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Opioidology Part 3: Opioid-Philia vs Opioid-Phobia | Pain Pod · Pharmacy Podcast Network

• 0:05
  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession.
• 0:10
  Speaker 2: Welcome to the Pharmacy podcast Network.
• 0:22
  Speaker 3: This is the Pain Pod. You want to see pain
• 0:27
  Speaker 3: look at me?
• 0:34
  Speaker 4: Welcome to the Pain Pod, the podcast for all things
• 0:39
  Speaker 4: pain management, hosted by the pain Guy, doctor Mark grow.
• 0:49
  Speaker 1: We'll be collaborating with numerous pain management experts talking about
• 0:53
  Speaker 1: substance usage disorders, the latest treatment modalities, and most important
• 0:59
  Speaker 1: important focus on the pain of our patients as leading
• 1:02
  Speaker 1: providers of pain care. And now here's our host, a
• 1:08
  Speaker 1: man wanted in all fifty states, a suburban city like
• 1:13
  Speaker 1: Mountain man without the beard, from the hills of West
• 1:18
  Speaker 1: Virginia and certified in weapons of mass destruction response.
• 1:24
  Speaker 3: Yes, doctor Mark Holbly.
• 1:32
  Speaker 2: All right, welcome back everyone too.
• 1:34
  Speaker 5: But Pain Pod, Well, today we have actually a continuation
• 1:39
  Speaker 5: there's always new information, but a continuation of what I
• 1:43
  Speaker 5: was terming opioid ology, you know, the overall We started
• 1:47
  Speaker 5: with the story of our opioid crisis. Everything opioid overall,
• 1:54
  Speaker 5: we navigate into even within the clinical realm of opioid selection.
• 1:58
  Speaker 5: And we're going to kind of kick at today with
• 2:01
  Speaker 5: something that really caught my eye. Turns out. I'm sure
• 2:04
  Speaker 5: you know this, and you might be of the same mind. Heck,
• 2:07
  Speaker 5: you are listening to the pain pod. There's other people
• 2:10
  Speaker 5: thinking about the same things of this overall opioid story
• 2:13
  Speaker 5: per se.
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  Speaker 2: You know, what we.
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  Speaker 5: Got ourselves into is a country and quite frankly globe
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  Speaker 5: for that matter.
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  Speaker 2: But you know the you know, the good.
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  Speaker 5: Parts and the unfortunate parts of the overall story of
• 2:24
  Speaker 5: you know, unfortunately, the loss of lives in the big
• 2:27
  Speaker 5: picture due to drug overdoses still certainly paling in comparison
• 2:32
  Speaker 5: to alcohol related deaths and tobacco realia deaths.
• 2:34
  Speaker 2: But that's a.
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  Speaker 5: Whole other can of worms. But we have had some
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  Speaker 5: improvements in recent years when it comes to, you know,
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  Speaker 5: decreasing the overall drug overdose deaths in our country. And
• 2:48
  Speaker 5: it used to be well into the six figures, and
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  Speaker 5: we had quite a dip. And I really want to
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  Speaker 5: you know, I don't want to underemphasize when I say
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  Speaker 5: a dip, because that's a lot of heartbeats saved or
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  Speaker 5: at least not lost. Right, there was not that long
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  Speaker 5: ago we had about one hundred and eleven thousand drug
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  Speaker 5: over dose deaths each year in our country. We made
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  Speaker 5: it down to about seventy five thousand more recent days.
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  Speaker 5: The bigger picture, though, is the hope that it's not
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  Speaker 5: a momentary decrease, that it actually continues overall. Right, but
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  Speaker 5: you know, a big picture. An American still dies about
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  Speaker 5: every six minutes from a drug overse death. So this
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  Speaker 5: is well beyond clinicians, healthcare professionals, this is society overall
• 3:34
  Speaker 5: now in trying to put together all the information. This
• 3:37
  Speaker 5: is where there was an article that certainly caught my
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  Speaker 5: eye recently and pulling in some of the authors here
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  Speaker 5: today to talk it through a little bit more granularly.
• 3:46
  Speaker 5: But you may recall if you haven't listened, check it
• 3:49
  Speaker 5: out the first opioidology episode of the pain Pod. I
• 3:52
  Speaker 5: went over what is illustrated actually on pain Guide dot us.
• 3:57
  Speaker 5: When you go on the tab for pain Pod, you
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  Speaker 5: could see one of the.
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  Speaker 2: Charts to really look a little bit deeper and earlier.
• 4:06
  Speaker 5: As far as the numbers of what goes into you know,
• 4:09
  Speaker 5: drug overdose tests, opioid overdose tests, prescribing of controlled substances,
• 4:14
  Speaker 5: particularly opioids. The trends overall going back further than just
• 4:18
  Speaker 5: you know what leads us to saying all the extremes.
• 4:22
  Speaker 5: There's a lot of blurred lines when it comes to
• 4:24
  Speaker 5: pain addiction and substance utilization. Of course, there's a lot
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  Speaker 5: of extremes out there these days and in the past,
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  Speaker 5: things like opioid philia, opioid phobia, you know, really building
• 4:34
  Speaker 5: upon what we talked about in Opioidology Part one as
• 4:37
  Speaker 5: far as the pain Pod episode, but I.
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  Speaker 2: Really want to jump into it today with the article.
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  Speaker 5: We'll have it in the show notes of course, and
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  Speaker 5: certainly within thepain Guy dot Us website as well. But
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  Speaker 5: you know, titled the Burden of Acute Pain in the
• 4:52
  Speaker 5: United States in the wake of the Opioid Crisis. I
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  Speaker 5: was in Frontiers in Pain Research and we got to
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  Speaker 5: some of the authors with us here today. So I
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  Speaker 5: really want to welcome James and Jim to the microphone here.
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  Speaker 5: So well, hey, flip a coin. Gents, who wants to
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  Speaker 5: go first for a little intro of yourself?
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  Speaker 3: James, wrotn't you go ahead?
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  Speaker 6: Sure? Well, thank you for that introduction, Mark, thank you
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  Speaker 6: for having us here on your show to talk about
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  Speaker 6: this topic. My name is James Hackworth. I'm a scientist
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  Speaker 6: by training, actually physicist. Had the opportunity for almost the
• 5:28
  Speaker 6: last fifteen years to work in drug development, and almost
• 5:32
  Speaker 6: all that time at least in part or wholly in
• 5:36
  Speaker 6: pain drug development, and actually founded a company a few
• 5:42
  Speaker 6: years ago to develop a pain drug, which is what
• 5:47
  Speaker 6: brought Jim and I together, because that company was then
• 5:49
  Speaker 6: acquired by our card employer, Tris Pharma. I actually have
• 5:54
  Speaker 6: a personal connection to these topics as well. My parents
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  Speaker 6: grew grew up in Syota County, Ohio, which is probably
• 6:03
  Speaker 6: not familiar to many of your listeners. It's a small
• 6:07
  Speaker 6: population county tucked along the Ohio River in southern Ohio,
• 6:11
  Speaker 6: and it had the infamous distinction of being really one
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  Speaker 6: of the first places where the opioid crisis hit back
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  Speaker 6: in the nineties, and actually I believe the first place
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  Speaker 6: that fake pain clinics started being set up, and people
• 6:27
  Speaker 6: would come from far away to go there to get
• 6:31
  Speaker 6: prescriptions of oxyconton or whatever. And at one point twenty
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  Speaker 6: five years ago or so, it was in the top
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  Speaker 6: ten prescriptions of opioids in the country of any county
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  Speaker 6: despite having a fifty seventy five thousand people something like that.
