- Well, good morning everybody. My name's Paul.
Wanna thank a lot of people. We got the PowerPoint up yet?
- Well, okey-dokey.
But first, welcome. Thank you all very much for being here.
Wanna thank the University of Nevada School of Medicine
and the ECHO program, especially Chris and Troy
for all the work you do behind the scenes
to make this come together.
And then I have Dr. Patterson and Dr. Lewandowski
with me, both experts in the field.
Dr. Patterson has his own practice specializing in
pain management and dealing with chronic pain patients.
And Dr. Lewandowski has been a psychologist
for over 35 years who specializes also in chronic pain.
I am a substance use counselor licensed
in multiple states and this is what I do.
A lot of times with pain and with opioids and
all of the other medications that
come along with this situation.
Who do we have in the audience today?
Can you please introduce yourself?
Let's start with
- [Technician] I'll start with Becky Bailey.
- Becky Bailey.
- Hi, my name's Becky Bailey.
I am with Nevada Rural Hospital Partners.
- [Paul] Nice to have you Becky.
- [Becky] Thank you.
- [Technician] And then is it Dr. Voltar.
- [Dr. Voltar] Yeah, hi. I'm a geriatric fellow at UNR.
- Well, hello! Welcome, good morning!
- [Dr. Voltar] Thank you.
- [Technician] And Candy Copeland?
- [Candy] Hi. I'm a UNR student and I'm a nurse practitioner.
- [Technician] Great, thanks for joining us.
- That was a nurse practitioner?
- [Technician] Yeah.
- Okay. - Good. Good, good, good.
- [Technician] And Justin Heath?
- [Justin] Hi.
- Hi, Justin.
- [Justin] Hi, I'm here in Fallon, Nevada. Family medicine.
- Thank you.
- Dr. Chrysler?
- [Dr. Chrysler] Yeah, I'm just an old-timer.
(laughing) new. Unfortunately, doesn't seem to be too new.
(laughing) - Thank you, Dr. Chrysler.
- [Technician] Alright, Dr. Cole?
- [Dr. Cole] Hi, Barry Cole.
A semi-retired neuropsychiatrist and pain educator.
- Wonderful. Thank you, Dr. Cole.
- [Technician] Tyson Deprey?
- [Tyson] Yeah, I'm a physician assistant out
in Lovelock and just really enjoy these ECHOs.
- Okay, good to have you.
- [Technician] And I believe we have
Dr. Christensen out in Ely.
I don't think we have audio for him today, though.
- Oh, hello, Ely.
- [Technician] Hello, Dr. Christensen.
- Okay, are there any cases you'd like to present?
Does anybody have any outstanding, complicated
cases or anything that comes to mind that you'd like to uh,
to get some input with?
Okay, let's keep this interactive.
If something does come up,
just raise your hand or type it in.
Troy will get our attention and we'll all jump on it
and try to give the optimal advice or care possible.
One of the things that really stands out
about ECHO is that you don't have to do this stuff alone.
A lot of the time when somebody has chronic pain issues,
they have an awful lot of things that are going on.
And if you're a physician and you only get to see the person
for a limited amount of time, the other specialists
that are on your team can spend an hour with that
person and really dive down into getting to the core issues that come
along with chronic pain.
And so, right now, if you have any staffing issues or
anything that is a concern,
utilize the power of this group
so that you're not alone and you can
provide that optimal care by sharing
everybody's experience.
Okay, so with that being said, on with the show.
Okay, so Oxy To Heroin - How Did We Get Here?
Look at this, it's 2017. We're already in November.
I was just talking to Chris about how fast
this year has flown by.
We're already here in November and then
I'm starting to think how did we get from medications to heroin?
And something really resonated with me.
I heard that this is a sad time in our history.
And it boils down to social isolation
and that made me start thinking about
what are we doing, what are the movements
that are going on, what is happening in
the country and how,
really my focus a lot of times is,
trying to educate not only older people, but really
trying to get to people talking to adolescents.
Because whenever I look at an adolescent,
they have a cell phone.
And whenever they'regetting their information,
they're getting it in little sound bites.
And when I'm looking at addiction,
try taking a phone away from an adolescent.
(laughing) That's the behavior that comes along with addiction
and then I'm wondering who's raising our kids and then
why is society going this way.
So, when I'm putting all this stuff together,
I was talking to Dr. Lewandowski about this before,
we have so many things to cover in the last 20 years
that brought us to this place in time.
And one of the things that's really important is
medications, opioids, are not to be demonized.
These are great medications and proven really effective
for acute pain. And the vast majority of your patients will follow your lead,
your directions. So, we have to be really careful, especially with the verbiage
that we use with the medications
and the regimen that you put patients on.
So, we're gonna review overdose deaths in the
United States, examine the physiological, psychological
opioid use dependence and discuss treatment
and hopefully we can get through this.
