The prescription opioid epidemic in a nutshell

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lobelsteve said:
It's about time we had equality for female perverted physicians. I think they have a new TV show of a woman judge that does this.
Click to expand...
Hey, didn't you apply to work at this office?
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http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=9

Clin J Pain. 2014 Jul;30(7):557-64. doi: 10.1097/AJP.0000000000000021.
The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription.
Edlund MJ1, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD.
Author information

Abstract
OBJECTIVE:
Increasing rates of opioid use disorders (OUDs) (abuse and dependence) among patients prescribed opioids are a significant public health concern. We investigated the association between exposure to prescription opioids and incident OUDs among individuals with a new episode of a chronic noncancer pain (CNCP) condition.

METHODS:
We utilized claims data from the HealthCore Database for 2000 to 2005. The dataset included all individuals aged 18 and over with a new CNCP episode (no diagnosis in the prior 6 mo), and no opioid use or OUD in the prior 6 months (n=568,640). We constructed a single multinomial variable describing prescription on opioid days supply (none, acute, and chronic) and average daily dose (none, low dose, medium dose, and high dose), and examined the association between this variable and an incident OUD diagnosis.

RESULTS:
Patients with CNCP prescribed opioids had significantly higher rates of OUDs compared with those not prescribed opioids. Effects varied by average daily dose and days supply: low dose, acute (odds ratio [OR]=3.03; 95% confidence interval [CI], 2.32, 3.95); low dose, chronic (OR=14.92; 95% CI, 10.38, 21.46); medium dose, acute (OR=2.80; 95% CI, 2.12, 3.71); medium dose, chronic (OR=28.69; 95% CI, 20.02, 41.13); high dose, acute (OR=3.10; 95% CI, 1.67, 5.77); and high dose, chronic (OR=122.45; 95% CI, 72.79, 205.99).

CONCLUSIONS:
Among individuals with a new CNCP episode, prescription opioid exposure was a strong risk factor for incident OUDs; magnitudes of effects were large. Duration of opioid therapy was more important than daily dose in determining OUD risk.
 
101N said:
http://www.jabfm.org/content/27/3/329.full

Risk of Adverse Health Outcomes with Increasing
Duration and Regularity of Opioid Therapy

Purpose: The purpose of this study was to examine trends in frequency and daily dosage of opioid use and related adverse health outcomes in a commercially insured population.

Methods: We examined medical claims from the Truven Health MarketScan commercial claims database for 789,457 continuously enrolled patients ages 18 to 64 years to whom opioids were dispensed during the first half of 2008. We tracked them every 6 months until either opioid use was discontinued or the end of 2010. We compared outcomes among all opioid users with those for patients who used opioids with only limited interruptions during the index period, referred to as “daily users.” We contrasted the experience of daily users, other users, and nonusers for various outcomes.

Results: Of all claimants, 10.7% had at least one opioid prescription during the first 6 months of 2008. Of these, 39.9% continued through a second 6-month period, and 18.0% continued through the end of 2010. Only 9.0% of all users qualified as daily users, but 87.1% of them continued some use of opioids through the end of 2010. Only 43.8% of all users who continued use through 2010 initially qualified as daily users. Among all users who continued use through 2010, days of use and daily dosage increased with duration of use. Among daily users, only dosage increased, rising from 101 to 114 morphine milligram equivalents/day over the 3 years. The prevalence of benzodiazepine use was greater for daily than all users, exceeding 40% among daily users who continued opioid use for 3 years. Drug abuse and overdose rates increased with longer use. Daily users accounted for 25.0%, other users for 43.6%, and nonusers for 31.4% of opioid analgesic overdoses.

Conclusions: Adverse health outcomes can increase with accumulating opioid use and increasing dosage. Existing guidelines developed by specialty societies for managing patients using opioids daily or nearly daily do not address the larger number of patients who use opioids intermittently over periods of years. Practitioners should consider applying such guidelines to patients who use opioids less frequently.
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I have a hard time making people understand this essential point: "This study demonstrates that patients receiving daily opioid therapy are at the highest risk of opioid overdose but still account for only a quarter of opioid overdoses among an insured population. The remaining group of opioid users accounted for a larger fraction of these overdoses. This suggests that the application of existing clinical guidelines for treatment of chronic noncancer pain,(14,15) while they focus on the group at highest risk, should not necessarily be restricted to daily users with chronic pain conditions...."

How do you message it? The high-dose/high risk user is the "hot-spotter," but the problems is deeper and broader than most people are able or willing to understand...
 
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drusso said:
I have a hard time making people understand this essential point: "This study demonstrates that patients receiving daily opioid therapy are at the highest risk of opioid overdose but still account for only a quarter of opioid overdoses among an insured population. The remaining group of opioid users accounted for a larger fraction of these overdoses. This suggests that the application of existing clinical guidelines for treatment of chronic noncancer pain,(14,15) while they focus on the group at highest risk, should not necessarily be restricted to daily users with chronic pain conditions...."

How do you message it? The high-dose/high risk user is the "hot-spotter," but the problems is deeper and broader than most people are able or willing to understand...
Click to expand...

Ah, yes those that cruise medicine cabinets - or purchase, share, trade - are a large portion of ODDs. But the community reservior for these folks are the high dose patients. So, the problem remains the same: the doctors who prescribe for, and the high dose patients for whom they are prescribing.

Stigma has a role here.
 
And now for something completely different...

Lower Opioid Overdose Death Rates Associated with State Medical Marijuana Laws
EMBARGOED FOR RELEASE: 3 P.M. (CT), MONDAY, AUGUST 25, 2014

Media Advisory: To contact author Marcus A. Bachhuber, M.D., call Katie Delach at 215-349-5964 or email[email protected]. To contact commentary author Marie J. Hayes, Ph.D., call Margaret Nagle at 207-581-3745 or email [email protected].

To place an electronic embedded link to this study in your story: Links for this study and commentary will be live at the embargo time: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.4005 and http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.2716.

JAMA Internal Medicine

Bottom Line: States that implemented medical marijuana laws appear to have lower annual opioid analgesic overdoses death rates (both from prescription pain killers and illicit drugs such as heroin) than states without such laws although the reason why is not clear.

Author: Marcus A. Bachhuber, M.D., of the Philadelphia Veterans Affairs Medical Center, and colleagues.

