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Today on The Fundamentals, our guest is Dr. Pooja Lagisetty, an assistant professor of internal medicine and a research scientist at the Center for Clinical Management and Research at the Ann Arbor VA. Her research focuses on addressing access barriers and developing multidisciplinary interventions to better treat chronic pain and addiction across general medical settings. Her research has been influential in understanding stigma and disparities for individuals with pain and addiction.

You can learn more about Dr. Lagisetty here, and you can follow the Dr. Lagisetty @PoojaLagisetty, the U-M Institute for Healthcare Policy & Innovation @UM_ihpi and the U-M Department of Internal Medicine @UMIntMed on Twitter.

Resources

• Find out more about the research stories mentioned at the top of the show at the links below:
  • How one state beat national surgery opioid trends
    Prescribing guidelines accelerated Michigan’s progress over the rest of the nation, study shows
  • Zip code and hospital quality may both affect the risk of dying after surgery
    People who lived in under-resourced neighborhoods and underwent operations at lower-quality hospitals were more likely to die within 30 days.
• You can learn more about The Fundamentals on our website.
• Learn more about other exciting research happening at the University of Michigan, by checking out Health Lab, Michigan Medicine's daily online publication featuring news and stories about the future of healthcare.

The Fundamentals is a part of the Michigan Medicine Podcast Network, and is produced by the Michigan Medicine Department of Communication. You can subscribe to The Fundamentals on Apple Podcasts, Google Podcasts, Stitcher or wherever you listen to podcasts.

Transcript

Kelly Malcom:

Welcome to The Fundamentals, a podcast focused on the incredible research and researchers at Michigan Medicine. I'm your host, Kelly Malcom.

Jordan Goebig:

And I'm Jordan Goebig.

Kelly Malcom:

The opioid epidemic, fueled by both prescribed and illicit versions of the drugs, has wreaked havoc on this country, but figuring out how to help people who are in pain or who have use disorders is a complex issue. Our next guest gave me a new and deeper perspective on the opioid crisis.

Jordan Goebig:

Absolutely, and she won't be our only guest covering this general theme this season, but I did appreciate having a perspective from a chemist and then getting one from a more clinical side and also learning about the resources and collaborations happening at the university to address the opioid crisis. This week, I found a recent article from Michigan Medicine about a statewide effort to treat the pain of surgery patients that led to a drop in opioid prescriptions and refills that I thought was interesting.

Kelly Malcom:

Our guest also talks about health disparities and disparities in access to care. Another unfortunate example of this is a recent study that found that living in an under-resourced neighborhood may affect a person's recovery from surgery, even if their operation takes place at a high quality hospital.

Jordan Goebig:

For folks that want to know more about these topics, we have a significant amount of research stories written about them, as well as a number of collaborative projects going on. We'll make sure to provide links to the show notes. Now, let's get on to our guest.

Kelly Malcom:

Today's guest is Dr. Pooja Lagisetty, an assistant professor of internal medicine and a research scientist at the Center for Clinical Management and Research at the Ann Arbor VA. Her research focuses on addressing access barriers and developing multidisciplinary interventions to better treat chronic pain and addiction across general medical settings. Her research has been influential in understanding stigma and disparities for individuals with pain and addiction.

Specifically, her work has highlighted treatment access barriers for individuals with chronic pain, following policies aimed at reducing prescription opioid supply and racial disparities in the receipt of medications for opioid use disorder. Welcome, Dr. Lagisetty.

Dr. Pooja Lagisetty:

Thanks for having me.

Jordan Goebig:

We're so excited to have you today, and we are ready to just jump right into things and get to know you a little bit better. I'm going to kick us off with just hopefully not too tough of a question, but I'd love to learn a little bit more about what point in your career you started to focus on chronic pain and addiction and where did the passion for these topics come from?

Dr. Pooja Lagisetty:

When I think back at where my interest first was sparked, I would probably say it was during residency. I did my residency training in Boston, in Massachusetts, and my outpatient clinic, so I'm a primary care physician, my outpatient clinic was in Charlestown, which is a little neighborhood of Boston of largely working class individuals. This neighborhood had really been struck hard by the prescription opioid epidemic during the time of my training.

