The Intersection of Pain and Withdrawal: Reviewing New CDC Opioid Guidelines


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Daniel Litwin (00:15):

Hello everyone. And welcome to another episode of Vital Spark, a Spark Biomedical podcast. I'm your host, Daniel, Litwin the voice of B to B and folks. Thanks so much for joining us on another episode of this show, as we continue to explore important trends, people, technologies, and tell the important stories around and behind opioid recovery and treatment. So, as we get into today's conversation, I wanna make sure that you're all caught up on previous Spark Biomedical content. So, make sure that you're heading to our website Spark Biomedical.com. Again, that's Spark Biomedical.com. There you'll find previous episodes of the show as well as, um, more resources and research, uh, around our treatment, uh, devices, our therapy methods, and, uh, just more updates on the current state of the opioid epidemic as well. Uh, you can also subscribe to Vital Spark on Apple podcasts and Spotify just hit that subscribe button and you'll have a full catalog of previous conversations plus notifications when we drop new episodes.

Daniel Litwin (01:21):

So today's episode is all about the intersection of pain and addiction. And this is in the context of recent updates to the CDCs, a 2016 guideline for prescribing opioids, for chronic pain, something our audience should be relatively familiar with, but you know, after years of scandal pain, death, right, it's encouraging to see the CDC at least maintain and its updates. It states that opioids should not be seen as a first line of defense for chronic pain therapy and even in several cases for acute pain. So that language remains in their guideline update. However, the updates to the CDCs guidelines do put more emphasis on the role of the physician on clinical judgment in deciding when to prescribe opioids with a removal of language on opioid prescription recommended limits. And that's, what's drawing a lot of conversation today. Physicians are wondering what's next? How do we maneuver this new environment?

Daniel Litwin (02:20):

So we wanted to pose the questions on the podcast today. What will be the consequence of physicians being back in control of the minutia of opioid prescriptions per patient's needs? And then does this open the door to bad actors overprescribing again, or rekindling the flames of the opioid epidemic, which, uh, you know, is still continuing today, and does opioid deaths again continue at distressingly high levels. We really want this episode to focus on strategies for the physicians specifically for pain doctors on how to weigh their role and responsibility in the opioid crisis. And in the context of the CDCs removal of opioid limits, what are pain doctors' challenges today? How do we fix them? So let's go ahead and get to the meat of the conversation. I'm very pleased to welcome our guest today, Dr. Michael Sprintz, he's founder and CEO of Sprintz Center. Dr. Sprintz. Great to have you on how you doing.

Michael Sprintz (03:13):

I'm doing great. Thanks very much for having me.

Daniel Litwin (03:15):

Oh yeah. Thank you again for taking some time out of your day to walk us through some of the important updates to the CDCs guidelines and, uh, better understand what the impacts are gonna be. I'm sure your colleagues are already trying to figure out what are next steps here, right? How do we, uh, begin to maneuver this new environment? Uh, and so we're gonna get actionable. We're gonna get strategic, but before we do so I want to highlight your career accolades here for our audience, because I think it just really speaks to why your perspectives are so important today. So bear with me while I recite your bio back to you here. But, um, for our audience, Dr. Sprintz is a national subject matter expert on the intersection of chronic pain and addiction. He's also a triple board certified professional in pain, medicine, addiction, medicine, and anesthesiology.

Daniel Litwin (04:06):

He currently serves as a member of the FDA's analgesic and anesthetic drug products, advisory committee. He was also a member of the joint commission standards review panel for pain assessment and management, as well as the joint commission's technical advisory panel for pain assessment and management in behavioral healthcare. And along with founding the Sprintz Center, he also founded IM health and Solarian Inc, which develops innovative software that help healthcare providers identify and help patients who may be struggling with dependency on prescription drugs and other addictive substances. And finally, Dr. Sprintz himself is on his own personal 20-year journey of recovery. So, Dr. Sprintz, thanks again for joining us. Uh, I, I, I hit on some of the, uh, the big hitters there, but if you don't mind, you know, if there, if there's anything I missed that you think is important to highlight, or if you want to connect the dots for our audience, with how your background here really informs, uh, and supports the perspective you're gonna be offering on today's topic.

Michael Sprintz (05:06):

Absolutely. Um, no, that, that was really wonderful. Um, I am, uh, one of the big things for myself that I found and, you know, I'd never recommend anyone to have a problem with, with substance abuse or addiction, but, you know, I was really fortunate in, in getting help and being in recovery. And so the fact of being an expert, both in being fellowship trained in pain management, being boarded in addiction medicine, but also having been an IV opiate addict, I understand the perspective really from multiple angles. And that really gives me a, a unique view of things, uh, that has, has really been beneficial both for, for me and the way that not only that I help my patients, but also when I do presentations or when I do consulting work, I'm able to help, um, other organizations and other physicians understand what the problem is and how to address it better.

Daniel Litwin (06:01):

Yeah. I mean, uh, I I'm sure that personal experience has, you know, given you an even stronger tool belt of empathy, of understanding the minutia of maneuvering, um, you know, the, the more sensitive aspects of helping someone through their recovery journey, uh, which I'm sure is gonna be once again, front of mind for pain doctors, especially with these changes to, um, the CDCs guidelines. So before we get to those guidelines, though, I want to just more accurately frame up the context of the current opioid epidemic. So I'm gonna throw some numbers at you, uh, but then give you an opportunity to expand on what you're seeing in your practice. Uh, but a February, 2020 report from the commission on combating synthetic opioid trafficking found that 100,000 Americans died from overdose deaths. And that was from April of 2020 to April of 2021. Uh, the majority of those came from fentanyl and synthetic opioids, uh, and a hundred thousand. That number is double the number of people who died due to traffic fatalities and gun-related violence in that same 12-month window. So really stark numbers there, very concerning numbers. What is your pulse on the current epidemic, right? Where are things at, from how you see them? Uh, and what are some experiences that you've faced, uh, whether quantitative or qualitative over the last year and a half?

