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In this episode, we welcome special guest Ronald A. Zent, a family physician, to discuss the ongoing opioid crisis. With a fourfold increase in opioid prescriptions and overdose deaths from 1999-2010, Ronald shares his insights on how the medical community has been duped and the role of big pharmaceutical companies in influencing the prescription of dangerous and addictive medications.

Ronald also shares his views on pain management and encourages prescribers to think critically about their actions and consider the potential consequences for their patients. He encourages a more robust discussion on pain in general and emphasizes the importance of avoiding outpatient long-acting opioids and allowing fentanyl only in a hospital setting, if at all.

Join us for a thought-provoking discussion on the opioid crisis and the role of health care professionals in reducing the number of needless deaths from prescription overdoses.

Ronald A. Zent is a family physician.

He shares his story and discusses his KevinMD article, “How were we duped and what can we do about the opioid overdose crisis?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Ronald Zent. He’s a family physician. His KevinMD article is titled “How were we duped and what can we do about the opioid overdose crisis?” Ronald, welcome to the show.

Ronald A. Zent: Thank you so much, Kevin, for having me, and thank you for all that you do with your platform, allowing voices to be heard from other health care professionals, nurses, doctors, and everyone who is in the health care arena.

As for my background, I had a circuitous route to becoming a physician. I was going to be a minister at one time, and then I changed and ended up going to Mexico for medical school for a couple of years in Guadalajara. I transferred to the University of Oklahoma in Tulsa and then came out to California in, like, 1980 and ’81, and finished up at the Loma Linda family practice residency.

I’ve had lots of experience. I’ve had a wonderful, wonderful career. I’ve been an executive physician, a chief medical officer, and on all kinds of boards of directors. But I have to say, I’ve never had any burnout. I know a lot of your people who write in will talk about burnout and how we can solve all that. I’ve never had any of that, so I’ve just been very, very fortunate.

Today, I supervise PAs and nurse practitioners out of a clinic, and I also have a small concierge, or direct primary care, practice. I also volunteer teaching UC Irvine students and then the Cal Poly students who are osteopathic students, out of a free clinic one Saturday a month. I really, really enjoy that. I get to mentor and teach and just be involved, so it’s just real, real positive in every way.

I’ve been an independent contractor, I’ve been an employee, and I’ve been a partner. We had been bought out twice by surviving entities, where one of them was CVS Pharmacy and the other surviving entity was UnitedHealthcare. After UnitedHealthcare bought us out in 2014, I decided I didn’t want to participate and be part of that culture, for whatever reasons, and so I ended up doing some locums. I never really opened up another practice, but I did some locums and travel.

I had the opportunity to work with the Native Americans. I went down to the bottom of the Grand Canyon a couple of times for two weeks and just had a wonderful time, and I worked in Northern California. The reason I bring that up is that at the bottom of the Grand Canyon, at what’s called the Supai clinic, with the Havasupai Indians, they don’t allow any alcohol to be sold there, but there is so much alcoholism among the Arizona population that lives there. I was just struck by that. I didn’t see any real addictions to opioids.

But then I went to work in Hoopa, up in Northern California. It’s the second-largest reservation in California. The medical directors were Native Americans themselves, and they bought into all this with pain. They actually allow the sale of alcoholic beverages on the reservation, so you don’t see the alcoholics there or alcohol addiction, but you do see the drug addicts. It just breaks your heart to see that and to see everybody who was on methadone. Even the medical directors said, “How did this happen? How did we get badgered into thinking that pain was a sixth sign, a sixth vital sign?”

So I did this article just off the top of my head, almost, one evening. I looked at a couple of websites and read the November 2022 guidance from the CDC on opioids. Like I mentioned in the article, we’ve all been touched by this. It’s coming across just rampantly, whether it’s the border or coming through the ports of Long Beach, Los Angeles, and New York, but we’re seeing a flood of opioids. We all know that fentanyl is so much more powerful, naturally, than just your plain morphine.

