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Join Amy Baxter, a clinical associate professor of emergency medicine, as we explore the intricate balance between physicians’ roles in perpetuating the crisis, addressing systemic factors, and the influence of pharmaceutical industry-sponsored education. Discover the brain’s response to pain and opioids, contextual risk factors for opioid use disorder post-surgery, and the potential of non-opioid alternatives.

Amy Baxter is a clinical associate professor of emergency medicine at Augusta University, federally funded for neuromodulation research to reduce needle pain, multimodal low back pain, and opioid reduction. After attending Yale University and Emory Medical School, she completed her residency and a child maltreatment fellowship at Cincinnati Children’s Hospital Medical Center, an emergency pediatrics fellowship in Norfolk, Virginia, and a K30-NIH Clinical Research Certificate at UT Southwestern Medical Center. She is also CEO, Pain Care Labs, and can be reached on Twitter @AmyBaxterMD.

She discusses the KevinMD article, “Ending the opioid crisis starts with physicians.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Amy Baxter. She is a clinical associate professor of emergency medicine at Augusta University, and she’s the CEO of Pain Care Labs. Her KevinMD article today is “Ending the opioid crisis starts with physicians.” Amy, welcome to the show.

Amy Baxter: Thank you so much for having me, and thank you for existing, along with the show itself.

Kevin Pho: We’ll get into the article a little bit. First off, share your story and journey to where you are today.

Amy Baxter: Sure. I grew up in Lexington, Kentucky. I’ve always wanted to be a doctor, and I always wanted to be an emergency doctor. Then I did a residency in pediatrics, a child abuse fellowship and an emergency fellowship at King’s Daughters, and then a clinical research fellowship at UT Southwestern. Then my husband said, “No more fellowships. Get a real job.” At the time I was doing peds emergency at UT Southwestern, and then for about 15 years I did procedural sedation and peds ER at Children’s Healthcare of Atlanta Scottish Rite.

Kevin Pho: So you’re in the midst of a series of articles on KevinMD exploring the opioid crisis and pain management. Before we get into all that, how did you get interested in this area?

Amy Baxter: I think, like most of us, I wanted to address suffering, and my path has been very eclectic, as befits an ADHD pediatrician. I started with needle pain research. Actually, I started with child abuse and PTSD research, then needle pain, then identifying burns and scald burns in children. Then I was thinking about the pain faces scale and thought it would be hysterically funny if the last one was vomiting. So my first grant was actually making the BARF scale, the Baxter Animated Retching Faces scale, but in part because I felt that there’s oftentimes a lot more suffering from nausea than pain, and we really weren’t addressing it. All of those things made me very attuned to issues of what was causing pain.

Also, I was raised in the ’90s, so I had a “No pain” button that Purdue Pharma gave me at one of their OxyContin lectures. I really believed that no pain was the goal, and I also believed that opioids aren’t addictive if you’re really in pain. And I think, like all of us to some extent, we were so exposed to pharma in our education and in our multiple-choice-test approach to medicine that we also get a little suborned by pharma as the primary solution.

Kevin Pho: I also trained in the ’90s, and I remember those “No pain” buttons and pain as the fifth vital sign, things like that. Just to go a little deeper, how do you think that influenced some of the issues that we’re facing today regarding the opioid crisis and pain management?

Amy Baxter: I mean, it goes way before that. Julius Caesar said it’s easier to find men to volunteer to fight and die than to suffer pain with patience. St. Augustine said pain is the greatest of evils. And I think that when you have a medical model, you are looking for how to cure something, you’re looking for how to eliminate something.

The reality of pain, which we understand much better now because of functional MRIs that only became available in the very late ’90s, is that pain is not a switch. It’s not one place. It’s not a sensation that you can turn off or on. Pain is actually this spasm of reaction throughout the brain that involves memory and identity and fear and options and sorting, and it can be enhanced by previous bad experiences that connect to all these things. So if you understand pain as a survival system, and understand that the brain is connected and that what you’re feeling is a lot of what you expect to feel, that changes how you approach it.

McMaster University, or McGill, does a phenomenal job on all different levels of pain education, and one of the great quotes I got from there was, “Pain is your brain’s opinion of how safe it is.” So if we’re looking at pain in that way, then ignoring the biopsychosocial is ridiculous, but trying to come up with a way to turn the switch off is equally futile.

The final thing, which I don’t think we appreciate, and certainly a lot of this is still residual from the Sacklers and Purdue Pharma, is that we don’t get much pain education in med school. On average in the U.S. you get about 12 hours; in Canada you get 20. That’s not enough to learn about what we know about how pain works. It turns out that I really believed that opioids turned off pain, and they don’t. They’re a reward system. They stimulate mostly dopamine. So rather than giving opioids out of compassion because they turn off pain, what we’re doing is activating the reward system, so you feel pain but you don’t care. And it turns out that doesn’t work very well with orals, because they’re so slow, and after a few days your opioid receptors involute anyway. So giving rewards is probably also not the best way for outpatient pain relief.

Kevin Pho: All right, so let’s talk more about your KevinMD article. Today’s article is the first in a series. It’s titled “Ending the opioid crisis starts with physicians.” How did this particular article come about?