I was really fortunate to have preceptors who were, I guess, ahead of the game and already providing medications for opioid use disorder in general medical settings and started to train me on treating patients with addiction in general medical settings. I think at that point I became interested and didn't realize that it would become my life path from a work perspective quite yet, but I give those preceptors credit for inspiring me.

Jordan Goebig:

Really interesting. Thank you for sharing that.

Kelly Malcom:

How has the opioid epidemic changed how you and your colleagues practice medicine? It might even be helpful to define when the opioid epidemic began, if there is such a definition, and what effects it's had on practice.

Dr. Pooja Lagisetty:

I will say people have used opioids for centuries. When we think about the opioid epidemic in America, I think a lot of people really start to think about it beginning closer to the early 2000s when we started to see the rise in prescription opioid related overdoses. Not to say that there wasn't a lot of non-prescribed opioid use happening in the '70s and the '80s and even before the '70s, but that's when the opioid epidemic really, one, reached national attention, and two, it really started to affect our healthcare system.

Because as you can imagine, before the 2000s and before the prescription opioid epidemic in general, a lot of the opioids that people were using were non-prescribed. They were illicit market opioids. It wasn't necessarily something that you as a doctor had to deal with or the healthcare system felt like was a medical condition that they had to deal with. I would say since the 2000s, there's been this growing realization that addiction is something that is something to be treated in the healthcare system.

Kelly Malcom:

Does that now affect how you prescribe? I'm wondering how things got kicked off. Was there a new drug that entered the market, really what triggered the medicalization of opioid use?

Dr. Pooja Lagisetty:

Yeah, good question. I think it's multifactorial. Like I said, in the 2000s, we started to prescribe a lot of prescription opioids, and that was the first time, I think, people started to think about opioids being kind of a medical therapeutic option. We probably don't have the time to go into how the pharmaceutical industry promoted opioids at that time, but clearly they were promoted as a safe option for the treatment of pain. As physicians started to believe that narrative, their use really expanded and they were marketed heavily to patients as well.

There were a lot of factors that went into things at the same time. Pain also became kind of considered a vital sign. We would ask patients every time they came into the hospital or clinic, how bad your pain is. We started to recognize pain as a treatment option. But I think before we even go there from the medicalization, so that's the medicalization of prescribed opioids, and that was what really garnered attention. But like I said, opioids always existed. Illicit opioids were always on the market in the form of other...

Whether that was heroin back in the day and whether that's fentanyl today, those opioids were always there. It was just, like I said, considered something that people did recreationally on their own time and not necessarily... It was almost considered a vice or something bad that people did and not something that needed to be treated by doctors. But when we started to use opioids to treat pain, in that very different medical context around the idea of pain, then we started to think, oh, well, maybe this is a doctor problem and this is something that needs to happen in the healthcare system.

However, with that said, we are still doing a good job treating pain in the healthcare system and using opioids for the treatment of pain, although that's getting harder and harder too. I wouldn't say that the healthcare system has embraced treating opioid use disorder or addiction. The medications that we use to treat opioid use disorder are still very rarely used in the healthcare system, and it's hard for us to convince doctors into providing that treatment no matter what we've done with respect to policies.

When we think about the word opioid, it's so broad and diverse. Some things have been really treated in the healthcare system for a while, specifically pain and other situations like addiction. We're trying our best to convince our healthcare providers to embrace the treatment of addiction within the healthcare system.

Jordan Goebig:

One of the words that you've used several times is opioid use disorder, which I hadn't honestly never even heard of. I'm ignorant on this topic in terms of I've definitely consumed a lot of popular culture media related to opioid use, maybe watched a popular Hulu series not too long ago. I remember watching Intervention when I was in high school and things like that, but I really don't know a lot about it. I had never heard this term before. I would love to hear from you, how do you define chronic pain versus opioid use disorder and what does that mean?

Dr. Pooja Lagisetty:

Remember, opioids is the drug class. It's a type of drug, and that drug can be used for a variety of reasons, similar to alcohol. We can use it to increase our ability to be social, decrease our anxiety, make us feel good. Maybe we just like the flavor of it. We can use that drug for a variety of reasons. Sometimes alcohol is even used medicinally historically as well. Opioids similarly can be used for a lot of reasons. Socially, they make us a little bit more social. They relax us. They can also treat pain. They can help people go to sleep. They could do all kinds of things.

