Episode 63 | Dr. Mark Bicket – Update | THE CHALLENGES OF OPIOID THERAPY

Mark C. Bicket, MD, PhD, F.A.S.A  is a pain physician and anesthesiologist at the University of Michigan, where he directs research on pain and opioids and still sees patients every week. His work helped reveal both how over-prescribing opioids after surgery fed the broader crisis and how often pain goes under-treated, and he now runs large real-world studies, designed hand-in-hand with patients, on how to treat pain more safely and humanely.

See Dr. Bicket’s links below:
https://medschool.umich.edu/profile/7161/mark-bicket

PainGuide – Self Management Program
https://painguide.com/

Transcript

SPEAKER_02 0:00

I think we're emerging into a time where, you know, we've kind of gone one way, we've gone the other way. Um, we're recognizing that there is no quick fix here. Um, you know, my take, uh, at least on prescription opioids, like these aren't good or bad medicines. These are medicines just like every other type of prescription or treatment that we have in the medical setting that we can offer where um they have risks, they have benefits, and we need to consider them as they are appropriate for individual patients. And um, in our public discourse, we may have lost a little bit of sight of some of these nuances that really needed to guide these clinical interactions.

SPEAKER_06 0:41

Dr. Mark Bickett is a pain physician and anesthesiologist at the University of Michigan, where he directs research on pain and opioids and still sees patients every week. His work helped reveal how over-prescribing opioids after surgery led to broader crisis and how often pain goes undertreated. He now runs large real-world studies designed hand in hand with patients to understand how to treat pain more safely and humanely. As always, I can be reached at Afton at Aftonhazet.com. Hi, Mark. We just had such a fascinating conversation at lunch the other day that um given your work and and what you're doing, we thought it would be great timing to have you on the show. So I'm just delighted to have you come by the podcast. Welcome.

SPEAKER_02 1:33

Thank you so much, Afton. It's been really great to listen to the show and also work with you here.

SPEAKER_06 1:40

Thank you. Thank you. You've just you've been a terrific addition to the team. And so um I think people are really gonna enjoy what you have to say. So um we always begin our podcast by kind of setting the stage. I I the listeners really enjoy kind of understanding who our guests are and kind of how they got to where they are. And so, can you give us a sense of you know what brought you to this point of becoming a physician, an anesthesiologist, somebody who does pain research and so on? What brought you here?

SPEAKER_02 2:12

Yeah, that's a great question. And everybody has a story to share. Um, you kind of captured the quick version being a pain physician and anesthesiologist here at Michigan who studies um both clinical and um health services research. Um, and I still enjoy seeing patients uh every week. So um how I got here, um I'm originally from Oklahoma and kind of grew up in a probably a little different um perhaps line of work than a lot of individuals helping out on my grandfather's cattle ranch.

SPEAKER_07 2:46

Wow.

SPEAKER_02 2:47

And so um, you know, had certainly seen a few different varieties of what um the future could look like and got really interested in um the sciences, um thought about going into medicine, have a family member who who's also a physician and um has served as a role model for me and um got fascinated with the field of anesthesiology for a couple of different reasons. Um, but it was really some time in the pain clinic that um kind of opened my eyes to a lot of the evidence gaps that patients are facing, that also questions that I have when it comes to how our pain medicines work, what are the pros, what are the cons, and how should we be approaching them? And that really was what motivated me to kind of take off into a career focused on asking these questions and trying to provide answers, both like to the patients that I see in clinic and also to the kind of broader public as well.

SPEAKER_06 3:43

Yeah. Thank you, Michael. First of all, I didn't know about the cattle ranch, so that is absolutely intriguing to me.

SPEAKER_02 3:48

So I'm yeah, it was great. I mean, we got paid a nickel a bale for all in hay. Summers in Oklahoma. I remember counting up uh how many bales of hay you'd have on every load, and you'd want to keep good track of them because that that was how you got paid.

SPEAKER_06 4:04

You needed you needed your nickels, understanding.

SPEAKER_02 4:06

There you go.

SPEAKER_06 4:06

Yeah, no, I grew up around horses and uh it's you know, it it is a different world, but I I know the smell of hay and the feel of a bale, and and it's funny how we find our ourselves to these places.

SPEAKER_01 4:17

That's right.

SPEAKER_06 4:18

So um you did pick an opportune time to do the work that you do, right? You were kind of on the coattails of what was a very ugly chapter in our medical history. You know, that was the you know, opioid overdose epidemic. So can you kind of bring us up to date? Where are we now?

SPEAKER_02 4:39

Yeah, it's a great question. A lot of people in the field have detailed, you know, the backstory that had existed even before I had really even started my training and some of the repercussions from it. And so while I won't get go into that whole um kind of like line of work, because I think a lot of these other authors and individuals have have served it well, you know, I came in at a time where the field was starting to question some of the perhaps over reliance and um really overemphasis on prescription opioids as the main way to address what was being perceived as a more important issue, uh, which I think we all would agree that pain merits discussion, merits treatment. Yeah. Um it just happened that it was getting uh done so in a fairly both prescriptive and maybe narrow way. Um what we know now, right, is that uh pain, and especially for people who have chronic pain, right, um this aspect of you know, it impacting individuals' lives, it's multidimensional. And so any way that tries to simplify that beyond these many domains that it impacts is likely going to skip some corners or maybe cut some corners, uh skip some skip some steps.

SPEAKER_07 5:56

Yeah.

