- Hello! So, I am Liz Jesse.
As I said, I am not the normal person
that is in front of you.
I'm gonna tell you a about some things
that are happening at Wednesday Nite at the Lab
in the next couple of weeks.
This Thursday, on April 4th,
we have a lecture on glass and glass blowing in modern chemistry.
And the very next day we have a special,
Thursday night edition of Thursday Nite at the Lab,
we'll call it that.
Where we are going to be introducing
a new art installation, if you haven't seen it yet,
if you go right around the corner,
there's a new exhibition called Ubiquitous.
So the lecture is gonna be on the making of Ubiquitous
and the prion research that actually inspired it.
And then, the very next day,
is kind of a really big weekend for us here on campus.
That is our large Science Expeditions science open house.
It is three days of an open campus
where researchers invite people in
to share the research that they have been doing.
So since you all obviously, you enjoy lectures,
on Friday, we're on the east end of campus,
and we're actually gonna have a lecture
at the Wisconsin Historical Society
on Using Deep Sea Robotics
to explore the Great Lakes ship wrecks.
Also Ruthanne Bessman will be at One Alumni Place
do some origami work.
And on Saturday we're gonna be in the west end of campus,
there's about 50 exploration stations
over at the Discovery Center.
Engineering Expo is also taking place on Saturday.
And then Sunday we're gonna be over in the medical campus.
Where we're gonna, and at the same time there's gonna be
trolleys that are gonna move you around on campus,
it's all free, it's open to the public,
kid friendly, so come back and join us next week as well.
But tonight we're all here,
so welcome to Wednesday Nite at the Lab.
My name is Liz Jesse and I'm a Science Outreach Specialist
at the UW-Madison Biotechnology Center.
On behalf of the Biotechnology Center,
UW-Extension and Cooperative Extension,
Wisconsin Public Television,
the Wisconsin Alumni Association
and the UW-Madison Science Alliance
I would like to thank you for coming out tonight
to Wednesday Nite at the Lab.
We do this every Wednesday night 50 times a year.
Tonight it is my extreme pleasure to introduce June Dahl.
She is a professor emerita of Neuroscience
at UW-Madison School of Medicine and Public Health.
Dr. Dahl completed her BA in chemistry
from Macalester College in St. Paul Minnesota
and she earned her doctorate
in physical chemistry from Iowa State University.
She arrived in Madison with her husband
when he joined the UW-Madison chemistry department.
In 1984 she was appointed to
the Controlled Substances Board,
Wisconsin's drug Regulatory Authority.
It was service on that board along with a bill
introduced into Congress in 1986
to make heroin available for paying treatment for the dying
that led to her focus on educational and policy issues
directed at improving the management of pain.
Tonight Dr. Dahl will provide a review
of opioids and their use and she will address
the importance of maintaining a balance
so that efforts to reduce abuse of these drugs
do not interfere with the appropriate medical use.
Ladies and gentlemen please join me in welcoming June Dahl.
[audience applauds]
- So I selected this as the title
of the comments I'm going to make to you tonight.
"The Opioid Crisis: An Historical Perspective"
and what I would like to do
is define some terms starting with the word opioid
since we're going to talk about the opioid crisis.
What are these drugs?
And I suspect all of you know what they are.
They relieve pain, they cause sedation,
they suppress cough, they cause constipation
and they include the illegal drug heroin
and also a lot of pain medicines
that are available by prescription.
None of them is available over-the-counter
at this point in time.
And they're drugs like oxycodone and hydrocodone
and codeine and morphine
and there are a whole bunch others.
One of the points I would like to make is that
some of these drugs contain other things besides opioids.
And one of them that's very commonly prescribed is Vicodin,
which is hydrocodone and acetaminophen.
And the acetaminophen is a rather dangerous drug.
If you take a lot of it you can have
severe damage to the liver.
Now that was a description of some of the opioids.
