Hi Reddit! I am Mark Bicket, a physician, researcher and expert in pain medicine at Johns Hopkins Medicine. My research focuses on treatments of acute and chronic pain, including prescription opioids. Ask me anything about how we treat pain!


Hi Reddit, my name is Mark Bicket, M.D., I'm director of the Pain Medicine Fellowship training program at Hopkins. My research focuses on treatments of acute and chronic pain, including prescription opioids for pain and how those medications are taken by patients and supplied by prescribers.

Recently, I led an investigation on what happens to opioids prescribed for pain after surgery in JAMA Surgery. Our team found that most opioid pills remained unused after patients recovered from their procedures, and most patients did not dispose of the unused pills. It’s important to improve pain relief while balancing the risks and problems from opioids, as many of us know someone affected by the opioid crisis.

I look forward to answering your questions at 1pm ET

I've seen some research that people who use cannabinoids for pain relief are less reliant on opioids. Do you think this could be a solution--or at least put a dent in--the opioid crisis? Is it easy enough to do research on cannabinoids for pain relief? Or are there too many restrictions in place?


The National Academy of Sciences report here shows evidence that medical cannabis does effectively treat chronic pain. But we don’t yet know what the adverse outcomes may be. That will require more research. The recreationally available varieties vary in the ratio of chemicals that are in them. It looks like most of the studies done use an oral cannabis extract - nabiximol. Findings from research don’t easily translate to recreational products because they typically deal in this one type. The issue is that there are restrictions on what we can use in research. Many federal universities are conservative with their research efforts because the DEA continues to list marajuana as a schedule 1 drug. There may be a risk of losing funding based on the project because of this.

Link: https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state

Are there ways in development to alleviate pain without such addictive medicine?

I lost my little sister to opiods. Would her previous gastric bypass possibly have exacerbated how much of the drug her body absorbed with a thinner stomach lining? (They ended up putting her on a long term regiment for back pain. When she died they said it was "just under what should've killed her")

Any thoughts on medical cannabis for pain alleviation? thank you for your time Mark whether i hear back or not.


I’m so sorry to hear about your sister passing. Developing drugs to allieviate pain without addicition is one of the million dollar questions right now & there are a great number of people looking into this. The National Institutes of Health recently held a series of meetings to address important questions in this effort and I think the summary of the June meeting addresses your question. For most people on long-term opioid meds, there are likely non-opioid medications that will reduce the amount of opioids they would need to control their pain.

The way we manage pain is a really personalized process & there are different methods we can use, drug & non-drug, but that is a conversation that each patient needs to have with their physician to find what works best for them.

Link to the series here: https://www.nih.gov/opioid-crisis

I have chronic eczema on my hands. The pain can be excruciating at times. What can I do to mitigate the pain? At times I want to sever my hands. It's that bad.


I am so sorry to hear this. My best advice is to contact your doctor or make an appointment with a board-certified pain management expert. I will preface this by saying I am not an expert in eczema, but there are two principles we try to address generally with our patients: managing the pain itself and mitigating the disease process if possible. Your best bet is to get on a good management program for your eczema to control the disease. For you or other people with a condition that is causing pain, modifying the course of that disease process is the best next step to pursue. Explore the different therapies for treatment with your doctor. That could range from medication to lifestyle changes. Work with your doctor to identify specific triggers & how to avoid them.

If you are interested in making an appointment with a Johns Hopkins exert, you can contact our department of dermatology: http://www.hopkinsmedicine.org/dermatology

My mother has MS and is starting to develope chronic pains in areas of her body. With the crackdown on the abuse of opiods going on, She has trouble getting a basic amounts of pain medication to keep her at a comfortable level. Do you think we will have a better way to determine whether a person is truly in need versus being addicted?


Opioid prescriptions are historically high compared to where we have been in the past. But, the story of your mother is not uncommon. Prescribers are becoming more aware of the opioid epidemic and are exploring other therapies for pain management.

A far as determining a patient’s need for a prescription, we are making some promising developments with FMRI measurements & determining the neural signature of pain. They’re not quite ready for prime time, but are in the pipeline. Your mother may want to seek help from a board-certified pain specialist to help determine the appropriate level of pain medication.

Hi Mark, good to have you. I don't know an awful lot about pain medication, though I do suffer from some low-level chronic back pain, so perhaps I should learn more!

Two questions if I may:

1) My understanding is that opioids are considered the gold standard for pain relief - is there anything being looked into as a similar standard with a lower addiction potential?

2) How do you see the future of treating the psychological component of pain?


For your first question, among the many types of receptors our spinal cord has, opioid receptors that play the most important role in our pain pathways. But we also need to recognize that other important receptors do make a difference in how we experience pain. Examples of those include norepinephrine & serotonin. Because opioid medications address the opioid receptors directly, they are the gold standard for acute pain relief.

The NIH has an initiative addressing the development of less addictive pain drugs & held their first series of meetings this summer: https://www.nih.gov/opioid-crisis

For your second question, in general non-pharmacologic measures to treat pain have been underappreciated & resources such as cognitive behavioral therapies should be explored. Psychologists play an important role in the multidisciplinary treatment of pain.

What are your thoughts on the treatment of pain holistically? Ex: Turmeric for inflammatory pain


There are a number of treatments out there that many people use that have not been evaluated via high-quality trials (by western standards). Generally, the goal is to shift from opioids to other therapies, we just don’t yet have enough data with them to predict their side effects or unintended consequences. The best advice I can give is to talk to your physician as you think about pursuing holistic therapies.

