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38 SPOTLIGHT ON OPIOID EPIDEMIC Treating Pain Amid the Opioid Epidemic: 4 Questions With University of Tennessee Medical Center's CMO By Brian Zimmerman K nox County, Tenn., home to University of Tennessee Medical Center, tallied 118 deaths related to opioid overdoses in the first seven months of 2016. As UTMC is positioned in an area of the country hard hit by the opioid epidemic, the hospital addresses patient pain in a unique fashion, emphasizing multimodal analgesics and pro- tocols designed to identify drug dependence in patients. Jerry Epps, MD, was named CMO of UT Medical Center in April. With a clinical focus on pediatric and cardiology anesthesia, Dr. Epps has been practicing anesthesia in the state of Tennessee for nearly 30 years. In that time, he's witnessed the rise of the opioid epidemic first hand. In 2014, opioid overdose deaths in Tennessee reached a record high of 1,263, according to the Tennessee Department of Health. Dr. Epps spoke with Becker's about pain treatment at UT Medical Cen- ter and issues pertaining to the opioid epidemic. Note: Responses have been lightly edited for length and clarity. Question: Has UT Medical Center experienced an increase in treating individuals suffering from opioid addiction? Dr. Epps: Yes, there is no question. In Tennessee, we also have the prob- lem of poor behavioral health services. So these services are a limited resource for our institution. We have patients who are in the thralls of drug abuse who do get help and are on a treatment plan to combat ad- diction with medications like buprenorphine, naloxone or Suboxone, a combination of the two. Only certain physicians are certified to pre- scribe those drugs, so we coordinate with the medical director of Cher- okee Health [headquartered in Knoxville] because they have physicians with the certification to prescribe these medications. We also treat preg- nant women who are on these medications, so we have to coordinate care across our two institutions. Q: What role do you feel the patient's expectation of pain plays in the opioid epidemic? How does the Pain Manage- ment Pathway at UT Medical Center address patient expec- tations? JE: Our pain pathways are both specific pathways for the patient and are also a standardization of procedures across the system. We start with assessing the baseline pain, or where the patient's pain starts when they come through the door. Assessment of baseline pain establishes the true goal of analgesic control in the hospital setting. We have an escalation process to address patient concerns, so for the patients who have chron- ic pain who don't feel that their pain is being addressed, we do have an outside source who can come in and conduct an evaluation. Also, our pain pathways encourage the use of nonnarcotic medication especially as it pertains to neuropathic pain, or chronic pain, pain is coming from the nerves themselves. Historically we've always used a pain scale, in which patients rate their pain by numbers 1 to 10. e problem is a patient comes in the estab- lished pain was eight, the patient expects it to go to zero, the providers' expectation is we are not going to get their chronic pain down to zero. We're trying to move away from the scale and focus instead on function. We can say to the patient "we want you to get up and walk aer this pro- cedure." We want to focus on a patient's functional ability and get the pain under control as opposed to just focusing on a number. Built into our pathways are red flags designed to signal to nurses and caregivers when the cause of the pain is not being treated appropriately. If the pain is outside the expected location, if it is in excess or out of pro- portion for the type of injury, or if a nurse's intuition or gestalt is telling them something is off, then this will prompt a reexamination of the pain. An experienced nurse can tell something just is not right. Q: The DEA recently reduced opioid manufacturing quotas by 25 percent. How helpful do you think recent actions tak- en by the federal government will be in curbing the rates of opioid abuse? JE: It's really too little too late. If this had happened 10 to 15 years ago when the epidemic was surging, I might have a different answer. In 2013, the DEA allowed manufactures to increase opioid production by 25 per- cent because they thought there was going to be shortage. e new reduc- tion still puts us above where we were in 2010 and 2012. Tennessee Gov. Bill Haslam and his task force have greatly diminished the number of pills being prescribed [in Tennessee], but we're still see- ing deaths. We know when the number of prescriptions diminishes, pa- tients are switching to illicit drugs as opposed to illicitly obtained pre- scription narcotics. We're continuing to see high rates of heroin deaths and deaths due to narcotics being manufactured in other parts of the world. Fentanyl, the most commonly used pain control medication in surgery and anesthesia, is being manufactured in South America, Mex- ico and China. ese fentanyl pills are designed to look like oxycodone and there have been a slate of deaths related to these drugs. Carefentil is being made to look like medication that resembles oxycodone. Care- fentil was designed to be used to tranquilize large animals such as ele- phants and is extremely potent. I don't think the DEA's efforts are going to make that much difference at all. Q: In your opinion, what is the future of pain management going to look like? JE: e big difference now is identifying whether the patient has neuro- pathic pain or acute pain, and finding a way to incorporate multimod- al nonnarcotic pain medication. e use of preemptive analgesia will continue to increase. is process can block the nerve impulse of pain from reaching the brain and the pain can be greatly diminished. We'll also see an increase in use of medications like gabapentin [a nerve pain medication] to treat neuropathic pain. From the physician prescribing side, there's going to be even more attempts to make sure that the pills prescribed will be limited in number. We're seeing evidence that physicians are starting to decrease the number of pills pre- scribed. Pill mills are dramatically decreasing across the South. If you would have asked us [physicians] in the past if a patient is given a limited number of pills, would that patient likely become addicted to narcotics aer one procedure, most of us would have probably said no. Now we know a significant amount of people who are opioid naive who get one prescription of narcotics are still taking them a year later. at fact changes the physician perspective of treating pain with narcotics. Additionally, about half the people we prescribe narcotics to don't take the full prescription. When pills tend to lie around the house, improper use is more likely to occur. On the cutting edge of things, we have what we described as pharmacoge- netics. What we have recognized is that there are certain genes that predict addiction tendencies. Individuals reacted differently to medications. For example, codeine must be metabolized in the liver but 10 to 12 percent of Caucasians cannot metabolize it at all, which renders the medication inef- fective. Now we can do a swab inside of your cheek and get your DNA and discover if you have addictive indicators in your DNA and how you process narcotics. Going forward, I imagine we will prescribe medicine based on individual DNA makeup. n