Michael Sprintz (07:28):

Well, it it's, um, the, the numbers are shocking and they're disturbing. And I hate to say it, they're not surprising, unfortunately, um, something I had, I had said a long time ago prior, what, right when COVID, uh, COVID 19 had hit, I said that we were gonna end up having it, that it's all of a sudden the, the opioid crisis and really a substance abuse crisis was pushed to the back burner for obvious reasons. And, um, the problem though, was it didn't go away. In fact, it got worse and we are, we have been in a national and almost a global cultural trauma with COVID. The number of deaths are astounding. And suddenly when people were isolated, there was there's emotional, uh, or I'm sorry, there's social isolation. There was there's financial uncertainty, there's health, uncertainty. There was so much uncertainty and fear, uh, that, uh, all played into people, wanting to find relief from these uncomfortable feelings and the issues going on. And so a lot of people relapsed, a lot of people who, uh, who didn't have previously developed substance use problems started to, I mean, the amount of benzo, uh, diazepines has increased, uh, the amount of alcohol use has increased across the board for people with, and without substance use disorders. So we're seeing it. Um, and now we're, we're seeing the consequences of those, um, those things play out. And it's unfortunate.

Daniel Litwin (08:59):

So then would you say that the, the main second wind motivator for the crisis was COVID or are there other factors at play here?

Michael Sprintz (09:10):

Uh, well, COVID, I mean, COVID through gasoline on a fire that was already burning really well. We started to, to, um, make some, make some dents into, uh, addressing the opioid crisis where the, the original concepts that people, I think when, when it first really hit public attention in 2017, late 2016, um, I, I think that initially everyone believed the problem was, was just opioids. That opioids are the problem. And if we get rid of opioids, then suddenly it's all gonna go away. And, and that showed a lack of understanding of the problem that we're dealing with. And I think that now what's happened is people of start are starting to understand both not just in the medical community, but in ideally on the policy level, understanding, uh, the, the, you know, the neurobiological nature of addiction and that you can't solve the problem by getting rid of a drug.

Michael Sprintz (10:11):

Um, and you know, when we talk about the overdoses, you know, one of the things that happened was that as the availability of prescription opioids decreased, the addiction didn't change, the demand didn't change. And so people went elsewhere to try and find it when they could no longer get it where they were and that, and once you start buying stuff on the street, it's a crapshoot in terms of what you're getting. And it, uh, I mean, sadly, it wasn't surprising that there was a, um, that there was a spike in overdoses that has, has occurred ever since they started decreasing the availability of prescription opioids. Now, that being said, there's the same problem also as well. We don't want to just have prescription opioids everywhere for, for people there, there was a legitimate and appropriate reason to try and and limit that. And I think that what we're starting to now understand is that pain doctors need to have a basic understanding of addiction, medicine of how do I identify someone who has a problem and where can I refer them rather than just discharging them or ignoring the problem.

Michael Sprintz (11:19):

And it's, uh, the other half of this is that you had an, a lot of patients with the original CDC guidelines, uh, which were meant for primary care doctors, not for pain doctors, but it kind of was this, it was swept across the board where everyone was afraid of getting sued or going to jail. Um, and, uh, so everyone started to abide by that including pain doctors, and a lot of people were just cut off and cut off or kicked out. And that, and then the people who may not have had a substance use problem, but, and those that did as well. And so that's where you found people buying 'em on the street going through withdrawal and all the unintended consequences that sometimes happen when we make, you know, when we have policies that are, um, a, that need to be thought through a little bit more

Daniel Litwin (12:09):

Interesting. So then it sounds like the initial, um, policy approach was too much of a one size fits all then, and, and swung the pendulum too far in the other direction. Is that, is that kind of the assessment you're making?

Michael Sprintz (12:26):

Yeah, it was, um, I, I think that obviously the intent was good. Um, one of the things that one of my favorite phrases these days, unfortunately, is unintended consequences and, and there, there were some serious unintended consequences that hadn't really been thought about well enough when the policies were originally made. Which is why we have new policies, right. They, they made the policies in, in 2016 and their intent was good, but all of a sudden, everyone was like, holy crap, this is look at what's happening. Now we need to readjust and rethink these policies to something that, you know, again, like you said, the pendulum went too far in the other direction because it was too far on the, on the, the free pres not free, but the, the over-prescribing of medications, um, it was too far and now it's swung farther back and we're starting to get towards something that's a little more rational.

Daniel Litwin (13:22):

Well, that tees me up perfectly for talking about the changes to the guidelines. So, like I mentioned, uh, the 2016 CDC guidelines for opioid prescriptions have evolved, uh, the language around, you know, avoid using opioids as the first line of defense for pain treatment remains. That's still where the CDC is planting their flag, but they're also kind of leaning back a little bit and reassessing, um, the relationship between, uh, the physician and their patient, as well as removing some of the prescription limits. So I guess if you had to, you know, peak under the hood a little bit, why do we see these specific guideline adjustments and what are your immediate thoughts on, um, on this strategy?

