The prescription opioid epidemic in a nutshell

Discussion in 'Pain Medicine' started by 101N, Nov 30, 2012.

  1. 101N

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  3. algosdoc

    algosdoc algosdoc

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    Interesting Prop-aganda. I actually agree with much of the presentation except their conclusions and some of their assertions that opioids result in addiction in 25%. There are few studies that would support that allegation or perhaps the authors did not understand the definition of addiction. Substance abuse is definitely present in 25% but not addiction. Ballantyne's quote needs to be further delineated as to what she was referring....
    Overall the presentation is very similar to mine presented to our state legislature.
     
  4. Ducttape

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    im not sure that is correct with the new proposed DSM-V criteria.

     
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  5. algosdoc

    algosdoc algosdoc

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    True, but the term "addiction" has been equated to dependence by most psychiatrist over the past 30 years. It will be interesting to see what criteria are used to define "addiction" if any, in DSM V
     
  6. lobelsteve

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    How do we as pain specialists like to define addiction?

    I use any 2 of the 4 C's, or one if severe problems exist:

    I separate out criminal behavior as the 5th C and mark that as a definition of addiction as well. Unless it relates to pure diversion with no intent to take the medicine.
     
  7. Ducttape

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    and apparently the psychiatric community voted to include dependence in the definition by 1 vote, whatever that means. more importantly, some important members acknowledge that the addition of dependence into addiction in DSM-III was a mistake.


    the DSM-V criteria will get rid of "abuse", and will include craving. it will also apparently eliminate the legal/criminal criteria.
     
  8. algosdoc

    algosdoc algosdoc

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    I crave it as a welcomed improvement given the abuse of the word addiction. :)
     
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  9. 101N

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    American exceptionalism

    http://www.guardian.co.uk/society/2012/nov/28/painkiller-addiction-plague-united-states?CMP=twt_gu

    Painkiller addiction: the plague that is sweeping the US

    The US is leading the way in eradicating pain, but in doing so has created an unwanted byproduct: painkiller addiction. Prescription pill overdoses are killing 15,000 Americans a year, and the toll is growing

    Ed Pilkington

    The Guardian, Wednesday 28 November 2012 14.00 EST

    Jump to comments (204)




    Mark Maynard, who became addicted to painkillers when he was prescribed them for back pain after falling off a roof. Photograph: Ed Pilkington for the Guardian


    For almost two decades Geni Swartzwelder has played an elaborate game of hide-and-seek with her daughter Heather. Every day, Geni, 52, takes a bottle of little white pills and sneaks it away to a secret location. Every day, 32-year-old Heather then goes on a hunt for the bottle. Many days she succeeds in finding it. Geni knows because when she counts the pills at the end of the day, she often finds their numbers depleted.

    The game began when Heather was 14. Geni noticed, haltingly at first but with growing alarm, that her husband's opioid painkillers, prescribed after he was injured in a motorbike accident, were coming up short: "Heather tried to convince us that we'd lost them, but there was no other way, and in the end we concluded she had to be taking them. So I started hiding them, every day, some place different."

    Geni was forced to confront the fact that her only child had begun stealing her husband's pills and had become hopelessly addicted to them. When her efforts to hide the drugs failed, the Swartzwelders bought a metal safe and locked them up. That put a stop to the game, but not for long. Heather used the family video camera to film her mother opening the safe and studied the footage to extract the combination.

    Heather's father died three years ago, but the game of hide-and-seek goes on. Now Geni hides her own little white pills – she has end-stage cancer and takes opiate derivatives, medically prescribed synthetic heroin, to ease the agony in her back and chest.

    Geni desperately wants to increase the strength of the medicines she is taking because she is in excruciating and intensifying pain. But she knows that, if she does, the consequences for her daughter could be devastating: "I'm in pain, very much so, more and more each day," she says. "But I know that if I move to stronger drugs, I could make her problems so much worse."

    Geni's dilemma captures in microcosm one of the great unfolding tragedies of our time. Over the past 20 years, societies in the developed world have made it a priority to eradicate pain, encouraging hospitals and doctors to combat it as aggressively as they might a life-threatening virus. A public expectation has taken hold that we should all be entitled to lead pain-free lives, in rather the same way that we have come to expect to be able to own a car or to holiday abroad; but the pursuit of painlessness has come at a high price. The level of prescribing of opioid painkillers – Percocet in Geni's case – has soared, and with it the incidence of addiction, and addiction's grim best friend: fatal overdoses.

    The same escalating use and abuse of powerful painkillers can be found in rich societies from the UK, across Europe to the antipodes. But the country that really knows all about prescription pill excess, and the human toll it claims, is the US. Americans make up less than 5% of the global population but consume 80% of the world's supply of opioid prescription pills. Sales of the drugs have increased more than fourfold in the past 10 years, grossing $11bn (£7bn) annually. To express that figure more personally, in 2010 enough of Geni's pills, or their brand-name equivalents, were handed out by doctors to medicate every American adult with a typical dose of hydro– codone, a pure opioid as powerful as morphine, every four hours for a month.

    The more pills handed out, the more cases of addiction; the more cases of addiction, the more illegal street trafficking of the drugs; the more illegal street trafficking, the more snorting and injecting of the crushed pills; the more snorting and injecting, the more overdoses; the more overdoses, the more deaths. The result is that about 15,000 Americans are dying every year from prescription pill overdoses – triple the rate of a decade ago, according to the US government body the Centres for Disease Control, which has declared the problem an epidemic. The death toll exceeds that caused by heroin and cocaine combined, and in 17 states has become the No 1 cause of injury deaths, surpassing even car crashes.