If we can't, this is part of a two-part series,
we'll be here again in another couple of weeks
and we'll take it from wherever we leave off today.
When we're looking at the epidemic of drug overdoses,
this started in 2003, you can see this.
Of course my heart goes to that little red dot
where Nevada is, straight up from San Diego,
if you can see that, there we go,
and we were already in there.
You can see how this epidemic for drug overdose deaths,
these are deaths, ripples across the United States
and it gets bigger every year throughout the country.
The important thing to notice with this is
alcohol-related deaths are not going down.
Cocaine-related aren't going down.
These are just new things that are being introduced or new
movements that are taking over.
Here we go with drugs involved in US overdose deaths
in 2000 through 2016 and so when we're looking at this,
open up the slide a little bit more there Troy.
Look at the 64,000 drug overdose deaths.
That's a lot. That's 2016.
Sharpest increase is related to fentanyl
and fentanyl analogues, that's the synthetics
that you're seeing a lot of.
Course, methadone, meth, cocaine,
natural and semi-synthetic opioids, heroine,
and synthetic opioids, this is important to
recognize because at this point it's considered an
epidemic and now we're getting the attention from
the government and the powers that
be to jump into prescribing,
not recommendations, but requirements.
So we look at 64,000 deaths.
We hear these stats all the time
and they're almost mind-numbing.
So, how do we put 64,000 drug overdose deaths into perspective?
Well, let's take 64,000.
Then we have 8,760 hours a year.
Just divide it.
So by the time we get through this hour,
there's gonna be 7 deaths from overdoses,
which is the equivalent of a 737 jet crashing every day.
Now if a plane falls out of the sky once a year or so,
that's a big deal. - Big news. Yeah.
- Yeah, but if we do that every day?
That's where we are folks.
This is more deaths than auto accidents and
gun shot wounds combined.
So, let's follow the prescriptions.
The amount of opioids prescribed per person
varied widely among counties.
These are the counties in the country.
Let's go to home. There we go.
And you can see that's black
and then we'll bring it back, there we go.
So, there we are.
So we're taking the national perspective
and then we're bringing it back home.
Now, a couple of you remember that I
was at the hospital in ICU the other, about three weeks ago
ago with one of my good friends who's girlfriend gave
me a call and said there's something wrong
with this person. Come over, you have to try to take care of him. So I arrive at his
house and he had his fibula operated on.
Well, when you're younger, a lot of times you just wrap
that thing up and stop weight-bearing
you know, take care of it, so.
But, he went to a surgeon, the surgeon
does what surgeons do, he operated on it.
I mean, you go to get your oil changed,
you're gonna get your oil changed, right?
So, he goes in, has the surgery on the fibula,
he's 76-years-old, if the doctor says to do something
and his girlfriend's the same age, the doctor says
to do something, you do it, right?
There's no questions. It's follow everything exactly by the instructions.
So, these are the post-operative medication instructions.
We'll go through 'em real quick and just highlight
some areas that really resonated
with what got him into this situation.
So patients are typically provided medications prior
to surgery so they may be filled ahead of time.
The prescription will expire in less
than two weeks under DEA rules.
Please fill them and store them safely at home.
Okay, so when an older person sees DEA and
it's gonna expire in less than two weeks,
that says get your stuff now.
So they run to the pharmacy,
they fill that thing up. Further instructions may be given.
Generally patients receive a block from
an anesthesiologist, that's the next paragraph.
So then it explains you have two medications,
both of which are double-strength.
Now this is somebody who's never had an
opioid in their life and he's getting a double-strength ten milligrams.
Now the ten mil, when you're looking at a Percocet,
that comes with 325 acetaminophen,
that's the combination package.
So you also get a medication for nausea
but you've got Norco as a back-up to the Percocet.
So patients starting with the stronger medication
and switch to lesser pain medication in a few days.
- I find that interesting that, you know, if you
really look at converting hydrocodone to oxycodone,
oxycodone is not that much stronger.
They're almost a one to one equivalent
and so I find that interesting that
they're accounting here and this
is one being a lot stronger than the other, but
if you look at it, you know,
in a morphine milligram equivalent, there's not much difference.
- Thank you, that's an excellent point.
When we're looking at the body, whether it's oxy
like Dr. Patterson's talking about, the similarities here
for the power in strength or heroine,
the receptors don't recognize the difference.
They're receiving the chemical and
they're going to act accordingly.
So, when we're looking at oxy,
oxy's about two times more powerful than morphine.
Heroine's about four times more powerful than morphine.
So let's keep that in mind because they all
break down really quickly.
You have longer acting ones like methadone,
that's a longer acting,
but then you also have to wonder
if they're using anything else including the methadone.
So, here's the regimen that my dear friend is on.
Set the hydrocodone aside, okay,
and don't mix with the oxycodone.
On the evening of your surgery, take a whole Zofran
30 minutes before bed and half an oxy at bedtime.