I've just put this slide in very quickly
to tell you that there are a lot of others
and you can distinguish them one from the other
by how long they last or by how they are given.
So there are short-acting drugs and long-acting drugs
and then they're ultra short acting drugs.
And the only one that's really used a lot today
in the ultra short-acting category is fentanyl,
which can be given intravenously or transmucosally.
Now when we talk about these drugs perhaps you can tell me
how long do short-acting opioids produce pain relief?
Do you know how-- - Two hours. - Two hours!
Somebody else got another number?
- Four. - Four!
Well you could both be right because how do we know
how long a drug gives pain relief?
You ask the patient.
I always tell the students that every patient
is an individual pharmacologic experiment.
So you can't just read a textbook
or a manuscript and figure out how long it lasts.
You have to ask the person.
So some people get six hours of pain relief from morphine.
But most get three to four and some may even get two.
In the long acting category
there's a whole range of durations
from eight hours to perhaps even as much as 24.
And something like fentanyl doesn't last long at all.
You have to keep giving it in order to get an effect
There also are antagonists.
And has anybody here not heard of naloxone or Narcan?
Everyone has because it's used a lot
to reverse the respiratory depressant effects
of morphine and other opioids.
And another drug in this family is naltrexone.
And you can see that there are a whole bunch of brand names there.
Again that's used for different purposes.
And then they're the new kids on the block
and these are the abuse deterrent opioid formulations.
And they've been put together to try to keep people
from abusing this class of medicines.
How well do you think they work?
Well I would say that anybody
who is determined to abuse a drug
can figure out a way to circumvent the formulations.
And so they aren't abuse proof
but that's not a surprise to you.
So that was the overview of opioids.
But what about the word crisis?
I looked that up in the dictionary.
You all probably know because you're more learned than I,
what's a crisis?
Any event that's going to lead or is expected to lead
to an unstable and dangerous situation.
And it can affect an individual or it can affect a group
or a community or a whole society.
And crises have damaging effects at various levels.
Is there a crisis involving opioids?
And what's the evidence for that crisis?
Well actually there's more than one crisis
relating to opioid analgesics.
One of them relates to overdosage and deaths.
And I've put some figures up here
but you can't really be certain about the numbers.
How many people die of overdose in a year?
It's not certain and we get various numbers.
But I want to compare the number of deaths
with the number of deaths of soldiers
who died during the Vietnam War
and also the number of persons who died of car crashes
back in 1972 when car crashes peaked in this country
and then how many people died in 1995
because of HIV/AIDS infections.
So you can see that the numbers for opioids
are very large indeed.
So in fact there's another crisis with opioids
that I want to talk about.
And that is the fact that concerns about their diversion
and abuse is leading to their underutilization
and that's leading to people experiencing unrelieved pain.
So what's pain?
It all starts with pain actually.
And we get different feelings about what pain is
depending upon the era in which we get information.
If we look at the giants of ancient Greece,
Plato and his student Aristotle.
They considered pain to be an emotional
not a sensory experience.
And pain was an independent being that invaded our bodies,
took it over.
If you've had severe pain doesn't that
sometimes feel that way to you?
Aristotle said that pain's
"like a spirit that enters through an injury".
This traditional view of pain as an external force
has been a persistent one.
Pain is often seen as an act of God or of gods
as a kind of punishment or a test of faith.
And the word pain actually comes from the Latin
that means penalty.
During the Renaissance, Descartes took a different view
and in the 1600s he refuted the idea
that pain came from the outside.
He proposed the pain was due to
an internal mechanical process,
that the body was a machine.
And pain was a disturbance within the machine.
And then we go to evolutionary theory
where pain is a way that the body defends itself.
And it reminds us to avoid the causes of pain in the future.
The intensity should be proportional
to the risk that the stimulus creates for us.
However natural selection is rarely perfect
so some things are disproportionately more painful
than the risk they pose.
And I ask you to think about the lowly paper cut.