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  Speaker 6: And unfortunately, this topic that we're talking about touched my
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  Speaker 6: family very deeply. My grandmother's sister thirty years ago or so.
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  Speaker 6: Younger sister was in a really bad auto accident, was
• 7:01
  Speaker 6: prescribed opioids, and of course they helped her pain, but
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  Speaker 6: she became addicted even after her injuries had healed, and
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  Speaker 6: really started a very long, probably about fifteen year addiction,
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  Speaker 6: in which case she really wrecked her own life and
• 7:21
  Speaker 6: wrecked relationships with family, and eventually died of an overdose,
• 7:29
  Speaker 6: which is obviously was devastating for the family. But then
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  Speaker 6: I also because of that, got to see the other
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  Speaker 6: side of the coin that we're talking about. My grandmother,
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  Speaker 6: her sister, when she got to be elderly, was in
• 7:43
  Speaker 6: tremendous pain all the time. She had very bad astero
• 7:47
  Speaker 6: arthritis all over her body, and she also had diabetic gropathy,
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  Speaker 6: which she got to be older caused a lot of
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  Speaker 6: pain in her lower legs, and she she couldn't take
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  Speaker 6: end sets for the austro arthritis because she was on
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  Speaker 6: eloquess for a separate issue and doctors wouldn't allow it.
• 8:08
  Speaker 6: She took pre gabbling for the diabetic gropathy, but it
• 8:12
  Speaker 6: didn't give her much relief, and so the doctors offered
• 8:15
  Speaker 6: her opioids, and because of what happened with her sister,
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  Speaker 6: she refused to take them. You know, she was well
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  Speaker 6: into her eighties. But I don't want to ge addicted.
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  Speaker 6: I don't want that to have It's like, you know, Grandma,
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  Speaker 6: it's probably fine, but she went and touch them. And
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  Speaker 6: so she really lived about the last decade of her
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  Speaker 6: life in really severe pain basically round the clock. And
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  Speaker 6: it was really painful to see and so kind of
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  Speaker 6: sort of both sides of the topic here very personal to.
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  Speaker 5: Me absolutely, and you know, I just want to throw
• 8:46
  Speaker 5: it out there too. Thank you for sharing that because
• 8:49
  Speaker 5: you know, a lot of times in our life conversations,
• 8:52
  Speaker 5: whether done a podcast or all of us all listeners
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  Speaker 5: to there's a lot of touch points with this overall
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  Speaker 5: opioid story overall. So thank you for sharing that. There
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  Speaker 5: means a lot of course for hearing the touch points.
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  Speaker 3: Well, I'll pick it up from there.
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  Speaker 7: My name is Jim Potenziano, also a scientist by training.
• 9:15
  Speaker 7: I've got a dual PhD. Former academic. I've been in
• 9:20
  Speaker 7: the pharmacy industry a long time. I chose to leave
• 9:24
  Speaker 7: my academic position and go into the farma industry just
• 9:29
  Speaker 7: because you could have a broader impact, quite frankly, and
• 9:32
  Speaker 7: I've spent my whole career doing medical and development in
• 9:35
  Speaker 7: the industry. Initially I was engaged in pain because my
• 9:42
  Speaker 7: training was in and rout development of chemotherapeutics, and I
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  Speaker 7: spent a lot of time around cancer and people in
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  Speaker 7: cancer related pain, so I got a good exposure from
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  Speaker 7: that perspective.
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  Speaker 3: My first job was with Johnson and Johnson.
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  Speaker 7: And we were as a companytruggling with transdermal fentanyl. Titration
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  Speaker 7: was a real problem. We spent a lot of time
• 10:07
  Speaker 7: talking to people about how to use the product. You've
• 10:10
  Speaker 7: got a very good experience with it. But it was
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  Speaker 7: also at the same time that the whole oxy codone
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  Speaker 7: evolution was occurring, and so I've been in it for
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  Speaker 7: a long time.
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  Speaker 3: I've developed a few products over the.
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  Speaker 7: Years in the pain industry, and actually joined Triss because
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  Speaker 7: I had looked at the initiatives that they had and
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  Speaker 7: thought that this could really add some substantial value to
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  Speaker 7: the pain environment.
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  Speaker 3: So thank you very much.
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  Speaker 7: As with James, I appreciate Mark you having us on
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  Speaker 7: and I look forward to the discussion.
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  Speaker 5: Of course, we want the movers and shakers on here
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  Speaker 5: all the time, and I think we have both of
• 10:51
  Speaker 5: you here today in that regard.
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  Speaker 2: So no, again, one of the things that really.
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  Speaker 5: Catches the eye and hopefully folks can read through listen
• 11:00
  Speaker 5: through today, you know, was uh, this this article that
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  Speaker 5: both of you were part of. There's other authors of
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  Speaker 5: course too, but you know, the burden of acute pain,
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  Speaker 5: particularly in the the shadows of the opioid crisis overall. Now, James,
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  Speaker 5: the personal stories you shared certainly dive right into that,
• 11:17
  Speaker 5: of course, but you know, when thinking about what you
• 11:21
  Speaker 5: guys were putting together, you know, you know, collaborating with
• 11:25
  Speaker 5: other authors there it's a lot of dynamic concerns within
• 11:27
  Speaker 5: our overall opioid crisis, the story and the big picture,
• 11:30
  Speaker 5: you know, in the realms of addiction, pain management and beyond.
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  Speaker 5: What would you summarize the big picture takeaways for that article, Like,
• 11:39
  Speaker 5: what would be the biggest things there to take away?
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  Speaker 3: James?
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  Speaker 7: You want to pick up the takeaways and then I'll
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  Speaker 7: go into some of the more detail underneath it.
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  Speaker 6: Yeah, sure, so i'd say that one did. We're doing
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  Speaker 6: this in the backdrop of like pain is continuing to
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  Speaker 6: rise in the US, cute pain in particular, as we
• 12:02
  Speaker 6: get you know, the population gets older. Obviously age and
• 12:05
  Speaker 6: obesity or two of the biggest drivers of acute pain.
