2016 Public Health Grand Rounds 10/21

PUBLIC HEALTH GRAND ROUNDS Linking Research to Community Health Improvement Jointly sponsored by the Department of Public Health Sciences & URMC Center for Community Health

(speaking off mic)
- And you can sign too, I should've had you sign your own--
- [Fields] Oh god no I don't do that, that's the worst.
- The basic, yeah.
- [Fields] I can sign, or I can talk but I can't sign--
- Not at the same time, that would be really hard.
- Hi. - Hi.
- How are you? - Good.
- Interpreter. - Okay good.
- I thought somebody was standing on the other side.
- [Woman] Are you're gonna be standing here?
- I will probably be standing right behind here
because I have notes and stuff.
- [Woman] Am I okay right here, okay.
- Yeah.
Yeah usually we're on the other side,
but you have folks sitting over here, is that it?
- Yeah. - Got it, got it.
No problem and hopefully that will work for the recording,
I think it should be fine. (laughing)
- [Fields] With my voice you're in charge.
- Chair's in your way or not, we can certainly move it out.
Okay welcome everybody,
for the sake of time I think we'll go ahead and get started.
Thank you all so much
for coming to Public Health Grand Rounds today
on this very dreary rainy crazy day.
Really a full house speaking to this epidemic
and so I'm really glad we picked this topic
for discussion today.
Public Health Grand Rounds is a joint effort
between the Public Health Sciences Department
and the center for community health.
I'm Teresa Greene, I'm in both departments
and the director of community health education and policy.
So welcome, thank you,
we have set up Public Health Grand Rounds
to be a collaborative effort
between what's going on in the community and public health.
Links to what's going on in research
and clinical enterprise here at University of Rochester
and nothing like the opioid epidemic
to touch on both of those points at the same time
so thank you very much.
We particularly invited Dr. Fields
and particularly about this topic today
in response to a community need
that is growing rapidly here in Monroe County
and throughout the country which I'm sure we'll talk about.
The hospitals in Monroe County have picked the opiod crises
as one of their focus points
for their community health improvement plan
and so we plan to have this as a level setting discussion
and then hopefully another presenter in the spring
talking about this same issue so thank you very much
for the input from last semester
talking about this being a topic
you wanted to hear more about
and the hospitals see this as a priority as well.
Speaking about those topics
you all should've grabbed an evaluation on the way in,
please complete those, we really do read them,
for feedback to the presenters,
but also to gather topics for discussion
for the next Public Health Grand Rounds series.
You'll see we have another session in two weeks
on November fourth, please feel free to attend that as well.
So without further ado Dr. Fields.
So Dr. Fields is currently a first year fellow
in addiction medicine at the University of Rochester,
having just completed his residency
in emergency medicine here at U of R as well.
He developed an interest in addiction medicine
during residency, initially encountering
the subject of addiction and overdose
while in his toxicology rotation as an intern.
Dr. Fields is currently working on projects
related to adolescent addiction medicine,
emergency department protocols for opiod dependent patients
and training physicians to recognize and treat addiction
and addiction related problems.
So thank you very much and join me in welcoming Dr. Fields.
(audience applauding)
- Hi.
Oh it's just fine, there we go.
Alright.
There we go.
So first thing's first I'm not being paid for this,
there's no conflict of interest.
Oh this is not the presenter view, I can't see what.
Oh no.
There's supposed to be presenter view.
- [Teresa] I'm sorry I left and wasn't.
- It had been setup in the previous view.
- You just start there, yeah,
from the beginning and hopefully that will do it for you.
You should be able to click with this.
- No there's a, we're supposed to point it.
See, there's notes and stuff like--
- Yeah yeah.
That I don't know so. - That's weird.
- Go back and maybe the presentation one?
Slideshow.
- Oh there it is. - Presenter view, perfect.
- Thank you so much.
Clearly I'm not a tech--
- I don't do those note so I don't know that part.
- Oh no they don't even have it.
(audience laughing)
- Presenter view can't be done.
Deep breath. (laughing)
- Alright.
Okay, so this will be a little bit more rough.
- [Teresa] Didn't know.
- I swear I had great jokes
and written notes and stuff for myself.
So no conflict of interest,
as I was saying I don't claim any ownership
over any of the charts and stuff in here.
As you can see I'm clearly not very tech savvy
and so I can't make pretty charts and graphs
so I borrowed them and sited them wherever possible.
Just to be clear what are we talking about here?
Opioids, opiate, heroin, you'll hear me use these terms
mostly interchangeably during this talk
because as far as your body's concerned,
well this is one of my friend's dogs, his name is Potato,
but we also call him Tater
and regardless of what you call him
he's a mopey sack of fur and similarly
regardless of whether you use the term opiod, opiate,
heroin, narcotics, what I'm referring to here
are drugs that's bind to the mew receptor in your brain
and cause the effects that we see with overdose.
The big question is whether this is an epidemic or not?
Often times when I bring this up to people
I'm met with a bit of skepticism,
you all probably would not be here if you weren't already
at least buying into this concept a little bit.
I wouldn't be up here if it weren't an issue,
but people often ask me when I bring it up,
"really, is this really an epidemic?"
And hopefully over the next couple of minutes,
in the next few slides I'll be able to get that
pretty definitively demonstrated
because that's the basis for the rest of this talk
is that we are indeed in the middle of an epidemic
and we do need to address this
as you address any other epidemic.
So these are words from the CDC,
I could not have put it better myself.
In the 15 years from 2000, 2014, half a million people
in the United States died from drug overdoses.
About 60% of those in 2000,
in 2014 were from opiod related overdoses.
Think about those numbers for a moment,
that's a lot of people.
That's more than car crashes.
One and half times the number of people that die
every year in motor vehicle accidents
die in drug overdose deaths.
These are the numbers of heroin related addiction
and overdose, there's a little misleading
because these two lines are on different scales
so we are not indeed having more deaths
than there are people addicted, that defies logic,
at least my logic,
but as you can see since 2000 all the levels,
all the rates of addiction are going up
in every demographic group.
It's becoming more common,
there's no predilection for age, race, gender, creed, none.
All people are being effected by this.