And now I’m reading, just a few days ago, that they’re selling fentanyl and OxyContin over the counter in Mexico. That was the Los Angeles Times article just four or five days ago. So we all can acknowledge it. Even President Biden talked about this the other day. It’s a real, real problem, and so I just have a heart for it all.

Kevin Pho: As a family physician in your practice, just paint us a picture. Tell us about some of the impacts that the opioid crisis has made that you’ve seen personally in your family practice.

Ronald A. Zent: Well, in the old days, we were the pain management doctors. My personal experience was that if I prescribed these medications, it would be on a limited basis, and I would have that conversation with patients. Currently, with my very small practice, I do have a patient that I’ve given some Vicodin to, but when I say given some, I mean maybe 30 pills a year or so.

But the thing I see is other practices that have had these problems, and they referred to pain management more. In California, we have so many big, large groups that it’s so easy just to refer to pain management. Then, in my experience, they would just continue whatever their dose was. It’s not like they’re trying to modify it, in my experience, when I’ve talked to these anesthesiologists who run these practices. Yes, they give some epidurals, and yes, they do this for chronic pain, but they just kind of maintain and have contracts.

I’d like to see more of a robust, comprehensive approach. I saw one of your podcasts where one of your guests had chronic pain, and she read Norman Cousins’ book on laughter as the best medicine. I love them. So I’m not a physician who’s ever said that you don’t have any pain. I’m just a person who has said, “Can we modify this? Can we incorporate your family? Can we incorporate your support system to where we could modify this?” So that’s kind of been my experience.

Kevin Pho: You mentioned how some entities have classified pain as a vital sign, right? So pain is the fifth vital sign. Tell us what you think about that. Do you think that has played a role in today’s opioid crisis?

Ronald A. Zent: Yes, I do. I think it’s played a tremendous role. Again, I never really bought into that. I’ve had colleagues say, “You’ve got to write these drugs. You’ve got to write them.” I said, “No, I don’t think I have to. I’ll try this and try this, and if I do give somebody an opioid, it’s going to be for a very, very short term.”

Kevin Pho: Who was pressuring you? Who was telling you to write?

Ronald A. Zent: Well, I’ve had some urgent care physicians. This guy was on the medical board. He wasn’t officially on the medical board, but he was an advisor, and he went to the meetings and said, “Yeah, this is a vital sign. We have to do this.” But I never bought into it.

I’ve been around urgent cares. I’ve developed and built them, and we didn’t really have opioids. We didn’t use opiates. We certainly didn’t have any Demerol. We only gave the injectable anti-inflammatories. Occasionally, we’d write some Vicodin or Norco. I didn’t dictate what my physicians wrote, but they knew that when drug seekers came in, they had to be very, very careful. I’m all on board with how we nationally keep a record of this now, so any patients who get these controlled substances, we now track them much, much better than we ever could before.

But to answer the question of who told me, it wasn’t one individual. The Medical Board of California wanted you to have a CME talking about pain. I do recall that, so you had to take a pain course. Now, they didn’t say you had to write the opioids at all. But like I said in my article, how is it that we consume such a vast amount based on our population? Those are not my statistics. Those come from the CDC and other articles that I’ve read.

Kevin Pho: So you wrote in the article that Americans, at 4.4 percent of the world’s population, consume over 50 percent of narcotics. That’s the data that you cited in your article. So tell us about the new CDC recommendations. Just give us, in a nutshell, what exactly has changed.

Ronald A. Zent: Yeah, I can’t remember how many pages it was. I want to say about 15 or 20 pages or so. But basically, it said that it was misapplied, meaning that in certain circumstances, patients have suffered more pain based on the restrictions of not writing these drugs, so now it’s OK, in essence, to write them again. That’s what really got me just up in arms, so to speak. Why are they coming out and doing this? Well, they felt like people who were denied some of these narcotics were really being harmed.

