The prescription opioid epidemic in a nutshell

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PHARMA sponsored opioid advocate remains nonplussed by prescription opioid overdose deaths.

“Unfortunately, news media, government agencies, and others have portrayed abuse and addiction associated with prescribed opioids as problems of much larger proportions than seems warranted by the evidence.”
SB. Leavitt, MA, PhD

Proviso: Pain Treatment Topics is supported in part by medical education grants from Purdue Pharma L.P. (a maker of buprenorphine products) and Teva Pharmaceuticals (a maker of fentanyl-related products). Neither of those organizations had any role in the initiation, development, or review of this UPDATE article and they are in no way responsible for its content; all facts are from the sources cited, all opinions are expressly those of the author.

http://psychcentral.com/news/2009/01/21/opioid-abuse-less-than-imagined-among-pain-clients/3675.html

http://updates.pain-topics.org/2013/04/opioid-dose-alone-may-not-influence.html

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Prominent IM doc arrested for manslaughter and other charges


BY KEITH EPPS / THE FREE LANCE–STAR

A Stafford doctor was arrested Friday morning on 95 felony charges—including involuntary manslaughter—police said.

Nibedita Mohanty, 54, was indicted Monday by a Stafford County grand jury on 72 counts of illegally distributing drugs, 22 counts of obtaining money by false pretenses and involuntary manslaughter.

The indictments were sealed pending the doctor’s arrest, which occurred on Courthouse Road in Stafford.

It was not immediately clear what led to the manslaughter charge. A Sheriff’s Office release only says that it stems from an overdose death “directly related to Mohanty’s practice of over prescribing pain narcotics.”

Stafford Sheriff’s Capt. Billy Bowler said more information regarding that charge might be released sometime next week.

Other than the manslaughter allegation, the charges against Mohanty aren’t a surprise. Her office on Garrisonville Road and her home on Marlborough Point Road were raided in January. Numerous records, bank statements, computers and cash were seized.

In affidavits for search warrants filed in Stafford Circuit Court, Mohanty was accused of operating a “pill mill” and her North Stafford medical practice was described as a haven for drug abusers and dealers.

During an investigation that began in 2011, police claimed they had identified 46 people who were prescribed drugs by Mohanty that were involved in trafficking prescription drugs. The FBI and the DEA have assisted Stafford authorities in the probe.

The records said Mohanty wrote an average of 50 prescriptions a week, and a doctor who reviewed her prescribing practices said the volume of drugs and other factors indicated something was amiss.

William Winfred Price, Mohanty’s former live-in boyfriend, was the only one of four informants named in the court documents. The others were described as patients who had addictions or legal troubles stemming from drugs they supposedly got from Mohanty.

One informant told police he went to Mohanty at the suggestion of a friend who told him she would prescribed anything for $250.

The affidavits also alleged that Mohanty was involved in tax and insurance fraud.

Mohanty, who practices internal medicine, has been practicing in Stafford for more than 20 years and until recently served as chief of medicine at Stafford Hospital.

She and her attorney, Charles Roberts, released a letter in March in which she adamantly denied any wrongdoing.

“I strongly deny the allegations set out in the news reports and the search warrant affidavit as I have not prescribed medicine to any patient who I knew or had reason to believe was abusing the drugs or selling the medicine to others,” Mohanty wrote in a letter to The Free Lance–Star.

She said she was shocked to have her home and business raided based on information from people she described as drug dealers, drug addicts and convicted felons. She was especially critical of Price, who she accused of intentionally damaging her reputation because she had him arrested following a domestic incident last year.

Price was convicted of several misdemeanors and spent time in jail.

Mohanty wrote at the time that as the result of the investigation, she had permanently given up prescribing pain medication.

“I wish to thank all of my patients and other members of our community for their outpouring of support during this crisis, and I anticipate this investigation ultimately will show that I have not violated any laws,” wrote Mohanty, who had not been charged at the time.

Sheriff’s spokesman Bill Kennedy said the investigation is ongoing and no additional information will be provided at this point.

A date for Mohanty’s initial court appearance in Stafford Circuit Court had not been set as of Friday.

http://news.fredericksburg.com/news...th-involuntary-manslaughter-94-other-charges/
Posted: Saturday, May 11, 2013 12:00 am | Updated: 11:55 pm, Sun May 12, 2013.

BY BILL McKELWAY Richmond Times-Dispatch

A Stafford County doctor and former hospital chief who was arrested Friday on multiple felonies prescribed tens of thousands of doses of narcotics to clinically fragile patients with existing drug addictions, according to disciplinary files and criminal charges.

Dr. Nibedita Mohanty was taken into custody Friday morning by Stafford authorities after a monthslong investigation on charges that include involuntary manslaughter in the death of a 41-year-old female patient two years ago.

