Chronic Pain, Opioids, and Addiction among Older Adults with Dr. Sudheer Potru

#088- [CEU podcast] Is it safe to prescribe opioids to older adults to manage chronic pain?  Many older adults are prescribed opioids to manage chronic pain. But in the midst of the opioid crisis and risk for addiction, the question arises, "can older adults use opioids safely?" 

In this continuing education (CE) podcast episode  you'll learn: 

• the history of opioid crisis
• the challenges and stigma faced by those living with chronic pain and substance use disorders. 
• the impact of involuntarily withdrawing opioids from patients, 
• new methods for openly discussing pain
• the difference between "physical dependence" and "addiction"
• get an expert answer to the question: "is addiction really a disease?"

Click here to learn more about earning continuing education (CE) credits for this podcast.

About today's guest...
Dr. Sudheer Potru is a triple-board-certified anesthesiologist, interventional pain specialist, and addiction medicine specialist with strong interest in both opioid safety and addiction medicine. He is an assistant professor at Emory and the medical director of the Atlanta VA's complex pain clinic, which specializes in treating veterans who have chronic pain associated with high-dose opioid use or substance abuse problems. He sits on multiple national committees related to pain and substance use disorders and is actively involved with research and advocacy related to these topics. He has given numerous regional and national talks to both anesthesiology and pain societies on the topic of addiction and how best to manage vulnerable patients around the time of surgery and when they have chronic pain issues as well.

Go to the show notes page here

PROFESSIONALS: Grab your free guide to working with older adults here


Attention Social Workers, Therapists, Counselors, Psychologists, Aging Life Care Experts... Click here to get Continuing Education Credits

Transcript

Dr. Regina Koepp  
Welcome back to another psychology of aging continuing education Podcast. Today we're talking about a really hot topic topic on chronic pain, opioids and addiction among older adults. I want to kind of set the stage about why this is so important. Close to 30% of adults in the United States are living with chronic pain. And the vast majority of these folks are 65 and older. Of course, if you listen to this podcast, we have a lot of episodes on pain. And and you've heard over and over again, that a high percentage of people living with chronic pain also experienced depression. One thing you've also heard I'm sure is about the opioid crisis and the complexities of using opioids with older adults, but also just in the in the management of chronic pain. And so I wanted to bring on an expert to really talk about the complexities and the nuances of chronic pain and managing chronic pain and what to do when people are suffering and when to use opioids and how to use them safely. Can we do that? And what about the opioid crisis? How much responsibility are physicians and medical systems taking in relation to the opioid crisis? I also want to say there was a report I think, in 2017. Yeah, from the Centers for Medicare and Medicaid studies that showed that among users of Medicare and Medicaid, so Medicare and Medicaid beneficiaries have some of the highest and fastest growing rates of diagnosed opioid use disorder. So it's critical that we're having this conversation today and learning some skills and tools and in just broadening our and deepening our knowledge about chronic pain and opioid use among older adults addiction and the opioid crisis. So let me tell you about today's guest, Dr. Sudhir pitru. Dr. Patru is a triple board certified anesthesiologist, interventional pain specialist and Addiction Medicine Specialist with strong interest in both opioid safety and addiction medicine. He's an assistant professor at Emory University School of Medicine, and the Medical Director of the Atlanta VA is complex pain clinic. This clinic specializes in treating veterans who have chronic pain associated with high dose opioid use or substance abuse problems. He sits on multiple national committees related to pain and substance use disorders and is actively involved with research and advocacy related to these topics. All right, let's jump into today's episode. So dear poacher, thank you so much for joining us. I'm curious if you could like start by sharing a little bit about your current work and what inspired you to work with people with chronic pain, addiction, and just that population all together?

Dr. Sudheer Potru  
Yeah, absolutely. So this is an interesting story, you know, so I when I finished so I am an anesthesiologist and I did training in what's called interventional pain medicine. So I finished my training in Chicago back in 2015. And I got out thinking I was going to be just an interventional pain specialist for anybody who doesn't know what that is, essentially, it's a doctor who prescribes medications for pain and does different types of injections. And primarily, like the focus is on really just like, really like the spine and like the joints, like musculoskeletal pain is really sort of the emphasis. So I was working in this space, in a few hospital based pain clinics up in Michigan. And, you know, it was in a rural area, like in the thumb of Michigan, if you're not not aware of the full geography of Michigan, of course, it looks like a hand and I was working in places that are up here, Detroit's like, a little bit closer to like down here. And so, you know, so I was driving out, you know, to some rural areas, primarily Caucasian primarily, you know, maybe you would call it says socio economically disadvantaged to some extent, unfortunately, the really kind of place where addiction can be endemic in that vicinity with it's just ripe for issues. And so I kept encountering patients. So I was doing operating room anesthesia was putting patients to sleep for surgery, and I was working in our pain clinics. And they just kept encountering patients over and over and over who had signs and symptoms of opioid and alcohol addiction. And because I was in a rural area, there aren't many addiction resources to speak of in those areas. There are barely any pain resources, speak up, for sure. And so I started thinking about actually trying to treat some of these patients myself, because there was just nobody around to take care of them. And so I talked to my partners about it. And I talked to my practice administrators about it. And you know, the unfortunate thing is that we realized we just didn't really have the infrastructure to kind of do some of these things to prescribe suboxone and other different things to be able to take care of some of these folks in the right way. And I realized that Did you know the interventional pain work I do. It's fascinating. And I absolutely love it. But it just seemed to me like there was a bigger problem and a bigger issue. And I started to read more about it. And I became really fascinated by the, you know, the understanding of the neurobiology of addiction and all these other different things. And so, it just worked out well that my wife was finishing her training at the time. And so we were looking for jobs all over the place. I had worked in the private sector for a couple of years. But I started looking around for more opportunities, kind of an academic, so I could do some teaching and some research and kind of work a little bit more sort of within this addiction space that you can't really do in a private practice pain setting. And so I was fortunate enough to get a position here in Atlanta and our VA. So I started working with veterans basically, who have like typically like chronic pain and like addiction issues, also chronic pain and like on who are on high dose opioid medications, who might need a rotation who might need a taper who might need just like a safety check to make sure everything is kind of going well and as it should be. And so that's been primarily my focus. And so what I did is, so this past year, actually, I just got my third board certification in addiction medicine, which is which is really exciting for me to be able to kind of do that, and sort of have like an additional expertise and be able to take care of people who are really in some of these kinds of complex and very challenging situations. And so that's kind of so what I've been doing pretty much for the last like couple of years is working in that clinic, obviously taking care of veterans providing like advice, some of my colleagues, the VA, and frankly, a lot of my colleagues just in Atlanta and across the country about kind of how to deal with some of these like challenging sort of patients scenarios. Additionally, I've been like looking at how what substance abuse and addiction really look like in kind of the perioperative space, like for people who are undergoing surgeries and different things like this, how to manage some of the medications when they're undergoing anesthesia, you know, thinking about all that, because that's obviously a very complicated and challenging topic, too. So

Dr. Regina Koepp  
they didn't ask you a question or Yeah, you said Suboxone? Right. Can you just for our listeners, explain what Suboxone is?

