Dr. Mirzada, so we have some time for Q&A. Dr. Mirzada, would you come up and maybe you and Mr. Blaney can use the two podium? While they're coming up, a couple of housekeeping issues. I just want to make sure people are aware that the Joint Section on Pain biannual meeting is going to be a little less than a year from now. In March, it's going to be in concert with the Spine and Peripheral Nerve Section. It'll be the Wednesday and Thursday and their meeting is Thursday through Saturday, so we'll have a little bit of overlap. There's been a lot of discussion and I'm not sure on the final verdict on this, but you may want to keep your programs and copy the agenda for things that you've gone to and submit that with your CME to your state if your state requires CMEs for pain management. I don't believe it's going to be broken down by the AANS as to whether it's for pain management, but we're going to see if we can get that through quickly. Any questions? I'll qualify this by saying I really treat acute pain. I don't treat chronic pain after I've operated on someone, they get out three months, they're having trouble, I send them on to pain management. But I think all of us have seen in our practice these people who have been treated chronically with narcotics, often in the low stable dose, maybe a pill or two a day, sometimes for 10 years, sometimes you know people, family or relatives who have done that for medium to long term. They don't have that same addictive quality you see in your office. Who are these people? Is that appropriate? How are we going to deal with that in the future? I'm sorry, who are which people? The people who appear to be being treated with narcotics for medium to long term and tolerating them on low doses. Does that really exist? Is that really a reasonable treatment in this day and age? I don't know. I would just say, speaking from my practice, I know patients that are on long term stable doses, a couple pills a week for their arthritis or patients with sickle cell anemia, they have to have their opioids if they have a crisis or things like that. There are definitely patients that are out there. I think that in my experience, I think we haven't done a very good job about making sure they don't develop side effects and assess that their function is good and make sure that they're not developing osteoporosis and treating hypogonadism from long term opioid use. I think those patients are out there and they're probably going to suffer a fair amount depending on how tight the restrictions are. Most of the restrictions are for 30 days for chronic pain patients and it is going to increase the work burden from our PCPs and pain management colleagues. But there are lots of patients out there that have really been abusing these medications. And I've seen a lot of patients where you're like, you really should be coming off and you try and talk to them about opioid-induced hyperalgesia and they're like, it's the only thing that gets me through the day. I know it doesn't help my function, but it gives me half an hour of relief. A couple of those have been able to convince to come off their opioids and you see them a year later and they're frankly very happy that they did. I have a lot of those patients. My approach has been, I'm documenting everything and continuing to treat them. But what's happening now is these guidelines, obviously think about these guidelines, obviously there's been a position of patients that need care, but the guidelines are not going to take them as long. So what's happening in the last several months is, one by one it's like we're only covering two years, nine months, a month of medication. Yeah, so we've done a lot of advocacy, as was discussed by the last speaker, through the MA and also on our own. And it's hard. And what I would say is I think the biggest problem that I see, given that 25 to 40% of patients undergoing spinal surgery, lumbar spine surgery in the state of Michigan are not opioid naive, is that a lot of these regulations they separate, there are only two groups to them. There are acute pain patients and chronic pain patients. There's no consideration of the chronic pain patient who then has acute pain from a surgery or from something else. And those patients are really going to suffer a lot under some of the laws, the way they're written. And in our state, there's stuff that's supposed to go into effect in June, and basically the state medical board has said we cannot do it because we have no idea how to implement what you guys passed in the middle of the night on December 27th, 2017. Yeah, and that's a really positive action by the medical board. Not all medical boards have done that. One other development coming to a state near you, it's pretty much already in Michigan. In your PDMPs, you'll see something called a risk score. And how many people have seen something like that in your PDMP? Okay, a couple. It'll happen more. And it's yet another variation on the theme of CDC's guidelines. Those algorithms, the AMA, we've been trying to get at what those algorithms are so we can share them with physicians who can tell us whether they have any kind of validity or not. So far, they have not shared it with us. In Michigan, the PDMP developer has this risk score. Anything you could be measured against, and again, I really don't like to be a pessimist about it, but it's about risk, right? I mean, you