Interview with Dr. Katrina Hedberg

To start off, could you give us a brief overview of the work that you do in your role?

 

I actually have two roles, two job titles. One is State Epidemiologist and that means I get trained as a epidemiologist and we look at diseases and things like risk factors in the population. My other job is State Health Officer and in that role, it’s looking at not just what the data shows, but how do you implement prevention strategies, and how do you address things. You collect the data, and then you have to do something about the data, and then there’s an evaluation component. So I spend quite a lot of time thinking about that: how do we address problems like the opioid overdose?

In your role, what was the most memorable experience that you had?

 

I think it’s less about what my own personal memorable experience is and more about my role with the state. I think that 20 years ago people weren’t thinking that opioid overdose was really a problem because you didn’t see it very much. Because it was the opposite: pain became the vital sign, and we were very concerned about that. And so it’s really happened in a short time and we’ve seen a market increase in the opioid overdose as well as the opioid overdose gap. That peaked in the late 2000s and later on we started to see a decline in overdose deaths, but that was probably because methadon had been prescribed to our Medicaid population because it was inexpensive, but people died from it, and it was taken off the preferred drug list. We saw a decrease in deaths, but at that time we didn’t see a decrease in opioid prescribing. What is important about this is that the data shows that it’s a relatively new problem that is 15 years old at least. It’s not just a response of one agency or even one person, it really does take an integrated approach. We have to get a lot of data, but we also have a very strong role in convening people into understanding what the data shows and also convening people at the federal state, local levels, as well as health systems into figuring out how to work together. There isn’t one cause of it, and there isn’t going to be one solution. My career in public health is really about that integration and collaboration that we do to respond.

It looks like collaboration among different factors is a very important part of working to alleviate the crisis.

Yes it is important. I do think that from a state government role there a lot of things that the government can do and a lot of things that the government cannot do. One of the things that we can do is that convening role, at least when it comes to health care, the different types of insurance that might be competing, different health systems. Clinicians wouldn’t say they’re competing but they’ve got a patient load. People do look at us as a neutral system that’s able to do that convening to address the problem.

Was there anything that you came across in the course of your work that changed your perspective on the crisis?

To me, just recognizing that there was a crisis took a little bit of a wake up call, and even though the rates were rising, there wasn’t much attention on it until the late 2000s, so about 10 years ago, even though it had been happening for a while. But once more people were aware of it, and again it was multifactorial, it took a broad response as well. I think it was about the multifactorial response and collaboration. The thing that I am hopeful about, at least in Oregon, is that at least it’s been recognized by a number of the different players. In our convening role we do of course help to convene the medical care system but also, for example, law enforcement, health insurance payers, not just the people delivering, etc. That’s really our purpose here in Oregon.

 

Based on what you’ve seen, what do you think is the biggest barrier that’s preventing people who have opioid use disorder from seeking help?

I work in the public health division; I’m the lead here. A lot of the work that has to do with direct client service is in a different part of our state agency, so I can’t comment. In the governor’s opioid task force there was a document that was prepared for that task force to specifically look at those barriers, so I’m not in the best position. Again what I do in public health is we’re very interested in how we prevent people from overdosing and becoming addicted in the first place. My role really has been much more around helping people find non-opioid pain management, looking at the data, and making sure we decrease the amount of opioids prescribed. The direct treatment is covered in another part of our agency.

In terms of helping to reduce opioid prescriptions in favor of other approaches to pain management, how has that effort been going?

Actually, I think quite well. Collaboration in our agency when it actually came to looking at how did we improve non-opioid pain management, that’s something where we collaborated with our medication office very closely. Oregon is one of the states that really has prioritized non-opioid pain management such as acupuncture, cognitive behavioral therapy, chiropractors, etc. We’ve been working across the agency to increase access to those. At the same time, we’re decreasing prescriptions of opioids, so I think one of the take home messages that we have is: all of us experience pain at some point and there is unfortunately a fraction of the population whose pain ends up becoming chronic and the question is how can you address that in a compassionate manner. I think one of the misconceptions is that people with chronic pain think that opioids is the only answer. Opioids are just one drug or medication in the tool box and they actually aren’t that effective when it comes to chronic pain. It’s not that we’re just cutting people off and that’s the end of it; it really is trying to address that people overall experience pain but how is the physical pain and the psychosocial factors. And other things can be done to address it.