Background: Prescriptions for opioid painkillers for chronic pain have increased in the United States and so have overdose deaths. However, less attention has been focused on how the availability of alternative nonopioid treatment, such as medical marijuana, may affect overdose rates.

How the Study Was Conducted: The authors examined the implementation of state medical marijuana laws and opioid analgesic overdose deaths in the United States between 1999 and 2010. Three states had medical marijuana laws prior to 1999, 10 states implemented laws between 1999 and 2010 and nine states had laws that went into effect after 2010, which was beyond the study period. The authors also considered New Jersey’s law effective after the study period because it took effect in the last quarter of 2010. The authors analyzed state laws and death-certificate data.

Results: States with medical marijuana laws had a 24.8 percent lower average annual opioid overdose death rate compared to states without such laws. In 2010, that translated to about 1,729 fewer deaths than expected. The years after implementation of medical marijuana laws also were associated with lower overdose death rates that generally got stronger over time: year 1 (-19.9 percent), year 2 (-25.2 percent), year 3 (-23.6 percent), year 4 (-20.2 percent), year 5 (-33.7 percent) and year 6 (-33.3 percent).

Discussion: “In summary, although we found a lower mean annual rate of opioid analgesic mortality in states with medical cannabis laws, a direct causal link cannot be established. … If the relationship between medical cannabis laws and opioid analgesic overdose mortality is substantiated in further work, enactment of laws to allow for use of medical cannabis may be advocated as part of a comprehensive package of policies to reduce the population risk of opioid analgesics.”
 
drusso said:
And now for something completely different...

Lower Opioid Overdose Death Rates Associated with State Medical Marijuana Laws
EMBARGOED FOR RELEASE: 3 P.M. (CT), MONDAY, AUGUST 25, 2014

Media Advisory: To contact author Marcus A. Bachhuber, M.D., call Katie Delach at 215-349-5964 or email[email protected]. To contact commentary author Marie J. Hayes, Ph.D., call Margaret Nagle at 207-581-3745 or email [email protected].

To place an electronic embedded link to this study in your story: Links for this study and commentary will be live at the embargo time: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.4005 and http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.2716.

JAMA Internal Medicine

Bottom Line: States that implemented medical marijuana laws appear to have lower annual opioid analgesic overdoses death rates (both from prescription pain killers and illicit drugs such as heroin) than states without such laws although the reason why is not clear.

Author: Marcus A. Bachhuber, M.D., of the Philadelphia Veterans Affairs Medical Center, and colleagues.

Background: Prescriptions for opioid painkillers for chronic pain have increased in the United States and so have overdose deaths. However, less attention has been focused on how the availability of alternative nonopioid treatment, such as medical marijuana, may affect overdose rates.

How the Study Was Conducted: The authors examined the implementation of state medical marijuana laws and opioid analgesic overdose deaths in the United States between 1999 and 2010. Three states had medical marijuana laws prior to 1999, 10 states implemented laws between 1999 and 2010 and nine states had laws that went into effect after 2010, which was beyond the study period. The authors also considered New Jersey’s law effective after the study period because it took effect in the last quarter of 2010. The authors analyzed state laws and death-certificate data.

Results: States with medical marijuana laws had a 24.8 percent lower average annual opioid overdose death rate compared to states without such laws. In 2010, that translated to about 1,729 fewer deaths than expected. The years after implementation of medical marijuana laws also were associated with lower overdose death rates that generally got stronger over time: year 1 (-19.9 percent), year 2 (-25.2 percent), year 3 (-23.6 percent), year 4 (-20.2 percent), year 5 (-33.7 percent) and year 6 (-33.3 percent).

Discussion: “In summary, although we found a lower mean annual rate of opioid analgesic mortality in states with medical cannabis laws, a direct causal link cannot be established. … If the relationship between medical cannabis laws and opioid analgesic overdose mortality is substantiated in further work, enactment of laws to allow for use of medical cannabis may be advocated as part of a comprehensive package of policies to reduce the population risk of opioid analgesics.”
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THey probably just changed cause of death from opiate to polysubstance.
 
ill be surprised if this is not picked up by Big M as a reason to have more medical marijuana states.

the media will play with it - even though there is no direct causal relationship of MM laws to opioid rate in each specific state.
 
drusso said:
And now for something completely different...

Lower Opioid Overdose Death Rates Associated with State Medical Marijuana Laws
EMBARGOED FOR RELEASE: 3 P.M. (CT), MONDAY, AUGUST 25, 2014

Media Advisory: To contact author Marcus A. Bachhuber, M.D., call Katie Delach at 215-349-5964 or email[email protected]. To contact commentary author Marie J. Hayes, Ph.D., call Margaret Nagle at 207-581-3745 or email [email protected].

To place an electronic embedded link to this study in your story: Links for this study and commentary will be live at the embargo time: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.4005 and http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.2716.

JAMA Internal Medicine

Bottom Line: States that implemented medical marijuana laws appear to have lower annual opioid analgesic overdoses death rates (both from prescription pain killers and illicit drugs such as heroin) than states without such laws although the reason why is not clear.

Author: Marcus A. Bachhuber, M.D., of the Philadelphia Veterans Affairs Medical Center, and colleagues.

Background: Prescriptions for opioid painkillers for chronic pain have increased in the United States and so have overdose deaths. However, less attention has been focused on how the availability of alternative nonopioid treatment, such as medical marijuana, may affect overdose rates.

How the Study Was Conducted: The authors examined the implementation of state medical marijuana laws and opioid analgesic overdose deaths in the United States between 1999 and 2010. Three states had medical marijuana laws prior to 1999, 10 states implemented laws between 1999 and 2010 and nine states had laws that went into effect after 2010, which was beyond the study period. The authors also considered New Jersey’s law effective after the study period because it took effect in the last quarter of 2010. The authors analyzed state laws and death-certificate data.

Results: States with medical marijuana laws had a 24.8 percent lower average annual opioid overdose death rate compared to states without such laws. In 2010, that translated to about 1,729 fewer deaths than expected. The years after implementation of medical marijuana laws also were associated with lower overdose death rates that generally got stronger over time: year 1 (-19.9 percent), year 2 (-25.2 percent), year 3 (-23.6 percent), year 4 (-20.2 percent), year 5 (-33.7 percent) and year 6 (-33.3 percent).

