The prescription opioid epidemic in a nutshell

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The fact that you had to edit their title, and explain that it was dependence, not addiction, tells me everything I need to know about these researchers.
You are mad they didnt give you the picture credit. Looking good, amp.

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Don't get me wrong, I'm not justifying it, but isn't sensationalism to say '50,000 pills'? If you do the math, if you give 120-140 pills a month (ends up being 30 mg q6) to 30 folks over the course of a year, you will get these numbers. Again, I don't plan on placing anyone on those amounts of opioids, and 30 Q6 of Oxy is a lot, and I'm not justifying it, but, well, you get my drift
 
Adverse cardiac events associated with incident opioid drug use among older adults with COPD

Adverse cardiac events associated with incident opioid drug use among older adults with COPD

Abstract
Purpose

We evaluated whether incident opioid drug use was associated with adverse cardiac events among older adults with chronic obstructive pulmonary disease (COPD).

Methods
This was an exploratory, retrospective cohort study using health administrative data from Ontario, Canada, from 2008 to 2013. Using a validated algorithm, we identified adults aged 66 years and older with non-palliative COPD. Hazard ratios (HR) were estimated for adverse cardiac events within 30 days of incident opioid receipt compared to controls using inverse probability of treatment weighting using the propensity score.

Results
There were 134,408 community-dwelling individuals and 14,685 long-term care residents with COPD identified, 67.0 and 60.6% of whom received an incident opioid. Incident use of any opioid was associated with significantly decreased rates of emergency room (ER) visits and hospitalizations for congestive heart failure (CHF) among community-dwelling older adults (HR 0.84; 95% CI 0.73–0.97), but significantly increased rates of ischemic heart disease (IHD)-related mortality among long-term care residents (HR 2.15; 95% CI 1.50–3.09). In the community-dwelling group, users of more potent opioid-only agents without aspirin or acetaminophen combined had significantly increased rates of ER visits and hospitalizations for IHD (HR 1.38; 95% CI 1.08–1.77) and IHD-related mortality (HR 1.83; 95% CI 1.32–2.53).

Conclusions
New opioid use was associated with elevated rates of IHD-related morbidity and mortality among older adults with COPD. Adverse cardiac events may need to be considered when administering new opioids to older adults with COPD, but further studies are required to establish if the observed associations are causal or related to residual confounding.
unfortunately, it is a retrospective study. but thought provoking. (fwiw, I avoid opioids for COPD patients due to respiratory issues, with possible exception of butrans)
 
Adverse cardiac events associated with incident opioid drug use among older adults with COPD


unfortunately, it is a retrospective study. but thought provoking. (fwiw, I avoid opioids for COPD patients due to respiratory issues, with possible exception of butrans)

I do the same, butrans or no opioids. Even when the butrans is expensive on their medicare plan. I tell them I"m not going to write them standard opioids that could kill them, just because they're cheaper.
 
Long-time lurker here since my med school days and all through fellowship to now. I'm not a pain medicine physician, but I do see a lot of pain and MSK complaints. I'm personally very stingy with opioids and have really only used them for fractures. Just wanted to share my appreciation for this forum. It's often a significant point of contention when I don't prescribe patients opioids, the regular occurrence of which is professionally taxing. But then I read this thread and this forum and feel confident that I've made the right decision and that I have colleagues that are for responsible prescribing as well.

More germane to this thread, I had no idea this was a law in Alabama and I've been practicing here for over a year now. This does NOT help the opioid epidemic issue, at all:

Charges against ex-doctor dismissed

"A Tuscaloosa judge has dismissed criminal charges against a former doctor accused of over-prescribing painkillers. James Fullerton Hooper, 70, was charged with five counts of trafficking opium and five counts of distribution of a controlled substance in June 2016. The Tuscaloosa County District Attorney’s Office asked that the cases be dismissed after Hooper’s attorney presented case law stating a physician cannot be charged under the state’s drug trafficking and distribution laws for writing prescriptions. Tuscaloosa County Circuit Court Judge Al May dismissed the charges late Wednesday afternoon."
 
