Managing Patients in the Opioid Crisis Era

Podcast Transcript

Dr. Alex Rae-Grant: Neuro Pathways: a Cleveland Clinic podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of Neurology and Neurosurgery. Welcome to another episode of Neuro Pathways. I'm your host Alex Rae-Grant, Neurologist in Cleveland Clinic's Neurological Institute. In an effort to explore the latest advances in neurological practice, today we're going to talk about managing patients in the opioid crisis era. I'm very pleased to have Dr. David Streem here with us. Dr. Streem is a staff physician in Cleveland Clinic's Department of Psychiatry and Psychology and medical director of Cleveland Clinic's Alcohol and Drug Recovery Center. David, welcome to Neuro Pathways.

Dr. David Streem: Thanks for having me.

Dr. Alex Rae-Grant: I'd love for our listeners to get to know you a bit better. Tell us a little about yourself. Where are you from, where did you train, and when did you begin your career at the Cleveland Clinic?

Dr. David Streem: Well, I grew up in Cleveland, so I'm a native Clevelander. I went to college in Boston where I studied Biomedical Engineering at Boston University. Then I came back to Ohio for medical school at Ohio State. And while there, I had the opportunity to work in the psychiatry department at Cleveland Clinic. And I just fell in love with the place. I fell in love with the approach, the culture, and the leadership. And I just decided that this was a place that I could definitely establish my career and grow.

Dr. Alex Rae-Grant: Just to ask you, how long have you been with the clinic?

Dr. David Streem: In total I've been with the clinic 20 years.

Dr. Alex Rae-Grant: First let's start off. How does Cleveland Clinic approach alcohol and drug recovery, David?

Dr. David Streem: Well really, one of the things I love about Cleveland Clinic is they approach alcohol and drug recovery the same way we approach other disease states. And it's very much a medical model, starting with physician leadership, evidence-based practice, and continuous quality improvement.

Dr. Alex Rae-Grant: If you could just tell us a bit more about the value of an evidence-based practice in this area. I mean how does that help?

Dr. David Streem: First of all, most patients with opiate use disorder, they need to go through treatment about five times on average. Of course there's fewer and there's more. If you only look at an outcome as narrow as long-term sobriety or one year of sobriety, after each of those five treatments on average, you'd come to the conclusion that the first four treatments were failures and the fifth was a success even if exactly the same thing happened in each treatment.
But the reality is when you talk to these patients, each treatment has its own journey and life, and each patient learns different things in each treatment. So when you hear from them, they'll say it wasn't that four treatments were failures and the fifth was a success. Each treatment provided me necessary information and skills that I needed to get to the destination, achieve the goal that I wanted to achieve. So for them, it's all part of one longer journey. And as an organization, struggling with how do we take those indicators and turn them into something measurable, it's a great challenge that we're all doing our best to rise to.

Dr. Alex Rae-Grant: As you say, it's really a journey over time with individual steps.

Dr. David Streem: Yes. And then the wonderful thing is that there's a lot of, and a very growing, amount of evidence-based in the country, in the world. So there are a number of tools that we are trying to incorporate into our system to deliver what we believe and what all of the evidence published tell us yields the best outcomes for patients.

Dr. Alex Rae-Grant: Let's take a closer look at opiate abuse, specifically as it relates to surgical patients. How does Cleveland Clinic develop procedures that mitigate opiate abuse in our large surgical practices?

Dr. David Streem: Well, I think this starts with future preparation. So preparing and thinking about this, certainly, well before a particular patient comes for their surgery. And then also designing methods to educate patients so that they understand why we're going to be doing things a little bit different in this surgery than maybe they've had the experience in the past. One of the things I've really enjoyed about my work is the physician team approach and the fact that as part of a medical staff, part of my job is to help our surgeons and anesthesiologists and wonderful pain management specialists to develop and direct new approaches, especially for particular types of surgeries whether they be obstetric type surgeries, orthopedic surgeries, neuro surgeries, to use, again, evidence-based practice to identify how can we use non-opiate and expose people to less opiates over the course of their perioperative course.
And then what we've found is that the vast, vast, vast majority of patients, when they hear about these things that we're doing and these things that we're going to do during their surgery, and they also hear about the efforts we're going to make to get feedback from them as to how successful these are, the patients are extremely appreciative and open to a different approach, which has been very heartening. And I think it bodes very well for our future and the future of the addiction crisis.

