The prescription opioid epidemic in a nutshell

[lobelsteve]

There is no safe dose. "If you're not tapering; you're harming."

Yup, Going down slow, he is on board, just need a NS to help with the new paddle array, his last one is in 8 pieces from T8-S1 revision.

---

Members don't see this ad.

 

[drusso]

So because some feral overuses, we should never do diagnostic mbb/facets?

MRI-based spine care = "Trolling for moles..."

 

[101N]

So because some feral overuses, we should never do diagnostic mbb/facets?

Feral is a misnomer coined by a yahoo.It implies that over use is rare.

 

[ampaphb]

Feral is a misnomer coined by a yahoo.It implies that over use is rare.

Bogduk is a yahoo?

 

[emd123]

There is no safe dose. "If you're not tapering; you're harming."

This is a feel-good slogan and I like it in spirit, but let me pick it apart a little bit, because I've started hearing this repeated and can see it extrapolated way beyond its truth or intent.

I agree that, "When in doubt don't start, don't dose escalate, don't prescribe opiates" if there's no good reason. But these studies showing "There is no safe dose" apply only to populations at large. It doesn't apply to any individual patient. Yes, there are patients on very low dose opiates that OD and have harm, but there are some that don't and who do benefit. In fact, the great majority of patients on low dose opiates, do not overdose or have any measurable harm. (You can try to argue they may not benefit, or benefit sufficiently, but that's an entirely different issue from proving harm). You could take large populations of patients regarding any drug, or any treatment, even those generally accepted as extremely safe, and get the same results.

Does elective surgery "cause harm" and is it "unsafe"?

Well, I'd say, no. But surgery isn't safe for everyone and it isn't harmless for everyone. If you take a cross-section of 10,000 people who've had surgery, you'll find a certain number that had "harm," that had bowel perf, got septic, died on the table from reactions to anesthesia or surgical misadventure. I'm sure you could correlate more surgeries, and more surgical time, with more risk of harm. That is extremely easy to do. But can you extrapolate that to say, "If you're operating, you are harming" or "If you aren't canceling surgeries, you are harming"?

No you can't.

So again, you can take a cross section of 10,000 patients on very low dose opiates (or any drug, treatment or surgery) and say there is no dose, frequency or exposure low enough to completely eliminate risk to all patients receiving it, but that is not the same as proving that harm occurs to all those on it. Similarly, there is no car ride short enough to eliminate all risk of harm. Nor does that prove all car rides cause harm, or that there is no car ride ever worth the risk of taking.

They need to change there wording from "There is no safe dose," to "There is no zero risk dose." The former implies all doses cause at least some harm in all patients (like something with zero therapeutic benefit, ie, arsenic, cyanide, etc) versus the latter which applies to something with dose dependent risk, yet with clinical utility in settings where risk is low enough and outweighed by the legitimate utility or need.

 

[101N]

Med Care. 2015 Aug;53(8):679-85. doi: 10.1097/MLR.0000000000000384.
Opioid Poisonings in Washington State Medicaid: Trends, Dosing, and Guidelines.
Fulton-Kehoe D1, Sullivan MD, Turner JA, Garg RK, Bauer AM, Wickizer TM, Franklin GM.
Author information

Abstract
BACKGROUND:
Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision.

OBJECTIVES:
To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings.

METHODS:
The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning.

RESULTS:
Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions.

CONCLUSIONS:
It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

 

[emd123]

Med Care. 2015 Aug;53(8):679-85. doi: 10.1097/MLR.0000000000000384.
Opioid Poisonings in Washington State Medicaid: Trends, Dosing, and Guidelines.
Fulton-Kehoe D1, Sullivan MD, Turner JA, Garg RK, Bauer AM, Wickizer TM, Franklin GM.
Author information

Abstract
BACKGROUND:
Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision.

OBJECTIVES:
To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings.

METHODS:
The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning.

RESULTS:
Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions.

CONCLUSIONS:
It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Lol.

Medicaid patients on methadone who also are on benzos? I can't think of a higher risk population or drug combination imaginable, that absolutely cannot be extrapolated to populations at large or to physician practices at large.

Some of us have already realized long, long ago, that methadone, combined with benzos, in the insurance pool at absolute highest risk of drug abuse and overdoses (Medicaid) is a patient and public health disaster, yet some people need an article published in Med Care. 2015 to prompt revised guidelines to tell them what is a blatant and obvious, absolute disaster in waiting?

Wow.

 

[drusso]

This is a feel-good slogan and I like it in spirit, but let me pick it apart a little bit, because I've started hearing this repeated and can see it extrapolated way beyond its truth or intent.

