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0:00 [Music] my name is Chris Johnson and I'm an emergency physician and I'm going to talk to you today about the opioid epidemic I have been involved in fighting this epidemic in this crisis and watched evolve from my experience as an ER physician for the last 15 years I've sort of had a seat on the frontlines if you will and unlike some of the other talks or other presentations you might have heard about this epidemic I want to talk to you about how it happened and more maybe more importantly why it happened and I'm gonna tell you right now it was not an accident no one should leave this no one
0:45 should leave this lecture wondering I guess no one saw that coming people saw it coming and I'm gonna talk to you about how that happened I'm gonna begin with an apology on the behalf of the medical industry we failed you those of us in charge of looking out for your health and safety failed you and I'm going to detail that failure in the next 17 minutes my background I'm originally from Virginia and I moved to Minnesota to train emergency medicine at Hennepin County Medical Center and I trained there from 2000 and 2003 and that was my introduction to the problem of substance use and I'll be honest when you when you train and work in a County Hospital it can be a little dismissive of it because in a County Hospital population you see lots of social pathology broken families parents incarcerated you know lack of
1:31 opportunities and education and you kind of think well substance use goes along with that but then in 2003 I graduated my residency and I began practicing here in Methodist Hospital in st. Louis Park and I was seeing the same thing I couldn't go a shift without seeing a patient coming in with chronic pain exacerbation or possibly an overdose on high doses of opioids that they were taking every day and this is why I began investigating the cause of this problem and hopefully come up with some solutions so the problem what are opioids and why are we talking about them well a little history the use of opioids as a medicine for pain goes back as far as written civilization the Greeks the Assyrians the Persians all documented use of this medicinal plant for
2:16 the use and treatment of pain and the traditional method of getting morphine was this this is the seed pod of the opium poppy Papaver somniferum and the way you collected that medicine was you made a slice in it and collected this milky substance which contains morphine now the reason it's called somniferum actually goes back to Roman mythology somnus was the god of sleep and so when we give patients or you've seen someone receive these drugs they become tired or sleepy they are somnolent and as we all remember somnus first appeared in our literature with Ovid's metamorphoses which was the latin epic poem detailing of the history of the world up until julius caesar and 15 volumes i thought the first nine volumes flew by by the way but they're like the last six is you want to get to the Rubicon you know you got an army and actually morphing comes
3:04 to us from mythology as well Morpheus was the Greek god of dreams and opioids help treat pain in two basic ways one is that they actually block the strength of the nerve the pain nerve signal from periphery to your spinal cord and so that inhibits the experience of pain but the more important one for our purposes is this hope you always make you feel good and by altering your mood they alter your perception of pain pain is an emotional experience sort of like all of life is and what opioids do is they increase your mood by increasing dopamine in your reward center and this is a simplified version but if this is this is your brain and your reward center without opioids and you have a little steady stream of dopamine in your reward center and you your brain feels okay and then what happens with opioids
3:51 heroin morphine whatever is that you have this flood of dopamine and you think my god that was awesome and that is that is how it effects your experience of pain the problems that opioids carry risk on they also bind receptors in your brain that control your breathing and in high enough doses can stop your breathing and once you stop breathing you've got a few minutes to restore oxygen to your brain or heart or you die thereafter of association or cardiac arrest so what's the problem the problem is that the United States has four and a half percent of the world's population but we consume 30% of the world's opioid pain relievers that sounds crazy was it always like this it
4:37 was not from the years 1992 to 2012 the number of prescriptions of opioids in this country tripled and I don't have to tell you the population of this country did not triple but the number of prescriptions is actually only part of the story here's another part the size of the prescriptions got bigger so it wasn't just the number of prescriptions being written the amount of opioid in every prescription massively increased this graph here you can tell that these are years at the bottom but this is oxycodone consumption in the United States and blue and Europe in red and so here we are oxycodone as the pain reliever in percocet so here we are a little bit above Europe per person up until the mid 90s and then we did that so it wasn't
5:22 just a number it was the size of the pills we had this massive increase in opioid exposure in this population coming from the medical industry but that's only part of our problem now you guys have all seen the stories about heroin and fentanyl and I would encourage you not to view these as separate problems they are intimately related and followed on the heels of the increase in opioid prescribing these are opioids they bind the same places of the brain do not view them as dramatically separate chemicals okay three out of four users of heroin began with pills and often what happens is that a patient who became dependent on the pills over years and found their supply getting a more difficult to come by or too expensive they would turn to heroin which was often cheaper the result of this massive increase in opioid prescribing and now uses of heroin and
6:08 fentanyl has led to a massive increase in overdose deaths in the year 1999 the total number of opiate overdose deaths in this country was 6,000 that was 4,000 from prescription opioids and then another 2,000 from heroin in 2016 that number had climbed to 50,000 if you want to know what 50,000 looks like well that would be 16 World Trade Centers and you're still 2,000 short and all of you might remember we went to war over just one of these the United States has four and a half percent of the world's population but we have 27 almost 20% of the world's drug overdose deaths so how and why did this happen this has been a problem that we've seen in the inner cities but then it's also now moved out to the suburbs and the