Three hours later, take half an oxy.
So they go to bed at ten.
So girlfriend, one, "Wake up honey,
"you have to take your oxy."
"Okay, I'll take it cause it say's it, right there."
Three hours later, six hours after you've started,
take an oxy with a whole Zofran.
Three hours later, one, two, three,
four, buzzer goes off, they had their alarm clock set,
"Wake up honey, you have to take your pills." "Okay, dear."
Okay, continue this routine until the pain starts.
Cause the whole idea is to keep him ahead of the pain
at which time you will increase to a whole OxyContin
and this is somebody who's naive to opioids.
You will increase,
you will increase to a whole oxycodone
every three hours while
you continue the whole Zofran every six hours.
Then it goes into if your surgery's after noon,
then at the bottom, if you're having issues
with oxycodone such as nausea,
itching, too sedated, et cetera, you can switch to the
hydrocodone at any time.
Never says stop.
Never says discontinue.
Never has an exit strategy or what success looks like.
It never has a timeframe,
it just says you're gonna keep on doing this until it's done.
Most patients believe that hydrocodone
is about 25% less strong but others prefer it to oxy.
Don't start your medications and do no get behind once
the pain starts.
There's no gray area, there's no options here.
You'll be a lot more comfortable if you
schedule doses and stay ahead, which they did.
So, when I get to his house,
I didn't recognize this person.
He was a great blob.
He was sweating.
His eyes were rolling back. He couldn't form his sentence.
We need to get this guy to the emergency room.
The emergency room doctor said we were one,
maybe two pills away from an overdose situation.
What happens when they're older and we talked about this
at another ECHO program,
was see, acetaminophen is what's closing down the liver and then that
impacts the kidneys. So you have the constipation from the opioid
and the liver's being closed down by the acetaminophen.
You also have dehydration.
You have a toxic environment being created.
Now this is, he was in the ICU for three days.
This hospital stay was for five days total.
He says he's back to normal mentally,
but that kind of assault took a big hit on his psyche.
And he's a guy with a lot of swagger,
but it really impacted him emotionally, as well as physically,
because he almost overdosed.
And this is not the kind of guy who's
living under a bridge with a needle in his arm.
This is the kind of thing that we have to look at
when we're looking at somebody who has opioid dependence.
Now, when we're looking at addiction,
you might wanna avoid that word,
try and look at dependence.
and psychological.
A person really doesn't have a choice.
If they had a choice, they wouldn't be addicted or dependent.
They don't want to be held hostage by this.
But you can see by somebody who's following this by the book
can really get into trouble.
Now I talked to the physician's been talked
to and so they're switching up their words but this is something that
you want to be careful about when you
are prescribing and sending somebody
off with these narcotics. Any questions?
- I got a comment.
It's interesting, a lot of the chronic pain patients
that I see will come to my clinic and we gotta remember that those
statistics that Paul was showing earlier are unintentional overdoses.
These patients weren't trying to kill themselves.
And a lot of times, I'll see patients who come
to me that I believe they're on a very unsafe regimen, you know?
They'll be on soma, a pain medication and
then a benzodiazepine and then a lot of
times I'll tell them like, "Look, this is an unsafe regimen.
"We need to get you off your benzodiazepine.
"You know, let's talk to someone immediately.
"I'll give you a different muscle relaxant."
And then we talk after those, if they're on an
unsafe morphine milligram equivalent (mumbling),
a lot of times a patient will look at me like
I'm crazy and say, "Doc, I've been on
this for ten years and my body
"is used to it and an overdose isn't gonna happen to me."
Well, I can tell you in two or three different
cases where patients have been referred to me
after they've had an overdose for being on
that type of regimen for 15 years.
And what ends up happening,
is it's a chemical balance in your body.
As we get older, you're exactly right,
our kidneys and our livers don't work as well,
two, we're probably having more medications
added on by our physicians
to treat underlying issues because it's only natural
that as we get older we have cholesterol,
blood pressure or other disease processes ongoing.
And so even though you were on those medications
previously adding other medications may inhibit
or compete with the enzymes that break
down these medications.
And then lastly, I've seen cases where a
patient ends up with a simple UTI, urinary tract infection,
and I get a phone call saying, "Hey, what are you
prescribing your patient as (mumbling)
Or came through the hospital, is in the ICU
and they overdosed on the pain medications.
And I'll go back and look at a patient's records and
they've been on the same medication for
two, three years. And I'm telling them,
"Look, I haven't changed their medications."
And so a lot of times what happens is, either the antibiotic
or it's the way their body reacts
to that urinary tract infection.
It can make that drug more readily available
in their system and so I try to explain this to patients, like,
"Look, you may be taking these as
prescribed and it may have been safe
"for ten years but one simple change in your
"body physiology and you may be in the ICU
"with a ventilator, on the ventilator."