I agree that, "When in doubt don't start, don't dose escalate, don't prescribe opiates" if there's no good reason. But these studies showing "There is no safe dose" apply only to populations at large. It doesn't apply to any individual patient. Yes, there are patients on very low dose opiates that OD and have harm, but there are some that don't and who do benefit. In fact, the great majority of patients on low dose opiates, do not overdose or have any measurable harm. (You can try to argue they may not benefit, or benefit sufficiently, but that's an entirely different issue from proving harm). You could take large populations of patients regarding any drug, or any treatment, even those generally accepted as extremely safe, and get the same results.

Does elective surgery "cause harm" and is it "unsafe"?

Well, I'd say, no. But surgery isn't safe for everyone and it isn't harmless for everyone. If you take a cross-section of 10,000 people who've had surgery, you'll find a certain number that had "harm," that had bowel perf, got septic, died on the table from reactions to anesthesia or surgical misadventure. I'm sure you could correlate more surgeries, and more surgical time, with more risk of harm. That is extremely easy to do. But can you extrapolate that to say, "If you're operating, you are harming" or "If you aren't canceling surgeries, you are harming"?

No you can't.

So again, you can take a cross section of 10,000 patients on very low dose opiates (or any drug, treatment or surgery) and say there is no dose, frequency or exposure low enough to completely eliminate risk to all patients receiving it, but that is not the same as proving that harm occurs to all those on it. Similarly, there is no car ride short enough to eliminate all risk of harm. Nor does that prove all car rides cause harm, or that there is no car ride ever worth the risk of taking.

They need to change there wording from "There is no safe dose," to "There is no zero risk dose." The former implies all doses cause at least some harm in all patients (like something with zero therapeutic benefit, ie, arsenic, cyanide, etc) versus the latter which applies to something with dose dependent risk, yet with clinical utility in settings where risk is low enough and outweighed by the legitimate utility or need.

Okay, How about this , "What are the unintended consequences of tapering and discontinuing opioid therapy in patients with chronic pain?" Has *ANYONE* studied this? In other words, do we know the natural history of what happens to people who are more or less marched through a mandatory taper of chronic opioid therapy? Does any harm come to them? Do they become "shiny happy people holding hands?" Or, do they get unnecessary medical interventions, hospitalizations, surgeries, lost productivity, etc? Do they sign up to be Rotory Club members or become shut ins?

If the utility of **ANY** medical therapy can be represented as the quotient of a BENEFIT/RISK ratio, then what happens when meta-analyticians, non-content experts, and policy-makers ration the therapy based solely upon "denominator data" instead of the entire quotient? Most people don't think to ask this question because they are not trained to think about it...

Here is how it works : research changes policy, policy changes payment, payment changes practice.

 

[emd123]

Okay, How about this , "What are the unintended consequences of tapering and discontinuing opioid therapy in patients with chronic pain?" Has *ANYONE* studied this? In other words, do we know the natural history of what happens to people who are more or less marched through a mandatory taper of chronic opioid therapy? Does any harm come to them? Do they become "shiny happy people holding hands?" Or, do they get unnecessary medical interventions, hospitalizations, surgeries, lost productivity, etc? Do they sign up to be Rotory Club members or become shut ins?

If the utility of **ANY** medical therapy can be represented as the quotient of a BENEFIT/RISK ratio, then what happens when meta-analyticians, non-content experts, and policy-makers ration the therapy based solely upon "denominator data" instead of the entire quotient? Most people don't think to ask this question because they are not trained to think about it...

These are extremely good points and questions. I agree these are concerns.

 

[lobelsteve]

Okay, How about this , "What are the unintended consequences of tapering and discontinuing opioid therapy in patients with chronic pain?" Has *ANYONE* studied this? In other words, do we know the natural history of what happens to people who are more or less marched through a mandatory taper of chronic opioid therapy? Does any harm come to them? Do they become "shiny happy people holding hands?" Or, do they get unnecessary medical interventions, hospitalizations, surgeries, lost productivity, etc? Do they sign up to be Rotory Club members or become shut ins?

If the utility of **ANY** medical therapy can be represented as the quotient of a BENEFIT/RISK ratio, then what happens when meta-analyticians, non-content experts, and policy-makers ration the therapy based solely upon "denominator data" instead of the entire quotient? Most people don't think to ask this question because they are not trained to think about it...

Here is how it works : research changes policy, policy changes payment, payment changes practice.

Research changes policy? Like when they locked out ISIS at your states WC meeting?

