Search for tag: "prescription"

Interviewer: You've tried the sprays and the pills for your seasonal allergies, but they just don't seem to work. So what are the next steps to finding allergy relief?

Dr. Gretchen Mae Oakley is a nose and sinus expert at U of U Health. She's really good with allergies too. So in our previous conversation with Dr. Oakley, we talked about managing those symptoms with prescription and over-the-counter sprays and other medications. If you haven't listened to that podcast, be sure to check that out first. But Dr. Oakley, if those sprays and pills aren't working, what are the next steps that you would take with a patient?

Dr. Oakley: The main next step that we generally talk about with patients is allergy testing, and that is identifying what the patient is specifically allergic to or the things, you know, they're specifically allergic to. And the goal behind doing that allergy testing and the reason we don't necessarily do that upfront is because the main goal is kind of a step towards the immunotherapy option. And this is a treatment for allergies that can be very effective for a lot of patients who, you know, are still struggling after medical therapy. And the idea behind it is basically desensitizing your immune system to the allergies, so it's less reactive to that allergen or those allergens.

Interviewer: And it seems like most people I talked to that have allergies, they'll be like, "Oh, I need to go get my allergies tested." In their mind, it's the first thing that you do. Do you find that to be common?

Dr. Oakley: I do. Yeah. I get that question actually a lot, "Should I be allergy tested?" And it's certainly satisfies our curiosity in many cases of, you know, what we're allergic to, but it doesn't necessarily change the treatment if we haven't done those medical management steps yet, because if, you know, whether you're allergic to this specific pollen or that specific, you know, weed, or this tree, or that grass, you're still going to be using those as, you know, your earlier steps. You're still going to be using, you know, those nasal steroids sprays first or the oral antihistamines first and the antihistamine sprays first, because that has, you know, a broader effect, you know, on all of those.

So that's what we generally don't do that upfront, because it doesn't necessarily change our first couple steps and, you know, the treatment. But it does affect, you know, our later steps. If we're thinking of immunotherapy, we need to know what we're specifically treating for that to work. And so that's kind of where it comes in and the point behind the testing, you know, at that stage generally.

Interviewer: Yeah, so your patients that you take at that point to the testing stage, I'd imagine they're just not finding any sort of relief from the first steps, or their allergies are just so terrible. I mean, what kind of patient then makes it to the testing stage usually? You're able to . . . I would imagine the medical things that you do first, the sprays and the pills take care of a lot of what patients experience.

Dr. Oakley: Yeah. I would say the patients that generally get to that next stage are those that are getting either really severe or really bothersome seasonal allergies that are refractory to the medical therapy. And they just don't want to, you know, suffer every summer, all summer or every spring, all spring. Those are good candidates for immunotherapy. They're getting breakthrough symptoms despite those, you know, medical treatments.

Other patients will have year-long allergies because they may be allergic to, you know, dust mite, and it's all around them. It's in their house. And, you know, there are things they can do, like, you know, try cleaning their house really well. However, we've not seen that those things will fix the problem in a noticeable way. They'll still get their symptoms. And so, you know, those patients are suffering all year, and, you know, there are immunotherapies that can help with those perennial allergies.

An additional option, for example, would be a patient who has a cat that they're allergic to, but they're very, you know, emotionally connected to their cat. It would be distressing for them to get rid of their cat, or it's a partner's cat and, you know, they can't necessarily avoid it. It's not so easy to always get rid of a pet. So that'd be another case where immunotherapy may, you know, play a good role for that patient.

Interviewer: When you get to that point, you do some of the testing, and then after you get the results, how do you proceed to the immunotherapy and how does that work?

Dr. Oakley: So generally, we're identifying the allergies that are causing, you know, the sensitivities that the patients have based on how they respond to, for example, skin prick testing, which would be the most commonly used allergy testing upfront. It can be done, you know, in the office. Patients are tested for multiple allergies at once usually on their arm. You're using a grid system to see what skin responses are the most significant to determine what they're, you know, most allergic to. And those are the allergies that you target, you know, their worst reactions with the immunotherapy. And the idea behind the immunotherapy is giving them very small but ramping up doses of that thing that they're allergic to, to just gradually desensitize the immune system to it.

