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Addiction, Health Policy, Pain, Public Health

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

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My recent trip to Washington D.C. to speak before a congressional subcommittee on the problem of opioid misuse was all about unmet expectations.

First of all, I never expected to get invited to testify for the U.S. Congress. A 2012 article I wrote in the New England Journal of Medicine on the problem of doctors over-prescribing opioids to patients was picked up by Washington Post journalist Charles Lane in a piece he did, “The legal drug epidemic,” which was subsequently read by Alan Slobodin, chief investigative counsel for the House Committee on Energy and Commerce. Slobodin then sent a message to my in-box asking to “discuss the opioid abuse problem.” I almost deleted it as a hoax. But Keith Humphreys, PhD, my mentor and chief of the mental health policy section in our department, assured me it was real.

Second, not really understanding how government works beyond what I learned from the animated musical cartoon “I’m Just a Bill” when I was seven years old, and being a regular reader of the New York Times, which has almost convinced me that everyone in Washington is against everyone else and nothing ever gets done, I prepared myself for the possibility that various members of the committee might just be looking for sound bites to support their pre-ordained opinions. I was wrong.

Slobodin and his staff were curious, earnest, intelligent, and dedicated to understanding the opioid problem at the deepest level. At the hearing itself, where I and other experts testified on the problem of opioid misuse, overdose, and addiction, Congressman Tim Murphy (R-PA), and Congresswoman Diana DeGette  (D-CO) didn’t go for each other’s jugular like a couple of vampires out of Twilight, which I thought might happen. Instead, they were courteous, collegial, and again, struck me as truly dedicated to ameliorating the problem of addiction in this country.

Third and finally, I didn’t imagine that my testimony would make much of a difference, yet some of my suggestions were picked up by members of the committee, including Bridgette DeHart, a senior policy advisor for Congresswoman Yvette D. Clarke (D-NY). DeHart is a whip-smart young woman who in ten minutes of conversation conveyed to me her sophisticated understanding of the opioid epidemic. She talked about incorporating one of my suggestions – mandating physician education on the use of Prescription Drug Monitoring Databases (PDMDs) at the time of DEA-licensure – into a larger bill that Clarke and her team are working on.

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Aging, Medicine and Society, Pain, Palliative Care, Patient Care, Stanford News, Videos

“Everybody dies – just discuss it and agree on what you want”

"Everybody dies - just discuss it and agree on what you want"

Earlier this week, my colleague pointed to a New York Times essay penned by VJ Periyakoil, MD. In it, Periyakoil calls for a role-reversal in talking about end-of-life issues and encourages patients to take the lead in starting such conversations with their doctors. “Without these conversations, doctors don’t know what the patients’ goals are for living their last days,” she writes. “What are their hopes, wants, needs and fears? Do they want to die at the hospital connected to a machine? Do they want to die at home? The current default is for doctors to give patients every possible treatment for their condition, regardless of its impact on the patient’s quality of life, the cost or the patient’s goals.”

Periyakoil goes on to describe a letter that she and her colleagues created to help facilitate these patient-doctor conversations. The video above expands upon the Stanford Letter Project, which helps patients map out what matters most to them at the end of life, and includes the candid thoughts of numerous older adults.

“If I’m brain-dead, unplug me,” one woman says matter-of-factly. “And I want to die painless. No pain – just put me to sleep and don’t let me wake up.”

In the doctor’s office, one man shares his reason for writing a letter and expressing his wishes: “One of the worst things in the world that you can have happen [is you’re on] your deathbed and you’re putting the burden of life-altering decisions on a family member that has no clue of what you really want or don’t want.”

Advises another older man: “Don’t be ashamed of it – everybody dies. Just discuss it and agree on what you want.”

Previously: How would you like to die? Tell your doctor in a letter, In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues, Study: Doctors would choose less aggressive end-of-life care for themselves, On a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions

Aging, Pain, Palliative Care, Research, Stanford News

How would you like to die? Tell your doctor in a letter

How would you like to die? Tell your doctor in a letter

writing a letterAsking patients how they would like to die is not a question that comes easy to most doctors. Not surprisingly, most of us – doctors and patients alike – prefer to avoid the topic completely. That’s not good, says VJ Periyakoil, MD, director of palliative care education and training at Stanford.