I remember reading that there are some concerns that efforts to reducing opioid prescriptions could adversely affect patients who are suffering from acute pain. In your opinion, what would be the best way to strike a balance between the two?

One of the things we know about acute pain is that the majority of people have gotten an opioid at some point for acute pain. One of questions is how many drugs do you need. At the same time, I ask people who’ve gotten the opioids, I ask how many of you took them all and it’s about the same number. Very few people take all of the opioids prescribed. One thing is to make sure that they get their pain addressed, but they get 30 pills for 30 days worth; they get a small amount, so they don’t take more than they need. That’s a way to balance. But if the person takes all their medication and their pain isn’t gone, then they need to see their provider again before they get an automatic refill. I do think it’s a little bit more labor intensive, but at the same time it is that we’ve been fast and loose with prescribing opioids, so a lot of people have extras left, and of the people who are taking the 30 days, the likelihood that their pain becomes chronic increases exponentially up to a month or so. By the time people are up to 3 months, most of those people end up being on opioids for a year and that’s what we’re trying to avoid. We’re focusing on what are the various ways to manage the pain before people become chronic opioid users.

When it comes to the doctor-patient relationship, what do you think are some ways that it can be improved when it comes to something like pain management and overprescribing opioids?

I don’t think pain should actually be the fifth vital sign, meaning that if people are coming in for a blood pressure check -- a vital sign means you ask the patient what’s your heart rate, what’s your breathing, what’s your weight and height, etc. -- those are standard, that makes them a vital sign instead of asking about pain, we should wait for the patient to mention, “Oh doctor I’m in here because….” That’s the first step: to change the conversation. A couple of other things to change the conversation are to focus on maintaining the person’s functional status so what we’re really trying to do is maintain on just functional status. When the effort is solely on pain, that may or may not address how well they’re functioning. A lot of people for example let’s just say have arthritis, they might be stiff in the morning, or it might hurt a little when they’re walking, but actually one of the things that helps loosen them up is getting physical exercise. When you ask them about pain, they might say, that yeah I have some pain. So instead ask them: are you able to walk, can you do activities of daily living, they might well be able to do that. I think the conversation has to be around expectations around moving to wanting to maintain the quality of life and function rather than having the one specific question about pain. And there does have to be a conversation about what are the different things. I had mentioned physical activity, also about their weight, the kinds of food they eat, whether or not they have enough sleep. There are a number of things to address the quality of a patient’s life.

So the best approach is something more holistic that takes into account of the patient’s lifestyle habits, diet, etc.

Yeah that is exactly true. We have something here in Oregon called the pain commission and they have developed a mandatory pain training, so all physicians are required to take it at least once. The training looks at a modern way of approaching pain, which is not just the firing of certain pain receptors. It really is: what is the overall experience of pain and how do you address the holistics. And the second thing is also having patients understand that. I think it’s true for a lot of us that if you have some infection or fever then you expect to get a pill or medication. The expectation should really be that you want to feel better. I would say it’s true especially when people have a fever, and very often it’s a virus and antibiotics won’t help you. You need to understand that you may be feeling bad, but a pill may not be the solution. That is also true for pain, especially chronic pain: you might be feeling bad, but physical therapy might be a much better option than opioids. I don’t want to discount the over-the-counter pain medication. A lot of those are very effective, so considering all of the tools in the toolbox, we’re trying to avoid the “I’m in pain and I need opioids.”

