What You Need to Know about Opioids with Dr. Richard Rosenquist

Podcast Transcript

Nada Youssef: Hi. Thank you for joining us. I'm your host, Nada Youssef, and today we are talking opioids. So please put in your questions in the comment section below, and we'll read them here live as we go along. And today, our featured expert is Dr. Richard Rosenquistosenquist, Chair of the Department of Pain Management at the Anesthesiology Institute here at Cleveland Clinic. Thank you so much for being here today. 

Dr. Richard Rosenquist: Thank you for the opportunity. 

Nada Youssef: Great. And can you just introduce yourself a little bit to our viewers so they know a little bit more about you?

Dr. Richard Rosenquist: Sure. I'm an anesthesiologist by primary training and a pain management specialist by subsequent training. I've been here at Cleveland Clinic for six and a half years, and I've been practicing pain medicine for the last 30 years. 

Nada Youssef: Great. So what kind of patients come to see you?

Dr. Richard Rosenquist: I see a wide variety of patients, from people who come in with very, very common things like low back pain to those who come in with cancer pain or other more unusual diagnoses such as complex regional pain syndrome or postsurgical pain syndrome, so it's just some examples. 

Nada Youssef: Great, great. Thank you. Okay, and as always, please remember this is for informational purposes only, and it's not intended to replace your own physician's advice. I want to start with just a very general question. What specific drugs are considered opioids?

Dr. Richard Rosenquist: The drugs that people are most familiar with are things like morphine. Other drugs that are commonly prescribed after surgery, like hydrocodone, or the trade name is Vicodin, things like Percocet, which is oxycodone, or things like Dilaudid, which are hydromorphone. There are others, but those are the most common. 

Nada Youssef: Those are the most common ones? Great. And to get a little bit scientific, what exactly does an opioid do to the human body?

Dr. Richard Rosenquist: There are lots of things that the opioids do to the human body. The most common thing that people associate opioids with is to actually take an opioid and have it interact with a portion of the brain that decreases our responsiveness to pain signals, either existing or things that are going to come our way. 

Nada Youssef: Okay. So short term, that works. Long term for chronic users, is there a negative effect for long-term users?

Dr. Richard Rosenquist: There are many complications that are associated with using opioids long term. The most common things people experience are things like constipation, sometimes nausea, or sedation. But from a long-term standpoint, what we initially thought, "Well, this is great. We're going to give them medicine. We're just going to treat chronic pain," didn't turn out the way we thought it was, and we didn't have the scientific evidence many years ago. But along the way, people have learned a lot about narcotic pain medications. One of the things that narcotics do is they actually cause the nervous system to be inflammed, and so they can actually act like a rheostat and in the chronic setting make people have more pain for a given stimulus than they would if they never were taking the opioid pain medication. So there are things we've learned now that we never knew in the beginning, and they turn into complications that we never anticipated. 

Nada Youssef: And we're starting to see the effects now. Okay. Thank you so much for that. I'm going to start reading off some live questions that we're getting, as well as some presubmitted ones. 

Dr. Richard Rosenquist: Sure. 

Nada Youssef: I want to start with Annabelle. Are there safe alternatives to opioids?

Dr. Richard Rosenquist: Sure. When we look at pain medications, it depends on what you're using them for. So for example, if you're having surgery. Let's say that you're having surgery on a knee or an ankle. There are nerve blocks that can be done as part of your surgical experience to give you pain relief afterwards to minimize your need for narcotic pain medications during that acute postsurgical phase and then transition to other things like nonsteroidal antiinflammatory drugs or using drugs that are normally used for seizures as a way to help control pain medication as well. 
In the chronic pain setting, we try to make a diagnosis. So for example, if somebody has diabetic neuropathy in which they have painful nerves from damage related to their diabetes, we'll often time use an antiseizure medicine or some of the antidepressant medicines because they've been proven to have good effect in helping to relieve that pain. Sometimes in the chronic setting, the best we can hope for is to dial the volume down, in a sense, because I can't make the diabetes go away or can't make 20 years of diabetic neuropathy go away, but I may be able to turn the volume down so that they have less pain every day or less pain when they're trying to sleep at night. 

Nada Youssef: Okay, great. Now, are opioids ever prescribed for anything besides pain?