Let's go a little more specific, New York,
'cause those are national trends
and you know nation trends being what they are,
maybe all that addiction's out west,
maybe it's in Florida, who knows?
They have the pill mills there right?
In New York state we've actually done a fantastic job
of keeping our prescription overdose deaths
pretty stable since 2011, almost no change,
which is pretty impressive
especially given the change from 2013 to 2014
on the national trend.
But during that time we've also been seeing
a continuing rise in our death rates from heroin.
The national death rate from heroin has been rising as well
and we're keeping pace, but higher than they are.
These lines, so this last one
you might not be able to see is 2014
and so when you continue graphing these out
for the numbers for 2015 that blue and black line intersect.
Which means in 2015 for the first time more people died
in the state of New York from heroin overdoses
than prescription opiod overdoses.
Take a step back for a second,
that means that until 2015 prescription opiods,
drugs we were prescribing
were killing more people than heroin
and we weren't even talking about it, it wasn't an issue.
Even more specific, Monroe County.
2014 was and still is our peak year
for heroin and fentanyl related deaths investigated
by the Monroe County medical examiner office.
It's mostly Monroe County and then those other
little counties that surround us that contract to us.
But you can see the trend, even if you exclude October 2014
with that one outlier spike there's still a doubling
or tripling of the per month number of overdose deaths
being investigated by the ME's office.
These are underestimations,
these are numbers of cases
that are being investigated by the ME.
This does not include cases where
patients are dying in the emergency department
and nobody realized that it was opiod related.
These are cases where the body's actually found in time
to suspect that it was an overdose
and they're not just long gone and there's no determination.
So these numbers are our best guess,
or our best guess estimate,
but probably lower than the real numbers.
Away from all the pretty graphs and charts
825 people in 2014 in the state of New York
died from heroin.
That's 159 more than the year before.
Nearly 25 times the number of people a decade before.
33 people in 2004 in the entire state of New York.
I think it's, last time I looked about two million people.
33 people died in 2004.
The death rate per million people
went from 1.7, no that two million's totally wrong estimate,
I apologize, forget that part.
20X, thank you, the two was there.
Per million people the heroin death rate
went from 1.7 to 41.8.
What other disease had a death rate
that sky rocketed like that in a decade
and wasn't addressed?
As I mentioned earlier our prescription overdose
related deaths have been fairly stable,
but still about four times what they were a decade ago.
And these numbers are continuing to rise.
So now that we've gotten all the depressing stuff
out of the way, let's get a little bit of basic information
because I know a lot of you may not really have a great idea
of what exactly these drugs are that we're talking about
so these are the gratuitous pictures of papaver somniferum,
a beautiful, beautiful innocent flower
that mankind has vilified.
Really is gorgeous.
So this is the flower that opium comes from.
So the way opium is generated
is these seed pods up here, there we go, that thing,
gets scored by an instrument
and as with most plants when you score it
the plant exudes a latex.
That latex initially looks white and milky
and over the next couple of days it oxidizes,
turns brown, kind of blackish in color.
That dried latex is then collected and that is opium.
That's what the opiate of the masses was for millennium
and then that opium contains a lot of alkaloids
that are then able to be refined
and the three most common are morphine and codeine,
which are most relevant for people
and there's a third one called thebaine
which serves as a precursor
to a lot of the semi-synthetic opiods that we use,
hydrocodone, hydromorphine, oxycodone.
Yeah, I had other notes, can't see them.
So opiods, the term opiod specifically
refers to all opiods, all opiates natural, synthetic,
semi-synthetic, anything that is like the compounds
in opium, anything that binds to the opiod receptors,
this is the most generic term, I try to use this one
because it doesn't draw any distinctions
between the ones that are man made or natural
because functionally they're all kind of the same.
They just very in some of their pharmacologic factors,
but they all have the same overall effect on us.
Opiates is a more specific term
that is a little bit more vague,
I'm not sure how you can be vague
and specific at the same time,
but it's not as defined.
I will often end up saying it.
Really what I mean is opiods,
it just rolls off the tongue better,
and then opium as I mentioned is the dried latex
harvested from papaver somniferum.
So what is heroin?
Heroin technically is diacetylmorphine.
Which for the chemists in the office, or in the room,
looks like that, those are the two acetyl groups.
You're never gonna have to look at that again.
So diacetylmorphine undergoes
extensive first pass metabolism.
What that means is that when you ingest it,
it gets absorbed by the intestines,
funneled through the liver, gets broken down,
and it gets broken down directly into morphine.
However diacetylmorphine is about two
to four times more potent than morphine,
and so what that means is when you eat it
you're getting less of an effect
than when you shoot it or smoke it,
which is why people tend to abuse heroin,
intranasally, smoked or injected
because eating heroin doesn't have the same effect.
Those acetyl groups that you saw on there
that I pointed out and then quickly put away.
Those make the molecule nonpolar
allowing it to cross the blood brain barrier a lot quicker
leading to a dramatic euphoric inducing rise in serum levels
which is part of what reinforces the drug using behavior.
As I mentioned before it is a pro-drug,
it's broken down into morphine,
but it's an active pro-drug
and so a lot of drugs that we take,
they're pro-drugs but they're not doing anything
in their pro-drug from, they have to metabolized first,
that's not the case with this.
This is more potent fist,
gets metabolized and then it's still pretty potent.
Who knows what these are called?
I'll give a pause, so the interpreters can switch.
These are bags, stamps, folds,
this is the basic unit
shall we say of heroin that you buy on the street.
Super variable in terms of the content
that you'll find within it,
vague numbers that the internet
has tried to convince me of were .05 to .1 grams per fold,
but as I mentioned super variable,
depends on the potency of the heroin inside,
depends on the region you're in.
Most users that you talk to
will refer to the amount that they use
by the numbers of bags they use per use.
This is bundle.
Bundles are generally how people actually buy heroin.
It's in this region a pack of ten folds.
Some other places it'll be considered a standardized weight
with variable number of folds in it.
As I mentioned very variable.
The black market is not exactly known
for its quality control and consistency.
These are heroin rocks,
this is often how its shipped,
this is what you get out of the initial chemical process
that then gets broken down into the final product.
