The Opioid Overdose Epidemic Ep 3 – The Doctor’s Perspective

Dr. Stephen Grinstead: Currently I’m the co-founder and chief clinical officer for Triple Diagnosis Chronic Pain Addiction Mental Health Program in California, and my story goes way back to age 12 when I first got exposed to opioids.

And at age 12 I was injured and sent home with a prescription. Found out it stopped all the chaos from growing up in an alcoholic family system, so I was often running until I wasn’t. And I got in recovery—and I’d been in quality recovery since January 1981—and a year and a half later I got injured and paralyzed and ended up in a really bad pain situation, and had to make a decision. Do I want to go back to where I was? Or do I want to find a different way to manage my pain? And I found a different way.

And then since 1984 I’ve been working with people with chronic pain and co-existing addiction and other mental health problems. And it’s been a long journey. In the 90’s I went back and got my graduate degrees including a Doctorate in Addictive Disorders and I’ve also been training other healthcare professionals and have trained over 40,000 healthcare professionals since 1996. So, I’ve been in this for a long time and I’m still very passionate about it.

Dr. Stephen Grinstead: I’m out on the conference circuit all the time, all over the United States and Canada, and this is, I like to tell people that in the western and United States and western medicine, we’ve had a love-hate affair with opioids. There’s been wide pendulum swings from being opioid-phobic. But then in the 90’s, 1990’s, there was a group of physicians that started advocating that pain needs to be managed with opiates because there’s no ceiling dose you can keep titrating or dousing people up as high as you can until it masks the pain.

And, they said it’s safe, it’s effective, if you have physical pain you won’t get addicted, and a lot of those physicians now are really regretting that stance. Many of them were actually working for some of the pharmaceutical companies and promoting some of the high-powered super-opiates and it’s been scary.

And then they were advocating with the Joint Commission of Hospital Accreditation to make pain a vital sign. So now there’s a higher pressure on prescribers—they’ve got to manage people’s pain. I’m from California, in California, a physician is damned if they do and damned if they don’t because if they don’t adequately address pain, they’re subject to litigation and if they do what the FDA and DEA consider over-prescribing, they could lose their license or even go to prison.

Dr. Stephen Grinstead: It’s been a really confusing, frustrating journey, not just for the patients, but also for their healthcare providers. And over the last couple of years, there’s been a large outcry to change this prescribing.

You know, most people who get hooked on prescription opioids, do so one or two pathways. One is an injury and they go to the emergency room, the other is having a surgical, either medical or dental surgical procedure, and instead of given a 2 or 3 day supply, they’re given a 30-day supply and then they build tolerance rapidly.

Some people, anywhere between 10-20% of the population, is high risk of becoming immediately psychologically dependent and then abusing, misusing, pseudo-addiction, and addiction. So, it’s been frustrating to stand back, I really started promoting this addiction-free pain management model I developed since 1996 and up until the last couple of years, not too many people had been listening.

Dr. Stephen Grinstead: Unfortunately, most doctors are time-crunched. They’re time-limited, they don’t have a lot of time to spend with the patient and a lot of the time they don’t do the right screening assessments. They don’t ask the right questions and people that are high risk are put on opiates without an exit plan and not monitored effectively.

The Centers for Disease Control say the prescription opioids prescribing remains about stable and as many as 1 out of 5 with non-cancer pain are some type of mild pain related diagnosis are prescribed opiates in an office visit as the first line of pain management. And that’s just really not indicated in many cases. Many cases some of the people may need to be on something as benign as ibuprofen or acetaminophen—Advil or Tylenol.

So, they don’t screen for risk potential—biopsychosocial-spiritual risk potential. People going into surgery sometimes aren’t screened for what’s going to happen post-surgical. Last couple of years there’s been a lot of research done on there’s non-opioid alternatives for post-surgery now for at-risk people. And we need to screen. There’s a number of screening instruments out there that people use—Opioid Risk Tool, the patients with pain screening instrument for substance abuse potential, there’s all kinds of different ones, the opioid assessment for patients, the D.I.R.E. is another one that can be often easily used.