Interviewer: I remember getting those as a kid. I've had more success with the first line of defense in later life, with some of the new medications that came out, I don't know, probably 20 years ago now, but I say new. So like my experience was the immunotherapy didn't really help me. Do a lot of people experience success with it?

Dr. Oakley: It's generally considered to be 80% to 90% effective. But, you know, it's not 100% effective, as you said. So some people don't get that response. It's generally very effective, but it is a commitment. It's very much a time commitment. You know, it's a three to five-year treatment where patients are coming in anywhere from a weekly to a . . . or I should say anywhere from a twice weekly to a monthly basis for injections, you know, to get that benefit.

Interviewer: Yeah. I remember it was twice a week I'd go in and get those allergy shots. So if immunotherapy doesn't work then, then it sounds like the last option is surgery, and I didn't even know there were surgical methods for allergies. Talk about that.

Dr. Oakley: Well, I should clarify because surgery is more of an assistive option.

Interviewer: Oh, okay.

Dr. Oakley: So not so much a treatment. It doesn't specifically cure or treat allergies. It helps with the symptoms, but in and of itself would not be sufficient. It goes along with these other treatments. So surgery can address some of the more bothersome nasal obstruction symptoms. For example, well, let's just say specifically from anatomical factors, like a deviated septum or enlarged turbinates, which are, you know, shelves of tissue in the nose that warm and humidify the air but can get quite enlarged with allergies. So treating some of those anatomic, you know, factors can improve symptoms of nasal congestion, but you need to treat the trigger as well, the ongoing allergy trigger. So that's that medical management or immunotherapy as well. So the surgery helps, but it's not a treatment in and of itself.

Interviewer: If somebody is listening to this and you just would want them to take away one thing after we're done with our conversation, what would that be?

Dr. Oakley: The main thing I would say is don't suffer in silence. This is a really common problem with many options for treating it. We know from, you know, research study after research study that there is a significant improvement in quality of life when these allergies are managed appropriately in patients rather than just struggling with really bothersome and really distressing, you know, symptoms on a day-to-day or seasonal or yearly basis. You know, try some of these easier steps. Don't hesitate to come in and get some, you know, formal consultation and talk about other options that can really, really benefit you.

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: So, when it comes to opioids and being prescribed opioid painkillers, do most doctors at this point in time all operate from a similar paradigm when it comes to whether they should prescribe them, whether they should not prescribe them to a particular patient? Or do patients still need to kind of have a working knowledge of opioid pain pills? Because they scare me. I hear some of these stories and they sound a little frightening.

Dr. Miller: Well, as you know, the news is out that opioids are very addictive. The statistic is something like 80% of current heroin abusers had started out on prescription opioids. And so we have a track record in this country now over the last 30 years of overprescribing opioid narcotics for the treatment of pain, and that has led unfortunately to an increase in deaths from opioids and heroin use and other bad things.

So, in answer to your question, there is not a policy about prescribing opioids that applies to all physicians. And, more importantly, we're not yet all completely on the same page about how to use and treat people with opioid painkillers.

Interviewer: Yeah. So, to some extent, the consumer, the healthcare consumer should have a working knowledge. And as somebody that might find myself in the healthcare system, how would I know whether or not it's appropriate for me if all doctors aren't operating from the same paradigm as of yet? And why is that? Why aren't they? Is it just because the information hasn't caught up to everybody yet?

Dr. Miller: I think that's part of it. They're individual prescribing practices, and some physicians don't prescribe opioids very commonly while others do. And presumably, the ones that are now prescribing opioid for pain and do quite a bit of that are well versed in how to use that, setting up contracts with their patients on how to take opioids and when to report in and when to get their refills and so forth.