Between these two stages there's usually
a lot of processing, it gets cut
or essentially diluted with different substances
in order to try and increase their profit margin
because at the end of the day most people involved in this,
that's what is to them, a business.
And this is the oft mentioned black tar heroin,
that I can't look at it, it makes me sick to look at so.
But it's not just heroin.
So let's do a quick experiment.
All the prescribers in the room,
doctors, NP's, PA's, I want you to put one hand up.
Everybody in here who writes prescriptions.
Okay, now I want you to put your hand down
if in the past week you've prescribed any of these,
Roxicet, Percocet, Vicodin, Dilaudid,
I did those, Roxicodone, or OxyContin.
So, how about the past two weeks, the past month?
I know you never prescribe anything,
you anti-prescribe them.
So these are I mentioned before not really any different
than the heroin that people are buying on the street.
It's just stamped into a pretty pill,
sold off of a shelf,
maybe with a sustained release formulation
so it lasts longer,
but functionally it's hitting the same receptor,
it's causing the same changes in their brain.
Some states have more prescriptions than others though.
There's a lot of variability as we just witnessed.
Some people prescribe opiods all the time,
some people never do,
and there's variability in that based on
what type of medicine you're practicing,
what type of patients you see,
where you are within our medical system,
but before you get too much into the details in this
I want you to lean back, take a deep breath,
kind of take the whole thing in as a generalized picture,
and compare it to that one.
This is a heat map, or a heat graph
of the centers of heroin overdoses
in the United States in 2014.
There's the, at least to me,
expected Appalachia concentration and south west.
And going from that slide to this one
hopefully if you relaxed yourself enough
you saw something kind of like this with those two overlaid.
I find it hard to believe that there's not a connection
between prescription opiods and heroin deaths
when you look at the concentrations of where people
are dying and where they're getting prescriptions.
Now just to be clear, this slide can be a bit confusing,
these numbers here are the number of prescriptions
written per 100 people over the course of that year
and so what that means is for example,
in the state of New York,
in 2012 for every 100 people
there were somewhere between 52 to 71
opiod prescriptions written,
that does not mean that half of the people
in the state of New York had a prescription in 2012,
it means that over the course of that year
there were that many written.
You could have one person who gets a monthly prescription
that would account for 12 of those 52.
Now if you're anything like me,
the first time I saw this I immediately looked
to the state of New York and was actually pretty shocked
to see that we're way on the lower end of this spectrum.
To kind of exemplify that this is another,
this is the same information as this,
just graphically orientated a bit different
and there's us in New York, right there.
The only states with fewer opiod prescriptions that us
are California and Hawaii.
I wouldn't expect them to have a ton of opiods,
they've got beautiful beaches, sunsets.
(audience laughing)
We have lake effect snow. (audience laughing)
So what this tells me though,
I get an odd sense of relief from this
because as much as it feels like we here
are inundated with heroin and opiods, we have nothing,
we have nothing compared to almost everywhere else
in the United States.
Prescriptions are way more prevalent everywhere else,
and so you may ask yourself, how'd we get here?
I wasn't even alive in 1980 but who knows who this?
- [Audience Member] David Byrne
- Yes.
The Talking Heads, I wish I could've seen them live, man.
Anyways from 1980 on consumption of oxycodone
in the state of New York was pretty stable.
I was a little surprised when I first saw this,
there was like no changes really, despite the Talking Heads,
they had no effect on it,
but then this happened,
and I know what you're thinking,
"ah that's oxycodone, maybe something new came out,
"maybe, you know, other drugs got pulled off the market,
"and this one was replacing it."
It wasn't just oxycodone though.
Yeah 1996 hydrocodone underwent the exact same rise in 1996.
I don't like being a conspiracy theorist
that's not why I went to school,
that's not why I got a science background,
but I find it hard to believe
that it was all just coincidence.
This is graph of promotional spending
for three different long acting opiod analgesics
with relatively similar mechanism of action
and relatively similar approved indications for use.
I haven't read any of the words on this slide
since it came up because I'm a slow reader,
but see one of those graphs is a lot taller than the others,
like way taller than the others.
That's for OxyContin, which came out in 1996,
that same year that oxycodone use skyrocketed,
the same year that hydrocodone use skyrocketed.
The same year that this statement was put out
by the American Pain Society
that we should start addressing pain as a vital sign.
Now don't get me wrong,
I'm not saying pain shouldn't be addressed,
I'm not saying that
this isn't something we need to focus on.
The treatment of pain is ultimately why all of us
went into medicine, we all want to help people.
It is a noble and worthwhile life's pursuit,
but at some point we need to start drawing the distinction
between pain and suffering,
because there is a difference between these two
and when we forget that
it becomes easy to get lulled into
over prescribing of medications
that will treat pain and do nothing for suffering.
It's easy to get lulled into that
when you've got papers like this,
and I use the term paper loosely,
supporting the use of opiod prescribing.
This is one of the first and most commonly sited papers
encouraging opiod use for acute pain, acute non-cancer pain.
Just to be clear this is not a randomized control trial,
this is not a retrospective chart review,
this is not any sort of actual peer reviewed publication,
this is a letter to the editor.
This is a group of two physicians out of Boston University
who hopefully actually did this
and actually sat down and actually looked at their charts
and these are reliable numbers that they're saying,
I would hope so, but either way there's no method.
This is not subjected to the same process
that all the other references we use to base
our medical practice on have been through.
Peer review has its flaws, but it's there for a reason.
You wouldn't base your clinical practice
on a letter to the editor
for almost anything else in medicine,
and that's what we've been doing
for the better part of 30 or 40 years.
About six years after that original paper came out
this paper came out which,
which I guess kind of broadened the indications
and applications of opiods from primarily chronic use
for cancer related pain into everybody else with acute pain
or non-acute pain.
We've gotten better since then, things are improving,
we've realized earlier this year
that pain probably doesn't, sorry,
treating pain alone doesn't necessarily improve
your clinical care or your outcomes.
The American Medical Association called
to actually walk back that statement
about treating pain as a fifth vital sign.
That we need to focus more on appropriate management
and treatment of pain and suffering and less
on just making the number better as we've been doing.
