Chronic opiate users are full of ****

[Apollyon]

Literally.

There was a thread last year talking about it, with suggestions how to treat it. I just wanted to mildly bitch about it for a bit.

Where I now work, there is an FM guy that is the biggest prescriber. In the ED, about a quarter of my patients are abdominal pain. About 1/5 are full of stool - so, 1 out of 20 are just constipated. Out of those 5/100, one to two will be chronic opiate users on large doses (100 MED) for their, well, chronicities.

That means I am seeing about 1 to 2% of my patients as opioid induced constipation. They all get mag citrate, and a recommendation to 1. not have anyone over the house and 2. be CLOSE to the bathroom. They also get Colace.

Now, my question: for those of you that do write narcs, with the first Rx, is there an Rx for Colace (with "at LEAST 8 ounces of water!") to go with it? When I was an intern in NYC, the Mt. Sinai residents had a card they carried, with one side pain regimens, and the other bowel regimens, and that's when I first heard "the best treatment for constipation is not to become". I don't recall any of the patients that "Dr. X" sees being on ANY bowel regimen.

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[Ducttape]

no, i dont like colace.

the first rx is for prune juice:applesauce:bran fiber ceral 1:1:1.

the second rx is for a taper.

if absolutely necessary, i do consider other agents - miralax, senna.

i have tried relistor with 50/50 success.

i have not tried amitiza.

 

[Apollyon]

From the ED, I don't think I would do Relistor or Amitiza.

(Apologies - I am not a pain doc. I just see the pts in the ED.)

 

[lobelsteve]

no, i dont like colace.

the first rx is for prune juice:applesauce:bran fiber ceral 1:1:1.

the second rx is for a taper.

if absolutely necessary, i do consider other agents - miralax, senna.

i have tried relistor with 50/50 success.

i have not tried amitiza.

Oops. Fiber bulks. Opiates slows. Bigger and slower is a traffic jam. 200 mg bid colace for all. Increase fluids to gallon of water per da y. Miralax 2tbs tid until diarrhea then 1tbs tid.

 

[emd123]

no, i dont like colace.

the first rx is for prune juice:applesauce:bran fiber ceral 1:1:1.

the second rx is for a taper.

if absolutely necessary, i do consider other agents - miralax, senna.

i have tried relistor with 50/50 success.

i have not tried amitiza.

The best prescription for opiate induced constipation is to reduce the opiate. It works every time.

 

[Aether2000]

Naltrexone is very effective for constipation, but the side effects in the chronic opioid patient are quite severe!

 

[oreosandsake]

not advocating for, but wondering if anyone has seen one of these..

http://www.medtronic.com/patients/gastroparesis/device/index.htm


another idea - one pulse generator/multiple leads - some to the dorsal column, some to the gut, some to the brain...!

 

[Ducttape]

Naltrexone is very effective for constipation, but the side effects in the chronic opioid patient are quite severe!

Relistor is methyl naltrexone bromide... Should not stimulate withdrawal symptoms.

 

[jabreal00]

As a gastroenterologist I just want to pipe in. One, unfortunately, chronic opiates paradoxically makes functional abdominal pain worse. Pain receptors are upregulated in the GI tract often necessitating escalating doses of opiates. Two patients eventually will develop functional gastroparesis which further compounds things. Colace or stool softeners are just not very effective for constipation. It's okay if someone is fairly regular but there's a need to soften stools.

Osmotic laxatives (Miralax) are my go to. Most patient will require one to two scoops (17 grams a scoop) a day to see effect. The good thing about Miralax is one can titrate the dose as much as needed for effect. It takes about 2-3 days before one starts seeing effect. I tell them to increase to twice daily if no effect after 5 days. Miralax shouldn't cause loose or watery stools at low doses. After fiber supplementation, osmotic laxatives are the first line recommended pharmacological agents for chronic constipation according to the major GI societies.