Dr. Richard Rosenquist: Rarely, if ever. 

Nada Youssef: Okay. Okay. Good to know. I'm going to jump onto Lana. What is the difference between dependence and addiction?

Dr. Richard Rosenquist: Everybody who takes opioids for a period of time is going to develop physical dependence. That means that if we suddenly stop the medicine, you will go through the physiologic process of withdrawal. You'll have diarrhea. You'll have gooseflesh, the "cold turkey" that they talk about. It doesn't matter. The difference between addiction and dependence is that the person who's addicted is going to do whatever it is, regardless of the consequence, to get more of that drug, whether it's lie, cheat, steal, whatever, right? Take somebody else's meds, whatever. They're going to do whatever it takes to get more medicine, right? Even if they're going to be in trouble, or lose their job, or whatever. That's the addiction. 

Nada Youssef: Okay. This is very good information. Thank you. And on to Howard. I got prescribed an opioid after my surgery. How soon should I stop using it before they start having a negative effect on me?

Dr. Richard Rosenquist: As soon as you can convert to something that is not opioid is when you should stop. So for some people, that's two pills. For some people, that's a week. But we know from statistics that have been gathered now nationally that the longer you're exposed to narcotic pain medications, the higher the risk that you're going to become dependent on them. So in March, the Centers for Disease Control published a look at national statistics, and they said that in general, if you're exposed to narcotic pain medications or opioids for eight days, there's about a 12% chance you're going to be on them a year later. If you're exposed to them for 30 or more days, there's a 29.9% chance that you're going to be on them a year later. So the risks, even with relatively short-term exposure, are much higher than we ever would've anticipated. 

Nada Youssef: Sure. And now you said it affects everybody differently, so with some people it will be three days, somebody eight days. 

Dr. Richard Rosenquist: Certainly. 

Nada Youssef: Are there any red flags that people should be looking out for or watching out for to know when it should be time to stop?

Dr. Richard Rosenquist: It's not so much that you get a red flag that says I should stop, but if you're still taking the medications long after the period of expected healing, you can't imagine a day going by where you don't take the medication, then you should be reevaluated and say, "Why am I still having the pain at this point? Is the medicine that I'm taking contributing to the pain? Is there something wrong with the healing that's going on, or do I need help to walk off of these medications?" And sometimes even very legitimate use can turn into a degree of physical dependence, and even at relatively small doses. Your body goes through this, "I don't feel quite right without it," until you get several days beyond it, and that could even be somebody who's taking one tablet a day. If you try to stop that, they feel crummy for a period of time. 

Nada Youssef: Things start to change. Okay. Thank you. And then we have Peter. If I have a history of addiction, will I be subscribed something different than someone without addiction in their history?

Dr. Richard Rosenquist: It depends under what setting. We have people who come in, and they're addicted. And let's say that they have a planned surgical procedure. You're coming in for a planned total knee replacement, and you have a history of addiction, and you've been treated, and you've been in Narcotics Anonymous for a period of time, and you're clean. You've established care with an addiction specialist. Sometimes even a small exposure can put someone at risk for having recurrence of falling back to old habits, so ideally you would talk to the surgeon and the team preoperatively, and you develop a plan that would be as heavily based on nonnarcotic medications as possible. They might give you very short-term medications and then rapidly walk you off using other pain medications to help minimize your exposure and your risk of recurrence. 

Nada Youssef: So we're customizing it per patient with [crosstalk 00:09:15] history. 

Dr. Richard Rosenquist: Ideally. 

Nada Youssef: Okay, great. And then we have Robin. What does Tramadol do besides keep me awake at night? I need a knee replacement. 

Dr. Richard Rosenquist: Tramadol is also a narcotic-type pain medication. It's on the weaker end of the pain medications that are out there, so if it's really not doing anything other than keeping you awake at night, maybe you should go back and talk with your physician and see if something else can be prescribed or developed to help control your pain so you can sleep at night as you get ready for your knee replacement. 

Nada Youssef: Good to know. Jumping on to Brittany. What is a common treatment to manage fibromyalgia pain?