- And then, like you're talking about, this
person has diabetes, too, and is overweight.
So you can see that everything is compounding.
Then when we look at the aging process between 30 and 40,
it's really not that dramatic.
But from 60 to 70, you were saying everything
ages little bit faster.
Another thing is, when you're talking about the trifecta,
the somos, the benzos,
and the painkillers, these are opioids right now.
The next big push you'll probably see
it's kind of predictable, some benzos.
It's comin'.
So how did we get here, what happened?
Okay, so quick, this hasn't just happened overnight.
We didn't just wake up and everybody's on opioids.
This has been a calculated sales strategy
for about 20 years.
Purdue financed, "Pain as the Fifth Vital Sign."
This is a brilliant marketing campaign.
It's to help marketing OxyContin.
So, they have their drug OxyContin and
they're wondering how do we market this thing?
Well, if I had one pill that will take care of pain
for 12 hours
and I create the need or the perception of
need that it's a vital sign, it's brilliant.
Now here's what happens.
For blood pressure, pulse, temperature
and respiratory rate, you absolutely need those.
Without those, you die.
For pain, they're demonizing pain
and saying you are supposed to be pain-free and it's subjective.
So you tell the doctor if you're feeling any pain.
The doctor then has the obligation, especially
if they're getting rated on Press Ganey
or any of (laughing) those surveys,
you have the obligation doctor to
make sure this person doesn't have any pain.
Okay, so put a happy face here if
the he doesn't have any pain.
This was approved by the Joint Commission
on Accreditation of Healthcare Organizations in 2000.
So 2000, we're at 2017, there you go.
Now, we have one pill.
It will take care of 12 hours of pain relief.
But we're starting to have some breakthrough pain.
This strategy brought the two doctors who were
running Purdue Pharmaceuticals
into the wealth category of the Rockefellers and the Mellons.
They said, "With breakthrough pain, you titrate up from 40 milligrams
to 80 milligrams." So, if the person's taking a 40 and they're having
breakthrough pain at hour eight,
you increase the dose to 80.
Well, we know this is not longitudinal.
We now have higher peaks and lower
troughs with the opioids that are being introduced, meaning
that there's more euphoria
and deeper withdrawals.
So now we've started that addiction cycle.
- Hello? - Hello.
- I had trouble getting to ask you a question.
If we can back up a bit?
- Yep.
- The case you presented, unless I'm missing something here,
you've gotta treat the doctor, so to speak,
not the patient. The patient you can take
care of easily enough if you get there.
So the question is, when you spoke to the doctor,
what kind of response did you get, number one,
does anybody look at the practice
trends of this physician?
Does AB 474 really gonna change practice
of this type of physician and what are the penalties?
From what I can see, in AB 474, there are no penalties.
So yeah, we can get back anybody in pain medication
and I think Barry Cole was one of the first to start it to
get people who if they're gonna be in pain treatments
by doctors they oughta know the basics,
they oughta know the rules,
they oughta know the ethics and like I said,
I'm an old-timer, I don't see what's changed.
So, Barry do you want to comment on it?
I mean is there a physician monitoring
who takes the lead?
I don't expect you guys to but I do expect
the Board of Medical Examiners, whether
it's the osteopaths or the MDs?
We ought to have a single board.
Is anybody (mumbling)
We got at least one doctor in the state legislature who smiles,
bends around, nice guy, doesn't get anything done.
Who's gonna take the lead?
Who's gonna make sure that, you know, going back,
I've been around a long time.
I had a fractured a proximal tibia.
It was insignificant.
My spiral fractured a tibia was important,
but the fibula, who the hell operates on that to
start with? (laughing)
I can laugh about it in the locker room, but you know.
I had a neighbor next door who's now in a care home,
she came wobbling out to the mailbox
and she had a little stiff and she's in her 80s at the time.
Yeah, she wakes up stiff and has some thing.
She goes to a doctor now, you can call me racist or whatever,
you know, it just happens to be
somebody from a different culture
from a different country, from a different perspective,
who gave her oxycodone to take for her pain.
I didn't know that.
I said, "Marge, what's your problem?
"You know, you can't stand up?"
I don't know. Somebody, they gave me some medicine
to take before I go to sleep.
I look at the label and I said, "Holy Christ,
"stop the damn thing."
I mean, who is monitoring the physicians?
Who's putting, who's gonna make 'em accountable?
- Dr. Cole?
- I mean the rest of this stuff that you're doing
is great and the people that goin'
into pain management should have to take a
certifying exam to show that they understand at least
what they're doing even if they
don't follow the obvious parameters of
what they should be following.
- Well, we have the,
this is why the CDC guidelines are coming
out the way they are and we have the
PMP that is supposed to be monitoring them.
We have SB 474.
