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17 Articles in Volume 20, Issue #1
20/20 with Lynn Webster, MD
Correspondence: Opioid-Induced Hyperalgesia; Pain Care in Older Adults
Don’t Discount the Role of Diet for Chronic Pain Relief
Editorial: Why Haven’t There Been More Breakthrough Analgesics?
Gasping for Air: Sleep-Disordered Breathing and Chronic Opioids
How can botulinum toxin be used in chronic pain syndromes?
Inside the Potential of Peripheral Kappa Opioid Receptor Agonists
Neurodestructive Interventions for Cancer Pain
Obesity and Pain Care: Multifaceted Considerations for Treatment
Obesity and Rheumatoid Arthritis: What Clinicians Should Know
Sickle Cell Pain Crisis: Clinical Guidelines for the Use of Oxygen
The Complexity of Sickle Cell Pain: An Overview
The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception
The Rapid Rise of Non-Opioid Pain Policies
Treating Pain by Overcoming Communication Barriers
Visual Artists Tackle What Pain Looks Like
Will 2020 Be the Year of Patient Education?

20/20 with Lynn Webster, MD

In the kick-off to a new PPM conversation series, icon Dr. Webster shares his vision, from the beginning of pain management as a specialty to a future where digital medicine and behavioral support may lead the way.
Pages 73-74
This discussion is part of a new conversation series led by Editors-at-Large Jeff Gudin, MD, and Jeffrey Fudin, PharmD, in honor of PPM’s 20th anniversary of publication. A condensed transcript follows. Access the audio file.
 

Dr. Gudin: Tell us how your career started? How did you get interested in pain management?

Dr. Webster: Well that was a long time ago, but let me put things in perspective. Most people probably don’t appreciate that it was as recent as the late 1970s when it was first reported, at least clinically, that there were opioid receptors on the spinal cord, and it was suggested that that’s where we could modulate pain.

That information was soon coupled with the use of epidural, or periaxial anesthesia, and the realization that we could use small concentrations of local anesthetic in an epidural, sometimes with an opioid, to provide sensory blockade without motor blockade. Well, that became an interesting concept to me and to a few other people in the country... Soon after emerged an interest to establish and run acute pain services; there weren’t many at the time, and almost all of them were in private practice, not in academic sites.

Dr. Gudin: It almost sounds like this was a time before pain management bred into its own specialty?

Dr. Webster: You’re absolutely right. There were no pain services. In fact, I was right at the beginning of when we thought pain services – at least acute pain services dealing with post-
operative pain, could be addressed. The whole concept about patient-controlled analgesia, or PCA, was that you could give the control to the paient and that they would end up using less opioids, and you could get them discharged with greater satisfaction more quickly.

Dr. Fudin: I remember when PCA was a really big thing and hospitals were starting to implement it. Policies were written locally, regionally, and nationwide – they were mostly epidural back then. But, of course, it morphed into subcutaneous and IV PCAs.

Dr. Webster: This was also the concept on which extended-release formulations would later be based, because most people did not appreciate that the whole concept of continuous release, that is PCA with a basal infusion, with boluses, was going to be more effective in controlling pain with overall less opioids than if you gave them an IM injection every four to six hours.

Dr. Fudin: So, being a pioneer, what were the most pertinent challenges you encountered as a new pain management specialist, and then as president of a major pain organization (AAPM)?

Dr. Webster: Well there have been a lot of challenges, but I think everyone would probably place the difficulty with insurance companies as our number one challenge. From the day I started to treat patients for pain, struggling with the payer system to get authorization for the most effective treatment has always been difficult. It’s the reason why, so often, we had to default to the cheapest, and probably the more dangerous options, and that was to use opioids.

Dr. Gudin: As a practicing clinician, I share those same challenges of payers and of managed care putting up obstacles to what really equates to what we call multidisciplinary treatment of pain. Everybody wants to see multidisciplinary treatment, but nobody’s been willing to support it.

Switching gears, I’d love to hear your opinion on the misinformation regarding opioid analgesics. When you look at the science, we have these endogenous receptors that bind to a naturally occurring chemical and produce pain relief. Where do you think we went right and where did we go wrong with the concept of utilizing opioids for pain?

Dr. Webster: Clearly, we did not appreciate that there was a subset of the population for whom an opioid was dangerous. And I think that our belief set was ‘The sky’s the limit’ as I’ve written about in my book (The Painful Truth). I clearly remember believing that you could give just enough opioids and people would have good pain relief. Because the other misunderstanding at the time was that if you titrate it slowly, you would not have respiratory depression. And, there was a notion that if you’re treating pain, you are basically preventing the development of a substance use disorder. Those three elements together led to a lack of understanding because we were all very ambitious about trying to help our patients. It was not mal intent but rather a lack of having good science and support.