SPEAKER_02 5:56

Right. And not necessarily lead to the uh the best treatments that we could. I I think we're emerging into a time where you know we've kind of gone one way, we've gone the other way. Um we're recognizing that there is no quick fix here. Um, you know, my take, uh, at least on prescription opioids, like these aren't good or bad medicines. These are medicines just like every other type of prescription or treatment that we have in the medical setting that we can offer where um they have risks, they have benefits, and we need to consider them as they are appropriate for individual patients. And um, in our public discourse, we may have lost a little bit of sight of some of these nuances that really needed to guide these clinical interactions. And so um in order to help that, we still have a number of research gaps and just basic information that you know is challenging for uh the field to share with both the clinical community, with the patients listening to this podcast, with others. And so a lot of work's still to be done.

SPEAKER_06 7:00

You bring a um a sane approach, right? I think that there's been a lot of reactivity around the opioid question, and and rightly so. There were harms, there were dangers, and there are also harms and dangers to patients who have benefited. So let's kind of look at both sides of the story. So about a year ago, uh the FDA released data that really detailed the kind of the potential harms of long-term opioid therapy. I know you've you've written about this, but let's just start initially with what did they report?

SPEAKER_02 7:33

Yeah, the meeting that um kind of unveiled this um information uh showed some studies that were um required by the FDA of opioid manufacturers. And uh it goes back several years to a requirement that the FDA had for some post-marketing studies done on prescription opioids. And so they had tasked the opioid consortium with basically designing what they perceived to be well-done studies or using rigorous instruments to understand what are rates of opioid misuse, um, opioid use disorder, other challenging opioid um related harms that um come about. And this was specifically in the setting of long-term prescription opioid use. So these are individuals who typically get it for, you know, we think of more than 90 days of prescription use and who continue on there. And so um then they all had also used some other data sources to look at rates of people um passing away or dying based on if they got exposed to long-term prescription opioids or not, and kind of what the rates look like for that. And so, in sharing the data, um we had the opportunity to evaluate how the studies were done and then ask questions about it. And these rates of um opio use disorder of opioid use certainly seemed to be a bit higher than what we had known in prior studies out there. They helped to kind of like pinpoint the risk. Um that being said, you know, the I think the clinical community and patients um who've had interactions with the healthcare system have known that this this harm or this risk discussion has really been emphasized in the last five to ten years. And we now have really precise data on what the harms are like. Um on the flip side, what we don't really have right now are the supporting studies for that complement of that. And the complement is like, what's the benefit? How well are people doing on it? And so there is still an outstanding post-marketing requirement that they have to generate a study on that topic. Um most of the studies that we have right now kind of go up to about nine or 12 weeks to show benefit in that regard. Um, and that really challenges, I think, the conversation. So if you're a patient with living with chronic pain and thinking about prescription opioids, um, you know, we have great data on harms. It's challenging to have these similarly detailed conversations on what the benefits look like. Um we do, you know, I'm in the pain clinic and hear from patients, right, who benefit from this and um express their descriptions of look, my functions better. Um, these things are happening. And so, you know, it's it's a little bit of a disconnect between the fact that um individually I can hear from a patient who tells me about the benefit, and then out in the landscape of the research studies that are out there, it's it's tricky to find these well-done studies that um help line up with that patient experience. And so certainly that's again an active area right now where there's probably gonna be more written after this conversation about it.

SPEAKER_06 10:47

And and and thank you for that. And and it's true, it's it feels like the pendulum has swung so far to the other side that you know opioids are being held back from people who very well may be benefiting. And so those studies that does help us maybe do a better job of identifying who those patients are could be incredibly helpful, right? So we know the harms, we have oodles of data there, but can we learn more about the benefits?

SPEAKER_02 11:16

Yeah, I think the the group that I have the biggest concern about from like a just a health standpoint is probably people who are on prescription opioids now in our health system, because um it's been clear that um through several kind of different lines of evidence, no, none of which is like really causative, but many lines that support this. Um, you know, it's one thing to start someone on prescription opioids and that initiation. Um on the flip side, I think we're hopefully we're merging into um uh uh an area where a viewpoint for someone who's on prescription opioids, they've been on it for several years. Their physician has prescribed it and they have a therapeutic relationship there. Um, you know, peeling someone off or saying that, look, you're no longer gonna receive your prescription opioids. Um, that itself, you know, hasn't always been viewed as an intervention or as you know, uh people think about, okay, well, we're just gonna uh stop a treatment or take it away. But this in effect is is also changing someone's care and can lead to harm. And there's a greater appreciation now for that. Um certainly, you know, some individuals listening into this podcast or uh others may know someone, right, who's gone through that experience or or had that, but even having tragic outcomes that come from that. And so um, you know, these two groups need to be thought of in a very different way, even though it's the same medication. And I think that goes back to this idea about this nuance where um you know things are just not as simple as um kind of, oh, it's good, oh it's bad. And in this case, you know, actually pulling back from the prescription opioids um is a harm into itself that we we may need to think of, or it has a risk to it, um, and and is a question that really needs to be thought of and considered on on a very case-by-case basis. And and this is some of the conversations I have in clinic as well, where you know, if someone does want to come down, but they're having challenges, what can we do?

SPEAKER_06 13:10

So And that I think is so useful for clinicians to think about too. That here you have a patient comes in, they're on four years of uh opioid, long-term opioid therapy, yet they have very high levels of pain and a lot of side effects, but they say, hey, if I'm not on these opioids, you have no idea how bad it is, right? So, you know, what do you do for that patient? I mean, you know, you don't want to say, hey, well, let's take away your opioids. You know, you say, well, you clearly believe you're you're benefiting on this, but I wonder if um maybe there might be an option for you. Do you ever have people just taper down like an experiment and just see how they feel on the other end? And then maybe that point decide whether to continue long-term opioid therapy or try something else. Have you doing it?