guys deal in risk every day. But if you do something for a patient who has an elevated risk, and you don't know what that elevated risk really is, where does that leave you as the physician trying to provide care? So it's like it's limbo. I mean, how many people, you know, we always talk about where it's just saying, the chair of our task force, she's a psychiatrist, and she always talks about her training that she was taught, you know, never do two things at once. Because you don't know what's, you don't know which, if it works, you didn't know which one worked, and if it fails, you don't know which one, you know, which one failed, although probably both failed. But all of these policies about pain have been happening all at once. And, you know, and to your question about, you know, what do you do, keep in mind, payers and others and state legislators are measuring success based on a couple of things, which is primarily are there fewer opioids in the supply chain? And in your institutions, when you can't get IV opioids for surgery, guess what? That's a success, because that's fewer opioids in the supply chain. Oh, my God, that's crazy town. My kids like to call it cray cray. Total crazy town. And so, but those are the effects of policy. What organized medicine, what I would say needs to continue to happen, and, you know, and together, is highlight what the effects of patients are. And evaluate these policies. There's so much public policy that has zero evaluation to it on the effects of patients. So in your practices, you know, as part of that documentation, and I know this is extra work. It's extra work. You don't want to do extra work. But if there's a problem, if there's a problem because of some, like, you know, really dumb policy, document it. Share it with AANS staff. Share it with your state medical society. Because the only way we change those crazy policies is if we know how it's affecting patients and physicians. Great. You seem to be in a very important position as a liaison between physicians and authorities. And some of the things that you expressed there are very much in everybody's mind. There are almost no naive, virgin patients, and not even three years old, because they heard that from their mothers. So basically, everyone, as you have stated, when they go to surgery, they have had some degree of pain medication, opiates pain medication. We have a recent, I call it a problem, development trying to solve the crisis of general practitioners by ordering, ordaining, basically, these new nurse practitioners who in this state can have their own office without a doctor's supervision and can write opiates incentives. The CDC was very adamant about October last year, I think, advising that if at all possible, we should not prescribe benzodiazepines and opiates because of the respiratory depression and subsequent death. Well, I have had personal involvement with these practitioners, including sending a letter and including a copy of the CDC memo. Well, the patient came back with the same thing. I had to tell her, well, you have to make a decision. Let me treat you with the hydrocodone I'm giving you. This is a patient with five back operations and with everything else already. And I was comfortable with that. But you can't have your value. And if you want to have your value, then I'm going to discharge you, give you some medication to show you don't have seizures or something for a few weeks, and then seek someone else. But that causes only a chain reaction that patients start looking for doctors, some more doctors. The government, unilaterally, without much investigation, perhaps on time, or with reason, is closing so-called pain clinics or pain management doctors right and left. And as you said, there are hundreds of patients out on the street without treatment. We get calls in, basically, one of the days, which is quite often in this area. I don't know, 20 calls at a time. I mean, I don't even take a patient unless I have a full copy of all the previous records. But they want to be seen yesterday, not even a month from now or tomorrow. So it's a really problem for the managing physician to act properly at the same time that something that you mentioned also happened to me about your friend, the oncologist. Well, I am a neurosurgeon, but I am doing pain management as well. So I was compared with my so-called peers, the one in this room. And I am in that big number in a national level. But that's not true. I can show you everyone, all my charts and all my papers, everything else, in which all these patients are going down and everything being done and all that. But in papers, I'm a bad guy at the national level because I am compared with the wrong peers, just like your friend. So things like that are at a legal level. I don't have time or they don't even know who to contact just to change my national MPI, which is where the thing comes. So we do need to move on to the next thing. But what I would suggest is that for people who are interested in advocacy, contact the NNS. If you don't have the time to do it, please make sure you join the pain section and pay your dues. That supports a lot of the work that we're doing for this sort of thing. I am a member. I pay already. Excellent. Excellent. Excellent. So we're going to move on to the next speaker.

pain management

opioid use

chronic pain

restrictive opioid regulations

advocacy