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The 9th Annual Pain Care Skills Training taking place at SOUTHCOM Conference Center of the Americas in Miami, Florida, brings colleagues and subject matter experts together to learn more about optimizing care and integrative approaches to pain management within the Department of Defense (DoD). The focus will be in sharing best practices, conducting hands on training and learning integrative approaches. The overall goal of the Pain Care Skills Training will be to promote readiness, restoration of function and relief of pain while decreasing the use of opioids.
Transcript
Okay, our next speaker, our final speaker for the morning, is Dr. Victor Rivera. And boy, our speakers just keep getting better, and better, and better, from Dr. Lewis, to Mardian, Lieutenant Commander, Dr. Rivera you’re up against a tough group here. But, we’re so happy that you are coming today to speak with us, we’ll put your slide on functional medicine approach for managing chronic pain. Really give us a, really open our eyes and give us a completely different perspective with the paradigm of functional medicine. I’m very excited about that, and your background, you’re a native from Pasadena, Texas, Texas, and a 2000 graduate of Texas Chiropractic College, and you stayed and worked as a chiropractor before then entering bachelor of science human biology, doctor of chiropractic, after the American College of Acupuncture and Oriental Medicine. And then, finally, on to medical school in USCIS, one of our former pain fellows, and doing a fantastic job in this area, and we’re grateful to have you today to talk to us a little bit about functional medicine. (applause) Do you want this (muffled speaking)?
No, (muffled speaking).
Okay, awesome.
Thanks. All right, well thanks for having me. And thank you Commander Mellon, that was great. So my talk today will focus on how functional medicine can be utilized for the management of chronic pain. I have no disclosures, and these are primarily all my opinions. So the objectives, to understand the role of functional medicine, and how it can be utilized for the management of chronic pain, and then understand the concepts of how functional medicine investigates root causes to create personalized treatment plans, and then become familiar with ways to incorporate functional medicine tools into your practice. So, quick background. Again, yeah, prior to medical school I went to chiropractic college, and during chiropractic college we had about a year of clinical nutrition, and that pretty much started my kind of passion in nutrition and then after chiropractic college I was working during the day as a chiropractor and going to school at the American College of Acupuncture and Oriental Medicine in Houston, and in there, kinda learned how food is utilized for just management of all diseases and stuff. So then that kind of helped to hone in some of kind of my nutritional background. Then I decided to go to med school, and in med school I kinda lost that emphasis. Remember gettin’ a nutritional book, it was about this size, during one of our intersessions at USCIS, and that was it. We were told, “Hey, if you’re interested “in clinical nutrition, “there’s a book that you can get in the admissions office,” and that was our course (chuckles). So then graduated medical school, went to internship, and then after internship, this is where it really all started for me. I was at the flight surgeon course and got a call that my daughter had a seizure. Then she was worked up, and it was idiopathic. And she was having a seizure every 20 minutes, and it would start at different locations, so she didn’t have anything structurally wrong with her, they did a full workup, tried her on all these medications, she was refracted to all the medications, and then for the last ditch effort they decided to do the ketogenic diet on her. Well, after a few weeks, her seizures stopped, so they decided to start weaning her off, probably about the three month mark, and then as they began to wean her off, the seizures returned. So they kept her on the ketogenic diet for another year and a half. And at that point, she’s been drinking oil for meals, and she was seven at the time. And very, very little carbs. And, anyway, she started talking about all the foods that she wanted to eat after coming off the diet, and I was like, “Whoa, this can’t be good,” so I started doing a lot of research. One, to figure out why that worked. And then, two, how she could protect her brain, right, from this occurring again. So, in my research, I kinda got exposed to how powerful nutrition is into treating not only seizures, but all kind of, all disease states. And I read a book called UltraMind by Mark Hyman, who’s the, who’s a board member of the Institute of Functional Medicine, and also the director of the Cleveland Clinic Center for Functional—
[Lewis] So it would make a difference. Because, I mean, there’s lots of challenges, obviously, with central brain stimulation, but I’m wondering if other people are looking indirect ways to create the same corrections. There are some studies that are looking at this. They’re still limited. There are still a lot of technical challenges that have yet to be overcome in terms of using this as a true biomarker for pain response. One is the way that the data is processed, one is the, having a large enough sample size, because the effect size is still, I think, I think in some conditions it’s smaller than in others, so depending on what you’re looking at. But there has been some work. I think the one that probably has, at least that I’m most aware of, specifically in acupuncture, which is a little bit different, but there are some efforts to find those correlations pre- and post-treatment, for instance. But that’s still pretty early.
