Navigating the opioid crisis

Listen to this episode for an up-to-date overview on opioid crisis from guest Bobby Mukkamala, MD, chair of the American Medical Association’s Substance Use and Pain Care Taskforce. Dr. Mukkamala talks to host Alex McDonald, MD, of the Southern California Permanente Medical Group, about the latest data, systemwide steps to create change, and clinical strategies that can help doctors balance pain management with addiction prevention.

Guest

• Bobby Mukkamala, MD, Chair, American Medical Association Substance Use and Pain Care Taskforce

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Welcome everyone to today’s PermanenteDocs Chat. I am your host as always, Alex McDonald. I practice family and sports medicine here in Fontana, California. In this week, we are joined by Dr. Bobby Mukkamala, who is president-elect of the American Medical Association. He’s also the chair of their Substance Use and Pain Care Task Force, and really a very strong voice on evidence-based policies to curtail the opioid crisis. So Bobby, thank you for joining us. Bobby, let’s start by telling us who you are and what you do.

Bobby Mukkamala, MD: Thanks, Alex. I’m a private practice otolaryngologist here in Flint, Michigan. It’s the town that my parents moved to from India back in 1970, and I share this home office and my office with my wife Nita, who’s an ob-gyn. As you mentioned, I’m serving as president-elect of the American Medical Association. But before that position, I had the honor of serving as chair and continue to serve as chair of our work related to substance use disorder and pain care. A lot of people question why is an otolaryngologist in this role as chair of this work related to substance use disorder. Some of that reason was that many years ago I got my X waiver to prescribe buprenorphine, and I did that just because a lot of our advocacy work is around pain control and substance disorder management.

As we started to see our country going in the wrong direction, I just didn’t feel comfortable as a leader within the AMA saying you should get your X waiver, not knowing what that was like to do it myself. So I got my X waiver. And I think that got the attention of folks within the AMA saying, hey, non-pain physicians embracing this work and the collective group of physicians embracing this work is how we will move in the right direction. So that’s how an otolaryngologist gets to chair this work at the AMA.

Where we’re at navigating the opioid crisis

AM: I love that, putting your money where your mouth is, so to speak, leading by example. And as a physician in a leadership role, that’s so valuable. Well, let’s start by telling us where we are right now with the opioid crisis. Are there glimmers of good news this year, where we’re still at a hundred thousand overdose deaths? Can you talk about where we are in the opioid crisis and are we making progress?

BM: The latest news is great, with approximately 10,000 fewer deaths. Clearly we’re going in the right direction. What’s interesting about the latest data is that we’re still not sure why. Is this because of efforts? Because of conversations like this? Maybe it’s because of naloxone? Or is it because we are decreasing the amount of illicit substances that are coming into this country? Is it better treatment? We don’t know yet, but what I would say is that we’ll take it , that’s 10,000 more people that are alive today than would’ve been had we not had this change in trajectory. So where we are is a step in the right direction, but there’s still a ton of preventable deaths related to opioids. The first thing to do is we have an obligation to do better. We shouldn’t just say, okay, we’re going in the right direction and we can take our foot off the gas.

We need to continue in this work because otherwise, especially when we don’t know why, this could go easily in the wrong direction. Next year, statistics could be worse. The other thing is that the vast majority of these deaths [under age 24], 80% are due to illicit fentanyl. That’s been the case for years. In addition to that, cocaine and methamphetamine [are] surpassing prescription opioids as far as the cause of these deaths, and it’s been that way now for many years. Yet the focus seems to continue to be on prescription opioids. There’s still so many programs and hospitals across the country looking at prescription opioids and trying to restrict how many opioids we write for our patients. And there’s a consequence to that; patients with real pain are suffering with pain. That’s why our task force that used to be pain management and substance use disorder separately, is actually the substance use disorder and pain care task force. So what we do over here to try to decrease the burden of substance use disorder isn’t leaving people out in the cold, so to speak, as far as their pain management goes. So that’s why it’s critical to have that conversation in the same room so we know what the consequences of those things are.

Challenges in prescribing opioids for pain management

AM: That is such a great point. There’s so much emphasis, especially for us as physicians, to prescribe for opioids to minimize even initial refills or don’t even start it. But the fact that so much of this is really coming from illicit use and use disorder [is] the bigger challenge. And to your point about the unintended consequences, one of my colleagues here who practices hospice and palliative medicine is having trouble getting opioids for his patients. So we’re having to struggle with a limited supply of these medications because of manufacturing restrictions, and now we’re having to choose, okay, can we give these medications for acute pain? Do we have to save them for those who have palliative and hospice? And it brings up a lot of ethical challenges for those of us who practice on the front lines.

