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The prescription opioid epidemic in a nutshell
- Thread starter 101N
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Great work by Anthony Bourdain highlighting the opioid epidemic in MA: http://www.cnn.com/video/shows/anthony-bourdain-parts-unknown/massachusetts/index.html
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Saw it. Interesting.
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Well, would you looky there. PDMPs work, if you use them: http://www.cmajopen.ca/content/2/4/E256.full
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A who's who of our KOLs: http://www.businessweek.com/pdfs/chicago_pain_lawsuit.pdf
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http://www.bizjournals.com/portland...tion-is-this-newly-approved-pain.html?ana=fbk
2 of our own SDNers.
Painrounds fight club.
2 of our own SDNers.
Painrounds fight club.
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I don't think that we're really all that far apart on the issue...
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Only because you know he can kick your butt.
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except that I have cat-like reflexes...
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Where we may be headed:
http://m.theatlantic.com/health/arc...-experiments-with-prescription-heroin/383086/
http://m.theatlantic.com/health/arc...-experiments-with-prescription-heroin/383086/
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I predict that the outcome of the experiment will be a technical success and a practical failure. Lather, rinse, repeat...
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Map of the opioid prescribing epidemic: https://ppsg.medicine.wisc.edu/
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We need an overlay map. This one is consumption. We need prescription location. Many of our pill mills cater exclusively to out of state clients.
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A fellow in my state - Jim Shames - who has done a great job on reining in over prescribing has proposed a
'dash board' that will be 'pushed' to all prescribers. It will include MED, methadone, co-prescribing of benzo's
and sedatives, and metrics that suggest doctor shopping. My understanding is that our PDMP will begin
pushing these data to us next year.
'dash board' that will be 'pushed' to all prescribers. It will include MED, methadone, co-prescribing of benzo's
and sedatives, and metrics that suggest doctor shopping. My understanding is that our PDMP will begin
pushing these data to us next year.
Last edited:
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Now we are starting to drill deeper into the real causes of opioid overdoses.
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Much needed work.
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Doctors agree that prescription drugs are overused to treat pain, saying it is a significant problem.
Doctors say they think painkillers are prescribed too often.
By Kimberly Leonard Dec. 8, 2014 | 3:00 p.m. EST + More
Nine in 10 doctors report prescription drug abuse is a moderate to large problem in their communities, and 85 percent believe that prescription drugs are overused in clinical practice, a new doctor survey finds.
About half of doctors say they are less likely to prescribe prescription painkillers than they were a year ago, though the study did not seek to understand whether this was because they had seen adverse effects in their own patients or whether it was because of increased education within the medical community about prescription drug addiction, says Dr. G. Caleb Alexander, study leader and co-director of the Center for Drug Safety and Effectiveness at the Johns Hopkins School of Public Health. "There are many drivers of physicians’ prescribing patterns, ranging from their own clinical experiences to the effects of media, influential scientific publications, clinical practice guidelines and interactions with drug companies," he says.
The report, which surveyed 420 members from the American Medical Association and was published in the group's journal Monday, examined doctors' beliefs and self-reported practices about prescription drug abuse. It found that about 65 percent to 84 percent of doctors reported being "very" or "moderately" concerned about addiction, deaths or car accidents related to painkiller abuse.
“Our findings suggest that primary care providers have become aware of the scope of the prescription opioid crisis and are responding in ways that are important, including reducing their overreliance on these medicines,” Alexander said in a statement. “The health care community has long been part of the problem and now they appear to be part of the solution to this complex epidemic.”
[READ: Teens with Addiction Have Few Recovery Programs]
Though doctors admit to being concerned about the effects prescribing painkillers, 88 percent of respondents say they are confident in their skills related to prescribing, and nearly half are comfortable using the drugs for chronic non-cancer pain. "Doctors tend to be confident individuals, and in some cases, they may also underestimate the risks of these medicines relative to their benefits," Alexander says.
A press release from Hopkins also theorized that the attitudes may reflect the fact that doctors tend to perceive their own clinical skills and judgment as superior to that of their peers. Prior studies have shown that most doctors believe their colleagues’ prescribing decisions are swayed by pharmaceutical marketing and promotion, yet they themselves are immune to such effects.
One of the most common reasons people seek medical treatment is to alleviate chronic pain, which affects 116 million Americans, according to the National Institute on Drug Abuse. Often, doctors treat pain with prescription drugs called opioids or narcotics. Other pain-relief methods can include acupuncture, massage or physical therapy.
[ALSO: Few Depressed Americans Seek Care]
Most recent figures from the National Institute on Drug Abuse show that the use of prescription drugs nearly doubled between 2000 and 2010, leading to abuse, addiction, injury and death. A White House report from a few years ago found that prescription drug abuse is the nation's fastest growing drug problem. According to results from the 2010 National Survey on Drug Use and Health, an estimated 2.4 million Americans used prescription drugs nonmedically for the first time that year.
The drugs work by binding to receptors in the brain, blocking the feeling of pain, and are effective when used properly, though they are highly addictive. Medications include hydrocodone, oxycodone, morphine and codeine. When patients stop taking narcotics they can get cravings, become unable to sleep and develop mood swings. "Despite all of their dangers – and they do have many – opioids still play an important role in providing pain relief to some patients," Alexander says. "The problem isn’t that these medicines exist, but rather, that they have been widely used in settings beyond the evidence base, and at great cost to the public health."
[MORE: Most Americans With HIV Aren't Treated]
Drug abuse is defined by the National Library of Medicine as taking medication in a way that is different from what the doctor prescribed whether taking one that was prescribed for someone else, taking a larger dose that you are supposed to, snorting or injecting them when not directed to do so, or taking them with drugs or alcohol. These approaches can slow breathing, affecting the amount of oxygen that reaches the brain.
"Most of the preventable injuries and deaths from opioids during the past decade have been among patients using these drugs for non-cancer pain, and chronic or high dose opioid use for non-cancer pain can be especially dangerous," Alexander says.
In the survey, most doctors also reported high frequency of adverse events, including that tolerance occurred "often." Fifty-six percent reported physical dependence, and 36 percent reported ceiling effects, meaning additional doses fail to produce additional relief.
Doctors say they think painkillers are prescribed too often.
By Kimberly Leonard Dec. 8, 2014 | 3:00 p.m. EST + More
Nine in 10 doctors report prescription drug abuse is a moderate to large problem in their communities, and 85 percent believe that prescription drugs are overused in clinical practice, a new doctor survey finds.
About half of doctors say they are less likely to prescribe prescription painkillers than they were a year ago, though the study did not seek to understand whether this was because they had seen adverse effects in their own patients or whether it was because of increased education within the medical community about prescription drug addiction, says Dr. G. Caleb Alexander, study leader and co-director of the Center for Drug Safety and Effectiveness at the Johns Hopkins School of Public Health. "There are many drivers of physicians’ prescribing patterns, ranging from their own clinical experiences to the effects of media, influential scientific publications, clinical practice guidelines and interactions with drug companies," he says.
The report, which surveyed 420 members from the American Medical Association and was published in the group's journal Monday, examined doctors' beliefs and self-reported practices about prescription drug abuse. It found that about 65 percent to 84 percent of doctors reported being "very" or "moderately" concerned about addiction, deaths or car accidents related to painkiller abuse.
“Our findings suggest that primary care providers have become aware of the scope of the prescription opioid crisis and are responding in ways that are important, including reducing their overreliance on these medicines,” Alexander said in a statement. “The health care community has long been part of the problem and now they appear to be part of the solution to this complex epidemic.”
[READ: Teens with Addiction Have Few Recovery Programs]
Though doctors admit to being concerned about the effects prescribing painkillers, 88 percent of respondents say they are confident in their skills related to prescribing, and nearly half are comfortable using the drugs for chronic non-cancer pain. "Doctors tend to be confident individuals, and in some cases, they may also underestimate the risks of these medicines relative to their benefits," Alexander says.
A press release from Hopkins also theorized that the attitudes may reflect the fact that doctors tend to perceive their own clinical skills and judgment as superior to that of their peers. Prior studies have shown that most doctors believe their colleagues’ prescribing decisions are swayed by pharmaceutical marketing and promotion, yet they themselves are immune to such effects.
One of the most common reasons people seek medical treatment is to alleviate chronic pain, which affects 116 million Americans, according to the National Institute on Drug Abuse. Often, doctors treat pain with prescription drugs called opioids or narcotics. Other pain-relief methods can include acupuncture, massage or physical therapy.
[ALSO: Few Depressed Americans Seek Care]
Most recent figures from the National Institute on Drug Abuse show that the use of prescription drugs nearly doubled between 2000 and 2010, leading to abuse, addiction, injury and death. A White House report from a few years ago found that prescription drug abuse is the nation's fastest growing drug problem. According to results from the 2010 National Survey on Drug Use and Health, an estimated 2.4 million Americans used prescription drugs nonmedically for the first time that year.
The drugs work by binding to receptors in the brain, blocking the feeling of pain, and are effective when used properly, though they are highly addictive. Medications include hydrocodone, oxycodone, morphine and codeine. When patients stop taking narcotics they can get cravings, become unable to sleep and develop mood swings. "Despite all of their dangers – and they do have many – opioids still play an important role in providing pain relief to some patients," Alexander says. "The problem isn’t that these medicines exist, but rather, that they have been widely used in settings beyond the evidence base, and at great cost to the public health."
[MORE: Most Americans With HIV Aren't Treated]
Drug abuse is defined by the National Library of Medicine as taking medication in a way that is different from what the doctor prescribed whether taking one that was prescribed for someone else, taking a larger dose that you are supposed to, snorting or injecting them when not directed to do so, or taking them with drugs or alcohol. These approaches can slow breathing, affecting the amount of oxygen that reaches the brain.
"Most of the preventable injuries and deaths from opioids during the past decade have been among patients using these drugs for non-cancer pain, and chronic or high dose opioid use for non-cancer pain can be especially dangerous," Alexander says.
In the survey, most doctors also reported high frequency of adverse events, including that tolerance occurred "often." Fifty-six percent reported physical dependence, and 36 percent reported ceiling effects, meaning additional doses fail to produce additional relief.
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http://www.nytimes.com/2014/12/09/b...-use-more-of-them-for-longer-study-finds.html
Patients Prescribed Narcotic Painkillers Use More of Them for Longer, Study Finds
By KATIE THOMASDEC. 9, 2014
Inside
Photo
Overdoses of opioids like morphine led to 16,000 deaths in 2012, says the Centers for Disease Control and Prevention. Credit Stuart Isett for The New York Times
While a major public health campaign has had some success in reducing the number of people who take potentially addictive narcotic painkillers, those patients who are prescribed the drugs are getting more of them for a longer time, according to a new study.
Nearly half the people who took the painkillers for over 30 days in the study’s first year were still using them three years later, a sign of potential abuse.
The report, released on Tuesday by the pharmacy benefits manager Express Scripts, found that nearly 60 percent of patients taking the painkillers to treat long-term conditions were also being prescribed muscle relaxants or anti-anxiety drugs that could cause dangerous reactions.
The study looked at the pharmacy claims of 6.8 million Americans who filled at least one prescription for an opioid between 2009 and 2013. Opioids include commonly used drugs like codeine, morphine, oxycodone and hydrocodone.
“Not only are more people using these medications chronically, they are using them at higher doses than we would necessarily expect,” said Dr. Glen Stettin, a senior vice president at Express Scripts. “And they are using them in combinations for which there isn’t a lot of clinical justification.”
Overdoses involving prescription drugs are a leading cause of accidental death in the United States, and opioid painkillers play a role in about 70 percent of such cases, according to the federal Centers for Disease Control and Prevention. Opioid overdoses led to 16,000 deaths in 2012, the agency said.
In addition, people who abuse or misuse opioids often take benzodiazepines like the anti-anxiety drug Xanax, C.D.C. data shows.
With few exceptions, patients who are taking an opioid painkiller should not be prescribed other drugs with a sedative effect, such as muscle relaxants or benzodiazepines, because of a risk that the combined drugs could slow down the respiratory system.
The study found that nearly one-third of patients were prescribed an opioid and a benzodiazepine in the same month, and around the same percentage were prescribed a muscle relaxant and an opioid at the same time. About 8 percent of patients were taking all three types of drugs — a combination known as a “Houston cocktail,” which gives a heroinlike high — during the same period. And 27 percent were taking more than one opioid at a time, another hazardous combination.
