Bobby Mukkamala, MD: Welcome to the American Medical Association Physician Education Podcast on the Opioid Overdose Epidemic. Through expert discussions and insights, this podcast will feature information that can help physicians of all specialties address the epidemic of opioid overdoses. Free CME is available.
I'm Dr Bobby Mukkamala, board certified otolaryngologist and a member of the American Medical Association's Board of Trustees. It's also my privilege to chair the AMA Task Force on Substance Use and Pain Care. There are many treatment options for pain management, some of which include prescribing opioids, which has gotten much attention of late, but many that do not involve prescribing opioids.
In this episode, we'll discuss available treatment options and best practices in opioid prescribing, including considerations for determining the most appropriate pain treatment approach. Joining me in this discussion is Dr Steven Stanos, a specialist in pain medicine, physical medicine and rehabilitation, and executive committee member of the American Academy of Pain Medicine. Welcome, Dr Stanos.
Steven Stanos, DO: Thanks for having me, Bobby.
Mukkamala: Glad to have you. So, Dr Stanos, can you share with our listeners a bit about your work in pain management? Tell us what you've been up to.
Stanos: So, I've been here in Seattle, I run pain services for Providence Swedish and we have a comprehensive pain clinic and includes interventional procedures, addiction medicine, medical management in pain rehabilitation, where we have our own embedded physical and occupational therapist, psychologist and relaxation therapist. So, I've been busy with that. I'm very active with the American Academy of Pain Medicine and completed an advocacy fellowship a number of years ago around interdisciplinary care. So, a lot of my interest is including trying to help to increase access for multidisciplinary or interdisciplinary care for treatment of pain.
Mukkamala: Good to know. You've been very busy. So, I'd like to start by discussing with you the range of treatment options for pain management. So, you know, looking back, opioids have been considered the mainstay in pain management.
And I recall routinely prescribing weeks of opioid treatment for postoperative pain from my training. We did it because that's what we were taught to do. And that's the way that everybody did it. Now, things have changed for the better. The 2022 CDC guidelines for prescribing opioids recommended an approach that's multimodal, including non-opioids and multidisciplinary, including non-pharmacologic options completely. So, Dr Stanos, what are some examples of the non-opioid treatment options that are available?
Stanos: Well, we have, you know, really so many options, and I think of the non-opioids being other medications, including antidepressants, muscle relaxers, there's a whole range of topical analgesics. So on the medication side, we have a lot of options.
On the non-medication side, what we describe as more restorative therapies that include not just physical therapy, but occupational therapy, exercise. Also, mind body techniques like Tai Chi and Xi Gong. And then the whole kind of traditional area which includes interventional procedures many times Fluoroscopic guided or ultrasound guided spine injections or joint injections. And you can't also forget behavioral health, and so that could include counseling, cognitive behavioral therapy, mindfulness training and a whole kind of evolving area around behavioral health.
The other part that I think that's also grown is neuromodulation, and that includes spinal cord stimulation in various other interventional procedures that patients also could potentially benefit from. The key, Bobby, I think is that it's really looking at patients and figuring out a treatment plan that is biopsychosocially based. You know, understanding the biologic issues, the psychologic issues, and the social issues.
Mukkamala: Yeah, it's such a perfect word to describe it. Biopsychosocial sort of encompasses all the different options there. So, can you share an example of a story of a patient you've worked with where a non-opioid pharmacologic treatment worked well?
Stanos: It's interesting. I think if you ask any clinician to think of a case, you quickly think of a number of cases altogether. And I'll just say in our clinic, I had a patient that just finished the program. She was here, you know, three days a week for a month, but saw our physical therapist and psychologist and relaxation therapist.
Her treatment was for chronic neck pain, but she had a myofascial pain as well. So, the muscles themselves were causing radiating pain into her head, which she was thinking was kind of a migraine, but was really coming from her neck. And she had a lot of weakness in her shoulder muscles. So, in her case, exercises to strengthen her shoulder blade muscles to keep her shoulders in a better position and condition her muscles better helped.
She had a lot of underlying kind of anxiety and stress in her life. And that also contributed to increasing her muscle pain. So, we taught her different breathing techniques that she could use throughout the day to kind of continue to keep her nervous system as quiet as possible. She did well with learning how to pace her activities.