• 12:08
  Speaker 6: It's we're seeing more and more acute pain episodes, whether
• 12:12
  Speaker 6: that's post surgical, post emergency department visits. And I think,
• 12:18
  Speaker 6: as Mark, as you know very well, and I think
• 12:20
  Speaker 6: most of your listeners know, there aren't a lot of
• 12:23
  Speaker 6: therapeutic options for more severe pain, especially and often opioids
• 12:30
  Speaker 6: are the only thing that you can give someone to
• 12:34
  Speaker 6: treat a lot of the more severe acute pain. And
• 12:38
  Speaker 6: that then, of course there's a lot of risks with opioids,
• 12:40
  Speaker 6: which which we'll get we get into the paper, and
• 12:42
  Speaker 6: we'll get into in this discussion, but it really puts
• 12:46
  Speaker 6: clinicians and patients in between a rock and a hard place,
• 12:50
  Speaker 6: so to speak. On the one hand, there are legitimate
• 12:53
  Speaker 6: risks of prescribing an opioid, even for short term, and
• 12:58
  Speaker 6: the paper goes into that. And on the other hand,
• 13:01
  Speaker 6: and I think probably something that's that's not as appreciated,
• 13:05
  Speaker 6: there are significant medical long term risks to not treating
• 13:09
  Speaker 6: pain effectively when it's especially when it's more towards the
• 13:13
  Speaker 6: severe end. Pain can easily become chronic. If you don't
• 13:17
  Speaker 6: treat it when it's in the acute phase. And so,
• 13:21
  Speaker 6: as you know, as we've been out talking to people
• 13:23
  Speaker 6: over the last few years in connection with what we're doing,
• 13:28
  Speaker 6: it is it's apparent that a lot of people have
• 13:31
  Speaker 6: sort of one of these two problems in mind. But
• 13:34
  Speaker 6: we see, we don't see didn't see a lot of
• 13:36
  Speaker 6: balance where people were kind of thinking about these dual
• 13:39
  Speaker 6: problems at once, that the need to treat pain as
• 13:42
  Speaker 6: being an urgency, but the also the need to find
• 13:46
  Speaker 6: a way to not cause downsides related to prescribing opioid
• 13:50
  Speaker 6: as an urgency. And so we decided to look at
• 13:53
  Speaker 6: with our other authors, decided to go and look at
• 13:55
  Speaker 6: what all the research is that that really can inform
• 14:00
  Speaker 6: what the real risks are rather than we're just sort
• 14:02
  Speaker 6: of thinking and panic moment, what are you know, what
• 14:04
  Speaker 6: are the numbers really behind the risk of prescribing opius
• 14:08
  Speaker 6: for short term and also what are the risks of
• 14:10
  Speaker 6: if you're saying, Okay, well that's too scary, what are
• 14:13
  Speaker 6: the risks of not prescribing and not treating pain or
• 14:17
  Speaker 6: potentially leaving pain ineffectively treated.
• 14:22
  Speaker 3: So I think that's.
• 14:23
  Speaker 7: Actually a great lead into you know, what did we
• 14:26
  Speaker 7: find out and where are we today? And there's a
• 14:29
  Speaker 7: bifurcation as you look at this, And frankly, I think
• 14:34
  Speaker 7: if you talk to people generally who treat pain all
• 14:37
  Speaker 7: the time, they probably don't look at it with the
• 14:40
  Speaker 7: same eye.
• 14:41
  Speaker 3: As many do.
• 14:43
  Speaker 7: But we have to keep our eye on the people
• 14:45
  Speaker 7: and the needs for the product, because ultimately it gets
• 14:48
  Speaker 7: down to what are we trying to do. You know,
• 14:51
  Speaker 7: we're trying to basically treat the appropriately treat pain and
• 14:55
  Speaker 7: make sure that we've got the right recipes to do that.
• 14:58
  Speaker 7: So what we what kind of did is we started
• 15:01
  Speaker 7: to think about this that by fourcation in terms of
• 15:04
  Speaker 7: provider reluctance on one side versus patient reluctance or challenges
• 15:11
  Speaker 7: on the other side.
• 15:12
  Speaker 3: And so let me start with the provider.
• 15:14
  Speaker 7: And some of the things that we actually thought about
• 15:18
  Speaker 7: contemplated in this paper.
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  Speaker 3: I'm sorry, sounds good, okay.
• 15:23
  Speaker 7: So you know, it's interesting because as if you looked
• 15:27
  Speaker 7: at the numbers and totality and you did this as
• 15:30
  Speaker 7: a proxy of numbers of opioid scripts, you would probably think, well,
• 15:35
  Speaker 7: there's really is there really a problem that if you
• 15:38
  Speaker 7: look the last ten years, we're nearly cut in half.
• 15:41
  Speaker 3: With a number of opioid scripts that have been written.
• 15:45
  Speaker 7: And the bottom line is it goes back to what
• 15:49
  Speaker 7: I was saying.
• 15:50
  Speaker 3: If you are sitting in the right place, and for.
• 15:52
  Speaker 7: Example, if you are a pain physician and you've become
• 15:58
  Speaker 7: very comfortable with the downsides of these things and you
• 16:02
  Speaker 7: are comfortable with the utility of them and where to
• 16:06
  Speaker 7: use them, it becomes a conversation for you that's much simpler.
• 16:10
  Speaker 3: But it's really not that simple.
• 16:12
  Speaker 7: And as you look at this from a more holistic standpoint,
• 16:17
  Speaker 7: and you bring the people in who more historically use
• 16:20
  Speaker 7: these products, because as we know, a lot of people
• 16:23
  Speaker 7: and areas of medicine have actually fallen out of use
• 16:28
  Speaker 7: of these And I love.
• 16:30
  Speaker 3: To give this example.
• 16:31
  Speaker 7: My partner is a dentist, and she's been a dentist
• 16:34
  Speaker 7: for over twenty years. And I always tell people it's
• 16:39
  Speaker 7: a very interesting dynamic when we talk about this because
• 16:43
  Speaker 7: in the last let's call it five years, she is
• 16:48
  Speaker 7: largely and it's not just her, many of her colleagues
• 16:51
  Speaker 7: have gone away from the use of opioids. They'll get calls.
• 16:54
  Speaker 7: She had a couple of dental offices. She would get
• 16:58
  Speaker 7: calls on the weekends for emergencies frequently, whether it be
• 17:02
  Speaker 7: an abscess or broken tooth or whatever, but people in
• 17:05
  Speaker 7: substantial pain, and what she ended up doing many times
• 17:10
  Speaker 7: was going to the more rudimentary let's get you on
• 17:12
  Speaker 7: an antibiotic and get you started and get you scheduled
• 17:15
  Speaker 7: as soon as possible, simply because it became too big
• 17:20
  Speaker 7: a risk in that area to be writing opioids out,
• 17:25
  Speaker 7: which is historically something that that profession probably would have done.
• 17:30
  Speaker 7: And if you step back and ask, well, is this
• 17:33
  Speaker 7: the only area of medicine, I think the answer becomes
• 17:36
  Speaker 7: obviously no. As we researched it, we talked to more people.
• 17:41
  Speaker 7: There's certainly gen more generalized areas of medicine. Primary character,
• 17:46
  Speaker 7: that's we've seen dramatic decreases in the amount of opioid
• 17:50
  Speaker 7: that's been used, whether that's cute or chronic pain. And
• 17:55
  Speaker 7: even when you point to the more acute end of
• 17:57
  Speaker 7: this and look at it from the side of emergency medicine,
• 18:02
  Speaker 7: there has been a substantial decrease in the use.
• 18:06
  Speaker 3: And frankly, we're out talking with some.
• 18:09
  Speaker 7: Of the developmental initiatives that we're doing with Emergency Medicine
• 18:13
  Speaker 7: Department that frankly have kind of gone away from this
• 18:17
  Speaker 7: in their entirety, so that from a providers standpoint will
• 18:22
  Speaker 7: show you that there is a disconnection between the way
• 18:26
  Speaker 7: things used to be and the ease of use of
• 18:28
  Speaker 7: some of these products and where we are today.
• 18:32
  Speaker 3: And then if you just simply flip over to.
• 18:34
  Speaker 7: The patient, there's a different story, but not less complex,
• 18:39
  Speaker 7: and it goes back to some of the things that
• 18:41
  Speaker 7: James was talking about. The people are not as knowledgeable
• 18:46
  Speaker 7: about what everything is in the opioid environment. They're reacting
• 18:52
  Speaker 7: to what's being said in the government. You can't help
• 18:56
  Speaker 7: but hear things, whether it's a net flick's documentary or
• 19:02
  Speaker 7: if it's the news that you turn on, or even
• 19:04
  Speaker 7: if you're listening to podcasts or even reels that people
• 19:08
  Speaker 7: are getting their information from. There's a lot of fear
• 19:12
  Speaker 7: that has been born out of what's gone on, and
• 19:15
  Speaker 7: there's a lot of uncertainty.
