Danielle: Good evening Jacksonville and happy Saturday. I’m Danielle. and welcome to the conversation with
Dr. Ali Kasraeian. As always you too can join the conversation just give us a call, 340-1045. How are you doing today Dr. Ali?
Dr. Ali: I’m good how are you?
Danielle: I am doing just fine. What do we got going on today?
Dr. Ali: Today we are talking about the new opioid laws that took effect in July and the reason I thought about this show is, we have had discussions with Dr. Brian Erikitus [inaudible] who’s an acute care trauma surgeon, who has written prolifically on this and does a lot of work in terms of both educating other physicians but also kind of being very proactive in the management of pain around acute surgical procedures, which is what we talked about before.
We had the show with Dr. Senile Joshi [inaudible], joining Dr. Erikitus and I talking about how this could potentially impact both patients and physicians and I thought the missing piece of this would be having a specialist in the management of pain to discuss the spectrum of how this could be better managed.
Is this law going to have benefit in terms of the opioid epidemic and how do you manage the patients who have chronic pain with this, and the law doesn’t effect, but the perception of how to deal with pain from both the primary care physician, the patients that are be taking care of and how pain specialists look at how to manage pain in a more comprehensive manner.
So to help me have this discussion is my dear friend Dr. Michael Green, who’s double board certified in both interventional pain medicine as well as physical medicine and rehabilitation and he actually did a fellowship in it, in interventional pain at a very, very prestigious organization at the Department of Pain Management at Temple University.
The other thing I kind of found out reading about my good friend was that we both share our degree in psychology out of college, which is kind of interesting. I don’t meet too many psych majors in the world of medicine because everyone does biologies or chemistries or the institute had a pre-med major.
So mike welcome to the show.
Michael Green: Thanks for having me.
Dr. Ali: So let me ask you, going from your degree in psychology, how did you one, decide to become a physician and how of all the specialties that exist within the realm of exposure in medical school did you decide to become a specialist in the management of pain, which a lot of us who don’t deal with that find it potentially painful specialty because you’re dealing with, I don’t mean to make light of it, but you’re dealing with people at a time where everyone else in regular approaches have tried to manage with their pain and they haven’t been successful. So a lot of times a patient that you see one, may be at the end of the ropes in terms of how they’re dealing with their pain and the frustrations that it can’t possibly be managed. So you either bring reality or hope to the discussion and hopefully a little bit of both.
Michael Green: So initially I knew I wanted to go into medicine pretty early in my educational training and to get into medical school, you have your prerequisites with your lab courses and your biologies and physics-
Dr. Ali: But not psychology.
Michael Green: Correct, but not psychology. So I sort of looked around to see what I could bring into it from a different perspective to try to round out the education in addition to those courses that were mandated that I take. So I took some introduction to psychology courses and I really liked the content.
Dr. Ali: It was my first class in college and I just thought it was the greatest.
Michael Green: Yep I agree, I agree. Then through medical school you get to do all your rotations and get exposures to different areas which led me towards physical medicine and rehabilitation. I had been an athlete in my younger days and was looking towards the idea of potentially sports medicine, looking towards the idea of rehabilitation of injured athletes or other injuries and then as I was coming down towards the final couple years of residency and looking into what I could sort of, sub-specialize in, I came along interventional pain because the residency director at my program was actually the interventional pain specialist for the hospital.
So I spent a lot of time with him and really enjoyed seeing how you could change these lives of these patients that whether acutely or chronically had been dealing with debilitating issues and then putting together a treatment plan for these people and really being able to change their day-to-day and change the ongoing effect of the debilitating issues for them.
Dr. Ali: So it’s interesting, the interest in the management of pain has gotten a lot of attention over the past few years, unfortunately stemming a lot around the opioid epidemic and some very, very publicized overdoses, people like Prince for example, were brought light to the fact that this could potentially be a very, very big problem and a much bigger problem than we estimated.
Now if you look at the statistics, 42,000 people overdose from opioids, which include heroin. Again a lot of the things that they found, about 80% of Americans who were found to use heroin reported that they had exposure to opioids that aren’t heroin, prescription medications and things of that nature, before they made their way to the more illicit version of these medications, which is heroin.
2017, so between November of 16 to November of 17, 73,000 people overdosed from opioids, so it brought light a potential problem. So when you look at this through this spectrum and you and I talk a lot about how to address this problem and how to be a little bit more proactive and smarter about how we deal with the acute pain that I deal with surgically. But when you saw this develop, both in training and now and a lot of the attention that we get now is from that, what are your thoughts in terms of people taking a little bit of personal accountability when they’re prescribed pain medication, how physicians have to interact in this realm and then lastly, some of the laws that are in place, are they reactive and too extreme that it could potentially not help things, or do we now have a solution that’s going to really wipe this problem out?
Michael Green: I think that’s a very good question and I think it’s sort of-
Dr. Ali: Thank you Michael.
Michael Green: It’s sort of multiple questions.
Dr. Ali: I try.
Michael Green: … And you do well with it. First of all, it becomes a very difficult balance to maintain, because with the way that our society and our culture is at this time is that patients feel that it is their right to have relief of their pain and their symptoms, which is why I get up and go to work every day, to make those normal tasks that they have to do to be functional a little bit more tolerable.
Coming along with that however, is a trust that has to develop between the provider and between the patient. As you mentioned and alluded to that accountability for the patient, there’s a lot that goes into that from our end to make sure that medications, once a patient’s deemed appropriate for controlled-substance management, to make sure that the medications are being taken as prescribed, to make sure that there aren’t any other dangerous drug-to-drug interactions from medications that they may be getting from other providers.
As you had mentioned as well, patients who have become accustomed to these sorts of treatments as these medications become more difficult to obtain through the legal route, they turn to things such as heroin, which unfortunately in some areas is easier to get ahold of than a prescription medication.
Dr. Ali: So some of these laws that are basically, Florida has one, Michigan has one and Tennessee now has laws in place that make it that physicians have to have a limit in terms of how much opioids are prescribed in the acute setting, meaning that someone has a surgical procedure or they break something or something happens that causes a new onset of pain. Which again if we kind of define pain, one of the things to be mindful of that definition is basically the acute setting is something that happens right away and is short term.
Chronic pain is more debilitating, longer lasting pain that’s been going on for a long, long time. So it’s very important for us to differentiate the discussions when you’re having that. Acute pain is defined as a normal predictive physiologic and time-limited response to some kind of adverse chemical, thermal or mechanical stimulus and again these are trauma, surgery and illness something of that nature.
Chronic pain’s a little bit different and the particular legal ramifications that we’re discussing, not acute pain or more chronic pain is pain associated with cancer, a terminal condition, palliative care associative pain and then traumatic injury which actually gets a injury severity score of greater than nine. So it was deemed to be a severe trauma.
So the idea with these laws is that the less opioids are out there the less opportunity for abuse there is. How do in your expertise as a pain expert, how do people go from having a limited amount of pain medications in the acute setting and then become opioid addicts then get to the point where they turn to heroin? Because for me in my brain I have a little bit of difficulty grasping with that because one, most people don’t feel very good when they take opioids, they’re not euphoric for most people, they don’t make them feel great. Some people get …