As I wrote in an Inside Stanford Medicine article on Periyakoil’s new study on end-of-life conversations:

End-of-life conversations help clarify for doctors what matters most to patients in their waning days of life… “What are their hopes, wants, needs and fears? Do they want to die at the hospital on a machine? Do they want to die at home? We can’t know unless we have a conversation,” she said.

Her study, published today in PLOS One, surveyed more than 1,000 medical residents and found that most balk at talking with seriously ill patients about what’s important to them in their final days, especially if the patient’s ethnicity is different than their own. Of those surveyed, 99.99 percent reported barriers, with 86 percent rating them as very challenging.

The upshot for Periyakoil, as she explains in a New York Times column published today, is that if we want to have a say in how we die, we should start that conversation ourselves.

To get these conversations started far and wide, she has launched the Stanford Letter Project – a campaign to empower all adults to take the initiative to talk to their doctor about what matters most to them at life’s end. The project’s website hosts templates for a letter about this to your doctor to get the conversation rolling. The templates are in Mandarin, Spanish and Tagalog as well as English – and Periyakoil says translations in additional languages will be available soon.

Previously: In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues, Study: Doctors would choose less aggressive end-of-life care for themselvesAsking the hardest questions: Talking with doctors while terminally ill, On a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions
Photo by Gioia De Antoniis

Addiction, Events, Pain, Patient Care, Public Health, Stanford News

The problem of prescription opioids: “An extraordinarily timely topic”

The problem of prescription opioids: "An extraordinarily timely topic"

photo (2) 2Suffer from pain? Or become an addict? Bemoan the epidemic of pain? Or decry the epidemic of opioid addiction?

At first glance, pain and addiction appear to conflict, to occupy distinct never-overlapping planes. But in reality, pain and addiction anchor two ends of a spectrum, with a lot of gray area in between, said Anna Lembke, MD, director of the Stanford Addiction Medicine Program.

Lembke and Sean Mackey, MD, PhD, chief of pain medicine, squared off in a good-natured debate of sorts moderated by chief communications officer Paul Costello last week at a Stanford Health Policy Forum on “The Problem of Prescription Opioids.”

“This is an extraordinarily timely topic,” Dean Lloyd Minor, MD, said in his introduction. “These issues really reflect a dilemma of wanting to bring the best compassionate care and science to our patients, yet also needing to respect the adverse effects that can occur.”

The statistics on both sides are sobering. The two experts told the audience that in the U.S., more than 16,000 people per year die of opioid overdose and 100 million people live in pain.

And both Lembke and Mackey shared harrowing tales of the suffering of their patients. Lembke once was called to consult on a women suffering from low back pain who had a opioid addiction identified by two previous psychiatrists. Yet in the exam room, the patient threatened to sue if she didn’t receive an opioid prescription, Lembke said. Cases like that prompted her to pen a provocative 2012 essay titled “Why doctors prescribe opioids to known opioid abusers.”

But Mackey treats patients who are suffering deeply, including a woman whose foot injury from a vehicle accident morphed into a pain syndrome affecting her upper extremities.

The current opioid addiction problem stems from a historical pattern of failing to treat pain, even in dying patients, Lembke said. Yet the pendulum swung too far and now doctors feel obligated to prescribe drugs such as opioids, she said.

At the Stanford Pain Management Center, teams of specialists work together to treat pain as a complex condition that affects many parts of the body and mind, Mackey said. Patients are treated with physical therapy, psychiatry and a variety of other specialties to try to allow them to participate in meaningful life activities, he said.

Although care at Stanford is top notch, it is an outlier and thousands of other patients are exposed to poor pain management practices. In addition, pain is now widely recognized as a disease, but addiction remains stigmatized, Lembke said.

When doctors recognize a opioid-seeking patient, they should treat the addiction, not boot the patient out of their practice.

Lembke and Mackey stressed that education about both pain and addiction ought to receive increased attention in medical schools. And patients need to take a role in treating both their own pain, and their addictions, they said. They do share common ground, Lembke said.

