Dose is an indepent risk factor that vigorous downstream surveillance measures can't adequately mitigate against. Surveillance measures may make you feel better, and look good in the event of a board review, but it's a false sense of security. If you are prescribing > 120MED with regularity you are putting your patients at risk regardless of how many pill cnts, UDS, or f/u visits you are performing.
I agree, in general about dose, but I take a slightly different view as to
why dose is so important. I don't think it's the dose itself that affects the patient, but:
The highest risk patients that affect the dose.
We all know that with slow dose titration, the human bodies' ability to develop tolerance and adjust to very, very high doses of opiates is profound. In laboratory-like conditions, there is no ceiling to opiate dose, and very high doses can be tolerate if slowly titrated and doses are taken regularly without variation. The key is, "laboratory-like conditions." Patients don't live in a vacuum or in laboratory-like conditions.
Most importantly, and this is something that may have been said, but I haven't heard said out there:
Dose is a marker for the highest risk, and the patients least appropriate for opiate treatment in the first place.
Just think about how someone ends up on ultra-high dose opiates, like the patient Algos mentioned, on 20-30 Roxicodone per day (assuming 30mg). That doesn't occur in isolation, in a short period of time or likely under the care of a single prescriber, usually. Often times these are patients that may in fact have legitimate medical need and are started on an opiate at some point. At some point they develop tolerance and the dose is increased. At some point, tolerance develops again and dose is increased to a certain level. At some point the physician reaches the ceiling of his comfort zone on dose. At this point, one of two things are going to happen. Either the patient realizes that they're on a much higher dose of opiates than they started on, they still have some pain, and always will have some and that they're satisfied with some pain relief at the dose they're at. They realize their pain control will never be 100% perfect, even with endless dose titrations. They maintain on this low or moderate dose long term. That's one type of person, and a very reasonable person.
The other, is the person who just cannot level off and stay at a dose, any dose. It may have nothing to do with addiction, diversion or anything nefarious. They just want more pain relief and want just one more dose increase, stronger or different medicine to bring it. No matter what the dose, tolerance develops and that magical feeling of "zero pain" just never stays around.
So they become dissatisfied, and they switch doctors. Naturally, they find one comfortable with the doses they're on and more importantly, comfortable with the one thing they've know to reduce their pain, at least temporarily, in the past: further dose increases and a belief that opiates in some form are the default solution. The cycle continues to repeat, with endless dose escalation, repeated tolerance development, and dissatisfaction when the pain relief wears off. Therefore, such patients,
who probably are the very worst candidates for chronic daily opiates to begin with self-select for the highest doses, due to their propensity to repeatedly develop tolerance combined with the least realistic expectation of a 100% pain-free life. Ultimately once they hit the ceiling of any particular doctors dose comfort zone, they look for a doctor who will do the only thing they believe and have been told, will reduce their pain: more and stronger opiate medications.
This can all occur in patients with completely legitimate medical need, combined with a well intentioned doctor that believes that opiates, if titrated slowly and carefully enough with the proper monitoring do not have or need a dose limit. This cycle is most likely to be perpetuated in those most insistent upon more medication, in greater doses, more frequently. It is least likely to occur in someone with the tendency or capability to accept and deal with soome level of pain, and that there is a limit to what an opiate can do
at any dose. Throw in a poorly trained or unscrupulous doctor, combined with a patient who's doing their best to hide an addiction, and you accelerate the cycle dramatically and have a recipe for disaster.
So, in conclusion, if you want to reduce risk, yes, lower dose or have dose limits such as 120mg MED. You'll absolutely see risk reduction in your population, but
not necessarily in any given patient. What you will see, is a risk reduction in your patient
population, because those that are
already higher risk and therefore on higher doses, will
leave your patient population and move on to one that is more risk tolerant, or move on to another source of opiates entirely. Ultimately, you select out the highest risk population by taking the highest doses off the table, and are left with a much more stable, and lower risk group of patients.
) It's another tool in the bag and it will lower meq across the board while providing same pain relief. PCP starts patient on Norco 10mg and gets them to 4x per day or more. If and when appropriate and can make 4-6 pills go to 2 pills per day.
Effect of Abuse-Deterrent OxyContin., the selection of OxyContin as a primary drug of abuse decreased from 35.6% of respondents before the release of the abuse-deterrent formulation to just 12.8% 21 months later (P<0.001). Simultaneously, selection of hydrocodone and other oxycodone agents increased slightly, whereas for other opioids, including high-potency fentanyl and hydromorphone, selection rose markedly, from 20.1% to 32.3% (P=0.005). Of all opioids used to “get high in the past 30 days at least once” (Figure 1B), OxyContin fell from 47.4% of respondents to 30.0% (P<0.001), whereas heroin use nearly doubled.