Michael Sprintz (14:13):

Well, I think that they, uh, I think that they kept what they kept because the bottom line is we want, we understand the problems, uh, and the risks of opioids and exposing people to opioids. Um, we know that there's a genetic component to, to developing addiction or addictive disease. We also know that there are environmental factors like trauma, early childhood trauma increases the risk for, for substance use disorders, as well as chronic pain. So we have a very susceptible population. And so it makes sense that we wanna avoid using opioids if at all possible when treating pain in general, you know, any kind, uh, and that we should look towards other, um, other medications and therapies and interventions, which may not necessarily be just pharmaceuticals. There's a lot of different interventions for pain, but to try a multimodal approach, to decrease that risk of exposing someone who may have the, uh, the predisposition to develop addictive disease.

Michael Sprintz (15:18):

So we don't wanna make the problem worse. And I think that the CDC was great in that, um, in making that clear, uh, about opioids, they, what I do like about the changes are, is that it wasn't, uh, the changes made it less dogmatic. And again, guidelines are guidelines. Guidelines are not laws. Guidelines are literally, this is what we recommend in general, but you as a clinician and, and clinicians should utilize their own judgment when making decisions, but throughout the country, it really was viewed as the, the risk of it was viewed as if I don't do these, then, then I will be accused of practicing below the standard of care. And that becomes, you know, when you think about, unfortunately we live in a society that that is rather litigious. And, you know, when, when we think about managing our patients, it comes down, it, it really is pretty simple, do the benefits of whatever therapy we're considering outweigh the risks and that's, and that's really, when it comes down to if the benefits outweigh the risks, then it makes sense that one would move forward.

Michael Sprintz (16:31):

And that includes, uh, you know, a discussion with the patient and having their own input when I'm making decisions for patients. I think about two things, one what's best for the patient, right. And that includes benefits and risks. So what's best for them. And the second thing is what would I say on the stand, if I were on the stand and someone, you know, and whether that would be for Congress or whether that would be in, in a courtroom that someone goes, well, you know, Dr. Sprintz, why did you do this? If I can answer that first question? Well, this was what was best. What I felt in my professional opinion was best for the patient and the, and the benefits outweighed the risks. If I have, if I do that part, then I generally don't have to worry about that second part.

Daniel Litwin (17:11):

So why then, uh, do you think the CDC even went in the guidelines direction rather than there be some firm policy around opioid prescription limits or the relationship with how physicians can even prescribe opioids to their patients? Um, you know, especially with sort of the weight around this crisis, it is a national epidemic. So why guidelines, why not laws, right? I mean, is that a dynamic even worth unpacking?

Michael Sprintz (17:43):

Well, no. I mean, I'm happy to talk about it. It, it really, the, the issue is, is that patients, individual patients and laws tend to work on a population level. And, you know, there are, there are patients. And it's interesting when I first opened my practice, you know, back in 2013, you know, I, I was the one who was, did an integrated chronic pain and addiction or substance abuse practice. And no one was doing that at the time. I was the only, and so everyone thought I was the crazy guy, but what was interesting is in the beginning, I thought there wasn't really much use for, you know, that no, there's not really a need for opioids in, in a lot of, uh, in most patients. And then the more patients I saw there, there were, I, I kept running into patients where it was totally appropriate for their, their chronic pain condition, that opioids were appropriate for that patient.

Michael Sprintz (18:37):

And they were an appropriate patient. So I always, you know, I always evaluate a patient. Well, one is their pain condition appropriate for opioids in any way. That's the first question, cuz if they're pain condition, if opioids are not appropriate for what their pain condition is, we shouldn't be prescribing them. But the second part is, is my patient appropriate for them. And I think that if, if they've made laws, the problem with making laws as it's going to be sweeping and you can't, it's a physician doesn't wanna spend, you know, um, half spend a hundred thousand dollars in their life in court trying to defend, uh, this one patient who was appropriate for opioids because the law said they weren't. And so that, that would've been a disaster. So I think that, I think that it was a very good decision in making guidelines and or recommendations that gave physicians the ability to practice medicine.

Daniel Litwin (19:36):

So then as a, uh, physician, uh, yourself as a professional in this field, what are your thoughts on the guideline changes? Do you feel like they're a step in the right direction to fixing that, um, you know, pendulum swing over correction?

Michael Sprintz (19:52):

Yeah, I do. It was definitely an improvement from where they were in the 2016 guidelines. No question about it. Um, it, you know, it's, uh, they're not perfect, but rarely are these things perfect because it's a consensus agreement on a number of experts and I've been on different expert panels. That is a consensus in which there are different perspectives and views. And it's important also to, for me to acknowledge that being an expert in both chronic pain and addiction, I have a different perspective than most pain docs do. And the unfortunate part that, that I wanna bring up in honor is that the vast majority of pain doctors were not trained in anything relating to substance abuse and how to identify that in their, in their patients and, and they are now being expected to. So one of the things that I would have liked to have seen was, you know, from a policy level is starting to, um, have core competency requirements for pain doctors in understanding the basics of addiction medicine and how, and, and the basics of management.

Michael Sprintz (21:03):

Not that they have to become addiction doctors, but these specialties are converging. And a lot of my talks over the last, you know, 10 years, I, you know, pain doctors are not comfortable managing patients with addictive disorders. Addiction doctors are not comfortable managing patients with substance abuse, patients who have chronic pain conditions. And so I've been talking to, you know, I do a lot of talks for on the addiction side, helping to educate them about pain and understanding the basics of pain because addiction, doctors need to understand that. And then on the pain side is educating pain for pain providers on the basics of identifying and managing patients, uh, who have potential substance use disorders. So that's really where I think we should go from a policy standpoint is starting to incrementally mandate some basic core competencies among the physicians and then, uh, um, give them the tools they need to do their job well, you know, get, educate them.

