Central Line
Episode Number: 92
Episode Title: Opioid Updates
Recorded: March 2023
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA’s Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. ADAM STRIKER:
Welcome to Central Line.
I'm Dr. Adam Striker, your host and editor. And today I'm joined by Dr. Anuj Aggarwal.
Dr. Aggarwal is a member of the ACE editorial board and a pain specialist at
Stanford University. He wrote two opioid focused items appearing in the latest
issue of ACE. And I wanted to learn more about the topics. So
I invited him to join me today. And for those of you who may not remember, ACE
stands for Anesthesia Continuing Education. Dr. Aggarwal, welcome to the show.
DR. AGGARWAL:
Thanks, Dr. Striker
Thanks for having me.
DR. STRIKER:
Yeah, certainly. Before
we delve into the topic, do you mind telling us a little bit about your
background and your experience with ACE?
DR. AGGARWAL:
Yeah, I'm a practicing
chronic pain physician. I also practice general anesthesia in the OR at
Stanford. As you mentioned, I specialize in orofacial pain, but I have a specialty
and interest in pharmacology. I oversee and direct the curriculum for
pharmacology education at the medical school at Stanford. And I've been a part
of ACE now for about two years. And like to read the right questions about
pharmacology, anesthesia, and sort of current changes and new topics that are
developing within our field.
DR. STRIKER:
And you contributed a
few items on the topic of opioids to the new issue of ACE. Opioids is obviously
such a large topic and it's an important one. Why don't you start by telling
us, in your words, why the issue of opioids is still so salient? What do you
think that we should be focusing on?
DR. AGGARWAL:
Yeah, I think the reason
opioids are such a salient topic is that in many ways they're the oldest of
medications we've we use in medicine. We've used them for thousands of years.
And part of it is because they're so powerful, they have so many effects, and
they really go to some of our most core physiological functions. Motivation,
behavior, how we interpret the world, our interpretation and experience of
pain, and our response to stress. And so the use of
opioids is really central to the practice of modern medicine. It allows us to
do surgery and anesthesia, as all of us know. But the salience to me is really around that, I think there's a misunderstanding often
that we know a lot about these medications because we've used them for so long.
But actually our use of the medication predates our
understanding of them. And as we understand more and more about the molecular
and scientific underpinnings of how opioids work, I think we've come to realize
that they're much more complicated pharmacological agents than we perceived.
And it really comes to light when we think about something such as the opioid
epidemic. This really transient problem in American
and even in other societies of the role that opioids play when they interact
with us at an individual community and then at a national level.
DR. STRIKER:
I do want to get to, you
know, a few specific items. One of them is a new opioid that's on the market
called Olceridine, trade name is Olynvic.
From what I understand, it's the first in a new class of opioids approved by
the FDA. Why don't you go ahead and tell us a little bit about this particular drug and how how it
differs from our conventional opioids?
DR. AGGARWAL:
Yeah, Olceridine is the sort of new opioid that's on the market,
and it is in a sort of inherited vein of us--and by us means to the scientific
community--trying to develop a better opioid sort of the holy grail of
developing an opioid that can give us all of the great effects that we desire
of opioids, namely analgesia, without the adverse effects that we associate
with opioids, including dependence, euphoria, respiratory depression and perhaps
sedation.
And for a very long
time, you know, once we you know, in the 70s we really discovered the opioid
receptors, the various subtypes of the opioid receptors. And as we started to
figure out that opioid receptors are g-protein coupled receptors, we started to
detangle the molecular underpinnings of opioids from the drugs themselves. And
I think many of us learned in medical school, sort of all of
those secondary messenger systems and how g-protein coupled receptors work. But
as the science evolved, particularly in the 90 seconds and the early 2000, we actually came to realize that these receptors are much more
complicated and that while opioid receptors are g-protein coupled receptors and
have pathways that go via the g-protein, they also have other different types
of pathways, particularly a beta arrestin pathway.