I find those extraordinarily painful.
And think on the other hand about the real agony of gout.
I found-- probably can't see this too well--
but I found this online of course where everything is.
And I can see this incredible red swelling.
This is enormously painful.
And I like this cartoon much better.
You see this ugly little being.
I like his tail and I don't know why I think it's a male
rather than a female but this is the gout
and you can see how he's going after the joint.
And then we should consider the pain
of what some have called wounded warriors.
These are persons who are injured in conflicts.
Seriously wounded soldiers were questioned
after receiving their wounds
by Lieutenant Colonel Henry Beecher.
And these individuals had been injured
during the invasion of Anzio in Italy.
If you ask young kids about the Anzio beachhead invasion
they have no idea what you're talking about.
But I suspect you folks do.
What he found was that if he surveyed these soldiers
12 hours after their injuries that 25% of them said
they had slight pain,
32% had no pain and 3/4 of them felt so little pain
that they didn't think they needed medication.
The soldiers wounds released them
from this horrendous situation which might
ultimately threaten their whole being.
This wasn't the case with veterans of the Iraq War
and it's not the case with persons
who are injured in accidents,
industrial accidents that produce similar kinds of lesions.
Those persons are very vigorous in their demand,
I should say, I wrote pursuit here,
but it's really demand for pain relief.
And the International Association for the Study of Pain
put these concepts together very nicely
when they created a definition of pain in 1975.
They recognized the dual nature of pain
and said "it's an unpleasant
"sensory and emotional experience
"associated with actual or potential tissue damage
"or described in terms of such damage.
That certainly captures very well the kinds of reports
that we see from individuals who were injured
in various situations.
Now we need to talk because I was asked to do so,
a little bit about the history
of opioid analgesics themselves.
The history of embracing and rejecting their use.
How many times has this pendulum swung?
One, two, three, four, 10, 12?
What do you think?
Actually the swing has really been
fairly large and numerous.
And so we need to look a bit about opium history.
The earliest reference to opium growth and use
was in about 3400 BC.
That was even before I was born.
By 1300 BC the Egyptians were cultivating opium
and they named it on the basis of the capital of Egypt
at the present that time which was Thebes.
Hippocrates who is considered to be the father of medicine,
noted way back when the pain-killing properties of opium.
And around 330 BC Alexander the Great
introduced opium to Persia and India.
and then comes Paracelsus.
Any chemists in the audience know about this individual.
He is putatively the father of toxicology
and he's the person who actually compounded laudanum.
Laudanum is 10% opium and alcohol.
And that led me to ask the question is
when did alcohol come into human use?
Anybody got a guess?
10,000 years ago.
Because of course you don't have to take
the alcohol from some plant or anything like that.
It's produced when plants ferment
so it's pretty accessible if you look out for it.
Thomas Sydenham who's considered
the father of English medicine or the British Hippocrates
recognized the power of opium around 1680.
He wrote a couple of things that I think
are one statements that we ought to think about
that I really adhere to at the present time.
He said opium and I would substitute opioid analgesics
is "one of the most valued medicines in the world
"which does more honor to medicine
"than any remedy whatsoever."
He also wrote that "among the remedies
"which it has pleased God Almighty to give to man
"to relieve his sufferings none is so universal
"and efficacious as opium."
Those words are still true today.
And so in many ways these are God's gift to humanity.
What's this?
That's a poppy! Isn't that gorgeous?
That's the source of opium.
Now how do we get opium from this poppy?
Well not from grinding up the poppy leaves, not at all.
But from waiting for the plant to dry and form these pods.
And notice that wonderful drip there?
Opium comes from that juice of the poppy pods.
And people can score these pods, open them up
and the juice will run out.
Now the poppy juice contains morphine
and also contains codeine and thebaine.
And thebaine is important because it serves as
a raw material for the synthesis of other opioids.
One of the opioids that's got great attention
all of the time is heroin.
