Opioid Overreaction (1 Viewer)

[Tau837]

Task Force: Canada's Chronic Pain Patients ‘Simply Deserve Better’

“Some Canadians have been unable to access opioid medications when needed for pain and function. Others have faced undue barriers to obtaining or filling their opioid prescriptions, and some have had their opioid dose abruptly lowered or discontinued. This has resulted in unnecessary pain and suffering, and has led some Canadians to obtain illegal drugs to treat their pain,” the task force found.

“People living with pain have limited access to the services they require and often face stigma and undue suffering as a result of their condition. This stigma often intersects with other forms of discrimination related to poverty, housing and employment instability, mental illness, race and ethnicity, and other factors further complicating the challenge of living with pain. Canadians living with pain and their loved ones simply deserve better.” ...

Last month, a federal task force in the U.S. released a final report on recommended best practices for pain management. It found nearly identical problems as the panel in Canada — and called for a balanced approach to pain treatment that focuses on individualized patient care, not rigid prescribing guidelines that have triggered a pain crisis for millions of Americans.

 

[Tau837]

Let’s Reset the Discussion on Pain Management and Opioid Misuse

The headline is not mine. It is from a tweet this week from U.S. Surgeon General Dr. Jerome Adams who is the 20th Surgeon General of the United States.

“First we must acknowledge that we have a crisis of ‘untreated’ and undertreated pain in the U.S. and it can lead to suicide, self-medication with illicits and other bad outcomes.”

 

[The Big Guy]

Let’s Reset the Discussion on Pain Management and Opioid Misuse

Taking people that are addicted to legit pain meds and have become addicted will just lead them to search out unsafe illegal drugs to replace them. 

We need a better answer somehow.

 

[Tau837]

An Open Letter to the Virginia Board of Medicine

The following is a letter sent to William L. Harp, MD, Executive Director ,Virginia Board of Medicine

CC:   Patrice Harris, MD, President, AMA,   Barbara L McAneny, MD, Past President, AMA, Andrea Trescot, MD, Past President, American Society of Interventional Pain Physicians,  Chad Kollas, MD, Vanilla Singh, MD, formerly Chair of the HHS Pain Management Task Force, Sean Mackey, MD, Stanford University, Lynn Webster, MD, Past President, American Academy for Pain Medicine, Seema Verma, Administrator, HHS/ Centers for Medicare and Medicaid Services, Nora Volkow, MD, Director, National Institutes on Drug Abuse, Staff of the American Academy of Family Practitioners

 BCC:  

           ~400 medical professionals, journalists, and knowledgeable patient advocates networked in the Alliance for the Treatment of Intractable Pain

Dear Dr Harp

Thanks for the courtesy of a response to my [earlier] correspondence. As you suggest, I have reviewed the Board Briefs linked from your letter. In that document, I find the following, to which I wish to respond substantively and immediately to the Board:

TO TAPER, OR NOT TO TAPER?

A number of pain management patients have contacted the Board of Medicine to ask what can be done about their practitioner reducing their dose of opioid analgesic. Usually the story is that the patient has been on a stable dose for months or years, experienced adequate pain control, was able to function, and demonstrated no signs of abuse. The practitioner tells the patient that the dose must be decreased to meet certain guidelines from regulatory agencies. The patient has little choice but to accept the reduction. Invariably, a rapid reduction leads to a significant increase in pain. Despite appeals to the practitioner, the opioids stay at the reduced level and may be further reduced. Patients sometimes believe the Board of Medicine has established draconian regulations for pain management that are hurting patients in Virginia. If they are not familiar with the Board’s regulations, they contact the Board.

Board staff’s first response to such inquiries from patients is to let them know that the regulations are reasonable and provide practitioners great latitude in treatment. The regulations do not have ceiling doses for opioids and do not require reductions to levels that are ineffective for the patient’s pain. The second response is to encourage the patient to have an informed discussion with the practitioner. Board staff has been at medical meetings where a significant percentage of practitioners indicate they have not read the opioid regulations, despite them having appeared in the Board Briefs five times since March of 2017. To aid the discussion with the practitioner, Board staff will send the regulations to the patient. Then they are able to carry the regulations to the next visit and discuss their treatment plan with the practitioner. This may be well-received by the practitioner, or it may not.

If not, the decision, by the patient or mutually, may be that a new practitioner is needed. The Board’s response to questions about finding follow-up practitioners is to teach patients how to use the Advanced Search option on the Doctors’ Profile System to search for pain management practitioners in their area.

BOTTOM LINE

If the clinical decision is to reduce the amount of opioid, the tapering should be done safely and competently. The Board recommends the Stanford Course on tapering by Anna Lembke, MD; it is an excellent guideline for tapering opioids safely with as little discomfort and risk to the patient as possible

==============End Extract =============

Please transmit the following to every member of your Board, and be aware that it will shortly be released and promoted widely in Social Media:

(1) If based upon or referenced to the 2016 CDC guidelines on opioid prescribing, then Virginia regulations cannot possibly be "reasonable." It is now widely understood by both patients and medical professionals, that the CDC consultants group cherry-picked medical research, specifically to find reasons to restrict therapy employing opioid analgesics. This was substantially a political not medical agenda. There were no Board Certified physicians in the consultant writers group who had ever managed patients in community practice. Proceedings were instead dominated by addiction treatment specialists, influenced improperly by Physicians for Reasonable Opioid Prescription (PROP), led by Dr Andrew Kolodny and Dr Jayne Ballantyne.