SPEAKER_02 13:54

Yeah, it's it's a great question. You know, one thing in our conversations today, you know, we need to be clear as a physician, right? We can certainly talk about examples in clinic um and just need to recognize it's different than clinical advice for listeners out there, which you know, as everyone probably is aware of. But um, you know, the approach here is probably actually pretty similar to most of our approaches with um analgesics for chronic pain. And so, you know, one way to broaden out the conversation, um, there's been a lot of use of other prescription analgesics. Um, there's a whole question about, you know, how is GABA penton prescribing doing right now for chronic pain? Right. Um but there are other um longer-term medications that um have stronger lines of evidence for certain types of chronic pain out there. Um, and with all of them, you know, it makes sense after being on them for whether it's a period of a few months or someone's been on them a year or two, to understand what it is like. Is that medicine as a providing a therapeutic benefit that makes a lot of sense? Um I've at least had several experiences with patients who've been fortunate to have their chronic pain intensity resolve over time. Um, and we did not know whether that was actually due to the medicine itself or just changes in their physiology over time. And so um, in some cases, we've done some of these dose reductions, again, not just of prescription opioids, but maybe gabapentin, maybe something else, and um have found that they find their pain levels actually stay about the same and their functioning is still doing well as well, too. So it's not necessarily to say this works for everyone, but um there is a time to kind of call into question under a you know fairly stable course saying, Oh, are these medicines really really needed? Um and you know, for those who have the ability to uh function well without them, sure the risk-benefit profile is a little different. Um, you know, it's not here to say, look, across all the medicines, we need to discount all of them. They serve, you know, uh very helpful functions for many patients out there. And so both things can be true at the same time. And I think that's one of the challenging things. Um this isn't necessarily like an anti-medication statement. It's just uh, you know, oh, we just need to check in and ask some fundamental questions here and make sure that the patient is truly being served because um they can be both served by the having the medicine available and by, you know, seeing if that medicine is still needed.

SPEAKER_06 16:24

Right. Thank you for saying that. Um so I'm not a physician, but my understanding is that typically almost with any medication, everything from you know, from hypertension to antidepressants, that there is uh a goal of having people on the lowest levels that they can still benefit from, right? Just to reduce side effects and to improve function. And so I don't think that you know analgesics necessarily are any different than that. You know, you know, wanting to experiment to find, you know, the the best dose for one where you can balance side effects and and so on with um with benefit.

SPEAKER_02 16:59

That's right. And you know, for the listeners out there, we know pain, like we've mentioned before, it's this multidimensional, uh many, many different inputs to it. And you know, the prevailing view about it is that um we certainly have nervous system contributions to it. Um this is a involvement of the brain and our nervous system. And because of that, these side effects impact that organ that we have and um can lead to whether it's sedation or um in prescription opioid cases, you know, the these other well-known side effects and and adverse effects that have happen on a on a very population basis level. But um the those two things are intertwined and it's been challenging to separate separate those two for for some time.

SPEAKER_06 17:45

Yeah. I love your approach though, Mark, because you come at the kind of the opioid question in such a sane way, right? It's like we understand the harm. So really let's do a better job of understanding potential benefits. Who benefits, what are the benefits? Um we don't want to throw the baby out with a bath water, right? So what what it what what do you think needs to happen next as far as uh studies to help us understand more about potential benefits for long-term object therapy and chronic pain?

SPEAKER_02 18:16

Yeah, it's uh it's an interesting question, and I think one where um, you know, we have fortunate we're fortunate in the United States to have some groups that fund comparative effectiveness research, and they do make pain a priority for that. Um and so one of the kind of uh biggest players in the United States right now is the patient-centered outcomes research institute. And so this is a group that um started a few years ago whose real mission is to generate evidence that is actionable by um key stakeholders, right? And so patients are kind of one of the prime groups here, not the only group. Um, but they do, you know, wonder about uh informing other audiences, whether it's policymakers or perhaps clinicians. Um but at the heart of it really is this like centeredness on the patient experience. What are the gaps and what questions do they really need to know about?

SPEAKER_07 19:11

Yeah.

SPEAKER_02 19:12

And so it's not just necessarily that long-term goods are the only, that's the only place for them. Um, but this is a group that um has made pain a priority, which is a wonderful thing, I think, for listeners of this podcast to know about and and track as they continue to fund work um that's meant to really benefit um all Americans.

SPEAKER_06 19:31

Yes. And and and we've talked about Cory. We've talked about it in more the the uh jargon version of the name, but it is an absolute critical finder, especially for comparative effectiveness research, to you know, really understand, given A or B, what is better, and also in terms of what is better by patient standards, right? What we all put judgments on what is a good outcome, but patients may have a different view of that. You have a number of PCORI studies.