And some early work showed that perhaps the analgesia from opioids was mediated
via this g-protein dependent pathway, but that some of the adverse effects,
namely respiratory depression, were mediated via the beta arrestin
pathway. And this began this sort of race to see could we develop an opioid
that could preferentially activate the analgesic pathway without the
respiratory depression pathway. And Oliceridine is in
this vein of being what we call a biased agonist, meaning it biases itself
towards one pathway versus the other in the hopes of developing, quote unquote,
a safer opioid.
DR. STRIKER:
That's actually a label, from what I understand, biased ligand
label.
DR. AGGARWAL:
The FDA has given it
sort of a label. If you look at the packaging of it, that it is the mechanism
of action is that it's a biased opioid agent, correct.
DR. STRIKER:
And it's not proven.
This is still a theory. The g-protein versus the beta arrestin
pathway that.
DR. AGGARWAL:
Yeah, well, like with
everything I think, you know, as we discover more and more things can seem very
clear at the beginning and as we gain experience with them, we start to realize
that the story is more complicated. So very similarly, you know, the story was
actually we discovered morphine and then we discovered heroin or diacetylmorphine and diacetylmorphine or heroin was marketed
as a safer alternative to morphine, extended release Oxycodone was in the 90s
and marketed as a safer, maybe alternative to oxycodone, immediate release. We
sort of been down this road before. And essentially what happened was really at
the turn, going from the 90s to the early 2000, there was a lot of animal data
showing a lot of promise around this biased agonism that if you could really preferentially get just the g-protein pathway, you
would have a lot of safety margin. And the drug development really started to
take off around that period of time. Now we're about
20 years ahead. And in that 20 years, what's happened
is that this theory of biased agonism has become much more complicated in that
we've discovered there's other pathways that it's not a very it's not a clean,
biased agonism. And with all opioid medications, the story is a little bit more
complicated. And while things may have a little bit more safety, it may only be
around one adverse effect. But because opioids have so many different adverse
effects to be able to globally say they're much safer, becomes a much more
complicated label or question to answer.
DR. STRIKER:
Yeah like everything
it's it's simple for us to all think about when it's
linear or there's one variable, if you will, and then you start introducing the
other variables, everything becomes more complicated. Obviously, this is no
different. Let's talk about clinical use of Olinvyk.
How is it is that administered IV, orally? How is it
going to be utilized in the clinical realm?
DR. AGGARWAL:
Yeah. So
it's an intravenous only medication and it's been approved essentially by the
FDA for management of pain in acute settings, particularly around post-operative
pain. The studies that were done with Oliceridine
were really done around utilization in pca systems.
So clinically, the way the FDA has approved it and sort of I perceive that it's
going to be introduced into clinical use is really going to be around acute
pain management in the PACU post-operative period as well as within a monitored
hospital setting. Given that the comparative advantage theoretically of the
medication is that it may have less respiratory depression. The issue was that
the clinical trials weren't really well powered to study decreased incidence of
both respiratory depression or constipation. And there
are some mixed findings that we found. But when you actually
look at their efficacy of Oliceridine to treat
pain, it's pretty effective when you compare it to morphine, very similar
whether or not it's safer and resulted in less side effects. It's actually sort of a mixed question, but it got the FDA label
of the unique mechanism of action.
DR. STRIKER:
When I was reading about
the FDA approval or the indications, it's indicated when other traditional pain
medications have failed. Is that correct?
DR. AGGARWAL:
You know I think this is
one of the complicated issues around the approval of new opioids or new
medications for pain that they generally get this labeling that it's approved
when other traditional medications have been proven to be ineffective. However,
I think what we find in practical, real world clinical use is that these
medications get quickly substituted or can be substituted as first line. But
yes, the official labeling would be that if for individuals who have not had a adequate response or have had
significant adverse effects to what we would consider our traditional
medications.