• 19:17
  Speaker 3: People don't know.
• 19:19
  Speaker 7: That it may not be better options for them at
• 19:22
  Speaker 7: the upper end of pain, and so they tend to
• 19:27
  Speaker 7: be very nervous about the utilization even when it's a
• 19:32
  Speaker 7: necessary and what we've seen out of this is it
• 19:36
  Speaker 7: really is an inhibitory factor whether that is treating their pain,
• 19:40
  Speaker 7: or getting them more functional so that they can sleep
• 19:43
  Speaker 7: and heal better, or even things like making them functional
• 19:47
  Speaker 7: enough so that they can actually do the physical therapy
• 19:49
  Speaker 7: post procedure that they need to do. So it's really
• 19:53
  Speaker 7: a kind of a conundrum that bears itself out as
• 19:58
  Speaker 7: what are our options going forward?
• 20:00
  Speaker 3: How are we going to deal with this?
• 20:01
  Speaker 7: And this is some of the things that we started
• 20:03
  Speaker 7: to contemplate at this paper.
• 20:06
  Speaker 5: It's a lot, to say the least, so I appreciate
• 20:09
  Speaker 5: you guys highlighting these there so.
• 20:13
  Speaker 6: And just to I think that the paper is focused
• 20:16
  Speaker 6: on a lot of the things that Jim was talking
• 20:17
  Speaker 6: about the medical side, but I'd like to it's worth
• 20:20
  Speaker 6: mentioning it. There's a massive economic cost to all of
• 20:23
  Speaker 6: this as well. When we started and just as a teaser,
• 20:26
  Speaker 6: the paper focuses mainly on the medical or actually have
• 20:29
  Speaker 6: started looking into the economics and are probably going to
• 20:31
  Speaker 6: be coming out with a sequel that's more economically focused,
• 20:36
  Speaker 6: But as a teaser, when we look at started looking
• 20:38
  Speaker 6: at all the related healthcare costs and loss of productivity
• 20:43
  Speaker 6: costs related to addiction and related to under treating pain,
• 20:48
  Speaker 6: it's it's pushing a trillion dollars, and then when you
• 20:51
  Speaker 6: start looking at all of the societal costs that you know,
• 20:54
  Speaker 6: law enforcement and crime and everything that goes along with addiction,
• 20:59
  Speaker 6: it's probably over at trillion dollars, and I mean trillion normally.
• 21:03
  Speaker 6: To get a dollar amount that's that's got that many zeros,
• 21:06
  Speaker 6: you gotta be talking about an AI company or something,
• 21:10
  Speaker 6: so massive economic impact as well. And so we think
• 21:15
  Speaker 6: that all of this points to really an urgent need
• 21:19
  Speaker 6: for the development of safer, less addictive therapies that can
• 21:25
  Speaker 6: you treat pain at the level of opioids, but with
• 21:28
  Speaker 6: you know, very different risks. And and so I think
• 21:34
  Speaker 6: because I think that the the opioid not going away
• 21:39
  Speaker 6: and the opioid problems are really inherent in their use.
• 21:44
  Speaker 5: Absolutely, and you know, I can I appreciate the teaser,
• 21:48
  Speaker 5: of course, but you know, the big picture here of
• 21:50
  Speaker 5: what you and all authors in the article and just
• 21:54
  Speaker 5: in general conversation really of you know, looking at provider, patient, society,
• 21:59
  Speaker 5: economic imp act, policy impact. It's just a lot. But
• 22:04
  Speaker 5: to only discuss or cover one aspect is just such
• 22:08
  Speaker 5: a shortcoming. So it's I appreciate that going over all
• 22:13
  Speaker 5: aspects that that's incredibly important. I'm sure both of you agree. Now,
• 22:21
  Speaker 5: perhaps we could even jumping into a portion of that here,
• 22:25
  Speaker 5: maybe we dive a bit deeper into this balancing act
• 22:29
  Speaker 5: that I think came up a couple of minutes ago.
• 22:31
  Speaker 5: You know, I worded the.
• 22:33
  Speaker 2: Whole opioid phobia.
• 22:34
  Speaker 5: You know, danger, danger everybody, danger, good golly, versus the
• 22:38
  Speaker 5: opioid philia perhaps of the past. You know, utilization across
• 22:42
  Speaker 5: the board universally, not just acute severe pain.
• 22:45
  Speaker 2: When we're talking.
• 22:45
  Speaker 5: Opioids, you know, there's risks, of course, dare we say
• 22:51
  Speaker 5: informed consent needed within you know, clinical practices and interactions.
• 22:56
  Speaker 5: All medications come with their baggage. Good golly, if I
• 23:00
  Speaker 5: had a nickel, we still make nickels, right, Yeah, if
• 23:02
  Speaker 5: I had a nickel for every time I said that.
• 23:04
  Speaker 2: Yeah, But there's there's truth in that. Of course.
• 23:08
  Speaker 5: There's a lot of adverse drug events, side effects, whatever
• 23:11
  Speaker 5: we want to call them. You know, when it comes
• 23:13
  Speaker 5: to prescription opioids, we have things like and I usually
• 23:15
  Speaker 5: hesitate to say minor because you know, the first one
• 23:19
  Speaker 5: that typically comes to mind is constipation.
• 23:20
  Speaker 2: It's like, well, that's not rescipraty depression.
• 23:22
  Speaker 5: So is it minor, Well, you know, if you're the
• 23:25
  Speaker 5: patient that's experiencing it.
• 23:27
  Speaker 2: It might really matter that day or that month for
• 23:29
  Speaker 2: that matter.
• 23:30
  Speaker 5: So, you know, constipation all the way up to scale
• 23:32
  Speaker 5: to things like substance use disorder, addiction, even respiratory depression.
• 23:37
  Speaker 2: There's there's a lot overall there.
• 23:40
  Speaker 5: I don't know, James, if you wanted to add anything
• 23:43
  Speaker 5: in that realm too, particularly with the background of all
• 23:45
  Speaker 5: everything you guys have done in the realm of prescription opioids.
• 23:48
  Speaker 6: Of course, yeah, thank you, Mark, I'd love to. I
• 23:52
  Speaker 6: think that you're thinking about it the kind of the
• 23:53
  Speaker 6: way we did. There's sort of as a clinician, if
• 23:56
  Speaker 6: you say, you say, okay, I'm gonna you know, we've
• 23:59
  Speaker 6: got Sophie's here, but I've got a patient in tremendous pain,
• 24:02
  Speaker 6: so I'm gonna go ahead. I'm gonna give them the opioids.
• 24:03
  Speaker 6: So I think, you know, there's a long list of
• 24:07
  Speaker 6: things that you know, in the industry we kind of
• 24:09
  Speaker 6: tend to brush over as like, you know, no manageable.
• 24:13
  Speaker 6: You know, things like you know, constipation. You mentioned things
• 24:16
  Speaker 6: like you know, qt prolongation. These drugs can can mess
• 24:20
  Speaker 6: with your hormone levels, you know, itching or parietess, sedation,
• 24:24
  Speaker 6: you know, patients go through you know, potential, you know,
• 24:28
  Speaker 6: range of things when you're treating them. The thing that
• 24:31
  Speaker 6: I think really drew our interest more though than that
• 24:36
  Speaker 6: even was okay, what happens when you walk away? Like
• 24:40
  Speaker 6: are there potentially you know, when the treatment's over, because
• 24:42
  Speaker 6: then the focus here was more on the acute pain treatment,
• 24:45
  Speaker 6: which is should be self limiting. What are the sort
• 24:50
  Speaker 6: of secondary risks to giving an opiate to someone? And
• 24:54
  Speaker 6: and started looking at, you know what all the literature
• 24:56
  Speaker 6: says about, you know, the risks of things like dependence.