Of the patients taking the mixtures, two-thirds were being prescribed the drugs by two or more doctors, and nearly 40 percent filled their prescriptions at more than one pharmacy, which could be a sign of poor coordination of medical care or an indication that a patient was shopping around for a doctor willing to prescribe a drug inappropriately, Dr. Stettin said.
“It begs for the use of active monitoring and also for better coordination of care,” he said.
Dr. Andrew J. Kolodny, chief medical official of Phoenix House, a drug treatment organization, said that the drop in overall opioid prescribing was a good sign. However, he said he was disturbed that doctors were continuing to give opioids to many patients for long periods of time.
“It suggests that we still have a lot more work to do in better informing the medical community that opioids may not be safe or effective for long-term chronic pain,” said Dr. Kolodny, who has been critical of opioid prescribing practices.
Most experts now believe that while helpful in treating pain from injuries and surgery, opioids should be discontinued as quickly as possible. However, the Express Scripts study found that a large percentage of patients, nearly half, who took an opioid for 30 days or more continued to use the drug long term. Dr. Stettin said patients with chronic pain should be receiving longer-acting drugs that work round the clock. But the study found that about half of those patients were taking short-acting opioids.
“It’s just not the proper way to manage chronic pain,” he said. “That’s a red flag that they are either not being managed correctly, or something else is going on.”
Other aspects of the report mirrored previous research on opioid painkillers. Their use is more prevalent among women and the elderly. Opioid use also varies greatly by geography: people in the Southeast — particularly those living in small cities in Kentucky, Alabama, Georgia and Arkansas — tended to use opioids in greater concentrations than in other regions of the country, especially large cities.
Dr. Stettin said he was heartened that overall use of opioids had fallen, especially for people using them to treat short-term ailments.
Given their addicting potential, he said, “It’s our hope that physicians remain reluctant to start people on an opioid pain medication when they’re not necessary, and that there’s an increase in public awareness that people shouldn’t want to get involved with these medications if they don’t need them.”
Patients Prescribed Narcotic Painkillers Use More of Them for Longer, Study Finds
By KATIE THOMASDEC. 9, 2014
Inside
Photo
Overdoses of opioids like morphine led to 16,000 deaths in 2012, says the Centers for Disease Control and Prevention. Credit Stuart Isett for The New York Times
While a major public health campaign has had some success in reducing the number of people who take potentially addictive narcotic painkillers, those patients who are prescribed the drugs are getting more of them for a longer time, according to a new study.
Nearly half the people who took the painkillers for over 30 days in the study’s first year were still using them three years later, a sign of potential abuse.
The report, released on Tuesday by the pharmacy benefits manager Express Scripts, found that nearly 60 percent of patients taking the painkillers to treat long-term conditions were also being prescribed muscle relaxants or anti-anxiety drugs that could cause dangerous reactions.
The study looked at the pharmacy claims of 6.8 million Americans who filled at least one prescription for an opioid between 2009 and 2013. Opioids include commonly used drugs like codeine, morphine, oxycodone and hydrocodone.
“Not only are more people using these medications chronically, they are using them at higher doses than we would necessarily expect,” said Dr. Glen Stettin, a senior vice president at Express Scripts. “And they are using them in combinations for which there isn’t a lot of clinical justification.”
Overdoses involving prescription drugs are a leading cause of accidental death in the United States, and opioid painkillers play a role in about 70 percent of such cases, according to the federal Centers for Disease Control and Prevention. Opioid overdoses led to 16,000 deaths in 2012, the agency said.
In addition, people who abuse or misuse opioids often take benzodiazepines like the anti-anxiety drug Xanax, C.D.C. data shows.
With few exceptions, patients who are taking an opioid painkiller should not be prescribed other drugs with a sedative effect, such as muscle relaxants or benzodiazepines, because of a risk that the combined drugs could slow down the respiratory system.
The study found that nearly one-third of patients were prescribed an opioid and a benzodiazepine in the same month, and around the same percentage were prescribed a muscle relaxant and an opioid at the same time. About 8 percent of patients were taking all three types of drugs — a combination known as a “Houston cocktail,” which gives a heroinlike high — during the same period. And 27 percent were taking more than one opioid at a time, another hazardous combination.
Of the patients taking the mixtures, two-thirds were being prescribed the drugs by two or more doctors, and nearly 40 percent filled their prescriptions at more than one pharmacy, which could be a sign of poor coordination of medical care or an indication that a patient was shopping around for a doctor willing to prescribe a drug inappropriately, Dr. Stettin said.
“It begs for the use of active monitoring and also for better coordination of care,” he said.
Dr. Andrew J. Kolodny, chief medical official of Phoenix House, a drug treatment organization, said that the drop in overall opioid prescribing was a good sign. However, he said he was disturbed that doctors were continuing to give opioids to many patients for long periods of time.
“It suggests that we still have a lot more work to do in better informing the medical community that opioids may not be safe or effective for long-term chronic pain,” said Dr. Kolodny, who has been critical of opioid prescribing practices.
Most experts now believe that while helpful in treating pain from injuries and surgery, opioids should be discontinued as quickly as possible. However, the Express Scripts study found that a large percentage of patients, nearly half, who took an opioid for 30 days or more continued to use the drug long term. Dr. Stettin said patients with chronic pain should be receiving longer-acting drugs that work round the clock. But the study found that about half of those patients were taking short-acting opioids.
“It’s just not the proper way to manage chronic pain,” he said. “That’s a red flag that they are either not being managed correctly, or something else is going on.”
Other aspects of the report mirrored previous research on opioid painkillers. Their use is more prevalent among women and the elderly. Opioid use also varies greatly by geography: people in the Southeast — particularly those living in small cities in Kentucky, Alabama, Georgia and Arkansas — tended to use opioids in greater concentrations than in other regions of the country, especially large cities.
Dr. Stettin said he was heartened that overall use of opioids had fallen, especially for people using them to treat short-term ailments.
Given their addicting potential, he said, “It’s our hope that physicians remain reluctant to start people on an opioid pain medication when they’re not necessary, and that there’s an increase in public awareness that people shouldn’t want to get involved with these medications if they don’t need them.”
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"Doctors agree that prescription drugs are overused to treat pain, saying it is a significant problem."
Of course they agree. The local doctors, whether interventionists or anyone taking care of non-malignant pain patients, regularly claim that they are strict, don't prescribe, don't agree with the routine use of opioid even when the data shows some of them prescribing to 90-100% of their Medicare population. https://projects.propublica.org/checkup/
Of course they agree. The local doctors, whether interventionists or anyone taking care of non-malignant pain patients, regularly claim that they are strict, don't prescribe, don't agree with the routine use of opioid even when the data shows some of them prescribing to 90-100% of their Medicare population. https://projects.propublica.org/checkup/
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http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=1
J Pain. 2014 Dec 5. pii: S1526-5900(14)01026-8. doi: 10.1016/j.jpain.2014.11.007. [Epub ahead of print]
Assessing Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose?
Liang Y1, Turner BJ2.
Author information
Abstract
Current research on the risk of opioid analgesics with drug overdose does not account for the total morphine equivalent dose (MED) of opioids filled by a patient. In this study, time from first opioid prescription until drug overdose was examined for 206,869 privately insured patients aged 18-64 with noncancer pain and >2 filled prescriptions for Schedule II or III opioids from 1/2009 to 7/2012. Opioid therapy was examined in 6-month intervals including 6 months before an overdose and categorized as mean daily MED (0, 1-19, 20-49, 50-99, >100 mg) and total MED divided at top quartile (0, 1-1830, >1830 mg). Survival analysis was used adjusting for demographics, clinical conditions, and psychoactive drugs. Relative to no opioid therapy, persons at highest risk for overdose (adjusted hazard ratios
of 2 to 3) received a daily MED of ≥100 mg regardless of total dose or a daily MED of 50-99 mg with a high total MED (>1,830 mg). The HR was significantly lower (1.43, 95% CI: 1.15 to 1.79) for 50-99 mg daily MED with a lower total MED (<1,830 mg), while HRs for lower daily MEDs did not differ by total dose. This analysis suggests that clinicians should consider total MED to assess risk of overdose for persons prescribed 50-99 mg daily MED.
PERSPECTIVE:
When addressing risks for drug overdose, this analysis supports the need for clinicians, administrators, and policymakers to monitor not only daily opioid dose but also total dose for patients receiving 50-99 daily MED.
Copyright © 2014 American Pain Society. Published by Elsevier Inc. All rights reserved.
J Pain. 2014 Dec 5. pii: S1526-5900(14)01026-8. doi: 10.1016/j.jpain.2014.11.007. [Epub ahead of print]
Assessing Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose?
Liang Y1, Turner BJ2.
Author information
Abstract
Current research on the risk of opioid analgesics with drug overdose does not account for the total morphine equivalent dose (MED) of opioids filled by a patient. In this study, time from first opioid prescription until drug overdose was examined for 206,869 privately insured patients aged 18-64 with noncancer pain and >2 filled prescriptions for Schedule II or III opioids from 1/2009 to 7/2012. Opioid therapy was examined in 6-month intervals including 6 months before an overdose and categorized as mean daily MED (0, 1-19, 20-49, 50-99, >100 mg) and total MED divided at top quartile (0, 1-1830, >1830 mg). Survival analysis was used adjusting for demographics, clinical conditions, and psychoactive drugs. Relative to no opioid therapy, persons at highest risk for overdose (adjusted hazard ratios
of 2 to 3) received a daily MED of ≥100 mg regardless of total dose or a daily MED of 50-99 mg with a high total MED (>1,830 mg). The HR was significantly lower (1.43, 95% CI: 1.15 to 1.79) for 50-99 mg daily MED with a lower total MED (<1,830 mg), while HRs for lower daily MEDs did not differ by total dose. This analysis suggests that clinicians should consider total MED to assess risk of overdose for persons prescribed 50-99 mg daily MED.
PERSPECTIVE:
When addressing risks for drug overdose, this analysis supports the need for clinicians, administrators, and policymakers to monitor not only daily opioid dose but also total dose for patients receiving 50-99 daily MED.
Copyright © 2014 American Pain Society. Published by Elsevier Inc. All rights reserved.
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The updated list. Please share:
Opioid Dose & Risk of Overdose
1.Opioid prescriptions for chronic pain and overdose: a cohort study.Dunn KM, Saunders
KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ,
Campbell CI, Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.
2.Emergency department visits among recipients of chronic opioid therapy. Braden JB,
Russo J, Fan MY, Edlund MJ, Martin BC, DeVries A, Sullivan MD.Arch Intern Med. 2010
Sep 13;170(16):1425-32.
3.Association between opioid prescribing patterns and opioid overdose-related
deaths.Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow
FC.JAMA. 2011 Apr 6;305(13):1315-21. doi: 10.1001/jama.2011.370.
4.Opioid dose and drug-related mortality in patients with nonmalignant pain.Gomes T,
Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN.Arch Intern Med. 2011 Apr 11;171(7):
686-91.
5.A history of being prescribed controlled substances and risk of drug overdose death.
Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W,
Loring LD. Pain Med. 2012 Jan;13(1):87-95.
6. High-risk use by patients prescribed opioids for pain and its role in overdose deaths.
Gwira Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W, Paulozzi LJ, Jones TF.
JAMA Intern Med. 2014 May;174(5):796-801.
7. Prescription Histories and Dose Strengths Associated with Overdose Deaths (pages
1187–1195) Anne Hirsch, Scott K. Proescholdbell, William Bronson and Nabarun
Dasgupta Article first published online: 15 FEB 2014 | DOI: 10.1111/pme.12391
8. Risk Factors for Serious Prescription Opioid-Related Toxicity or Overdose among
Veterans Health Administration Patients. Zedler B, Xie L, Wang L, Joyce A, Vick C,
Kariburyo F, Rajan P, Baser O, Murrelle L. Pain Med. 2014 Jun 14. doi: 10.1111/pme.
12480.
9. Clin J Pain. 2014 Jul;30(7):557-64. 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.
10..J Pain. 2014 Dec 5. pii: S1526-5900(14)01026-8. doi: 10.1016/j.jpain.2014.11.007. Assessing
Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose? Liang Y1, Turner BJ2.
Meta-Analyses of Opioids for CNP
1.Opioids compared to placebo or other treatments for chronic low-back pain Luis
Enrique Chaparro,*, Andrea D Furlan, Amol Deshpande3, Angela Mailis-Gagnon, Steven
Atlas, Dennis C Turk Editorial Group: Cochrane Back Group Published Online: 27 AUG
2013
2.Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and
association with addiction.Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales
KH, Kosten TR, Fiellin DA.Ann Intern Med. 2007 Jan 16;146(2):116-27. Review.