DR. STRIKER:
Because of the particular intravenous use in an inpatient setting, it won't
be that won't be necessarily a barrier to its use.
DR. AGGARWAL:
I don't think so. But I
think the to me, the central portion of it is thinking that it's much safer.
And I think historically we've fallen into this trap before about thinking that
a new opioid was safer. And I think clinically at times it has lowered our
caution and our guardrails around the use of opioids. And given that there is
research and data showing that the intensity of use of opioids and duration of
use of opioids are factors in prolonged use of opioids after surgery, including
other risk factors that are patient dependent, falling into the trap that, oh,
we have a new safe opioid when the reality is we're actually still learning
about its use and its effects in humans, particularly in large patient
populations, I think just wants us to understand that this is a new tool. It
works a little bit differently. But it's unclear how and why this is. You know,
while the FDA has given it the labeling and in the package insert about the
fact that it's a biased opioid agonist, there's actually some
controversy around that within the sort of basic science committee. There are
pharmacologists and researchers who say that Oliceridine
effect might not actually be due to biased agonism, but it actually
might just be because it's a partial agonist similar to buprenorphine.
And we know that buprenorphine has significantly less respiratory depression
and GI side effects compared to our traditional opioids as well. And it's just
sort of goes to the fact that while a nice story would be very convenient and
it sort of has this labeling of the nice story, perhaps the science isn't quite
there and the science is a little bit more uncertain
and skeptical about exactly how this medication may work.
DR. STRIKER:
Sounds interesting.
Well, we'll certainly have to see how that all plays out. I do want to shift
gears a little bit and talk about long term opioid use, especially after
surgery. Let's do that right after a short patient safety break. So please stay
with me.
(SOUNDBITE OF MUSIC)
DR. JEFF GREEN:
Hi, this is Dr. Jeff
Green with the ASA Patient Safety Editorial Board. We can learn from errors,
near misses and adverse events by using formal analysis of the unreliable
systems that played a role in the scenario. Through error analysis we can
investigate errors, identify and address their causes,
and prevent future occurrences of similar events. Root cause analysis is a
detailed retrospective review of an event by a multidisciplinary team using
tools such as the Five Whys and the Ishikawa or Fishbone diagram to identify
and repair the underlying or root causes of errors. Failure mode effect
analysis is a prospective process using subject matter experts to identify
weakness in a process where system failure could occur by measuring the
frequency, severity and detectability of failure
points. The discipline of human factors engineering can assist in the
development of safety systems that prevent inevitable human errors from
reaching the patient and causing harm. It's a worthy endeavor for health care
to adopt the goal of achieving zero events of preventable harm.
VOICE OVER:
For more information on
patient safety, visit asahq.org/patientsafet22.
DR. STRIKER:
Okay. We're back talking
with Dr. Aggarwal on the topic of opioids. I wanted to talk a little bit about
long term opioid use after surgery. What do you think the listeners, mainly
anesthesiologists of this podcast, should be on the lookout for when it comes
to this topic?
DR. AGGARWAL:
Yeah. You know, I think
there's been a lot of appropriate focus on the use of opioids in the
perioperative period. Particularly as we've rightfully embraced our role as
perioperative physicians, our ability to modify and change the trajectory of
individuals after surgery becomes more and more important. And I think opioids
is a place where anesthesiologists have done a lot of excellent work in regards to reducing the exposure of individuals to
opioids and helping guide our surgical colleagues into safer prescribing
practices upon discharge. And I think while there's been a lot of focus around
reducing the intensity of pain after surgery and reducing the exposure of
opioids to individuals after surgery, there's increasing data to suggest that
there are other factors, namely that there are vulnerable, potentially
vulnerable patient populations who may be more likely to continue to use
opioids for a prolonged period of time after surgery, putting them at risk of
developing an opioid dependence or a new opioid addiction. And again, it's one
of those places where, as we study it, more things come into more focus and we figure things out with a little bit more
detail. But clearly there seem to be certain risk factors that patients bring
to surgery that put them at risk of utilizing opioids for prolonged periods of
time after surgery. And I think as anesthesiologists, we can help identify
these patients when we evaluate them before surgery and perhaps develop
programs to better guide these patients throughout the perioperative period.