She many times kind of would overdo her activities and that would make her pain worse. And so, we taught her some basics around cutting her activities down into parts. And in other positional things, ergonomic things she could do, in her case, was using her computer. So, various non-pharmacologic things I think helped her and really helped to get her muscle tension, her strength better, but also control her anxiety.
The other issue with that patient is her sleep was significantly impaired and her sleep and insomnia also made her muscles more sensitive to pain. So, getting her, teaching her some sleep hygiene principles, as well as some techniques she could do before she went to bed. And then we started some other medications to help sedate her a little bit so she could sleep easier also helped her.
So, I, you know, these patients are so complex, Bobby. It's always, I think, fascinating how each patient can benefit from active strengthening, behavioral interventions and then, you know, medications to help her sleep. And then education about some of the other things she was doing that probably were maladaptive and that were also contributing to the suffering she was experiencing.
So, each patient, again, has such a unique story and we have to think of the underlying, you know, pathophysiology and target our interventions that way as well.
Mukkamala: And as far as, you know, there's always barriers to doing what we think is best for our patients, right? And management of their pain is no exception. And it seems like, you know, it seems like there's a lot of them, and any doctor, and I should say probably every doctor, knows what prior authorization hurdles are like to overcome. And so, you know, can you, can you tell me about how you've managed to get over those barriers?
Stanos: I think sometimes there's a barrier that there's lack of access to a full comprehensive model.
The other institutional ones we see a lot of really include more on the insurance side. You know, many patients don't have coverage for certain procedures, or they have limited behavioral health coverage, and so that's been many times a barrier. Some of those patients, unfortunately, could have coverage, but then they have extensive co-pays, and so co-pays many times can limit that.
The third one I always think of is more the impact on the patient's life. Do they have transportation to get to therapy. Do they have internet access so we can do virtual visits? I do think insurance continues to be a problem for not just the pharmacologic management, but also non-pharmacologic management.
Another barrier, Bobby, which we sometimes don't think about is the barrier of the patient and maybe the patient's understanding of the treatment you want to offer. And so, it really takes a lot of time by the clinician to try to explain to the patient the real goals of going to physical therapy or why we're referring a patient to a behavioral health specialist. Because if you don't do that, that could be a significant barrier for the patient because they may not feel comfortable or they may have kind of unrealistic expectations about that intervention.
Mukkamala: Yep. No, great point. Exactly. I mean, we have to, it's a team-based decision making that happens there with both the physician and the patient. So that's a great point. What about the role of opioid prescriptions in that overall multimodal approach to pain treatment? How do opioids fit into a multimodal plan?
Stanos: It's definitely, I think, can be a part of opioid therapy for certain patients, and it has to kind of fit in with the other pharmacologic options.
There's definitely patients with acute pain that could benefit from opioid therapy. And then those patients that may have maybe failed other medications and opioids could be of benefit, maybe for subacute and chronic pain are also an option. But it really has to be done in a patient-centered way. You know, balancing the analgesia with improvement in function.
Versus the other side of trying to limit any potential harm for the patient, whether it be, you know, dependency, aberrant use of medications, and in some cases, you know, preventing patients developing an opioid use disorder. Those things all kind of come into that whole thought process, when we're thinking about, you know, what's the role of opioid therapy?
Mukkamala: So, let's, let's dive a little bit deeper into that and talk about opioid prescribing. So, in 2022, as we mentioned, the CDC guidelines talk about using a risk benefit assessment for opioid related decisions related to dosing rather than adhering to strict recommendations, which was the big criticism and fallout from their original recommendations. So, what does that risk benefit assessment mean and what does it look like in practice?
Stanos: I think risk assessment is so important and I always have thought that anywhere in pain medicine, anywhere in medicine, we're risk stratifying patients for any intervention. Obviously for opioid therapy, given the potential harms that they could cause, it's even more important.
So, the risk mitigation strategies can include, you know, first when assessing the patient, you know, really understanding the psychosocial issues. And so, is there a history of substance abuse, psychiatric disorders, family history of misuse of substances, pre-adolescent sexual abuse, things like that that may cause changes to the nervous system and may, in a sense, increase the risk for someone developing problems with opioid use.
Those are important. The other parts are, you know, other medications that patients may be on. Benzodiazepines, other centrally acting medications maybe risk factors. And then there's so many other, you know, medical conditions that also may be important, pulmonary disease, elderly patients that are at risk for falls.