3. Opioids in chronic non-cancer pain: systematic review of efficacy and safety.
Kalso E, Edwards JE, Moore RA, McQuay HJ. Pain. 2004 Dec;112(3):372-80. Review.
4. The Effectiveness and Risks of Long-term Opioid Treatment of Chronic
Pain: http://effectivehealthcare.ahrq.gov...nic-pain-opioid-treatment-protocol-131219.pdf
Opioid Dose & Risk of Overdose
1.Opioid prescriptions for chronic pain and overdose: a cohort study.Dunn KM, Saunders
KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ,
Campbell CI, Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.
2.Emergency department visits among recipients of chronic opioid therapy. Braden JB,
Russo J, Fan MY, Edlund MJ, Martin BC, DeVries A, Sullivan MD.Arch Intern Med. 2010
Sep 13;170(16):1425-32.
3.Association between opioid prescribing patterns and opioid overdose-related
deaths.Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow
FC.JAMA. 2011 Apr 6;305(13):1315-21. doi: 10.1001/jama.2011.370.
4.Opioid dose and drug-related mortality in patients with nonmalignant pain.Gomes T,
Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN.Arch Intern Med. 2011 Apr 11;171(7):
686-91.
5.A history of being prescribed controlled substances and risk of drug overdose death.
Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W,
Loring LD. Pain Med. 2012 Jan;13(1):87-95.
6. High-risk use by patients prescribed opioids for pain and its role in overdose deaths.
Gwira Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W, Paulozzi LJ, Jones TF.
JAMA Intern Med. 2014 May;174(5):796-801.
7. Prescription Histories and Dose Strengths Associated with Overdose Deaths (pages
1187–1195) Anne Hirsch, Scott K. Proescholdbell, William Bronson and Nabarun
Dasgupta Article first published online: 15 FEB 2014 | DOI: 10.1111/pme.12391
8. Risk Factors for Serious Prescription Opioid-Related Toxicity or Overdose among
Veterans Health Administration Patients. Zedler B, Xie L, Wang L, Joyce A, Vick C,
Kariburyo F, Rajan P, Baser O, Murrelle L. Pain Med. 2014 Jun 14. doi: 10.1111/pme.
12480.
9. Clin J Pain. 2014 Jul;30(7):557-64. 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.
10..J Pain. 2014 Dec 5. pii: S1526-5900(14)01026-8. doi: 10.1016/j.jpain.2014.11.007. Assessing
Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose? Liang Y1, Turner BJ2.
Meta-Analyses of Opioids for CNP
1.Opioids compared to placebo or other treatments for chronic low-back pain Luis
Enrique Chaparro,*, Andrea D Furlan, Amol Deshpande3, Angela Mailis-Gagnon, Steven
Atlas, Dennis C Turk Editorial Group: Cochrane Back Group Published Online: 27 AUG
2013
2.Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and
association with addiction.Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales
KH, Kosten TR, Fiellin DA.Ann Intern Med. 2007 Jan 16;146(2):116-27. Review.
3. Opioids in chronic non-cancer pain: systematic review of efficacy and safety.
Kalso E, Edwards JE, Moore RA, McQuay HJ. Pain. 2004 Dec;112(3):372-80. Review.
4. The Effectiveness and Risks of Long-term Opioid Treatment of Chronic
Pain: http://effectivehealthcare.ahrq.gov...nic-pain-opioid-treatment-protocol-131219.pdf
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Express Scripts Report: A nation in pain 2014: http://lab.express-scripts.com/publications/~/media/d48ef3ee579848e7bf3f14af536d7548.ashx
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Couple of new interesting studies:
Pain Med. 2014 Dec 19. doi: 10.1111/pme.12634. [Epub ahead of print]
Dose Escalation During the First Year of Long-Term Opioid Therapy for Chronic Pain.
Henry SG1, Wilsey BL, Melnikow J, Iosif A.
Author information
OBJECTIVE:
To identify patient factors and health care utilization patterns associated with dose escalation during the first year of long-term opioid therapy for chronic pain.
DESIGN:
Retrospective cohort study using electronic health record data.
SETTING:
University health system.
SUBJECTS:
Opioid naïve adults with musculoskeletal pain who received a new outpatient opioid prescription between July 1, 2011 and June 30, 2012 and stayed on opioids for 1 year.
METHODS:
Mixed-effects regression was used to estimate patients' rate of opioid dose escalation. Demographics, clinical characteristics, and health care utilization for patients with and without dose escalation were compared.
RESULTS:
Twenty-three (9%) of 246 patients in the final cohort experienced dose escalation (defined as an increase in mean daily opioid dose of ≥30-mg morphine equivalents over 1 year). Compared with patients without dose escalation, patients with escalation had higher rates of substance use diagnoses (17% vs 1%, P = 0.01) and more total outpatient encounters (51 vs 35, P = 0.002) over 1 year. Differences in outpatient encounters were largely due to more non face-to-face encounters (e.g., telephone calls, emails) among patients with dose escalation. Differences in age, race, concurrent benzodiazepine use, and mental health diagnoses between patients with and without dose escalation were not statistically significant. Primary care clinicians prescribed 89% of opioid prescriptions.
CONCLUSIONS:
Dose escalation during the first year of long-term opioid therapy is associated with higher rates of substance use disorders and more frequent outpatient encounters, especially non face-to-face encounters.
See comment in PubMed Commons below
Drug Alcohol Depend. 2014 Dec 10. pii: S0376-8716(14)01975-9. doi: 10.1016/j.drugalcdep.2014.11.031. [Epub ahead of print]
Experience of adjunctive cannabis use for chronic non-cancer pain: Findings from the Pain and Opioids IN Treatment (POINT) study.
Degenhardt L1, Lintzeris N2, Campbell G3, Bruno R4, Cohen M5, Farrell M3, Hall WD6.
Abstract
BACKGROUND:
There is increasing debate about cannabis use for medical purposes, including for symptomatic treatment of chronic pain. We investigated patterns and correlates of cannabis use in a large community sample of people who had been prescribed opioids for chronic non-cancer pain.
METHODS:
The POINT study included 1514 people in Australia who had been prescribed pharmaceutical opioids for chronic non-cancer pain. Data on cannabis use, ICD-10 cannabis use disorder and cannabis use for pain were collected. We explored associations between demographic, pain and other patient characteristics and cannabis use for pain.
RESULTS:
One in six (16%) had used cannabis for pain relief, 6% in the previous month. A quarter reported that they would use it for pain relief if they had access. Those using cannabis for pain on average were younger, reported greater pain severity, greater interference from and poorer coping with pain, and more days out of role in the past year. They had been prescribed opioids for longer, were on higher opioid doses, and were more likely to be non-adherent with their opioid use. Those using cannabis for pain had higher pain interference after controlling for reported pain severity. Almost half (43%) of the sample had ever used cannabis for recreational purposes, and 12% of the entire cohort met criteria for an ICD-10 cannabis use disorder.
CONCLUSIONS:
Cannabis use for pain relief purposes appears common among people living with chronic non-cancer pain, and users report greater pain relief in combination with opioids than when opioids are used alone.
Pain Med. 2014 Dec 19. doi: 10.1111/pme.12634. [Epub ahead of print]
Dose Escalation During the First Year of Long-Term Opioid Therapy for Chronic Pain.
Henry SG1, Wilsey BL, Melnikow J, Iosif A.
Author information
- 1Department of Medicine, University of California Davis School of Medicine, Sacramento, California, USA; Center for Healthcare Policy and Research, University of California Davis, Sacramento, California, USA.
OBJECTIVE:
To identify patient factors and health care utilization patterns associated with dose escalation during the first year of long-term opioid therapy for chronic pain.
DESIGN:
Retrospective cohort study using electronic health record data.
SETTING:
University health system.
SUBJECTS:
Opioid naïve adults with musculoskeletal pain who received a new outpatient opioid prescription between July 1, 2011 and June 30, 2012 and stayed on opioids for 1 year.
METHODS:
Mixed-effects regression was used to estimate patients' rate of opioid dose escalation. Demographics, clinical characteristics, and health care utilization for patients with and without dose escalation were compared.
RESULTS:
Twenty-three (9%) of 246 patients in the final cohort experienced dose escalation (defined as an increase in mean daily opioid dose of ≥30-mg morphine equivalents over 1 year). Compared with patients without dose escalation, patients with escalation had higher rates of substance use diagnoses (17% vs 1%, P = 0.01) and more total outpatient encounters (51 vs 35, P = 0.002) over 1 year. Differences in outpatient encounters were largely due to more non face-to-face encounters (e.g., telephone calls, emails) among patients with dose escalation. Differences in age, race, concurrent benzodiazepine use, and mental health diagnoses between patients with and without dose escalation were not statistically significant. Primary care clinicians prescribed 89% of opioid prescriptions.
CONCLUSIONS:
Dose escalation during the first year of long-term opioid therapy is associated with higher rates of substance use disorders and more frequent outpatient encounters, especially non face-to-face encounters.
See comment in PubMed Commons below
Drug Alcohol Depend. 2014 Dec 10. pii: S0376-8716(14)01975-9. doi: 10.1016/j.drugalcdep.2014.11.031. [Epub ahead of print]
Experience of adjunctive cannabis use for chronic non-cancer pain: Findings from the Pain and Opioids IN Treatment (POINT) study.
Degenhardt L1, Lintzeris N2, Campbell G3, Bruno R4, Cohen M5, Farrell M3, Hall WD6.
Abstract
BACKGROUND:
There is increasing debate about cannabis use for medical purposes, including for symptomatic treatment of chronic pain. We investigated patterns and correlates of cannabis use in a large community sample of people who had been prescribed opioids for chronic non-cancer pain.
METHODS:
The POINT study included 1514 people in Australia who had been prescribed pharmaceutical opioids for chronic non-cancer pain. Data on cannabis use, ICD-10 cannabis use disorder and cannabis use for pain were collected. We explored associations between demographic, pain and other patient characteristics and cannabis use for pain.
RESULTS:
One in six (16%) had used cannabis for pain relief, 6% in the previous month. A quarter reported that they would use it for pain relief if they had access. Those using cannabis for pain on average were younger, reported greater pain severity, greater interference from and poorer coping with pain, and more days out of role in the past year. They had been prescribed opioids for longer, were on higher opioid doses, and were more likely to be non-adherent with their opioid use. Those using cannabis for pain had higher pain interference after controlling for reported pain severity. Almost half (43%) of the sample had ever used cannabis for recreational purposes, and 12% of the entire cohort met criteria for an ICD-10 cannabis use disorder.
CONCLUSIONS:
Cannabis use for pain relief purposes appears common among people living with chronic non-cancer pain, and users report greater pain relief in combination with opioids than when opioids are used alone.
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So much for concept of pseudo-addiction.
Pain. 2013 Nov;154(11):2487-93. doi: 10.1016/j.pain.2013.07.033. Epub 2013 Sep 24.
A pharmacoepidemiological cohort study of subjects starting strong opioids for nonmalignant pain: a study from the Norwegian Prescription Database.
Fredheim OM1, Borchgrevink PC, Mahic M, Skurtveit S.
Author information
Abstract
Clinical studies of short duration have demonstrated that strong opioids improve pain control in selected patients with chronic nonmalignant pain. However, high discontinuation rates and dose escalation during long-term treatment have been indicated. The aim of the present study was to determine discontinuation rates, dose escalation, and patterns of co-medication with benzodiazepines. The Norwegian Prescription Database provides complete national data at an individual level on dispensed drugs. A complete national cohort of new users of strong opioids was followed up for 5 years after initiation of therapy with strong opioids. Of the 17,248 persons who were new users of strong opioids in 2005, 7229 were dispensed a second prescription within 70 days and were assumed to be intended long-term users. A total of 1233 persons in the study cohort were still on opioidtherapy 5 years later. This equals 24% of the study cohort who were still alive. Of the participants, 21% decreased their annual opioid dose by 25% or more, whereas 21% kept a stable dose (± 24%) and 34% more than doubled their opioid dose from the first to the fifth year. High annual doses of opioids were associated with high annual doses of benzodiazepines at the end of follow-up. It is an issue of major concern that large dose escalationis common during long-term treatment, and that that high doses of opioids are associated with high doses of benzodiazepines. These findings make it necessary to question whether the appropriate patient population receives long-term opioid treatment.