[Audience Member] Youssef Said (muffled speech) on first base, just a quick question, kind of along the same lines. In terms of peripheral nerve stimulation, the trials are very early and spread PNS, but are you seeing any central remapping with central nerve stimulation that you’ve kind of come across?
[Lewis] Not that I have come across. I think that’s very ripe, but I think that’s still challenged. I think the, I think the interest in, I think there’s a couple things. One is, if you find something that works, then, you know, just stay with it. Why do a lot of research to look at the central effects? I think that’s a part of it. The second part is that, it really requires looking at, it requires looking at all of the really dimensions that we’re talking about here, so I haven’t seen a study where that’s been parcellated out. I’ve seen some attempts, but nothing definitive. Don’t know if that answers your question, but it’s ongoing.
[Stevens] Captain Stevens, Corpus Christi. I know anecdotally, when I see my patients, they have the continuum of fibromyalgia, pelvic pain, sometimes low back pain, I always ask the question, “Were you abused when you were a child?” So many of ’em were. So, are there, is there a physical change, or a trigger or something that happens that maybe remaps this pain thing, and how can we use that?
[Lewis] Yeah, so that is, I think that’s a common experience among providers, and I think it’s certainly been recognized as a risk factor in a number of painful states. We even see it in chronic symptoms of concussion. But history of abuse, or of really of any behavioral health diagnosis prior to injury. So, I think that there is a recognition of that, and an appreciation of that, in terms of the epidemiologic studies. How that influences this I don’t think has been clearly described, but I think that is, I think that would be a very important and relevant study to look at. The– How much time do I have?
[Moderator] Oh, you’re good.
[Lewis] Okay. So this is, so I’m gonna go on a tangent a little bit here. So the National Institute of Mental Health is really, has been working on something called the Research Domain Criteria for several years now, which is the idea of taking a mental, then the focus there is on mental health, but that really applies in pain as well. Is to take the symptoms and develop a model, a cognitive model that can be then used to develop new treatments. So, for instance, when the studies in adolescents with anxiety, when they show faces, so a spectrum of faces from very happy to very angry, a sequence of 10, and then you put kids without a history of anxiety in the scanner, they’ll select, they’ll say, “Okay, the midpoint that’s neutral is maybe,” and I’m just making up these numbers, ’cause I don’t remember them exactly, they say maybe say the midpoint is five. You take anxious patients, they will be shifted, perceptually, over to a three. So that we, someone without anxiety would interpret as mildly positive, they will interpret as neutral. So this perceptual bias is now being looked at in terms of a target for anxiety disorders. And my Gestalt, although I haven’t seen anything that shows this yet, is that that same bias probably influences response to pain. And my guess is that’s probably very early on in the developmental process. Kinda the earlier in the developmental process that adversive stimuli occurs, probably the greater the degree of risk for subsequent comorbidities along with pain. That’s just me talking, so I’m glad that we have a disclaimer slide early on, but I think, so while that hasn’t been borne out yet, I think that’s the approach to take to answer your question. And I haven’t seen that study yet, but I am, at least in terms of correlations with what I’ve been describing. I think it’s certainly been described in terms of the epidemiology, but not in terms of neurophysiology.