SPEAKER_02 20:01

Yeah, it's it's certainly important to note, you know, besides some funding from uh the National Institute of Health and the state of Michigan, um, that uh PCORI is one of the groups where I do lead two different um projects that are related. And they they are um touching on questions um about prescription opioids here. Yeah, the questions are shifted a little bit to um kind of an earlier question than about prescription opioids for chronic pain. Um and these really um are meant to help understand um the need and kind of benefit and risk of prescription opioids for um acute pain, and particularly acute pain for certain cases after surgical procedures. Um in these kind of uh key procedures that we've chosen with the help of patients, uh this questions come up. You know, guidelines recommend somewhere between zero to five pills or zero to ten pills. And um, it's a bit unclear to everyone, okay, say you do the five or ten pill option. What are people's outcomes? We'll say you do the zero pill option. And so this is a very natural point in the United States now to help answer this question. Um, you know, it's been really interesting to design these studies, um, to perform these studies, and and we're about to get some results probably in the next, you know, whether it's 12 to 18 months from a couple of them, um, with a set of partners along the way, besides just our typical research team. And um these are some of the stakeholders I spoke about, which include patient partners. And it's been really great to um involve them, not just as like someone who comes and joins the study, but someone that we dialogue with actually through, you know, okay, hey, we're asking these key questions. Does this make sense to you? Like what matters to you? Um, and so you know, there have been a few surprising things I think we've learned along the way that have really shaped our research that, you know, otherwise without them, I I don't think we would have really Emphasized as much.

SPEAKER_06 22:01

Yeah. So our our listeners have met some several of our patient advocates, Chris Feasley, Tom Norris, who um actively, you know, help us with our research and and from a very um skilled but also um caring standpoint, right?

SPEAKER_02 22:19

We yeah, I that's it's amazing to hear from them. And you know, I would encourage any listener here to go back and hear their voices on that podcast about their experiences with it. And from my standpoint as someone who leads a study, it's also really important for me to share that um there are individuals who like I I've spoken with with Chris Beasley at a couple of meetings, um understanding about the pain landscape and care and like so sophisticated. And um, and that is helpful, and that is a important perspective to have when you're building a study. But also on the flip side of other patient experiences out there, you know, many listeners on this podcast are likely in prime position to serve as a stakeholder. And I I just want to make sure that there's this uh kind of dispel the myth that somehow um you need to have any more experience than just your own lived one to come and actually help along the way. And that if you do have the opportunity as a patient to um provide input or serve in one of these capacities uh and it makes sense, I I would certainly strongly consider that because um it is very important for us to have a lot these different perspectives out there. And in particular, not everybody has that level of sophistication or training that the Chris Chris Wiesel does. And that actually is important and it's a very helpful perspective because we don't want to make assumptions or skip steps that um are gonna help when we go to explain our work and show its relevance and make sure it's meaningful for people's lives at the end of the day. Um because if we're not doing that, then we're we're definitely you know need to need to make sure we're in the right frame and approach um to maximize the opportunities that we have to make the most of these studies.

SPEAKER_06 24:09

And kind of goes back to the question of, you know, why we do what we do, the research that we do. I mean, it always comes back to the patients that we hope that we're answering questions, that we're seeking um knowledge in areas that actually matter to the people who live with these chronic um symptom diseases and and chronic pain. Um yeah, I you know, I I would encourage anybody who has an interest because they really we have our patient um advisors are everywhere from you know, physicians who actually are also have chronic pain to people who really know next to nothing about medicine except that they've lived with these conditions and know what it is like and have friends that you know also live these conditions and just have a sense of how life is disruptive and and what works and what doesn't work and what messaging is helpful. And so, you know, we we love our patient partners. You you know, please, anybody, you can reach me at aftonhassid.com. Um always help help happy to funnel you to uh to um people who can benefit from from your knowledge.

SPEAKER_02 25:14

Um Yeah, it's certainly really important for the community to have that awareness um and to understand that what that engagement is like and that um you know you don't you don't need a sophisticated degree to make a meaningful contribution in these cases and really um you know these perspectives are so helpful to us, again, to make these results more meaningful. You know, I I just uh kind of mentioned that for one of our studies we were starting out um, you know, a study again, looking at kind of how well do prescription opioids work for pain after surgery. And um we knew we needed to focus on, you know, how are people's pain scores? This is an acute pain study, so the pain number here is perhaps a bit more central than you know, we might make it for like a chronic pain study. Um, and so we had shown our outcomes to a group of um uh uh panelists who are, you know, patients who've either gone through the surgery itself or um had someone that they know, family member who went through it. And um the the really surprising thing to us was that um as we started to unpack, you know, how their days after surgery went, they'd say, like, yeah, oh, I remember this this pain on the first day after surgery. It was really intense. And then um about half to like maybe two-thirds of the group very quickly then shifted to like, yeah, I took these pain medicines and then I just felt awful. And the the impact of side effects, it's been reported in the literature, but like but these these stories that were shared with us um were so impactful in shifting our framework to um really better track side effects. We were planning to do it anyway, but much more as like a secondary or even you know, kind of just safety outcome. And um, the more we kind of it's like layers on, and you start peeling back a little bit, you don't know which maybe you're gonna find in there. Um maybe the better analogy is like the the thread that you just start pulling and it's kind of like where's this gonna take us? And um we did a another round of more either one-on-one or uh uh, you know, other panels and can very consistent signal in speaking with these patients who, you know, oh, if we hadn't heard that story, this study would have been designed very differently. And um, you know, again, we don't necessarily have results on this yet, but um, you know, that we were so impressed by what our patients, stakeholders had shared with us. Uh, we ended up um, besides pain, making our like the key safety focus um in the first few days after surgery, focusing on these side effects because they were so debilitating. And so so it wasn't just a measure of like, did you have a side effect? But it was like, how much does it impact your life? Right. And so um, to us, that really fundamentally changed how we approached that study. And um, you know, in retrospect, it sounds kind of obvious now, but at the time, you know, we kind of have have a perspective that we take on it. And um so thankful for giving that perspective and the individuals who shared their time with us um so we could course correct and really like sharpen our approach again to make it more meaningful and relevant to what their experiences that they shared with us were like. So again, we'll have the results that are coming out. Um we obviously don't know them because we can't look at the data until the until the study's done. But um, for one of the studies, we are kind of in the last like about, you know, um one uh 10% of the study or about 100 patients and um hopefully going to wrap up that enrollment in the next kind of six six to seven months. So excited for that to happen.