Michael Sprintz (22:10):

It's not fair to, uh, just expect everyone to know something that they were never trained. And that that's kind of what happened in that middle ground, in, in the early parts of the opioid epidemic. And suddenly they were responsible and no one had taught them anything. And they're like, well, wait a minute. I thought it was, I, I thought this was okay. I thought this was what we were supposed to do. And then suddenly overnight, it's not in fact you're killing people. And, and so, uh, a lot of the docs were stuck and in rural areas where you do have primary care docs that are prescribing because they want to care for their patient. The problem is, I think a lot of doctors don't have good boundaries, you know, sometimes saying no is the best way we can potentially save a patient's life.

Daniel Litwin (23:00):

You hit on a bunch of really important things there, um, physician education. That's huge. Um, we'll follow up on that here in a little bit. Also the weight that, um, you know, that patient physician relationship can have on the physician, but then also those dynamics of the rural settings specifically where you have, um, you know, a primary care doctor that maybe in another setting in another environment, wouldn't have this kind of, um, you know, really deep one on one connection with their patients where even outside of the office, right. They're going to church together, you see 'em at the local supermarket. Also, you have to tell that person, no, I'm not gonna give you opioids for your pain. That's really heavy. Right. And so let's dig in a little further there. Um, let's talk pain doctors, uh, but even just physicians in general here. Um, but again, most physicians have at least some kind of touchpoint with opioid prescriptions and having to walk that fine line between having patients use opioids when it's truly necessary versus finding non-opioid or non-pharmaceutical treatment options. So how are pain doctors? And if you want to, uh, expand that out a little more generally, uh, you know, physicians and general primary care physicians, how are they entangled in the opioid crisis today? Um, and if you had to sort of track a little timeline on the, their role during, you know, the initial growth of the epidemic versus what their role is today and, um, you know, the positive or negative consequences of their actions.

Michael Sprintz (24:36):

Well, I mean, I think that in, in, you know, in the beginning, you, it was a mess. It, it was a mess. And, you know, everyone who has seen, seen this stuff about the, the, the pharma companies and detailing docs and, you know, they, we, as, as physicians, we tend to do what we were trained in. You know, this is what I practiced in. This was what my attendings taught me. And, and so changing that initially takes a little bit of time, you know, ask anyone who's ever been on a diet, right change is uncomfortable and, and hard. And, um, I think that, especially when there wasn't a lot of quality evidence based education for providers on what to do and how to handle it, um, you know, that that's a piece of it. And I think that you, you touched on a great point where a lot of providers, they have relationships with their patients.

Michael Sprintz (25:30):

They know their family, they go to church, especially in smaller towns and saying no is hard. And, um, I, I always kind of joke that a, that a, a large number of, of healthcare providers are, um, you know, have, have codependent tendencies because we're, we, we wanna be healers. We wanna be liked. We want, we wanna help people. We wanna fix things. And all of those things set us up to not have good, healthy boundaries with our patients where, Hey, you know, Mrs. Jones, I'd love to take care of you. I'd love to do all these things. However, in this situation, opioids are not appropriate for you. Um, and, and the risks really do outweigh the benefits. However, here are some, here are these other options and opportunities for managing your pain that we can do. And holding that boundaries really challenging, um, especially with, with patients who may have a substance use problem.

Michael Sprintz (26:26):

Uh, I wanna also acknowledge one other piece that has played into all of this. So, and, and that, that has to do with the way that healthcare is structured right now with the payers have continued to decrease reimbursement, and as they decrease reimbursement, you know, the amount of patients a doctor has to see per day increases. So as that number of patients per day increases the amount of time that we can spend with a patient decreases. And we know that the, the less amount of time that we have with a patient, the more likely it is that we will write a prescription. And when we're dealing with a patient with chronic pain who may or may not have a substance use disorder, these are complex patients that it takes experience and knowledge and time to engage with them to really understand what's going on. So for most providers, you know, if you've got 10.7 minutes to spend with a patient they're spending, you know, nine of them trying to figure out what's what the heck's going on.

Michael Sprintz (27:27):

And then they have to put it all together with seeing them, treating them, diagnosing them, writing them the medications, or, or therapies, um, and doing all of that in that short period of time versus, and I'm a big proponent of leveraging technology, uh, as, as a tool to help make the most of the amount of time that providers have with their patients. Um, so it's, it's a setup on a lot of different levels. You know, all these factors have played into it that help to have created the crisis we're in, but by owning those things and identifying them and, and addressing each of those, um, issues will make a big difference in solving the crisis long term.

Daniel Litwin (28:09):

I wanna throw some more stats your way, uh, you know, to make this just a numbers podcast. But, um, there was a, uh, SAMSA report on key substance use and mental health indicators in the us from 2020 that, you know, I think backs up a lot of the points you were saying here. And I think introduces some new layers of context specifically for pain doctors, too, that I wanna get your thoughts on. So let me just read some of these out to you, and then I'll open up the floor for you to gimme your thoughts. Uh, but one of the key stats that stood out to me here was, uh, among people aged 12 or older in 2019, who misused prescription pain relievers in the past year. So, you know, again, remember the context here of, of the the time period pre-pandemic, uh, the most common 65%, the most common main reason for their last misuse of a pain reliever was to relieve physical pain, right? So physical pain, immediate connection with, and a large possibility of opioid misuse. Uh, another stat here more than one-third of people who misused pain relievers in the past year obtained pain relievers the last time through prescriptions or stole pain relievers from a healthcare provider, typically getting the pain relievers through a prescription from one doctor.