Dr. Sudheer Potru  
Absolutely. So, suboxone so there are three medications that are FDA approved for what we call opioid use disorder, which is the fancy medical name for opioid addiction. So there's one which is called methadone, which many of you are probably familiar with, which is prescribed and dispensed in a methadone clinic, which is a federally regulated facility. There's a medication called buprenorphine with it's probably better known by its trade name Suboxone. What it is, is essentially, it's a different type of opioid different type of medicine that basically can block cravings and withdrawal symptoms related to you know, opioid withdrawal or opioid addiction very, you can prescribe it in an office based setting, which is nice. And there is another medication called naltrexone, which is it works a little bit differently than the other two, but it's very, very effective as well. So when I say Suboxone, and buprenorphine, I kind of I apologize for using the trade name, of course, but I'll be probably using them, you know, relatively interchangeably. It's just a lot of people when they hear the word buprenorphine, they're like, Oh, my God, that's a really long thing. And I can't wrap my mind around that a lot of people have at least heard the term suboxone before, that makes a little bit easier for them understand?

Dr. Regina Koepp  
Yeah, thank you. So congratulations on your third board certification and integrative medicine. And this combination, I think, is really timely and really key given the opioid crisis that we're are we actually emerging out of the opioid crisis? What's What's your So can you give us a sense of what the current state of things is within the opioid crisis itself?

Dr. Sudheer Potru  
Absolutely. So a lot of people don't realize that Opioid Prescribing actually reached its peak in 2000 2011 2012, is when we were at the highest amount of opiate prescribing. So imagine that my top hand is opioid prescribing. Imagine that my bottom hand is overdoses as you can. So I wish I could do this as you can put my hands backwards. But as you can see opiate prescribing come down. We're actually seeing opioid overdoses go up. Unfortunately,

Dr. Regina Koepp  
I need to repeat that, because the listeners won't be able to see you. So as Opioid Prescribing is decreasing,

Dr. Sudheer Potru  
decreasing. Now, we're actually seeing opioid overdoses escalate substantially, gosh, which is a fascinating trend. And the reason is because, well, there are a lot of different reasons. I won't, I don't need to go too much into the Sacklers and Purdue pharma, and I will if you want me to, but the reality is that, unfortunately, there's a whole lot of illicit fentanyl and heroin and other different things that are coming in from other places all across the world, whether that's East Asia, or South America or whatever it might be. The reality is that prescription opioid overdoses, they weren't necessarily even that many back then. But now they're even less because there are lots of opioids in circulation. What's happening is the reason why people are dying primarily, unfortunately, is because of this illicit fentanyl that's kind of flowing in from overseas and other different areas. So You know, it's to the, to the average, you know, I think, layperson, you would probably think that, okay, well, we're prescribing less medications, there's less out there. But, you know, as a result, unfortunately, the there are a lot of folks who have realized just how powerful you know, some of these things can be and started to take advantage. Fentanyl was, of course, a drug that we I as an anesthesiologist, and using the operating room, primarily, you actually supposed to use it for, you know, in situations where patients are having surgery, or when they have like cancer pain, or different things like this, but it different things have changed. And, unfortunately, all of the Post Traumatic Stress, depression, anxiety, isolation, all that stuff that's obviously worsened substantially in the COVID pandemic has just escalated all these problems and all these issues, patients who are in recovery, you know, they had their support networks, they had their families, they had jobs, they have other things to keep them busy. A lot of them don't have those things anymore, or struggling for financially or for whatever reason, and unfortunately, are relapsing. And when you relapse from a heroin addiction on the fentanyl unfortunately, it can, it can often be fatal, just because it's so much more powerful of a drug. Right. So it's a sad situation. That's why, you know, we need to I would be nice if we were emerging from the COVID epidemic, or I should say, the opiate epidemic, but things I think we're starting to get a little bit better in 2019. But then, after everything happened, you know, unfortunately, things are worse. We finally hit on you guys probably have seen this on the news. We finally hit in a calendar year over 100,000 drug overdoses in the United States of America, which, as of 2016 2017 2018, it was still escalating, but we were still only maybe in the 60 to 70,000 range. So it's really the problem is actually getting much, much, much worse,

Dr. Regina Koepp  
unfortunately. And these are deaths by overdose. These are deaths by

Dr. Sudheer Potru  
overdose. That's correct. And it's any overdose. It's not just opioids, obviously. But, you know, unfortunately, we know that fentanyl is playing a significant role. But we think that at least probably 60 to 65%, if not more, I mean, who really knows, honestly, on some level are involved. Involved illicit fentanyl.

Dr. Regina Koepp  
So is it accurate to say that with the opioid epidemic, which is prescribers? When did the opioid epidemic start? What do you say?

Dr. Sudheer Potru  
You want the government answer you want the real answer?

Dr. Regina Koepp  
The real answer,

Dr. Sudheer Potru  
the real answer, probably like 2002 2003.

Dr. Regina Koepp  
And what's the government answer?

Dr. Sudheer Potru  
2011 2012. Wow. Yeah. The reality is that people were overdosing and dying a lot earlier. It's just that the things that they were overdosing on weren't as strong, which means it was using they're using primarily heroin back then. Right, which is not nearly as strong as fentanyl is. So you can give a dose of naloxone, which as you guys know, is a nasal spray that paramedics will use to revive folks who are overdose. And usually they only need, you know, one dose, maybe two at most, right? With fentanyl, they need a lot more. And so oftentimes don't actually need an infusion, they need like an IV drip, actually, of naloxone actually to remain alive and breathing. Which means that you know, it's obviously much harder to do and much harder to treat. No layperson on the street, anybody can stick a spray in somebody's nose a couple of times, but it's impossible to really provide that kind of medical care outside of any medical scenario right outside of an institute

Dr. Regina Koepp  
will write an IV drip of. Yeah, right. You can't do that. On the street. Exactly. Wow. So 2000 to 2003. Why is there a discrepancy between the real and the government answer?

Dr. Sudheer Potru  
I mean, so I shouldn't say I shouldn't say maybe I overstated things a little bit. I wouldn't necessarily say it's one answer versus another. I think it's, I think the real beginning of it was really, oh, 203. And I think it just started to escalate probably substantially more so 2010 2011 2012, to the point where, you know, where we really started to realize that, you know, we were causing, we may have actually been causing a problem, right. And we were causing a problem, we'll be honest, right? You know, a lot of the initial opioid exposure that happened was through pharmaceutical opioids, right, which was, you know, in large part, potentially due to marketing and some other different things, you know, back in the early late 90s, early 2000s. You know, that convinced physicians and other practitioners that opioids were safe medications that didn't really cause a lot of issues. We sort of learned the hard way, that's not really the case. And so now, you know, unfortunately, we're dealing with the consequences of that. But I really think the opiate epidemic is not only just a function of the actual meds themselves, the function of problem due to significant significant gap in access to mental health care in this country. Unfortunately, it's really been a significant issue where people are basically using some kind of drug right, as a chemical coping mechanism, right, essentially. So But what I think a lot of people don't realize is that, you know, of course you psychologists are smart about these things. But there are a lot of folks who don't realize that kind of pain and post traumatic stress and anxiety are all kind of tied up together in terms of processing in the brain in the limbic system, specifically, in the in the amygdala, where you have that sort of emotion, kind of behavioral sort of memory, that's very rudimentary, you know, primary sort of primal, I should say, sort of area, you have all these past traumas and depressions and anxieties that ultimately get kind of mixed up with chronic pain. And half the time, you know, even the poor patient doesn't even really understand that that's happening much less as a practitioner, and they're basically like, oh, my gosh, like, I take this opioid and it makes me feel better, right? But the mechanism of action of an opioid is really to kind of just relax you, right? Just make you feel better by releasing dopamine in your brain and just, you know, kind of enhancing your overall emotional state, at least temporarily. So what they're what we actually are doing is we're treating probably both physical pain and suffering when we prescribe an opioid to some extent, which isn't necessarily the worst thing in the world. But the problem is, when we end up treating a little bit more psychological suffering, as opposed to physical pain, right, then we kind of going down the slippery slope, and it can create some issues. I read a study from 2017, showing that 51% of the opioids prescribed in the United States of America go to people who have some sort of mental health disorder, right. So more than half of the opioids that are prescribed in the United States are going to somebody who has something like a depression, like an anxiety, like a post traumatic stress, something like that. So it really does, again, kind of begs the question, what is it that we're actually treating, you know, what is it that we're actually taking care of using these medications? And, you know, if we're using something like psychoactive, like an opioid, whatever it is, and we could be potentially creating a bigger problem.