We've got increased efforts to identify abuse,
misuse, diversion, and to rethink
whether we should be using opiods
and whether there's any other therapies we can use.
Did any of you read this article this past April,
I think it was April, right?
June, thank you, yeah even says June there.
In the New York Times, my mom ripped this out
of her New York Times and mailed it to me.
I'd already seen it three times on the internet by then,
but she made sure I was gonna hear about it,
and it's actually one of the coolest articles I've read
in a really long time.
Not because there was anything truly earth shattering
or groundbreaking about it,
but because it took stuff we already knew
and kind of pulled it all together
and put it together in an easy to digest
real world applicable way.
Now I'm not the crunchiest of granola-iest people out there.
Some of the stuff in here
stretches my credulity a little bit,
reiki I don't know,
but all the other things that this group used,
massage, trigger point injections,
therapeutic harp, I want a therapeutic harp at work,
that would make me feel better.
These are things that they used clinically
and not only did patients like those treatments
better than getting opiods,
it helped their pain more, there were fewer side effects.
They're putting their data together
to actually publish it right now
but they had fantastic outcomes.
And I think this is a movement
that's gonna start to be emulated elsewhere.
So we're on the homestretch now.
Very true, I learned so much from Ted.
So where are we going, what are the next steps now?
Now that we have identified that we have a problem,
and let's face it, we do have a problem,
we in America have a prescription and illicit opiod problem.
Anybody in recovery can tell you the first step
to addressing your problem is admitting you have it.
So we've got that, the president has addressed it,
or the president has acknowledged it,
most medical societies have acknowledged it.
Now in order to continue moving forward,
we start with discussions like this.
To tell practitioners who are seeing patients
on a daily basis this is real, think about it,
maybe change your practice,
start doing things a little bit differently,
read the new journal paper that tells you another way
of managing pain other that prescribing Percocet.
I know CME mandates are a very unpopular subject.
Earlier this year the state of New York
imposed a new CME mandate,
I don't know if it's for everybody
or if it's just for emergency physicians.
I know we now have to do three hours
of opiod prescribing CME every two years.
It's a slippery slope
and I understand the complaints against it,
but at the end of the day
more and more states are imposing this
and when they're for medications
that as we mentioned are more dangerous than heroin,
or at least have been, I don't think it's unreasonable.
There are lot of other things we have mandated CME about,
I think something that has been
literally killing patients is reasonable,
but we have to find the balance between it.
Three hours may be a bit much.
I know some states have a one hour mandate,
some states have a two,
but it's a pretty simplistic way
of getting some basic knowledge out there.
Read an article, take a five question test,
be done with it the next two years.
And then resident education,
some of you may have noticed
that I am something of a whipper snapper.
I just finished residency this past June
and I can tell you from personal experience
that not just the emergency medicine program,
but other programs throughout this hospital and others
are starting to address opiod addiction
and how it impacts their practice.
Every field of medicine sees patients that are addicted
at various points during their addiction.
Maybe you're the doc who prescribed
that first opiod prescription that made somebody go,
"hey, I feel normal on this, I really like this,
"I'm gonna keep doing this until somebody makes me stop."
Maybe you're the doctor that saw the heroin addict
for the abscess in his arm
where he missed a vein and shot into the skin
and got infected.
Maybe you're the cardiothoracic surgeon
who is fixing the endocarditis
because of the addict who could not stop shooting up
and putting bacteria right into his bloodstream
seeding an infection.
Everybody will deal with this at one point or another,
and by including it into the training curriculum
we're teaching people how to better address it
instead of just vilifying people as a weak willed addict
as we've done for decades now.
You can realize there's something more there.
Most people at the end of the day want to be a good person.
Most people at the end of the day
don't want to be subjected to the will of a drug
that often times they don't even want to take anymore.
They just feel helpless to stop.
So now we've acknowledged as a problem.
We've talked to our compatriots,
said yes there is a problem.
We've put our hands in the center, done a little cheer,
we're going to go out and address the problem
and we walk out of this conference room into a hallway
with Ebola dripping from the ceiling.
That is a literary device that I'm told is called a metaphor
there's no Ebola in this room or out there I hope.
But we gotta decrease new exposures
as you would with any epidemic and to decrease new exposures
I know at least me personally,
this is I have gone about starting to do it
in my practice in emergency medicine.
When I see somebody with an ankle sprain,
it's really easy, really easy,
to put A strap around it, give them some Vicodin
and get them out of my hair.
Super easy, they're happy,
it's easy for me so I guess I'm happy
and they go home, we get paid, none the wiser.
But you know what's better for the patient?
To RICE it, it takes a little longer to feel better,
but it's better for them, they'll actually heal quicker
because they're going to allow themselves to heal
and they don't end up on oxycodone.
Rib fractures, rib fractures are one of the most painful
things that we don't admit you to the hospital for
unless you have tons of them.
Two or three rib fractures, you can kind of go home.
It's just pain control and taking deep breaths
so usually we give opiods for it,
but there's actually really good evidence
that Lidoderm works fantastic for it.
Dental pain, that's one of the most common,
chief complaints in an emergency department
for somebody that is trying
to get an opiod prescription to misuse it,
because there's no way to really tell
if somebody has dental pain.
A lot of people have really bad looking teeth
that don't hurt them at all
and a lot of people have perfect looking teeth
that hurt like crazy and you have no way to reliably tell,
but instead of giving a prescription
I do a nerve block,
and I'm so grateful that we have Eastman Dental
because within 48 hours
I can tell somebody go see Eastman Dental.
Even if it's Friday night,
Monday morning they can go see Eastman Dental,
and they'll help determine
whether there's truly something
that needs to be fixed or not.
Now for some truly hippy stuff.
(audience laughing)
I had the great privilege
of being exposed to a lot of complimentary
and alternative medicines
very early on in my medical career at Georgetown.
Through their mind body medicine program.
As I mentioned I've got a strong science background.
I am a skeptic to my core.
I didn't believe any of this stuff when I started doing it.
I took the course because I wanted to see
the other point of view,
I wanted to get all the information about it
so that i could debunk it
because I thought this stuff,
I thought it was all placebo and quackery,
and you know what even if it is, it works,
and especially when it comes to pain control,
whether it's placebo or not, if it works, it works.