Michael Sprintz (29:29):

So I'm here to tell you that pain is not just physical. All right. Pain is an experience. Pain is, it is, it can be physical, but it's also emotional. It's psychological, it's energetic. Sometimes it's even spiritual pain is you can have a physical injury to a part of the body, but, you know, and you'll know that some people can tolerate physical pain, incredibly well. And other people can't, you know, they have a hangnail and they, and they lose it. Uh, and so what that tells us, you know, the, the, the pain tracks in our brain are also, we have, we have, um, we have, uh, I guess pain tracks or, or sort of like wire circuits that, that measure or detect pain, physical injury. But those, there are also circuits that go into our limbic system, which, which regulate our emotions and memory and salience, or, or relevance of what does this pain mean to me. And that's really important to understand that pain is never just physical. It's what we tell ourselves about the pain that impacts how we experience the pain. And, and I think that that plays a really big role in, in, uh, in a substance abuse, as well as, um, people's recovery from pain or how they handle it.

Daniel Litwin (30:51):

Yeah. And that's, that's a great point too, because I think having that more holistic view of what pain is and how it affects the person experiencing it can give, you know, not only friends and family, but also physicians, better indicators for what to look at, right. If all they're looking for is, do you feel physical pain? No, I'm fine there. Okay, great. You know, got it done. We win. But like, they aren't really looking for, is this person psychologically? Yeah. Right. Is this person still psychologically traumatized from love it? That's great, but right, exactly. Yeah. There's just so many layers to unpack. And so I'm glad that you bring that up. Uh, and the other stat that I want to throw out here and get your thoughts on, then I think, uh, just further validates why it's important to be viewing this crisis as specifically around prescription opioids and not just opiates at large is, um, in the same report, 9.7 million people aged 12 or older misused prescription pain relievers in that past year.

Daniel Litwin (31:54):

Now that's compared to only, I mean, only, but comparatively only 745,000 people who used heroin. So 9.7 million people misusing prescription pain relievers, 745,000 people used heroin. Now, naturally both of those numbers should be coming down. Right. But, um, why do you think that really says about where we're at in the crisis right now that, you know, um, opioids that are supposed to be for treatment that are supposed to have, uh, you know, an air of thoughtfulness of efficacy behind them are actually being misused more than, um, you know, a, a drug that is basically well known as being just an addictive substance. What are your thoughts?

Michael Sprintz (32:38):

Well, you know, let be clear. Heroin is actually used in other countries as a potent opioid pain reliever. It's, it's legal as a, as a scheduled drug. And, and for us, you know, fentanyl is a drug, I'm an anesthesiologist as well. And we used fentanyl in the operating room all the time when used appropriately. These are great medications. They're fantastic when used inappropriately is where we get all, all of the problems. And I I'm questioning that last, I'm questioning that last stat. Um, because, uh, you know, when they talk about, uh, um, when we talk about heroin use versus illicit opioid use on the street, a lot of people are buying their pills on the street and they think they're buying oxycodone, but it's, it's a guy who's been pressing, you know, TA powder and fentanyl and, um, and some other stuff that, that are doing it. Um, that is a problem.

Daniel Litwin (33:37):

Yeah. And, you know, maybe it's even UN unfair to compare the two, uh, because of the context around, um, you know, why people seek them out. Uh, and, and to your point, yeah. You know, just demonizing the concept of heroin entirely. I mean, to your point is it's used medically and it's used medically with efficacy. Um,

Michael Sprintz (33:59):

Not, not in the us, it's not medically used

Daniel Litwin (34:01):

In the right, not in the us.

Michael Sprintz (34:04):

Um, I think that the, the issue is, I think we keep the, one of the mistakes we make is that we overly focus on the drug and we're, we're overly focusing on a symptom. We're not focusing on the cause or, you know, treating the cause. Now I agree that managing the availability of opioids is part of the solution. I don't wanna imply that it's not cuz it is, but it's really about getting education for providers about identifying and, and solving, identifying and referring patients who, who may have a problem. It's also about making, uh, access to, um, quality, mental health and substance abuse treatment available for, uh, for a large number of our population. That's, that's the other piece of this, you know, and, um, because there will be some patients who may not get better, but there's a lot of patients who don't ever get the opportunity to get better because they were either just discharged from their practice and then they bounced back to the emergency rooms, or they bounced back to their primary care doc who, who doesn't know what to do. They're like find me another pain doctor. And meanwhile, you gotta prescribe all these things for me. And, uh, and everyone feel, everyone feels stuck. Everyone feels trapped in a situation that they don't feel like they have as much control over as they would like. And my goal is to try and help empower policy makers, to make rational policy, um, decisions that really help solve the C treat the cause rather than just the symptom.

Daniel Litwin (35:45):

So let's get to some strategies now for physicians, for pain doctors. Um, I guess, how do you see the guidelines having an immediate impact on how, uh, professionals in the space should maneuver their work? Right? How does this adjustment of the CDCs opioid prescription guidelines change some of the ways that you think, uh, physicians, providers, uh, need to be more thoughtful about their opioid prescription habits, uh, but also ways that they need to be more cautious with some of the ways that the guidelines, uh, you know, open up and provide more freedom for them to use their own discretion.

Michael Sprintz (36:24):

I, I think for some doctors it's gonna be scarier because they actually have to really think about it and make good decisions, um, which means they have to educate themselves on this. Uh, I think overall it's, it's great. I think we're, it's absolutely a step in the right direction. I think that this is a good way to move towards it because it gives doctors the, the freedom to prescribe when they feel it's appropriate, where they feel that the benefits of prescribing opioids outweigh the risks. And as long as they document that, well, it's, it's generally not an issue. Um, uh, I think that the fear of, of consequences, uh, is more than what actually occurs in the real world. And I think that what it does though, is it challenges doctors to grow. And it's hard when everyone, and I wanna acknowledge this, everyone's working hard.