Dr. Regina Koepp  
Yes. You know, I think physicians and prescribers have been in a tough spot. You know, my experience of physicians, I know a lot of physicians I work with a lot of physicians, is they're caring, they're, they become a physician to help people to alleviate suffering, you know, to help people find hope and meaning and activity in their life, like most physicians are good hearted, and want to be helpful. And I just, you know, it's a real emotional bind. And with this with this opioid epidemic, because physicians are prescribing, and then it's with information that was not accurate. And now they're in this kind of loop where they want to alleviate suffering, their tools are more limited now, because of the concerns about opioids. You know, most physicians want to be helpful alleviate pain and suffering. And I don't want them to be vilified either, because I think physicians are kind of under a tremendous amount of pressure and a shorter amount of time with their patients. And in the midst of COVID, in the midst of pain and suffering, we know that the majority of people with mental health concerns, get their antidepressants from primary care providers. So primary care providers are really kind of overbearing, and holding society, like you know, and so I don't want to vilify physicians for wanting to help people. And I'm angry with the the pharmaceutical company, right that companies that created this and gave false messaging and false hope to people and created a bigger problem. So I just want to put that out there and wanted to get like your sense of what is the sort of morale among your colleagues who are treating suffering or treating pain or kind of holding this together in the midst of COVID and the opioid crisis? You know, it's both the COVID and opioid crisis, right? And what is the pulse of physicians right now?

Dr. Sudheer Potru  
I mean, I think in general, like the COVID pandemic made it very clear to a number of physicians that they were expendable, right, as the demise of the private practice has been continuing over the course of the past three or four decades, and corporate equity is coming in and kind of buying up more physician practices, and kind of just being like, I'm buying you out. And here's a salary and you're gonna do whatever I tell you to do. Loss of autonomy, loss of, you know, the problems like with reinsurance and insurance reimbursements and coverage for treatments and different things like that, which weren't nearly as much of an issue three or four years ago. Obviously, the rising student loan like student debt burden is a significant issue. Physicians are more burned out in 2022. And then they have ever been in history. And when basically, they discovered that you know, a lot of the they were a lot of them were let go by their employers because There was no patient volume or whatever it was. And they said, You know what? I can't believe I've been slaving away for somebody else for all these years, right? I thought this is what I was supposed to do, I thought I was supposed to complete my training, get out, you know, get a job, you know, hopefully make some money, take care of people, you know, and do good in society. And we just find ourselves handcuffed in a number of different ways, whether that's by governmental regulations on medications, whether that's by, you know, like, just general concerns about liability, whether that's by insurance, whatever it might be, right. And the reality is that the American healthcare system is a much tougher place to practice and doesn't 22 Then, literally, and then it has been at any time in human history to this point. And so I think so thinking about that, from like a global standpoint of how physicians are feeling right now, in general, obviously, COVID. And the opioid epidemic has not made anything easier, right. So that's like, even my colleagues in pain management, we're used to prescribing opioids, you know, we're used to like taking care of patients who have chronic pain. I mean, the reality is that the stresses on our patients are actually so much more now than they've ever been. So whatever coping strategies, they had to help deal with their pain and different things or have been altered, right or had been reduced. And I think, you know, so much of that is, is affecting them, they're asking for more meds or asking for this or asking for that, you know, it's kind of making all of us to some extent, more uncomfortable maybe than we were before. But yeah, and so this is, this is what I keep telling everybody that I talked to you I say, you know, pain and addiction, this is a burden that can't just fall on primary care Doc's you can't just fall in the mental health, space, pain and addiction are things that kind of everybody in the health system sort of has to be able to try anyway to step up to help take care of the people in a in a better, more effective, more collaborative way. But at the end of the day, the you know, CMS, and insurance companies don't want to really reimburse you and take care of addicted patients, because it's not a liquid thing, right? It's not it's not procedural, right? In medicine, anything that's procedural is lucrative, right? So people say, Well, why should I do something that number one, maybe I'm not super comfortable with and number two, that nobody's really going to pay me a lot of money for and I'm just going to struggle to keep my doors open, if I, you know, take care of more patients who are like this. You know, so but I think that one of the things that is kind of coming out of this that has been good is that more patients are now refusing opioids, and we're just saying I don't want them from the beginning, which is really good, because potentially, they're not subjecting themselves to a problem or a potential problem, I guess, down the line. You know, and one of the things I think that's really nice, especially about the VA, in particular, is that there's really trying to emphasize self care, right? Active care for pain management Now, previously, in the biomedical model of pain, as opposed to the bio psychosocial model of pain, right? You know, we were kind of so focused on okay, like, where's the problem? Like, what's the issue on the MRI? Like, do you have arthritis in your knee? Like, what's going on in the neck? Like, I need imaging, like, I need to find like a specific physical problem, right? That's what we kept saying over and over and over again, for the last 50 years. And this is what patients sees done, right? This is what they thought, like, oh, like, you know, if there's a problem, if it can be fixed, and I'll just be better, right? And everything will I won't need any medications and everything will be fine. Right?

You know, but what we've realized is that, you know, if you MRI, there's actually a really nice study out there showing that if you take the lumbar spine of the average 30 year olds, you will find something, you will literally find something on that MRI. And if that 30 year old is savvy enough and reads those results on their own, they're going to say this is the cause of my pain, this tiny little finding, this is the reason why I'm having all this pain. And the reality is that as a pain doctor, as a spine, Doctor, I know that that's not true, right? I know that that can't possibly be causing the level of pain that this person is experiencing. But you know, we're so kind of ingrained in that biomedical model of thinking that we think, okay, we're treating something biological, let's use an opioid, as opposed to treating something with bio psycho social, let's utilize physical therapy, psychotherapy, you know, other different types of antidepressants, different things like that. And we, you know, have created this sort of situation where people kind of don't like being told, especially now that everyone's always assumed that they're told, Oh, you're telling me the pain is in my head, I created this or something, I say, No. Pain is not in your head. It's definitely not in your head. It feels very real to you, I guess that it feels super real to you, but I cannot find a biomedical cause for it, which doesn't make you crazy, which doesn't make you like a bad person, right? It just means that I have to treat you in a different ways. And I treat somebody who has a herniated disc and needs an epidural steroid injection, right? It's just a different way that I have to treat them and conceptualize their pain. But you know, who really wants to hear that? So no pain? Exactly. And it's still pain. Because pain, according to the ISP, right. The International Association for the Study of pain is a subjective experience. It is by its very nature of subjective experience that nobody except the person experiencing can actually understand, which is what makes it so hard.

