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[@PeterAttiaMD] The Hidden Factors That Predict Long-Term Opioid Use | Sean Mackey, M.D., Ph.D.

· 4 min read
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@PeterAttiaMD - "The Hidden Factors That Predict Long-Term Opioid Use | Sean Mackey, M.D., Ph.D."

Link: https://youtu.be/7U2ay6hRZ30

Short Summary​

The medical community is focused on minimizing opioid prescriptions, particularly before patients leave the hospital post-surgery, aiming to reduce long-term dependence. Research has identified pre-operative psychological vulnerabilities, such as depression and trauma, as risk factors for persistent opioid use, but further research is needed to understand the long-term effectiveness and safety of opioid prescriptions for specific patient populations and chronic pain management, though funding for such studies is limited.

Key Quotes​

Here are four quotes from the transcript that represent valuable insights:

  1. "What we have learned is that there are vulnerabilities that people bring to an injury or surgery and being placed on opioids that set them up for more likelihood of persistent opioid use." (Highlights pre-existing conditions impacting opioid dependence risk.)

  2. "When we talk about psychology and psychological factors, we're talking about neurosciences. We're talking about the brain and we're talking about specific brain systems, regions, networks." (Emphasizes the biological basis of psychological factors, moving beyond a purely subjective understanding.)

  3. "Even even in the world we live in today where we understand that for a nonzero potentially non-trivial segment of the population, the introduction to opioids that ultimately destroys people's lives is delivered by the medical system." (Acknowledges the role of medical prescriptions in initiating opioid addiction.)

  4. "Meaning, we need to figure out for whom opioids work. Um, 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 datadriven studies to find out who is 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?" (Points out a significant gap in research: understanding opioid efficacy for specific individuals, due to a focus on non-opioid alternatives and risk identification.)

Detailed Summary​

Here's a detailed summary of the YouTube video transcript, presented in bullet points:

Key Topics:

  • Opioid Use and Dependence: Focuses on the risks of opioid prescriptions, particularly the potential for long-term dependence.
  • Pre-Operative Factors and Opioid Use: Explores how pre-existing psychological and neurological conditions can influence the likelihood of persistent opioid use after surgery.
  • Psychology and Neuroscience: Emphasizes the connection between psychological factors (like depression and anxiety) and underlying brain systems/neurology.
  • Screening and Assessment: Discusses methods for screening patients for risk factors that may predispose them to opioid dependence.
  • Research Gaps: Highlights the lack of comprehensive research on the long-term effectiveness and safety of opioid prescriptions for chronic pain.
  • Funding Challenges: Acknowledges the difficulty in securing funding for research that explores the potential benefits of opioids for specific patient populations due to a focus on non-opioid alternatives.

Arguments and Information:

  • Goal of Inpatient Opioid Management: Ideally, the medical system aims to manage pain with opioids in the hospital setting and transition patients off them before discharge, although it's acknowledged that some surgeries necessitate post-discharge opioid prescriptions.
  • Vulnerabilities and Risk Factors: Patients with certain vulnerabilities (e.g., pre-operative depression, anxiety, catastrophizing, early adverse childhood events, PTSD, trauma) are more likely to develop persistent pain and opioid dependence after surgery.
  • Neuroscience Perspective on Psychology: Psychological factors are linked to specific brain regions and systems, suggesting a neurological basis for these vulnerabilities.
  • Depression and Self-Loathing: A study found that self-loathing (as a component of depression) was a strong predictor of persistent opioid use after surgery, more so than other aspects of depression like anhedonia.
  • Need for Randomized Controlled Trials: The ideal research approach would involve large-scale randomized controlled trials to determine the impact of opioids in different patient categories (e.g., those with varying levels of depression, anhedonia, self-loathing).
  • Lack of Will for Comprehensive Opioid Research: There is a lack of societal and scientific will to conduct comprehensive research into the long-term effects of opioid prescriptions, particularly for chronic pain, especially in identifying potential positive use cases.
  • Focus on Risk Identification: Current research efforts are primarily directed toward identifying individuals at risk of opioid dependence, rather than exploring the potential benefits of opioids for specific patient populations.
  • Unanswered Question: The fundamental question of "for whom do opioids work in the long term?" remains unanswered due to limited research funding and a prevailing emphasis on non-opioid alternatives.