CDC guidelines

[lobelsteve]

Or decriminalize all drugs and let the people figure it out for themselves.

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[Aether2000]

It wouldn't hurt my feelings!

 

[DrCommonSense]

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.

Can you show that for any other drug?

You want a standard that no drug on the market can prove.

Ergo, we should remove all drugs by your logic due to efficacy concerns related to pain.

The risk of NSAIDs, Lyrica, etc are greater than the benefits as well considering none of them have long term benefit studies.

When I prescribe NSAIDS because a patient states it "helps" with increased risk of heart attack, stroke, kidney failure and mortality (especially in older patients, MI patients, etc) am I on thin legal ice?

When I prescribe Neurontin and Lyrica because patients claim it helps despite increased risk of suicidal ideation, swelling, grogginess that can lead to fatal car accidents, etc despite having zero long term studies, am I on thin legal ice?

Think about that for a second.

 

[emd123]

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.

But you prescribe opiates, don't you?

 

[Ducttape]

Can you show that for any other drug?

You want a standard that no drug on the market can prove.

Ergo, we should remove all drugs by your logic due to efficacy concerns related to pain.

The risk of NSAIDs, Lyrica, etc are greater than the benefits as well considering none of them have long term benefit studies.

When I prescribe NSAIDS because a patient states it "helps" with increased risk of heart attack, stroke, kidney failure and mortality (especially in older patients, MI patients, etc) am I on thin legal ice?

When I prescribe Neurontin and Lyrica because patients claim it helps despite increased risk of suicidal ideation, swelling, grogginess that can lead to fatal car accidents, etc despite having zero long term studies, am I on thin legal ice?

Think about that for a second.

im thinking you are again postulating straw man arguments to justify using opioid medications, because you do not feel there are viable alternatives.
not being able to come up with an alternative to prescribing opioids is not justification towards prescribing them.

I could use your argument to justify prescribing heroin for pain. or, in fact, the best thing would be to prescribe a tincture of opium/marijuana/cocaine all rolled up in disability papers...

 

[DrCommonSense]

im thinking you are again postulating straw man arguments to justify using opioid medications, because you do not feel there are viable alternatives.
not being able to come up with an alternative to prescribing opioids is not justification towards prescribing them.

I could use your argument to justify prescribing heroin for pain. or, in fact, the best thing would be to prescribe a tincture of opium/marijuana/cocaine all rolled up in disability papers...

Actually my argument is very clear and you are strawmanning it.

You are exclusively using a metric for efficacy for opioids that ZERO other drugs on the market have shown either. I would listen to your argument if you were able to show the alternative drugs made the cut under these arguments.

Ergo, either you need to reject all drugs along these "efficacy" argument lines and offer zero prescription drugs or admit you are just applying a different standard for efficacy to opioids over NSAIDs, neuroleptics, etc. because you don't like opioids.

Considering zero drugs on the market have long term efficacy studies based upon pain and have REAL side effects, all of them fail the risk/benefit ratio of your previous arguments.

 

[Ducttape]

Actually my argument is very clear and you are strawmanning it.

You are exclusively using a metric for efficacy for opioids that ZERO other drugs on the market have shown either. I would listen to your argument if you were able to show the alternative drugs made the cut under these arguments.

Ergo, either you need to reject all drugs along these "efficacy" argument lines and offer zero prescription drugs or admit you are just applying a different standard for efficacy to opioids over NSAIDs, neuroleptics, etc. because you don't like opioids.

Considering zero drugs on the market have long term efficacy studies based upon pain and have REAL side effects, all of them fail the risk/benefit ratio of your previous arguments.

this is not an either/or situation.

It has never been an either some other drug/or opioids.

I think your view of pain medicine is so narrowed and skewed that it is pointless having any further discussion... it is long past the possibility of being meaningful.

 

[Aether2000]

It seems almost pathologic or defending a business empire to attempt to justify opioids because of their "safety". They are not safe in high doses. They are not safe when rapidly escalated. They are not safe when combined with alcohol (out of the control of the physician). Nor are they safe due to the opioid dependency they create. They are not safe with gabapentin nor with benzodiazepines. They are also not safe for the physician when most of their patients receive them (DEA and board concerns). But each to his own...

 

[Blitz2006]

Thanks for the links timeoutofmind, good studies.

Whats the deal with tramadol for neuropathic pain? Good idea? Bad idea?

 

[DrCommonSense]

It seems almost pathologic or defending a business empire to attempt to justify opioids because of their "safety". They are not safe in high doses. They are not safe when rapidly escalated. They are not safe when combined with alcohol (out of the control of the physician). Nor are they safe due to the opioid dependency they create. They are not safe with gabapentin nor with benzodiazepines. They are also not safe for the physician when most of their patients receive them (DEA and board concerns). But each to his own...

NSAIDS aren't safe in high dosages or rapidly escalated either. In fact, almost no drugs are.

