Dr. Vanila Singh on the problem of excess medications leftover in the medicine cabinet~
“When someone has a surgery, they’ll get X amount of tablets, and I think it’s become clear that in many cases those are too many tablets, so they remain in the medicine cabinet, and they can be a target of folks who do suffer from addiction and start to have behaviors that make them do things that we would never expect.”
Brian Wilson: From her years practicing pain management and Anesthesiology to her current position at the Department of Health and Human Services, Dr. Vanila Singh has experienced the opioid crisis from many angles. She’s a doctor, a teacher, and a policy advisor who has seen chronic pain face to face. She joins us to talk not only about the current administration’s strong stance on the opioid crisis but also about how we got here.
How We Got Here – The Opioid Epidemic
Dr. Vanila Singh: The first wave really began with opioid prescriptions, perhaps the over-prescribing or the excess tablets. This came with different needs to one, address pain, but also not having all the treatment modalities out in the rural areas, or even the urban areas, so it really started with that first wave. Then, the second wave really was heroin use, which was available in larger quantities, used by a larger number of people, and it really actually increased over four-fold from 2010 with nearly 13,000 Americans dying from heroin in 2015.
Then, the third wave, which is the wave that you hear about, is really the opioid epidemic with fentanyl, fentanyl being an agent that’s 50 to 100 times more potent than morphine. It’s a synthetic, you hear about it coming from overseas in our postal services. So, we are at this time noticing a significant decrease in prescribers for opioids. However, there is the challenge that remains both for the licit, the legal prescription, but also the illicit market with fentanyl and other drugs. So where we are today is we have much more of our sources from HHS and other federal government agencies and state agencies and communities aware. I would say that we’re perhaps more fortified as we start to really get a grasp of this public health issue.
Licit Opioids in Pain Management – From Too Much to Too Little
Brian Wilson: I’m wondering about whether or not there was a time during this whole process where, because we became concerned about opioid use, perhaps we got a little too stingy, is the only word I can come up with, with the drug, so that … In fact, there were people who needed the drug who were having trouble getting it. Have we sort of figured that out by now?
Dr. Vanila Singh: Well, what you bring up is the challenge and nuances of all this, and the pendulum swings one way and then it swings the other. It’s important to note opioids, like you already mentioned, can be misused and people with addiction can utilize it in a wrongful manner and tragically have overdose and even death. On the other hand, we know that it has usefulness in the surgical arena, or hip fractures, but to also moderate that with other treatment modalities.
Yeah, I think that oftentimes, there’s this sense of a one-size-fits-all. That is definitely not true. We know as human beings that people come with their own background, their own beliefs, and their own medical issues and conditions that make us not “Toyota Corollas”, where we’re treating everyone exactly the same. That has probably lent itself often to where patients aren’t getting the treatment they need. So, I would just say that really a patient-centered approach is really always called for. Whenever we move away from that is when we get into trouble.
Prescribing the Right Dosage
Brian Wilson: How do you determine what is the right dosage, as a doctor, so that you’re treating the pain but not over-medicating to the point where it can become an addiction?
Dr. Vanila Singh: First is really risk assessment of a patient. When someone is going to be initiated on opioids, it’s assessing do they have an increased risk, which you can assert from family history, whether it’s opioid use but it could be alcoholism, the patient’s own history, their mental health state, any psychological trauma, and putting together a complex sort of story. So, it’s really individualized, and the best care is always individualized, where you see the patient, what their health issues are, and perhaps what surgery they’re about to have, or whatever the indication might be for the consideration of an opioid.
People’s perception of pain differs, and so what the right dose is, there is no stating it. We have guidelines, and those really go with starting with non-opiate pharmacologic uses, such as acetaminophen or NSAIDs if applicable, but then starting with the lowest effective dose, so with surgeries, you would anticipate many surgeries, with moderate to severe surgeries especially, that there’s going to be opioid use. Generally, when the team sees a patient, they can assess from past surgeries how that person is going to do, but then you have to take into account if the patient has had a history of chronic pain. Are they already on opioids? That could move to the fact that they may be tolerant and may require more, and may actually be better served if indicated with other treatment modalities, nerve blocks, other pain medicines that aren’t opioids.
I would say in a short answer, it really has to be individualized. There’s no number, and episodic regular evaluation is very important, patient education that they’re informed of the risks of taking this medicine, and that there are alternatives. I think all of those things together really start to put people on a path where the opioids may be utilized for a shorter duration and then other treatment modalities can be used if needed, or the patient can come off of it. But, in short answer, it really has to be patient-centered and individualized.