[Moderator] Any other questions? Okay, with that, Colonel Lewis, thank you again very much. (applause) Okay, our next speaker today is Dr. Aram Mardian, Dr. Mardian comes to us today from Phoenix. He is a clinical associate professor, family and community and preventative medicine, University of Arizona, a board certified family physician, also certified addiction medicine, pain medicine, medical acupuncture, he’s the founding chief of the founding pain and wellness center at the Phoenix VA. I’ve known Dr. Mardian for many, many years now. His chapter on acupuncture is one of, I highly recommend it, and the textbook I don’t know, because I pulled out the chapter, and is really amazing. And it is one of the most wonderful things that we have for our trainees in explaining the science behind acupuncture. Dr. Mardian worked with me on our VA-DOD opioid clinical practice guideline. Again, Dr. Mardian’s one that never says no. Whenever we from the Military Health System have a request, Dr. Mardian always steps up to the plate and is so generous with his time in doing that with us. Today, he is giving us this fantastic presentation on something that’s very near and dear to us, something that he’s pioneered in the VA, and really has led efforts in the VA, and that’s on opioid tapering. And with that, Dr. Mardian, I’m gonna bring you up. (applause)
[Mardian] Okay, can everyone hear me okay? I see maybe one or two nods, I’ll assume yes. Very good, well it’s an honor to be here, thank you. That was a wonderful first lecture, beautiful way to honor Dr. Hickey, and a wonderful way to start us out with a lot of the underpinnings that I think we’ll see in our opioid talk, and really throughout the day, the next few days. I usually have the luxury to complain coming from Phoenix and the Pacific time zone, of the time change, gettin’ up early, but here I’m humbled by people coming from Japan and all over the world, so I think it’s time for me just to stop whining about that. (audience laughs) So, I, so okay I have no disclosures, and these are my own views. So objectives to start out, I’d like us to describe the characteristics of what I’ll call a collaborative opioid tapering process. Want you to be able to list the three Cs as a pneumonic to think about substance use disorders, and then identify evidence-based treatment for opioid use disorders. Next slide, so we’re very familiar with these converging public health crises, right? The opioid crisis, chronic pain crisis, I’ll spend just a few minutes talking about our current state, which we’re all well aware of that in the room here, we’ll talk a little bit about the current state, and then we’ll talk just a bit about the background, some of the models of pain care and our healthcare system that got us here, as a way to think of how can we transform those, how can we change those, not only in opioid tapering, but in the larger context of chronic pain care. Next slide, please. So, again, staggering numbers, almost 400,000 deaths from 1999 to 2017 from both prescription and illicit opioids, next slide. And then this is a dramatic increase, a five-fold increase from 1999 to 2016. Next slide. So I think many of you have probably seen this slide, this is from the CDC. This essentially looks at the three waves of the opioid epidemic, so on the far left side here, really a start of this epidemic was in the large increase in prescribing prescription opioids, and the overdose deaths that were related to that. Then, in about 2010, the deaths from heroin started to increase dramatically as our second wave. Both of those have started to level out, but unfortunately now those larger trends being overshadowed by the deaths from synthetic opioids, primarily illicitly-manufactured Fentanyl, which are still increasing. Next slide, please. So, really our major adverse effects from opioids, overdose death and addiction, so from 2016 numbers, 1.8 million Americans having an opioid use disorder related to prescription opioids. And then some of these are overlapping, but 626,000 had a heroin-related opioid use disorder. Next slide, please. So, chronic pain is the most common, the most costly, and the most disabling of chronic conditions, right? So we have been spending a lot of money, over $600 billion annually in both care and lost productivity, and we’re not doing very well. And I’d like to talk about and make a little bit of a connection between our current opioid situation and how we got here based on models of pain care. Next slide, please. Kind of staggering numbers, looking at a trillion dollars up until 2016, then an additional $500 billion projected. This is the cost of the opioid epidemic, again, both in the cost of care and lost productivity. Next slide, please. Again, so what we’re doing is not working very well, this shows the share of newly-disabled workers from 1961 on the left-hand side, over to 2011 on the right-hand side. We see on the left-hand side low back pain, musculoskeletal disorders being quite low down on that list, and then coming up to the top and the largest proportion of newly-disabled workers in 2011. Next slide, please. So, in response to this, we’ve had many national guidelines and