Fibro patient wants off cannabis and back on opioids

Discussion in 'Pain Medicine' started by drusso, Mar 14, 2017.

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  1. drusso

    drusso Moderator Emeritus Lifetime Donor 10+ Year Member

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    58 y.o. female dog-groomer with approximately 20 year history of wide spread pain tapered and discontinued from COT 40 MEQ 2 years ago. Meets original and revised diagnostic criteria for FMS. Owns and operates her own business. She cultivated and trialed multiple strains/hybrids of cannabis including C. sativa, C. indica and C. ruderalis including multiple CBD concentrations. She presents with recent botanical analysis of some of her batches from an accredited cannabis testing laboratory. She also trialed various routes of administration and preparations (tinctures, salves, etc). "They all basically made me high or didn't work." Denies euphoria from full mu agonists. Tramadol makes her "jittery." Desires to return to Norco 10/325 QID...

    What's your next move?
     
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  3. bronchospasm

    bronchospasm Junior Member Lifetime Donor 10+ Year Member

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    No evidence that opioids work for Fibro.
     
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  4. bedrock

    bedrock Member 10+ Year Member

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    exactly. I wouldnt write for it
     
  5. Papa Lou

    Papa Lou ASA Member 2+ Year Member

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    While I respect and also preach this advice I'll be the first to say you guys, whom I respect nonetheless, sound like dogmatic fools. There's no evidence for a lot of things that work really well as we all know already. This person seems like a credible source based on the information that drusso has provided. You take her word for it and prescribe it. And if you won't then don't be critical of the one who does. You're just wrong here. FYI I'm also the fool who dogmatically says no to this patient the majority of the time (and so I'm wrong).
     
  6. NOSfan

    NOSfan 7+ Year Member

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    COT contraindicated in FM.

    Perhaps LDN.
     
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  7. DrCommonSense

    DrCommonSense

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    Give her the study that confirms the people who are on THC get off opioids. That should do it.
     
  8. MaximusD

    MaximusD Anatomically Incorrect 10+ Year Member

    Explain that opioids over time will increase her pain not improve it. It is a syndrome of sensitization and opioids only worsen that. It's not dogma, it's understanding pathology and making medical decisions... IF you are convinced fibromyalgia is an independent fiagnosis, it is irresponsible to prescribe opioids in its treatment.
     
  9. MaximusD

    MaximusD Anatomically Incorrect 10+ Year Member

    Certainly there would be better options than hydrocodone. Perhaps something with NMDA antagonism?
     
  10. drusso

    drusso Moderator Emeritus Lifetime Donor 10+ Year Member

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    I agree with you. It is your experience that patients find that information acceptable and those conversations go smoothly?
     
  11. SeniorWrangler

    SeniorWrangler 5+ Year Member

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    I'm pretty dubious, the literature doesn't support it and in my limited experience, the patients like low-dose opioids but they don't result in any increase of function, if anything they lead to a slow decrease in function over time. Just my 0.02
     
  12. epidural man

    epidural man ASA Member 10+ Year Member

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  13. Gauss

    Gauss Damnit Jim! 10+ Year Member

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    did you wean her off the opioids originally? If so, why go back? If not, then what about this "request" makes you consider using non-standard of care?
    This sounds like diversion
     
  14. drusso

    drusso Moderator Emeritus Lifetime Donor 10+ Year Member

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    I weaned her and she went away and started using cannabis. After two years she's ready to call cannabis quits, "Cannabis (in all it forms) failed me. I was more functional on opioids--4 Norco 10/325 per day." I don't see any evidence of diversion.
     
  15. neutro

    neutro 7+ Year Member

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    cymbalta?
    lyrica?
    MAYBE 5 tabs of tylenol # 3 for breakthrough pain per month.

    Complementary modalities of pain management:
    CBT
    Massage
    Accupuncture
     
  16. DrCommonSense

    DrCommonSense

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    What is the literature on Lyrica in terms of functional benefit for fibromyalgia or VAS improvement compared to side effects?
     
  17. BobBarker

    BobBarker Member 10+ Year Member

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    Naltrexone. Perfect time to try it. Nothing to lose.
     
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  18. clubdeac

    clubdeac 7+ Year Member

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    Tell you're not comfortable prescribing for her diagnosis but she is welcome to grow her own poppy plants and see what concoctions she can come up with
     
  19. bedrock

    bedrock Member 10+ Year Member

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    Agree time for naltrexone.
     
  20. Ligament

    Ligament Interventional Pain Management Lifetime Donor SDN Advisor 10+ Year Member

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    "Since you produce federally illegal drugs, I cannot prescribe controlled substances to you. You should also switch to cat-grooming, this will allow your fibromyalgia to level-up to the maximum power level."
     
  21. neutro

    neutro 7+ Year Member

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    what is the literature behind ESIs for discogenic LBP or long term benefit of radicular pain.

    we do them for symptom relief after assessing risks and benefits like 90% of modalities in pain management.

    lyrica is no different.
     