DR. STRIKER:
You know, it's
interesting because what you're describing is our shift in focus from perhaps case based anesthesia to patient based anesthesia, which is
something we as anesthesiologists should always be doing. But we tend to fall
into the trap of basing our treatment or the anesthetic to a great degree on
the case we're doing. This is what I usually do for this surgery. This is what
I usually give my patients when they have this done. It certainly sounds like
this is one of those aspects of anesthetic care that could really hammer home
that shift in thinking as we know more about it and the practice changes that
it probably I imagine it will shift our focus as practicing anesthesiologists
even more towards the patient per se. Do you think that's right?
DR. AGGARWAL:
I think so. I mean, I
think I would say that we actually in some ways, we do
this already. You know, in some ways, when we think about a patient who is
coming in for surgery and may have multiple, we would say sort of cardiac risk
factors, we change our anesthetic and we have developed systems to help ensure
that those patients go through surgery safely. And I think when it comes to
pain, I think for very understandable reasons, we've focused really on pain.
Once the individual starts feeling pain or starts reporting pain. And I think
there's this over the past really decade, there's been this shift towards
thinking, why can't we plan for patients pain before they have the pain? And
taking it one step further, thinking about, well, what are risk factors for
patients to have complicated pain management cases and histories after surgery?
And so to me, in many ways, when I do an anesthetic or
I'm planning an anesthetic, it's the same way I would think about, well, this
patient has multiple cardiac risk factors. I sort of think about, well, does
this patient have risk factors for prolonged opioid use or increased pain,
perhaps things such as preoperative use of benzodiazepines, preoperative use of
antidepressants, history of depression, history of substance use disorder, and
seeing if we can partner with our surgical colleagues and within our systems to
develop appropriate pathways that can ensure that these patients get the best
care. Understanding that our responsibility is not just in the operating room,
but it really goes on to see how these patients do long term after their
surgeries as well.
DR. STRIKER:
Do you think that that's
well understood throughout the anesthesia community when it comes to pain
specifically, maybe as opposed to other aspects of the anesthetic? Or is this
something that you think we still need to to work on
as a as a community of practicing physicians?
DR. AGGARWAL:
I think we've made
significant strides. We've introduced opioid sparing techniques, the explosion
and use of regional anesthetic techniques, the focus on opioid cessation and
tapering after surgery. But I think the piece that we as a specialty have a lot
more work to do is in that preoperative period. And I think for a long time it
was because all we could do was really identify the risk factors. But question
was, could you intervene and do something before surgery? And this is where I
think the data is starting to emerge that, yes, actually we
can have interventions before surgery that can improve outcomes after surgery.
And you know, the question, what I wrote for ACE was really
about identifying the preoperative risk factors. It's because I think
what we're going to see over the next ten years is the research really starting
to come out showing that guided specific interventions, things such as
psychological interventions, interventions with our addiction colleagues in at
risk individuals, self-guided educational interventions for patients who are at
risk of prolonged opioid use after surgery are going to result in better
outcomes for these patients. And so while we've
focused a lot on cessation of opioids after surgery and we've focused a lot on
identifying some of those risk factors, I think where our specialty is starting
to see data emerge and where the movement is going to be is about intervening
before surgery to help improve outcomes after surgery.
DR. STRIKER:
Now, do you think
certain patients are getting opioids discontinued too soon after surgery
because of this concern? In other words, there are certain patients who may not
be as much at risk for issues afterward when it comes to, you know, opioid
usage. So are we are we being too constrained when it
comes to some of our post-operative patients and the need for certain pain
medications?