And heroin is actually diacetyl morphine
and why is it so abused?
Well because it's less bulky than morphine
and it's easier to smuggle.
What's the source of morphine today?
Where does it come from? - [Man] The juice.
- The juice, that's right!
There is drugs that cannot be synthesized
de novo in the laboratory
and opioids are one category
and cardiac glycosides constitute another category.
I'm sure it won't be long
before there are synthetic processes
to produce morphine in the laboratory.
But right now that's not the case.
So here are some structures for chemists
who love to look at structures.
And there's morphine, notice those two hydroxyl groups.
And they get acetylated
and the acetylation transforms that molecule to heroin.
Down below morphine is methadone.
You ever heard of that?
It's a long-acting orally effective drug
it could also be given parenterally.
Methadone was synthesized by a German chemist
during the Second World War
because their supply of natural opioids was cut off
and they needed a very effective medicines to treat pain.
Notice hydromorphone in the upper right-hand corner.
And that's very similar to morphine.
It is in many ways except it's more potent.
Does that mean it's more effective?
No, it just means you give less of the drug
to get the same pharmacologic effect.
And notice down in the bottom corner is the drug naloxone.
Many of you already knew what that drug was
but I told you before this is an opioid antagonist.
So you can see by simple transformation
of the structure of morphine to naloxone,
you get a compound that is an antagonist of opioid actions.
Doesn't have actions of its own.
It's just a blocker.
- [Man] Can I ask you why is that?
- Why is that? - Yeah.
- I have no idea why that is.
It has something to do with structure activity relationships
but I can't answer your question easily.
It would take me about 20 minutes.
But we can do that later. How's that?
Is it a deal? - [Man] Okay. [laughs]
- I don't think he really wants to have 20 minutes
but he asked the question.
So a little bit about opium history.
Before 1800 crude opium was widely available
in the United States and it was an ingredient
in multi drug preparations.
And of course as I've already told you
in laudanum which was 10% opium in alcohol.
And it was very valued
for its calming and soporific effects.
It was also a specific treatment for GI illnesses.
Given that opioids cause constipation
it's an interesting balance
to think about treating GI illnesses.
It was a drug that was prescribed,
well really supplied very freely by physicians
in calm teething children
and it also calmed hysterical housewives.
Now I don't know if it calmed
hysterical house husbands or not
[laughter]
but I will look into that.
- [Man] Yes, yes it does. - I've gotta find that.
- [Man] In a pill form. - In pill form!
A drug that calmed people down was very appealing
because physicians had almost
nothing to work with at that point in time.
There weren't effective agents,
there wasn't even aspirin.
So that was the good times when there was opium.
And it was freely available.
So we're talking about the history
of embracing and rejecting the use.
What happened?
What happened was that morphine use
became a booming business in the 1800's in this country.
It had been isolated from opium
by a German pharmacist in 1803.
And he named it morphia
after Morpheus the Greek god of dreams.
And manufacture of morphine salts started in 1832
and the hypodermic needle was perfected
in the middle of the century.
Wasn't this wonderful for those persons
who were serving in the Civil War?
During the 1800s there was a dramatic increase
in the consumption of morphine
and the per capita peaked in 1896.
just at the end of the century.
And then the pendulum swung back.
Reaction to the freewheeling use of the 1800s.
And in 1906 there was a Pure Food and Drug Act.
In 1914 the Harrison Act which regulated and taxed
the production, importation and distribution
not only of opiates but also of cocoa products.
And then in 1919
the Supreme Court outlawed addiction maintenance.
And then in 1937 there was what was called
the Marijuana Tax Act and marijuana was linked to
other alarming drugs such as cocaine and heroin.
So that was the era when marijuana became
really bad stuff.
And in the 20 years between 1930 and 1950
the severity of the anti-drug laws increased
and it peaked in 1956 when there was the death penalty
for the sale of heroin to minors.
And I thought about that when I heard that
Trump had recommended the death penalty
for narcotic dealers in this country.