 

[ampaphb]

Organization changed its name Wed. Now called Spine Intervention Society

 

[drusso]

Organization changed its name Wed. Now called Spine Intervention Society

They should just change their name to this:

 

[ampaphb]

The organization formally known as http://www.independent.co.uk/news/w...s-mean-and-what-are-its-origins-10369601.html

 

[Jcm800]

bump. need to get this to 1000 posts

 

[101N]

Dirty business: https://www.documentcloud.org/documents/2195731-insysdoj.html

ELLEN F. ROSENBLUM
Attorney General

FREDERICK M. BOSS
Deputy Attorney General

DEPARTMENT OF JUSTICE
OFFICE OF THE ATTORNEY GENERAL

FOR IMMEDIATE RELEASE:
August 5, 2015

CONTACT: Kristina Edmunson,
(503) 378-6002,
[email protected]


AG Rosenblum Settles with Pharmaceutical Company Insys over Unlawful Promotion of the Powerful Opioid Subsys®


SALEM—Oregon Attorney General Ellen Rosenblum today reached a $1.1 million settlement with Insys, the company that manufactures the schedule II opioid drug Subsys, to resolve allegations that the powerful drug approved by the Food and Drug Administration (FDA) to treat cancer pain was marketed in Oregon for off-label uses such as non-cancer neck and back pain. The Assurance of Voluntary Compliance (AVC) also resolves allegations that the company provided improper financial incentives to some doctors to increase Subsys prescriptions, targeted doctors for aggressive promotion of Subsys when the doctor was not qualified to prescribe the drug, and deceptively promoted Subsys for treatment of mild pain. Oregon is the first government entity to settle with Insys for this alleged misconduct.


“Subsys is a very powerful narcotic that has been approved for only a very specific and narrow use,” said Attorney General Rosenblum. “Schedule II drugs have a very high potential for abuse and addiction, and it is unconscionable that a company would promote such a powerful drug for off-label uses as well as misrepresent to doctors the benefits of the drug.”


Under the AVC filed in Multnomah County Circuit Court, the company may not make any false or misleading claims when marketing Subsys in Oregon and must comply with all laws relating to the marketing and promotion of prescription drugs, including federal anti-kickback laws. The company may also not market Subsys in Oregon as a treatment for mild cancer pain, or mild pain of any kind, unless the FDA expressly approves the promotional claim.


The settlement requires Insys to pay $533,000 to the state of Oregon. An additional $567,000 will be paid to a non-profit or governmental organization identified by the Oregon Attorney General to help prevent opioid abuse and misuse in the state. Total Oregon Subsys sales for the time period of the investigation were $511,000.


In addition to the Insys settlement, Attorney General Rosenblum also announces a $2.1 million grant to the National Association of Attorneys General to help combat the misuse and abuse of opioids. The grant, which will be administered by the Oregon Department of Justice, comes from the $28 million Neurontin SettlementGrant program created from the 2004 Neurontin multi-state settlement that was led by the Oregon Department of Justice.


Rosenblum commended the work of Assistant Attorney General David Hart and his investigative team at the Oregon Department of Justice.

Oregon Department of Justice

 

[ampaphb]

Pathetic. Given how much they made, this is a drop in the bucket, and the cost of doing business

 

[TravelerNC]

You guys think this organization might be onto something? They propose treating opioids the same way alcohol and nicotine are treated. If all drugs (including heroin, methamphetamine, crack cocaine) were legally regulated and controlled like alcohol and nicotine, you guys wouldn't have to have to worry about fending off drug seekers. Drug seekers could go buy their drug of choice the same way they now purchase alcohol and nicotine. And, as with alcohol and nicotine, people who then find that they have problems with drug use can go to their doctor for help, or not. In any case, Law Enforcement Against Prohibition (copssaylegalizedrugs.org) seems to have concluded that prohibition has been an abject failure.

 

[Ducttape]

You guys think this organization might be onto something? They propose treating opioids the same way alcohol and nicotine are treated. If all drugs (including heroin, methamphetamine, crack cocaine) were legally regulated and controlled like alcohol and nicotine, you guys wouldn't have to have to worry about fending off drug seekers. Drug seekers could go buy their drug of choice the same way they now purchase alcohol and nicotine. And, as with alcohol and nicotine, people who then find that they have problems with drug use can go to their doctor for help, or not. In any case, Law Enforcement Against Prohibition (copssaylegalizedrugs.org) seems to have concluded that prohibition has been an abject failure.

Traveler, i know you are trolling, but i will respond, succinctly, to your post.

legalization of alcohol and cigarettes has done so much to improve the health of the US population, hasnt it? the #1 contributor to accident fatalities. the #1 preventable cause of cancer. the #1 preventable cause of heart disease. the #1 preventable cause of death in the US...

Irrespective of the future status of any drug, physicians are clearly bound to do what is ethically right - and a primary goal of that is to do no harm. there is strong and unequivocal evidence that the current illicit substances (yes, including marijuana in certain populations) are life threatening and dangerous, and their combination use with opioids are compounded and without medical merit. We physicians should never be recommending recreational use of any of these controlled substances because of that.

to quote the Sharks, with that: "Im out".