Mohanty, 54, a graduate of the Virginia Commonwealth University School of Medicine, according to a profile, had her license suspended in April on an emergency basis.

According to state Board of Medicine documents released Friday, the doctor allegedly prescribed thousands of doses of powerful narcotics to the 41-year-old patient “notwithstanding (the doctor’s) awareness of drug-seeking behavior and information that should have indicated the patient was abusing or had become addicted.”

Mohanty’s patient records showed diagnoses of five separate illnesses with no supportive testing of the woman who died June 1, 2011, of “acute combined oxycodone and (an antidepressant) toxicity.”

Two weeks before the patient’s death, the woman had been admitted to the hospital for a drug overdose, but on May 31 was prescribed 500 doses of pain medication by Mohanty. A patient note initialed by Mohanty indicated the woman had not taken pain medications in two months before hospitalization.

Stafford investigators said that the doctor faces 95 separate charges, including 72 counts of felony distribution of narcotics, 22 counts of obtaining money by false pretenses through insurance fraud, and the manslaughter charge.

A sheriff’s spokesman declined to identify the deceased patient. Mohanty is expected to be arraigned Monday although the investigation is continuing.

A 39-page medical board statement of particulars linked to the license suspension proceeding describes Mohanty prescribing thousands of doses of narcotics to patients, sometimes without physical tests for alleged conditions.

A 27-year-old woman allegedly was treated by the doctor for 25 months, during which the woman was prescribed 21,635 doses of oxycodone, nearly 2,000 doses of Opana, and some 12,000 doses of other narcotics. She was found unresponsive from an apparent medical overdose, but was revived.

Key medical board allegations also involve instances in which the physician allegedly knew patients were selling prescribed narcotics on the street but continued to supply them prescriptions.

Search warrants issued by Stafford investigators and published in a Fredericksburg newspaper earlier this year quote investigators as being told by patients that Mohanty “will give you anything you want for $250.”

Physician profiles list Mohanty, a former chief of medicine at Stafford Hospital, as board-certified in internal medicine, and search warrants show she has been under federal, state and administrative investigation since at least 2011. One affidavit alleged that of 67 patients listed in Mohanty’s records, 46 were involved in trafficking prescription narcotics.

Investigators called in a medical expert to assess their findings and patient doses, tracking more than 13,000 prescriptions. Investigators learned from a boyfriend that Mohanty kept tens of thousands of dollars of cash on hand, at one point paying for a $50,000 swimming pool with cash from a paper bag.

http://mobi.timesdispatch.com/richmond/pm_/contentdetail.htm?contentguid=
 
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Favorite quote:

"This pilot study indicates that TF is effective and desired as a preferential opioid for breakthrough pain by a high percentage of chronic, non-malignant pain patients."

TF= transmucosal fentanyl. Oy.



i like this one:

"Serum cortisol concentrations that are too high or too low are biologic markers that call for aggressive pain management to bring the cortisol level into normal range"

i felt as if i was reading a book... hmm... for some reason, Goldilocks comes to mind...
 
Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment.

AuthorsMurphy JL, et al. Show all Journal
Clin J Pain. 2013 Feb;29(2):109-17. doi: 10.1097/AJP.0b013e3182579935.

Affiliation
Chronic Pain Rehabilitation Program, James A. Haley Veterans' Hospital, Tampa, FL 33612, USA. [email protected]

Abstract
OBJECTIVES: Although the efficacy of interdisciplinary treatment for chronic noncancer pain has been well-established in the literature, there is limited research examining interdisciplinary programs that require opioid cessation. As the long-term use of opioid analgesics remains controversial, further investigation is warranted. The aim of this study was to evaluate the associations between opioid cessation and subsequent multidomain treatment outcomes among veterans admitted to a pain rehabilitation program at a large Veterans Affairs tertiary care hospital in the southeastern United States.

METHODS: A retrospective design examined the medical records of 705 consecutive admissions comparing those using opioids at admission with those who were not. Participants taking opioids agreed to taper off of these medications using a "pain cocktail" approach; otherwise patients received identical treatment. Outcome measures were administered at program admission and discharge.

RESULTS: Repeated measures analyses were used to compare responses across time. Those who completed the program (n=600) demonstrated improvement in all outcome measures from admission to discharge, and the opioid group improved as much or more than the nonopioid group on all measures despite opioid cessation during treatment.

