Dr. Kadish sat down to discuss the opioid epidemic with Dr. Lipi Roy, MD, an internal medicine doctor with expertise in addiction and nutrition. As a physician and public health advocate, Dr. Roy’s experiences were shaped by caring for patients in a range of diverse settings, from high-volume hospitals (Duke Medical Center, Massachusetts General Hospital) to homeless shelters and jails (NYC Rikers Island). Dr. Roy has been featured as a speaker in various broadcast and print media outlets including Charlie Rose, CNN, The Dr. Oz Show, and The New York Times.
Dr. Kadish: Do you think that we’re getting a handle on the opioid epidemic, or is it still out of control?
Dr. Roy: I think we’ve made a lot of progress, both at the national and local levels. It’s taking a lot of effort and it’s going to need even more effort for us to see a significant impact, which we’re not seeing yet. But I remain really hopeful that we’re going to see at least a flattening, if not a decrease in overdose deaths. We need to really focus on addiction more broadly. As a reminder, alcohol and tobacco kill far more people than opioids.
Dr. Kadish: How did we get to this point?
Dr. Roy: It’s interesting. There are really three stages of the “current opioid crisis.” The first is really overprescribed opioids, driven mostly by Purdue Pharma. Once doctors were told this, that we need to cut down on opioid prescribing, doctors abruptly cut back on their prescribing, and that led to increased use of illicit opioids, including heroin. That was Stage Two. And then Stage Three, was really the introduction of fentanyl into the drug supply. A lot of drug dealers are cutting drugs with fentanyl and using such a small amount that it is having a potent effect. People will always use drugs to numb pain and suffering. I just want to create an environment where drug abusers are getting the care that they need and deserve. If we were having a leukemia epidemic, people would be getting connected with oncologists and nutritionists and radiation oncologists, getting the care they need, but we just don’t seem to be doing that for addiction.
Dr. Kadish: There was a while where physicians were focused on pain relief. One of the things that physicians were doing was looking at the effectiveness of alternative, non-opioid methods of pain treatment.
Dr. Roy: I’m so glad you brought up the concept of pain. This is the core marketing messaging of Purdue—that we are undertreating pain, and the appropriate way to treat it is through opioids. They were right in that, as a medical profession, we undertreat pain. However, it was patently false to say the evidenced-based way of treating pain was through these long-acting powerful opioids. There was absolutely no evidence to support that. So, you know, the two points I always make when asked is that, as physicians, we get very little training on pain management, and even less, if anything, on addiction. And I’m slowly seeing changes in that direction, in a positive way. Medical students are really asking, or demanding, this education, and a lot of schools and graduate programs are incorporating both pain management and addiction training into their curricula.
I always remind an audience that for pain, pharmacotherapy isn’t even first line. A lot of pain, musculoskeletal pain, really gets better with conservative methods of pain management, like ice, heat, massage. Then there should be a step-line approach or algorithm. So, I think that’s the main strategy when it comes to pain. I am concerned, however, with this current crisis. The pendulum is swinging too far the other way, and people who have been legitimately and appropriately taking their prescribed opioids who are now being abruptly cut off. That’s inappropriate. They should be getting whatever works for them. It’s just that doctors and PA’s don’t train on how to really examine and evaluate and manage acute and chronic pain.
Dr. Kadish: What do you think the most effective way to train healthcare practitioners in pain management is?
Dr. Roy: You have to start during training. As for the people that are already out in practice, there’s a lot of ways to get information. The national agencies and local, city and state organizations have been working hard to get information out there through webinars. PCSS is an excellent, online, free means of accessing training by leaders. There’s a lot of ways to learn about how to best manage pain and the best way to assess a person’s pain. It’s not one time and you’re done; there are patients with chronic conditions and they need to be evaluated constantly. Ongoing education, reading, going to webinars, attending conferences—that’s how I really learned a lot, and then I reached out to colleagues and other physicians.
Dr. Kadish: You talk about the fact that there are a lot of ways to treat pain. Are you convinced that the current algorithms are adequate and clear now? Or that the physicians who want do the right thing by their patients—to treat pain—have enough information to be able to do that?
Dr. Roy: I’ve given several webinars and talks on pain management, and the interception of pain and the current opioid epidemic. One example that I cite is that there’s a website called MyTopCare.org and it was actually started by researchers and clinicians at Boston Medical Center. It offers really clear algorithms and other tools, objective tools, to assess a patient’s pain. Opioids should really never be the first line unless it’s something like acute pain, such as acute appendicitis. But like everything we do in medicine, it’s not just you read it once and you do it and you’re now really good at it—it takes lots and lots of practice, working the kinks out in terms of how to have those conversations, that’s the challenging part; how to speak to patients in a way that’s not judgmental. I know we get these lessons in medical school, but we often lose sight of them or we’re not always necessarily good at it, so as with everything, practice makes perfect.
Dr. Kadish: I think 11 states have now legalized the recreational use of marijuana. Do you think that marijuana is in any way related to the use of harder, addictive drugs, or even that this is reasonably welcome therapy?
Dr. Roy: Thank you for asking that. There has been a lot in the news about cannabis and marijuana. So, my first response is, that at the very least, it needs to be decriminalized. As you know, in this country, it’s not only still criminal just to possess it, it’s still considered a Schedule 1 drug. Schedule 1 drugs are regarded as having no medical benefit, and that’s simply not true with marijuana. We’ve been using marijuana and forms of it for years. Now that we’re getting more and more data indicating that there’s clear health benefits, and at the very least, it should not be a Schedule 1 drug, and it should be decriminalized.
At Riker’s Island, the nation’s second-largest jail, where over 50% of the men and women behind bars has some type of substance abuse issue or disorder, we absolutely need to decriminalize it so that people just stop getting arrested. It’s Black Americans, especially Black men, who are disproportionately impacted by these archaic laws that we still have in this country. So, that’s the decriminalization part of it.
The other part is, we need far more data, far more research, to support the medicinal use of marijuana. Here’s the bottom line: the vast majority of people in this country who use drugs do so recreationally; they will never go on to develop an addiction. The people that do usually have pain or trauma or stress, and who doesn’t have that? So, if they’re going to be using—whether it be marijuana, LSD, or you name the drug—drug use will never go away. So let’s at least create an environment where, should people develop high-risk behaviors, doctors know how to identify it, and they know how to treat it or at least refer people to the treatment that they need.
Dr. Kadish: My last question is this: In terms of treating people with addiction, is there one specific approach that you consider most effective?
Dr. Roy: Yes, the data’s very clear. Addiction is a chronic medical disease, a disease of the brain. It is not a sign of moral weakness or failure. So, once you identify that this is an illness, that should be trigger number one to get people care. Point number two is that most people with addiction, once connected to the appropriate treatment and care, get better. So we’re trying to train far more primary-care physicians, providers, family medicine doctors, ob/gyns, pediatricians, as well as internal medicine physicians, to understand what addiction is. We want them to be able to identify risky behaviors or high-risk behaviors in the patient, and then, if it’s opioid addiction, to at least have an x-waiver so you can prescribe people Narcan. I frankly think that every physician, regardless of specialty, should have some basic training in addiction medicine and be able to have an x-waiver so they can prescribe Narcan. Frankly, we need to get rid of the x-waiver altogether, but hopefully that’ll happen soon. Then with the other substances—let’s say alcohol, cannabis, cocaine, methamphetamines—we need to refer people to a higher level of care or a specialist; to treat co-occurring mental illness, either through primary care or psychiatry, and get people to counseling. There’s a lot of services out there.