See (among many other papers) https://medium.com/@stmartin/neat-plausible-and-generally-wrong-a-response-to-the-cdc-recommendations-for-chronic-opioid-use-5c9d9d319f71#.wzchd1kkl

Neat, Plausible, and Generally Wrong: A Response to the CDC Recommendations for Chronic Opioid Use - Medium

(2) The resulting CDC document made strong recommendations on the basis of vague, weak, or unsupported evidence and biased opinion; it conflated a general lack of long-term trials with a lack of effectiveness for opioid analgesics. It was silent on the effects of genetic polymorphism in the inherently wide range of minimum effective opioid dose levels.  Moreover, several practitioners who contributed to writing or peer review have since publicly repudiated the results.

https://academic.oup.com/painmedicine/article/19/4/793/3583229

(3) The AMA (in Resolution 235 of its November 2018 House of Delegates meeting, and again in Board of Directors Report 22, June 2019 ), the American Academy of Family Practitioners, and other professional organizations representing over half of US practitioners have repudiated the dose thresholds proposed by the CDC guidelines as a basis for risk and benefit review (NOT as mandatory guidance on maximum dose, as acknowledged by public CDC "clarifications" in April 2019).

https://www.painnewsnetwork.org/stories/2018/11/14/ama-calls-for-misapplication-of-cdc-opioid-guideline-to-end

(4) As noted in my original correspondence, it is now well established that rates of opioid prescribing by physicians are completely unrelated to rates of either substance abuse disorder or overdose-related mortality. "Over-prescribing" as a presumed source of our so-called "opioid crisis" is nothing more than an unsupported mythology. The evidence for this insight is reviewed here:

http://www.lynnwebstermd.com/over-prescribing/

Over-Prescribing Did Not Cause America’s Opioid Crisis

and here

https://www.statnews.com/2019/06/28/stop-persecuting-doctors-legitimately-prescribing-opioids-chronic-pain/

Stop persecuting docs for legitimately prescribing opioids for chronic pain

We also know that the primary influences which have led to forced tapering of otherwise stable patients have little to do with actual medical evidence of benefit. There are no published data demonstrating such benefit and many reports of active harms including medical collapse and suicide. What is instead going on is that Federal and State drug enforcement authorities are conducting a campaign of provider intimidation and unjustified malicious prosecution intended to coerce the medical profession. It is time somebody in your profession developed a backbone and said "no" very loudly and publicly to such misdirection.

When a State Medical Board responds to patients in the manner quoted above, you make yourselves accessories to patient abuse and desertion which comprise a fundamental violation of human rights. It is apparent that the Board has forgotten the fundamental dictum under which all physicians must practice: "First do no harm." If you can't do better than this, then it is time you resigned en mass and went looking for a more honest line of work.

If you care to read any of the referenced sources, the links are in the open letter, linked at the top of my post.

I am a member of the Alliance for the Treatment of Intractable Pain copied on this email that was then posted as an open letter on LinkedIn. I also live in Virginia, so this particularly hits home to me and my wife, who is disabled and takes prescribed opioids to manage her pain.

My wife's neurologist, who treats her pain, has had several complaints filed against his practice by the Virginia Board of Medicine for prescribing opioids at levels greater than 500 Morphine Milligram Equivalents (MME) per day. In each instance, Virginia BOM investigators came to his practice and reviewed records on those patients. They found that his treatment was reasonable enough that he was not penalized in any way, yet they directed him to lower each of those patients to no more than 500 MME/day. He did so in order to preserve his license and practice. At this point, he has just 2 patients above 500 MME/day - 1 cancer patient and my wife.

The quoted extract is at least partly BS - the part where it says Virginia regulations "...do not have ceiling doses for opioids and do not require reductions to levels that are ineffective for the patient’s pain..." Perhaps they are making a semantics argument, saying it is not in written regulations while knowing full well that they scrutinize doctors prescribing above 500 MME and force them to cut to that level. But to do that would be a level of deceit that would be shocking to me.

We live in daily fear that the Virginia BOM will file a complaint about my wife's treatment. She is over 1200 MME/day and has been for at least a decade. If he is forced to reduce her to 500 MME/day, I expect she will take her own life. We have discussed it many times. As I see it, it would amount to the Virginia BOM taking my wife's life. 

 

[Terminalxylem]

An Open Letter to the Virginia Board of Medicine

If you care to read any of the referenced sources, the links are in the open letter, linked at the top of my post.

I am a member of the Alliance for the Treatment of Intractable Pain copied on this email that was then posted as an open letter on LinkedIn. I also live in Virginia, so this particularly hits home to me and my wife, who is disabled and takes prescribed opioids to manage her pain.

My wife's neurologist, who treats her pain, has had several complaints filed against his practice by the Virginia Board of Medicine for prescribing opioids at levels greater than 500 Morphine Milligram Equivalents (MME) per day. In each instance, Virginia BOM investigators came to his practice and reviewed records on those patients. They found that his treatment was reasonable enough that he was not penalized in any way, yet they directed him to lower each of those patients to no more than 500 MME/day. He did so in order to preserve his license and practice. At this point, he has just 2 patients above 500 MME/day - 1 cancer patient and my wife.

The quoted extract is at least partly BS - the part where it says Virginia regulations "...do not have ceiling doses for opioids and do not require reductions to levels that are ineffective for the patient’s pain..." Perhaps they are making a semantics argument, saying it is not in written regulations while knowing full well that they scrutinize doctors prescribing above 500 MME and force them to cut to that level. But to do that would be a level of deceit that would be shocking to me.

We live in daily fear that the Virginia BOM will file a complaint about my wife's treatment. She is over 1200 MME/day and has been for at least a decade. If he is forced to reduce her to 500 MME/day, I expect she will take her own life. We have discussed it many times. As I see it, it would amount to the Virginia BOM taking my wife's life. 

That is the highest MME/day that I have ever seen. I can understand your passion for the topic, but realize ultra-high dose opioid users are a very small percentage of the chronic pain pie, and few non-pain specialists would feel comfortable prescribing doses in that range. I suspect your wife is in the upper 1% of patients requiring pain meds, a number far less than the percentage of opioid prescriptions that are abused/misused, even considering more restrictive policies. I'm not sure there is a good way to avoid inconveniencing patients like her to prevent many others from using opioids inappropriately. But just as abrupt tapering and grossly undertreating pain patients is wrong,  declaring our current policies far too restrictive isn't the answer either.

 

[AAABatteries]

But I'll ask again, what's the difference between this and Advil?  

I’m not jumping in to the opioid conversation as I know virtually nothing about them - but as a quick tangent, Advil is also something I avoid as there are studies showing it’s bad for the kidneys.

I consider myself fortunate that I don’t have any real pain and definitely not chronic pain.  In general, I try to limit my meds to none and if I have a little hip or back pain I just deal with it in other ways.  I know many folks don’t have that option and it sucks - being in pain is the worst.

ETA - I should point out that I avoid them now - use to take them often as I was unaware of the possible issues

 

[Gawain]

That is the highest MME/day that I have ever seen. I can understand your passion for the topic, but realize ultra-high dose opioid users are a very small percentage of the chronic pain pie, and few non-pain specialists would feel comfortable prescribing doses in that range. I suspect your wife is in the upper 1% of patients requiring pain meds, a number far less than the percentage of opioid prescriptions that are abused/misused, even considering more restrictive policies. I'm not sure there is a good way to avoid inconveniencing patients like her to prevent many others from using opioids inappropriately. But just as abrupt tapering and grossly undertreating pain patients is wrong,  declaring our current policies far too restrictive isn't the answer either.

Our justice system is predicated on the notion that it's better for 100 guilty people to go free than to jail one innocent person.

Seems like you don't think the same standard should apply to people facing an even worse outcome than prison. Better for one person to suffer terrible pain than to trust others, eh?

 

[AAABatteries]

Seems like someone made a comment earlier in the thread about pain evaluation. Is anyone working on a device that would be able to actually rate a persons level of pain?

Hypothetically, if someone could convince you it works or works some large percentage of time, would you be willing to allow it to make the call on whether drugs are needed?  

I always think of that stupid chart with the faces on it to gauge your pain.  Seems like maybe there’s something they could come up with to measure kind of like they do on Law and Order SVU when they show the perverts brain lighting up when he’s looking as bad stuff.

 

[Terminalxylem]

Our justice system is predicated on the notion that it's better for 100 guilty people to go free than to jail one innocent person.

Seems like you don't think the same standard should apply to people facing an even worse outcome than prison. Better for one person to suffer terrible pain than to trust others, eh?

I’m saying there has be be a happy medium where we treat chronic pain appropriately while minimizing opioid abuse. 

Considering there is no objective way to evaluate pain, and prescription opioids are harming a heck of a lot of people, your legal comparison does not apply. The idea is to balance the risks vs. benefits of using the drugs, which is still out of whack IMO.

 

[Terminalxylem]

Seems like someone made a comment earlier in the thread about pain evaluation. Is anyone working on a device that would be able to actually rate a persons level of pain?

Hypothetically, if someone could convince you it works or works some large percentage of time, would you be willing to allow it to make the call on whether drugs are needed?  

I always think of that stupid chart with the faces on it to gauge your pain.  Seems like maybe there’s something they could come up with to measure kind of like they do on Law and Order SVU when they show the perverts brain lighting up when he’s looking as bad stuff.

That person was me. JustWinBaby quickly poo-pooed it, correctly pointing out the multifaceted nature of pain. But I believe some combination of vital signs and markers of inflammation/pain pathways could help identify most patients with legitimate pain. Coupled with a better understanding of addiction, we could probably cut down on a lot of unnecessary prescriptions.

Anyone who works in healthcare can attest how poor the current numeric/visual analog scales are; we can definitely do better. Functional MRIs may help understand how pain is processed, but are impractical for use with every patient.  And there are devices called dolorimeters which try to quantify discomfort, but I don’t think they are useful for all types of pain.

 

[Terminalxylem]

I’m not jumping in to the opioid conversation as I know virtually nothing about them - but as a quick tangent, Advil is also something I avoid as there are studies showing it’s bad for the kidneys.

I consider myself fortunate that I don’t have any real pain and definitely not chronic pain.  In general, I try to limit my meds to none and if I have a little hip or back pain I just deal with it in other ways.  I know many folks don’t have that option and it sucks - being in pain is the worst.

ETA - I should point out that I avoid them now - use to take them often as I was unaware of the possible issues

If you have no preexisting kidney disease and use them acutely at the recommended dosage, medicines like Advil (NSAIDS) are unlikely to harm you. Older people and those with risk for kidney disease (ex. diabetics) or gastrointestinal bleeding should probably avoid them in favor of Tylenol.

 

[wikkidpissah]

I’m not jumping in to the opioid conversation as I know virtually nothing about them - but as a quick tangent, Advil is also something I avoid as there are studies showing it’s bad for the kidneys.

I consider myself fortunate that I don’t have any real pain and definitely not chronic pain.  In general, I try to limit my meds to none and if I have a little hip or back pain I just deal with it in other ways.  I know many folks don’t have that option and it sucks - being in pain is the worst.

ETA - I should point out that I avoid them now - use to take them often as I was unaware of the possible issues

i've eaten 3000mg of ibuprofen a day for chronic arthritic pain for fifteen years without an ounce of kidney trouble (the docs are more amazed my stomach hasnt sploded) so the range is pretty wide there. standard blood panels can monitor damage closely enough on whether its right for each individual that it shouldnt be a concern. and there are prescription NSAIDs out there that offer even greater help with a lot of everyday pain

 

[Tau837]

That is the highest MME/day that I have ever seen. I can understand your passion for the topic, but realize ultra-high dose opioid users are a very small percentage of the chronic pain pie, and few non-pain specialists would feel comfortable prescribing doses in that range. I suspect your wife is in the upper 1% of patients requiring pain med

I am well aware of all of this.

I'm not sure there is a good way to avoid inconveniencing patients like her to prevent many others from using opioids inappropriately

I posted that she would likely end her life if force tapered to 500 MME/day. You call that inconvenience?  

You want to rephrase that?

But just as abrupt tapering and grossly undertreating pain patients is wrong,  declaring our current policies far too restrictive isn't the answer either.

I completely disagree with the bolded. There is a wealth of information available, much of it posted/referenced in this thread, that shows that the current policies are having zero/minimal effect on opioid overdose deaths while doing significant harm (suffering, deaths) to the pain patient population.

 

[Terminalxylem]

i've eaten 3000mg of ibuprofen a day for chronic arthritic pain for fifteen years without an ounce of kidney trouble (the docs are more amazed my stomach hasnt sploded) so the range is pretty wide there. standard blood panels can monitor damage closely enough on whether its right for each individual that it shouldnt be a concern. and there are prescription NSAIDs out there that offer even greater help with a lot of everyday pain

That’s a lot, above what is typically recommended. In addition to bleeding and kidney injury, your heart and liver (rarely) can be dinged by NSAIDS. If you require such high doses chronically, you may want to consider one of the newer prescription NSAIDS, which may be less toxic.

 

[Terminalxylem]

I am well aware of all of this.

I posted that she would likely end her life if force tapered to 500 MME/day. You call that inconvenience?  

You want to rephrase that?

I completely disagree with the bolded. There is a wealth of information available, much of it posted/referenced in this thread, that shows that the current policies are having zero/minimal effect on opioid overdose deaths while doing significant harm (suffering, deaths) to the pain patient population.

You are too emotionally invested in this topic to remain objective. Nobody wants your wife to commit suicide, but more frequent, shorter prescriptions and more intense monitoring, along with added inconvenience and healthcare costs are likely the price your wife will pay for such high MME. And I’ve pointing out the problems with much of your reasoning already, including an expected lag in policy change and reduction in opioid abuse, problems defining the the extent of harm caused by opioid abuse (it ain’t just OUD) and the anecdotal nature of most of you info + poor data on opioid benefits in chronic non-cancer pain.

 

[wikkidpissah]

That’s a lot, above what is typically recommended. In addition to bleeding and kidney injury, your heart and liver (rarely) can be dinged by NSAIDS. If you require such high doses chronically, you may want to consider one of the newer prescription NSAIDS, which may be less toxic.

they tried me on 3 or 4 of em, but they didnt touch me, which made me wonder if there wasnt a large placebo effect in the ib, but my neuropathy (from stenosis, most of my adult life) wakes me up without it, so idk. gabapentin lifted that beautifully but gave me such terrible dreams i almost cracked. so i'm back w ib, tho mostly just night doses now and crunch along w the arthritis during the day

 

[culdeus]

This needs to go to the politics board at this point.  @Joe Bryant

 

[Gawain]

I’m saying there has be be a happy medium where we treat chronic pain appropriately while minimizing opioid abuse. 

Considering there is no objective way to evaluate pain, and prescription opioids are harming a heck of a lot of people, your legal comparison does not apply. The idea is to balance the risks vs. benefits of using the drugs, which is still out of whack IMO.

I don't think you can dismiss the analogy that quickly.

You want to cause harm to people in the interest of the public welfare, just like the same arguments that are used for stop and frisk or racial profiling. For you, the ends justify the means. I side more with personal responsibility. We shouldn't treat anyone that wants pain relief as a drug addict.

There's a level of guilt that's needed to convict someone. Perhaps the same level could be used before condemning a person to a fate worse than prison. Your statement that there's no objective way to evaluate pain is flawed, or else we'd never know when an infant is in pain. There's also been great work into digital markers for pain.

There are also several objective ways to measure if someone's just hunting for pills. The onus should be on the prescriber to eliminate prescriptions from those who are seeking the high, not play gatekeeper for those who need legitimate pain relief, just like the justice system has to prove guilt and not force the accused to prove innocence.

 

[rockaction]

Weird, and I'm chiming in, but considering that the "opioid crisis" is usually preceded by the words "public health," a macro view of things seems to logically flow thenceforth. Perhaps if we thought a little more about the goals and aims of "public health" we'd have a better footing upon which to agree.  

 

[Tau837]

You are too emotionally invested in this topic to remain objective.

I am emotionally invested but well informed on the subject. I don't think I am any less objective than you are, for example.

Nobody wants your wife to commit suicide, but more frequent, shorter prescriptions and more intense monitoring, along with added inconvenience and healthcare costs are likely the price your wife will pay for such high MME.

You missed the point of the post you responded to. Thus far, there has been no option for any patient flagged in the practice to go to more frequent, shorter prescriptions and more intense monitoring. There has only been forced tapering. So your response is not on point.

Furthermore, I flatly reject that stuff for pain patients like my wife anyway. There is no medical basis for it. She has been on high dose opioids for pain for 21 years, and has been on generally the same level of dosage she is at now for at least 7 years. None of her meds have been diverted. She has not overdosed. She has not sought or used illegal drugs. She doesn't even drink. There have literally been no negative issues. 

And to subject a patient like her to more frequent, shorter prescriptions means what? She already gets prescriptions every 28 or 30 days. She already sees her pain physician every 3 weeks or so. What would more frequent mean? His practice could not sustain more frequent visits from all of his high dose pain patients. There is no room in the schedule. It is also extremely difficult for patients with serious pain to get to appointments; making them more frequent inevitably means appointments will be missed sooner or later, and then what?

And to subject her to "more intense monitoring" means what? More intense than seeing her in person every 3 weeks? More intense than supporting a urine test whenever asked? More intense than supporting a blood test whenever asked? Seriously, what are you envisioning here? What you are advocating doesn't make sense. At least not for stable patients exhibiting no negative behavior or side effects.

You are basically just advocating that we sacrifice the lives, or at least the quality of the lives, of patients in serious pain. For what gain? Opioid prescribing is already at a 15 year low, yet opioid overdose deaths are at a 10 year high. You're not taking in the information provided with any objectivity, the exact thing you accused me of above.

including an expected lag in policy change and reduction in opioid abuse

Opioid prescriptions have been reduced year over year for 7 years now. How much of a lag do you think is necessary to see improvement?

How do you explain the fact that overdose deaths are highest in young people, despite the fact that the highest rates of opioid prescribing are for older people? I can tell you how to explain it - overdose deaths are not caused by opioid prescribing.

problems defining the the extent of harm caused by opioid abuse (it ain’t just OUD)

So let's make policy to attack problems we have trouble defining? Say that out loud and tell me it makes sense.

the anecdotal nature of most of you info

I have linked more than 30 references in this thread. None of them were anecdotal. The fact that you would post this shows that you either lack reading comprehension or objectivity or both.

 

[Tau837]

In case anyone wants to understand better about the impact of "inconvenience" on people with chronic illness, I highly recommend the Spoon Theory.

 

[Terminalxylem]

This needs to go to the politics board at this point.  @Joe Bryant

What is political about this discussion?

 

[Tau837]

they tried me on 3 or 4 of em, but they didnt touch me, which made me wonder if there wasnt a large placebo effect in the ib, but my neuropathy (from stenosis, most of my adult life) wakes me up without it, so idk. gabapentin lifted that beautifully but gave me such terrible dreams i almost cracked. so i'm back w ib, tho mostly just night doses now and crunch along w the arthritis during the day

There is a spectrum of metabolizing of certain medications, from poor to ultra-rapid. Patients who fall in different places on that spectrum can have markedly altered response to some drugs. Depending on your genetic profile, you may process some medications too quickly, or others, too slowly, which can both cause complications. This is also affected by ethnicity.

From The Effect of Cytochrome P450 Metabolism on Drug Response, Interactions, and Adverse Effects:

Cytochrome P450 enzymes are essential for the metabolism of many medications. Although this class has more than 50 enzymes, six of them metabolize 90 percent of drugs... Genetic variability (polymorphism) in these enzymes may influence a patient's response to commonly prescribed drug classes...

Maybe you are an ultra-metabolizer, GB. Testing has shown that my wife is, which is a significant reason she is on such high dosage pain medication. This issue is also a significant reason why one size fits all policy is not appropriate.

 

[Terminalxylem]

I don't think you can dismiss the analogy that quickly.

You want to cause harm to people in the interest of the public welfare, just like the same arguments that are used for stop and frisk or racial profiling. For you, the ends justify the means. I side more with personal responsibility. We shouldn't treat anyone that wants pain relief as a drug addict.

There's a level of guilt that's needed to convict someone. Perhaps the same level could be used before condemning a person to a fate worse than prison. Your statement that there's no objective way to evaluate pain is flawed, or else we'd never know when an infant is in pain. There's also been great work into digital markers for pain.

There are also several objective ways to measure if someone's just hunting for pills. The onus should be on the prescriber to eliminate prescriptions from those who are seeking the high, not play gatekeeper for those who need legitimate pain relief, just like the justice system has to prove guilt and not force the accused to prove innocence.

Holy carp. Nobody is advocating treating patients in pain as addicts, nor promoting harm. I'm just stating a difference of opinion regarding how restrictive opioid prescriptions have become. I agree that some providers are going overboard in limiting access to meds, but many, many patients are still being prescribed opioids inappropriately. We still haven't found the appropriate balance.

And spare me the nonsense about objectively measuring pain. It's guesswork with infants, just as it is with adults. That digital stuff may eventually be useful, but at this point, it's just a concept which hasn't been clinically validated.

The onus has always been on prescribers, and tools like prescription drug monitoring programs are helping to identify potential for abuse. But ultimately, physicians are asked to call some patients' bluffs, even though you can never truly know how much pain is legitimately helped by meds. Moreover, diversion of appropriately prescribed opioids remains a major problem, forcing clinicians to rethink the amounts they prescribe. The end result is some patients with chronic pain are going to hop through more hoops to obtain the same meds they've been taking for years. That's unfortunate, but isn't a fate worse than prison, or a situation forcing droves of patients to the brink of suicide as has been suggested.

 

[Terminalxylem]

they tried me on 3 or 4 of em, but they didnt touch me, which made me wonder if there wasnt a large placebo effect in the ib, but my neuropathy (from stenosis, most of my adult life) wakes me up without it, so idk. gabapentin lifted that beautifully but gave me such terrible dreams i almost cracked. so i'm back w ib, tho mostly just night doses now and crunch along w the arthritis during the day

Have you tried pregabalin (Lyrica) or duloxetine (Cymbalta), which are both FDA-approved for the treatment of neuropathic pain?  The former worked wonders for me after Neurontin had zonked me out.

 

[Doug B]

i've eaten 3000mg of ibuprofen a day for chronic arthritic pain for fifteen years without an ounce of kidney trouble (the docs are more amazed my stomach hasnt sploded) so the range is pretty wide there.

This is about how much I’ve been taking in recent days to fight off the pain associated with a dental abscess - actually, a little more because dental pain is harder to tamp down. You and I are roughly the same body weight (I am built like a pro offensive tackle with a beer gut ), and I’ve been kinda counting on my size being a good counterbalance for the dosages.

Going to the dentist tomorrow. Won’t need opioids — I’ve had abscesses before, and it’s the antibiotics that knock ‘em out. But then an NSAID like ibuprofen is very helpful for controlling the swelling. I’ll be curious to see if he prescribes me a different NSAID altogether.

 

[wikkidpissah]

There is a spectrum of metabolizing of certain medications, from poor to ultra-rapid. Patients who fall in different places on that spectrum can have markedly altered response to some drugs. Depending on your genetic profile, you may process some medications too quickly, or others, too slowly, which can both cause complications. This is also affected by ethnicity.

From The Effect of Cytochrome P450 Metabolism on Drug Response, Interactions, and Adverse Effects:

Maybe you are an ultra-metabolizer, GB. Testing has shown that my wife is, which is a significant reason she is on such high dosage pain medication. This issue is also a significant reason why one size fits all policy is not appropriate.

i've found metabolism to also be very much a factor in SSRIs. many are the folks i've counseled who had no success w the first few they tried but then landed on the right one and it was like coming home

Have you tried pregabalin (Lyrica) or duloxetine (Cymbalta), which are both FDA-approved for the treatment of neuropathic pain?  The former worked wonders for me after Neurontin had zonked me out.

Cymbalta was the last thing i tried. Was nowhere near as effective as the gabapentin and wasn't worth the side effects. They're just genericizing Lyrica now - i was on Medicaid when it was 1st suggested & declined because of the cost to the state of VT

This is about how much I’ve been taking in recent days to fight off the pain associated with a dental abscess - actually, a little more because dental pain is harder to tamp down. You and I are roughly the same body weight (I am built like a pro offensive tackle with a beer gut ), and I’ve been kinda counting on my size being a good counterbalance for the dosages.

Going to the dentist tomorrow. Won’t need opioids — I’ve had abscesses before, and it’s the antibiotics that knock ‘em out. But then an NSAID like ibuprofen is very helpful for controlling the swelling. I’ll be curious to see if he prescribes me a different NSAID altogether.

Yeah, size has a lot to do w the high dosages. Dont envy you - had a lot of abscesses when losing my teeth, but had my Mary's drug cabinet for those occasions. GL -

 

[Tau837]

Lawyer Calls for DOJ to End ‘Indiscriminate Raids’ on Doctors

Neither has Dr. Forest Tennant. In November 2017, DEA agents raided the office and home of Tennant, a prominent California pain physician who was flagged for “very suspicious prescribing patterns.” In a search warrant, the 76-year old Tennant was depicted as the kingpin of a drug trafficking organization that spanned several states.

“I know based on my training and experience that patients traveling long distances to obtain controlled substance prescriptions is another ‘red flag’ of drug abuse and addiction,” wrote DEA investigator Stephanie Kolb, who led a two-year investigation of Tennant.

But Kolb, who was self-employed as a dog walker and pet groomer before she started working for the DEA in 2012, failed to note that Tennant only treated intractable pain patients, many from out-of-state, and often prescribed high doses of opioids because of their chronically poor health. Some patients were in palliative care and near death, and one committed suicide after learning of the raid, fearing she would lose access to opioid medication.

Tennant denies any wrongdoing and was never formally charged, but retired from clinical practice a few months after the raid.

“It’s hard to continue operating when they never closed my case, and so I’m going to retire and move on,” Tennant told PNN at the time. “That’s on the advice of both my lawyers and my doctors."

I didn't post the entire article, which contains other interesting facts. I posted this in part because when we lived in California, my wife saw Dr. Tennant a few times. He was 2-3 hours away, so she did not become a regular patient, although we very much valued the opinions he gave us about her health.

It seems it is a good thing that she did not transfer her care to him given what happened. We know other patients of the practice, who were forced by the DEA action to find other providers. The DEA seized all of his records, which caused many patients fear that it put them in the cross hairs of the DEA; perhaps that fear was unfounded, but I understand it, since we had those thoughts ourselves. In many cases, Dr. Tennant's patients couldn't find alternative care and were abruptly force tapered. We did not know the patient who committed suicide but do know patients whose lives were completely disrupted by this situation.

 

[Tau837]

Are Rx Opioids the Culprits or Scapegoats for Opioid Crisis?

In a separate analysis, the CDC and Agency for Healthcare Research Quality found no correlation -- not even a weak one -- between opioid prescribing rates and overdoses when comparing data from each state.

No correlation. Overreaction indeed.

 

[bigmarc27]

Johnson & Johnson ordered to $572M for roles in Opioid problems. 

https://www.nytimes.com/2019/08/26/health/oklahoma-opioids-johnson-and-johnson.html

Other drug companies plead out. 

 

[Gawain]

Johnson & Johnson ordered to $572M for roles in Opioid problems. 

https://www.nytimes.com/2019/08/26/health/oklahoma-opioids-johnson-and-johnson.html

Other drug companies plead out. 

Buried in the lede here is that OK wanted 16 billion. This is being hailed as a victory for JNJ, not a defeat. 

 

[flapgreen]

I work in Healthcare. It's an epidemic. Even the elderly are hooked on this stuff. Yes, there will be times where people who really need it have a more difficult time of getting it, but it's just how it is.  The abuse has led to this. 

 

[flapgreen]

Johnson & Johnson ordered to $572M for roles in Opioid problems. 

https://www.nytimes.com/2019/08/26/health/oklahoma-opioids-johnson-and-johnson.html

Other drug companies plead out. 

Where's the responsibility of the doctors prescribing them or the people abusing them? 

 

[Henry Ford]

I tried to address this type of stuff in the other opioid thread and me and one other person were essentially met with "how-dare-you" or crickets.

I didn’t see that - or this entire thread.  The way we’ve treated this “opioid crisis” is abominable for chronic pain patients.  

There are pharmacies now that will only fill a week of opioids.  It’s illegal in Louisiana to write an opiate prescription for more than 30 days or to write one without physically seeing the patient. Or to write long term prescriptions unless you’re a pain management doctor.

There are people with chronic, disabling nerve pain who are now expected to pony up the money, time, and effort to get to pain management doctors every 30 days, have to be drug tested to get in the door, and it takes months to get an appointment. 

Not surprisingly, there’s anecdotal evidence that pain patients are committing suicide when they can’t get their medication. 

 

[TheIronSheik]

I didn’t see that - or this entire thread.  The way we’ve treated this “opioid crisis” is abominable for chronic pain patients.  

There are pharmacies now that will only fill a week of opioids.  It’s illegal in Louisiana to write an opiate prescription for more than 30 days or to write one without physically seeing the patient. Or to write long term prescriptions unless you’re a pain management doctor.

There are people with chronic, disabling nerve pain who are now expected to pony up the money, time, and effort to get to pain management doctors every 30 days, have to be drug tested to get in the door, and it takes months to get an appointment. 

Not surprisingly, there’s anecdotal evidence that pain patients are committing suicide when they can’t get their medication. 

Yup.  I go once every 6 weeks and I get drug tested probably 4 times a year.  Each time, it usually costs me about $120 out of pocket.  And where I used to get 90 for my copay, I now get 30 for the same price.  The cost to me has increased 5 to 6 times what it used to be to get my pills.  

 

[Henry Ford]

Are Rx Opioids the Culprits or Scapegoats for Opioid Crisis?

No correlation. Overreaction indeed.

There’s another unfortunate side effect as a result of this manufactured scapegoating of prescription opiates. 

People believe that when you overdose on oxycontin your breathing stops and you die.  That’s what happens on fentanyl and heroin. 

OxyContin makes your organs shut down, and while you generally breathe in enough vomit to cause pneumonia symptoms, you don’t usually die quickly.  So terminal patients are trying to commit suicide with their pain medication because of the news talk about overdose deaths and find that they’re starving to death or dying of thirst on a DNR in hospice care for a week or two while their families watch.

Sure makes great news to blame the pain pills, though. 

 

[Doug B]

I work in Healthcare. It's an epidemic. Even the elderly are hooked on this stuff. Yes, there will be times where people who really need it have a more difficult time of getting it, but it's just how it is.  The abuse has led to this. 

Letting the perfect be the enemy of the good.

Addiction's not going anywhere. Addicts will find a way. Meanwhile ... figure out a way that the pain patients can have their medications.

 

[bigmarc27]

Where's the responsibility of the doctors prescribing them or the people abusing them? 

I work in healthcare too. I agree with both your posts. I just hop in time to time to see people still thinking this is business as usual.

 

[flapgreen]

Letting the perfect be the enemy of the good.