    Apart from the sheer scale of the crisis, the profile of victims is striking. Unlike the crack cocaine epidemic of the 80s and early 90s that wrought havoc particularly among younger African Americans, those who succumb to a prescription pill overdose are likely to be white, male and middle-aged.

    The other factor that sets this disaster apart is its source. Track the supply of Percocet, OxyContin, Vicodin, Opana, or several other opioid painkillers involved in overdoses, and you will eventually arrive not at a Mexican or Colombian drug cartel or an international smuggling ring, as might be the case with heroin or cocaine, but at the medical doctor.

    "It started as a genuine attempt by doctors to help those who needed it," says Dr David Caraway, Geni's physician. "There was a rationale to treating pain aggressively with opioids. But 10 years down the line we have come to understand the consequences."

    Caraway points out that in the late 90s the Joint Commission on Accreditation of Healthcare Organisations, a private body that provides guidelines for hospitals, launched an initiative that encouraged doctors to wage war on pain wherever they found it. It focused on opiate derivatives, drugs that work by modulating pain messages as they pass up the spine to the brain. For years, opioids had been regarded as a drug of last resort, suitable only for the most severe cases. Now the emphasis began to shift towards prescribing them for chronic pain.

    At around the same time, drug companies, led by Purdue Pharma, the manufacturer of the leading opioid painkiller OxyContin, embarked on a massive marketing push. In 2001, Purdue Pharma spent $200m promoting OxyContin. Primary care physicians, in particular, were targeted, and their patients induced to try out the drug with 30-day free trial periods.

    Concerns about potential addiction were assuaged in promotional videos that claimed the incidence of addiction was less than 1%. Sales grew and grew, to about $3bn for OxyContin in 2010.

    Caraway knows intimately the outcome of what he describes as this "perfect brew" of official encouragement and Big Pharma marketing. He is a specialist in pain management and vice-president of the professional body that represents such experts, the American Society of Interventional Pain Physicians. He also works at a pain management centre, the Centre for Pain Relief Tristate, right at the heart of the painkiller epidemic, in the small town of Huntington, which sits at the intersection of three states straddling the Appalachian mountains – West Virginia, Kentucky and Ohio.

    Since the prescription pill tragedy began some 10 years ago, Appalachia has been in the thick of it. This beautiful area of rolling, wooded hills – about as close to the pastoral idyll of rural England as you get in the US – hides levels of poverty and poor education on which drug addiction breeds. Appalachia has long been accustomed to high levels of addiction to tobacco, alcohol and meths, and in the past decade it has similarly embraced "Hillbilly Heroin" as opioid painkillers have come to be known locally.

    Caraway has watched the epidemic take hold. He remembers his astonishment when he first started seeing patients coming in with signs of addiction to massively powerful opiate painkillers, having been put on them for comparatively mild complaints: "That was stunning to me – that a primary care doctor would write large doses of potent opioids for relatively benign pain conditions was extraordinary," he says.

    He also remembers the moment the penny dropped – the realisation that the US was falling into a crisis of epic proportions. It was when a patient came to see him who had been complaining of muscle aches and pains of the sort you might feel after a long run, or if you had a light case of flu. His doctor had put him on 540mg a day of the most commonly prescribed opioid painkiller, OxyContin. "Let me give you a little understanding about that," Caraway says. "OxyContin is up to two times more potent than morphine. So this is the equivalent of about 1,000mg of oral morphine. That's a whopping dose that is every bit as potent as heroin, every bit as addictive. I was stunned that someone would prescribe this level of medicine to someone who wasn't suffering from end-of-life cancer."

    After that experience, Caraway watched as similar cases became more and more common. And he watched as the problem fanned out from the medical world into the realm of illicit drug dealing as addicted patients, desperate for money to pay for their habit, began to sell the prescription pills on the street: "I've seen it tear apart families, and lead to loss of life. The most horrifying thing I've seen is that this is causing hopelessness leading to suicide and murder," Caraway says.

    Among those he has tried to help wean themselves off the drugs was an engaged couple. Shortly before the wedding, the woman overdosed on painkillers and died: "He was devastated, but he kept on taking the pain pills," Caraway says. Other patients have included a judge who became addicted after treatment for an injury, a sports star, whom he wouldn't name, who lost everything – his wife, six children and home – to the habit, and CEOs of major companies.

    Caraway treats patients who have severe pain and genuinely need treatment with powerful opioids. He does not treat active abusers. But several of his patients have had experiences relating to the epidemic of painkiller addiction. Take John Brumfield, 61, who ruptured a disc in his spine and has been on painkillers for many years. After friends heard that he was on them, Brumfield started observing something strange: "If we had people over to the Super Bowl or a holiday season party, I'd notice that my medicines would come up short, no matter how good friends they were."

    Twice people broke into his house to get to the drugs. Like Geni, he ended up installing a safe to secure the drugs. And he stopped having parties: "You don't know how sad that is, to know the lengths even your friends will go to to get these drugs," he says.

    A couple of years ago Brumfield went one better – he implanted what is essentially a mobile safe into his body. Under Caraway's supervision, he had a box embedded under the skin of his stomach into which opiate derivatives can be injected and then pumped in micro amounts through a tube direct into his spine: "No one can get at my drugs now. I no longer have to worry about people I thought of as my friends trying to take it from me," Brumfield says.