recommendations and policies, the CDC and the National Pain Strategy in 2016, the VA-DOD guidelines in 2017, next slide please. And then in the two to three years since, we’ve seen some confusion around how to implement these guidelines. Such that the authors of the CDC guidelines in April published this New England Journal article talking about policies and practices that are inconsistent with the CDC guidelines. So, clearly this is an area that requires a nuanced approach, it’s an area that does not lend itself well to following a recipe, I think, unfortunately, that’s what many of us have maybe been wanting, and this article really shows us some of the unintended consequences. So, looking at inflexible application of recommended dosage and duration thresholds, hard limits, and then abrupt tapering, resulting in sudden opioid discontinuation. Really are not what the CDC guidelines, the VA-DOD clinical practice guidelines, or really any policies have really been recommending. Next slide. So, what are we looking at? Really, an individualized and whole-person pain care approach. And again, the lecture by Dr. Lewis really shows us some of the neurobiological underpinnings of this approach. Next slide, please, so both the DOD and VA looking at shifting from a model that focuses on disease to a model that focuses on health and health promotion. Next slide. Siddhartha Mukherjee is an American oncologist. On the left-hand side here, he talked about, this is his view of the biomedical model of pain. And so this is the model that really has allowed and been some of the underpinning of both of these public health crises. So, in his view he talks about this model that we can think of from the antibiotic era, that has worked very well, right? So have disease, take a pill, and kill something. And that has worked phenomenally well in areas of infectious disease, but when we take that model and we apply to something complex like a chronic illness as chronic pain or addiction, we end up with high costs and low value care. So looking at a biopsychosocial or a resilience or neuroplasticity approach over on the right-hand side, we think of, again, using mind and body to change our brain and our relationships. We think of retraining our brain, changing the relationship to the environment, both our internal and, sorry, our external and internal environment, that exteroceptive and interceptive environment, cultivating mindfulness and positive affect, right? So an area that we haven’t focused on very much over the last few decades. And engage in meaningful and enjoyable activities. Next slide, please. So to implement this, we really need to think about pain differently. In the pain world, this biomedical model translates to finding the one pain generator and really aiming to counter that through numbing, destruction, removal, and in some cases that can work well. Particularly with more acute pain, but with chronic pain, particularly when we’ve had major changes in the various brain networks that were described, we don’t do so well. That model focuses, again, on passive treatments. Treatments that are done to me, pills, procedures, and surgeries. Switching over to this other model requires a major change. So again, a change to health-based system, and this idea of changing relationships to our various sets of contexts. So intrapersonal, interpersonal, activities, and then, interestingly, how we approach challenge, right? So our next slide we look at how do we approach challenge and stress is a way we can think about resilience. So again, this shift to positive health. Alex Zautra from Arizona State University had his three-part definition of resilience, and I encourage you to think about as we think about our patients. So the first part of that is recovery from adversity. So when we have challenge, a stressor, adverse experience, how do we return to positive affect, and return to, and our second point here, sustainability of purpose, how do we return to our values and our important goals in the face of adversity and challenge? Our third definition here, looking at growth, so finding new insights, form or strengthen social bonds, and gain mastery in the face of challenge and adversity. Next slide. So, thinking now, starting to shift to looking at medications and opioid tapering, it behooves us to take a step back and think about where is our therapeutic focus? Thing about opioid tapering, can be very enticing to focus on the medication. That can be pretty easy if we only focus on the medication. We might focus on pathology, or are we focusing on the whole person? So, when we’re focusing on medications, or disease, or the pathology, we’re doing a couple things. One, we’re potentially jeopardizing the therapeutic relationship, and then two, we may actually do more harm than good. Next slide. So the goals of our treatment, again, to shift to a long-term focus. In pain care, we’ve often been focused on a very short-term focus. And if we do that with opioid tapering, we’re probably not gonna get very far. So, long term, positive health focus, looking at minimizing adverse effects, we’re never going to eliminate them, and then supporting self-efficacy and