What more do you need?
I mean pain is one thing
and as we mentioned suffering is worse.
Not only does this stuff address
a lot of the pain people experience,
but it addresses the suffering more so.
Biofeedback, meditation, massage.
These techniques do work
and I think it's something that's strongly under emphasized
and there's more and more evidence mounting behind it,
and so if anybody's interested in it
I would encourage you to look up this program.
I'm not sure if we've got one similar here
but they're popping up all over the country
and I'd be happy to put you in touch
with the advisor that I worked with
down there at Georgetown, he's the nicest guy in the world.
So in terms of prevention,
ultimately at some point
we have to decrease the supply of medication
because if you build it they will come.
If you make it they will use it.
So in order to decrease it,
step one is just writing fewer prescriptions
through some of the steps that I had mentioned.
Think about it twice,
does that patient really need that prescription
or is it more harmful to them.
Turns out if you actually talk to patients
and tell them the risks of that medication,
the true risks of it.
A lot of times they're happy to go home in pain
and know that you were trying to protect them
from the risk of that medication.
Especially when I have seen young adults
and especially if I'm seeing young adults
with their parents there.
Kids in their 20's
who have really messed up their knee playing a sport.
You put them in a knee brace and tell them,
"this is gonna suck for weeks to months,
"it's gonna suck, there's no way around it."
No matter whether you ice it,
no matter whether we inject it, take pills, it's gonna hurt,
it's gonna be tough to walk,
but if we start you on these pills now
the likelihood is you're probably going to continue on them
for the next six to 12 months.
Most outpatient prescribers aren't going to want to do that.
It's going to be harder to get off of them,
and I have had a ton of patients and their parents tell me,
"thank you,
"thank you for not just prescribing that medication.
"Yeah we're happy to do all these other things
"to get our pain under control,
"if we need it later we'll talk to our doctor about that."
When you decide that you do want to actually write
for an opiod prescription do it for a shorter duration.
If you're truly prescribing for acute pain
why are you sending a four week script in?
This is actually one of the things
that was noticed in some of the studies
from the past few years about opiod prescribing,
is the number of scripts that were being sent
for 60, 90, 120 tablets,
their indication was an acute injury
that should be gone within a week.
There's no need for that many pills.
This is something that I think is awesome.
I don't know if anybody heard the news from last week
but the DEA announced that there's gonna be a 25% decrease
in the number of approved opiod manufacturing
whatever they want to call it.
There's gonna be a quarter less drugs manufactured
in the United States that fall into this opiod category.
Some of the medications are being reduced even more.
Hydrocodone, I believe it's Hydrocodone,
Hydromorphone, yes Hydromorphone is being decreased 66%.
So some of these drugs that are being made
and either just being stockpiled
or being turned out for really cheap
because of the volume of them,
the supply is gonna decrease
and hopefully if market forces work properly
when supply decreases, prices will increase
and insurance companies being what they are,
when their prices go up,
they pass those prices all on to the consumer
usually in the form of increased copays.
This is a mixed bag
because if somebody truly needs a medication
it's not fair to have an increased copay
to prevent them from being able to get it,
but the other way to do it
is through prior authorization.
Have any of you tried writing for Lidoderm before?
It's a pain, about half of the insurances
want you to do a prior authorization,
which may not be too bad
coming from an outpatient primary care office.
From the emergency department it's next to impossible
because I'm not there everyday,
other people then see that patient,
nobody knows who the patient was,
we don't have followup.
Prior authorization doesn't work.
I can't prescribe Lidoderm from the emergency department
because about half the time I prescribe it
patients aren't able to get it, they complain,
they come back, I get yelled at.
So I've taken to writing people for lidocaine ointment
and telling them to just put a big goober of that
underneath a bandage a put it on
because it's the closest I can get
to getting somebody Lidoderm.
That same thing could be done for opiates.
If somebody needs more than a day or two of opiates,
prior authorization.
Prescription monitoring programs.
If you prescribe in the state of New York
and you are not familiar with this
you are way behind the eight ball.
The process is not too hard to get setup with,
as residents it's a lot more complicated
so a lot of residents will gripe about it,
but for an outpatient prescriber it's not hard
and it's fantastic.
I can't tell you the number of times
that I've gained insight
into what was bringing a patient into the department,
or what was going on in their life just by looking at this.
It gives you information about their addresses,
their pharmacies, their doctors
and you can see whether somebody's actually able
to followup with their primary care doctor regularly
or are they constantly bouncing around
from urgent care to urgent care to ED to urgent care?
Plus as house MD always tells me, "everybody lies,"
and this let's you catch them in their lie.
Plus it matters, it makes a difference,
in the state of New York and Tennessee
implementation of the prescription monitoring program
decreased the number of patients
who were getting prescriptions
from multiple providers by 75% for us and 36% for Tennessee.
That's incredible, and even better than that
was the state of Florida
when they closed down a bunch of the pill mills
and started saying that physicians
could no longer disperse medication
or hand out the actual pills from their office,
decreased the number of oxycodone deaths by 50%.
Can you imagine if there was something,
a law that could be passed that would decrease
the number of people dying from overdose
by 50% almost overnight?
Pretty cool.
And so this happened earlier this year,
hopefully you've guys have heard about this.
The comprehensive addiction and recovery act
was signed into law by President Obama on July 22nd,
did a lot of different things.
Increased naloxone availability,
so there's more and more training for police,
first responders, firefighters, EMT's,
to not only have the naloxone onboard,
but how to use it, how to determine if it should be used.
There's also increase in funding
for community training programs,
I know Strong Recovery has naloxone training event,
was it monthly, first Monday of every month?
Tuesdays, thank you.
Unfortunately we're in a little bit
of an naloxone shortage right now,
which hopefully will be fixed soon.
We mentioned the prescription drug monitoring programs,
that this provides money to help roll out
to those states that have not already done so.
Increasing the prevalence of drug court programs.
It seems like a given for us here in Rochester,
we have oldest drug court program in the state of New York.
It was one of the first ones in the country.
It is fantastic,
if you've ever got like a Tuesday morning off
just go head down to the drug court.
