Opioid Agonist Therapy Underused, Data Suggest

[TheLoneWolf]

Opioid Agonist Therapy Underused, Data Suggest

The low rates of opioid agonist therapy administration over time suggest that additional efforts are needed to promote this intervention in acute care settings, according to the researchers.

www.medscape.com

When you take policy statements from family docs seriously. Have others learned nothing from the past 30 year opioid disaster in the US?

Giving a long acting morphine to those with OUD is not in their or society's best interests.

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[VA Hopeful Dr]

This is why no one reads Canadian journals

 

[Ducttape]

Yes, it is canadian.

But I expect US data is no different.

Essentially requesting ER docs and hospitalists to prescribe OUD therapy - I'm sure is unlikely to happen in US either.

 

[NJPAIN]

Opioid Agonist Therapy Underused, Data Suggest

The low rates of opioid agonist therapy administration over time suggest that additional efforts are needed to promote this intervention in acute care settings, according to the researchers.

www.medscape.com

When you take policy statements from family docs seriously. Have others learned nothing from the past 30 year opioid disaster in the US?

Giving a long acting morphine to those with OUD is not in their or society's best interests.

My thoughts exactly. There is a big push to swing the pendulum back in the wrong direction.

 

[TheLoneWolf]

This is why no one reads Canadian journals

And miss out on peak comedy like this:

How a powdered fentanyl program has improved a client’s quality of life

[See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.211515][1] I’ve tried titrated injectable opioid therapies and none of them worked, so when they came out with the powdered fentanyl program, I thought I’d give it a try. So far it seems to be working pretty good. I’ve been on it for

www.cmaj.ca

 

[hyperalgesia]

And miss out on peak comedy like this:

How a powdered fentanyl program has improved a client’s quality of life

[See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.211515][1] I’ve tried titrated injectable opioid therapies and none of them worked, so when they came out with the powdered fentanyl program, I thought I’d give it a try. So far it seems to be working pretty good. I’ve been on it for

www.cmaj.ca

"Me Likes Nose Candy - A Scientific Approach to Getting Dat Fix"

 

[Doctodd]

Opioid Agonist Therapy Underused, Data Suggest

The low rates of opioid agonist therapy administration over time suggest that additional efforts are needed to promote this intervention in acute care settings, according to the researchers.

www.medscape.com

When you take policy statements from family docs seriously. Have others learned nothing from the past 30 year opioid disaster in the US?

Giving a long acting morphine to those with OUD is not in their or society's best interests.

but wait....the govt says the ADA protects the patient.....

Opioid Use Disorder

This page provides some basic information about Opioid Use Disorder (OUD) and the ADA’s protections for people with OUD.

www.ada.gov

 

[TheLoneWolf]

but wait....the govt says the ADA protects the patient.....

Opioid Use Disorder

This page provides some basic information about Opioid Use Disorder (OUD) and the ADA’s protections for people with OUD.

www.ada.gov

The ADA does protect the patient. The DEA is the one who comes after you.

 

[Doctodd]

The ADA does protect the patient. The DEA is the one who comes after you.

Im not worried about the DEA coming after me for not writing opioids. Im worried about disgruntled patients and their attorneys who already threaten to sue websites that arent ADA compliant.

That being said, low dose MS Contin is the only drug ill prescribe if i suspect a risk of abuse potential because it doesnt give the euphoria everything else does.

edit: also buprenorphine

 

[lobelsteve]

Im not worried about the DEA coming after me for not writing opioids. Im worried about disgruntled patients and their attorneys who already threaten to sue websites that arent ADA compliant.

That being said, low dose MS Contin is the only drug ill prescribe if i suspect a risk of abuse potential because it doesnt give the euphoria everything else does.

The DEA will not see it that way. And science suggests pure agonists do not differ in patients with abuse risk.

 

[bedrock]

Im not worried about the DEA coming after me for not writing opioids. Im worried about disgruntled patients and their attorneys who already threaten to sue websites that arent ADA compliant.

That being said, low dose MS Contin is the only drug ill prescribe if i suspect a risk of abuse potential because it doesnt give the euphoria everything else does.

The DEA will not see it that way. And science suggests pure agonists do not differ in patients with abuse risk.

I'd definitely argue that if you decide to prescribe beyond muscle relaxers, neuropathics, NSAIDs, and tramadol, that only buprenorphine medications would be accepted as lower risk (butrans, belbuca), by the DEA. I doubt they would similarly accept morphine or any other pure opioid agonist

 

[Ducttape]

but wait....the govt says the ADA protects the patient.....

Opioid Use Disorder

This page provides some basic information about Opioid Use Disorder (OUD) and the ADA’s protections for people with OUD.

www.ada.gov

you might want to read the whole page before drawing unsupported conclusions...

they do not protect those who are active users.

Exception: Illegal Drug Use​

The ADA does NOT protect individuals who are currently illegally using drugs. This includes illegal drug use that was recent enough to support a reasonable belief that the use is current or that continuing use is a real and ongoing problem. Learn more about what current illegal drug use means at The Americans with Disabilities Act and the Opioid Crisis.