Dr. Regina Koepp  
Yeah, and this is where you know, you're I identified a couple of things. One is that there's a major gap in access to mental health care, and to their stigma around mental health care, which is if it's all in my head that's not worthy. Or if I'm suffering with mental health concerns, and that's Manifesting with physical pain and suffering in these multiple ways, that's not good enough to treat, like there's a stigma that that's not good enough to treat, or that's not an acceptable type of pain, or an acceptable type of suffering. But there's some moral judgment around it that's creating that stigma. And so there's a double whammy. One is there are gaps and two, that there's massive stigma, especially for chronic pain, and, and opioid people who are using opioids to manage the chronic pain, and also have mental health concerns. And so I think you're really pointing out two really important features that we have multiple work, we have a lot of work to do, to one shift the messages around opioid youth, and that everybody needs to take responsibility for that and to to shift messages around stigma around mental health, which we all have to kind of rally to do together.

Dr. Sudheer Potru  
So one other thing that I'll point out is that, you know, I think for the average person, the average individual, like layperson who's listening to our discussion, I mean, I think so much of this really comes down to, like, obviously, getting appropriate care for all of your different conditions, whether those are physical health conditions, mental health conditions, whatever it might be, but just not being afraid to, like reach out and really look for that help and look for look for ways to kind of improve your life. But you know, more Americans are living with chronic pain now than they ever have. Because, you know, we live longer than we previously did. And, you know, if you trust our caveman bodies, right, you know, but back when we were cavemen, we lived to be until about, you know, maybe 3035 years old, 40 years old Max, right. Now, we live until 8090 100 years old. And I mean, one way of thinking about it is that maybe the human body was not necessarily, you know, built to exist for such a long, extended period of time. And now we survive heart attacks, we survive cancer, you know, children who used to die, you know, three or four days after birth, and now living to be 4050 years old, we're dealing with all the consequences of that, too, which means that people are going to develop, obviously, arthritis, spine issues, all these other different things, which means a lot of people a lot more people are developing chronic pain than they ever have before. You know, and it creates this burden, right of all these issues in association with all the problems associated with the treatments that we have, right? So all the things that we have to deal with. And it's just creating this significant burden, initiating also a mental health burden, and all those people who are depressed because they can't do the things that they used to do. And it's just, it's unfortunately, sort of a tough situation. And until we do a better job kind of thinking about these things from a higher level and kind of initiating care for these mental health conditions and etc. From an earlier standpoint, the more so we're gonna end up in these situations where people are just really struggling.

Dr. Regina Koepp  
Yes. I'd like to talk for a minute about opioid use and abuse and older adults, if we can. I know that. I think the CDC had identified that among adults living with chronic pain that adults 65 And older make up 60% of that population. So is the the vast majority of people living with chronic pain are over 60 or 65 and older. And I know that with opioid use and a 2017 CMS study, so that's the set the Centers for Medicare and Medicaid studies, I think, identified that older adults and people with disabilities have are the highest, you have the highest rates of opioid abuse, and have that are the fastest growing group of opioid abusers in 2017. I don't know what the state of that is now, but I'm curious if you could talk about kind of what what you're seeing in research, and I know you just wrote an article, but But what you're seeing in your practice and in research and veterans are actually an interesting population, because veterans who you treat the veteran population, one of two veterans is 65 and older. So it's actually skews older, the veteran population does. But so can you talk about the older adults pain, opioid use?

Dr. Sudheer Potru  
Absolutely. So, you know, there are a couple things that happen physiologically for us as we age that kind of is a little bit concerning about medications, right? So there's something called the beers list or the beers criteria where they look at basically medications that potentially should be avoided as much as possible in the elderly, which are primarily things like really sedating medication, some opioids, antidepressants, certain types, different things. But really, when we look at the the pharma ecology and the physiology of it, what happens is that as you get older, your liver is not as effective at, you know, metabolizing drugs, your kidney is not as effective at excreting or basically urinating out those drugs. And you have some changes, basically, within the what we call the total body water, which basically affects, you know, pharmacologically the way these medications work inside you without getting into all the fine details about it. Essentially, what that does is it creates a problem where we think that if the medication is not metabolized as effectively, we think that it has a longer acting sort of duration of action, as we say in your body, right? If you're if you're an elderly patient, which means that you know, anything that's prescribed, right, that is, either whether it's psychoactive or whether it's metabolized by the liver can potentially present an issue. And we have to be very careful with that. So a lot of times, you know, I have seen, you know, for better for worse, I've seen 85 to 90 year old patients who are just on boatloads of opioids, and they say, you know, Doc, this is the only thing that's ever worked for me. You know, I'm not having any problems with it, why does everybody telling me I need the dose needs to come down? Like, you know, I don't understand what, why they're saying all these things. And I tried to explain to them, I'm like, Look, this is not a function of you. This is a function of your body, and the fact that you're not 40 anymore, you're 90, right? You know, that changes, right? Things change with time. And so we just have to be careful with all of that physically. I mean, in my clinical experience, like people who have been on opioids for a long time, often tend to gain tolerance, right to a lot of other effects and different things. But, I mean, the reality is that, you know, the these medications, and I always have to explain this to my patients is that they're not treating the site of pain, right? They're treating the way that your brain feels about the pain, right? And oftentimes, that explanation to patients, when I say, I'm not treating your back, I'm treating your brain with these medications, or whoever is treating with your brain with these medications. A lot. For a lot of them. It's a sort of lightbulb moment, because they've never heard anything like that before. And literally, I'll show them a model of the brain. And I'll say yes to opium birds here, the opium route here, the OP birds here, like a point, like different places. And I'll say, and I'll point the spine, they'll say, but it doesn't really work there, right? And they'll be like, Oh, my gosh, like, nobody's ever explained that to me before. Like, can you help me get off this stuff? Like, I don't, I don't want to I don't want to do this anymore. And I'm like, Yeah, I mean, it's one thing to try to do that when you're 40. Right. It's another thing to try to do that when you're 7580 years old, and you've been on medications for 30 years, right? It presents like a really significant challenge, whether it's, you know, thinking about how to do a taper or pharmacologically thinking about how they're going to tolerate it mentally, physically, from a functional standpoint, all other kinds of stuff. And so I think one of the other things that's really important to think about is function, right? I feel like this is one of the things that gets lost in the shuffle. When people talk about opioid doses. And you know, what we call morphine equivalents, which is essentially supposedly the amount of opioid that mon might be taking in a given day. You know, we use these Yeah, I'll just say it, pain scores, which are absolute and complete garbage, right, we've been using pain scores for a long time, and they are trash. The reality is that pain scores have not been shown to do anything, except really probably result in probably more opiate prescribing, that's really actually what's happened as a result of them, whether it's the fifth vital sign and all that other nonsense that happened back in the day.

