Would you give this guy opioids?

Discussion in 'Pain Medicine' started by PMR 4 MSK, Jun 5, 2008.

  1. PMR 4 MSK

    PMR 4 MSK Large Member
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    Hypothetical case:

    You've got a 50-ish patient, chronic back and neck pain, axial neck, axial and radicular back. He's tried a lot of conservative treatment including multiple meds, PT, HEP, a couple LESI's and a L4-5 laminectomy 3 years ago.

    He's tried and failed several NSAID's, tramadol, gabapentin and pregabalin, amitrptyline, venlafaxine - all the usual suspects, none with significant improvement in either pain or functioning.

    He's been on hydrocodone 10/325 mg QID for the past 2 years, it "takes the edge off" and keeps him working as a machinist. No Hx substance abuse, no opioid issues in the past as far as you can tell from the records available. He is a smoker, infrequent alcohol use.

    After a review of recent MRI and Hx/PE, you discuss/offer him interventional procedures such as TFESI, FJI/RFA, maybe even SCS. He politely declines them all, saying injections haven't helped him in the past, some have made him worse and he doesn't want more surgery. Further PT unlikely to help, plus his schedule really doesn't allow for it. He's got about 10 years to retirement. Fill in the rest of the history with your experiences with this patient - we've all seen him.

    If you had been treating him for a few months, would you continue to prescribe the opioid? If this was your first visit with him, would you take over precribing? Would the referral source matter? Would his insurance matter (e.g. BCBS vs WC vs Medicaid)?

    What this gets down to is, would you be willing to prescribe opioids to this guy for the next 20 - 30 years or so, given that he appears to be a straight shooter, appears low risk for abuse, but you're not likely to do any other procedures on him?
     
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  3. 2win

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    I have this dillema few times a week - I didn't find an answer yet. My good sense is telling me to prescribe narcotics - on the other hand his PCP can do it...Of course I have thoughts about insurance. I am tempted to keep the BCBS and WC and kick out the Medicaid. If I believe that the procedures are useful and the guy refuses I will kick him out after a while ( time necessary to build a relation and for the pateint to gain confidence in my judgement). Reason: means that the patient doesn't believe in my judgement and the relation is not beneficial for him. He can pay cash - still I don't care.
     
  4. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Yes.




















    UDS, SOAPP-R, Prior records, imaging, op notes in chart. Pharmacy records x6 months.

    Activity, Analgesia, Adverse effects, Aberrant behaviors documented in every note. 6 months of monthly visits, than q3 months if still a straight shooter. Seems an ideal candidate for chronic opioids. Check TEstosterone levels.
    Tell him what procedurs would make most sense andif dose escalation occurs, a procedure will be performed to get back to lower dose. I typically do not trust procedures performed at other facilties unless the note comes with adequate imaging. I'd also discuss the use of long acting meds for chronic pain and try and eliminate or reduce the BT stuff. QID is not ideal, but if it is working (functional vs non-functional- not VAS) who cares.


    I think this guy is what we would call a practice builder for pain management. He behaves, he works full time, and he is not a PITA. Satisfies all criteria. He still needs a home exercise program.
     
  5. algosdoc

    algosdoc algosdoc

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    Yes, provided the INSPECT or pharmacy query shows no signs of abuse, and that random UDS does not show aberrant behavior. I believe we are obligated to go beyond prescribing opiates and must couple scrutiny and continued monitoring. That is one thing most PCPs refuse to do.....adequately monitor the patients taking opiates. In 590,000 Ameritox UDS samples, 11% have illicit drugs in the urine, 30% have an unprescribed and non-disclosed drug in the urine, and 38% fail to have the prescribed drug in the urine (even after adjusting down for prn meds). Given the rate of substance abuse and diversion, we the pain physicians are the stewards of appropriate opiate prescribing in a sea of PCPs happily willing to prescribe 60-80mg hydrocodone a day forever without ever testing their patients ....
     
  6. Tenesma

    Tenesma Senior Member

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    i'd recommend he be weaned off opioids as they do not appear to be giving him much relief - taking the "edge" off doesn't cut it.

    but best political answer is to say to the PCP that you agree with continued opioid analgesics with random urine tox screens - if the pain escalates, then he should be re-evaluated by you. That there should be NO escalation of dosing, and if the medication becomes less efficacious then the medication should be weaned to off..

    if all you are doing is opioid refills, then just have the PCP do it... what the PCP really wants is the following: Clear guidelines on how to monitor, manage the patient with you as a safety net... so document your notes very clearly...
     