Michael Sprintz (37:21):

We are all working hard, we're working more, um, more hours for less pay every, you know, and, and that is in almost pretty much every industry. So everyone is stressed right now. Um, however that doesn't absolve us of the responsibility of doing the very best we can in, in, um, taking care of our patients, we have to listen to our patients. It's the number one thing I hear, um, from, from my patients is of that, you know, no doctors listen to me, they don't hear me. And so for, for docs, you know, one of the things I would say is take a moment and be present with your patient because you'll get a lot of information just by pausing and listening. And once they get educated on the basics of identifying substance use problems, they'll start to be able to figure out whether it is whether there's a problem or not, and what to do about it.

Michael Sprintz (38:17):

And I always, I, I have, uh, a number of partners who, when they first joined my practice, they didn't have, you know, enough training or experience in, in addiction medicine. And one of my first things that I told them was if something doesn't feel right, it's not right. You may not even be able to pinpoint why something's not right, but trust that and move from there where the previous guidelines had these hard and fast rules. And so suddenly, you know, patients who had saw the doctor for 15 years that were on higher doses of opioids, suddenly they walk in one day and the doc is like, look, you're going down to 50 morphine equivalence tomorrow. And so, well, you know, that's not a really good that that's actually a horrible way to manage patients in, in that. And the doctors felt stuck and the patients felt stuck.

Michael Sprintz (39:09):

Everyone got stuck. And there was a lot of, um, there was a lot of people who suffered tremendously from that. And I, what we have now is that, you know, they're, they're telling us, you know, in the guidelines, Hey, do clinical drug testing. I was on, um, the American society, addiction medicines expert panel on drug testing for appropriate drug testing in, in clinical medicine and drug testing when done appropriately is absolutely essential to identifying patients who may be struggling with a problem. Cause addiction is not, this, it's not this thing. You either have it, or you don't, it's not an on and off switch. It's a progressive disease. You know, where some, for a long time, people may not have a problem, but then they lose a job. They get divorced. I don't know, COVID pandemic hits and suddenly their stress level increases and they lose their job.

Michael Sprintz (40:00):

And next thing you know, they're drinking two bottles of wine a night, even though they're being prescribed opioids. And we as providers need to be able to start to understand that. So drug testing is really important, checking the prescription drug database to see if the patient is getting medications, you know, that are dangerous, other opioids or other things that can increase the risk of overdose. You know, we need to know about those things. So there's a couple basic things that we can be doing that help us that help to guide us on, um, delivering better care for our patients.

Daniel Litwin (40:33):

I love that, you know, your interpretation here is that the core of this is going to be a positive because it, it allows for physicians to trust their gut a little bit more to apply their skills and, um, you know, allow that relationship, uh, you know, albeit with, um, some boundaries, but that relationship that they have with their patient to be their driving force for deciding how do I treat this patient? How do I make sure I keep them safe? Uh, and that's, you know, that's a powerful part of the job that, um, it sounds like the initial guidelines kind of sacrificed in favor of let's overcorrect. Right. Let's fix this issue right now. And it actually had some unintended consequences, like you said. Uh, now some of the other dialogue around the change in guidelines also says, well, we need to be careful. This could open the door to over prescription from bad actors. too. Would you agree that that's something that we should be worrying about? I mean, what, what are your thoughts on that part of the dialogue?

Michael Sprintz (41:32):

So my thought is that bad actors are bad actors, whether, you know, they're just because the previous guidelines over prescribers still overprescribed, regardless of the guidelines. So bad actors are going to continue to be bad actors. Um, you know, that's why they're bad actors. And, but the vast majority of doctors aren't the vast majority of doctors are just trying to do the right thing. They're trying to give good care to their patients within these boundaries. And, um, so I think that it's always important to, um, to be concerned about, um, the, the, the outliers, the bad actors who are going to overprescribe, but that's not something that these, you know, if you actually wrote guidelines to prevent, if the whole thing was written about preventing bad actors, well, then you just, then you take it all the way to the extreme and you just cut out all opioids for everyone.

Michael Sprintz (42:31):

And that is not a good idea. It's a horrible idea. Um, we can't, we can't write policy based on the behavior of a few. We ha you know, we have to take into account that the vast majority of physicians are, are really doing the best they can to deliver good care. And the guidelines should be within that context. And then law enforcement, you know, the bad actors who are overprescribing, they are statistically above the mean, uh, and so in that regard, there are ways to identify who is, you know, truly overprescribing. And we have ways of tracking that. So I think that it should be addressed for the, for the inappropriate and illegal, um, you know, prescribing of, of medications. That's a law enforcement issue. It shouldn't be a healthcare policy issue for everyone.

Daniel Litwin (43:23):

Fair point. If someone out there wants to overprescribe, because they're just hell-bent on being a bad actor. Yeah. Uh, I don't think some CDC guidelines are gonna stop them necessarily. So,

Michael Sprintz (43:35):

Yeah, I heard, I heard a long time ago from, from a cop that, you know, locks are meant to keep honest people out. You know, if someone really wants to, they're gonna do it. If someone is built there, and if someone is a completely unethical provider and they're using their license just to, to prescribe, they're gonna charge cash. They're not going to, you know, or maybe they'll take insurance. I don't know, but whatever they're gonna do, they're gonna be building their whole business model, if you will, without ethics and without caring for the patients. And they're going to do it no matter what the guidelines say, right. Because they're, they don't care. They don't care about the patients, but the vast majority of doctors do.

