CDC guidelines

[DrCommonSense]

some of the reasons:
- because opioids are addictive and NSAID are not.
- because the vast majority of NSAID are sold OTC and not via prescription.
- because when people OD on NSAID, typically nothing happens besides some gastric distress, and there is significantly less potential for OD death than with opioids.
- because the risk to the rest of the community is higher with opioids than with NSAID. esp kids, who do not become NSAID addicts when they raid family medicine cabinets.
- because opioids are not regulated by DEA or DOH. because there is no black market for opioids.

I could go on and on and on........




fwiw, this is a strawman argument, arguing we should ban something else - in this case, NSAID - because it might have increased risks compared to opioids. NSAID use is not directly related to opioid use.

lets go out on an extreme, and postulate a different strawman argument and argue, since we have to monitor closely how we prescribe opioids, we should more closely monitor who we allow to buy guns, as there are 31000 gun related fatalities in the US. Right? Or, one will argue not inappropriately - not related.

Why are NSAIDs sold OTC when more than 4 times as many people die of legally obtained NSAIDs per year than legally obtained opioids? Surely if opioids were dangerous more would die of opioids than NSAIDs. Only when you add in illegal sources of Fentanyl, heroin, stolen drugs, mixed drugs/alcohol/prescriptions does this dubious argument come to a higher death count than NSAIDs.

How is it a strawman when all of the weak arguments you present are present for NSAIDs including higher mortality rate than legally prescribed narcotics, higher morbidity from GI bleeds and ZERO evidence of long term benefit?

The only weak argument you can make is that it is "addictive" for a segment of patients but doesn't reflect higher morbidity or mortality evidence among legally prescribed patients.

---

Members don't see this ad.

 

[DrCommonSense]

It's all about risk/benefit and number needed to treat, and number needed to harm.

It's not all black and white, "This drug, good. That drug, bad."

But if you want to take look at taking some nsaids off the market?
Fine.
You'll have many allies and you won't get much argument from me.
Vioxx already has been spiked. Same with bextra and bromfenac.
Many others are just as bad as these but have better lobbyists working to protect them.

Just don't take the original nsaid aspirin since it's reductions in death from MI are historic and better than even tPA.

And don't take Ibuprofen, since it's just about the only thing I ever take for pain and has never hurt my GI track, heart or kidneys.

But if you wanted to start picking off the ones with the worst track record and start a campaign, then go ahead. You won't get any argument from me.

But none of that, N O N E of that, makes the risks of opiates, any less. Don't fall into that trap.

The guy above made it "black and white" and claimed that anyone who prescribes opioids for nonterminal pain states is a drug "dealer" based upon dubious arguments about long term benefit without comparing it to alternatives such as NSAIDs.

When discussing opiates in isolation those arguments are sound but once alternative medications are brought into the discussion the claims become very dubious.

Treatments aren't done in isolation but in comparison to the alternatives. If we just arguments against drug efficacy/safety in isolation for pain states, there would literally be ZERO medications that could be prescribed that show long term efficacy for pain coupled with low morbidity/mortality profiles.

 

[DrCommonSense]

It's high. They're both too high. And if you want to use that argument to prescribe less NSAIDs, too, I think that's a sound and logical argument. You'll have my attention, with that one. But if you're line of reasoning, "Opiates are bad for people. NSAIDs are just as bad. Therefore we should prescribe people lots of both NSAIDs and opiates", then you've lost me. We should be trying to find reasons to be cautious about both. We should not be looking for reasons to be cavalier about such adverse side effects.

But don't get me wrong. I'm not saying we shouldn't ever prescribe anyone an opiate, nsaid or any other drug with potential side effects. We just have to be very aware of the downsides. And make good choices.

If the argument is to prescribe the lowest possible dosage of opiates and to wean down ridiculously high dosages of opiates, then I can get behind it.

if the argument is to ban all opiates with zero good alternatives for any pain state outside of terminal cancer patients, I can't support that in good faith.

 

[emd123]

Do you have those references around? I have been looking for some stuff on pain/threshold/timing.

We've been doing a lot more work with this micro/low-dosing intrathecal paradigm where you wean folks off their systemic opioids, and patients at 6 - 8 weeks off their opioids are markedly worse in function, pain scores, QOLs. I understand chemical dependence can take a while to reset, and opioid abstinence syndrome can last for a long time, but I don't think this is just iatrogenic chemical dependence for folks.

If you're saying that you think there is a real subset of patients that get more benefit from harm or some amount of opiate, I think you're right.

 

[emd123]

I will post as a separate topic the literature supporting withdrawal of opioids, but my own clinical experience was with 100 patients that were withdrawn from an average of 350mg MED down to an average of 108 MED over a period of 4 months and there was no changes in VAS scores or functionality assessment.

I agree. In my fellowship, there were a few old school attendings that had patients on massive MED's. Guess what?
Their pain was 7-10/10 before they took their massive does opiates, and around 3-5/10 when they took it.

Now that I manage only patients on 1-90 MED, guess what my low to moderate dose patients generally rate their pain at, on VAS?
About 7-10/10 before they take their opiate, and about 3-5/10 after they take their opiate.

I must say that my exposure to some of the old school attendings that had people on massive dose opiates, was very beneficial to my education. It taught me that it's pointless, and taught me not to do it. In training, there are two types of attendings that teach you just as much but in a different way: Those that show you what to do, and those that show you what not to do. But it's your job to decide who's who.

 

[lobelsteve]

Now we can discuss the intermediate drug, and probably one that needs better access. Tramadol.

 

[emd123]

The guy above made it "black and white" and claimed that anyone who prescribes opioids for nonterminal pain states is a drug "dealer" based upon dubious arguments about long term benefit without comparing it to alternatives such as NSAIDs.

