Other specialties' red flags

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ateria radicularis magna

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Had a urologist friend recently inform me that folks seeking pain relief for kidney stones is a common red flag for opioid-seeking in his practice. I thought it would be interesting to start a list of what other specialties' red flags are for opioid-seeking.

1. Urology -- kidney stones
2. Family practice -- cough (sizzurup)
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Many specialties - us, neuro, rheum, GI, Uro - have a "central pain" phenotype. IMO, it's more fruitful for US to codify that, rather than trying to spy the doctor shopper. The CS phenotype identifies who will abuse opioids but also: pain sensitivity & severity, pain chronicity, post-op opioid use, injection failure, & patient satisfaction with care prior to being seen. Grail.

Wolfe was right, lots of CNP conditions aren't discrete biological entities: http://onlinelibrary.wiley.com/doi/10.1002/art.24553/full

Here's another way to look at it. What do all of these disease severity scales
fail to control for:

NRS/VAS/VRS/Wong-Baker
Dentists/OMFS: RDC/TMD
Neuro: MIDAS
GI: IBS Questionnaire
Ortho: WOMAC, DASH
Rheum: DAS28
Spine: ODI/NDI/STArTBack*
Uro: PUF Questionnaire

*STArTBack is a bit of an exception.
 

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A mouse study:)



"There are several reasons to focus on pain catastrophizing. First, from the perspective of a psychosocial researcher who's looked at almost every potential psychological factor related to pain and disability, pain catastrophizing is the single most robust predictor of how people are going to do when they have pain. We talk about reproducibility; this is a finding that is highly reproducible."

  1. Elevated pain sensitivity in chronic pain patients at risk for opioid misuse. Edwards RR, Wasan AD, Michna E, Greenbaum S, Ross E, Jamison RN. J Pain. 2011 Sep;12(9):953-63. doi: 10.1016/j.jpain.2011.02.357. Epub 2011 Jun 16.
  2. Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain. Martel MO, Wasan AD, Jamison RN, Edwards RR. Drug Alcohol Depend. 2013 Sep 1;132(1-2):335-41. doi: 10.1016/j.drugalcdep.2013.02.034. Epub 2013 Apr 22.
  3. The association between negative affect and prescription opioid misuse in patients with chronic pain: the mediating role of opioid craving. Martel MO, Dolman AJ, Edwards RR, Jamison RN, Wasan AD. J Pain. 2014 Jan;15(1):90-100. doi: 10.1016/j.jpain.2013.09.014. Epub 2013 Oct 12.
  4. The association between catastrophizing and craving in patients with chronic pain prescribed opioid therapy: a preliminary analysis. Martel MO, Jamison RN, Wasan AD, Edwards RR. Pain Med. 2014 Oct;15(10):1757-64. doi: 10.1111/pme.12416. Epub 2014 Mar 10.
  5. Pain Med. 2015 Aug 3. doi: 10.1111/pme.12886. [Epub ahead of print] Evaluation of How Depression and Anxiety Mediate the Relationship between Pain Catastrophizing and Prescription Opioid Misuse in a Chronic Pain Population. Arteta J1, Cobos B1, Hu Y1, Jordan K2, Howard K1.
  6. J Rehabil Res Dev. 2016;53(1):25-36. doi: 10.1682/JRRD.2014.10.0230. Correlates of prescription opioid therapy in Veterans with chronic pain and history of substance use disorder. Lovejoy TI1, Dobscha SK, Turk DC, Weimer MB, Morasco BJ.
  7. Drug Alcohol Depend. 2013 Jan 1;127(1-3):193-9. doi:10.1016/j.drugalcdep.2012.06.032. Epub 2012 Jul 18. Risk for prescription opioid misuse among patients with a history of substance use disorder.Morasco BJ1, Turk DC, Donovan DM, Dobscha SK.
  8. Risk for prescription opioid misuse among patients with a history of substance use disorder. Morasco BJ1, Turk DC, Donovan DM, Dobscha SK.
  9. J Rehabil Res Dev. 2016;53(1):25-36. doi: 10.1682/JRRD.2014.10.0230. Correlates of prescription opioid therapy in Veterans with chronic pain and history of substance use disorder. Lovejoy TI1, Dobscha SK, Turk DC, Weimer MB, Morasco BJ.
  10. Pain, pain catastrophizing, and history of intentional overdoses and attempted suicide. Sansone RA, Watts DA, Wiederman MW. Pain Pract. 2014 Feb;14(2):E29-32. doi: 10.1111/papr.12094. Epub 2013 Jun 30.
  11. J Addict Dis. 2014;33(1):28-32. doi: 10.1080/10550887.2014.882728. Pain, pain catastrophizing, and past legal charges related to drugs. Sansone RA1, Watts DA, Wiederman MW.
  12. Pain Med. 2009 Sep;10(6):1084-94. doi: 10.1111/j.1526-4637.2009.00679.x. Epub 2009 Aug 7. Do pain patients at high risk for substance misuse experience more pain? A longitudinal outcomes study. Jamison RN1, Link CL, Marceau LD.
  13. Leander J, Duarte J, Maratos F, Gilbert P. Predictors of painkiller dependence among people with pain in the general population.Pain Med 2014;15:613–624.
  14. Pain Med. 2016 Mar 1. pii: pnw010. [Epub ahead of print] Changes in Pain Sensitivity and Pain Modulation During Oral Opioid Treatment: The Impact of Negative Affect. Edwards RR1, Dolman AJ2, Michna E2, Katz JN3, Nedeljkovic SS2, Janfaza D2, Isaac Z4, Martel MO2, Jamison RN5, Wasan AD6.
  15. Anesthesiology. 2015 Oct;123(4):861-72. doi: 10.1097/ALN.0000000000000768. Psychiatric Comorbidity Is Associated Prospectively with Diminished Opioid Analgesia and Increased Opioid Misuse in Patients with Chronic Low Back Pain. Wasan AD1, Michna E, Edwards RR, Katz JN, Nedeljkovic SS, Dolman AJ, Janfaza D, Isaac Z, Jamison RN.
 