 

[emd123]

You guys think this organization might be onto something? They propose treating opioids the same way alcohol and nicotine are treated. If all drugs (including heroin, methamphetamine, crack cocaine) were legally regulated and controlled like alcohol and nicotine, you guys wouldn't have to have to worry about fending off drug seekers. Drug seekers could go buy their drug of choice the same way they now purchase alcohol and nicotine. And, as with alcohol and nicotine, people who then find that they have problems with drug use can go to their doctor for help, or not. In any case, Law Enforcement Against Prohibition (copssaylegalizedrugs.org) seems to have concluded that prohibition has been an abject failure.

We don't make marijuana or other drug laws or enforce them. You're wasting your time here. Go to a DEA or Congress forum where they can change any of this. What we think of drug policy is irrelevant. We do have to follow them though, to keep our DEA licenses and jobs to avoid bankruptcy and foreclosure. You might as well go to an automotive forum to rant about changing submarines.

 

[lonelobo]

Traveler, i know you are trolling, but i will respond, succinctly, to your post.

legalization of alcohol and cigarettes has done so much to improve the health of the US population, hasnt it? the #1 contributor to accident fatalities. the #1 preventable cause of cancer. the #1 preventable cause of heart disease. the #1 preventable cause of death in the US...

Irrespective of the future status of any drug, physicians are clearly bound to do what is ethically right - and a primary goal of that is to do no harm. there is strong and unequivocal evidence that the current illicit substances (yes, including marijuana in certain populations) are life threatening and dangerous, and their combination use with opioids are compounded and without medical merit. We physicians should never be recommending recreational use of any of these controlled substances because of that.

to quote the Sharks, with that: "Im out".

Actually I would say the legalization of Alcohol has not worsened the Health of the US population as compared to prohibition when bathtub Gin was all the rage.
If we really gave a sh't about the health of the US population, we would outlaw fast food and Junk food which is responsible for more health problems than ETOH, tobacco, Drugs combined.

 

[Ducttape]

come to NY State. "we" are already doing that, or trying to.

trans fat
labelling of calories
limitation on drink sizes (tho that has been stopped)
the increase in minimum wage will also help reduce the populations' overall reliance on fast food.

 

[101N]

come to NY State. "we" are already doing that, or trying to.

trans fat
labelling of calories
limitation on drink sizes (tho that has been stopped)
the increase in minimum wage will also help reduce the populations' overall reliance on fast food.

And that all makes sense, unfortunately. However, I would like to see more specific behavioral 'nudging'.

 

[emd123]

come to NY State. "we" are already doing that, or trying to.

trans fat
labelling of calories
limitation on drink sizes (tho that has been stopped)
the increase in minimum wage will also help reduce the populations' overall reliance on fast food.

I know, it's been a smashing success because Americans are all so skinny now, and care about nothing but their 5k race personal bests

 

[Ducttape]

So you would choose we just ignore it I presume. That's what got us into this mess.

 

[Ducttape]

http://www.mayoclinicproceedings.org/article/S0025-6196(15)00345-6/abstract

Abstract
Objectives
To determine what proportion of a geographically defined population who receive new opioid prescriptions progresses to episodic or long-term patterns of opioid prescribing and to explore the clinical characteristics associated with patterns of opioid prescribing.

Patients and Methods
Population-based drug prescription records for the population of Olmsted County between January 1 and December 31, 2009, were obtained using the Rochester Epidemiology Project medical records linkage system (N=142,377). All medical records were reviewed for a random sample of 293 patients who had a new (“incident”) prescription for an opioid analgesic in 2009. Patients were followed through their medical records for 1 year after their initial prescription date, with patterns of opioid prescribing categorized as short-term, episodic, or long-term.

Results
Overall, 293 patients received 515 new opioid prescriptions in 2009. Of these, 61 (21%) progressed to an episodic prescribing pattern and 19 (6%) progressed to a long-term prescribing pattern. In multivariable logistic regression analyses, substance abuse was significantly associated (P<.001) with a long-term opioid prescribing pattern as compared with an short-term opioid prescribing pattern. Past or current nicotine use (P=.03) and substance abuse (P=.04) were significantly associated with an episodic or long-term prescribing pattern as compared with a short-term prescribing pattern.

Conclusion
Knowledge of the clinical characteristics associated with the progression of a short-term to an episodic or long-term opioid prescribing pattern could aid in the identification of at-risk patients and provide the basis for developing targeted clinical interventions.

 

[drusso]

http://www.mayoclinicproceedings.org/article/S0025-6196(15)00345-6/abstract

Uh...so don't prescribe long-term (greater than 120 days) opioid analgesics to smokers with active or remote substance use disorders....check...

