■ MD-UPDATE: Describe the current state of opioid use, abuse, misuse, and addiction in Kentucky.
Kentucky is consistently ranked in the top five for opioid abuse, misuse, and overdose. The problem is even worse in south and east Kentucky where 50 percent of the population has a friend or family member using opioids for non-medical purposes. The indigent and Medicaid populations are most affected, where statistics show Medicaid recipients have a twofold greater opioid use and six times the overdose rate of the general population. This problem disproportionately affects young and middle-aged adults, where one in seven Kentuckians under the age of 30 have used an opioid. Opioid misuse and abuse in younger ages are of an even greater concern given the detrimental impact on brain development.
■ What are the factors driving these conditions? Are there underlying causes for the opioid problem?
It is widely accepted now that misunderstandings, falsified information, and exaggerated study claims from the pharmaceutical industry drove this epidemic. As greater obligation was placed on providers to 100 percent eliminate pain (an unrealistic expectation), an illusion evolved that escalating doses of opioids was not only the solution but inhumane to even question. Use of these medications ballooned under the guise that tolerance was avoidable if used properly and addiction was rare. Certain adverse effects of opioids were never discussed – the CNS impact on affect and depression, the hormonal changes, decreasing immunity, tolerance, and physical dependency. The increasing rates of overdose and heroin use were interpreted as finding means to prescribe more safely and monitor compliance. Despite ample evidence showing lack of efficacy in long-term settings, ever growing numbers of patients were prescribed opioids without any further attention at fixing the underlying problem causing pain until a surgical option was unavoidable.
■ Is the opioid problem unique to Kentucky, or unique to a particular region or population of Kentucky?
Kentucky is by no means unique in this problem, however, we have a substantial head start compared to many other regions of the country The epicenter of the opioid epidemic is Appalachia, but, Kentucky’s also on the leading front to address this problem. This is a problem that does not discriminate across socioeconomic lines, demographics, or gender.
■ Describe what you see regarding the opioid problem in your medical practice.
I am excellent at fixing a wide variety of orthopedic, neurologic, and degenerative pain problems, often circumventing the need for surgery. However, my colleagues often view my field and myself as the controlled substance manager for patients. This is a travesty, because when inundated with opioid maintenance it limits the time and resources I can offer the opioid-naive patient who has a much better prognosis under my care than someone chronically maintained on opioids. The vast majority of pain issues are treatable if opioids are avoided. Once introduced, however, the long-term prognosis drops rapidly and substantially.
■ Is there any consensus among pain medicine physicians about what needs to be done?
Yes, there is consensus that medicine needs to re-evaluate how we view and use pain management as a specialty. While some view it primarily as palliative care for chronic conditions, the field is better suited in seeing patients at the front end of their pain problem. Using our focal diagnostic and workup skills, we are well-suited to diagnosing and isolating the specific origin of pain. In doing so the goal then becomes to regenerate the damaged tissue through rehabilitation, correcting defects in the mechanical chain, improving the conditions for tissue healing, or moving into regenerative interventional techniques.
■ Are there areas of disagreement among pain medicine doctors on the causes and options for dealing with the opioid problem?
The CDC guidelines provide a best-practices consensus but there is still some gray area where the literature does not have clear guidance. Like anything on a spectrum, some physicians and practices rely more heavily on opioids than others. For non-malignant pain patients in our practice, we consider opioids as a rescue therapy for intolerable episodes but an ineffective maintenance therapy if patients are opioid-exposed daily or around-the-clock. Another area that has some controversy but a growing body of evidence is in regenerative versus steroid-based techniques. We have gradually transitioned toward regenerative medicine and lessened our use of steroid-based injections with better outcomes.
■ What are the after-effects of legislation (SB2 and HB1) enacted in 2012 to change the reporting and prescribing of controlled substances in Kentucky?
HB1 was very controversial at the time, but it put Kentucky in the forefront of the opioid epidemic. At that time we were only one of four states in the country with progressive laws challenging the status quo of opioid management. These laws have had a beneficial impact on shutting down unscrupulous practices. There are still some elements of these laws that hinder care and warrant re-evaluation, particularly in rural regions, but overall it has been helpful for those challenging the opioid-driven messages. Some say that the increase in heroin is attributable to this, but I believe that is mislabeling correlations. Heroin was on the rise long before the legislative changes, and that trend is ongoing.
■ What needs to be done now?
We need to unify our messaging to patients. The onus cannot be just on pain specialists to educate the masses. While physicians have plenty to complain about as far as regulation and restrictions, we cannot blame the need to wean opioids on that. Patients need to be educated on the limits of opioids, such as the hypersensitivity that occurs with opioid use, the rebound pain when opioids wear off, or the fact that often pain for a chronic opioid recipient reflects withdrawal rather than physiologic pain. The message should be that opioids have a short-term benefit but a long-term harm and are not the only effective means for pain management.
LEXINGTON MD-UPDATE Publisher Gil Dunn recently sat down with pain medicine specialist Danesh Mazloomdoost, MD, to discuss the state of the opioid problem in Kentucky and trends in pain medicine.
Mazloomdoost is the medical director of Pain Management Medicine, a multidisciplinary practice begun by his parents in the 1990s, with locations in Lexington, Corbin, and Mt. Sterling. Mazloomdoost is currently the vice speaker of the Kentucky Medical Association (KMA), vice president of the Lexington Medical Society (LMS), and a board member of Physicians for Responsible Opioid Prescribing (PROP). He is an advocate for a paradigm shift in healthcare to reduce its reliance on opioids and guides patients through rehabilitative and regenerative techniques to heal the underlying causes of pain.
Contact Dr. Mazloomdoost at 859.275 4878 or firstname.lastname@example.org.