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So if you can't find any articles that are directly on point, try to overwhelm, assuming no one will read 15 articles.

It turns out, there is one ***** this board who will review your nonsense. I've seen you use this tactic in your prior tirades. But I am that most dogged of opponents who takes the time to review your cut and paste silliness.

None of the articles you cited do anything more than suggest there might be an epidemiologic association between central sensitization and addiction. Nothing that supports the definitive, dogmatic, absolutist position you take that CS and addiction are causally related.

My citation is, indeed, a mouse study. It is also directly on point to our discussion.
 
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CS is a diagnosis of exclusion/waste-bucket. It is a useful clinical heuristic, but a therapeutic cul-de-sac for patients. Who would accept a diagnosis of CS on the basis of a clinical interview or paper-and-pencil test given that there is no cure? It's reminiscent of how MS was diagnosed prior to MR---very poorly. At worst, it can be self-serving to the clinician: Once you convince yourself that a patient has a CS syndrome, there is no need to continue doing anything because there is nothing to do. It is the chiropractic subluxation lesion of biopsychosocial pain management.
 
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If LDN is safe, keeps them off of opioids, and "somehow" provides sustained pain reduction and improved function perhaps it is a good alternative to the so-called low dose COT that many of these patients are receiving. Pharmaceutical chicken soup? I have zero experience with it.
 
If this is, in fact, a rebound phenomenon, does it increase tolerance. Can you develop dependence?

If it is an antagonist before triggering the rebound, are patients in greater pain for that 2-3 hr period?

Lastly, naltrexone appears to only be manufactured in 50mg tabs. Even if you wanted to, how would you prescribe it (typical "low dose" is 4.5mg)?
 
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Compounded is pretty cheap in these parts.
One of the small pharmacies I use does mail order. If you guys want the rep to contact you PM me.
 
ampaphb said:
If this is, in fact, a rebound phenomenon, does it increase tolerance. Can you develop dependence?

If it is an antagonist before triggering the rebound, are patients in greater pain for that 2-3 hr period?

