Opioids are one the greatest discoveries humans have ever made. Even in the era of the opioid epidemic opioids are still an irreplaceable tool for pain management. Pain specialist Dr. Halena Gazelka joins today to discuss opioid stewardship, long-term pain management and the unique role of kitty litter in the opioid crisis.
- Purchase Ending the Crisis by Dr. Holly Geyer
- Learn more about pain management and safe opioid use on our Opioid Resource Center
- Comments or questions? Email us at firstname.lastname@example.org.
- If you or a loved one are dealing with a substance use disorder, visit Substance Abuse and Mental Health Service Administration.
Read the transcript:
Dr. Benjamin Lai: Hello, welcome to Ending the Opioid Crisis. I’m Dr. Benjamin Lai.
Dr. Holly Geyer: And I’m Dr. Holly Geyer.
Dr. Benjamin Lai: This is a podcast series aimed at getting a deeper understanding of the opioid crisis that has ravaged our country.
I’m thrilled to have Dr. Helena Gazelka on our podcast today. Dr. Gazelka is a good friend of mine, works as a pain medicine physician and an anesthesiologist at Mayo Clinic in Rochester, Minnesota. Up until very recently, she also served as chair of the Opioid Stewardship Group.
Dr. Gazelka, welcome to the podcast. Helena, why don’t you introduce yourself to our audience a little bit more?
Dr. Halena Gazelka Thank you so much, Ben. Thank you, Holly. It’s my pleasure to be here today. It’s very fun for me to get to be on a podcast talking about opioids with the two of you because we’ve done so much work on this together.
As you said, Ben, I am an anesthesiologist specializing in pain medicine and palliative medicine, and I have led the Mayo Clinic Opioid Stewardship Program from 2016 until last year when it was turned over into your capable hands.
Dr. Benjamin Lai: Halena, I would love to know how you got involved in opioid stewardship. Can you tell us a little bit about how this all started and what were some of the initial challenges?
Dr. Halena Gazelka: Oh, boy. Well, my ignorance was the first initial challenge. Actually it’s just an incredible story. Physicians, we are lifelong learners. Naturally, I prescribed opioids. I was a pain physician and a palliative medicine physician, but I wasn’t well versed in the opioid epidemic or how we prescribed opioids at Mayo Clinic. I, of course, knew the emerging guidelines that were coming out and things like that.
But, I was asked by leadership at Mayo Clinic to begin to investigate: what do we do at Mayo Clinic as far as prescribing opioids? There was a lot of concern about overprescribing at that time nationally, and a lot of efforts to target the opioid epidemic from various viewpoints, including that of how we provide medications to patients.
And I admit that I was scared when they asked me to do this. It seemed like a very large task, and it was a Herculean task. But, the wonderful thing is that you meet so many colleagues at Mayo Clinic, and I have worked now with many different areas and areas of expertise, including you and Holly.
Dr. Benjamin Lai: Helena, through your work, you and the group, the Opioid Stewardship Group, came up with some prescribing and monitoring guidelines. What were some of the challenges and what were some of the results of these guidelines coming into play and how were they received by practices at Mayo Clinic?
Dr. Halena Gazelka: Well, I think one of the biggest challenges of guidelines is that who knows, right? People are different. How they metabolize opioids is different. What pain conditions they might be suffering from is different.
So, it’s very difficult to put solid numbers on what you should prescribe, how long you should prescribe it, who you should prescribe it to. And those are a lot of the concerns that we had at Mayo when making our guidelines, but also the challenges that we have seen in state and federal governments as they have embraced legalizing opioid prescribing to some extent. It’s also a topic that we worked on significantly internally and externally to the clinic. And so I think that was the biggest challenge.
The second was probably being evidence-based. So, I’ll explain what that means: as physicians at Mayo Clinic, we attempt to practice medicine that there is data for. So if an internist is going to prescribe a blood pressure medication, they want to go to the literature, they want to understand: for this person’s situation, what is the best blood pressure medication? What is the correct dose to start a patient at? And it’s not willy nilly – there’s a lot of evidence for for how medicine is practiced. However, it is lacking significantly in opioid prescribing. And so that was a real challenge when we were making guidelines as well: that we provide a framework, but that we not be so prescriptive that we’ve limited providers from doing the right things for their patient.
