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. Following will be notes for The Opioid Crisis.

Jay S. Lee, MD, is a health services research fellow at the University of Michigan Center for Healthcare Outcomes & Policy, and a General Surgery resident at the University of Michigan. He received his undergraduate degree in Chemical Engineering from the University of Michigan, and his medical degree from the University of Michigan. Dr. Lee’s research focuses on characterizing variation in postoperative opioid prescribing and consumption, with a specific interest in opioid use after cancer surgery. His research is supported by a T32 training grant from the National Cancer Institute. After residency, he plans to complete a fellowship in Complex General Surgical Oncology, and pursue a career in academic surgery.

Cancer patients are generally given opioids post-surgery, and since the opioids help manage the patients’ pain, these prescriptions are a good use of opioids. However, these patients are often observed taking those medications longer than necessary. Years ago, doctors didn’t know how much opioid to prescribe, and often over-prescribed. Now that the epidemic is in the front of their minds, they are surveying patients to see how many opioids are actually being taken in order to make a guess at how much they should prescribe. They found the the actual number used is much lower than they have been prescribing. Doctors have also been spending more time talking to patients about the risks of opioid use, and patients have been responsive by taking less of the medication.

The discussion question that accompanied this lecture was: Several of our experts have mentioned the pharmaceutical industry’s aggressive promotion of opioids to doctors and patients as a significant contributing factor in the opioid crisis. Should there be some controls or limits on the pharmaceutical industry’s influence on physicians? If so, what should they be? If not, why?

Wow. Of course there should be some limits on the pharmaceutical industry’s influence on physicians! At the very least, physicians should receive no kickbacks from any pharmaceutical company, ever. I wish there could be a go-between who gathered all the information about the new meds and talked to the physicians in a disinterested way – rather than the physicians talking directly to people who are trying to market the drug.

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.