    Mark Maynard, 37, knows what addiction to prescription pills does to you. In 2006 he was working on a metal roof when he slipped and fell nine metres (30 feet), smashing seven vertebrae. He was put on OxyContin and rapidly became addicted. He had to take ever larger doses to ease the pain, and suffered cravings when he went without. At the peak of his addiction, he was taking each day 250mg of OxyContin, three 800mg Ibuprofen tablets, three doses of Neurontin, two of Lyrica, plus Diazepam and Ativan. His nadir came a couple of years ago, on Christmas Eve. He had taken his two children to his mother's house and stayed up to wrap the presents. He took too much OxyContin and passed out; when he woke up eight hours later he was in the living room. "I'd wet myself, the kids had gone, and I was on my own with wet pants, not remembering anything that had happened."

    After that, Maynard pulled himself together. Under Caraway's care he gradually reduced his intake and is now on a much lower dose of painkiller and doing well. But many friends have not been so lucky. He knows 10 or so people who are in prison or have overdosed and died as a result of opioids.

    Black-market drugs are freely available in the area, most of them trafficked through the so-called OxyContin Express: people travel down to Florida, home to many unscrupulous doctors and their "pill mills", where prescriptions for painkillers can be bought no questions asked, and bring the spoils back to Appalachia to be sold on the street for up to $100 a pill. "It's hard to find people round here who don't take pain medicine," Maynard says.

    Finally and very belatedly, the US authorities have begun to grapple with the problem. The Centres for Disease Control has named painkiller abuse a No 1 priority, police have begun closing down pill mills in Florida, physicians are being educated about the dangers of overprescribing, and in Appalachia new rules have been introduced that require doctors who treat more than half of their patients for chronic pain to be registered. Purdue Pharma has also reformulated OxyContin so that if the pills are crushed, they turn into a gloop that cannot be injected or snorted.

    But now the genie is out of the pill bottle, it is very hard to put back: pill mills closed in Florida pop up again in Georgia or Maine; addicts who were using OxyContin switch to Opana or another brand name. The insatiable desire for Hillbilly Heroin continues unabated. "This is still getting worse," says Caraway. "In our pursuit of 'pain-free', that elusive modern goal, we have created a monumental problem of drug addiction, abuse, lost productivity, crime and death."

    • Help us track the uses and abuses of prescription drugs by completing the world's biggest drug survey, supported by the Guardian. The confidential, anonymised online survey asks respondents what drugs they use, why they take them, and what the social medical and legal consequences of their drug use are. More details here.

    • This article was amended on 30 November 2012. The original said that in 17 states prescription pill overdoses had become "the No 1 killer, surpassing even car crashes". To clarify: this was a reference to such overdoses becoming the leading cause of "injury deaths" – defined by the Centres for Disease Control as including those that are "caused by forces external to the body. Examples of causes of injury death include drowning, fall, firearm, fire or burn, motor vehicle traffic, poisoning, and suffocation."
     
  10. algosdoc

    algosdoc algosdoc

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    If Maynard were indeed addicted, he should have been taken off all opioids. The concept of addiction is frequently confused by the public with chemical dependency or withdrawal. Addiction is a behavioral issue that is not eliminated by conversion to lower dose opioids any more than what is seen with higher dose opioids. The side effects from higher dose opioids indeed are problematic and may result in overdose and death, but this is completely separate from "addiction". However, prescription opioids are indeed overprescribed to a significant degree in the US as is the gist of the article, notwithstanding the errors in terminology and assertions.
     
  11. 101N

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    The distinctions between tolerance, dependence, and addiction are obviously not as black & white as you are suggesting. (1) Moreover, the term 'pseudo-addiction factors it as well. While still taught in pain management fellowships and opioid talks, the term is probably just a 'pseudo-phenomena' that has no real definition, just an N of 1 anecdote by Haddox.

    Pain physicians and drug company spokesmen have been playing fast and loose with these definitions for two decades. The chickens - opioid epidemic - are now coming home to roost.

    Arch Intern Med. 2012 Aug 13:1-2. doi: 10.1001/archinternmed.2012.3212. Opioid Dependence vs Addiction: A Distinction Without a Difference? Ballantyne JC, Sullivan MD, Kolodny A.
     
  12. algosdoc

    algosdoc algosdoc

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    Oh I see....another article by the gods of perpetual suffering.... lol.... While pseudoaddiction is an artifice concocted to explain why physicians should endlessly escalate the dosage of opioids, the side effect of a person overdosing and passing out for 8 hours (interesting...many people I know pass out for 8 hours each night) is not in the same universe as a person who is injecting the drugs IV, snorting the drugs, stealing or buying off the street in escalating doses, using a concoction of illicits, etc. The guy that takes an extra tablet one time and sleeps for 8 hours may be a substance abuser and should be held accountable for their actions. In this case, the guy was inappropriately labeled an addict and had medications reduced instead of eliminated. An addict is an addict...continued prescribing in such situations where a person is deemed an addict has and should be cause for action against medical licensure.
     
  13. Ducttape

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    The phrase " he suffered cravings" implies that this person was indeed addicted, not purely dependent. ( unless his "cravings" were w/d sx - a distinct possibility).

    Those who are craving the drug may just be at the precipice where they fall into the pit of pure addiction.

    And while most ppl sleep for 8 hours, few do this while doing a task such as wrapping presents, nor do most ppl soil themselves...
     
