Where Are We? Opioids and Options

[Upbeat Guitar Music]

Mike: Welcome everyone to Avoiding the Addiction Affliction, brought to you by Westwords Consulting, the Kenosha County Substance Use Disorder Coalition, and by a grant from the State of Wisconsin's Dose of Reality: Real Talks, reminding you that opioids are powerful drugs, and that one pill can kill, appropriate to today's conversation. I'm Mike McGowan.

Mike: Dr. Sterling Elliott is the clinical pharmacist lead for ambulatory surgery practice at Northwestern Memorial Hospital in Chicago. As a Wisconsinite, we won't hold that against you, Dr. Elliott. He specializes in matters related to post-operative pain management and ambulatory surgeries.

Mike: Dr. Elliott's expertise on patient-centered pain management education and harm reduction efforts has been featured on numerous Chicago as well as national print, radio, and television outlets. He speaks at conferences, including keynote sessions, shares his expertise in pain management, the American opioid epidemic, and harm reduction with Narcan.

Mike: The Illinois Human Performance Project has featured his expertise on panel discussions for high school athletes, their families, coaches, trainers, including, which is why I bring this up, a recent webinar on the drugs Kratom and 7-OH, which we'll talk about a little bit later. Dr. Elliott has lent his expertise to legislative advocacy efforts at the federal and state levels, which he and I were talking about before we hit record.

Mike: Welcome, Dr. Elliott. Thanks for joining us.

Sterling: Oh, it's a pleasure to be here. Thank you for asking me to join you, and I'm looking forward to chat.

Mike: Yeah. This is one of those where I get frustrated that we limit it to a half an hour, 40 minutes or so, because we could talk all day. But where are we in the pain management field and the and the opioids?

Mike: We, we know some people say opioids are prescribed still too much, and others say, "Oh, wait a minute, I need them for pain."

Sterling: Yes. It's like everything else in the American consciousness today, is that we have this spectrum that we all live on. The truth the case in most circumstances lies in the middle.

Sterling: But the reality is that opioids are still a significant component if not still an anchor component of managing pain in the United States of America. I think there is a, there is unquestionably a philosophical shift that's taken place over a period of about 20 or so years. I think by and large, those who treat pain and work in that area are really of the mindset that the degree to which you can limit opioids and make them a lower line option to manage pain, you're going to do a lot better for the best interest of your patient, right?

Sterling: We have guidelines that first came out, the first time pain guidelines came out from the CDC was in 2016. And you think about how long opioids were the anchor of pain management. And at that point, the stage at which the problem had existed, you think, wow, took that long to write guidelines, and it did.

Sterling: But it was important that it happened. But guidelines, and I was speaking at a summit a couple of days ago in Washington, DC, and I was on a panel. And one of the panelists with me was a psychiatrist who runs a division of the National Institute on Drug Abuse. And we were talking about it, in the question and answer session, and we talked about the idea that guidelines are produced and developed at, for lack of a better term, a glacial pace.

Sterling: It just move incredibly slowly before consensus comes out. And then to get revisions is equally laborious, right? CDC by 2022 had put out a set of guideline, revised guidelines to their first set. So that time period is really, that believe it or not that's lightning speed in the world of guidelines, right?

Sterling: And I think what that means is that it remains this element of important an important battle in the public consciousness, right? And so I think that's important to understand- ... that there's this general mindset. And one of the big shifts in those guideline changes was that in 2016, they tried to put forth some concrete dosing strategies. By 2022, they had said, "Don't look for significant dosing markers. Look for how to incorporate opioids if you need to into a patient-centered plan that's focused on patient wellbeing." And I think that's critical because what we've done for so long in this country is we've focused pain treatment on how badly does someone think it might feel.

Mike: Oh, yeah. The zero to 10 and the smiley faces thing.

Sterling: And we've all seen it and it's, it's probably contributed to a lot more detriment than it has wellbeing, right? And I think one of the key shifts that we have to continue to work on, and the guidelines certainly help us get there, is that idea of how are you doing?

Sterling: You're going to have some pain. It's not the end of the world if you do. But let's figure it out, and let's manage it to a point where you continue to do fine and do even better. And that's what we're trying to do.