DISCUSSION: Results indicated that both groups experienced significant improvement on outcome measures, and that opioid analgesic use at admission had no discernible impact on treatment outcome in this large sample of veterans with moderate to severe chronic pain syndrome. The clinical implications of these findings for long-term chronic pain treatment, in light of the risks associated with opioid analgesics, are discussed.
 
interesting...

retrospective.

reassuring that patients taken off opioids can do as well as those who are kept on - and obviously without the continuing risk of COT.

hard for COT proponents to say that COT is providing significant benefit, if there is no discernible impact on treatment outcomes...
 
VA patients (captured by clinic), no other place to go, and forced through treatment.

No private practice can duplicate the resources thrown at these patients to make them better.

But opiates do not improve function on the face of things. THey decrease function on the face of things. Coupled with properly selected treatment regimen (PT/HEP/injections/adjunct meds) can show function and maintain FT work. I'd like to know the work status of the n=600 VAMC patients.
 
Interesting study. Faults are of course the participation was voluntary, and the results were given only for those opioid patients that completed the program. What about the patients that did not want to give up the opioids in the first place and refused to participate? What about the number of patients that failed to complete the program? Also VA patients in my area are not a closed system with patients frequently seeing physicians both in the VA and in private practice. Our PMP has yet to have VA prescribing data entered into it, therefore patients can easily be receiving opioids from multiple physicians, even when the patients are enrolled in studies.

There are at least 6 other studies however that demonstrate identical findings, with the same patient selection problems- only those that can eradicate opioids have the effect measured in all these studies. Yet, it is compelling information that suggests given enough resources for multidisciplinary treatment (resources that are not available to most pain patients) that non-opioid therapy is effective for some patients that can be weaned from opioids.
 
i take it from a different perspective, even though i am not a PROPster.

multidisciplinary approaches are most effective, and limiting/stopping opioids should not impede potential benefit ('doc, i HAVE to have my meds to get better" - uh, no, according to this study, you dont).
 

Taken from an amazon review of the book:

"Meier, never having suffered from chronic pain, can never understand what this struggle is like, and it is a shame that he didn't try harder to get the story from the people that live in pain, or the fear of it, every day. Some people need opiates to function, like some diabetics need insulin. Our society and government need to accept that."
 
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Embattled board mulls prescription abuse solutions
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BY LISA GIRION AND SCOTT GLOVER,
Los Angeles Times
June 5, 2013, 2:03 a.m.
Under pressure from state lawmakers to reform, the Medical Board of California on Tuesday embarked on a search for a new executive director and considered a host of proposals aimed at combating reckless prescribing by doctors that is contributing to overdose deaths.

At a specially convened meeting, the board discussed the need for urgency in developing new guidelines for prescribing OxyContin, Vicodin and other narcotic painkillers that have fueled a national prescription drug death epidemic. Panel members also expressed tentative support for a proposal that would form specialized enforcement teams to identify and investigate doctors engaged in suspect prescribing.

State legislators have threatened to disband the board if it didn't show significant progress in correcting problems highlighted in a Los Angeles Times investigation published last year that exposed failures in the board's oversight of doctors. The investigation identified 3,733 prescription drug overdose deaths in Southern California from 2006 through 2011. Nearly half of those deaths involved at least one prescription written by a physician to the decedent, and 71 physicians had three or more patients fatally overdose on drugs they prescribed, the paper reported.

The board was unaware of the vast majority of the deaths. In some instances, the deaths occurred even though the doctor was under investigation by the board and the inquiry had dragged on for months or years.

Several lawmakers have proposed moving the medical board's investigators to the attorney general's office, hoping to improve oversight of doctors. Some board members said Tuesday they wanted to maintain control over their investigators.

"I have to agree with the Legislature that we have not done a good job," said board member Michael Bishop. "If we can demonstrate that we can clean up our own house … then it's in the interest of the public to keep the investigators on our side. But if we fail to do that, I think it's going to be a forced hand."

Board members, who previously have been defensive in the face of the criticism, acknowledged the need for action, embraced some reform proposals and proposed some new ones, such as the specialized prescription drug enforcement teams. Even though staff members said the agency did not have the resources, board member Dev GnanaDev asked them to put together a proposal to develop such teams.

"This is an urgent matter," he said.

At the outset of Tuesday's meeting, board President Sharon Levine announced that the board's executive director, Linda K. Whitney, had notified the board of her decision to retire effective June 1. Whitney's notice came just days before the board was to discuss her continued employment "and the selection of an acting executive director, if necessary" according to an item on Tuesday's agenda.

Whitney and Levine declined to answer questions regarding the circumstances surrounding the departure.

"I retired. Thank you very much," Whitney said, before abruptly hanging up the phone on Tuesday. The board voted Tuesday to appoint Kimberly Kirchmeyer, a board deputy, as acting executive director.

Whitney, 60, has not been publicly criticized by board members or politicians seeking to reform the panel. But at a board meeting in April, several members complained about how the board was being represented in the media during her tenure.

