Sean Mackey, M.D., Ph.D.
speaker
373 appearances
1 recordings
1 series
first heard Apr 2025
last heard Apr 2025
Sean Mackey, M.D., Ph.D.’s voice in public audio — every appearance, attributed to the second.
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Appearances
Have I had that happen? Yes. And I'm still embarrassed to this day.
I've learned my lessons. I haven't run that experiment. That's a great idea. But I typically use the amitriptyline when I need some sedating help at night for sleep and pain because of dual action. I like the dicipramine because it has less of that sedating property. And I'll tend to go to that and the nortriptyline. And you can titrate blood levels, for instance, like the nortriptyline.
And those drugs, so where do they work? They work in the brain. They work in the brainstem. One of the classic areas down deep in the brainstem is a rostral ventral medullary region where descending pathways are coming down. And some of the key neurotransmitters there are serotonin and norepinephrine. So we're not necessarily using these drugs for their mood-changing properties.
We're using them because they hit the same systems as they do in pain. And that's the beauty of them. And that's some of the messaging we have to give patients when we've prescribed them an antidepressant is like, okay, Mrs. Jones, Mr. Smith, we're not doing this.
These are great, great, great pain drugs, but they were never FDA approved. Why were they not FDA approved? Because they're off patent. There's no money to be made.
Yeah. It is a very nuanced question. I think a little preamble first. I don't take money from either the opioid companies. I don't take money from the litigation that's ongoing because there are tens and tens of billions of dollars at play right now. I don't take money. End of. I am not pro-opioid. I am not anti-opioid. I am pro-patient. I view them as a tool.
I view them as a tool much like the other medications, interventions, mind-body, physical rehabilitative complementary tools that we use. They have a particular place. I have a personal deep place. appreciation for the destruction that these agents can cause. I come from a family very deep in addiction, very deep. I've lost close family members to opioid overdose.
I've lost close family members to alcoholism. I am personally petrified of these drugs. And I have gone through surgeries that the surgeon said, you can't get through this without an opioid. And I'm like, I'll be fine. Because my approach is avoidance. With that said, I have learned a long time ago not to project my personal experiences onto my patients.
That had to come through age, wisdom, whatever. It is true. Prescription opioids were over-prescribed. They were over-marketed. They were bad actors doing bad things. But it's not that simple a story. I sometimes get frustrated because I feel like you can make really simple sound bites out of this complex societal issue when it was a perfect storm that hit.
Yes, you had a letter to the editor of New England Journal saying that nobody got addicted, like 38 patients or some nonsense, and Purdue and others ran with this, and I get that, and they did bad things. You also have to put things in the context of what was going on in society. There was growing awareness of pain, as there should be. There was growing pressures to do something about it.
People have brought up the pain as the fifth vital sign as an example. People have different opinions about that. Did it have bad consequences? Yes. Did it have good consequences? Hell yes. Run the counterfactual. Do you want to go back to a time when we're not asking patients after surgery their pain? Do you want your mother, your daughter back in that time? And I think the answer is clearly no.
But also there was other pressures. And Peter, you witnessed those firsthand. What was going on back in the 90s and the 2000s? After surgery, there was this massive push to get people out of the hospital and put them in their home. we were replacing care in a hospital with care in the home. In the hospital, we had time to see their trajectory.
We could titrate their opioids or whatever, get them tuned up, dialed in, and then send them home. Now, Surgery, overnight, you're home, let's give you a bucket of whatever. And the reason for that was surgeons and docs don't like getting called at 3 a.m. for pain control. So pressure to put people out in the home environment. On top of it, docs get lousy training for pain. What is the average?
Seven hours, I think, in medical school. That's, by the way, 40 hours of pain. So great if you've got a dog. Not so great for... So you've got this pressure. And by the way, not only on top of that, but now you've got the introduction of patient satisfaction scores. I have to imagine in your private practice, you don't have to measure Press Ganey and patient satisfaction scores.
But in hospitals, everybody does. Or at least they did. I think they're coming to their senses. And so one way of addressing the satisfaction, give more opioids. And there's more. There's many, many, many pressures that came to bear that helped create this problem of which there were bad actors out there.
I have a slide, yeah, on the opioid crisis. I call it the perfect storm. You're absolutely right. And in the end, and here I'm going to be a little bit reductive when it comes to the docs roles in this. I'm going to borrow from my friend, Professor Keith Humphreys. There are three kinds of physicians out there. There are the majority of the physicians doing the right thing for the right reasons.
There are the next group, which is a much smaller group, physicians doing the wrong thing for the right reasons. And at the very top of that pyramid, a little group, you got physicians doing the wrong thing for the wrong reasons. Those people at the top take away their license, put them in jail.
But you had a group of people here in the middle that were doing the wrong thing for the right reasons, that they either didn't have the right education, they thought they were helping people. Did they contribute to the problem? Yes. Have they gotten educated? Yes. I didn't answer your question, though.
Let me now circle back, and I hope you'll forgive that little bit of soliloquy on my perspective of that 20 years. I don't use opioids as a first-line agent ever. Almost never. End of life. Cancer. But usually by then, they've tried other things before they're getting to us. I will use end-of-life cancer pain. I'll use opioids liberally as needed.
Frequently, we have an acute pain service in the hospital that sees about 30 to 50 patients a day. Based on what?
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