So there is a spectrum of understanding of how to prescribe opioids. It starts back with medical student training and then residency training. We have not had what I would consider to be top-of-the-mark training in opioid use throughout our medical training, and that's changing over time.

Interviewer: Gotcha. Just takes a little time for that to kind of roll out, yeah.

Dr. Miller: It takes time.

Interviewer: So, back to my original question. I asked somebody who might find themselves in the healthcare system and now I'm trying to determine, "Is this really the right course of action for me or not?" how would I make that informed decision?

Dr. Miller: That's a great question. It starts with a question. So asking your physician how your pain can be best controlled is the way to start. What is the best way that you, meaning the physician, think that your pain should be treated? How do we do that?

In general, it depends on the type of procedure you're having or the pain you're experiencing. And the plan is really to start slow and use non-opioid substances or drugs, like non-steroidal anti-inflammatories like aspirin or ibuprofen or Tylenol, or other modalities, like massage or other physical therapy efforts.

Interviewer: Which I've read, and people might find this hard to believe actually can be just as effective if not more effective than opioids for chronic pain, those types of things.

Dr. Miller: That's true. Yeah, I think we were under the misassumption that opioids treated all types of pain pretty easily as a public, and that's not true. There are many other ways to treat pain. Acupuncture is another way that works well for some patients.

But again, you have to assess the severity of the problem, the potential severity of the pain. So if you have an open abdominal procedure where the muscles of the wall of the abdomen are cut, you're very likely going to have some pretty intense pain for a while.

And then you work with the physician to decide how much pain medicine you need and for how long. So, in general, shorter courses are preferred. And you don't want to be taking large amounts of opioids for a long period of time for a problem that is healing itself.

So, again, you start with questions. You start with, "What is the best way to treat the pain you might anticipate that I will have? What is your standard of practice?" or "I have this particular pain. What do you think the best way for me to have it treated is?" And then listen carefully to what they tell you.

If it starts off with a conversation that seems unclear or moves very quickly to opioid narcotics, then you might want to ask more questions about why are we starting with that particular medication rather than something that's potentially less addictive.

Interviewer: If we were to try to draw a visual path, I have the feeling that opioids might be prescribed for chronic pain, which is long, ongoing pain, like severe back pain that you're suffering from, or it could be pain that you might experience during a surgical procedure. Those would be the two different paths possibly?

Dr. Miller: Right. So there's chronic pain, pain that you can expect to have for weeks and months and perhaps years.

Interviewer: Yeah. And those are the types of things that some of these other modalities, as you said, massage, acupuncture, physical therapy, exercise could possibly mitigate and would be a better option.

Dr. Miller: Correct. At least trying that initially or working through that without using opioids initially would be a good point.

Some of the illnesses that we've gotten away from prescribing opioids would be things like migraine headaches, fibromyalgia, types of pain that are chronic, that don't really have a well-understood initiating cause or a cause that we think is going to heal over time, or pain that is episodic. If you treat that with opioids, sometimes that leads to a higher rate of addiction.

Interviewer: Gotcha. And in a surgical procedure, say I'm going to go into a surgical procedure and my physician says, "Yeah, this is going to be pretty intense for a couple of days. I'm going to recommend opioids." They're saying it right away, but they're also saying it's only going to be for a couple of days possibly. Should I be frightened of that?

Dr. Miller: No, you should not. I think most surgeons now are very well aware of the amount of narcotics that they're going to need for the particular duration of healing that you're going to experience.

If you're getting a month's worth of narcotics for a procedure that you might expect to be out of the hospital for in several days, then that is probably too much, and you could just say, "How many days do you think I'll be needing to take these medicines?" And then you might ask to say, "Look, why don't you just give me a week or two weeks or whatever you think is best for this particular healing period?"

Interviewer: Read an interesting article. The surgical department here actually did a study that found out that, as of right now, prescribing of opioid-based painkillers after a procedure is . . . they don't take the individual into consideration. Everybody would get them whereas they felt that they should talk to each patient to try to figure out what would be appropriate for that patient.