Amy Baxter: Well, I was really interested in the ERAS articles that came out, probably starting five years ago, so enhanced recovery after surgery, and I was really impressed with the fact that there are lots of places that were giving opioids after surgery either sparingly or not at all, and there was no correlation between satisfaction or pain and how many opioids people took.

I have been making devices for pain for a number of years, and an orthopedic surgeon was testing them. He had already found that the amount of opioids for ACL reconstruction was really dependent on how many pills he gave. They were all given 50 Percocet, and people would take 25, but he said, “You know, they’re strong. They’re athletes. They only took 25.” So he decided to just give 30 and see what would happen, and they took 15. And there was no change in the pain and no change in satisfaction. So those two things together made it pretty apparent to me that what was happening was that opioids were one tool in a tool kit that carried a lot of risk but actually didn’t give any benefit for pain. With the devices he was testing, the interesting thing was that people only took 10, and they didn’t have coaching, so that is a whole different thread.

But the take-home that I think is important is that when I wrote an article about five years ago that got on Doximity, maybe it was 2019, about “Let’s just have three to throw,” so give people something in their pocket to fall back on, but otherwise let’s think about what our other pain management options are post-op, I was castigated. So many people were furious at the suggestion that we limit our opioids.

Kevin Pho: Really? What was some of that reaction when you wrote that article? Like you said, you were castigated. Give an example of some of that feedback.

Amy Baxter: Oh, man. Emergency doctors saying, “You have no idea. I cannot not write a script,” or “I am here to make people better, and my superpower is writing prescriptions, so this is what I do, and it makes people better.” Another person said, “They’re not addictive if you’re really in pain,” which is a complete lie, but that was part of the training we got. And I think that there also were a few people, some people who contacted me offline and said, “Look, I appreciate what you’re trying to do, but my son had really horrible pain with his wisdom teeth, and he wouldn’t have gotten through it without some opioids.” It turns out, also in 2019, a paper by Schroeder et al. found that 6.4 percent of young people who get their wisdom teeth out and get opioids have opioid use disorder within a year.

With the article that we’re talking about now, it really began occurring to me that we are talking a lot, even SAMHSA, the government’s Substance Abuse and Mental Health area, and I’m funded by NIDA now, even we, and all of what we’re doing is looking at established addiction, or we’re looking at social factors that lead to opioid use disorder. And I crunched the numbers, and the reality is that we have about 84 million prescriptions that are given for post-injury or post-op pain. Of the people who use opioids, for their first misused opioid, about 44 percent of them are getting it from a medicine cabinet, from someone, and about 28 percent are getting it from a doctor that they had surgery with. Overwhelmingly, of misused opioids, only 20 percent come from the street. The rest of it comes from us. We are the ones who are giving it.

And I’ve got a graphic, for those of you who are following along at home. I’ve looked at about 100 articles. There are so many articles on how many people who started opioid-naive are still using opioids 90 days out, and it’s about 6.5 percent. It doesn’t really matter what the surgery is. So my articles coming up are going to be about the fact that there are genetic mechanisms we understand now, and there are better ways that we could be preventing opioid use disorder, not just by keeping opioids out of the medicine cabinet, but also by understanding who is more at risk and then giving them other options before surgery.

Kevin Pho: Just to clarify, someone who is opioid-naive and goes through some type of orthopedic surgery, just having post-op opioids afterwards, whether it’s 15 Percocet or 20 Percocet, that puts them at risk for opioid use disorder going forward? There’s a substantial number of those who go on to become addicted to opioids, is that correct?

Amy Baxter: Yeah, it’s crazy. With those who are not opioid-naive, we actually do know what the risk factors are. Risk factors are previous opioid use, for one thing; catastrophizing, so anxiety about pain, anxiety about the meaning of pain; female; younger people are actually usually more at risk; and certainly having a family history of disorders is a risk factor. But one of the big things that we are not talking about is something called rapid metabolism.

I worked with a nurse in the ER, in the ED, who became addicted to fentanyl and opioids, and it started with one night. She was on call, and she said that her stomach was hurting. So I took her into another room, and I said, “You know, I think this is your gallbladder.” And it was, and she got her gallbladder out, and that was her first exposure to opioids. I ended up hiring her later and asked, “Dude, I don’t understand. How could this happen? I mean, you’re stealing fentanyl from children, and you were just such an incredible nurse, and I know how much you care about children. Where did something flip?” And she said, “From the very first pill I took, you don’t understand. I have always felt anxious. I don’t feel comfortable in my own skin. This made me feel wonderful. I felt loved. I felt worthy. I felt accepted. I felt so great. How can you not want to feel that way?”

For most of us, opioids do not make us feel that way, but there are a number of different factors, and one of them is probably something called cytochrome P450 2D6, which is a metabolism that is present in different percentages of people based on race and background. But between 5 and 15 percent of people are going to feel fantastic when they get an opioid, and that is a risk factor that they may not know about until they take their very first one.

Kevin Pho: And in your article you gave us a statistic: 80 percent of opioid use disorder starts with pills prescribed for pain.

