lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,266
3,207
281
Canton GA
www.stevenlobel.com
Status
Attending Physician
110 posts as a med student, and you ask a ridiculous question in a baiting format.

Troll much?

Ask the rest of the question or provide context.

All pure agonists are the same. Oxy has streetability.
Go browse opiophile.org and see what people like more than Oxy these days.
 

Doctodd

10+ Year Member
Jul 4, 2005
3,303
398
281
Miami, FL
Status
i only use it for cancer patients or difficult postop patients in the hospital who can still eat....when they cant eat anymore i go to Duragesic....i dont write it for any outpatients that i can think of. The only outpatients i see get MSContin or Kadian or Embedda as ext release opioids. I have one woman on Methadone and one guy on Duragesic 50 who doesnt take anything for breakthru.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
Oxycontin works really well for 35 year old divorced single mothers of 2-3 young children, who are depressed, anxious, on disability, morbidly overweight and non-compliant with most other medical management and use it to cope....

other than that, i think it is useless..
 

Jcm800

10+ Year Member
Jul 13, 2008
5,637
729
281
Status
Attending Physician
Oxycontin works really well for 35 year old divorced single mothers of 2-3 young children, who are depressed, anxious, on disability, morbidly overweight and non-compliant with most other medical management and use it to cope....

other than that, i think it is useless..

second that
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,266
3,207
281
Canton GA
www.stevenlobel.com
Status
Attending Physician
It's not the drug, it's the patient.

Bad drugs: heroin (not legitmate medical treatment)

Not so good drugs: partial agonists, mixed agonist/antagonists

Other not so good drugs:

Darvocet: toxic active metabolites and not stronger than tylenol, cardiotoxic, neurotoxic.
Demerol: toxic active metabolites can induce seizures with renal impairment
Methadone: active metabolites and unpredictable metabolism, increased central apnea risk more than other opiates.

The rest are just like ordering off of a menu...at a bar....and you need to be 21 to get into a bar, you need to meet certain criteria for opiate use for chronic, malignant or non-malignant pain. That is part of why we have a sub-specialty.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
heroin is just as legitimate as oxycontin... it just gets morphine to the brain faster...

why would fentora be legitimate when the intent is the same as heroin?

i believe heroin is still used in Great Britain as an IV analgesic intra-and post-operatively.
 

Mister Mxyzptlk

10+ Year Member
May 16, 2006
4,885
1,009
281
Yewston, TX
Status
Attending Physician
A C-I substance is a dangerous addictive compound without a good lobbyist.
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,266
3,207
281
Canton GA
www.stevenlobel.com
Status
Attending Physician
heroin is just as legitimate as oxycontin... it just gets morphine to the brain faster...

why would fentora be legitimate when the intent is the same as heroin?

i believe heroin is still used in Great Britain as an IV analgesic intra-and post-operatively.
Fentora is a useful drug for hospice. Same with Actiq.
Heroin needs to be smoked or injected. Purification issues would exist, and it is C-I.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
i just don't understand why you single out another opioid just because of a DEA classification... an agonist is an agonist is an agonist is an agonist...

if you really believe that narcotics are indicated for your patient, what is the big difference between smoking heroin, rubbing actiq on your gums, sucking fentora into your cheeks, rubbing fentanyl on your skin, chewing oxycontin???

:)
 

knoxdoc

New Member
10+ Year Member
Jul 27, 2006
622
51
271
Status
Attending Physician
What are some legitimate uses for OxyContin?

Supplemental income.
 
Feb 2, 2010
245
1
0
Status
MD/PhD Student
110 posts as a med student, and you ask a ridiculous question in a baiting format.

Troll much?

Ask the rest of the question or provide context.

All pure agonists are the same. Oxy has streetability.
Go browse opiophile.org and see what people like more than Oxy these days.

Dude, this is a *student* forum. I can't help it if you all are bigshot attendings at your own private practice clinics comparing golf club memberships. One day I wish I could get there, but until then, I have nothing to contribute except actual medical questions, since I am (wait for it) a student doctor. Not trolling - MD/PhD and just matched.

So far:* Difficult post-op who can still eat (pre-duragesic)
* Outpatient: none except MS Contin, Kadian, Embedda, Duragesic 50, Fentora, Actiq
* Don't prescribe Darvocet and Demerol bc their byproducts are toxic TOXIC.
* Methadone unpredictable
* Supplemental income

I don't see any clinical scenarios/vignettes for where it could be used other than cancer pain. Yet it's one of the most prescribed drugs ever, probably due to a lot of abuse still, but some of it has to be "legit". Therefore I'm asking circumcstances where you as practitioners would feel comfortable prescribing this for a few weeks/months/years.
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,266
3,207
281
Canton GA
www.stevenlobel.com
Status
Attending Physician
Dude, this is a *student* forum. I can't help it if you all are bigshot attendings at your own private practice clinics comparing golf club memberships. One day I wish I could get there, but until then, I have nothing to contribute except actual medical questions, since I am (wait for it) a student doctor. Not trolling - MD/PhD and just matched.