Dr. Miller: Correct. So what that study or that . . . it's not a study, but what that approach shows is just what you and I are talking about, that every patient has an individual need for the way their pain is treated and that depends on the procedure. So it depends on the type of the procedure, the length of the incision, the area of the procedure, and then the assumed time of healing.

So laparoscopic procedures, where they make very small incisions, are likely to heal quite a bit faster and would need less pain control and possibly could be managed without narcotics. Larger procedures, possibly longer periods of time, a week to two weeks, where they might need opioids. Again, it's quite individual.

And this is another thing. The science is not well worked out in terms of why one person's pain requires more and different types of analgesics than others. It's not known yet. So everybody is a little bit different.

Interviewer: And I think that brings up an important point too, that another way that people get into trouble is they are prescribed to take a certain amount over a certain time and they're like, "Well, I know my body and I don't normally react, so I'm going to take two instead of one." And with Tylenol, it's probably not a good idea, but with opioids, it's a really bad idea to start changing that dosage.

Dr. Miller: Yes. Again, we're not entirely clear why some people start on a path and then become rapidly addicted to opioids and seek opioids for the pain relief. It's not quite clear. Some people can be on opioids for some time and stop and it's not a problem. We don't really understand that completely.

Interviewer: But maybe not a gamble worth taking if you think you could . . .

Dr. Miller: Well, yeah. What we know now, given the evidence of the '90s and the last decade, is there was too much opioid prescribing, and it did lead to higher rates of addiction. So, obviously, the more opioids that are out there that people are taking for longer periods of time or perhaps in higher doses leads to higher rates of addiction.

Interviewer: So the important takeaway from this, it sounds like, is if you're finding yourself in position where that is a recommended way to deal with your pain from a physician, to start having a conversation. Because not having that conversation and just perhaps taking those pills could lead to a place you don't want to be.

Dr. Miller: That's correct, or it could lead you to have excess opioids at home, whatever type or form you have, and somebody else could maybe use that and that would lead to some problems down the road for them.

Interviewer: What about a resource if somebody wants to read a little bit more? The CDC? Is that a good place to go to learn more? Or National Institutes of Health?

Dr. Miller: CDC has guidelines, and we've actually repurposed the guidelines in our community clinic group as a training tool and an education tool for physicians in our community clinic group to read and learn from. So the CDC would be a good place to start.

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Announcer: "Health Hacks" with Dr. Troy Madsen, on The Scope.

Dr. Madsen: Today's health hack is having an antibiotic in your bag when you travel. The antibiotic I really have in mind here is Ciprofloxacin. And the reason for it is urinary tract infections. So if you're female and you're traveling, you may have experienced this before. I mean anyone could experience it, but urinary tract infections are more likely in females. And if you're traveling and you experience a urinary tract infection, you know how miserable this can be.

If you're in a foreign country or just even another city, just trying to get in to find health care, interrupt your plans, getting the help you need to get a prescription for exactly what you know you need can be an incredible headache. So I think it's not at all unreasonable if you're going on a big trip or, you know, if you meet with your doctor just to ask them, "Can I get a prescription for an antibiotic to have on hand for this kind of situation?"

I think it's a reasonable thing to have. Typically you know when you have a urinary tract infection, and studies that have been done have shown that if a person feels like they're having a urinary tract infection, they're probably right.

So the health hack here is have an antibiotic on hand. Ciprofloxacin is one that I recommend that works very well for urinary tract infections. Take it with you when you travel. If you have symptoms of urinary tract infection, you can take this, avoid a trip to an ER or to some health care facility in a foreign country.

Announcer: For more health hacks, check out thescoperadio.com. Produced by University of Utah Health.

Dr. Jones: Oops, you now have a contraceptive emergency, but your doctor's clinic is two hours away and you don't have the car. The closest pharmacy is an hour away, but the pharmacist is your father-in-law. So what are your options? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Okay, the condom broke or you didn't use protection. What are your options?