Amy Baxter: Yeah. Only 20 percent of people start with street drugs or heroin. In the ’60s, most people who bought heroin started with heroin, about 70 percent, and most of them had also started with the gateway drugs, you know, started with marijuana or started with alcohol or started with cocaine or started with Quaaludes. It’s really flipped around now, because it’s so much harder to find alcohol if you’re young. It’s so much harder to steal things and have it not be noticed. But everybody has opioids sitting around in their medicine cabinet.

I’ve had so many injuries. I’ve broken my neck twice, I broke my back once and I ripped my rotator cuff. I’ve had a lot of injuries that have caused pain. And when I got spasms recently, my shoulder was completely frozen up, and I asked people in my community, “Hey, does anybody have any Flexeril? Does anybody have just a pill, just for a day, so I can get through?” because it was the weekend. And so many people said, “Oh, yeah, I’ve got some pills,” and they were all opioids. One person had eight containers of opioids. So now we’re in a situation, since OxyContin, since Purdue Pharma, where most opioid use disorder starts with something that we physicians prescribed with the best of intentions.

Kevin Pho: So tell us the path forward. Because like you said, a couple of years ago when you wrote that article, you got such negative feedback from other practicing clinicians. Clearly there’s a strong bias towards the status quo and what we’ve been doing for decades now. How do you change our minds? How do you change the minds of clinicians?

Amy Baxter: There are some really great articles that have asked us that question: What are the barriers to non-pharmacologic, or to a mix of over-the-counter and sleep aids and non-pharmacologic, physical, mental, all these other different things? What are the barriers? Different studies show different things, but the first barrier is obviously education. We are not trained on how the brain works or how pain works, and we’re not trained on what works for pain. When I ripped my rotator cuff, I asked the ortho to write for massage for me, because muscles that are tense and stiff pull on the nerves and cause pain. He said, “Massage? Does that work, or do you just want to chill?” Massage is something that is routinely done in Canada and in many places in the world, acupuncture, all these sorts of things. We’re not educated on them.

The thing I didn’t know, Kevin, and this is awful, the thing I didn’t know is how money flows in this country for pain management, and really for anything. Every single monetary decision is based on what’s going to get covered, and what gets covered comes from the Social Security guidelines for Medicare, statute 6.3, which states that Medicare is required to take care of illness and bodily deformity in seniors, and everything flows from that. One of the other parts of the statute says that they don’t pay for comfort items. They don’t define what comfort items are, but there are so many things now: cryotherapy, heat. Bracing is actually not great because it stiffens you, but it gets paid for, because the thought is that it’s stopping bodily deformity. But the reality is that things that keep you moving, things that manipulate muscles and certainly treatments, acupuncture is now covered in most places, but all of these other things don’t fall directly under bodily deformity or illness, and so they’re not paid for.

Because of that, and because the appropriations for Medicaid and Medicare are dictated by Congress but the responsibility was dictated by statute, CMS has all the responsibility but no authority. So they can’t stop and say, “OK, we’re spending $17 billion on blood thinners.” That $17 billion could give every person with a knee replacement an $80 physical device that decreases pain, but we don’t. It’s kind of like money spent at the end of life or at the beginning in NICUs. We don’t really have a good equilibration mechanism.

Kevin Pho: We’re talking to Amy Baxter. She is a clinical associate professor of emergency medicine at Augusta University. She’s the CEO of Pain Care Labs, and today’s KevinMD article is titled “Ending the opioid crisis starts with physicians.” Amy, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Amy Baxter: Sure. There’s beautiful data, there’s so much data, that for most of the things we’re prescribing home opioids for, they actually don’t help. For wisdom teeth, ibuprofen works better, study after study. The other thing I’d like people to know is about opioids in the hospital, IV. I think we’re throwing the baby out with the bathwater, but actually there’s a lot of data from trauma, from battlefields, from PTSD and burns, that the more morphine in the first 24 hours, the less PTSD and the less chronic pain. There’s a particular receptor that’s been discovered that’s probably the reason for that. So I’m not worried about opioids IV in the hospital for less than seven days, but after three days the opioid receptors start to involute and become tolerant, become less sensitive.

So what I’d really like to see is, post-op, let’s give three to five pills, if you feel like you can’t wean yourself off of prescribing that many. But do a little education. Figure out what the evidence-based non-pharmacologic mechanisms of treatment are, and find resources that can provide them to your patients. And also try to advocate some for Medicaid and Medicare to pay for non-pharmacologic mechanisms. There’s something called the NOPAIN Act. It was added at the end of 2022 to support and pay for any proven devices, or really anything that was non-opioid that reduced opioid use after surgery. CMS recently announced that instead of enacting it this year, which would have been required by statute, they’re going to put it off until 2025. So there’s a link where the public can comment on this until September 11th.

But try to find ways to intentionally increase your knowledge of non-pharmacologic options, decrease the number of prescriptions that are sold and tell people to throw away the pills in their medicine cabinet. We can reframe pain so that just being more comfortable is the goal, not being pain-free.

Kevin Pho: Amy, thank you so much for sharing your time and insight, and thanks for coming on the show.

Amy Baxter: Thank you so much for your forum and for having me.