  7. lobelsteve

    lobelsteve SDN Lifetime Donor
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    My PCP's will be happy to send the patient to another doc if all I do is give them a 1/2 page lecture on how to manage chronic pain with opioids. I am board certified subspecialty blahbalh- my expertise is not to be substituted for a 1/2 page explaining its ok to do XYZ. I'll always do a better job managing these patients for the same reason the endocrinologist does a better job managing DM and the cardiologist does a better job managing CAD.
     
  8. Tenesma

    Tenesma Senior Member

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    please explain how you will be able to "better manage" a guy who is getting the exact same RX for a chronic condition at every visit....

    clearly we are superior at actively managing (ie: initiating, weaning, changing) these issues - but to take-over the RX is purely a marketing gimmick and nothing more- and would bore most of us to death...

    and, no, cardiologists and endocrinologists don't take-over metoprolol and insuling prescriptions unless there are active issues going on...
     
  9. lobelsteve

    lobelsteve SDN Lifetime Donor
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    In my area, they do and I do. If the medication becomes ineffective, for the appropriate documentation, to assess the warning signs of abuse, addiction, diversion, to have the appropriate informed consent and agreement for treatment paperwork, to assess activity, to better understand side effects of opioids, etc. Maybe we don't need a fellowship?

    Who am I, AMPA? Your post downgrades and disrespects the entire field of Pain Medicine. It might be slick, it may be more profitable, but if a PCP can manage these patients better than I can......they just can't.
     
  10. PMR 4 MSK

    PMR 4 MSK Large Member
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    Just to play round-table-discussion a little more, why not escalate, since the meds "just take the edge off?" If you agree to prescribe HC 10 mg QID, at what point would you consider increasing if he reported decreasing effectiveness or you perceived tolerence? Tenesma, whom I believe is mainly opiate-free in his clinic (you're my hero...), said what he believes - this is the max the pateint should go. Anyone willing to do a trial of Avinza, Duragesic, etc?

    I'm pretty sure we don't have any Oxycontin prescribers here, do we? 10 years ago, this guy would probably already be on it...
     
  11. 2win

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    If the function is ok I wouldn't go higher. I still belive in opioid rotation so I'll change the meds from time to time if criteria are met ( dysphoria...). Tenesma is lucky - I am on lobelsteve side. I would like to be with tenesma but I will loose 50% of my patients. I do believe also that we're better for opioid management than PCPs. And yes - I am one of the f...s that still has patients on Oxycontin. just my 2 cents
     
  12. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I have lots of patients on Oxycontin, lots of patients on Avinza (consultant), lots of patients on Kadian (consultant), lots of patients on Fentanyl, lots of patients on MSContin (cheaper), lots of patients on Duragesic, many patients on Opana, 1 patient on Methadone. I will soon have lots of patients on Hydromorphone long acting and Vicodin XR 15/500 bid.

    When a medicine is in the same class as other medicines, I cannot fathom a scientific basis for not using it. Methadone has inherent risks from a physiological and therefore medicolegal standpoint. The risk with Oxycontin has nothing to do with the drug and everything to do with the patient. If your ability to determine who is at moderate or high risk for abuse/addiction/diversion is no better thn the PCP's- you should avoid prescribing all opioids. Take down the "Pain Center" sign and call yourself "The Feral Injectionist".

    Saying you will not prescribe a medication because of X,Y,Z that has nothing to do with adverse events, side effects, or black box warnings (as they apply to the mechanism of action) is sticking your head in the sand. An opioid is an opioid (except the ones that cause cardiotoxicity/neurotoxicity (propoxyphene), seizures when in CRI/CRF (meperidine), or the rare but real possibility of QTc prolongation and Torsades (methadone)). I'm astounded by the number of Pain Doctors who think there are bad drugs. There are only bad people or sick people. We have an obligation to the public to help sort out the bad guys (with law enforecement asistance DIVERSION) from the sick guys (abuse/addiciton with clinical psychology, wean from opioids, addiciton psychiatry), from the folks who hurt and are not sick with addiction, or bad with diversion. If you have a pain patient with low risk for abuse/addiction/diversion and do not use every and all modality to try and relieve their pain- you are a charlatan. Its about risks and benefits, and only ignorance on the part of the physician. Rant off.

