Episode 050: Prescribing Opioids During an Epidemic

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Brian: Thank you for joining us today on our podcast. My name is Brian Fortenberry, and today, we're going to be talking about an issue that, unfortunately, is facing the entire country and, in particular, Tennessee, the area we're in. We're going to be discussing some opioid issues and opiates in general, and we have someone here today to help us navigate that, Dr. Greg Mancini. Doctor, thank you for being here.

Dr. Mancini: Thanks for having me, Brian.

Brian: Before we really get started here, Dr. Mancini, tell us a little bit about yourself and about your background.

Dr. Mancini: Sure. Well, I'm a general surgeon, and I practice in Knoxville. My practice is based at the University of Tennessee Medical Center, and it's a practice that involves teaching and education. That's a passion of mine. I, like many general surgeons, kind of have a specialty within it, and that's in minimally invasive and robotic surgery.

Brian: Okay.

Dr. Mancini: The irony of that is over the last 15 years of my practice, I've been supposedly doing keyhole surgery on patients, which you would think would not be a big pain inducer, but despite kind of advanced surgical techniques, even in my practice, I saw a kind of a spiraling increase in prescribing, and so that's one of the things that I find quite contradictory in that. I've been looking at my own practice. I started that analysis about five years ago, and I didn't like the trajectory it was going. I've kind of taught myself and those who would listen about maybe how to think differently about prescribing opioids, and there's been a lot of more discussion in the public sphere and some movement in the legislature that has really brought this to the forefront, and so this is timely. I appreciate the opportunity to share my thought.

Brian: Well, I really appreciate you taking the time out of your busy schedule as a physician and all the other activities you have going on. You mentioned general surgery, and you tend to do these robotic procedures and people will often say, well, these minimally invasive surgeries. You would think, just by the terminology, oh, that's not going to be as painful, and maybe it's not as a big belly case or having an open case. You're seeing this increase, then, in opioid or narcotics prescribed there. What did this look like in your own practice, and is there other ways around this?

Dr. Mancini: I think there are. Today, minimally invasive surgery has moved into lots of different areas, and it's a great added benefit to patients. Along with that should be, really, a decrease in our opioid prescribing, and it's a bit of a mystery of why the prescribing habits have changed, whether it laxity amongst us as physicians, whether it's more demand from patients. It's probably a combination of things of why there's been an increase in prescribing, but the reality is is that that's really not a sustainable plan when we are at the point where we're seeing such negative results from opioids that it's those bad patient results that help us refocus and say, "Is there a different way?" I think your questions is right. Where does the realization of us needing to do it differently, where does that lead us to?

I've got good news for listeners out there, is that there are many more options today, prescribing and controlling pain, particularly in the perioperative world, and that's the world that I live in. I'm not an expert in chronic pain, but in surgery, we are quite used to what we call acute pain, pain that should last days or a few weeks but then normalizes. That's actually the first exposure many patients get to opioids. I really, I appreciate you calling them narcotics, because that's actually what they are. I think when people think about being prescribed narcotics, they say no, but if they'll take an opioid, they will. That's a little ... one of those word jargons that's been used to make them not seem as dangerous as they are, so I think you've kind of hit something there that I think that the public is starting to also understand. I'd like to talk a little bit more about what are some of the other options out there and what are some of the downsides of prescribing opioids, because those are the things that patients need to understand.

Brian: Yeah. Let's talk about some of those other options, because, like you said, maybe a few years ago in medicine, that was where you went. You had pain, and you had a narcotic or opioid that you prescribed, but tell us some of the other options that are out there now.

Dr. Mancini: Sure. Thankfully, the pharmaceutical industry continues to make newer products. I don't particularly favor any one. I actually favor a philosophy, and that is what we call multimodality therapy. For the listeners that may not know what that means, it's really using two or three medications that can work synergistically, so they work together. They work by different mechanisms, but when you put them together, they can actually have an additive benefit. When you tell someone, "Oh. Well, can you take Tylenol," and they say, "Well, yeah, but I don't take that for surgical pain. I just take that for headaches," well, they're usually taking it at doses and intervals that are right for headaches, but there's actually a better dose that can be taken that can be helpful.

I also tell patients, "Have you taken Ibuprofen?" which people often know is Advil, and they say, "Well, sure. I'd take that for a headache or a fever, but I wouldn't take that for surgical pain." Right?

Brian: Sure.