6:55 affluent it has affected some of our greatest artists but it doesn't spare the athletes so how and why did this happen I would like to tell you that it was good intentions gone awry perfect storm wrong place wrong time but that is simply not true the medical industry has changed dramatically in the last 20 years in particular the powered influence of the pharmaceutical industry and the ascendance in in my profession again of meeting corporate imperatives above all else so how did the opioid manufacturers gain control of the marketplace they did a number of tactics that I'm going to talk you through number one is this the recruit pain specialists at academic centers to be the sort of key opinion leaders and thought leaders and their goal is to convince the medical community workaday
7:40 Doc's like people people like me that aren't reluctance to use opioids for chronic pain conditions what was misplaced that opioids were safer than then we had thought they were and that there was so much pain out there it was we were negligent in how much pain we were permitting to occur that pain was an undertreated epidemic there was a number of these doctors that they recruited but probably possibly the most important one was this gentleman here dr. Russell Portnoy he was the subject of the Wall Street Journal article pain drug champion has second thoughts published in 2012 he saw his job as rehabilitating the medical community of Opio phobics people with an irrational fear of opiates he was president of the American Pain Society in 1995 and was the American Pain Society that came up with this pain was a vital sign I
8:26 remember these buttons when I was a resident my faculty had it I had it you warm on your scrubs patients you know pain was to be taken as seriously as blood pressure heart rate temperature in terms of predicting potential more morbidity for a patient that's how seriously we were to take their reported pain levels doctor Portnoy published an article a position statement in the clinical Journal of pain in 1996 stating that the risk of addiction from opiates when used for pain was less than 1% less than 1% for that sir sounds safer than I was led to believe do you know where that less than 1% statistic came from it came from an article in the New England Journal of Medicine it became no it was published by 1980 by Jane Porter and Herschel Jick
9:13 and it demonstrated that opioids were less than 1% became addicted to opiates and I'm gonna use the balance of my time to go through that study the statistic I'm just kidding you can read the whole thing in 90 seconds this is it it was a five sentence letter to the editor this is the study that supposedly proved that opiates for use with pain they weren't addictive now all they did was they didn't actually intend this to say that at all I mean remember this this was written in 1980 and like 16 years later they're now saying it proves opiates aren't addictive all they did was they followed hospitalized patients who had an acute injury about 12,000 of them and then followed them afterwards
9:59 to see how many developed addiction they were put on opiates indefinitely these were acute injury patients who just received a dose or two in the hospital it said nothing about treating chronic pain with obits and this was the great failure of medical ethics this is where we truly let the population down because that sort of paragraph is in scientific terms is called an observational study you look after the fact and you observed that's interesting okay that's the beginning of the process that's not the end what you should do after you observe this is like how do we prove this do we think that more people can take these safely indefinitely let's do an experiment the experiment was never done the longest experiment done for opiates for use with chronic pain
10:45 was 12 weeks most were just six it is on the bat basis that we started prescribing opioids on an indefinite basis to patients now what does dr. port and I say now about opiates well in a taped interview I gave innumerable lectures about addiction in the 80s and 90s that weren't true if I had an inkling of what I know now then I wouldn't have spoken the way I spoke by the way the Wall Street Journal also identified millions in donations to his pain clinic which pays him from opioid manufacturers tactic to market to the primary care doctors this was not done until 1996 and one product changed all that oxycontin released by Purdue Pharma in 1996 as a continuous release preparation of oxycodone which again is the pain reliever in percocet prior to 1996 and oxycontin extended release opioids or
11:32 ongoing use of opioids was reserved for hospice patients it was it was prescribed typically by pain specialists and cancer doctors for people at sort of end-of-life care but here's the thing you can't make billions on hospice patients first there aren't that many and then number two they expire you can make billions on back pain and that's exactly what they set out to do and the way you get to back pain and treat people for a long time and the most people as you get to primary care and that's exactly what happened in unprecedented numbers drug representatives flooded the the primary care clinics often making you know a visit every week they would have gifts and food and flattery there's multiple like this forty conferences in five years that's like one more than every two months and they invited the doctors
12:18 the nurses the pharmacist everyone involved in the opiate delivery food chain was included and they didn't forget the patients for patients you got free drugs oxycotin had a starter coupon program where your first prescription was free now tell me that isn't like the creepy guy outside the high school with a little bag because I'm your friend you just try this tactic 3 influence government and regulatory bodies to favor increase prescribing you needed to do this for a couple reasons one is you still have to get approval for your product to make sure you could you know it was indicated in market to market it and the other reason is that while the the pain specialist sort of gave us permission to prescribe if you really want to increase prescribing have a stick not just a carrot but a stick and