The idiocy of using ridiculously high opioid dosages was a problem that foolish physicians did do in the past and some currently.

However, I refuse to believe my 65 year old patients that are on 2 Tramadols or Norcos a day for 10 years are going to become "heroin" addicts and need to get onto NSAIDS when they are perfectly content with their current medications with zero loss of medications/overdoses/etc.

 

[DrCommonSense]

this is not an either/or situation.

It has never been an either some other drug/or opioids.

I think your view of pain medicine is so narrowed and skewed that it is pointless having any further discussion... it is long past the possibility of being meaningful.

Cool then don't discuss the issue.

If you keep thinking that 70 year old engineer with zero addiction history that is on 3 Tramadols a day due to previous surgeries/OA/kidney insufficiency/etc is a real risk to become a heroin addict in the future despite being stable on this dosage for years with clean UDS findings and zero losses of medications, then you can believe that.

If me giving that 65 y/o old housewife with 3 Norcos per day for intractable pain that they have been stable on for >4 years with zero UDS problems and are at risk for becoming a heroin addict on the street, believe what you want.

I disagree and no amount of screeching is going to change the reality that these people have EXTREMELY low risk profiles.

Isnt it amazing that this isnt the profile of patients that are driving the heroin crisis.

 

[DrCommonSense]

But you prescribe opiates, don't you?

yeah isn't that interesting huh?

 

[painfree23]

Cool then don't discuss the issue.

If you keep thinking that 70 year old engineer with zero addiction history that is on 3 Tramadols a day due to previous surgeries/OA/kidney insufficiency/etc is a real risk to become a heroin addict in the future despite being stable on this dosage for years with clean UDS findings and zero losses of medications, then you can believe that.

If me giving that 65 y/o old housewife with 3 Norcos per day for intractable pain that they have been stable on for >4 years with zero UDS problems and are at risk for becoming a heroin addict on the street, believe what you want.

I disagree and no amount of screeching is going to change the reality that these people have EXTREMELY low risk profiles.

Isnt it amazing that this isnt the profile of patients that are driving the heroin crisis.

I agree with this, and I think that's why the CDC guidelines were put in place, so that we make sure UDS are negative, no abberent behavior. The hardest thing is implementing them in system where the culture is used to the old way.

 

[Aether2000]

I agree, a couple of tramadol or Norco a day will have a very low risk of addiction. However they can result in OD if mixed with alcohol, so as long as the random urine drug testing performed on these patients never show any alcohol, then you are golden. But what about the same patient receiving Xanax 2mg TID from their PCP plus Restoril at night plus trazodone along with gabapentin from their neurologist. Are the two Norco a day still considered safe? How much of risky drug combinations would trigger the withdrawal of the Norco?

 

[Ducttape]

If I have said or implied that you can’t prescribe, then i apologize.

You or anyone, as a well trained board certified (I assume) pain physician, can evaluate a patient, establish a working relationship with the patient, consider the risks and benefits of low dose opioid therapy, and do your due diligence with continuing use, with the knowledge of the addictive potential and risks to morbidity and mortality, and it is wholly appropriate. In your opinion, even necessary.

The boundaries have to change from where they have been set, and many - if not most - people are not appropriate for COT, and only those of us actively dying “deserve” high dose opioids. There have been no boundaries - because in large part the marketing of Big Pharma - and/or PCPs were unaware.

We as a society have to change how we think about a lot of things - feeling good about oneself all the time,participation awards, eat all you want, get high from drugs or THC, or whatever- and using narcotics to get high is one if those things.

 

[kstarm]

My partner's patient has had non-surgical moderate to severe spinal stenosis with neuropathic pain into his legs and was placed on oxycontin in the 1980's. He had been on 10mg of oxycontin a day for over 20 years. No escalation, abberencies, etc. My partner convinced him to see how he would feel off of it. After ~4 weeks of stopping the medication it was the first time in over 20 years that the patient has been pain free, and continues to be. I think over enough time even at low doses patient become hyperalgesic, especially in neuropathic pain states. I am becoming less convinced that there is a role for low dose opioids for chronic pain.

I am also less convinced that super high escalating doses for patient's at end of life (outside of perhaps actively dying in the hospital/hospice setting) is helpful. I have seen too many cancer patients in the hospital on insane regimens while still having 9/10 pain, and few adjuvants/interventional procedures have been considered. I would love to hear a palliative docs perspective on the opioid epidemic and what role do they see that they play, what is appropriate in light of what we now know and are learning about opioids, etc.

 

[Aether2000]

Totally agree. I posted in another thread over 25 studies that support the concept that opioids are actually causing more pain, since after reduction or elimination of opioids, the pain improves as does function.

 

[mid|ine]

So isn't it a little dishonest to only claim there is "no long term evidence that opioids help chronic pain". By that logic, there is no long term evidence any medication current used on the market works to help chronic pain.

Why say that in isolation?

Because there is SIGNIFICANT evidence of HARM with long term opiates.