Dr. Alex Rae-Grant: You want to give us some of the specific kinds of recommendations that we give to the surgeons at the clinic? And how has that changed from where we used to be and what's the difference?

Dr. David Streem: Well, probably the biggest thing that we've changed for our opiate use disorder patients, so people that have already been diagnosed with opiate use disorder, and that are prescribed medication, usually buprenorphine for the office-based treatment of opiate dependence. So buprenorphine is an opiate. And as such, it should be considered as we're developing a perioperative management plan. So when buprenorphine first became available for this purpose, the original recommendations that came down from the Substance Abuse and Mental Health Services Administration as well as others were to taper people off of the buprenorphine, and then during the surgery and the post-op period you'll use full opiate agonists. And then when the need for perioperative opiate analgesia was over, to restart them on the buprenorphine.
What we've found since then really is that is not the best approach. We're continuing buprenorphine in most circumstances throughout the perioperative period. A number of new guidelines have come out that have shown that when we do this, actually the outcomes are excellent. It also reduces the risk of relapse before an operative procedure can actually occur. So the patients are safer, they're more comfortable, they actually get better analgesia, and they have a better patient experience. And for us, that's what it's all about. It's taken some time to help the organization understand that change in approach, but now that we have that understanding and that collaboration, as long as we're able to start before the surgery occurs, we really can expect a really nice outcome for most surgeries.
There are differences how we manage that depending on how much opiate analgesia is normally needed. Smaller or less orthopedic type surgeries, obviously there are sometimes some mitigating changes that we can make. Sometimes just increasing the buprenorphine dose allows us to get away without using any opiates at all. And of course, working with both the surgeons and the anesthesiologists to use pre-medication to minimize the need for opiates generally. But particularly in the population that has a history of opiate use disorder, that is very much appreciated by folks in addiction treatment services like myself.
And also, these patients who are usually pretty desperate by the time they need surgery, because opiate exposure in the past got them to a very dark place. And they realize that that's usually, especially for joint replacement surgeries or neuro surgeries, that's very often going to be at least part of the perioperative management. So they come into it with a lot of apprehension and fear. And usually when we're able to implement our approach, then the outcome can be really tremendous. And the patients are very happy.

Dr. Alex Rae-Grant: That sounds great. So it sounds like an awful lot of systems changed to get where we are now. Who did that and how did that all come about with all these different surgeons in these different locations? A lot of communication and work.

Dr. David Streem: Yeah. There's a lot of opportunities. I really take every single surgery that I'm involved with very seriously, and we look at it with the individual surgical specialists, the surgeons and the anesthesiologists. And I really try to spend some individual time with each of them, especially if we haven't worked together before, making sure that they understand what the approach is and why we're taking that approach. And the time that I have the freedom to take as part of a staff model organization is tremendously liberating.

Dr. Alex Rae-Grant: Well I know, David, we talked a lot about surgical management of opiates. But maybe let's switch to the medical side. What about those people with chronic headaches and opiates? What's the situation there?

Dr. David Streem: Well the chronic headache population can be a particularly challenging population, and their opiate use disorder risk is very significant. And that's why I've very happy that the Cleveland Clinic developed a migraine, adult migraine care path that is available to all Cleveland Clinic providers. So I am someone who treats patients who very often do suffer from chronic migraine or episodic migraine. And I am not a headache specialist per se, so it's been really great to be able to open up this very professionally done evidence-based document and use that as at least a starting point to address, again, non-opiate approaches to manage migraine and to be ensured that I'm always recommending the best evidence-based practice, even though this isn't my area of specialization. And I've just been really happy with a lot of the results of that. Patients who have struggled with migraine, often for many years. Often again, because they're my patients, the have a history of opiate use disorder or other addiction problems. And so they're very mindful of avoiding opiates.
And when we can use these non-opiate approaches and really have a major impact on quality of life, that's something that's just very pleasing to me, pleasing to the patients of course. They end up functioning better, they have less time off of work, and they're more able to meet their role obligations because they're not so affected by their migraines. So very often in my work, I'm asked opinions like I am now about my focus on addiction in general and opiate addiction particular. But I also get to benefit from all the other experts within the Cleveland Clinic, and the care path has definitely been one way that I've benefited from that.