Discussion: “In summary, although we found a lower mean annual rate of opioid analgesic mortality in states with medical cannabis laws, a direct causal link cannot be established. … If the relationship between medical cannabis laws and opioid analgesic overdose mortality is substantiated in further work, enactment of laws to allow for use of medical cannabis may be advocated as part of a comprehensive package of policies to reduce the population risk of opioid analgesics.”
Click to expand...

https://com-psychiatry-dpi.sites.medinfo.ufl.edu/files/2014/08/MMJ-Rx.pdf
 
Non scientific, but more chilled out patients on MJ, may feel they need to take less of their xanax + oxy, so they don't overdose. Still chemical copers, but breathing chemical copers
 
that link was very revealing, 101N. the first study did not seem to support the data out there:

a very quick googling got this from Washington - the rate of prescription overdose rate went from 0.4 per 100,000 in 1995 to 7.4 per 100,000 in 2010.

http://www.doh.wa.gov/portals/1/Documents/2900/DOH530090Poison.pdf

"Colorado has the second highest rate of prescription pill abuse in the country. Overdose, which is primarily caused by prescription opiates, killed twice as many Coloradans in 2010 than drunken driving related accidents,” said Lisa Raville, executive director of the Denver-based Harm Reduction Action Center.
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http://www.drugpolicy.org/news/2013...w-bill-expands-access-life-saving-overdose-an

and from the CDC, both Washington and Colorado are above the national average in OD rate. Average state overdose drug rate in 2007 was 11.9. Colorado clocked in at 15th at 14.6, Washington 14th at 14.7.

Oregon is just below national average at 11.4, but California is below at 10.4.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
 
We need to remember COI's when reading reports on THC. Is the department, or the PI, funded by industry or are tax dollars derived from industry earmarked to support the research.
UW, in particular, should be very circumspect here.
 
Hat tip to Dr. Melissa Weimer @ OHSU for this one:

http://www.ncbi.nlm.nih.gov/pubmed/...ng+disabled+medicare+beneficiaries+and+morden

Med Care. 2014 Sep;52(9):852-9. doi: 10.1097/MLR.0000000000000183.
Prescription opioid use among disabled medicare beneficiaries: intensity, trends, and regional variation.
Morden NE1, Munson JC, Colla CH, Skinner JS, Bynum JP, Zhou W, Meara E.
Author information

Abstract
BACKGROUND:
Prescription opioid use and overdose deaths are increasing in the United States. Among disabled Medicare beneficiaries under the age of 65, the rise in musculoskeletal conditions as qualifying diagnoses suggests that opioid analgesic use may be common and increasing, raising safety concerns.

METHODS:
From a 40% random-sample Medicare denominator, we identified fee-for-service beneficiaries under the age of 65 and created annual enrollment cohorts from 2007 to 2011 (6.4 million person-years). We obtained adjusted, annual opioid use measures: any use, chronic use (≥6prescriptions), intensity of use [daily morphine equivalent dose (MED)], and opioid prescribers per user. Geographic variation was studied across Hospital Referral Regions.

RESULTS:
Most measures peaked in 2010. The adjusted proportion with any opioid use was 43.9% in 2007, 44.7% in 2010, and 43.7% in 2011. The proportion with chronic use rose from 21.4% in 2007 to 23.1% in 2011. Among chronic users: mean MED peaked at 81.3 mg in 2010, declining to 77.4 mg in 2011; in 2011, 19.8% received ≥100 mg MED; 10.4% received ≥200 mg. In 2011, Hospital Referral Region-level measures varied broadly (5th-95th percentile): any use: 33.0%-58.6%, chronic use: 13.9%-36.6%; among chronic users, mean MED: 45 mg-125 mg; mean annual opioidprescribers: 2.4-3.7.

CONCLUSIONS:
Among these beneficiaries, opioid use was common. Although intensity stabilized, the population using opioids chronically grew. Variation shows a lack of a standardized approach and reveals regions with mean MED at levels associated with overdose risk. Future work should assess outcomes, chronic use predictors, and policies balancing pain control and safety.
 
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i wish they wouldnt call it an "antidote". yes, it reverses the effect, but it does nothing for the addiction....

also, of note, i remember the troll from several months ago who insisted most heroin comes from afghanistan. this article specifically states, supporting my position, that most of heroin comes from central america/columbia....
 
http://www.nytimes.com/2014/09/09/h...n-region&region=top-news&WT.nav=top-news&_r=0
To Curb Abuse, Patients Allowed to Return Unused Pills to Pharmacies
By CATHERINE SAINT LOUISSEPT. 8, 2014

Photo
09drug-master675.jpg

Chief of Police Douglas Hockenberry emptied medications that were anonymously deposited in a MedReturn box in police headquarters in Camp Hill, Pennsylvania. The state has 200 MedReturn boxes and plans to install 100 more.CreditJessica Kourkounis for The New York Times

Continue reading the main storyShare This Page
  • have soared in recent years.

    More than 70 percent of teenagers say it is easy to get prescription drugs from their parents’ medicine cabinets, according to a 2014 Partnership for Drug-Free Kids study.

    “The sooner we get those unused medications out of the home and medicine cabinets, the better and safer it is for everyone,” said Carmen A. Catizone, executive director of the National Association of Boards of Pharmacy.

    Until now, consumers have had limited options for the disposal of controlled substances. Twice annually, citizens could anonymously return them to police departments during thousands of national “take-back” events organized by the D.E.A.

    In the past four years, these events have removed from circulation 4.1 million pounds of prescription medications. (The next one is Saturday, Sept. 27, from 10 a.m. to 2 p.m.)

    Still, about 3.9 billion prescriptions were filled at pharmacies alone in 2013, according to the Kaiser Family Foundation.

    “They only removed an infinitesimal fraction of the reservoir of unused drugs that are out there,” said Dr. Nathaniel Katz, an assistant professor of anesthesia at Tufts University School of Medicine in Boston who studies opioid abuse. “It’s like trying to eliminate malaria in Africa by killing a dozen mosquitoes.”

    Dr. Katz is optimistic that the D.E.A.'s decision could have a powerful impact. Putting drop-off receptacles for controlled substances in pharmacies will mean consumers have year-round access to disposal services.