 

When it comes to non-opioid medications for pain management, have there been other medications identified that can be very effective in alleviating pain that do not contain opioids?

Absolutely. But it does depend on your condition. Pain is not pain. If you get cut with a knife, you have very acute pain. If you ran a marathon, your muscles would be aching which is very different from if you cut yourself with a knife or if you had lower back pain. Each of these potentially respond to different things. Let’s say I had neuropsy, my feet are tingling. Physical therapy may not help that, but if I ran a marathon, physical therapy may very well help that or even ice may help. I think people need to realize that there’s a whole variety of treatments and pain.

What kind of role or responsibility do you think pharmaceutical companies should have in the effort to alleviate the crisis?

We were speaking about this earlier: that we all in some point of our lives had some kind of medication, whether it’s over the counter or a prescription, so we do rely on drug manufacturers to produce medication. At the same time, drug companies are trying to make a profit and I think that that’s a kind of attention now where we do rely at the same time on this idea of having to sell more and more, which makes it difficult. I hope that working with the drug companies, there is some role in trying to make sure that we address the problem. At the same time we all do rely on medication. It’s not that all the drug companies are terrible and we have to get rid of them at all, but I do think that there is responsibility in this direct marketing when it comes to certain drugs, instead making sure these same drugs are available and at the same time not being overused or overprescribed. Sometimes the public expects these medications, which needs to change. It needs to be more between the doctor and the patient instead of this direct marketing to patients.

If somebody gave a magic wand that allowed you to change any policy in order to more effectively alleviate the crisis, which policy would you change?

I don’t think that there is a single policy. It took us years to get into this problem and it’s going to take this concerted effort. I do think that there are a number of policies that we have been looking at and you can look at the relevant provisions in the Governor’s Health Code, which address a number of things. I do think we need to have a change in expectations both on the sides of people who experience pain and how their pain can be addressed, which might not be opioids, and the same on the clinician’s side. I’m really concerned about the high levels of opioids that some people are on and that really increases their chances of overdosing. A discussion with the patient and provider about what are the different tools in the toolbox so that people can be taken off opioids or on the lowest level. I think we need to change the conversation. We want the pain to be addressed in a way that’s not harmful to their health and safety.

It’s more of a discussion of changing people’s expectations or attitudes surrounding the issue of pain management or taking a different kind of perspective on it.

Yeah, there have been a number of studies of what happens in emergency departments in Europe. I think I read one about an emergency department in the Netherlands. And they have injuries that come in, they have car crashes, those kinds of things, but what they offer is entirely different. It’s things like ice and physical therapy or if someone breaks an ankle: you wrap the ankle and address the injury and sew things up, and their opioid prescribing in the department is a fraction of ours. I do think that has to do with expectations -- it’s not that people are saying, oh you’re not going to give me a drug so I’m not going to go in, but they might even be getting prescription strengths, ibuprofen. They have their pain addressed, but not with opioids. It’s their different expectations that they have. It’s not that the problem is different, it’s that we have a very different response to it in the United States.

Since your specialty is prevention, I know that there are some patients who are at higher risks of becoming dependent if they’ve had a previous trauma in the past or have a genetic predisposition. Is there a way to identify that?

I think that that’s part of the conversation when you do a psychosocial evaluation. Now, in an emergency department, I don’t expect everyone in the emergency to come with a sprained ankle, so in the emergency department if something happens, the pain should be addressed and that if that includes a small amount of opioids, that’s okay. But the patient should then be referred to a provider that can address the long term issues. I do expect the primary provider to be doing the psychosocial evaluation to understand the patient and if they did have trauma in the past, then they need more intervention and support not only around the physical pain but the other aspects of things going on in their life. So I wouldn’t expect that in urgent care or the emergency department because they don’t have time to do that. But the people in the emergency department should research if the person has a history with opioid use disorder because if somebody does have a history in being addicted to drugs, then you don’t suddenly want to add opioids back on top of that. They should also be looking at the prescription drug monitoring program because it may be that the patient is on chronic opioids and have a primary care provider who’s working with the patient to taking them off and have a treatment plan. And suddenly, if the emergency department gives them a lot of opioids, then the treatment plan is out of the window. So what I would say is that the history of trauma and substance abuse are all important and should be dealt with in a primary care setting. And the urgent care and emergency departments should only be addressing the immediate issue they need to follow up with primary care.