Number one, you can cross your fingers and hope you don't get pregnant. If you and your partner are young and healthy, and the "oops" came around your fertile period, and isn't that usually just the case, the chance of getting pregnant is between one and three, and one in four.

Two, you can use emergency contraception. Emergency contraception comes in three types, and they're all quite different. One is a progesterone hormone common in birth control pills that's taken in a higher dose in a pill within 72 hours of unprotected intercourse. One brand name is Plan B, and the others are Take Action and Next Choice One-Dose. These are available over the counter in many pharmacies, but not all, and should be taken as soon as possible, as it won't work after you ovulate and become pregnant.

Another pill, called Ella, is available by prescription, and it works for up to five days by blocking ovulation.

And lastly, a copper IUD can be placed, and it's the most effective, but it requires that you see a clinician who can place it and place it right away. And depending on your insurance, it can be hundreds of dollars, but it offers highly effective contraception that's immediately reversible for up to 12 years.

If you want to get emergency contraceptive pills, you can get them online and delivered to your home. This is not cheap, and you need a credit card, but several websites are available to women around the country, and FedEx delivers almost everywhere. You can Google "emergency contraception online," but be careful as you need a credible and reliable source.

The Princeton University website on emergency contraception is good, and the website, bedsider.org, will take you step-by-step. Both of these can direct you to the best places to order emergency contraception online. Both of these will also give you more in-depth information about emergency contraception.

Ella, the pill that works for up to five days, might be the best choice. Plan B needs to be taken sooner and isn't as effective for women over 165 pounds. You need to go to the websites recommended by the Princeton emergency contraception website or bedsider.org and set up an account.

You need to fill out a questionnaire that might take 10 to 15 minutes, and then fill out shipping and billing information. You need a credit card, and the current price for online consultation, the medication, and the overnight shipping, but probably not on Saturday or the weekend, is $67. It comes in a little box wrapped up in a bigger box, and you have to be present to accept it at your home.

If you want them to send the prescription to a local pharmacy, the one where your father-in-law doesn't work maybe, you can give them the number and it's a little cheaper, but you have to pick it up pretty soon. Don't wait a week.

Many women who would choose emergency contraception have limited access. They don't have a doctor. They don't live near a health clinic that will take drop-ins. Emergency rooms don't consider this an emergency, and it's very expensive to use an emergency room for emergency contraception.

Women might prefer privacy and confidentiality, which they might not have in their local small-town clinic or pharmacy, where everyone knows everyone. Getting emergency contraception online is an option, but it isn't cheap. You need to have a home address to receive the delivery, and you need a credit card.

Of course, we all hope that you and your partner are well-covered with contraceptive methods that are effective and that you don't have to think very much about so you won't even need emergency contraception. But if you need emergency contraception, there are some options, much better than crossing your fingers.

Thanks for joining us on The Scope.

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Dr. Gellner: Are you giving your child the correct dose of their liquid medicine? Many parents aren't. I'll talk about proper medication dosing on today's scope. I'm Dr. Cindy Gellner.

Announcer: Keep your kids healthy and happy. You are now entering "The Healthy Kids Zone" with Dr. Cindy Gellner on The Scope.

Dr. Gellner: No parent would intentionally give their child the wrong dose of medicine, but it happens more than you think. A new study shows parents end up giving more than twice as much as instructed in some cases. With little kids up until 12 years old or 88 pounds, everything is based on weight. That's why your pediatrician has to take the extra time and calculate how much liquid medicine to give whenever they give you a new prescription.

You know those little medicine cups that come with all the liquid medicines? Turns out they're not the most accurate and that little device is what was used during most dosing errors. Have you tried measuring 2.3 milliliters with a plastic cup? You can't. Using an oral syringe to measure your child's liquid medicine is much better.