• Taking MOUD or other opioids legally prescribed by a doctor for a valid purpose is not considered to be current illegal drug use when they are taken as directed.

they are also not discussing requiring prescribing to drug users.

the ADA is protecting those with opioid use disorder especially those on medication treatment for their addiction.

 

[Doctodd]

im talking about the disgruntled patient who doesnt get her meds and claims she has OUD....not talking about anyone who actually diverts or abuses. And then to PROVE the patient is diverting or abusing is an entirely different process that i dont want to be a part of. Any patient and their attorney can claim they have OUD and then claim we are violating the ADA and threaten or extort a physician.

 

[Ducttape]

again, read the document.

no where does it state that a doctor has to or is forced to prescribe opioid medication to someone with a history opioid use disorder.

you are exaggerating what limited part of the document you did read (just the title?) to justify your world view that you are being forced to do something you do not want. NOTHING in that document or the linked documents state anywhere that opioid prescriptions have to be offered for patients with OUD.

nothing in the document talks about a disgruntled patient not getting meds - with the exception of ongoing treatment for OUD.

explicit statements are made that patients are not covered by the ADA if they are illicitly using drugs - "illegal use of drugs that occurred recently enough to justify a reasonable belief that a person’s drug use is current or that continuing use is a real and ongoing problem". so someone tests positive for illicits, they are not covered by the ADA.


the ADA is there to make sure that disabled people are not discriminated against.

it seems increasingly obvious that there is a need for this.....

 

[Orin]

no where does it state that a doctor has to or is forced to prescribe opioid medication to someone with a history opioid use disorder.

Yeah, I agree that we're over worried about being 'forced' to prescribe. No one is doing that.

"There are many kinds of discrimination against individuals with OUD that can be illegal under the ADA. Here are a few examples:

• A doctor’s office or medical facility refuses to admit a patient because they take MOUD."

The question is whether that refusal to admit or consult on a patient with pain and comorbid OUD or addiction is an ADA violation, as that is actually a relatively common occurrence in practices I suspect.

 

[Ducttape]

personally i see these patients all the time.

its actually easy because if they ask about opioids, just say "you are on suboxone and narcotics wont work. you need to stay on your maintenance meds. lets talk about other treatments."

 

[au bon pain]

I'd definitely argue that if you decide to prescribe beyond muscle relaxers, neuropathics, NSAIDs, and tramadol, that only buprenorphine medications would be accepted as lower risk (butrans, belbuca), by the DEA. I doubt they would similarly accept morphine or any other pure opioid agonist

Agree that tramadol and bup are lower risk than full agonists of any kind. In my area it seems like many docs are slowly moving away from fulls. What I'm finding insane though is that so many PCPs, surgeons, pain docs etc near me continue to initiate/precipitate COT at all for MSK patients. Seems like rates of this are increasing again primarily with tramadol and bup products as they seem to have this impression that they are the "safe ones"...without recognition of the fact that 1) they are still opioids that suck for chronic MSK pain and 2) there is no "safe" opioid.

 

[lobelsteve]

Agree that tramadol and bup are lower risk than full agonists of any kind. In my area it seems like many docs are slowly moving away from fulls. What I'm finding insane though is that so many PCPs, surgeons, pain docs etc near me continue to initiate/precipitate COT at all for MSK patients. Seems like rates of this are increasing again primarily with tramadol and bup products as they seem to have this impression that they are the "safe ones"...without recognition of the fact that 1) they are still opioids that suck for chronic MSK pain and 2) there is no "safe" opioid.

I argue tramadol is not a true opioid. But pragmatically if we consider it a true opioid it is safe. From the DEA:

In 2020, there were a total of 6,974 tramadol exposures, of which there were 3,075 single substance exposures and 3 associated deaths.

And from Medscape:

The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) system has estimated that more than 100,000 hospitalizations and more than 16,000 deaths in the United States each year are due to NSAID-related complications, with costs greater than $2 billion.

 

[au bon pain]

I argue tramadol is not a true opioid. But pragmatically if we consider it a true opioid it is safe. From the DEA:

In 2020, there were a total of 6,974 tramadol exposures, of which there were 3,075 single substance exposures and 3 associated deaths.

And from Medscape:

The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) system has estimated that more than 100,000 hospitalizations and more than 16,000 deaths in the United States each year are due to NSAID-related complications, with costs greater than $2 billion.

From the DEA ( https://www.deadiversion.usdoj.gov/drug_chem_info/tramadol.pdf ) :

"Tramadol is an opioid analgesic and opioid activity is the overriding contributor to its pharmacological effects."

The bolded statement you quote I'm guessing comes from poison control center #s which often paint a very incomplete picture of prevalence for medication SEs since they typically require somebody to actually call the poison control center which...just ain't that frequent relative to the total amount of exposures to this patient each year. And safety is more than binary life vs death.

Here's just one random paper with a wider view and a higher n:
"Safety Events Associated with Tramadol Use Among Older Adults with Osteoarthritis" (Safety Events Associated with Tramadol Use Among Older Adults with Osteoarthritis)
"Tramadol use was associated with increased risk of multiple ER utilizations, falls/fractures, CVD hospitalizations, safety event hospitalizations, and mortality (new users only) compared to nonuse."

