Speaker 1: You are listening to Your Practice Made Perfect, support, protection and advice for practicing medical professionals. Brought to you by SVMIC. 

Brian: Hello, welcome to our podcast. My name is Brian Fortenberry. On this episode, we are going to be discussing something that is prevalent in much of the country and certainly more so in some areas than others. It's the ongoing opioid crisis. Joining us today to discuss this and give us some incredible insight is Doctor Rett Blake. Doctor Blake, thanks for joining us. 

Dr. Blake: Thank you for having me. I appreciate the opportunity to be here. 

Brian: Doctor Blake, really before we even delve into the subject matter, tell us a little bit about yourself, about your practice, and your work in the opioid area. 

Dr. Blake: Well, I'm a pain physician. I practice out of Chattanooga, Tennessee. I've been doing primary pain, multidisciplinary practice for the past 10 years. We see a lot of different pain patients. We treat them with different medications, injections, physical therapy, and a variety of different tools to try to hopefully help people deal with some of their chronic issues. 

Brian: You speak of this multi-modality, when it comes to helping people through their pain. One of the things that, kinda to me is a big thing is this opioid crisis that we face. It's really a narcotic. Patients, sometimes they're wanting just to feel better from the pain aspect. They're becoming more aware of the issues that can creep in whenever they start using pain medicines that are narcotics. What are some of the risk of opioids that patients really need to be aware of if they're in a situation where they're going to start using those for pain medication? 

Dr. Blake: Well, opioids have a lot of different risks. That's why when we talk about the best ways to treat pain, opioids are not the first choice. They are one of many, different ways to treat pain. One of the main reasons is because of the risk. Opioids have risk of overdose and death and addiction. There are multiple different side effects that opioids can cause, as well as the potential for abuse and misuse of the medications. 

Brian: They are vast, right? I mean, there is deep risk within this. What are some of the specific risks in the, maybe the overdose area, or addiction or side effects that patients really need to be aware of? 

Dr. Blake: Well, everyone is different. Every individual is exactly that, an individual. No two people respond exactly the same way. There are a lot of different factors that make one person more or less likely to have an overdose event than another person. Age is one of those. Obviously, the older a person is, the more likely, the more susceptible they are to the effects of medications. Dose, for someone who's taking a low dose of opioid, that's less likely to cause an overdose event than someone that's taking high dose opioids. And then, there are issues of other different drugs that people can use. There are a lot of different CNS depressants out there. Some of them are fairly benign. Gabapentin is a very commonly used neuropathic pain medication that makes people more likely to have overdose events. Benzodiazepines, like Valium or Xanax, make people more likely to have overdose events, especially when they're combined with opioids, and in any different CNS depressing agent. Some of these are as simple as antidepressant medications. 

And then, there are medications like antibiotics that can affect the metabolism of other medications and cause those to increase or decrease over time. Different medication combinations can make people more likely, more susceptible to overdose. The different illnesses. Someone that has a long history is emphysema or another pulmonary or lung disease, obstructive sleep apnea, say someone that snores a lot and has some obstruction in their upper airway. That obviously puts someone at a higher risk for an overdose event. 

People that have different metabolism whether they have renal function that impairs how they get rid of a medication, or if they have liver dysfunction, that impairs how they metabolize the medication. All of those different things can affect the way a patient processes medications, and may make them susceptible to overdose. That could even change within an individual patient. 

If someone has been on a medication that they've been stable on for a long time, and then they get acute pneumonia, well now they have an additional new pulmonary problem that they didn't have a week ago, or a month ago, or a year ago, that can now make them susceptible to a dose of medication that they were previously stable on. There are a number of different factors that play into someone's risk for overdose. 

Brian: The interesting thing to me is often we hear overdose. The first thing in a lot of people's mind they go straight to is an intentional overdose, where someone is a drug addict or purposefully just trying to get a high, has taken too much, and overdosed. What I'm hearing from you is, there are so many other factors that a lot of these people that are affected by these overdoses, their intention may not at all have been to try to get high. It was just a combination or how their body is set up. Is that correct? 

Dr. Blake: Both of those are possibilities. When we look at accidental overdose deaths, they do exclude intentional suicides. They do include overdoses from people using recreational drugs, even things like heroin. Even someone that has a drug addiction, doesn't intentionally overdose. They don't die on purpose. They're just overwhelmed by the addiction that they're suffering with. 

There are a lot of people that are just taking their medication for pain, that can have not in the course of addiction, but you still have the possibility of overdose. Tom Petty is probably the classic example of that. I don't know the details of that story, but it seems that he accidentally overdosed on chronic pain medication. Now, there may be more to that story, but that does seem to be an example of that. 

Brian: Whenever you start looking at a patient that comes into your practice, it's hard to know really when they walk in the door, if they're going to be susceptible to overdose. Is that correct? 

