Pill First Pain Treatment: What Kentucky Needs to Know About Alternatives and System Change

Welcome to the Kentucky Pain Reversal Show. In today’s episode, we take a step back to examine the broader chronic pain and opioid landscape in Kentucky. Chronic pain has become not just an individual struggle, but part of a larger story shaped by medical, cultural, and economic forces. We’ll explore how the current system of pain management closely tied to long-term medication use developed, where it stands today, and what’s often missing from the conversation about real solutions. Joined by Dr. Nair, we’ll shed light on the evolution of opioid prescriptions, the impact of state interventions, and why pills remain the default for so many despite alternative options. This isn’t about blame; it’s about clarity, progress, and forging new paths forward in pain management for Kentuckians.

00:00 OxyContin's impact in Kentucky

06:53 Accessing and prescribing opioids

09:01 How opioids affect the brain

11:58 Understanding tolerance and dependency

16:00 Understanding opioid prescription practices

18:03 Why pain pumps are underused

20:54 Wrapping up with Dr. Nair

Podcast Website - https://thekentuckypainreversal.com/

Dr. Ajith Nair Clinic - https://kentuckianapainspecialists.com/

Media Partner - https://tophealth.care/

Transcript

SPEAKER_01 0:19

Welcome back to the Kentucky Pain Reversal Show. In the past few episodes, we've walked through how chronic pain develops from the initial injury to medications to early treatment decisions and even surgery. But today we're stepping back to look at the bigger picture. Because here in Kentucky, chronic pain isn't just an individual experience, it's part of a much larger story. So for many people, pain management has become closely tied to long-term medication use. And for a lot of patients, that path didn't come from poor choices. It came from following the system as it exists. So in this episode, Dr. Nyer helps us understand how that system developed, why it continues today, and what both patients and providers may be missing when it comes to long-term solutions. This is not a conversation about blame. It's a conversation about clarity and what needs to change moving forward. Let's continue. Hi, Dr. Nyer. Welcome to episode five. How are you?

SPEAKER_00 1:17

I'm doing great. It's a pleasure to be with you again.

SPEAKER_01 1:20

You as well. So we've talked before about how individuals get pulled into chronic pain, but today I want to zoom out and take a step back first. How would you describe the overall pain and opioid landscape here in Kentucky?

SPEAKER_00 1:37

Well, over the last few years, in fact, the overall opioid overdoses actually has come down. And it is kind of interesting that that's happening, but I attribute that to closer monitoring by the state government and more checks and balances in place. So things are getting better. There still are a fair number of overdose deaths in Kentucky, and a good percentage uh consists of prescription overdose deaths. So, but despite those numbers and figures, things are getting better.

SPEAKER_01 2:21

Well, that's great to hear. I mean, progress over per perfection, right? We're not going to solve the problem overnight. But it seems from what you're mentioning that it's trending in the right direction, uh, which is what we can hope for. And you know, there's still uh progress to be made and a long way to go, but at least um, you know, we are trending upwards to the right from from what you said. Right. Great. Kentucky's often mentioned uh when people talk about opio opioid dependence in the US. Uh, from your perspective, how did we get here? Why Kentucky?

SPEAKER_00 2:57

Well, back in the 70s, 80s, Purdue Pharmaceuticals came out with Opsy Content. And that was the beginning of the downward trend in Kentucky's opioid misuse and abuse. Um, when this drug came out, it was advertised to healthcare professionals as a very safe, very few side effects, efficient way to control pain. And so a lot of doctors were using it without understanding its huge uh dependency, huge abuse potential. This in fact was occurring quite a lot in rural Kentucky, especially in eastern Kentucky, where there are a lot of uh coal miners, and decreased access to health care. So they really didn't have access to uh specialized care. So their primary care doctors or general practitioners would treat any and every condition with a narcotic. So this started getting out of hand, and at that point, Kentucky ranked up in the in the top three or four states with the highest abuse and misuse of opioids. Now, since then, over the last uh decade, uh the Kentucky state government they've put in prescription monitoring plans, and you know, there's a greater awareness of the abuse. And one good thing that Kentucky has done is that it has used the dollars that were obtained from um lawsuit settlements with big pharma to do good, to try and set up programs to help people uh that are addicted uh to opioids and to try and help them rehab. So the the you know, the dollars have been used effectively to reduce the the death rates for opioid overdoses.

SPEAKER_01 5:22

Dr. Nyer, this is just mind-blowing to me. It's so wildly interesting that this started not so much as a medical issue, but a cultural and economic issue, talking about the the coal miners and their lack of access to proper health care. I mean, that's it's you know, you hate to hear that, but it's simply incredible to learn that that's where it started. Um, talk to us a little bit more about this cultural economic start of this issue and and exactly kind of what you mean uh by that more specifically.