Mike: It's funny you should say that, because my parents both had difficulties with chemicals.

Mike: And so my first ACL surgery back in the days when they cut open half your leg, right? I didn't know what they gave me, but I loved it. And I said, "What is this stuff?" And they said, "Morphine." And I said, "Can you give me something else? I don't wanna end up like my parents." And the doctor said "You're gonna hurt."

Mike: And I said, "Okay I'd rather hurt." So I've always tended to mark the lower end. I'm in less pain than I probably actually am, but there were people who I'm sure would do the opposite, right?

Sterling: And there were, there are, and there will continue to be.

Mike: Yeah.

Sterling: But I think... and you're touching on another element, which is that at a point in time we called pain a fifth vital sign, and we really did everything in our power, and we made patients believe it was right to do everything in our power to try and eliminate that pain.

Sterling: And it's not... I don't know that's an immediate realistic goal, right? Particularly when you're dealing with pain that comes from injury, whether you inflicted the injury upon yourself 'cause you fell and you hurt yourself, or you went in for surgery and a surgeon intentionally inflicted some injury leading to pain because he or she was gonna fix a problem that was continuing to give you a lot of pain for a different reason, right? It's not going away like that. It just isn't. I wish it would. It'd be great, it'd be fantastic, but it's not gonna happen. So in the absence of an ideological goal that's not attainable. Let's work in the world of pragmatism here, right? Let's be pragmatic about it, and let's try to get this thing under control and keep you making progress toward getting even better.

Mike: What alternatives currently are you comfortable with?

Sterling: Oh there's a number of things. I think that when you look at, we talked about the CDC guidelines, and even from the 2016 guidelines they started to impress upon this. The 2022 guidelines made it even more of a foundational principle, and that is that non-opioid options should remain top of the table of ways to help patients get themselves through pain.

Sterling: And that includes some of the tried-and-true drugs like acetaminophen, the brand name we know, we all know as Tylenol. A lot of the anti-inflammatories, the nonsteroidal anti-inflammatories, are great options. There was a point in time where a lot of surgical disciplines were a little hesitant to use a lot of the anti-inflammatories.

Sterling: One of the things we know about inflammation in the body is that while it causes aggravation, it could cause that pressure and that stiffness and it hurts, and it limits your ability to move and things like that, we do need some of it when you're injured because that helps direct some of those chemicals that your body makes on its own to get to that site and help healing, right? So you don't ever wanna blow out inflammation. It's one of the reasons why we've never really gone to steroids as a large scale pain relief strategy. They could be. They're great. They're the best anti-inflammatory- ... drug we've ever seen. They work reliably, and they work exceptionally every time.

Sterling: But they can actually tamp down too much of that inflammation, and it'll hurt your healing. Years ago, there was some data that suggested that the anti-inflammatory drugs might really do the same. It wasn't great data. Years later, we came to a consensus that it wasn't great data, and we started redeploying these anti-inflammatories.

Sterling: And man, when you do that, you make a lot... You help your patients make a lot of progress. So I'm a big fan of that. Certainly the local anesthetics, those are the caine drugs that we hear about. They're the one people I think know most commonly. There's two people know most commonly. The first is lidocaine.

Sterling: The second is the brand name Novocaine, which is actually a drug that hasn't been on the market in the United States in about 40 years now, right? But it's the name everybody knows. But the drugs in the caine family are great. They actually, you put them at the site above where the pain is a problem, and it acts as a roadblock.

Sterling: It doesn't allow that pain signal to get anywhere near your spinal cord. And if it can't get to your spinal cord, then it can't get anywhere near the point on your brain that says, "Ow, this hurts." We've used those, and we've developed some different iterations of those, and those are great.

Sterling: And then we're starting to see some development of some new oral medications that are out there that are trying to act in ways that avoid those opioid pathways that get you into so much trouble. Those are really promising, and I'm interested in seeing how those go. Probably the most top-of-mind one is a drug the generic name is called suzetrigine.

Sterling: The brand name is called Journavx. And it's manufactured by a company that's out of Boston. And what they've done is they've leveraged all this knowledge that they have about the sodium channels in the human body, and that's really what's responsible for causing changes in the flow of sodium, which leads to the pain signaling.

