Observations From the Rx & Illicit Drug Summit

Just a brief recap of my experience at the Rx and illicit Drug Summit in Atlanta (from 4/1 to 4/4).

There were three sessions and a poster worth mentioning. It is interesting that the faculty is starting to address the opioid crisis from the vantage point of chronic pain and opioid use.

In one session, Dr. Stephan Kertesz discussed his study (CSI Opioids) on the effects of tapering leading to suicides among people on long term opioid therapy for chronic pain. There was not much data presented other than a few anecdotes. He pointed out there are diverse circumstances surrounding these overdose deaths.  Dr. Kertesz discussed the logistics and ethics in doing the study and how people are screened and interviewed. They have about 20 cases so far. The study involves a qualitative interview of family or close friends of the person who passed away to better understand the circumstances of the event and when possible, review medical records. This study is ongoing available at CSI-opioids for anyone who wishes to enter. He mentioned Ann Fuqua who has a much larger base of people on opioids who have died by suicide due to tapering.

A second session highlighted a group from Ventura California composed of a forensic pathologist, psychiatrist (Dr. Joseph Vlaskovits, MD) and social worker. Their program involved a “look back” to contact prescribers via a non-threatening letter who were administering opioids to someone within one year of when their patient suffered a fentanyl related overdose death.   This notification was done via a letter informing the prescriber of a death of one of their patients. During the question-and-answer period, I asked whether people who suffered an overdose death due to fentanyl were tapering their opioids during the period before the overdose. Dr. Vlaskovits (the psychiatrist) answered flat out “their group did not find tapering to be a factor in any of the fentanyl overdoses they reviewed.” Their sample was small, approximately 100 to 200 people.  The presenters from Ventura also shared they offer an online educational program regarding opioid prescribing (presumably along the CDC guidelines) to those who receive letters notifying them of a death of one of their patients. This has resulted in a reduction in opioid prescriptions being written. In addition, programs known as “academic detailing” exist in Ventura, California and Illinois. In academic detailing, a “reputable practitioner” or in some cases a pharmacist performs one on one reviews with a practice which has been flagged due to prescribing outside certain norms established by either a licensing or hospital board. This is done in a non-threatening manner. I understand in the case of an “expert” after the academic detailing reports to the hospital or licensing board and gives a verdict whether any other action is appropriate. This is certainly a step forward for physicians compared to the DEA conducting reviews of medical practices without oversite.

In the third session, Dr. Chad Kollas (a palliative care specialist) and Bobby Mukkamala share a presentation on “An Honest Discussion About the Nation’s Overdose and Death Epidemic: Perspectives and Recommendations From the American Medical Association and Practicing Physicians”. Dr. Mukkamala from the AMA discussed how opioid overdose deaths have not paralleled drops in opioid prescribing. Dr. Mukkamala also shared anecdotes from this own practice regarding the difficulty for post op surgical patients with pain to obtain opioids. Dr. Kollas presented data from his own practice in palliative care on how a series of 100 patients are doing well on long term (four years) of opioids with reduction of pain, improvement of function, and reduced overdose risk (DOI: 10.1089/jpm.2023.0251). I asked Dr. Kollas and Dr. Mukkamala about how they feel about the statement in the CDC guidelines that there is no scientific evidence verifying opioids work long term (> 6 weeks) for chronic pain and Dr. Kollas countered – well “you have this series I just presented. That is evidence.” I think Dr. Kollas knows the CDC wants randomized controlled trials which are difficult to do as Dr. Lawhern has mentioned without enrichment design. Dr. Mukkalama discussed there likely will be a push from the AMA to pass laws in all 50 states similar to ones recently passed in Colorado and Minnesota to protect prescribers who judiciously administer opioid therapy for patients with chronic pain. If these laws are enacted in all 50 states, this could influence physicians to change their prescribing habits. However, I have not heard that many prescribers are using this law to obtain opioids for a patient during conferences I have attended on treating patients with pain and/or addiction. In Minnesota, the law requires two prescribers to sign off to allow a patient with severe intractable pain patient to receive opioids at higher doses than the CDC guidelines allows.

There was a poster presented by Dr. Jay Kucera, a pain specialist from Florida, who also notes the adverse climate regarding prescribing opioids to chronic pain patients requiring opioids is creating a “perfect storm” where people with complex needs to treat pain are not receiving inadequate treatment. His poster noted internists are frequently referring patients on opioids to pain management and there are not enough pain specialists to handle the influx of these patients. Pain specialists are overwhelmed with the volume of these patients. Dr. Kucera’s poster outlined how these patients may wind up on illicit drugs when they are unable to obtain care.

My limited impression from this conference is I don’t think the CDC guidelines will change anytime soon unless there is more advocacy. There is too much support, at least among the attendees at the conference, including some physicians for the current CDC guidelines. A disturbing fact outlined by some of the physicians who attended the conference is many new grads are coming out of residency are being trained to not use opioids for chronic pain. They simply think opioids are inappropriate.

My own feeling is that in addition to the initiative to pass more laws giving prescribers leeway to appropriately prescribe opioids when needed at higher doses for chronic pain, more physician champions are needed to support this cause, like for example, Dr. Kollas, Dr. Mukkamala and Dr. Kucera. Physician champions would help physicians become more comfortable in prescribing opioids given the current severe regulatory climate.

I met with Grant Baldwin, one of the writers of the CDC guidelines, after a presentation on how the CDC is helping organize states’ desperate efforts to find care for patients on opioids after a practice has closed due a DEA shut down. It’s a chaotic process and the CDC does the best it can and is trying to reassure prescribers and the state medical boards not to crack down on physicians who agree to accept these patients in their practices. It appears there is little communication between the DEA and the CDC other than the DEA notifies the CDC that a practice will be closed. The DEA pretty much interprets the laws and makes the decision to close a practice and the CDC tries its best to coordinate a response.

I asked Dr. Baldwin if the CDC has ever done a survey on how physicians, especially pain management, feel about the CDC guidelines in terms of how the guidelines affect their practice.  He said to his knowledge, no such survey has been done. Dr. Baldwin seemed somewhat open to the idea.

A key point was repeatedly stressed at the summit among organizations that were able to improve care in their communities. To get something done that is of great value, stakeholders need to set aside their egos and aim for a common goal. No one alone should be trying to obtain the credit. I believe if advocates can begin to do that, the job to restore opioids to their proper place in prescribing will get done.