BM: Yeah, absolutely. It’s just so interesting that there was a time [when] there was litigation associated with pharmaceutical companies pushing opioids. I remember people coming to my office when I first started my practice talking about the latest narcotic pain medication for post-tonsillectomy pain — a really rough procedure to recover from — and talking about how the opioids that they have aren’t addictive. And now we know how wrong that was. So to go from that point to now, for those post-tonsillectomy patients, to have to go to 3 different pharmacies in the Flint area to get a prescription filled and not having it be in stock because we use a liquid narcotic pain medication for adults after tonsillectomy, it’s just really hard to find. And so now they’re back to crushing tablets and things like that.

So we’ve gone from one bad situation to another bad situation where patients with pain, acute pain, post-surgical pain, are struggling in the way that you’ve described, in addition to people with chronic pain. And having to ration that is just not where we should be. That’s exactly where people will seek other means. It’s something that needs treatment, particularly acute pain. So in that situation, people will oftentimes use illicit substances to control that real pain. And that’s not at all where we want to go.

The problem of illicit fentanyl

AM: My next question is by limiting the spigot on this side, how much are we causing the flood over here? And can you delve into that stat a little bit more, that 80% of drug overdoses are due to illicit street drug use? Is that correct?

BM: Absolutely. Illicit fentanyl is the number one cause of that. Then there’s also cocaine, there’s methamphetamine, other smaller segments, xylazine. It just seems like every year our pain care task force is always looking at what’s coming around the corner into our communities, what can we anticipate? And it’s never a dull moment, unfortunately, because it’s constantly changing, what’s laced with what. Again, this isn’t something that’s getting dispensed, 30 tablets in a prescription cup, at the pharmacy. This is anybody’s guess about what’s happening in these communities.

It is illicit substances, but not necessarily something with predictability. Like, okay, if it’s this color pill, it’s going to be this percentage. Rainbow fentanyl is something that was on the streets that’s still on the streets, that who knows how much fentanyl is in this stuff. And that’s why people that are trying their best to recover from their substance use disorder and then have a relapse, and then go out and use something, are oftentimes at the highest risk of dying and overdosing from that because they just don’t know what they’re getting.

The many factors driving the opioid crisis

AM: That’s something I don’t think we realize necessarily, specifically those of us who don’t [encounter it] in our everyday work. As a family physician, I treat patients with pain and chronic pain, and I do use some opioids, but I don’t really get a lot of exposure to the use disorder world and the ramifications downstream. I think some people argue that the opioid crisis really represents a failure of the health care system, not to put too strong a point on it. Do you agree with that and what does that mean for us as a physicians regarding how we approach treatment, patient education, and effective pain management?

BM: In short I disagree. I would say that it’s multifactorial; it’s an epidemic with many causes and the health care system is a convenient scapegoat sometimes. We need to look at particular elements to identify what needs to change. And sure, as physicians, we’ve learned a lot in the past. It used to be when I was in my training, every person that got their tonsils taken out got a prescription for Tylenol with codeine elixir regardless of age and with a bunch of refills. Now I know that if they’re under 18, Tylenol and Motrin work just as well. So we avoid narcotic medication. And even those adults, for every surgical procedure, we realize that dispensing 30 with 3 refills, the average person takes less than a third of that. And so that sits in a medicine cabinet.

So there is a responsibility for health care to be introspective, see what it is that we’re doing, and what needs to change based on data. But beyond that, we’re just one part of this system, insurers are another big part of that system, and things like prior authorization that leads to delay in denial of care. Every person listening today knows how hard it is to find care when somebody needs it. The premium dollars that we spend that are tightly held by insurance companies to delay and deny that care. And that’s why it’s critical that we continue to push and say, look, if physical therapy is something that’s going to be useful for this patient to deal with their pain, and that physical therapy is something that is either denied or something that is limited in how often they can get it or for the duration that they can get it, that’s not serving this patient well. That pain is real, and if the only other alternative is an opioid medication that we want to avoid, then don’t have us go through the hurdle of prior authorization to do what’s best for that patient. And that’s what we see so much, that the prior authorization burden in health care in general, but particularly as it relates to management of somebody’s pain, is something that really is a headwind in going the direction that we want to go, which is to take better care of these patients.

AM: Your point regarding opioids being one tool in the toolbox of the myriad of treatment options we have for both acute and chronic pain, I always tell patients that when I am prescribing an opioid, I go through all the risks and benefits and I say, look, this is part of a comprehensive pain management strategy. We need you on your SNRI, we need you on Motrin and Tylenol as first line, we need you on perhaps a neuroleptic medication. We need you on physical therapy, really making sure that we are using all the tools in our toolbox versus just one which can obviously have all these downstream consequences. And I think the word is getting out to physicians, but as you said, there’s all these barriers to making sure we focus on non-opioids as part of a comprehensive approach.