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Long-time lurker here since my med school days and all through fellowship to now. I'm not a pain medicine physician, but I do see a lot of pain and MSK complaints. I'm personally very stingy with opioids and have really only used them for fractures. Just wanted to share my appreciation for this forum. It's often a significant point of contention when I don't prescribe patients opioids, the regular occurrence of which is professionally taxing. But then I read this thread and this forum and feel confident that I've made the right decision and that I have colleagues that are for responsible prescribing as well.

More germane to this thread, I had no idea this was a law in Alabama and I've been practicing here for over a year now. This does NOT help the opioid epidemic issue, at all:

Charges against ex-doctor dismissed

"A Tuscaloosa judge has dismissed criminal charges against a former doctor accused of over-prescribing painkillers. James Fullerton Hooper, 70, was charged with five counts of trafficking opium and five counts of distribution of a controlled substance in June 2016. The Tuscaloosa County District Attorney’s Office asked that the cases be dismissed after Hooper’s attorney presented case law stating a physician cannot be charged under the state’s drug trafficking and distribution laws for writing prescriptions. Tuscaloosa County Circuit Court Judge Al May dismissed the charges late Wednesday afternoon."

Does not apply to federal prosecution by DOJ/DEA/FBI.
 
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Long-time lurker here since my med school days and all through fellowship to now. I'm not a pain medicine physician, but I do see a lot of pain and MSK complaints. I'm personally very stingy with opioids and have really only used them for fractures. Just wanted to share my appreciation for this forum. It's often a significant point of contention when I don't prescribe patients opioids, the regular occurrence of which is professionally taxing. But then I read this thread and this forum and feel confident that I've made the right decision and that I have colleagues that are for responsible prescribing as well.

More germane to this thread, I had no idea this was a law in Alabama and I've been practicing here for over a year now. This does NOT help the opioid epidemic issue, at all:

Charges against ex-doctor dismissed

"A Tuscaloosa judge has dismissed criminal charges against a former doctor accused of over-prescribing painkillers. James Fullerton Hooper, 70, was charged with five counts of trafficking opium and five counts of distribution of a controlled substance in June 2016. The Tuscaloosa County District Attorney’s Office asked that the cases be dismissed after Hooper’s attorney presented case law stating a physician cannot be charged under the state’s drug trafficking and distribution laws for writing prescriptions. Tuscaloosa County Circuit Court Judge Al May dismissed the charges late Wednesday afternoon."

Judge is wrong on laws in his own state.
 
I prescribe no benzos, except 1-2 pills prior to MRI or procedure (only 5% of time)

But I get many referrals where patients are in benzos by their pcp and also low-moderate dose opiates. Should we be taking an absolute headline approach of zero tolerance, ie, no opiates at all, ever, if an benzos?

Or a case by case basis?

It is worth noting the CDC edict on this from 2016, specifically addresses this issue to "Primary care physicians" and not psych, pain or other specialties

How often do you continue an opiate (assuming reasonably low-moderate dose, not higher than 120 MED) if someone is already on both?

Sometimes? Never? Often?


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I prescribe no benzos, except 1-2 pills prior to MRI or procedure (only 5% of time)

But I get many referrals where patients are in benzos by their pcp and also low-moderate dose opiates. Should we be taking an absolute headline approach of zero tolerance, ie, no opiates at all, ever, if an benzos?

Or a case by case basis?

It is worth noting the CDC edict on this from 2016, specifically addresses this issue to "Primary care physicians" and not psych, pain or other specialties

How often do you continue an opiate (assuming reasonably low-moderate dose, not higher than 120 MED) if someone is already on both?

Sometimes? Never? Often?


Sent from my iPhone using SDN mobile

Address the guidelines with the patient. I am willing to Rx opiates if patient willing to stop BZD. I am not accepting new patients that will remain on both. I am weaning all existing patients on both BZD and opiates to less than 60 meq unless they stop BZD.
 
Nationwide 10% of those being prescribed opioids are also being prescribed benzodiazepines, half from the same doctor. From 40-80% of opioid deaths in some locations have benzos also on board.

