As opioid overdose deaths surpass 100,000 annually in the U.S., the crisis has reached a devastating peak, and physicians play a critical role in addressing it. AMA President-Elect Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Taskforce explores the latest data, policy shifts, and clinical strategies that can help doctors balance pain management with addiction prevention. This episode was created in collaboration with the PermanenteDocs Chat podcast, and is hosted by family physician Alex McDonald, MD.
As opioid overdose deaths surpass 100,000 annually in the U.S., the crisis has reached a devastating peak, and physicians play a critical role in addressing it. AMA President-elect Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Taskforce explores the latest data, policy shifts and clinical strategies that can help doctors balance pain management with addiction prevention. This episode was created in collaboration with the PermanenteDocs Chat podcast and is hosted by family physician Alex McDonald, MD.
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Unger: Welcome to Moving Medicine, a podcast by the American Medical Association. Today’s episode is produced in collaboration with the PermanenteDocs Chat podcast. The host, Dr. Alex McDonald, talks with AMA President-elect, Dr. Bobby Mukkamala, about the nation's overdose epidemic. Dr. Mukkamala is an otolaryngologist at his solo practice in Michigan and serves as chair of the AMA Substance Use and Pain Care Task Force. They'll discuss the latest data, system-wide steps to create change, and clinical strategies that can help physicians balance pain management with addiction prevention. Here’s Dr. McDonald.
Dr. McDonald: Welcome everyone to today's Permanente Docs Chat. I am your host, as always, Alex McDonald. I practice family and sports medicine here in Fontana, California, and this week we are joined with Dr. Bobby Mukkamala, who is President-elect of the ... Excuse me, vice chair, oh, I'm going to get this wrong, of the American Medical Association. He's also the chair of the Substance Use and Pain Care Task Force, really a very strong voice on evidence-based policies to really curtail the opioid crisis. So, Bobby, thank you for joining us. I apologize, I butchered your last name.
Dr. Mukkamala: Not at all, happens all the time, Alex. It's Mukkamala, but no, no problem.
Dr. McDonald: Mukkamala. All right, I'll try and get that right, I'll practice that a couple times.
Dr. Mukkamala: Bobby's just fine.
Dr. McDonald: Well, thank you so much for joining us. If you have questions, please drop those into the Q&A box, we'll try to get to as many of those as we can live. These are short and high yield, so we really want to kind of get those questions in early. Bobby, let's start by telling us who you are and what you do.
Dr. Mukkamala: Sure, yeah, thanks Alex. I'm a private practice otolaryngologist here in Flint, Michigan. It's the town that my parents moved to from India back in 1970, and I share this home office and my office with my wife, Nita, who's an OB/GYN, sort of an odd combination of ENT and OB/GYN. But as you mentioned, I'm serving as president-elect of the American Medical Association. But before that position, I had the honor of serving as chair and continue to serve as chair of our work related to substance use disorder and pain care. A lot of people question why is an otolaryngologist in this role as chair of this work related to substance use disorder? I think some of that reason was that many years ago, I got my X-Waiver to prescribe buprenorphine, and I did that just because a lot of our advocacy work is around pain control and substance use disorder management as we started to see our country going in the wrong direction.
I just didn't feel comfortable as a leader within the AMA saying, "You should do this, you should get your X-Waiver," not knowing what that was like to do it myself. So, I got my X-Waiver, I did it online and did the testing and got my X-Waiver. I think that got the attention of folks within the AMA saying, "Hey, non-pain physicians embracing this work and the collective group of physicians embracing this work is how we will move this in the right direction." So now that's how an otolaryngologist gets to chair this work at the AMA.
Dr. McDonald: Great. No, and I love that, putting your money where your mouth is, so to speak, or leading by example I think is so important. As a physician, especially, and a leader in leadership role, that's so valuable so thank you.
Dr. Mukkamala: Absolutely.
Dr. McDonald: Well, let's start by telling us where we are right now with the opioid crisis. There is some glimmers of good news this year. We've still past 100,000 overdose deaths this year but can you talk about where we are in the opioid crisis and are we making progress?
