Stanford’s Jordan Newmark, MD, on “Opioids and Back Pain”

Stanford’s Jordan Newmark, MD, on “Opioids and Back Pain”


JORDAN NEWMARK: Thank
you all for being here. This is a real
pleasure and a topic that I’m strongly
interested in, and I want to say thank you all
again for being here to listen. And I want to thank a couple of
particular people on the sides here. I’m a father of
relatively newborn twins, and I know how hard it is
to take care of children. And I see some people
here that have brought their babies and small
kids to participate, so I think it’s
great that we have families here to listen and to
take all this information in. And so I understand packing,
diapers, and strollers. It’s very hard to do, and
so just thank you for that, for those that did this. Anyways, we’re going to talk
about opioids and back pain, and I just need to figure
out how to advance. I’m assuming it’s this button. Ah, excellent. OK. So I have to stay here. OK. So you’ve heard a lot about the
interdisciplinary team-based approach when it comes
to pain management, and I just want remind everybody
of how important that is– that you need multiple
providers, physicians, physical therapists,
pain psychologists, other folks involved
in your care– to optimize your outcomes. And it’s unrealistic
to think that any one single treatment is going to
give you an optimal outcome. So it’s all about
patient-centered care with the team with
the patient’s goals and their functions in mind. OK. And we’re going to
get into why that’s important in the context of
opioids in just a moment. So again, I stole
this from Dr. King, who gave an outstanding
talk just a few moments ago. So you see, the
patient’s in the middle– Their particular problem,
their goals for function. And you see surrounding them in
smaller circles the physician, the physical
therapist, and the pain psychologist all
cross-talking to each other. That way, the right hand knows
what the left hand is doing and all of the care
can be coordinated. So keep that in mind as
I tell you about opioids. So this is an
image of explaining what an opioid actually is. That way, we’re all
on the same page. So an opioid is a
medication, such as morphine or hydromorphone or Vicodin. You may have heard
of these things, and they’re derived from the
opium poppy, which is a plant. It’s a flower, and you can
see up here the sap coming out of the flower. That is actually where
opioids are extracted from. And once those medications
are made off of that sap, these medications work in the
brain and in the spinal cord– what we call the “central
nervous system”– to try to quiet down any kind
of pain-related signaling or activity that’s occurring. So that’s how it
provides pain control, and opiates are an ancient,
ancient methodology and medication
for treating pain. It’s been around since 3000
BC, perhaps even earlier. And it’s a well-proven
way of treating pain. But as I said, that’s
just one particular tool of the many tools
that exist for pain. So it’s just a small
piece of the puzzle, and it’s unrealistic
to think that just one particular thing is going
to make a large outcome. Now, when it comes
to opioids, we need to think about–
what are the risks and what are the
benefits and what are the expectations
associated with it? We need to put it into
context, so we’re going to go through that right now. So what are the
benefits of opioids? Well, like I said, it’s
a true and through method for controlling pain. It’s an outstanding treatment
if you’ve had surgery, if you have what we
call an “acute injury” or an injury that’s fresh. For some patients,
for chronic pain that’s been going
on for a long time, it’s well-suited
for those patients also in certain
circumstances, but it always has to be put in the context
of a goal and a function. So when I prescribe
opioids, for example, I always tell the
patients, “Please use this medication in
conjunction with something that you’re doing.” So for example, if you’re going
to fly on an airplane for five hours to go on a
business trip and that’s going to be painful
for you, that’s an appropriate use
of the medication because it’s paired
with a function. Or let’s say you’re
in physical therapy and you’re having
trouble getting through that physical
therapy session. You pair the opioid with that
function or that activity. That way, you can get
more bang for your buck. I don’t think it’s
appropriate to use it and not pair it with a function. You’re just giving somebody
a sedating medication, but we’ll go into that later. So what are some of
the risks, and what are some of the
other things that we need to think about when
we’re talking about opioids? So it turns out that opioids
work on many different systems within the body, so I’m
just going to kind of go from head to toe and talk
to you guys about– what are the other systems that
are involved when opioids are introduced into your system? So starting up
top with the head. So they cause sleepiness. They cause sedation. That’s not always a
good thing because we’re trying to optimize
function and activity. OK. Other things to think about
are the cardiopulmonary system. So our heart beats with
a particular rhythm, lub-dub lub-dub. You’ve probably heard
people talk about this. So it turns out
that certain opioids can change the rhythm of your
heart while it’s beating, and so you have to
think about that if you have heart disease underlying
your health concerns. Other things opioids do are they
affect the respiratory system. They’re what we call
“respiratory depressants.” So they make your
breathing function go down, and that can be–
I hate to say– it could be very dangerous–
in some cases, even fatal. So we have to be extremely
cautious with patients when we dose the
opioids because we don’t want their respiratory system
to go down and, frankly, have people stop breathing. It’s a major problem. Other issues
working down further are the GI system, so