So what we what we look at now these days are, you know, especially me as a pain doctor, I look at function. So if I see a patient, I'm going to say, Okay, Mr. Jones, like, you know, you can walk 50 feet to your mailbox before your back starts to hurt. Okay, so now that somebody is prescribing you these two or three, you know, hydrocodone pills a day, how far can you walk? Is it 150 feet? 200 feet? Is it half a mile, whatever it is, right? I look at are you able to perform your activities of daily living? Are you able to, you know, kind of mow the grass and cook your dinner and do the walk your dog do the things that you need to do to actually get through the day. And if somebody is really not kind of achieving that level of function, like functional improvement, I kind of point that out to them, they say, look, the whole point of these medicines was to basically help you do ABCDE, f and g, but you're doing only a out of those, like seven things, right? Also, like if you tell me that your pain score without these medicines is a nine. And with these medicines, it's an eight. If you're telling me they're resulting in a 12% improvement, right? Or whatever it is, and you're getting, you know, you're you're filling your body with these things that are just kind of affecting your brain, they kind of have to think about the risks and benefits of that, right, just like any other clinical decision that we make as clinicians risk and benefit is so important to think about. A number of clinicians now are basically unfortunately, emphasizing those risks over emphasizing the benefits. And so a lot of them are tapering the opioids or discontinuing them without really kind of looking at the patient who's underneath and what they're doing on a daily basis. And they're doing that. As you said, it's not their fault, right? They're doing that in part because, you know, they want to make sure they don't fail. gonna cause harm that you first want to do no harm. And they're also getting messaging from the top, from administrators from the government from other different places saying coffee, opioids are risky, like, they're bad medicines, like, we've been telling you the wrong thing all this year. So now you have to like start aggressively cutting these things down. So patients, they get loss of function, they get withdrawal, they get, I mean, all these other kinds of unintended consequences. And oftentimes, they can't even get access to opioids, right, even when they may be indicated might be helpful in some of these more, you know, tough situations, I have a patient who's, you know, even if they are 6570 years old, yeah, of course, I'm not thrilled about the idea of putting them on, on opioid medications about really happy, but if I know that they have other medical comorbidities, that I can't do injections for them, they're not good candidates for surgery, you know, they're and they have like a pain condition that is just probably going to be with them for the rest of their lives. You know, understanding all the pharmacology and the physiological changes that happen, it doesn't necessarily mean that they can't still get benefit from opioids and enjoy their golden years. Right. But I think, you know, so many clinicians are just terrified of causing a problem, right? That, you know, it's not, I don't think it's even really like the, oh, the DEA is gonna come after me, and they're going to audit my charts, right, it's not really a significant issue. I've testified in a few cases where the DEA has actually done that, and they were pretty egregious instances of actual, like pill mills, as opposed to, you know, just regular physicians trying to do their job. So the reality is that I think they're just worried about causing a problem for these, you know, elderly patients are vulnerable, right, and they have a lot of different things going on from time. So I think that there are some concerns about that have correlated with people getting less and less medicines, the real challenge is that, you know, the data that we have, that you referenced about them being you know, potentially abusing opioids, and different things like this is really like, it presents some challenges, because we know that substance use disorders are most common, typically in populations under 30. And the reason why that is, in case you didn't know is that the brain does not fully develop, of course, until the age of 25, or 26, meaning that, you know, you're likely to make more bad decisions, you're likely to drive too fast, you're likely to do drugs, you're likely to do all those things, your likelihood of developing an addiction as much higher at that age, the likelihood of developing a true substance use disorder as you get older, it's definitely still there. Don't get me wrong, but it's substantially less than it is when you're much younger. So, you know, I think I think about it in two ways. I definitely don't want people, you know, having a problem and getting addicted to things, if I can avoid it. I'm never going to support somebody taking something and being addicted to it, but at the same time, if it's helping them with their parents, helping them with their function, if they're getting a little bit of euphoria out of it. Is that really the worst thing in the world? I don't know, I think you asked five different doctors, you probably get five different answers on that one. But that's sort of kind of what I think about the situation that we need to like, everything needs to be balanced, right painkiller needs to be individualized. Addiction care, of course, needs to be individualized as well. And we need to look at these patients in the context of their lives, as opposed to just this is a number you're 80 years old and drawn 120 morphine equivalents. What does that actually mean? Like, is there a meaningful way for me to reduce that by doing some other nonpharmacologic treatments? Or, you know, is this kind of where you are and where you're going to be for the rest of your life? And, you know, like I said, every clinician will probably answer that a little bit differently.

Dr. Regina Koepp  
I really value your perspective, as you're, you're saying, it's not all or nothing, we need to sort of evaluate each case independently. Treat each case independently, there might be benefits that can enhance functioning and quality of life, which might be the goal for many patients. You know, you were saying, and, and I get it, like physicians are kind of hamstrung. They're, they're, you know, I kind of see them as you were describing them as middle managers who have the highest levels of stress in business. You know, they're like getting information from the top, and then they are trying to help their patients and they're tied. And then there's the moral dilemma and ethical dilemma of do no harm and the in the context of an opioid epidemic, you know, it's a really challenging place to be, are there consultative supports for physicians to get like, you know, I'm thinking of just the average primary care provider has 15 minutes with a patient who, you know, is trying to do their best and don't have access to all the information that a triple boarded person such as yourself and right, has, are there consultative supports for physicians, and

Dr. Sudheer Potru  
yeah, so I mean, there are pain specialists everywhere. I mean, of course, it's easier to find them closer to major cities, right, because most physicians want to live closer to major cities if they can, but the reality is that, you know, those those support systems exist everywhere. And, you know, we, I think the number of pain fellows like so, to train to become a pain specialist. You do a four year residency, typically in either anesthesiology or physical medicine rehabilitation, or neurology actually, and then you do a one year fellowship in pain management. I will tell you one year is not nearly enough to learn everything they need to know about chronic pain, I didn't really feel comfortable as a pain specialist maybe until my fifth or sixth year out, which is just a couple of years ago. But that's really kind of where that support is, as of now. And we're expanding the number of pain fellowships every year, basically, because we know we have this dearth or scarcity of pain physician. But at the same time, a number of primary care physicians are saying, Well, look, you know, I have this resource that's in my community, everybody who's on an opioid is going to go to a pain specialist is maybe not the sort of appropriate treatment either, right? You know, it's not like, I mean, at the end of the day, a doctor is a doctor, right? You know, on some level, if you have a DEA number, you should be able to manage, you know, some level of prescription opioids in an appropriate patient who's relatively straightforward. If they're not straightforward, need help? And if they're complicated from a pain or psychological sort of standpoint, yes, you send those samples out to your mental health folks and your pain specialists and all the different things to get support. But, you know, the reality is that we are there still, I mean, it's there, but it's still not enough. And it's even the pain specialists. Now, I think there are still more of us, and there are psychiatrists out there. So a lot more of us, actually. Right. And I think that that's created Well, in certain areas anyway, the reality is that a good you know, psychiatrists, and psychologists is invaluable in taking care of patients who have chronic pain. Because, you know, there's so much psychiatric and psychological overlay with that whole bio psychosocial model that I talked about that in order to to some of these things out and get appropriate treatment, right, it's just the reality is even a pain specialist as even as good or as maybe mental health savvy, as some of them might be, are still not trained mental health professionals, right. They know how to do injections, like they know how to prescribe medication safely, and all that stuff. But you know, they're gonna have challenges. I mean, I have challenges. I'm an addiction medicine specialist. And even I don't really, really truly understand how to take care of a patient with like a borderline personality disorder, or bipolar disorder, or other different things. I'm those patients are super challenging for everyone. And they're even more challenging for somebody who doesn't have psychiatric training, or psychological training. So, you know, I those are the people often who are the highest, like health care system, utilizers, right, you know, who the frequent fliers in the emergency rooms, all these other different things, and they have so many problems, so many issues that they're tough to take care of. So, you know, that's a long way of saying, yes, there are some support systems out there. And there are like different places that you can reach out to, like, you know, they're like, you know, some of the governing bodies and pain management and addiction medicine, different things, will have complicated services like that, just you can ask them a question different things, and I'm happy to send you some links, Regina, we can maybe get some of those posted. But you know, it's it's a tough place to be in health care, taking care of taking care of patients chronic pain right now, there's just no two ways about it.