Addiction's not going anywhere. Addicts will find a way. Meanwhile ... figure out a way that the pain patients can have their medications.

I don't disagree with that. It's a tough one, though. 

 

[rockaction]

I didn’t see that - or this entire thread.  The way we’ve treated this “opioid crisis” is abominable for chronic pain patients.  

There are pharmacies now that will only fill a week of opioids.  It’s illegal in Louisiana to write an opiate prescription for more than 30 days or to write one without physically seeing the patient. Or to write long term prescriptions unless you’re a pain management doctor.

There are people with chronic, disabling nerve pain who are now expected to pony up the money, time, and effort to get to pain management doctors every 30 days, have to be drug tested to get in the door, and it takes months to get an appointment. 

Not surprisingly, there’s anecdotal evidence that pain patients are committing suicide when they can’t get their medication. 

It is a tough issue. As far as this thread, though? After I posted that, there then went on to be a long, drawn-out debate about it with the two sides making very long involved arguments pro- and con- each side, mainly by Just Win Baby and Terminalxyxlem, IIRC. My comment was certainly a time-bound one, and people had their say after I made the comment. 

It is a problem that needs to be addressed. That's really all I was saying -- people then began to take opposing sides on the issue. 

 

[Henry Ford]

Where's the responsibility of the doctors prescribing them or the people abusing them? 

Doctors who overprescribe lose their licenses, have them restricted, or go to prison.  People abusing them go to prison or sometimes even die.  

I’d say there have been some pretty serious consequences there. 

 

[Doug B]

Letting the perfect be the enemy of the good.

Addiction's not going anywhere. Addicts will find a way. Meanwhile ... figure out a way that the pain patients can have their medications.

I don't disagree with that. It's a tough one, though. 

The hard, "cold equations" decision: The delivery of opioids to pain patients -- as an overarching nationwide system -- is going to have to guiltlessly bear a certain baseline number of addicts. Dropping the number of addicts down to zero shouldn't even be countenanced. It's OK if a given delivery system -- one that ends up helping pain patients -- allows a given small number of addicts to take advantage.

Hammering out acceptable levels of the items in red above is where the rubber meets the road.

 

[flapgreen]

Doctors who overprescribe lose their licenses, have them restricted, or go to prison.  People abusing them go to prison or sometimes even die.  

I’d say there have been some pretty serious consequences there. 

There have been very few consequences to doctors.  The people dying or going to prison hasn't stopped the rate of abuse. 

 

[Henry Ford]

There have been very few consequences to doctors.  The people dying or going to prison hasn't stopped the rate of abuse. 

That's primarily because addiction isn't really about the drug.

 

[eoMMan]

"Oxygod" is going to prison for awhile.

 

[culdeus]

There’s another unfortunate side effect as a result of this manufactured scapegoating of prescription opiates. 

People believe that when you overdose on oxycontin your breathing stops and you die.  That’s what happens on fentanyl and heroin. 

OxyContin makes your organs shut down, and while you generally breathe in enough vomit to cause pneumonia symptoms, you don’t usually die quickly.  So terminal patients are trying to commit suicide with their pain medication because of the news talk about overdose deaths and find that they’re starving to death or dying of thirst on a DNR in hospice care for a week or two while their families watch.

Sure makes great news to blame the pain pills, though. 

This post is super confusing.  What exactly are you trying to say?  That you can't OD easily with oxy, ok noted?  Therefore ________? (fill in blank)  Or are you against DNR from some sort of religious angle?

 

[Henry Ford]

This post is super confusing.  What exactly are you trying to say?  That you can't OD easily with oxy, ok noted?  Therefore ________? (fill in blank)  Or are you against DNR from some sort of religious angle?

There are people in end of life care watching this whole "OPIOIDS ARE THE DEVIL" news cycle who wish to end their lives.  They believe by using them they will get a quick, relatively painless death that will not burden their families.  Instead they get a long, drawn out starvation or organ failure death that is very difficult on their families and on them.  It's a bad thing.

 

[D_House]

There are people in end of life care watching this whole "OPIOIDS ARE THE DEVIL" news cycle who wish to end their lives.  They believe by using them they will get a quick, relatively painless death that will not burden their families.  Instead they get a long, drawn out starvation or organ failure death that is very difficult on their families and on them.  It's a bad thing.

If that is happening then it is a failure on the part of the providers caring for these patients. The whole point of hospice is comfort-directed care. And hospice care is a fully covered benefit that should not be burdensome to family.

Opioids are effective first line agents for multiple symptoms during end of life care. One minor consequence I’ve seen from the (mostly accurate) media portrayal of the opioid epidemic is the occasional end-of-life patient or family that doesn’t want to use opioids due to fear of addiction or sedation.

 

[culdeus]

There are people in end of life care watching this whole "OPIOIDS ARE THE DEVIL" news cycle who wish to end their lives.  They believe by using them they will get a quick, relatively painless death that will not burden their families.  Instead they get a long, drawn out starvation or organ failure death that is very difficult on their families and on them.  It's a bad thing.

I mean I'm not sure what to do about this aspect of things.  I wouldn't imagine this situation is unique to oxy.  

 

[Henry Ford]

I mean I'm not sure what to do about this aspect of things.  I wouldn't imagine this situation is unique to oxy.  

It's not a failure of the health care industry, it's a failure of the media and government in shouting about prescription pain pills being the cause of all this death.