    It would be a “very positive” development if such access gets consumers in the habit of returning unused drugs to the pharmacies from which they were obtained, Dr. Katz said.

    “It’s more likely to accomplish the objective of minimizing the reservoir of potentially fatal medications in our medicine cabinets than can be accomplished by intermittent programs,” he said.

    Flushing controlled substances, especially prescriptions that might kill a child or pet with a single dose, remains an option for consumers, as is throwing out other prescriptions in zipped plastic bag mixed with kitty litter, but both are discouraged because of environmental concerns.

    The Environmental Protection Agency favors disposal through drug take-back programs over flushing to keep medicines from entering streams and rivers. Yet the Food and Drug Administration recommends flushing unused medications when the potential for harm someone in the household is great.

    The new programs will be voluntary. Pharmacies may choose to register with the drug agency to take back controlled substances or to receive leftovers through the mail.

    To minimize the risk that returned drugs might be stolen, the D.E.A. will require authorized collectors running mail-back programs to have and use an “on-site method of destruction to destroy returned packages.”

    Organizations collecting unused drugs could be pharmacies, including those within a clinic or a hospital, narcotic treatment programs or so-called “reverse distributors” — companies contracted by other collectors to destroy controlled substances. Retail pharmacies or hospitals and clinics with on-site pharmacies may manage collection receptacles at long-term care facilities.

    But some experts warned that there is no guarantee that pharmacies would establish take-back programs or set up collection receptacles, and that a number of issues must be resolved.

    Police departments often use incinerators, for example, to destroy seized illicit drugs, but a local pharmacy might not be able to accommodate an incinerator, limiting the number that could accept packages of prescriptions by mail.

    The new rules do not require a particular method of destruction, so as long as the drugs are permanently and irreversibly altered. Reverse distributors must do so within 30 days.

    Whether communities, pharmacies, insurance programs, patients or pharmaceutical companies must pay for disposal costs also is not addressed in the new rule.

    Mitch Rothholz, the chief strategy officer of the American Pharmacists Association, which supports the idea of pharmacy take-back programs generally, suggested that the costs of the system should not be “a burden on the pharmacy.”

    Keeping returned medications secure also poses challenges.

    To get prescribed drugs off the streets, police stations in 49 states have installed roughly 1,500 permanent steel boxes made by MedReturn, a Wisconsin company.

    Anytime the boxes “are available to the public, they have to be under law enforcement eyes, because they are gold at the end of the rainbow for someone with an opioid addiction,” said Gary Tennis, secretary of the department of drug and alcohol programs in Pennsylvania, which has 200 MedReturn boxes and plans to install 100 more.

    In a letter to the drug administration last year, the American Pharmacists Association expressed concern that pharmacies might be held legally liable should a secure drug drop-off receptacle be broken into and its contents stolen. Without more clarification, the association cautioned, “there may be limited participation by pharmacies.”

    But the biggest obstacle may be convincing the public that it is irresponsible to hold onto medications that are no longer needed.

    “With our opioid crisis, the level of overdoses we have and the amount of kids who are stealing these drugs, to be a good citizen you must get rid of your prescription drugs as soon as you’re finished with them,” Mr. Tennis said.
 
We've purchased one of these and donated it to our local sheriff's department.





101N said:
http://www.nytimes.com/2014/09/09/h...n-region&region=top-news&WT.nav=top-news&_r=0
To Curb Abuse, Patients Allowed to Return Unused Pills to Pharmacies
By CATHERINE SAINT LOUISSEPT. 8, 2014

Photo
09drug-master675.jpg

Chief of Police Douglas Hockenberry emptied medications that were anonymously deposited in a MedReturn box in police headquarters in Camp Hill, Pennsylvania. The state has 200 MedReturn boxes and plans to install 100 more.CreditJessica Kourkounis for The New York Times

Continue reading the main storyShare This Page
  • have soared in recent years.

    More than 70 percent of teenagers say it is easy to get prescription drugs from their parents’ medicine cabinets, according to a 2014 Partnership for Drug-Free Kids study.

    “The sooner we get those unused medications out of the home and medicine cabinets, the better and safer it is for everyone,” said Carmen A. Catizone, executive director of the National Association of Boards of Pharmacy.

    Until now, consumers have had limited options for the disposal of controlled substances. Twice annually, citizens could anonymously return them to police departments during thousands of national “take-back” events organized by the D.E.A.

    In the past four years, these events have removed from circulation 4.1 million pounds of prescription medications. (The next one is Saturday, Sept. 27, from 10 a.m. to 2 p.m.)

    Still, about 3.9 billion prescriptions were filled at pharmacies alone in 2013, according to the Kaiser Family Foundation.

    “They only removed an infinitesimal fraction of the reservoir of unused drugs that are out there,” said Dr. Nathaniel Katz, an assistant professor of anesthesia at Tufts University School of Medicine in Boston who studies opioid abuse. “It’s like trying to eliminate malaria in Africa by killing a dozen mosquitoes.”

    Dr. Katz is optimistic that the D.E.A.'s decision could have a powerful impact. Putting drop-off receptacles for controlled substances in pharmacies will mean consumers have year-round access to disposal services.

    It would be a “very positive” development if such access gets consumers in the habit of returning unused drugs to the pharmacies from which they were obtained, Dr. Katz said.

    “It’s more likely to accomplish the objective of minimizing the reservoir of potentially fatal medications in our medicine cabinets than can be accomplished by intermittent programs,” he said.

    Flushing controlled substances, especially prescriptions that might kill a child or pet with a single dose, remains an option for consumers, as is throwing out other prescriptions in zipped plastic bag mixed with kitty litter, but both are discouraged because of environmental concerns.

    The Environmental Protection Agency favors disposal through drug take-back programs over flushing to keep medicines from entering streams and rivers. Yet the Food and Drug Administration recommends flushing unused medications when the potential for harm someone in the household is great.

    The new programs will be voluntary. Pharmacies may choose to register with the drug agency to take back controlled substances or to receive leftovers through the mail.

    To minimize the risk that returned drugs might be stolen, the D.E.A. will require authorized collectors running mail-back programs to have and use an “on-site method of destruction to destroy returned packages.”