Dr. Mancini: I describe to them that you can take them at higher doses and at more sustained intervals, and it starts to have an effect that would be similar to that which we see with a narcotic medication. Then, when you begin to build them together and see that they actually work on two different ways within the pain system, and then you can start leveraging the two strengths of them. Now, you actually have something that's superior to an opioid in many cases and then doesn't come with the side effects that come along with opioids, which people don't think about. They just think about, "Well, it's the pain reliever," but when you take that pain tablet, there are negative consequences of things that certain patients have. They can have a lot of nausea. They can have constipation, and then, when you do abdominal surgery on somebody and then they have difficulty with their intestines, that, itself, prompts emergency room visits and poor outcomes.

I think it's thinking in terms of multimodality, thinking one or two or three medications that can be taken together, using them to optimize for patients, and using that as our first line choice. I don't think we're going to see a day where we never use opioids, but we certainly can make a big impact in the total number used. That'd be, actually, a good thing for patients and our society.

Brian: I love to hear the fact that there are other options, and I love the fact that you said we can go to these first. There's no need of taking a machete to something that we can use a much smaller instrument for in different doses. When you have these patients that have used this multiple modality with that, what has been your success rate when you do that? I mean, you may not have hard, fast numbers, but through your experience, what have you seen that to work like?

Dr. Mancini: Well, what I described before is simply the outpatient part of the multimodality therapy. That's not going to be all that's in that bucket of what we're going to do to treat patients, so let me take that a step further.

Brian: Please do. Yes.

Dr. Mancini: In surgery, we have the chance of doing what we call nerve blocks on patients, and they're even new age and it's out there, that increase the duration in which you're going to have that numbing effect. Right?

Brian: Right.

Dr. Mancini: If you have an incision that you put a numbing medicine, much like you would get Novocaine at a dentist's office that numbs your lips or your jaw so you can have that, they're creating newer agents out there that can last three, four, five days, which is the main time period in which those nerves are going to be upset, so you, in surgery, can actually numb that for a particular area. If I do a hernia surgery in the groin, I can deaden the nerves to the groin. If I do an incision in the mid belly, I can numb that, as well. The person comes out, and they don't have the pain that they expected. Right? That starts with surgery, and then it continues in the outpatient setting. We've reduced their need for the opioid with that pain block, and now this combo therapy that is, in fact, over-the-counter gets a chance to work.

What I describe now in my opioid prescription for routine outpatient surgery, which I think a lot of general surgeons and different types of surgeons, like orthopedic surgeons, do a lot of outpatient surgery, I describe the opioid, now, as the rescue medicine, not as that first line medicine, but actually, if you really need it. It's there for you. It's prescribed, but it's going to be what we go to if you're really struggling with pain. You will have patients use it, and that's okay, but we've used that as kind of a parachute instead of our first thing.

Brian: I think that is part of getting a handle on this epidemic that you hear is out there, is it not being the first line. Like you said, if you can have the patient expectation coming out of surgery after a block of, "Wow. This isn't as bad as I thought" and then be able to maintain that relief from pain using over-the-counter medications and the combinations at the dosages that you give, that really helps the patient. Then, hopefully, you're going to keep them from going to that rescue medicine.

Dr. Mancini: Right. I think one of the important things that we've ... This is a surgeon saying this, and we're not known for our warm and fuzzy. Right? But our patients actually bring a tremendous amount of anxiety to the surgery process, and they're worried about, oh, lots of things. They're worried about coming through surgery. Right? They worry about how long are they going to be out of work. They worry about the finances. They worry about pain. They bring all of that, and they're actually primed. That anxiety raises their worry, and actually, that becomes physical. Right?

Brian: Right. Yeah.

Dr. Mancini: I believe that that conversation and that plan that a patient knows, and then we do the plan. Their confidence builds, and they say, "Wow. I'm not having the pain I expected." Right?

Brian: Right.

Dr. Mancini: That calms their anxiety, and that reduction in anxiety almost may be as beneficial as the actual pain block itself. We don't want to be treating anxiety with opioids or narcotics. Right?

Brian: Right.

Dr. Mancini: How much is imagined or worried pain versus real pain? That's why a plan that a patient understands and says, "That's right for me," and then they begin to see the results of that. They can follow the plan, and then you have the results that we want, which is a low opioid. Right? Surgery is oftentimes the first time that someone ever has an opioid in their system, and what we don't know about each of our own chemistry is how much that opioid is going to have a resonating feeling. We have many patients who are prescribed an opioid, they get tremendously sick and say, "I will never take one of those again," but we do have patients, maybe 10, maybe 15% of our population, it affects a part of their brain where it's a reward, and they get a little bit of a high from it. It's eye-opening for them.

