsibly but won’t even be considered for them. So where it used to be that we were exposing a lot of people to risk and not doing justice to people with problems of addiction, now we’re getting ready to further stigmatize pain patients once again.
We did a survey with the fibromyalgia and chronic pain foundation and we looked at experiences of people going to pharmacies and getting stigmatized and not being able to get their medicines and 37% of them went home contemplating suicide. People with pain deserve better. They just deserve better than that. These are law abiding citizens, and they should not be embarrassed in front of their neighbors in the pharmacy,
Prescribers, pharmacists, and unintended consequences
There’s a history of the way in which clinicians who do pain management interact with pharmacists. In the early days docs would take umbrage if they got a call from the pharmacist [asking] “Are you sure about this prescription? Is this the amount you meant?” and so on. In a way we were slow to enfranchise pharmacists into the team in pain management and that was a mistake. Now, because of the uproar, there are pharmacists who are getting more proactive, and pharmacies not wanting to stock opioids, and sometimes it leads to stigmatization of patients again, and patients with legitimate prescriptions are having a hard time getting them filled.
But I think far and away the most important change--not one initiated by pharmacies, but which will impact peoples’ experiences in pharmacies--is the rescheduling of hydrocodone and the requirement for office visits to get a prescription. Here’s a statistic: 26 million refills of hydrocodone are done a year. If even a fraction of those refills turn into office visits--a large fraction--it’s going to overwhelm the healthcare system. In New York State the first year that benzodiazepines went on triplicate prescription, the prescribing of them went down by 57%--in one year. I was living in New York at the time, I can tell you that anxiety disorders did not go away to the tune of 57% that year. I think what we know is if you raise the hassle level doctors will look for solutions that involve less hassle, ie, alternatives to opioids and some people are going to just get cut off.
There are other unintended effects that might manifest. We know from some of our data that the bigger the first opioid prescription, the longer the person is likely to be on opioid therapy. So although the intention of the rescheduling was to decrease exposures, the effect might actually be to increase the duration of opioid exposure.
After surgery, I had oxycodone given to me in the surgery center on the first in-person visit and then was moved to hydrocodone because it could be called in and I didn’t happen to have an office visit planned that time. Imagine a world in which you have to have an office visit, and imagine I’m responding to oxycodone; what on earth would be the incentive to switch to hydrocodone in that instance? So what I’m predicting here is a possible increase in oxycodone use; we may see a spike in oxycodone prescribing, which runs counter to what I think the intent is, to try to decrease the amount of prescription drug abuse that we have.
Here is something else that’s interesting: people often mistakenly talk about how hydrocodone is the most abused drug we have. Well hydrocodone is also the most prescribed drug we have in the whole country--not the most prescribed opioid, the most prescribed drug. So yes, there is a lot of diversion and abuse of it but it’s not actually overrepresented as a function of the amount of that’s prescribed. Oxycodone, on the other hand, is actually already overrepresented as a drug of abuse given the number of prescriptions.
Heroin: Unintended consequence or behavioral coincidence?
There’s no question we’re having a resurgence of heroin in the country. Prescription opioids were widely available and the prescription drug abuse epidemic emerged. And then when prescription opioids became less available, people, some moved over to heroin.
But I don’t think we know well enough how many of the people that went from prescription opioids to heroin were ever using the opioids legitimately. I try to remind people that 85% of the addictions in the world are manifested by the age of 35. So an opioid exposure in a younger person should be taken that much more seriously, even if they have an injury that most providers would agree should be treated with opioids. I can tell you I did this for 25 years, and even in the opioid heyday, rarely was our team falling over ourselves to use opioids as first-line treatment in young people. If for no other reason than the known hormonal effects, we didn’t take a potential 40-year opioid exposure lightly, and so we looked for alternatives. And so I think there is a group of people, who are young, who got exposed in so-called acute pain management, who probably went on prescription opioids for a time, some of those people went unassessed and ran into trouble, and then when the prescription opioids dried up that might have led a subset of those people to heroin. So when I hear that so many of these heroin users now are young people, many of whom may have been using prescription opiates, it makes me wonder how many of those people were ever pain patients vs people who were stealing from grandma, borrowing from medicine cabinets, taking from friends, buying on the street. I don’t think we know that number very well.
Green Shoots: Signs of hope for effective pain practice?
I think there’s always reason for hope. There are a lot of people out there, lots of great advocacy groups out there trying to speak up for pain patients. The National Fibromyalgia & Chronic Pain Association is doing a lot of great work. I think though that the best signs of hope for the future are projects that are out there that are multifaceted and that view this as a public health problem. They don’t just approach them as law enforcement. They don’t approach it just as a clinical issue. Things like recovery high schools, where kids who have had a problem can go back to a school that’s drug-free and monitored. There are give back programs and NADDI sponsored drop boxes that they’re willing to put in police precincts. And the pinnacle in many respects is Project Lazarus because Project Lazarus did what everybody thought was impossible: they dramatically decreased opioid deaths without dramatically decreasing opioid prescribing through a very coordinated public health approach. The part of it that gets most of the attention was the naloxone that they made available, to decrease overdose deaths. But Project Lazarus also got providers to more aggressively use the prescription drug monitoring program, they taught about addiction, they taught about pain, they enfranchised the emergency room doctors. It was a multifaceted approach, exactly the approach that we need. So there’s reason for hope that there are people out there who are starting to view this as a public health problem and are coming up with sophisticated public health solutions.