And I think, Ben, I’ll just add this, that one of the things that I have always held as the highest of standards is that this is a stewardship program. And I remember telling the group early on I wanted to call it a stewardship program because it implies that there is great value in what we are protecting.
I think opioids are one of the most valuable discoveries that mankind has ever made. They’ve been around for thousands of years to treat pain, and they’re very important. And eradication of opioid prescribing was never our intention; it was good stewardship of it.
Dr. Holly Geyer: Halena, you’ve shared some great perspectives on the concept of opioid stewardship, and when it comes down to the patient’s perception of it, what can they expect to see as it’s practiced? Meaning, from the moment they walk into their doctor’s office, what does it look like practically?
Dr. Halena Gazelka: Well, Holly, I think it’s gotten a little bit difficult. There actually has sort of come to be a bit of a stigma around pain, but also around need to be managed with opioids. And that’s unfortunate because just as people have trouble with diabetes, or have trouble with their blood pressure, or have trouble with other medical diagnoses, they have chronic pain as well. This is what I spend my my life seeing patients in the clinic for.
And I think it’s unfortunate that we are limited by this perception that someone might be seeking opioids, that they might want to misuse them. It’s simply not true. Patients want their pain treated. And so, when they are embracing management with opioids with their physician, it’s a conversation that needs to be called out.
Why would I use this instead of some other techniques to manage pain? What is the limit? How will we know if it works? How will you manage me? Because most physicians have a structured way that they follow patients who are on opioids, and we certainly do at Mayo Clinic. We see them for regular visits, we want to assess how they’re doing, assess their function.
We do urine toxicology screens to be sure that they’re taking their medications appropriately to protect them and to protect us. We often sign an agreement with the patient that we will be the only providers of those medications for them. There is a lot of information out there, Holly, and so people can go and find information on opioid management and questions that they might want to take to their physicians.
And I think that’s really important to be armed with information.
Dr. Benjamin Lai: Halena, you made a really good point. I mean, there’s so much attention on opioids and the opioid epidemic. A lot of our patients are concerned about taking opioids or being prescribed opioids. Interesting point you raised is at one of our podcast team members actually said something about having a procedure recently, a kidney stone procedure recently, and he received fentanyl in the hospital.
And rightfully, because there so much attention on fentanyl, he was concerned. Do you have any comment on that, the use of fentanyl in the hospital? And is there a difference, Halena, between fentanyl that’s prescribed and fentanyl that people can get on the street?
Dr. Halena Gazelka: That’s a really interesting question, Ben. It sort of harkens to how when you’re so familiar with something, you forget that others might not be. What I can tell you is that as an anesthesiologist in a procedural list — so, I do not do O.R. anesthesia, but I do do pain procedures where I sedate patients or I direct the nurse to give medications to sedate them while I’m doing the procedure.
Fentanyl is the most common medication that we use. It’s an incredible medication. It works quickly. It’s gone quickly, and it has profound pain relieving properties. It’s a tremendous opioid that is manmade. Unfortunately, bad fentanyl is also being manmade. [Fentanyl is] most of what is flooding the drug market in the drug community where drugs are being contaminated and people are overdosing at incredible rates.
Most of that fentanyl is ultra potent. So, fentanyl is an extremely potent opioid, far more potent than morphine, 50 times more potent than heroin, which most people know is quite potent. Tiny amounts can do a lot of damage. And that’s what we’re seeing in the community where people are overdosing so frequently, is that there is fentanyl contaminating the drug supply intentionally because it gives a better high, it keeps people coming back for drugs…many reasons.
It’s cheap and easy to manufacture, but that’s not the same as when a physician uses fentanyl or a medical expert uses fentanyl to sedate someone or to provide pain relief at the time of a procedure or otherwise.
Dr. Holly Geyer: Halena, you made a good comment there about it being a synthetic opioid, and I think patients oftentimes get a bit confused by all the terms out there – “synthetic,” “illicit, “street.” Would you mind just making a comment about how we can differentiate those and what those mean?