“All we think about every day is how we’re going to do it better,” Mackey said.

Previously: Assessing the opioid overdose epidemic, Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Is a push to treat chronic pain pressuring doctors to prescribe opioids to addicts?, Why doctors prescribe opioids to patients they know are abusing them and Study shows prescribing higher doses of pain meds may increase risk of overdose
Photo by Becky Bach

In the News, Pain, Patient Care, Research

More benefit than bite: Potential therapies from “pest” animals

More benefit than bite: Potential therapies from "pest" animals

512px-Scary_scorpionA painful spider bite can make you question why such creatures exist. Yet just because “pests” like spiders, scorpions, and snakes lack the appeal that kittens and puppies possess, it doesn’t mean they aren’t important or useful.

Yesterday, an article from Medical News Today drove this message home by highlighting some of the medical benefits we derive from six of the creatures we tend to complain the most about. As writer Honor Whiteman explains in the story, scientists are exploring ways to use toxins and substances produced by so-called pest animals, such as spiders scorpions, and reptiles, to treat chronic pain, repair nerves, and develop new ways to kill the human immunodeficiency virus.

From the piece:

In 2013, MNT [Medical News Today] reported on a study published in Antiviral Therapy, in which researchers revealed how a toxin found in bee venom – melittin – has the potential to destroy human immunodeficiency virus (HIV).

The investigators, from the Washington University School of Medicine, explained that melittin is able to make holes in the protective, double-layered membrane that surrounds the HIV virus. Delivering high levels of the toxin to the virus via nanoparticles could be an effective way to kill it.

A more recent study published in September 2014 claims bees may also be useful for creating a new class of antibiotics. Researchers from the Lund University in Sweden discovered lactic acid bacteria in fresh honey found in the stomachs of bees that has antimicrobial properties.

The story cites several other potential uses for venoms and animal-derived substances, such as my favorite example, Gila monster spit:

In 2007, a study by researchers from the University of North Carolina at Chapel Hill School of Medicine revealed how exenatide – a synthetic form of a compound found in the saliva of the Gila monster, called exendin-4 – may help people with diabetes control their condition and lose weight.

The compound works by causing the pancreas to produce more insulin when blood sugar is too high. In the study, 46% of patients who were given exenatide in combination with diabetes drug metformin had good control of their blood sugar, compared with only 13% of control participants.

As Whiteman explains in the article, many of these potential medical treatments are still in the early stages of development. Yet some therapies, such as the synthetic version of the compound found in Gila monster saliva, exenatide, are already in use, offering hope that other animal-derived medical treatments may be available in the future.

Previously: Tiny fruit flies as powerful diabetes modelFruit flies headed to the International Space Station to study the effects of weightlessness on the heartBiomedical Indiana Jones travels the world collecting venom for medical research and Tarantula venom peptide shows promise as a drug
Photo by H Dragon

Pain, Patient Care, SMS Unplugged

Comfort care: “We always have something to give”

Comfort care: "We always have something to give"

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

15952622460_20fb32e76a_z A hospital can be full of discomfort. My patients tell me that the food is unappetizing. The beds hurt their backs. The noise echoing through the hallways at night makes it impossible to sleep. And for those patients near the end of life, the treatments being offered may no longer be of benefit, causing more pain than good.

The answer to discomfort for those who are very ill is comfort care, the use of palliation when life-advancing measures are no longer indicated or desired. These measures include things like giving morphine to dull the pain and ease the breath, applying lip balm over cracked skin, offering ice chips to revive the mouth, adjusting blankets or fans, deciding not to press on someone’s chest, to stifle their airways with tubes, if their status declines. The decision to turn to comfort care often means that a patient can receive a private room in the hospital for family to stay close, to feel sunlight through a window. The triumph of comfort over the many indignities of being away from home.

Death does not need to happen in a hospital, yet too often it happens here. In January, I saw two people die. One was old. He had lived a full life; his room was decorated with photographs from his youth, his tall form in a service uniform, or in a tuxedo on his wedding night, half-cropped face suspended in a laugh.

