Dr. James McFerrin talks about the effects of the opioid crisis on chronic pain clients and outlines treatment options and considerations.
Rosemary Cope: Welcome to this edition of the Vanderbilt Health and Wellness wellcast. I'm Rosemary Cope with Work/Life Connections. Our guest today is Dr. James McFerrin, who is a consulting psychiatrist with Work/Life Connections and an Assistant Professor in the Department of Psychiatry. He is a member of the American Psychiatric Association and The American Society of Addiction Medicine. Chronic pain changes lives and it is estimated that about 100 million people deal with it. It impacts self-image. It affects others. It interrupts plans. It is a disease that sometimes the person living with doesn't even understand and others don't accept. Being bedridden one day but unimpaired the next can be difficult to explain. Dr. McFerrin, we hear so much about the opioid crisis these days. How is it affecting those with chronic pain?
Dr. James McFerrin: Thank you, Rosemary, and it's always a pleasure to work with you. I have been in private practice and worked with university and academic and other settings for over 30 years as a psychiatrist. First, I would like to say I am not a pain management specialist; however, as an M.D., I see all sorts of disorders, emotional, psychological, and certainly physical, and chronic pain in, I would say the last 12-15 years has emerged as a huge problem in our society, and now with opiates and dealing with the opioid crisis, which I think most everyone has heard of that, has become really a top-drawer issue for all of us who are practicing. So, let me start with chronic pain. Then, I'm going to put you on the spot.
Rosemary Cope: Okay.
Dr. James McFerrin: First, there are multiple overlapping causes of pain in the same physical location. So, when a person has a symptom, first, we have to identify to understand the combination of pain states and what are the mechanisms that cause pain. So, as a physician, I always want to pursue the cause before I start the treatment, not just throw things on the wall and see if something works and something doesn't. We do like to be scientific or quasi-scientific about it. Fortunately, we have a lot of research now and we have some government guidelines that help us. In other words, I want to reference the TMA website. TMA stands for Tennessee Medical Association, and whenever we go online, be sure the website is reputable or credible, and that, number one, they are not trying to sell you something, and number two, they are not trying to treat you. So, why is this a problem in Tennessee? What has changed from your standpoint from what you understand?
Rosemary Cope: I think that sometimes there is an ease of getting these medications that wasn't there before, there are more choices now, and people are also a little more savvy about options that are available to them to treat pain, whether it is through print media, something they have heard on the radio or T.V., or even a friend.
Dr. James McFerrin: And we are a global society. We are a national influence of media, of resources. You can get most any drug you want online from China. These are daunting issues. But what about Tennessee? Let me give you a few statistics and then I won't bore you too long with this, but in 2017, Tennessee ranked in the top 10% per capita prescription rate for opioids in the U.S. What does that mean? That means 90% of the states had fewer prescriptions written per-person than in Tennessee. Hey, we are at the top, and we don't want to be at the top of a survey like this. The unintentional overdose deaths increased to 1,776. Just a year earlier, in 2016, there were 1,631. So, although fewer prescriptions or amounts were written, we had an increase in deaths. Now, how does this compare to other sorts of deaths? Talk about motor vehicle accidents, homicide, or suicide. Add all of those together and there were more unintentional overdose deaths from opiates. Oh, my gosh! That really gets my attention.
Rosemary Cope: Absolutely.
Dr. James McFerrin: One hundred sixteen million U.S. adults, more than the numbers affected by heart disease, diabetes, cancer, adding all those together, have some form of chronic pain. Now, I am not saying everybody is addicted, but pain is a huge, huge issue. That's about one in four. So, I am getting a little older. You know, my knee hurts after I play tennis or, you know, back or neck pain. So, I can take a pill and immediately it goes away, or I feel better, or it gives me more energy, but is that really the best plan, and it's an insidious thing. Substance abuse, I always consider when I am teaching residents at Vanderbilt, it's not about bad people, but it's about a bad disease, and sometimes we make choices that are not the best for us. So, Rosemary, here you are. You came into me, I'm your doctor, and you have a pain problem. Well, tell me about your knee. What did you do to your knee?
Rosemary Cope: You know, I've had problems with it over and over and over again. I used to play tennis like you and there was a lot of wear and tear and now I think I've torn the meniscus and I just have a lot of pain, almost all the time.
Dr. James McFerrin: Oh, okay. So, you hurt it, and did it get better for a while?
Rosemary Cope: A little bit.
Dr. James McFerrin: Oh, okay, and then what did you do?
Rosemary Cope: I started using it more because it felt better.