Dr. Richard Rosenquist: The most common approaches to treating fibromyalgia are going to be involving aerobic exercise program. There are FDA-approved medications such as Cymbalta and Savella, Lyrica, Gabapentin, that have indications to help control the kind of widespread pain you see in fibromyalgia. There are other things like mindfulness-based stress reduction, aquatherapy programs, and others. Typically you're trying to make sure there's not something else going on and then helping to control the symptoms. The cornerstone is really a physical activity type of program along with psychological support, and we have a shared medical appointment that is a joint effort between the Neurological Institute, the Anesthesiology Institute, and the Rheumatology Institute that involves different providers coming in to provide education and treatment approaches for bigger groups of patients at the same time. 

Nada Youssef: Great. That's excellent to know. Thank you. I have ... let's see ... Karen. What are the best options for treating the pain of osteoarthritis, or are there better options these days for treatments of the condition?

Dr. Richard Rosenquist: Osteoarthritis is one that, to the extent that we can do something that helps minimize the complications or the progression of the disease, so that if somebody has inflammation of the joints and there's no contraindication to using a nonsteroidal antiinflammatory drug, those would be good choices as a primary approach. And whether it be an oral agent or a topical agent, there are different ways to try to do that. If people are heavy, losing weight helps to reduce the impact with every step. The general math is that for every pound you're overweight, when you take a step, you increase the force on your knee by about four pounds, so it really makes a difference in terms of trying to keep your weight down. And then doing other exercise programs that help maintain the muscular strength around the joints. And if your knees hurt a lot, many times an aquatherapy program allows people to exercise without having the pain from the arthritis.

Nada Youssef: And that's because the pressure under water is [crosstalk 00:12:16].

Dr. Richard Rosenquist: Right. When you get chest-high water, about 70% of your weight goes away, so all of a sudden you're much lighter on your feet-

Nada Youssef: Well, that makes sense.

Dr. Richard Rosenquist: ... than you would be otherwise. 

Nada Youssef: Great. And then we have Julie. I want to get off my morphine. What will be my next steps?

Dr. Richard Rosenquist: One of the most appropriate ways is go in and talk with the prescriber, and tell them that you would like to come off of your medication. Ask them to work with you to develop a organized withdrawal program so that you're tapered off the medication, and it's done so in a gradual fashion so that you don't have withdrawal symptoms. 

Nada Youssef: And does that depend on how long they've been on it?

Dr. Richard Rosenquist: It depends a little bit on how long, and how big the dose is, and how much of a hurry the individual's in.

Nada Youssef: I see. 

Dr. Richard Rosenquist: If you're concerned that you may have an addiction component, you could certainly meet with people who are in the addiction specialty and have them evaluate you or talk about other ways to approach it so that you can get additional help, but if you're otherwise just wanting to get off, the prescribing physician should be able to give you an approach that helps to bring you down gradually. 

Nada Youssef: So see your physician to start taking those steps. 

Dr. Richard Rosenquist: See your physician.

Nada Youssef: Great. Mike has whiplash. A local pain specialist suggested an epidural and facet injections. What do you recommend?

Dr. Richard Rosenquist: I think that the best approach is to get a good evaluation and to take a standpoint that you'd like to have diagnostic things done to determine the correct diagnosis. Is it something that is coming from your spine, in which case facet injections might be an appropriate approach. Or is it something that's coming because you have nerve roots that are pinched or a cervical disk herniation that showed up on your MRI and they're treating radicular symptoms, or pain that might be radiating down your arm or between your shoulder blades as opposed to just neck pain. But it really involves them doing a careful evaluation and coming up with the diagnosis to guide next treatment steps. If you haven't done physical therapy, I would also suggest that you start with conservative approaches first. 

Nada Youssef: So it sounds like a trend. What you're saying here is basically don't mask the pain. Find out what the problem is and try to get to that. Correct?

Dr. Richard Rosenquist: Ideally, making a diagnosis helps us be far more effective in developing a treatment plan that's likely to produce the outcome that patients want. Many of the medications are only covering the symptom. They're not addressing the underlying problem. 

Nada Youssef: The actual condition. That makes sense. And I have Callie. How can I tell if I'm becoming addicted?