DR. AGGARWAL:
I think this is sort of
a huge question about opioid prescribing. It really appeared for a long time
that almost all of us in the post-operative period were too generous. We were
over prescribing opioids and patients weren't using the amount
of opioids that we were prescribing. And over really the past decade, there's
been a steep decline overall in American medicine about around the prescription
of opioids in many places, very rightfully so. And a lot of that has been by
giving guidance to prescribers who mainly are not actually us as
anesthesiologists, but our surgical colleagues around how much and how often
should patients be taking opioids after certain types of surgeries? Sort of to
go to your point, Dr. Striker, that case based surgical anesthetic and
perioperative or post-operative care. I think what we are starting to see,
though, is perhaps an overapplication of pathways and protocols to all
patients. You have a certain type of surgery, say a knee replacement, you get X
amount of opioids and that's it that everybody's going
to fall into that pathway. But we all sort of know that there are patients who
are not going to fall into that pathway. And there's one thing about
identifying them once they're already using more opioid or are not tapering off
their opioid as expected. But I think there's sort of a shift into thinking,
well, how many of these people could we have predicted would not have fallen
into these pathways or the expected protocols, and thus should we have
different protocols or different interventions for these individuals so that
they get the more appropriate level of care and perhaps more intensive care
than the majority of patients may need, particularly
around pain management or opioid prescribing.
DR. STRIKER:
Right. And certainly opens up another few avenues of discussion,
potentially the protocols and and how we're applying
them to different patients. But I see a lot of chatter, whether it's social
media or discussion boards or at meetings about, you know, the use of opioids.
It seems like some really believe in minimizing opioid use and some are
advocates of liberal opioid use when needed. I would imagine, you know, the
right approach is like we talked about patient based and it's
probably part of a comprehensive plan. I guess I just want to get your take on
this idea of minimizing opioids. Is that the right term we should be using or
is it should it be just appropriate use of opioids? It's kind of more of a
philosophical question in how we how we address the topic, I guess.
DR. AGGARWAL:
No, I think, Dr.
Striker, it's such a great question. And I think if you asked ten physicians,
you would get ten different philosophies around opioids. One of the guiding
cornerstones to me around opioids is, first, understanding that opioids are not
pain medications. I think when we think about opioids as pain medications, we
fall into the trap of, well, you just give it and the
patient's pain gets better. And that's not what opioids are. Opioids are simply
medications that work on the opioid receptor, and they have a myriad of
effects. We use Loperamide to treat diarrhea, which is an opioid. And so opioids are not just for pain. And so
the first thing to me about philosophically is they're not pain medications,
they're opioids, and they work on the opioid receptor. And so
then what do opioid receptors in our body do? They really modulate in many ways
our response to stress. And one of those elements is modulating our experience
of pain. And so for me, I think about the appropriate
use of opioids is to help modulate and change the experience of pain for our
patients after surgery. And then the question is to what end and to what goal?
And to me, the goal of surgery is recovery and appropriate healing. It is not
to eliminate pain. And so. When think about opioid prescribing after surgery, to
me the goal is opioids should be prescribed appropriately and at the right
amount so that the experience of a patient's pain is modulated to the
appropriate degree so that they're able to achieve our post-surgical goals. And
to me, post-surgical goals are not the elimination of pain or to be pain free.
Pain is a part of our healing process. It does not mean that patients need to
suffer, but it also doesn't need to mean that they can't experience any pain.
And part of that's preparing patients for surgery as well. To understand that
patients need to go into surgery expecting a degree of pain as part of their
healing process. And so to me, it's not about being
restrictive or being about liberal, about opioids. Similarly, as we aren't
restrictive or liberal about other medications. It's about using them
appropriately to get the goal that we have in mind and perhaps changing it to
reducing or eliminating pain, to changing our goal to helping patients achieve
the goal of the surgery is a way to help guide our prescribing of opioids.
