Welcome to the MedSoup podcast, where we talk about trending healthcare topics. I’m your host, Laura Schumachers, let’s dig in.
Today we are joined by Dr. Robert Wilson, the founder and medical director of piedmont Interventional Pain Care. Doctor Wilson has served patients in Salisbury in the greater Rowan County region for over 15 years. He is board-certified in both anesthesiology and pain medicine by the American Board of Anesthesiology.
He completed his residency in anesthesiology and a fellowship in pain medicine at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. Dr. Wilson is trained in the latest pain management techniques and therapies and is an avid speaker providing information to the public and medical professionals across the United States about the latest interventional pain treatments. He is an active advocate for the prevention of opioid abuse and serves on the opioid task forces for the Department of Health and Human Services, the Industrial Commission of North Carolina, the North Carolina Medical Board, and the North Carolina Medical Society. Additionally, Dr. Wilson is the president-elect of the Pain Society of the Carolinas, also known as PSOC, a long-standing member of the PSOC, and has served as chairman of the government advocacy committee. Dr. Wilson, thanks for joining us today.
Alright, current opioid use has sort of a stigma attached to it. So, how do you approach that in your practice?
Dr. Robert Wilson 1:42
Well, at Piedmont Interventional Pain Care, we’ve always had the philosophy of trying to perform procedures or minimally invasive surgery that would cut the need for opioid pain medications. My practice philosophy really hasn’t changed over 20 years since I’ve been practicing. What has happened in the last three years, especially since the Center for Disease Control has published some guidelines for opioid prescribing. We have gotten even tighter as far as our prescription writing. But the reality is, we have patients who have these global diseases that we cannot perform procedures that work well enough for them and we try different types of medications that will work for them. Sometimes we can get by writing non-opioid pain medications and different sorts of adjuvant medications that will system with their pain.
But we also have to understand is that chronic pain is like chronic diabetes, chronic hypertension never goes away. Anytime we can find a procedure that works for the patient and decrease or stop their opioid pain medication. Anytime we can us another medication that is non-opioid for their problem, we’ve always practiced that way. But, because of the current climate with the opioid crisis, everybody has tightened their belts some as far as writing pain medications. But I’ve always been an advocate for the patient and make sure they get the medications they need.
There is a proper use of opioids in pain management?
Dr. Robert Wilson 3:30
There is, from the standpoint of medications being written for chronic pain. You have to understand that I trained in this field in the late nineties when we were told and taught by those who are instructing us that pain medications could be written in higher doses. If one got tolerant to it, you would just simply write more medications. The pharmaceutical industry-backed that of course, I recognized early on and even during my fellowship that patients who are getting more and more opioids, as far as their dosing increasing, really didn’t get that much better if they just got more tolerant to it. And at the end of the time, you were finding patients that were taking the medication to avoid withdrawing. I recognized in my training there was really a limit to how much you could write for. I also recognize that, if you could do a procedure to avoid using them altogether, it’s much better. When you attack the problem of inflammation or different types of nerve pain at the source of it, you don’t need to write for pain medication including opioids that help cover that.
So, proper use of opioids, I think and always have felt, is best handled by those of us who do the profession who are trained to use it or board-certified to use it. We did find in the past primary care doctorers were writing a lot of these types of pain medications. If there is anything that happened good out of the CDC guidelines, we’re no longer seeing patients come to our door on massive doses of opioid pain medications. We are finding them that they are pretty opioid-naive and it’s much easier to control their problem doing appropriate interventional pain therapies, then I am minimizing the amount of medication they need for their pain.
I would assume that the majority of the patients would prefer to be off of medication if they can, but you know some that are on and I mean, how do you prevent them from abusing?
Dr. Robert Wilson 5:44
In our clinic, we’ve always monitored patients from the standpoint of doing urine drug screens, doing pill counts, and simply counseling the patients. You have to be careful when you write these medications because you can write them for a patient to take it two times a day, or three times a day, but you find some patients will take all of their medication in the 15 day periods when it was written for a 30-day period. So, the only way to really monitor these patients is a combination of all the things I mentioned.
