Prescription ODs level, illicit fentanyl skyrockets

[emd123]

Prescription ODs have leveled off, while illicit fentanyl ODs are skyrocketing, but the media is lumping them all in one big basket called the ‘opiate crisis,’ not making the important distinction. The illicit drug markets have nothing to do with doctors, pharmacies or pharmaceutical companies at all. I’m not saying that we in the medical community shouldn’t look for ways to improve things. We should. But we could prescribe zero opiates next year and the skyrocketing illicit fentanyl ODs won’t be affected one bit. Everyone lumps the two separate problems, which have separate causes and solutions, together and blames the doctors and suffering patients. Apparantly we’re much easier and defenseless targets compared to the drug dealers and drug abusers that violate the law.

The government and the media are dishonestly conflating prescription OD deaths with illlicit opiate deaths. This needs to stop.

http://www.jpands.org/vol23no1/lilly.pdf

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[Ducttape]

you are missing the big picture.

the illicit markets are stimulated by new addicts. how to they get to be addicts? commonly through prescription medications (either their own prescription or friends/family). so we have a big responsibility.


we need to make sure we introduce as few new people as possible, and reduce the vast tonnage of prescription opioids floating out there right now.


and be careful of conclusions. the study admits that they use NIDA data for opioid assessment up to 2015, then uses data from CDC Wonder for the most recent data. now NIDA does derive information from CDC Wonder, but there may be some qualifiers that alter what NIDA would post.

looking at his numbers, you could also make the conclusion that we have done nothing to change death rate from prescription opioids, as the numbers on his chart of deaths due to prescription opioids is essentially unchanged (Table 2 - All prescription opioids not including illicit fentanyl: 2014 - 16,765; 2015 - 16,610; 2016 - 16,809)

 

[Timeoutofmind]

Ummm...

No.

Look at the data.

Many people on street opioids got started with prescription opioids, either there own or someone else's.

And there is substantial evidence people misuse prescription opioids.

And also there is substantial evidence opioids make CNP worse, or at least dont help. So dont worry about "suffering patients" in this regard.

Seriously people.

I continue to be shocked by the logical fallacies so prevalent in these discussions among people of so many different disciplines. I was reading a pain periodical yesterday, and saw so many similarly all over the place arguments by people in positions to influence policy and publishing. Scary.

 

[emd123]

Ummm...

No.

Look at the data.

Many people on street opioids got started with prescription opioids, either there own or someone else's.

And there is substantial evidence people misuse prescription opioids.

And also there is substantial evidence opioids make CNP worse, or at least dont help. So dont worry about "suffering patients" in this regard.

Seriously people.

I continue to be shocked by the logical fallacies so prevalent in these discussions among people of so many different disciplines. I was reading a pain periodical yesterday, and saw so many similarly all over the place arguments by people in positions to influence policy and publishing. Scary.

So, you’re okay with being blamed for illicit fentanyl overdose deaths. And you think my 90-year-old patient who needs Percocet to walk and stay out of a nursing home, should be shafted because drug dealers import fentanyl from China. Bold stance, but...okay.

Many of my patients are on no opiates at all. I haven’t started a chronic non-cancer patient on an opiate (that wasn’t already on them and proving compliance) in about 5 years. I don’t dose escalate my opiate ‘legacy’ (started by someone else and demonstrate compliance and lack of aberancy) patients. I don’t have a single patient on opiates over 90 MME/day and 75% of my opiate patient are on <50 MME/day. Some are on <5 MME/day. My local competitors prescribe 500-900% more (not a misprint) opiates than me (per Medicare data on ProPublica’s website). My job would be much easier if I didn’t care and just let the flood gates open. But I don’t. I do the right thing and work hard, banging my head against the wall to hold the line on prescribing as much as humanly possible, every clinic day.

So if opiates ever get banned, then so be it. And if and when a day comes that I decide to prescribe zero opiates, then so be it. But until then, I’m not about to accept blame for the fentanyl traffickers that are smuggling illegal fentanyl into the country, that never was made by a legitimate pharmaceutical company, nor ever dispensed by a legitimate pharmacist, was never prescribed by a doctor or ever used by a patient with legitimate medical need.