    I am not a high dose opioid guy, but I believe the WHO when they say opioids are an essential medication and need to be available for medical care at all times (but not for every patient).:eyebrow:+pity+
     
  13. Tenesma

    Tenesma Senior Member

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    - i truly believe that opioids are poorly indicated for most if not all chronic non-terminal conditions...

    the patient has to show the following
    1) no risk factors for abuse
    2) no history of abuse
    3) functional improvement
    4) effective pain management

    the PCPs who send patients with opioid issues to Pain Specialists, are typically asking two questions
    1) "I am not sure if I am missing something, opioids seem to be working but I want to make sure that we aren't missing a diagnosis, or we can't fine-tune the management"
    2) "I am having difficulty with this patient because they are not improving, and I am not comfortable with continuing opioids in this patient"

    Either way, what they like to have is documentation...

    I consider myself a consultant and have no desire to take over patient's medical management unless there are acute/active issues that need rapid changes - which for chronic pain is rather the exception then the rule (cancer being the exception)...

    I agree with the WHO that opioids are essential medications for the appropriate patient - but the WHO also advocates NSAIDS - does that mean that the pain specialist needs to manage the NSAIDS in a chronically stable patient as well?

    steve - i am not sure you read my post the way it was meant to be read... i ain't dissin' our field -

    about >40% of patients who come to see me for pharmacologic consultations drive >1 hour (from far-flung PCPs)... the PCPs gladly take over my recommendations and send them back if there are problems - i apply that same philosophy for the in-town PCPs... so far no problems...

    the principle that pain specialists have to assume the prescription of all pain meds is going to further heighten the shortage of access to pain specialists...

    when patients say that narcotics take the edge off - i qualify that... does it allow them to work, take care of their kids, dress themselves, walk to the bathroom... otherwise I automatically wean them...

    You would be SURPRISED with how many patients come back and thank me 6-10 weeks later... they usually state that their pain level is unchanged (and a few actually find their pain levels to be better), and they are usually ecstatic that they have regular bowel movements and a return of libido... in fact, in quite a few of those they adamantly refuse ever going back on narcotics.... so in all of the "benevolence" of pain physicians over-prescribing opioids, we may have actually been doing more harm than good.

    i had a guy with chronic axial thoraco-lumbar pain with unremarkable imaging - he is a high-functioning police chief who was taking 18 oxycodone 10mg/day to take the "edge off"... I weaned him off oxycodone over the course of three months (well his PCP weaned him based on my recs) - and he came back with a miraculous recovery with no more than an ache here and there -

    less is better than more

    look at the ASIPP numbers --

    the population of the US went up by 14% over the last 12-15 years --- the prescription rate of methadone went up >900%, the prescription rate of oxycodone went up >600%, etc... we are over-prescribing and under-treating is my opinion
     
  14. ampaphb

    ampaphb Interventional Spine

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    I would agree to take over the patient's care, assuming the following pre-conditions:

    The patient understand that injections are a part of the treatment regimen, and I will only write prescriptions if he is willing to undergo them. As Steve said, I have seen far too many bad esi's, or esi's when facets or sij's should have been performed, to accept that his procedures were done the way I would do them

    The patient understand that qid SAOs are never appropriate in my practice. I may well convert him to half his morphine equivalent in a LAO formulation, with no more than 30 tabs of a SAO/mo for BT pain.

    Under those pre-conditions, I would accept him as a patient. I would also explain to the PCP by phone that once his medication regimen stabilizes, I would like to send the patient back for them to continue to write his meds. Once I get them on board as a member of the medical team, I run into very little push-back.
     
    #13 ampaphb, Jun 7, 2008
    Last edited: Jun 7, 2008
  15. Tenesma

    Tenesma Senior Member

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    unfortunately there are too many patients who are willing to go through repeated injections in return for prescriptions - in my previous practice, the day we stopped prescribing opioids was the day we saw 25% of our chronic pain patients refuse further injections...

    that in of itself was eye-opening!
     
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  17. lobelsteve

    lobelsteve SDN Lifetime Donor
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    depending on the practice, you could have had sex for Rx's instead of procedures for Rx's. I do neither and cannot delineate the difference.

    (this is a joke).

    I applaud what you do. But IMHO, the PCP will need to send the patient back to me far too often to make it worthwhile not to just do the job right myself. I have 25% of my patients not on opioids, maybe a little bit higher. But that is their choice. I offer opioids to all patients that have moderate to severe pain and lack the very risk factors you mentioned above. If I see problems in follow-up, I can nip them in the bud- whereas the PCP would have to send the patient back to me after it is already to late and they have reached the point of a chemical coper, or peripheral and central sensitization has set in- either way- then everything we do becomes less effective.
     
  18. Tenesma

    Tenesma Senior Member

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    i agree with the nipping in the bud concept - very true...
     