I think that was the word that was used.
So now we look at some of the other perspectives.
And here's one about the use of medications
for controlling pain in persons who are dying of cancer.
This was published in 1941
in the Journal of American Medical Association.
Dr. Lee wrote "The use of narcotics in terminal cancer
"is to be condemned if it can possibly be avoided.
"Morphine and terminal cancer are in no way synonymous.
"Morphine usage is an unpleasant experience
"to the majority of human subjects
"because of undesirable side effects."
Wow.
"Dominate in these lists of unfortunate effects
"is addiction."
What about all those people who abuse these drugs
because they really liked them?
And then the pendulum swings again
because an emphasis came on end-of-life care
and that changed the perspective on the use of opioids.
In 1948, Dame Cicely Saunders began her work in England
and she applied the name hospice care
to specialized care of the dying.
That term actually goes back to medieval times.
It means a place to shelter weary or ill persons
who have traveled long distances.
The interesting thing was that Dr. Saunders used heroin
to treat her patients who were dying.
Remember heroin is diacetyl morphine.
It's a controversial way to give morphine.
For some reason Dame Saunders thought
that there was something special about heroin.
And it took a lot of convincing
to get her to change her mind.
In 1967 she founded St. Christopher's Hospice in London.
And then in '74 Florence Wald,
who was Dean of the School of Nursing at Yale
established the first Hospice in the United States
in Branford Connecticut.
But this was a focus really on cancer pain.
And in 1984 a bill was introduced into the Congress
to make heroin available to treat pain
in the terminally ill.
Now this bill did not become law,
but this bill stimulated my interest
in impediments to effective pain control.
That was the summer, 1984,
when our family did its Washington trip.
And the Washington Post published an editorial
strongly supportive of the heroin bill.
Well I tried to get into the paper to talk to the editors
and I didn't succeed in that.
I was told I didn't know what I was talking about.
And I tried to talk to members of Congress,
equally unsuccessfully, but I came back to Madison
and I decided we ought to do something about pain
in a way that heroin's availability couldn't possibly do.
And with that kind of desire
we established some programs here
to focus attention on cancer pain.
And it worked very well because in 1986
the World Health Organization
introduced the analgesic ladder,
gave a perspective on how to treat the pain of cancer
as it increases in intensity.
But that was also a time
when there was a lot of illegal drug use.
In the 60s there was astonishing increase
in the use of illegal drugs.
In 1970 the Controlled Substances Act was passed
and in 1973 the Drug Enforcement Administration
was established and Richard Nixon set up its purpose
which was to wage an all-out global war on the drug menace.
What did Nixon's efforts really do?
Well what they really did
was to reduce the production of opium by Turkish farmers.
And in so doing we've had
a shortage of morphine in this country,
a shortage of morphine to treat persons in pain.
Unfortunately cancer pain management,
which started so beautifully with efforts in England
and subsequently in Connecticut,
it remains a significant concern in ambulatory oncology
and I've given a reference in this slide
to a paper from 2014 that discusses the problem
and tells us that the magnitude and scope
of pain treatment inadequacy hasn't decreased substantially
in the past decades in the United States
despite the fact that there's been
a long-standing awareness of this problem.
- [Man] It's just gotten worse too.
- Just gotten worse in many ways. Good for you.
In the early 1900's nearly 900
ECOG Eastern Cooperative Oncology Group clinicians
were surveyed about paint treatment barrier.
Half of them thought their patients had good pain control
and a number of the clinicians surveyed
cited many concerns about pain assessment,
about the adverse effect of opioids,
about the reluctance that patients had
to report their pain and take their medications.
And medical oncologists today in 2018,
still identify those barriers to effective pain control.
Also it was seen long ago, 20 years ago or more,
that non-Hispanic white patients
and patients with the most obvious burden of illness
are most likely to receive adequate cancer pain management.
That shouldn't surprise us at all.