Under Whitney, the board failed to mine prescribing data collected by the state to identify potentially reckless doctors, despite a recommendation by the U.S. Centers for Disease Control and Prevention to do so.

Whitney said she did not tap into such data because the board was a complaint-driven agency that did not engage in proactive investigations.

Lawmakers said that attitude was a fundamental problem with the board's approach to oversight.

As it stands, the Legislature is set to abolish the medical board at the end of the year — a move key lawmakers have said they would reconsider if the agency makes significant changes.

Sen. Curren Price (D-Los Angeles), who chairs the committee that oversees the board, said he is not convinced progress has been made. Price said he remained concerned about a culture that resulted in the board "not having the laser focus on consumer protection and enforcement that we think they need to have."

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Related Content
California's medical board backs some prescription-drug-abuse reforms
 
It is disturbing that the US government (CDC) suggests using the patient monitoring systems to sanction physicians. But WTH- they tap our phones and internet so what do they care.
 
It is disturbing that the US government (CDC) suggests using the patient monitoring systems to sanction physicians. But WTH- they tap our phones and internet so what do they care.

What's disturbing to me is that a "pain doctor" can read that article and some how contort the message into 'intrusive big government'. 3700 prescription overdose deaths over a 5yr period and no plan to curtail them.

We need public MED reporting data on all physicians in the US. This will forcast where the deaths will occur and allow preventative measures to be taken.
 
What's disturbing to me is that a "pain doctor" can read that article and some how contort the message into 'intrusive big government'. 3700 prescription overdose deaths over a 5yr period and no plan to curtail them.

We need public MED reporting data on all physicians in the US. This will forcast where the deaths will occur and allow preventative measures to be taken.

ANy data on percent deaths from from Pain physicians vs those just prescribing a lot of opiates.

Surgeons, Psychiatrists, Pediatricians, Ob/Gyn, and FP/IM are the biggest problem in Georgia. Rarely is it an actual pain doctor that has a series of overdose deaths.
 
link doesn't work

By CURT ANDERSON

MIAMI -- Federal authorities have reached an $80 million settlement with the Walgreens (WAG) pharmacy chain over rules violations that allowed tens of thousands of units of powerful painkillers such as oxycodone to illegally wind up in the hands of drug addicts and dealers, officials said Tuesday.

Mark R. Trouville, chief of the U.S. Drug Enforcement Administration's Miami field office, said Walgreens committed numerous record-keeping and dispensing violations of the Controlled Substances Act at a major East Coast distribution center in Jupiter, Fla., and at six retail pharmacies around the state. The drugs also included hydrocodone and Xanax.

Authorities said the Jupiter center failed to flag suspicious orders of drugs it received from pharmacies, and the retail outlets routinely filled prescriptions that clearly were not for a legitimate medical use. The upshot was many more doses of prescription drugs were available illegally on the street.

Trouville called Walgreens' actions "a clear example of inexcusable corporate conduct that existed only for greed and profit. National pharmaceutical chains are not exempt from following the law."

Walgreens is the nation's largest pharmacy chain with more than 8,000 stores and sales in 2012 of $72 billion, according to the company's website. A spokesman at the Deerfield, Ill.-based company said a statement might be issued later.

Florida has been a major East Coast source of highly addictive painkillers for illicit dealers and addicts. An ongoing crackdown in recent years - including passage of better prescription monitoring laws and numerous arrests of doctors, clinic operators and pharmacy owners - has reduced the number of illegal "pill mills" operating in the state.

Miami U.S. Attorney Wifredo Ferrer said the Walgreens civil penalty was the largest in the history of the Controlled Substances Act. He said Walgreens also agreed not to dispense certain tightly-controlled drugs for two years through the Jupiter distribution center and the six Walgreens locations: two in Fort Pierce and one each in Hudson, Port Richey, Fort Myers and Oviedo.

"We're tackling the problem from an entirely new angle," he said of pursuing a civil penalty rather than criminal prosecution.

The settlement also resolves similar allegations against Walgreens retail pharmacies in Colorado, Michigan and New York, Ferrer said.

A surge of oxycodone prescriptions at Walgreens became apparent after 2009, according to the DEA. To take one example, the store in Hudson went from 388,100 oxycodone units purchased in 2009 to more than 913,000 in 2010, then to 2.1 million in 2011. Trouville said the national average for pharmacy purchases of oxycodone is about 73,000 units.

"No one with an ounce of common sense can believe this is the proper way to conduct the business of medicine," he said.

In addition to the penalty and the two-year ban on dispensing certain drugs, the settlement requires that Walgreens create a new department to ensure regulatory compliance, a new training program for employees and that it end compensation for pharmacists based on prescriptions filled.
 