Dr. Mukkamala: Yeah, absolutely. The latest news is great with fewer deaths, approximately 10,000 fewer deaths, clearly, we're going in the right direction. What's a little interesting about the latest data is that we're still not sure why. Is this because of efforts, is it because of conversations like this? Is it because of naloxone? Is it because we are decreasing the amount of illicit substances that are coming into this country? Is it better treatment? We don't know yet, but what I would say is that we'll take it. That's 10,000 more people that are alive today than would have been had we not had this change in trajectory. And so, where we are is a step in the right direction but there's still a ton of preventable deaths related to opioids. And so, the first thing to do is we have an obligation to do better. We shouldn't just say, "Okay, we're going in the right direction, and we can take our foot off the gas."
We need to continue in this work because, otherwise, especially when we don't know why, this could go easily in the wrong direction. Next year, statistics could be worse. And then, the other thing is that the majority of these deaths, the vast majority of these deaths, 80%, are due to illicit fentanyl. I mean, that's been the case for years. Now, in addition to that, cocaine and methamphetamine sort of surpassing prescription opioids as far as the cause of these deaths, and it's been that way now for many years, but yet the focus seems to continue to be on prescription opioids.
There's still so many programs and hospitals across the country looking at prescription opioids and trying to restrict how many opioids we write for our patients, and there's a consequence to that. Patients with real pain are suffering with pain, that's why our task force that used to be pain management and substance use disorder separately, is actually the substance use disorder and pain care task force. So, what we do over here to try to decrease the burden of substance use disorder isn't leaving people out in the cold, so to speak, as far as their pain management goes. And so, that's why it's critical to have that conversation in the same room so we know what the consequences of those things are.
Dr. McDonald: Yeah, that is such a great point regarding ... There's so much emphasis, especially for us as physicians, to prescribe opioids and to minimize even initial refills or don't even start it, but the fact that so much of this is really coming from the illicit use and the use disorder … I don't want to say population, but that being the bigger challenge. And then, to your point also about the unintended consequences, one of my colleagues here who practices hospice and palliative medicine is having trouble getting opioids for his patients who are on hospice and palliative, and so we're having to struggle with ... We have a limited supply of these medications because of manufacturing restrictions and now we're having to choose, "Okay, can we give these medications for acute pain? Do we have to save them for those who have palliative and hospice?" It brings up a lot of ethical challenges for those of us who practice on the front lines.
Dr. Mukkamala: Yeah, absolutely. It's just so interesting that there was a time and there was litigation associated with pharmaceutical companies pushing opioids. I remember people coming to my office when I first started my practice talking about the latest narcotic pain medication for post-tonsillectomy pain, a really rough procedure to recover from, and talking about how the opioids that they have aren't addictive, and now we know how wrong that was. And so, to go from that point to now, for those patients that are in pain, for those same post-tonsillectomy patients to have to go to three different pharmacies in the Flint area post-op trying to get a prescription filled and not having it be in stock because we use a liquid narcotic pain medication for adults after tonsillectomy, and it's just really hard to find. And so, now they're back to crushing tablets and things like that.
And so, we've gone from one bad situation to another bad situation where patients with pain, acute pain, post-surgical pain, are struggling in the way that you've described, in addition to people with chronic pain, and having to ration that is just not where we should be. That's exactly where people will seek other ... I mean, pain doesn't just go away if you think it away so it's something that needs treatment, particularly acute pain. And so, in that situation, people will oftentimes use illicit substances to control that real pain, and that's not at all where we want to go.
Dr. McDonald: Yeah, and I guess that's my next question is, by limiting the spigot on this side, how much are we causing the flood over here? Can you delve into that statistic a little bit more that 80% of that drug overdose are due to illicit street drug use? Is that correct?
Dr. Mukkamala: Yep, absolutely, yep. And so, illicit fentanyl is the number one cause of that, right? And so, then there's also, there's cocaine, there's methamphetamine, other smaller segments, and xylazine. It just seems like every year our pain care task force is always looking at what's coming around the corner into our communities, what can we anticipate. It's never a dull moment, unfortunately, because it's constantly changing, what's laced with what. Because this isn't, again, something that's getting dispensed 30 tablets in a prescription cup that you're getting at the pharmacy, this is anybody's guess about what's happening in these communities.
And so, it is illicit substances but not necessarily something with predictability like, okay, if it's this color pill it's going to be this percentage. Rainbow fentanyl is something that was on the streets, that's still on the streets. Who knows how much fentanyl is in this stuff, and that's why people that are trying their best to recover from their substance use disorder and then have a relapse and then go out and use something are oftentimes at the highest risk of dying and overdosing from that because they just don't know what they're getting.
Dr. McDonald: Yeah. No, I think that's something I don't think we realize necessarily specifically, those of us who don't work in this realm in our everyday work. Again, as a family physician, I treat patients with pain and chronic pain. I do use some opioids, but I don't really get a lot of exposure to the use disorder world and the ramifications downstream. I think because of some of this there's a lot of people, and some people argue that the opioid crisis really represents a failure of the health care system, not to put too strong a point on it. Do you agree with that and what does that mean for us as physicians regarding how we approach treatment, patient education and just effective pain management?
Dr. Mukkamala: Yeah, I guess I would say, in short, that I disagree. I would say that it's multifactorial as we say in medicine, so it's an epidemic with many causes. The health care system is sort of a convenient scapegoat sometimes, but we need to look at particular elements to identify what needs to change. And sure, as physicians we've learned a lot in the past. It used to be when I was in my training, every person that got their tonsils taken out got a prescription for Tylenol with codeine elixir, regardless of age, with a bunch of refills. Now I know that if they're under 18, Tylenol and Motrin work just as well, and so we avoid narcotic medication. And even those adults for every surgical procedure we've realized that dispensing 30 with three refills, the average person takes less than a third of that, and so that sits in the medicine cabinet.
And so, there is a responsibility for health care to be introspective, see what it is that we're doing and what needs to change based on data. But beyond that, we're just one part of the system. Insurers are another big part of that system and things like prior authorization just leads to delay in denial of care. Every person listening today knows how hard it is to find care when somebody needs it. The premium dollars that we spend that are just tightly held by insurance companies to delay and deny that care. That's why it's critical that we continue to push and say, "Look, if physical therapy is something that's going to be useful for this patient to deal with their pain, and that physical therapy is something that is either denied or something that is limited in how often they can get it or for the duration that they can get it, that's not serving this patient well.
That pain is real, and if the only other alternative is an opioid medication that we want to avoid, then don't have us go through the hurdle of prior authorization to do what's best for that patient. That's what we see so much, the prior authorization burden in health care in general, but particularly as it relates to management of somebody's pain is something that really is a headwind in going the direction that we want to go, which is to take better care of these patients.
Dr. McDonald: Yeah. No, and your point regarding just the opioids being one tool in the toolbox regarding the myriad of different treatment options we have for both acute and chronic pain. I always tell patients that when I am prescribing an opioid, I kind of go through all the risks and benefits and I say, "Look, this is part of a comprehensive pain management strategy. We need you on your SNRI, we need you on Motrin and Tylenol as first line. We need you on perhaps some kind of a neuroleptic medication. We need you on physical therapy." And really making sure that we are using all the tools in our toolbox versus just one, which can obviously have all these downstream consequences. I think the word is getting out to physicians but, as you said, there's all these barriers to really making sure we focus on non-opioids as part of a comprehensive approach.
Dr. Mukkamala: Absolutely. When the toolbox that's right in front of us that's unlocked has a Phillips head and a regular screwdriver, but what we need is a hex wrench and it's in a locked toolbox over there, that doesn't do us much good. And so, the same way, if prescribing opioids is something that we can do but prescribing physical therapy or other pain care for those patients with chronic pain, a procedure, if that's something that has a hurdle to get to and it's going to take months, this patient's in pain. It's not like a crooked nose that I deal with. Somebody that's been stuffy and can't breathe through the left side of their nose for years, okay. Prior auth isn't great for them either but it's not going to have the consequences of prior auth for somebody that is dealing with acute pain or chronic pain that is now waiting to get the appropriate procedure because of the burden of prior authorization. That's just not right.
Dr. McDonald: Yep. No, I completely agree with you. I completely agree with you. You mentioned several different things which may be helping curtail this opioid crisis and the over deaths, and I think one of the biggest things right now that's becoming more commonplace is the use and availability of naloxone as a rescue medication for patients who may be overdosed. You can get it some places without a prescription. Do we think this is working? Do you think that's a piece of the puzzle? And do we see that maybe some people might see that as a safety net and say, "Oh well, it's not as big a deal because you can just take naloxone if you have problems or if you take too much." How should physicians begin to address some of that concern? I see this a lot in my HIV population or patients who are high risk of HIV. They just want to take pre-exposure prophylaxis and then they don't use contraception and have a higher risk of contracting HIV. That's just one example. Are we worried about that in some respects or is that we're not quite that there yet?
Dr. Mukkamala: Yeah. I guess I'm not worried about that because naloxone … it's not a safety net. I mean, it's an evidence-based, time-tested medication that saved hundreds of thousands of lives over the past decades. And so, the myth of reliance on naloxone is kind of like the same myth that seat belts encourage risky driving, right, like I'm going to drive poorly because I've got a seat belt. And so, all physicians should offer a prescription for naloxone. I mean, you don't even need it now because it's over the counter.
Dr. McDonald: Exactly.
Dr. Mukkamala: And that's a wonderful development. I guess one side note there is that it's over the counter but at 50 bucks a packet. It's prohibitive for a lot of people and I know there's a lot of community programs to do that, but it sure would be nice to see that price come down. But for example, at AMA headquarters in DC where we have our advocacy office, we have naloxone available on every floor there at the AMA building. We haven't had to use it, there hasn't been an overdose at the building, but Union Station is literally a few buildings down the road, down the street. And so, if it's available, hopefully we'll never need it but it's good to have it. Just like you go to any airport, and you'll see the defibrillators.
Dr. McDonald: Yep.
Dr. Mukkamala: It's just the fact that we had defibrillators, we were having people figure out how to shock people back into a normal rhythm at the same time where we said this nasal spray is going to be prescription only. I think it's that kind of argument that got it to be over the counter, where if we can shock people out of an arrhythmia you can certainly spray them up the nose with some naloxone if they're having an overdose. But getting back to the safety net thought and the inadvertent encouraging use by having it be available, readily available. I would say that does having an EpiPen available make somebody with a peanut allergy say, "I'm just going to have that peanut butter and jelly sandwich." They just don't do that, there's just no way they would do that. And so, in the same way, having Narcan isn't going to make somebody with a substance use disorder, an addiction, just say, "Oh, I'm just going to take it because I know I've got Narcan.”
It's good to have it, for sure, but this isn't something that's like a choice. This is something that's a medical condition, this is an addiction. And so, it's the dependence that needs to be treated and I don't want us to get too hung up in thinking that having the naloxone available is going to somehow make them less likely to pursue a solution. There's a lot of examples now in emergency departments where, yes, we will save their life with naloxone, and pray that we do, but instead of just sending them out the door, let us get them hooked up with something like buprenorphine treatment. Get them plugged into a clinic, hand them off, that warm handoff to the next person to receive them so it doesn't become a revolving door of just saving their life with naloxone until we can't.
Dr. McDonald: Yep, yep. It's sort of teaching them to fish versus giving them a fish, is the example I use a lot of times with my patients, wanting to make sure that we give them the tools that they can then be successful and healthy and don't end up back in the emergency room or wherever they may end up being.
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Dr. Mukkamala: Yep, absolutely.
Dr. McDonald: Of all the strategies which are currently being implemented to combat the opioid addiction and the epidemic of overdose, what are the most promising? I know you mentioned we don't really know what's working and what's not working because we're just trying all these different things, but what has the most evidence and what are you most optimistic about?
Dr. Mukkamala: Yeah. I guess what I would say is we know what works in these defined cases where we have studies to show that things like harm reduction strategies, we have data about that. What we don't know is what we were referencing earlier, is that what caused this major drop across the country, in all these states? And so, that needs investigation. But I really like this question because the actions that the AMA task force recommends are actually the ones that some states and medical schools and departments of insurance are actually doing today.
We don't need innovation so much as we need action. We need the states to continue to remove barriers, to care for patients with pain and those with mental illness or substance use disorder. We need medical schools to embed that, comprehensive pain care as part of the curriculum and substance use disorder treatment training into the curriculum. And we need enforcement of current laws. We have some laws in the books, but we need implementation and enforcement of those laws, things like we mentioned, like prior authorization and decreasing those barriers. And then, for primary care and other specialties, if we can start treating a few patients for an opioid use disorder, we should do that.
The evidence shows that buprenorphine works, and that treatment is improved by that. But again, like I mentioned earlier, we used to have to get an X-Waiver, we really don't need to do that anymore. Just like the generation ago when primary care doctors a while ago were sort of hesitant to start patients on an antidepressant because it's like, "Ah, you know, it's something new, I'm not sure about that." Now we do it routinely, we don't even think twice about it. In the same way, we need to get to that comfort level treating somebody that we can recognize, based on the statistics that we see on our EHR that comes up about the opioids that they're using and their history because we know them better than the emergency room physician. We know who's at risk and building up the comfort of the primary care physician base to take care of our patients with that condition, just like we built up that base to take care of mental illness and depression a generation ago. That's when we really start to move in the right direction with this.
Dr. McDonald: Yeah, as a primary care doctor, thank you, I think you're absolutely right. I mean, this is something that I have had a little bit of training on, but I don't know, you've inspired me to learn more and to get more involved here because I think you're absolutely right. As kind of the gateway to the health care industry, primary care can be so powerful in terms of just stopping a problem before it becomes greater.
Dr. Mukkamala: Yeah, I think just demystifying it. When all of a sudden, we need an X-Waiver to be able to use this medicine buprenorphine, it's like, "I'm not sure about that, it's a lot of hours of CME, it must be dangerous." Now that that's gone, it's something that we should be comfortable doing. And so many states have a CME related to pain care and substance use disorder already, that we just need to eliminate the stigma of the medication and use it in a way that's actually going to help us.
Dr. McDonald: Yeah. I have some colleagues in my office, in primary care, who basically because of some of these barriers and challenges and difficulty dealing with opioids just in terms of prescriptions and availability, they basically just say, "I'm not prescribing opioids. It's not safe, I'm not going to do it." What would you say to those physicians?
Dr. Mukkamala: Especially for people that have a substance use disorder or pain issue, in particular, so they're coming in with chronic pain. Up until this point, they had a source of medication for that pain, and it was something that they had, with their physician, agreed to do. Now all of a sudden that physician retires, new physician comes in and says exactly what you just said, "I'm not comfortable with that. Somebody's going to be looking at the numbers that I prescribe and the scrutiny. I just don't want to deal with it." So, the physician makes that decision. The pain hasn't gone away, and so now this patient is scrambling.
In a town like mine where we don't have enough physicians for the population we have, it is going to be extraordinarily difficult for that patient to be able to find a physician, let alone find a physician that's comfortable helping them manage that pain. And so, that's why it's critical that we raise the level of conversation within the physician community, but also resources. Because even if that physician says, "Okay, I understand, but I did this work and I think that this is something that should be managed with a non-opioid treatment, so let's do this." And then, boom, prior authorization. Can't execute the plan that this physician and this patient came up with together, and that still leaves them as if the physician never prescribed it in the first place.
And so, these are the barriers, both with our own comfort level with this diagnosis, and then the hurdles that we have to climb over even when we have the comfort to treat that diagnosis, dealing with things like prior authorization.
Dr. McDonald: Yeah, wonderful. This has been such a phenomenal conversation; we can go on and on. I really appreciate your insight and your nuanced approach here because there's so many shades of gray. It's not all about one thing or the other, and it's really about doing what's best for the patient. And so, I really appreciate all the work that you are doing, and the AMA is doing because I think this is hard and there's not easy solutions, but we have to all be in this together, as you mentioned at the beginning.
Dr. Mukkamala: Yeah. The stigma associated with this lives on. When we see a patient that's blue from an anaphylactic reaction, we have no issue at all jumping in and doing what we need to do to control that anaphylaxis. When we see a patient that's blue from an opioid overdose, all of a sudden, the stigma becomes this barrier and we really need to do a good job of, not just us but law enforcement, our communities, changing the stigma, so the blue patient from anaphylaxis isn't seen any differently than the blue patient from an overdose.
Dr. McDonald: Wonderful. That's great, great insights to end on so thank you so much, Dr. Mukkamala, I really appreciate your time and energy.
Dr. Mukkamala: Absolutely. No problem, Alex.
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Disclaimer: The views expressed in this podcast are those of the speaker and are not meant to represent the views of The Permanente Federation, the Permanente Medical Groups or Kaiser Permanente, or the views and policies of the AMA.