SPEAKER_06 28:40

Is that cares for kids or is that your other study?

SPEAKER_02 28:44

Um that's the uh yeah, that's the the one that's um in the adult population.

SPEAKER_06 28:47

Okay.

SPEAKER_02 28:48

Um and that was kind of the the first one that we started called CARES.

SPEAKER_07 28:50

Yeah.

SPEAKER_02 28:51

Um and then we we are running a kind of a parallel study um asking us a similar question, um, a slightly different group in this one adolescents and young adults. And that's the Cares for Kids study. And it's it's been a lot of fun to engage with um both parents as well as adolescents or representative adolescent groups. Um, a lot of enthusiasm, a lot of great ideas. Um, and they've really helped us connect well with um this really important group of people who are undergoing surgical procedures at like a very key time of life, right? Um, which, you know, are individuals who are, you know, perhaps perhaps they're, you know, in high school or college or um just starting out with work or things like that. Um, really key time of their life to have surgery and then um understand what their pain management after surgery is like about, you know, are they going back to school? Are they going able to go back to work? Um how does that look like? Um, how does this influence their lives? And and in that one, we follow them out for 12 months after their procedure. So um it's been great to collaborate with uh groups, you know, whether they've been in Los Angeles, at Children's Hospital Los Angeles, um at um Stanford is another group, and then um at Nationwide Children's, and then we're expanding to a few more sites and it's really excited to work with these groups um and continue to engage with our partners as we do that research.

SPEAKER_06 30:22

I love that work that is so exciting because I don't think enough is done with this you know, adolescent, young adult subpopulation. Any take homes, just you know, even anecdotally observations, what makes these younger folks so much different than older folks, other than maybe this is a really transition point in their life often, but anything that you know just kind of strikes you?

SPEAKER_02 30:45

Yeah, you know, um they certainly do have so many years ahead in terms of you know what an exposure could mean from either both potentially benefit or harm. Like we don't want pain undertreated for sure. Yeah. And you know, I think it's a key question of like, is that happening? And are there certain groups where, oh wow, like you know, it's standing out that their pain numbers and and their need for certain types of analgesics may differ from uh kind of a different group that says, you know, oh I'm I'm doing well that way. Yeah um you know, their um interaction and function has has been um great, both of them, both groups have used a study app. And you know, obviously many of the um groups who are in the teens and adolescence, you know, totally facile with this like, you know, let's use the phone to record, oh I gotcha. Yeah, we don't need we don't need uh much instructions or or things from that regard. Um but it's been it's been nice to both engage with them, and then typically uh, you know, for those who are under 18, we engage with a caregiver for them as well. And um, it's kind of been this tag team um to help us along the way. Um we've been super fortunate to uh get good advice about ways to engage with them. And so, for example, when we send them study reminders, you know, we obviously we're not trying to be you know super annoying, but uh we do need that data really helps us out about how their pains do and what their side effects that they're having. And uh to date, we've been really fortunate getting some really solid responses back. And so um the engagement that we've seen there has been kind of top-notch and kind of one of the one of the wonderful, I think, benefits that has spilled from other advice as we've conducted the study from this stakeholder group as well.

unknown 32:27

Yeah.

SPEAKER_06 32:28

So is your primary outcome transition from acute to chronic pain? Is that kind of where you are most focused on these in these studies, or what what is the uh primary focus?

SPEAKER_02 32:39

Yeah, so there's um kind of uh we declared kind of two um outcomes that were kind of of equal importance to us based on these conversations. Yeah. Because we took those conversations from adults that we had and used those to inform and accelerate our conversations in the one in the conversations we had with the cares for kids, both patients, stakeholders, and and caregivers. And the stories were very similar. So this seemed to be more of a universal uh aspect to people's recovery after surgery. Um one we've certainly mentioned about this need to focus on you know how intense is the pain, and in particular in the first couple days after surgery, is when we hear from most people about it. Oh, this being the the height of that experience and impacting people's function the most. And then the uh at the same time, we elevated this, you know, um, adverse effect, side effect from the medication or or what they were experiencing, what they perceived to experience uh have from the medication um as the primary safety outcome. And so we consider both of those kind of co-primary outcomes for those studies.

SPEAKER_06 33:47

Great. Good. Well, thank you. And good luck on it. I I'm excited in the next 18 months or so to see some results.

SPEAKER_02 33:54

Yeah, it'll be it'll be great to um both get the results back. Um and then, you know, it's also interesting because um, you know, we check in with the stakeholder groups every few months on the products for the study. And then also uh, you know, soon we'll be able to share with them some of the preliminary results and get their help in terms of the best ways to explain this and frame this for people who are coming through. And so um it's nice to be able to feel like we're moving a little bit outside of the traditional um academic spheres, right? Where we might publish a paper and and really help this data connect back with uh communities where it needs to um land and and perhaps have larger impact than uh just you know find finding that journal on the shelf that uh might want to publish the study.

SPEAKER_05 34:41

There are 86 billion neurons in the human brain. Complex networks connect these remarkable cells so we can breathe, move, think, communicate, and feel pleasure, and pain. Changes in some of these brain networks are thought to underline chronic pain, but these networks are not part miner. Stress, sadness, fear, and loneliness can affect brain networks and make your pain worse. But healthy eating, sleep, and exercise can help your brain make new connections, and so can mindfulness, joy, friendship, and love. Because this is true, the power to create a new tomorrow with less pain and a more rewarding life already resides within you.