So far:* Difficult post-op who can still eat (pre-duragesic)
* Outpatient: none except MS Contin, Kadian, Embedda, Duragesic 50, Fentora, Actiq
* Don't prescribe Darvocet and Demerol bc their byproducts are toxic TOXIC.
* Methadone unpredictable
* Supplemental income

I don't see any clinical scenarios/vignettes for where it could be used other than cancer pain. Yet it's one of the most prescribed drugs ever, probably due to a lot of abuse still, but some of it has to be "legit". Therefore I'm asking circumcstances where you as practitioners would feel comfortable prescribing this for a few weeks/months/years.
Because at this point you know nothing except what the media has fed you, and you've listened to posts that all should have been in Dark Orchid, you completely misunderstand the point being made.

As pain physicians, we treat chronic non-malignant pain differently than PCP's (I hope), and differently than each other. There are legitimate prescribing criteria, legitimate patients, and legitimate need for opiates for chronic non-malignant pain. Start with www.fsmb.org and look up pain treatment. Nice book available to get started.

Oxycontin is a long acting opiate no different than Duragesic, MSContin, Kadian, Embeda, Avinza, Opana. Methadone is a short acting opiate with a long half life- analgesic effect is 6 hrs max. Heroin is a street drug and cannot be adequately classified as treatment. Fentora and Actiq are indicated or breakthrough cancer pain and provide near instant relief (5-8min to onset), but last less than 1 hour- making them useless for most pain physicians treating chronic pain.
 

knoxdoc

New Member
10+ Year Member
Jul 27, 2006
622
51
271
Status
Attending Physician
I don't see any clinical scenarios/vignettes for where it could be used other than cancer pain. Yet it's one of the most prescribed drugs ever, probably due to a lot of abuse still, but some of it has to be "legit". Therefore I'm asking circumcstances where you as practitioners would feel comfortable prescribing this for a few weeks/months/years.
OK buddy, now we are getting somewhere with this, we just needed some clarification. I don't rx Oxycontin at all. It has a very high abuse potential and has a very high street value. Are any of the other long-acting opioid formulations any more appropriate for prescribing? My opinion is no, but the argument can be made that there are other long-acting opioids that are less likely to be abused than oxycontin and the street value is not as high.

Why is it so commonly prescribed? There are multiple answers to this. 1) Purdue did a lot of unscrupulous advertising - does it hurt their bottom line if 3.2 million Americans abuse their medication (data from CASA report 2004)? 2) Many docs are clueless about the original indication for oxycontin - terminal cancer related-pain, so they prescribe it in a non-judicious manner. 3) Patients "in pain" will place a huge burden of guilt on docs to prescribe "something stronger for my pain" and will not relent until the doc pulls out the OC rx. 4) Many docs do not have even the slightest clue that the efficacy of opioids for chronic, non-malignant pain is weak at best. 5) Pill mills can make a boatload of cash by catering to abusers.

When someone comes in requesting it, I think of Nancy Reagan and I "Just say no."
 

drusso

Moderator Emeritus
Lifetime Donor
20+ Year Member
Nov 21, 1998
7,600
2,604
481
Over the rainbow
Status
Attending Physician
Ditto Steve.

For chronic non-mallignant pain, I like the long-acting morphine products especially Avinza and Embeda. I also prescribe methadone using the "low and slow" principle and find it to be useful in patients who can reliably take their medications, not overconsume, etc.

The fentanyl patch is good choice. Long-acting oxycodone is a third-line choice because it is very euphorogenic---hence it abuse potential. Oxycodone metabolites are active at dopamine receptors. I've had very reliable chronic pain patients ask to be taken off of long-acting oxycodone because it re-activates cravings and makes them feel "high" which is exactly the reasons others seek to abuse it...

All that being said, I'm *starting* fewer and fewer patients on long-acting opioids now than 3 years ago. I'm finding that small amount short-acting (even if required daily) is better than starting opioid niave patients on LA therapy.
 

ampaphb

Interventional Spine
10+ Year Member
May 13, 2007
4,352
723
331
New Orleans, LA
Status
Attending Physician
Therefore I'm asking circumcstances where you as practitioners would feel comfortable prescribing this for a few weeks/months/years.
This is a public forum. You could be a student, but you could equally likely be a drug seeker. If that were the case, what you could be looking for is an MD/DO to provide you an appropriate scenario you and your colleagues could then present to the next unsuspecting PCP you visit when you doctor-shop to obtain narcotics. So please don't take offense or call us names, but rather understand why we are gun-shy when someone basically asks what story can I tell to get a script for oxycontin?