  19. lobelsteve

    lobelsteve SDN Lifetime Donor
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    We're all on he same team, I just like pointing out the differences between practices amongst us and amplifying (not AMPAfying) them. All correct.
    THere are certain practices that I have seen that lead to getting a population of drug addicts, seekers, and miscreants. I think we could probably start another thread on the pitfalls of improper policies and practices that lead to "the waiting room from hell".

    Cheers.
     
  20. PMR 4 MSK

    PMR 4 MSK Large Member
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    I used to see a lot of #3 - "I was dumb enough to start this scumbag on opioids and now I'm sorry I ever did, but will you please rescue me? BTW, I gave him just enough opioids to get him through until his appt with you today. (Withdrawal starting in 3... 2... 1...)" I love when referrers do that!
     
  21. ampaphb

    ampaphb Interventional Spine

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    At UVA they had a rule - no narcotics on the first visit.

    Took care of many of the "I just moved here and am about to run out of my meds" scammers.
     
  22. mille125

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    my practice style is closer to steve's. i believe that if the opioid is improving a patient's function, then a reasonable pain physician should write for the medicine and not dump it on the PCP. i have probably tapered as many patients as i have started on opioid therapy. almost all of my patients who notice improvement in function are on relatively low doses of opioids (ie oxycontin 20 bid, opana 10 tid, duragesic 50ug, methadone 10 mg tid, avinza 30-60 qd, mscontin 15 qid, etc). opioid rotation is needed. escalation is rare..


    tenesma and i have had repeated discussions about his stance on this. i do not care to rehash any of these arguments. we will agree to disagree.


    i really think that you need to use your clinical judgement. i applaud steve on his posts..
     
  23. mille125

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    i have read the data and do recognize that there is a rare but real chance of QT prolongation with methadone (even though I have never seen this with an n> 1000 methadone pts)


    However, i really get the sense that a lot of this "paranoia" is being propagated by the pharmaceutical companies (ie makers of oxycontin, avinza, etc.). i too can throw together a study were a patient is on methadone, zoloft, droperidol, and other agents and gets prolonged Qt and blame it on methadone. or make a study with patients on 200 mg of methadone and blame it on methadone. unfortunately this does describe a lot of studies that physicians take as "gospel". what do you think steve or others?
     
  24. Tenesma

    Tenesma Senior Member

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    mille - i agree about methadone press - in fact, the drug reps (i still don't understand why they come to me when they know my prescribing patterns or lack thereof) are citing this more and more frequently in order to encourage the use of opana, fentora, avinza, etc... methadone is a good drug for the right person and the right condition...

    look at the recent "CME" insert for chronic pain/opioids in Pain News - it is subsidized by Endo, Alpha and others - and the authors are all on their speaker bureaus - look at what they say about methadone - it is a clear jab...
     
  25. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Thanks,

    I am anti-methadone. It's good cause it's cheap. THe risk is overstated.
    But the risk exists with this drug and no other opioid. The plaintiffs attorney will ask me why I chose this drug and I can say it is a good opioid, it also hits the NMDA receptor, etc. Then he'll ask me the risk of QTc prolongation. THen he'll ask what other drugs cause this. THen he'll show the list of 100 drugs that interact with methadone. Then he'll mention the cost.

    I think methadone is fine for other docs. As long as they have an EKG copy on the chart, an updated med list, and a special informed consent discussing the very small but real risk of Torsades.

    If mille has 1000 patients no problem on methadone, and 1000 other docs did the same thing, I could guarantee at least one death related to Torsades, a few related to accidental or intentional overdose (occurs with all opioids), and a media outcry.

    I only urge extreme caution when choosing a medication within a class that can have life threatening consequences like no the med in the class. If we were talking blood pressure- the drug would be minoxidil, If we were talking depression it would be the MAO's (Nardil).
     
  26. Tenesma

    Tenesma Senior Member

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    there are more oxycontin deaths compared to methadone deaths...

    and the reality is that most medications prolong QT interval anyway

    and the fact that methadone is actually cardio-protective (thanks to ischemic pre-conditioning)...

    clearly the media and the drug companies are pushing a different message, but i believe the risk of torsades in appropriate dosing is not very impressive... and i don't consider methadone clinics to be appropriate at dosing...

    look at all the other meds we prescribe with REAL pro-arrhythmic effects (ie: tricyclics...) - with REAL blindness (topamax), etc...
     
  27. mille125

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    Steve,


    I hate to say it but I think that the drug reps and the media have gotten to you. Isnt advertising and marketing a powerful thing? It is amazing that a majority of docs do not think that all of this advertising can affect them. Yet, the pharmaceutical company continues to pour millions of dollars into advertising. Why would they do this? I will let you decide.