13:05 in 1992 the primary client of the FDA since 1992 is basically the pharmaceutical industry and this was a direct consequence of something called the Prescription Drug User Fee Act half of the FDA's budget is now provided by the industry and that actually that that came out of the AIDS crisis actually it wasn't some malevolent thing back then in the 1980s we had all these people with HIV and they're expiring and there's this clamor like what are we gonna do for all these patients and the FDA was overwhelmed and said look we'd like to do these trials to get you helpful for medicines but we don't have the budget to do it and so the industry stepped in but ever since then they've been dependent on the industry for their funding and it is very difficult for a regulatory body to regulate an industry when it depends on the industry for money and in the 1990s they approved
13:51 opiates for chronic pain again based on no studies longer than 12 weeks and here's the stick part get those pain scores down the the pharmaceutical industry influence the Joint Commission which is responsible for evaluating and accrediting hospitals this was on the wall of every emergency department room I worked in you know zero to ten what's your pain level at nurses were compelled to recheck on the patient's our what's your pain level we got to get that down the Joint Commission published a guide in 2001 about pain management and that was funded by Purdue Pharma and told us that the risks of opiate use had been exaggerated tactic for they blur the lines between patient advocacy and academic groups and marketing take a look at this group partners against pain pain it's not something you need to you you can have to manage alone you have a partner and look at they're holding hands like who would argue against that
14:38 they're fighting pain and loneliness but if you scroll down to the bottom of the screen this was purely a creation of Purdue Pharma what they call unbranded outreach that was 1993 and take a close look at these academic societies it's the American Academy of pain management that's the forum president dr. Lynn Webster we have an epidemic on our hands and the status quo is failing us curious thing about that Academy they've got a corporate counsel and look who's on it Purdue Pharma endow Pfizer jell-o makers of opiates so is farmer the one to blame well they are they certainly a part of it I mean they they these were there this was their marketing strategy but I want to caution you that it's too easy to just blame the pharmaceutical industry the
15:24 pharmaceutical industry sells all over the world this crisis didn't happen in Japan it didn't happen in Germany happen here so what is it why did it happen here as opposed to these other countries that they have patients who have chronic pain pharmaceuticals do they they sell them there too well this is from my performance of review in the year 2012 those are my arms I'm very proud Chris we are also proud of you for the work you are doing with chronic pain but it's such a fine line between increasing risk of open addiction and hCAP scores what age cap scores are those are your patient satisfaction surveys they do not exist for your health they exist for you as a customer to get you coming back
16:11 medicine in America unlike other countries is first and foremost a business enterprise and every business enterprise has as his primary obligation is to make money for the owners and investors and in the process enrich the participants even not-for-profits have investors their bondholders in fact fiduciary responsibilities which all these executives undertake compels them to do this for this reason American medicine is not incentivized for your long term health is incentivized to sell you health care services but this leads to an unavoidable conflict in health care healthy patients don't need to buy health care now why would this pose a risk for opioid crisis because a system driven to sell services thrives and patients are in a state of chronic disease and that is precisely the model that opiates employ it checked off a lot
16:56 of boxes for us it allowed us to expand the customer base pain is a vital sign pain is an epidemic pills solve the problem visit or quit you can see tons of patients and turn them over pills are by prescription only we corner the market you know tylenol doesn't solve this opioids do and treatment is lifelong and indefinite patients become dependent on these opioids and keep coming back so what do we do about this to pass forward a short term in a long term in the short term we need to prevent creating new opiate dependent patients in the long term reform a system that created this studies do not support the use of these medicines for management of chronic pain if you have back joint neck pain do not start these medicines they don't work in the long term medical assisted therapy helps patients who who have developed opiate use disorder but is a very imperfect
17:42 solution it cuts your rate of overdose in about half but your risk of death is still three to five times higher if you're on medical assistant therapy that if you never developed a problem at all bottom line is this the American system is a failure in addition to overcharging you we are not getting you good medicine good therapy that is well driven by science and it's not because doctors want to cause harm our incentives are broken we need a different type of system one that rewards outcomes or at least stops rewarding just the sales of services this would be more in line with the Hippocratic oath and what other countries do so what can you do going forward well we can at least acknowledge that opioids don't work for chronic pain as far as I'm aware the American Medical Association American Heart Association none of them have acknowledged this we need to interrupt the financial relationship between doctors and the industry we need to make research more
18:29 scientific and make the FDA independent and we can need to stop volume-based revenue for doctors and Clinics oh and let's stop this whole talk about morality and this is a challenge I would even say to the traditional recovery industry we have created addiction in mice in chimpanzees insects pigeons we don't talk to them about their character defects so this is my final slide I conclude here this is a painting by Edward Munk it's called despair it is derived from the Latin verbs better which means to hope so despair literally means without hope I got involved in this problem because I was initially very frustrated with trying to manage these patients in the emergency department but the more you learn about these patients and what they're going through what their families are going through it is a world of suck you do not want to wish that on anyone
19:15 and so I argue for reducing opioids because I don't not because I want them to suffer pain but because I don't want them to enter this life of misery and I want a healthier system from my colleagues who many of our great people that want to practice effective compassionate medicine because we all deserve better you [Music]