In answer to your question, there is no circumstance where I would initiate use of oxycontin as my initial therapeutic long-acting drug of choice. There are better, safer options with far less abuse potential,
 

Disciple

Senior Member
10+ Year Member
Oct 18, 2004
2,502
309
281
Status
Attending Physician
Long-acting oxycodone is a third-line choice because it is very euphorogenic---hence it abuse potential. Oxycodone metabolites are active at dopamine receptors. I've had very reliable chronic pain patients ask to be taken off of long-acting oxycodone because it re-activates cravings and makes them feel "high" which is exactly the reasons others seek to abuse it...
I agree with you, but that seems to be a point of contention on this board.

Is it more euphorogenic (makes a case not to use Percocet either), or is it the 40% bolus with Oxycontin, or both?


I'm *starting* fewer and fewer patients on long-acting opioids now than 3 years ago. I'm finding that small amount short-acting (even if required daily) is better than starting opioid niave patients on LA therapy
I think the question is, whether or not you think a patient can control him/herself and self-manage their symptoms day-to-day (activity restriction/modification) without overusing their medication, because they will develop tolerance.
 
Last edited:

PMR 4 MSK

Large Member
10+ Year Member
5+ Year Member
Oct 1, 2007
4,182
27
0
Status
Attending Physician
Looking at realistic statistics from my 10 years in private practice:

Probably 75% of patient with pain, even severe, don't want opioids due to stigma and fears, some realistic, some not. You could probably get someone of them to take opioids, and they will likely do well and not develop abuse issues. Most will do fine on non-opioid alternatives.

From the 25% that does want pain pills, at least 50% of them are chemical copers who exaggerate their pain level to get the pills they want that are relieving the anxiety of their pain and social situations more than the pain itself. This group is largely innapropriate for opioids and are better managed with antidepressants and psychotherapy. On opioids, they will frequently run out early, and/or report lost and stolen meds. They will develop apparent tolerence quickly and will frequently request increases in drug dose, frequency or monthly allotment.

Of the 12.5% that remains, at least half of them are true substance abusers - addicts and dealers looking to score easy, cheap drugs.

You now have maybe 5-6% that are appropriate for opioids, want them and will do well on them, so about 1 in 20.

Now of that 1 in 20, how many need a long-acting opioid, and of those who require a LAO, how many will benefit more from Oxycontin than any of the others? Rather low numbers, I believe.

LAOs were sold to us in the 90s as more effective for severe pain than SOAs due to less peaks and troughs, and less abuse potential, both of which have been proved to be false.

Oxycontin suffers from name recognition by drug abusers. MS Contin, made by the same manufacturer, has been around for several years longer, is essentially bio-equivalent to Oxycontin, but far less sought by abusers. They'll take it in a pinch, but it is rarely a drug of choice.

Opiates of choice vary by locale. I've lived in places where everyone is on either Vicodin 5/500 or Norco 10/325, to the exclusion of almost every other hydrocodone product. In other places its Lortab 10s, in still others its Lorcets. Vicodin ES was very popular in one place I lived, Norco was very rare. Interestingly, I've never seen Zydone or Maxidone as the local hydrocodone preparation of preference.

Some addicts prefer codeine. Almost all would kill to get hydromorphone. When they go to the ER, they want demerol.

I imagine much of a local drug culture's drug preferences are determined by which opiate preparations the local doctors prescribe, generating a snowball effect.

Oxycontin has the same indications as any other LAO - severe, intractable pain unrelieved by less potent meds and requiring 24-hour/day pain control. But indications do not determine if a particular patient should receive a drug.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
... not to mention that an 80mg of 90 tablets of oxycontin can generate about 6k in profit per month.... at least according to one of my patients...
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,266
3,207
281
Canton GA
www.stevenlobel.com
Status
Attending Physician
... not to mention that an 80mg of 90 tablets of oxycontin can generate about 6k in profit per month.... at least according to one of my patients...
They are paying too much. Max should be $7k for 90x80mg. Most folks can deal it out for $5k- 1 buyer less risk, less profit. Pure capitalism, with commensurate risk of jail, death, etc.
 

mid|ine

Interventional Spine
10+ Year Member
Aug 2, 2006
702
20
251
Cincinnati, OH
Status
Attending Physician
I believe heroin is used in about every country but the us. Its used in Canada. There is nothing different or evil about it. Its just a narcotic.