 

[Ducttape]

Or, more apropos, any short term opioid prescribing puts a significant portion of the population at risk for long term prescribing. PCPs, ortho, ER docs take note.

Also, this study confirms that the rate of substance abuse is much greater than the old quoted 0.5%.

 

[lobelsteve]

Or, more apropos, any short term opioid prescribing puts a significant portion of the population at risk for long term prescribing. PCPs, ortho, ER docs take note.

Also, this study confirms that the rate of substance abuse is much greater than the old quoted 0.5%.

Porter and Jick et Brute? The only folks who quoted that were on the payroll of big Pharma. It was a letter to the editor in NEJM, not an article.
N Engl J Med. 1980 Jan 10;302(2):123. Addiction rare in patients treated with narcotics. Porter J, Jick H.

 

[101N]

CDC Draft Guidelines for Opioid Prescribing


1. Non-pharmacological therapy and non-opioid pharmacological therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks.


2. Before starting long term opioid therapy, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.


3. Before starting and periodically during opioid therapy, providers should discuss with patients risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.


4. When starting opioid therapy, providers should prescribe short-acting opioids instead of extended-release/long acting opioids.


5. When opioids are started, providers should prescribe the lowest possible effective dosage. Providers should implement additional precautions when increasing dosage to 50 or greater milligrams per day in morphine equivalents and should avoid increasing dosages to 90 or greater milligrams per day in morphine equivalents.


6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of short-acting opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days will usually be sufficient for non-traumatic pain not related to major surgery.


7. Providers should evaluate patients within 1 to 4 weeks of starting long-term opioid therapy or of dose escalation to assess benefits and harms of continued opioid therapy. Providers should evaluate patients receiving long-term opioid therapy every 3 months or more frequently for benefits and harms of continued opioid therapy. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids when possible.


8. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid-related harms are present.


9. Providers should review the patient’s history of controlled substance prescriptions using state Prescription Drug Monitoring Program data to determine whether the patient is receiving excessive opioid dosages or dangerous combinations that put him/her at high risk for overdose. Providers should review Prescription Monitoring Program data when starting opioid therapy and periodically during long-term opioid therapy (ranging from every prescription to every 3 months).


10. Providers should use urine drug testing before starting opioids for chronic pain and consider urine drug testing at least annually for all patients on long-term opioid therapy to assess for prescribed medications as well as other controlled substances and illicit drugs.


11. Providers should avoid prescribing of opioid pain medication and benzodiazepines concurrently whenever possible.


12. Providers should offer or arrange evidence-based treatment (usually opioid agonist treatment in combination with behavioral therapies) for patients with opioid use disorder.

 

[emd123]

CDC Draft Guidelines for Opioid Prescribing


1. Non-pharmacological therapy and non-opioid pharmacological therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks.


2. Before starting long term opioid therapy, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.


3. Before starting and periodically during opioid therapy, providers should discuss with patients risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.


4. When starting opioid therapy, providers should prescribe short-acting opioids instead of extended-release/long acting opioids.


5. When opioids are started, providers should prescribe the lowest possible effective dosage. Providers should implement additional precautions when increasing dosage to 50 or greater milligrams per day in morphine equivalents and should avoid increasing dosages to 90 or greater milligrams per day in morphine equivalents.


6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of short-acting opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days will usually be sufficient for non-traumatic pain not related to major surgery.


7. Providers should evaluate patients within 1 to 4 weeks of starting long-term opioid therapy or of dose escalation to assess benefits and harms of continued opioid therapy. Providers should evaluate patients receiving long-term opioid therapy every 3 months or more frequently for benefits and harms of continued opioid therapy. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids when possible.


8. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid-related harms are present.


9. Providers should review the patient’s history of controlled substance prescriptions using state Prescription Drug Monitoring Program data to determine whether the patient is receiving excessive opioid dosages or dangerous combinations that put him/her at high risk for overdose. Providers should review Prescription Monitoring Program data when starting opioid therapy and periodically during long-term opioid therapy (ranging from every prescription to every 3 months).


10. Providers should use urine drug testing before starting opioids for chronic pain and consider urine drug testing at least annually for all patients on long-term opioid therapy to assess for prescribed medications as well as other controlled substances and illicit drugs.


11. Providers should avoid prescribing of opioid pain medication and benzodiazepines concurrently whenever possible.


12. Providers should offer or arrange evidence-based treatment (usually opioid agonist treatment in combination with behavioral therapies) for patients with opioid use disorder.

Those are good guidelines, but there's a glaring omission:

What to do about chronic pain patients already on opiate doses much greater than those they recommend (>90-120mg MED)?