Dr. Halena Gazelka: Yeah, I think that’s a great question, Holly. My mom always used to say, “Those things that you’re always talking about – opioids – because opioid doesn’t mean anything to people. That’s just the opioid epidemic. So what’s an opioid?”
An opioid is a medication that is derived from a poppy flower. There are poppy plants that have naturally occurring opioids, and that’s just the substance that has pain relieving properties.
So, common medications that actually come from the plants are things like morphine and morphine-related medications. Now, we have also been able to manufacture in the lab other opioid medications such as fentanyl, but they’re still related to each other. They still have a similar structure. It’s just that fentanyl doesn’t occur in nature and morphine does.
Dr. Holly Geyer: Every 8 minutes, someone in the US dies of an opioid overdose. The drugs we have long trusted to help kill pain are now killing us. But what if we were equipped with the information to use opioids wisely, store them safely, avoid their risks, and reverse their problems? What if we could help loved ones misusing opioids and support them as they seek treatment?
My book, Ending the Crisis, shares Mayo Clinic’s collective insight into the lives of every person struggling to understand opioids and their role in managing pain or dealing with the complications caused by these powerful drugs. Visit the link in the notes of this episode or visit mcpress.mayoclinic.org/opioids to get your copy today.
Dr. Benjamin Lai: Halena, a common question I get from patients who get prescribed opioids is: I still have a left over supply of opioids. I don’t want this in my home. Where can I get rid of my opioids?
Can you tell our audience a little bit more about where they might be able to dispose of their unused medications?
Dr. Halena Gazelka: Yes, Ben, absolutely. The best place to get rid of unused opioids is to take them to a take back center. So, for instance, in our Mayo Clinic pharmacies, we have boxes that are locked where it works like a mailbox, essentially, and people can put in drugs that they no longer need. What happens to those drugs is that they are then removed securely and incinerated or burned and destroyed. Here in Rochester and also in other areas where Mayo Clinic works, many sheriff’s departments, or government centers, or police will have places where you can also return opioids.
A funny thing that we have done at Mayo Clinic is that twice a year — we weren’t able to do it during COVID very much — but we have had take back days. The DEA, the Drug Enforcement Agency sponsors, these take back days twice a year. Typically, they’re in April and October, and then medical centers and others will collect any medications that people want to bring back to them to be destroyed. So, that’s a great way to get rid of them.
There is information on the Internet, Ben, that if you only have a couple of pills and you need to get rid of them, it’s probably safe to flush those. There’s concern for the groundwater, concern for too much opioid in the water supply, so you wouldn’t want to be flushing lots and lots of these pills, but if you’ve got five left or 10 left after surgery or a procedure, that’s probably an acceptable thing to do.
Another thing that we used to tell hospice patients when I was a hospice medical director was that you can destroy opioids by dissolving them and putting them in kitty litter, interestingly, because they can’t be reconstituted very easily. Now, the neat thing is a device company has come up with a neat bag where you can put that pain medicines in the bag and then you can pour water in there and it allows them to be destroyed and not reconstituted.
Many pharmacies offer these. And so, if an individual is picking up a prescription for opioids, say, after surgery or after a procedure, they might say, “do you have any of those bags that I could use to destroy my opioids later?”
All of those are viable options. And certainly, not keeping them in the medicine cabinet. The worst thing that people can do is to keep these medicines in their medicine cabinet where kids might get a hold of them, teenagers might get a hold of them, people might steal them. It leads significantly to concerns about diversion and abuse of them.
Dr. Holly Geyer: Halena, you did a great job at the beginning, kind of describing your background in the field of anesthesiology, and you described yourself as a proceduralist. Can you talk a little bit about the role of procedures in pain management, and why that might be an option for patients as opposed to going straight to opioids for pain management?
Dr. Halena Gazelka: I love that question, Holly, because it is an exciting time to work in pain medicine. There are many, many options that individuals have for pain management other than taking medications. When I see patients in the clinic, I talk to them about a number of things.
I talk to them about: Do we need to diagnose where your pain is coming from? Sometimes patients need imaging studies or other forms of laboratory studies to figure out why do they have this pain that they have and what exactly is causing it.
