Q&A with APhA2017 keynote speaker Elliot J. Krane, MD

Krane will speak about potential solutions to the opioid crisis

As public and private organizations come together to try to find solutions to the opioid crisis, pharmacists stand as the last barrier against diversion. Elliot J. Krane, MD—a practicing physician and professor of anesthesiology, perioperative, and pain medicine at Stanford University Medical Center—will give attendees an inside look at the epidemiology of pain in the United States and discuss the role pharmacists can play in finding solutions to the opioid crisis in his keynote address, “Inside America's Opioid Epidemic: Pharmacists on the Front Lines,” at the 2017 APhA Annual Meeting & Exposition Opening General Session in San Francisco on Saturday, March 25.

Krane spoke with pharmacist.com to provide a glimpse of what he’ll talk about. He also offered a few ideas for what to do and see in the City by the Bay.

What do you hope the audience at your presentation will take away from your talk?

One of the things I hope to communicate to the audience is that generally speaking, it’s not patients who take their medications as prescribed who are dying. It’s more commonly the people who are diverting the medications, self-medicating, or using them for recreational purposes, or patients otherwise taking them not as prescribed.

There are many causes and sources of the opioid problem. Some of the papers in my talk will show the prevalence of opioid deaths is proportional to the unemployment rate. One source of the opioid crisis is that the economy has been stagnating since about 2001. Even though the numbers of the economic recovery look good, the recovery has not uniformly benefited a lot of our society. It has gone to the wealthy, while the working classes in places where the opioid crisis has hit hardest—in Appalachia, the Rust Belt, and rural Maine and New Hampshire, for example–have been left behind.

What kinds of solutions to the opioid crisis do you envision?

One solution could be for pharmacists and physicians in states or at the national level with their corresponding societies to work together to establish a system with a national database of prescribers and patients. The database should be national because patients often live near state borders. Every opioid prescription should be checked against the database to make sure there’s no suspicion of diversion or multiple sourcing of controlled substances. There can be a method that would recognize and tag individuals who are not legitimate pain patients, like a national no-fly list. 

Pharmacists are more and more commonly providing individualized patient education, and most patients who take opioids would benefit from more education on how to take their medications, how to store them, and what other prescriptions and substances should not be combined with opioids, beyond the usual admonition not to drink alcohol.

What do pharmacists need to know when they work with patients with chronic pain?

A lot of patients who have legitimate pain and take higher-than-average dosages of pain medications are treated with suspicion. There’s a need to recognize first of all that there is a large number of patients who are in significant pain, and their lives and livelihood are impaired by it. They don’t choose to be in pain and on opioids. These patients should not be denied their opioid prescriptions because of the blanket application of recent guidelines, but it’s a growing trend to deny them. Sudden withdrawal because of denied prescriptions can lead to calamitous medical complications and even suicide, which has been documented to have occurred in the present climate.

What do pharmacists need to know when they work with physicians who specialize in pain management? And with physicians who don’t specialize in pain management, but have patients with conditions that cause chronic pain?

Some physicians are obviously unethical prescribers and run pill mills. But leaving aside these criminal elements, pain physicians are generally suspicious of potential abusers. Now toxicology screening is routine in many pain practices to make sure patients are taking only the opioids they’re prescribed and not any illicit substances in addition. The prescribers who are part of this problem are generally not the ones taking care of patients in pain clinics, but those in surgical clinics and primary care clinics. Many of these prescribers don’t understand the intricacies of pain management or how these drugs work, and they’re not as suspicious or able to recognize the illicit user.

There are also legitimate patients being misprescribed drugs because the prescriber doesn’t recognize certain risk factors like sleep apnea or counterindication with benzodiazepines [that patients may be taking].

Any suggestions for what meeting attendees should do and see in San Francisco?

The Moscone Center is walking distance from the [San Francisco] Museum of Modern Art, which has a fabulous collection but is not overwhelming in size. There’s also the Contemporary Jewish Museum and the de Young, a fine arts museum specializing in Asian art. The Fisherman’s Wharf Segway tour is a lot of fun. For authentic California, there’s the grittier side of SF in the Mission District. It’s not upscale, but it has phenomenal restaurants in the area bounded by 16th and 19th Streets, and Valencia and Dolores Streets.  Don’t miss the Tartine Bakery and Bi-Rite Creamery. The Ferry Building is great on a sunny day, with many places to eat and Humphry Slocombe ice cream, and you can catch the ferry from there to Sausalito, another tourist destination.