Pain. 2013 Nov;154(11):2487-93. doi: 10.1016/j.pain.2013.07.033. Epub 2013 Sep 24.
A pharmacoepidemiological cohort study of subjects starting strong opioids for nonmalignant pain: a study from the Norwegian Prescription Database.
Fredheim OM1, Borchgrevink PC, Mahic M, Skurtveit S.
Author information
Abstract
Clinical studies of short duration have demonstrated that strong opioids improve pain control in selected patients with chronic nonmalignant pain. However, high discontinuation rates and dose escalation during long-term treatment have been indicated. The aim of the present study was to determine discontinuation rates, dose escalation, and patterns of co-medication with benzodiazepines. The Norwegian Prescription Database provides complete national data at an individual level on dispensed drugs. A complete national cohort of new users of strong opioids was followed up for 5 years after initiation of therapy with strong opioids. Of the 17,248 persons who were new users of strong opioids in 2005, 7229 were dispensed a second prescription within 70 days and were assumed to be intended long-term users. A total of 1233 persons in the study cohort were still on opioidtherapy 5 years later. This equals 24% of the study cohort who were still alive. Of the participants, 21% decreased their annual opioid dose by 25% or more, whereas 21% kept a stable dose (± 24%) and 34% more than doubled their opioid dose from the first to the fifth year. High annual doses of opioids were associated with high annual doses of benzodiazepines at the end of follow-up. It is an issue of major concern that large dose escalationis common during long-term treatment, and that that high doses of opioids are associated with high doses of benzodiazepines. These findings make it necessary to question whether the appropriate patient population receives long-term opioid treatment.
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Lawsuit seeks to make drugmaker pay for OxyContin abuse
Prescription drug abuse has killed more than 20,000 Americans a year, filled jails and treatment centers and spawned a resurgence in heroin use. And nowhere is the pill problem more prevalent than in Kentucky's Appalachians, where officials trace its roots to the aggressive marketing of one potent drug: OxyContin.
For seven years, they've forged ahead with a civil lawsuit that seeks to make drugmaker Purdue Pharma pay. As early as next year, it could bring the first-ever jury trial pitting Purdue against an addiction-plagued state over the painkiller, which experts say may lead more communities to file suits. Chicago and two California counties already have.
"This is about holding them accountable," says Kentucky Attorney General Jack Conway. "They played a pre-eminent role in the state's drug problem. This started to explode in the mid-1990s, when Purdue Pharma was marketing OxyContin. The resulting opiate epidemic … is a direct result."
The suit alleges that an aggressive and deceptive marketing campaign misled doctors, consumers and the government about OxyContin's addiction risk, ultimately saddling taxpayers with millions of dollars in social, health care and other costs.
Company lawyers in legal documents say more than a billion dollars is at stake and cite the potential for a "ruinous" verdict. As it's typically difficult to find drug companies liable for harm caused by their products, University of Louisville law professor Timothy Hall says Kentucky's lawsuit frames the issue in a new way, taking a page from the fight against Big Tobacco.
"We disagree on the merits of this lawsuit," says a statement from Richard Silbert, associate general counsel for Connecticut-based Purdue. "Courts in Kentucky and elsewhere have dismissed claims against Purdue because the evidence did not establish that our marketing caused the harm they alleged. We believe that the Commonwealth likewise" won't be able to show it.
No one doubts Kentucky has one of the nation's biggest drug problems. A common refrain in Kentucky's hardscrabble hills is that an entire generation has been lost to pain-pill abuse, with overdoses tearing children from parents and parents from children.
Former OxyContin addict Brad Ellis serves beef brisket that he prepared to program director Maurice Washington at Chad's Hope, a Christian drug addiction treatment center in Manchester, Ky. Ellis, who completed the recovery program at Chad's Hope himself, works as a chef for the organization and lives on the grounds with other staff and students.(Photo: Luke Sharrett for USA TODAY)
Brad Ellis, 37, of Louisa, Ky., says he was first prescribed OxyContin after a back injury while in the Army. By the time he got home in 2001, he was hooked. He went from doctor to doctor in Appalachia seeking pill scripts and paid people to bring him the drugs from pill mills in Florida. He crushed and snorted them for a quick high.
Addiction wrecked his life, leading to a divorce, broken relationships with children and parents, and jail time. He withered to 118 pounds, "a walking skeleton."
"It was almost a constant addiction for 17 years," said Ellis, who has been sober for 23 months. "Pain pills in this area are huge."
'DROVE THIS REGION CRAZY'
With more than its share of poverty, illness and chronic pain, Appalachia's coal country was vulnerable to pain pill abuse when this drug twice as potent as morphine came along.
Shortly after OxyContin's federal approval in 1995, the lawsuit alleges, Purdue employees promoted the long-acting oxycodone medication as less addictive than immediate-release opioids — telling some health care providers that the drug didn't even cause a buzz.
A 2004 report by the then-U.S. General Accounting Office says Purdue encouraged primary-care doctors to prescribe the drug for a wide range of injuries and conditions — not just severe pain with serious illnesses like cancer. The Drug Enforcement Administration complained that the company promoted this sort of prescribing to doctors who weren't well-trained in pain management, while also giving out OxyContin "starter coupons" for patients and promotional items such as fishing hats and plush seal toys, which are now sold online as collector's items.
OxyContin prescriptions for non-cancer pain shot up tenfold between 1997 and 2002.
In a May 2007 settlement of a Virginia criminal case, Purdue and three executives pleaded guilty to federal charges that they intentionally misled doctors, regulators and patients about OxyContin's addiction risk and potential for misuse. Purdue agreed to pay $600 million in fines; the executives, $34.5 million total. A portion went to reimburse states' Medicaid programs.
But Kentucky refused the $500,000 it was offered, filing its own lawsuit in Pike Circuit Court, with Pike County as a co-defendant. Purdue had it moved to federal court, and it resided in New York for years until being returned to Pike County, where Pike, but not the state, settled its claims.
All the while, Kentucky was drowning in a sea of prescription pills. OxyContin became so ubiquitous it was dubbed "hillbilly heroin." Retail distribution of oxycodone skyrocketed elevenfold between 1997 and 2010, and Kentuckians abused opioids and died of overdoses at some of the nation's highest rates.
"OxyContin changed the face of addiction in this region," says Dan Smoot, president of the eastern Kentucky anti-drug organization Operation UNITE. "It made addicts out of people who otherwise weren't. It drove this region crazy."
When the federal government approved an abuse-deterrent formulation of OxyContin in 2010, many addicts turned to other opioids — mostly pills, but also heroin.
"We've lost nearly an entire generation to prescription drug overdose while Big Pharma has reaped huge profits," said U.S. Rep. Harold "Hal" Rogers, a Republican. "I've been trying to hold (Purdue) accountable for years."
PURDUE HOPES TO PREVAIL
Silbert, the Purdue lawyer, agrees that prescription drug abuse is a serious problem and says that's why the company reformulated the drug to make it harder to snort or inject.
Purdue officials remain confident they will prevail — as they did in a 2001 Kentucky lawsuit brought by addicts. In that case, a U.S. District Court judge wrote that they "failed to produce any evidence showing that the defendants' marketing, promotional, or distribution practices have ever caused even one tablet of OxyContin to be inappropriately prescribed or diverted."
Purdue acknowledges the state's suit will be tougher, especially since their request to move it out of Pike County was denied. In a survey, their expert found that seven in 10 people agreed OxyContin has devastated local residents' lives.
The fight has now turned to the issue of "request for admissions," or what the plaintiff asks the defendant to admit — including allegations that Purdue caused OxyContin to be "excessively overprescribed."
Pike County Circuit Court Judge Steven Combs ruled that Purdue missed a deadline to respond to the state's admissions request, effectively meaning the company is considered to have admitted to the whole list — while he ruled the opposite way for co-defendant Abbott Laboratories. Purdue appealed the decision and lost, then appealed again to the state Supreme Court, which hasn't yet ruled.
If the decision isn't overturned, Purdue lawyers say that will limit them in defending themselves on the case's merits. Combs' orders "confront Purdue with the risk of an immense and ruinous judgment," and damages sought "could produce a record-breaking verdict," lawyers wrote in court documents.
Conway says he's preparing for trial but is open to a fair settlement and would like any money to go toward drug education and treatment.Treatment is what saved Ellis, who now works as a cook at Chad's Hope in Manchester, Ky., the faith-based treatment center where he got clean. Ellis blames only himself for his addiction and says only God could free him from its grip.
"God's what pulled me up," he says. "I don't even crave the drug anymore."
Prescription drug abuse has killed more than 20,000 Americans a year, filled jails and treatment centers and spawned a resurgence in heroin use. And nowhere is the pill problem more prevalent than in Kentucky's Appalachians, where officials trace its roots to the aggressive marketing of one potent drug: OxyContin.
For seven years, they've forged ahead with a civil lawsuit that seeks to make drugmaker Purdue Pharma pay. As early as next year, it could bring the first-ever jury trial pitting Purdue against an addiction-plagued state over the painkiller, which experts say may lead more communities to file suits. Chicago and two California counties already have.
"This is about holding them accountable," says Kentucky Attorney General Jack Conway. "They played a pre-eminent role in the state's drug problem. This started to explode in the mid-1990s, when Purdue Pharma was marketing OxyContin. The resulting opiate epidemic … is a direct result."
The suit alleges that an aggressive and deceptive marketing campaign misled doctors, consumers and the government about OxyContin's addiction risk, ultimately saddling taxpayers with millions of dollars in social, health care and other costs.
Company lawyers in legal documents say more than a billion dollars is at stake and cite the potential for a "ruinous" verdict. As it's typically difficult to find drug companies liable for harm caused by their products, University of Louisville law professor Timothy Hall says Kentucky's lawsuit frames the issue in a new way, taking a page from the fight against Big Tobacco.
"We disagree on the merits of this lawsuit," says a statement from Richard Silbert, associate general counsel for Connecticut-based Purdue. "Courts in Kentucky and elsewhere have dismissed claims against Purdue because the evidence did not establish that our marketing caused the harm they alleged. We believe that the Commonwealth likewise" won't be able to show it.
No one doubts Kentucky has one of the nation's biggest drug problems. A common refrain in Kentucky's hardscrabble hills is that an entire generation has been lost to pain-pill abuse, with overdoses tearing children from parents and parents from children.
Former OxyContin addict Brad Ellis serves beef brisket that he prepared to program director Maurice Washington at Chad's Hope, a Christian drug addiction treatment center in Manchester, Ky. Ellis, who completed the recovery program at Chad's Hope himself, works as a chef for the organization and lives on the grounds with other staff and students.(Photo: Luke Sharrett for USA TODAY)
Brad Ellis, 37, of Louisa, Ky., says he was first prescribed OxyContin after a back injury while in the Army. By the time he got home in 2001, he was hooked. He went from doctor to doctor in Appalachia seeking pill scripts and paid people to bring him the drugs from pill mills in Florida. He crushed and snorted them for a quick high.
Addiction wrecked his life, leading to a divorce, broken relationships with children and parents, and jail time. He withered to 118 pounds, "a walking skeleton."
"It was almost a constant addiction for 17 years," said Ellis, who has been sober for 23 months. "Pain pills in this area are huge."
'DROVE THIS REGION CRAZY'
With more than its share of poverty, illness and chronic pain, Appalachia's coal country was vulnerable to pain pill abuse when this drug twice as potent as morphine came along.
Shortly after OxyContin's federal approval in 1995, the lawsuit alleges, Purdue employees promoted the long-acting oxycodone medication as less addictive than immediate-release opioids — telling some health care providers that the drug didn't even cause a buzz.
A 2004 report by the then-U.S. General Accounting Office says Purdue encouraged primary-care doctors to prescribe the drug for a wide range of injuries and conditions — not just severe pain with serious illnesses like cancer. The Drug Enforcement Administration complained that the company promoted this sort of prescribing to doctors who weren't well-trained in pain management, while also giving out OxyContin "starter coupons" for patients and promotional items such as fishing hats and plush seal toys, which are now sold online as collector's items.
OxyContin prescriptions for non-cancer pain shot up tenfold between 1997 and 2002.
In a May 2007 settlement of a Virginia criminal case, Purdue and three executives pleaded guilty to federal charges that they intentionally misled doctors, regulators and patients about OxyContin's addiction risk and potential for misuse. Purdue agreed to pay $600 million in fines; the executives, $34.5 million total. A portion went to reimburse states' Medicaid programs.