    Tenesma is right. There are more deaths secondary to oxycontin compared to methadone. Hydrocodone remains the most abused and diverted drug across the board. I am not anti or pro any of these drugs. I have used methadone in many patients as I previously discussed. There have been side effects like with any medication. No one has had torsades and died. The pharmaceutical companies would love to see methadone disappear. If you go back and read the studies that indicate torsades with methadone, you will see that these cases occurred with massive dosages (greater than 100 mg day) or in concert with many other drugs that also prolong the Qt interval. Most pain doctors dose their patients at 15-40 mg per day. You cannot tell me that these serious effects occur frequently at this dosage.

    Many, many drugs that we use have a risk of rare but severe side effects. Just a few off the top of my head:

    1) Topamax- Metabolic acidosis
    2) Zanaflex- Seizures
    3) Lyrica- Blindness, addiction (I have seen two patients who just cannot get off of this med. The company has been notified)
    4) Neurontin- Severe lymphedema
    5) Trileptal- Severe hyponatremia
    6) Lamictal- Steven Johnsons syndrome
    7) Duragesic- Overdosage in high temperature states (fever, etc)


    What is one to use without being sued? I guess we will have to ask the attorneys.........ha ha ha


    In all seriousness though, Steve, methadone really is a safe drug if used by someone who knows how to dose it (which should be all pain mgmt doctors). You are a very skilled physician and I am confident that you will make the best choice for your patients. That choice may or may not be methadone. Dont let the big pharma industry sway your choice on dubious data.....
     
  28. PMR 4 MSK

    PMR 4 MSK Large Member
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    Steve plays good, defensive medicine, and I have to agree that with every choice of medication, you have to think in the back of your mind what the lawyer is going to ask you when it all goes south.

    On the flip side, when he (the lawyer) asks you why you chose Oxycontin which "clearly" (he'll use that word) is high risk, and he'll cite all the media hype in front of a jury, who will believe Maury Povich over any unknown (to the public) pain guru.

    No matter what med you choose, it has a downside, and the opposing lawyer can and will use that data or media hype against you, and will find a doc he can pay to argue that you never should have prescribed that particular drug, to that particular patient, or in that dose, or that frequency, or for that length of time. Or that you should have ordered this lab or that one, or some other test which "clearly" would have prevented the bad outcome. He will try to paint you as the village idiot.

    Any of the Scheisters reading this forum now would agree, which is why this case is hypothetical, just to bring out debate. If you haven't been deposed, even for a personal injury case as the treating doc or as an expert witness, just wait until you do. The opposing lawyer has a way to imply everything you do is wrong, incompetant, malpractice, etc.

    IMO, there is no one opioid that "clearly" is worse or better than any other. We can argue scientific data, but we all know you can make data say anything you want. The fact is, we practice medicine outside of studies, where they exclude people who could screw up their plans for the conclusions. Those excluded patients are our patients and we have to make real-world decisions that can affect who lives and dies.

    As in all of medicine, if the patient does well, you're the hero. If not, you're the villain, and you must pay. If you agree to put this hypothetical patient on opioids, potentially for life you take on all the risk. If you chose not to, your risk shifts in another direction. To me, it's all about balancing the risks and rewards.
     
  29. mille125

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    what exactly is the "reward" for not treating this patient??
     
  30. mille125

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    i find your responses to be interesting. To me it appears as if you are uncomfortable prescribing opioids (correct me if I am wrong). You have outlined a classic patient who should be considered for at least a trial of long acting opioids. You describe a patient who has low abuse risk, with a chronic pain condition, in which nonopioid medications and invasive procedures have been unsuccessful. You also describe a patient who has had an improvement in function from opioid therapy. Why are you uncomfortable starting this patient on an opioid trial? If so, why are you in this field?


    Worried about risk. You should be. This is what the informed consent is for. All of my patients who are on long term opioids sign a detailed consent. The first thing that I tell my patients is that they should not drive. I know that many do not follow my advice and feel that they lose their independence. However, it is clearly stated in bold letters that my medical advice is that they should not drive. I also list other possible side effects (decreased testosterone, risk of addiction and dependence, constipation, etc.). If a competent patient read this, understands it, and signs it, I believe that you have removed yourself from medical legal risk.


    I am curious to know why you are uncomfortable. Is it medical legal or some other reason?
     
  31. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I'll keep you guys in mind when I need to send a patient for MMT.

    Seriously, I am glad lots of folks like to Rx Methadone. If you want the literature to review I have several articles. Methadone is relatively safe, but I'd happily write for Oxycontin any day over Methadone.

