A pain specialist's perspective on the opioid epidemic: A discussion with Dr. J. Mark Bailey

By John J. Murphy, MDLinx
Published August 5, 2017

Key Takeaways

Background The rate of opioid overdoses tripled from 2000 to 2015 in the United States. Meanwhile, the number of opioids prescribed peaked in 2010 and then decreased each year through 2015, according the Centers for Disease Control and Prevention (CDC).

Despite the decrease in opioid prescribing, opioid-related overdose death rates continue to skyrocket—largely due to use of illicit opioids, including heroin and "street" fentanyl. From 2014 to 2015, the death rate from heroin increased by 20.6%, while death rates from synthetic opioids other than methadone, such as fentanyl, increased by 72.2%, CDC reported.

"As our nation's opioid epidemic worsens, it is critical that state medical and osteopathic boards—and the physicians and physician assistants they license and regulate—have updated guidance on the responsible management of chronic pain," said Humayun Chaudhry, DO, MACP, President and CEO of the Federation of State Medical Boards (FSMB). "It is also critically important for clinicians to assess whether opioid analgesics, when prescribed by them, are not being abused, misused, or diverted."

Accordingly, FSMB issued revised "Guidelines for Chronic Use of Opioid Analgesics" in May 2017. Pain specialist and neurologist J. Mark Bailey, DO, PhD, served in the workgroup involved in revising the FSMB guidelines. Dr. Bailey is a clinical professor in the Department of Neurology at the University of Alabama at Birmingham. Interestingly, Alabama has the highest level of prescription opioid use in the country. But compared with other states, Alabama was ranked 26th in prescription overdose deaths in 2015.

Pain specialist and neurologist J. Mark Bailey, DO, PhD

In this interview, Dr. Bailey explains FSMB's reasons for revising its opioid guidelines, and describes a pain specialist's perspective on the opioid crisis. He also characterizes the challenges facing physicians and patients in lowering doses and reducing opioid prescriptions.

MDLinx: From your perspective in pain management, can you provide a snapshot of the current opioid epidemic?

Dr. Bailey: When we talk about the opioid epidemic, in my mind we're talking about overdose death rates, which result from medications not prescribed for that individual person, but from the street or from a friend or some other source. As a chronic pain physician, most of the patients who I see aren't likely to be in that category. The people I see have a terrible pain-causing disease of some kind or another. One of my obligations to these patients is to make sure they do have something wrong with them when I see them for the first time. And if they don't have something wrong with them, then they don't get opioid pain medicines. So a lot of preselection happens before they become one of my patients.

To get back to your question about the opioid epidemic, those overdose death rates are indeed skyrocketing, and that's why we have the current crackdowns on opioid prescribing and guidelines that recommended less and less pain medicine and fewer dosages.

MDLinx: Regarding the FSMB guidelines, were they updated in response to the current crisis, or are they updated on a regular schedule or calendar basis?

Dr. Bailey: No, not on a calendar basis. The last update was in 2012, and obviously a lot has happened both from demographics and from regulatory standpoints since then. So the guidelines were updated because it was felt that it was time to make them more pertinent to what's going on now.

MDLinx: What were the key changes made to the FSMB guidelines?

Dr. Bailey: The changes made were the types of measures that are being emphasized now in pain management and pain medicine across the board. There's an emphasis on risk assessment for each patient, an emphasis on minimizing doses, and an emphasis on addiction referrals earlier rather than later, if that seems to be a problem. So the changes made to the FSMB guidelines are very current in what's appropriate right now in pain management.

MDLinx: Have practice guidelines of other medical or government organizations also changed recently?

Dr. Bailey: The CDC guidelines that came out in March 2016 made headlines. Both regulatory and third-party payer entities seem to have paid a lot of attention. When the CDC guidelines were first proposed, there were a lot of concerns for a lot of reasons. There were recommendations that the pain organizations did not particularly care for—one being the limitation of particular morphine milligram equivalent doses per day. The pain organizations wrote to the CDC during the comment period and posed their concerns, but these seemed to have been largely ignored. From what I could tell, the CDC guidelines were released with very little modification. I, myself, received a denial of service for something that I had ordered just two weeks after the guidelines had been published. So the third-party payers were very much on top of this.

MDLinx: As a pain management specialist, what challenges are you now facing in treating patients?

Dr. Bailey: Recommendations for pain management have changed so drastically in the last, say, 15 years. Back then, the dogma taught to pain doctors was that if patients were having more pain, you gave them more medicine. Then if the patient had less pain and didn't have side effects, that was good—the dose response curve was linear. So as you'd expect, you ended up with people on high doses of pain medicine.

Now, the emphasis is on reducing doses and keeping people below certain morphine milligram equivalent doses per day, and more focused on non-opioid pain management—and I'm completely in agreement with that. But a lot of my legacy patients—the people I've been treating for 15 years who have been on high doses of pain medicine—I'm now reducing them back to guideline-recommended amounts. That's been rough for some of these folks because they've been on the same amount for a long time. A good number of them are working people who have been very functional on these higher doses, but now I'm reducing their doses to stay within guideline-recommended numbers.

Another major problem is that for these non-opioid treatment options that are being offered—cognitive behavioral therapy, as an example—the insurance companies are not paying for that. Opioids are cheaper and insurances will cover them. So it's a catch-22 for a lot of my patients, I'm afraid.

MDLinx: How do you help patients to deal with that?

Dr. Bailey: I try to reduce their doses at reasonable schedules—that is, slowly. But ultimately they're going to have to get by on less medicine and modify their lifestyles accordingly.

I will say I have been pleasantly surprised that an awful lot of them—not all of them, but a good amount of them—are actually doing better on the lower doses. They feel better and they have fewer opioid side effects, like constipation and cognitive slowing, etc.

MDLinx: What can pain specialists and other physicians do to help curb this epidemic? 

Dr. Bailey: I think the biggest thing that we have to do is change our mindset about prescribing medicines. We in the US consume about 80% of the world's opioids, but I don't think US citizens hurt any worse than citizens in other countries. I don't think we're more prone to pain conditions. Instead, I think there's a prevailing attitude among both American people and physicians that if you get some symptom, you take a pill to make it go away. I think that attitude is going to have to change a whole lot and physicians of all stripes are going to have get with the program, so to speak, and not give somebody a big bottle of narcotics for every stubbed toe or pulled tooth. I think we've been way too free with our opioids and now our patients expect that.

MDLinx: Do you see an end to this epidemic? If so, how or when?

Dr. Bailey: I think that's a fascinating question. In our state, the legislature has imposed regulations and guidelines to reduce dosages of pain medicine, so we'll see if that reduces opioid deaths or not. When the coroner's report comes out next year, we should be able to see if the opioid death rate goes down. If it does, then what they're doing is the right thing. If overdose deaths don't come down, they're going to have to rethink what they're doing.

Quite frankly, I think that restricting physicians in what they do to treat their patients is probably not the best target to be shooting at to curb overdose death rates. It's generally not my patients who are dying of overdose deaths. It's people who are illicitly obtaining and using, and kids at parties and that kind of thing. So I don't think restricting pain docs, or physicians in general, is going to change much of that. But we should have an answer when the coroner's data comes out next year.

About Dr. Bailey: J. Mark Bailey, DO, PhD, is a pain specialist and clinical professor in the Department of Neurology at the University of Alabama at Birmingham, in Birmingham, AL.

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