Any time you hear a patient tell you
that they, that those judges do not care
and they're just messing with you.
That's not the case, it takes an hour if not less,
of sitting in that court to see how much those judges
truly care and really want people to do better,
to be successful in their recovery
and drug court helps people get their lives back together.
Basically it's the idea of forced recovery
versus I guess chosen recovery.
If you are not choosing to go into recovery yourself
they can force you to and as long as you improve
you'll get out, you avoid jail,
you can get your GED, get job training.
Anyways I can keep going on, but.
We'll talk about addiction treatment
and medication assisted treatment in a moment.
CARA also enables those with prior drug problems
to qualify for Federal Financial Student Aid.
There was a question on the FAFSA application
that asked if you had been arrested for,
the terminology on it was essentially
have you been arrested for a drug crime before
and if so you would not qualify for aid.
And so let's say you're 16, got mixed up,
had a bunch of marijuana that you were buying
to share amongst some friends and you got a drug charge.
You're applying for your FAFSA now at 18,
that could prevent you from getting financial aid.
Or maybe I don't know minor laws,
pop it all back two years,
your initial arrest was 18 and then you're at 20 applying.
If you have reformed the rest of your life and doing well
why shouldn't you qualify to get assistance to get training
to improve your life to be a member of your community?
This last thing, I'm not quite sure how it fit in
with the rest of the addiction act,
but I'm absolutely stocked about it
because I know we've benefited from this
in the emergency department,
a lot of our vets who are,
who have training in emergency medical treatments,
we've got bunch of nurses and techs
who have these experiences and they're among our best
and I think this is a big area of improvement
because we've got so many vets coming back unemployed
who have the skills to get involved in the medical community
and so where are we going?
Treatment programs is the last thing left,
to talk about really.
There's four stages of treatment programs,
outpatient, residential, inpatient and detox
and I guess you could call it an escalating order.
I put a lot of words on here
because I didn't want to seem biased
about one over the other.
Those outpatient programs are typically,
it's referred to as intensive outpatient treatment
where you meet in typically a group setting
for two or three sessions a week
and then one or two sessions a week
with an independent, or an individual councilor.
Not all of these places offer medication assisted treatment.
They are kind of dispersed across all the city
in different parts of town.
The residential programs are also known as halfway houses
or supportive living.
These are places where there's no treatment onsite,
but it's a clean house, a sober community
to allow people to get out of their often unstable,
unsafe, drug filled or high drug prevalence housing
and get in somewhere that they can get some stability
for a few weeks to few months.
Try to get some time behind them in their recovery,
develop some coping mechanisms,
get some training, get a job,
give them a safe place to kind of get a new start.
If somebody needs more than that,
if they need a place that's gonna be a lot more focused
then there's inpatient treatment.
This is what we have a dearth of in Rochester.
Norris has probably the largest number of inpatient beds
and there's some inpatient at Unity and Conifer.
This is your classic admission.
When somebody is typically admitted for an addiction
this is one of the places.
It's not really hospital based,
but it's similar they've got nurses on staff,
they'll manage your medications for you.
They hold everything there, there's treatment on site.
Pretty rigorous program.
This, the largest limitation is,
whether your insurance will approve it
and how much of it they'll approve.
Sometimes it's limited to one to two weeks
and then they have to kind of transfer you
into another program.
The most intense level is detox.
We have one detox center here in Rochester,
it's Syracuse Behavioral Health.
Why it's called Syracuse Behavioral Health is beyond me.
I think the company started in Syracuse,
and they're going to be undergoing some expansions
in the next few years,
kind of adding on a little rapid access clinic
that it think is still in the process of being developed.
If you write down only one thing the entire time you're here
write down this website, I love this PDF thing,
there's actually a second page that comes with it.
Anytime I have a patient that I suspect
is either addicted, whether they realize it or not,
has a family member who is addicted,
realizes it or not,
wants treatment, doesn't want treatment,
maybe just something seems off about them
and I notice they have a lot of opiods, benzos,
what have you on their medication list.
This is a very non-threatening piece of paper
to include with somebody's discharge instructions
that's basically saying if you want treatment
for any of these things, these are the places you can go.
Contact information, who to call,
and websites to get more information.
So what is medication assisted treatment?
We're almost done.
Medication assisted treatment
is what addiction physicians like myself
are kind of specializing in.
Right now there's three main medications
that are used to assist in the recovery process,
methadone, buprenorphine and naloxone.
Methadone is the one that's been around the longest
as formalized recovery.
Unfortunately there's a tremendous amount of negative stigma
associated with methadone,
not everybody on methadone is grungy,
needle marked as you would suspect from pop culture.
There are plenty of people on methadone
who have re-assimilated into normal life,
who have jobs, who have gotten their kids back.
It works.
Typically it's a daily dispensing program.
Sometimes people will graduate
and get what are called take homes.
Sometimes if you do very well
and have recovered successfully
they'll get you a week of take homes.
The other option is buprenorphine.
Buprenorphine is an interesting medication
it finds the same receptor a lot stronger
so it will kick other opiods off the receptor,
but it binds to it in a way
that doesn't turn it on all the way.
So instead of turning that amp up to 11,
it turns it to like 4,
and so you get some activation,
keep you out of withdrawal, keep you from getting cravings,
but it doesn't get you high, it doesn't get you buzzed,
it doesn't impair you and it allows a lot of people
to feel normal again,
and it also provides a lot of mood stabilizing effect.
You'll see a lot of people in recovery have mood disorders,
whether that's because they originally had a mood disorder
that led to them using drugs
or if their drug use led to them developing a mood disorder.
We don't know but the buprenorphine
tends to help a lot with that.
It's typically started off as a,
either bi-weekly or weekly prescription
and as people continue to do better
most folks will graduate to coming in every month.
Occasionally I've seen people getting,
maybe two months at a time.
It's dosed once or twice a day, safe medication.
Naloxone is the classic antagonist,
it's got a very short half-life,
not a controlled substance, any physician can prescribe it.
For people who are in recovery
it's typically a tablet they take once a day.
And just basically blocks the receptor,
prevents you from using opiods.