Used in most countries under the name diamorph or diamorphine (as in diacetylmorphine, aka heroin).
 

jabreal00

10+ Year Member
Feb 20, 2009
590
96
271
USA
Status
Attending Physician
There is no reason to prescribe OxyContin for non-cancer related chronic pain IMHO.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
jabreal00 ---- you have to be careful w/ the use in cancer pain as well.... there are a few cancer patients who get hooked on the stuff or start selling them to supplement the income.... this is primarily in non-terminal chronic cancer patients (remember that breast cancer patients can now live 10-20-30 years after their diagnosis).
 

jabreal00

10+ Year Member
Feb 20, 2009
590
96
271
USA
Status
Attending Physician
jabreal00 ---- you have to be careful w/ the use in cancer pain as well.... there are a few cancer patients who get hooked on the stuff or start selling them to supplement the income.... this is primarily in non-terminal chronic cancer patients (remember that breast cancer patients can now live 10-20-30 years after their diagnosis).
Agreed. I meant terminal cancer pain. I had a lady with metastatic breast Ca as a resident with cauda equina syndrome. She was in horrific amounts of pain. She could get what ever narcotic she wanted for me during her last weeks of life.
 

surftheiop

10+ Year Member
Dec 4, 2008
1,940
27
0
Status
I'm a pre-med biomedical engineering student and I was sort of trolling through here out of general interest and have seen the several threads about the dangers of long term opiate painkillers.

What about the dangers of long term NSAID use? I know something like 1200mg/day is the initial treatment for various back/neck/joint pain. Recently I feel like I have seen ton of specials on TV about "dangers of NSAIDs" and the warnings on the bottles are getting bolded/highlighted. So how long can you manage someone's pain with 800-1200mg of a NSAID before you start having to worry about the various side effects?
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
2 years in a younger patient without underlying kidney disease.
 

PMR 4 MSK

Large Member
10+ Year Member
5+ Year Member
Oct 1, 2007
4,182
27
0
Status
Attending Physician
I'm a pre-med biomedical engineering student and I was sort of trolling through here out of general interest and have seen the several threads about the dangers of long term opiate painkillers.

What about the dangers of long term NSAID use? I know something like 1200mg/day is the initial treatment for various back/neck/joint pain. Recently I feel like I have seen ton of specials on TV about "dangers of NSAIDs" and the warnings on the bottles are getting bolded/highlighted. So how long can you manage someone's pain with 800-1200mg of a NSAID before you start having to worry about the various side effects?
24 hours.

We (are supposed to, I do) warn patients when we prescribe NSAIDs, either OTC or Rx, about the potential side effects, such as nausea, reflux, peptic ulcer, elevated blood pressure, MI and CVA risk, kidney damage. Any of these can occur in any patient regardless of age or health.

The old thoughts of only worrying about elevated BP in older patients is changed by the fact that HTN is occurring more and more in younger patients, especially in the obese. Last year I had a 22 yo have 130/75 BP initially, 3 months later it was 165/95 on nabumetone.

Ulcers can occur at any age. They can and do kill people.

NSAID-induced nephropathy is more common in older individuals, making NSAIDs relative contraindicated after age 70 (controversial). I've never seen it in a young person with normal initial kidney function.

800-1200 mg of "NSAID" depends on the drug. They all have different doses. 1200 mg of piroxicam would probably kill most people. 1200 mg salsalate probably wouldn't touch much more than than a minor ache.

So the answer is "it all depends" like most things in medicine. In general, I use them for 2 - 8 weeks and then see if people can go off them.

If you have to go long-term, celecoxib is probably the safest (also controversial).
 

surftheiop

10+ Year Member
Dec 4, 2008
1,940
27
0
Status
24 hours.

We (are supposed to, I do) warn patients when we prescribe NSAIDs, either OTC or Rx, about the potential side effects, such as nausea, reflux, peptic ulcer, elevated blood pressure, MI and CVA risk, kidney damage. Any of these can occur in any patient regardless of age or health.

The old thoughts of only worrying about elevated BP in older patients is changed by the fact that HTN is occurring more and more in younger patients, especially in the obese. Last year I had a 22 yo have 130/75 BP initially, 3 months later it was 165/95 on nabumetone.

Ulcers can occur at any age. They can and do kill people.

NSAID-induced nephropathy is more common in older individuals, making NSAIDs relative contraindicated after age 70 (controversial). I've never seen it in a young person with normal initial kidney function.

800-1200 mg of "NSAID" depends on the drug. They all have different doses. 1200 mg of piroxicam would probably kill most people. 1200 mg salsalate probably wouldn't touch much more than than a minor ache.

So the answer is "it all depends" like most things in medicine. In general, I use them for 2 - 8 weeks and then see if people can go off them.

If you have to go long-term, celecoxib is probably the safest (also controversial).
I have a couple follow up thoughts because I find the whole idea of risk analysis for prescribing medications to be interesting. Coming from engineering school expected there to essentially be something like medication risk analysis actuarial tables, equations or computer models that could quantify risk based on variables like age, health conditions, BP, etc. But it seems accessing risk is more based on general guidelines with some hard and fast rules thrown in and then its up to physician's judgment. (I figured if they can develop models to estimate numerical risk for a chemical plant or stock-market, why not a person?)