  22. geauxg8rs

    geauxg8rs 7+ Year Member

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    Maybe she needs adderal for really late onset adhd. Works well for pot refractory conditions
     
  23. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    I think there are 2 sticky points for me.

    1. are opioids appropriate for her pain condition? does she have fibromyalgia, and if so, does one believe that opioids are appropriate?
    2. what to do with the fact that she was so "in to" cannabis.

    what would I do? besides punt to drusso (from across the country)...

    how bout telling her to return in 5 weeks. in meantime, no cannabis/no opioids. see pain psychologist, work on lifestyle changes, get in to yoga, etc. discuss butrans.

    in follow up, obtain UDS; review pain psychology assessment; trial butrans; if she is insistent on Norco, bow out.
     
  24. MaximusD

    MaximusD Anatomically Incorrect 10+ Year Member

    Nope lol, but I'm their doctor and the prescription pad is mine. If I were to use opioids I would prescribe them in a way that only allowed for 1-2 tabs per day to reduce the risk of dependence. They are an adjunct at best in this setting, and at worst they can do actual harm.
     
  25. SeniorWrangler

    SeniorWrangler 5+ Year Member

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    From Cochrane database:
    "Authors' conclusions
    Pregabalin 300 to 600 mg produces a major reduction in pain intensity over 12 to 26 weeks with tolerable adverse events for a small proportion of people (about 10% more than placebo) with moderate or severe pain due to fibromyalgia. The degree of pain relief is known to be accompanied by improvements in other symptoms, quality of life, and function. These results are similar to other effective medicines in fibromyalgia (milnacipran, duloxetine)."
    http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011790.pub2/full

    So, like many pain treatments, really good for a small group, but you don't know who is in that group. Sounds like a reasonable approach is to have patients try it for several months if they can afford it with their insurance and then decide.
     
  26. neutro

    neutro 7+ Year Member

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    ok chief.
     
  27. Tapspatellas

    Tapspatellas 7+ Year Member

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    I give all the FMS drugs a good try, though they all have approval for unconvincing studies. Occasional I get one of those 10-15% that responds reasonably well to one. I am aggressive about getting them off the non-helpful polypharmacy too. So many come to me on cymbalta 60, lyrica 225 bid, a TCA, muscle relaxer, tramadol, NSAIDs, (not counting the ones on bzd and opioids too). If there was a definite helpful one, we keep it, otherwise slowly wean each and see what happens with function and pain. Restart if it was helpful.
     
  28. oreosandsake

    oreosandsake 10+ Year Member

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    I always tell patients that they do not suffer from ODS = Opioid Deficiency Syndrome

    have prescribed LDN - have never had any success with it. feel like most of these folks have tried all the SNRI, SSRI, gabapentinoids already. patients like meds with "first dose effect" especially those who enjoy chemical coping with life.

    when they bring up CAM therapies I encourage it. gluten free, yoga, meditation, reiki, acupuncture, tai chi, walks on the beach, book club, a puppy, a kitten...

    there is a slew of youtube vids from patients who "cured themselves of fibromyalgia"
     
  29. DrCommonSense

    DrCommonSense

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    Except radicular pain due to a disc herniation can be clearly differentiated and the pathology can be confirmed on an MRI study. Sure there is variance in the etiology of the condition and the severity of pathology compared to imaging but at least there is something.

    What the hell is there to diagnostic fibro? You are literally giving an extremely expensive drug that has terrible side effects for a diagnosis that isn't clear using imaging/labs/etc.

    How do you diagnose this?

    So essentially any criticism you can make about esi from an efficacy to cost stand point is triple that for lyrica.
     
    Last edited: Mar 18, 2017
  30. DrCommonSense

    DrCommonSense

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    Remember all the those "studies" were performed by consultants for Pfizer where they did the analysis.

    Also, even with their very biased studies, they only find a very small group that shows be for a disease there is zero evidence for.
     
  31. SeniorWrangler

    SeniorWrangler 5+ Year Member

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    If you're going to blow of the Cochrane review, I'm not sure it's worth discussing. The evidence is crappy but all evidence in pain medicine is crappy.
     
  32. DrCommonSense

    DrCommonSense

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    I can agree on that.

    But the reality is all evidence for basically all of procedural medicine and most of big pharma is crappy.

    For instance, look at the followup on the courage study after another 10 years or so for stents in stable CAD showing zero mortality benefit.

    Or prostate surgeries with zero mortality benefit for the vast majority of cancers after 10 years.

    Or back surgery. Most ortho surgeries.

    Etc etc etc.
     
  33. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Tell her the standards of care in medicine have changed in the past two years and opioids are no longer considered indicated for the treatment of fibromyalgia.
     