When I met him, he was on a morphine drip, no longer able to speak. To gauge the adequacy of his pain control, we looked at his heart rate, his blood pressure, scouring for signs of bodily agony. He was tucked into a warming blanket, yellow hospital socks on his feet. Every morning we circled around him, whispering hello into the room where he slept, taking stock of the fluorescent etches of the vital signs monitor, the coolness of his legs.

When he passed, we pronounced him after checking for a pulse and listening for a heartbeat. I felt solemn, but also grateful for his smooth passage.

The second person I saw die was young. She had been full of life and her death ripped up all those who loved her. As she became more ill, and more confused, her family made the brave decision to transition to comfort care. There was nothing gratifying about it, her loss was unspeakable. But perhaps the final moments, free from the blinking of machines, the infusion of drugs that upset her bowels and irritated her veins, carried a dim current of peace.

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Events, Pain, Stanford News

Advances in diagnosing and treating a painful and common jaw disorder

Advances in diagnosing and treating a painful and common jaw disorder

3439490784_46b2cfd9e3_zOn New Years Eve, Australian rapper Iggy Azalea shared with her Twitter followers that she was diagnosed with a temporomandibular joint dysfunction (often referred to as TMD or TMJ). The singer is among the estimated 10 million Americans who suffer from the condition, which is more common in women than men and people ages 20 to 40.

Symptoms of the disorder include a stiffness of jaw muscles, limited movement, clicking or locking of the jaw and radiating facial pain. It was previously believed that problems with how the teeth fit together or the structure of the jaw caused the condition. But in talking to Michele Jehenson, DDS, a clinical assistant professor at the Pain Management Center at Stanford, I was told, “There is still a lot we do not know about what causes [temporomandibular joint dysfunction] but one thing we do know is that they are not caused by upper and lower teeth misalignment or improper jaw position. We now believe that TMD susceptibility is, at least, partly genetic.”

Since the causes of the TMD are not clear, diagnosing the condition can be challenging. Currently, there is no standardize test for providers to use to diagnose patients, so physicians continue to rely on the clinical evaluation, including palpation, range of motion and auscultation. But imaging technologies are starting to play a more important role. Jehenson noted, “We now have more accurate imaging such as cone beam CT scans or MRIs. Some dentists use joint vibration analysis or EMG, but these electronic sensors have been shown to be unreliable and lead to over diagnosis.”

Over the past two decades, there as been a significant amount of research on the outcomes of TMD treatments. As Jehenson told me:

Evidence is very clear that aggressive and non-reversible treatments for TMD (braces, jaw surgery, crowns, full time wear of appliance, jaw repositioning) are rarely indicated. The best treatments should be conservative. Depending on the case, treatments are usually a mix of medication (oral or topical), nighttime appliance wear, injections, physical therapies, behavior modification and counseling, sleep and stress management.

To learn more about the diagnosis and treatment of TMD, join Jehenson for a Stanford Health Library talk on Thursday at 7 PM Pacific Time. During the event, she’ll l further discuss evidence based versus non-evidence based treatments. Those unable to attend in person can watch the talk online.

Photo by Eric Allix Rogers

Addiction, Pain, Public Health, Research

Medical marijuana and the risk of painkiller overdose

Medical marijuana and the risk of painkiller overdose

medical marijuanaAfter a study published this fall showed that that opioid overdoses (e.g., with painkillers such as Oxycontin) occur at lower rates in states with legalized medical marijuana, many people interpreted the results as proof that using medical marijuana lowers an individual’s risk of overdose. For example, some speculated that marijuana allows people in pain to forgo using opioids or at least use them in lower doses. Other suggested that medical marijuana reduces users’ consumption of alcohol and anti-anxiety medications, both of which make opioid use more likely to lead to overdose. Still others hypothesized that medical marijuana improves mental health, reducing the risk of intentional opioid overdose (i.e., suicide attempts),

However, all of this speculation was premature. Many things that are associated when geographic areas are compared are not associated in the lives of the individuals who reside in those areas. For example, geographic areas with higher rates of cigarette smoking and higher radon exposure have lower cancer rates, even though individuals who smoke and/or get exposed to radon have higher rather than lower risk of cancer.