Did you have anything? - Yeah, so I was gonna say,
so, I mean, the monitoring piece here,
a couple things. One, so they are,
with Bill AB 474, the PMP,
so let's say physicians prescribing more than 365 days,
I know that there's triggers in there
to red flag that physician, which then that goes to the
Nevada Board of Pharmacy which then
I think turns that over to the Nevada Board of Medicine.
So, I think there are some triggers within
AB 474 that if there's over-prescribing
or something doesn't look right, it will red-flag that physician, which
then the Board of Pharmacy
turns over to the Board of Medicine.
But you are correct, besides certain parameters,
there really isn't any way to monitor.
I think usually how they catch these things is there's a
patient complaint that goes to the Board of Medicine.
The Board of Medicine then requests records
and then they match it up versus
what the physician is doing versus what the state law is.
I think you're right. Sometimes it's just pure circumstance on how they catch
the physician. There really isn't a lot of checks and balances
moving forward with these laws.
Just puts a framework in place that they
expect you to abide by.
- I happened to speak to, inadvertently,
I wound up talking to the physician who's, for the state
who's the head of Health and Human Services.
You know what his response was?
"What, do you want me to go ahead and prosecute 'em?
"You want me to be the overseer?"
And I said, yeah, exactly. Well, he didn't like that.
And he is not gonna take that responsibility.
So the question is, who is?
I would say, you guys are obviously interested
and everybody else that does pain medicine
should be interested in getting rid of the bad apples.
So who would present, you know...
I don't think the legislators have a clue.
- Yeah, I think a lot of these bills that they're passing,
all they're doing is
deterring or trying to deter primary cares from prescribing,
which then means, you're exactly right,
a lot more referrals towards my clinic.
There's days I show up at the end of the day and
there's a stack of 20 patients sitting on my desk.
That's impossible in a month.
Some months we may get 250 referrals.
Do you think we can handle 250 new patients a month?
Not even close, even with myself, another physician
and four or five mid-levels, we may get through 65 or 70
new patients in a 30 day span.
Interesting enough, we recently had a patient referred
to us and took us two and a half weeks to get in.
That's good.
There's some times you wait six to eight weeks to
see me and the patient turned us in to their insurance
company saying that we didn't see them
fast enough and we got a letter and
complaint and had to justify why it took us two
and half weeks to see them. So, you can't
win on either side and that's what's gonna happen
here is I think more and more of these
laws are gonna deter people from prescribing,
they're gonna dump these patients which then,
what do the patients do in the meantime?
It's not their fault that they got started
on these medications that some circumstances.
They don't understand the dependency part of it
and they want to avoid the withdrawals because they
don't know what's ongoing
and they're kind of left high and dry because these
physicians are dumping them off at the curb.
- The comment before I shut up is that
you missed is you know why we have this increase in use
of opiates and all the rest it's the culture.
I mean, how can you, not one medical organized group
in Nevada stood up and said one word
when Segerblom, the lawyer senator was pushing
marijuana for recreational use.
Nobody. So how can the youth walking around
with a cell phone and everything else, take it seriously when you say don't use it,
be careful and all of that.
You can go out and buy it.
And you know, you can argue until it's blue in the face.
But it's not innocuous. It's part of the continuum.
It should never have been there.
Anybody that doesn't accept that premise,
I wonder if they should be in medical care.
It doesn't make sense to me.
You put all this together,
we have nobody taking responsibility,
taking leadership to really educate the
legislators and make it mandatory
penalty for those that don't follow.
That's tough. Ask Barry, he's pretty quiet this morning.
He's probably saying, "I've been there, done that.
"I'm tired." (laughing)
- Thank you, doctor. The thing with marijuana,
just to put it into perspective,
at least we have the FDA to regulate and CDC.
A marijuana industry is regulated in this state,
not by the FDA, not by anything medical,
though they like that name,
it's regulated by the department of taxation.
So we need to, I guess, educate them, too.
But they made three million dollars in the
state off of the 27 million that they made
in one month, I heard.
So, it's capturing that adolescent market.
think that's what you're talking about
and they're doing a fine job there.
- [Barry] Hey, this is Barry Cole.
If I may jump in,
since Len's thrown down the gauntlet as it were.
(laughing)
First of all, what you learn when you work for the
Division of, like, Mental Health/Mental Hygiene,
which is now changed names, but
the doctor that I think Len is talking about is the head of the whole
health department for the state of Nevada.
The philosophy that governs pretty much everything in the
state level is, never assume
ill-will because usually ignorance and stupidity is the explanation.
So it isn't that people are going at this
willy-nilly and for bad reasons.
What we're faced with now is none of us officially learned
to do pain management unless you were
crazy enough to ever do a pain fellowship and we are
few and far between which means the
burden of managing pain the US
is based on primary care medicine doing the lion's share of it.
So, the evaluation and mitigation strategy,
they refuse to require it unless you prescribe
a specific agent, a medication that comes
with a REMS requirement.
