Transcriber: Annet Johnson Reviewer: Emma G
So the year was 2012
and the opioid crisis had become personal.
Five young student athletes in my local community
had undergone various surgical procedures.
Six months later, they were dead of opioid overdoses.
I know this because my wife is a local town florist.
She had to prepare the flowers for those devastated families.
All I knew is that I was an orthopedic surgeon,
doing what I had been taught.
From day one in my training, I was told,
“What you do hurts.
You use saws, you use hammers.
You’re going to hurt people.
You need to make sure that their pain is under control.”
So that’s exactly what we did.
The problem was, something wasn’t right.
Not only was I an orthopedic surgeon,
but I had become a pain management specialist.
What does that mean?
First and foremost, they’d told me, “You’re going to use opioids.
You know why?
Because they’re inexpensive and they’re minimally addictive.”
How far from the truth was that?
What I was doing: I was seeing patients,
writing refills for opioids,
weaning patients off opioids prescriptions as well.
I had belligerent patients
that were threatening to take me to the Board of Registration in Medicine
because I was neglecting their pain.
Something was wrong.
Why were we doing this?
How did this happen?
There must have been great science, research,
studies that show that these new opioids were going to be less addictive.
Look at this:
this is a one paragraph letter to the New England Journal of Medicine
written by a single doctor based on his observation in a clinic.
There was no science.
There was no randomized controlled trial.
There was certainly no peer review.
You know what happened?
One of the largest pharmaceutical companies that manufactured
these new opioids grabbed that letter.
They then used it in their sales school to educate all of their salespeople:
“opioids are minimally addictive.”
What did those sales people do?
They went around educating doctors,
trying to convert doctors to use these new medications
because “they were minimally addictive.”
How far from the truth was that.
This was one of the most pivotal moments in the opioid crisis.
Pain became a vital sign.
What’s a vital sign?
It’s something you can measure:
it’s your pulse, it’s your respirations, it’s your blood pressure,
easily measured, objective findings.
What about pain?
Pain is one of the most subjective things that we can measure.
Do the same operation on two people:
one person it’s twelve out of ten,
the next person it’s two out of ten.
How much more confusing could this be for clinicians?
But the societies were influenced by this process.
Pain became the issue of our medical generation.
We were confused.
We weren't sure what was happening.
But one thing for sure
is that opioids were much more addictive than we were told.
So I have three numbers here:
6, 13, and 30.
In 2017,
the Center for Disease Control published an article about opioid prescribing.
They took a look at thousands of patients that had been prescribed opioids.
And there were three inflection points.
The first was if you wrote a 24-hour prescription of opioids to patients,
6 out of 100 had a chance of being on opioids at one year
after a single day prescription 24 hours.
If you gave them a 10-day supply of opioids,
13 out of 100 had a chance of still being on opioids at one year.
If you wrote a one-month prescription, which was very common at that time,
literally one third of those patients could still be on opioids at one year.
The truth is about opioid addiction
it does not care about the color of your skin,
the zip code in which you live,
or the amount of money in your bank account.
If you are genetically predisposed to being an opioid addict,
it will happen to you.
Addiction chooses you, you do not choose addiction.
What had happened, slowly, without our knowledge,
without me knowing,
elective surgery had become an inadvertent gateway
to the opioid crisis.
The question was, “What could we do different?”
Our young kids were dying, our communities were being devastated,
and we were contributing to the process.
There had to be a different way.
We’re all used to anesthetics.
We go to the dentist because anesthetics work.
The problem with anesthetics is always
that they wear off at a short period of time:
I talk about post-surgery pain as this “storm of pain.”
What do I mean by that?
The first 72 hours your pain is severe.
After 72 hours, the chemicals get pushed out and it doesn’t hurt so much.
What if we could develop a local anesthetic
that would last two or three days?
And that’s exactly what happened in 2014.
A pharmaceutical company came up with a formula
for a sustained action of lidocaine or anesthetic.
And we were seeing things we had never seen before.
Patients undergoing some of the most painful operations
could literally go through without opioids.
It was amazing.
From there, we looked at multimodal approaches.
What do I mean by that?
Let’s try other medications that work differently in different mechanisms
that aren’t addictive.
So now, we could combine those medications as well.
And we could safely and effectively take our patients through elective surgery,
minimizing their exposure to these addictive opioids.
What a wonderful thing.
This is what you want to see.
This young gentleman is 18 years old.
He just had ACL surgery,
he’s in the recovery room,
what has been known as one of the more painful surgeries.
We don’t need pain as a vital sign.
We don’t need to score or a number for his pain
with smiley faces or frowny faces.
You just need to look at his face.
He is comfortable.
He’s going to go home.
His parents brought him to me specifically,
because of my opioid-sparing philosophy.
This young man did not take a single opioid pill,
and these were some of the athletes that were so addicted
or potentially addicted to medication.
So why was it that we had this solution and it was falling on empty ears?
There was skepticism everywhere.
We tried to fill the lecture halls.
Nobody wanted to listen.
The hospital administrator said,
“These opioid alternatives are too expensive, we can’t afford them.”
I said, “Go look at your ICU, go look at your emergency room.
They’re filled with patients suffering from opioid addiction.”
Doctors would not change because they had never been taught this.