self-management. Our psychologist in our inter-professional pain team has taught me this first bullet point here. So, rather than thinking about a pain treatment plan for a body part, we think about a plan for the person with pain. And again, so taking a step back, looking at the whole person. Looking at active treatments, the passive treatments that we use can be very powerful. And we think of those as bridging treatments to help our patients gain that self-efficacy. Sometimes if we don’t have that focus, our passive treatments can have the opposite effect, and impairing self-efficacy. And then finally, making sure that we’re not just looking at a body part, but looking at medical, psychiatric, substance abuse comorbidities, and treating those as they come up. I’d like to introduce a concept of logical fallacies here. So, treating patients with chronic pain, and particularly with opioids, can be, trigger emotional responses both in the clinician and in our patients. And that, if it’s unexamined, can lead us to be vulnerable to these fallacies of reasoning, these errors in reasoning. So I’d like to introduce a couple of these. And these really can affect even the most experienced clinicians. When they’re present, what do they do? Well, the reduce our flexibility, and they tend to point us in a more rigid application of our treatment plan. So our first one I call the “Now Forever” fallacy. So this one really assumes that the plan I’m making today unconsciously is a forever plan, right? So if I make a plan today to not taper a patient, sometimes that can morph into the idea to keep the patient on opioids, right? And in the past, three years ago, five years ago, 10 years ago, I would argue that really, unconsciously, we kinda put patients into these buckets. Do I keep a patient on opioids, or am I tapering? And that can almost be a life plan, which I’d argue is not in the patient’s best interest. So, keeping in mind that the decision I’m making is an individual decision at a certain point in time, and it will likely, very likely, change as my patient changes, as our interaction changes over time. Our second one is the “Black-White” fallacy. So this, again, thinking of only binary treatment options and binary treatment decisions, right? And so this can, again, kind of back us into a corner, particularly in these emotional situations. I strongly recommend for us to look at choice points. We have many of them, but sometimes we lose sight of that as we become under stress in these situations. So, we might make a decision to taper, but that ch– we can offer a patient many choice points. And that choice point may be would you, well, okay, today there’s a lot of fear, there’s a lot of emotion in the patient’s cards, so maybe our decision is not to taper today, and our choice points are would you like to start a small change in two weeks, in four weeks, or in six weeks? It might something as simple as, if we’re on different formulations, would you like to look at this type of formulation to reduce first, or this type of opioid to reduce first? So, trying to bring in as many choice points as possible. The next is our “Accept, Fix” fallacy. This one is based on the idea that acceptance is similar to giving up, right? And so if we accept our current situation, that’s giving up and, which would be antithetical to moving forward. Obviously not a choice that many of us would wanna make. When we do this, we often our stuck in what we call the medical merry-go-round. So an endless rotation of passive therapies without helping us improve function, without helping us improve our quality of life. So, when we’re thinking about our treatment plan, recognizing that accepting our present reality is often paradoxically necessary for us to move forward. Thinking about opioid naive versus opioid exposed patients is another very important way for us to think about these populations. Again, thinking about some of the neurobiological changes, these are quite dramatic, and we’re learning more and more about those changes in an opioid-exposed population. So, in the VA-DOD guidelines, we’re very specific to call out these different populations. Recommendation 1-A is to recommend against initiation of opioid therapy for chronic pain. And so much of the change in opioid prescribing, the opioid, the amount of opioids being prescribed, some of the low-hanging fruit is really, in this population, is not starting long-term opioid therapy for chronic pain. A much more complex situation in recommendation 14 is recommending tapering when risks outweigh benefits. And again, we were somewhat prescient in this second parenthetical comment, abrupt discontinuation should be avoided unless absolutely necessary. FDA issued an advisory about this in April of this year. Next slide, please. So again, just this broad set of treatments, as we’re talking about opioid tapering, remembering that our foundational treatments for patients with chronic pain are really our active therapies, and I put these in two large buckets, our psychological therapies, we have multiple subtypes of that, cognitive behavioral therapy, acceptance and commitment therapy, mind, health, space stress reduction, all have