DR. STRIKER:
Well, do you think that
we do a good job as anesthesiologists in preparing the patients for that or
creating realistic expectations in that regard? There's obviously a lot of
yield to doing that, but do you think that we have a long way to go or are we
doing a pretty good job of that?
DR. AGGARWAL:
I think this is a place
that not just us as anesthesiologists, but I think us as a larger medical
community have work to do. You know, I remember when I was training as a
resident, which was not very long ago, and even when I was in medical school,
there was, you know, a lot of talk about like painless surgery, pain free
surgery. You're going to be completely comfortable after surgery. You've got
all these new techniques and technologies with and the explosion of regional
anesthetics, etcetera, that you won't be you won't have any discomfort after
surgery. And and I think that sort of does a
disservice to our patients in many ways where pain is a normal part of that
healing and sort of I think we as medicine can do a better job of preparing our
patients to have realistic expectations after surgery. I think it's it's something that makes me very uncomfortable to talk to
patients that, you know, it's not going to be everything's not going to be
perfect after surgery. You're going to have some discomfort. It's going to be a
recovery. But I think what we've seen and there's some research coming out that
the more you prepare patients before surgery and the more that they have
realistic expectations around recovery after surgery, they actually
have less pain and they do better after surgery. I think as a global
medical community, I think we have some work to do around setting realistic
expectations after surgery. But we've made definitely strides,
particularly over the last 10 to 15 years, around understanding that patients
need to be prepared for what is going to be after surgery.
DR. STRIKER:
Do you think our
surgical colleagues share that sentiment in general? That's obviously an area
that we should certainly target. But is that something that needs a lot of work,
or do you think they're doing a good job of preparing patients for the
surgeries they're having?
DR. AGGARWAL:
I think as
anesthesiologists, we have a lot to offer our surgical colleagues. Our surgical
colleagues are amazing at what they do, but sometimes they aren't thinking as
completely about the perioperative experience. And I think as a specialty that
that's really where we come in. And where I think sometimes see the disconnect
is there are not robust systems in place for a variety of reasons that go
beyond just our training and what we think should be done, but also around
reimbursement and funding and logistics and staffing. But I don't believe there
are enough robust systems to catch and identify patients preoperatively around
pain and then to have timely and robust tools to have patients be consulted on
and intervened on after surgery who seem to be at risk and not following the
appropriate pathways that most of our surgical patients would seem to follow. I
mean, I think these are just in general, really challenging systems-based
problems. But that's where I think anesthesiologists have really succeeded, is
in many ways in building robust systems that have increased patient safety and
looking at pain as a component of patient safety. And, you know, when I look at
the national landscape, I see a lot of exciting work by a lot of our colleagues
who are looking at this space. I see some positive movement, but I think we're
in the early stages of what these systems are going to end up looking like in
ten, 20 years.
DR. STRIKER:
As you stated, we offer
such a breadth of expertise when it comes to the perioperative arena. And the
reason I ask about the surgical colleagues is obviously just because they're
the ones that see the patients first, they're the ones that bring the patients
to us and we see them in a short period of time before the actual operation, typically
in the acute setting. Yet, it sounds like there are plenty of opportunity for for us as perioperative experts to to
weigh in in some fashion, whatever the system is, a little bit ahead of time to
try to optimize the patient experience.
DR. AGGARWAL:
Yeah. And I think we've
sort of led and assisted our surgical colleagues in understanding the types of
patients who may need more evaluation for elective surgery around cardiac risk
factors, pulmonary risk factors, etcetera. I think we on an individual basis
can, within the places and systems that we practice, help educate our surgical
colleagues, perhaps around some of the risk factors that may result in more
pain or really prolonged opioid use after surgery to alert the surgeons, just
as you identified Dr. Striker, because they were the ones who are first
interacting with these patients in the perioperative period to think about like,
well, maybe this patient seems to have certain risk factors, perhaps we should
consult somebody, consult somebody in our anesthesia group who can maybe
connect with a pain specialist or an acute pain specialist and see, is there
something that we can do prior to surgery to get them ready for what is to
come? And I think some of those little things that we all do actually on a day
to day basis, as we make those relationships with our surgical colleagues, with
the types of cases that we do in our various practices, I think this is where
something that appears as simple as being like, well, what are the risk factors
or what do we understand to be the risk factors of prolonged opioid use can
become really quite important in those conversations as we make those
relationships and have those relationships with our surgical colleagues.
