So with the current opioid epidemic, prescribers are getting worried that opioids are unsafe. Many people providers are actually stopping opioid medications all together. So the question for us is, is there ever a place for long-term opioid therapy? And what should we be doing for people who are already on high doses? So those are two separate questions. >> Clearly, for palliative care and hospice there doesn't seem to be any reasonable reason not to offer a person who's incredible pain opiods if we understand that this is going to be part of the end of their life, yeah. >> So in palliative care situations, usually those are time limited? >> Okay. >> What about chronic pain? Much of the opioid crisis has been fueled by the massive amounts of opioids that were prescribed for people with chronic pain. They would need daily dosing for long periods of time, if not a lifetime. This is not for treatment of opioid use disorder, but this is rather for treatment of pain. We've done a terrible job with finding alternatives to opioids. But I guess, the question then is how do we go about finding those alternatives, finding what's working? And if nothing else is working, do we think it is okay to basically put that person on a prescription for their pain for the rest of their life if it's the only thing that's working? >> And I think Ellen can speak really well to this, since this is a specific area of research for her. But I think it just comes back to a theme that we've been talking about a lot which is optimizing safety. And if I think there are systems and providers out there who've become so opiophobic that they'll just stop prescribing opioids to patients and the risk associated with that is great. Okay, from the patient perspective, there's increased rates of suicide of patients living with chronic pain who are not interfacing with care, that there have been for so long or have lost. I've had patients present to me at a methadone clinic asking to get on methadone and they don't meet criteria for an opiate use. So sort of they just have physiologic dependence on the opioids, which we know is going to happen. They haven't lost control but they don't have a provider to prescribe it to them when they did last month. And so that doesn't optimized safety in any way, so I think we have to think about from a healthcare system standpoint, how we implement structures that can optimize safety and decrease risk. And so some of that is looking at ways to decrease opioids. Some of that is looking at how do payers pay for some of these non-opioid things that we do have evidence that actually work for chronic pain? >> For some kinds. >> What's up? >> For some kinds of chronic pain. >> For some kinds of chronic pain. >> And we have to be able to draw that distinction between the kinds of pains for which it works and the kind of pains for which it doesn't work. Where it merely covers up the pain and the underlying problem is not going to get any better. >> Indeed, indeed. >> But also, I think the other thing we want to talk about is the the impact of watching a loved one in chronic pain on the family. >> Indeed. >> It tears families apart. >> Yeah. >> And that we need to find ways to avoid that as well by treating the whole family and not just the patient sometimes. >> That's a good point. >> You're next to share your thoughts. >> So Janet, you mentioned just that clinically, I do work in a chronic pain and opioid setting. And in general we think about kind of two categories if you will, of patients, people who were started on long-term opioid therapy when that was the thing, it's kind of the thing to do. That's what we were taught in medical school, right? And then other people who are in chronic pain, but I have not yet started opioid therapy. And so for that second group or the people who are not on opiates yet. There finally has been some long-term and by long-term, I mean 12 months studies that actually are putting into question the actual benefits of long-term opioid therapy. Showing that it doesn't necessarily work better than nonsteroidals or other non-opioid therapies, and that the side effects are a lot greater. So we do have long term study showing that if given the choice probably NSAIDs are better and certainly have less side effects. Now, that study was done by Dr. Krebs and is for knee osteoarthritis and back pain. But there are some people who do come to our clinic who have tried really everything that we have and their quality of life and their function is so low. And so the approach we take now is just to make sure that they really understand the risks, all the risks. And that they understand that once you go down the road of long-term opioid therapy, it is very difficult to come off. To make sure that people understand that there is a risk of developing an opiate use disorder and what that would look like if they were to develop that. And why we're going to monitor it and how we're going to make sure that that either doesn't happen or how we would treat it if that did occur. So making sure that people are consented and then also making sure that we have very functional goals. That we will continue this treatment if the benefits are outweighing the harms, but if the harms are outweighing the benefit or if the benefit is not outweighing the harms then we're going to have to rethink treatment. That's generally how we're thinking about it and kind of the same then is true for people who are already on high doses. We look at the person overall and say are the harms outweighing the benefits? Could we get equal benefits at a lower dose and minimize the harms? And then provide multimodal non-opioid therapy in conjunction with usually an opioid taper or minimizing of harm. Some kind of regimen to minimize harm and really support the person in a full multimodal treatment plan. I think a major take-home message that you've mentioned though, is that for people who are on high doses, do not just stop their opiates. That's when people are dying and just like you, they're coming into our clinic too for that reason. They got their opiates last month and all of a sudden they're being told I can't do this anymore, I can't give you this medication. >> Yeah, and I wanted to highlight the point listening to you talk into professionalism is so key here, right? So what you're describing, multimodal programs and Shannon's Clinic that has physical therapy embedded in it and pharmacy embedded in it and talking about risk benefits. It's really hard as a single primary care provider to have that conversation with a patient. And have them leave the room with you both feeling like that was a successful conversation in 15 minutes. And I really do think that just as we've talked about interprofessionalism in addiction treatment and collaborative care models being so beneficial to everybody feeling like the treatment program is really creating benefit. I think when we're talking about these complex chronic conditions in terms of mental health conditions, chronic pain, things that often times go hand-in-hand with addiction. Having an interprofessional team not only helps our own well-being as providers, but certainly helps the patient really understand that the message is uniform. >> And I think the conversation that you're having at your clinic is one that didn't occur five years ago, the risks of going on this medication. >> That's right. >> And the benefits versus the harm, and you hear from a lot of patients where I never knew I was going to get to this place, I didn't realize that was going to happen. I have no pain, but I didn't realize I was going to up my dose, up my dose and have less benefit from that. So I think that's part the education and informing our patients of this is the risk, especially if you've exhausted every other option. >> But this is go up and up, but they don't, they do plateau at some point. >> Yes, yeah, true. >> So you just have to remind patients that we'll get to an effective dose, if we have to increase it, we'll increase it. And we'll monitor you, you're our patient for the long term. >> Right. >> Yeah, I think a lot of people, the nature of opiates are typically though that we do get tolerant to them. And so many, many patients come in and what used to work is no longer working and the idea of tapering is as unthinkable, it's incredibly scary. And so people end up feeling very stuck, this is a medication that worked, it's not working anymore, I'm not functioning, but I can't stop either. And it's a very scary place for a lot of our patients. I think bringing a lot of empathy and trying to understand where they are and let them know that as a healthcare team we're going to back you up and we're going to support you.