Dr. James McFerrin: Oh, okay. But it got better for a while? But now it's chronic. It's kind of there all the time.
Rosemary Cope: Right.
Dr. James McFerrin: Okay. So, what kind of pain do you have? So, I'm a doctor and I'm supposed to be scientific. Let's break the pain state down into four different areas. So, I'll use some terminology, but then I'll explain it, too, because I don't always understand this terminology. We say "nociceptive." In other words, there's a noxious insult, a mechanical/thermochemical ... you burned it, you fell on it, you stretched it. You said you tore the meniscus. So, you did something acute. So, we know that you hurt that part of your body. The next one is "inflammatory." Well, what did you do? You got better or you took a little aspirin or you took naproxen or something?
Rosemary Cope: I took some naproxen.
Dr. James McFerrin: Naproxen. I like that one. It doesn't hurt my stomach.
Rosemary Cope: Right.
Dr. James McFerrin: And it got better and then it flared up again.
Rosemary Cope: Yes.
Dr. James McFerrin: So, that's inflammatory. So, that's a different type. What about me when I lifted and cleaned out the garage and carried those boxes and then I hurt my back? Well, that's called "neuropathic." That has to do with the nerves. So, I pulled something or collapsed a disk or did something, so it's nerve damage. That's the third type. And the last would be, oh, you walked in kind of funny - what's wrong, Rosemary? What did you do? Well, nothing that you know of?
Rosemary Cope: No. I'm just walking and all of the sudden, I have this horrible pain now and it won't stop.
Dr. James McFerrin: Okay. Well, we took an x-ray and there's nothing wrong with the bones. Let's do an MRI. No, it's totally normal. Oh, you're just making that up.
Rosemary Cope: No, but it hurts.
Dr. James McFerrin: Well, I can't find anything wrong with it. We've got all of these really sophisticated tests. Sometimes there's dysfunction and it happens and we can't find the cause. We call it "dysfunctional" or we call it "centralized." Sometimes it's in the brain. It's a pain sensation in the brain. So, I've been really scientific. I've showed you all my knowledge and all that schooling. I've got four pain states. What am I going to do with that? Okay. Well, here's some opiates and you're fine. That'll get you out of my hair and I won't have to worry about you until you call in three days later and want a prescription. Well, I say that because you ought to take my license away if I do that. I need to find out what kind of pain it is of these four types and I need to follow guidelines. As of 2017/2018, the state of Tennessee has led the nation in the guidelines in helping us understand and know how to prescribe effectively. Not always the opiates, sometimes the NSAIDs ... I might send you for physical therapy. You might do acupuncture. Do you believe in acupuncture?
Rosemary Cope: I haven't tried it yet.
Dr. James McFerrin: Well, you know, the insurance companies do. About 15 years ago, they said this really works. Acupuncture sometimes is very good. There's even ... I know you work as a psychologist. Even therapy sometimes help diminish or manage pain symptoms, pain perceptions. So, there are a number of treatments and we will talk about that. So, what about the guidelines from the State? I'll just say that I don't need the government to step in and tell me how to manage pain. That makes me angry. I'm a doctor. I went to school.
Rosemary Cope: You ought to know what you're doing, right?
Dr. James McFerrin: I should. And you know what? The government has stepped in and it has helped tremendously. It is starting to help. We have guidelines that are proven. There are many studies and research projects that show this helps us manage the pain effectively and appropriately, sometimes better than just prescribing opiates. So, we have ... I encourage you, since our time may be running short, you know, look on the websites and see that there are many ways to manage pain. There are many ways to document and discover what type of pain responds best to whatever type of treatment.
Rosemary Cope: And so, what I'm really hearing you say, Dr. McFerrin, is that it isn't all about, "I have a feeling, I'm in pain, and there's a pill for it, and that's all there is," but we have lots of choices, and people with chronic pain aren't just locked into a certain way of treatment.
Dr. James McFerrin: In fact, I would ask that you look at the website, if you are really interested in this, to find the non-opiate treatments for chronic pain and it tells you there are a lot of medications and some other therapies that work. There's also a checklist for using opiates and how to use them. I won't go into what doctors need to do, but we have to go on a website and we have to look up what is being prescribed, what has been prescribed, and make sure it's safe, that's it's the right amount, and we are held to task for that. That is a good thing, that physicians, providers, nurse practitioners, we have to do our job not to make this worse, to turn this around in a reasonable period of time and make sure the best treatment for the best relief of pain.
Rosemary Cope: Well, thank you so much for your insight into this and that's really appreciated because people need to know that there are options available to them.