good evidence behind them. And then exercise or movement therapy. And again, the way I think about this is what’s an enjoyable way to move our bodies? And we have various disciplines that can help us, yoga, Tai chi, physical therapy, recreational therapy. In our clinic we look a lot at nutrition, so we have a dietician who has created our anti-inflammatory diet program that is now available throughout our health system as an active treatment. Passive therapies, again, looking at things like acupuncture, spinal manipulation, as our bridging therapies to help support our patients, maybe as they’re tapering, when they’re doing something that’s particularly challenging for them, to help them move forward in a more active direction. Highly recommend taking a look at this Lancet low back pain series. Summarizes much of what I’ve talked about so far. This was published, there were three articles, just last year for a worldwide Lancet collaborative. And again, they talk about this notion of using positive health. They didn’t use the term resilience, but their definition here is ability to adapt and self-manage to challenging situations, is really the definition of resilience. And then our biopsychosocial framework that we’ve talked about. Unfortunately, we overuse low-value treatments, so treatments that are high cost and have relatively little evidence of benefit, and so this collaborative recommending reducing the inappropriate high use of imaging, rest, opioids, spinal injections, and surgery. All right, like to switch gears just a little bit now, and we’ll be jumping into the, some of the meat of the opioid tapering section. So, it can be helpful to consider three groups when we think about opioid tapering. Our first group are those engaged, when I say engaged I mean engaged with us as a treatment team, and open to tapering. Our next group is those diagnosed with opioid use disorder, and then our third group are those not engaged, and really not open to tapering. And there are different levels of evidence for each of those. For that first group open to tapering, we have some weak evidence. With opioid use disorder we have rather strong evidence of what to do, and then that last group we have very very little evidence. So, this meta-analysis published in 2017 in the Annals of Internal Medicine does provide some low-quality evidence that when we’re looking at either tapering or discontinuing opioids, the patients can actually improve function, pain, quality of life. That’s important to recognize that the majority of studies included in this meta-analysis were interdisciplinary pain programs. So these are programs where patients, again, are engaged, right? They’re engaging in intensive treatment. So it’s important that we don’t extrapolate this data too far. Also it’s important to recognize the caveat of this is very low-quality evidence. But we do have some evidence to suggest in the right scenario, with the right support, we can improve patients’ outcomes with opioid tapering. Next slide. Now, we do shift to really quite strong evidence when we look at how to treat patients with opioid use disorder. So, is this all patients on long-term opioid therapy? No? What’s the percentage? Well, we don’t really know. Does anyone remember what the percentage industry told us about 20 years ago? So we were told that the incidence of addiction was less than one percent, right, when we’re using opioids for long-term opioid therapy. We know that that’s not true now. We don’t know what the actual rate is, but anywhere from 10% one meta-analysis showed, the CDC cites up to 25%, Boscarino et al have demonstrated a lifetime prevalence for patients on long-term opioid therapy of 41% of any opioid use disorder. And that appears to be related to both the dose and duration of therapy. So, again, with a diagnosis of opioid use disorder, we have clear evidence that use of medication-assisted treatment, these are two Cochran meta-analyses, one for Methadone, and one for buprenorphine, for the medication-assisted treatment for opioid use disorder. Both showing good evidence that these reduce illicit opioid use, increase retention in treatment, and then other evidence, one 2018 article showing that we reduce both all cause and opioid-specific mortality when we use medication-assisted treatment for opioid use disorder. So again, we have quite strong evidence when we have diagnosed opioid use disorder. We’re gonna jump in a little bit to this group of engaged and open to tapering. So, it’s important to recognize that these groups are not fixed. Our patients may come in not at all either engaged with therapy or open to tapering. Until we start to talk about a more collaborative approach. So again, everything we talked about in the first 15 minutes or so, making sure that our patients know that we’re not focusing just on the pill that they’re coming in with. “Hi Mr. Smith, we’re gonna talk about your Vicodin today.” “Hi Mr. Smith, I’d like to get to know you, “I’d like to understand the person with pain,” right? So, our first step is that therapeutic relationship, and a collaborative opioid tapering process. Making sure our patients understand that we, our goal is to