Sterling: And they figured out a specific subtype of that sodium channel to block. And when you do that, you block a lot of the pain signaling without blocking some of the other components of the sodium channel issues that lead to some of the problems, right? The biggest reason we've got to be really careful with the caine drugs, with the local anesthetics, is that when you block sodium channels of all kinds, you're also gonna touch some sodium channels that we've come to learn only live in the heart.

Sterling: And the most dangerous thing we know can happen when you use the local anesthetics, the caine drugs, is that if you block the channels in the heart, whenever you block the movement of sodium, you also block the opposite movement of potassium.

Mike: Yeah.

Sterling: And that's what leads to cardiac arrest. So probably the most critical, adverse effect we call it, of using the local anesthetics is the possibility of a cardiac arrest.

Sterling: So it's fascinating that this company has used its longstanding knowledge of the sodium channels to do that, and it's a new product that's out there. So it'll be interesting to see what kind of footprint it makes.

Mike: It's interesting you would say that when I asked because I noticed that you didn't leap off and mention what I did in my introduction, which some people are using, which is Kratom, right?

Mike: And 7OH.

Sterling: Yeah.

Mike: So my guess is that you're not advocating gas station pain relief.

Sterling: Gas station pain relief. No, right? They still... the term you hear everybody throw around is gas station heroin. And no I think first of all, Kratom is one of those things that's sold across counters essentially to make money, right?

Sterling: And there's no other way to say it. It has some properties that work similar to opioids. I will say this one of the areas that Kratom, at least as far as we know right now, doesn't touch, is the part of the brain that governs things like constipation and most importantly the rate at which you breathe, right?

Sterling: 'Cause people die from an opioid overdose because you stop breathing. Very simple. You die because you stop breathing. You can't move any oxygen to the brain, and your brain is dead. A very simple explanation of how that goes. So if you're not impacting that pathway that works on the breathing component, is a huge element of safety when it comes to preventing death, right?

Sterling: But it still doesn't necessarily mean that it's not touching the dopamine portions of your brain, and that's what drives the problems that people get into with addiction and seeking the reward.

Mike: And Kratom is a plant.

Sterling: Kratom is a plant. Listen, Kratom is a plant. Morphine ultimately comes from a plant, right?

Sterling: The base of all opioids is the opium chemical that comes from the poppy plant. It's typically produced in the areas around Afghanistan and Pakistan, right? So you refine the opium. The first iteration that you refine to is heroin. The next iteration that you refine to is morphine.

Mike: Yeah. If Kratom is poppies, then 7-OH is...

Sterling: Yeah. Now the Kratom plant is not a poppy plant. It's a different plant.

Mike: But I'm just...

Sterling: Yeah.

Mike: So if heroin is to poppy plants, which 7-OH is to Kratom.

Sterling: To Kratom, 7-OH is a concentrated version of, it's a concentrated version of the active chemical that causes the opium or the opioid-like effects that you see in Kratom.

Sterling: The chemical that causes the effects in a Kratom plant is called mitragynine. 7-OH is simply a shortened way to say 7-hydroxymitragynine. And you would, you put a chemical group structure called the hydroxy group, which is an OH group, on there, and it changes the way the chemical moves in the body, and it makes it more potent.

Sterling: So you can use less 7-OH to get the same if not greater effect than you would need from straight Kratom.

Mike: In preparation for this, I tried to figure out where we're at legally, right? Yeah. And while Kratom is generally viewed as, eh, okay. 7-OH is not viewed as okay. And while the FDA says one thing, California does one thing, Connecticut does another, some states do nothing. Where are we at?

Sterling: That's exactly where we're at. (laughs)

Mike: (laughs)

Sterling: No, it's true. What you just described is exactly what's true, right? On the federal level, the Federal Controlled Substance Act, it really has no place for it to be regulated. There's just no mechanism in the Federal Controlled Substance Act that allows DEA to start to put specific recommendations in there and specific regulation strategies.

Sterling: And so DEA has the same feeling as you and I have right now, and that is exactly what do we do with this? Now, all that said, what DEA is publicly stating, and has publicly stated for years since Kratom's come into the American marketplace, is to say that Kratom is a substance of concern, and FDA mirrors that belief.

Sterling: So it gets left, as many things do, it's the concept of states' rights. In turn, it's a legal constitutional concept called states' rights, and it leaves it to the states to put in the stringent regulations. And so for that reason, you essentially have 52 different frameworks for doing that.

Sterling: You've got the 50 states, you've got the District of Columbia, and the Commonwealth of Puerto Rico, and they can all apply their own distinct regulatory approaches. And they are, and they vary differently. Yeah.

Mike: And you're part of a group who advocates and lobbies and tries to educate legislative body.

Mike: In fact, you just came back from Washington?

Sterling: I got back from Washington, DC last night.

Mike: Yeah. Thank you for doing this. How did it go? What's the group again? What's the group?

Sterling: The group is a group called Voices for Non-Opioid Choices, and the group is now what? Seven years old, I believe.

Sterling: And the founding members who are colleagues of mine on the board of directors, are, three of them are, will tell you they are members of the worst club on Earth to be a member of. They all lost sons to opioid overdoses as a consequence of having had trouble after they first started using opioids as prescription drugs to help manage pain after surgery, sports injuries.

Mike: Yeah, that's part of the problem we're having with the drugs we were just talking about, the pseudo-pharmaceuticals for whatever it is. Did you see John Oliver's thing on, on his show a couple of weeks ago on HBO?

Sterling: I didn't have a chance to see it, no.

Mike: He did a whole half an hour on what's available at gas stations and whatnot and how sometimes it's dirt and sand, and sometimes it's stuff that can actually kill you.

Sterling: Yes. And, the reality is the clandestine street market looks like that a little bit too. And what's so concerning is that when we go ahead and treat somebody, if you have surgery. We're gonna say, "Mike, this is gonna hurt a little bit." We're gonna tell you some things to do to manage that pain, because we want you to keep doing your rehabilitation work and your recovery. And as you do that and you move, you're gonna feel better. Now, I'm gonna give you, in your toolbox here, 12 of these opioid pills. When we do that, there- there's sort of two things that are underpinning everything we're doing.

Sterling: Number one is that I want you to use them really only when the pain becomes so significant that you can't make that progress that we were talking about. That's number one. Number two, I believe entirely that the 12 pills I gave you are the absolute most you'll need to help you with that, and it's my great hope for you that you'll need far fewer than those 12.

Sterling: I don't anticipate that you'll need another round of them. And when you're done with the small fraction of the only 12 I'm gonna give you, I want you to get rid of them when you don't need them anymore. That's not how this goes sometimes.

Mike: No, it doesn't. (laughs)

Mike: You got a relative that says, "You still got some of those?"

Sterling: You should get rid of them, right? I always tell people, consider that the pain umbrella. So once the storm comes through, the umbrella is of no use to you. Find a place to get rid of them. You can look for those kiosks. Pay attention to those take back day events that go on at the end of every April and the end of every October if that time's up for you.

Sterling: And if it rains again, we'll get you a brand-new umbrella.

Mike: (laughs) That's great. Yeah. People don't do that, though, do they, doctor? They say "I better hang on to this umbrella because it might rain again."

Sterling: Absolutely. And they end up in cabinets. And it's interesting. I heard one of the panelists when I was in Washington the other day talking about the fact that one of their good friends, he's an orthopedic surgeon in Louisiana. And one of their good friends is a realtor.

Sterling: And whenever she's listing a house and putting a house for an open house, one of the things she tells her client is, "I need you to clear out your medicine cabinets of anything like the pain pills, and you have to get rid of them." Because there are people who come through open houses looking into bathroom cabinets for this kind of stuff.

Sterling: It happens, right? Grandchildren come over to see how Grandma's doing, 'cause they know Grandma had surgery. Do they care about Grandma's well-being? Yes, they do, but sometimes they also care about the pain pills that they know are in Grandma's cabinet. So you gotta be careful of all of that.

Mike: Yeah, and we were talking off air.

Mike: You're optimistic when you talk to legislators and those that can construct laws.