There's a new great intermuscular injection called Vivitrol.
Basically it means you need to be responsible once a month.
If you can get yourself together once a month
to get your injection
then you can't use for the rest of that month.
I think it's a great idea.
But really everything we're talking about
is a symptom of a larger problem.
We don't just have an opiod problem,
we have a drug and alcohol problem.
All of the people who die from opiods
pales in comparison to all the people
who have tobacco and alcohol related illness in America
and I'm not up here on a soapbox,
I'm not getting preachy.
I realize it's not reasonable
to expect people not to drink, not to smoke,
it's so embedded in our culture.
Clearly prohibition did not work,
but there's gotta be a balance.
We have to find a balance between the two,
and I think our society right now
is struggling to reach that balance
and at the end of the day
remember all the people that you're seeing in treatment,
try not to refer to them as addicts.
I've made a point, or try to make point
throughout this not to say addict
because people are so much more than that,
they're people first and they're people who are struggling
or coping with addiction.
They can recover, I see it everyday.
People who get back into the world
who you would never expect three years ago were homeless.
Get their kids back, get their life back on track.
It works, we just need to give it a chance
and if I think we've got time for questions.
(audience applauding)
Yes?
- [Audience Member] Aaron thanks for the talk.
To what extent is the contraction of availability
of prescribed opiods translating
into increased precipitation of heroin?
- I'm not sure I understand the question, sorry.
- [Audience Member] There's a lot of effort
among prescribers and legislators to decrease access
to prescribe new--. - Oh.
- [Audience Member] And for those folks
who can't get prescribed the kind of things they used to
and have an increased access to them,
is this translating into then going for street dope?
- So the evidence behind that is quite as clear cut,
but there has been trends of increased heroin use
as the rates of prescribing have decreased.
Especially in our area, we had a couple of,
I don't want to call them pill mills,
but there were essentially a few pain docs
who had tons of patients on very large quantities of opiods
and when those docs got shut down
all the sudden prices on the street went up a bit for pills
and at the end of the day heroin is meeting the same need
that a lot of people were getting their Oxytocin for
only it's way cheaper,
like dramatically cheaper for the same fix,
and so it's not something we can point to
and say definitively yes,
these prescriptions are leading to heroin use,
but when you talk to people in recovery
it's a very common phenomemon
that most of them first started on pills,
either their own or a family members
and later advanced, not advanced that makes it sound good,
but progressed to using heroin.
Yes?
- [Audience Member] I'm certainly concerned
with like the anti-increase in hospitals
and I recently was one of those New Yorkers
who have prescriptions for an opiate
after not accepting surgery, but surgery.
And I did notice that the amount of pills
they were prescribing were much less
than when my daughter had a fractured ankle,
two years before.
But there was no instructions or anything
like well what they said you can't take it
more than every four hours
but they didn't say for the first two days
you might take it every four hours
then you should be down to maybe three times a day
you know what I mean?
It seems to me there's a lot of people
that would find your prescription.
- Yeah,
especially with antibiotics for example
we always tell people until you finish your prescription,
take it as instructed until you finish it
and I think as physicians
we have to sit back on our haunches
by saying you put the as needed on there, right?
Take as needed, well you're still having pain
so it seems needed so you take it
and that's how you get to the end
of your prescription really well.
I always kind of make the point to patients
when I do write opiate prescriptions,
I tell them stretch this out as long as you can,
like this is how many I'm gonna give you,
but honestly if you feel you need it more than this
and you want it for, you need to get a little pain relief
for seven days instead of the three days
that I'll write you to cover,
just take it less, it'll last you longer.
But yeah that's a very good point.
One of the other issues on that,
I was actually just talking to somebody outside beforehand
about disposing of medications.
Right now there's not very good systems in place
to dispose of medications.
They say like mix it up with kitty litter
or flush it down the toilet.
- [Audience Member] That is true.
Well actually if you go to continental agencies
opiods can be flushed down the toilet.
- Oh they can, they changed that now?
- Yeah. - Oh fantastic.
I was gonna say I was always told
don't flush them down the toilet.
- [Audience Member] But the other thing is
American National Association has recommended
not having pain as the fifth vital sign.
At the University of Rochester
is pain still listed as the fifth vital sign
on the nursing records?
- I was gonna say, I know it's still listed as a vital sign.
I think, yeah, actually the last I saw people in clinic
they wouldn't let me fill out their vital signs
unless I put a pain score in.
- [Audience Member] See, so that's something to do.
Try and change it.
- We'll run that up the flagpole.
Yep?
- [Audience Member] If the patient comes in
and they're either in detox,
or in withdrawal looking for detox,
or they're, or if they were to stop suddenly
they'd be at risk for withdrawal
and there's no beds available for them
at Syracuse Behavioral Health.
If they went to the ED in that condition
would they be treated for withdrawal?
- So yes they would be treated for their withdrawal.
I would be careful not to give them the impression
that they're going to be admitted
because especially if it's opiod withdrawal
it's pretty tough to actually get somebody admitted
for opiod withdrawal 'cause the general medical opinion
on the matter is it's not life threatening
so a lot of people say, "well at the worst
"you're going to feel really bad for the next few days,
"but as long as you keep in enough fluids you'll be fine."
And for the most part that's not incorrect.
There are a lot of adjunctive medications
that you can prescribe, Clonidine, Zofran, Phenergan
that can help with a lot of those symptoms.
Especially we're working on some new ways of addressing this
in the emergency department to hopefully try
to get people into outpatient recovery
or detox a little bit easier.
Hopefully within the next year or two the
kind of rapid access center
over by Syracuse Behavioral Health
will be up and running
and what they'll be able to do there
is patients can walk in
and they'll basically help triage patients
to whatever level of care is deemed appropriate,
what that patient requires.
To help them on that next step to their sobriety.
Does that answer your question, kind of?
Okay.
- Really great talk,
talking about preventative measures.
So you do refer people to counseling or services,
detox, halfway houses.
But thinking in the back of my mind it's really great,
but what about for deaf clients
as we need language access.
'Cause some places are really great
about including interpreters,
like here or the emergency room,
but once that stops deaf patients get really overwhelmed.