Then there's the confusion of milliliters versus teaspoons versus tablespoons. It's hard to keep straight. That's why pediatricians have recommended only using milliliters when given dosing instructions to parents. It's a lot easier to measure accurately. The study that just came out in the Journal of Pediatrics showed that in nine different trials, almost 85% of the parents made at least one dosing error. And more than 68% of the errors were overdoses. About 21% of parents, at least once, measured out more than twice the proper dose.

It was the device used to give the medicine that had the biggest effect on errors. When those little plastic medicine cups were used, there were four times as many errors as when an oral syringe was used. If you have questions about how to use an oral syringe, ask your pediatrician or the pharmacist when you pick up your prescription.

Oral syringes are usually available in the baby aisle of most stores. But if your child is prescribed a medication, the pharmacy should always give you a few to take home with your prescription. Be sure to clean those with hot, soapy water and rinse thoroughly after each use. Remember, even a little bit too much of any medicine can be too much for your little person. Be sure you are accurate when giving them liquid medicines.

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Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you. Get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question on The Scope.

Interviewer: Today's listener question is about drug side effects. This particular individual is taking a prescription medication, and there are some side effects that the label warns about. What should you do if you experience one of those side effects? And to answer our listener question this week, it's Barbara Crouch. She is the director of the Utah Poison Control Center.

Barbara: I think the first thing you should do is talk to your pharmacist about it. They may be side effects that we can do something about, reduce the severity of those adverse effects and allow you to continue with the medication, especially if it's necessary. But if this is a side effect that comes up after hours, certainly the Poison Control Center is there 24 hours a day and is staffed around the clock with pharmacists and nurses who have expertise in toxicology and adverse drug effects.

And always, the next time you visit with your doctor, you should be talking about those adverse effects. I mean, some are natural extensions of what the drug does, and in order for the drug to work, we sort of, it's sort of a risk/benefit balance. But there are many of these adverse effects that we don't need to deal with, and there are other ways that we can deal with it, so always communicating with your pharmacist about those issues, certainly feel free to contact the Poison Control Center, and it's also a good conversation with your doctor.

Interviewer: And you'd say if you start experiencing those side effects, do that pretty immediately?

Barbara: Absolutely. You don't want to wait on that. I mean, some adverse effects are just that - they're nuisances. They're annoying. But there are some that are more severe in nature that are warnings, and so absolutely, you should communicate immediately.

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Interviewer: Using Imodium to treat opioid withdrawals: a bad idea. We'll find out more about this disturbing trend next on The Scope.

Announcer: This is "From the Frontlines" with emergency room physician Doctor Troy Madsen on The Scope. On The Scope.

Interviewer: Doctor Troy Madsen is an emergency room physician at University of Utah Health Care and he said he'd seen a couple instances where people are using Imodium, which is an anti-diarrhea medication, as a way of trying to treat their withdrawal symptoms from opioids. I find this hard to believe. What's going on?

Dr. Madsen: Yeah. So this is really interesting. So as you may know, there's an opioid epidemic in our country and the Centers for Disease Control has acknowledged this and said we have so many people who are using opioids now. So prescription opioids, things like Percocet, Norco, Oxycodone are using that for to get high. Essentially what they may consider it legal high because they're getting a prescription or it's a prescription medication they're buying from someone.

So then, these individuals may then be saying to themselves, "I really can't be doing this. I need to get off this medication." So they're finding things on the Internet that discuss using Imodium or loperamide is the generic name and using that to sort of detox, taking that as a bridge to give yourself some of the same effects as the opioids give you while allowing your body to adapt and adjust and then gradually get off the medication.

Interviewer: So, first of all, bad idea trying to self-treat an addiction like that?

Dr. Madsen: Absolutely, not a great idea. But the reason they're doing this is because it's probably been out there for years and then I think it's just gained steam with some people posting things on the Internet about this. But Imodium or loperamide is actually an opioid. It doesn't give you the same high as things like Oxycodone, but it has kind of the same effects, acts on some of the same receptors in the body.