 

[Ducttape]

its not a glaring admission.

we dont exactly know what to do with them. there are no succinct "guidelines" for these Legacy patients.

do you have guidelines for these patients? Can you post them?

 

[lobelsteve]

Here.

 

[101N]

Guidelines for Legacy Pt's.

1. Grandma/Grandpa MED < 90, no aberrancy = Amnesty
2. Dose > 90, no aberrancy, taper to or below 90
3. MED 300 & above without aberrancy. Rx naloxone & taper or convert to Suboxone.

 

[lobelsteve]

Guess who is not going to show up as a new patient to see me on Monday?

 

[Ducttape]

Guidelines for Legacy Pt's.

1. Grandma/Grandpa MED < 90, no aberrancy = Amnesty
2. Dose > 90, no aberrancy, taper to or below 90
3. MED 300 & above without aberrancy. Rx naloxone & taper or convert to Suboxone.

I'm not disagreeing, but do we have definitive enough EBM to insist on these as guidelines, especially #2?

 

[emd123]

I'm not disagreeing, but do we have definitive enough EBM to insist on these as guidelines, especially #2?

I agree in general with some dose threshold. But the 120 MED threshold has been touted for years now by some people nationally and by certain posters on this board. Now it's 90? Who made that change and based on what concrete evidence and research?What will it be next year? 85? 40? Back up to 120?

Although, I'm on board with the overall concept, I agree that the number itself seems very arbitrary, and it needs to be either evidence based, or if unable, then sufficiently vague and non-rigid to account for that fact.

Otherwise, every year we'll end up having to jerk patients' med doses around based on some arbitrary number chosen by some panel.

 

[pastafan]

I agree in general with some dose threshold. But the 120 MED threshold has been touted for years now by some people nationally and by certain posters on this board. Now it's 90? Who made that change and based on what concrete evidence and research?What will it be next year? 85? 40? Back up to 120?

Although, I'm on board with the overall concept, I agree that the number itself seems very arbitrary, and it needs to be either evidence based, or if unable, then sufficiently vague and non-rigid to account for that fact.

Otherwise, every year we'll end up having to jerk patients' med doses around based on some arbitrary number chosen by some panel.

http://annals.org/article.aspx?articleid=2089370

One large, fair-quality retrospective cohort study (n = 9940) found that, compared with nonuse, recent opioid use was associated with an increased risk for any overdose events (adjusted hazard ratio

---

, 5.2 [CI, 2.1 to 12.5]) and serious overdose events (adjusted HR, 8.4 [CI, 2.5 to 28]) (Appendix Table 2) (42). The annual overdose rate was 256 per 100 000 person-years among patients who had recently received prescribed opioids versus 36 per 100 000 person-years among those who had not. Higher doses were associated with increased risk. Compared with an MED of 1 to 19 mg/d, the adjusted HRs for overdose ranged from 1.44 (CI, 0.57 to 3.62) for an MED of 20 to 49 mg/d to 8.87 (CI, 3.99 to 19.72) for an MED of at least 100 mg/d. A similar pattern was observed for serious overdose.

 

[lobelsteve]

http://annals.org/article.aspx?articleid=2089370

One large, fair-quality retrospective cohort study (n = 9940) found that, compared with nonuse, recent opioid use was associated with an increased risk for any overdose events (adjusted hazard ratio

---

, 5.2 [CI, 2.1 to 12.5]) and serious overdose events (adjusted HR, 8.4 [CI, 2.5 to 28]) (Appendix Table 2) (42). The annual overdose rate was 256 per 100 000 person-years among patients who had recently received prescribed opioids versus 36 per 100 000 person-years among those who had not. Higher doses were associated with increased risk. Compared with an MED of 1 to 19 mg/d, the adjusted HRs for overdose ranged from 1.44 (CI, 0.57 to 3.62) for an MED of 20 to 49 mg/d to 8.87 (CI, 3.99 to 19.72) for an MED of at least 100 mg/d. A similar pattern was observed for serious overdose.

---

But the real question is: Are we as board certified pain physicians part of the problem? I say no. The vast majority of Rx's are not coming from us. The problem isn't the drug, it is the prescriber not assessing the risk. Why we don't let PCP's do epidurals, heart surgery, or colonoscopies. It is a specialist thing. We need education or regulation to solve the problem. Addicts are going to be 9% regardless. They should have to see us or Psych and not the PCP who lacks the training, education, experience to deal with this.

Money changes, politics, money changes research, money does not change outcomes. But it can buy ice cream. And motorcycles.