When discussing opiates in isolation those arguments are sound but once alternative medications are brought into the discussion the claims become very dubious.

Treatments aren't done in isolation but in comparison to the alternatives. If we just arguments against drug efficacy/safety in isolation for pain states, there would literally be ZERO medications that could be prescribed that show long term efficacy for pain coupled with low morbidity/mortality profiles.

If you've been on this board for a while, you'd know @algosdoc was not saying "anyone that prescribes opiates is a 'drug dealer' unless the patient has cancer." He prescribes patients opiates and isn't calling himself or anyone on here 'a drug dealer.' That misses the whole point. His point, and everyone else's point on this board is to try the best we can to "Do no harm."

That doesn't mean no one gets opiates ever, and that no one gets any nsaids, ever. But it means we're all on here trying to share ideas on how to become better doctors and help each other. If you think you have a patient who's life is better with an opiate, in a way that outweighs the risks, prescribe it to them and don't feel the slightest bit of guilt about it. I will do the same. But don't let that prevent you, or the rest of us, to try and determine the best ways to reduce risk and harm.

 

[BobBarker]

Now we can discuss the intermediate drug, and probably one that needs better access. Nucynta.

Fixed

 

[emd123]

If the argument is to prescribe the lowest possible dosage of opiates and to wean down ridiculously high dosages of opiates, then I can get behind it.

I think that's pretty much what most everyone on here is saying. That's what I'm saying.

if the argument is to ban all opiates with zero good alternatives for any pain state outside of terminal cancer patients, I can't support that in good faith.

Again, I'm not suggesting this, and I don't think anyone else on this board it. It's very unlike to happen in our lifetimes, but if it did happen it sure as hell would make my job a helluva lot easier.

 

[Timeoutofmind]

I think that's pretty much what most everyone on here is saying. That's what I'm saying.

Again, I'm not suggesting this, and I don't think anyone else on this board it. It's very unlike to happen in our lifetimes, but if it did happen it sure as hell would make my job a helluva lot easier.

1. technically, MSIR 30 tid is 90 MED.

2. technically, the CDC guidelines are to be "used" by all doctors, regardless of pain management or not. the FSMB also encourages 90 MED.

3. remind the PCPs that the 90 MED they are prescribing is important in that the patient has still failed to get better, and that is where you come in, specifically to offer something other than more opioids.

Maybe you guys should just all take all of your patients off all of their opioids and put them all on Suboxone. Doesn’t matter what dose of opioids they were on. Even over 400 mg. Their pain will improve. Even though the Suboxone is a tiny tiny fraction of the potency of the opioids where they were on.

Can we just quit kidding ourselves here? At least on an anonymous form?

 

[emd123]

Maybe you guys should just all take all of your patients off all of their opioids and put them all on Suboxone. Doesn’t matter what dose of opioids they were on. Even over 400 mg. Their pain will improve. Even though the Suboxone is a tiny tiny fraction of the potency of the opioids where they were on.

Can we just quit kidding ourselves here? At least on an anonymous form?

I agreed with you in my last post, so I have absolutely no frickin' clue what point you're trying to make here.
I give up.

 

[Aether2000]

My point indeed is that there are some that will benefit from low dose opioids without significant side effects and with modest benefit. There are even fewer that are actually deriving benefit from high dose opioids, and unless you can control what all other doctors prescribe (including sedatives/hypnotics, benzodiazepines, multiple sedating nocturnal medications) or what the patient takes (alcohol), via frequent UDS with actions taken to discontinue opioids in cases where these are discovered then we as physicians are placing the patient at extreme risk. Finally, unless we can demonstrate that we are not simply treating patients with opioid maintenance to prevent withdrawal, then we are indeed no different than drug dealers or methadone clinics since that is exactly what they do. We need much better tools to use than a VAS that we know will escalate on withdrawal, and we also know patients are psychologically hooked to this class of drugs, expressing great trepidation if told the dosage will be reduced. Their hostility on dosage reduction is partially irrational fear based on their experience when they overuse their meds and run out early, lose, or have meds stolen- not infrequent occurrences. But hostility is also linked to psychological addiction and their candyman taking away their candy, that they believe is a right since they were on the same dosage for long periods of time. We must be able to parse out those patients whose baseline pain actually needs chronic opioids for management and those who suffer chronic pain that is not being aided in FUNCTIONAL IMPROVEMENT with opioids. We cannot rely on VAS since patients will lie or amplify pain in order to keep their supply of opioids uninterrupted. There are a couple of functional measurement devices that patients can wear to measure function including the Fit Bit, Apple Watch, etc. Perhaps all patients coming into the program should be given these devices to wear for 30 days before opioids are initiated, then have them wear them again for a month 4 months after stable doses are reached. If there is no significant (>30%) improvement in function, then opioids should be weaned. The most elaborate functional assessment device is the new MDT IPG.

 

[Aether2000]

Here is an article demonstrating the disconnect between patient perception of opioid effect and clinical outcomes:

Pain Med. 2016 Dec 29. pii: pnw263. doi: 10.1093/pm/pnw263. [Epub ahead of print]

Discrepancies Between Perceived Benefit of Opioids and Self-Reported Patient Outcomes.
Goesling J1, Moser SE2, Lin LA3, Hassett AL2, Wasserman RA2, Brummett CM2.