SPEAKER_00 5:58

Well, so when these patients were being prescribed these opioids, uh, and then once the government understood that prescription drugs in the state was a problem, and then they started putting into place legislation, what then happened was another phenomenon. Because there was a reduction in access of these prescription opioids, a lot of uh patients or persons that were using these opioids now didn't have access. So then they turned to the streets. So now you've got another demand. And of course, when there's demand, somebody's gonna supply these drugs. And it came in the form of carfentinol, which is the illegal form of fentanyl, uh, mostly coming in from north of the border. So that opened up another can of worms uh with regards to opioid abuse.

SPEAKER_01 7:03

Well, tell us more about the the role that the physicians and healthcare systems and the reimbursement models played in shaping that pill-first approach to pain.

SPEAKER_00 7:13

Well, first of all, to access an opioid prescription would be fairly easy. A patient needs to have a pain complaint. And as I said earlier, I believe that most physicians are good people. When they have patients who complain of pain, they're gonna try everything that they know to help deal with the pain. And what we have readily available are prescription opioids. The problem is that patients can very quickly develop a dependence on these prescriptions, and inevitably they're going to require more of the medication. So even though doctors are coming from a good place, they want to help their patients, they write these prescriptions, there is sometimes a failure to identify who are these patients that are overusing, abusing, and maybe treating other ailments or issues with these opioids. So I think that that's one aspect of it. And of course, the access to alternative ways to treat pain.

SPEAKER_01 8:31

So I know we've talked about in past episodes, right? You know, once that we start treating the pain, then you need more pills in order to continue to feel the same level of relief, right? So that's kind of on perhaps not so much the fault or the culpability of the patient so much. It's just our biology uh as humans, which is fortunate that we have a solution, but unfortunate that you know it works in that way. But so the the patients are also still uh going back to the biology and kind of our humanness. Why are so many patients naturally gravitating towards pills when better options may exist? Is it just it seems easy, or uh what is that reasoning behind that?

SPEAKER_00 9:21

Well, in order to understand and answer that question, it's important to know that while the patients are really not to blame, it's mainly receptor physiology. Whenever an opioid is consumed in the brain, there is a sudden release of dopamine, which, as you know, it's the reward neurotransmitter in the brain. And that causes the patient to have a sense of well-being. So picture this the patient who has chronic intractable pain from having multiple back surgeries, they're in pain 24-7. But when they take a pain pill, the dopamine release is going to be there. They will feel like their pain is coming down, that they're able to do some of the things that they want to do. But unfortunately, it only is short-lived. It might help for about two or three hours. Then they would either have to take their next pill. Now, so that explains why patients feel good when they take pain pills. But the downside is as the patient keeps taking these pills to be able to have a better quality of life, they inadvertently develop a dependence on it, and then they become tolerant to the dose that they've been receiving. So they will find out very soon that by taking the same dose, it doesn't last as long and it doesn't give them enough pain relief. So that's the beginning of tolerance. And the way that patients cope with tolerance would be to take their pill earlier or to take more of their pill. So now they're gonna end up running out of their prescriptions, and that may trigger some red flags with the person who's prescribing these pills. So much so that the patient may get cut off from these medications, and that may be their first, you know, realization that they are either tolerant to the medicine or that they may turn to other sources to get these medications.

SPEAKER_01 11:38

Okay, so I think you just revealed why you are board certified in addiction medicine. That was uh a wonderful uh kind of distinction in between that dependence, the toleration, and the addiction, because there's different levels to that, right? We don't go from zero to addicted uh all in one day. It's a it's a gradual process. Um help us understand why it's so important for patients to understand that distinction, because I'm not sure you know everyone really kind of understands that there's a progression there. It's kind of like we well, either you are or you aren't.

SPEAKER_00 12:16

So, as part of tolerance, as I just mentioned, a lot of times patients, even though they may realize that they are tolerant to these medications, they also will feel that if they did try to reduce the dose, that they would start having these very uncomfortable symptoms like jitteriness, sweating, having goose flesh uh sensation, or abdominal pain, or just general sense of anxiety. These are signs of early withdrawal, and this points to the patient being dependent on the drug. So, any attempt to lower the dose, this patient starts feeling symptomatic. Hence, they would either want to continue the medication or to have the dose increased. So there is a fine line between uh dependency and addiction. Now, addiction is when the patient resorts to certain behavior patterns which are not very acceptable. This can include doing things that they know are wrong. So, for instance, let's say a patient takes a fair amount of pills and they're not able to function. Maybe they're not able to walk properly or drive properly, they will still continue consuming these medications despite these detrimental effects. So much so that they may even try to um doctor shop so that they can get enough of these medications. So these are these are signs where the patient's behavior pattern changes from first taking medications as they're prescribed to going off the deep end and trying to do things that may not be legal.