Certainly agree that nsaids have risks, especially in the elderly+ comorbidities.
But considering just how widespread nsaid use is (the article you cite mentions that 30 Billion doses of nsaids are used each year in the US alone), the n of legit safety events attributed to their use is tough to determine and likely low overall across the population.

But hey sure everything has risk, and the best we can do is try to balance risks:benefits as much as we can and move on. If convincing data emerges showing tramadol is actually a great tool for chronic pain, I'll maybe consider using it slightly more frequently.

 

[lobelsteve]

From the DEA ( https://www.deadiversion.usdoj.gov/drug_chem_info/tramadol.pdf ) :

"Tramadol is an opioid analgesic and opioid activity is the overriding contributor to its pharmacological effects."

The bolded statement you quote I'm guessing comes from poison control center #s which often paint a very incomplete picture of prevalence for medication SEs since they typically require somebody to actually call the poison control center which...just ain't that frequent relative to the total amount of exposures to this patient each year. And safety is more than binary life vs death.

Here's just one random paper with a wider view and a higher n:
"Safety Events Associated with Tramadol Use Among Older Adults with Osteoarthritis" (Safety Events Associated with Tramadol Use Among Older Adults with Osteoarthritis)
"Tramadol use was associated with increased risk of multiple ER utilizations, falls/fractures, CVD hospitalizations, safety event hospitalizations, and mortality (new users only) compared to nonuse."

Certainly agree that nsaids have risks, especially in the elderly+ comorbidities.
But considering just how widespread nsaid use is (the article you cite mentions that 30 Billion doses of nsaids are used each year in the US alone), the n of legit safety events attributed to their use is tough to determine and likely low overall across the population.

But hey sure everything has risk, and the best we can do is try to balance risks:benefits as much as we can and move on. If convincing data emerges showing tramadol is actually a great tool for chronic pain, I'll maybe consider using it slightly more frequently.

DEA is wrong on MOA of tramadol.
Mu binding? Weaker than Lomotil.
Even the metabolite is weaker than codeine.

 

[au bon pain]

DEA is wrong on MOA of tramadol.
Mu binding? Weaker than Lomotil.
Even the metabolite is weaker than codeine.

DEA can be wrong?

 

[CleanUp]

im talking about the disgruntled patient who doesnt get her meds and claims she has OUD....not talking about anyone who actually diverts or abuses. And then to PROVE the patient is diverting or abusing is an entirely different process that i dont want to be a part of. Any patient and their attorney can claim they have OUD and then claim we are violating the ADA and threaten or extort a physician.

This is 100% true.

I’ve literally had counsel tell me that I could definitely fight cases like this but it wouldn’t be worth my time or my money to do so just to “win”.

 

[Laryngospasm]

I would also wager that almost all of those tramadol deaths involved either other drugs or seizures. The problem for us is somewhat of damned if you do damned if you don’t scenario when it comes to opioids.

 

[Doctodd]

again, read the document.

no where does it state that a doctor has to or is forced to prescribe opioid medication to someone with a history opioid use disorder.

you are exaggerating what limited part of the document you did read (just the title?) to justify your world view that you are being forced to do something you do not want. NOTHING in that document or the linked documents state anywhere that opioid prescriptions have to be offered for patients with OUD.

nothing in the document talks about a disgruntled patient not getting meds - with the exception of ongoing treatment for OUD.

explicit statements are made that patients are not covered by the ADA if they are illicitly using drugs - "illegal use of drugs that occurred recently enough to justify a reasonable belief that a person’s drug use is current or that continuing use is a real and ongoing problem". so someone tests positive for illicits, they are not covered by the ADA.


the ADA is there to make sure that disabled people are not discriminated against.

it seems increasingly obvious that there is a need for this.....

you arent understanding.....im not worried about the DEA.

 

[Ducttape]

i again suggest that you are making a mountain out of a molehill.

the ADA is a very specific. patients actively using or that you suspect are actively using are not covered by the ADA.

I argue tramadol is not a true opioid. But pragmatically if we consider it a true opioid it is safe. From the DEA:

In 2020, there were a total of 6,974 tramadol exposures, of which there were 3,075 single substance exposures and 3 associated deaths.

And from Medscape:

The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) system has estimated that more than 100,000 hospitalizations and more than 16,000 deaths in the United States each year are due to NSAID-related complications, with costs greater than $2 billion.

not really apropros...

adding information on NSAID doesnt add to the discussion on opioid agonists such as tramadol. that is a separate problem that requires addressing.

fwiw, 60,000,000 americans are taking prescription NSAID. 84 million NSAID prescriptions are written per year. that doesnt include the OTC NSAID use...

 

[Doctodd]

you arent understanding.....im not worried about the DEA.

Sounds like you aren’t familiar with attorneys. You don’t have your own website that is ADA compliant?

 

[Ducttape]

 

[Pain Applicant1]

Not sure about MS Contin for OUD as I don't have experience using it for that diagnosis but BUP works great for many of these patients. It should be more readily available and more people in here should help facilitate this.