Dr. Regina Koepp  
Yeah. Just a few minutes ago, you were talking about maybe an older patient who was compliant on pain medication, maybe opioid medication, maybe a low doses for many years didn't have any struggle. And and you had started to talk about the risk of tapering. You know, there's, there's this sort of dilemma of like, do we involuntarily taper people? Do we taper people like, how forceful is it, you know, are is the system and then and then physicians acting in line with the system? So in a person who's been, you know, compliant, getting benefit, and maybe not abusing the substance? And what are the downsides of involuntarily tapering, somebody who sort of meets that criteria?

Dr. Sudheer Potru  
So there is data? And you're not gonna like hearing this? Nobody will. There's data that actually came out of the VA in 2020, showing that involuntarily tapering opioids that are improving pain and function can increase the risk of suicide? Because it makes perfect sense, right? If you have something that's a treatment that's working well, right, you have a patient who's improving, who's doing better, their urine drug screens are appropriate, you're checking their prescription drug monitoring, and they're getting all their stuff all their meds from one doctor, you know, from the same pharmacy and you know, everything looks like the way it's supposed to. And because there are a couple of things that happen if we're involuntarily tapering them, because we're being told to do it from the top or because we ourselves are scared of liability, then we're not putting the patient first, unfortunately, right. And the patient is saying, I am saying I need this medicine. It is helping me function and you are not listening to me, right? Yeah, I'm doing everything you've asked me to do. Right? I've done every I signed my contract. I did my urines I did this. I did that. I did everything you asked me to do, right? All the mitigation strategies are in place, right? harm reduction strategies are in place. But if you're still doing this, then I don't know what to say to you as a physician, right. And I've had people tell me that before they'll say This is not just you know, here in Atlanta a lot of times, even other places, like, Oh, my primary care doc, stop my meds, you know, they just said, you know, I, I didn't need them anymore. It's what they told me and I said, No, they were like helping me function, they're helped me do this, help me do that. And you know, a creates a really difficult situation for them because you know a lot for a lot of them. The reason why they have function to some extent is because they're on these meds, right, and they might not really have much otherwise, depending on the situation. So, if an elderly person, particularly who has other medical comorbidities, maybe even forget about the pain, maybe they have heart problems or lung problems, they may not be able to walk very far, they may not be able to do this, they may not be able to do that. So for them even going to the supermarket is like a big task, right, you know, picking up groceries, if they're not really able to do that, you know, without some level of alleviation of their pain, you know, it kind of presents them with this, you know, situation of, well, what am I doing? What am I still doing here? Like, why am I still living, I'm not functional, right? You know, I can't really live by myself anymore. So they lose, you know, their pain control, sometimes they lose their independence, they lose a lot of different things. And it makes them depressed naturally, just like it would make any of us depressed 30 year olds with chronic pain or super depressed because they're supposed to be young, like having the time of their lives and partying and meeting people and doing this doing that, whatever. And when they can't, I mean, they get super depressed, and it's no different than somebody who's 75 Even if they have lived a little bit longer.

Dr. Regina Koepp  
Right, right. And I think when we had prepared for this, we were talking about the the risks of involuntary withdrawal or tapering. And so one was suicide. And then and then you're you're pointing to now like worsening functional ability? And, and does it also have the effect then? So when people involuntarily taper? Are they generally bolstering with other supports, like mental health? Or, um, because I'm imagining it would then worsen pain? I mean, if they're taking the medicine for pain, and then,

Dr. Sudheer Potru  
right, I mean, the idea, of course, is to try I mean, okay, in theory, if you're going to taper somebody, opioids, you, you look at it, you look at the risk benefit, right? That's the first thing that you look at, you say, okay, is this giving you enough benefit to justify the risk that I'm taking by prescribing it to you, right, and those risks being things like respiratory depression, nausea, constipation, possibly death, obviously, in theory is always possible. So it's deemed that the risks outweigh the benefits, right? If the clinician deems that the risk is more than the benefit, then the clinician should be saying to themselves, as you correctly point out, okay, well, what else am I going to do for your pain, other than give you this particular drug, am I going to give you some other medication, and magnet send you off to therapy, or you're gonna go to your pain specialist and try to get some injections or different things? Right. You know, and I think that we, a lot of clinicians that I've worked with, are really good at taking things away, but not necessarily good at suggesting things that might be helpful, or maybe only suggesting things that might be temporarily helpful or beneficial. But I think that's where this kind of piece of, of self care and active care related to pain management comes into play and is so important. Because the longer that you expect things to be done to you to alleviate your pain, the more you're going to struggle when those things go away, right. And if you are able to kind of think about managing your pain in ways that's more sort of based on you, as opposed to based on some external factor, right, so it improves your sense of locus of control, it probably improved your sense of, you know, depression, anxiety, isolation, all those other different things, and hopefully, on some level actually improves your physical pain as well, right? I mean, but at minimum, we know it's going to the fact that you're doing something you're taking a step to do something about your pain is obviously going to make you feel better, at least on some level that you're trying and you're actively doing something as opposed to I'm just sitting on my couch, taking some pills and watching TV and just hoping I'm gonna have a reasonable day.

Dr. Regina Koepp  
Right. Right. I also think this involuntary taper, you know, involuntary means that the patient is not in agreement with the decision. Right? So, at one point, a physician said, Yes, I will prescribe this. Now the physician is saying you can't be on this anymore. And I can imagine for the patient, it would lead to a lot of mistrust in that provider. And in the healthcare system. It's like a bait and switch. Wait, wait, you prescribe this for me before? But why not? Now? When I'm actually getting benefit from Yeah.

Dr. Sudheer Potru  
So the way I look at that situation, because I have done this, I have done involuntary tapers before, because I have discovered that the risks outweigh the benefits. The reality is that if you have somebody who's prescribed opioids 15 years ago versus now right, things change, right? They're there, their pain state changes, right, their back gets worse or their knee gets worse right, their mental health state may change, they may have more depression, anxiety, whatever it might be, their body changes, right. We talked about aging already and the physiologic physiologic changes that happen with that. You know, so in that situation, they may be their tolerance may have changed, right? They may need more and more and more of these And they may be having more and more side effects and different things like that. So it's important to look at the entire clinical picture. And when I do this, when I do this for patients, I tell them, I say, Look, you know, I know that somebody has done this for you before. And I know that you don't like the idea of me taking this treatment away from you. But I'm looking at the facts here. And this is what the facts tell me, right? That ABCDE F has happened in this time, right? You know, the medication is working better for you 10 years ago, it's not really working very well for you, now, you're not able to get off the couch, you're not able to do this, you know, where I'm worried because you asked for, like, early refills several times, right? You know, so even, you know, all this stuff, when you think about it, it's not really working, it's not really helping, it makes sense for me to either taper this or change it to something else, or think about a different strategy for your pain entirely, or possibly all three of those things, right? So, you know, I think taking a look at everything comprehensively, and really looking at a patient's history is really kind of gives you what gives you a sense of what to do in that situation. But you're absolutely right. I mean, if somebody does that, without really a full and thorough explanation of why they're doing it, they're just gonna be like, This guy's, uh, you know, for lack of a better term a jerk, right, and saying, you know, he doesn't want to take care of me, he doesn't care about me, et cetera, et cetera, et cetera.