That's a patient that is now at risk, because they have the chemistry, and the way that their body handles that, they're a high risk patient. If we don't prescribe that, and we don't unmask that, and we don't test that, it's okay. We should be reducing our prescribing so that we aren't finding those patients who are vulnerable and actually increasing their vulnerability with that prescription. It's a lot harder to get them off than it is to ever start them. It's always better to leave the toothpaste in the tube than try to put it back in, and that's the way addiction is. Addiction is a part of our human biology, and opioids are a vulnerability. We should recognize that our, particularly our young and youthful are vulnerable, and the way to not put them vulnerable is not to test with opioids.

Brian: That is so true. Just the common sense tells you that if you have never experienced it, then you're much less likely to head down that road.

Dr. Mancini: You're not missing it.

Brian: Yeah. Exactly, and not only that, the fact that it's probably very difficult on most people when they walk in that door for you to be able to look at them and go, "Well, this is a patient that's going to say 'Uh. I don't like that,'" or, "This is a patients that's going to fall in love with it." You really can't tell from first appearance. Right?

Dr. Mancini: I can't tell. I can't tell who's going to be somebody who's at risk or not, and so I sleep better at night when I have prescribed less, because I know I've put less into the system. The other thing to talk about is  that many of our patients who get their prescriptions filled may only take a few tablets themselves, and then those tablets, if they've been given a prescription for 30, they take five or six. Then, 25 of them sit in their medicine cabinets. They're not throwing them out. They're not returning them to pharmacies. They're just sitting there, and that represents a vulnerability, too. Right?

Brian: Sure.

Dr. Mancini: We have youngsters around. There at a natural experimentive phase of their lives, and we know that there, a significant risk of the unused opioids is the illicit use, is that our young folks take it. They do it in a party situation, and then, that's a starting point for some kids.

Brian: Part of it is just, like you said, availability. I mean, if it's not available, if it's not sitting there in the medicine cabinet, then you're a lot less likely. Right?

Dr. Mancini: It is, and what's so interesting is about four years ago, we all started to recognize this, and we said, "Well, why don't we have a way for people to return their unused opioids," but that, themselves, is a security risk. The pharmacies were worried about ... They sometimes face threats from robbery. We see where there's theft and robbery, and if you're a pharmacy, you don't want to be taking these pills back. Trying to figure out a way to reduce that misuse by turning things back in, that's still being worked out. But if we don't prescribe them or have them filled in the first place, to see how we've moved the needle.

Brian: I'm assuming, then, whenever you're using this multiple modality to treat the acute pain that a surgical patient has had, I'm assuming it gives you the opportunity, since you're using the opiate as a rescue drug, to prescribe much, much less. Correct?

Dr. Mancini: Absolutely. We are always looking for help, as physicians, to help rein in certain topics, particularly a moving one, and we had help from the state a few years ago when they changed the scheduling and made it more difficult to phone in refill prescriptions. That was helpful. Then, on Friday afternoon, if a patient is calling and having pain, we say, "You need to move, at this point, to over-the-counter medications, because now there is no way for me to call you that in. I have to write a physical prescription." That's a wonderful help. There are some unintended consequences to that, as we saw a little bit of a rise in the number of pills prescribed. One way to bring that number back down is to set that expectation and that limit with your patient, and they don't need as much of a rescue. Right?

Brian: Yes.

Dr. Mancini: If you write a prescription that is literally a rescue, he may need 12 or 10 and not 30 or 40 or 60. When the patient understands it's a rescue, they use it as that lifeline and not as the base, and so my goal with my patients is to encourage them to actually bring me the prescription that they have never turned in. My goal is to have a stack of unfilled prescriptions, obviously that are outdated ... Right?

Brian: Sure.

Dr. Mancini: ... because they ... so they won't be turned in, is to have a stack of unused opioid prescriptions. That, to me, is success. That should be the marker of our success, and I think that you're going to see the consciousness about this change. We are in the data revolution in medicine and following the data about complications and readmission rates and lengths of stays and DVT rates. I think you're probably going to see opioid be another marker of how successful that we are, is how many of our patients are following a non-opioid plan. Right?

Brian: Got you.

