That was great. Before you wander off the stage, Ken, are there any questions or comments from the audience? Yes, sir. Good afternoon. I'm Dr. Correa. I practice here in Louisiana in New Orleans, and it's an excellent presentation. I have a business statement and a question. The statement is, oh, this is very nice, but for the practitioner, I'm a neurosurgeon. I've done pain all my life, from DBS up and down. But right now, I'm doing a lot of medication because I see patients with six, seven operations. They don't need it anymore. Insurance companies don't approve another round of physical therapy, et cetera. So these patients are on medication or have been on medication in an uncontrolled way for many years. So now comes the government that has reduced the amount. Well, it's easy to say when you're not confronting the patient in a one-to-one in a four-by-four room. These patients fight for their life. You mentioned some of them will not have any relief unless they have pain medication. The question, they immediately say, well, everyone's going to go to illegal drugs, mainly heroin. Well, that's apparently, it's probably true, and it has been stated in the Pain Practitioner magazine. But on the other hand, the government had only provided us, in my opinion, with one weapon. We had the other ones, like pain counting pills, monthly or whatever, that they come in on each visit during determinations, analysis, and if necessary, sent to a lab when there was a doubt. But they also gave us the famous PMP, where it's very nice. The problem is, since the government is mainly formed by attorneys, I assume, or people that are non-doctors, well, it's easy to say, but no one is going to risk being re-elected by their group of population if they're going to put something which damages that group of population, basically taking the only thing they have, which is the pain medication. So what they do, they suggest to the doctors, and you mentioned something about it, how to practice. But without saying, doctor, you need to give so much medication. So we have the CDC saying 80 mg of morphine, 90 could be mortal. We have states saying 120. Medicaid in this state will only pay with 120. They don't say you have to prescribe for 120. They say we only pay for 120. So immediately the patient says, I'll pay for the rest. But that's not the issue. Then that's another 30 minutes of discussion with the patient that, yes, saying that they pay is because they haven't determined something that they have to tell the doctors. That man doesn't want to order the doctors. Doctors don't want to take direct orders on how to practice medicine. So it's a conflict of interest right there. Then the famous PNP has done only one thing, transform whatever is an opiate into the equivalent of morphine, which they took as a measurement. Well, that's erroneous because they are not taking into consideration multiple factors. And in my opinion, the number one factor is the diagnosis. They only have one magic word, which is the Disney world, it's Disneyland, and it's called cancer. And then you can prescribe anything you want. But if the patient, oh, no, I don't want to have cancer. No one wants to have cancer. But we know that on cancer patients, we can prescribe with you. We have to try to do our best to comply with federal guidelines, and so on, so on, so on. So that's the statement. The question is, what do we do? That sounds like a question for the chair. Yeah, no, I'm happy to. I mean, you touched on so many important points. Yeah. So I mean, honestly, I hardly know where to start, and we could spend a whole day on this. But you are spot on that the burden has really been shifted to those practitioners on the front line. And I think we have an obligation to be advocates for our patients, and not only for their treatment, but also for their safety. So it's all about balance. There are concerns, which you touched on, that restricting opioid supply will drive patients to illicit drugs. Not sure how that's going to play out. There have been some very vocal opponents of this whole issue of cutting supply who say, well, we're going to have patients commit suicide when they lose their opioid. So I think it's important to keep in mind, we aren't being told we can't use it. But certainly, we have a much heavier burden these days as providers in making opioids available to our patients if they are necessary. If you look at the Federation of State Medical Board's guidelines on opioid prescribing, I think they were just revised sometime in the last maybe six or nine months. They make it clear that opioids are acceptable for pain management, but they have pretty strong recommendations about how to manage the patients, which includes that if the patients don't have improvement of pain or improvement of function, they maybe shouldn't be on opioid. I think part of what we're seeing is the backlash from how liberally opioids were prescribed over the last 10 or 15 years. I remember early to mid-2000s, I'd have patients sent to me for implantation of a morphine pump. And they were on, I mean, fentanyl patches and Actiq lollipops and 120 hydrocodone a month. And still, the pain is 11 on the 10-point scale. And the referring doc says, well, put in a pump, please. The patient's failed oral opioids. So I think we are in the middle of this backlash. And I also just want to comment on your statement about the treatment of cancer pain. Because I think this is something that concerns a lot of us in the field, that there is a moral imperative to treat cancer pain as aggressively as possible. And for reasons that aren't always clear to me, there does not seem to be that moral imperative to treat non-cancer pain as aggressively. And I'm just speaking personally, not as an ANS person or Academy of Pain Medicine. I just think that's not right for our patients. I think we should focus on treating the pain. And as long as we think that there's a legitimate source for pain, it's not more on the psychosocial side, not drug-seeking. I think we have an obligation as providers to do our very best to take care of these people. So maybe one more quick question, and then probably time to move on. Thank you very much. My name is Michael Yang from the University of Calgary. You show some very impressive numbers in terms of the epidemiology of death secondary to opiate medication or illicit drugs. But do we know how much of those deaths are from street drugs, street opiates, versus ones that are actually prescribed by a medical practitioner? You know, I can't. That's a good question. I can't give you the exact figure. But my understanding is that the majority of the opioid-related deaths now are not prescription. They're the big focus on this in fentanyl. I mean, that could be prescription. A sense that it's more illicit opioids at this point. And do we know whether there's a percentage of conversion rate of people who are prescribed opioids that become eventually on illicit opiate medications afterwards? Well, yeah, only from that one graph that just actually came out of the C. I don't have my slides here. Came out of the CDC. Again, you can get that pyramid chart online that about 5% of patients who start on opioid for legitimate purposes will develop opioid use disorders. And then about 1% go on to frank misuse and use of illicit drugs. Thank you very much. Yeah, so the rate of opioid-related fatalities continue to increase. Opioid prescribing has actually dropped a little bit every year since 2012. Some of it is a measurement issue. I think that in 2012 and prior years, coroners weren't quite as aware of this as an issue and weren't doing talk screens quite as religiously. So there were some issues with the data. Thank you very much.

neurosurgeon

government's reduction of pain medication

conflicting guidelines

opioid-related deaths

fentanyl