• 25:02
  Speaker 6: You know, we obviously talk a lot in the paper
• 25:04
  Speaker 6: and think it's top of mind, you know, the addiction problems.
• 25:07
  Speaker 6: But people can develop you know, significant dependence to opioids
• 25:11
  Speaker 6: by not doing anything wrong, by just taking them as
• 25:14
  Speaker 6: their clinician is prescribing them and taking them for as
• 25:17
  Speaker 6: long as is needed for their pain, they can become dependent.
• 25:21
  Speaker 6: In fact, it happens in you know, probably more than
• 25:24
  Speaker 6: ten percent. The research says somewhere sort of eleven to
• 25:27
  Speaker 6: thirteen percent of patients who are getting an initial opio
• 25:30
  Speaker 6: prescription are becoming dependent. And that's something you see. You know,
• 25:35
  Speaker 6: even with short term use, that can happen as fast
• 25:38
  Speaker 6: as a week. And as I think a lot of
• 25:41
  Speaker 6: your readers probably appreciate, opio withdrawal is is bad. You know,
• 25:46
  Speaker 6: you feel like you're dying when you're going through withdrawal,
• 25:48
  Speaker 6: and it keeps a lot of people, you know, using
• 25:51
  Speaker 6: these drugs for much longer than they would otherwise, and
• 25:56
  Speaker 6: sometimes you know, permanently. The other part though, going down
• 26:02
  Speaker 6: the other path here of what can happen is patients
• 26:07
  Speaker 6: often feel euphoria with these drugs. People they feel pain, relief, good,
• 26:11
  Speaker 6: but they also feel some of patients feel really good.
• 26:16
  Speaker 6: In fact, one study showed that the twenty five percent
• 26:19
  Speaker 6: of people who received opioids in an emergency department setting
• 26:24
  Speaker 6: experienced euphoria as one example. There a results of studies
• 26:27
  Speaker 6: on that, and it's clear that that, you know, people
• 26:30
  Speaker 6: that are misusing opioids are often driven by that feeling
• 26:34
  Speaker 6: of euphoria that they're they're feeling that on the first
• 26:37
  Speaker 6: prescription and then they're saying, hmm, but if I wasn't
• 26:39
  Speaker 6: in pain, this would be really fun and sometimes seeking
• 26:43
  Speaker 6: out more and we're seeing you know, a lot of
• 26:46
  Speaker 6: the misuse of prescription opioids are coming from that, you know,
• 26:51
  Speaker 6: that initial prescription. It's not like, you know, somebody has
• 26:53
  Speaker 6: to use for long. It's often and there have been
• 26:56
  Speaker 6: studies where they interview people that were in addiction, and
• 27:01
  Speaker 6: often they would say, first host, I knew that that
• 27:04
  Speaker 6: was my drug, that was something that I wanted more of,
• 27:09
  Speaker 6: and yeah, so there's.
• 27:12
  Speaker 7: Some really interesting anecdotes around this too when people.
• 27:15
  Speaker 3: Ask me, is this a real problem? I listened to
• 27:18
  Speaker 3: a really interesting.
• 27:19
  Speaker 7: Podcast to an individual who was a professional who basically
• 27:26
  Speaker 7: hurt us back in a sports league that they had
• 27:29
  Speaker 7: for the company, and then went on to become an
• 27:32
  Speaker 7: addict because of the pain medication that he had and
• 27:36
  Speaker 7: then subsequently became one of the most notorious bank robbers
• 27:40
  Speaker 7: in the United States to support that habit. And I
• 27:43
  Speaker 7: know we've all heard things like this, but I think
• 27:46
  Speaker 7: for the lay public, it's interesting for them to actually
• 27:50
  Speaker 7: have that type of exposure and have that material out there,
• 27:52
  Speaker 7: because I think they tend to think that, well, it's
• 27:56
  Speaker 7: more of a safety issue and don't necessarily understand that
• 28:00
  Speaker 7: dopeminergic component of it that is really important and that
• 28:04
  Speaker 7: which leads to that addiction.
• 28:06
  Speaker 3: A lot of the times, Jim.
• 28:08
  Speaker 5: For a moment there, I thought you were actually talking
• 28:10
  Speaker 5: about me, just the first part of the sentence.
• 28:12
  Speaker 2: Anyway, I had and I think we've talked about this.
• 28:16
  Speaker 5: Before when I had an illustrious episode of nephrolithiasis kidney
• 28:21
  Speaker 5: stones and the incredible pain associated there was, you know,
• 28:25
  Speaker 5: a cute outburst of the pain, and ended up utilizing
• 28:29
  Speaker 5: what was prescribed for me at the time. It was
• 28:31
  Speaker 5: a T three you know, codine with a cidamnifin you know,
• 28:35
  Speaker 5: mostly perceived as being oh lower on the total pole.
• 28:38
  Speaker 5: But it's all about the dosage.
• 28:40
  Speaker 2: Baby.
• 28:41
  Speaker 5: Anyways, in that acute situation, I had not eaten yet,
• 28:44
  Speaker 5: but the pain needed to be taken care of it.
• 28:46
  Speaker 5: On that empty stomach, I can tell you that dopamine
• 28:48
  Speaker 5: was flowing, and you know, but obviously the choice was
• 28:52
  Speaker 5: not made to continue or you know, seek more and
• 28:56
  Speaker 5: all that.
• 28:57
  Speaker 2: A total different pathway. But my point in bringing.
• 28:59
  Speaker 5: This up is it's all of us and any of
• 29:03
  Speaker 5: us that can have these experiences. So I really appreciate
• 29:08
  Speaker 5: you bringing that up.
• 29:09
  Speaker 6: That's and I think that's that's that's great example. I
• 29:14
  Speaker 6: think they and I know there's been a lot of
• 29:15
  Speaker 6: debate in the pain community over the last you know
• 29:18
  Speaker 6: years about Okay, we hear about all the heroin and
• 29:21
  Speaker 6: fentanyl addiction and the deaths, and you know, how connected
• 29:25
  Speaker 6: is that with the prescription of opioids, And that was
• 29:28
  Speaker 6: one of the things we wanted to really investigate in
• 29:30
  Speaker 6: the paper, and it's clear that there is a causal
• 29:32
  Speaker 6: link in many, many cases. In fact, one study found
• 29:36
  Speaker 6: that the majority of people addicted to these illicit drugs
• 29:40
  Speaker 6: had that exact path was exactly what we're talking about.
• 29:43
  Speaker 6: That they were pain patients that got a prescription, felt
• 29:46
  Speaker 6: high and then made the wrong choice which took them
• 29:49
  Speaker 6: down a one path. And the other research has shown
• 29:55
  Speaker 6: that you know, way more than half, you know, maybe
• 29:58
  Speaker 6: eighty percent of heroin users initially we're misusing prescription opioids.
• 30:03
  Speaker 6: And then the final sort of part of this on
• 30:06
  Speaker 6: the sort of the consequences side and how this is
• 30:09
  Speaker 6: leading to addiction is it's not even it doesn't even
• 30:13
  Speaker 6: seem possible to stop this as a clinician by picking
• 30:16
  Speaker 6: the right patient or counseling the patient, because actually we
• 30:19
  Speaker 6: get into the misuse of these prescription opioids, most of
• 30:22
  Speaker 6: it's not even happening with the patient that's prescribed them.