Lastly, naltrexone appears to only be manufactured in 50mg tabs. Even if you wanted to, how would you prescribe it (typical "low dose" is 4.5mg)?
Click to expand...
Peter you can get compounding pharmacies to do it for pretty cheap. I did that for a handful of patients out in NC. Now that I'm at the VA I just have them break a 50mg tablet into 4ths or 8ths if possible. I think Steve does the same thing. Haven't had any issues yet at the higher dose
 
a 50 mg pill - cut in quarters, then crush the remaining quarter, divide that up 3 ways (for 4.1 mg... roughly).
 
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clubdeac said:
Peter you can get compounding pharmacies to do it for pretty cheap. I did that for a handful of patients out in NC. Now that I'm at the VA I just have them break a 50mg tablet into 4ths or 8ths if possible. I think Steve does the same thing. Haven't had any issues yet at the higher dose
Click to expand...
8ths? Not sure my folks know what an 8th is!

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If drug x - gabapentin, pregabalin, duloxetine, LDN, THC, oxycodone, - were to significantly change
the course of catastrophizing/CS, we'd have known it long ago. Hard to conceptualize how any drug will
improve dispositional pessimism. Drugs are better for hardware problems than software problems.

However, as freddydpt has suggested, maybe ECT?

Pain. 2006 Apr;121(3):276-80. Epub 2006 Feb 21.
Electroconvulsive therapy improves severe pain associated with fibromyalgia.
Usui C1, Doi N, Nishioka M, Komatsu H, Yamamoto R, Ohkubo T, Ishizuka T, Shibata N, Hatta K, Miyazaki H, Nishioka K, Arai H.
Author information

Abstract
The pathophysiology of fibromyalgia remains unknown. Several reports have recently suggested the novel concept that fibromyalgia is due to the central nervous system becoming hyper-responsive to a peripheral stimulus. The effect of electroconvulsive therapy (ECT) as pain remedication in cases of fibromyalgia without major depressive disorder was studied in a prospective trial lasting three months. All of the patients taking part in the study fulfilled the American College of Rheumatology diagnostic criteria for fibromyalgia. Technetium-99m ethyl cysteinate dimer single photon emission computed tomography was used to assess regional cerebral blood flow (rCBF) before and after a course of ECT. Pain assessment in the patients was undertaken by use of the visual analog scale (VAS) and by evaluation of tender points (TPs). Beck's depression inventory (BDI) was further used to assess depressive mood change in the patients. Our study clearly demonstrated that pain was significantly less severe after ECT, as indicated by the VAS scale for pain and the evaluation of TPs. A further notable observation was that thalamic blood flow was also improved. We conclude that a course of ECT produced notable improvements in both intractable severe pain associated with fibromyalgia and also in terms of thalamic blood flow.

http://link.springer.com/article/10.1007/s11916-002-0019-4?wt_mc=Affiliate.CommissionJunction.3.EPR1089.DeepLink#page-1
 
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Non-opioid options for kidney stone pain...

http://www.practicalpainmanagement....oward-almost-opioid-free-emergency-department

Drs. LaPietra and Rosenberg created the protocols, which focus on 5 conditions that commonly present to the ED: kidney stones, lumbar radiculopathy, acute headache and migraine, musculoskeletal pain, and extremity fracture or joint dislocation (see Table 1). For patients with kidney stones, the protocol calls for intravenous lidocaine. “It gives patients tremendous amount of relief because it’s secreted in urine and anesthetizes and blocks nerves through a sodium channel blockade,” said Dr. Rosenberg. He believes it also helps patients pass the stones more quickly. "About 75% of patients get complete pain relief with IV lidocaine," he said.
 
101N said:
Non-opioid options for kidney stone pain...

http://www.practicalpainmanagement....oward-almost-opioid-free-emergency-department

Drs. LaPietra and Rosenberg created the protocols, which focus on 5 conditions that commonly present to the ED: kidney stones, lumbar radiculopathy, acute headache and migraine, musculoskeletal pain, and extremity fracture or joint dislocation (see Table 1). For patients with kidney stones, the protocol calls for intravenous lidocaine. “It gives patients tremendous amount of relief because it’s secreted in urine and anesthetizes and blocks nerves through a sodium channel blockade,” said Dr. Rosenberg. He believes it also helps patients pass the stones more quickly. "About 75% of patients get complete pain relief with IV lidocaine," he said.
Click to expand...
Why do that when Toradol works wonderfully well?
 
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