And a lot of deaf patients can't go doctor shopping
especially 'cause the need for words.
So what would you do to address that problem?
It would be nice if there was a public health class
for doctors talking about how to support or government,
money from the government,
address communication needs and access,
maybe a line added for that
'cause it's been really overlooked.
And when patients go into rehab
who pays for that kind of communication access,
but other than that you were great, wonderful.
- So this is a topic that's close to my heart.
So as a coda I grew up with deaf parents
and I understand there's only one center in Rochester
that has ready access to interpreters and that's Norris,
they don't have them on site,
but they have access to contact them to get there
and it makes it very very difficult.
I actually want to talk to you afterwards.
- But I'm also referring to national issues as well,
not just Rochester, I mean Rochester we are very fortunate,
we have a large deaf community,
we have strong hospitals,
they are really wonderful in providing resources,
but nation wide it's a real issue.
- But the fact that even here we don't have access.
There's a huge lack of access for deaf people
even here in Rochester.
So you can imagine there's even less nation wide.
It is a problem, you're right,
there's no good answer right now.
This is something I actually wanted to speak to you later
to talk about.
Yep?
- [Audience Member] Just a real quick question,
do you know of the patients that are prescribed,
emergency or outpatient, narcotics,
what percentage of them will eventually
become addicted to that narcotic in some way.
- That's a great question.
Based on that letter to the editor,
the number is less than 1%,
which we know is patently false now.
There's no good evidence on it quite yet
but the general thoughts
is that somewhere between one in 10 to one in 20 people
will probably develop some sort of misuse,
abuse or addiction stemming from that initial exposure.
A lot of people view addiction
kind of like an allergic reaction almost.
Most people are fine with peanuts.
Some people their body responds really badly to peanuts.
Most people are fine getting a dose of oxycodone
or Dilaudid when they're in acute pain.
It treats their pain, they feel better.
Pain goes away, meds go away, none the wiser,
but there are some people where their body
for whatever reason does not respond the same way
and they develop this craving for it,
this urge to get it again
and we think that's part of where the origins
of addiction come from.
Yep?
- [Audience Member] So remembering your map
that you showed us about prevalence
and about how bad in the southern states
and the Appalachian regions that's not a new addition.
The mentioning of the decreasing the,
how many pills available or at least
kind of trying to make that less available
but knowing those are some of the poorest areas
in the United States maybe bigger than that.
How do you sort of see that being managed
if you are decreasing the number
of addictive substances available
but then trying to have a methadone clinic
where they're going to have a viable option.
- So I think the viability of a methadone clinic like,
West Virginia would be pretty good.
There's a pretty high number of addicts
and as long as there's enough people
who are willing to go, Medicaid and Medicare
do pay for treatment at a methadone clinic.
I don't think that would necessarily be the issue
but I think I see what you're getting at
in terms of an area where resources are more scarce.
People are already dependent.
Maybe they don't have transportation
to get to recovery treatment,
maybe they don't have the means to afford their copay,
or you know, it is a real problem.
It's not an accident that impoverished communities
have higher rates of addiction,
the two kind of go hand in hand,
and there's no good answer for it as of yet.
I think expanding treatment availability.
There's some talk about modifying some of the laws
surrounding addiction treatment for rural communities.
In our area I know one of the issues
is down in the southern tier
people who want access to a buprenorphine clinic,
suboxone clinic, they have to drive an hour,
two hours, just to get to it
and if that's something you're expecting them to do
once or twice a week initially
that's a huge burden on a lot of people.
Yes?
(audience member speaking off mic)
I've become a skimpy prescriber.
So I think over the course of the past six months
as I finished residency and starting doing all of this
and started seeing a lot of the outcomes
it just made me start to think twice
about some of the medications I was prescribing,
whether they really needed to be done or not.
Especially out of the emergency department.
Admittedly we'll sometimes be a little cavalier
about some of the prescriptions we're willing to write
because we see it all you know?
We are very comfortable prescribing opiods
for the treatment of acute pain or acute injury
and it's easy to become complacent with it.
And sometimes we'll joke when patients get admitted
that we easily give them four milligrams of morphine,
no big deal, and the minute they're admitted
that dose is scaled back, it's for a reason.
It's definitely made me more kind of introspective
about the stuff I'm prescribing.
(audience member speaking off mic)
I don't know if I want them to or not.
I don't know if I want them to.
Yeah I guess ideally yeah,
right now you guys are watching me but,
it's tough to answer
because I'm still figuring out my own personal practice
and I will probably fluctuate a bit
over the course of the next year or two,
but I think this is something
that at the end of the day does matter,
in terms of preventing exposure
and so hopefully this will be a trend that progresses.
I thought you were, nope.
- [Audience Member] Really nice lecture,
could you maybe comment on
what you think the role of buprenorphine is
in the emergency department in the hospital,
maybe in the primary care clinic in helping?
- Yeah so buprenorphine
has the wonderful ability to take somebody
out of withdrawal without incapacitating them.
It's next to impossible to overdose on it.
It's an incredibly safe medication as I mentioned earlier.
Right now there are a lot of restrictions around
who can prescribe buprenorphine for addiction.
If you see somebody who has chronic mild pain
and they're using large doses of a painkiller
you can prescribe them buprenorphine for pain
and not need that special license,
you just have to be clear
that you're prescribing it to them for pain.
So often times we will use buprenorphine
in the emergency department especially with your oversight
to start people on buprenorphine,
to treat their withdrawal, usually with the transition
into and outpatient treatment clinic.
That's one of the things that we're working on
trying to improve right now
is trying to smooth that transition
so that patients can be seen as the young lady asked earlier
be seen in the emergency department
for their acute withdrawal,
be started on buprenorphine
and then be transitioned into a clinic
where they can be followed.
That ideally should be how we address this.
Not always feasible,
there's kinks we're working out right now.
Is there anything in particular that you?
(audience member speaking off mic)
Yeah I think it, I think there's certainly
room to grow in terms of its use because of how safe it is,
we certainly freely give out medications
that are far more dangerous
but I think it's just determining the system's in place
to make sure that we're not
just giving somebody a script for it with no followup plan.
- [Woman] Thank you very much.
(audience applauding)