 

[Ducttape]

pesonally, im not okay with being blamed for the 16,809 deaths from prescription opioids.

im also not okay with being blamed for having them go off the deep end and buy illicit fentanyl off the streets.

but when they got addicted to prescription opioids from you in the first place, or even in the second place when they steal it from someone who you prescribed but didn't control their drug supply, then you are responsible, however indirectly.

no one is denying you thinking that you are helping some 90 year old patient who "needs" Percocet. but think hard about writing for the population who transform in to addicts.

the solution is to limit who we prescribe. you know that.

 

[Timeoutofmind]

So, you’re okay with being blamed for illicit fentanyl overdose deaths. And you think my 90-year-old patient who needs Percocet to walk and stay out of a nursing home, should be shafted because drug dealers import fentanyl from China. Bold stance, but...okay.

Yes, the medical establishment in the form of opioid prescribing has contributed to the disturbing trend of current illicit fentanyl overdose deaths based on the above points that I made. I dont really see how thats a disputable point. This despite the fact that there are many other parties that have contributed as well.

And your 90 year old does not need Percocet.
Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE... - PubMed - NCBI

Again, so many missed connections logically.

Take homes we can all agree on:

1. Opioids do not help CNP
2. They are abused
3. People who abuse them at times move on to illicits

I think it is honestly just too painful for us to look right into the mirror in the face of our ongoing opioid prescribing. Hence, all the odd and tangential type arguments that get thrown around.

 

[emd123]

Double post

 

[Timeoutofmind]

15 tabs a month of norco 5s or tramadol for people with significant pathology who have no risk factors (a small segment of the people we see) who have failed non-opioid alternatives if they are either working or elderly.

I have not a lot of people on this regimen

No one on more than this.

My thought process is that at this dosing the immunologic, endocrine, and CNS side damage from chronic opioid therapy are almost entirely mitigated. (And most importantly tolerance is minimal so I think patients actually do have some benefit). My only concern is exposure to the addictive potential of these drugs (even at this dosing). I have a frank talk with them about this.

Will wean anyone who wants. I wean a decent amount for the PCPs

 

[emd123]

Yes, the medical establishment in the form of opioid prescribing has contributed to the disturbing trend of current illicit fentanyl overdose deaths based on the above points that I made. I dont really see how thats a disputable point. This despite the fact that there are many other parties that have contributed as well.

And your 90 year old does not need Percocet.
Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE... - PubMed - NCBI

Again, so many missed connections logically.

Take homes we can all agree on:

1. Opioids do not help CNP
2. They are abused
3. People who abuse them at times move on to illicits

I think it is honestly just too painful for us to look right into the mirror in the face of our ongoing opioid prescribing. Hence, all the odd and tangential type arguments that get thrown around.

Do you prescribe opiates?

My bet is you do, in some amount, but that you just think you do it better, or less, or use medicines you think give you greater moral high ground.

Hell, even the most anti-opiate Propsters prescribe opiates. They just think theirs are better (suboxone, which they charge cash for). Even the most viscously anti-opiate agency of all, the DEA itself, says they have some legitimate medical use. That being said, if the DEA reclassifies opiates at schedule I tomorrow, fine. I'll gladly prescribe none to anyone. And maybe that's what needs to happen. But still, it won't put the slightest dent in the illegal fentanyl trade coming from China nor heroin coming from Afghanistan.

 

[emd123]

15 tabs a month of norco 5s or tramadol for people with significant pathology who have no risk factors (a small segment of the people we see) who have failed non-opioid alternatives if they are either working or elderly.

Ahh.... just as I thought. You went from "opiates do not help chronic non-cancer pain" to "opiates help my patients with chronic non-cancer pain because I do it better."

Just a minute ago, you were saying that US doctors that prescribe any amount of opiates, were responsible for illicit, non-prescribed fentanyl deaths.

I'm confused. Are you saying you prescribe opiates which don't work and you accept responsibility for the skyrocketing deaths from illicit fentanyl made in labs in China?

 

[Orin]

Maybe we need to see the prospective double blinded RCT looking at overdose deaths in patients prescribed opioids vs not.

The SPACE trial shows no difference in safety outcomes for opioid prescribing vs non opioid prescribing, so that's level I evidence that opioids aren't that bad right?

 

[Timeoutofmind]

Ahh.... just as I thought. You went from "opiates do not help chronic non-cancer pain" to "opiates help my patients with chronic non-cancer pain because I do it better."

Just a minute ago, you were saying that US doctors that prescribe any amount of opiates, were responsible for illicit, non-prescribed fentanyl deaths.

So, does that mean you're to blame now, for the skyrocketing deaths from illicit fentanyl made in labs in China?

I think it means that there is a definite risk even with my extremely stringent prescribing criteria/protocol that people could become addicted and in that case yes move on to illicits. Again, this is beyond dispute. It is just a matter of fact.

I am not sure how helpful my protocol is, as there is no RCT representing anything like it. It makes some sense to me and seems to be humane and very low risk.

And I think you are making much of nothing as I maybe have two dozen patients tops who actually meet all of that criteria! Most of the patients who would meet those criteria are not interested when I bring opioids up!! And I imagine that others' practices would be similar in terms of patient profiles.

Thanks for the good discussion! Healthy talks this profession NEEEEEEEEEDS to have. No judgment passed on any people on this forum, I know that many of us are struggling to do the right thing in a lot of different and challenging contexts.

 

[emd123]

I think it means that there is a definite risk even with my extremely stringent prescribing criteria/protocol that people could become addicted and in that case yes move on to illicits. Again, this is beyond dispute. It is just a matter of fact.

I am not sure how helpful my protocol is, as there is no RCT representing anything like it. It makes some sense to me and seems to be humane and very low risk.

And I think you are making much of nothing as I maybe have two dozen patients tops who actually meet all of that criteria! Most of the patients who would meet those criteria are not interested when I bring opioids up!! And imaging others' practices would be similar in terms of patient profiles.

Thanks for the good discussion! Healthy talks this profession NEEEEEEEEEDS to have. No judgment passed on any people on this forum, I know that many of us are struggling to do the right thing in a lot of different and challenging contexts.

I agree. And I'm not trying to be argumentative. But in this thread, you said these 3 things:

1) Opiates don't work.
2) You prescribe opiates that don't work, and
3) Doctors that prescribe opiates that don't work are responsible for deaths from illicit fentanyl that no doctor ever prescribed.

 

[Ducttape]

Hell, even the most anti-opiate Propsters prescribe opiates. They just think theirs are better (suboxone, which they charge cash for). Even the most viscously anti-opiate agency of all, the DEA itself, says they have some legitimate medical use. That being said, if the DEA reclassifies opiates at schedule I tomorrow, fine. I'll gladly prescribe none to anyone. And maybe that's what needs to happen. But still, it won't put the slightest dent in the illegal fentanyl trade coming from China nor heroin coming from Afghanistan.

not today. ours - er more likely yours, since im of the Baby boom generation - is a lost generation.

Millenials are lost. Generation Z might be lost too.

 

[Ducttape]

Maybe we need to see the prospective double blinded RCT looking at overdose deaths in patients prescribed opioids vs not.

The SPACE trial shows no difference in safety outcomes for opioid prescribing vs non opioid prescribing, so that's level I evidence that opioids aren't that bad right?

actually, that's not correct. the study did not look at long term use and the effects of long term use, but even at 12 months out:

Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]).

 

[Timeoutofmind]

2) You prescribe opiates that don't work.

Not really

I dont think that around 100 low dose IR tabs monthly as a sum total to all my patients in my entire practice qualifies as "prescribing opioids" in any meaningful sense.

Literally a drop of a drop of a drop in the bucket.

I think you are again missing the forest for the trees.

 

[emd123]

Not really

I dont think that around 100 low dose IR tabs monthly as a sum total to all my patients in my entire practice qualifies as "prescribing opioids" in any meaningful sense.

Literally a drop of a drop of a drop in the bucket.

I think you are again missing the forest for the trees.

No I'm not 'missing the forest. "

Saying "Opiates don't work," is not the same as saying "Doing opiate the way I do them" works.

"Opiates don't work," absolutely does not equal "Low dose opiates taken sparingly, works."

There's a big, BIG, difference there.

If "opiates don't work," then they should be banned, outright. Period.
If "Low dose opiates do work, the way @Timeoutofmind does them," then that requires opiates remain legal, prescribable with gobs and gobs and gobs and gobs of rules and regulations to make tens of thousands of doctors, do it the way you think it should be done and massive efforts by law enforcement to keep them out of the hands of abusers.

I happen to agree with you. The less opiates the better. But that does not equal "Opiates don't work, period."

 

[lobelsteve]

If you allege opiates do not work then turn in your DEA registration and be done with it otherwise shut up. Opiates works for non-cancer pains in a select group of patients. Opiates are not useful for patients with moderate to high risk for abuse and or addiction and this is readily screen for. The reason we have follow-up visits is to rescreen every 1 to 3 months. If you are a working-age adults and non-working then you do not have an adequate functional status to use opiates. If you have any history of addiction and or abuse you are not a candidate for conventional opiates. This has turned into a big pissing contest and all of you are incorrect. If we take a diction for the disease it is and get it treated and do it the right way many of these problems will be solved. This would mean free government treatment for addiction and no ability to have filled a controlled substance outside of the addiction Clinic

 

[drusso]

If you allege opiates do not work then turn in your DEA registration and be done with it otherwise shut up. Opiates works for non-cancer pains in a select group of patients. Opiates are not useful for patients with moderate to high risk for abuse and or addiction and this is readily screen for. The reason we have follow-up visits is to rescreen every 1 to 3 months. If you are a working-age adults and non-working then you do not have an adequate functional status to use opiates. If you have any history of addiction and or abuse you are not a candidate for conventional opiates. This has turned into a big pissing contest and all of you are incorrect. If we take a diction for the disease it is and get it treated and do it the right way many of these problems will be solved. This would mean free government treatment for addiction and no ability to have filled a controlled substance outside of the addiction Clinic

I agree with Steve. The problem is "works" is not a crisp endpoint and "death" is. Thus, "pain management" becomes "cosmetic pharmacology for the altered comfort crowd."

 

[Orin]

actually, that's not correct. the study did not look at long term use and the effects of long term use, but even at 12 months out:

Look at the next line on that:
"""
There were no significant differences in adverse outcomes or potential misuse measures (Table 3). Two hospitalization or ED visit events were determined analgesic-related: 1 hospitalization in the nonopioid group and 1 ED visit in the opioid group. No deaths, “doctor-shopping,” diversion, or opioid use disorder diagnoses were detected
"""

12 months is a pretty long term study, but I guess we can wait 5 years before making any definitive conclusions.

 

[emd123]

If you allege opiates do not work then turn in your DEA registration and be done with it otherwise shut up. Opiates works for non-cancer pains in a select group of patients. Opiates are not useful for patients with moderate to high risk for abuse and or addiction and this is readily screen for.

Agree. That's why when I see someone say categorically that opiates don't help anyone with CNP, that they do cause harm, yet that same person prescribes opiates to patients with CNP in any amount, then I'm left scratching my head.

 

[emd123]

... no ability to have filled a controlled substance outside of the addiction Clinic

Now this idea, I like.

 

[Ducttape]

Look at the next line on that:
"""
There were no significant differences in adverse outcomes or potential misuse measures (Table 3). Two hospitalization or ED visit events were determined analgesic-related: 1 hospitalization in the nonopioid group and 1 ED visit in the opioid group. No deaths, “doctor-shopping,” diversion, or opioid use disorder diagnoses were detected
"""

12 months is a pretty long term study, but I guess we can wait 5 years before making any definitive conclusions.

if you look at table 3, those were secondary adverse outcomes. the medication related symptoms themselves were primary outcomes, and were clinically significant at p=.03.

you are right, 12 months is not sufficient to say long term, although this is probably the longest study that I am aware of.

and I am not sure the study was sufficiently powered enough to determine misuse.

 

[Orin]

if you look at table 3, those were secondary adverse outcomes. the medication related symptoms themselves were primary outcomes, and were clinically significant at p=.03.

you are right, 12 months is not sufficient to say long term, although this is probably the longest study that I am aware of.

and I am not sure the study was sufficiently powered enough to determine misuse.

"The primary adverse outcome was a patient-reported checklist of 19 medication-related symptoms,17 modified from the original version by adding common analgesic adverse effects (eg, memory problems, sweating).18"
The primary adverse events were medication side effects, weighted to capture the effects of opioids. I assume few are worried about prescribing opioids because of that. The significance is almost incidental, even with them adding adverse effects specific to capture opioid related problems.

The secondary adverse events were hospitalizations, ED visits, falls, illicit drug use, misuse behaviors, etc, which were no different. I think that's more what we worry about when write for opioids.

I agree, this is study is probably not powered for definitive conclusions either way on misuse, as it's a very small difference.

 

[emd123]

http://www.jpands.org/vol23no1/lilly.pdf

"Not all opioids are identical in abuse potential and likely lethality, yet government statistics group causes of death in a way that obscures the importance of identifying specific agents involved in deadly overdoses. Searching the CDC Wonder database reveals that the recent spike in deaths is primarily due to illicit fentanyl. Targeting legal prescriptions is thus unlikely to reduce overdose deaths, but it may increase them by driving more users to illegal sources."

 

[kstarm]

http://www.jpands.org/vol23no1/lilly.pdf

"Not all opioids are identical in abuse potential and likely lethality, yet government statistics group causes of death in a way that obscures the importance of identifying specific agents involved in deadly overdoses. Searching the CDC Wonder database reveals that the recent spike in deaths is primarily due to illicit fentanyl. Targeting legal prescriptions is thus unlikely to reduce overdose deaths, but it may increase them by driving more users to illegal sources."

Wait, because patient will use illegal opioids if I don't prescribe I should continue to prescribe them. Similarly, if they threaten suicide or violence I should continue to prescribe them because those are bad outcomes too? Based on this and the overwhelming data on the the epidemic: If I prescribe opioids I put my patient at risk, If I stop their opioids I also put them at risk (based on this article). How should we as doctors proceed?

 

[244913]

Wait, because patient will use illegal opioids if I don't prescribe I should continue to prescribe them. Similarly, if they threaten suicide or violence I should continue to prescribe them because those are bad outcomes too? Based on this and the overwhelming data on the the epidemic: If I prescribe opioids I put my patient at risk, If I stop their opioids I also put them at risk (based on this article). How should we as doctors proceed?

I personally think they should just legalize drugs

Put all the money saved in the farcical “war” towards infrastructure and increasing reimbursement for chronic pain E/M codes

 

[Ducttape]

Wait, because patient will use illegal opioids if I don't prescribe I should continue to prescribe them. Similarly, if they threaten suicide or violence I should continue to prescribe them because those are bad outcomes too? Based on this and the overwhelming data on the the epidemic: If I prescribe opioids I put my patient at risk, If I stop their opioids I also put them at risk (based on this article). How should we as doctors proceed?

just say no. don't get started.

the ones already on are in a tough spot with no good solution.

docs who love opioids miss a key point - dont start prescribing COT for younger patients so the future can change.

The primary adverse events were medication side effects, weighted to capture the effects of opioids. I assume few are worried about prescribing opioids because of that. The significance is almost incidental, even with them adding adverse effects specific to capture opioid related problems.

actually, it is clinically significant at p=0.03.
and multiple studies have pointed out that medication adverse effects are the most common reason for cessation of opioids, usually per patient request, not the other effects you mention.

if it weren't such a concern, I wouldn't have made a Smartphrase just to check the more common ones that I ask about every visit:

Opioid Medication Side Effects:

Constipation: ***
Mental status changes: No
Drowsiness/fatigue/sedation: No
Mood: No changed. Not depressed.
Nausea/Vomiting: None
Itching/Rash: None
Myoclonus: No.
Muscle Aches/Myalgias: No
Respiratory concerns including depression: No.
Hormonal changes: None obvious.
Other: ***

Risk of Addiction: ***

Addiction questionnaire:

 

[emd123]

docs who love opioids miss a key point - dont start prescribing COT for younger patients so the future can change.

Yes. Thank you!

This is EVERYTHING. If we don't do this one thing, we have no hope of every ending or even slowing the opiate scourge. This is THE most important thing. Everyone is focused, obsessed with the current opiate generation. But as important, perhaps more important, is to avoid creating another generation, of currently opiate naive patients, dependent on opiates in the future. People on opiates are one thing, one issue with one set of solutions. People not yet on opiates are another ball of wax. As the current generation ages out, we don't want to create another dependent generation to replace them. We do need to do our best to fix the current generation's opiate problem, but we cannot lose site of what we need to do to keep from creating a new dependent generation to replaces them.

It's much easier to not start an opiate naive patient on opiates, than it is to take an opiate dependent patient off opiates, and therefore we have a much greater chance of avoiding harm by not writing the first prescription, than by trying to stop opiates in someone already dependent.