The only way to understand the influence of medical marijuana on individuals’ risk of opioid overdose is to actually research individuals, and that is what an Australian team has done. In a recently published study of more than 1,500 people who were on prescribed opioids for pain, they examined experiences with medical marijuana.

Seeking pain relief from medical marijuana was common in the sample, with 1 in 6 participants doing so and 1 in 4 saying they would do so if they had ready access to it. The results did not support the idea that medical marijuana users are at relatively low risk of opioid overdose. Indeed, on every dimension they appeared to be at higher risk than those individuals who did not use medical marijuana for pain.

Specifically, relative to individuals who only used opioids for pain, the medical marijuana users were on higher doses of opioids, were more likely to take opioids in ways not recommended by their doctor, were over twice as likely to have an alcohol use disorder and four times as likely to have a heroin use disorder. Medical marijuana users were also over 50 percent more likely to be taking anti-anxiety medications (benzodiazepines), which when combined with opioids are particularly likely to cause an overdose.

Neither did the medical marijuana users have better mental health. Almost two-thirds were depressed and about 30 percent had an anxiety disorder.   These rates were half again as high as those for non-medical marijuana users.

Medical marijuana thus appears to be commonly sought for pain relief among people who are taking prescribed opioids for pain. But in this population, it’s a marker for much higher rather than lower risk for opioid overdose.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He has served in the past as a senior advisor in the Office of National Drug Control Policy in Washington, DC. He can be followed on Twitter at @KeithNHumphreys.

Previously: Assessing the opioid overdose epidemicTo reduce use, educate teens on the risks of marijuana and prescription drugs and Study shows prescribing higher doses of pain meds may increase risk of overdose
Photo by David Trawin

Health Costs, Pain, Public Health, Research

Study examines trends in headache management among physicians

Study examines trends in headache management among physicians

4175034274_63cd0d4a7c_zAn estimated 12 percent, or 36 million Americans, suffer from migraines, resulting in an economic loss of $31 billion each year due to lost productivity, medical expenses and absenteeism.

Making lifestyle changes, such as exercising regularly, getting adequate sleep, reducing stress and cutting food triggers from your diet, have been shown (.pdf) to be effective ways to manage headache symptoms. But research recently published in the Journal of General Internal Medicine shows that physicians are increasingly ordering medical tests and providing referrals to specialists instead of offering counseling to patients on how changing their behavior could relieve their pain. Medical News Today reports:

The study, which analyzed an estimated 144 million patient visits, found a persistent overuse of low-value, high-cost services such as advanced imaging, as well as prescriptions of opioids and barbiturates. In contrast, the study found clinician counseling declined from 23.5 percent to 18.5 percent between 1999 and 2010.

The use of acetaminophen and non-steroidal anti-inflammatory drugs like ibuprofen for migraine remained stable at approximately 16 percent of the medications. Meanwhile, the use of anti-migraine medications such as triptans and ergot alkaloids rose from 9.8 percent to 15.4 percent. Encouragingly, guideline-recommended preventive therapies – including anti-convulsants, anti-depressants, beta blockers and calcium channel blockers – rose from 8.5 percent to 15.9 percent.

Unlike with the treatment of back pain, researchers found no increase in the use of opioids or barbiturates, whose usage should be discouraged, although they were used in 18 percent of the cases reviewed.

Researchers also found a significant increase in advanced imaging such as CT scans and MRIs, from 6.7 percent of visits in 1999 to 13.9 percent in 2010. The use of imaging appeared to rise more rapidly among patients with acute symptoms, compared to those with chronic headache.

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Pain, Science, Stanford News, Videos

Graduate student explains pain research in two-minute video

Graduate student explains pain research in two-minute video

Earlier this year I wrote about some fascinating research from the lab of chemist Justin Du Bois, PhD, who has been working with naturally occurring toxins with the goal of developing ways of combatting pain. This class of toxins is found in a number of poisonous animals, including the newts scurrying around Stanford campus, puffer fish and mollusks in red tides.

Now, graduate student Rhiannon Thomas-Tran, who has been working with Du Bois, produced a great video describing their approach, complete with some pretty creative drawings.

Previously: Toxins in newts lead to new way of locating pain

Stanford Medicine Resources: