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What Anti-Opioid Strategies Could Really Lower the Death Toll?

Anesthetist Dr. Richard Hurley discussed with Robert J. Marks the value of cognitive behavior therapy — reframing the problem

In a recent podcast, “Exercising Free Won’t in Fentanyl Addiction: Unless You Die First” (May 4, 2022), Walter Bradley Center director Robert J. Marks interviewed anesthesiologist and pain management expert Dr. Richard Hurley on the scourge of opioids and what information strategies might help combat it.
Yesterday, they looked at highly addictive opioids like Oxycontin, Percodan and Fentanyl and the many needless deaths that result from their misuse. Today, the focus is on strategies for prevention.

Note: Robert J. Marks, a Distinguished Professor of Computer and Electrical Engineering, Engineering at Baylor University, has a new book, coming out, Non-Computable You (June, 2022), on the need for realism in another area as well — the capabilities of artificial intelligence. Stay tuned.

This portion (the second half of the episode) begins at approximately 09:00 min. A partial transcript and notes, Show Notes, and Additional Resources follow.

Robert J. Marks: There was a series called Dopesick on Hulu. Michael Keaton starred as a physician that got hooked on Oxycontin. And it went through the addiction that spread through Appalachian and southern Ohio a decade or so ago. And the Oxycontin comes in pills. Fentanyl comes in lollipops. Has there been any pushback from the medical community about the prescription of these drugs? Can any physician write a prescription for Oxycontin or Fentanyl?…

Richard Hurley

Richard Hurley: Okay. So in 2016, the CDC [Centers for Disease Control] came out with 12 guidelines for primary care physicians and what they should write. And let me just go through those real quickly so you’ll understand what happened. Any physician can write a prescription for Fentanyl, but by the way, that’s usually done in a patch. Now, you could write it in most of the orals, the buccals, and the sublinguals. The sublingual sprays are predominantly for cancer pain, breakthrough cancer pain. But anybody can write that as long as they have a license to practice, like in Texas, and also have a license through the DEA [Drug Enforcement Administration]

Robert J. Marks: Are those for people who are terminally ill and you’re just trying to make them comfortable until death comes?

Richard Hurley: The only patients that I use the suckers, the sublinguals, are patients, primarily, who have head and neck cancer. And they’re not “opioid naive” at all. And the only way you could control their pain was the orals.

Now, for most patients who get Fentanyl, we prescribe a Fentanyl patch (the trade name is Duragesic). They come in a patch that looks like a bandaid. And the bandaid is designed to deliver the drug through the skin, into the circulation and then into the central nervous system. And they’re labeled at 12 and a half micrograms per hour, 25 micrograms per hour, 50, 75 and so on.

And that drug is so lipophilic! It penetrates the skin, fat… It does take 11 hours to penetrate to get through. But once it’s through, it’s fine. And these patches, you change them every three days.

Robert J. Marks: I see. So they’re kind of slow release in a way.

Richard Hurley: Right. That’s correct. But people who abuse it will then take the patch and scrape it off and take the drug. If you scrape it off, it looks like a little gel. And they’ll put that under their tongue, the whole amount. A three-day supply.

That drug was used a lot by nursing homes,because the nurses would only have to give their pain medicines every three days. They didn’t have to run in every two hours. And then they would take those patches off. They’d throw them into the dumpster. And people would die in the dumpster to get them. And by the way, they were called “chiclets.”

Yeah, that’s a chiclet. And that’s been on a sweaty arm for three days and now you’re going to put it in your mouth? Oh, my gosh.

So the 12 [new] guidelines, let me do this real quick. Opioids are not the first line anymore. You’ve got to try over-the-counters. You’ve got to try exercise. You’ve got to try interventional cognitive behavioral therapies. If you do decide to do them, you have to establish realistic goals for pain and for function. You have to discuss the risk and benefits. You must start out with short-acting pain medicines, not long-acting like Oxycontin. You got to use the lowest effective dose, and they really want it under 15 morphine milli equivalents … and certainly not to exceed 90. If you’re going to treat acute pain, you can only treat it for 3 to 10 days, 10 days now in Texas. You can evaluate the benefits and harms frequently. So initially, when I put them on there, you need to see them every one to 2 to 4 weeks, then you’ve got to do mitigating strategies.