SPEAKER_04 36:00

Dr. Hassett's book, Chronic Pain Reset, can be found on Amazon and independent bookstores everywhere.

SPEAKER_06 36:09

That's all we really hope for. Well, you know what? We'll have you back on the podcast if you'll if you'll join us and you can talk about your results and hopefully it'll get to more and different ears.

SPEAKER_02 36:18

That's right. No, that'd be great. Thanks, Afghan.

SPEAKER_06 36:20

I think we're heard in 119 countries and territories now, so it's kind of exciting to uh to ha have that kind of reach with especially when you're doing such important and remarkable work, Mark.

SPEAKER_01 36:33

Oh wow.

SPEAKER_06 36:34

So for our patients who have to deal with clinicians and and uh insurance companies and you know living with chronic pain every day, um do you have any specific advice for them in their own care for their chronic pain?

SPEAKER_02 36:54

Yeah, this is um uh certainly a large topic. And I know um, you know, we talked today about some of the challenges that we have when it comes to offering solid evidence, um, great advice as it comes from you know, grounded in uh the studies that we have. Um, you know, I I don't want to dissuade anyone from a reality that, you know, one of the um you know strongest elements for an individual patient can be that relationship that they have with their clinician, right? And that um at times that can perhaps serve in a therapeutic purpose, right, um, on par with some of these other treatments that we have to offer. Um and, you know, we're doing, I think, a better job of opening up the um treatment space in chronic pain. We're seeing more studies done with um interventions that address kind of the whole person that tap into this idea that you know pain builds on this biopsychosocial approach. Um, it's important to be very clear, right? This doesn't mean pain is just in your head and made up. And I've I know you've had listeners, I'm sorry, you've had guests on who've really like nailed those points home, but these are worthwhile mentioning because that message isn't out there in all corners of the world just yet.

SPEAKER_07 38:14

That's right.

SPEAKER_02 38:14

And it's a very real experience. And um, while there are ways to adapt and change that, that's that's not under anyone's conscious control. And you know, uh, I know from seeing patients in the in the clinic, right? This isn't uh just some condition that is just in someone's head. These are this is a it's a real manifestation uh pathophysiology that's happening here. So um for patients, you know, I I think it it always helps um in terms of coming into interactions, having a plan. I find that from my perspective when I've seen the patient and some of the patients I've had that um seem to gain the most out of our visits will often come in with their set of questions. Um oftentimes, you know, we've helped to focus on like what are the key um things in life that they really want to do? Um and in kind of what is it that is standing in the way of doing that. Um and so sometimes that certainly could be a pain. Sometimes it's that that could be the side effect from the medication, sometimes that could be some other aspect that um we need to help kind of craft and individualize that treatment plan. And so a lot of this really does help come down to facilitating some of these interactions. I'm certainly well aware of how quick, right, um some of these clinic visits can be, you know, in in our health system. And so um, you know, answering this question, you know, what is it you want to be able to do um, you know, really that helps ground in this very, you know, clear aspect of where things should flop follow from and helps establish, you know, kind of clearly and concrete ways what what people's goals are.

SPEAKER_06 39:50

I I think that's really important too, and what's important to the patient. And you know, my suggestion is always go in with what you want, know what it is, and tell your clinician what you want. And if it's doable, you'll figure out a way how to do it. But um I um I think it's sometimes it's just hard to communicate, you know, I want X and I would feel feel better if I could do Y. And, you know, and it's a million things you don't want to bother the doctor, or you don't think it's important, but you know, sometimes people just want to get back to their lives. And that can be a really wonderful goal. How do we get back to pieces of life, pieces of the life that feel meaningful, and rather than just kind of surviving and paying bills and doing all the things that you have to do, being able to do things that feel rewarding is important.

SPEAKER_02 40:39

Yeah, it's certainly really important to think about what these future phases and stages of life look like and um what what can be done, what what would you know someone like to emphasize and really focus on and um you know, create things where where they can look forward to um going through whether things might change just a little bit or maybe consider something else new. Um these are certainly really important conversations for individuals to have with their clinicians.

SPEAKER_06 41:07

Thank you for that, Mark. And before I let you go, I also want to talk a little bit about the work that you're doing. You study cannabis and um and its use in chronic pain. And right now that kind of feels like we're reheating the opioid epidemic question and all that angst. Um, where are we with cannabis and chronic pain?

SPEAKER_02 41:27

Oh, wow. Yeah, what a question. Um, you're absolutely right that this has been a key question, I think, understanding um, you know, we've had a changing relationship with the acceptability of cannabis um in recent years, many states having, you know, first medical and then recreational access to it as well. Um, you know, even in April of this year, we've seen uh kind of uh changes. It's certainly a dynamic environment. I thought it was dynamic a few years ago. And um with some federal rulemaking, right? We're seeing reclassifications of medical cannabis as a schedule three, I think. This is the most current one, but with any podcast, we know this could change very well in the future while the recreational is staying schedule one. That's a whole big way to say that it's again quickly changing. Um it's certainly challenging even for leaders in the field to keep up with some of these policy changes and their impacts. And the way that translates, I think, for a lot of your listeners is that the average clinician out there may not have full awareness of how these things are shifting and impacting. Um, you know, what is the takeaway I have from past experiences that kind of make us think about cannabis and challenges that we've had with other pain treatments in the past? Well, I you know, we we really need to pull back from this idea of like this being an all-good or all bad kind of thing. And really things are going to have risks and potential benefits. And um as a clinician, if without evidence to guide us, it is a little bit like feeling in the dark about making recommendations. Um, here again, we can speak to some of the challenges and some of the risks we know when it comes to cannabis exposures. Um, these also have a really important key link to someone's age, it seems like, with earlier exposures being much different given how long it takes the brain to develop executive function, other things like that, um, compared to function perhaps later in life. Um a lot of people do experience chronic pain.