NSAID Bleeding Risk: Smoke But No Fire
By John Fauber, Reporter, Milwaukee Journal Sentinel/MedPage Today
Published: May 30, 2012
Related Article
Narcotic Painkiller Use Booming Among Elderly
One of the main arguments for initiating use of narcotic painkillers with older people with chronic, noncancer pain is the concern that the alternative treatment -- nonsteroidal anti-inflammatory drugs -- can cause serious internal bleeding.

But that concern appears to be based on an overblown estimate of NSAID risk, Journal Sentinel/MedPage Today investigation found.

The most frequently cited estimate of the risk, 16,500 deaths each year from NSAID-related GI bleeds -- is flat-out wrong, according to the researcher who first issued that estimate back in 1998.

"That's an an old number," said Gurkirpal Singh, MD, an adjunct clinical professor of medicine at Stanford University. "That's history."

Singh said his initial calculation of 16,500 annual deaths was based on early 1990s data.

The U.S. Centers for Disease Control and Prevention says the actual number of deaths in 2008, the most recent year available, is about 3,400, based on a review of death certificates. And that number includes all gastrointestinal bleeding deaths, not just those caused by NSAIDs.

Singh noted that lower doses of the nonprescription drugs are used today. And they are often taken with proton pump inhibitors such as Prilosec and Prevacid, which reduce acid in the stomach and result in less bleeding.

Nevertheless, opioid proponents continue to cite the 16,500 number.

It was brought up at the American Geriatrics Society's annual meeting in 2009, when the group announced its new guidelines recommending opioids and said NSAIDs should be used rarely.

It is used in a presentation on the AGS website as part of a continuing medical education activity funded by opioid maker Janssen Pharmaceuticals.

That presentation was created by James Katz, MD, of George Washington University, who at the time was a paid consultant for opioid-maker UCB Pharma.

Katz declined to comment.

Lewis Nelson, MD, an emergency medicine and medical toxicology specialist in New York, said the 16,500 deaths attributed to so-called nonsteroidal anti-inflammatory drugs does not seem possible.

"I could count 100 opioid-related problems for every nonsteroidal recognizable problem I see," Nelson said. "I literally don't see nonsteroidal problems and I see tons of opioid-related problems."

Byron Cryer, MD, a gastroenterologist at the University of Texas Southwest in Dallas, said it is wrong to overstate the risks of the nonprescription drugs.

"Anybody proposing an alternative therapy is going to peddle a worse-case scenario," said Cryer.

A paper in the American Journal of Therapeutics estimated the number of deaths tied to gastrointestinal bleeding caused by the drugs at 3,200 a year.

That paper was published in 2004 -- five years before the AGS issued its new guidelines.
 
NSAID Bleeding Risk: Smoke But No Fire
By John Fauber, Reporter, Milwaukee Journal Sentinel/MedPage Today
Published: May 30, 2012
Related Article
Narcotic Painkiller Use Booming Among Elderly
One of the main arguments for initiating use of narcotic painkillers with older people with chronic, noncancer pain is the concern that the alternative treatment -- nonsteroidal anti-inflammatory drugs -- can cause serious internal bleeding.

But that concern appears to be based on an overblown estimate of NSAID risk, Journal Sentinel/MedPage Today investigation found.

The most frequently cited estimate of the risk, 16,500 deaths each year from NSAID-related GI bleeds -- is flat-out wrong, according to the researcher who first issued that estimate back in 1998.

"That's an an old number," said Gurkirpal Singh, MD, an adjunct clinical professor of medicine at Stanford University. "That's history."

Singh said his initial calculation of 16,500 annual deaths was based on early 1990s data.

The U.S. Centers for Disease Control and Prevention says the actual number of deaths in 2008, the most recent year available, is about 3,400, based on a review of death certificates. And that number includes all gastrointestinal bleeding deaths, not just those caused by NSAIDs.

Singh noted that lower doses of the nonprescription drugs are used today. And they are often taken with proton pump inhibitors such as Prilosec and Prevacid, which reduce acid in the stomach and result in less bleeding.

Nevertheless, opioid proponents continue to cite the 16,500 number.

It was brought up at the American Geriatrics Society's annual meeting in 2009, when the group announced its new guidelines recommending opioids and said NSAIDs should be used rarely.

It is used in a presentation on the AGS website as part of a continuing medical education activity funded by opioid maker Janssen Pharmaceuticals.

That presentation was created by James Katz, MD, of George Washington University, who at the time was a paid consultant for opioid-maker UCB Pharma.

Katz declined to comment.