Author information
Abstract
OBJECTIVE : There is little empirical evidence supporting the long-term use of opioid therapy for chronic pain, suggesting the need to reevaluate the role of opioids in chronic painmanagement. Few studies have considered opioid use and opioid cessation from the perspective of the patient. METHODS : This prospective structured interview study included 150 new patients seeking treatment for chronic pain at an outpatient tertiary care pain clinic. RESULTS : Of the 150 patients, 56% (N = 84) reported current opioid use. Opioids users reported higher pain severity (t(137) = -3.75, P < 0.001), worse physical functioning (t(136) = -3.82, P < 0.001), and more symptoms of depression (t(136) = -1.98, P = 0.050) than nonusers. Among opioid users, 45.6% reported high pain (>7), 60.8% reported low functioning (>7), and 71.4% reported less than a 30% reduction in pain severity since starting opioids, suggesting that many patients are unlikely to be receiving adequate benefit. Overall, 66.3% of current opioid users reported moderate to high opioid-related difficulties on the prescribed opioids difficulties scale, and patients with depression were more likely to report greater difficulties. There was no association between helpfulness of opioids over the past month and opioid-related difficulties (r(75) = -0.07, P = 0.559), current pain severity (r(72)=0.05, P = 0.705), or current pain interference (r(72) = 0.20, P = 0.095). CONCLUSIONS : Despite clinical indicators that question the benefit, patients may continue to report that their opioids are helpful. Such discrepancies in patients' perceptions will likely pose significant barriers for implementing opioid cessation guidelines in clinical practice.

 

[DrCommonSense]

My point indeed is that there are some that will benefit from low dose opioids without significant side effects and with modest benefit. There are even fewer that are actually deriving benefit from high dose opioids, and unless you can control what all other doctors prescribe (including sedatives/hypnotics, benzodiazepines, multiple sedating nocturnal medications) or what the patient takes (alcohol), via frequent UDS with actions taken to discontinue opioids in cases where these are discovered then we as physicians are placing the patient at extreme risk. Finally, unless we can demonstrate that we are not simply treating patients with opioid maintenance to prevent withdrawal, then we are indeed no different than drug dealers or methadone clinics since that is exactly what they do. We need much better tools to use than a VAS that we know will escalate on withdrawal, and we also know patients are psychologically hooked to this class of drugs, expressing great trepidation if told the dosage will be reduced. Their hostility on dosage reduction is partially irrational fear based on their experience when they overuse their meds and run out early, lose, or have meds stolen- not infrequent occurrences. But hostility is also linked to psychological addiction and their candyman taking away their candy, that they believe is a right since they were on the same dosage for long periods of time. We must be able to parse out those patients whose baseline pain actually needs chronic opioids for management and those who suffer chronic pain that is not being aided in FUNCTIONAL IMPROVEMENT with opioids. We cannot rely on VAS since patients will lie or amplify pain in order to keep their supply of opioids uninterrupted. There are a couple of functional measurement devices that patients can wear to measure function including the Fit Bit, Apple Watch, etc. Perhaps all patients coming into the program should be given these devices to wear for 30 days before opioids are initiated, then have them wear them again for a month 4 months after stable doses are reached. If there is no significant (>30%) improvement in function, then opioids should be weaned. The most elaborate functional assessment device is the new MDT IPG.

That is why the vast majority of my patients who have been prescribed have easily made the CDC guidelines or were already titrated down far below 90MME. I agree that higher dosages made no sense before for the vast majority of cases.

 

[emd123]

Quotes relevant to this thread, from the CDC white paper:

“there is considerable variability in the specific recommendations (e.g., range of dosing thresholds of 90 MME/day to 200 MME/day), audience (e.g., primary care clinicians versus specialists), ”

Note they don’t specify any definite 90 MME/day limit and specifically imply appropriate dose expectations may need to vary based on specialty status.


“5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day (recommendation category: A, evidence type: 3).”

They specifically state >90 MME/day isn’t a hard ceiling and that greater than can be justified if you document justification. (I’ve simply chosen not to exceed 90 MME/day as a risk management judgement call, mainly because of their next line:

“there is now an established body of scientific evidence showing that overdose risk is increased at higher opioid dosages.”


In regards to the cancer Pain question:

“not intended for patients undergoing active cancer treatment, palliative care, or end-of-life care”

They specify it’s not for cancer/end-of-life patients.

This CDC paper is actually quite good. It’s long, but I think it should be mandatory reading for anyone specializing in Pain. This paradigm shift seems much more attuned to my experience in the real world, than the “Pain is the fifth vital sign: opiates aren’t addictive if you have real pain” stuff from the 1980’s that got us where we are.

 

[Ducttape]

Why are NSAIDs sold OTC when more than 4 times as many people die of legally obtained NSAIDs per year than legally obtained opioids? Surely if opioids were dangerous more would die of opioids than NSAIDs. Only when you add in illegal sources of Fentanyl, heroin, stolen drugs, mixed drugs/alcohol/prescriptions does this dubious argument come to a higher death count than NSAIDs.

How is it a strawman when all of the weak arguments you present are present for NSAIDs including higher mortality rate than legally prescribed narcotics, higher morbidity from GI bleeds and ZERO evidence of long term benefit?

The only weak argument you can make is that it is "addictive" for a segment of patients but doesn't reflect higher morbidity or mortality evidence among legally prescribed patients.

entire point is strawman. im talking opioids, not others. whether one prescribes NSAID based on its risk is entirely independent of prescribing opioids. this is not a either/or, even though you like to make it so. you have failed to note that I personally have never recommended anyone prescribe NSAID.

have you ever asked a patient "well, you can meloxicam, or you can have oxycontin"? I mean, etodolac vs subsys, I can see that.......

 

[EtherBunny]

I agree 100% with the commentaries by altos and emd. I'm in the same camp in terms of treatment philosophy and scientific basis for clinical decision making. It's good to hear that I'm not alone.