I’d like to recognize that nonpharmacologic methods of dealing with pain, like cognitive behavioral therapy, have been undervalued in our medical system. I think those are another valuable way that should be emphasized outside of drugs to deal with chronic pain.

I broke my leg a few months ago and after the surgery I was given a prescription for some morphine pills to be taken as needed. They really didn't do much or anything. This reminded me that when ever I've been given prescriotion pain killers, usually big pink and white tablets, they never realy did much. And i always ended up trowing away most of the prescriptions.

I'm not a drug user (illicite) so it would be odd that I wouild have built up a tolerance.

Are there drugs thst just don't work in some people or do I just have a high treshold . Maybe they were just placeboes.


Your pain thresholds may be different, because there is data suggesting that in normal individuals there is an extremely wide range of what people consider painful. What’s painful for one person may not be painful for you. Another possible explanation may be genetic differences that cause you to metabolize the drugs differently. It’s more commonly seen in opioids like codeine and tramadol.

I’m doubting that if you got a prescription for morphine in the U.S. that someone switched it out for a placebo.

Opioids have been around for a long time...what changed recently that made addiction such a problem on a public health level?


We began to recognize the undertreatment of pain starting in the 90’s, both chronic pain and acute pain like what you’d have after surgery. At the same time, pharmaceutical companies were marketing meds directly to consumers & physicians.

There were many well-intended prescribers operating in a healthcare system with time constraints and were unable to spend a lot of time with their patients - and providing a prescription to a patient is easier than talking to them about lifestyle modification or educating them on how to best address their disease.

As someone who prescribes an opioid medication, one of our goals is to not have a patient needlessly suffer, but it is extremely difficult to predict a patient's pain management needs.

The balance between providing treatment for pain relief and evaluating the patient holistically is tough thing to manage. It’s something that needs far more research, education and discussion among health care providers and patients

There are a good national academies report - the national pain strategy - that outlines some of these challenges here: http://nationalacademies.org/hmd/Reports/2017/pain-management-and-the-opioid-epidemic.aspx

Hey Mark, what's your favorite thing about Baltimore?


I really enjoy the trails. I like the NCR trail down by the water & visiting the farmer’s markets there. In reality, I probably enjoy the crabs the most.

There is a neuropsychiatrist in Deerfield Illinois who has a patent on a treatment that combines ketamine infusions as well as transcranial magnetic stimulation. In addition to its use in the treatment of mental disorders, he also uses it for the treatment of chronic pain with very effective results. My question is this: what is your idea on the future relationship of managing pain between opiate drugs and treatment based therapy?


I think we all are working toward a future where we still maintain some access to opioids to help treat pain, but instead of prescribing them as we are now, as first or second line, they would be more appropriately used as 4th or 5th line of treatment for pain management. Non-opioid drugs & non-drug therapies, such as ketamine & TMS, as mentioned here will move to the forefront as the first few lines of treatment for these conditions.

Hopkins saved my life! During the course of my cancer care at Hopkins, I underwent chemo, full body radiation, and a half matched bone marrow transplant. I was given plenty of opioids but I took them as little as possible to avoid issues.

I have chronic pain issues in my foot due to what is likely neuropathy caused by injections of vincristine. I was prescribed gabapentin, but it seems to be less effective with each day. Are there any alternatives for real relief, preferably something that doesn't involve more pills? I still have morphine and tramadol, but I would rather not take them.


I'm so glad you were happy with your treatment here!

One of my colleagues Tom Smith does some work with scrambler therapy that has been shown to help people with chronic pain - particularly with chemotherapy-induced peripheral neuropathy: http://www.hopkinsmedicine.org/profiles/results/directory/profile/8283165/thomas-smith

Apart from that I know you don’t want more pills but, the first line therapy is typically duloxetine. I’d recommend you speak with your physician or a board-certified pain management expert about your treatment options.

What is your opinion on neuromodulation?


For those who aren’t familiar, neuromodulation involves creating an electrical field around your neurons to help alleviate pain - one example is spinal cord stimulation, which is administered via a device that is implanted in the body with a lead that lies in the epidural space.

It’s a pretty well-tested treatment for complex regional pain syndrome and there have been a lot of new promising developments in the technology used that are undergoing testing for people with chronic pain - like pain after back surgery.

What's the big deal with allowing people to keep their leftover pills?

Quite frankly, if I want to take a drug, I should be allowed to take it.

I don't have addiction issues, I can take a muscle relaxer or opioid once in awhile without losing control.

It seems like a lot of the good medicine can do in our everyday lives is getting limited by the people with addiction problems.


More than half of people who misuse opioids obtain them as leftover pills from friends and family members. 36 percent get them from physicians prescriptions. These two groups account for 90 percent of opioids being abused. Certainly opioids have a role when prescribed in the setting of a legitimate doctor-patient relationship. In the case of opioids today, we truly are facing a nationwide epidemic that surpasses harm from other commonly-recognized epidemics in the past (HIV, motor vehicle accidents, etc.) and prescription opioids play a role.

We need to put forward efforts to safely store of opioid medications so they don’t end up in the hands of child that could ingest them accidentally or taken by others for non-prescription use. Disposing of medications, like pill take-back programs at a pharmacy or other FDA disposal recommendations when therapy is concluded also plays a role in helping to stem the epidemic.

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