SPEAKER_06 43:31

For younger people, what what what is different in how the brain um reacts to exposure to cannabis compared to an older adult?

SPEAKER_02 43:39

Yeah. Uh and you know, uh from a kind of brain development standpoint, our neurology colleagues will talk to us about this ability of um kind of the basic cells of the brain called neurons to kind of adapt, change, and learn. And kind of a fancier way to talk about that is this idea of neuroplasticity. And so individuals as they're going through in growth, you know, while their their you know general physiology may be um being mature in their teens or um you know early maybe early 20s, the brain is still maturing in terms of um these kind of links that it's having. And so um really any any type of medication that's gonna impact how those nerves function um is gonna perhaps you know have a more profound impact because those neurons um are a little bit more changeable or malleable in that way. And so that's just a very you know general uh description of of what a more uh complex process underlying um human development is. Um but that's why this exposure that happens at a younger age is thought to be uh perhaps at a much more uh vulnerable time of life than perhaps someone who is more senior or has more lives uh years lived on on Earth right now. So um, you know, I'd say, you know, from a standpoint of being a clinician, it we can have challenges in clinic talking about, you know, am I aware even of, you know, people will come in and ask me questions of, hey, you know, what what do you recommend about these cannabis products? And um, you know, even with the recent rulemaking changes, it's hard to uh be give specifics about either, you know, the formulation, the dose, these other things, because many of the state products have not been um tested or examined in studies. Um and um that being said, you know, we we do have individuals who certainly through um their experiences report to us that hey, it's helping out a lot with this aspect, that aspect. And when we do surveys of asking patients about, you know, what's the most common reason people use this? A lot many people will tell us that it is because of chronic pain, among other conditions that they have.

unknown 45:57

Yeah.

SPEAKER_06 45:58

But pain certainly dominate. And and I'm gonna ask you just to back up and provide another definition for our non-clinician or researcher uh listeners. When you talk about Schedule I and Schedule Three, talk a little bit about what Schedule I versus Schedule III means and how that change um reflects kind of the zeitgeist of what's going on.

SPEAKER_02 46:16

Great. So from the standpoint of um drug prescribing in the United States, um typically clinicians um need to have what's called a controlled substance license to prescribe things that are uh have therapeutic potential but perceived to have greater risk than the typical medication that's out there. Um and so the risk that these medications have is perceived to be greater than just you know what's available over the counter or even other things that could be prescribed. Um the risk is not all the same among drugs that are perceived to be riskier than those in general. And so um there's a kind of a ranking system for them in which um they call it the schedules, and they generally go one through five. And so um at schedule one are things that are deemed to be um both risky, um, perhaps have some um likability or addiction potential, um, but also have no therapeutic purpose. And so um this is where cannabis had been for quite some time. Um schedule two, schedule three, schedule four, schedule five, these are perceived as being risky. Um, these are also perceived as having therapeutic value. And so um, you know, in April of 2026, what we saw from the federal government um was movement for um at least what looked like um medical cannabis products to go into the schedule three um category. And the recreational products, which um are just consumed without that medical certification by the states, um, remained in the schedule one. Um what that um uh helps in a sense is uh, you know, our ability, Schedule I has a number of restrictions that go with it beyond even the restrictions that come along with just a scheduled substance. Um these matter clinically, but they also matter um from this. Can we generate better evidence for patients and Americans out there because of the hoops that you have to go through as a researcher trying to use a Schedule I substance versus another subject, another substance that says, okay, there's a therapeutic potential. Um, this does give us a boost in terms of uh having a little bit less paperwork to do when it comes to um studies that will clinically compare um perhaps medical cannabis products and help, you know, perhaps uh in a year or two when we chat again and we ask that question, you know, I'm in the clinic and someone comes up and says, Can you give me evidence about this uh you know medication? Um, how is it gonna, how's it really compared to another? I'm maybe, maybe we can answer that because these studies will be a little easier to do. What we're seeing right now in general is that um some of the uh more recent studies about cannabis, whether it's THC, CBD products, or you know, others out there, um, are often coming out of some of our European um countries or colleagues where they're under a different oversight than the FDA. Um and so that's both health because we do see you know some studies showing promise. Um hard to kind of point to specific products right now that, you know, oh, we should really say, oh, we need this in the US market right now. But um that being said, you know, we do need similar studies in our populations. Um and that's one of the reasons why we have the FDA and one of the ways that um we're hopeful that this change could accelerate our ability to generate this knowledge and identify these products that we are hopeful will help people's chronic pain.

SPEAKER_06 49:44

Thank you. You explained it so much better than I could have ever appreciated that because there was a lot of jubilation kind of in the cannabis research community say, oh my gosh, now maybe we can do some of these studies that are really, really needed. You know, that's right. We there's there is promise here. We certainly anecdotally hear from our patients, and um, it's great that we're gonna be able to maybe do some of these important studies without all the restrictions and then well and I I want the information to obviously be timeless, but you know, we are in the kind of like late spring to early summer of 2026 right now.