And then there's some seminal events
we need to be concerned about.
In 1986, Russ Portenoy and Kathy Foley
of Memorial Wloan-Kettering published a seminal paper
on the use of opioid analgesics
for the treatment of chronic non-cancer pain.
Remember the discussions previously had all been about
treating pain in persons who had cancer.
And then in the 1990s extended-release opioid formulations
were introduced and the one of course we've heard most about
is Oxycontin, which is extended release
or controlled release or sustained release Oxycodone.
In 1997 the pain standards from the Joint Commission
were promulgated.
Which meant that healthcare facilities
could no longer ignore pain.
And I was extraordinarily pleased to get a grant
from the Robert Wood Johnson Foundation
to work with the Joint Commission
to develop these standards.
And it's been really frustrating to read
that those standards are responsible for
our current problems with diversion and abuse of opioids.
Apparently if you don't ask anybody about pain
you won't ever have a problem because you don't have to treat.
In the early 2000s there was a rapid increase
in the prescribing of opioid analgesics
and then also an increase
in the diversion and abuse of drugs
and increased deaths from these drugs.
And sadly a lack of evidence for the efficacy of opioids
for the management of persistent,
I'm using that word instead of chronic,
persistent non-cancer pain.
What's the future?
What are the crises in pain management
that we need to be concerned about?
Well one of them I've already suggested is the case
and that is the lack of evidence for outcomes
and inadequate education of primary care providers.
And it's upon this group of providers
that the major burden of care has fallen.
There's a lack of access to multidisciplinary care.
Well, why is that so darn important?
Because we have to use the diversity of methods
and drugs in order to manage pain effectively.
There is an inadequate reimbursement
for behavioral and physical therapies.
And then as I said already there's an uncertainty
about the value of opioid treatment
for chronic non-cancer pain.
And a big problem with managing chronic pain,
persistent pain in persons who have
a history of substance use disorders
as you probably know we no longer talk about
drug abuse and drug abusers,
we talk about substance use disorder
and persons with substance use disorders.
The vocabulary has changed in the last three years.
And again repetitive, repetitive uncertainty
about the risk and indeed the meaning of addiction.
So what are the benefits and what are the risks
associated with opioid treatment?
If you're interested in reading anything
I'd be happy to email you papers that provide some insights
into the answers to these questions.
The effectiveness of opioids for chronic pain
has not been adequately studied,
but a very astute clinician wrote in a paper
in the New England Journal of Medicine in 2016,
that "The absence of evidence is not evidence of absence."
So when he wrote about the use of opioids
for the treatment of chronic pain,
he really was emphasizing the necessity
of achieving the right balance.
How do you balance effective treatment of pain
against any potential for diversion and abuse?
And he rightly wrote about the right balance
being achieved through education.
There's some very interesting quotes
that I will share with you as quickly as possible.
One of the things was shared by Chris Pasero,
who was a nurse practitioner and advocate,
a medical director of surgery said to a director of nursing
at a prestigious hospital in California,
"Please inform all bedside nursing personnel
"to refrain from asking patients if they have pain.
"The prevailing understanding is that
"patients are more likely to complain about pain
"if nurses ask if they have it.
"If necessary doctors will determine
"if the patient has pain."
[crowd murmurs] - [Man] That's how it is at the VA.
- [June] Why? - [Man] That's how it is at the VA.
- Oh no that wasn't the VA.
- [Man] I'm saying they do that today.
- Oh a similar perspective.
A reaction to the Joint Commission standards
which I take personally from Jane Ballantyne
and Mark Sullivan who are at the University of Washington.
"We believe that opioids will still be over prescribed
"unless changes are made to the blanket requirement
"to treat on the basis of the report of pain."
They actually believe that you shouldn't ask people
if they have pain because if you do
they might give you a report
and that you might make a decision about treatment
based upon that patient report.
Well that's not the way to do things.