    Organizations collecting unused drugs could be pharmacies, including those within a clinic or a hospital, narcotic treatment programs or so-called “reverse distributors” — companies contracted by other collectors to destroy controlled substances. Retail pharmacies or hospitals and clinics with on-site pharmacies may manage collection receptacles at long-term care facilities.

    But some experts warned that there is no guarantee that pharmacies would establish take-back programs or set up collection receptacles, and that a number of issues must be resolved.

    Police departments often use incinerators, for example, to destroy seized illicit drugs, but a local pharmacy might not be able to accommodate an incinerator, limiting the number that could accept packages of prescriptions by mail.

    The new rules do not require a particular method of destruction, so as long as the drugs are permanently and irreversibly altered. Reverse distributors must do so within 30 days.

    Whether communities, pharmacies, insurance programs, patients or pharmaceutical companies must pay for disposal costs also is not addressed in the new rule.

    Mitch Rothholz, the chief strategy officer of the American Pharmacists Association, which supports the idea of pharmacy take-back programs generally, suggested that the costs of the system should not be “a burden on the pharmacy.”

    Keeping returned medications secure also poses challenges.

    To get prescribed drugs off the streets, police stations in 49 states have installed roughly 1,500 permanent steel boxes made by MedReturn, a Wisconsin company.

    Anytime the boxes “are available to the public, they have to be under law enforcement eyes, because they are gold at the end of the rainbow for someone with an opioid addiction,” said Gary Tennis, secretary of the department of drug and alcohol programs in Pennsylvania, which has 200 MedReturn boxes and plans to install 100 more.

    In a letter to the drug administration last year, the American Pharmacists Association expressed concern that pharmacies might be held legally liable should a secure drug drop-off receptacle be broken into and its contents stolen. Without more clarification, the association cautioned, “there may be limited participation by pharmacies.”

    But the biggest obstacle may be convincing the public that it is irresponsible to hold onto medications that are no longer needed.

    “With our opioid crisis, the level of overdoses we have and the amount of kids who are stealing these drugs, to be a good citizen you must get rid of your prescription drugs as soon as you’re finished with them,” Mr. Tennis said.
Click to expand...
 
http://www.twcc.com/articles/2014/09/24/a/anti-addiction-groups-call-for-new-fda-chief

Anti-addiction groups call for new FDA chief
WASHINGTON (AP) — Anti-addiction activists are calling for the Food and Drug Administration's top official to step down, saying the agency's policies have contributed to a national epidemic of prescription painkiller abuse.

In a letter released Wednesday, more than a dozen groups ask the Obama administration's top health official to replace FDA Commissioner Dr. Margaret Hamburg, who has led the agency since 2009. The FDA has been under fire from public health advocates, politicians and law enforcement officials since last October, when it approved a powerful new painkiller called Zohydro against the recommendation of its own medical advisers.

The new letter is the first formal call for new leadership at the FDA over the issue.

"We are especially frustrated by the FDA's continued approval of new, dangerous, high-dose opioid analgesics that are fueling high rates of addiction and overdose deaths," states the letter, which is addressed to Health and Human Services Secretary Sylvia Burwell, who oversees the FDA and other health agencies. The groups signing the letter include Physicians for Responsible Opioid Prescribing, a 900-member advocacy group that petitioned the FDA to drastically restrict opioid use. The FDA rejected that petition last year.

A spokesman for the Department of Health and Human Services said opioid abuse "is a serious issue and one that the secretary is focused on."

"Secretary Burwell appreciates hearing from stakeholders on the important issue of prescription opioid abuse, and looks forward to responding to their letter," said spokeswoman Tait Sye, in a statement.

Deaths linked to the addictive medications, including OxyContin and Vicodin, have more than tripled over the last 20 years to an estimated 17,000 in 2011, the most recent year for which the Centers for Disease Control and Prevention reports figures.

The CDC has called on doctors to limit their use of the medications to the most serious cases of pain, such as cancer patients and end-of-life care. But the vast majority of prescriptions written in the U.S. are for more common ailments like arthritis and back pain.

Hamburg has supported broad use of the drugs, noting that 100 million Americans reportedly suffer from chronic pain.

The letter to HHS says the commissioner and the FDA are out of step with efforts by the CDC and other parts of the federal government.

"Dr. Hamburg's support for using opioids to treat chronic non-cancer pain is squarely at odds with efforts by the CDC to discourage this widespread practice," states the letter, which is signed by the National Coalition Against Prescription Drug Abuse and 15 other groups.

FDA spokeswoman Erica Jefferson said Hamburg has been "a tireless public health advocate" for over 20 years.

"Preventing prescription opioid abuse and ensuring that patients have access to appropriate treatments for pain are both top public health priorities for the FDA," Jefferson said in a statement.

The calls for Hamburg's resignation come almost a year after the FDA approved Zohydro, the first extended-release, pure form of hydrocodone ever cleared for the U.S. market. Hydrocodone was previously only available in immediate release, combination pills that contain smaller amounts of the drug.

Commissioner Hamburg has defended the drug's approval by saying that it fills an important medical niche. Older combination pills like Vicodin mix hydrocodone with other drugs like acetaminophen, which can cause liver damage at high levels.

Members of Congress from West Virginia, Massachusetts and Kentucky have introduced bills to ban the drug. And attorneys general from 28 states asked the FDA to revoke the drug's approval or require that the pills be reformulated to prevent users from crushing them for snorting or injection.

But Wednesday's letter also criticizes the FDA for approving drugs that are actually designed to be harder to abuse.

The groups take issue with the agency's July approval of a new painkiller called Targiniq, which combines oxycodone with the ingredient naloxone. The addition of naloxone is designed to block the euphoric effects of oxycodone when it is snorted or injected. But the groups point out that Targiniq tablets can still be abused by simply chewing them — the most common approach to abusing painkillers.

The FDA has faced criticism from lawmakers representing states that have been hardest hit by opioid abuse, including Sen. Joe Manchin of West Virginia, Sen. Charles Schumer of New York and Congressman Hal Rogers of Kentucky.

Media representatives for all three lawmakers declined to comment on the letter. The American Pain Society, which represents physician pain specialists, also declined to comment for this story.
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Portenoy Opioid Talk Sparks Controversy
Published: Sep 28, 2014



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Russell Portenoy, MD, is still sought out as a key opinion leader on these drugs -- and his latest speaking engagement is at a 2-day National Institutes of Health workshop on opioids that begins Monday.