Dr. Richard Rosenquist: That's a hard question, but if you find yourself obsessing about the medication, if you find yourself going through periods of time where you're getting symptoms such as shaking chills or sweats, diarrhea, or other things when you don't have the medication, if you think that you're giving other things up in life or your relationships or other things solely to pursue the drug, then I would ask myself if I'm becoming addicted to the medication. And if you are, you could certainly go to the addiction treatment center and have somebody do a formal evaluation to help you really determine whether or not you're becoming addicted to the medication. 

Nada Youssef: Is there a limited quantity when prescribed an opioid, or can people get a month supply, or how does that work?

Dr. Richard Rosenquist: Typically the federal guidelines allow us, in somebody who's getting chronic medication, you can prescribe up to a month at a time, okay? And if somebody is on long-term stable medications, you can prescribe three one-month prescriptions for a total of 90 days. But no more than 90 days. And the patient has to be seen. And if you're working in the state of Ohio, you have to check the OARRS report before providing another prescription within that 90-day interval. 

Nada Youssef: Okay. Thank you. And June. Can cryotherapy help manage pain?

Dr. Richard Rosenquist: Absolutely. So there are certain things in which cryotherapy is useful, and there are a couple of different kinds of approaches to cryotherapy. There's the kind of total-body cryotherapy in which people are exposed to temperatures that are well below 100 degrees below zero for a very brief period of time-

Nada Youssef: And let me stop you for a second. What is cryotherapy, for those that don't know what it is?

Dr. Richard Rosenquist: There are different kinds of cryotherapy. There is cryotherapy in which you create a freezing lesion at a specific spot using a cryoprobe. So in some case where somebody's had a peripheral nerve injury, or for example if somebody's had an amputation and the end of the amputated nerve develops a large ball that we call a neuroma that can become very painful, people are going in with a cryoprobe, putting it into that painful neuroma, and freezing the neuroma as a means of providing pain control. People go in with certain kinds of tumors and put cyroprobes in and freeze the tumor as a way to treat the tumor. So that's one form of cryotherapy.
There are other forms of cryotherapy that are popular among athletes and star people and many others, in which they get into a very cold room, either completely or into a chamber with their head out and their bodies exposed to very cold temperatures. And those who feel that that's very helpful for their general health and diffuse widespread pain or things like osteoarthritis.

Nada Youssef: So people would do that just for health issues? You don't have to have an actual condition?

Dr. Richard Rosenquist: No, and that's something that is not required from a prescription standpoint. So somebody can go to a cryotherapy location and enroll to get those treatments. 

Nada Youssef: Is that a temporary thing, or do people go once a month, or-

Dr. Richard Rosenquist: It's a temporary thing, and people keep going, yes. Some people go once a month. Some people go more often. I think from a local standpoint, I believe one of our star players, LeBron James, actually does cryotherapy. 

Nada Youssef: Oh, excellent. Great. Thank you. And George. What can I do for bottom-of-the-foot pain. I'm on my feet for eight hours. 

Dr. Richard Rosenquist: It depends on the reason that you're having foot pain. It can be arthritis in the foot joints themselves. It can be from a nerve pinch that might be called a Morton's neuroma. Sometimes people get plantar fasciitis, in which the fascia that's connecting the heel to the front of the foot becomes inflammed and painful. So part of it, again, goes back to getting the right diagnosis, and then saying is it getting an orthotic for my shoe, is it getting a better pair of shoes, is it getting better arch support? In some cases, people go in and do certain kinds of injections, but again, which way you point or what you do is dependent on knowing what the cause is so that you can aim in the right direction. 

Nada Youssef: Yes, yes. And Carol wants to know what about my quality of life being on pain meds versus living with pain?

Dr. Richard Rosenquist: That's a hard thing, and one of the reason that, when we look at people who are in chronic pain, medications that we use, regardless of whether they're narcotic pain medications or anticonvulsants, antidepressants, antiinflammatories, all of those are looking at the overall person to try and say, "Can I help get the pain under better control? But more importantly, can I help the patient get their function back?" And if all you do is medications but you don't do other things ... so people who live in chronic pain frequently find themselves with depression or anxiety or other things. So if you don't address the depression and anxiety, then they don't get better. If they're physically deconditioned, the muscles themselves can become painful. So if you don't do anything about physical conditioning, then you're not going to get better. 