So the problem with chronic pain and opioids
is that it's chronic pain is very prevalent
and it's among the most debilitating medical conditions
but also among the most controversial and complex to manage.
How many people in this country have persistent pain?
He knows. How many?
- Oh I don't. - Oh, you don't know.
- [Man] I thought you were asking all the people-- - All the people in the room.
100 million, how's that?
A trivial problem right?
The limited therapeutic alternatives
for this horrendous problem have combined to produce
an over reliance on opioid meds.
And this, associated with
this alarming increase in diversion
and overdose and addiction,
that physicians understandably have questions
about whether and when how to prescribe opioid analgesics
for chronic pain.
Josh Bloom wrote an article
that he published online very recently
and he said, "In 2016 it's reported that--"
I don't know how many people died
of a drug overdose, maybe 43,000,
maybe the number is 33,000 that involved opioids,
as 18,000 deaths from natural
and synthetic opioids and methadone
but the important comment he made,
which I emphasized before and want to again
is that in 2005 at least half of the people who died
from prescription opioid overdoses
had also taken a benzodiazepine.
44% of the time they had taken alcohol.
These sedative drugs are very lethal
when combined with opioid analgesics.
The other important point is that now we've seen
a change in the source of the drugs
that are abused or are involved in opioid overdoses,
90% of opioid overdose deaths in the recent years
were a result of illicit fentanyl
and its analogs, or heroin,
or a combination of opioid drugs with other drugs of abuse.
And alcohol is certainly a drug of abuse.
The other point he made
which is very important is that pain patients
who use opioids correctly and responsibly
are not the persons who are dying of overdose.
They're not.
Now how about controlling the swing of the opioid pendulum?
Again another article published recently
in the New England Journal of Medicine.
Some clinics have established policies
of not prescribing opioids at all.
And yet we know that opioids are an important part
of the therapeutic armamentarium.
And as the pendulum swings
from liberal opioid prescribing
to a more rational measured and safer approach,
we can strive to ensure that it doesn't swing too far,
leaving patients suffering as a result
of injudicious policies.
What about the effect of opioids and non-opioids
on pain related function in patients with
chronic pain problems?
There was a paper published relatively recently
in the Journal of the American Medical Association.
The authors concluded that treatment with opioids
was not superior to treatment with non-opioids
for improving pain related function over 12 months.
They said that the results do not support
the initiation of opioid therapy
for moderate to severe chronic back pain
or hip pain or knee pain if it's due to osteoarthritis.
But they don't support discontinuation of therapy.
so this JAMA paper has attracted an awful lot of attention.
And the results have been used to justify
aggressive tapering or immediate discontinuation.
What happens if you cut somebody
who's been on an opioid for a long time
and you stop their drug?
- [Man] We're going through withdrawals.
- Yeah you go through terrible withdrawal.
And Medicare misread the recommendations.
The CDC gave a 90-milligram red flag
for patients in acute pain
who are just starting opioid therapy.
It's not for patients with chronic pain
who have been taking opioids for a long period of time.
And yet the results were used to justify aggressive tapering
or immediate discontinuation.
To repeat what's on line one:
actions "that could harm people"
And so the authors of that publication
which recommended that you not start opioids
with persons who have certain osteoarthritic pains
said we can't walk away from patients
who've been treated for years even for decades,
we've created double tragedy for those patients.
So how many times does the opium pendulum swung?
Well, here's another report.
It was an Internet post.
I tried to get the source.
This describes John, a former cable company salesman
who's used Oxycontin, that horrible drug,
to treat the severe back pain caused by injury
sustained during a mugging in 2011.
Before he found a medication that worked for him
he said "My wife was about to leave me
"because I was a miserable bastard.
"When you're in that much pain you just want to go to sleep
"and not wake up."
Last fall John was told that by a physician assistant
that his dose was going to be reduced.
It had been 60 milligrams three times a day.
The PA said this was too high
and would have to be dramatically reduced under a new rule.