  14. algosdoc

    algosdoc algosdoc

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    Craving can also means when the blood levels of a drug fall below 50% of the peak value, the person feels the necessity to acquire medication at that point to keep the levels from crashing. That is NOT equal to addiction. Soiling yourself during sleep is NOT equal to addiction. There is not enough information given to qualify a person for "addiction", and in fact the opposite is suggested by the continued use of opioids as prescribed by his physician. An alcoholic is not told by their AA sponsor to just cut down on alcohol use, or worse, the sponsor buys them the drinks for the alcoholic, continuing to supply them with an addictive drug. The parallel would be a physician that claims a patient is "addicted" to prescription opioids, yet continues to treat with prescription opioids for pain. An addict cannot be just a little addicted anymore than they can be a little pregnant: from the pain medicine viewpoint, they are either addicted or not.
     
    #13 algosdoc, Dec 8, 2012
    Last edited: Dec 8, 2012
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  15. Ducttape

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    i beg to differ.

    the new DSM-V guidelines, from which we will all have to base the definition of addiction, now includes craving as addiction.


    in this particular situation, the crux of the matter is whether his cravings were w/d or to get high. (ergo my comment unless his "cravings" were w/d sx - a distinct possibility).



    and i would disagree that being maintained on opioids implies that a patient is not addicted. A "much lower dose of opioids" may mean Suboxone 1-2 pills a day or methadone once a day, at doses used for addiction.


    this scenario suggests more likely to be addiction than dependence, imho. it implies he self-medicated, he put his children in harms way with having no knowledge of their safety or whereabouts, he was not able to maintain his bowel habits. the response of his parents suggest that this was not an unusual occurrence - they left with the kids, instead of calling 911.
     
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  17. algosdoc

    algosdoc algosdoc

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    Utter nonsense. Suboxone for an addict maintains the addiction. It is no less addictive than trying to use hydrocodone to treat heroin addiction. Whereas patients are duped by slick tv commercials implying suboxone is neither an opioid nor addictive I certainly hope physicians are a little more informed.
     
  18. lobelsteve

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    This may sound stupid but.....

    Methadone: Isn't it proven to reduce death/morbidity as opposed to heroin?

    Why would an addictionologist substitute methadone or suboxone for other opiates besides heroin?

    I thought heroin was more fatal as it varied greatly in potency (street drug), contaminants, and the use of IV.

    I cannot see any rationale for using an opiate to treat another opiate addiction.
     
  19. 101N

    101N Banned
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    double post
     
  20. 101N

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    Are you serious? Abstinence alone works in something like 20 to 30% of opioid dependent patients.
     
  21. lobelsteve

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    But how does this change anything? Is 100mg per day any better than 100mg of Lortab per day?
     
  22. Ducttape

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    obviously, we dont have all the information on this aforementioned scenario.

    what we do know makes me to suspect that there is an opioid problem, and the patient acknowledges this.

    i for one would not prescribe this person opioids, based on the limited information (including middle aged gentleman with chronic nonmalignant pain, polypharmacy, requiring high dose therapy, selfmedicates, almost ODs, has young children, etc etc).

    the pain doc that is prescribing him a lesser amount of opioids must have considered the possibility that the person is addicted, and has determined that he is not, and has decided that continued prescriptions would be appropriate.
     
  23. algosdoc

    algosdoc algosdoc

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    Perhaps the pain doc needs to be in jail and be stripped of his medical license for perpetuating a presumed addiction by continuing to prescribe opioids.
     
  24. 101N

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    Arch Intern Med. 2012 Aug 13:1-2. doi: 10.1001/archinternmed.2012.3212. Opioid Dependence vs Addiction: A Distinction Without a Difference? Ballantyne JC, Sullivan MD, Kolodny A.

    The lost generation...

    The Washington State experience attests
    that there are many patients who
    are currently being treated with highdose
    opioids and who are unwilling
    to taper their opioids despite persisting
    pain and known risk. These patients
    are highly demanding to their
    providers. There are also patients,
    usually with shorter-term or more intermittent
    use, who are motivated to
    taper, and their doses can be tapered
    relatively easily either in an outpatient
    or an inpatient setting.8 For the
    recalcitrant cases, understanding dependence
    and accepting that this dependence
    demands therapy similar to
    addiction maintenance treatment, including
    regular and continued counseling
    and monitoring, will go a long
    way toward being able to treat the patients
    without removing a class of
    medications on which they have
    become dependent.
    In light of new
    evidence that is revealing the limitations
    and dangers of high-dose longterm
    opioid therapy, we can and must
    question the wisdom of providing
    such therapy in the first place. However,
    for the patients who are already
    affected, the solution cannot lie
    in abandoning them as they struggle
    with established dependence.
    Dependence on opioid pain treatment
    is not, as we once believed, easily
    reversible; it is a complex physical
    and psychological state that may
    require therapy similar to addiction
    treatment, consisting of structure,
    monitoring, and counseling,
    and possibly continued prescription
    of opioid agonists. Whether or
    not it is called addiction, complex
    persistent opioid dependence is a serious
    consequence of long-term pain
    treatment that requires consideration
    when deciding whether to embark
    on long-term opioid pain
    therapy as well as during the course
    of such therapy.