SPEAKER_01 14:18

I love uh the terminology you just uh said there of uh behavior patterns and how being aware of that and that really kind of puts you into one of those buckets there. Um that's that's so interesting. I have I have a question. This is a very obviously professional podcast. However, um is goose flesh the same as goosebumps that you just mentioned?

SPEAKER_00 14:45

Um, you know, it it depends on the context of where you use it, but in general it was the same.

SPEAKER_01 14:52

Okay. Um what what would be what would be the difference? Um I'm so interested.

SPEAKER_00 14:57

Well, sometimes you can have certain skin tick conditions that can give you goosebumps. Okay, but in general, if you were suddenly uh startled, or if the weather suddenly changes and you feel very cold, or signs of withdrawal. These are the things that'll cause the the hair on your skin to stand on end, and that's what we describe as goose flesh appearance.

SPEAKER_01 15:22

Okay, so it really is kind of the uh the outside stimulation that determines whether it's goose flesh or goosebumps?

SPEAKER_00 15:30

Well, to some extent, but keep in mind withdrawal symptoms are in fact coming from within as opposed to changes in the temperature.

SPEAKER_01 15:39

Right, or listening to really incredible music. Like some okay. That's that's so interesting. I hope our listeners enjoyed that little tidbit because I sure did as a non as a non-professional. All right. Um, back to our our talk track here. One of the most concerning uh patterns is uh the escalation of the pills, higher doses, more prescriptions. Um, at what point can it become dangerous, even if it starts not in uh a negative abusive place, but it actually starts from just legitimate pain?

SPEAKER_00 16:20

Well, you know, there's a lot of information in the medical world uh where it takes only about 90 days to start developing tolerance to prescription opioids. And tolerance is inevitable, increasing the dose and frequency is also inevitable, but then there are two things that kind of balance things out, and that is the prescribers of these medications should be aware of what their limits are, or in other words, the standard of care. And when a doctor prescribes opioids outside of the standard of care, then there can be scrutiny. That is part of why Kentucky has prescription electronic monitoring. So this is essentially the government understanding how prescribers prescribe these medications and the frequency. So standard of care is very important, and when you go outside of standard of care, then the practitioner has to be careful. Now, there are many situations where a patient who has developed tolerance may require more medications. Therefore, these patients should be referred either to a pain specialist or an addiction specialist so that the patient can be evaluated and recommendations can be made so that these drugs can be prescribed safely.

SPEAKER_01 17:58

Good to know, good to know. So, given everything that we have discussed, why do you think that so many patients still never hear or it's not uh kind of widely shared about or written about, uh perhaps like interventional options like pain pumps that we've talked about before or spinal cord stimulation? It really just always circles back to pills. Why are we not hearing about this?

SPEAKER_00 18:23

You know, I think that's a great question. You know, I've thought about this for the longest time because pain pumps have been around for at least four decades. So, uh, but despite it being around, it's not common knowledge, even in the medical world, that these are options to treat pain. In fact, when I look at my oncology colleagues who treat cancer pain, and I've spoken to them many times about a pain pump, their response is, well, I can keep increasing the dose of morphine such that the patients won't have that much of pain. But then I made the argument that, well, the more opioids that you give to the patient, the more that their meditation is clouded, their ability to do their day-to-day activities is diminished. So, how does that improve quality of life? With a pain pump, as I'd mentioned earlier on, you're giving a fraction of the dose that you would be giving by mouth to have much better control of pain. So I think it is a lack of knowledge, lack of education, lack of awareness, and I think on the patient's part, they fall into a rut. They get their pills, they think that this is the only thing that's gonna get them through the day. And it's convenient. You pop a pill, you'd feel better for a little bit of time, then you pop another pill to feel better for some more time. It's easier for them. And I don't think that they think about that the ramifications, the problems associated with dependence, tolerance, and possibly addiction. By the time they realize that sometimes it can be too late. And it takes it is a very it is very difficult to get somebody from addiction back to where they can live a normal life.

SPEAKER_01 20:22

All right. Well, I am so excited for the next episode to unpack more about the other options, which I think is where we're going. Um, and we've talked so much about uh the pills and why and how, and I'm so interested to keep unpacking this topic with you, Dr. Nyer. So thank you all for joining us for episode five of the Kentucky Pain Reversal Show. Today's conversation is helping us put something into perspective that the opioid challenge in Kentucky, A, it didn't happen overnight, and B, that it wasn't created by any one person or group. It's the result of a system that for a long time focused on managing pain rather than truly resolving it. But understanding how we got here, as with anything, is always the first step towards changing what comes next. Like we always say, lower the pills, lower the surgeries, stop the pain. Dr. Nyer, thank you again. And we will see you next time for episode six.