I sincerely hope that opioid prescriptions for non-malignant pain become the exception rather than the norm. Opioids are the bane of this specialty. No question about it. An enormous mess was created in the 80s, 90s, and early 2000s. It's a mess that will take many years to clean up unfortunately. At least the process is well underway.

 

[Timeoutofmind]

Also what comes to mind is all the patients I see who report 80% improvement, or similar numbers, after an injection...and have not reduced their opioid utilization one iota!

 

[DrCommonSense]

entire point is strawman. im talking opioids, not others. whether one prescribes NSAID based on its risk is entirely independent of prescribing opioids. this is not a either/or, even though you like to make it so. you have failed to note that I personally have never recommended anyone prescribe NSAID.

have you ever asked a patient "well, you can meloxicam, or you can have oxycontin"? I mean, etodolac vs subsys, I can see that.......

You haven't personally recommended any medication under your analysis of "scientific basis for chronic pain".

Instead of what you don't recommend, name something you do recommend when the patient comes in with pain into your office. What meds are you prescribing or are all meds out?

When a patient comes to my office, what should I prescribe them if they require a medication for pain control or should I not prescribe anything?

 

[Ducttape]

I’m not going to on this thread as all it will do is to serve to be used as further straw man arguments... other than to say I do what most people on this board do.

 

[drpainfree]

I’m not going to on this thread as all it will do is to serve to be used as further straw man arguments... other than to say I do what most people on this board do.

I think DrCommonSense has a legitimate question: what other pharmacological options do you offer to these patients and how do you approach the conversation with these patients who are already on opioids? I'm on the same page with everyone here, but would like to hear how other people here carry out this conversation with their patients, skillfully.

He is not arguing about anything. Don't be so militant and argumentative. We're here to learn and to exchange ideas.

You seem to like to label everyone with "straw man arguments". While it sounds sexy, it doesn't really address the question.

 

[Aether2000]

First, you must take charge of your practice with a definitive plan to reduce opioids below a self specified level, or percent reduction, or the decision that you will not prescribe opioids any longer after weaning from opioids. Weaning, over 1-6 months is reasonable if patients have self control, with methadone being at the higher end of weaning periods. While very gradual weaning is performed, treat symptoms (clonidine or tizanidine, possibly temporarily adding klonopin or ativan), and consider beginning CAM therapies as a primary method of pain control and also as a distraction technique for chronic pain. Also consider:


Cannabis Cannabinoid Res. 2017 Jun 1;2(1):160-166. doi: 10.1089/can.2017.0012. eCollection 2017.

Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self-Report.

Reiman A1, Welty M2, Solomon P3.

Author information

Abstract

Introduction: Prescription drug overdoses are the leading cause of accidental death in the United States. Alternatives to opioids for the treatment of pain are necessary to address this issue. Cannabis can be an effective treatment for pain, greatly reduces the chance of dependence, and eliminates the risk of fatal overdose compared to opioid-based medications. Medical cannabis patients report that cannabis is just as effective, if not more, than opioid-based medications for pain. Materials and Methods: The current study examined the use of cannabis as a substitute for opioid-based pain medication by collecting survey data from 2897 medical cannabis patients. Discussion: Thirty-four percent of the sample reported using opioid-based pain medication in the past 6 months. Respondents overwhelmingly reported that cannabis provided relief on par with their other medications, but without the unwanted side effects. Ninety-seven percent of the sample "strongly agreed/agreed" that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% "strongly agreed/agreed" that taking cannabis by itself was more effective at treating their condition than taking cannabis with opioids. Results were similar for those using cannabis with nonopioid-based pain medications. Conclusion: Future research should track clinical outcomes where cannabis is offered as a viable substitute for pain treatment and examine the outcomes of using cannabis as a medication assisted treatment for opioid dependence


J Psychopharmacol. 2017 May;31(5):569-575. doi: 10.1177/0269881117699616. Epub 2017 Apr 4.

Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep.

Piper BJ1,2,3, DeKeuster RM4,5, Beals ML6, Cobb CM4,7, Burchman CA8,9, Perkinson L10, Lynn ST10, Nichols SD11, Abess AT12.

Author information

Abstract

A prior epidemiological study identified a reduction in opioid overdose deaths in US states that legalized medical cannabis (MC). One theory to explain this phenomenon is a potential substitution effect of MC for opioids. This study evaluated whether this substitution effect of MC for opioids also applies to other psychoactive medications. New England dispensary members ( n = 1,513) completed an online survey about their medical history and MC experiences. Among respondents that regularly used opioids, over three-quarters (76.7%) indicated that they reduced their use since they started MC. This was significantly ( p < 0.0001) greater than the patients that reduced their use of antidepressants (37.6%) or alcohol (42.0%). Approximately two-thirds of patients decreased their use of anti-anxiety (71.8%), migraine (66.7%), and sleep (65.2%) medications following MC which significantly ( p < 0.0001) exceeded the reduction in antidepressants or alcohol use. The patient's spouse, family, and other friends were more likely to know about their MC use than was their primary care provider. In conclusion, a majority of patients reported using less opioids as well as fewer medications to treat anxiety, migraines, and sleep after initiating MC. A smaller portion used less antidepressants or alcohol. Additional research is needed to corroborate these self-reported, retrospective, cross-sectional findings using other data sources.


Med Acupunct. 2017 Aug 1;29(4):229-231. doi: 10.1089/acu.2017.1234.

Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population.

Crawford P1,2, Penzien DB3, Coeytaux R4.