Everybody has a different idea about pain medications. Some are very strict and take no more than what they should, others try to self medicate. We’ll perform urine drug screens and pill counts and continue to counsel them. But at a certain point, if we feel like the patient’s going to do harm to themselves, we have to stop writing the medication.
Another point to make is that by doing urine drug screens, we not only screen for the prescription medications that they’re on but we also screen for illicit drug use including marijuana, cocaine, heroin, methamphetamine. So, it’s obvious that we find a patient using a list of medications, we will not write for any pain medications in the opioid class and we would do only procedures only in those types of patients.
We certainly don’t want our pills getting on on the street being sold or being traded for illicit drugs, add to the opioid crises that we have.
How would you describe the current state of the opioid crisis in the US right now?
Dr. Robert Wilson 7:28
The current state is…well it’s an interesting question. Because I mentioned earlier the CDC guidelines that came out 3 years ago were revolutionary from the standpoint of what they’re trying to accomplish. Understand also, the CDC guidelines written for primary care, they were not written for pain specialists. Unfortunately, the insurance companies jumped on board and made it even more difficult for pain providers, like myself or board-certified and qualified to do so to write for pain medications.
We predict this a part of our pain society when we talked to the medical board that we would find a mass exodus of patients being written for pain medication by the primary care people, and that’s exactly what happened. There’s been several studies looking at the state of Tennessee, for example, the number of pain patients who could not find anyone to write their chronic pain medications and they’re looking a the suicide rate that these patients are who have taken their lives.
So really what’s happened in the last three years and to this point in April of this year, the CDC put out new guidelines regarding what the guidelines were intending to do. So many different organizations like mine that contacted them about patients who are harmed because of their inability to get the pain medications that they need. These are patients who are judiciously taking the medicine as prescribed, were not abusing them, etc. The CDC director in April 10th of this year wrote that the agency that the CDC is working diligently with, to evaluate the impact of these guidelines and to clarify it’s recommendations to help reduce the unintended harm.
So, a lot of chronic pain patients were suddenly stopped from their pain medications and went into withdrawal, etc, and they try to get into a pain clinic like mine and we just could not handle all us who practices type medicine, could handle that load and we had patients that harm has happened to them. So, the way to look at is the pendulum has swung from one extreme to the other we predicted three years ago and it’s not coming to fruition from the standpoint of what we’re seeing. So, the crisis is, again as I said earlier, the good thing about it is we don’t see as much pain medication written by primary care. They tend to send those patients to us and be properly managed. The downside of it is all is that patients were abruptly stopped, harm has happened.
I know that you’re actually very active on many legislative committees and governing bodies in reference to this topic, And, what are some of the activities you’re involved in right now?
Dr. Robert Wilson 10:29
I’ve been involved in the Physician Education Committee of the Department of Health and Human Services here in North Carolina. I’ve helped with the industrial commission here in North Carolina to write the policy for opioids and the opioid task force. Also, in the committee, the opioid task force for North Carolina Medical Board, meeting with them on occasion when it’s called upon. When we’re called up, then also doing talks around the state for North Carolina Medical Society as well.
One interesting point I want to bring up is that about a year ago, we were at the North Carolina attorney general’s office. There was some legislating that was pending and we as the government asked the Pain Committee for the Carolina’s were concerned about the way it was written. We met with a member there and we’re sure their intent of the legislation just wasn’t spelled that well enough and the legislation was rewritten and it did go ahead and state some of the concerns we had with the ability of just any law enforcement person getting on the prescription monitoring program and seeing who’s writing medications, etc. So, no idea that legislation was to investigate those who look like a concern based on the amount of a medication, the amount of morphine milligram equivalents they’re writing for. And it was rewritten to reflect our concerns and then we’re happy about that.
