Solving the Opioid Crisis: A Physician’s Perspective

The University of Michigan is teaming up with Coursera to create Teach-Outs which are week-long MOOC lecture series which address problems currently faced in society today. The following are notes for lecture set 2 of Solving the Opioid Crisis.

This is an interview with Pooja Lagisetty, whose research interests focus on culturally tailored behavioral interventions, social determinants, health disparities, neighborhood determinants of chronic diseases, and urban design. She is a primary care physician who provides medication assisted therapy (MAT) for opioid addiction to patients at the Ann Arbor VA, has studied the literature about MAT in primary care, and is involved in efforts to increase the number of primary care teams that provide MAT to patients as a way to combat the shortage of treatment options.

In Dr. Lagisetty’s interview, she said that the opioid crisis is drawing international attention because people die of opioid overdose at much higher rates than of other drug types. However, it’s not just the overdosing that is a problem with opioids – there is a spectrum of severity, but that even people who will never overdose can have their lives hijacked by drug use.

Risk factors that doctors should look for are addiction to other drugs, lower socioeconomic status, depression/mental illness, misuse of drugs (higher or more frequent dosing than prescribed), and the use of the drug with benzodiazepines. (Though, personally, I am loathe to suggest doctors choose to not prescribe pain medications for people based on socioeconomic status or because they’re depressed!)

Medication assisted treatment of addiction (e.g. Methadone, Buprenorphine, Naltrexone) is more successful than quitting without medications, but there is very low accessibility. This low accessibility is due to many factors. For one, Methadone has to be prescribed within a specialized facility. Buprenorphine and Naltrexone can be taken home by patients, but must be prescribed by specialists. Unfortunately, there aren’t many specialists because there is a stigma attached to treating addiction patients, and many doctors don’t want to be associated with that stigma. Furthermore, there is a stigma for the patients that go to addiction specialists, so they are less likely to go than they would to a primary care physician.

Dr. Lagisetty suggests that the reason our society has such an opioid over-prescription problem in the US is because doctors treat pain like a vital sign: “how much pain are you in on a scale of 1 to 10?” Because of this understanding of pain as a vital sign, doctors and patients in the US now think that patients should be as pain-free as possible. She says that she doesn’t think other cultures are like that.

The first discussion question with this lecture was: As patients, should we ever experience pain? If so, when? If not, why?

Wow. I’m not sure how to answer that question. I can see where she’s going with the question – because of the addictive properties of opioids, where should doctors draw the line for prescribing pain medications? I simply don’t know the answer to that question. I’ve never been in real pain before, so I don’t want to make blanket statements about something I’ve never experienced. However, I have been around patients who have claimed to be in a lot of pain and were upset when the doctor didn’t prescribe them pain medications. At the time, I sympathized with them – though I recognized that the ones who complained the most about their pain were the ones who complained the most in general. And this is an example of where the squeaky wheel might not actually get the attention.

The second discussion question with this lecture was: How would you characterize your society’s attitude towards “acceptable pain,” and do you think it has changed over time? (Please indicate where you reside.)

I live in the US, and I’ve never thought about “acceptable pain.” Pain feels different to different people. We will never know how another person feels. Dr. Lagisetty says that in the US we think pain should be minimized if at all possible, and I suppose that’s probably true.