I’ve noticed when it comes to opioid prescriptions, they can come from other sources, whether it was a dentist, or sports medicine, or even veterinarians. When it comes to these other sources, what are your thoughts on how to address that?

 

We are in the process. We have our guidelines in Oregon for chronic opioid prescribing, which was modelled after the CBC guidelines. We right now have a task force looking at acute prescribing guidelines. In addition to the urgent care that I talked about and primary care in emergency departments, we are also looking at post-surgical because people after surgery might want them but we don’t want them to be on high on long term. So it’s still physicians, but again it’s a little bit different than what we talked about with chronic pain. Dentists are going to be addressed by that. Veterinarians is a little bit hard because they’re not prescribing for humans and the question about whether humans are taking some of these opioids that are prescribed for animals, I don’t know. That’s a good question, but it’s a small part of the problem. The dentists are not prescribing much, but it’s usually the introduction. The first time that people, teens, kids, take opioids is often when they have their wisdom teeth out, so our prescribing guidelines are addressing dentists saying that if you need it for wisdom teeth, along with whatever surgery, give the smallest amount, shortest duration, so they’re not prescribing a lot. And sports medicine, again post-injury, it may be, that’s the primary thing, people need a small amount of opioids, but a lot of those sports injuries are muscular and skeletal and what they really need is physical therapy, ice, and movements. With some sports injuries, like if they’ve had a head injury at the same time, you don’t want to give them opioids because you want to make sure that they maintain their cognitive functions. We’re considering all of those for our acute pain guideline.

Regarding the prescription drug monitoring program that’s been done in Oregon, does it look like that it has been effective in reducing opioid prescriptions overtime according to the data?

There are actually a couple of things, sort of data pieces. Oregon’s opioid overdose deaths are starting to decline, both from prescription opioids and heroin. Our heroin deaths have not declined the same amount, but they have not gone up. A lot of people ask if you decrease prescription opioids, will you have an increase in heroin, and we have not seen that in Oregon. But we do know that the population that is on high dose has declined and continues to decline as well as specifically in our Medicaid population as I mentioned, we’re working closely with them on prescribing. I think we are one of the few states that has seen a decline in these overdose deaths.

 

Are there any additional thoughts or ideas you’d like to share?

I think you’ve covered it. I think this is a complicated problem, and we’d all like there to be one thing that can end the problem, but there isn’t. It took us a while to get here, and we’re working so many different strategies. What I will say is that at least when we’ve had different meetings with other agencies, as well as provider groups, people usually do identify the problem and they do want to collaborate on coming up with a solution. I do think we’re moving in the right direction in Oregon; we’re not there yet, but we are making progress.

What do you think makes the opioid crisis different from other drug epidemics?

I’m just trying to think whether or not we’ve had a drug epidemic that has been focused on a prescription drug. We’ve been concerned and currently are on things like illicit synthetics that have been imported from China. Illicit drugs, that means we need to partner with law enforcement and medical examiners and do those kinds of things. This one is different because it is prescription, so working with your provider and community to decrease prescriptions is what has made this unique. We are starting to see some problems with other prescription drugs: one of the new ones is benzodiazepines like valium and those kind of drugs in which we’re starting to see an increase in both prescriptions of those and problems. Together with opioids, if people get prescriptions of both of these simultaneously, it’s very dangerous, and people are really at risk of overdosing. So we want to be sure that, yes, opioids is unique and it’s within the medical care system compared to the past, and I do think that there are other drugs in the system that are also causing problems and will need to be addressed.