Opioids within the medical context have been used to treat chronic pain or acute pain after a surgery. You can get some pills. Chronic pain is basically pain that's lasted more than 90 days. That becomes the chronic aspect of it. You can use those opioids to treat your pain all day long and not have what we would define as an opioid use disorder. An opioid use to disorder, I think the easiest way to think about it is when the opioids start to affect your ability to function in your roles and responsibilities, if it's affecting your ability to hang out with your kids.

If you're driving dangerously. If it's something that you're craving all the time or you're thinking about all the time, then you have an opioid use disorder, and that's just a big fancy medical word for addiction. But if you're just physically taking that opioid for a long period of time and it's not negatively impacting your roles and responsibilities, you don't have an opioid use disorder. A lot of people have been on prescribed opioids let's say for 10 years by their doc, and they don't necessarily have an opioid use disorder, unless it's affecting their ability to function in their daily life.

Jordan Goebig:

I really appreciate that. Actually I had a C-section, an emergency C-section, when I gave birth and I was offered pain medication when I was leaving the hospital. I declined. I really did. I feel so stupid now. It was fine. I'm fine. I recovered. But I remember declining anything stronger than Tylenol because I just got so nervous. I mean, I know my doctor knows best, but I just like, I can do this. I didn't know what a C-section recovery was going to be like, and I'm fine again, but it's good to hear those things from you because I feel like I didn't really advocate for my pain after my surgery because I was really nervous that I was going to get something and it was going to impact me and some negative way. I just didn't know what I was doing. I should have just listened to my doctor who just had an emergency C-section. Again, I'm fine, baby's fine, but it did keep me I feel like from advocating for myself and seeking treatment, that might have just helped because having a kid's really tough right after especially.

I really appreciate that. I think this hopefully segues a bit into my next question, what barriers do individuals with chronic pain face when they're trying to receive care and treatment? I know that's an area that you've done a lot of research on.

Dr. Pooja Lagisetty:

I think going back to this idea of intersectionality of what opioids do, I always try to explain the backstory here, which is there's a lot of stigma attached to opioids now. Opioid phobia I guess you could use if you wanted to use that term, but an opioid phobia in some ways is rightful. This one drug has thrown us into a major epidemic, and there should be a reasonable fear around it. Because as we just discussed, there are some people that obviously can take that medication for a C-section and do just fine. Take it for a few days and be okay.

There's other people that take it long term for many years and also are still theoretically okay. And then there's others where the medication can really cause an opioid use disorder. I think the trouble here is that for doctors and for anyone, honestly, figuring out where a person's going to land on that spectrum when they take that medication is really, really difficult. We can create risk factors and risk scores to try to figure out who is going to be just fine and who is not going to be fine, but none of that really works out that well. That has created a lot of fear around the medication in general.

If I see a patient who just had a C-section and maybe has some pain, I'm thinking to myself as a doctor, can I give this patient some medication to help with their pain? And how do I reasonably give them this medication and not start what could be 10 years of potential physical dependence on the medication or an opioid use disorder? With that said, a lot of doctors and clinicians in general are just saying, well, if the medication's so dangerous or has this danger potential, then I'm just not going to give it at all.

You guys fooled me. You told me it was safe a few years ago. I gave it to everybody, and now I'm saying no and I'm not going to do it. A lot of docs have gotten to the point where they're just closing their doors. They're closing their doors because they're fearful of the drug. They're also closing their doors because there's a lot of administrative bureaucracy tied to it now. When I prescribe a patient an opioid, I have to check the prescription drug monitoring program, which is a computer login to see if they've gotten prescriptions at other pharmacies.

I have to give them a contract that says that they understand the risk versus benefits of taking that medication. I have to demonstrate in my note that I have an established relationship with the patient, that I've described all of these things. And then on top of it, I can write that prescription for less than seven days with some regulations in the State of Michigan, or if I write them a 30-day prescription, then the moment those 30 days are over, I have to go through that whole process all over again. And all of that takes a lot of time.