 

[emd123]

http://annals.org/article.aspx?articleid=2089370

One large, fair-quality retrospective cohort study (n = 9940) found that, compared with nonuse, recent opioid use was associated with an increased risk for any overdose events (adjusted hazard ratio

---

, 5.2 [CI, 2.1 to 12.5]) and serious overdose events (adjusted HR, 8.4 [CI, 2.5 to 28]) (Appendix Table 2) (42). The annual overdose rate was 256 per 100 000 person-years among patients who had recently received prescribed opioids versus 36 per 100 000 person-years among those who had not. Higher doses were associated with increased risk. Compared with an MED of 1 to 19 mg/d, the adjusted HRs for overdose ranged from 1.44 (CI, 0.57 to 3.62) for an MED of 20 to 49 mg/d to 8.87 (CI, 3.99 to 19.72) for an MED of at least 100 mg/d. A similar pattern was observed for serious overdose.

---

If we're getting to where zero mg is the safest dose, which it is, then let's go there now. Let's not waste our time pretending 90mg or any other arbitrarily chosen cutoff is magically safe, as if one mg higher is deadly and 1 mg below is without risk. It's like the frickin' 5 blade razor. It's perfect and no one can imagine anything better, until some dweeb comes along and shocks the world with a six blade razor claiming its radically better.

I'm aware of all these studies and I think they're very valuable studies. They show dose dependent risk for opiates. They show that ZERO mg is the safest dose, not 90mg daily morphine. My point was, what studies show that 90 mg is somehow the magic number?

This study doesn't show that. The highlest category is "at least 100mg/d." That category would include patients at 100mg/day, 120mg/day and 1,000mg per day.

You can't possibly believe that the overdose risk of 1,000 mg/day is no greater than 120mg, can you?

My point: Whatever cutoff you choose, be it 100mg/day like this study, or 120mg or 150mg, or whatever, that category will include doses up to infinity. Therefore, the dose just under the cutoff will appear to be the "safe dose." But still not safer than something even lower.

The other categories are very narrow and share roughly the same risk. But a category of "greater than" some number creates a very, very large risk ratio because it would necessarily include doses way off the scale. Then, if you take the dose just under that cutoff, it's going to look like that's the magic number. If they had made that category ">120mg/d" or ">200mg/day" that would still be the highest risk group, in fact it would be higher since you've left out some low dose people. Then you could conclude:

"190mg per day is the safest dose!"

Also, since it's a dose dependent risk, anyone who has any dose limit in their practice, for example, 40mg/d, I can go to them and say, "30 mg is safer!"

Here's where it's a big deal to me. I've made a point have a dose limit in my practice of 120mg/day, though I prefer no to start if they're on none, and not to dose escalate if they're on less than 120mg/d. It took some very difficult work to get every single one of my patients to at or below that threshold. The numbers over it was not many, and all were started on those doses by someone else. All in all it's worked out great. I have what is consider a very low dose Pain practice with many patients on zero mg, or low to moderate doses. Only a few patients deemed low risk and proper candidates, monitored very closely are on 120mg/day, and none over that limit.

But what do we do now, now that someone came along and arbitrarily picked 90mg as a threshold? Do we break the backs of our compliant, controlled, non-addict, non-diverting patients, because someone else picked this dose which actually isn't the safest dose, because 80mg is safer than that, 70mg safer than that and zero safer than all?

Then when they come along next year and say "Nope, 40 mg is the threshold, 40 is safer"? Because 40 mg is less risk than 120mg, or 90 mg or 60 mg?

So if what we're getting at, is that the only safe dose is zero mg per day, then let's just get right to zero mg per day. Let's not play these silly games of every year, some resident that wants to do a research project, "See! 80 mg/day is safer than 90mg! Over 80 is deadly!" then "70mg is safer! Over 70mg is deadly!"

Because the only risk free dose is zero.

Ultimately it has to do with the patient, more than the dose. The most dangerous patients shop around for the highest doses. A little old lady on 200mg morphine per day maybe be infinitely lower risk than a 29 yr old addict that walks out the door with a prescription for 80mg/day (MS ER 40mg #60 pills) or even 20 mg/day intent on injecting the whole bottle tonight. This data applies to populations much better than individual patients. We cannot forget that.

 

[Ducttape]

i do have to agree with what 101N said on the other thread, emd. your post is rhetoric based without pretense of having any scientific foundation.

we dont need more expert opinions such as this. we need something more concrete. posting a study for most individuals does mean vetting out the topic and the conclusions. you can be tooting sure that any link i post, i have read in its entirety as best as i can (some do not allow full text) and spent appropriate time reviewing the study and statistics, how it was done, the results and conclusions.


you ask the question - the answer is that it is a balance of risk/reward, thats one reason why it cant be zero, and in a select population, the "reward" can be considerable and beneficial.

also, zero is not a risk free dose, as pointed out by drusso, in studies he has posted that show there is a distinct percentage of people who were never prescribed opioids yet managed to overdose on prescription opioids.



lobel, there are some that prescribe opioids copiously. some of us are the problem. i dont have to rehash the names.

we need an organization that is willing to acknowledge that opioids should not be prescribed for chronic nonmalignant pain, in almost all circumstances. for some reason, i dont get the feeling that that organization is out there.
AAPManagement?
ASIPP?
ISIS?
APS? (haha)
AAPM? (hahahahahaha)

 

[emd123]

your post is rhetoric based without pretense of having any scientific foundation.