Dr. Fudin: I’m wondering, now, where do you think we’re headed in pain medicine? Are there future drugs or technologies we should be thinking about?

Dr. Webster: Unfortunately, in the near future, I think that people with pain are going to struggle getting access to the treatments that are available. However, long-term, there’s a silver lining with the opioid problem that we’ve experienced over the last one to two decades, and that is there is interest by NIH to help fund the development of safer and more effective analgesics. They’re not all going to be pharmacologic treatments though, take neuromodulation, for example.

I would add that I had great successes by the way using spinal cord stimulation in a number of patients. And I think that improvement in that technology is going to help a lot of patients. We’re also looking at virtual reality as a possibility for helping a large number of patients, as well as digital medicine that provides forms of cognitive behavioral therapy and other sorts of behavioral support.

But some of the more mind-boggling innovations are going to come with human gene therapy. There is a professor at the University of Utah who is proposing using CRISPR technology to alter the genes that can modulate the production of pro-inflammatory cytokines in the disc, for instance.

Dr. Gudin: One purpose of this conversation series is to highlight the icons of our specialty. When I think about ‘Dr. Lynn Webster,’ I think about the Opioid Risk Tool; I think about sleep apnea associated with opioids, especially extended-release opioids. And I know some of your newer research is based on monitoring respiratory depression from medicine. Tell us a bit about some of your accomplishments, which to me, have made a huge difference in the world of pain medicine.

Dr. Webster: Thanks, Jeff. The Opioid Risk Tool is something I am proud of. Recently, Martin Cheatle at the University of Pennsylvania further validated it as a tool to help assess for the risk of apparent drug-related behaviors if you’re prescribed an opiate.... But I think more important for our field was the paper that demonstrated the magnitude of sleep apnea with chronic opioid therapy ... and our report on the use of benzodiazepines and how they contribute to respiratory depression.

I also did a lot of work about 15 years ago with methadone. We were seeing insurance companies forcing doctors to use methadone instead of branded drugs. The problem was that none of us were trained to use methadone for acute or chronic pain, and because of its unique pharmacologic properties, we were seeing a disproportionate number of people dying from overdose. A lot of that was because patients were taking too much. And some of it was because of physicians not knowing how to prescribe it.

It was at that time that I thought we had to do something about the problem of overdose deaths. I had done enough research to start a foundation (LifeSource) which then merged into a program with the Utah Department of Health. Over a two-year period, we were able to reduce the number of unintentional overdose deaths by about 30%.

Dr. Fudin: It’s truly heartwarming to hear you speak, especially with such passion. Before wrapping up, I want to ask where you see the pain specialty as a career moving in the future. What would you advise to young residents and fellows entering the field today?

Dr. Webster: What we need is more education, better education, and broader education. I think the use of multidisciplinary treatments will gain support but probably not until we change our healthcare system. We reward doctors for episodes of care, whether they are helpful or not. As soon as we pay for outcomes, improved outcomes, we’re going to see much more multidisciplinary treatment, rather than maybe those services that are just generating money.

Dr. Fudin: As a clinical pharmacist, I think all of us would like nothing more than to see a team approach to pain management that involves all the specialties ... pharmacotherapeutics, behavioral health, medicine, the maximum utilization of physician extenders such as nurse practitioners and PAs. No one person can do it all.

Dr. Webster: Agreed! As for my advice for pain residents and fellows, I would say, focus on the needs of your patients properly and everything else will fall in line. Don’t limit the tools to how much you’re going to get paid, which reminds me of a quote by Maya Angelou, to paraphrase: ‘People will forget what you said, and what you did. People will forget how much money you made, but people will never forget how you made them feel.’ In medicine, that’s true of your colleagues as well as your patients.

 

Lynn Webster, MD

About Dr. Webster: He is the past president of the American Academy of Pain Medicine (AAPM), is board-certified in anesthesiology and pain medicine, and certified in addiction medicine. Developer of the widely used Opioid Risk Tool, Dr. Webster has led crucial research on the relationships between sleep apnea, benzodiazepines, and opioids; established LifeSource to stop overdose deaths; and authored more than 300 scientific abstracts, manuscripts, journal articles, and books. He currently serves as vice president of Scientific Affairs of PRA Health Sciences and continues to help physicians safely treat pain patients while working to develop safer, more effective therapies for pain and addiction.

 

Throughout 2020, we will be featuring more dialogues on the evolution of pain management over the past two decades and what the future may hold. To get involved, email the editorial team. See additional episodes, with Peter Staats, MD, Nathaniel Katz, MD, Suzanne Amato Nesbit, PharmD, and with Drs. Carmen R.Green and Johnathan Goree.
 
 
Last updated on: September 21, 2020
Continue Reading:
The Future of Pain Management: An Experts' Roundtable
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