But Kentucky refused the $500,000 it was offered, filing its own lawsuit in Pike Circuit Court, with Pike County as a co-defendant. Purdue had it moved to federal court, and it resided in New York for years until being returned to Pike County, where Pike, but not the state, settled its claims.
All the while, Kentucky was drowning in a sea of prescription pills. OxyContin became so ubiquitous it was dubbed "hillbilly heroin." Retail distribution of oxycodone skyrocketed elevenfold between 1997 and 2010, and Kentuckians abused opioids and died of overdoses at some of the nation's highest rates.
"OxyContin changed the face of addiction in this region," says Dan Smoot, president of the eastern Kentucky anti-drug organization Operation UNITE. "It made addicts out of people who otherwise weren't. It drove this region crazy."
When the federal government approved an abuse-deterrent formulation of OxyContin in 2010, many addicts turned to other opioids — mostly pills, but also heroin.
"We've lost nearly an entire generation to prescription drug overdose while Big Pharma has reaped huge profits," said U.S. Rep. Harold "Hal" Rogers, a Republican. "I've been trying to hold (Purdue) accountable for years."
PURDUE HOPES TO PREVAIL
Silbert, the Purdue lawyer, agrees that prescription drug abuse is a serious problem and says that's why the company reformulated the drug to make it harder to snort or inject.
Purdue officials remain confident they will prevail — as they did in a 2001 Kentucky lawsuit brought by addicts. In that case, a U.S. District Court judge wrote that they "failed to produce any evidence showing that the defendants' marketing, promotional, or distribution practices have ever caused even one tablet of OxyContin to be inappropriately prescribed or diverted."
Purdue acknowledges the state's suit will be tougher, especially since their request to move it out of Pike County was denied. In a survey, their expert found that seven in 10 people agreed OxyContin has devastated local residents' lives.
The fight has now turned to the issue of "request for admissions," or what the plaintiff asks the defendant to admit — including allegations that Purdue caused OxyContin to be "excessively overprescribed."
Pike County Circuit Court Judge Steven Combs ruled that Purdue missed a deadline to respond to the state's admissions request, effectively meaning the company is considered to have admitted to the whole list — while he ruled the opposite way for co-defendant Abbott Laboratories. Purdue appealed the decision and lost, then appealed again to the state Supreme Court, which hasn't yet ruled.
If the decision isn't overturned, Purdue lawyers say that will limit them in defending themselves on the case's merits. Combs' orders "confront Purdue with the risk of an immense and ruinous judgment," and damages sought "could produce a record-breaking verdict," lawyers wrote in court documents.
Conway says he's preparing for trial but is open to a fair settlement and would like any money to go toward drug education and treatment.Treatment is what saved Ellis, who now works as a cook at Chad's Hope in Manchester, Ky., the faith-based treatment center where he got clean. Ellis blames only himself for his addiction and says only God could free him from its grip.
"God's what pulled me up," he says. "I don't even crave the drug anymore."
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Pain:
December 2014 - Volume 155 - Issue 12 - p 2441–2443
doi: 10.1016/j.pain.2014.09.011
Commentary
Burden of disease is often aggravated by opioid treatment of chronic pain patients: Etiology and prevention
Breivik, Harald*; Stubhaug, Audun
Free Access
[email protected]
For more than two decades, Danish doctors have prescribed opioids for chronic noncancer pain more liberally than have doctors in the neighboring countries. We have been looking to Denmark for the long‐term effects of this liberal practice [4] that, as early as 2003, Jφrgen Eriksen called “working in a minefield” [4,11]. In this issue of Pain,Ekholm and coworkers in Per Sjφgren’s research group report data from the ongoing health surveys in Denmark: They followed 13,127 persons from the 2000 and 2005 surveys for up to 11years. In all, 20% (2557) had chronic pain, and 7% of these (167) were on long‐term and 15% (375) on short‐term opioid therapy at baseline [10]. Their data are from face‐to‐face interviews of the cohorts in 2000 and 2005 and from the Danish national registries of drug prescriptions, hospital admissions, and causes of death.
Patients with chronic pain not on opioids and those on short‐term opioid therapy had increased risk of all cause mortality compared with persons without chronic pain (odds ratio [OR)=1.4, P<.01). These findings agree with other cohort studies that followed up participants for as many as 17years [18,20,24,33]. Those participants treated long term with opioids in the year preceding the surveys in 2000 and 2005 had almost double the risk of death (OR=1.8; 95% confidence interval [CI]=1.3–2.4) up until end of 2011 compared with pain‐free persons, but were not significantly different from chronic pain patients without opioids or those on short‐term opioid treatment. When corrected for possible confounding factors (age, gender, education, co‐habitation, smoking, alcohol intake, body mass index, Charlson Co‐morbidity Index), the risk of death was slightly less (OR=1.7). The investigators did not find any specific causes of death. Previously reported increased risk of death from cancer [20] or cardiovascular disease[20,24,33] in chronic pain patients was not found in chronic pain patients with or without opioid treatment by Ekholm et al. [10]. They did not report any overdose deaths or suicides in the long‐term opioid‐using group. Suicides occurred in 1/10,000person‐years among those with chronic pain (not using opioids) and those without.
Thus, Ekholm et al. [10] documented that opioid treatment does not significantly increase the already high risk of death among chronic pain patients in Denmark. With only 167 patients on long‐term opioid treatment at baseline, there is a real risk of underestimating the increased risk of death by opioid therapy. Unfortunately, in this study there are no data on diversion and overdose deaths among other users of opioids in Denmark. Our impression of the Scandinavian scene is that it is nothing like the mega‐numbers of prescription opioid overdose statistics from the United States [25]. It may well be that the robust health care system in Denmark, and the focus on ill effects of uncritical opioid prescribing during the last 10years in Denmark [11]and the other Nordic countries [4], appear to have prevented such opioid‐misuse catastrophes that now are highly visible in the United States [25].
Back to Top | [10]. The long‐term opioid treated pain patients had even higher risk of injuries or intoxication than the chronic pain patients who were not on opioid treatment, but not significantly different from those who were treated short‐term with opioids [10].
Chronic pain patients have a poor quality of life [19,34], high risk of disability [19,23], depression [22], and an increased risk of suicide attempts [31]. Inactivity, economic ruin, social isolation, stigma, and co‐morbidities all probably contribute to the increased risk of injuries and intoxication compared with that in persons without chronic pain[10].
Inappropriate long‐term opioid treatment obviously can aggravate the already‐high burden of disease in chronic pain patients. We do not know the long‐term outcome of pain management with opioids in the 167 patients on long‐term opioid treatment at baseline in 2000 and 2005, or what happened to those on short‐term opioids, or those not on opioid treatments at baseline [10]. The results of this study would be more valuable if we had information on what happened to opioid treatment during the 6‐ to 11years after baseline. In an analysis in 2005 of some of the sample from 2000, it appears that more than 9% recovered annually, 4 times more often in persons not on opioids than those on opioid therapy in 2000 [30]. So how did this changing therapy affect the results in 2011? Clearly one cannot assume that the treatment regimens at baseline were constant during these long years with chronic pain. Unfortunately, there is no information about dose or how many of the 542 patients exposed to opioids in 2000 and in 2005 developed problematic opioid use or iatrogenic opioid addiction.
Back to Top | [2], the endocrinopathies [27], immunosuppression [29], and malnutrition [21].
Potentially dangerous interactions can occur between opioids and other drugs prescribed for chronic pain or for other health problems. Opioids can cause QT prolongation, well known during methadone treatment [7], but this can occur with other opioids as well, for example, oxycodone [13]. Drugs that can increase the risk of QT prolongation and polymorphic ventricular arrhythmias from opioids are antidepressants, antibiotics, and a long list of other drugs [8]. Benzodiazepines and alcohol increase the sedative effects of opioids, increasing the risk of pneumonia in older adults [9].
Interference with metabolism of potent opioids, again best documented for methadone [7], can be caused by many drugs (psychotropic drugs, antibiotics, anticonvulsants, antihistamines, and antiretroviral drugs). A case report illustrates well how ciprofloxacin can cause accumulation of methadone, severe sedation, and respiratory depression [17].
Serious serotonin syndrome can be caused by several opioids, tramadol in particular, but also fentanyl [26], especially when interacting with serotoninergic antidepressants prescribed for chronic pain or for the depression that is present in up to 100% of chronic pain patients [22]. These serotoninergic complications are dangerous because many doctors still do not recognize in time [2] the typical triad with the following:
a. mental symptoms (nervous, anxious, agitated, poor‐quality sleep),
b. increased sympathetic nervous system activity (high blood pressure, tachycardia, diaphoresis, mydriasis, lively intestinal motility),
c. and the most typical—augmented tendon reflexes with inducible myoclonus [2,3].
Treatment involves stopping all serotoninergic drugs. However, once hyperpyrexia appears, the serotonin syndrome is rapidly fatal unless intensive medical care is applied, with serotonin‐antagonists and life‐saving cardio‐respiratory support [2,26]. This diagnosis is easily missed in a post mortem examination.
Reports of tramadol‐related deaths are increasing in countries where tramadol is prescribed for chronic pain [15]. These deaths cannot be due to respiratory depression from this weak opioid agonist [32]; rather, they may be caused by unrecognized and untreated serotonin syndrome from tramadol, potentiated by other serotoninergic medications [2,3,26]. Denmark has a higher use of tramadol for chronic pain than the other Nordic countries [16].
Back to Top | [10,11]. The “flood of opioids” has caused “a rising tide of death” in the United States [25]. This rising tide of prescription opioid–related overdose deaths has not reached the Nordic countries. This is true also for Denmark, with its long history of liberal prescription of opioids. This may be due to the warnings from Jφrgen Eriksen, Per Sjφgren, and others about dangers of too liberal opioid prescribing during the last decade [11]. Still, the U.S. experience may cause the opioid policy pendulum to swing back (again!) to the restrictive opioid regulations that we had before the 1980s. The many mitigating actions in that direction taken by the authorities in the United States appear to have limited effects on abuse, while already reducing access to opioids for chronic opioid‐sensitive pain [1,12]. Finding the right balance between too liberal and too restrictive opioid regulations will continue to be a major challenge in pain medicine for a long while [12].
Back to Top | [14]but continues to be a double‐edged sword that is difficult to handle [5]. It requires deep pharmacological knowledge, experience, resources, considerable patience, and mental energy from a group of helpers who are able to take care of the whole bio‐psycho‐social conundrum of the chronic pain patient [5,28]. GPs should not start long‐term opioid treatment without being in collaboration with a pain center. Torsten Gordh’s pain center in Uppsala, Sweden, in collaboration with the addiction medicine department, documented that it is possible to rehabilitate opioid‐misusing chronic pain patients back to long‐term satisfactory pain relief and quality of life [28]. They accomplish this by converting the failed opioid treatment to methadone, in addition to helping the patients with other aspects of their chronic disease [28].
It is difficult to predict who will eventually develop problematic opioid use. Therefore, all chronic patients with opioid‐sensitive pain who are offered long‐term opioid treatment must have a strict regimen from day 1: Collaboration with 1 pharmacy, 1 pain management group, with 1 responsible pain specialist (with a stand‐in), and with the patient’s general practitioner. Frequent evaluation of effects and adverse effects is mandatory. Opioid therapy must be discontinued as soon as it is clear that lack of pain relief and adverse effects are detrimental to the patient’s health. This is the difficult part of long‐term opioid therapy for chronic pain. It is demanding for patients as well as for health care providers. Starting is easy; stopping becomes increasingly difficult with time. The reward system is involved from the first dose; tapering and stopping inappropriate opioid treatment may be difficult already after a few months. This is in part due to withdrawal causing increased pain sensitivity, with break‐through pain aggravating the original pain condition. The easy way, when pain relief is not satisfactory, is to escalate the dose. This brings the patients and their health care providers into the “minefield” described by Jφrgen Eriksen more than 10years ago [4,11].
Howard Fields expressed a “glimmer of hope” that we will have safer opioids in the future by combining a MOP‐receptor agonist, responsible for analgesia, reward, and addiction, with a DOP receptor antagonist, reducing the undesirable effects while retaining the analgesic effects of the MOP‐agonist [12]. There are also ongoing clinical trials with a NOP (nociceptin‐orphanin) receptor agonist, cebranopadol, that has a profile of effects different from MOP agonists (www.clinicaltrials.gov).