SPEAKER_02 50:14

And so, like, you know, say, you know, it's it's a year's past or two years have passed. I mean, very well given how dynamic this is, we could certainly see shifts in other directions, um, whether it comes from different schedules or other approaches towards their regulation.

SPEAKER_06 50:29

It's exciting. It's a it's you know, it's it's a cool time to be a pain researcher, right? I I I feel like we're there's some really interesting work that's being done and we're making some advancements, and it just kind of feels like a hopeful time. So, well, before I let you go, I wanted to um ask you if there's any resources you would like to share with our audience, and we certainly can link anything that you mention in the show notes.

SPEAKER_02 50:51

Great. Um, you know, I I imagine uh based on some past uh uh speakers that you've had, uh some of our resources here at the University of Michigan have certainly been shared with others. But um, you know, I may mention them just because there are many times I will find patients in clinic who have not yet heard of them. Um, you know, and so for example, um the pain guide um that we have, right? Um it's hard sometimes to um explain that a free resource is sometimes one of the best ones that we kind of think about um that's out there, and that can generate some skepticism. Um that being said, you know, when it comes to the number of times I recommend that in the course of a clinic to someone who hasn't yet heard about it as a starting block and building block, that you know, those are the basics I think certainly to for for individuals to start with and then help go from there. So um, you know, other um resources, um, you know, I I would definitely recommend this being one of the conversations individuals have with their clinicians. I certainly um see a number of individuals who um we treat both in the pain clinical setting with kind of traditional analgesics as well as in perhaps a kind of like whole person approach, um, using uh you know things that aren't necessarily uh medications for their treatment. And I, you know, I I do like how those both interact with each other. And so some of these books that really detail approaches for individuals about mindfulness-based stress reduction, um, what meditation approaches, um, or you know, even the kind of meditative aspects that come from yoga are ones. And so um, it's not to say that one of those has to be the perfect all fit, but um it's kind of like more of like the sampling of the menu from the Zabat to the others about uh, you know, which ones may be the right choice for an individual patient out there. Um because even if they didn't work at other times of life, you know, they may be things that are worth revisiting.

SPEAKER_06 52:58

So that's true, if we're thank you so much. And we will go ahead and link those. Um as we wind down, I always want to see if there's anything we left on the table. Is there any question that you were hoping that I'd ask you that we didn't get to?

SPEAKER_02 53:10

No, overall it's been a wonderful conversation. I mean, you know, the um both the challenge and opportunity is the number of kind of open questions that are out there. Um we in the community are certainly very um optimistic about continued emphasis of the need for better evidence for patients who live with pain. That's both acute pain, but also chronic pain. It's important, I think, for people to recognize that as you know its own entity. And we we've seen a little bit of movement, but I think the field is only going to help refine and grow stronger in that way as the evidence becomes firmer. Um, I know for me, you know, uh some of the moments that really stand out are ones where, you know, I've helped someone who has started to have chronic pain at a key time in life, you know, perhaps figure out, you know, what's going on, what's the diagnosis, and how can we help chart their course forward. And many times that may involve a medication, it may involve something else. Um, but really, you know, helping them get a piece of their life back, helping them, you know, when they tell me, oh yeah, okay, my sleep's a lot better, or oh, I was able to make it to my daughter's wedding, you know, that certainly never gets old as a physician um in the pain clinic. And, you know, at the same time, when we see people for surgery and um maybe they're able to have their shoulder repaired and come out of surgery and are saying, Oh, yeah, it feels feels great. You know, no problem in the first 24 hours because we did uh either nerve block or nerve catheter. It's it's uh it's it's a great experience. So really appreciative for these opportunities and also being able to speak with you and listeners today. So thank you so much.

SPEAKER_06 54:50

Well, thank you so much. And just just a word to patience. Please tell your doctors when things go well. We love hearing it. There's nothing more rewarding than knowing that you're getting your life back, and there might be some role that we played in that. So well, uh last question for you, Mark. What brings you joy?

SPEAKER_02 55:06

Yeah, uh, you know, um, some of those more, you know, smaller uh interactions, I think that uh maybe I just mentioned, you know, one of them uh certainly certainly I remember having a a patient who is uh a nursing student who was having some chronic pain issues. It took us, you know, through a couple of uh evaluations to figure out um, you know, she had a diagnosis of fibromyalgia that was new onset and um helping that patient unpack that particular situation, right? And how to how to think about uh moving through, you know, what uh her training would look like, um what mattered to her, what her goals were and doing that um certainly is is one that stands out from the clinical setting. Um but even you know, two weeks ago um was at the surgical center and uh able to help uh some of our patients who are having um these shoulder surgeries, right, come through and have a better experience because we are able to offer them nerve blocks and and other sparing techniques that make sure that they have the fewest amount of side effects and still get pain control. So yeah, those are those are really, really nice moments, I think, for me.

SPEAKER_06 56:15

You are a good doctor and a great researcher and a ton of fun to hang out with. Thank you so much, Mark, for your time. Really appreciate it.

SPEAKER_02 56:22

Great. Thanks so much, Apton.

SPEAKER_04 56:25

If the Chronic Pain Research Podcast too has brought you some inspiration and hope, please consider joining the community of listeners to have helped find our production or support for us to keep creating content for those impacted by Chronic Pain or for the support the show link in our show notes in each episode. Today's episode was produced and edited by William Haskell, a powerful pilot just like you, one of a books, and a team at Venue by 4M. Our music score called Just Doc was produced by Bohemian Roosters. That's it for today. Join us in two weeks for another episode of Chronic Pain Music.