For, example my healthy 21 y/o friend had really bad back pain and goes to PC provider. Doc says to take 4x800mg Ibuprofen/day and that its "safe" to take the dosage as long as its not for "too long".

It seems like given the fact that so many statistics and records are kept regarding medicine there should be some computer program where you could type in "21 y/o, male, BP: XX/YY, weight: ZZZ,etc." and then by comparing with some statistics data base it would show an approximate numerical risk of different side effects based on the duration of treatment. I know it sounds like a tall order for a computer program, but insurance actuaries have done analysis that seems somewhat analogous to this for a long time even without the massive computing power of today's computers.

Does this sort of analysis exist in medicine today? Would it even be helpful or change decision making if you could "put a number" on someone's risk?
 

clubdeac

10+ Year Member
Aug 16, 2007
3,254
538
281
Status
Attending Physician
Yeah it would be helpful. I think part of the problem is research. There aren't enough studies looking at the various NSAIDs that address all of these questions... duration, numerous patient variables etc. It would take forever to conduct enough studies to be able to develop a risk stratification analysis that could be factual. We know some stuff but a lot is extrapolation and anecdotal.

However, I've wondered the same thing. How long can you keep someone on an NSAID before the risk of complications outweighs the benefit. I think too many patient variables are involved to make a general blanket statement. Tenesma where did you get 2 yrs for a young patient. Not that I disagree. Just wondering if there is any literature supporting this. And PMR4MSK, where's 24 hrs come from? I assume you're basically saying the risk is there from day one
 

surftheiop

10+ Year Member
Dec 4, 2008
1,940
27
0
Status
Yeah it would be helpful. I think part of the problem is research. There aren't enough studies looking at the various NSAIDs that address all of these questions... duration, numerous patient variables etc. It would take forever to conduct enough studies to be able to develop a risk stratification analysis that could be factual. We know some stuff but a lot is extrapolation and anecdotal.

However, I've wondered the same thing. How long can you keep someone on an NSAID before the risk of complications outweighs the benefit. I think too many patient variables are involved to make a general blanket statement. Tenesma where did you get 2 yrs for a young patient. Not that I disagree. Just wondering if there is any literature supporting this. And PMR4MSK, where's 24 hrs come from? I assume you're basically saying the risk is there from day one

What I wonder is with the shift towards electronic medical records, if there will be a time in the somewhat near feature where you could basically just search for correlations of almost anything using shared databases of millions of patients anonymous medical histories. Maybe we will see google launching a "GoogleMD" app or something.
 

PMR 4 MSK

Large Member
10+ Year Member
5+ Year Member
Oct 1, 2007
4,182
27
0
Status
Attending Physician
I have a couple follow up thoughts because I find the whole idea of risk analysis for prescribing medications to be interesting. Coming from engineering school expected there to essentially be something like medication risk analysis actuarial tables, equations or computer models that could quantify risk based on variables like age, health conditions, BP, etc. But it seems accessing risk is more based on general guidelines with some hard and fast rules thrown in and then its up to physician's judgment. (I figured if they can develop models to estimate numerical risk for a chemical plant or stock-market, why not a person?)

For, example my healthy 21 y/o friend had really bad back pain and goes to PC provider. Doc says to take 4x800mg Ibuprofen/day and that its "safe" to take the dosage as long as its not for "too long".

It seems like given the fact that so many statistics and records are kept regarding medicine there should be some computer program where you could type in "21 y/o, male, BP: XX/YY, weight: ZZZ,etc." and then by comparing with some statistics data base it would show an approximate numerical risk of different side effects based on the duration of treatment. I know it sounds like a tall order for a computer program, but insurance actuaries have done analysis that seems somewhat analogous to this for a long time even without the massive computing power of today's computers.

Does this sort of analysis exist in medicine today? Would it even be helpful or change decision making if you could "put a number" on someone's risk?

Ok, we'd like that, but still would not know exactly what to do.

Say the data is crunched and shows for a particular patient, he has a 1% of an ulcer with 7 days of use of ibuprofen, 10% with 30 days, 15% with 90 days and 18 % with 180 days of use. How long should he take it? Depends on your risk tolerence. The curve is complex.

What you propose is what we do heuristically in our heads based on limited data available and our years of practice. And we try to cover ourselves for when we get sued.

If I give 1000 people an NSAID for 30 days, some of them will get ulcers - let's say 5% (50). Of that 50, probably 25% will end up in the hospital and a few of them may die of complications from GI bleed. Some of the survivors may sue me. Some of the non-survivors' families may sue me. How many? Which ones?

Do I not give NSAIDs at all since I may kill someone and/or be sued for it? Do I risk-stratify and only give it to low-risk individuals? Does the patient take on any of the liability when I advise him of the risks?
 

surftheiop

10+ Year Member
Dec 4, 2008
1,940
27
0
Status
Ok, we'd like that, but still would not know exactly what to do.