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Nationwide 10% of those being prescribed opioids are also being prescribed benzodiazepines, half from the same doctor. From 40-80% of opioid deaths in some locations have benzos also on board.

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I feel like way more than 10% are on concomitant opioids and benzos!
 
I think we see a population that is populated with a higher percentage. Nationwide it is 10%- in my practice it seems like 40%. Probably because I live in the land of the near-dead where everyone is anxious about living and anxious about dying.
 
I don't have many people in my practice up to 120 MED, and none over, but I think due to this thread, and this forum in general, I'm lowering my practice limit to 90mg MED and no more than 60 MED if they insist on having their psych or pcp prescribe benzos (I prescribe zero benzo's accept for 1-2 tab for an MRI or stim/kypho, zero methadone, zero soma and zero roxicodone 15/30mg). Since I went to the 120 MED policy, my practice got a lot more enjoyable and rewarding, although let's face it, Pain is still Pain.

I don't have that many patient up to 120 MED, so I don't see it being too much trouble to switch. Going from 120 MED to 90 should not be too hard, by doing an opiate rotation and at 25% dose equivalent reduction. I'm actually looking forward to this, although it'll be a tough discussion for a few people in the next couple of months. I've find that my happiness in practice is inversely proportional to the amount and frequency of opiates I prescribe. I think long term, for career satisfaction, not to mention risk reduction, I and likely my patients too, will be better off, the lower I (and they) go.

And if some patients need high dose and even ultra-high dose, and choose to change practices, that's okay. They can seek a practice that offers that service. But I don't think it's incumbent upon me, to be all things to all people. That being said, I have some little old ladies that need a couple pills per day to walk instead of being wheelchair bound and I think in those patients (assuming no aberrancy or diversion) that a low-moderate dose dose improve their quality of life, as well as pain and function with acceptable and minimal downside risk. Taking opiates totally off the table for those people is probably no necessary or prudent. But who knows, maybe 2018 will see me and others taking it down to 60 MED. Then 30 MED? And so on?

I don't know.
 
To me this graphic largely states that illicit drugs (heroin, illicitly obtained fentanyl lacing heroin) have become a far greater menace compared to prescription opioids. In this era of restrictive prescription opioid access, people are turning to more risky heroin, and are dying in greater numbers.
 
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To me this graphic largely states that illicit drugs (heroin, illicitly obtained fentanyl lacing heroin) have become a far greater menace compared to prescription opioids. In this era of restrictive prescription opioid access, people are turning to more risky heroin, and are dying in greater numbers.

1st law of thermodynamics applies to addiction. The societal carrying rate is 10% for addiction. 200000 opiate addicts for 12000000 in 1880, 5000000 opiate addicts (abuse and not really addiction) for 309000000 in 2010.

It is the person. Not the drug. Supply determines what they will abuse.
 
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The surprising metric is that despite all the actions of the courts, the CDC, the DEA, the state medical licensure boards, and the attorney generals, that the death rate from prescription opioids continues to escalate.
 
The surprising metric is that despite all the actions of the courts, the CDC, the DEA, the state medical licensure boards, and the attorney generals, that the death rate from prescription opioids continues to escalate.

I don't have the source on me, but I thought I read that deaths from prescription opioids went down in 2016 compared to 2015 (first such decrease in a decade), but that the overall deaths from opioids of all kinds (including heroin, and black market fentanyl) continue to skyrocket, (as docs are prescribing less so people getting drugs illegally), so the overall deaths from opioids of all kinds is up in 2016, but not prescription opioids.

I know this doesn't match the graph Steve posted. I'll have to find where I read that.
 
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Tiger Woods had pain, anxiety, sleep drugs in system during arrest - CNN
http://www.cnn.com/2017/08/14/health/tiger-woods-toxicology-report/index.html
A urine test revealed hydrocodone and hydromorphone, two opioid pain medications; alprazolam, prescribed for anxiety and panic disorders; zolpidem, a sedative prescribed for insomnia; and metabolites of alprazolam and of THC, the active ingredient in marijuana.
(could not find story on foxnews. i know some of you hate cnn, but sorry)
 
Tiger Woods had pain, anxiety, sleep drugs in system during arrest - CNN

(could not find story on foxnews. i know some of you hate cnn, but sorry)

Article gets it wrong. Hydrocodone and hydromorphone as its metabolite. And woods said unexpected reaction to medications. Clearly, this is expected reaction. Also sounds like he did not have Rx for the drugs he was taking as he said he was doing this without medical advice.
If he OD'd, it would be another Rx drug death. Even if the drug not Rx'd to the person....
 