You got to give them Naloxone if they’re going to get more than 50 morphine equivalents. You can’t let them take benzos — benzodiazepines — at the same time. And they can’t drink alcohol. Then you got to review the prescription drug information that’s put out by the state now. And so I can pull up the patient’s name and see if somebody else is prescribing them other medications.

I have to do urine drug testing to see if they have illegal medications or alcohol in their urine. You kind of avoid the use of opioids with benzos and with alcohol.

Robert J. Marks: What are benzos?

Richard Hurley: Benzodiazepines would be like Valium, Ativan, Lorazepam, Ambien. And then you’ve got have a way to offer medication-assisted treatment, either using Suboxone or possibly Methadone or cognitive behavioral therapy. So all of these things came out in 2016.

And the opioid problems in Appalachia in 2000 — their death rate was the same as the general population. It was amazing. I mean, they didn’t have a big issue with it. But by 2017, the overdose death rate in Appalachia was 72% higher than the general population.

One of the things they figured out was, interestingly enough, that the prescription writing was 45% higher than the general population. So there was a lot of abuse going on. And some of that was due to marketing of Oxycontin and those kinds of things.

Robert J. Marks: Yeah. That’s what the Dopesick series was talking about. The company kept on coming out with pills with higher and higher dosage. And they kept saying that, if you had this slow release of the opioid, over time it wasn’t addictive, which turned out to just be company hype. It didn’t work.

My friend who was addicted to opioids — I think probably this happened before all of these restrictions came in. In other words, he was given Fentanyl whenever he said, “Ooh, I feel uncomfortable.” And it was just an overdose. He became addicted totally from prescriptions. And he wanted to — he was tempted to — go to the street, but decided not to and suffered the consequences of doing that.

I also read todays a warning from the DEA, the Drug Enforcement Agency. It says, “Many fake pills made with Fentanyl look like prescription drugs. And as many as” — and this blew my mind — “two in five counterfeit pills may contain a fatal dose of Fentanyl.” And, I understand, on the street, they also begin to do things like cut cocaine with some Fentanyl. And so even though you buy some sort of other drugs, there’s a good chance that it’s cut with Fentanyl in order to give it a bigger hit.

So this is really serious. But it sounds like, from the medical side, that things are pretty well tuned right now. And they seem to be working pretty well. Have the statistics gone down after the imposition of these criteria?

Richard Hurley: Before the guidelines came out, prescription opioid writing was actually going down. Now, it has dropped precipitously since 2016. But have the overdose deaths gone up? The answer to that is yes. Over a hundred thousand last year. And 72% of those are Fentanyl-based.

What has happened is that those guidelines… If the CDC came out with a guideline for you at Baylor University, how long would you think it would take before that became the standard of care? So not only did it become the standard of care among physicians, it also led to legislation. They made those recommendations into law. So the biggest problem we had then is that, if I had a patient that needed more than 50 milligrams of morphine a day, and I told them, “Now, I can’t order it because of the recommendation of the CDC guidelines,” where do you think they went? Straight to the street!

Robert J. Marks: Have you had incidents where…

Richard Hurley: Absolutely. And you read them in the obituary.

What has actually happened is that, when we started cutting them back and they couldn’t get their medication, and Fentanyl was so easy to get, that was it. I can’t believe this, but actually the addict will actually go try to get the drug that killed the most people. In other words, I like what I’ve got, but if that dose killed that person, I bet you if I took just a little bit less than that, that would be the best high I’d ever have. Isn’t that something?

Robert J. Marks: I tell you addiction and the wiring of the brain to these dopamine hits is really dangerous. I was going to ask if you had any advice for the addicted. You mentioned exercise, which I think is interesting. What happens when you exercise? How does that help you?

Richard Hurley: Well, I always tell my patients, if you actually do something, function-wise, walk a block, walk a flight of stairs, walk a mile, achieving a physical goal is actually pain-relieving. And you may have noticed that yourself. I couldn’t do 10 pushups and now I can do 11. In other words, if you set physical goals to patients and they actually do them, it actually is pain relieving. If you set a goal like, I’m going to lose 10 pounds in the next three months, setting goals and actually accomplish them, actually creates, again, the same kind of pleasure sensation. Now, granted, it’s not as powerful as the opioids, but those things are definitely helpful.

Robert J. Marks: You also mentioned cognitive behavioral therapy… Does this include groups like AA and that are similar to AA?