Lewis Nelson, MD, an emergency medicine and medical toxicology specialist in New York, said the 16,500 deaths attributed to so-called nonsteroidal anti-inflammatory drugs does not seem possible.

"I could count 100 opioid-related problems for every nonsteroidal recognizable problem I see," Nelson said. "I literally don't see nonsteroidal problems and I see tons of opioid-related problems."

Byron Cryer, MD, a gastroenterologist at the University of Texas Southwest in Dallas, said it is wrong to overstate the risks of the nonprescription drugs.

"Anybody proposing an alternative therapy is going to peddle a worse-case scenario," said Cryer.

A paper in the American Journal of Therapeutics estimated the number of deaths tied to gastrointestinal bleeding caused by the drugs at 3,200 a year.

That paper was published in 2004 -- five years before the AGS issued its new guidelines.


what about the cardiovascular risks of NSAIDS? a bigger problem IMHO.

also, NSAIDS vs. opioids is a false choice. why does it have to be "either/or"
 
The naive and historically unread would draw conclusions that unfiltered data poses no risk to a profession.....they are wrong. Suppose a physician prescribes moderately high dose opioids to 50% of their population and has zero deaths per year compared to a PCP that prescribes moderately high dose opioids to 4% of their population but has a death rate of 5 per year. MED data would hold the former physician in contempt but the latter physician would not even show up on the radar. My friend you have to think beyond the fluff of issues surrounding opioids, and realize that it is a very complex issue that is only simplified by simpletons (ie government).
 
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The naive and historically unread would draw conclusions that unfiltered data poses no risk to a profession.....they are wrong. Suppose a physician prescribes moderately high dose opioids to 50% of their population and has zero deaths per year compared to a PCP that prescribes moderately high dose opioids to 4% of their population but has a death rate of 5 per year. MED data would hold the former physician in contempt but the latter physician would not even show up on the radar. My friend you have to think beyond the fluff of issues surrounding opioids, and realize that it is a very complex issue that is only simplified by simpletons (ie government).

Obesity and tobacco use are risk factors for back pain. But they are not causative of back pain. It's not such a hard concept to grasp.

In a similar vein, MED > 100 is a risk factor for OD death, not a guarantee of OD death but a bona fide risk factor for OD death(1,2,3). But the risk here is death, not back pain. Being able to identify a risk factor for for an outcome as devastating as death, and intervene prior to, is the job of government, public health, and our medical boards.

MED prescribing data should be published and accessible to the public.


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. doi: 10.1001/archinternmed.2011.117.

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.

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. doi: 10.1059/0003-4819-152-2-201001190-00006.
 
Again, the studies are flawed, flawed, flawed. I have personally spoken with one of the authors that admits such. However, I will concede higher MED taken in context of aberrant behavior or dumb prescribing by other physicians of sedating meds are factors. But MED by itself? You can't say that unless you have controlled for the above two factors. The studies you cite did not. When there are clearly demonstrated multifactorial origins of an effect, you cannot pick out one of the factors and draw conclusions about effect unless you control for the other origins of an effect. Therefore it is not only disingenuous but scientifically unsound to publish MED without examining other variables occurring simultaneously.
 
I think algos is right. It's all relative. A patient who's been on a stable dose of 100mg morphine tid for years is at no more risk of death/overdose than a patient on 5mg oxycodone tid. What matters is aberrant drug related behavoirs (misuse), comorbid psychiatric illnesses, concommitant use of psychotropic medications, etc. If you look purely at dose, it by itself doesn't mean a thing. However, I would argue that those on higher doses of opiates are more likely to have the above mentioned risk factors. Hmmmmm
 
I think algos is right. It's all relative. A patient who's been on a stable dose of 100mg morphine tid for years is at no more risk of death/overdose than a patient on 5mg oxycodone tid. What matters is aberrant drug related behavoirs (misuse), comorbid psychiatric illnesses, concommitant use of psychotropic medications, etc. If you look purely at dose, it by itself doesn't mean a thing. However, I would argue that those on higher doses of opiates are more likely to have the above mentioned risk factors. Hmmmmm

No, the published data shows that OD DEATH's are directly related to MED. Nonfatal OD's, on the other hand, appear to be multifactorial.

Do not kid yourself, dose matters.
 
MED directly correlates to death if:
1. You have lost control over your pain population and have a high rate of abuse of the prescribed drug.
2. You have lost control over your pain population and they are permitted to drink alcohol, use illicit drugs, take methadone from any other source, or take benzodiazepines.
3. You do not recognize polypharmacy as a risk factor with multiple sedating medications being prescribed.
4. You rapidly escalate the dosage of opioids.
5. You insufficiently monitor your patients by not having frequent follow up, fail to use or act definitively on toxicology tests, or have NPs running out of control with prescribing in your practice.
6. You fail to act or adjust dosage downward in case of respiratory related hospitalizations or fail to act when patients have renal/liver failure (frequently due to inadequate follow up intervals).