DR. STRIKER:
Yeah. And just another
further example of how the science of anesthesiology, no matter how much we try
to simplify it, or how much it appears to be simple, it continues to take on
complexities and continues to be a work necessitating further investigation and
study and a constant evolution of care giving. And why, you know, I still think
it's one of those arenas that does not seem like there's much more to learn and
yet always fascinated that when you look, there does appear to always be more
to learn and more to figure out and still tons of mystery.
DR. AGGARWAL:
Yeah. And I think, you
know, being on the ACE editorial board, that's been one of the joys is to
continue to explore as the science of our specialty evolves and as new issues
face our society. And and we as anesthesiologists
respond to those issues facing our society. Everything from, you know, I think
a lot about the opioid epidemic. But as our specialty responded to the COVID
pandemic, for me, when I write or write my ACE questions, I'm often thinking
about, well, where is the science today? What are the scientific principles
that we've known for a long time and how are they still relevant and evolving
to our practice as new issues, new technologies, new drugs come to our
specialty and affect how we're going to be able to deliver better, safer, more
equitable care.
DR. STRIKER:
Yeah, absolutely. Well,
along those lines. Before I let you go, let's talk just a tiny bit more about
the ACE process. And you already alluded to just now how you choose maybe the
topics you write on, but are there some specific thoughts with, when you
finalize a question or why you choose a specific kind of a question versus
another? What what other little nuggets can you offer
us as to what goes into your thought process when you finalize questions?
DR. AGGARWAL:
Dr. Striker When I'm
thinking about the ACE questions, I'm trying to balance relevance to most of,
you know, our community as practicing anesthesiologists and also balancing sort
of that edge of where is the science today and what's
changing. And one of the things that may be a little bit sort of mysterious is
like some of these questions may seem like like the
question about that, onne question that I wrote about
Oliceridine, is like, well, you know, I don't have it
in my practice or this is going to be this might be an
expensive drug. We're not going to see it. But to me, when I'm thinking about
the questions, it's not necessarily about that the specific procedure or the
specific drug itself, but it's really about like, what's the basic concept and
how is that basic concept changing around how do opioids work and what may be
in the talk, or when individuals are going to meetings, or they're getting
marketing materials from companies, what are they going to be seeing? And so when I'm picking and thinking about an ACE question, it's
about trying to help my colleagues keep up to date and process the large amount
of science and material that's coming into our specialty while making sure that
we continue to refresh for myself and also for my colleagues around the core
concepts that we use every single day in practice. And, you know, when we have
our meetings and all of the editors talk, part of what
we come to realize is our field is continuing to change every single month and
every single year. And all of us need to keep abreast of the latest
developments and the latest scientific advances. But at the same time, we can't
forget the very basics and the very foundations of our specialty. And so we try to balance the two when we write our questions for
for our colleagues as part of the ACE questions.
DR. STRIKER:
Well, Dr. Aggarwal, it's
been a fascinating discussion. And so I just want to
thank you for all your time.
DR. AGGARWAL:
Thank you so much, Dr.
Striker, for having me. It was my pleasure.
(SOUNDBITE OF MUSIC)
DR. STRIKER:
And this issue. Ace, 28,
publishes in early April, just like this podcast. And for listeners interested
in learning more, visit asahq.org/ace or A.C.E. for more information on this
topic and many other topics that this issue touches on.
To all our listeners,
thanks for tuning in to this episode of Central Line. Please tune in again next
time and take care.
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