I think we agree, really. If what we're getting at, is that the right choice is "no opiates" as you worded it (or dose of "zero mg" as I worded it) in most chronic non-cancer pain, then let's get right to it and not play around with games such as, "120 MED is good in 2014," then it's 2015 it's not and only "90 MED is okay in 2015" and so on.

I think ultimately, it will not turn out to be so simple. I think we'll continue to have a bell curve of physicians who believe in various doses of, and indications for, opiates. Personally, I'm very comfortable with the approach of very strict screening and monitoring combined with:

"When in doubt: don't start opiates, don't dose escalate, and don't go over a dose threshold (pick your arbitrary cutoff of choice whether it's 60, 90, 100, 120, 150, or 200 MED or whatever)."

Where I don't want to be and where I think most of us shouldn't want to be is on the high dose, high risk end of that bell curve. But as long as we've got patients on the stratospheric high doses, all of our jobs will continue to be difficult.

 

[101N]

IMO this group has the most potential: APS. A SIG could be developed for the orthox.

 

[drusso]

CDC Draft Guidelines for Opioid Prescribing


1. Non-pharmacological therapy and non-opioid pharmacological therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks.


2. Before starting long term opioid therapy, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.


3. Before starting and periodically during opioid therapy, providers should discuss with patients risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.


4. When starting opioid therapy, providers should prescribe short-acting opioids instead of extended-release/long acting opioids.


5. When opioids are started, providers should prescribe the lowest possible effective dosage. Providers should implement additional precautions when increasing dosage to 50 or greater milligrams per day in morphine equivalents and should avoid increasing dosages to 90 or greater milligrams per day in morphine equivalents.


6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of short-acting opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days will usually be sufficient for non-traumatic pain not related to major surgery.


7. Providers should evaluate patients within 1 to 4 weeks of starting long-term opioid therapy or of dose escalation to assess benefits and harms of continued opioid therapy. Providers should evaluate patients receiving long-term opioid therapy every 3 months or more frequently for benefits and harms of continued opioid therapy. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids when possible.


8. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid-related harms are present.


9. Providers should review the patient’s history of controlled substance prescriptions using state Prescription Drug Monitoring Program data to determine whether the patient is receiving excessive opioid dosages or dangerous combinations that put him/her at high risk for overdose. Providers should review Prescription Monitoring Program data when starting opioid therapy and periodically during long-term opioid therapy (ranging from every prescription to every 3 months).


10. Providers should use urine drug testing before starting opioids for chronic pain and consider urine drug testing at least annually for all patients on long-term opioid therapy to assess for prescribed medications as well as other controlled substances and illicit drugs.


11. Providers should avoid prescribing of opioid pain medication and benzodiazepines concurrently whenever possible.


12. Providers should offer or arrange evidence-based treatment (usually opioid agonist treatment in combination with behavioral therapies) for patients with opioid use disorder.

Has anyone inspected a list of the Core Expert Group (CEG) that the CDC consulted in developing these guidelines?

 

[101N]

Good question, need to post that & their disclosures.

 

[ampaphb]

http://www.cdc.gov/drugoverdose/prescribing/guideline.html

 

[drusso]

http://www.cdc.gov/drugoverdose/prescribing/guideline.html

The Core Expert Group includes CDC scientific staff, professional society representatives, subject matter experts, state agency representatives, and an expert in guideline development methodology. (????) This group reviews the evidence and consults on CDC-drafted recommendations.

*Please note that the Society of General Internal Medicine, American Academy of Family Physicians, and American College of Physicians were represented in the Core Expert Group.

Subject matter experts but no pain experts?

 

[101N]

What does a 'pain expert' bring to the table?

 

[ampaphb]

Given that you hold yourself out as an expert in pain management (https://www.corvallisclinic.com/providers/paul-coelho-md) don't you find just a hint of irony (and more than a modicum of hypocricy) in asking that question?

 

[101N]

What do you bring to the table Peter? What qualifies you - or David -to speak about opioid prescribing?

 

[drusso]

What do you bring to the table Peter? What qualifies you - or David -to speak about opioid prescribing?

Not much I suppose...

https://olis.leg.state.or.us/liz/2015R1/Downloads/CommitteeMeetingDocument/57826