Author information

Abstract

Background: Acupuncture is being offered to patients as part of routine medical care in selected military bases in the United States. There is little published information about the clinical outcomes associated with acupuncture in these clinical settings. Objective: The goal of this research was to assess clinical outcomes observed among adult patients who received acupuncture treatments at a United States Air Force medical center. Materials and Methods: This retrospective chart review was performed at the Nellis Family Medicine Residency in the Mike O'Callaghan Military Medical Center at Nellis Air Force Base in Las Vegas, NV. The charts were from 172 consecutive patients who had at least 4 acupuncture treatments within 1 year. The main outcome measures were prescriptions for opioid medications, muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDS) in the 60 days prior to the first acupuncture session and in the corresponding 60 days 1 year later; and Measure Yourself Medical Outcome Profile (MYMOP2) values for symptoms, ability to perform activities, and quality of life. Results: Opioid prescriptions decreased by 45%, muscle relaxants by 34%, NSAIDs by 42%, and benzodiazepines by 14%. MYMOP2 values decreased 3.50-3.11 (P < 0.002) for question 1, 4.18-3.46 (P < 0.00001) for question 3, and 2.73-2.43 (P < 0.006) for question 4. Conclusions: In this military patient population, the number of opioid prescriptions decreased and patients reported improved symptom control, ability to function, and sense of well-being after receiving courses of acupuncture by their primary care physicians.


J Altern Complement Med. 2016 Aug;22(8):621-6. doi: 10.1089/acm.2015.0212. Epub 2016 Jul 15.

Integration of Complementary and Alternative Medicine Therapies into Primary-Care PainManagement for Opiate Reduction in a Rural Setting.
Mehl-Madrona L1,2,3,4, Mainguy B5, Plummer J6.

Author information
Abstract
BACKGROUND:
Opiates are no longer considered the best strategy for the long-term management of chronic pain. Yet, physicians have made many patients dependent on them, and these patients still request treatment. Complementary and alternative medicine (CAM) therapies have been shown to be effective, but are not widely available and are not often covered by insurance or available to the medically underserved.

METHODS:
Group medical visits (GMVs) provided education about non-pharmacological methods for pain management and taught mindfulness techniques, movement, guided imagery, relaxation training, yoga, qigong, and t'ai chi. Forty-two patients attending GMVs for at least six months were matched prospectively with patients receiving conventional care.

RESULTS:
No one increased their dose of opiates. Seventeen people reduced their dose, and seven people stopped opiates. On a 10-point scale of pain intensity, reductions in pain ratings achieved statistical significance (p = 0.001). The average reduction was 0.19 (95% confidence interval [CI] 0.12-0.60; p = 0.01). The primary symptom improved on average by -0.42 (95% CI -0.31 to -0.93; p = 0.02) on the My Medical Outcome Profile, 2nd version. Improvement in the quality-of-life rating was statistically significant (p = 0.007) with a change of -1.42 (95% CI = -0.59 to -1.62). In conventional care, no patients reduced their opiate use, and 48.5% increased their dose over the two years of the project.

CONCLUSIONS:
GMVs that incorporated CAM therapies helped patients reduce opiate use. While some patients found other physicians to give them the opiates they desired, those who persisted in an environment of respect and acceptance significantly reduced opiate consumption compared with patients in conventional care. While resistant to CAM therapies initially, the majority of patients came to accept and to appreciate their usefulness. GMVs were useful for incorporating non-reimbursed CAM therapies into primary medical care.

 

[Ducttape]

I think DrCommonSense has a legitimate question: what other pharmacological options do you offer to these patients and how do you approach the conversation with these patients who are already on opioids? I'm on the same page with everyone here, but would like to hear how other people here carry out this conversation with their patients, skillfully.

He is not arguing about anything. Don't be so militant and argumentative. We're here to learn and to exchange ideas.

You seem to like to label everyone with "straw man arguments". While it sounds sexy, it doesn't really address the question.

SO you have fallen in to his trap.

If u want to die scuds treatments to provide patients when confronted with the “give me some narcotics or else” dilemma, make a new thread and I’ll be happy to reply.

After dinner with the kids, tho.

 

[DrCommonSense]

First, you must take charge of your practice with a definitive plan to reduce opioids below a self specified level, or percent reduction, or the decision that you will not prescribe opioids any longer after weaning from opioids. Weaning, over 1-6 months is reasonable if patients have self control, with methadone being at the higher end of weaning periods. While very gradual weaning is performed, treat symptoms (clonidine or tizanidine, possibly temporarily adding klonopin or ativan), and consider beginning CAM therapies as a primary method of pain control and also as a distraction technique for chronic pain. Also consider:


Cannabis Cannabinoid Res. 2017 Jun 1;2(1):160-166. doi: 10.1089/can.2017.0012. eCollection 2017.

Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self-Report.

Reiman A1, Welty M2, Solomon P3.

Author information

Abstract

Introduction: Prescription drug overdoses are the leading cause of accidental death in the United States. Alternatives to opioids for the treatment of pain are necessary to address this issue. Cannabis can be an effective treatment for pain, greatly reduces the chance of dependence, and eliminates the risk of fatal overdose compared to opioid-based medications. Medical cannabis patients report that cannabis is just as effective, if not more, than opioid-based medications for pain. Materials and Methods: The current study examined the use of cannabis as a substitute for opioid-based pain medication by collecting survey data from 2897 medical cannabis patients. Discussion: Thirty-four percent of the sample reported using opioid-based pain medication in the past 6 months. Respondents overwhelmingly reported that cannabis provided relief on par with their other medications, but without the unwanted side effects. Ninety-seven percent of the sample "strongly agreed/agreed" that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% "strongly agreed/agreed" that taking cannabis by itself was more effective at treating their condition than taking cannabis with opioids. Results were similar for those using cannabis with nonopioid-based pain medications. Conclusion: Future research should track clinical outcomes where cannabis is offered as a viable substitute for pain treatment and examine the outcomes of using cannabis as a medication assisted treatment for opioid dependence


J Psychopharmacol. 2017 May;31(5):569-575. doi: 10.1177/0269881117699616. Epub 2017 Apr 4.

Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep.

Piper BJ1,2,3, DeKeuster RM4,5, Beals ML6, Cobb CM4,7, Burchman CA8,9, Perkinson L10, Lynn ST10, Nichols SD11, Abess AT12.

Author information

Abstract

A prior epidemiological study identified a reduction in opioid overdose deaths in US states that legalized medical cannabis (MC). One theory to explain this phenomenon is a potential substitution effect of MC for opioids. This study evaluated whether this substitution effect of MC for opioids also applies to other psychoactive medications. New England dispensary members ( n = 1,513) completed an online survey about their medical history and MC experiences. Among respondents that regularly used opioids, over three-quarters (76.7%) indicated that they reduced their use since they started MC. This was significantly ( p < 0.0001) greater than the patients that reduced their use of antidepressants (37.6%) or alcohol (42.0%). Approximately two-thirds of patients decreased their use of anti-anxiety (71.8%), migraine (66.7%), and sleep (65.2%) medications following MC which significantly ( p < 0.0001) exceeded the reduction in antidepressants or alcohol use. The patient's spouse, family, and other friends were more likely to know about their MC use than was their primary care provider. In conclusion, a majority of patients reported using less opioids as well as fewer medications to treat anxiety, migraines, and sleep after initiating MC. A smaller portion used less antidepressants or alcohol. Additional research is needed to corroborate these self-reported, retrospective, cross-sectional findings using other data sources.


Med Acupunct. 2017 Aug 1;29(4):229-231. doi: 10.1089/acu.2017.1234.

Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population.

Crawford P1,2, Penzien DB3, Coeytaux R4.

Author information

Abstract

Background: Acupuncture is being offered to patients as part of routine medical care in selected military bases in the United States. There is little published information about the clinical outcomes associated with acupuncture in these clinical settings. Objective: The goal of this research was to assess clinical outcomes observed among adult patients who received acupuncture treatments at a United States Air Force medical center. Materials and Methods: This retrospective chart review was performed at the Nellis Family Medicine Residency in the Mike O'Callaghan Military Medical Center at Nellis Air Force Base in Las Vegas, NV. The charts were from 172 consecutive patients who had at least 4 acupuncture treatments within 1 year. The main outcome measures were prescriptions for opioid medications, muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDS) in the 60 days prior to the first acupuncture session and in the corresponding 60 days 1 year later; and Measure Yourself Medical Outcome Profile (MYMOP2) values for symptoms, ability to perform activities, and quality of life. Results: Opioid prescriptions decreased by 45%, muscle relaxants by 34%, NSAIDs by 42%, and benzodiazepines by 14%. MYMOP2 values decreased 3.50-3.11 (P < 0.002) for question 1, 4.18-3.46 (P < 0.00001) for question 3, and 2.73-2.43 (P < 0.006) for question 4. Conclusions: In this military patient population, the number of opioid prescriptions decreased and patients reported improved symptom control, ability to function, and sense of well-being after receiving courses of acupuncture by their primary care physicians.


J Altern Complement Med. 2016 Aug;22(8):621-6. doi: 10.1089/acm.2015.0212. Epub 2016 Jul 15.

Integration of Complementary and Alternative Medicine Therapies into Primary-Care PainManagement for Opiate Reduction in a Rural Setting.
Mehl-Madrona L1,2,3,4, Mainguy B5, Plummer J6.

Author information
Abstract
BACKGROUND:
Opiates are no longer considered the best strategy for the long-term management of chronic pain. Yet, physicians have made many patients dependent on them, and these patients still request treatment. Complementary and alternative medicine (CAM) therapies have been shown to be effective, but are not widely available and are not often covered by insurance or available to the medically underserved.

METHODS:
Group medical visits (GMVs) provided education about non-pharmacological methods for pain management and taught mindfulness techniques, movement, guided imagery, relaxation training, yoga, qigong, and t'ai chi. Forty-two patients attending GMVs for at least six months were matched prospectively with patients receiving conventional care.

RESULTS:
No one increased their dose of opiates. Seventeen people reduced their dose, and seven people stopped opiates. On a 10-point scale of pain intensity, reductions in pain ratings achieved statistical significance (p = 0.001). The average reduction was 0.19 (95% confidence interval [CI] 0.12-0.60; p = 0.01). The primary symptom improved on average by -0.42 (95% CI -0.31 to -0.93; p = 0.02) on the My Medical Outcome Profile, 2nd version. Improvement in the quality-of-life rating was statistically significant (p = 0.007) with a change of -1.42 (95% CI = -0.59 to -1.62). In conventional care, no patients reduced their opiate use, and 48.5% increased their dose over the two years of the project.

CONCLUSIONS:
GMVs that incorporated CAM therapies helped patients reduce opiate use. While some patients found other physicians to give them the opiates they desired, those who persisted in an environment of respect and acceptance significantly reduced opiate consumption compared with patients in conventional care. While resistant to CAM therapies initially, the majority of patients came to accept and to appreciate their usefulness. GMVs were useful for incorporating non-reimbursed CAM therapies into primary medical care.

So im goin

SO you have fallen in to his trap.

If u want to die scuds treatments to provide patients when confronted with the “give me some narcotics or else” dilemma, make a new thread and I’ll be happy to reply.

After dinner with the kids, tho.

Cool so your solution to the opioid crisis is to get everyone high on "medical" THC all day while amazingly they won't abuse narcotics going forward right? I mean I never get patients that use BOTH THC and narcotics (with cocaine and others) right? People who smoke THC all day are never known to use other drugs or anything right?