• 30:27
  Speaker 6: Most of it is just the pills get out there
• 30:29
  Speaker 6: and then they're stolen or otherwise diverted to someone else.
• 30:34
  Speaker 6: And most of it, so most of the abuse or misuse,
• 30:38
  Speaker 6: I guess is the preferred term now, is happening in
• 30:40
  Speaker 6: someone that as a clinician you don't even see. And
• 30:43
  Speaker 6: so to us this is all pointing to, you know,
• 30:46
  Speaker 6: the need for a better option.
• 30:50
  Speaker 5: Absolutely, and you know it's just more spokes. There's so
• 30:55
  Speaker 5: many branches and spokes within this overall major concern, you know,
• 31:00
  Speaker 5: kind of pivoting a little bit. But what we already
• 31:02
  Speaker 5: brought up earlier, of course, is well what about not
• 31:04
  Speaker 5: treating pain? You know, that's quite frankly harmful as well,
• 31:09
  Speaker 5: you know, particularly considering you know mentioned earlier.
• 31:12
  Speaker 2: I think it was James mentioned, you know, going.
• 31:15
  Speaker 5: Obviously from acute to even sob acute and then chronic
• 31:17
  Speaker 5: pain along the way, hopefully not picking up any central
• 31:20
  Speaker 5: sensitization either. That's you know, things amplify pretty quick. Any
• 31:26
  Speaker 5: thoughts there, that's.
• 31:27
  Speaker 3: Actually a real challenge.
• 31:29
  Speaker 7: And as I started saying earlier, I think it depending
• 31:34
  Speaker 7: on where you sit in your comfort for utilization of
• 31:38
  Speaker 7: different product.
• 31:39
  Speaker 3: It's either a positive or a negative.
• 31:42
  Speaker 7: And I think you know, the avoidance of opioid due
• 31:47
  Speaker 7: to concern, which I think everybody is aware of, is
• 31:52
  Speaker 7: very prevalent, and it's just one of those things that
• 31:56
  Speaker 7: you have to be careful about, you know. And if
• 31:59
  Speaker 7: you just take a a painful procedure as an example,
• 32:02
  Speaker 7: you have a shoulder surgery, you have a knee surgery,
• 32:06
  Speaker 7: something of that nature, and you don't use it well,
• 32:11
  Speaker 7: then left uncontrolled, we know that we can go to
• 32:15
  Speaker 7: as you were saying, mark the end of quantification. That's
• 32:19
  Speaker 7: an outcome I think that no one wants. But it's
• 32:21
  Speaker 7: also not as predictable as anybody wants. But if you
• 32:25
  Speaker 7: look at it from the other side and I briefly
• 32:27
  Speaker 7: touched on it before, and you take it from the
• 32:30
  Speaker 7: patient's perspective, you have consequences that there are more immediate.
• 32:35
  Speaker 7: And so if you think about it from a patient's perspective,
• 32:39
  Speaker 7: either reluctance or their unwillingness to prescribe them can lead
• 32:43
  Speaker 7: to a lot of negative things. It is we have
• 32:45
  Speaker 7: a surgery in the family very recently. They are very reluctant,
• 32:51
  Speaker 7: a very educated person to taking it, and after about
• 32:55
  Speaker 7: three days of watching this, I basically just said, no,
• 32:58
  Speaker 7: you have to take it. You are not leaping at all.
• 33:01
  Speaker 7: You are never going to heal. And that becomes a
• 33:04
  Speaker 7: true issue. And as I said, this whole concept of
• 33:09
  Speaker 7: making sure that you need to do what you're doing
• 33:12
  Speaker 7: hip surgeries as we know it today you're up walking
• 33:14
  Speaker 7: the same day. How much more reluctant are you going to.
• 33:17
  Speaker 3: Be able to do that or go to your physical
• 33:19
  Speaker 3: therapy if you're in excessive pain.
• 33:22
  Speaker 7: So it's really dependent on the types of pain that
• 33:27
  Speaker 7: we're talking about the intensity of pain that we're talking about.
• 33:31
  Speaker 7: But that's really kind of the message, right, So when
• 33:35
  Speaker 7: you look into things like severe post surgical pain, we
• 33:40
  Speaker 7: know that you can get in and get yourself into
• 33:43
  Speaker 7: the development of chronic pain.
• 33:46
  Speaker 3: And the more intense.
• 33:47
  Speaker 7: And the longer the duration, the more opportunity it has
• 33:51
  Speaker 7: to become centrally sensitized and have a longer term problem
• 33:55
  Speaker 7: with it.
• 33:57
  Speaker 5: We basically need to have our cake and eat it too,
• 33:59
  Speaker 5: right exactly. Well, you know, like any conversation in this accord,
• 34:06
  Speaker 5: we usually leave with more questions than answers. But you
• 34:09
  Speaker 5: know what you guys alluded to, perhaps a second version
• 34:14
  Speaker 5: of an article or you know, a follow up part two.
• 34:17
  Speaker 5: But even before that, like, was there anything that didn't
• 34:20
  Speaker 5: make it into the article? Would you like to share
• 34:23
  Speaker 5: here with our listeners.
• 34:24
  Speaker 6: I think we're the article you know, didn't didn't make
• 34:29
  Speaker 6: it into the article. I think is probably you know,
• 34:31
  Speaker 6: some of the you know, the research attempts to then
• 34:34
  Speaker 6: solve this problem. I think, you know, we're not the
• 34:38
  Speaker 6: far from the first people to recognize these issues and
• 34:41
  Speaker 6: the need for better treatments. It's you know, pain. Drug
• 34:44
  Speaker 6: development is is hard. There have been you know, failure
• 34:48
  Speaker 6: after failure of new mechanisms, people trying to develop things
• 34:51
  Speaker 6: that that in the lab or in animals looked great
• 34:55
  Speaker 6: and just for one reason or another, uh, didn't make it,
• 34:59
  Speaker 6: you know, in two.
• 35:01
  Speaker 3: Didn't make it to approven approval.
• 35:03
  Speaker 6: Whether you're talking about you know, the P thirty eight inhibitors,
• 35:05
  Speaker 6: the anti NGF drugs, the trip B one drugs, There's been,
• 35:09
  Speaker 6: you know, mechanism after mechanism that have failed. I think
• 35:13
  Speaker 6: the positive news is that there are at least a
• 35:16
  Speaker 6: couple of mechanisms that seem to have gotten past that
• 35:20
  Speaker 6: hurdle and are succeeding. You know, I think the one
• 35:24
  Speaker 6: that's probably top of mind for everyone is whoseetrogene, which
• 35:26
  Speaker 6: is the Vertex Drugs sodium channel blocker, selective sodium channel blocker,
• 35:32
  Speaker 6: and the selective is obviously very important, selective for the
• 35:34
  Speaker 6: one point eight pathway that was approved almost a year
• 35:39
  Speaker 6: ago in the US, which blocks pain signaling in the
• 35:43
  Speaker 6: periphery or blots one of the important pain signaling pathways
• 35:46
  Speaker 6: in the periphery. And I think, you know, has the
• 35:49
  Speaker 6: potential to replace you know, some opioid use. A second one,
• 35:55
  Speaker 6: one that's near and dear to our heart hearts is
• 35:58
  Speaker 6: the dual nup mop agonists or dual n MR drugs,
• 36:04
  Speaker 6: which are full agonists at the MEW receptor, just like oxycodone,
• 36:09
  Speaker 6: pick your favorite opioid, but also full agonist at the
• 36:13
  Speaker 6: NOP receptor, which turns out to really fundamentally change what
• 36:19
  Speaker 6: you get from those drugs. You still get the opioid
• 36:21
  Speaker 6: level analgesia, but with a very different safety profile, very
• 36:26
  Speaker 6: different abuse profile, dependence profile, et cetera. And that's a
• 36:32
  Speaker 6: mechanism that's not approved yet but is through phase three
• 36:36
  Speaker 6: and has shown clinically a very different profile. And so
• 36:41
  Speaker 6: I think, you know, there's hope on the horizon we think.