BM: Absolutely. When the toolbox that’s right in front of us that’s unlocked has a Phillips head and a regular screwdriver, but what we need is a hex wrench and it’s in a locked toolbox over there, that doesn’t do us much good. The same way, if prescribing opioids is something that we can do, but prescribing physical therapy or other sort of pain care for those patients with chronic pain, a procedure, if that’s something that has a hurdle to get to and it’s going to take months, this patient’s in pain. It’s not like a crooked nose that I deal with. Somebody that’s been stuffy and can’t breathe through the left side of their nose for years, OK, prior auth isn’t great for them either, but it’s not going to have the consequences of a prior auth for somebody that is dealing with acute pain or chronic pain that is now waiting to get the appropriate procedure because of the burden of prior authorization. That’s just not right.

How naloxone is helping curb overdose deaths

AM: I completely agree with you. You mentioned several different things which may be helping curtail this opioid crisis and the overdose deaths, and I think one of the biggest things right now that’s becoming more commonplace is the use and availability of naloxone as a rescue medication for patients who may be overdosed. You can get it someplace without a prescription. Do we think this is working? Do you think that’s a piece of the puzzle? And do we see that some people might see that as a safety net and say, oh, well, it’s not as big a deal, you can just take Naloxone if you have problems or if you take too much. How should physicians begin to address some of the concern? I see this a lot in my HIV population or patients who are high risk of HIV, they just want to take pre-exposure prophylaxis and then they don’t use contraception and have a higher risk of contracting HIV, [as] one example. Are we worried about that in some respects or we’re not quite there yet?

BM: I’m not worried about that because naloxone, it’s not a safety net. It’s an evidence-based, time-tested medication that saved hundreds of thousands of lives over the past decades. The myth of reliance on naloxone is like the myth that seat belts encourage risky driving, “I’m going to drive poorly because I’ve got a seatbelt.” All physicians should offer a prescription for naloxone. You don’t even need it now because it’s over the counter.

AM: Exactly.

BM: And that’s a wonderful development. I guess one side note there is that it’s over the counter, but at 50 bucks a packet it’s prohibitive for a lot of people. I know there’s a lot of community programs to do that, but it sure would be nice to see that price come down. But for example, at AMA headquarters in D.C. where we have our advocacy office, we have naloxone available on every floor there at the AMA building, and we haven’t had to use it. There hasn’t been an overdose at the building, but Union Station is literally a few buildings down the street, so if it’s available, hopefully we’ll never need it, but it’s good to have it. Just like you go to any airport and you’ll see the defibrillators. It’s just the fact that we had defibrillators, we were having people figure out how to shock people back into a normal rhythm at the same time where we said, this nasal spray is going to be prescription only. And I think it’s that kind of argument that got it to be over the counter, where if we can shock people out of an arrhythmia, you can certainly spray them up the nose with the naloxone if they’re having an overdose.

But getting back to the safety net thought and the inadvertent encouraging use by having it be readily available, I would say does having an EpiPen available make somebody with a peanut allergy say, I’m just going to have that peanut butter and jelly sandwich? They just don’t do that, there’s no way they would do that. So in the same way, having Narcan isn’t going to make somebody with a substance use disorder and addiction say, oh, I’m just going to take it because I know I’ve got Narcan. It’s good to have it for sure, but this isn’t something that’s a choice. This is something that’s a medical condition, this is an addiction. It’s the dependence that needs to be treated, and I don’t want us to get too hung up and thinking that having the naloxone available is going to somehow make them less likely to pursue a solution. There’s a lot of examples now in emergency departments where, yes, we will save their life with naloxone, and pray that we do. But instead of just sending them out the door, let us get them hooked up with something like buprenorphine treatment, get them plugged into a clinic, hand them off to the next person to receive them. So it doesn’t become a revolving door of just saving their life with naloxone until we can’t.

AM: It’s teaching them to fish versus giving them a fish, is the example I use a lot of times with my patients, to make sure that we give them the tools that they can then be successful and healthy and don’t end up back in the emergency room or wherever they may end up being.

BM: Absolutely.

Current strategies to combat the opioid crisis

AM: Of all the strategies which are currently being implemented to combat opioid addiction and the epidemic of overdose, what are the most promising? I know you mentioned we don’t really know what’s working and what’s not working, we’re trying all these different things, but what has the most evidence and what are you most optimistic about?