Or I can prescribe them Yoga all day and magically they won't ever use illegal Fentanyl or Heroin. Hasn't seemed to work very well for me but maybe you have some extreme Yoga success rates that don't work in your neck of the woods. Somehow I doubt it though.

 

[Aether2000]

The response was based on medical evidence, albeit low level medical evidence. Do you have any medical evidence to the contrary?

 

[DrCommonSense]

The response was based on medical evidence. Do you have any medical evidence to the contrary?

What "evidence"?

Show me ANY states that have decreased their narcotic overdose rates using THC all day. Some survey that is biased by medical THC proponents doesn't strike me as strong "evidence".

 

[DrCommonSense]

SO you have fallen in to his trap.

If u want to die scuds treatments to provide patients when confronted with the “give me some narcotics or else” dilemma, make a new thread and I’ll be happy to reply.

After dinner with the kids, tho.

Yeah its my trap to ask what pharmacological solutions you have outside of opioids for these patients that is "evidence based" for long term chronic pain control.

See the problem I have is I have REAL patients that come in that ask for solutions. Telling them what I can't do compared to what I can do for them doesn't usually make them happy.

A patient "self report" doesn't show me much "evidence" for anything.

Also telling patients to smoke weed all day to get off their pain meds doesn't strike me as particularly great. Or do some more yoga.

 

[lobelsteve]

The response was based on medical evidence, albeit low level medical evidence. Do you have any medical evidence to the contrary?

Someone hijacked algosdoc account?

 

[DrCommonSense]

Someone hijacked algosdoc account?

Dude presents a case report about how some patients perceive THC helping with the narcotic crisis somewhere and that is "evidence" now.

I can present millions of chronic opioid users claiming the same thing about the necessity of narcotic usage for their pain state as well but somehow I doubt algos would find that to be "evidence" of the benefits of opioids.

 

[lobelsteve]

The response was based on medical evidence, albeit low level medical evidence. Do you have any medical evidence to the contrary?

Medscape: Medscape Access

Medical cannabinoids are here to stay, but intellectual honesty is imperative if we are moving toward exploiting their potential benefits. Owing to rising THC concentrations of products, "medical" marijuana is rarely good medicine.

 

[drusso]

Medscape: Medscape Access

Medical cannabinoids are here to stay, but intellectual honesty is imperative if we are moving toward exploiting their potential benefits. Owing to rising THC concentrations of products, "medical" marijuana is rarely good medicine.

Recommended reference on the therapeutic basis for cannabinoids (Spoiler alert: Its not all about THC):
http://cannabisclinicians.org/wp-content/uploads/2013/10/Russo-Entourage-Effect-2011.pdf

 

[Orin]

Show me ANY states that have decreased their narcotic overdose rates using THC all day.

Analysis | Legal marijuana is saving lives in Colorado, study finds
American Public Health Association (APHA) publications

NIMBY, but I've heard good things from other folks about it in some patients.

 

[Aether2000]

We have more EBM that opioids are ineffective for chronic pain than effective. We have some naiscent evidence other avenues of pain control hold hope although I agree there needs to be more EBM. We have unequivocal evidence marijuana is not associated with overdose death while opioids absolutely are. Not advocating marijuana but it is available by prescription in half the states and readily available on the streets in all states, and is currently being used as a surrogate to opioids.

 

[Aether2000]

For completion sake, the actual latest estimates on nonsteroidal anti-inflammatory drug deaths is 3200 per year in the United States as published by Tarone. Given the massive use of these drugs in the United States compared to the death rate, it is easy to calculate the death rate from opioids is much much higher than that of nonsteroidal anti-inflammatory drugs.

Consider also the growing impact of kratom as a substitute for opioids. It is legal to grow the plant or import the powder in most states. It is estimated over 100,000 people in the US are currently using Kratom, a number that is escalating every year.

 

[NJPAIN]

Since no one has done the prospective double blind study needed to show long term efficacy, we revert to the next level of evidence- the effect of withdrawal of opioids gradually. Several studies show an improvement in pain on withdrawal of chronically prescribed opioids. Until there are definitive studies that otherwise demonstrate sustained efficacy without dosage escalation in opioids, I must presume most patients taking opioids are simply iatrogenically chemically dependent, and therefore cannot justify starting any new patient on long term opioids. What I see in the heroin population is that there is no euphoria or effect of heroin at all, even at high doses when taken chronically. They all take heroin to avoid withdrawal symptoms. Similarly, it is my belief that most chronic pain patients take opioids to avoid withdrawal symptoms (including acute escalation of pain, prompting them to believe they need the opioids for pain control). Heroin addicts and patients taking chronically prescribed opioids for pain are largely physiologically equivalent- the only difference is the drug dealer.

Amen. My observation as well after 25 years of practice.

 

[DrCommonSense]

Analysis | Legal marijuana is saving lives in Colorado, study finds
American Public Health Association (APHA) publications

NIMBY, but I've heard good things from other folks about it in some patients.

Opioid deaths are up in Colorado when adding in heroin deaths

Colorado heroin deaths doubled in five years

 

[DrCommonSense]

For completion sake, the actual latest estimates on nonsteroidal anti-inflammatory drug deaths is 3200 per year in the United States as published by Tarone. Given the massive use of these drugs in the United States compared to the death rate, it is easy to calculate the death rate from opioids is much much higher than that of nonsteroidal anti-inflammatory drugs.

Consider also the growing impact of kratom as a substitute for opioids. It is legal to grow the plant or import the powder in most states. It is estimated over 100,000 people in the US are currently using Kratom, a number that is escalating every year.