But in general, nobody's ever been trained in pain medicine.
We all just sort of wing it.
What we knew in the 80s and nobody wants to go back
and admit this. Mike Lewandowski,
you remember this at the Sierra Pain Institute,
pain goes down when you wean patients from opioids.
Opioids are for short-term use, they're for cancer use,
they were never intended for chronic maintenance therapy.
This whole experiment was ill-gotten.
I launched OxyContin in 1996.
I re-launched it in 2010 in the reformulation.
Some of the things that I've heard are factually not correct.
It was the VA, guy named Bob Kerns
who pushed "Pain as the 5th Vital Sign."
Yes, Purdue opportunistically funded
some of those activities about 99, 2000,
but by then the Joint Commission
had already bought in
so had the Federation of the State Medical Boards.
Many state medical boards began taking action against
physicians and we live in a complaint-driven
system where if somebody denounces you,
yeah, the Pharmacy Board gets excited,
the Nursing Board gets excited, but even back in
the year 2000, Keith McDonald was saying
Nevada's biggest problem was hydrocodone.
If you divided the number of hydrocodone dispensed
in Nevada by then the population, every Nevadan
received 43 Vicodins a year.
I never got any. I'm still upset about that.
(laughing) Somebody got my Vicodin.
And then the other issue was that when we look at
what could be done, there's so much that
could be done to correct this problem.
Nobody is willing to focus on what's happened.
It's no longer a pill problem.
It's that you've now got organized crime
has moved into this.
We're moving not to OxyContin, we're moving
to heroine, we're moving to fentanyl,
we're moving to carfentanil and all of
the solutions to get prescribers to stop prescribing
doesn't matter because I can tell you,
when I look at a urine drug screen,
if you're not, because it's always cross-contaminated
in the north with Moly MDMA and if you get it
sourced out of Las Vegas Clark County,
it'll have both Moly and a little bit of LSD contaminant.
So we can now see that the Chinese are involved,
the Mexican cartels are involved, you know,
because you can fly it in through like
a million different ways.
And that's what's happening world-wide.
Chinese making fentanyl, carfentanil.
I was over in the Philippines two years ago,
they have a big, and he now treats people with drug problems by killing them.
I don't think we want to do that in the US,
but it's sort of a fascinating problem
that back to the original statement, never assume
ill-will for what's better explained by the
ignorance and stupidity around us.
- I think you're exactly right.
I mean now, it's a what happened over early 2000s
to 2010 is there's that patient or that physician education part.
I'm sure primary cares went to conferences and they hear,
"Hey, you need to treat your patients'
pain and you need to aggressively do this."
And then you know you have the legislation and the
HCAHP scores and all that to back it up
to tell physicians to prescribe more.
Just two years ago, I know a physician that was over in Kaiser
in California and he was working
the urgent care and with this, of all the opioid crisis,
he's only prescribing opiates for the patients
who need it or deserve it.
And say a patient would come down with a sprained ankle.
He would tell them the PRICE principles,
pressure, rest, ice, compression, elevation
and maybe give them an anti-inflammatory.
Well, three months into the job,
his administrator pulls him aside and says,
"Hey, your satisfaction scores are terrible.
"You don't get a bonus this quarter."
And guess what that did?
He told me straight out, he's like,
"Everybody who comes through the urgent care now
gets a script for pain meds to go.
I've gotten a bonus every quarter since."
So there's this network that's been set up
over the last one to two decades that needs
to be broken down.
It's incentivizing physicians to do the wrong thing.
There needs to be more physician education in the other direction.
I can tell you another negative experience
I had is that a patient I caught doctor shopping.
Patient thought they needed 14 hydrocodone a day.
I mean the Tylenol in that alone is not right.
I weaned the patient down to four a day
and all of a sudden one day, I checked the,
and this was before it was mandatory to check the PNP,
I checked them twice a year.
All of sudden pull up and I see that the
patient's getting 120 pills from me
but on top of that, they're getting 120 pills from
the primary care that referred 'em over.
So I called the primary care and I'm like,
"Hey, you know, when's the last time you saw this patient?"
Turns out that they haven't even seen them in eight months.
You know what it was?
The primary care told me I wasn't doing my job.
The patient called and complained about me
and so she was calling in the hydrocodone
for her every month to make the patient happy while
she found her another provider.
(laughing) You're not doing the right thing.
You know, that's primary cares undercut me
and the primary care was telling me I didn't know
what I was doing. I offered to take that primary care to dinner to teach them
a little bit more about pain management
and they told me that they didn't have enough time and hung up on me.
- And if I could add to what Dr. Cole said,
it's interesting because in the 1980s
when we were really doing interdisciplinary pain management
care with Dr. Richard Kroening, that may recall,
people were getting better and they were getting
off the meds. So, you know, essentially
what I think we need to do today is,
my new mantra is, teach skills and reduce pills.