Imagine if you're a clinic that's taking care of two or 3,000 patients and a few hundred are on opioids, that's a lot of time going to writing and prescribing this medication. What a lot of clinics are doing now is saying, well, if you're already on the opioid and we started it, sure, we'll keep treating you. But if you're coming from another clinic, then we're not going to take you because we don't want to add to our pool of all of these administrative hurdles. Well, imagine you're a patient and you've been on this medication for 10 years and your doctor retired or your doctor moved to another city.

And now what? I have studies that have shown that roughly 40% of clinics will take on a new patient who is requiring opioids for long-term pain. That means 60% of the phone calls that you're making to these clinics, they're saying no. They're not even letting you walk in the door. And that 40% number is just to see you in clinic. It doesn't mean that the doc's actually going to prescribe it for you.

It's becoming increasingly challenging to find a doctor who's willing to start and/or carry on prescriptions for pain because there is, like I said, reasonable fear around the medication, but perhaps the pendulum swung too far in some ways and it's making it difficult to find the treatments that patients probably do need.

Jordan Goebig:

An extension of this is that you do work in health inequity and how these different types of barriers impact different populations. Could you talk a little bit about that as well?

Dr. Pooja Lagisetty:

Yeah. What we do know historically is that when people were wanting opioids for pain or for pain treatment, we know that in general, white populations are more likely to receive that opioid, whether that be in the emergency room, whether that be after a surgical procedure, et cetera. We have historically provided white individuals better pain treatment. So in some ways, the prescription opioid epidemic disproportionately affected white individuals.

Now, some people could say, "Oh, is this like reverse disparity? Did that benefit Black individuals because we didn't give them opioids at that time, at least in the form of prescription opioids?" Well, I would argue treating somebody inequitably for their pain or inadequately treating their pain is never a positive disparity. Even if they didn't get an opioid, they were inadequately treated for their pain, which was equally wrong.

But now what's happening, unfortunately, is that as the prescription opioid epidemic, not that it doesn't exist anymore, but now what we're seeing with respect to overdoses is largely synthetic opioids, which are fentanyl derivatives. We're finding that the rate of overdoses is actually now disproportionately affecting Black and brown individuals rather than white individuals, which was not true during the prescription opioid epidemic. I guess you could kind of say that the face of the epidemic is shifting.

What's unfortunate is now there are three medications that are evidence-based to treat opioid use disorder, buprenorphine, methadone, and naltrexone. Two of those medications are opioids themselves, buprenorphine and methadone. Methadone, you have to go to an outpatient treatment program, so a very specialized clinic, pick up your methadone dose every day. Those clinics only exist in certain communities. Buprenorphine, on the other hand, can be prescribed similar to oxycodone or Percocet or all these other opioids that we use for pain.

But what we're finding or what our studies have shown, including ones by my team, is that this one medication that can theoretically be picked up at any clinic, any primary care clinic, any emergency room, and could be a life-saving medication is now disproportionately only going to white individuals. Even though the face of the epidemic has shifted, we're now finding that a similar pattern to the full agonist opioids that clinicians are giving this medication mainly to white individuals.

Even as the epidemic shifts, we're now seeing treatment disparities specifically around buprenorphine. Those disparities are not always true in other medications. Methadone, on the other hand, like I said, which happens in specialty treatment programs, a lot of methadone clinics are largely located in urban environments that have historically been largely minority neighborhoods. We don't necessarily see the same disparities shake out with methadone.

But again, the reason that there's so much interest in the disparity around buprenorphine is that this one medication has the potential to be in every person's neighborhood irrespective of where you live. If there's one medication that has the ability to treat individuals across regions and race, it's theoretically buprenorphine. There's a researcher named Helena Hansen who's really done a lot of great anthropology research on this topic.

She even talks about how when buprenorphine was initially marketed and when laws initially came out to allow the use of buprenorphine in non-specialty settings, which there was a law in 2000 called DATA 2000 that allowed this. It was even advertised to Congress as a drug to largely treat like suburban patients, which was a code word for white well-off patients.

Even a lot of the pharmaceutical marketing was largely to prescribers that were living in suburban environments. Some of these disparities are probably deeply rooted in even the way the medication was initially legally passed.

Kelly Malcom:

This sounds like a very complex issue. You have populations with untreated pain. You have populations who had their pain treated, but then developed a problem. What are people to do? If you have pain and it's the type of pain that just not touched by Advil or anything else that you would turn to normally, can you realistically go to your primary care physician and have them prescribe you an opioid?