Richard Hurley: Certainly. You could certainly say that’s a part of the group. But basically, what they try to do is change your thought processes in terms of a situation. So you may have a situation, but is that situation causing your emotional change? Or is it the interpretation?…

Richard Hurley: I have patients that come into my office and I ask them, “Well, tell me about your pain.” And they’ll say, “Well, my back pain, I feel like somebody is cutting me in two with a knife.”

Richard Hurley: Obviously, they may have had back surgery, but they weren’t cut in two… In other words, many patients make it dramatic or catastrophize their pain, “Doctor, you don’t understand what I’m going through.” And yet 65% of all patients who are over 65 have at least three to four weeks of crippling back pain every year.

Robert J. Marks: Wait, say that again. What percent?

Richard Hurley: 65% of all Americans after the age of 65 will have at least three weeks of significant lower back pain. Every year. Those numbers are well done. So what they try to do is to help them to deter…

Robert J. Marks: I used to be afraid of needles. And then one day, and I think this touches on what you were talking about, one day I decided, look, it doesn’t hurt that much. I’m more afraid of the needles than I am of the pain. So I started to actually look at my arm when the needle went in. And it wasn’t that bad. It was just this change in perspective that took away that fear. And I think that’s what you’re talking about with this cognitive intervention.

Richard Hurley: I explain this to my patients in this way. If I came into the room, didn’t introduce myself to you, and slapped you in your face, your response might be one of horror and you might leave. Or you might slap me back. But if I came into the room with a suitcase and I opened it up and it was full of hundred dollars bills, and I said, “This is yours, tax free,” and then I slapped you, your response would be totally different.

You might say, “Why’d you do that?” But you wouldn’t walk out. And you probably, at the end of the visit, would say, “Thank you for the million dollars.” It’s the state of mind in which this happens that creates an emotional response like you had. You didn’t have the emotional response to the needle. You set your thought processes that way.

I don’t have any problem with needles. My problem is flying on an airplane. It starts from the time I start packing in the morning, to the time I get to the terminal, to the time I check in, to the time I go through with my bags and take my shoes off. By the time I get there, I’m a basket case. And the way I get through it is to watch an action movie on my phone.

Robert J. Marks

Robert J. Marks: Is that right? Okay. Emo Philips tells a joke about him being despondent and kind of depressed. And he went to a therapist to get cheered up. And the therapist charged him a hundred dollars per hour. And then he realized that if he was walking down the street and he found a hundred dollar bill, that that would really cheer him up. So he decided not to go to his therapist anymore, that saving that a hundred dollars was going to be good enough for him. Dr. Hurley, any last thoughts?

Richard Hurley: What I tell my patients is, “You have to make up your mind what you’re going to do at the very end.” And the problem with opioid addiction is it starts when we’re young teenagers and stuff. We really don’t have a firm grasp of the problems. And we want to experiment. And the peer pressure, as you know, is just terrible.

Robert J. Marks: And we think we’re immortal when we’re young.

Richard Hurley: Right. Parents are nervous about talking to their young children about sex. But for some reason, they’re nervous about talking about drugs. A teenager’s got to “just say no,” like Nancy Reagan said. They got to have that just imprinted in their brain from day one. Otherwise, it’s a sad situation. And it’s bringing our life expectancy down. We used to live to be 82 years old. It’s dropping every year because of opioid deaths.

Robert J. Marks: Really? And that’s the prime reason that the death age is . . .

Richard Hurley: Yeah. If you’re supposed to live to be 82 and you overdose at age 15, what do you think that does to the average?

Robert J. Marks: Oh, that really screws up the average.

Next: In a new episode, we meet “Stretch,” who became addicted to medically prescribed Fentanyl.

Here’s the first part of this episode: Opioids: The high is brief, the death toll is ghastly. Fentanyl has medical uses in, say, open heart operations where the patient is on life support; otherwise, it is a one-way ticket off the planet. Anesthesiologist Richard Hurley tells Robert J. Marks how Fentanyl affects the brain and why the street version is so deadly.

Show Notes

  • 02:48 | Introducing Dr. Richard Hurley
  • 03:04 | What Does It Mean to be Board Certified?
  • 06:09 | Why Are Opioids so Addictive?
  • 09:07 | The Horrors of Detox
  • 14:30 | Has There Been Pushback by the Medical Community?
  • 21:32 | Issues with Fake Pills
  • 24:27 | Advice for the Addicted

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What Anti-Opioid Strategies Could Really Lower the Death Toll?