MED by itself is NOT necessarily independently a risk factor since the studies above were not controlled. There was no control over how the OD patients actually took their medications, in some cases no autopsy reports (toxicology is insufficient to determine cause of death), and patients were clearly receiving other medications from sources outside those prescribed. They also did not control or evaluate prescribing/control practices of the physicians.

If you don't give a flip about your patients or how you conduct your practice and haven't a clue as to interactions of medications, then yes, MED does matter.
 
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MED directly correlates to death if:
1. You have lost control over your pain population and have a high rate of abuse of the prescribed drug.
2. You have lost control over your pain population and they are permitted to drink alcohol, use illicit drugs, take methadone from any other source, or take benzodiazepines.
3. You do not recognize polypharmacy as a risk factor with multiple sedating medications being prescribed.
4. You rapidly escalate the dosage of opioids.
5. You insufficiently monitor your patients by not having frequent follow up, fail to use or act definitively on toxicology tests, or have NPs running out of control with prescribing in your practice.
6. You fail to act or adjust dosage downward in case of respiratory related hospitalizations or fail to act when patients have renal/liver failure (frequently due to inadequate follow up intervals).

MED by itself is NOT necessarily independently a risk factor since the studies above were not controlled. There was no control over how the OD patients actually took their medications, in some cases no autopsy reports (toxicology is insufficient to determine cause of death), and patients were clearly receiving other medications from sources outside those prescribed. They also did not control or evaluate prescribing/control practices of the physicians.

If you don't give a flip about your patients or how you conduct your practice and haven't a clue as to interactions of medications, then yes, MED does matter.

#2 Do you absolutely prohibit your opiate patients from being on any amount of benzo whatsoever? (I don't personally prescribe benzos chronically, but have patients referred to me all the time who are already on them.)

#6 Do you routinely check LFTs and renal function on your patients and if so, how often?

Thanks.
 
Once a year liver and renal if not performed by PCP.
Max opioids are 120MED with any benzos at all however if patient has severe COPD the opioids are much less if they are receiving any benzos. We don't restrict prescribing of benzos by other physicians, but do restrict the prescribing of opioids when people take benzos. If a patient states they would rather be off the benzo in exchange for better pain relief, they must be off for 3 months by both PMP and UDT.
 
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No, the published data shows that OD DEATH's are directly related to MED. Nonfatal OD's, on the other hand, appear to be multifactorial.

Do not kid yourself, dose matters.

Problem is you cannot stop an epidemic on a case by case basis and there has to be some collateral damage. Looking at high prescribers will result in less prescriptions period, some real patients will be affected, but less then the objective patients who are misusing/abusing and diverting, there are casualties in any war. I personally welcome it. We are kidding ourselves, those that make our livings doling out opiates, that we are "helping" people. My procedures may not always help them, but it certainly does in a lot of people, and the ones that I don't help, I don't make into junkies at least.

Would you take opiates? Would you give it to your mom? Maybe in extreme cases, but the vast number of patients on opiates are not extreme, they are run of the mill chemical copers. This is what needs to be stopped
 
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Problem is you cannot stop an epidemic on a case by case basis and there has to be some collateral damage. Looking at high prescribers will result in less prescriptions period, some real patients will be affected, but less then the objective patients who are misusing/abusing and diverting, there are casualties in any war. I personally welcome it. We are kidding ourselves, those that make our livings doling out opiates, that we are "helping" people. My procedures may not always help them, but it certainly does in a lot of people, and the ones that I don't help, I don't make into junkies at least.

Would you take opiates? Would you give it to your mom? Maybe in extreme cases, but the vast number of patients on opiates are not extreme, they are run of the mill chemical copers. This is what needs to be stopped

Agree, but even if you and I never started one patient on opiates the rest of our careers, there's enough millions of patients dependent on them (some abusing them, some not), that we still have our work cut out for us managing the ones already on meds. You can't discontinue everyone's meds. It has to be done on a case by case basis. Who is benefitting without aberrancy (possibly continue with close monitoring) vs who isn't benefitting or is showing aberrancy (discontinue)?

I agree, though, the focus should be away from viewing opiates as a pain "cure-all" and rather viewing them as very problematic long term. Also, infinite dose increases without any common sense limit, has to stop. There needs to be a paradigm shift. Unless the DEA makes them all schedule I and bans them (won't happen), there's going to be a lot of work to do on the ground deciding who gets what, and a lot of messes to clean up.