Say the data is crunched and shows for a particular patient, he has a 1% of an ulcer with 7 days of use of ibuprofen, 10% with 30 days, 15% with 90 days and 18 % with 180 days of use. How long should he take it? Depends on your risk tolerence. The curve is complex.

What you propose is what we do heuristically in our heads based on limited data available and our years of practice. And we try to cover ourselves for when we get sued.

If I give 1000 people an NSAID for 30 days, some of them will get ulcers - let's say 5% (50). Of that 50, probably 25% will end up in the hospital and a few of them may die of complications from GI bleed. Some of the survivors may sue me. Some of the non-survivors' families may sue me. How many? Which ones?

Do I not give NSAIDs at all since I may kill someone and/or be sued for it? Do I risk-stratify and only give it to low-risk individuals? Does the patient take on any of the liability when I advise him of the risks?


The highlighted is the reason I think this sort of algorithm isn't far off. Imagine if instead of drawing from the sample of patients you have physically treated, the program could draw from all the patients that your entire hospital or country had treated.

As far as what do do next if you completely hypothetically knew the numerical risk a treatment posed, I think other fields already have done quite a lot of work in those areas. I know that economists have pretty good methods of figuring out how much people value their own life based on the physical risks that they take for financial gain. (Like working a more dangerous job for higher income, driving a less safe care to save money, etc).

Using the sorts of methods the behavioral economists and psychologists use, there are probably numerical ways to compare the quality of life benefit provided by the treatment to the risk posed to that specific individual.

Obviously this all rather hypothetical right now, but when you consider the oceans of data that companies like Google can process, it doesn't seem so far-fetched.
 

surftheiop

10+ Year Member
Dec 4, 2008
1,940
27
0
Status
Just to show I'm not completely nuts, here is a program made by Wolfram (makers of Mathematica) that estimates risk of developing heart disease


You can type in Age, Sex, LDL/HDL, Blood pressure, Diabetic (Y/N), Smoker (Y/N)


http://www.wolframalpha.com/input/?i=heart+disease+risk+50yo+male&f1=111+mg%2FdL&f=HeartDisease.ldl_111+mg%2FdL&f2=54+mg%2FdL&f=HeartDisease.hdl_54+mg%2FdL&f3=120+mmHg&f=HeartDisease.sbp_120+mmHg&f4=80+mmHg&f=HeartDisease.dbp_80+mmHg&a=*FP.HeartDisease.smoking-_Yes&a=*FP.HeartDisease.diabetes-_No
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
2 years??? pretty much a guesstimate based on experience, anecdotal stories, the fact that the average long-term data on cox-2s are about 16-20 months (if you look at the studies)....

clearly anything could happen in the first 2 years that could be lethal...

but in my book, if you have been on an NSAID for 2 years without adverse event, it is time to take a break from the medication, re-assess a variety of things and wait a year or so before re-initiating...

i am also pulling that out of my ass... but vioxx got dinged because of deaths that occured up to 12 months after discontinnuation of the drug... so clearly Merck and lawyers felt that the 12 months was a fair marker as well

no data --- but this is the art of medicine until we are replaced by supercomputers... or Doctors of Nursing if you place much faith in Obamacare
 

Pharmavixen

foxy pharmacist
10+ Year Member
7+ Year Member
Jan 20, 2008
1,043
14
151
Canada
Status
Pharmacist
If you have to go long-term, celecoxib is probably the safest (also controversial).
Just delurking to comment: there was a MA which showed that with respect to CV risk, naproxen is the safest NSAID.

Okay I just found it: "Kearney PM et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase
the risk of atherothrombosis? Meta-analysis of randomized trials. BMJ 2006;332:1302-5." When traditional NSAIDs and COX IIs were compared with respect to CV risk, there was no diff. But when naproxen is compared to COX IIs, there's an increased risk for the COX IIs: RR = 1.57; p = 0.00006. For MIs the RR of COX IIs is 2.04. (Granted this MA included all the COX IIs including the nasties like rofecoxib.)

However, with respect to GI risk, the CLASS trial was found to be fudged, where they violated their own protocol, providing the 6-month analysis that showed celecoxib was superior to traditional NSAIDs in mitigating GI risk. If you take the data at a year, the superiority of celecoxib disappears.

Where I work (in a jail) we use lots of celecoxib for short term tx. But LT? I'm not so sure. (We used to hand out Vioxx like candy. No lawsuits so far...)

We got rid of Oxycontin last year, replacing it with M-Eslon (do you have that stateside? It's LA morphine in a capsule that you can open, which we do, in order to thwart diversion). So far, no complaints about efficacy, though tons of bitter complaints about the opening of the capsules.