the stomach and the gut. Opioids are associated with
pretty bad constipation, so it’s something
to be aware of. They affect your
gut in that way. The skeletal system. They’ve been associated
with osteoporosis. So thinning of the bones,
weakening of the bones, making you more
prone for fracturing. So something that you
need to be aware of. And one other thing that I’m
going to spend a bit of time on is testosterone levels. Men and women both
have testosterone, and moderate to
high dose opioids will drop your
testosterone levels. And so let’s think
about this for a minute. Testosterone is a hormone
in your body associated with energy, with your
mood, with libido. And these are things that are
very important for optimizing your function. And so now, we’re talking
about a medication that could potentially drop that down. That is not conducive for
good pain management care. And so for my patients in
particular, I will actually, if they’re on a moderate
to high dose opioid, I will draw their
testosterone levels. And I’ll show it to them in
the clinic and say, “Hey, look. A normal person’s
testosterone is supposed to be at this level. Yours is actually lower. That could be contributing
to the dysfunction that you have or the lack of
energy, whatever it may be.” So it’s something that we
need to talk more about which doesn’t get enough attention. So with long-term
opioid, use I mentioned before that it
works in the brain and in the central
nervous system. It does a couple of
funny things over time that we’re going to talk about. So the first thing
that it does, it causes something called a “tolerance.” So what that means is
the more medication you take over
time, you need more and more opioid to get the same
effect that it once gave you. So in the beginning you take
a dose, you get a good effect. Over time, you need more
to get that same effect. And as you go up and up
and up on the dosing, some of those side effects
that we mentioned become more and more concerning. And so you may not be
getting the same pain control you once have, but your
risks are going up. So we need to be
aware of tolerance. And an associated
term with “tolerance” is called “cross-tolerance.” What that means is, if you’re on
a particular opioid– let’s say it’s morphine–
and then you decide to take a different opioid–
like hydrocodone– you will be tolerant to that
other medication, too, because
they’re very similar and your system has
kind of already seen it. OK. The other thing
that can happen is something called “dependence.” What “dependence” means is that,
without taking the medication, you go into withdrawal. And there’s many
medications in the world that cause dependence. So for example, let’s say
you wake up late for work and you miss your cup of coffee. Can any of you tell
me what will happen if you miss your cup of coffee? AUDIENCE: Yeah. Yeah. JORDAN NEWMARK: Yeah. Everyone’s shaking their head. Just shout out some
things that would happen. AUDIENCE: Headache. JORDAN NEWMARK: Headache. That’s a big one. So people that get headaches
by missing their caffeine have a dependence on it,
and that’s not anything kind of derogatory, so to speak. It’s just a natural
thing that occurs. It turns out opioids
have the same effect. So if you don’t
take your opioid, you will have
withdrawal symptoms. OK. So I think having
realistic expectations for what opioids can do and not
do for you is very important. OK. So I kind of
mentioned this before, but just to expect that a single
anything– a single injection, a single medication, a
single intervention– is going to make a major
impact on your pain, it’s just not realistic. You need that team-based
interdisciplinary approach, and so same goes for opioids. And what concerns me sometimes
is I see patients that tell me, “Well, I took this medication. It didn’t give me the effects. I’m going to go up. And when I went
up, it didn’t quite give me the effect
that I’m looking for. So I went up again.” And as I mentioned,
the more and more you go up without incorporating
the other modalities into your care, you’re
putting yourself at risk and you’re going to
have more side effects. So that is not optimal
pain management. OK. And what I tell my patients when
that situation is occurring is, “I really think that your pain
condition”– whatever it is, let’s say it’s back pain–
“for whatever reason, it’s just not responsive to
opioids and we don’t know why. So maybe you should
just back off, ween, and try something else because
you’re just putting yourself at risk for no good reason.” OK. OK. So like with any
high-risk journey– let’s say you’re going to fly
into outer space one day– you need flight verification. Going into outer
space is certainly a lot harder and more involved
than taking a red eye from LA to New York. But even with that, there’s
flight crosschecks that occur. There’s safety systems
that are in place. This is one thing that makes
opioids very unique amongst all the other medications
that we prescribe in the house of
medicine, is that we need a lot of
extra safety checks to make sure that you’re safe. So I’m going to outline what
some of those safety checks are for opioids. The first one is
informed consent. And so I’m going to ask you
guys– who’s ever filled out an informed consent form like
for surgery, for a procedure? Even for the flu shot,
sometimes you have to sign them. OK. I see a lot of hands, so people
know what informed consent is. I’m just going to outline
it for those who don’t know. Informed consent is a process. It’s a process by which the
clinician and the patient discuss very frankly the risks,
benefits, and alternatives associated with whatever risky
thing you’re going to do, whether it be a surgery or
a medication or whatever. Opioids are no different. So that conversation
needs to occur so that everyone is
on the same page, and it actually is a document