That’s the basis of good pain management, is knowing where the pain is coming from, and it’s often missed. Sometimes people are given medications that sort of cover or help with the pain, but they really have no idea what it is they’re dealing with.
So, diagnostics are important. Physical therapy is incredibly important. So, I myself have had troubles with low back pain and I can tell you that I faithfully went to physical therapy, did my core work, and have not had further episodes of back pain. That doesn’t always happen, but physical therapy is really, really important in rehabilitating people and helping them to maximize their potential and reduce their risk of further pain.
Procedures are interesting – I do those as a pain medicine physician. We often use either ultrasound or live X-ray called fluoroscopy because we can see the anatomy using either ultrasound or the boney anatomy using X-ray. And then we’re often targeting joints in the back —we do take sacroiliac joints, lots of other injections and procedures to assist with pain, and those are often best ordered and evaluated by either a primary care physician who is familiar with them or a pain management physician who specializes in that area.
But, there are lots of options. And then the last thing I always talk to patients about are medications. There are a lot of medications that we extrapolate from the intention that they were formulated for to manage pain. And I’ll give an example: there are multiple good antidepressants that I don’t give to my patients for depression. I give them to them for pain management, and a lot of people are not familiar with that until they’ve had the right conversation with the right provider to find that out.
So, there are a lot of good options. And then the most, I guess, complex procedures that we do as pain management physicians are the implanting of devices. We call it neuromodulation. So, basically, devices that help to manage pain by working directly on the nervous system. Those are spinal cord stimulators, peripheral nerve stimulators, intrathecal pumps or intrathecal drug delivery systems. So, lots of options.
Dr. Benjamin Lai: That’s a great summary, Halena. As a primary care doctor, I oftentimes refer patients over to pain specialists like yourself. The number one question is: how long is it going to last? If I get an injection in my back, is it going to be six-week relief or is it going to be a one-year relief? How do you counsel your patients on what to expect from these procedures?
Dr. Halena Gazelka: That’s a great question, Ben. And honestly, what I can tell you is it depends on the individual and why we’re doing the intervention, and it depends on the intervention we’re doing. So, if you think about some of the steroid-based interventions, those we usually think of lasting a number of months for people. Now sometimes one is all it takes.
We’ve all known someone who had sciatica, right? They have what we would call a radiculopathy or a nerve pain that goes from their back down one of their legs, and it can be excruciating. It’s often caused by a derangement in a disc in the back, which is one of our little shock absorber cushions between our bones. And, sometimes, giving someone an epidural steroid injection to help them get over that really difficult time with their sciatica can be really successful.
There are other back issues, such as arthritis in the back, which is often caused by facet joints or facet joints, some people call them. It’s extremely common as we age and people will respond to steroid-based injections. But, there are procedures that can last six months to a year that we can do for arthritis in the back and have much more profound effects and reduce the risk of getting steroids all the time.
So, it really does depend on what it is that we’re trying to treat.
Dr. Holly Geyer: Thank you, Helena. Part of my world is working in the in-patient environment, and when patients that come to the hospital need to get admitted, oftentimes the condition that brings them there is something related to pain and needs to be addressed while they’re hospitalized.
I know we have a lot of options available. Could you speak a little bit about why doctors choose the types of interventions and pain medications they use in the hospital environment?
Dr. Halena Gazelka: Yeah, you’re right, Holly. When someone is in the hospital with pain management, the key thing is: how do we get them out of the hospital? We know that it’s not good for people to be in the hospital any longer than they need to, and it’s exorbitantly expensive as well. And so, a lot of times we’re thinking about quick action.
So, steroid-based interventions, for instance. Often the injections that we do for people who are in the hospital because of pain involve using local anesthetic to numb and then corticosteroids, which help reduce inflammation over time, and they often work quite rapidly. Sometimes we use opioids in the hospital for people who are in very severe pain on a limited basis. We typically say we want to start the medicine, try to get them over this hump while we build our tool kit.
So, I always tell patients that anything that I can do for them, be it an intervention, be it a medication, be it sending them to the pain rehab center or to physical therapy, they’re all just tools in a toolbox and one tool on its own is unlikely to be significantly successful over a long period of time.