Daniel Litwin (44:20):

So. Okay. If the concept of, um, you know, these guidelines are going to enable bad actors is, you know, um, not necessarily the biggest point concern because okay, bad actors are going to be bad actors. We should be focusing more on what can we do to make sure our honest well-intentioned physicians are doing the best job they can. Then that kind of leads us to another possibility here of, um, a relaxing of the prescription limits and a more of an emphasis on trust, your gut, trust, your intuition, use your knowledge base and your skill to determine what's right for this patient could not be as effective if we have physicians that don't have all the tools that they need are not completely educated on how to gauge whether or not their patient is at risk of addiction, et cetera, et cetera. So do you see that as the potential, you know, biggest challenge facing physicians today in maneuvering these new guidelines? Yes. No. Why or why not?

Michael Sprintz (45:19):

Yes, I do. Um, I, I think that, that you hit, you hit the nail on the head that it really is a problem in that the doctors want to do well. And the problem is, is that many of them are not educated on how to do that. Um, you know, I, would've loved to have seen, um, a, a recommendation in the guidelines of a minimum core competency in addiction medicine, or a minimum CME, not in proper opioid prescribing, because I, I I've seen so many of those courses and they're basically like, and if the patient has a substance use problem, then you shouldn't prescribe for them. Great. Yeah. We know that that doesn't solve the problem. Um, the problem is how do I know? So, you know, having, you know, having some mandates for, um, having mandates that are specific about education on identification and proper management of patients with chronic pain and potential substance use disorders, now that's moving towards, um, that's moving in the right direction where now you actually are creating a situation where it's pushing providers to get the education that they need to enable them to deliver good care and make those decisions and to make, to make better decisions for their patients.

Michael Sprintz (46:41):

Um, I, I think that would've been, uh, the next step, or I think that would've been really, really helpful to have there because that would then empower, that would create the opportunity to empower physicians, to become educated in the areas that they need education in.

Daniel Litwin (46:59):

Well, then what are your strategies for making that a reality, right? Um, if it's not in the guidelines, um, who needs to take on that burden of pushing forward, continued education, better tools, best practices for providers, you know, is this something that providers need to take the initiative on themselves? Is it the industry? I mean, what do we see?

Michael Sprintz (47:20):

It's, it's all of the above, um, it's it's policy from the government. It is the medical board's requirement. It is the medical school's requirements start teaching addiction medicine in medical schools. And that is starting now, which is great. Uh, you know, I love that. Um, and what I'm also seeing now are the medical societies are, are starting to, um, are, are, are starting to put out recommendations and guidelines as well. Um, I was a member. I, I represented ASAM, the American society of addiction medicine with, um, a 14 specialty group of, uh, all the societies from anesthesiologists to all the subspecialties and surgeons in putting together, um, principles of appropriate postoperative management of patients with chronic pain. And there is a couple, um, statements about, you know, if there's an issue or a question about substance use disorder, you should consult an addiction medicine specialist, or a behavioral health specialist where we're starting that process of getting providers down, you know, into the shoot of, Hey look guys, or, and guy people, Hey, look, people you need to, um, you need to be educated on these things and if you're not that's okay, but you need to ask for help then.

Michael Sprintz (48:39):

And telemedicine is wonderful about that because now with the, with the, you know, explosion of telehealth services, which are not gonna go away having a, you know, a subject matter expert, you don't need to have one in your town. You can do consults, uh, um, via telehealth that can help you manage it. Um, one last final point too, that the, the guidelines talk about is they talk about, you know, if a patient's not appropriate, that you should taper them down. One of the things that I have seen is that in the pain community, um, historically with opioid withdrawal management or, or tapering, if you will, is, has not been done in a way, um, that's really enabled success for the patients. And that's one of the things that, uh, what I do love about the Spark device in and of itself is it, it, it helps with managing opioid withdrawal symptoms, but it does it utilizing electrical stimulation rather than chemicals, you know, rather than another drug.

Michael Sprintz (49:45):

So it's a new tool. And, um, and in, and in full disclosure, I do, uh, do some consulting work for them as well, but the, the, the product itself is another tool in our toolkit to help providers taper patients safer because we want our patients to succeed. Um, when we just cut their opioid doses down, um, without supporting or without treating any of their withdrawal symptoms, what you have is this low level of withdrawal in our patients and low level opioid withdrawal hurts. So here I have a chronic pain patient that I decrease their dose by 10% or 25%. And they're, and they're in, and now I can't understand why they keep complaining of pain. They keep complaining of pain because they're in low level withdrawal for the next six months and everything hurts and they feel like crap. And so I think that educating providers on, on appropriate ways of, of tapering their patients down off of opioids, or just down to a, to a lower level of opioids is another educational piece that needs to happen.

Daniel Litwin (50:52):

A lot of those solutions are very structural, right? And they're also very, um, you know, very, uh, focused on training a new generation, as well as establishing continued education for physicians. Do you have any strategies or recommendations for current physicians for pain doctors today? You know, what can they take on themselves? Uh, what can they do to better equip themselves, um, to, uh, prevent themselves, you know, from further recreating the current crisis through their treatment?

Michael Sprintz (51:23):

The be there's a couple suggestions that I would make for pain doctors. The first thing is educate yourself. So there are more and more CME that are out there. I would recommend the, um, ASAM the American society of addiction medicine every year, we have a pain and addiction. Um, pre-conference workshop, it's a full day of education on chronic pain and addiction. That's a great thing to attend, uh, this year. Um, I'm in Texas and, uh, Texas pain society for the first year. Um, we had a half day workshop on pain and addiction, and I did most of the, of the lectures on that. And so what's great is the pain societies are now providing these CME and these educational opportunities for pain docs to, um, uh, to get educated. So that's the number one thing is get educated. Do your, don't do your CES. In something that you already know how to do, get your CES in substance use, uh, you know, in something related to chronic pain and substance abuse, cuz you need to know that it really, you really need to know it and it's it, you know, where I see things moving in the future, ultimately there will be this convergence, there will be core competencies within the the pain world that you just have to know these things in order to get licensed. Cause you can't avoid it anymore.