Sterling: I am. Listen I think that there is a recognition across party lines that the opioid issue is something that needs to be solved, right? The latest CDC statistics tells that 122 people are dying every day from an opioid overdose.

Mike: That's coming down though, right?

Sterling: Oh, it's come down a lot, right? Yeah. The height of this thing was 22, 23, where we were seeing like almost 220 people dying every day, right? So the numbers have come down. That's great, but that's still 122 every day too many. Because they're all preventable deaths.

Sterling: Every death that happens as a consequence of an opioid overdose is preventable, and you need to get through it and you need to get around it. And, you'll hear people too, there are groups of people who will say, "I don't believe those numbers. I think those numbers are higher." And they very well may be, but the process by which we were measuring them at the height of this thing hasn't changed.

Sterling: So if the numbers today are lower than what you think is true, the numbers then were higher than what were reported as well. So I think it moves in a proportional basis, and it shows that there's an effort and that the things we're doing are making progress. And legislators at the federal level and in many states are conscious of trying to do their part, right?

Sterling: So yes, I'm optimistic. It's why I do this work with this group. It's why I go to Washington, D.C. at least once a year.

Mike: And your group was partially responsible for enacting legislation that will sunset, right?

Sterling: Yeah.

Mike: And so what we tend to do is, okay, we fixed it, and then we let things sunset.

Mike: Then it gets to be bad again. So we have to continue. I would think you would say, to advocate and enhance.

Sterling: Yes. In fact, that was one of the themes that we were trying to impress upon all the advocates that came to our conference and that went up to Capitol Hill and went to talk to segments of the government with us.

Sterling: And that is that this is a moment in time where we've gotta fight that uniquely American sensibility and keep our foot on the gas. I told the panel when I was there, when I was flying out Tuesday morning I was looking for something to pass the time while I was up in the air, and I ended up watching Talladega Nights.

Sterling: And I told the panel, I said, "It's like Ricky Bobby always says, you keep your foot on the gas 'cause if you ain't first, you're last," right? And I think that's really true, and that's one of those things. Listen, I walked into offices of congresspeople, senators, and we had an opportunity to sit down with some folks at HHS.

Sterling: And to all of them at some point I said, "This is a moment where we have to philosophically decide we're gonna put our foot on the gas and we're gonna grab our hands around this thing and flip it in a better direction." The American opioid crisis, I would argue, at an inflection point right now.

Sterling: And what are you gonna do with it? Because we've got practices in place to control the supply, but the ultimate win is going to be in fundamentally altering the demand portion of the economic equation.

Sterling: I've written about the problem as an economic exercise.

Mike: And yeah, and given that, I know you're an advocate for harm reduction, and that still is somewhat of a divisive in some communities.

Mike: So like I drove past yesterday a vending machine, a harm reduction vending machine. And that they had to fight to get.

Sterling: Yeah. And listen harm reduction, the idea of the availability of Narcan and making sure the public knows how to use, it is important and on the whole there's good in it.

Sterling: What we were telling legislators and members of the federal government this past couple of days is that while deaths by overdose are down, the number of overdose incidents is not declining. That's because we're better at keeping people alive and giving them a second chance.

Mike: Say that again. Say that again.

Sterling: Yeah.

Sterling: While the number of deaths as a consequence of an overdose are down, they're down significantly, the number of overdose incidents is not down.

Mike: That's significant.

Sterling: People are still getting in trouble and overdosing. And that's why I talk about we've gotta move on the demand, right?

Sterling: The demand is there to go get the item and use and ultimately misuse it. If you're fortunate enough to be in the presence of someone who's got the solution to your death and knows how to use it, there's a real good chance you're gonna survive. Much better than years ago.

Mike: Do you do that when you do trainings?

Mike: 'Cause I do. I advocate when I talk to social workers, "Are you trained? Are you carrying Narcan?" And I'm amazed at the number who say no.

Sterling: Oh, yeah. (laughs) Listen, I traveled back and forth to Washington, DC with three doses in my backpack, in my bag. And when I was in a number of different offices on Capitol Hill, and in the HHS building, I pulled out a dose to show them.

Sterling: Absolutely.

Mike: That's great. What was their reaction to that?