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  34. algosdoc

    algosdoc algosdoc 10+ Year Member

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    True- starting opioids again for more than a month will doom the patient to using them long term, possibly forever
     
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  35. 101N

    101N 5+ Year Member

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    Pain Pract. 2015 Oct 7. doi: 10.1111/papr.12364. [Epub ahead of print]
    Evaluating Guideline-recommended Pain Medication Use Among Patients with Newly Diagnosed Fibromyalgia.
    Halpern R1, Shah SN2, Cappelleri JC3, Masters ET2, Clair A2.
    Author information

    Abstract
    OBJECTIVES:
    To compare pain medication treatment changes across cohorts of newly diagnosed patients with fibromyalgia (FM) treated with guideline-recommended medications or opioids.

    METHODS AND DESIGN:
    Retrospective claims data analysis examined adult commercial health plan members newly diagnosed with FM (initial diagnosis = index date) from January 2008 to February 2012. Patients had 6-month pre-index and 12-month postindex periods and received pain medication within 6 months postindex; cohorts were based on the first postindex medication. Guideline-recommended medication cohorts were anti-epileptic drug (AED), serotonin-norepinephrine reuptake inhibitor (SNRI), selective serotonin reuptake inhibitor (SSRI), and tricyclic antidepressant (TCA). Short-acting and long-acting opioid (SAO, LAO) cohorts were also identified. Pairwise comparisons with the SAO cohort were conducted. Cox proportional hazards regressions modeled the likelihood of receiving guideline-recommended therapy.

    RESULTS:
    The final sample was 96,175 patients (mean age 47.3 years; 72.5% female), distributed into SAO (57%), SSRI (22%), AED (10%), SNRI (6%), TCA (3%), and LAO (2%) cohorts. The SAO cohort had the most discontinuation (49% vs. 6% to 22%, P < 0.01) and the least augmentation (29% vs. 35% to 50%, P < 0.01). Regression analyses indicated that patients with (vs. without) pre-index guideline-recommended medications were 2 to 4 times more likely to receive them postindex. Patients in the opioid cohorts were about half as likely to receive subsequent guideline-recommended medications.

    CONCLUSIONS:
    Opioid use was widespread among patients with FM. Once patients received opioids postdiagnosis, the likelihood of receiving guideline-recommended medications was small. These real-world results indicate an opportunity may exist for improved FM management using recommended therapies in clinical practice.
     
  36. drusso

    drusso Moderator Emeritus Lifetime Donor 10+ Year Member

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    UPDATE: Patient requested referral to a "Fibromyalgia Center of Excellence." Records sent at patient's request.

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  37. SeniorWrangler

    SeniorWrangler 5+ Year Member

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    It's like those Visa ads. "They don't take American Express OR Medicaid."
    Have you heard back from any patients who have taken the Four R challenge?
     
  38. drusso

    drusso Moderator Emeritus Lifetime Donor 10+ Year Member

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    I'm certain that this Center doesn't have the local ACO contract to deliver behavioral health services.
     
  39. oreosandsake

    oreosandsake 10+ Year Member

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    Time to open up a McFrida? :pirate:
     
  40. BobBarker

    BobBarker Member 10+ Year Member

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    Yes but they are spending so much time with the patient it is essentially talk therapy.
     
  41. lonelobo

    lonelobo PAIN DOC 10+ Year Member

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    You couldn't pay me enough to spend 2 hrs with a Fibromyalgia patient
     
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  42. neutro

    neutro 7+ Year Member

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    lol. i talk to them, because i do not want to be rude...but i just keep it short, offer my plan and say
    "FM is not typically amenable to interventional pain modalities, unless there is well localized and superimposed pain source that we can go after. Opioids, esp. at the doses you are requesting (i.e. MED more than 50 - but for FM I drop it down to 20 :D), are generally contra-indicated since they cause fatigue and further deterioration of neurocognition".
    I do RECOMMEND: lyrica, cymbalta, CBT, PT/ aquatherapy/weight loss/accupuncture/ massage as per the discretion of the PCP.

    patient never gets too comfortable.

    Follow up 6 months - 15 minutes.
     
  43. clubdeac

    clubdeac 7+ Year Member

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    OMG really!?!? Are patients actually paying this?? If so, maybe I should start up a similar gig. That's insane.. It'd be the easiest $600 you ever made. Think how much damn info we have to get during an initial consult in like 15-20min. Imagine having 2 hours! And the patients probably love it. You take a thorough history and physical, order all the usual fibro labs (ESR, Vit D, intracellular Mg, B12, folate, homocysteine, TSH, CBC, EBV, CMV, pregnenalone, cortisol blah blah blah), and then come up with a detailed treatment plan which could include any number of CAM therapies and nutraceuticals. Seriously, it would be a cake walk and good money. No insurance denials, no prior auths, no peer to peer... hmmmm:thinking:
     
  44. SpineBound

    SpineBound Large Member 7+ Year Member

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    Agreed but in my area of inland southern california people are too poor/tight to pay cash for anything health related. This takes PRP off the table in my area.
     
  45. Crybaby

    Crybaby 2+ Year Member

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    I second the low dose naltrexone. Only downside is no insurance coverage. But then insurance does not cover THC...... at least not in my state :)
     

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