Does it depend on who you are? And then how would a patient know if they have a problem? How do you know if you have opioid use disorder? Is it self-evident? Do those people go and seek treatment at their primary care physicians, or is it maybe driven by the legal system or a caregiver? What insight do you have about interacting with your doctors once you have a problem?

Dr. Pooja Lagisetty:

Yeah, tough question. A couple things. I think it's important to understand semantics here. Your first question was, how do you go and get treatment for pain, which I think is different than how do you go and get treatment for when you have a problem, which would be the opioid use disorder, because I think those treatment landscapes are very different and the disparities and the access barriers are different for each of those scenarios. Even though it's the same opioid umbrella, those treatment landscapes are different.

Now, for the question around for treatment of pain and when Advil and Tylenol and all these non-opioid therapeutic options don't work, what do you do? The CDC and a lot of agencies are appropriately saying that at this point, what we do know about pain is that it's complex and that the ideal way to be treating pain is probably multimodal treatment. What do I mean by that?

That means that you should probably be getting physical therapy, that you should be given access to things like acupuncture or chiropractors, that you should potentially receive cognitive behavioral therapy or some type of behavioral therapy to help manage your way of coping with pain in addition to potentially receiving medications or procedural interventions like injections and things like that. Now, all of those things that I just described to you are not easy to access in most environments.

Insurers are working their hardest to figure out ways to reimburse for this ideal multimodal treatment. But as you can imagine, this is tough. It's tough for the average person to access all of the above. Even if you could access all of the above, how do you get time off from work to go to physical therapy and your acupuncturists and your behavioral therapy all to treat your pain? There's just a lot of barriers there. That's the gold standard.

But now if we were just talking about medications and whether or not you could find somebody to give you an opioid, I think your doctor would probably have a reasonable discussion with you about the risk versus benefits of getting that opioid and also a reasonable discussion about what the efficacy would be long-term. What we do know is that opioids are fine if they're taken in short courses and for acute scenarios. It's when you're taking it for the back pain that you've had for 10 years that it gets tricky.

Because if you start that opioid, the chance that your back pain will go away is really low. Are you signing yourself up potentially to be on that medication for a very long period of time? And then with that, absorbing all the side effects of that medication. That's the part that gets really tricky. I think a lot of docs are willing to give the medication for the acute scenario when they know they have an exit plan, but it's for the patients that don't necessarily have a condition that's going away anytime soon where everybody starts to get a little uncomfortable.

Kelly Malcom:

And then the other group, I know that Narcan was just recently approved for over-the-counter use, which sounds like a really big deal. What does that really mean for people with opioid use disorder?

Dr. Pooja Lagisetty:

Narcan's an interesting drug. Narcan is an opioid antagonist, so it reverses the effects of opioids, particularly in the setting of an acute overdose. This means that if you and I witnessed an overdose in a bathroom, we could use Narcan often intranasally and reverse that overdose and save lives. We know that Narcan saves lives. Over the past few years, we've done a lot of work around harm reduction to get Narcan in everyone's hand, particularly first responders. We're also prescribing Narcan.

When patients come into the hospital for procedures or if they're taking long-term opioids, we'll give them Narcan in case they have an accidental overdose. Now, with that said, a bystander has to give it to you. If you're having an overdose and you're by yourself, you can't administer your own Narcan. What's recently happened is, like you mentioned, there's been a push for Narcan to be over-the-counter, and this theoretically has the potential to improve access to Narcan, because it used to be that it was largely distributed through grant funds or through first responders or through a prescription.

Now, if it becomes widely over-the-counter, you could go to any Walgreens or CVS and pick up some Narcan. Now, the big question is how much will this cost. And not only how much will it cost over-the-counter, but will it still be covered by insurance? The example that as a primary care physician I can use is a Prilosec. It used to be a prescription medication. If you had insurance, it was covered by that insurance. But now if you go to Walgreens to pick up a box of Prilosec, you might be paying 10 to 20 bucks for 20 Prilosec, which is more expensive than you were paying when it was covered by insurance.