But if you’re built your toolbox, and you have different tools that you can take out at different times and for different purposes, then you’re likely to be pretty successful in managing pain as well. And so, in the hospital we use medications. Some of them are anti-seizure medications that actually work very well for nerve type of pain. Some of them are antidepressants, as I said.
Now, a lot of those medicines do take some time to work. So, we’re often trying to find something that we can do in the short term, such as an intervention, while we wait for those medicines to take up more space in the toolbox.
Dr. Benjamin Lai: Those are great points, Halena, that kind of multimodal approach to treating pain, right? I guess one last question I have — and I don’t know if any of us have any real good answer to this, and I would love your expertise on this — as a primary care doc, oftentimes, it can be frustrating getting insurance coverage for some of these procedures.
Do you have any tips and tricks or pearls that you could share with our patients and our provider audience?
Dr. Halena Gazelka: It is, sometimes, that’s a really good point, Ben, tricky getting insurance coverage for certain modalities of treatment that we would like to use or even for certain interventions. And I’ll give you an example: I was talking about facet joint injections. Well, Medicare, in their wisdom, has decided not to cover facet joint injections regularly for patients. It used to be kind of one of the backbones of our practice; I would go up to do procedures, I’m going up tomorrow to do procedures, and I would know that I was going to do lots and lots of facet joint injections with steroids.
We now treat facets in a different way: it’s called radiofrequency ablation. What we do is we actually kind of damage the tiny little nerves that supply sensation to those joints to give people longer lasting pain relief.
Now, the reasoning behind that by Medicare makes sense. You’re giving somebody longer lasting pain relief. One of the things that’s really important is just to know your insurance and to check with them. So, we typically have patients get pre-authorization for procedures or at least call their insurance and make sure that what they are getting will be covered. Because you’re right, there are often options.
I used to do anesthesia in the O.R., and I would work with residents. I would tell them there are probably at least five approaches you could take to how to anesthetize this patient for the duration of the surgery and pick one of them, defend it, and tell me why you’re going to do it. Same thing with procedures, there is more than one way to skin the cat, as that old saying goes. Picking what would be covered by the patient’s insurance is important.
Dr. Holly Geyer: Halena, you’ve been such a wealth of resources and information today. We’ve talked a lot about all of the opportunities out there to try and work to get pain relief. But, I would imagine there are some patients out there that say, “Listen, I have done all of it. I have struggled for years. My world is being taken over by this pain. I don’t think I’ve ever getting out of it.”
What final parting thoughts would you have to that population who feels that there is no hope, and that the pain is going to be there forever?
Dr. Halena Gazelka: And what I would say to you is that that’s possible. I meet patients every day who’ve been struggling for decades with pain and had a very difficult course. But what I would also say is that there is hope.
There’s almost never a patient who does not have some hope for some improvement in how we manage their pain. Sometimes it’s seeing a different provider and getting a different viewpoint. Sometimes it’s a great program, like a pain rehabilitation program, where the intention is not that I’m going to get rid of your pain or that you will be pain free after you go through this program. It is rather I’m going to help you live your best life in spite of the pain that you’re suffering from. And I would say that’s true of a lot of the patients that I see.
I talked about someone who comes in with an acute sciatica or a nerve type of pain, that’s going to go away in a couple of months. But you know what? I don’t see those patients in my practice very often because those patients are successfully treated by their primary care physician. I see patients who have intractable pain, who have physical diagnoses that cause severe pain for them.
And so, my goal is to help them live their best life, to build a tool box with them that has tools in it that they can take out and use when they return home after seeing me. So, I would say that I usually tell every patient that I see that one of my biggest goals today is to bring hope to you when I see you in the clinic.
Dr. Benjamin Lai: Halena, thank you so much for all your expertise, and you’ve just been an inspiration to all of us. We thank you so much for your time. We welcome you any time if you have any additional advice for us. So, thank you for your time.
That is all from us on today’s episode of Ending the Opioid Crisis. You can check out our website at https://mcpress.mayoclinic.org/opioids for more episodes of our podcast series and other resources for safe opioid use. If you or someone you know are struggling with an opioid or another substance use disorder, we recommend speaking with your health care provider or going to the Substance Abuse and Mental Health Services Administration website.
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