Edit: If there is any hope of getting the Rx abuse epidemic under control, these kinds of complaints are going to go way up, and state boards (and med-mal juries) need to back us up. If Drs start getting dinged for underprescribing, that will add immeasurable fuel to the fire.
 
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As a side note, Algos had posted something about faulty cause of death reports. Look at this study from CDC, where 50% of doctors admitted filling out inaccurate cause of death on death certificates. That brings any overdose data into question.

http://www.cdc.gov/pcd/issues/2013/12_0288.htm
 
THE use of narcotic painkillers, or opioids, has boomed over the past decade as drug makers and doctors have promoted them for a new use: treating long-term pain from back injuries, headaches, arthritis and conditions like fibromyalgia. Insurers have also grown to see pills as a cheaper way to treat chronic pain than other methods.
Multimedia

Graphic
The Soaring Cost of the Opioid Economy
Some patients are greatly helped by opioids, a large family of medications. Among the more widely used opioids are oxycodone, which is found in Percocet and OxyContin, and hydrocodone, which is used in Vicodin. Other potent opioids include fentanyl and methadone. Narcotic painkillers are now the most widely prescribed class of medications in the United States, and prescriptions for the strongest opioids, including OxyContin, have increased nearly fourfold over the past decade.

There is increasing evidence, however, that such drugs, along with being widely abused, are often ineffective in treating long-term pain and can have serious consequences, particularly when used in high doses. Along with the risk of addiction, side effects can include psychological dependence, reduced drive, extreme lethargy and sleep apnea.

The economic costs associated with the painkiller boom have also proved enormous, giving rise to a host of unanticipated medical, legal and social costs. Over the past decade, the legal — and illegal — use of these drugs has given birth to new businesses and expanded existing ones. These include urine-screening tests to make sure patients are taking the drugs properly, added sales of addiction treatment drugs, growing emergency-room expenses, law-enforcement budgets and skyrocketing costs for insurers.

In the short run, treating a patient with an opioid like OxyContin, which costs about $6,000 a year, is less expensive than putting a patient through a pain-treatment program that emphasizes physical therapy and behavior modification. But over time, such programs, which run from $15,000 to $25,000, might yield far lower costs.

Here is a brief guide to the economics of opioids.

Barry Meier is a reporter who covers business and medicine for The New York Times and the author of the Times e-book “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake.”
A version of this news analysis appeared in print on June 23, 2013, on page SR4 of the New York edition with the headline: Profiting From Pain.
 
101N thread on opiate bashing.

It looks like it has declined to nothing more than fear-mongering.

We can all agree that the pendulum has swung from more opiates for all to less opiate prescribing. But is there no such thing as rational opiate prescribing?

101N: You're as wackaloo as Portenoy, just at the opposite end of the spectrum and 20 years later.
 
101N thread on opiate bashing.

It looks like it has declined to nothing more than fear-mongering.

We can all agree that the pendulum has swung from more opiates for all to less opiate prescribing. But is there no such thing as rational opiate prescribing?

101N: You're as wackaloo as Portenoy, just at the opposite end of the spectrum and 20 years later.


no. the other end of the spectrum is to not prescribe ANY opioids for chronic non-malignant pain. thats not what he's saying
 
no. the other end of the spectrum is to not prescribe ANY opioids for chronic non-malignant pain. thats not what he's saying

I don't think we know what he is saying, because he's just posting links to articles.

What is he saying?
 
I would offer that if there are any other medically and financially viable alternatives that they should be used in lieu of opioids for chronic pain.
 
I don't think we know what he is saying, because he's just posting links to articles.

What is he saying?

less than 100 meq/day. i think.

i'd ask him, but he'd probably just respond with another link
 
Basically I follow the WA state guidelines (VonKorff). 100MED max - a few exceptions - no coprescribing benzo's/SOMA/pot/amphetamine salts, avoid methadone.

And now, another link for Lobel: https://oig.hhs.gov/newsroom/spotlight/2013/diversion.asp

What if a PCP refers to you, they're under 100MED and the PCP or psych wants to write for, lets say, Xanax 0.5 bid. They are going to write it the Xanax, not you, but you write the opioids and do procedures/adjuvants etc. Do you insist on benzo discontinuation in all cases?
 
What if a PCP refers to you, they're under 100MED and the PCP or psych wants to write for, lets say, Xanax 0.5 bid. They are going to write it the Xanax, not you, but you write the opioids and do procedures/adjuvants etc. Do you insist on benzo discontinuation in all cases?

I don't have a pat answer for this. It would be a case by case basis.

What I'm referring to are the legacy patients whose wacky previous doctor was prescribing opioids plus valium 10mg QID and Aderall or Ritalin to keep them awake.
 
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