    Published Online: August 13, 2012.
    doi:10.1001/archinternmed.2012
    .3212
    Author Affiliations: Departments of
    Anesthesiology and Pain Medicine
    (Dr Ballantyne) and Psychiatry and
    Behavioral Sciences (Dr Sullivan),
    University of Washington School of
    Medicine, Seattle; and Department
    of Psychiatry, Maimonides Medical
    Center, Brooklyn, New York (Dr
    Kolodny).
    Correspondence: Dr Ballantyne, Department
    of Anesthesiology and Pain
    Medicine, University of Washington
    School of Medicine, PO Box
    356540, Seattle, WA 98195 (jcb12
    @uw.edu).
    Financial Disclosure: Dr Sullivan
    has received educational grants from
    Pfizer and Covidien and has served
    on an advisory board for Janssen.
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    Jane C. Ballantyne, MD, FRCA
    Mark D. Sullivan, MD, PhD
    Andrew Kolodny, MD
     
  25. algosdoc

    algosdoc algosdoc

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    The authors are simply manufacturing a fanciful theory that addicts can have medication doses reduced as a fix for addiction. It is almost a laughable assertion. But given the lack of science behind the PROP FDA petition and the same authors poorly conceived conclusions, it is not surprising they have concocted a pseudo-non-addiction treatment. Lets take heroin addicts and simply give them less heroin.....that should fix the problem..... yeah, right.....
     
  26. 101N

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    Ok then, we've got it from an authority:)
     
  27. lobelsteve

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    So this article from the PROPsters says that if they are on it, they should continue it? And then they sit in front of the FDA saying to limit it to 90 days then abandon these patients.

    This makes my head hurt, pass the Oxycontin.
     
  28. Tenesma

    Tenesma Senior Member

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    i too used to think that dependence was reversible... it isn't... i have had patients missing the narcs so much even when their pain is improved... they never met the criteria for addiction but their lives did get messed up once they were started on those things.
     
  29. Ducttape

    Ducttape SDN Lifetime Donor
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    Ironically this seems to be the position we are adopting pertaining the marijuana problem - legalize it so it is not really a problem, ESP since it is not as dangerous as alcohol and it is natural, like hemlock and cyanite...

    Soon there will be a push to make cocaine legal, since it is natural......
     
  30. powermd

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    Please do... they should take all profit out of the drug trade.
     
  31. Jcm800

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    Carrawy put a pump in the patient so no one can steal his meds. Hmmm.....
     
  32. Ducttape

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    PROMPT is clearly more opioid friendly than PROP. There is an article an Anesthesiology News this week that does something of a comparison. However, it also seems more of the same old same old - focus on REMS, etc.


    On the other hand...

    he does associate with Fine and Fishbaum.

    also, please see this article written by him: http://www.medscape.com/viewarticle/586439
     
  33. 101N

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    PROMPT = Passik and Portenoy, the very same people who got us into this mess. Look up the disclosures on these drug advocates.

    http://paindr.com/prompt-membership/
     
  34. Jcm800

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    im starting an new organization called PRIK
    i dont know what it stands for, but i like the acronym. Im looking for members. I think SSdoc would like to sign up, he would fit in well, maybe Stim4u also:smuggrin:
     
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  35. lobelsteve

    lobelsteve SDN Lifetime Donor
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    SOmeone should call them an d ask Portenoy and Passik to sign out. But there are 20 people or so including Mike Brennan who is well respected.
     
  36. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Can we get T-shirts made?

    Be a Prik!
     
  37. Ducttape

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  38. algosdoc

    algosdoc algosdoc

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    It was just another extended release drug that would cost a fortune to patients and insurers. It can already be obtained via compounding pharmacies (without fungus, thank you). We really don't need another high opioid content drug that would inevitably be abused. Since the Feds don't have the guts to make all hydrocodone Schedule II, then they certainly don't need to introduce an even higher dose version of hydrocodone. It is not logical nor reasonable to maintain hydrocodone short acting as Schedule III but hydrocodone long acting a schedule II.
     
  39. drusso

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    http://online.wsj.com/article/SB10001424127887324478304578173342657044604.html?mod=wsj_valettop_email#articleTabs%3Darticle

    A Pain-Drug Champion Has Second Thoughts
    By THOMAS CATAN and EVAN PEREZ

    WSJ

    It has been his life's work. Now, Russell Portenoy appears to be having second thoughts.

    Two decades ago, the prominent New York pain-care specialist drove a movement to help people with chronic pain. He campaigned to rehabilitate a group of painkillers derived from the opium poppy that were long shunned by physicians because of their addictiveness.

    Dr. Portenoy's message was wildly successful. Today, drugs containing opioids like Vicodin, OxyContin and Percocet are among the most widely prescribed pharmaceuticals in America.

    Opioids are also behind the country's deadliest drug epidemic. More than 16,500 people die of overdoses annually, more than all illegal drugs combined.

    Now, Dr. Portenoy and other pain doctors who promoted the drugs say they erred by overstating the drugs' benefits and glossing over risks. "Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did," Dr. Portenoy said in an interview with The Wall Street Journal. "We didn't know then what we know now."

    Recent research suggests a significantly higher risk of addiction than previously thought, and questions whether opioids are effective against long-term chronic pain.

    The change of heart among former champions of opioid use has happened quietly, largely beyond the notice of many doctors. New York psychiatrist Joseph Carmody said he was "shocked" after attending a recent lecture outlining the latest findings on opioid risk.

    "It goes in the face of everything you've learned," he said. "You saw other doctors come around to it and saying, 'Oh my God, what are we doing?'"

    Because doctors feared they were dangerous and addictive, opioids were long reserved mainly for cancer patients. But Dr. Portenoy argued that they could be also safely be taken for months or years by people suffering from chronic pain. Among the assertions he and his followers made in the 1990s: Less than 1% of opioid users became addicted, the drugs were easy to discontinue and overdoses were extremely rare in pain patients.

    Many of those experts now say those claims were weren't based on sound scientific evidence. "I gave innumerable lectures in the late 1980s and '90s about addiction that weren't true," Dr. Portenoy said in a 2010 videotaped interview with a fellow doctor. The Journal reviewed the conversation, much of which is previously unpublished.

    In it, Dr. Portenoy said it was "quite scary" to think how the growth in opioid prescribing driven by people like him had contributed to soaring rates of addiction and overdose deaths. "Clearly, if I had an inkling of what I know now then, I wouldn't have spoken in the way that I spoke. It was clearly the wrong thing to do," Dr. Portenoy said in the recording.

    Speaking to the Journal in September, Dr. Portenoy tempered that statement with cautions about overturning what he sees as the positive change he achieved. He cited his 82-year-old mother, who has taken hydrocodone to control arthritis for 15 years. "If you insist on regulation, then you're consigning my mother and many millions of people like my mother to live in chronic pain," he said.

    Virtually no one wants to return to a time when doctors were reluctant to use opioids even for cancer patients. All sides also agree that there is a group of people who do well on opioids long-term, taming their pain while avoiding addiction or excessive sedation, although there is no research on how large this group is or how to identify them before they begin a treatment. There is also widespread agreement that they can be used, with caution, for acute pain, such as after an operation.

    But some specialists now question whether the drugs should be prescribed so freely for months or years to people with chronic pain that isn't related to cancer, as Dr. Portenoy proposed 25 years ago. "People lost sight of the fact that these are dangerous drugs that are highly addictive," said Jane Ballantyne, a pain specialist at the University of Washington. She once agreed with Dr. Portenoy and proponents of broad opioid use but now believes they need to be used more selectively.

    Opium-derived painkillers have been around for thousands of years. Early in the 20th century, heroin was sold as a cough suppressant. Heroin addiction in the U.S. skyrocketed. Congress banned the drug in 1924 and doctors became deeply wary about using opioids.

    Dr. Portenoy set out to change that. As a young doctor at Memorial Sloan-Kettering hospital in New York, he noticed that opioids were effective in cancer patients with terrible pain.

    In 1986, at the age of 31, he co-wrote a seminal paper arguing that opioids could also be used in the much larger group of people without cancer who suffered chronic pain. The paper was based on just 38 cases and included several caveats. Nevertheless, it opened the door to much broader prescribing of the drugs for more common complaints such as nerve or back pain.

    Charming and articulate, he became a sought-after public speaker. He argued that opioids are a "gift from nature" that were being forsaken because of "opiophobia" among doctors. "We had to destigmatize these drugs," said Dr. Portenoy.

    He rose to chairman of pain medicine and palliative care at Beth Israel Medical Center in New York. His small office is studded with awards and evidence of his offbeat sense of humor. He prominently displays a magazine mock-up that jokingly dubs him "The King of Pain."

    At medical conferences, his confident, knowing manner helped smooth the way for his message. Before an audience of government regulators, he once joked that he might tell a patient at low risk of abuse: "Here, [have] six months of drugs. See you later," he said, according to a Food and Drug Administration transcript. Amid laughter, he added, "It's just hyperbole. I don't actually do that."

    Steven Passik, a psychologist who once worked closely with Dr. Portenoy and describes him as his mentor, says their message wasn't based on scientific evidence so much as a zeal to improve patients' lives. "It had all the makings of a religious movement at the time," he says. "It had that kind of a spirit to it."

    Drug companies took notice. In 1996, Purdue Pharma LP released OxyContin, a form of oxycodone in a patented, time-release form, and rivals followed suit. Today, sales of opioid painkillers total more than $9 billion a year, according to IMS Health, which tracks sales for drug companies.

    In 2007, Purdue Pharma and three executives pleaded guilty to "misbranding" of the drug as less addictive and less subject to abuse than other pain medicines and paid $635 million in fines.

    Purdue Pharma says it has worked to discourage abuse of its drugs, adding that OxyContin is safe and effective when used properly.

    In the late 1990s, groups such as the American Pain Foundation, of which Dr. Portenoy was a director, urged tackling what they called an epidemic of untreated pain. The American Pain Society, of which he was president, campaigned to make pain what it called the "fifth vital sign" that doctors should monitor, alongside blood pressure, temperature, heartbeat and breathing.

    Dr. Portenoy helped write a landmark 1996 consensus statement by two professional pain societies that said there was little risk of addiction or overdose among pain patients. In lectures he cited the statistic that less than 1% of opioid users became addicted.

    Today, even proponents of opioid use say that figure was wrong. "It's obviously crazy to think that only 1% of the population is at risk for opioid addiction," said Lynn Webster, president-elect of the American Academy of Pain Medicine, one of the publishers of the 1996 statement. "It's just not true."

    The figure came from a single-paragraph report in the New England Journal of Medicine in 1980 describing hospitalized patients briefly given opioids. Dr. Portenoy now says he shouldn't have used the information in lectures because it wasn't relevant for patients with chronic noncancer pain.

    For such a widely used therapy, there is relatively little scientific evidence that opioid drugs are safe and effective for long-term use. "Data about the effectiveness of opioids does not exist," Dr. Portenoy said in his recent Journal interview. To get a painkiller approved, companies must prove that it is better at reducing pain than a sugar pill during short trials often lasting less than 12 weeks.

    "Do they work for five years, 10 years, 20 years?" Dr. Portenoy said in the Journal interview. "We're at the level of anecdote." Even so, he says, the drugs can still benefit carefully selected patients.

    Dr. Portenoy's ideas about opioids reached into mainstream medicine and attracted outspoken advocates. In a 1998 talk in Houston, Alan Spanos, a South Carolina pain specialist, said patients with chronic noncancer pain could be trusted to decide themselves how many painkillers to take without risk of overdose. According to a recording, Dr. Spanos said he understood that a patient would simply "go to sleep" before stopping breathing. While asleep, he said, the patient "can't take a dangerous dose. It sounds scary, but as far as I know, nobody anywhere is getting burned by doing it this way."

    Dr. Spanos declined to say whether he still agreed with his previous statements. He said opioids can be helpful and safe with proper use.

    One of Dr. Portenoy's chief complaints was that doctors were reluctant to prescribe opioids because they feared scrutiny by regulators or law enforcement. In the second half of the 1990s, he and his followers campaigned successfully for policies to change that.

    In 1998, the Federation of State Medical Boards released a recommended policy reassuring doctors that they wouldn't face regulatory action for prescribing even large amounts of narcotics, as long as it was in the course of medical treatment. In 2004 the group called on state medical boards to make undertreatment of pain punishable for the first time.

    That policy was drawn up with the help of several people with links to opioid makers, including David Haddox, a senior Purdue Pharma executive then and now. The federation said it received nearly $2 million from opioid makers since 1997. The federation says it derives the majority of its funding from administering medical licensing exams, credential verification, and data services.

    A federation-published book outlining the opioid policy was funded by opioid makers including Purdue Pharma, Endo Health Solutions Inc. ENDP -3.86% and others, with proceeds totaling $280,000 going to the federation. Endo declined to comment.

    Purdue Pharma said, "Dr. Haddox was recruited by the FSMB, so he did not have undue or inappropriate influence" on the federation's output. Purdue declined to make Dr. Haddox available to comment.

    The federation said it didn't believe its model policy contributed to increased prescriptions and said drug makers didn't influence its guidelines.

    In 2001, the Joint Commission, which accredits U.S. hospitals, issued new standards telling hospitals to regularly ask patients about pain and to make treating it a priority. The now-familiar pain scale was introduced in many hospitals, with patients being asked to rate their pain from one to 10 and circle a smiling or frowning face.

    The Joint Commission published a guide sponsored by Purdue Pharma. "Some clinicians have inaccurate and exaggerated concerns" about addiction, tolerance and risk of death, the guide said. "This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control."

    Purdue said the booklet emerged from a process that "represented the consensus of a broad range of interested stakeholders." Drug makers regularly pay for educational materials for physicians as an element of their marketing.

    The Joint Commission said its standards didn't encourage physicians and hospitals to increase prescriptions. "I think that's a very distorted and not helpful explanation of what's going on," said Ana McKee, the Joint Commission's chief medical officer.

    Over his career, Dr. Portenoy has disclosed relationships with more than a dozen companies, most of which produce opioid painkillers. "My viewpoint is that I can have those relationships, they would benefit my educational mission, they benefit in my research mission, and to some extent, they can benefit my own pocketbook, without producing in me any tendency to engage in undue influence or misinformation," he said.

    Dr. Portenoy and Beth Israel declined to provide details of their funding by drug companies. A 2007 fundraising prospectus from Dr. Portenoy's program shows that his program received millions of dollars over the preceding decade in funding from opioid makers including Endo, Abbott Laboratories, ABT +0.05% Cephalon, Purdue Pharma and Johnson & Johnson JNJ -0.08% .

    Endo, Abbott, Janssen and Purdue declined to comment. Cephalon's current owner, Teva Pharmaceutical Industries Ltd., TEVA -1.91% didn't immediately have a comment.

    In May of this year, the Senate Finance Committee opened an investigation into the financial ties between the pharmaceutical makers and the doctors and groups that advocated broader use of opioids. It asked opioid makers to disclose how much they had paid Dr. Portenoy, his program and several organizations he was involved with.

    After spending most of his professional life advocating greater use of the drugs, Dr. Portenoy said there is still little research to show whether patients who embark on long-term opioid therapy will ever be able to stop.

    Earlier this year, he said, he asked his mother whether she would stop taking her hydrocodone as part of a scientific study. She said no.

    "How difficult is it for her to get off these drugs?" Dr. Portenoy asked. "You have no idea and neither do I, because no one knows."
     
  40. 101N

    101N Banned
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    PRIK's exectutive board: Haddox (president), Portenoy (vice pres), Passik (secretary). Perry Fine, Scott Fishman, Bill McCarburg, David Jorannson, Howard Heit, Lynn Webster, William Hurwitz and Charles Manson board of governors. Their new journal - brought to you by Purdue and Medtronic : The Opiophile: Trust us we're experts!
     
    #39 101N, Dec 15, 2012
    Last edited: Dec 16, 2012
  41. emd123

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    drusso,

    I read the WSJ article. My question is:

    Where do we go from here?
     
  42. drusso

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    Two words: "Harm reduction."

    Avoid dose escalation. Don't "over-promise" what opioids can deliver for chronic pain. Eschew long-acting preparations as long as possible. Be compassionate to those made tolerant by other practitioners. Recognize, as Jane Ballantyne likes to say, "we're dealing with a lost generation (of chronic pain patients)." As imperfect and unproven as COT may be, even Roger Chou realizes that "you can't just take things away without offering alternatives."
     
