Will:  From my standpoint, we need to make it easy for the patients. Patients are like doctors—they’re people—and if you give people complex instructions to do things, it often happens that they won’t do them. It’s just human nature. Years back, I was told the recommended strategy [for opioid disposal] was to mix the pills up with kitty litter and crush them, and then put them in the trash, so you have a lot of steps involved, like ‘Where am I going to get the kitty litter?’ The more steps, the less likely it is to happen. So, what’s the easiest thing to do? Flush them down the toilet. We all use the toilet. It’s a one-step, two-step process. The potential harmful impact on the environment, I think, is pretty negligible, according to the FDA.

Ben:  I think it’s important to recognize that not all pharmaceuticals are the same, so the way that they may impact the environment, or the way they may be biodegraded, or handled by a water treatment plant, is variable. While there have been cases of certain medication classes causing notable problems in the environment, as with antibiotics or estrogens, that degree of damage to the environment has not been documented or identified among opioids and other sedating medications. For that reason, the FDA has come up with what they call the Flush List, which, while not comprehensive, is a list of medications that have been thoughtfully deemed to be best flushed since the more substantial risk to the people in that household or in that community who may be exposed to it, outweighs the potential, even negligible, environmental risks of flushing those medications down the toilet.

Will:  A lot of patients who are prescribed opioids have side effects from taking them. Let’s say, out of a hundred patients who are given an opioid prescription for something acute that brought them to the emergency department, probably up to half are going to have side effects that limit them from being able to continue taking the opioids. Usually, nausea is one of the main side effects, or patients will feel groggy or dizzy, or have other undesired effects that they don’t like. These side effects make it hard for them to continue taking opioids, and then they have pills they were prescribed that they now can’t take.

There have been some interesting studies showing that, in acute pain, the amount of unused opioids typically ranges from 60% to sometimes 80% of what the patients were initially prescribed. Those excess pills are what are in medicine cabinets, where children can get to them, or older patients take them when they thought they were reaching for a different medication. Mistakes can happen. Because of this, when you have pills that you know you’re aren’t going to use anymore, why wait around to see when you might need them again? Just go ahead and dispose of them. On the prescriber end, the message is getting out to start limiting the number of pills dispensed.

Ben:  I agree absolutely with what Will said, and I think, more and more, the guidelines are shifting us away from using opioids for chronic pain, or at least, not starting with them. We’re still seeing them used, and oftentimes, appropriately so for acute pain.  As a prescriber, you may want to err on the side of having the pain be controlled more so than not, so I think that also can account for the fact that these medicines are sometimes given for courses that may be longer than absolutely necessary, with the understanding that they’ll be taken as needed, as are many medications. For the patient, the appropriate time to get rid of those medications is when the reason they were prescribed the medication is no longer present, so there’s no longer a need for the medication.

Will:  I think that the landscape is changing. When I was in residency, say the early 2000s, I think there was more of an expectation that an opioid would be prescribed for pain. Increasingly, the message is getting out that not only do these medications have harms that can become problematic, but they also have limited benefits, especially for chronic pain. More and more, I’m hearing people say, ‘I just don’t want to go there. I had a cousin or an uncle who had problems with opioids, not necessarily addiction per se, but just didn’t end up being a good course of medication for them. So, I’d rather not go down that route.’

Ben:  I think it’s not uncommon for patients to come forward and say something like that, maybe referencing a negative story or saying, ‘I would be interested in medications, but I prefer something that’s not addictive, or potentially addictive.’ There is concern because of the media attention, but also a lot of people have friends and family members who have been impacted negatively, in some capacity, by this class of medications.

Will:  If we’re going to tell people opioids aren’t good [for chronic pain management or otherwise], we have to think about what else can we offer them, and really make it meaningfully accessible. I’m talking about physical therapy, chiropractic, acupuncture, yoga, psychological treatments like cognitive-behavioral therapy, mindfulness-based stress reduction, and other approaches. The message I send to patients is that the best kind of treatment is one where we come at it from a variety of different angles. We call it multimodal pain care.  Perhaps we bring in some medication, but we also add non-medication options, and those options where you’re actively doing something [to help relieve the pain] is, ultimately, going to be the most effective for you.

We’re fortunate at the VA as we have a lot of these options available to patients. They’re available. They’re affordable and accessible. That’s not always the case outside the VA. These things all have pretty good evidence in helping to alleviate chronic pain, but I think the broader healthcare system is struggling with the question, can we actually make them available for any person seeing treatments for chronic pain?

Will:   The Pain Management Collaboratory is a great opportunity to show that alternative pain management therapies work, and how they work, as well as study what dose of these therapies are needed to be effective, all in the integrated clinical settings of the VA and the DOD healthcare systems.  The studies within the Collaboratory are pragmatic trials, meaning, we’re trying to study treatments, and how they would be delivered in a real-world setting. In fact, that’s exactly how we’re implementing the studies, with actual providers who are working in their usual settings and delivering these kinds of integrated treatments.  The hope is that other healthcare systems will use this data to make alternative treatments more accessible. We then can expand these findings so that private payers may have the data they need to see that these are worthwhile treatments to invest in.

Ben:  I would add, as someone who has worked in the VA system, and now is primarily at a community health center, I’m feeling the deficit of those resources more acutely because, at our community health center, the majority of our patients are publicly insured, and then we have a sizeable population who are uninsured. While we have pretty good resources and are able to get medications for patients, some of these other multimodal options for pain control—like yoga, acupuncture, or physical therapy—are big hurdles for us to get for our patients, at least in a way that’s economically feasible for them. We have to be really creative and identify those free yoga classes in the community, or the Zumba class down the street, that may be accessible for more folks. It would be great to have these alternative therapies for pain management be more institutionalized, as something that’s supported by healthcare payers.