It's very much about developing other
ways to deal with pain than rather than
pass (microphone distortion) a pill in which he had good evidence
that what we were doing (distortion) was making a difference.
And that was in the 80s.
- Yeah, and I agree. I think nowadays,
we're in a what can you do for me now society.
Nobody wants to put the work in to get better.
Everybody thinks that they're
entitled to taking a single pill to feel better immediately.
Nobody wants to put in the work.
I mean, so I think it's not even just this movement,
but I think it's the way our
society has gotten to this point that
everybody thinks that they should have the
answer at their fingertips immediately.
- [Barry] Hey, let me just add one thing.
Richard Kroening taught all of us back in the 80s.
Richard used to say to new patients, "I have
"never cured anyone of their pain
"and I dare you to be the first."
The corollary was, don't even focus on pain in reduction,
focus on functional improvement.
So when I get a PSAT score,
if I'm even challenged to play this game,
I demand that they look at function,
not at the patient's elimination of pain
or the number of pills that I prescribe
because those are false (microphone cuts off).
- Yeah, I hear you.
- Okay, a really good note.
Let's just put it into perspective.
What slide number are we on?
- Eight, okay, remember eight cause we're gonna buzz
through a couple of these real quick.
There we go, okay, so we were talking about heroin
and fentanyl. This is a lethal dose of heroin.
That's a lethal dose of fentanyl.
Now, Dr. Cole was talking about carfentanil.
Has anybody seen two grains of salt?
That's enough to overdose me.
That's how powerful it is.
When we go back to the, and he was talking about
all of the products that are available,
if I am on the street and I need heroin or
I need a fix, and I found out there's some
really good stuff here, even though people
have overdosed on it, my thought process is,
"They can't handle it, I got this."
That's the most dangerous three words
that you can hear in my specialty.
I got this.
You're looking at somebody who's in a lot of trouble.
But you get some fentanyl that's disguised
or sold as heroin because really,
you're not able to see the ingredients.
They don't really come with the ingredient
label on the side, like how many carbs is on here,
and how much heroin's in here and all that stuff.
You're taking it, you're hearing
good stuff about it and you're finding out
that it's cheaper, you're going this way.
Then, I just want to buzz through this cause this is
where we were talking about.
Working With Patients.
If you tried to tell somebody, you know,
I'm gonna throw in benzos anyway,
cause I have somebody who I'm working with
who has been on benzos for 20 years.
He's up to three milligrams and he came
in looking for his fourth.
Because the only answer if you're doing
maintenance therapy with opioids or benzos is more.
If you're selling heroin and you want to
start up your business, where do you go?
You go to a methadone clinic.
They're lining up in the morning to pick it up.
Everybody is on it already and they're
either supplementing or they know
somebody who's gonna use it and you
could be the person who gets
them back to hooked on,
as opposed to the, titrating them down.
Cause that's a maintenance therapy.
And it works for some people.
But if you tried to tell somebody
that you're not going to provide them opioids
they're might be bad for them after they've
been on it for quite some time and they
build up their tolerance and now they're
dependent on it, there goes your
lunch break cause this is gonna take time.
And you are gonna be backed up now.
It makes a patient upset, just like we were talking,
Dr. Patterson was bringing up.
Yeah, okay, you're gonna get a complaint Press Ganey.
There goes your bonus. We were just talking about that.
Then the patient leaves and so you're out.
This is the system that is set up.
Now, if you played by the system's rules,
everybody makes money.
The insurance company, the patient might be,
they might think they're happy,
but they're not getting well.
- The other thing about the lost patient, too, is
I see this all the time that I'll have either an
abnormal drug screen or some issue
and I immediately after the patient leaves, I'll call the
primary care and say, "Hey, this
"patient had this abnormal drug screen.
"I'm gonna send it over to you."
"I'm assuming that the next place they're going
"is back to your office after me seeing them."
And I can't tell you how many times I'm
surprised that, you know,
that patient has an appointment four weeks later that when they no show
to that appointment.
And when you know, they've already no showed
but yet we've already run the PMP and I've seen
that they, even though I've called this other physician,
they've gone back to them and that physician
has continued to prescribe to them
what I called and warned them about
a month earlier and the abnormal drug screen positive
for meth or positive for that.
They go back to that primary care and the
primary care continues the party if not
personally caused it.
That's where I think we need to work together.
If I'm reaching out to you and I think there's a problem,
you probably need to back up your fellow physician.
I think a lot of times, these physicians feel
obligated that they need to redirect
that patient to another pain management doctor
and I don't even think when they refer them
to the other pain management doctor they're
up front in their records, that oh, yeah,
they were positive for meth.
Obviously there's not going to be relationship
with me in that patient but send them to
another pain management doctor with,
"Hey, they're positive for meth."