    Promethean likes this.
  43. 101N

    101N Banned
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    Where do we go from here:

    Pain Organizations & Fellowships: Recognize that there is a prescription opioid epidemic, get out in front of it publically - like Alexa Cahana - and be contrite, not defensive. Recognize – publically – the bias that PHARMA funding introduces into physician’s positions regarding opioid prescribing (1). Start insisting on yearly public disclosure of funding for academic department members and all AAPM, APS, and ABPM members. Phase two, prohibit PHARMA funded CME and create/enforce recusal rules for board members with significant PHARMA disclosures. Phase three, prohibit PHARMA funding for fellowship instructors and national pain group board members and journal editors.

    Physicians: Recognize that there is a prescription opioid epidemic and that a lot of what you were taught regarding opioid prescribing is harmful. Recognize the bias that PHARMA funding has had on our ‘thought leaders’, and that some of them- while perhaps well meaning – may be incapable of either self-criticism or change. Recognize that opioids used for chronic non-malignant pain may be good for ‘business’, but they are bad for patients and society. (The corollary here is that if your business model is based upon being a pusher, some of your peers will be looking for you and they will be unforgiving.) Move away from opioid prescribing as an ‘art’ and toward opioid prescribing as a science. Adopt the following – VonKorff’s (2) – opioid prescribing schema for chronic non-malignant pain: 0-50mgMED = low dose, 50-100MED intermediate dose, >100MED = high dose and high risk. Realize that, contrary to what you may have been taught, opioids are not the final common pathway for all non-malignant pain. Avoid PHARMA sponsored CME and look for disclosures whenever opioid drugs are discussed in writing, webcasts, position statements, or public speaking events. Avoid PHARMA speakerships for yourself and your practice. If you live with, work with, or learn from an opioid advocate for chronic non-malignant pain, serve them notice that the onus is on them to provide published, peer-reviewed, evidence to support their beliefs. Understand that the lost generation of patients – like most drug addicts – may be incapable of abstinence as a ‘cure’. Make friends with an addictionologist if you are unwilling to take these people on. In the absence of evidence, benchmarking is a tool that can be used to find the middle ground(3). Lastly, while we are in the midst of an opioid epidemic, under-prescribing also occurs.

    1.http://www.amazon.com/The-Truth-About-Drug-Companies/dp/0375760946/ref=sr_1_1?ie=UTF8&qid=1355615040&sr=8-1&keywords=Dr.+Marsha+Angel

    2.Opioid prescriptions for chronic pain and overdose: a cohort study.Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M.Ann Intern Med. 2010 Jan 19;152(2):85-92.

    3.Geographic variation in opioid prescribing in the U.S.McDonald DC, Carlson K, Izrael D. J Pain. 2012 Oct;13(10):988-96. doi: 10.1016/j.jpain.2012.07.007.
     
  44. Ducttape

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    parts of this i agree with. but i see danger in the conclusion of eschewing "long-acting preparations as long as possible", because, invariably someone will come to the corollary conclusion is that it is okay keeping someone on opioids if they are short acting preparations.

    i am also disturbed by the concept proposed by Ballantyne and Chou, and i have seen some patients who have been kept on COTs because of this thought process - that we HAVE to keep patients on regardless of degree of harm because of possible benefit + risk of withdrawal.
     
  45. drusso

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    On balance, there is evidence that there is greater harm caused by long-acting preparations compared to short-acting preparations in terms of opioid related endocrinopathy, glial cell activation, and disordered central reward mechanisms. In fact, one of PROP's "principles for more cautious prescribing" is to use short-acting preparations over long-acting preparations preferentially.

    Anecdotally, my experience has been that even the most recalcitrant chronic pain patients experience "good days" and "bad days" and round-the-clock exposure to opioids has always seemed misguided to me. My understanding is that one of the original rationales for use of longer-acting preparations was to decrease "pill burden" and avoid the "Fordycian" conditioning....but maybe I just enjoyed too many free Pharma-sponsored dinners and despite my advanced degrees and deep knowledge of the scientific method I am unable to process information while post-prandial.
     
  46. SSdoc33

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    Sign up? Ive been on the board of directors for a while now
     
  47. emd123

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    In reference to the above WSJ article. I appreciate it when anyone has courage enough to admit mistakes were made. I respect that. That's more impressive than running and hiding.

    For him to say what he's saying is very powerful and could really go a long way to helping solve the problems we have, as would his continued involvement. He even contributed to one of the PROP videos. As far as the others who have run and hid...not so much.
     
  48. Ducttape

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    i was taught, not so long aqo, that use of long acting preparations lead to slower development of tolerance to opioids compared to short acting preparations.


    -but the rationale of "im only on a short acting drug" is quoted frequently by patients.
    -data shows that the most commonly prescribed and abused drugs are hydrocodone-acetaminophen and oxycodone-acetaminophen.
    -the FDA acknowledged the risk of acetaminophen use and obviously reduced the recommended overall dose of acetaminophen to 3000 mg/day.


    imho, there are risks to both long acting and short acting, and suggesting that it is safer to use a short acting agent is missing the point entirely. most patients should not be on any opioids.

    kind of like "well, doc, beer has B vitamins, so its better than wine"...
     
  49. 101N

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    He is a central figure in the Senate investigation, he's trying to look publicly contrite. It's an act, privately he's still defensive about his positions. His arguments are a rehashing of the Hurwitz defence. He is a danger to society.

    The others aren't hiding, they are circling the wagons. IMO they all need to feel some heavy sanctions from the Senate.
     
  50. Jcm800

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    All of these political/inside issues with both PROP and PROMPT make the answer clear to me...

    PRIK is clearly the best alternative. Be a PRIK in 13!

    The first person to donate heavily, will be referred to as a BIG PRIK supporter...
     
  51. Ducttape

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    will he get a free jockstrap?
     

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