• 36:46
  Speaker 5: That's literally what I was hearing was the.
• 36:49
  Speaker 7: One thing I would like to sorry to interrupt, one
• 36:52
  Speaker 7: thing I would like to add to what James was saying,
• 36:55
  Speaker 7: because I've actually worked on some of these in different
• 36:57
  Speaker 7: organizations that I've been at, is the amount of effort
• 37:02
  Speaker 7: that's gone in and this is something.
• 37:04
  Speaker 3: I think that people, perhaps.
• 37:07
  Speaker 7: Even clinicians don't have a full appreciation for, is substantial.
• 37:11
  Speaker 7: And so it is very difficult in today's world, as
• 37:15
  Speaker 7: you may imagine, to try to get a ain product approved.
• 37:22
  Speaker 7: And a lot of that is because of mechanism that
• 37:25
  Speaker 7: may be attached or other types of things. But one
• 37:28
  Speaker 7: of the big things that becomes a problem is recognize
• 37:32
  Speaker 7: your comparitor is, especially in the upper end of pain
• 37:36
  Speaker 7: when you're looking at higher intensities, is an opioid and
• 37:40
  Speaker 7: opioids on the therapeutic side, and I'm not talking about
• 37:43
  Speaker 7: the things that we've talked about in terms of adverse
• 37:46
  Speaker 7: effects and the negatives that we know about opioids. The
• 37:49
  Speaker 7: downside when you're looking at development is the effect and
• 37:54
  Speaker 7: the efficacy of the house are actually very good, and
• 37:57
  Speaker 7: so a lot of times it becomes quite hard to
• 38:00
  Speaker 7: actually compare yourself to that. So when you find something
• 38:03
  Speaker 7: like James was talking about with this dual NMR receptor product,
• 38:10
  Speaker 7: then you you have an opportunity to actually play in
• 38:13
  Speaker 7: that same realm and make sure that you're looking at
• 38:16
  Speaker 7: it from a perspective of now we're actually looking at
• 38:19
  Speaker 7: something that could be equal while actually minimizing some of
• 38:23
  Speaker 7: the downsides.
• 38:24
  Speaker 5: It's an important point that I brought up there, Jim,
• 38:26
  Speaker 5: because you know, it's like MLB players, you know, going
• 38:30
  Speaker 5: up against MLB Draft league players. Sooner or later someone
• 38:34
  Speaker 5: will get drafted and make it, but it's not going
• 38:36
  Speaker 5: to be everybody. So that that's I hope that brings
• 38:40
  Speaker 5: some light to our listeners here too. All Right, you
• 38:43
  Speaker 5: two are probably thinking you're getting off easy here, But
• 38:45
  Speaker 5: there's always one or two questions I ask every guest
• 38:48
  Speaker 5: in the Pain Pod here. So here's my first one,
• 38:52
  Speaker 5: and James, maybe you want to go first. How do
• 38:54
  Speaker 5: you define pain?
• 38:58
  Speaker 6: That's a tough one. I think you know.
• 39:00
  Speaker 2: Always probously you can.
• 39:01
  Speaker 6: Go to the the textbook answer, you know is p RS.
• 39:05
  Speaker 6: Whoever defines you know? Pain? But I think you know,
• 39:10
  Speaker 6: and that's all right, But I think you know. I
• 39:12
  Speaker 6: think the important thing is not to define pain as
• 39:16
  Speaker 6: a broad category. And actually Jim and I were just
• 39:21
  Speaker 6: talking about this and he was actually probably said it better,
• 39:24
  Speaker 6: but I'll try to paraphrase and he'll jump in and
• 39:26
  Speaker 6: correct me. But you know, we think of pain, we
• 39:30
  Speaker 6: think it's probably not even right to think of pain.
• 39:32
  Speaker 6: It's more important to think of a pain type and origin,
• 39:37
  Speaker 6: and because that's going to get us to a better treatment.
• 39:40
  Speaker 6: You know, we used to think of cancer, right, people say, oh,
• 39:43
  Speaker 6: you've got cancer, and then it was like, well, now
• 39:45
  Speaker 6: we have. Then it became a type of cancer, well,
• 39:48
  Speaker 6: a carcinoma or melanoma or sarcoma or whatever. And now
• 39:52
  Speaker 6: it's it's almost like every cancer is an individual disease
• 39:56
  Speaker 6: because you're looking at the genetic footprint of that tumor
• 39:59
  Speaker 6: and then a it exactly that way. And so I
• 40:02
  Speaker 6: think it's probably to not to attempt to side up
• 40:06
  Speaker 6: your question, but to kind of sides up your question.
• 40:08
  Speaker 6: It's we shouldn't be defining pain. We should be defining
• 40:13
  Speaker 6: subtypes sub subtypes of pain in some cases.
• 40:18
  Speaker 3: So I let me just add a couple of things
• 40:20
  Speaker 3: to it.
• 40:21
  Speaker 7: And James, I think you did very good encapsulating our discussion.
• 40:25
  Speaker 3: The other bottom line is you actually have to look
• 40:29
  Speaker 3: at the patient too.
• 40:29
  Speaker 7: I mean, when we talk about pain, it's very important
• 40:33
  Speaker 7: to talk about it in the context with the way
• 40:35
  Speaker 7: it's being experienced, the type of pain that you're talking about, Yes,
• 40:40
  Speaker 7: very very important, But we also don't.
• 40:42
  Speaker 3: Need to treat a you know, a small issue.
• 40:46
  Speaker 7: With a big hammer or a big issue with a
• 40:49
  Speaker 7: small hammer. I think it's really important to put it
• 40:52
  Speaker 7: in context of what it is, and that's why it's
• 40:55
  Speaker 7: so important to think about it from a perspective.
• 40:58
  Speaker 3: Of what do we actually dealing with.
• 41:01
  Speaker 7: And that whole analogy that James and I were talking
• 41:04
  Speaker 7: about came about because I did my training in the
• 41:07
  Speaker 7: oncology arena and frankly in the olden days and I'm
• 41:12
  Speaker 7: probably aging myself a bit.
• 41:14
  Speaker 3: We did think about it in more simplistic terms.
• 41:17
  Speaker 7: And that's been a substantial evolution, and I would love
• 41:19
  Speaker 7: to see the same type of evolution come into pain medicine.
• 41:24
  Speaker 5: I got to give you guys credit. You were saying
• 41:26
  Speaker 5: that you might be side stepping, but you weren't. The
• 41:30
  Speaker 5: almost entire reason I always ask pain podcasts this question
• 41:33
  Speaker 5: is because it's something I ask patients as well. You
• 41:37
  Speaker 5: tell me what you think it is and your thoughts
• 41:40
  Speaker 5: there were very patient centric, and that's incredibly important overall,
• 41:45
  Speaker 5: whether it's in talking with a patient to set up
• 41:47
  Speaker 5: what the goals are actually going to be, or how
• 41:49
  Speaker 5: somebody defines their own pain, it's gonna be different. All
• 41:53
  Speaker 5: credit to IASP. I know they spent a lot of
• 41:56
  Speaker 5: time on that sentence slash paragraph, but it's going to
• 41:59
  Speaker 5: be different for everybody, So thank you gents. All Right,
• 42:02
  Speaker 5: but the follow up one, what is your favorite pain medication?