The art of helping chronic pain patients with opioid‐sensitive pain has become even more challenging in recent years by the frequent adverse interactions with other drugs that now are commonly prescribed for chronic pain. Still, going back to the intense opiophobic conditions of the 20th century is not possible. Long‐term, double‐blind, placebo‐controlled RCTs on opioid treatment are difficult and costly. However, a 6‐month (+1month follow‐up after unblinding) RCT showed that it is possible to maintain blinding with opioid doses in a safe and effective dose range [6]. It also showed how the positive “context‐sensitive therapeutic effect” continued to have a strong and increasing effect on subjective pain from hip and knee osteoarthritis during the entire double‐blinded period of half a year [6]. A pharmaceutical company sponsored that study. It is time that our health care authorities sponsor investigator‐initiated, large studies to determine the true cost–benefit profile of long‐term opioid treatment. Otherwise, we will continue to fumble our way forward, depending on the best possible indirect epidemiological outcome studies, like the Ekholm et al. study reported in this issue of Pain [10].
December 2014 - Volume 155 - Issue 12 - p 2441–2443
doi: 10.1016/j.pain.2014.09.011
Commentary
Burden of disease is often aggravated by opioid treatment of chronic pain patients: Etiology and prevention
Breivik, Harald*; Stubhaug, Audun
Free Access
[email protected]
For more than two decades, Danish doctors have prescribed opioids for chronic noncancer pain more liberally than have doctors in the neighboring countries. We have been looking to Denmark for the long‐term effects of this liberal practice [4] that, as early as 2003, Jφrgen Eriksen called “working in a minefield” [4,11]. In this issue of Pain,Ekholm and coworkers in Per Sjφgren’s research group report data from the ongoing health surveys in Denmark: They followed 13,127 persons from the 2000 and 2005 surveys for up to 11years. In all, 20% (2557) had chronic pain, and 7% of these (167) were on long‐term and 15% (375) on short‐term opioid therapy at baseline [10]. Their data are from face‐to‐face interviews of the cohorts in 2000 and 2005 and from the Danish national registries of drug prescriptions, hospital admissions, and causes of death.
Patients with chronic pain not on opioids and those on short‐term opioid therapy had increased risk of all cause mortality compared with persons without chronic pain (odds ratio [OR)=1.4, P<.01). These findings agree with other cohort studies that followed up participants for as many as 17years [18,20,24,33]. Those participants treated long term with opioids in the year preceding the surveys in 2000 and 2005 had almost double the risk of death (OR=1.8; 95% confidence interval [CI]=1.3–2.4) up until end of 2011 compared with pain‐free persons, but were not significantly different from chronic pain patients without opioids or those on short‐term opioid treatment. When corrected for possible confounding factors (age, gender, education, co‐habitation, smoking, alcohol intake, body mass index, Charlson Co‐morbidity Index), the risk of death was slightly less (OR=1.7). The investigators did not find any specific causes of death. Previously reported increased risk of death from cancer [20] or cardiovascular disease[20,24,33] in chronic pain patients was not found in chronic pain patients with or without opioid treatment by Ekholm et al. [10]. They did not report any overdose deaths or suicides in the long‐term opioid‐using group. Suicides occurred in 1/10,000person‐years among those with chronic pain (not using opioids) and those without.
Thus, Ekholm et al. [10] documented that opioid treatment does not significantly increase the already high risk of death among chronic pain patients in Denmark. With only 167 patients on long‐term opioid treatment at baseline, there is a real risk of underestimating the increased risk of death by opioid therapy. Unfortunately, in this study there are no data on diversion and overdose deaths among other users of opioids in Denmark. Our impression of the Scandinavian scene is that it is nothing like the mega‐numbers of prescription opioid overdose statistics from the United States [25]. It may well be that the robust health care system in Denmark, and the focus on ill effects of uncritical opioid prescribing during the last 10years in Denmark [11]and the other Nordic countries [4], appear to have prevented such opioid‐misuse catastrophes that now are highly visible in the United States [25].
Back to Top | [10]. The long‐term opioid treated pain patients had even higher risk of injuries or intoxication than the chronic pain patients who were not on opioid treatment, but not significantly different from those who were treated short‐term with opioids [10].
Chronic pain patients have a poor quality of life [19,34], high risk of disability [19,23], depression [22], and an increased risk of suicide attempts [31]. Inactivity, economic ruin, social isolation, stigma, and co‐morbidities all probably contribute to the increased risk of injuries and intoxication compared with that in persons without chronic pain[10].
Inappropriate long‐term opioid treatment obviously can aggravate the already‐high burden of disease in chronic pain patients. We do not know the long‐term outcome of pain management with opioids in the 167 patients on long‐term opioid treatment at baseline in 2000 and 2005, or what happened to those on short‐term opioids, or those not on opioid treatments at baseline [10]. The results of this study would be more valuable if we had information on what happened to opioid treatment during the 6‐ to 11years after baseline. In an analysis in 2005 of some of the sample from 2000, it appears that more than 9% recovered annually, 4 times more often in persons not on opioids than those on opioid therapy in 2000 [30]. So how did this changing therapy affect the results in 2011? Clearly one cannot assume that the treatment regimens at baseline were constant during these long years with chronic pain. Unfortunately, there is no information about dose or how many of the 542 patients exposed to opioids in 2000 and in 2005 developed problematic opioid use or iatrogenic opioid addiction.
Back to Top | [2], the endocrinopathies [27], immunosuppression [29], and malnutrition [21].
Potentially dangerous interactions can occur between opioids and other drugs prescribed for chronic pain or for other health problems. Opioids can cause QT prolongation, well known during methadone treatment [7], but this can occur with other opioids as well, for example, oxycodone [13]. Drugs that can increase the risk of QT prolongation and polymorphic ventricular arrhythmias from opioids are antidepressants, antibiotics, and a long list of other drugs [8]. Benzodiazepines and alcohol increase the sedative effects of opioids, increasing the risk of pneumonia in older adults [9].
Interference with metabolism of potent opioids, again best documented for methadone [7], can be caused by many drugs (psychotropic drugs, antibiotics, anticonvulsants, antihistamines, and antiretroviral drugs). A case report illustrates well how ciprofloxacin can cause accumulation of methadone, severe sedation, and respiratory depression [17].
Serious serotonin syndrome can be caused by several opioids, tramadol in particular, but also fentanyl [26], especially when interacting with serotoninergic antidepressants prescribed for chronic pain or for the depression that is present in up to 100% of chronic pain patients [22]. These serotoninergic complications are dangerous because many doctors still do not recognize in time [2] the typical triad with the following:
a. mental symptoms (nervous, anxious, agitated, poor‐quality sleep),
b. increased sympathetic nervous system activity (high blood pressure, tachycardia, diaphoresis, mydriasis, lively intestinal motility),
c. and the most typical—augmented tendon reflexes with inducible myoclonus [2,3].
Treatment involves stopping all serotoninergic drugs. However, once hyperpyrexia appears, the serotonin syndrome is rapidly fatal unless intensive medical care is applied, with serotonin‐antagonists and life‐saving cardio‐respiratory support [2,26]. This diagnosis is easily missed in a post mortem examination.
Reports of tramadol‐related deaths are increasing in countries where tramadol is prescribed for chronic pain [15]. These deaths cannot be due to respiratory depression from this weak opioid agonist [32]; rather, they may be caused by unrecognized and untreated serotonin syndrome from tramadol, potentiated by other serotoninergic medications [2,3,26]. Denmark has a higher use of tramadol for chronic pain than the other Nordic countries [16].
Back to Top | [10,11]. The “flood of opioids” has caused “a rising tide of death” in the United States [25]. This rising tide of prescription opioid–related overdose deaths has not reached the Nordic countries. This is true also for Denmark, with its long history of liberal prescription of opioids. This may be due to the warnings from Jφrgen Eriksen, Per Sjφgren, and others about dangers of too liberal opioid prescribing during the last decade [11]. Still, the U.S. experience may cause the opioid policy pendulum to swing back (again!) to the restrictive opioid regulations that we had before the 1980s. The many mitigating actions in that direction taken by the authorities in the United States appear to have limited effects on abuse, while already reducing access to opioids for chronic opioid‐sensitive pain [1,12]. Finding the right balance between too liberal and too restrictive opioid regulations will continue to be a major challenge in pain medicine for a long while [12].
Back to Top | [14]but continues to be a double‐edged sword that is difficult to handle [5]. It requires deep pharmacological knowledge, experience, resources, considerable patience, and mental energy from a group of helpers who are able to take care of the whole bio‐psycho‐social conundrum of the chronic pain patient [5,28]. GPs should not start long‐term opioid treatment without being in collaboration with a pain center. Torsten Gordh’s pain center in Uppsala, Sweden, in collaboration with the addiction medicine department, documented that it is possible to rehabilitate opioid‐misusing chronic pain patients back to long‐term satisfactory pain relief and quality of life [28]. They accomplish this by converting the failed opioid treatment to methadone, in addition to helping the patients with other aspects of their chronic disease [28].
It is difficult to predict who will eventually develop problematic opioid use. Therefore, all chronic patients with opioid‐sensitive pain who are offered long‐term opioid treatment must have a strict regimen from day 1: Collaboration with 1 pharmacy, 1 pain management group, with 1 responsible pain specialist (with a stand‐in), and with the patient’s general practitioner. Frequent evaluation of effects and adverse effects is mandatory. Opioid therapy must be discontinued as soon as it is clear that lack of pain relief and adverse effects are detrimental to the patient’s health. This is the difficult part of long‐term opioid therapy for chronic pain. It is demanding for patients as well as for health care providers. Starting is easy; stopping becomes increasingly difficult with time. The reward system is involved from the first dose; tapering and stopping inappropriate opioid treatment may be difficult already after a few months. This is in part due to withdrawal causing increased pain sensitivity, with break‐through pain aggravating the original pain condition. The easy way, when pain relief is not satisfactory, is to escalate the dose. This brings the patients and their health care providers into the “minefield” described by Jφrgen Eriksen more than 10years ago [4,11].
Howard Fields expressed a “glimmer of hope” that we will have safer opioids in the future by combining a MOP‐receptor agonist, responsible for analgesia, reward, and addiction, with a DOP receptor antagonist, reducing the undesirable effects while retaining the analgesic effects of the MOP‐agonist [12]. There are also ongoing clinical trials with a NOP (nociceptin‐orphanin) receptor agonist, cebranopadol, that has a profile of effects different from MOP agonists (www.clinicaltrials.gov).
The art of helping chronic pain patients with opioid‐sensitive pain has become even more challenging in recent years by the frequent adverse interactions with other drugs that now are commonly prescribed for chronic pain. Still, going back to the intense opiophobic conditions of the 20th century is not possible. Long‐term, double‐blind, placebo‐controlled RCTs on opioid treatment are difficult and costly. However, a 6‐month (+1month follow‐up after unblinding) RCT showed that it is possible to maintain blinding with opioid doses in a safe and effective dose range [6]. It also showed how the positive “context‐sensitive therapeutic effect” continued to have a strong and increasing effect on subjective pain from hip and knee osteoarthritis during the entire double‐blinded period of half a year [6]. A pharmaceutical company sponsored that study. It is time that our health care authorities sponsor investigator‐initiated, large studies to determine the true cost–benefit profile of long‐term opioid treatment. Otherwise, we will continue to fumble our way forward, depending on the best possible indirect epidemiological outcome studies, like the Ekholm et al. study reported in this issue of Pain [10].
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Pain:
December 2014 - Volume 155 - Issue 12 - p 2441–2443
doi: 10.1016/j.pain.2014.09.011
Commentary
Burden of disease is often aggravated by opioid treatment of chronic pain patients: Etiology and prevention
Breivik, Harald*; Stubhaug, Audun
Free Access
[email protected]
For more than two decades, Danish doctors have prescribed opioids for chronic noncancer pain more liberally than have doctors in the neighboring countries. We have been looking to Denmark for the long‐term effects of this liberal practice [4] that, as early as 2003, Jφrgen Eriksen called “working in a minefield” [4,11]. In this issue of Pain,Ekholm and coworkers in Per Sjφgren’s research group report data from the ongoing health surveys in Denmark: They followed 13,127 persons from the 2000 and 2005 surveys for up to 11years. In all, 20% (2557) had chronic pain, and 7% of these (167) were on long‐term and 15% (375) on short‐term opioid therapy at baseline [10]. Their data are from face‐to‐face interviews of the cohorts in 2000 and 2005 and from the Danish national registries of drug prescriptions, hospital admissions, and causes of death.