    THe deaths from Oxycontin are not due to sudden cardiac death while the methadone deaths are.
     
  32. Tenesma

    Tenesma Senior Member

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    show me the data that reveals a clear link between cardiac death and methadone... all we know is that methadone increases QT...
     
  33. PMR 4 MSK

    PMR 4 MSK Large Member
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    I used to be a big believer in opioids and a patient's "right" to pain relief. I now find that to be a fallacy. After treating thousands of patients with opioids, I find the rate of abuse too high, compliance with prescription and the opioid contract/agreement to be poor, outcomes to be poor, tolerence to be common and more problems with opioid patients than any other.

    I use them rarely in my practice. Whether someone is on the long or short term, they sign an agreement. The agreement typically does nothing except set up a menu of potentially punishable offenses. It serves the purpose of the doctor, but not the patient. For some practioners, it also serves as informed consent.

    Abusers will sign anything, then try to talk their way out of punishment, ala children. Once you start writing for opioids for multiple patients, and abusers find you, all their friends and family come to see you, and then their friends and extended famileies, etc.

    I disagree that he his necessarily a good candidate for long-acting opioids, as opposed to his current meds. I have yet to see conclusive research showing their superiority in outcomes. At best they smooth out the ups and downs of SAO's and reduce # pills per day. But I often find that theroetically equianalgesic doses do not translate well (E.g. pt on 40 mg hydrocodone ends up on 120 mg Oxycontin for the same self-reported pain relief).

    This patient doesn't need an opioid trial, he's had it - they work for him. His functional improvement is a self-report that he can work with the meds. However, there is no information indicating he cannot work without them. How about an anti-opioid trial? He tries living life for a while without meds and see if he can cope.

    To me, opioids are little more than a coping mechanism. Their effect is central, on the brain. Patients who want opioids for long term typically have poor coping mechanisms. Patients who can cope with their pain don't want opioids - I treat many right now.

    The main answer to your repeated question is that I've been down the opioid road too many times with too many patients, and been burned too many times. I no longer believe opioids for chronic non-malignant pain is appropriate for the majority of my patients. Similar to what Tenesma has said in previous threads, I am much happier now without them. Their are other pain docs in the community here who still routinely precribe them, sometimes at crazy doses. One even told me he writes over 2000 prescritptions for opioids every month.

    Along the same lines, I got tired of being a medical policeman, trying to catch the bad guys and punish them for their deeds. I got tired of phone calls telling me so-and-so is selling his pills, or is addicted, or whatever. I got tired of the threats of being sued by patients when they got cut-off or fired. I got tired of the creative excuses why the Oxycontin was not in their system, but hydrocodone and marijuana were. I got tired of opioids. I burned out.
     
  34. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I'd correct the statement to read " All you know is... "

    Having trained fellows, I've been asked near everything about everything tangential. Lots of times we have no good data. For this, we have strong and lots of data. But to get things rolling:

    Am J Med. 2008 May;121(5):e23; author repply e25.
    A community-based evaluation of sudden death associated with therapeutic levels of methadone.Chugh SS, Socoteanu C, Reinier K, Waltz J, Jui J, Gunson K.
    Cardiac Arrhythmia Center, Division of Cardiovascular Medicine, Oregon Health and Science University, Portland 97239, USA. [email protected]

    BACKGROUND: Published case reports have associated the therapeutic use of methadone with the occasional occurrence of sudden cardiac death. Because of the established utility of this drug and with the eventual goal of enhancing safety of use, we performed a community-based study to evaluate this association. METHODS: During a 4-year period, we prospectively evaluated all patients who consecutively had sudden cardiac death and underwent investigation by the medical examiner in the metropolitan area of Portland, Ore. Case subjects of interest were those with a therapeutic blood level of methadone (<1 mg/L), and case comparison subjects were those with no methadone identified. Patients with recreational drug use or any drug overdose were excluded from either group. Detailed autopsies were conducted, including the detection and quantification of all substances in the blood. RESULTS: A total of 22 sudden cardiac death cases with therapeutic levels of methadone (mean 0.48+/-0.22 mg/L; range 0.1-0.9 mg/L) were identified (mean age 37.0+/-10 years, 68% were male) and compared with 106 consecutive sudden cardiac death cases without evidence of methadone (mean age 42+/-13 years, 69% were male). The most common indication for methadone use was pain control (n=12, 55%). Among cases receiving methadone therapy, sudden death-associated cardiac abnormalities were identified in only 23% (n=5), with no clear cause of sudden cardiac death in the remaining 77% (n=17). Among cases with no methadone, sudden death-associated cardiac abnormalities were identified in 60% (n=64, P=.002). CONCLUSION: The significantly lower prevalence of cardiac disease in the case group implicates methadone, even at therapeutic levels, as a likely cause of sudden death. These findings point toward an association between methadone and occurrence of sudden death in the community. Clinical safeguards and further prospective studies specifically designed to enhance safety of methadone use are warranted.
     