That's why it help with diarrhea because if you've ever heard of someone who says, "Hey, taking all these Percocets and I can't have a bowel movement. It constipates me." Well, that's kind of how this stuff works for diarrhea. Same kind of idea. It slows down the bowels but also then acts on somebody's same receptors in the body that opioids act on that people are using for highs.

Interviewer: Yeah. So self-treating bad but, above and beyond that, Imodium causes other problems that you see then?

Dr. Madsen: It does. And the big thing we're seeing is some of these people are just taking such incredibly high doses that it's been putting their heart into these arrhythmias, these abnormal heart rhythms that are life-threatening. And that's where we see it in the ER. I've seen cases of people coming in who are in just these crazy heart rhythms, these life-threatening heart rhythms and it's because they're taking large doses of Imodium and then that is triggering this heart rhythm.

And really, it's the kind of heart rhythm where you've got to shock their heart to get them out of it, get them on medication, do something for it or their hearts just not going to keep working and they're going to die from this.

Interviewer: That doesn't sound much better.

Dr. Madsen: It doesn't. It's not a great thing to do.

Interviewer: It doesn't sound like a great solution to the original problem.

Dr. Madsen: Yeah, there's not. There are much better solutions to opioid addiction and to getting off that. It's a sort of thing where you've come into the ER, we will often get people into in-patient detox programs. We can also prescribe medications that can help with this. So I would not recommend taking Imodium or loperamide. Again, that's the generic name for it. I would not recommend taking that to treat an opioid addiction because of the threat of these abnormal heart rhythms.

And this really comes up because there was actually just a study published or report in one of the big emergency medicine journals talking about increasing cases of this and increasing calls to poison centers for people who are taking more and more of these medications to try and treat opioid addictions and then are having very bad effects from this.

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Announcer: We're your daily dose of health, science, conversation. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: Dr. Higgins, so when it comes to opioid pain pills, I'm getting the point personally, and I want to see how you would react to this with the physician perspective, that opioid pain medications, they're just really bad news and we really shouldn't have them in our medicine cabinets anymore. We really should look for other ways to treat pain because you continue to hear about deaths and overdoses and addictions. Am I being a little overstated on that?

Dr. Higgins: Yes and no.

Interviewer: Okay.
Dr. Higgins: There are certainly indications and uses for opioid pain medicines, where appropriate. And the presence of them in your medicine cabinet, by themselves, is not harmful. It is the chronicity of use, using them over a longer period of time, and ramping up the doses, which is, and this is proven in the literature, this is where people get in trouble.

Interview: What should we do about what seems to be going on? It seems almost like a national health epidemic. And there again, I may be overstating this.

Dr. Higgins: It's absolutely not overstating it. It is a national health epidemic. If you set aside cancer and heart disease, the thing that was most likely to kill an American under 65 was their car with some sort of motor vehicle accident. It was that way for some time. In 2003, it was the first year in the state of Utah where a prescription opiate was more than likely to lead your demise than a motor vehicle wreck. That was kind of revolutionary at the time. Now, it's that way in greater than half the states.

Interviewer: Okay. So we were kind of ahead of the curve.

Dr. Higgins: Yeah, it's nothing to be proud of.

Interviewer: Yeah, in a bad way, yeah. So it is something that we need to address. As a patient, if my doctor says, "I'm going to prescribe you some pain medication that's opioid-based," should I say, "I'd rather look for a different solution?"

Dr. Higgins: If you want to do that, your doctor should definitely respond. The old teaching was that as long as you had discomfort, the opioids [Audio skips 00:02:12] likely to be taking someone else's medicines. The people in the 40 to 60 age group are more likely to be taking their own medicine and they were on it chronically and they were on higher doses. And there are people here doing some pretty fascinating research on what the susceptibilities are. We may all have genetic susceptibilities to flip that switch. So even if you don't think you have "an addictive personality," then you can certainly develop one rapidly even if you don't think it's in you.
The other thing is to not necessarily judge those people that have had problems. Plenty of very prominent people and people who we wouldn't necessarily expect have certainly run into problems and, in some cases, have been fatal.