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You never threw them out, so they sit inside your medicine cabinet posing a risk to you, those around you and anyone who enters your home. Today going through medicine cabinets searching for drugs is done by people of all ages and backgrounds. In fact, over 70% of new opioid addictions begin in a home medicine cabinet. If storing unused and expired medications puts people at risk of accidental poisoning, addiction and death., why have them there at all?
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The Serious Problem of Leftover Medications in the Medicine Cabinet
Brian Wilson: So, Dr. Singh, when you talk about the drugs that can be found in the medicine cabinet, where some of this starts, what would you say to people who are wondering whether or not it can be a serious problem? Is it a serious problem, and how should they deal with that?
Dr. Vanila Singh: Well, I think that’s a great question because it’s the excess medicines often that are there. When someone has a surgery, they’ll get X amount of tablets, and I think it’s become clear that in many cases those are too many tablets, so they remain in the medicine cabinet, and they can be a target of folks who do suffer from addiction and start to have behaviors that make them do things that we would never expect. So, it’s really important to have the patient, one, be aware that they should be able to dispose of them. You know the take back days that the DA does twice a year, maybe those can be increased, means to actually neutralize those, if you will. So, I think that’s an important aspect of the excess supply that gets out there that does get misused, whether it’s a patient or often when it’s not the patient but someone the patient knows.
Brian Wilson: Well, I guess one thing we could all agree upon is if the supply is not there, it cannot be diverted or misused.
Dr. Vanila Singh: That’s right. That’s exactly right. One is addressing the demand. The demand comes from addiction, or in some cases people who are seeking and are undertreated in their pain and misusing that way, but the other comes from the supply. The supply, again being from excess medicine, tablets, or again from the black market.
Dr. Vanila Singh – “You can never forget the humanity of it.”
Brian Wilson: You and I have been talking about this in clinical terms. You, no doubt, have seen a lot of things. What has impacted you about this crisis on a personal level?
Dr. Vanila Singh: Thank you for asking that. Honestly, yes, I have this doctor hat, physician hat, and then of course in the official capacity that I am, but I will tell you, personally to have treated thousands of patients, which has spanned a majority of my career, it is very humbling to see people who go through despair and have suffered in a manner that a lot of times our society doesn’t appreciate.
I will say this. It is with those patients of mine that I have come to take this position and work in that official capacity, but I have seen that with a bit of empathy and reassurance how far that can go. I can recount so many different stories about even some of our veterans I’ve treated a patient who’s homeless, and top executives, and everyone in between. It has always been amazing to see how quickly people can really fall off their track with pain management because it effects them in a way that sometimes other diseases don’t, or it could be a part of a disease where they feel it, they suffer from it, and then they’re often judged.
It effects their ability to work, and it goes to the very heart of who they are. That takes a lot of effort and a complex array of really good people in their lives to really bring them back. So, I’ve seen that story over and over, and it is something that is really hard to articulate sometimes about what this really encompasses. The father of pain was someone named Dr. John Bonica and he started to write about this and the fact that we even have this.
We have some literature and recounting from the Civil War when phantom limb was described well. That gives me hope that we’ve come a long way, but you can never forget the humanity of it. So even in the policy position, it’s easy, some things make a lot of sense, they are well-intended, but I think we always have to remember how it actually impacts the person.
I’d just like to say that I think that the more awareness there is in the public, and particularly with friends and family of patients who suffer from acute and chronic pain, that more empathy, a reassurance, and understanding that this is deeper than most people realize, that “Hey, someone’s not strong enough or they’re weak, or just get over it,” sometimes the outward wound isn’t obvious. So, people have more empathy when someone has a cast on or a sling on, or crutches, or a diagnosis such as high blood pressure, diabetes or cancer, but that these patients truly do suffer, and reassurance with friends and family goes a long way.
Brian Wilson: Thank you very much, Dr. Singh. Can’t tell you how much we appreciate this.
Dr. Vanila Singh: Absolutely. Thank you so much.
Brian Wilson: If you’ve never had an opioid prescribed for you chances are you know someone who has. Be proactive, and educate yourself and your loved ones on how to properly handle and dispose of medications. It’s as easy as visiting DisposeRx.com. That’s disposerx.com.
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