partner with them. So our goal is not to come in and call all the shots. We need to make sure that what we’re doing is safe, and the treatment options that we offer to our patient are safe, and we’re comfortable with the safety of them, but beyond that, we really focus on partnering with them. So, identifying a whole-person approach. The prescription factors, we default to a gradual taper, right? So there’s no specific taper pace. That New England Journal of Medicine article from the CDC guideline authors talk about as kind of a point in the middle of 10% reduction every month, and that’s essentially what we default to in the VA-DOD guidelines, or even slower. Five percent, 10% a month. Sometimes another just real basic rule of thumb that I use is, as long as you can, it’s a type of pill that you can divide, so often a short-acting or immediate release, we think of starting with a half a pill reduction, right? And maybe a half a pill every month, making sure that we know that we can pause in there, right? So there’s no predetermined set time that we’re thinking about. We need to be off in three months, or six months, or twelve months. This is really a process that we want to work together with our patients. Now sometimes our patients come to us and say, “Doc, I’m traveling out of the country in four months, “I need to get off.” Great, we can move faster, but we wanna do that in a patient-centered sort of way. Using our routine risk mitigation strategies that we talk about in a variety of guidelines, so we gotta see our patients at routine visits, check urine drug screens, check our PMP, our prescription drug monitoring program, and then opioid overdose education and Naloxone distribution really should be universal in this population. Now, opioid use disorder may not be evident when we start a taper. And it may only become evident after we’ve initiated a first dose reduction or, in our experience, sometimes after we get down below a certain threshold of opioid medication, so we need to be extremely vigilant and watchful for the emergence of opioid use disorder symptoms. Our experience and others is that the context of the opioid taper is really, these factors are much more important than the prescription factors, right? So we have patients that are on very high doses, and we recommend reducing by a half a pill, and they communicate that their life is going to fall apart. Conversely, we have patients on low doses, or medium doses that, again, say, “Doc, I need to be off in four months,” and they make really significant reductions. They may have some physical symptoms, but they do quite well. So why is that? Well, Beth Darnall, a health pain psychologist from Stanford University has written and talked about the placebo and the nocebo effects of opioid tapering. So, the way that we set up expectations about tapering is critically important. The patient who is starting an opioid taper who is fearful, who is anxious, who there’s already an antagonistic relationship in our therapeutic relationship, how are they going to do, even with a very small dose? I think we’ve probably all experienced that that can go very wrong, and our patients don’t do well, versus if we have all of these other factors, commitment to a therapeutic relationship, whole person pain care, focus on health, trying to increase our patient’s positive expectations from the beginning, we can make sometimes large reductions and our patients do very well. So again, focusing on context, knowing some of the key factors about prescriptions, obviously important, but focusing on the context. Opioid use disorder, so one of the best places to start here is recognizing that this, both the condition of opioid use disorder, and the medication treatment that’s evidence-based and recommended for it, are both highly stigmatized in our culture still. And I would argue, almost certainly, a pretty significant portion of us here, in a large healthcare setting there’s a significant amount of stigma. Our idea to start with this is recognizing that there are neurobiological changes in the disease of addiction, opioid use disorder. This condition has strong behavioral components, so much in the way we think of our patients with diabetes, it’s a biologic disorder with strong behavioral components, how often do we discharge a patient from practice with diabetes who isn’t adherent to our lifestyle recommendations? Not very often, I would argue. Yet, this happens really quite frequently in certainly in civilian medicine, the private sector. So, recognizing the neurobiological underpinnings, starting with this non-stigmatizing approach, is really a non-judgmental approach is what will help our patients engage with us, and help us be able to offer these evidence-based, potentially life saving treatments. Again, in the context of whole-person care, when someone we’ve diagnosed opioid use disorder, in a patient on long-term opioid therapy, we certainly need to increase our risk mitigation strategies and really look closely at a team-based approach for medication-assisted treatment. We’re gonna shift gears here a little bit to our most challenging group. So this is our group that is not engaged and not open