Dr. Mancini: If you're not doing 70 or 80% of your surgeries in your care in a non-opioid way, you may be considered a non-quality provider. I think those are things that we should be working towards. I think that if we aren't smart as physicians, that it's going to be told to us by state entities or governing boards. I think that we, as physicians, should be changing that on our own and in the way that we feel is best for our patients instead of being told, but I do think that the consciousness about this is changing so that high quality surgery can be done and should be done on a low narcotic plan.

Brian: To take what you were saying maybe even a little further, now you're hearing about all of these reimbursement plans and programs, and if it turns into ... You were talking about readmission rates and stuff. Well, if you're prescribing a percentage of opiates that are at this, your reimbursement rate is going to be less. You don't want to get into that, and I think you're right. The self-policing by the physicians will probably be the best route to take.

Dr. Mancini: The smart money's in that spot. Yep.

Brian: Do you think education is really key when it comes to patients of this multimodality? They may very well not even understand or know that that is an option out there. Do you find patients that are coming to you, are they wanting the narcotics, as I call them, or are they just really wanting pain relief, and the education of making them understand there's other ways is helpful?

Dr. Mancini: That's a great and loaded question, because real life says it's a mix of that. Right?

Brian: Right.

Dr. Mancini: We have patients that come to us that have never had a narcotic that are worried, and they don't want it. They've heard, and they are open to not using a narcotic in their pain care. We have patients with chronic pain who do live on narcotics, and they're worried about not having enough to get through surgery. There are different patient populations out there, and those are two different patients. The best thing we can do is keep our naïve patients naïve to narcotics, and then, with our chronic patients, is not to escalate them. It's trying to figure out how to maintain and not escalate. Those are two different kind of plans, but you are right.

We have education as a barrier, not just to physicians, but to patients and their understand of this, and so we, as physicians, need some help in the areas to help educate the public. There are many forms that this could take, public service announcements. Those are tough, but I think what we're going to probably be looking at is developing educational modules that our patients will go through before surgery. They may watch a five minute web video, and then we get to check that box, that the patient's been ... has gone through the video, has read it. We do this for lots of different areas, right, and so this could be easy to do if it's implemented right.

Brian: Almost like part of the consent or whatever then. Right?

Dr. Mancini: Exactly.

Brian: Okay.

Dr. Mancini: Some people have even said that we need a consent for opioids, prescribing them. That's being batted around in the world of politics. I think that we need to educate our patients on how the opioids are limited, they have bad side effects, and the other things can work, and then we need to empower physicians, because physicians have barriers to access, because some of the medications that are new may not be easy to get in all areas, and so physicians hopefully will see that learning about a multimodality pain plan is something that's easy to do and can be implemented in their systems.

When the physician and the patient both come to that table, to that meeting, right, as we do before surgery. The patient is in a gown. They have an IV in. We're discussing the surgery. We're going through the consent. We're talking about wound care after surgery. We're talking about pain medication after surgery. That's all happening. Right?

Brian: Right.

Dr. Mancini: At that moment, if both people come to that desiring non-opioid plans, we know that we're on the right track, but right now, and the reason why this problem exists to the extent that it does, is the doctors are using an opioid plan, and the patients think that they should be on an opioid plan. That fundamental relationship, that communication on this topic is really broken. The organization that I work with, which is an organization called COMPAS, which is just a nonprofit that focuses on informing patients and physicians about other options, that's the core of that. That's the core of our mission and my mission, is to help physicians not have to fight the battle all themselves, to give into patients, but also prime patients to be open to a non-opioid plan.

If we do that, then that transaction that happens, which is the prescription, is going to happen less, and that's the overall thing that we're driving for. As much as we need help from the government and our physician societies, the biggest impact is going to be when physicians individually change and, one patient at a time, one prescription at a time, we prescribe less. That's where we should be targeting and aiming for.

Brian: The takeaway for me that is going to stick with me after this is when you said, "The physician and the patient come together with the same objective of treating the pain with non-opioid use and being on the same page," and I think you're exactly right. I think that's where it all starts, because there can be legislation, there can be laws, there can be guidelines, restrictions, everywhere from laws passed in Congress all the way down to hospital guidelines or reimbursements from insurance companies, but at the core of it, that's all kind of treating the symptoms. At the core of it is that relationship between the physician and the patient.

Dr. Mancini: You're exactly right, and if I've got you tuned into that, I'm hoping that our listeners have learned that, as well.

Brian: Well, I think you've done a fantastic job today. Dr. Mancini, I can't thank you enough for taking the time to be here to discuss this very important topic.

Dr. Mancini: Thank you very much.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast. The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time.