We had one inmate who was getting 1000 mg/day of Oxycontin from his PCP. Skeptical, our doc gave him M-Eslon 30mg bid. Later he raised it to 60mg bid, at which point the pt had no pain, and no WD symptoms.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
i think this reinforces previous points - nobody has a clue about NSAIDS, just like we don't have a clue about long-term risks of tricyclics, SSRIs, SNRIs, muscle relaxants and narcotics (well with the latter we have a bit of a clue)

i routinely for new patients will ask how long they have been on any specific formulation, and will frequently recommend holiday's, rotations, changes to different drug classes if they have been on a specific drug >2 years.... I tend NOT to make that recommendation for anti-convulsants, because if they are effective it is harder to find a replacement, and the long-term safety of neurontin, dilantin, tegretol seems relatively okay (kinda)
 

surftheiop

10+ Year Member
Dec 4, 2008
1,940
27
0
Status
Just for fun, I talked to a friend of mine who is a programmer for Apple and has also sold some stuff to Google. He said that the sort of programs I was talking about would be almost trivial to program, but currently the problem is that medical data is extremely protected and hospitals wouldn't share it with each other. He mentioned that something like this tried to happen in California, but that the red tape was just too much to overcome.
 

mjl1717

Senior Member
15+ Year Member
May 24, 2003
1,606
8
351
63
Westbury,NewYork
Visit site
Status
OK buddy, now we are getting somewhere with this, we just needed some clarification. I don't rx Oxycontin at all. It has a very high abuse potential and has a very high street value. Are any of the other long-acting opioid formulations any more appropriate for prescribing? My opinion is no, but the argument can be made that there are other long-acting opioids that are less likely to be abused than oxycontin and the street value is not as high.

Why is it so commonly prescribed? There are multiple answers to this. 1) Purdue did a lot of unscrupulous advertising - does it hurt their bottom line if 3.2 million Americans abuse their medication (data from CASA report 2004)? 2) Many docs are clueless about the original indication for oxycontin - terminal cancer related-pain, so they prescribe it in a non-judicious manner. 3) Patients "in pain" will place a huge burden of guilt on docs to prescribe "something stronger for my pain" and will not relent until the doc pulls out the OC rx. 4) Many docs do not have even the slightest clue that the efficacy of opioids for chronic, non-malignant pain is weak at best. 5) Pill mills can make a boatload of cash by catering to abusers.

When someone comes in requesting it, I think of Nancy Reagan and I "Just say no."
Great!!!!
And that would work, as you stated.. "Only for terminal cancer"...End of story!!!!
[since that line is firm but sensitive, look them right in the eye when you say this...]
 
Apr 21, 2010
1
0
0
Status
This is a public forum. You could be a student, but you could equally likely be a drug seeker. If that were the case, what you could be looking for is an MD/DO to provide you an appropriate scenario you and your colleagues could then present to the next unsuspecting PCP you visit when you doctor-shop to obtain narcotics. So please don't take offense or call us names, but rather understand why we are gun-shy when someone basically asks what story can I tell to get a script for oxycontin?

In answer to your question, there is no circumstance where I would initiate use of oxycontin as my initial therapeutic long-acting drug of choice. There are better, safer options with far less abuse potential,
Oxycodone is just plain nasty. I've taken it for over 10 years. I control my pain and have never gone up in dosage whatsoever. It seems to be the only thing that works for me, personally. So, I stay away from it unless I've exhausted all my options. I use a lot of herbs and supplements that sometimes help. I use acupuncture, work out religiously, and live a very healthy life style. I don't drink or smoke and am more fit than most my age. (I'm early 30's). It's a shame that all the drug seekers out there can ruin it for people who are truly responsible and don't get a high off of what should be used for severe pain. I am not a doctor but can understand why this drug is so far removed when a patient really is seeking help. There are a lot of honest people out there, I would hope. Just my 2cents.....
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
KristinCav - another reason why this forum should be private... from now on, I will ONLY post on the private forum
 

lonelobo

PAIN DOC
10+ Year Member
Jun 1, 2005
2,572
672
281
Southwest
Status
Attending Physician
The only time I use Oxy..... is after I have snorted up all my Gabapentin
 
Apr 22, 2010
35
0
0
Status
MD/PhD Student
lonelobo >>>
oxycodone (opiate) and gabapentin/pregabalin are not the same thing. Though it is an interesting choice to use both at the same time:)


i only use it for cancer patients or difficult postop patients in the hospital who can still eat....when they cant eat anymore i go to Duragesic....i dont write it for any outpatients that i can think of. The only outpatients i see get MSContin or Kadian or Embedda as ext release opioids. I have one woman on Methadone and one guy on Duragesic 50 who doesnt take anything for breakthru.
I use oxycodone often because it has less side effects than morphine and/or it is much ''comfortable'' . It is of course a much more abusive drug. When my patients are complaining of morphine/hydromorphone side effects, I can switch them to oxycodone.