Increasing the fiber can help but it's limited by adverse effect (bloating). Fiber helps to bulk the stool. Increased stool bulk decreases transit time in the colon, ie helping with BMs. However, if they have narcotic induced constipation many will have some element of gastroparesis. Certain insoluble high fiber foods may be hard to process from the stomach.

Stimulant laxatives (Senna or Bisacodyl) can also be effective but patient's may have loose watery stools with it.

But like some have alluded, the key is preventing these patient's from becoming constipated and weaning off or weaning down to the lowest effective dose for offending medications.

 

[Ducttape]

As a gastroenterologist I just want to pipe in. One, unfortunately, chronic opiates paradoxically makes functional abdominal pain worse. Pain receptors are upregulated in the GI tract often necessitating escalating doses of opiates. Two patients eventually will develop functional gastroparesis which further compounds things.....

But like some have alluded, the key is preventing these patient's from becoming constipated and weaning off or weaning down to the lowest effective dose for offending medications.

Please continue to educate your fellow gastroenterologists and GI surgeons about this.

i get at least 1 referral a week, mostly from the surgeons but also from timid GI docs that apparently dont have the guts (pun intended) to tell their chronic abdominal pain patients that their opioids can/are causing them to get worse.

they leave it up to the pain doc to "introduce" the concept that the opioids make things worse, and that they shouldnt be on the meds. we get stuck with trying to fix other provider's s#$t

(okay, that was a bad one).

 

[Aether2000]

However, I have had several patients with chronic abdominal pain from pancreatitis, IBS, ulcerative colitis, Crohns disease, etc that were placed on opioids by their GI doc with development of GI dysmotility. My thought was the same....wean them off all opioids. Did this on many patients and they were off for 3 months, but the dysmotility and abdominal pain issues continued. So it is not all due to opioids, and the fact that a person has dysmotility or increasing abdominal pain should not universally be attributed to opioids. Of course they cause dysmotility in a majority of patients, but are not the sole cause, and cessation of opioids may not lead to any improvement..... Just sayin....

 

[Ducttape]

However, I have had several patients with chronic abdominal pain from pancreatitis, IBS, ulcerative colitis, Crohns disease, etc that were placed on opioids by their GI doc with development of GI dysmotility. My thought was the same....wean them off all opioids. Did this on many patients and they were off for 3 months, but the dysmotility and abdominal pain issues continued. So it is not all due to opioids, and the fact that a person has dysmotility or increasing abdominal pain should not universally be attributed to opioids. Of course they cause dysmotility in a majority of patients, but are not the sole cause, and cessation of opioids may not lead to any improvement..... Just sayin....

how long do you wait post withdrawal for determining opioid hyperalgesia syndrome?

 

[jabreal00]

However, I have had several patients with chronic abdominal pain from pancreatitis, IBS, ulcerative colitis, Crohns disease, etc that were placed on opioids by their GI doc with development of GI dysmotility. My thought was the same....wean them off all opioids. Did this on many patients and they were off for 3 months, but the dysmotility and abdominal pain issues continued. So it is not all due to opioids, and the fact that a person has dysmotility or increasing abdominal pain should not universally be attributed to opioids. Of course they cause dysmotility in a majority of patients, but are not the sole cause, and cessation of opioids may not lead to any improvement..... Just sayin....

Opiods are a terrible idea for anyone with IBD, functional pain, or IBS. If someone is having abdominal pain with IBD then it means their disease is not under control and they need immunosuppressive therapy or they have a stricture or surgical issue. If their disease is in remission with medication or they don't have a stricture/fistula/abscess then it's not IBD causing their abdominal pain.

Don't get me wrong, opiates aren't the cause of their underlying functional pain. It just exacerbates things or makes it harder to treat.

Chronic pancreatitis is another beast. I give opiates for acute pancreatitis. If someone has chronic pancreatitis and chronic pain then I'd make sure they don't have a pancreatic duct stricture or stone that can be amenable to ERCP with stenting (generally poor success rate) or rule out underlying pancreatic malignancy (CP is increased risk for malignancy). Most of these patients should be referred to surgery for a pancreaticojejunostomy. This is the only thing in the literature that has been shown to provide long term relief of pain. Celiac plexus blocks done via EUS or by you pain docs only give transient relief and have better effect for those with cancer pain.

My wife is a pain doc so we kind of bounce ideas off each other. In my group I deal with a lot of functional abdominal pain patients. These patients I never consult pain. The problem is when I see a patient already on high dose opiates. I give them my spiel about weaning off opiates. Most have not interest due to codependency issues. I make sure there's no organic etiology. Once I do that, I give them my recommendations and treatment plan. It's up to the prescribing provider to wean off their patient.

Many GI docs who start opiates for questionable reasons or refer to pain are just taking short cuts. Unfortunately, this kind of thing happens in all specialties.

 

[Apollyon]

Thank you all for a good discussion.

Coincidentally, just this past weekend, had a patient come back (again) for constipation, who I personally got kicked off her 12mg Dilaudid/day pain contract (for gross violation), who said she "drank 3 1/2 bottles of magnesium citrate, and nothing happened". Umm, OK.

She burned out her welcome at our hospital, and, so, she asked EMS to take her to the next closest one (33 miles away from us, but "only" about 25 from her residence). They didn't do that.

Baby steps, baby steps...

 

[wadeos]

I am a little late chiming in on this post, but I encourage people to read up on studies of mu opioid receptors (ant)agonists (or withdrawl from them) and correlation with IBD. It is something that needs greater study, and something that should be considered prior to prescribing any opiate. May want to check out the following study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856226/?report=reader

 

[Apollyon]

From the ED, I don't think I would do Relistor or Amitiza.

(Apologies - I am not a pain doc. I just see the pts in the ED.)

As an update, I am with a different system now, and have done Relistor twice. One didn't go in the ED, and the other - did. With gusto.

To rehash a point, opioid tapers in the ED literally, by definition, don't exist (although people abuse the "literally" tag, mine refers to a perfect system; I am sure that there are wannabe angels that try to taper pt's in the ED, as the doc might be working a lot, and seeing the same pt, and the doc is dumb enough not to contact whomever it is prescribing).

 

[Ducttape]

http://www.internalmedicinenews.com...mination+tied+to+increased+substance+use+risk

Although at present, much of the research into this phenomenon is still bench science, Dr. Szigethy said a growing body of evidence provided in part by advanced neuroimaging techniques indicates that chronic narcotic use changes opioid receptors in some human adults from creating an analgesic effect, to a hyperanalgesic one instead, where the narcotics themselves start to create pain and exacerbate any existing bowel issues.

and, just to stir the fire, this model, which might be best for patients, will probably not work in fee-for-service private practice.

One central question the pilot program is expected to answer is whether it is feasible to do away with fee-for-service provider reimbursements, which Ms. McAnallen said are, in her opinion, at the crux of the current national health care crisis.

“You go to your physician, they do something, they submit a claim, they get a check. We haven’t put in a system that makes providers, whether hospitals or physicians, step back and say, ‘Let’s do this differently. I’m on a treadmill of fee for service. The more I produce, the more I get paid.’ This IBD pilot program is to really help us transform that payment structure.”

 

[101N]

http://www.internalmedicinenews.com/specialty-focus/mental-health/single-article-page/ibd-specialty-medical-home-relies-on-psychiatrist-insurer-to-succeed/5bf9872076d9faa0b76be4a5aed2ab08.html?utm_source=news_imn-enl150213_final&utm_medium=email&utm_content=Frequent discrimination tied to increased substance use risk


and, just to stir the fire, this model, which might be best for patients, will probably not work in fee-for-service private practice.

I think that model - heavy on behavioral health - would be cheaper and less harmful for the majority of chronic pain. Regardless of the payment scheme.

 

[Ducttape]

Cheaper for society, not for physicians who are billing fee for service you mean...

 

[Aether2000]

We tried the behavioral model at a university center. The department became insolvent and required millions of dollars in loans to bail it out....

 

[101N]

I think that if practitioners are paid to use EBM/Outcomes based care then the practice setting isn't so important. Hospital, employed, PP, big group, etc, same facts. Conversely, if we are paid to perform procedures, we will perform procedures and if we - pain - are paid based on our Press-Ganey scores, we will Rx lots of opioids.

The bigger issue for us is that if you believe that the majority of people with medically unexplained pain have a centralized process - suffering, SLS, PTSD, etc - there just isn't ANY compelling data that any intervention - behavioral or otherwise- works well at getting them functional, back to work, back to normal life roles, productive. So the factors that are deciding health policy in pain now are shifting from EBM/Outcome based care - because we don't have any - toward risk reduction and cost containment. I don't think this is a conspiracy, it's just where the evidence lies now. It's no secret that behavioral interventions are less risky and -should be at lease - less costly than further medicalizing these complaints.

Medically unexplained 'suffering' also needs public health interventions. The health policy incentives that permit the perpetuation dysfunction and disability need to be curtailed. A lot of medically unexplained pain/disability - not all - isn't a medical failure, it's just opportunistic health policy exploitation.(1,2,3) SLS may be a human tragedy - what if it were your kid, or sister? - but it's not a disability.

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504974/
2. Amazon product
3. http://www.wsj.com/articles/SB10001424052970203518404577096632862007046

 

[emd123]

I think that if practitioners are paid to use EBM/Outcomes based care then the practice setting isn't so important. Hospital, employed, PP, big group, etc, same facts. Conversely, if we are paid to perform procedures, we will perform procedures and if we - pain - are paid based on our Press-Ganey scores, we will Rx lots of opioids.

The bigger issue for us is that if you believe that the majority of people with medically unexplained pain have a centralized process - suffering, SLS, PTSD, etc - there just isn't ANY compelling data that any intervention - behavioral or otherwise- works well at getting them functional, back to work, back to normal life roles, productive. So the factors that are deciding health policy in pain now are shifting from EBM/Outcome based care - because we don't have any - toward risk reduction and cost containment. I don't think this is a conspiracy, it's just where the evidence lies now. It's no secret that behavioral interventions are less risky and -should be at lease - less costly than further medicalizing these complaints.

Medically unexplained 'suffering' also needs public health interventions. The health policy incentives that permit the perpetuation dysfunction and disability need to be curtailed. A lot of medically unexplained pain/disability - not all - isn't a medical failure, it's just opportunistic health policy exploitation.(1,2,3) SLS may be a human tragedy - what if it were your kid, or sister? - but it's not a disability.

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504974/
2. Amazon product
3. http://www.wsj.com/articles/SB10001424052970203518404577096632862007046

Right. And let's not kid ourselves, patients don't want so pie-in-the-sky Utopian, back-to-work, see a shrink suck-it-up, get moving again "program" any kind whatsoever. Any patient that wants that, already picked up the pieces, has moved on and doesn't need your or I. The majority want a quick pill or a shot to make them feel better NOW. All these other look-perfect-on-paper programs dreamed up in academia are 100% doomed to fail in the real world.

Instant gratification is the desired end point, and with hospitals and now even CMS buying into the patient satisfaction craze, this is set in stone.

 

[Ducttape]

agree that instant gratification is what is desired by most patients - see the big push to legalize marijuana. there are legitimate pain patients that do want what 101N is talking about. perhaps you havent met any yet. some need a little help to get there - whether it is a neuromodulator, referral to PT, an injection for temporary relief to get involved in PT, or just the knowledge that they have a irreversible problem that they cant expect a cure and they need to get on with their lives...

however, CMS and policy wonks are likely to support measures that benefit and provide cost containment - isnt that what the purported purpose of ACOs?

i do disagree with 101N on one point... there is some data and some evidence that CBT and psychological interventions do provide long term benefit.

 

[mille125]

Call me old fashioned but lactulose fixes the majority of these....