 

[DrCommonSense]

My partner's patient has had non-surgical moderate to severe spinal stenosis with neuropathic pain into his legs and was placed on oxycontin in the 1980's. He had been on 10mg of oxycontin a day for over 20 years. No escalation, abberencies, etc. My partner convinced him to see how he would feel off of it. After ~4 weeks of stopping the medication it was the first time in over 20 years that the patient has been pain free, and continues to be. I think over enough time even at low doses patient become hyperalgesic, especially in neuropathic pain states. I am becoming less convinced that there is a role for low dose opioids for chronic pain.

I am also less convinced that super high escalating doses for patient's at end of life (outside of perhaps actively dying in the hospital/hospice setting) is helpful. I have seen too many cancer patients in the hospital on insane regimens while still having 9/10 pain, and few adjuvants/interventional procedures have been considered. I would love to hear a palliative docs perspective on the opioid epidemic and what role do they see that they play, what is appropriate in light of what we now know and are learning about opioids, etc.

Opioids aren't good solutions to neuropathic pain outside of Nucynta or possibly low dose Methadone after exhausting other non narcotic medications.

Furthermore, no one should be placed on opioids without being reassessed on a consistent basis. EMG/NCS should be done every few years to determine the progression/severity of this condition with tapering off medications when improvement is noted.

Also what is "non surgical spinal stenosis"? Never heard of that causing "neuropathic pain" but can cause neurogenic claudication. I would need to know far more about this pathology to make any judgement on this situation.

 

[DrCommonSense]

Because there is SIGNIFICANT evidence of HARM with long term opiates.

There is significant evidence of harm from long term usage of NSAIDS, neuroleptics, etc as well.



Topamax + Alcohol can be really problematic, just ask "Dr" Oz.

Mehmet rightfully blames the police, hotel, pathologist, etc for this death and gives zero culpability to the person who mixed Topamax with Alcohol. I mean who needs personal responsibility right?

If we just restricted the amount of Topamax on the streets, this type of stuff wouldn't happen either. Mehmet should also point out that docs are responsible for allowing too much Topamax to get on the streets leading to these issues.

 

[Ducttape]

Please make a separate thread if you would like to discuss concerns about other medications and why to not prescribe them. It is an entirely appropriate topic. Just not on one pertaining CDC guidelines on opioids.

Thanks.

 

[lobelsteve]

Please make a separate thread if you would like to discuss concerns about other medications and why to not prescribe them. It is an entirely appropriate topic. Just not on one pertaining CDC guidelines on opioids.

Thanks.

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate

 

[lonelobo]

Opioids aren't good solutions to neuropathic pain outside of Nucynta or possibly low dose Methadone after exhausting other non narcotic medications.

Furthermore, no one should be placed on opioids without being reassessed on a consistent basis. EMG/NCS should be done every few years to determine the progression/severity of this condition with tapering off medications when improvement is noted.

Also what is "non surgical spinal stenosis"? Never heard of that causing "neuropathic pain" but can cause neurogenic claudication. I would need to know far more about this pathology to make any judgement on this situation.

What?

 

[SeniorWrangler]

Neuropathic pain is due to dysfunction of the pain fibers, which EMG/NCS doesn't measure. Some patients I treat for neuropathic pain have small fiber neuropathy confirmed by biopsy, which by definition doesn't affect EMG/NCS findings.

Also, I would point out that everybody talking about their patient on "a couple of Norcos" is talking about prescribing less than 40 Morphine Equivalents a day, which is consistent with the CDC guidelines.

 

[DrCommonSense]

Neuropathic pain is due to dysfunction of the pain fibers, which EMG/NCS doesn't measure. Some patients I treat for neuropathic pain have small fiber neuropathy confirmed by biopsy, which by definition doesn't affect EMG/NCS findings.

Also, I would point out that everybody talking about their patient on "a couple of Norcos" is talking about prescribing less than 40 Morphine Equivalents a day, which is consistent with the CDC guidelines.

Yes it is

But some are saying that we shouldn't prescribe opioids at all.

 

[Ducttape]

we probably shouldn't.

but when we do, it is after careful consideration of the risk benefit ratio, and consideration has to be given for long term along with short term outcomes.

its not done in a 10 min follow up appointment.

 

[Timeoutofmind]

we probably shouldn't.

but when we do, it is after careful consideration of the risk benefit ratio, and consideration has to be given for long term along with short term outcomes.

its not done in a 10 min follow up appointment.

so perfectly stated

 

[Showme]

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

Perfectly logical... I want you to be MY doctor

 

[101N]

Maryland has a problem and you are part of it. Prepare for change.

 

[lobelsteve]

View attachment 229848 Maryland has a problem and you are part of it. Prepare for change.

See tetweet from drusso. Forced tapers fail.

The issue is the increased risk of all cause mortality at higher doses. And how can you provide treatment for subjective phenomenon that increases risk of patient dying by 3 to 9 fold?