They weren’t familiar.
“I don’t want to go in front of the Board because I’m neglecting my patients.”
Patients knew nothing about it.
They didn't even know it was an option.
We were met with skepticism at every turn.
How do you change the paradigm?
How do you change the way in which we practice medicine?
I found myself a superhero.
This is Gabby Reece.
I like to call her the original “Wonder Woman:”
professional model, professional volleyball player,
married to Laird Hamilton, the world’s greatest surfer.
She needed a knee replacement.
Her and her husband had had many friends that had succumbed to the opioid epidemic.
She said,
“I’m going to go for a total knee and I’m not going to take any opioids.”
And she suffered, she suffered bad.
She literally told me she would sit in a closet crying
because her knee hurt her so much.
But she persevered.
She was strong and she did well.
She found out about what we were doing and she signed on immediately,
wanting to educate patients, empower patients,
to let them know they had a choice.
The “Plan Against Pain,”
the “Choices Matter” campaign that we did together:
we were on TV, we did radio, we spoke to anybody that would listen.
Slowly but surely,
patients started listening.
How do you change the paradigm?
How do you build consensus?
One doctor at a time, one patient at a time as well.
So what happened?
Well, other opioid-sparing superheroes joined the team:
orthopedic surgeons, anesthesiologists that had seen similar results,
gathered together.
We started to fill the lecture halls, people started to listen.
Five to six years in,
we were finally making a difference in the process.
That was wonderful.
I was very pleased, very happy, to be at the earliest wave of doing this.
But that wasn’t good enough.
What else could we do?
How else could we change the paradigm?
Can I see a show of hands of people in the auditorium
that believe in photosynthesis?
Right?
We were taught this in high school: photosynthesis.
We're on a planet that has a sun.
The sun shines down onto the plants, the grass, and to our trees.
It converts carbon dioxide to oxygen.
Our plants grow and they sustain life on our planet.
So should it come as a surprise that we as a species,
a successful species on a planet for 300,000 years,
in our deepest genetic code, that we would be sensitive to light?
And the truth is, we are.
What if we could harness the power of light
to help us heal ourselves
so our bodies and ourselves could eliminate pain and inflammation?
Could that be done?
The answer is yes and that’s called photobiomodulation:
photo meaning “light,”
bio meaning “living cells,”
and modulation meaning “to exert influence” on those cells.
If we could shine the right wavelength of light,
the right intensity of light, the right frequency of light,
we could stimulate our own cells in our own body to heal themselves,
to reduce inflammation and pain.
But guess what?
This was met with skepticism as well.
“We’ve never heard of such a thing.
I’m a doctor, I’ve been to medical school, it wasn’t in my medical school curriculum.
Why would I want to do something I’ve never heard of?”
Slow but sure, one doctor at a time,
they had fantastic results.
They shared it.
We have grown and now doctors around the country
are using laser to help treat their patients for pain management.
I was reading the Sunday “New York Times” about a year ago.
I picked it up and I read this article.
And a word came to mind:
“validation.”
Here I’ve been over a decade of my career,
struggling to change the way in which we think about managing our patients’ pain.
And here was an article in The New York Times
from the Centers for Disease Control.
The CDC, for the first time in many years,
decided to come up with a new prescriptive discussion
on how opioids should be prescribed.
They had said, “We need to use less opioids.
Not for a severe acute pain or for end-of-life or for cancer patients,
they have their place.
But for patients that are undergoing surgery and have acute pain
or subacute pain or chronic pain, what else can you do?
First and foremost, use less opioids.”
A wonderful validation.
They then also looked at alternative treatment options.
They looked at pharmaceuticals, different drugs.
They looked at medical devices, braces, physical therapy,
all the things you can think of.
And, yes, photobiomodulation and laser made the list as well
for alternative recommendations for the treatment of pain.
A validation of hard work to try and make change.
Not only was the change there,
but we’d been trying over a decade to communicate to Congress,
to our House of Representatives, to all of our legislators,
to say, “We need to develop these opioid alternatives.”
We were met time and time again that they’re too expensive, we can’t use them.
But now, finally, I have great news.
President Biden this past January signed into law the “NOPAIN Act,”
which has created a process for research and development on opioid alternatives
so that these opioid alternatives will eventually be used and paid for
by your insurance company.
Money should not be an issue,
as we're trying to save lives and make sure that we are safely
and effectively taking our patients through their surgical experience.
So as I finish, I want you to think about this:
the next time you have the most amazing idea to make the world a better place
and you're met with skepticism, what are you going to do?
There’s a favorite Hebrew saying that I know it’s called “Tikkun olam.”
To practice “Tikkun olam” literally means:
“to fix the world, identify a problem,
and change that problem, make the world a better place.”
Another favorite saying of mine is a French saying, “Machine de guerre.”
A “machine de guerre” literally means a “machine of war.”
Figuratively, it means someone that will not stop.
You all know them.
They see an idea, they’re going to change, they’re not going to stop,
they’re going to keep moving forward.
So I ask you today,
when you have the next great idea to make the world a better place,
will you practice “Tikkun olam?”
Will you be a “machine de guerre?”
Or will you allow your idea to fade away because they said no?
Thank you very much.
(Applause and cheers)