Sources within NIH have acknowledged that Portenoy's presence at the workshop (titled "The Role of Opioids in Treating Chronic Pain") may be seen as controversial -- not least because of a2012 Wall Street Journal article in which he admitted that he erred in overstating the benefits and diminishing the risks of opioid analgesics.

"[We] knew that Portenoy would bring an argument for when [opioids] are more useful, compared to those who oppose their use in almost any circumstance,"David Thomas, PhD, of the National Institute for Drug Abuse (NIDA) and meeting chair, told MedPage Today.

"The planning committee really wanted to represent the field and various aspects of the field," Thomas said. "In the two-and-a-half year planning process, we really tried to get balance and perspective."

Portenoy is a pain specialist at Beth Israel Medical Center and Albert Einstein College of Medicine in New York City. He gained renown in the 1980s and 1990s for advocating consideration of opioid painkillers for patients with chronic pain of all kinds, at a time when such use was discouraged. In the 2012 WSJ interview, he conceded that research had not backed up the effectiveness of opioids for these types of pain and that the risks of addiction and other adverse effects were greater than he previously had indicated.

But he has maintained that opioids still have a place in treating chronic noncancer pain.

Several other workshop participants declined to comment on the record about Portenoy's participation for this article.

Andrew Kolodny, MD, a critic of opioids and president of Physicians for Responsible Opioid Prescribing, who will attend the meeting, noted that it was not the decision of the entire work group to invite Portenoy.

"It is unfortunate that NIDA and the FDA invited someone with serious conflicts of interest," Kolodny said, "but there are some good experts involved."

The workshop is co-sponsored by NIDA, the NIH Office of Disease Prevention, the NIH Pain Consortium, and the National Institute of Neurological Disorders and Stroke.

Thomas said he hopes the 2-day program "will offer conclusions that lead to better use" of the drugs -- but few are convinced that will be the outcome. Even Portenoy acknowledged a "total lack of evidence" regarding long-term opioid use in chronic, noncancer pain.

Portenoy's paramount concern is that the opioid epidemic will negatively impact people who genuinely need their pain treated.

There's an "emerging signal in the U.S. that the current debate about appropriate levels [of opioids] for chronic pain is having negative consequences for some patients who are receiving opioids and having [their medications] reduced or denied," Portenoy said.

"If opioids are all that is available in a community and that people can access," Portenoy added, "to say categorically that this is the rule is just not justified. Doctors trying to help people with pain need to know what is feasible and available."

Kolodny disagreed that more cautious opioid prescribing would be bad for pain patients.

"Thousands of pain patients have been harmed because their physicians overestimated opioid effectiveness and underestimated risk," he told MedPage Today.

He added that he hoped the meeting would produce a strong statement about opioid use that would be put into practice by all stakeholders -- policymakers, professional organizations, and regulators.

This story contains additional reporting by Kristina Fiore.
 
lobelsteve said:
http://www.medpagetoday.com/PainMan...=breaking-news&xid=NL_breakingnews_2014-09-29


AAN: No role for opiates for HA, FMS, or LBP.
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I'm not referring to you Lobel, because I know you know the difference, but anyone who discusses treatment, what's indicted or not indicated, and refers to "LBP" or "HA" causes me to turn my ears off. LBP is a symptom, not a specific disease. HA is a symptom, not a specific condition. You cannot equate a FBS, severe facet disease, lumbar muscle strain or any of the other dozens of causes of back pain with each other. To say there's "no role for opiates in back pain," just shows the person makes no effort to diagnose their patients and treats them all the same; either all with opiates or all without. Is a 25-year old with an MRI-negative lumbar muscle strain "LBP" the same as a 65-yr old "LBP" with 3 failed back surgeries, residual scar and foraminal stenosis on MRI, severe diffuse facet disease above the fusion, and a grade II spondy that hasn't been fixed?

Hell no, they're not the same, and the treatments aren't either.

The fact that anyone who puts "Pain Physician" behind their name lumps the two together in one category, with the same indicated treatments and same contra-indicated treatments is very concerning, especially if their issuing so called policy statements that undoubtedly will be used by medical boards and regulators against physicians.

Part of the entire problem is that some physicians just see "back pain" or even just "pain" and conclude they're all the same, and all get the same final common treatment, ie opiates. No more should we equate them all and say they all need opiates, than we should equate them all and say they all shouldn't have a certain treatment, ie no opiates.

Also, this is basically an opinion piece from a single person. While I applaud the suggestion of dose limits, reducing the amount of diagnoses we use opiates for and having a much greater index of suspicion for med abuse and discontinuing therapy, there's a major glaring contradiction at the core of his article: on one hand he says the risks outweigh the benefits of opiates in chronic "low back pain, and headache" without actually breaking them down by cause or diagnosis, he then goes on to proceed how best to prescribe the drugs for chronic non-cancer pain. Which is it? Are the risks greater than the benefits in all these patients, or are they not? If they're not, don't tell everyone how to prescribe them, tell everyone to stop them immediately and taper. You can take the stance that a treatment doesn't work, causes addiction and death by overdose then proceed to write an article on how best to give that poison to your patients. If so, be intellectually honest and consistent, make the drugs all schedule I and ban them. Or, is it much more complicated than that, with some patients benefitting from the medications and others not, with some doctors prescribing them properly and others not?
 
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Without broad agreement on what constitutes a legitimate diagnosis (especially when the diagnosis is frequently speculative), it would be difficult to determine the appropriate use of opioids. It may be beneficial to not be so draconian and incisive about specific conditions or diagnoses delineation of inappropriate treatment. Perhaps using a 3 tier cautionary system would be of greater benefit. For instance those with a diagnosis of FMS, chronic tension HA, diffuse abdominal pain without etiology, chronic pancreatitis, etc could be a Tier 3: use opioids only in limited dosages if at all, and avoid dosage escalations. Tier 2 and Tier 1 could be defined to give broader agreement on opioids rather than "THOU SHALT NOT" verbage.
 