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id like to see what Mainers say about the law. I haven't heard any physician complaining about it.

it is, after all, after July 1 (and Fudin, a spokesperson for high dose opioids, article was written in 2016, way before law went into effect), when all chronic scripts were to be less than 100 MED. fyi, lots of exceptions to rules, including cancer pain, palliative pain, pts on high dose opioids given 6 months to taper down, pregnant women and acute pain in patients pushing total to over 100 MED...)
 
id like to see what Mainers say about the law. I haven't heard any physician complaining about it.

it is, after all, after July 1 (and Fudin, a spokesperson for high dose opioids, article was written in 2016, way before law went into effect), when all chronic scripts were to be less than 100 MED. fyi, lots of exceptions to rules, including cancer pain, palliative pain, pts on high dose opioids given 6 months to taper down, pregnant women and acute pain in patients pushing total to over 100 MED...)
What law? Are you talking about the CVS policy or actual law?
 
maine law, first... 100 MED or lower.

in terms of CVS, read the details very carefully....patients already getting scripts are exempt.

here is the exact wording, with my own emphasis thrown in.

"To support this goal, CVS Caremark will roll out an enhanced opioid utilization management approach for all commercial, health plan, employer and Medicaid clients as of February 1, 2018 unless the client chooses to opt out. This program will include limiting to seven days the supply of opioids dispensed for certain acute prescriptions for patients who are new to therapy; limiting the daily dosage of opioids dispensed based on the strength of the opioid; and requiring the use of immediate-release formulations of opioids before extended-release opioids are dispensed." (CVS Health Responds to National Opioid Abuse Epidemic With Enterprise Initiative)

its not written on the CVS site, but time.com notes this: "Here's how the changes will work: If a patient has a prescription for several weeks’ worth of opioids and wants to fill the prescription for more than seven days, he will need pre-authorization for the drugs—obtained after the pharmacy benefit manager speaks to the prescribing doctor—and will have to pay for them out of pocket."

so the workaround is to have the patient 1. get on chronic opioid therapy before Feb. 1, 2018, 2. opt out, or 3. essentially pay for the meds out of their own pocket.
 
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The article chides the DEA for over-reaching regulation while completely ignoring the very real risk of transmucosal or transbuccal fentanyl overdose. This attorney seems to believe if the doctors simply provides adequate documentation and hires a lawyer who specializes in pre-arrest evaluation of a doctor's prescribing practices (namely, his firm), then it will come out all roses. Of course he is ignoring the fact that the package insert, educational materials supplied by the companies, and TIRF education all note these products are ONLY for the use in cancer patients. Somehow, using a potent fentanyl drug that may not be far from IV injection pharmacokinetics, would seem to miss that important safety concern.
 
Why do we keep posting articles from paid Big Pharma shills who are not even clinical practitioners?


FWIW, I hold Forrest Tenants opinion in higher regard than someone who worked with Passik and Pourtenoy back in the day...

unlike forrest, fudin makes good points. most of us are in the middle. opiates work in select patients to keep them functional. the opiate epidemic is fake news as it relates to most pain docs treating their patients. Fudin is the 3/4 mark on the side of opiates. tennant is one extreme, kolodney is the other.

PROP and the ‘Opioid Lobby’

Is this you?
 
i disagree. He notes no limit to dosage, encourages PCPs to ignore any semblance of appropriate dosing, does not favor any urine testing, and has been known to take payments from Big Pharma.
 
first off, on foxnews, it was at the bottom of the page, 2 hours after release, below main articles pertaining NFL, Kennedy, Russians, Clinton.

but yes, very vague and more grandstandingish, but at least he did it after 9 months in office.
 
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