Some of these are a little more cumbersome to administer and score and some of them are simple. And the thing is, if the score indicates the person should then be referred to an addiction professional like myself, or someone like me, to do a further insight and do some appropriate planning and monitoring.

And a lot of the primary care practitioners don’t use these instruments and when they’re started on the opioids there’s a lack of education and they don’t have an exit plan. And it’s because they don’t have a lot of time to spend with people, it’s that cost containment in healthcare today. You know, they’re expected to see anywhere from 10 to 15 patients an hour, can you imagine that? I mean, how can you give people good treatment in that kind of time crunch?

And in the emergency room settings it can be even harder. They’re making split second decisions, they have somebody’s that’s dying from an auto injury and they have somebody complaining of lower back pain and sometimes just to get them off their back they’ll write them a script.

Dr. Stephen Grinstead: One of the things I’d like to talk about is the impact of this opioid crisis on healthcare. You know, last year, late last year, there was a white paper put out by FAIR Health Inc. and they’re a research type organization. And they were saying the cost for opioid-related treatment, prescription opioid-related treatment, rose over 1000% in 4 years.

And the costs are going way up in large part due to ER visits for people. And then we have the opioid drug overdose. The Journal of the American Medical Association put out a report and it was really clear that in 2010 58% of overdose deaths were due to pharmaceuticals, and of those 75% were opioids, 29% benzos, and then everything else. And then what also really drew my attention to that, when opioids were not the common cause, let’s say when benzodiazepines were the cause of the overdose death, 77% of the time the person also had opioids in their system.

So, we have a love/hate affair with this. And as of 2016, the rates are up again and guess who gets impacted the most? It’s the Medicaid or Medicare recipients. They’re twice as likely to be prescribed opiates and they’re 6 times more likely to experience an overdose. And this was in Pain Medicine News in 2016.

We’re seeing with the pendulum swing, we’re going back into the opioid-phobic now, there’s a lot of people who have not had a problem with their pain management protocols, they’ve been monitored effectively, they’ve been randomly tested periodically. They don’t have an abnormal increase in tolerance, they don’t demonstrate any of the abuse, misuse, or addiction symptoms, and now they’re being cut off their medications cold turkey and so now you need to learn to live with it, but they’re not taught how.

So yeah, some people are really getting hurt and it’s tragic. I get calls and emails and our company does all the time, sometimes from family members whose loved one committed suicide because they couldn’t get pain management. And it’s heartbreaking.

Dr. Stephen Grinstead: A lot of people don’t realize that addiction is a neurobiological brain disease that impacts people biologically, psychologically, socially, and spiritually. And like any other disease, it has a set of symptoms, it has a predictable onslaught, it has a way to put it in remission and stay in remission, and unfortunately like any other medical condition, like diabetes, hypertension, or asthma, it has a high rate potential for relapse.

Those medical conditions have a higher, higher rate of relapse than addiction does, yet we still stigmatize addicts and say, “if you take too much, you deserve to die,” is the message. It’s not a written message, well sometimes it is actually, but there is a lot of debate about this and I don’t get it. I think loved ones and family members, I think people getting out of treatment programs for opiate addiction should be given an emergency kit, and maybe they’ll never need it but how about somebody they used to run with and they’re having an overdose? They could save a life.

Dr. Stephen Grinstead: Even if it only saves one life, it’s worth it. But I think it’s saved a lot. But now we have people coming in and they’re saying, “Oh you’re just giving people a get out of jail free card. Let them suffer, let them die, let them go through withdrawal, let them get scared enough they’ll get help.” And that’s a very unhealthy attitude for a medical condition.

If you don’t do harm reduction you may never get people to have the opportunity of getting in recovery. Some recovery process has to start with harm reduction. That’s how the HIV and AIDS epidemic got handled so well back in the 90s. Is when they started doing harm reduction and education and needle exchange. But yet, there’s still this big stigma against that. And now the latest tool instead of needles now, now it’s giving them an emergency Narcan kit.

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