BM: What I would say is we know what works in these defined cases where we have studies to show that things like harm reduction strategies, we have data about that. What we don’t know is what we were referencing earlier, what caused this major drop across the country in all these states. And that’s what needs investigation. But I really like this question because the actions that the AMA task force recommends are actually the ones that some states and medical schools and departments of insurance are doing today. We don’t need innovation so much as we need action and states to continue to remove barriers to care for patients with pain and those with mental illness or substance use disorder. We also need medical schools to embed that comprehensive pain care as part of the curriculum and substance use disorder treatment training into the curricula. And we need enforcement of current laws. We have some laws in the books, but we need implementation and enforcement of those laws. Things like we mentioned, prior authorization and decreasing those barriers.

And then for primary care and other specialties, if we can start treating a few patients for opioid use disorder, we should do that. The evidence shows that buprenorphine works and that treatment is improved by that. But again, like I mentioned earlier, we used to have to get an X waiver. We don’t need to do that anymore. Just like a while ago when primary care doctors were hesitant to start patients on an antidepressants because, ah, there’s something new, I’m not sure about that. Now we do it routinely, we don’t think twice about it. In the same way, we need to get to that comfort level treating somebody that we can recognize based on the statistics that we see on our electronic health record that comes up about the opioids that they’re using and their history because we know them better than the emergency room physician. We know who’s at risk. And building up the comfort of the primary care physician base to take care of our patients with that condition, just like we built up that base to take care of mental illness and depression a generation ago. That’s when we really start to move in the right direction with this.

AM: As a primary care doctor, thank you. I think you’re absolutely right. This is something that I have had a little bit of training on, but you’ve inspired me to learn more and to get more involved here. I think you’re absolutely right, as the gateway to the health care industry, primary care can be so powerful in terms of stopping a problem before it becomes greater.

BM: I mean, just demystifying it, right? When all of a sudden we need an X waiver to be able to use this medicine buprenorphine, it’s like, I’m not sure about that, it’s a lot of hours of CME, it must be dangerous. Now that that’s gone, it’s something that we should be comfortable doing. And so many states have CME related to pain care and substance use disorder already, that we just need to eliminate the stigma of the medication and use it in a way that’s actually going to help us.

AM: I have some colleagues in my office in primary care, who because of some of these barriers and challenges and difficulty dealing with opioids, just in terms of prescriptions and availability, they say, I’m not prescribing opioids. It’s not safe. I’m not going to do it. What would you say to those physicians?

BM: Especially for people that have a substance use disorder or pain issue in particular, they’re coming in with chronic pain. Up until this point, they had a source of medication for that pain and it was something that they had with their physician agreed to do, and now all of a sudden that physician retires. A new physician comes in and says exactly what you just said, I’m not comfortable with that, somebody’s going to be looking at the numbers that I prescribe and the scrutiny, I just don’t want to deal with it.

So the physician makes that decision. The pain hasn’t gone away, and so now this patient is scrambling. And in a town like mine where we don’t have enough physicians for the population we have, it is going to be extraordinarily difficult for that patient to be able to find a physician, let alone find a physician that’s comfortable helping them manage that pain. That’s why it’s critical that we raise the level of conversation within the physician community, but also resources. Because even if that physician says, okay, I understand, but I did this work and I think that this is something that should be managed with a non-opioid treatment, so let’s do this. And then boom, prior authorization. Can’t execute the plan that this physician and this patient came up with together, and that still leaves them as if the physician didn’t ever prescribe it in the first place. These are the barriers, both with our own comfort level with this diagnosis and then the hurdles that we have to climb over, even when we have the comfort to treat that diagnosis, dealing with things like prior authorization.

AM: This has been such a phenomenal conversation. I really appreciate your insight and your nuanced approach here because there’s so many shades of gray and it’s not all about one thing or the other. It’s really about doing what’s best for the patient, so I really appreciate all the work that you are doing in the AMA, because I think this is hard and there’s no easy solutions, but we have to all be in this together.

BM: The stigma associated with this lives on. When we see a patient that’s blue from an anaphylactic reaction, we have no issue at all jumping in and doing what we need to do to control that anaphylaxis. When we see a patient that’s blue from an opioid overdose, all of a sudden the stigma becomes this barrier. And we really need to do a good job, not just us, but law enforcement, our communities, of changing the stigma. So the blue patient from anaphylaxis isn’t seen any differently than the blue patient from an overdose.

AM: Great insight to end on. Thank you so much, Dr. Mukkamala. I really appreciate your time and energy.

BM: Absolutely. No problem, Alex.

The views expressed in this podcast are those of the speaker and are not meant to represent the views of The Permanente Federation, the Permanente Medical Groups, or Kaiser Permanente.