And so, you really are looking at, you know, the medication risk factors, the social risk factors, and then all of the comorbid medical issues that a patient may have. And always remember that that assessment isn't just one time. Those things can change. And so all those, I think, have to be considered, whether it's for acute prescribing or even when you're taking over a patient that may have been on medications, you know, for many months or years.
Mukkamala: Thanks, Steven. As it relates to, you know, broadly what we're calling harm reduction, with various aspects of that, you know, from safe disposal to availability of naloxone, what are you seeing and what are you working on with your patients to reduce the consequences of opioid use?
Stanos: I really think of two really important areas. One being offering and having naloxone available. Naloxone being an antagonist or reversing agent for a patient or a family member that someone may develop a respiratory depression and overdose. And the second is education around safe disposal of unused medicines.
Mukkamala: Can you talk to us a little bit about the dosing changes or the guidelines?
Stanos: That's a great question. And like you said, in 2016 with the original guideline, there was really some misapplication of the guideline. And I remember the specific guideline was around dosing and the CDC highlighted that you really need to have caution around any dose, which still remains in the 2022 guideline.
But in 2016, it said that you can reassess benefits and risk when doses reach greater than 50 morphine equivalent and avoid increasing doses greater than 90 without carefully justifying a decision. Unfortunately, I think some groups and legislatures, as well as pharmacy benefit plans, took that the wrong way, and we saw that there were these inappropriate dose limits and cut offs that were being used and that, like you implied, led in some cases to patient harm.
So, the new recommendation, I think, really did a better job of trying to clarify opioid naive patients and what you're to do. And they actually remove those dosing thresholds or what we described as speed bumps. And then they have a different recommendation for if you take over a patient that's already on opioids.
So, for the opioid naive patients, whether it's acute pain or sub-acute pain or chronic pain, prescribe it the lowest effective dose. And really to use caution when prescribing at any dose, you're going to also need to carefully evaluate the individual benefits and risks when increasing any dosage.
And they explain the importance of avoiding increasing dosages above levels that are likely going to yield diminishing returns. And so, trying to avoid these unnecessary dose escalations. We do know that at higher doses, there is an increased risk for overdose. And so that's why we really want to try to keep dosages as low as possible.
The second part was with opioid tolerant patients or patients already on opioids. What it talks about is really reevaluating patients. If benefits outweigh the risks, you can continue opioid therapy, but try to optimize non pharmacologic interventions and techniques. Like if benefits, you know, no longer outweigh the risks, you know, you can optimize other therapies and then work to closely, gradually taper medicines. And so really being careful.
And I think what was most important was being patient-centered and, you know, not to look at strict cutoffs, but to really look at the individual patients. The final thing that I think was probably the most important was unless there's really life-threatening issues, even if a patient develops, say, opioid use disorder, you should not discontinue opioids abruptly. And what we've learned is destabilizing patients, that in itself can probably put a patient at greater risk for overdose.
Mukkamala: And this is where it kind of gets a little tricky, but how do you advise clinicians who work with patients at risk of an opioid use disorder on how to assess and treat their pain, right?
So, I'm taking out tonsils on somebody that I know is at risk of an opioid use disorder, but yet they're still going to have pain post-operatively. So, how do you work through that?
Stanos: You bring up a good point for, you know, post-operative pain management. I think having a clear discussion with the patient that this is the whatever X amount of time it is for the normal need for analgesics.
I think many times patients that may already be on opioids or they have a history of opioid use disorder, they may feel that they're going to have problems with their pain being treated. So, if they can understand what the kind of short-term goal is, I think that's really important. Giving them a small amount of pills and, you know, if it's a three or four day supply and you're expecting them to have three or four days of significant pain.
You know, I think doing those, having a good discussion with the patient about what's the clear expectation, in this case, for postoperative pain control. And also, what are the other interventions you're going to use besides the opioid?
Mukkamala: Yep. And so, yeah, it sounds like what I'm hearing is an emphasis on communication being critical between. You know, between physicians and other clinicians and our patients in those discussions, sort of looking at the CDC guidelines as guidelines, but with a lot of flexibility there, which is then modified by the results of those conversations.
Next, you know, we've covered what treatment options are available, including opioids and non-opioids, but can you talk a little bit about how you determine what the most appropriate treatment options are for an individual patient? What, what's your process of choosing that?
Stanos: That's a good question, Bobby. Unfortunately, you know, our patients come in with such different conditions. I'm in a chronic pain clinic. A lot of our patients have maybe already failed opioids or other medications. And so, I think first, really doing a good assessment and understanding is this nociceptive pain where it's maybe coming from a joint.