Patients with chronic pain not on opioids and those on short‐term opioid therapy had increased risk of all cause mortality compared with persons without chronic pain (odds ratio [OR)=1.4, P<.01). These findings agree with other cohort studies that followed up participants for as many as 17years [18,20,24,33]. Those participants treated long term with opioids in the year preceding the surveys in 2000 and 2005 had almost double the risk of death (OR=1.8; 95% confidence interval [CI]=1.3–2.4) up until end of 2011 compared with pain‐free persons, but were not significantly different from chronic pain patients without opioids or those on short‐term opioid treatment. When corrected for possible confounding factors (age, gender, education, co‐habitation, smoking, alcohol intake, body mass index, Charlson Co‐morbidity Index), the risk of death was slightly less (OR=1.7). The investigators did not find any specific causes of death. Previously reported increased risk of death from cancer [20] or cardiovascular disease[20,24,33] in chronic pain patients was not found in chronic pain patients with or without opioid treatment by Ekholm et al. [10]. They did not report any overdose deaths or suicides in the long‐term opioid‐using group. Suicides occurred in 1/10,000person‐years among those with chronic pain (not using opioids) and those without.
Thus, Ekholm et al. [10] documented that opioid treatment does not significantly increase the already high risk of death among chronic pain patients in Denmark. With only 167 patients on long‐term opioid treatment at baseline, there is a real risk of underestimating the increased risk of death by opioid therapy. Unfortunately, in this study there are no data on diversion and overdose deaths among other users of opioids in Denmark. Our impression of the Scandinavian scene is that it is nothing like the mega‐numbers of prescription opioid overdose statistics from the United States [25]. It may well be that the robust health care system in Denmark, and the focus on ill effects of uncritical opioid prescribing during the last 10years in Denmark [11]and the other Nordic countries [4], appear to have prevented such opioid‐misuse catastrophes that now are highly visible in the United States [25].
Back to Top | [10]. The long‐term opioid treated pain patients had even higher risk of injuries or intoxication than the chronic pain patients who were not on opioid treatment, but not significantly different from those who were treated short‐term with opioids [10].
Chronic pain patients have a poor quality of life [19,34], high risk of disability [19,23], depression [22], and an increased risk of suicide attempts [31]. Inactivity, economic ruin, social isolation, stigma, and co‐morbidities all probably contribute to the increased risk of injuries and intoxication compared with that in persons without chronic pain[10].
Inappropriate long‐term opioid treatment obviously can aggravate the already‐high burden of disease in chronic pain patients. We do not know the long‐term outcome of pain management with opioids in the 167 patients on long‐term opioid treatment at baseline in 2000 and 2005, or what happened to those on short‐term opioids, or those not on opioid treatments at baseline [10]. The results of this study would be more valuable if we had information on what happened to opioid treatment during the 6‐ to 11years after baseline. In an analysis in 2005 of some of the sample from 2000, it appears that more than 9% recovered annually, 4 times more often in persons not on opioids than those on opioid therapy in 2000 [30]. So how did this changing therapy affect the results in 2011? Clearly one cannot assume that the treatment regimens at baseline were constant during these long years with chronic pain. Unfortunately, there is no information about dose or how many of the 542 patients exposed to opioids in 2000 and in 2005 developed problematic opioid use or iatrogenic opioid addiction.
Back to Top | [2], the endocrinopathies [27], immunosuppression [29], and malnutrition [21].
Potentially dangerous interactions can occur between opioids and other drugs prescribed for chronic pain or for other health problems. Opioids can cause QT prolongation, well known during methadone treatment [7], but this can occur with other opioids as well, for example, oxycodone [13]. Drugs that can increase the risk of QT prolongation and polymorphic ventricular arrhythmias from opioids are antidepressants, antibiotics, and a long list of other drugs [8]. Benzodiazepines and alcohol increase the sedative effects of opioids, increasing the risk of pneumonia in older adults [9].
Interference with metabolism of potent opioids, again best documented for methadone [7], can be caused by many drugs (psychotropic drugs, antibiotics, anticonvulsants, antihistamines, and antiretroviral drugs). A case report illustrates well how ciprofloxacin can cause accumulation of methadone, severe sedation, and respiratory depression [17].
Serious serotonin syndrome can be caused by several opioids, tramadol in particular, but also fentanyl [26], especially when interacting with serotoninergic antidepressants prescribed for chronic pain or for the depression that is present in up to 100% of chronic pain patients [22]. These serotoninergic complications are dangerous because many doctors still do not recognize in time [2] the typical triad with the following:
a. mental symptoms (nervous, anxious, agitated, poor‐quality sleep),
b. increased sympathetic nervous system activity (high blood pressure, tachycardia, diaphoresis, mydriasis, lively intestinal motility),
c. and the most typical—augmented tendon reflexes with inducible myoclonus [2,3].
Treatment involves stopping all serotoninergic drugs. However, once hyperpyrexia appears, the serotonin syndrome is rapidly fatal unless intensive medical care is applied, with serotonin‐antagonists and life‐saving cardio‐respiratory support [2,26]. This diagnosis is easily missed in a post mortem examination.
Reports of tramadol‐related deaths are increasing in countries where tramadol is prescribed for chronic pain [15]. These deaths cannot be due to respiratory depression from this weak opioid agonist [32]; rather, they may be caused by unrecognized and untreated serotonin syndrome from tramadol, potentiated by other serotoninergic medications [2,3,26]. Denmark has a higher use of tramadol for chronic pain than the other Nordic countries [16].
Back to Top | [10,11]. The “flood of opioids” has caused “a rising tide of death” in the United States [25]. This rising tide of prescription opioid–related overdose deaths has not reached the Nordic countries. This is true also for Denmark, with its long history of liberal prescription of opioids. This may be due to the warnings from Jφrgen Eriksen, Per Sjφgren, and others about dangers of too liberal opioid prescribing during the last decade [11]. Still, the U.S. experience may cause the opioid policy pendulum to swing back (again!) to the restrictive opioid regulations that we had before the 1980s. The many mitigating actions in that direction taken by the authorities in the United States appear to have limited effects on abuse, while already reducing access to opioids for chronic opioid‐sensitive pain [1,12]. Finding the right balance between too liberal and too restrictive opioid regulations will continue to be a major challenge in pain medicine for a long while [12].
Back to Top | [14]but continues to be a double‐edged sword that is difficult to handle [5]. It requires deep pharmacological knowledge, experience, resources, considerable patience, and mental energy from a group of helpers who are able to take care of the whole bio‐psycho‐social conundrum of the chronic pain patient [5,28]. GPs should not start long‐term opioid treatment without being in collaboration with a pain center. Torsten Gordh’s pain center in Uppsala, Sweden, in collaboration with the addiction medicine department, documented that it is possible to rehabilitate opioid‐misusing chronic pain patients back to long‐term satisfactory pain relief and quality of life [28]. They accomplish this by converting the failed opioid treatment to methadone, in addition to helping the patients with other aspects of their chronic disease [28].
It is difficult to predict who will eventually develop problematic opioid use. Therefore, all chronic patients with opioid‐sensitive pain who are offered long‐term opioid treatment must have a strict regimen from day 1: Collaboration with 1 pharmacy, 1 pain management group, with 1 responsible pain specialist (with a stand‐in), and with the patient’s general practitioner. Frequent evaluation of effects and adverse effects is mandatory. Opioid therapy must be discontinued as soon as it is clear that lack of pain relief and adverse effects are detrimental to the patient’s health. This is the difficult part of long‐term opioid therapy for chronic pain. It is demanding for patients as well as for health care providers. Starting is easy; stopping becomes increasingly difficult with time. The reward system is involved from the first dose; tapering and stopping inappropriate opioid treatment may be difficult already after a few months. This is in part due to withdrawal causing increased pain sensitivity, with break‐through pain aggravating the original pain condition. The easy way, when pain relief is not satisfactory, is to escalate the dose. This brings the patients and their health care providers into the “minefield” described by Jφrgen Eriksen more than 10years ago [4,11].
Howard Fields expressed a “glimmer of hope” that we will have safer opioids in the future by combining a MOP‐receptor agonist, responsible for analgesia, reward, and addiction, with a DOP receptor antagonist, reducing the undesirable effects while retaining the analgesic effects of the MOP‐agonist [12]. There are also ongoing clinical trials with a NOP (nociceptin‐orphanin) receptor agonist, cebranopadol, that has a profile of effects different from MOP agonists (www.clinicaltrials.gov).
The art of helping chronic pain patients with opioid‐sensitive pain has become even more challenging in recent years by the frequent adverse interactions with other drugs that now are commonly prescribed for chronic pain. Still, going back to the intense opiophobic conditions of the 20th century is not possible. Long‐term, double‐blind, placebo‐controlled RCTs on opioid treatment are difficult and costly. However, a 6‐month (+1month follow‐up after unblinding) RCT showed that it is possible to maintain blinding with opioid doses in a safe and effective dose range [6]. It also showed how the positive “context‐sensitive therapeutic effect” continued to have a strong and increasing effect on subjective pain from hip and knee osteoarthritis during the entire double‐blinded period of half a year [6]. A pharmaceutical company sponsored that study. It is time that our health care authorities sponsor investigator‐initiated, large studies to determine the true cost–benefit profile of long‐term opioid treatment. Otherwise, we will continue to fumble our way forward, depending on the best possible indirect epidemiological outcome studies, like the Ekholm et al. study reported in this issue of Pain [10].
This is an important piece of scholarship. Based upon my experience interacting with European pain specialists, I find them much more "thoughtful" about our field and in their approach to treating chronic pain: Managing chronic pain is resource intensive, time intensive, HIGH RISK, work. It requires the collaboration of multiple specialists, including behavioral health providers, with frequent follow-up and careful monitoring of effects to be safe. Policy-makers cannot expect this work to be done cheaply or done by those without the proper training and CONTENT expertise (not meta-analyticians) in managing chronic pain.
Finding the right balance between too liberal and too restrictive opioid regulations will continue to be a major challenge in pain medicine for a long while [12] [14]but continues to be a double‐edged sword that is difficult to handle [5]. It requires deep pharmacological knowledge, experience, resources, considerable patience, and mental energy from a group of helpers who are able to take care of the whole bio‐psycho‐social conundrum of the chronic pain patient [5,28].
GPs should not start long‐term opioid treatment without being in collaboration with a pain center. Torsten Gordh’s pain center in Uppsala, Sweden, in collaboration with the addiction medicine department, documented that it is possible to rehabilitate opioid‐misusing chronic pain patients back to long‐term satisfactory pain relief and quality of life [28]. They accomplish this by converting the failed opioid treatment to methadone, in addition to helping the patients with other aspects of their chronic disease [28].
It is difficult to predict who will eventually develop problematic opioid use. Therefore, all chronic patients with opioid‐sensitive pain who are offered long‐term opioid treatment must have a strict regimen from day 1: Collaboration with 1 pharmacy, 1 pain management group, with 1 responsible pain specialist (with a stand‐in), and with the patient’s general practitioner. Frequent evaluation of effects and adverse effects is mandatory. Opioid therapy must be discontinued as soon as it is clear that lack of pain relief and adverse effects are detrimental to the patient’s health. This is the difficult part of long‐term opioid therapy for chronic pain. It is demanding for patients as well as for health care providers. Starting is easy; stopping becomes increasingly difficult with time. The reward system is involved from the first dose; tapering and stopping inappropriate opioid treatment may be difficult already after a few months. This is in part due to withdrawal causing increased pain sensitivity, with break‐through pain aggravating the original pain condition. The easy way, when pain relief is not satisfactory, is to escalate the dose. This brings the patients and their health care providers into the “minefield” described by Jφrgen Eriksen more than 10years ago
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I think a large ACO would be receptive to this model, though they would try to find a way to do it on the cheap, i.e. get a Pain doctor w/MBA to develop the program, or just copy a rival system's proven model.
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New Addiction Criteria: Diagnostic Challenges Persist in Treating Pain With Opioids (IASP)
http://iasp.files.cms-plus.com/FileDownloads/PCU_21-5_web.pdf
http://iasp.files.cms-plus.com/FileDownloads/PCU_21-5_web.pdf
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What Are We Treating WithLong-term Opioid Therapy?
http://www.etsu.edu/com/cme/documents/pain2012/thursday/Ballantyne Sullivan What are we treating.pdf
http://www.etsu.edu/com/cme/documents/pain2012/thursday/Ballantyne Sullivan What are we treating.pdf
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"The collective clinical experience from 20 years of liberal opioid prescribing for chronic pain, together with the findings of recent population-based studies, suggests that LtOT may benefit patients with severe suffering that has been refractory to other medical and psychological treatments but that it is not often effective in achieving the goals originally envisaged, such as complete pain relief and functional restoration. This reframing of LtOT is a more honest appraisal of how it is actually used in practice. It would allow better patient selection and help to avoid the disastrous effects of promising more of opioids than they can achieve."