  35. PMR 4 MSK

    PMR 4 MSK Large Member
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    I wish I had that faith in the system to protect me from my patients' stupidity, ignorence and malice.
     
  36. lobelsteve

    lobelsteve SDN Lifetime Donor
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    YOu still may get sued, but you'd win.
     
  37. Tenesma

    Tenesma Senior Member

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    thanks for the data
     
  38. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Sorry to be brash, there is a bit more data out there. I love to overstate the risk, and I do realize the value of the medication (not dollar value, QOL value). Remember, I am on the speaker panels for King and Alpharma....
     
  39. Tenesma

    Tenesma Senior Member

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    well the data needs a bit more introspection, because i think what drove their decision of diagnosing sudden cardiac death was the lack of underlying cardiac disease on autopsy...

    we know methadone is actually good for the heart (from an ischemic disease point of view) - unfortunately, most people using methadone are usually smokers, alcoholics and cocaine-addicts which probably negates the beneficial effects...

    so are we diagnosing sudden cardiac death because of better looking hearts? and thus relying on the data re: qt prolongation?

    i need to talk to my pathology buddies
     
  40. 2win

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    anybody have a study to compare rates of opioid prescription per capita USA versus EU or Japan?
     
    #38 2win, Jun 12, 2008
    Last edited: Jun 13, 2008
  41. MN1

    MN1

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    Well said. I couldn't have said it better myself.
     
  42. melodic minor

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    Not only do I agree with everything you stated, I'd like to ask this question: Are we really doing these patients a service by prescribing them long term opioids?

    When I was a fellow, my PD constantly impressed upon me that these drugs were never designed to be used on such a long term basis, and the consequences of such use could range from opioid induced hyperalgesia, to immune system depression, and supression of testosterone production.

    Does anyone ever consider that if you prescribe long term high dose opioids to someone so they can continue to do strenous labor with an already compromised spine, that the end result is that in ten years they'll be far worse when they develop advanced denerative disc and facet disease and spinal stenosis? Not to mention god help the anesthesiologist who has to manage that patient's post op pain.
     
  43. algosdoc

    algosdoc algosdoc

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    Opiate management of patients is indeed a thorny area fraught with potential pitfalls. That being said, for many long term stable doses of opiates can provide significant sustained pain relief without substance abuse or diversion. Opiate induced hyperalgesia is certainly not a universally occurring issue with opiate treatment and neither is testosterone suppression. These are well known side effects of the drugs. The idea that people should not receive pain relief due to the potential for injuring themselves trying to support their families doing a labor intensive job borders on playing God with other people's lives. It is not our charge to make unsubstantiated assumptions about what might happen long term due to patients work ethics or financial needs, and deny them treatment based on our elitist value judgements, clearly in the absence of scientific judgement. Frequently those that are the harshest critics of opiate management do not have other viable alternatives for patients living in the real world. Telling patients to stop taking opiates in the absence of abuse or diversion and in the presence of enhanced patient functionality appears to be pompous and arrogant to them when there are no other options offered to the patient other than endless needle injections (whose potentially profound side effects are minimized by the same doctors that maximize the opiate side effects). Telling patients to think happy thoughts is rarely a viable option anymore than prescribing tylenol. Pain medicine requires evaluation of the tools available and utilizing those that work, using the available levels of evidence to support their use. Long term opiate use is not a panacea, but it is a viable tool for many. There is some evidence of long term effectiveness (>1 year).
    Opiate prescribing may cause problems for a medical practice, attracts some patients that do not have chronic pain, and may subject the physician to unwanted interactions with law enforcement although extremely rarely is activity taken against physicians by law enforcement. Opiate prescribing comes complete with patient monitoring responsibilities. Those that find these unsavory or inconvenient should not prescribe opiate narcotics. Same for anticonvulsants or antidepressants. However, when all aspects of pain medicine are transferred to the family doc with the sole exception of needle work, do not be surprised to find family docs venturing into interventional pain since they view themselves as more adept at comprehensive pain treatment than are the pure interventionalists. Same for NPs and CRNAs. If we are to be pain physicians instead of technicians, we have to either provide comprehensive pain treatment or arrange for it, rather than telling the patient we stuck them 3 times with needles over the past 6 weeks and since they are not better, we are finished with them (patient reads: physician does not want to help, is incompetent, or is a mindless but ridiculously expensive block jock). Pain medicine is far more than prescribing exercises to be carried out by a physical therapists, prescribing psych to be carried out by a psychologist, or prescribing opiates to be carried out by their own family physician. It is more than jabbing needles into the spines of patients then telling them there is nothing wrong with them and they should just suck it up and get a job, but not too hard of a job.
    If we refuse to help a patient because of the self imposed limitations of our medical practice or because of hyperspecialization, then we have no right to criticize the actions of others that do attempt to help those that suffer.
     