Dr. Blake: It's very difficult. You never really know. You always try to use universal precautions and caution everyone about the risk of that and make sure that if you're going to prescribe opioids, that the patient's well aware that that's a risk. Now, there are different ways to screen that. Most overdoses occur as a result of, or in the process of addiction. There are some ways to screen for the risk of addiction. There are some ways to screen for the risk of abuse and misuse. You're right. It is difficult for physicians to identify that. 

When we look at whether or not physicians are good at screening for the potential for abuse, there's one study that says that when we just use the "eyeball" method, of, is my patient at high risk for opioid abuse, physicians were wrong about 95% of the time. Now, that was just one study. Most of the studies say that we're wrong about 50% of the time. That's not an implication of physicians not caring, or not doing what they should be doing. It's just that, that's an extraordinarily difficult task to look at a patient and identify whether someone is at high risk for abuse of an opioid or any other medication. It's a tough thing to do. There's often a lot to that story. 

Brian: There's the overdose that we've talked about, the addiction as well. We mentioned early on about side effects. What are some of the side effects that opioids can cause? Are they common? How common? What do people have to be aware of? 

Dr. Blake: The opioids have lots of side effects. Some of them are very common. Certain side effects like constipation will happen extremely commonly. Also, things like other GI side effects, just general stomach upset, as well as sedation. Again, if you take enough of medication, it will cause sedation. Now, what constitutes enough, is very different from everyone. There are also different cognitive and motor impairment that can occur from opioids. 

Opioids over the long term can change hormone levels, like testosterone. They could even over the long term cause what's usually referred to as opioid induced hyperalgesia, which means if you've been on this medication for a long time, things that would normally hurt start to hurt more because you've altered your nervous system's kind of normal response to pain. 

Brian: Wow. Those are things that you don't often think about, certainly making things more painful when you're on an opioid, you don't think about that. Is that fairly common? 

Dr. Blake: I don't think it's very common, but it certainly is possible. It's something that people need to be aware of, especially when people have been on high doses for a long period of time. It's more common the longer the opioid uses, and it's more common the higher their dose is. 

Brian: I got you. If someone is a chronic pain patient, and have been on these opioids for a longer period of time, these side effects could be more prevalent once their body has really built up the opioid is what you're saying. 

Dr. Blake: Absolutely. Yeah. 

Brian: I kinda wanna go back to addiction for a minute. I personally have known people before that have had procedures done, and the doctor prescribes them a narcotic, an opioid to help control the pain on a short period of time after the procedure. They were incredibly nervous about taking it. They worried so much about, I've never had anything like this. I don't wanna become addicted to it. What do we really need to know about that in regards to opioids as far as the addiction part? 

Dr. Blake: Certainly opioids are potentially addictive substances. That is something that we all know that they do on that risk of true addiction. When we're talking about addiction, I guess it's probably important that you understand the difference between dependence and addiction. Dependence is just if you take a substance for a long period of time and then you stop suddenly, you get withdrawal symptoms. That's not the same thing as addiction. 

Addiction is a chronic brain disease that involves multiple different central nervous system malfunctions that change the reward pathway. It's symbolized by craving the medication, a loss of control over your use of the medication, and continuing to use the medication even though it's clearly harming you. When you talk about the chances of that occurring, in chronic pain patients and people that take opioids for a long period of time, most studies the rate is about 10%. 

Although there are some studies that show that addiction can be as high as 25% in people that take opioids over long term. Most, it's around 10%. 10% is a very significant number, especially when you consider how frequently opioids are used and how often people have a broken bone or a surgery, or some other event that needs them to have acute pain medication. 

Brian: That is so interesting to hear the difference in addiction and dependency. Is there one that is more prevalent in our society than the other? 

Dr. Blake: I don't know about that. Dependence basically is, if you take enough of an opioid for a long enough period of time, the incidents of dependence is gonna be 100%. That's just going to happen, if you take enough of it. Just like nicotine. If you smoke cigarettes for a long time and then you stop, you get withdrawal symptoms. 

Brian: Right. 

Dr. Blake: Addiction is very common of course. Nicotine is the most commonly addictive substance. Alcohol is the second, and then opioids are probably right behind that. The social impact of opioids can be a lot more significant. It happens faster. Why some people get it and others don't, there are lots of different factors. There are genetic factors, there are social factors, there are environmental factors. Addiction definitely is the biopsychosocial model of how that develops and why it develops in certain people more so than others. 

Brian: Well, this is certainly a hot-topic issue around the country. It's been politicized a lot as well. Therefore the CDC and for instance even in the state we're in, the Tennessee Department of Health, have guidelines recommending screening of patients for the risk of abuse. What is abuse? How do they identify that? How is that different than what we've talked about? 