Dr. Alex Rae-Grant: So I'm going to step even further back from the specifics at this point. A lot of clinicians deal with opiates with their patients. And what are some of the things that they should consider when looking at a uniform but best practice approach to opioid management? I mean what are the important things for them to be aware of and implement in their practice?

Dr. David Streem: Well I think first of all you've got to look at the state regulatory environment. There's been a lot of changes in state regulations in many states, but in particular in Ohio. I think that also you have to look at how am I approaching objective evaluation of each patient, and then how am I ensuring that my patients are achieving the goals? And then I can demonstrate that they've achieved those goals over the course of time, and that those goals are maintained. A lot of times we do see folks who seem to do really well initially in the early stages of their treatment. And in my practice, every one to three months, even folks who are very stable will come back for follow-up visits. And part of that time we spend doing urine drug screenings. As long as those drug screens are negative or the results are reviewed by me, and if I need help I call up one of my pathologist colleagues over in the lab institute. And we monitor that over the long haul, partly because there are state regulations that mandate it, but partly because it's the right thing to do. And that allows us to identify patients who are doing well and being successful and patients who are still struggling.
I think that often times when patients are struggling with chronic opiate management, it very often means that the opiate as a class of drugs is probably not the right approach, which would lead us to revisit our diagnosis. What's the reason why we're using this class of drugs as opposed to a different class of drugs? And generally dose adjustment or adjusting to more direct routes of administration generally lead to more side effects and more frustration, and frankly more risk. So a lot of times what we're focusing on is revisiting, going back to good old fashioned diagnosis, medical diagnosis 101, physical exam, and really helping us to understand what exactly is the disorder here that we're treating. Let's make sure that we have the right target in our cross hairs before we take the actions that we want to take.

Dr. Alex Rae-Grant: So just as a self-serving question here. As a provider, how can I ensure that I'm keeping up with the latest state regulations and not getting myself in some kind of problem with my practice or licensure? What's the best way to go about that?

Dr. David Streem: Well first of all, consulting an attorney who has a special focus in medical practice management is really important. In psychiatry, of course, there's a very significant connection and interaction between psychiatric care and the law. In fact, that's a whole specialty for us. And I often say that good psychiatrists need good lawyers. We need that to operate. Regulations today are written very quickly. And there is a lot of oversight and review that occurs. But the process of moving regulations through those different levels of review has gotten very fast. And I think it's very difficult for a provider with a large practice and significant concerns to keep up with a lot of the regulatory changes. I think that the regulatory changes that have occurred, though, are there for a reason. And it's because we have morgues that are filling up with people who have passed far too young and often times with prescription pill bottles with doctors' names on them, and the patient's name on the bottle as well. So how do we take our practices and the abilities to prescribe that we're granted and turn that into a force for good for our patients, and always make sure that we're staying within the sidelines that are created for us even when those sidelines move?

And boy, lately they've been moving a lot... is a very significant challenge. I think that if you have concern that you're not up-to-date and up to speed on where those sidelines are, it's important to really seek consultation with other experts in the field, other practitioners. Or really look at the patients that are in your practice to decide if you can really serve them in a way that's safe, both for them and for you in your licensure and the rules that are out there. Because especially in Ohio, they're there because we've had this major, very scary epidemic that looks like it's at least on pause. There's been a slight improvement in Cuyahoga County. The number of overdose deaths, nationally, continues to go up. And right now we don't know whether the slight reduction in Cuyahoga County in overdose deaths heralds a larger reduction nationally or whether this is just a pause in an evolution in a worsening epidemic. Of course I have my hopes that things are going to get better, but we have to be prepared for the undesirable outcome of that data. And all of that comes back to watching that data and being mindful of it as quickly and as reasonably as we can.

Dr. Alex Rae-Grant: Well David, thank you so much for joining us today. We really appreciate your time and insights in all the work you do with... not the easiest population in the world. So thank you very much.

Dr. David Streem: It was a pleasure being here. Thanks.

Dr. Alex Rae-Grant: This concludes this episode of our Neuro Pathways podcast. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast. Subscribe to the Neuro Pathways podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. Don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website, consultqd.clevelandclinic.org/neuro, or follow us on Twitter at CleClinicMD. All one word. That's at C-L-E Clinic M-D on Twitter. Thank you for listening. Please join us again soon.