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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And I remember a really vigorous discussion here. And the one that I put forward and others put forward is we need to better understand what is the long-term effectiveness and safety of prescribing opioids to people with chronic pain. meaning we need to figure out for whom opioids work.
Today, we still don't have an answer to that question, and there's very little will to do it because the whole message in the scientific community is basically find non-opioid choices. So there's not a lot of interest in funding the studies to figure out for whom it works. There is a lot of active interest still, mainly through data-driven studies, to find out who's at risk.
But that type of study that you're talking about and others that are of longer term and bigger consequences. I just don't know when they're going to get done, who's going to fund those.
Oh, all the time. Yeah. I mean, I think he was ahead of the curve. Now, whether it completely eliminates any likelihood of opioids after surgery, that's a little too strong a statement. Look, it just reduces the requirement, right? I strongly believe that he was practicing good medicine and he was doing it ahead of his time.
Now, the idea of using a combination of lidocaine and marcaine and epi, as you well know, is lidocaine short-acting. So it's going to work pretty darn quick. And so you can get going with your surgery while the marcaine, the bupivacaine is kicking in. The epi is going to not only provide hemostate, it's going to reduce bleeding at the site, but it keeps the local contained.
There is something there there. And I think I haven't asked surgeons these days. And my sense is that's becoming more and more common practice, that there's a greater appreciation of the role of this concept of preemptive, preventative analgesia, anesthesia. I think it provides some benefit.
There was a big hoopla on this like 20 years ago when everybody thought we were going to find a way just to basically eliminate post-operative pain through these methods. Presumably didn't pan out. It just didn't pan out.
Absolutely. Getting back to your question, I think we're at an interesting crux in research and clinical care where We're gathering more and more high-quality data to better understand these vulnerabilities.
And I think we're going to be moving to the point of putting these into clinical decision support tools that can inform the docs and help them to assess a risk of a patient so that you can have an informed conversation with someone. Like you are at likelihood of having persistent opioid use because of what you bring.
I guess it a little bit is about their expectations. The challenge is when the ones who've had multiple surgeries that have been on opioids, they're expecting opioids, a lot of it's expectations. I think the more naive person, those go a little smoother. If you are professional, explain to them, but also allow them to make their own choices. Don't say, we're not going to give this to you.
But here you are in an increased risk. And that's always the discussion I have with patients, whether in the acute space or particularly in the chronic space.
Some people get better. Some people don't get better. I cannot yet predict who is going to respond and who's not going to respond. Is it a part of the work that your department does? Yeah. We actually have Dr. Jeanne T. Kong does the acupuncture. She's a pain doc. She does acupuncture.
And my view of acupuncture as a treatment, as a modality, is if you can afford the wallet biopsy and it doesn't cause you problems, then give it a try.
They do more so now on Medicare. And I think that the rules that went into place recently helped with that for older patients. I don't honestly know if it's translated down to the commercial carriers.
Yeah. Historically been hard to get that
Yeah. I've had some successes in back pain, musculoskeletal pain, migraines, headaches, oddly. And it's highly variable. I studied this. I had a really large program project grant to look at cortical mechanisms of this and predictors. We're putting in a paper now, which is a prediction model of real acupuncture versus placebo acupuncture.
Well, that's one option. And it turns out that many of these acupuncture points overlie peripheral nerves. And so when you twiddle the needle or apply electroacupuncture, are you doing a peripheral nerve stimulation? I don't know. But this is a Stridinger needle that looks for all intents and purposes like an acupuncture needle. It causes a little pinprick, but it doesn't actually do acupuncture.
And it's been shown to be a good placebo. What do I know about the mechanisms? Again, don't fully understand. I know that there is increases in peripheral adenosine that is released with acupuncture that has an analgesic effect at the primary nociceptor. I know that cortically in the brain, there are brain systems that are modulated with acupuncture. But how could I know exactly how it works?
And we still don't have good ways of predicting who's going to respond and who's not going to respond. But that's rather common amongst all of our pain treatments. You know, again, pretty safe. Absent some risk of infection, make sure that the facility you're getting at practices good hygienic approaches.
I think you'll want to get a true acupuncture specialist on to dry that.
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