Oxycontin is sometimes an agonist at k3 depending on the patient and the situation. We don't know exactly why.
eg: some research show that the k3 binding of oxycodone happens more often with diabetes, strange.
kappa receptors produce strange reactions like diuresis and dysphoria.
Dysphoria can be profound, watch out for meperidine and codeine (although they don't bind to k).
 
Last edited:

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,266
3,207
281
Canton GA
www.stevenlobel.com
Status
Attending Physician
Current Medications:
FISH-EPA ORAL CAPSULE CONVENTIONAL 1000 MG, 1 Every Day
MULTIVITAMINS ORAL TABLET, 1 Every Day
CALAN SR ORAL TABLET CONTROLLED RELEASE 240 MG, 1 po bid
DIOVAN ORAL TABLET 160 MG, 1 Every Day
VENTOLIN HFA 60 DOSE METERED, 4 times daily PRN
ASPIRIN BUFFERED ORAL TABLET 325 MG, 1 po QD
OXYCONTIN ORAL TABLET 12 HR 20 MG, 1 po tid
PARAFON FORTE DSC ORAL TABLET 500 MG, 1 Two Times A Day PRN
ALPRAZOLAM ORAL TABLET 1 MG, 1/2 -1 q8hr prn

Specialist: Steven M. Lobel, M.D.

PATIENT REQUESTS: PATIENT HAVING SEVERE ANXIETY ATTACKS AND WHEN HE ASK HIS PHARMACY AT WALGREEN, THEY TOLD HIM IT WAS FROM THE OXYCONTIN. PATIENT IS WANDERING IF YOU COULD CHANGE IT TO SOMETHING THAT WILL NOT CAUSE HIM TO HAVE ANXIETY ATTACKS.


Older patient with all meds by PCP except Oxycontin. Apparently, he is not much for the medication.
 

PMR 4 MSK

Large Member
10+ Year Member
5+ Year Member
Oct 1, 2007
4,182
27
0
Status
Attending Physician
Current Medications:
FISH-EPA ORAL CAPSULE CONVENTIONAL 1000 MG, 1 Every Day
MULTIVITAMINS ORAL TABLET, 1 Every Day
CALAN SR ORAL TABLET CONTROLLED RELEASE 240 MG, 1 po bid
DIOVAN ORAL TABLET 160 MG, 1 Every Day
VENTOLIN HFA 60 DOSE METERED, 4 times daily PRN
ASPIRIN BUFFERED ORAL TABLET 325 MG, 1 po QD
OXYCONTIN ORAL TABLET 12 HR 20 MG, 1 po tid
PARAFON FORTE DSC ORAL TABLET 500 MG, 1 Two Times A Day PRN
ALPRAZOLAM ORAL TABLET 1 MG, 1/2 -1 q8hr prn

Specialist: Steven M. Lobel, M.D.

PATIENT REQUESTS: PATIENT HAVING SEVERE ANXIETY ATTACKS AND WHEN HE ASK HIS PHARMACY AT WALGREEN, THEY TOLD HIM IT WAS FROM THE OXYCONTIN. PATIENT IS WANDERING IF YOU COULD CHANGE IT TO SOMETHING THAT WILL NOT CAUSE HIM TO HAVE ANXIETY ATTACKS.


Older patient with all meds by PCP except Oxycontin. Apparently, he is not much for the medication.
Just increase the xanax to 1-2 "bars" QID and the anxiety should go away... :D
 
Apr 22, 2010
35
0
0
Status
MD/PhD Student
All opiates produce dysphoria depending on the tolerance. It can be anxiety, paranoia, depression... unfortunately. This is why that kind of analgesic must be use in an acute period, but sometimes we cannot.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
281
Visit site
Status
Attending Physician
versatil... you obviously have a lot of knowledge...

but are you really coming on to this forum to educate board certified, fellowship trained pain specialists on the basics of opioids???

also please realize that probably 2/3 of what we discuss re: pain meds requires a certain amount of insider-scoop from day to day interactions with narcophiles... and it may be difficult for a newcomer to pick up on the nuance and sophistication of the likes of PMR/lonelobo/Mister M, etc...
 

mjl1717

Senior Member
15+ Year Member
May 24, 2003
1,606
8
351
63
Westbury,NewYork
Visit site
Status
versatil... you obviously have a lot of knowledge...

but are you really coming on to this forum to educate board certified, fellowship trained pain specialists on the basics of opioids???

also please realize that probably 2/3 of what we discuss re: pain meds requires a certain amount of insider-scoop from day to day interactions with narcophiles... and it may be difficult for a newcomer to pick up on the nuance and sophistication of the likes of PMR/lonelobo/Mister M, etc...
Beautiful! :thumbup: