Ira Cantor, MD: "Chronic Pain Patients Need Opioids"

[drusso]

The other opioid epidemic: Chronic pain patients in need of care - Philly

Is Dr. Cantor justified believing this??

“There was no good medical reason to taper your medications. They were helpful and weren’t abused. There aren’t new regulations, rather, recommendations about not using higher levels of opioid medications unless there is a compelling reason. Chronic severe pain, and deterioration of quality of life, are significant compelling reasons, if the medicines help decrease your pain, and if no other treatments can accomplish this.”

Ira Cantor, M.D., is an internal medicine physician specializing in pain management at Steiner Medical & Therapeutic Center in Phoenixville.

Steiner Medical and Therapeutic Center

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[TheLoneWolf]

The other opioid epidemic: Chronic pain patients in need of care - Philly

Is Dr. Cantor justified believing this??

“There was no good medical reason to taper your medications. They were helpful and weren’t abused. There aren’t new regulations, rather, recommendations about not using higher levels of opioid medications unless there is a compelling reason. Chronic severe pain, and deterioration of quality of life, are significant compelling reasons, if the medicines help decrease your pain, and if no other treatments can accomplish this.”

Ira Cantor, M.D., is an internal medicine physician specializing in pain management at Steiner Medical & Therapeutic Center in Phoenixville.

Steiner Medical and Therapeutic Center

Aka "I have a heart and others dont. Let me line my pockets doing refills while the rest of you mistakenly de-prescribe, I will go the other direction".

Sounds similar to Tennant and look what happened.

Pain news network and advocacy groups which shill for the pharmaceutical industry will be sure to quote this article as justification for high dose opiates for cnp.

 

[244913]

Aka "I have a heart and others dont. Let me line my pockets doing refills while the rest of you mistakenly de-prescribe, I will go the other direction".

Sounds similar to Tennant and look what happened.

Pain news network and advocacy groups which shill for the pharmaceutical industry will be sure to quote this article as justification for high dose opiates for cnp.

Maybe Dr Cantor should look into the 25 + studies which show that opioids do not improve chronic pain or function

- ex 61N

 

[Blitz2006]

Maybe Dr Cantor should look into the 25 + studies which show that opioids do not improve chronic pain or function

- ex 61N

You mind posting a couple of the "best" studies that support this.

Sent from my SM-G955U using Tapatalk

 

[lobelsteve]

Medical harm at higher doses. I think the data suggest 3x to 9x all cause mortality over 90meq.

But pushing lower for no good reason in a functional (working) patient with no addiction issues might go against guidelines as well. Especially in Canada.

 

[DOctorJay]

Sean Mackey on Pain Medicine's Civil War
Sean Mackey on Pain Medicine's Civil War

See post 69 from algos for studies


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[TheLoneWolf]

All vitriol aside, the cdc recommendations were probably created for this. To educate and guide pcps who don't understand that the use of opiates for cnp is risky and had some part in placing us in the current opoid epidemic. In reality, his views are probably no different than most prescribers a few years ago.

 

[Aether2000]

As the standard of care changes, there will be those that cling to mantras and unproven conjecture in spite of data and scientific advances in understanding the relationships between opioids, addiction, dependency, and neurologic changes.

 

[Ducttape]

its interesting. I get this feeling that he gets some sort of reward from telling patients that they don't need to taper.

however, when you look at his data on Medicare and propublica, he is not prescribing a lot of opioids. largest scripts in 2015 was for 64 oxycodone, 32 fentanyl, 40 morphine scripts.

for someone talking such a big game, he isn't prescribing...

and my question to him is this - do you feel the same about functioning alcoholics? or smokers who currently have good lung function and no obvious precancerous lesions?

 

[101N]

Watch "Dr. Feelgood" they - this twip, Hurwitz, Tennant - are all narcissists.

 

[Ferrismonk]

The other opioid epidemic: Chronic pain patients in need of care - Philly

Is Dr. Cantor justified believing this??

“There was no good medical reason to taper your medications. They were helpful and weren’t abused. There aren’t new regulations, rather, recommendations about not using higher levels of opioid medications unless there is a compelling reason. Chronic severe pain, and deterioration of quality of life, are significant compelling reasons, if the medicines help decrease your pain, and if no other treatments can accomplish this.”

Ira Cantor, M.D., is an internal medicine physician specializing in pain management at Steiner Medical & Therapeutic Center in Phoenixville.

Steiner Medical and Therapeutic Center

1. He's technically correct about the CDC's guidelines, except the inherent risk of overdose increases.
2. However, Lawyers, governments, and insurance companies don't understand this distinction.
3. Also, "internal medicine physician specializing in pain management". This isn't a thing. He's only got one hammer, so everything looks like a nail.

 

[Timeoutofmind]

Medical harm at higher doses. I think the data suggest 3x to 9x all cause mortality over 90meq.

But pushing lower for no good reason in a functional (working) patient with no addiction issues might go against guidelines as well. Especially in Canada.