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algosdoc said:
Without broad agreement on what constitutes a legitimate diagnosis (especially when the diagnosis is frequently speculative), it would be difficult to determine the appropriate use of opioids. It may be beneficial to not be so draconian and incisive about specific conditions or diagnoses delineation of inappropriate treatment. Perhaps using a 3 tier cautionary system would be of greater benefit. For instance those with a diagnosis of FMS, chronic tension HA, diffuse abdominal pain without etiology, chronic pancreatitis, etc could be a Tier 3: use opioids only in limited dosages if at all, and avoid dosage escalations. Tier 2 and Tier 1 could be defined to give broader agreement on opioids rather than "THOU SHALT NOT" verbage.
Click to expand...
That's a good idea.
 
i agree in principle to what you are saying algos, but involvement by any group - particularly government - will inevitably turn this concept into GUIDELINES.

clinical judgement will then be subjected to someone else's interpretation of these GUIDELINES, with the possibility that pain physicians will be required - and patients empowered to ask - to prescribe opioids for certain conditions.

i prefer a system where opioid therapy is not expected and not offered, unless certain conditions are met - appropriate screening, appropriate assessment for safety of use, risk of addiction, risk of complications from side effects, and appropriate determination (and follow through) of functional goals with regards to low dose opioid therapy, with high dose therapy requiring greater introspection by a staff of health care providers including psych (not for palliative care patients, of course, and many cancer patients fall in this category).
 
I agree that the issues of appropriate screening, risk assessment, etc. are really more important that diagnoses. It would be nice to avoid the absolute preclusion of opioids based on a specific diagnosis.
 
algosdoc said:
I agree that the issues of appropriate screening, risk assessment, etc. are really more important that diagnoses. It would be nice to avoid the absolute preclusion of opioids based on a specific diagnosis.
Click to expand...
What the guy in the above article is talking about is precluding them for entire chief complaints, ie "low back pain" which would include many diagnoses and not even just single diagnoses. Could you imagine how many ICD 9 codes could fall under the broad category of "low back pain"?

That's why you'll never see any of my charts list "low back pain" then have an opiate Rx to follow. There's always something much more specific, ie, lumbar radic, post-laminectomy, imaging, or something more than, "You walked in complaining of 'low back pain' and I as a doctor could do no better than sending you out with a diagnosis of 'low back pain.'" To me that is a dead give away that someone made zero effort to determine what's causing the pain, and what the specific treatments may be, specific to the diagnosis.
 
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emd, technically post-lami syndrome is not a diagnosis as it does not identify the actual pain generator. Is it from epidural adhesions? facet mediated? discogenic? battered root syndrome? SIJ dysfunction? pseudoarthrosis? hardware failure? :p
 
EMD has WAY, WAY too much confidence in our ability to Dx the cause of LBP. This was Bogduk's delusion.
 
clubdeac said:
emd, technically post-lami syndrome is not a diagnosis as it does not identify the actual pain generator. Is it from epidural adhesions? facet mediated? discogenic? battered root syndrome? SIJ dysfunction? pseudoarthrosis? hardware failure? :p
Click to expand...
Any of those are a hell of a lot closer to a real diagnosis than "low back pain."

With PLS, I know exactly what caused the pain. Exactly.

A scalpel.

That's the pain generator. They had a knife attack to the back. That's something, for Pete's sake. Which is much better, and much more specific than "low back pain" and a "hell if I know but I still Rx'd opiates." Of course we cannot be 100% precise with the exact cause or generator of the pain 100% of the time, or even the majority of the time, but I think we should make an effort. That's the point. If you see a crushed nerve root you can be a little bit more sure. That's helpful to me, much more than a nebulous stack of normal MRIs and X-rays. Doesn't mean the person with normal imaging doesn't have pain, but I'm a heck of a lot more comfortable with my treatment plan than if I see "normal."

If there's no cause of the pain, and all your imaging is normal, why do you throw an opiate at it? If you're just guessing and throwing random treatments at the patient based on their self diagnosis of "pain" without any clue as to what's causing the pain, why not just randomly try, an ESI? Why not randomly just have them get more surgery? Why not randomly put them all on fibro meds?

Why opiates? To me, with opiates the bar is, and should be higher. That's why we're in the disastrous state were in. We decided in the '80s that the patient diagnoses them self, and the treatment defaults to opiates for all. No "cause" of pain needed. Pain is a "disease" itself, and only the patient can diagnose this disease and there's only one final common treatment, determined by the person making the diagnosis (the patient). Pain = opiates without any thought process=

Disastrous.

Once you equate all pain, stubbed toe = five failed back surgeries = crushed nerve root = metastatic bone cancer = no cause of pain = opiates for all, then you're done. Your not needed. You might as well hand over your prescribing pen. The patient no longer needs you, because "pain" gets to the opiates. Neither cause, diagnosis, no the physician get in between.

Even if you slap "fibromyalgia" on as a diagnosis, that's something to go on. It guides you in some direction, of possible treatments and others not indicated. If you start and stop with only a chief complaint, you've accomplished nothing.

Hey, I have my name on zero textbooks. Take it for what it's worth.
 
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101N said:
EMD has WAY, WAY too much confidence in our ability to Dx the cause of LBP. This was Bogduk's delusion.
Click to expand...
Well at least I'm in good company as his name is on a few of my text books, and none of that seemed to hold him back any. Lol

But hey, it's all good. I'm under no delusion of how difficult (if not impossible) it is to always be sure the source or existence of a patients pain. But if you want to sign a bunch of charts with no diagnosis more specific than "low back pain," "neck pain," or "headache," then prescribe a bunch of narcotics for that, then go right ahead. It's no bother to me.

All kidding aside, I'm no Bogduk here. I'm just a guy observing what's going in around me, watching the times change and trying to adapt. To me "neck pain" with facet spondylosis on an MRI is different than "neck pain" with perfectly normal MRIs, X-rays, and emgs. Again, until the "pain detector machine" is invented, I can never be sure how much pain does or doesn't come with a particular set of diagnostic studies, normal or abnormal. But in an era where the government is hot to throw docs in jail and pull licenses, I'm sure as hell am going to make sure I've got a specific diagnosis, that's defendable, even if I can't be 100% sure how much pain it is or isn't causing. I think if all you've got to go as far as the reason for why you prescribed an opiate is "The patient told me so," and "I trusted him," then you're exposing yourself to unnecessary medic-legal risk. Look what Webster just went through. Cleared after an investigation, but not until his clinic was SHUT DOWN.