to tapering. So, one of the reasons this is most challenging is we have very little evidence to guide our approaches here. And I wanna encourage us to think about, again, this group is not a static group, but these are very dynamic. So our patients are switching in these groups throughout the course of their illness and in their interactions with us. Looking at a team-based approach, certainly in our VA and DOD settings, we know is critically important with not only this group of patients, but all of our patients. And we’re fortunate. In the VA, we have what we call primary care-mental health integration, I think there’s something, a very similar analog in many DOD settings. In the private sector, this is largely absent. And, unfortunately, this schism and siloing of care ends up not providing our patients with the most evidence-based practice. So, if we can intensify treatment, and begin to recognize that our patients coming in with low back pain may have untreated or under-treated anxiety, depression, PTSD, that in a setting that is only focused on pain procedures, we’re not gonna get very far. If we start to bring in our mental health colleagues, our movement colleagues, and look at a, now we can start applying some evidence-based treatments and begin to see this patient, who initially came in in the non-engaged, now starting to engaged, and may be more open to tapering in the future. It’s important to recognize that this group really has a differential diagnosis, right? So we can start to unpack it a little bit. One of the most common areas, again, I just touched on briefly, is this area of untreated underlying mental health conditions, right? This might be a diagnosis, or it may just be sub-diagnostic emotional distress. We talk about chemical coping, right? So patients may have, may be medicating that emotional distress, and no one’s really talked to ’em about that before. So, our patients that are coming in not open to tapering, this can be a wonderful place to start, and it can begin to unpack and show us more about that person coming in, and provide other ways for us to add support for that person, so that then they can shift over, hopefully, to that area of engaging with treatment, and becoming more open to tapering. Sometimes we’ll say things like to normalize this situation, we’ll say things like, “Mr. Smith, I would be surprised if “you weren’t fearful to make this change.” And we say that before they’ve even expressed any anxiety or any fear, since that is so common. So we know that opioids reduce a sensory aspect of pain, but we know that they do much more than that, and some papers actually suggest that the interaction in the emotional parts of the brain for opioids is actually more robust than in the sensory aspect. So bringing attention to the emotional, the social, and the reward-system aspects of opioids, again, can open up kind of new horizons for us to engage with that treatment. To illustrate that, I’d like to read a quote from the Odyssey. It really does a wonderful job of describing some of these other effects. So this is the T.E. Lawrence translation, and it says, “But Helen of the line of Zeus “called to mind another resource. “Into the wine they were drinking she cast a drug, “which melted sorrow and sweetened gall. “Which made men forgetful of their pains.” All right, so the next time that we recognize that opioids may be soothing someone’s loneliness, someone’s emotional distress, someone’s anger, someone’s sadness or sorrow, we can take a new lens and really shift towards helping them build skills to manage that, and often if we do that, since the opioid was the main thing that was helping with that, now that we give them other support, they can shift into this group that’s engaged in therapy and open to tapering. Next slide. We’re very comfortable with this idea of a risk-benefit analysis, right? We do this all the time in medicine. And when we read the CDC guidelines, other guidelines, we’re talking about, well, who do we taper? Well, we taper when the risks outweigh the benefits. So, this is a great place to start. First, we look at the risks of opioid therapy, and we recognize that there’s converging evidence that opioids, again, we talked about the overdose death, addiction risks, but have other risks. Can increase the risk of depression, can increase the risk of disturbing sleep, endocrine immune function, and so we have this converging evidence about the risk side of the equation. What about the benefit side of the equation? Well, we certainly have a lack of evidence, we don’t have strong evidence showing benefit. The best way to determine benefit is looking at a pre-treatment state and our current state, right? And ideally, multi-dimensional, so we’re looking at emotional, social, vocational, and physical functioning, both before we started opioid therapy, and in our current state. Well, how often do we have that? Unfortunately, not very often. So, the benefit side of the equation, we’re often left with our next best proxy, which is well, what’s our current functional state of our patient, right? And so our current functional state, unfortunately what we often see, is that our patients are not–