Daniel Litwin (52:48):

Dr. Sprintz, uh, thank you so much for all your insights so far. It's really been a pleasure getting to chat. I've got one more question for you, you know, being that we're on the Spark Biomedical podcast, uh, I do want to intersect our treatment into the conversation to close and just get your thoughts on if you see it playing any particular role. So more specifically here, what role would you see or would you recommend, uh, transcutaneous auricular neurostimulation therapy or tan therapy like our Sparrow device playing in a pain doctor's toolkit of treatment? Any thoughts there?

Michael Sprintz (53:21):

Yeah, I, I think it plays a, I think it plays a significant role and it will play a much larger role in, in, in the future because as the pain community is now starting to embrace and acknowledge and recognize the problem of substance abuse within their patient population and that they will be responsible for managing opioid withdrawal. And, you know, again, the spark device, like I said, is it's a great tool because it uses electricity instead of chemicals in order to help manage patients, um, who are, who are tapering down, uh, off of opioids to prevent opioid withdrawal symptoms. And I think that's a huge benefit, especially moving in the future. Um, uh, as, uh, as, as it, we keep on as more and more providers start to feel more comfortable with tapering their patients instead of discharging them that, uh, the, the Spark device will play a much larger role in the future with, um, uh, within the pain management community.

Michael Sprintz (54:22):

Um, it's playing a very big role in both the addiction medicine community as, as an alternative to, uh, other medications like me like methadone or buprenorphine. It uses electricity instead, and that's really starting to take off and, and it's a great, um, alternative solution to manage opioid withdrawal symptoms. And it's also doing a great job in neonatal withdrawal symptoms as well. I mean, the, the data's really impressive. So I see it happening already in the addiction side. And on the pain side, it's going to have a, a big impact moving forward. Um, as, as the pain community really starts to embrace, um, learning and understanding about substance use and how to manage it, um, because it's coming or actually it's here already, but it's the, the time of, of needing to learn about it and how to manage it is, is also here and it's starting and it's gonna get more and more so you guys can be, uh, or everyone can get ahead of the curve. Uh, and I would strongly recommend that.

Daniel Litwin (55:25):

And I think with that forward-looking note, we'll wrap up the podcast here for today. Uh, and yeah, you know, I think, um, pushing for education, pushing, uh, for there to be some structural adjustments to how we center this in the industry, uh, but also doing what we can as individual physicians, uh, and also supporting colleagues in coming together and making sure that, Hey, at our practice, we're gonna make sure we're all on the same page here. And we all, um, you know, are fully equipped to identify and properly treat patients who might have a predisposition, uh, or, you know, maybe leaning towards developing, um, an addiction. Yeah,

Michael Sprintz (56:07):

I did have one last final thought. Um, the one thing that I do wanna say, and, and I've told this to, to my partners when they first started in the practice, the everyone, no one likes having ever, you know, initially pain doctors are, are not comfortable with having addiction patients. What I can tell you is this, when you get comfortable with the basics of, uh, of identifying and managing substance abuse, and when you get comfortable with holding boundaries, what you will find in your practice is your practice gets easier. You, you tend to select for patients who want to get better, the emotional stress within your practice will go down. I promise you, um, it is absolutely worth doing so, um, that that really is the last thing I wanted. I wanna give the pain doctors hope it's not all you must do this. You must do this. What I also want them to know is when you do this, your practice will, will improve. Your outcomes will be better. Um, and you will actually not have nearly as much stress from, um, from patients in their active addiction because you'll know how to manage them. And it won't be that problem.

Daniel Litwin (57:14):

Dr. Michael Sprintz, founder, and CEO of Sprintz cCenter. Thank you so much again, for your time today, it's been such a pleasure. Um, getting your thoughts on this, pulling from your experience, not only in your personal journey of recovery, but also as a, uh, certified, uh, professional in this space. And so many accolades, it's just been so great, getting your perspective on, um, the nuances of this challenge and why it's important to hold those nuances, dear, because one size fits all solutions. As we've seen with the initial 2016 CDC guidelines do not always have the intended consequences. So we'll leave on that note, Dr. Sprintz, thanks again. And if folks wanna get in touch with you, um, they wanna pick your brain on the subject a little more, how can they learn more about your work and how can they get in touch?

Michael Sprintz (58:02):

Sure. The, the best way to reach me would, uh, be my email, which, uh, actually have two different ones. One is, um, M Sprintz S P I NT Z Sprintz center.com. Or you can email me at MichaelDrSprintz.com. Um, either way is fine. Uh, I am happy to help out any way that I can if people have questions, uh, or if I can be of assistance in any way,

Daniel Litwin (58:27):

Fantastic stuff. I think you're gonna be a really valuable resource for the community moving forward. And I appreciate you being so willing to share your knowledge and expertise. So thanks again, Dr. Sprintz and, uh, we'll chat it in soon. Great.

Michael Sprintz (58:40):

Thanks for having me

Daniel Litwin (58:41):

And thank you everyone for tuning into this episode of Vital Spark, a Spark Biomedical podcast. If you like what you heard and saw today, and you want previous episodes, you wanna make sure you don't miss out on future conversations, or you just want more information on Spark Biomedical as a whole. You can head to our website Sparkbiomedical.com. Again, that's Sparkbiomedical.com and make sure that you're subscribing to Vital Spark on apple podcasts and Spotify. I'm your host, Daniel, Litwin the voice of B2B. Then we'll catch you on the next episode of Vital Spark.