Deadly NSAIDS | American Nutrition Association

3200 is the lowest of all studies on the subject. NEJM reported 16,500 deaths/year already in 1999 from NSAIDs with >100K hospitalized from bleeding. This doesn't include all the increased risk of MI either.

 

[DrCommonSense]

We have more EBM that opioids are ineffective for chronic pain than effective. We have some naiscent evidence other avenues of pain control hold hope although I agree there needs to be more EBM. We have unequivocal evidence marijuana is not associated with overdose death while opioids absolutely are. Not advocating marijuana but it is available by prescription in half the states and readily available on the streets in all states, and is currently being used as a surrogate to opioids.

Marijuana for pain, PTSD: Studies find evidence lacking - CNN

There is no evidence of long term chronic pain benefit from THC.

"
Worse still, one study of veterans with PTSD showed a small but "significant" worsening of symptoms among veterans who either started or continued using cannabis during the study period, the team said.
"We found low- to moderate-strength evidence that cannabis use is associated with an increased risk for psychotic symptoms, psychosis, mania, and -- in active users -- short-term cognitive dysfunction," the authors noted."

 

[emd123]

Deadly NSAIDS | American Nutrition Association

3200 is the lowest of all studies on the subject. NEJM reported 16,500 deaths/year already in 1999 from NSAIDs with >100K hospitalized from bleeding. This doesn't include all the increased risk of MI either.

What the hell do NSAIDs have to do with opiates?
All your proving is that we should prescribe NSAIDs more cautiously, too, which most people would agree with anyways. Nothing having to do with NSAID dangers supports ignoring the dangers of opioids or any other drug. Because one thing is bad for people, that doesn't justify doing other things that are bad for people. It should be such a simple concept to understand.

 

[DrCommonSense]

What the hell do NSAIDs have to do with opiates?
All your proving is that we should prescribe NSAIDs more cautiously, too, which most people would agree with anyways. Nothing having to do with NSAID dangers supports ignoring the dangers of opioids or any other drug. Because one thing is bad for people, that doesn't justify doing other things that are bad for people. It should be such a simple concept to understand.

Who said we shouldn't prescribe opiates cautiously? I've already said that.

 

[emd123]

Who said we shouldn't prescribe opiates cautiously? I've already said that.

I don't know. I honestly have no idea what point you're trying to make, at this point.

 

[DrCommonSense]

I don't know. I honestly have no idea what point you're trying to make, at this point.

The point was very clear when you look back into the argument.

The argument against opioids being used for chronic pain was "lack of long term efficacy and death rates". My argument was that on those grounds alone, legally prescribed NSAIDs have the same problem yet some posters are pretending they are a good alternative to judicious usage of opioids.

My contention is largely that like everything else it "depends" on the patient population that is being prescribed and cost/benefit ratio for them whether opioid vs NSAID should be prescribed. Its not as simple as "opioids are evil and should never be prescribed outside of cancer" and that anyone that prescribes them at all unless its a terminal patient is now a "drug dealer".

 

[lobelsteve]

Deadly NSAIDS | American Nutrition Association

3200 is the lowest of all studies on the subject. NEJM reported 16,500 deaths/year already in 1999 from NSAIDs with >100K hospitalized from bleeding. This doesn't include all the increased risk of MI either.

Recent study showed 31% increase risk of MI when taking otc nsaids for a month.

 

[drusso]

Recent study showed 31% increase risk of MI when taking otc nsaids for a month.

Can glucosamine be a NSAID-sparing agent?

http://www.semarthritisrheumatism.com/article/S0049-0172(15)00270-X/abstract?rss=yes

 

[lobelsteve]

Can glucosamine be a NSAID-sparing agent?

http://www.semarthritisrheumatism.com/article/S0049-0172(15)00270-X/abstract?rss=yes

As safe and effective as limbrel.

 

[Aether2000]

Dr.CommonSense, when you can prove to us your patients are benefitting from opioids by showing us your prospective data on functionality of your patients before and after long term >1 year of opioids, then you will have made a point. When you can show us the data that the majority of those patients on disability when given opioids get off of disability when receiving long term opioids then you are making some common sense. But until then, if you are simply prescribing opioids because "my patients say it helps" without any validation of such other than the completely subjective VAS scale, then you are on very thin legal ice, as are all of us prescribing opioids. It is a specious argument to try to castigate all other treatments that have some evidence of effectiveness, arguing opioids are safer and more effective without a shred of evidence. Ultimately, it is not about what is better than opioids- it is all about opioids being prescribed and maintained without any legitimate medical purpose, given the risk>>benefits of opioids. It is not about alternatives, NSAIDS, nor marijuana. This is all about opioids. Show us the data. I have done the study in my own prior practice, and opioids were NOT helping with pain or function.

 

[Ducttape]

So im goin



Cool so your solution to the opioid crisis is to get everyone high on "medical" THC all day while amazingly they won't abuse narcotics going forward right? I mean I never get patients that use BOTH THC and narcotics (with cocaine and others) right? People who smoke THC all day are never known to use other drugs or anything right?

Or I can prescribe them Yoga all day and magically they won't ever use illegal Fentanyl or Heroin. Hasn't seemed to work very well for me but maybe you have some extreme Yoga success rates that don't work in your neck of the woods. Somehow I doubt it though.

so where in my posts do you see i said i ever supported THC?

or where in my posts did i say i ever tell patients "Yoga all day"?

this is not fake news. you are lying to try to prove your point.

 

[Timeoutofmind]

 

[Timeoutofmind]

 

[clubdeac]

Let's just use turmeric in place of NSAIDs, kratom in place of opioids and MJ in place of benzo's. Problem solved