There's a lot of unanswered questions around the Narcan over-the-counter. I think it has a lot of great potential here, but so much is going to depend on pricing and what the insurance companies are going to do now that it's revealed, and also stocking. Not all pharmacies are stocked equally. We've learned that even with buprenorphine that some pharmacies carry the bare minimum.

A lot of patients can't access buprenorphine even at the pharmacy, whether that's because they have a policy about how much they can stock, or whether it's because they are truly just trying to restrict that patient population from coming into their clinic. I think with the Narcan, it'll be interesting to see how pharmacies approach stocking it and how much pressure we can put on all pharmacies to keep it stocked.

Kelly Malcom:

Yeah, I just wanted to clarify, if you feel like you have opioid use disorder or a loved one has opioid use disorder, really what's the first step to getting help?

Dr. Pooja Lagisetty:

Great question. Addiction and opioid use disorder has historically been treated in the community, in the healthcare setting, you name it, lots of places. What we are trying to do is make it so that if you showed up into an emergency room and you had an opioid use disorder, you could get treatment. I will say at Michigan Medicine, that is true as of the last couple of years.

If you showed up at the emergency room, you have an opioid use disorder, they could start you on buprenorphine or methadone, and you would be seen by an addiction consultation team to get you hooked up to care, which is amazing, but not true at every emergency room. Primary care clinics, historically, docs used to have to have what we called an X waiver, so they'd have to go through eight hours of treatment, or if they were an advanced practice provider, 24 hours of treatment in order to prescribe buprenorphine.

In the past year, that policy has also changed, and so there's no longer a special waiver to prescribe buprenorphine. Now any doctor could give you that medication. The problem is a lot of doctors are still not giving that medication because they say that they don't feel comfortable prescribing it. Well, they probably don't feel comfortable prescribing it because for years, the drug was made to be a special medication that required eight hours of training. I talk to docs about this a lot, and I do a lot of training around this.

I always remind them that in medicine in general, we use a lot of drugs that are brand new that we don't get special eight hours of training for every time they're released. Often somebody tells us how to use it or we look it up on online resources and we figure out how to do it. We figure it out. But this medication has been made so special that it's made doctors or clinicians and general prescribers feel nervous about using it.

A lot of effort is being put into training prescribers to feel comfortable to use this medication so that you could theoretically walk into any clinic and be offered this medication. And then a lot of times patients aren't ready for medications. There's just three drugs. They're good. They're not awesome. And sometimes you're just not ready to stop, right? And in that situation, that's when harm reduction approaches such as Narcan, such as safe syringes, such as fentanyl test strips, there's all kinds of other options that are there for people who want to keep using opioids, but we just want to help them use them more safely.

Jordan Goebig:

My head is spinning in the best way. I feel like I've learned so much. I really appreciate this, and just going through everything and explaining things. And like I said, I didn't have a lot of a background in any of this, and I feel like I've learned so much and have a lot of feelings about all these barriers. I understand that there's systemic things at play, but I think you were telling that story and I'm like, she's going to bring up insurance about Narcan. I'm like, oh, I could feel it coming.

I'm like, oh, our systems are so frustrating. But it's great. It's a lot to think about. Just now transitioning into what you're doing and the future of this research and this field, are there any specific projects you're working on right now or any collaborators at Michigan Medicine that are just doing some really incredible things in this area that you would like to highlight?

Dr. Pooja Lagisetty:

Yeah, thanks for asking. I mean, I will say that I can still consider myself a relatively junior researcher and I'm incredibly grateful that I've had amazing mentorship here at Michigan and collaborators. My primary mentor is Amy Bohnert, who's done some incredible work in this space, but I've also worked with the Michigan Opioid Prescribing Engagement Network, individuals like Chad Brummett and Mark Bicket. I'm now starting to work a lot with some palliative care and pain physicians. The list can go on, including Dan Clauw has been there for me as well.

There's just a lot of great researchers that are doing work in this space from all kinds of aspects, whether that be the work that I'm doing, which is a little bit more stigma and access related versus thinking about better therapeutic options. I mean, three drugs to treat a major problem seems really sad. We need more therapeutic options as well. There's also great psychologists and psychiatrists that work in this space as well, thinking about behavioral approaches to treating addiction. There's a lot of great work happening at Michigan from all kinds of viewpoints.