I guess that rule is the CDC guideline
that didn't set any mandatory limit
but it recommended people not start on high doses
of 90 milligrams per day.
He said "My whole life turned upside down
"in a matter of 30 days, I'm back in bed now.
"I can't really get up very much.
"I'm right back where I started in 2011."
So we have another opioid crisis as well.
We have the crisis
where people are not getting adequate treatment
but there is a shortage of opioids
as a result of this call back of opioid availability.
And it's left many hospitals and surgical centers
scrambling to find enough injectable morphine
or dilaudid or fentanyl.
These are drugs given to patients who aren't abusers,
but are undergoing surgery or they've had cancer
or they have traumatic injuries.
This shortage which were reported last summer
has worsened now.
And then another opioid crisis.
It isn't just opioids.
Overdose deaths linked to legal and illegal drugs.
Remember benzodiazepines and alcohol.
The author of this comment said that he believes
there's an increase in deaths of despair,
that something deeper has gone wrong in American life,
because of poor mental health care,
jobs leaving parts of the country
and a growing sense of social isolation.
When the public was recently polled to ask their perspective
about the opioid abuse epidemic,
the results were very interesting to me.
A majority didn't deem addiction to pain medicine
was a natural national emergency.
And few people see it as an emergency
or a major problem in their own community.
So public and private sector leaders
are looking for a substantial increase in funding
for opioid addiction treatment programs.
Yet a large share of the public is really uncertain
about the long-term effectiveness of treatment.
So we have this lack of understanding
of the problems that exist.
Many medical experts say that the CDC guidelines
play up the hazards of opioids
while playing down their benefits.
The overall message is that clinicians should be stingy
with these medicines, prescribing only as a last resort
in maintaining the lowest possible doses.
Despite the CDC is protesting to the contrary,
the mission of preventing abuse and diversion
seems to be interfering with
the average pain practitioner's duty
to provide appropriate care.
And it leads in extreme cases to suicides
by patients who can't seem to get the relief that they need.
So concluding our challenge.
We need to maintain our focus on pain.
It's under-treatment is a major public health problem
in the United States.
Certainly the number of persons who have chronic
or persistent pain is just mind-boggling to me.
We need to maintain a balance.
We need to assure that efforts to reduce
the diversion and abuse of opioids
don't interfere with their appropriate medical use.
I think that is not the case at the present time.
I think there's a lot of interference
with appropriate medical use.
And don't forget our other prescription drug problem,
which I have alluded to more than once.
The benzodiazepines.
Deaths involving benzodiazepines increased from 1,135 in 1999
to 8,971 in 2015 and I couldn't find the 2017 data
to present to you but I doubt the number's gone down,
despite efforts to reduce the prescribing.
And thus the availability of benzodiazepines.
3/4 of guests involving benzodiazepines,
at least a couple of years ago,
also involved an opioid of lethal combination.
I think it's important also to accept the challenge
presented by the National Academy of Medicine.
We need a cultural transformation to better prevent,
assess, treat and understand pain of all types.
The level of ignorance is really profound.
It always astonishes me.
And the number of hours spent on pain
in medical school curricula is trivial
compared to the magnitude of the problem.
I think it also is important to embrace
the philosophy of the Dalai Lama.
Pain is inevitable.
We're all gonna get it,
unless we have this genetic predisposition
where we can't feel any pain.
We have this abnormal sodium 1.7 channel,
that voltage-gated channel and it's odd
because we don't feel pain.
But for all the rest of folks except those 200 or so persons
with that genetic abnormality.
Pain is inevitable,
but suffering is optional.
And what we've got to do is to make suffering
much less in this country.
It's not optional for us to allow things
to continue as they are and they're only
getting worse at the present time.
So I thank you for your very kind attention.
I'm sorry some of you could not sit down.
I wanted to tell you to come sit in here
there's seats in a row.
And I thank you for your attention.
[audience applauds]