• 42:06
  Speaker 2: And of course why so.
• 42:09
  Speaker 7: Let me take that one first because I'm going to
• 42:11
  Speaker 7: completely dove.
• 42:12
  Speaker 3: Tell it to what we just talked about.
• 42:13
  Speaker 7: Okay, this is actually really important and again we all
• 42:18
  Speaker 7: learn things formatively. For me, my favorite medication is the
• 42:25
  Speaker 7: one that's most appropriate for the person. And that gets
• 42:29
  Speaker 7: back to a little bit of what I just mentioned, right,
• 42:32
  Speaker 7: And I think it's really important to put it in
• 42:34
  Speaker 7: context of the person who's receiving it, the type of
• 42:37
  Speaker 7: pain that they have, what's.
• 42:39
  Speaker 3: Going to necessarily treat the pain?
• 42:42
  Speaker 7: Is it going to be something that we're going to
• 42:44
  Speaker 7: be looking at for a short duration.
• 42:46
  Speaker 3: Is it something that's going to be end of life therapy?
• 42:48
  Speaker 7: I think these are all really important components to say
• 42:52
  Speaker 7: that there isn't a magic bullet. There's going to be
• 42:56
  Speaker 7: things that we kind of talked about that are going
• 42:58
  Speaker 7: to give us better tools.
• 43:00
  Speaker 3: But ultimately, what it gets down to is make.
• 43:04
  Speaker 7: Sure you're considering the patient, the issues that they are,
• 43:07
  Speaker 7: where they're sitting at their time, within the confines of
• 43:10
  Speaker 7: the pain that they're having or the disease force that
• 43:13
  Speaker 7: they're experiencing, and choose the appropriate option because that's going
• 43:17
  Speaker 7: to be the one that's most impactful for them.
• 43:21
  Speaker 2: Thank you, sir.
• 43:22
  Speaker 6: And I would agree with everything that Jim said, but
• 43:25
  Speaker 6: I'll give you an actual product that fits into that.
• 43:30
  Speaker 6: I'll give you the product that that really helped my
• 43:32
  Speaker 6: grandmother the most. And because it's kind of a positive
• 43:36
  Speaker 6: but frustrating anecdote, the product that really that she could
• 43:40
  Speaker 6: take that really helped her was fulter and Gel and
• 43:44
  Speaker 6: I actually the the diclopin Act topical because you know,
• 43:49
  Speaker 6: she was able to take that because she didn't get
• 43:50
  Speaker 6: doesn't get a lot of systemic a circulation and can
• 43:54
  Speaker 6: help where you apply it. And I actually discovered this
• 43:59
  Speaker 6: not discovered. I learned about this medication when I entered
• 44:02
  Speaker 6: pharma and I went to and I said, like, I
• 44:04
  Speaker 6: think this could could help you. You got to talk
• 44:06
  Speaker 6: to your doctor about it. She was, you know, like
• 44:09
  Speaker 6: very happy. It's like, oh, I'm going to go talk
• 44:10
  Speaker 6: to my doctor. Well, of course, living in a rural area,
• 44:13
  Speaker 6: she talked to a doctor and a doctor never heard
• 44:16
  Speaker 6: of it. Okay, that didn't help, So that was a
• 44:19
  Speaker 6: dead end. So I said, well, let me see it
• 44:21
  Speaker 6: was at that time it was still prescription in the US.
• 44:24
  Speaker 6: You had to get it to a doctor. And so
• 44:26
  Speaker 6: I picked up some and outside of the US it
• 44:29
  Speaker 6: was over the counter, and so I picked up some
• 44:32
  Speaker 6: from her for her. Once brought it back to the US,
• 44:35
  Speaker 6: gave it to her. This is probably not fully legal,
• 44:39
  Speaker 6: so I'm outing myself. I gave it to her and
• 44:43
  Speaker 6: it was tremendous. It really had this massive effect, you know,
• 44:46
  Speaker 6: on her pain and was like a life saver for
• 44:49
  Speaker 6: you know, while the TWOBE lasted. And so for a
• 44:52
  Speaker 6: few years, every time I went I took a trip
• 44:55
  Speaker 6: outside of the US, I would end up in a
• 44:57
  Speaker 6: pharmacy to buy some of this. And but of course
• 45:00
  Speaker 6: it can't be as simple as well, just give me
• 45:02
  Speaker 6: a case of that. It was, you know, quote over
• 45:04
  Speaker 6: the counter, but you had to talk to the pharmacist
• 45:07
  Speaker 6: and then you know, get them to get provided for you.
• 45:11
  Speaker 6: And so you had to basically convince them that you
• 45:14
  Speaker 6: needed it while you're on your trip outside your country.
• 45:16
  Speaker 6: And so yeah, I get one or two tubes from
• 45:19
  Speaker 6: someone bring it back. That was you know, she was
• 45:21
  Speaker 6: great for a month or so and then out again,
• 45:24
  Speaker 6: and so it was. It was a nice thing when
• 45:27
  Speaker 6: it was there, but it was a frustrating experience as well.
• 45:31
  Speaker 5: It's an incredible experience that yeah, considering that was approved
• 45:35
  Speaker 5: it was Valentine's Day, I want to say twenty fourteen,
• 45:39
  Speaker 5: but about a decade ago when you got approved for
• 45:42
  Speaker 5: OTC in our country, I too saw it on shelves
• 45:45
  Speaker 5: and gift shops and hotels outside of our country. Good golly,
• 45:51
  Speaker 5: I think putting together what you guys were saying was
• 45:53
  Speaker 5: for you know, what's the favorite one, the one that
• 45:56
  Speaker 5: works and is accessible. We could never forget about the
• 46:00
  Speaker 5: access along the way as well too, So well, gentlemen,
• 46:03
  Speaker 5: thank you both very much. Hopefully it was a joy
• 46:06
  Speaker 5: ride for you here I go. I always got to
• 46:08
  Speaker 5: enjoy the adventure. But as far as our pain pod listeners,
• 46:11
  Speaker 5: I hope This was more than worth your time and
• 46:14
  Speaker 5: really spurred some thoughts to think about those spokes, the
• 46:18
  Speaker 5: branches of this overall opioid story that we have been
• 46:22
  Speaker 5: living and will continue to live along.
• 46:24
  Speaker 2: The way as well too.
• 46:25
  Speaker 5: All Right, so please, do you know, join us for
• 46:28
  Speaker 5: our next episode of the Pain Pod stand the edge
• 46:30
  Speaker 5: of your seats. We'll debut some new topics along the way,
• 46:34
  Speaker 5: but in that realm till the next time, Pain pot Nation.
• 46:38
  Speaker 5: Thank you and have a great day every day.
• 46:42
  Speaker 1: If you'd like to join Mark on the Pain Pod,
• 46:45
  Speaker 1: send us an email to publish you're at Pharmacy podcast
• 46:49
  Speaker 1: dot com and make sure to share the show and
• 46:52
  Speaker 1: subscribe on your favorite podcast directory.
• 46:56
  Speaker 3: Thanks for listening.