Dr. Regina Koepp  
Yeah. And then, you know, the downside to is and to get generalized to, to more of the health care system. And if you're in a population that already mistrust the health care system, you know, that could just add to the mistrust, and, and maybe withdrawal from the health care system. For other for other needs that you might have. I want to switch gears to a minute for a minute to talk about addiction. Can you define addiction? And kind of discuss a little bit about the neurobiology of addiction?

Dr. Sudheer Potru  
Absolutely. So when we look at I want to differentiate, and this is really important that a lot of people miss this. It's important to differentiate physical dependence from addiction. Right? If you talk to a layperson, they will tell you, Oh, my dad has been on pain meds for 15 years. He's addicted. Right? untrue. Well, it could be true, potentially. But the one thing I know from that one statement is that your dad is probably physically dependent on opioids, meaning that if he doesn't have an opioid he's going to withdraw, right? Addiction is specifically defined by pathologic behaviors, meaning that you are in some way messing up your life, you're screwing up your relationship with your family, you're missing out on major obligations that you have to do. Because you're busy using some substance or obtaining some substance, you're having cravings, you know, you might be having some some possibly tolerance or withdrawal symptoms and different things like this. But basically, like, it's, it's showing that the search for the substance has taken over your life, right. And that's basically how we define what we call a substance use disorder or SUD, where you can basically you can call that an opioid use disorder, or cocaine use disorder, or cannabis use disorder, alcohol use disorder, etc, anything kind of fits into those categories. So the neurobiology of it, essentially, is that so we as little babies, every time we start to do something that kind of advances our development, we get release of dopamine in our brains, right to basically make us do that gives us euphoria, and rewards us for doing the things that we're supposed to do. As we get a little bit older, we a dopamine release in our brains for doing life sustaining activities, things like eating, eating, drinking, peeing, pooping orgasming, we have sex, the idea of evolutionarily speaking to continue our reproduction, stuff like this. So the problem is the dopamine release that you get from these regular everyday life sustaining activities, is not nearly as much as you get from using illicit substance. Right. So if we think that, you know, your dopamine release from eating a meal is x, we think that, at least in rats, anyway, it's around 2x. And we think that if you have sex at a sex interact with around to x, we think that using amphetamines, probably about 10 to 12x. Heroin fentanyl, probably in the range of, I don't know, let's say 20 to 25x. You know, it's it's pretty crazy the amount of dopamine release that you actually get from some of these other illicit substances, which means that basically, what it does is it hijacks your brain, right? And says, Okay, well, I need this reward, I need this euphoria. And basically, you go after it and try to get it. The difference is that addiction doesn't develop in everyone, right? It only develops in some people. So because not everybody who drinks alcohol gets addicted to alcohol. So basically, the risk factors are, you have to think about genetics, right? So if you have a first degree relative who has some kind of addiction or substance use disorder, you are likely to developing it is like 40 to 60% higher then of course, there's all the various psychological factors associated with it, right? You have like, you know, poor socioeconomic status, like history of trauma, depression, anxiety, different things like that mental health issues. And then of course, exposure to a drug, you have to be exposed to a drug to ultimately become addicted to it. And there are a whole lot of other things that I could talk about, but essentially That's sort of the long and short of it. And obviously, like I mentioned before, the younger you are like, if you're a teenager or young adult in your early 20s, or maybe in your mid to late 20s, as well, you know, you're much more vulnerable to addiction at that time period, just because your brain is still developing the frontal lobe, which is in charge of executive planning and function, judgment, all that kind of stuff is not fully developed. And it really is only probably fully developed, maybe, like, by the time you're 30 years old, or so. So, you know, these are all important considerations to think of in the population.

Dr. Regina Koepp  
Now, I appreciate so much the distinction between the physical dependence versus addiction, that they're different things. Do they shift brain structure? In the same way? Um,

Dr. Sudheer Potru  
no. So physical dependence, as far as we understand at this point, it affects tolerance, right? You get tolerance and withdrawal symptoms as a result of physical dependence, but addiction actually rewires your brain. And I'll explain. So there's a really nice study that Nora Volkow, who's the head of NIDA did a couple years ago, where they took people who use cocaine, right, they had been sober for actually quite a long time. And what they did is instead of giving them cocaine, they show them pictures of cocaine. And when they did functional MRI studies, the reward centers in their brains lit up like Christmas trees. So the fact is, even though they had been away from using an illicit drug for so long, right, when they saw it, it's still that just seeing it gave them euphoria, it just gave them that sort of sensation of Oh my God, I feel amazing, kind of like when you see a picture of a piece of cake, right? And you're like, Oh, my God, I really want that cake and your brain feels really happy. All of a sudden, you feel good when you see that picture of cake, or when you see a cake on a plate sitting in front of you. It's literally exactly the same thing, right? So your brain has rewired in a different way. If you have a sweet tooth, or if you have a cocaine addiction, unfortunately.

Dr. Regina Koepp  
I was reading a New York Times opinion piece this past couple of weeks ago, and it was a physician who had was in recovery, was talking about that he did not believe that addiction was a disease. And I'm curious what your take is, is addiction a disease?

Dr. Sudheer Potru  
Absolutely this and if you ask the American Society of Addiction Medicine, every definition they have had, I think from 2005, moving forward, called addiction to chronic disease. And the reason why we know it's a chronic disease is because it relapses and remits. Right, there are patients who relapse, right, who do well for a really long time. And then they have a bad day, they have a bad week, they have a bad month, they meet somebody they haven't met in a long time, it's a trigger, whatever it is, and they go back. So addiction is not just a disease, but it's a chronic disease, right. And that's really important. When we think about how we treat high blood pressure and diabetes, which are chronic diseases, right? These diseases require lifetime long term management, with therapy with lifestyle changes with medications, sometimes, right, all three of those things. And so addiction requires also kind of a comprehensive approach to treatment, which unfortunately, is just not really particularly well funded in our country right now, really, not really well funded across the world, to be totally honest. And so that's why a lot of these patients, that's why you see a number of people relapse, they just don't have the framework that they really need to get the treatment that they need to prevent themselves from relapsing. But the nice thing is, which is really good. And I was actually just reading article about this yesterday, is that about 75%? We think anyway, this is all epidemiologic studies, we think that about 75% of patients who develop a substance use disorder actually do recover over time, that's like typically, sometimes it takes a long time, like typically eight to 10 years for a number of people. But depending on how it goes to this, some of them actually do much better, you know, they go on to, to live their lives in more meaningful ways can interact with society more meaningfully. And that's actually one of the interesting things about some of these medications, right. So I've had some patients who have put on Suboxone, and I've literally watched their lives just turn around, right, you know, if they went from, you know, being so focused on only a drug to, you know, reconciling with their families and getting their jobs back and, you know, finding a place to live and doing all these things, it's pretty, it's pretty incredible to watch that like sort of turnaround and that change. Because when I work, you know, that's why I really love some of the work I do in the addiction space because in the chronic pain space, a lot of times I do an injection, somebody's got you know, 20% improvement or 40% improvement, like they still can't go back to doing a lot of things that they want us to do but in addiction that's it's one of the things that really makes treating addiction worthwhile. It's just watching people go back reclaim their lives to become productive members of society and, you know, really kind of just improved their whole situation.