A lot of the work that researchers and collaborators I'd love to continue to get to know or sociologists and anthropologists who are really thinking about this from a cultural perspective, because I feel like stigma is something that really has to be understood from a cultural approach. I'd also love to work with more policy wonks, whether that be people at the school of law or whatnot, to just understand those approaches. But there's so many ways to combine research.

Is there a way for us to think about stigma and access, but also think about it from a translational therapeutic approach? What's great about the opioid research community at Michigan is that it's really large. I know before we started this podcast, I was just talking about how I randomly met a neighbor that was doing opioid law policy. I just think that there's so many people here that... What's great is that the institution's investing.

They're creating an opioid almost kind of like think tank initiative to really make sure that all of us are connecting, all the researchers are connecting, and that we have a unified place to go for resources, and also a way for us to interact better with the community, to provide more community-based participatory research, and also working with the state as the state works with State Opioid Response funds.

Kelly Malcom:

U of M has a really deep bench when it comes to opioid research, which is great, and it makes me feel like we can tackle this epidemic. Looking to the future, I mean, theoretically, the opioid epidemic will end at some point. I know it's still ongoing and the face has changed and the types of opioids that we're dealing with are slightly different. Do you see it ending and how do you see it ending? Because I know you do some research into educating the next generation of clinicians and having them think about this problem differently. How do you see us getting to a better state?

Dr. Pooja Lagisetty:

Yeah, I think I want to remind everyone that opioids have existed for centuries. When we talk about the epidemic ending, what we're talking about is a disproportionate rise in overdoses ending, so people dying from using opioids at a really high rate. Not that opioids will be out of our supply. I think that's one of the things that got tricky with the opioid epidemic in general was when it was a prescription opioid epidemic, it was like, well, let's just stop prescribing it. If we just take opioids out of the pool, the opioid epidemic will go away. Well, clearly that didn't pan out.

There's a lot less prescription opioids in our supply, and we're still dealing with higher rates of overdose than we did five years ago. And that's because the opioid supply has changed. Now we're dealing with super potent opioids such as fentanyl. When I think about the opioid epidemic ending, I don't think that we will be in a state where there are no opioids. People will be using opioids, whether that be recreationally or whether that be for pain, for whatever reason.

But what we could have is better systems in place so that people are not using that medication to a point that makes it dangerous for them, whether that be we have more harm reduction approaches available in the community, there's some countries that have safe injection sites for people who are using opioids, whether that be better education for clinicians to provide treatments, whether that be more community-based resources to improve the social determinants that are often linked to addiction, whether that be improving housing, improving access to food, improving access to care when it's multi-generations of addiction in your household.

There's a lot of stuff that has to come into play, but I think the things that will end what I would say this disproportionate rise of overdoses is largely going to not just be something we can do in the health system, it's not going to be something I can do as a doc, but it's probably going to be something that we can do with a bigger community public health approach that really recognizes social determinants of addiction and pain, because both of those things are interrelated, and also improves access to therapeutics.

I think a great historical example of a treatment like this was HIV. It was similarly stigmatized. It was similarly dangerous. And with a lot of great policies, a lot of great community organization, and a lot of great scientific advancement with respect to therapeutics, we've now turned what was a very deadly pandemic with HIV into a chronic illness that people can live with safely.

Jordan Goebig:

Dr. Lagisetty, you were in my head because I was like, I don't know if we have enough time, but I kind of want to ask her if she has an example. I swear I was thinking, I was like, I'd just love to hear if there is anything, but maybe that's a stupid question. You answered it on your own and very succinctly without me having to ask it and bumble around.

I appreciate that, and I appreciate you and your time in coming here and explaining these concepts to us. I think that both our Michigan researchers and honestly our lay audience is really going to appreciate hearing all of this information because I certainly did.

Dr. Pooja Lagisetty:

Thanks for having me.

Kelly Malcom:

Thank you so much for joining us, and we hope to find better ways to drop some of these access barriers and appreciate you doing all of this really important work.

Jordan Goebig:

Thanks for listening. The Fundamentals is part of the Michigan Medicine Podcast Network and produced by the Michigan Medicine Department of Communication in partnership with the University of Michigan Medical School. Find us and subscribe wherever you get your podcasts.