A good reason would be the 25 studies showing they make pain and function worse.
Another would be the very high rates of mis-use and abuse that occur with prescriptions opioids.
Another would be the high addictive potential that has the ability to destroy someone's/their families life.
Another would be the endocrine, immune, psychiatric and other organ system damage that occurs with chronic use.

 

[lobelsteve]

A good reason would be the 25 studies showing they make pain and function worse.
Another would be the very high rates of mis-use and abuse that occur with prescriptions opioids.
Another would be the high addictive potential that has the ability to destroy someone's/their families life.
Another would be the endocrine, immune, psychiatric and other organ system damage that occurs with chronic use.

So basically you have nothing to offer, no way of determining if the patient in your office will benefit from pain meds, and that no one should be on pain meds for any condition chronically?
In Chronic LBP, Outcomes Unchanged By Provider Specialty

You sound like an idiot- addiction is the person and not the drug. Iatrogenic addiction in the face of negative risk factors is extremely unlikely.
Misuse and abuse are due to poor screening of candidates for medication. And fixing the problem if it happens is an easy thing to do.
Organ system damage? You must be thinking of NSAIDs.

Did you do a fellowship? Sounds like GIGO.

 

[Ducttape]

Jeez lobelsteve, every time it seems you turn the corner you seem to go back to blanket statements that shows that you might not have changed colors... the “addiction is purely a personality disorder and I can figure out who is going to have problems from them because I know”...

Well, for starters, you cannot know if one will get addicted until you expose that person to the addictive factor. I don’t know if I am addicted to deep fried cockroaches because I haven’t and will never try them. And because of that, I won’t get addicted.

But once you start someone on a course of action - you can never undo the addiction. Stopping meds only stops addiction - for the prescriber.

And how accurate are your prescreening tests? 100%? I thought the only things guaranteed in life were death and taxes.

Your conclusion that people do not get addicted in the face of negative risk factors smacks of Porter and passik, not a 2018 board certified pain physician. Why monitor if you are so smug about your prescreening?

In terms of organ system, isn’t the bowel and the endocrine system affected by opioids? Do they completely reverse when stopping opioids? If so, prove it.

This is mostly a GIGO paper but it illustrates times’ point: A Review of Potential Adverse Effects of Long-Term Opioid Therapy: A Practitioner’s Guide


Okay, off my soapbox. I gotta see if there are any tasty cockroaches under the box...

 

[244913]

So basically you have nothing to offer, no way of determining if the patient in your office will benefit from pain meds, and that no one should be on pain meds for any condition chronically?
In Chronic LBP, Outcomes Unchanged By Provider Specialty

You sound like an idiot- addiction is the person and not the drug. Iatrogenic addiction in the face of negative risk factors is extremely unlikely.
Misuse and abuse are due to poor screening of candidates for medication. And fixing the problem if it happens is an easy thing to do.
Organ system damage? You must be thinking of NSAIDs.

Did you do a fellowship? Sounds like GIGO.

Pretty harsh Steve. We are all on the same team here..

I think we, as pain physicians, are a lot better at recognizing which patients are risky and poor candidates for opioid but we are in no way foolproof. The screening tests are mostly garbage.

Even when we pick “good candidates” there is still risk both for the patient and the community.

To illustrate a point- I inherited a guy on 90 MED and weaned him down to 40 over 2 months. Solid citizen- ORT score zero, worked full time had good family support etc.

One week after giving refill script, he calls my office- his meds were stolen at a super bowl party. ?family ? Friend, he didn’t know. He felt genuine remorse, I gave withdrawal meds and he’s actually usin this as an opportunity to stop completely which was a lot easier considering I cut his dose by 2/3

But I wonder- where did those meds go? Did they end up on the street? At a slumber party? If Algos is correct- which is usually the case- it takes what two weeks of exposure to get hooked for those with neural predisposition? Did this guys stolen rx create two new addicts?

That’s why I think with these meds, lower is better. Why? Less risk to the patient for one but ultimately less risk to the community in the case above.

A big component of battling this epidemic is reducing the supply.

- ex 61N

 

[lobelsteve]

This community and these threads are becoming blatant anti-opiate PROPaganda.
Do we not know what the risk factors are for addiction?
Do we not monitor for analgesia, adverse events, activity, and aberrant behaviors? If these develop, do you have a plan?
Do we not check for loss of control, continued use despite harm, compulsive use, cravings? If present and interfere with family, social, work obligations- do we know what to do? If illegal activity related to these items, do we know what to do?
Does you clinic employ strict rules regarding how, when, where, and why you would consider Rx for opiates?

If not, put down the pen.
If so, you are not part of the problem regarding opiate abuse and addiction. Being a pain physician should not be about # of Ferraris, # of folks you cut off of opiates. It should be about doing your best to treat the patient in front of you. If you feel that no opiate is ever safe for any reason at any time, then walk away or stop saying you are a pain physician. Use terms like addictionology, sports/spine.
Our jobs should be to care for the patient in front of us the best we can. As pain physicians that includes using all tools available to ensure an adequate functional status while minimizing risks.

Love hate relationships based on care provided, not narcotics provided?

Dr. Steven Lobel, MD - Canton, GA - Pain Medicine & Physical Medicine & Rehabilitation Pain Medicine | Healthgrades.com
Reviews | Dr. Steven M Lobel MD Reviews | Canton, GA | Vitals.com

We always discuss opiates as a pendulum swinging. Some people want to break the pendulum and hang the evils of society on doctors and pain medication. These are dark days for patients seeking relief and doctors trying to help people keep their jobs, golf, grandkids, etc as part of their lives.

The number of opiate deaths from patients prescribed that medication by their doctor? Not 62000, not 10000, not 5000. Problem is society, not us.

 

[101N]

"We always discuss opiates as a pendulum swinging."

No "we" don't. Opioids for CNP in working aged adults are more like thalidomide, Bextra, or Vioxx. They aren't on a pedulum, they are just a dangerous failure in the US.

 

[lobelsteve]

"We always discuss opiates as a pendulum swinging."

No "we" don't. Opioids for CNP in working aged adults are more like thalidomide, Bextra, or Vioxx. They aren't on a pedulum, they are just a dangerous failure in the US.

So, that's a no pain meds for anyone. Oops, unless we call them addicts. Then business as usual. Change opiate. Offer cbt, feel bad about taking med. Got it.

 

[lobelsteve]

Dr W. is a pain physician who has transformed the way he cares for patients. Dr. W says that monitoring those taking prescription drugs is the key to detecting dependency. Indiana is now using electronic systems like INSPECT to monitor those taking prescription drugs. Dr. W is a physician at Advanced Pain Management.

 

[Ducttape]

The problem is society.

It is the societal impression that pain needs to be eliminated. Pain has a purpose in life and it is not to make people in to addicts. When has opioids become a necessity for chronic nonmalignant pain? It wasn’t in my parents generation, or their parents. To have to say that a narcotic is the only option for an otherwise healthy patient is darkness indeed... that concept could be used to justify any drug use, including heroin and fentanyl and THC and soma and...



I find it specious your comment that one cannot “be” a pain physician if one does not prescribe opioids. By strictest definition, that would mean that an IPM Doctor is not a pain physician but his referrers and his mid levels actually may be.

I write opioids. I don’t deny it. I’m not saying it is not inappropriate to prescribe for certain patients in certain situations.

But clearly my bar is much higher than yours and I don’t trust myself to be able to detect someone who is going to become an addict by what he writes down on a piece of paper or after spending only 45 min of his life with him.

 

[lobelsteve]

The problem is society.

It is the societal impression that pain needs to be eliminated. Pain has a purpose in life and it is not to make people in to addicts. When has opioids become a necessity for chronic nonmalignant pain? It wasn’t in my parents generation, or their parents. To have to say that a narcotic is the only option for an otherwise healthy patient is darkness indeed... that concept could be used to justify any drug use, including heroin and fentanyl and THC and soma and...



I find it specious your comment that one cannot “be” a pain physician if one does not prescribe opioids. By strictest definition, that would mean that an IPM Doctor is not a pain physician but his referrers and his mid levels actually may be.

I write opioids. I don’t deny it. I’m not saying it is not inappropriate to prescribe for certain patients in certain situations.

But clearly my bar is much higher than yours and I don’t trust myself to be able to detect someone who is going to become an addict by what he writes down on a piece of paper or after spending only 45 min of his life with him.

I agree. But do not think i am pro opiate freely. No rx at first visit for a reason. Consult is to help determine if CS are even an option. If IPM is an option. PT or self directed exercises is not an option. It is mandatory including site specific exercises for painful condition as well as cardio.

I am good at procedures and better at lie detecting. I can tell who is not getting my signature on a script within 5 minutes for 90% of the consults. 10% get full due diligence. Pdmp urine drug screening, the rest of the outside records if not sent ahead of time as well as criminal background, screening tools. Any red flags and I can say no. I do say no. I literally throw my pen under the door and tell patient i cannot sign that rx. Yellpw flags might mean a month to month visit for frequent assessment. If not improving or maintaining a function, meds get stopped. If aberrant behavior, meds get stopped.

I have weaned most of my patients, some have left. 3 left over 200 meq. 19 more between 90-200. No new patients will get over 90meq from me even if at 240. Referring doc can get weaning done to 90 if i am going to continue if appropriate. No new patient can get opi+bzd. Choose one after i review to see if candidate.

 

[pjuer]

its interesting. I get this feeling that he gets some sort of reward from telling patients that they don't need to taper.

however, when you look at his data on Medicare and propublica, he is not prescribing a lot of opioids. largest scripts in 2015 was for 64 oxycodone, 32 fentanyl, 40 morphine scripts.

for someone talking such a big game, he isn't prescribing...

and my question to him is this - do you feel the same about functioning alcoholics? or smokers who currently have good lung function and no obvious precancerous lesions?

He does trigger point injections with bee venom

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