Now, we all know that for any kind of cancer pain or any kind of surgical pain, those are written, and that wasn’t what was on the board. It’s more chronic pain. The CDC article said, “We don’t think we should be administering these long-acting opioids like OxyContin. We think we need to back up and use them for the short term, but it’s still OK to prescribe them.”

This issue hasn’t really affected me personally in my practice as much as I’ve seen it among colleagues and friends and that kind of thing.

Kevin Pho: So what have you seen among colleagues and friends?

Ronald A. Zent: Well, they thought it was kind of crazy that they’ve come out with this too. I shared it with our PA staff, and I’ve talked to some physicians, and they said, “Yeah, but it probably isn’t going to change my personal practice, how I practice.” But I’ve just seen that most of the doctors have really ratcheted back and have not been prescribing it.

Kevin Pho: One thing that you mentioned was the quality of life, right? And there’s a danger that the pendulum has swung so far the other way that we’re not appropriately treating patients in legitimate chronic pain. Are there any alternative, non-opioid approaches that you’ve seen that would be helpful in these cases?

Ronald A. Zent: Well, absolutely. Like I mentioned, stress is a big factor. Family situations can make pain worse or make it better. So you want to tie into some support system for yourself. Maybe it’s self-help groups, maybe it’s biofeedback. I know in California we now have CBD and THC available, and I’m not opposed to that for some people, if it works for them and they don’t have the side effects. There are some pitfalls to that, but hey, if it works, it works, and if it’s safe.

There are all of those kinds of things. There’s exercise and diet, without getting too controversial about all that, but there are things that people can do. There’s counseling. There’s cognitive behavioral therapy, which works pretty well for people. So physical therapy, occupational therapy, all of it is great.

What I really believe in is that if a person can access stuff themselves and then self-improve that way, versus having a whole army of people who are helping them, if they can actually have that insight to help themselves, that would be ideal. So I’ve always tried to promote more independence in my practice. It turns out that patients became more dependent while I’m promoting more independence.

Kevin Pho: How do you do that? How do you promote more independence among patients?

Ronald A. Zent: Well, I try to say, “I’m the messenger.” If I believe in vaccinations, then I’m going to recommend them. I don’t have to have a big discussion of why I think they’re valuable and helpful. “Here, go to this website. Here, this is a handout. This is what the science is saying, so look at that. You don’t need to have a discussion with me.” So you’re doing your own public health review. You’re trying to have habits and behaviors that keep you as healthy as you can, and not dependent on what I necessarily say or do.

Now, absolutely, there’s a value to having that human touch. I do believe in that. And I do believe that the family doctor, primary care, is the one that is your advocate. He’s your friend, he’s your support system too, to encourage good behavior for what works for that person, within the culture and the context they have, with the highest respect for all patients, wherever you’re coming from. I try to meet them where they are. You try to have that empathy and understanding of who they are, because we’re all the same, but we’re all different.

Kevin Pho: We’re talking to Ronald Zent. He’s a family physician. His KevinMD article is titled “How were we duped and what can we do about the opioid overdose crisis?” Ronald, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Ronald A. Zent: Well, I think people who are in the health care industry, and people who have contact with patients, have to meet them where they are. We can’t be so absolute in our approach and so dogmatic. You want to know where the patient is coming from. And yet your own personal life has to be such that you do have that empathy, and you strive for that understanding of where they’re coming from. So that’s what I would say.

And then be involved, in any way you can, with improving the system and improving the care that you’re giving your patients. You’re going to Disneyland. You’re turning off all the problems at home, you’re wearing a smile, and you’re going to do the best you can that day for the patients. If you’re not happy with where you are in your professional life, then make a change, or adjust.

Like I say, I’ve had a wonderful career. I’m still working, and I enjoy it. I love it. I don’t have to have any of those negative things. My kids work for me, and they said, “Dad, you always try to have fun. Have fun in your practice. Make sure it’s enjoyable.” So that would be a take-home.

Kevin Pho: Ronald, thank you so much for sharing your time and insight, and thanks again for being on the show.

Ronald A. Zent: Thank you, Kevin. Bye-bye.