Is it neuropathic pain more, you know, affecting a peripheral nerve or a lumbar nerve root or cervical nerve root. Or is it what's described as nociplastic where the nervous system is sensitized like fibromyalgia? So, the assessment's going to be so important because that's going to help guide obviously kind of mechanistically how you're going to use medicines.
And so, that's probably the first part obviously a good assessment of the patient Also understanding besides just the analgesic, how is the pain affecting their mood? Is there more depression or anxiety? And how is this affecting their sleep? But really, I think setting the expectations is the key when we're starting an opioid.
Mukkamala: And do your recommendations for treatment options vary for different populations? I mean, your patient mix likely reflects the diversity of your community, and if it's anything like mine, it's not a homogenous community.
Stanos: Oh, it's, it varies significantly, and I think we talked about this even earlier. Just their medical comorbidities in themselves, you know, can be so important. Or you know, again, the psychologic factors, whether there's underlying depression, anxiety, does the patient have a lot of catastrophic thinking and, you know, from a psychological standpoint, those can all be risk factors for other problems.
Mukkamala: Yep. And where do you see opportunities to expand pain treatment options? I mean, how can we improve our treatment of patients with pain?
Stanos: Well, I think you mentioned the new 2022 guidelines from the CDC. I think they've helped to make them more patient-centered. I think where we've moved is, how can you use opioids for a select group of patients that we feel could benefit from that.
But also, how do we, as clinicians, start to really do a better job of adding the non-opioid types of interventions? But a lot of that is going to be, is going to be dependent on the physician, you know, taking a more active role and helping to be more creative. There's a lot of different apps that patients can use now that you can help guide patients for even doing self-management for depression or taking a mindfulness course.
So, it, we almost, as clinicians, I think, especially in primary care, we're, they're very busy, but there's other interventions I think they could learn to try to help provide to the patient and separate from sending them to a physical therapist or to another specialist.
So, I do think we can use technology in those ways especially with behavioral health interventions, which will help. So, I really, I think it's going and using technology the best way you can in trying to educate patients more and that takes a little bit more time. But I think then that empowers the patients.
And it helps, I think, build resilience for patients as well. A lot of times, I think we've in the past just thought of we write a prescription or give a medication and that's going to solve all the problems. And I think we've learned that that clearly is not the case. You really have to make the patient more active in the care, but we as a clinician have to do a better job of educating them and helping to kind of steer them in the right direction.
Mukkamala: Any closing thoughts or anything, reflections on what we've discussed today?
Stanos: I'm glad we were able to, you know, just kind of scratch the surface about the complexities around treating patients with pain. I do think it's important to remember that this is a biopsychosocial disease. I think the recent numbers came out, Bobby, that from health surveys from 2021, 7% of the population has high-impact chronic pain.
You know, that's pain that really affects function and their ability to work and do things and the things they love. So, it's a, it's a huge issue. And so, with that, you know, high prevalence of high impact chronic pain, how can we, you know, do a better job of you know, providing these non-pharmacologic interventions, but also helping to educate our patients.
And in the case where patients may need opioid therapy, you know, where can we continue to provide that for patients that can benefit? And then when they don't have, when they do have problems as well, you know, having access to good behavioral health, having good access to an addiction specialist that can also help you.
I think it can be very rewarding. I think a lot of times there's the misconception that these patients are challenging. Some of the most grateful people I've worked with are patients suffering with chronic pain that we've been able to give them their life back and, and they've learned to able to control their pain.
Mukkamala: Well said. Well, thanks for joining us, Dr Stanos. We really appreciate your guidance and sharing how you navigate these decisions of taking care of our patients with pain and those at risk or dealing with a substance use disorder. You know, we discussed options for management of pain in general, both opioid and non-opioid, but also non-pharmacologic.
And we dove into an assessment of how to manage opioid treatment of chronic pain and finally discuss sort of how to assess the patient as an individual in order to choose the best treatment for them. And as we physicians and other clinicians develop our thinking on how to improve the care of our patients and our communities, hopefully we will have patients getting optimal care.
So, thank you everyone for listening and we'll see you next time. Thank you for listening to the American Medical Association Physician Education Podcast on the Opioid Overdose Epidemic. Make sure you tune into other episodes in this series to learn more about opioid use, opioid use disorder, and harm reduction.
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