But, out of that meeting, the gentlemen I met with kept my email address. He wrote me an email about six weeks ago in regard to the patient that had contacted him. I want to use this as an example fo whats happened in this world of the opioid crisis and how far the pendulum has swung too far the other way. There’s a lady who is a retired schoolteacher who has sort of, what we call, a central pain problem with the result of multiple sclerosis. She was taking 5mg of oxycodone tablets per day and then the amount of morphine milligram equivalent, that’s 15mg. A lot of the guidelines have been written for 90mg or below so it was not much pain medication. But, without it, she couldn’t do her daily functions, do her laundry, couldn’t make the bed, to her housework, etc. So, her pain clinic that she was affiliated with again got very, very strict on writing medications and would not continue to write that opioid medication. Her neurologist also felt uneasy writing any of opioid medication. So, the gentlemen from the North Carolina Attorney General’s office contacted me and discussed the case and wanted to know if I could help her out, help him out. Because he’s getting a lot of phone calls regarding this very problem we’re talking about, patients being unable to get pain medication. So, about three weeks ago, we saw her in the office as a new, very legitimate patient, a patient that you don’t have concerns about abuse potential, etc. Although she went through the normal process this year when we saw her, she was so happy to find somebody just to write her a small amount of opioid medication.
So, again, the pendulum has swung so far the other way I’m finding now that people are recognizing this and the powers that be passing this legislation are now feeling some of the effects of it and they’re wanting us to help them out, which we are happy to do. But the reality is, we have to come to a middle ground somewhere on this because situations like this shouldn’t be anything that we should see.
Well in that situation just goes to show that you have to look at the whole picture, both sides, and you’re having to evaluate every single patient on the individual case-by-case basis because of how many need medication for the long-term. Somebody may need a short-term and the interventional technique or procedure that you can provide may help them to actually reduce or eliminate their need for some sort of medication.
Dr. Robert Wilson 14:58
Correct. We do a lot of different procedures. We do some minimally invasive surgery as well but our whole goal is just that or to go ahead and reduce the amount of pain medication they need. We have a lot of patients that come here from a primary care office or another pain clinic that does not interventional therapies. And, we’re able to perform procedures and start cutting back on their opioid medications, they feel better when we do it this way we’re attacking a problem at the site of the nerve where the problem is. We also implant these minimally invasive surgeries, spinal cord stimulation therapy that I’ve been using for the whole 20 years I’ve been out of fellowship.
The technology has gotten better, and better, and better. I see a big benefit in the VA population. We take care of those men and women who come back from their service years have spinal conditions that we would see in someone maybe 30-40 years older. So, for those difficult spinal cases, maybe they’ve had one, two, or three back surgeries and still hurt. The process of doing this proper spinal cord stimulation therapy is working out very well for them.
So, there’s someone that wants to schedule an appointment with you, do they need a referral or how can they do that?
Dr. Robert Wilson 16:18
No referrals are necessary in this office. We are again a completely independent office from the standpoint of our practice. They can simply call for an appointment. Now it may be that if you call us and want an appointment, we’ll ask if you’ve been to another pain clinic before. Some patients seek us out because they may have been discharged for illicit drug us or failed pilled counties, etc at different pain clinics before us. So, we will question those who have been at other clinics and get records, it’s only a prudent medical practice to do that. But the reality is that you do not have to be referred here. There’s maybe one or two insurance companies that require it but none of the others do it fact, a lot of referrals come by this way, self-referrals from family members or friends or someone who’s heard of us, and they’re able to get in this office without any problem.
What about VA patients?
Dr. Robert Wilson 17:18
VA patients as well, we work very closely with them. I’ve been working with the VA for probably eight or nine years now. I first started seeing a few patients that came here randomly not knowing how they found their way here. At that time I realized the need for the kind of services I provide because if the VA doesn’t have anyone here in Salisbury that has the training and skillsets to do what I do. So, they’re happy to send patients here and we have a very, very good relationship with them. But a VA patient can’t simply call here and make an appointment. They have to go to their primary care doctor at the VA and that person would have to set up the appointment here and have an official referral.
Well, great. Thank you very much for that information, I think that will be very useful.
Dr. Robert Wilson 18:05
Thank you very much.