Remember, we're judged by non-physicians who are DEA agents, juries, and medical board members that aren't necessarily Pain doctors. Put a diagnosis on there, for God's sake. It's not that hard. It will be a hell of a lot more respected and trusted if you put "discogenic pain" or "spondylolisthesis" or "facet disease" than "low back pain," to justify whatever treatment you've provided, opiates or otherwise. That already puts your level of care and documentation. way higher than most of these people getting into trouble with prescribing, whose charts show "(insert body part) pain" with no other clue how to go from there, but "pain must = opiates."

It still doesn't make me 100% sure any of that's causing said pain, but it sure as heck looks better if 100 charts are audited and they all show "low back pain" "neck pain" and "headache." Look for something concrete, and verifiable that could be causing the pain. It looks a helluva lot better than "I trusted him" with a shoulder shrug.

Hey, I have my name on zero textbooks. Take it for what it's worth.
 
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Article
emd123 said:
Well at least I'm in good company as his name is on a few of my text books, and none of that seemed to hold him back any.

But hey, it's all good. I'm under no delusion of how difficult (if not impossible) it is to always be sure the source or existence of a patients pain. But if you want to sign a bunch of charts with no diagnosis more specific than "low back pain," "neck pain," or "headache," then prescribe a bunch of narcotics for that, then go right ahead. It's no bother to me.

All kidding aside, I'm no Bogduk here. I'm just a guy observing what's going in around me, watching the times change and trying to adapt. To me "neck pain" with facet spondylosis on an MRI is different than "neck pain" with perfectly normal MRIs, X-rays, and emgs. Again, until the "pain detector machine" is invented, I can never be sure how much pain does or doesn't come with a particular set of diagnostic studies, normal or abnormal. But in an era where the government is hot to throw docs in jail and pull licenses, I'm sure as hell am going to make sure I've got a specific diagnosis, that's defendable, even if I can't be 100% sure how much pain it is or isn't causing. I think if all you've got to go as far as the reason for why you prescribed an opiate is "The patient told me so," and "I trusted him," then you're exposing yourself to unnecessary medic-legal risk. Look what Webster just went through. Cleared after an investigation, but not until his clinic was SHUT DOWN.

Remember, we're judged by non-physicians who are DEA agents, juries, and medical board members that aren't necessarily Pain doctors. Put a diagnosis on there, for God's sake. It's not that hard. It will be a hell of a lot more respected and trusted if you put "discogenic pain" or "spondylolisthesis" or "facet disease" than "low back pain," to justify whatever treatment you've provided, opiates or otherwise. That already puts your level of care and documentation. way higher than most of these people getting into trouble with prescribing, whose charts show "(insert body part) pain" with no other clue how to go from there, but "pain must = opiates."

It still doesn't make me 100% sure any of that's causing said pain, but it sure as heck looks better if 100 charts are audited and they all show "low back pain" "neck pain" and "headache." Look for something concrete, and verifiable that could be causing the pain. It looks a helluva lot better than "I trusted him" with a shoulder shrug.
Click to expand...

I completely agree. I call this, "thinking like a specialist." Move away from Gary Franklin's garbage diagnoses and use real medical/scientific terms. Document and chart as if you were going to present your patients at a multi-disciplinary grand rounds. Would you really say, "Lumbago?"
 
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while i agree in principle, a diagnosis does not justify an opioid trial. well, maybe "encounter for palliative care for terminal cancer"...

also, just to clarify (and be devils advocate) - its better to put anything down, even if it is in left field, than something that is more generic but more likely correct, eh?

and to further clarify - why do patients come in to see us? how many patients in your practice say "Hi doc, im here about my Spondylosis, lumbosacral, without myelopathy or radiculopathy"?

your diagnosis needs to start somewhere, and that somewhere is the patient complaint.

testing and imaging help determine treatment plan, and the suspected pain generator should be documented, but having a specific diagnosis usually will not impact discussion on opioid therapy (as there should be none)
 
Or we could limit opiate prescribing to ACGME pain specialists, and 2 weeks post-op, and 3 days for ER, and hospice.
Boom, problems solved. They show up by the hundreds and we say no to 90% of them.
 
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lobelsteve said:
Or we could limit opiate prescribing to ACGME pain specialists, and 2 weeks post-op, and 3 days for ER, and hospice.
Boom, problems solved. They show up by the hundreds and we say no to 90% of them.
Click to expand...

I think this is truly the way we should deal with our current mess.
 
How 100M becomes 40M

J Pain. 2014 Oct;15(10):979-84. doi: 10.1016/j.jpain.2014.05.009.
Prevalence of persistent pain in the u.s. Adult population: new data from the 2010 national health interview survey.
Kennedy J1, Roll JM2, Schraudner T3, Murphy S3, McPherson S2.
Author information

Abstract
Published adult prevalence estimates of chronic pain in the United States vary significantly. A more consistent pain measure is needed to assess unmet need for pain management in the general population. In this study, secondary analyses of the 2010 Quality of Life Supplement of the National Health Interview Survey are used to calculate the point prevalence of "persistent pain," which we defined as constant or frequent pain persisting for at least 3 months. Rates of persistent pain are also calculated by risk group, chronic condition, and disability status. Findings show that about 19.0% of adults in the United States report persistent pain. Rates of persistent pain are higher among women, adults aged 60 to 69, adults who rate their health as fair or poor, adults who are overweight or obese, and those who were hospitalized 1 or more times in the preceding year. Most adults who report conditions such as arthritis, carpal tunnel syndrome, or back or joint pain do not describe their pain as "persistent." Of the estimated 39.4 million adults who report persistent pain, 67.2% say their pain is "constantly present," and 50.5% say their pain is sometimes "unbearable and excruciating."

PERSPECTIVE:
Persistent pain, defined as self-reported pain "every day" or "most days" in the preceding 3 months, is a useful way to characterize health-related quality of life in the general population, and policy makers should consider including this core measure in ongoing health surveys like the National Health Interview Survey and the Medical Expenditure Panel Survey, the authors conclude.

Copyright © 2014 American Pain Society. Published by Elsevier Inc. All rights reserved.
 
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