Dr. Blake: Abuse would be a warning sign for addiction, right? Abuse is different than misuse in the sense that misuse is if I prescribe you a medication for pain, and I say, "You can take up to three pills of this medication for pain, per day," and you take it four times a day, you're still taking it for pain, but three a day wasn't enough so you took it a fourth time. That's misuse of the medication. You're still taking the medication for its intended purpose, which is for analgesia, or to minimize pain. 

Abuse is very different. Instead of taking it for pain, you were taking it for it's euphoric effect. Opioids have the potential to cause euphoria in some people. They don't cause euphoria in all people. Most people, they take opioids and it makes them feel nauseated. It helps their pain, but they don't like the way it makes them feel. In some patients, they take an opioid and it makes them feel great, buzzed or high. 

People take it for the same reason that they would use any other recreational drug, whether that's marijuana or cocaine or alcohol. It can cause a euphoric effect. If you're taking a medication that was prescribed for pain, but instead you're taking it because you like the euphoria that it causes, well that's abuse as opposed to misuse. It's the reason that you're taking it. If you are abusing the medication, and you like the euphoric effect of it, then you're obviously much more likely to develop an addiction. 

Brian: That stands to reason. I'm assuming the patients that come back to you, and go, "Man, this medicine makes me feel terrible. I just can't take it. I can't function. I just don't like it." Those are a lot less likely to be the addicts versus the people that say, "Boy, I get so much done, when I'm on this medicine. It makes me feel better." Those are the patients you probably obviously have to watch out for, right?

Dr. Blake: Right. There are multiple different screening tools, where you can screen a patient for their potential risk. There are probably almost a dozen of those, whether it's the SOAPP, or the COMM, or the ORT, or the PMQ, or the DIRE, or the BRI. These are all acronyms and abbreviations for different questionnaires. For instance, if I was gonna hand out the SOAPP score, which is the Screener and Opioid Assessment for Patients with Pain, that's what the SOAPP stands for. 

They fill out this form. It gives me a number. I say, "Oh, well, this number is very low, or this number is very high." These are very useful. If you're prescribing opioids in the state of Tennessee, they are required. They're strongly recommended by the CDC. If you are prescribing opioids, you need to figure out which one of these makes the most sense into your clinical practice and use that. They're also self administered questionnaires. They are not sacrosanct. 

If the patient wants to lie on them, they can simply misrepresent the truth on a questionnaire. It's not the end all, be all of risk assessment. You have to look at the overall clinical picture, which is looking at the patient's history of opioid use. Have they been to pain clinics? Have they gotten kicked out of pain clinics? Look at the results of their urine drug screen. Look at things on the prescription drug monitoring database. Those are all parts of this puzzle that give you an idea of whether this patient is low, medium or high risk for opioid abuse. 

You can get more detailed than that if you would like to. Criminal records, history of DUIs. Obviously, the more of this kind of behavior that you have, the higher risk for opioids. Even if it's not necessarily opioid specific, if you have a history of addiction to one substance, it makes you more likely to develop an addiction to another substance. Those screening tools are very useful but they aren't the whole picture. 

Brian: This is such a complex issue. There is no simple answers. As I mentioned before, the fact that it has become such a political hot topic, and it is something that everyone seems to agree on, that there is an opioid epidemic. It is such a problem. We have all of this information. Certainly, patients are more sensitive to it now. Physicians obviously much more sensitive to it, and the implications to their practice. There's so much information out there. What do we do with all of this? How do we process all of this information in the world we live in today? 

Dr. Blake: When you're assessing whether a patient is a low, a medium, or a high risk for opioid use, if someone is a high risk patient and you're a primary care physician, and you're not in a position to provide the appropriate monitoring for opioids, you probably just don't wanna write that patient opioids at all. Maybe even if someone is a moderate risk. Maybe you don't wanna write that patient opioids at all. Maybe you wanna refer to a specialist who's more able to handle the appropriate level of monitoring. 

The higher a risk a patient is, the less likely a physician should be to prescribe them opioids, unless they have extenuating circumstances, where they have severe painful pathology, multiple back surgeries, severe trauma that has caused, again, multiple different orthopedic surgeries or other diseases that are known to cause pain. If that's the case, and you have no choice but to write opioids, you have to monitor that patient very closely. You have to see them more frequently. You have to perform more urine drug screens, you have to perform more pill counts, to make sure that that patient is not accidentally walking down that slippery slope towards addiction. 

Brian: Well, Doctor Blake, thank you so much for your time and all of this incredible information in a very crucial topic that we face today in the medical community. Thank you for joining us. 

Dr. Blake: Thank you so much for having me. It was a pleasure. 

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast. 


The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state-to-state and change over time. All names in the case have been changed to protect privacy.