So it really is looking at the whole spectrum of treatments, and we provide people with what we refer to as multimodal, or interdisciplinary treatment. It may be a psychologist, a physical therapist, medications, exercise, changes in sleep pattern. They might use acupuncture, or Reiki or mindfulness-based stress reduction, or other things, or even antiinflammatory diets. I have patients who have dramatically improved their level of chronic pain merely by changing their diets. 

Nada Youssef: Okay. And since we're speaking diets, what are the super foods when it comes to antiinflammatory?

Dr. Richard Rosenquist: Well, more things that you try to avoid. You're trying to avoid the red meats, right? You're trying to avoid a lot of the white flours, right? You're going more towards fruits, vegetables, things like fish and chicken, but really staying away from the pork and the red meat and other things like that. 

Nada Youssef: So a lot like the Mediterranean Diet?

Dr. Richard Rosenquist: A lot like the Mediterranean diet. 

Nada Youssef: Great. And we have Linda. Could you use cryotherapy on cancer tumors? So going back to that. 

Dr. Richard Rosenquist: For some cancer tumors, they are using cryotherapy. So sometimes for tumors that are in the kidney, or the liver, or the prostate, they're actually going in and using a cryoprobe to freeze the tumor as a way of treating it.

Nada Youssef: Wow. And that's pretty effective?

Dr. Richard Rosenquist: Yes. 

Nada Youssef: That's great. And Jean. I have lower back pain into my hips and arms. My hands fall asleep, and I have restless leg often. Could they be symptoms of spinal stenosis, and what would you recommend for that?

Dr. Richard Rosenquist: They could be symptoms of spinal stenosis, and when it involves the arms and the legs, certainly it makes me think about whether or not this is coming from the neck as opposed to simply thinking this might be coming from your low back. So I would suggest that you get in and see somebody, get a formal evaluation that includes a good history and physical examination, and they may wish to do imaging studies of your neck, or your lower spine, or both. 

Nada Youssef: Great. Great information. And I have Michelle. What are pain management options when the patient cannot tolerate medications like Percocet or Vicodin in a postsurgical scenario? Is there something effective that isn't a narcotic?

Dr. Richard Rosenquist: Sure. It depends on what the postsurgical scenario is. So if somebody has peripheral nerve injury, as an example, sometimes using anticonvulsant medications, Gabapentin, Lyrica, or going to similar related families like Topamax, lamotrigine, or oxcarbazepine, if it's nerve-related pain, sometimes using antidepressants like Cymbalta or amitriptyline or helpful. Sometimes using antiinflammatories. Other less invasive things are things you end up taking by mouth. A TENS unit can be helpful. Sometimes nerve blocks are helpful, either temporary nerve blocks with local anesthetic and steroid or sometimes actually going in and freezing a nerve to provide a longer period of relief, so it depends on what the postsurgical pain problem is, why it's coming. Is it mesh? Is it a nerve injury? And making that diagnosis and developing a treatment plan. 

Nada Youssef: Great. Thank you. And Paul. When are opioids a good and safe option? What is the right way of using them?

Dr. Richard Rosenquist: For the most part, we choose opioids when we have no other good options, right?

Nada Youssef: Okay. 

Dr. Richard Rosenquist: And in general, the people that tend to do the best with opioids use them at low doses and tend to use them intermittently. 

Nada Youssef: Okay. 

Dr. Richard Rosenquist: So if I give you an opioid prescription. For example, I'll just use Percocet for the sake of discussion. If I give you one tablet four times a day, the first day you take it, you're going to love me. As you take those four tablets every day, day after day, many times they become like taking a Flintstone Vitamin, because you're exposed to it constantly, your body develops tolerance, there are other background changes that are taking place in your hormonal system and your nervous system, and it doesn't do after three weeks what it did the first day. Those people who get, let's say, 15 tablets in the month, and they say on Tuesday, I'm going to rake the yard. And when I rake the yard, it really is miserable. I'm going to take this medication either before I start this activity or immediately afterwards, tend to find that it works very well. So when it's that intermittent use, and I'm not taking it all the time, it tends to work really well. 

Nada Youssef: So planning ahead and knowing when you're going to be in pain is when you should be doing it. 

Dr. Richard Rosenquist: And then using it like any other tool. So if you say most days I don't need this tool, right?

Nada Youssef: Right, right. 

Dr. Richard Rosenquist: But on this day, for this event, and I have no other alternative, this is really, really helpful. 