"What else can you give for them?"
or "How can you help them get off these meds?" or
redirect them. I mean, usually, I've even gone to the other
end of that where the primary care redirects
them to me, records make no mention of them
being positive for meth somewhere else
and then I get them and I say, "Oh,
it looks like you were seeing pain management before.
"What happened there?"
"Oh, we just didn't get along."
And then I request the records, I take over prescribing
that day, request the records and a month later
I find out that they're positive two months
earlier at another place.
I mean I feel like I got sabotaged at that point.
Cause now guess what?
I'm moral and ethically on the hook because
I prescribed it then 30 days earlier.
We need to work together and have each other's backs.
- That is a really good point.
Also, when you're creating your team,
when you have psychologists and substance use,
and putting your team together who can attack these issues,
you want to make sure that everybody's on
the same page and that everybody has the same philosophy.
When you start off working with patients,
this seems pretty doom and gloom
so let's just look at solutions.
I'm not just gonna leave it hanging there.
(laughing)
- That's pretty bad. Okay, see ya!
- Solutions. In the beginning,
define what success looks like and the time frame.
Set up that time frame and make sure everybody
on your team understands that for acute pain you're going,
like you break your bone, well you know what?
The bone is hurt for a reason.
The bone is hurt so that you will be easy on it.
There's a disease type that people do not feel pain.
Does anybody know what that disease is?
It's leprosy.
And with those people who feel so uncomfortable
with them, we picked them up and put them on
a colony and let them go on their merry way,
but the idea there is,
they were chewing through their mouth.
They were chewing off their tongue.
They'd run into a tree, get gangrene,
their arm would be diseased and fall off.
So pain is not a bad thing.
Pain has been part of our evolution and we needed it
to keep us, to survive.
And now we're an anti-pain,
anti-emotional or physical pain, you can't
feel anything uncomfortable which is really a
deterrent to our health.
Then we have to define what the exit strategy is.
We're gonna start you on this
and then we're gonna titrate down.
And in a couple of months you should be completely
done with this and you know what?
You broke your arm.
It's gonna suck.
You're not going to be able to sleep some nights.
You're gonna be really sore and tender.
Physical therapy is gonna be difficult.
Dr. Lewandowski's talking about,
you have to get accountable.
You have to own your own health.
You have to be part of the team and you
have to put in the effort.
So, when we're doing this effort, yeah,
that's the healing process.
And you know what that pain is?
It's telling you that your body is working
and everything's going to be alright.
Dr. Patterson has a great contract/agreement
with his patients and it details every single thing,
that there's gonna be an agreement here.
We're both gonna work together
and this is what's going to happen.
Get a substance use specialist and mental
health provider, again we can spend an
hour with the patients and our time is time-limited.
The education is important and that's just
to let people know what the pain's doing,
why they're feeling agitated,
why they're feeling depressed, why they're feeling angry.
Well, you're amygdala's starting to wake up now.
Or all of the other areas that you've knocked out in your
brain are starting to wake up.
These are things you need to be aware of
and these are things that you can expect.
So, a couple of sessions with me
and it's pretty much okay, well you know what's gonna happen
unless it's the benzos
where you can look for maybe months of withdrawal symptoms.
So, create your team approach.
Not all practitioners are created equal.
Test your practitioners that are gonna be on your team.
Test 'em for knowledge. Test 'em for their bedside manner.
Test 'em for their philosophy.
Qualified and knowledgeable are different.
(laughing)
Dr. (laughing) referring to.
Know that a team member's philosophy
can help patients take an active role in their healthcare.
Let me see if I can, oh I'm getting a wrap it up sign!
Okay, so, I'll just...
We're less than 5% of the world's population here in the United States.
We consume over 90% of the opioid supply,
95% of the hydrocodone produced.
And once we get into opioids for maintenance,
you're looking at the long-term cause there's no
ceiling for opioids, the only answer is more.
- [Barry] Hey, this is Barry Cole.
Let me just say one thing about that comment
no ceiling for opioids.
There is, it's called metabolites.
And the metabolites can cause a world of problems
that make taking any more of the identified
opioid impossible. The other thing I wanted to bring up
is don't ask so much about pain,
ask patients what would you be able to do
when your pain is adequately managed
and then make them pin down things;
walk a block, carry a grandchild,
have sex with someone, pick whatever they want.
Monitor for when they can do those things
and see them as the markers of treatment success.
- Brilliant. Thank you.
I think the other ceiling is death. (laughing)
I think that's what we've learned that there is that the
ceiling is an accidental overdose.
And we're seeing 360,000 a year as of now.
- If I could be so bold, it's skills and not pills.
(laughing)
- We will continue on with this next time.
Please bring some cases or staffing.
Thank you all very much for your comments and the education.
It's a really good session.
Appreciate everybody.
- Thank you.
- Hey, thanks for your presentation and the great discussion today.
- [Panelists] Thank you, Paul.
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