Dr. Regina Koepp  
I'm thinking, what a message of hope, you know, there's a dark dark shadow side to addiction disorders and, and all the fallout and I know my family there's a lot of struggle and I've worked with a lot of my own clients and patients with who struggled for years and years and decades, I have to tell you city are one of my, the things I love most about being a psychologist are stories of redemption. And, and to me, it is the most unreligious spiritual experience I have that I get to kind of walk alongside my clients. You know, a lot of times I work with people for like a decade, I'm patients I've worked with for 10 years. And to get to a place like to be in the dark spaces with our patients, and then to be there alongside of them through all the struggle. And I I'll tell you, you know, anybody who specializes in works in addiction knows that that struggle can last a long, long time, with a lot of tragedy and trauma and pain in families and beyond. And then just this message of hope that it's possible to reclaim and redeem your life is so powerful. So just that it just, I'm left with so much hope with that this conversation. So thank you. Um, I have a couple of other questions. So say somebody with a say somebody has a chronic pain condition, and an addictive disorder, or an Addiction Disorder? How do I say Addiction Disorder, substance use? Disorder? How do you treat them for pain?

Dr. Sudheer Potru  
Hmm. It's complicated. So the first thing you do is, so you look at what they've already done, right? You look at their whatever their underlying pain pathology is, you look at, if they have mental health pathologies, you look at those, right? You look at their function, and you see what treatments they've had in the past, whether those have been medications, whether those have been, you know, therapy, whether whatever the situation might be. And you sit down with them, it takes a while. And you calmly explain to them, that prescribing things that are controlled substances that have addiction potential, has the potential to actually make their lives much worse. But it's also very important to think about where they are in their addiction journey. Right, if they are recently diagnosed, newly diagnosed, you know, their risk of of relapsing is very, very high, as opposed to if they've been in remission, you know, for a couple of decades, it kind of changes the options that you have, right. So I have patients who previously did have histories of opioid use disorder that's remote within 2030 years ago, they used to inject heroin, back in the day. And some of them I actually am managing on some Lotus prescription opioids for their chronic pain, and they're actually doing really well. I watch them a little bit more closely than I do my other patients, you know, who who don't have an IUD? Right. But, you know, I want to be i I'm very clear that you know, there any issues or any considerations, I'll have to think about changing Minister stopping it or whatever it might be? Not something I'd like to do very often, but every once in a while, you know, it's it's, it's appropriate. You know, I think in terms of thinking about the one that really presents a lot of issues is actually not even necessarily opioid use disorder, but actually, alcohol use disorder. So I think that, you know, obviously, the best case scenario for those patients who do have chronic pain and an STD is to really think about try to try to use any non pharmacologic means that you can. So whether that means like a, something like a physical therapy, chiropractic treatments, acupuncture injections, you know, different things like that are more likely to be a benefit. But I think, again, that piece that I keep going back to about that active self care, I think it's something that cannot be understated in this very, very complex, challenging population. Because if you can actually get them to do that, you can get a lot of things to improve, whether it's their pain, their mental health condition, whatever it might be. But, you know, obviously, maximizing all non pharmacologic treatment that you can use, you know, doing, you know, anti inflammatories, Tylenol is different things like this are like to be effective topical treatments, like various gels, ointments, patches, different things like this can be useful. And that's pretty much the way that I approached them. And I explained to them, you know, I look at their addiction history, like I said, and I say, you know, is it reasonable to consider doing some of these things, you know, based on what you had done previously, or maybe based on what you're doing right now, sometimes the answer is yes, sometimes the answer is no. And again, you have to individualize care of each patient just like you would do with chronic pain in general.

Dr. Regina Koepp  
Yeah. And to your point about alcohol use it is the most commonly used substance right and most common substance use disorder.

Dr. Sudheer Potru  
Yeah. About 80%, of substance use disorders in the United States are alcohol. Which makes sense, right? It's very, very commonly used as legal. So people use it. Oh, yeah, very, very available.

Dr. Regina Koepp  
Yeah. One final question. So a therapist is navigating care for an older adults living with chronic pain and possible substance use abuse or dependence. Oh, what would you recommend to therapists or mental health providers, senior care providers who are working with older adults who might have chronic pain and substance use, abuse or dependence?

Dr. Sudheer Potru  
I think the most important thing is to try to tease out that diagnosis if you if you can, which I mean takes time and takes effort and getting those people to the getting the resources that they need, getting them to the right place, whether that's an addiction medicine specialist, whether it's a pain specialist, whether it's both right, thinking about that, in that context is really critical, because managing that patient on your own. Even just for me, as a pain specialist, I mean, I feel pretty qualified to manage most patients who have pain in addiction, but I definitely don't feel qualified to manage the mental health aspects of certain things that they're dealing with. The reality is that we all have to play our part, right, we all have to collaborate in the Caribbean patients. But I think the most important thing is to make them realize that when you when you send out these referrals, or when you get them you let their primary care doctor know what you think is going on, to make it clear that you know, you're not going to abandon them, right to make it clear that you know, they're going to be supported right in this entire process. Because a lot of times chronic pain patients, I mean, are just so marginalized, right? They're marginalized at the five different specialists they've seen, who said, you don't have a problem, get out of here, go talk to somebody else. They've marginalized at the pharmacy, when they tried to sell their medication, they're marginalized at home with their families who can't see the issues that they're dealing with, are saying what the hell's wrong with you? Like, why can't you get up and get to work and do this, they're marginalized by their peers, they're marginalized by so many different people, right? And I think that, for them having a therapeutic ally, and a therapist is actually so important, right? Because they're, they're dealing with rejection, and with this marginalization from so many other areas, that just having a couple of relevant therapeutic alliances may be enough. You know, I've seen so many patients where I sit down and talk to them for like, 20 minutes, 25 minutes, because I'm at the VA, I have a little bit more time. They say, Doctor, you're the first you're the first person who's really actually addressed these issues with me and really listened to me, you're the first person Listen to me in like, 10 years that I've been dealing with this condition. And you know, I think being in the therapy space, you know, obviously, you guys have a unique role to be able to sort of do that, and you know, it, I'm not gonna lie, it is tough listening to people in pain all day long, it is not an easy thing to do. And, you know, Dr. Steiner, and I have talked about this before as well. But the reality is that, like, you know, you are actually making a tremendous difference in people's lives. And they may not they may not even vocalize it at the time, they may not even realize it until later. But, you know, just hearing that they have somebody who's on their side, who's listening to them, who's interested in their well being, because, you know, and who has the time to actually sit down and listen to them is so, so, so important. So I think those are the two things basically developing that alliance and getting them to to the specialists that at least may be able to provide an opinion or offer some sort of assistance, even if they're not actually taking care of the full problem.

Dr. Regina Koepp  
Yes. And this message of not abandoning and not contributing to that marginalization, is really paramount. Absolutely. Thank you so much for being here and giving us a really clear and helpful information, kind of, I feel like we've emerged in this conversation from the fog of the opioid and COVID epidemics and pandemics and, and that there's, you're sort of leaving us with a message of hope and action, that even walking alongside and not abandoning and supporting and, and maintaining an alliance and relationship can be so incredibly powerful in the, in the healing journey. And healing doesn't have to mean no more pain, right?

Dr. Sudheer Potru  
Exactly. You know, one of the things I've definitely realized is that the rapport that you develop with somebody, once you develop rapport, you can do anything and everything to them, and they will like happily go along with it. Once they trust you. There'll be like Doc, just to me anyway, they'll be like, Doc, do whatever you need to do and you do an injection do it, you need to do this, that do whatever it is do it. And I think that building that trust in that rapport is ultimately as you said, so so critical and helping manage their overall conditions for sure. So, thank you again for having me. This has been a wonderful experience, great conversation for sure.