Nada Youssef: Right. 

Dr. Richard Rosenquist: Right? And I'll have people come back and they'll say, "You gave me a prescription for 30 tablets nine months ago. I still have six left. But I'm getting worried, because I only have six left instead of 30 now," and they'll want a prescription. But that kind of use is low risk for addiction or problems, and they tend to have a pretty good result because they use it to accomplish a specific task.

Nada Youssef: Yeah. Very helpful. I want to ask you, mixing medications with opioids. So let's say I give birth and I get Percocet, and I'm already on some medications. Is there a danger of opioids use with other medications?

Dr. Richard Rosenquist: Certainly. The mixing of medications markedly increases the risk of adverse effects associated with those medications. So for example, this year the FDA came out with a black box warning about co-prescribing opioids, or narcotic pain medications, and benzodiazepines, or things like Valium, temazepam, or things like that. Why? Because there's a markedly increased risk of respiratory depression, right? And in one recently published study, the increase in respiratory depression was about tenfold, so there's a real concern that somebody could have a problem. But other things that are sedative drugs that could be like alcohol, so taking pain medications and drinking a lot of alcohol also increases your risk of stopping breathing. 

Nada Youssef: Sure, sure. Now do you suggest something like that because it could be different doctors prescribing? Is that like, a pharmacist should step in and say something, or who polices that part?

Dr. Richard Rosenquist: I think everybody has a role in doing that. We have a system in Ohio called OARRS, the Ohio Automated Prescription Reporting System, that allows me to look at an individual patient and determine what prescriptions they've been receiving within the state of Ohio. So if they're getting narcotics from me and benzodiazepines from somebody else, when I look at that OARRS report, it's my responsibility to actually acknowledge that and do something about it, have a conversation with the patient or with the other physician, or both, in order to make sure we take good care of that patient.

Nada Youssef: That's very good. 

Dr. Richard Rosenquist: We also can interact with some of the other state prescribing systems in the states that are adjacent to us, but if somebody's coming from out of state, you might not know that.

Nada Youssef: That makes sense. Thank you. Okay. Well, we have time for one more question. Let's see. My daughter gets severe itching on her face and burn-like appearance with Dilantin. What else could she try?

Dr. Richard Rosenquist: There are other narcotic pain medications, so that if she gets that with Dilaudid, I would suggest looking at some of the other narcotic pain medications, whether it be oxycodone or morphine or even some of the semi-synthetics like fentanyl, depending on the scenario. So if it's around the time of surgery, there's certain drugs that are available that aren't available for oral use outside the hospital, so it depends on what setting, and for how long, and what reason. 

Nada Youssef: And since we are talking about daughters and kids, I'm just going to put this one in here too before I go. I have Pat. I've heard that more and more children are becoming addicted to opioids. Should I worry about my children, and how big of an issue is this?

Dr. Richard Rosenquist: This is a huge issue. 

Nada Youssef: Yes. 

Dr. Richard Rosenquist: And when you look at young brains, because opioids hit the reward system, which is why people become addicted to them. Young people's brains are far more plugged into the reward system than the rest of us, so the risk of addiction is much higher in young people. If they're having a procedure that doesn't need opioids, don't give them opioids. People get into trouble from things like having their wisdom teeth out and then getting narcotic pain medications afterwards, when, for the most part, the evidence in studies suggests that people can't tell the difference between taking an antiinflammatory and a low-dose narcotic after having wisdom teeth removal. 

Nada Youssef: Sure, sure. Right. 

Dr. Richard Rosenquist: So if they don't need it, don't give it to them. It's a much higher risk.

Nada Youssef: Great. Thank you so much. Well, that's all the time that we have today. Is there anything else you want to tell our viewers before we let you go?

Dr. Richard Rosenquist: Be careful. Work with your doctor, and if you can find other alternatives, do so. 

Nada Youssef: Great. Thank you so much. And thank you guys for joining us. And before we go, next Tuesday, we are having an hour special as we talk to Dr. Mark Hyman about health misconceptions, so make sure you guys are tuning in. And for more health tips and information, make sure you are following us on Facebook, Instagram, Twitter, and Snapchat, just clevelandclinic, one word. Thank you so much for watching. We'll see you next time.