Sterling: Oh, I think the reaction was, "That's terrific. So you really, that, that's really a part of the solution." I said, "Yep." I said, and every time I've sent that bag through a screener at an airport or at an Amtrak station or whatever, nobody's ever asked me a question about, "Why do you have this in here?"

Mike: That's great. That's great.

Sterling: Either they know what it is, they recognize it, and they're like, "Let's go. That's good." Or it doesn't register as a problem. But all that said, we still have to get the number of overdoses down right? Still gotta get that down. You gotta get the number of people who are having use disorders down.

Sterling: You gotta do all of that. And so fighting this battle is a battle that's fought in 360 degrees around the entire problem, right? Sometimes when I talk to groups, I throw up a nice image that I found of a Kraken monster with all the ominous look and the tentacles, and I describe it that way, right?

Sterling: If you go after one tentacle, there's 11 or 12 other ones that are just gonna subsume you, right? And it's gonna make everything you're doing worthless. So the problem has to be approached from many directions and different pathways, and I like to think that my efforts sort of give credence to that.

Mike: I agree. And you're a big advocate for education, right?

Sterling: Yeah.

Mike: Because prevention and education affects the demand end of it.

Sterling: There's no question. I think one of the issues... I'm a big advocate of teaching people how to manage your pain, for God's sakes. Because one of the things that I believe is lacking in the whole pain management approach is that many people don't really understand what their tools are and how to best deploy them, right?

Sterling: And sometimes there's a little bit of nuance, and you gotta learn a little something about it. You gotta figure out what's going on here, right? I have pharmacy students that do a lot of this work with me when they're on rotation, and one of the very first things I teach them, one of the first things we do is we read the story of a legendary Major League baseball pitcher named Roy Halladay-

Mike: Sure, right.

Sterling: Who passed away in 2017 at 40 years of age when he crashed his plane into the Gulf of Mexico about four years after he had retired. When the tox screen came back, you had opioids, you had benzodiazepines, you had stimulants, you had antidepressants, you had muscle relaxers. You had this constellation of things we know are a problem, right?

Sterling: So we read that so we understand what the problem looks like and how it ends horribly. And I have a guy that's now become a good friend of mine, he's a former NFL offensive lineman, and he wrote a book about his experience with addiction. And it actually coincided with the fact that he was a 6'7", 340-pound closeted gay man.

Sterling: And that was powering his decision to go down that path of misuse of opioids that he was getting, had free rein to get because of the injuries that he would inccur, right? But he's alive today. He and I are friends, and we do some engagements sometimes, and it's because people intervened and helped him, right?

Sterling: So one of the things I always tell students is you gotta look at somebody and you gotta say, "Who are you and what's your deal?" And that's a big part of how you power teaching people what to do well.

Mike: That's awesome. That's awesome.

Sterling: Yeah.

Mike: That, and that would be a great part, if you're willing to come back on, that'd be a great lumping off point for the next time we talk.

Mike: Who are you and what's your deal?

Sterling: Who are you and what is your deal?

Mike: We could call that next podcast that.

Sterling: We could!

Mike: Dr. Elliott I share your optimism, and I think we just keep fighting. People ask me, "How are you still doing it with energy after all these years?" I'm like, "Because we keep seeing positive things happen," right?

Sterling: Yes. A, we keep seeing positive things happen. I feel like Hubie Brown now. And B, I should do a thick New York accent. And B, Even though we think we know how to help people, there's still a lot of people to help. At least 122 a day.

Mike: Yes. And there's plenty of people who want the help as well.

Sterling: Sure. There are people who want to get the help. Not all people who suffer the issue the first time are gonna want the help. And you may have to come back and back.

Mike: Yeah. That's fair.

Sterling: It's part of the process.

Mike: Those of you listening and watching know that I put a link to Dr. Elliott's access on the blurb of the podcast. Thanks so much for doing this. I really appreciate it, especially coming back from a trip to Washington. Really appreciate that.

Sterling: Happy to do it.

Mike: Yeah. We hope that, those of you listening, watching, find the courage and support wherever you are.

Mike: We thank you for listening. We want you to be safe. We want you to be well, and we also want you to be educated. It helps.