that is signed by the clinician and by the patient both. And then that’s filed
away and documented. So that’s informed consent. The next thing
that needs to occur is something that we call
“patient/provider agreements.” Sometimes, they’re called
“opioid contracts.” I personally don’t
like that terminology, so I just say
“patient/provider agreement.” And that basically
spells out the rules of engagement between
the clinician, the one that’s prescribing
the medication, and the patient who’s taking it. And the reason this is
important is because, again, these medicines are high-risk. And so one thing that these
contracts or patient/provider agreements often
say is you’re only going to get this medication
from one single source. Because if you’re getting
it from multiple sources and taking all of
that medication, you’re at risk for
overdosing and we don’t want that to happen. The other things
that are outlined in this document, the
patient/provider agreement, is expectations. So again, agreeing that, if this
medication isn’t working well for you, it’s not safe to
just keep going, going, higher, higher. Perhaps it’s better
to have an exit strategy to get off
of that medication and try something else. OK. Other systems that we use
for monitoring and for safety are quite a few. In fact, I think all 50
states now in our country have a database called a
Prescription Drug Monitoring Program. PDMP is the acronym. So what this computer database
does is all of the pharmacies that patients go
to, the pharmacy will send that information
to this website that clinicians can look at. So that way, we know
what medications you’re taking, who’s providing
it to you, and at what dosage. And that’s important
because, if I’m giving a patient an
opioid– which, again, is a risky medication–
I need to know if there’s other people
giving it at the same time. And if I don’t know
that, you’re at risk. OK. So you’ll probably
hear more and more about Prescription Drug
Monitoring Programs as time goes on. I believe it’s already
required in California, and it’s going to be
required for all clinicians in all states. So it’s kind of a
hot button topic. Two other systems
just to mention. One is urine drug
testing in the clinic. So it’s common for patients
that are taking opioids to have their urine
checked just to make sure that the medications
that we believe are there are truly there
and that there’s nothing else dangerous in the system. Because if those
things are found, that would make for an
important discussion between the clinician
and the patient to make sure that you’re safe. And then the last one is
in-office pill counts, so having the patient
bring their pill bottle to the clinic with whatever
medication is leftover and then you count
them together. This is an accounting
system to make sure that the medication isn’t
being consumed too quickly. Or if there’s a lot left
over, to maybe dose reduce because now you have extra
medication in your house that isn’t necessary. And we’re going to talk
about, in a couple of slides from here, why it’s important
to think about medications in your house and
the implications for medications in your
home and other people that may be in your home. OK. So just this week,
the FDA came out with a box warning
regarding benzodiazepines, which are sedative medications
often used for relaxation and for sleep, being
mixed with opioids. Because what happens
is, if you take opioids with other substances
that can cause sedation, they work together in
what we call “synergism.” So one plus one
doesn’t equal two. It equals more than two,
and so it puts patients at risk for
respiratory depression. So benzodiazepines
I just mentioned. Alcohol is another one. Never take your
opioids with alcohol. That is a recipe for disaster. OK. You’re going to have
that synergism effect and have both of
these substances reduce your breathing and
put you at risk for harm. So never ever do that. The other thing is if you
have a preexisting respiratory concern. So let’s say you’re developing
pneumonia, you have COPD, asthma, sleep apnea– which
is very common in our country right now– you
want to be extremely cautious with thinking about–
how does the opioid interface with that underlying pulmonary
problem or lung problem that you have? Because now, you
have multiple insults or multiple issues going on
with your respiratory system. So to be honest
with you, patients that I have that
develop pneumonia and they’re on opioids,
I want to know. Because during that
time frame, I’m going to reduce their
dose to keep them safer. So just something
important to be aware of. OK. So I just mentioned a
moment ago about medications in your house. You’ve got to make sure
that these medications are absolutely secure, that
they’re only your medication. They’re not to be shared. They’re not to be
used by anybody else. Because the other people
that are using them, we don’t know how they’re going
to respond to that medication. We don’t know what their
medical history is. Perhaps it’s a
teenager in the home. I don’t know if they
recognize that taking a lot of these pills
can do them harm, and so we don’t want people
around you and people in the community getting
harmed by these medications. So you’ve got to keep
them safe and secure, and they’re yours only. They’re not to be shared. So just to drive home
this one more time, pain management is a team sport. Optimal outcomes occur when
we have multiple clinicians, the physician, the
pain psychologist, the physical therapist,
and others all working together
and communicating to make sure that you have the
optimal care for your pain. And just to think that
any one single modality is going to make a major impact
is just not realistic. So you want to put opioids
and all other treatments that you’re in in context
of that bigger picture. That’s all I got. Thank you very much
for your attention. [APPLAUSE]

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