Interviewer: So at the end of the day, a physician perspective, what do we do to solve the problem?

Dr. Higgins: I think it's critically important of late that the public becomes aware and this happens through the lay press. And then, from a physician standpoint, we have to educate the patient at the beginning, the initiation of treatment. Secondly, have an exit strategy. Thirdly, entertain other modalities we can be using besides these medicines to treat the pain.

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Interviewer: In the future, your neighborhood pharmacy may be very different than it is today. We'll talk about that next on The Scope.

Recording: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Mike Feehan, a visiting professor in the College of Pharmacy at the University of Utah. Dr. Feehan, in five or ten years, how might our neighborhood pharmacy be different than it is today?

Dr. Feehan: That's a really interesting question. I think what might change in the future is, be a greater likelihood that you might not just be going in for your high blood pressure medication. You might be going in there to get your bottled milk, and at the same time you've been noticing that you've had this earache that's been building for the last couple of days. So rather than make an appointment to see your physician, you might just see a practice nurse at the pharmacy while you're there, get a diagnosis, get a prescription for an antibiotic, and talk to the pharmacist about what the risks and benefits of that medication are for you. Then get your milk on your way out.

Interviewer: So perhaps more kind of on demand health care?

Dr. Feehan: Yes, and we're seeing this happen now with the likes of CVS with their Minute Clinics. You can go and you can get seen for a limited range of primary care needs. You can get seen very quickly, and relatively affordably without having to go through the process of traveling and visiting your doctor.

Interviewer: One possibility is that the pharmacy would become more part of the health care continuum.

Dr. Feehan: Right, exactly, sort of acute care needs that might not require complex medical consultation but still require a trained health care professional providing advice. What we would like to see is a world where pharmacists are not being, perhaps, seen so much in the dispensing of medication role, but in a much more counseling the patient about what constitutes good health care, good adherence, things like that. Working in a model where that patient participation is encouraged.

Interviewer: So you're actually doing research to try to figure out what this future pharmacy of the future will look like. Tell us a little bit about what you're doing.

Dr. Feehan: Sure. We're actually doing one of the world's largest, most comprehensive surveys looking at what people might want in the potential range of services that could be offered by their pharmacies. We're also interviewing a large portion of pharmacists to see what services they may or may not be willing to provide. We're also looking to survey reimbursement decision makers to see whether these services would likely be reimbursed.

The basic approach is we'd like to build a linked model where we basically try and output, what is the optimum pharmacy, given all the range of services that you could provide? What is the pharmacy service package that will attract the most customers and provide pharmacists with the greatest degree of personal and occupational satisfaction. And to be sustainable, what are the services that are most likely to be reimbursed?

Interviewer: Correct me if I'm wrong, but this is kind of a new approach, right? I mean it's kind of looking at it from more of a business perspective than . . .

Dr. Feehan: Yes, that's one way to look at it. When we think about any purchase decision we make, human beings are very good simulators. Our brains are very good computers. So, if I were to ask you tonight, what are your dinner plans or where might you go, you might think, "Well, I could go to McDonald's, I could go to the local IHOP, or I could go to Ruth's Chris Steakhouse." That choice is made up of you determining which of all the different attributes are most important to you. Whether it's location, price, travel time, whether it's going to rain, and is there good parking?

So you factor in all those attributes and then you make a decision that's the optimal for you. This is done in industry all the time. We will build vertical discreet choice models, where we model what is the optimum configuration of any product or any service.

Interviewer: So you present people with different choices, and they pick from among those choices.

Dr. Feehan: What we try to do is present people with a real-world experimental choice. If I were to ask you, as a consumer, what is most important about whatever service or product you might want, probably everything becomes pretty important. In health care, if I asked you what's important, you're going to say that you want your health care to be delivered easily. You want good access. It has to be cheap. It has to be affordable. Unless we put a trade-off in there then you get this common sense response that everything is important. We all know that everyone wants the best quality health care for free or as close to free as possible.