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A model we should advocate for in every state: What can learn from New Mexico?
http://hscnews.unm.edu/news/education-program-successful-in-reducing-opioid-abuse010715
http://www.ncbi.nlm.nih.gov/pubmed/24922121
New Mexico innovation
The authors highlight five unique aspects of the New Mexico policy and educational initiative that account for these positive outcomes:
Opioid prescribing practices of health care professionals can be positively affected by mandated education without mandating prescription limits, which has translated into real-world, positive changes in practitioner prescribing.
Am J Public Health. 2014 Aug;104(8):1356-62. doi: 10.2105/AJPH.2014.301881. Epub 2014 Jun 12.
Rules and values: a coordinated regulatory and educational approach to the public health crises of chronic pain and addiction.
Katzman JG1, Comerci GD, Landen M, Loring L, Jenkusky SM, Arora S, Kalishman S, Marr L, Camarata C, Duhigg D, Dillow J, Koshkin E, Taylor DE, Geppert CM.
Author information
Abstract
Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexico's 2012-2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.
PMID:
24922121
[PubMed - indexed for MEDLINE]
http://hscnews.unm.edu/news/education-program-successful-in-reducing-opioid-abuse010715
http://www.ncbi.nlm.nih.gov/pubmed/24922121
New Mexico innovation
The authors highlight five unique aspects of the New Mexico policy and educational initiative that account for these positive outcomes:
- The statutory requirement that pain CME include education on addiction. There is insufficient communication and coordination between the pain and addiction communities, and that failure to provide clear and consistent guidance on the management of the co-occurring disorders of pain and addiction leaves clinicians with mixed messages;
- Physicians are not the only practitioners who prescribe opioids that are misused and abused. New Mexico is the only state requiring CME training on chronic pain and safe opioid prescribing for all practitioners with DEA registration;
- Unlike several other states that target only primary care physicians, no medical or surgical specialty in New Mexico is exempt from the CME requirement;
- Only New Mexico requires pain CME with each license renewal;
- New Mexico mandates both CME and the patient PMP querying every six months.
Opioid prescribing practices of health care professionals can be positively affected by mandated education without mandating prescription limits, which has translated into real-world, positive changes in practitioner prescribing.
Am J Public Health. 2014 Aug;104(8):1356-62. doi: 10.2105/AJPH.2014.301881. Epub 2014 Jun 12.
Rules and values: a coordinated regulatory and educational approach to the public health crises of chronic pain and addiction.
Katzman JG1, Comerci GD, Landen M, Loring L, Jenkusky SM, Arora S, Kalishman S, Marr L, Camarata C, Duhigg D, Dillow J, Koshkin E, Taylor DE, Geppert CM.
Author information
Abstract
Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexico's 2012-2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.
PMID:
24922121
[PubMed - indexed for MEDLINE]
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http://annals.org/article.aspx?articleID=2089370#.VLRgTLPtdyc.twitter
Reviews
Published online 13 January 2015
Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain FREE ONLINE FIRST
Roger Chou, MD; Judith A. Turner, PhD; Emily B. Devine, PharmD, PhD, MBA; Ryan N. Hansen, PharmD, PhD; Sean D. Sullivan, PhD; Ian Blazina, MPH; Tracy Dana, MLS; Christina Bougatsos, MPH; Richard A. Deyo, MD, MPH
[+] Author Affiliations
Ann Intern Med. 13 January 2015,()
oi:10.7326/M14-2559
ABSTRACT
Background: Increases in prescriptions of opioid medications for chronic pain have been accompanied by increases in opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness.
Purpose: To evaluate evidence on the effectiveness and harms of long-term (>3 months) opioid therapy for chronic pain in adults.
Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PsycINFO, and CINAHL (January 2008 through August 2014); relevant studies from a prior review; reference lists; and ClinicalTrials.gov.
Study Selection: Randomized trials and observational studies that involved adults with chronic pain who were prescribed long-term opioid therapy and that evaluated opioid therapy versus placebo, no opioid, or nonopioid therapy; different opioid dosing strategies; or risk mitigation strategies.
Data Extraction: Dual extraction and quality assessment.
Data Synthesis: No study of opioid therapy versus no opioid therapy evaluated long-term (>1 year) outcomes related to pain, function, quality of life, opioid abuse, or addiction. Good- and fair-quality observational studies suggest that opioid therapy for chronic pain is associated with increased risk for overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction, although there are few studies for each of these outcomes; for some harms, higher doses are associated with increased risk. Evidence on the effectiveness and harms of different opioid dosing and risk mitigation strategies is limited.
Limitations: Non–English-language articles were excluded, meta-analysis could not be done, and publication bias could not be assessed. No placebo-controlled trials met inclusion criteria, evidence was lacking for many comparisons and outcomes, and observational studies were limited in their ability to address potential confounding.
Conclusion: Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms.
Primary Funding Source: Agency for Healthcare Research and Quality.
This systematic review found scant and insufficient evidence that long-term opioid therapy for chronic pain improves function, quality of life, or pain outcomes. Serious harms of long-term therapy, such as risk for overdose and abuse and fractures, seemed to be dose-dependent.
Reviews
Published online 13 January 2015
Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain FREE ONLINE FIRST
Roger Chou, MD; Judith A. Turner, PhD; Emily B. Devine, PharmD, PhD, MBA; Ryan N. Hansen, PharmD, PhD; Sean D. Sullivan, PhD; Ian Blazina, MPH; Tracy Dana, MLS; Christina Bougatsos, MPH; Richard A. Deyo, MD, MPH
[+] Author Affiliations
Ann Intern Med. 13 January 2015,()
oi:10.7326/M14-2559ABSTRACT
Background: Increases in prescriptions of opioid medications for chronic pain have been accompanied by increases in opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness.
Purpose: To evaluate evidence on the effectiveness and harms of long-term (>3 months) opioid therapy for chronic pain in adults.
Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PsycINFO, and CINAHL (January 2008 through August 2014); relevant studies from a prior review; reference lists; and ClinicalTrials.gov.
Study Selection: Randomized trials and observational studies that involved adults with chronic pain who were prescribed long-term opioid therapy and that evaluated opioid therapy versus placebo, no opioid, or nonopioid therapy; different opioid dosing strategies; or risk mitigation strategies.
Data Extraction: Dual extraction and quality assessment.
Data Synthesis: No study of opioid therapy versus no opioid therapy evaluated long-term (>1 year) outcomes related to pain, function, quality of life, opioid abuse, or addiction. Good- and fair-quality observational studies suggest that opioid therapy for chronic pain is associated with increased risk for overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction, although there are few studies for each of these outcomes; for some harms, higher doses are associated with increased risk. Evidence on the effectiveness and harms of different opioid dosing and risk mitigation strategies is limited.
Limitations: Non–English-language articles were excluded, meta-analysis could not be done, and publication bias could not be assessed. No placebo-controlled trials met inclusion criteria, evidence was lacking for many comparisons and outcomes, and observational studies were limited in their ability to address potential confounding.
Conclusion: Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms.
Primary Funding Source: Agency for Healthcare Research and Quality.
This systematic review found scant and insufficient evidence that long-term opioid therapy for chronic pain improves function, quality of life, or pain outcomes. Serious harms of long-term therapy, such as risk for overdose and abuse and fractures, seemed to be dose-dependent.
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"Research is needed to understand long-term patient outcomes, the risks for opioid abuse and related problems, and the effects of different opioid prescription methods and risk mitigation strategies."Really? Sometimes I get the sense that people are just trying to pad their resumes...what did the reviewers think that this added to our understanding of the problem...
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This is the most comprehensive meta-analysis on opioid prescribing for CNP to date, it is important and it will change practice and funding for this harmful treatment.
This thread is now 2yrs old and the resistance to the message - opioids just don't work well for CNP - is wearing away. A lot has changed in two years.
This thread is now 2yrs old and the resistance to the message - opioids just don't work well for CNP - is wearing away. A lot has changed in two years.
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I don't understand how insufficient evidence changes anything. We've had insufficient evidence all along. We need RCT and Level I prospectively controlled studies to guide real policy and informed by legitimate experts not meta-analyticians.
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Because there is more or less insufficient evidence now than 2 year ago?
Imagine a floridly POSITIVE RCT study of "Vicosomaxanax" for treatment of patients with chronic migraine, fibromyalgia, and interstitial cystitis. Are payors going to line up and pay for it?
When I debrief Licensees and other prescribers about "what were they thinking" when they prescribed X,Y,Z for patient who went on to have a bad outcome, I never hear, "Well I knew that the evidence was insufficient, but..." Instead, I hear things that sound like poor boundaries, professional burn-out, sometimes knowledge deficits. It's not a "population health problem." It's a cumulative series of dyadic interactions. It RESULTS in a population health problem, but it starts between two people--prescriber and patient. So, instead of throwing money at meta-analyticians to churn out technical reports I'd rather see money spent on "up-skilling" prescribers in a given community. The Southern Oregon group has made the right investments.
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"The NIH says the challenge of when to use opioids and when to avoid them remains a question that available data can’t answer, and it’s a knowledge gap that needs to be filled as soon as possible. “For the more than 100 million Americans living with chronic pain, meeting this challenge cannot wait,” the report concludes."
http://time.com/3663907/treating-pain-opioids-painkillers/
http://time.com/3663907/treating-pain-opioids-painkillers/
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Science and review will not lead the way towards fixing this. A purely subjective phenomenon does not lend itself to science. Doctors are trained to be caring and to help their patients.
Nipe. The answers sre legal, regulatory, and education of physicians as well as a publicity campaign. Shine a light and watch bugs run. Both doctors being shamed from their habits and patients chemical coping and failing or addicts pretending to be pain patients.
Knowing when to say no to opiates. How hard is a 30 or 60 second PSA to produce. Its my chance to go Hollywood.
Nipe. The answers sre legal, regulatory, and education of physicians as well as a publicity campaign. Shine a light and watch bugs run. Both doctors being shamed from their habits and patients chemical coping and failing or addicts pretending to be pain patients.
Knowing when to say no to opiates. How hard is a 30 or 60 second PSA to produce. Its my chance to go Hollywood.
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You have a face for Radio
It's just a little weird that you have a poster of me in your office. But that is an awesome BMW. Now clad in carbon fiber. Who needs Lobel t-shirts?
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Thought it was required to be a member here, but it is at my house not office
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That is when I had more hair
we cant all be heartthrobs...
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http://www.medscape.com/viewarticle/838052#vp_2
http://annals.org/article.aspx?articleid=2089371
**Actioning the NIH panel's findings will change the direction of pain management for decades moving forward**
When it comes to managing patients with legitimate pain conditions, physicians have little training. Clinicians, said the panelists, "are often ill-prepared to diagnose, appropriately assess, treat and monitor patients with chronic pain."
The experts identified several important management issues for clinicians. "First, they must recognize that patients' manifestation of and response to pain will vary, with genetic, cultural, and psychosocial factors all contributing to this variation," they said.
Some physicians believe that patient expectations for pain relief are unrealistic. They're sometimes quick to label patients as "drug-seeking" or "addicts," and some even "fire" patients for merely voicing concerns about their pain management, the report notes.
"A more holistic approach to the management of chronic pain that is inclusive of the patients' perspectives and desired outcomes should be the goal," they write.
http://annals.org/article.aspx?articleid=2089371
**Actioning the NIH panel's findings will change the direction of pain management for decades moving forward**
When it comes to managing patients with legitimate pain conditions, physicians have little training. Clinicians, said the panelists, "are often ill-prepared to diagnose, appropriately assess, treat and monitor patients with chronic pain."
The experts identified several important management issues for clinicians. "First, they must recognize that patients' manifestation of and response to pain will vary, with genetic, cultural, and psychosocial factors all contributing to this variation," they said.
Some physicians believe that patient expectations for pain relief are unrealistic. They're sometimes quick to label patients as "drug-seeking" or "addicts," and some even "fire" patients for merely voicing concerns about their pain management, the report notes.
"A more holistic approach to the management of chronic pain that is inclusive of the patients' perspectives and desired outcomes should be the goal," they write.
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