  44. 2win

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    - you bring some interesting points for this debate:
    1) the informed consent IMO doesn't protect us against the lawyers ( I wish...) "If a competent patient read this, understands it, and signs it, I believe that you have removed yourself from medical legal risk." - they will say that they were in pain, distress and they didn't understand. How we determine the competency and document in our charts? I don't know - I believe that patient alert and oriented X3 is not enough.
    2) The driving issue - it is enough to advice the patient to don't drive or we should write a letter to DMV to suspend his (her) licence? I am still confused about this problem. Literature abunds about this...I would like to see some legal stuff.
    Though - we are better than others.
     
    #42 2win, Jun 12, 2008
    Last edited: Jun 12, 2008
  45. mille125

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    now this is very well said and you other "pain docs" need to take note...thank you algos
     
  46. 2win

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    I do believe that opioids are over prescribed. And pain undertreated.
     
    #44 2win, Jun 12, 2008
    Last edited: Jun 13, 2008
  47. Tenesma

    Tenesma Senior Member

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    algos and PMR have summed up good points of view on chronic opioids...

    but sometimes Algos's view on opioids (which is mirrored by many pain physicians, including my own) are misunderstood in the setting of "compassion", etc and end up being distorted into the concept that withholding opioids is inherently evil and wrong.

    i agree also with the fundamental concept that "just" doing injections does leave an unsavory taste in the PCPs mouths.... i find that PCPs really are thirsting for some type of improvement in patients with pain and if that isn't possible they desire a structured environment in which to manage the patient, as well as resources to fall back on when the patient becomes difficult to manage (usually because of personality disorders).

    for melodic minor - i personally feel we are doing most patients (especially young patients or patients with psychiatric issues) a dis-favor by starting chronic opioid management... We have to look at the big picture and realize that while we can usually get some form of control in the first few years of opioids, it usually becomes a quagmire 5, 10, 20, 25 years later....

    the best patient profile for chronic opioid management in non-cancer pain:
    >age of 50, either still working or demonstrated improvement in function while on opioids, no underlying personality disorder, no bipolar disorder, no history of substance abuse, evidence of underlying disease by exam and imaging...

    interestingly, the PCPs have figured out that profile, and they feel perfectly comfortable managing opioids in that category of patient - so therefore, we get the rest of the pack :D

    what really drives me nuts are those pain patients who have coping problems and rely on their opioids for coping - i am TOTALLY against the use of opioids for the management of depression, anxiety or dysfunctional coping mechanisms.
     
  48. Mister Mxyzptlk

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    The same argument would apply for people undergoing an ESI or a laminectomy. If we follow your logic then no informed consent in pain management is valid. People being treated for renal colic, MI, appendicitis, labor pain, etc, are all enduring pain and distress, yet their informed consent holds up.
     
  49. 2win

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    Yes - you're absolutely right. The point is that an "informed consent" doesn't protect any physician....a lot. Sad...I believe that what we'll protect us is a great relation with our patients. There are times when I preffer to excuse myself from they care when I see that a good physican -patient relationship is not in place.
     
  50. Tenesma

    Tenesma Senior Member

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    what do you guys do with liars?

    i would terminate the relationship the 1st time i catch them in a lie... is that too harsh?
     
  51. algosdoc

    algosdoc algosdoc

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    Depends:
    If they have illicit drugs in UDS other than marijuana, no more opiates.
    If they have marijuana in UDS, then 1 warning.
    If they have unprescribed opiates in UDS, then no more opiates.
    If they have none of the prescribed opiates in UDS, one chance to explain and if reasonable, will retest later.
    If patient states UDS test is incorrect, we have the lab run a GC/MS for confirmation.
    If there is a report (anonymous) that the patient is selling drugs, pill count within 24 hours of the call unless they are to be seen the next day, then pill count one week later.
    If our state INSPECT report shows chronic (more than one month) double dipping without disclosing this or without our assent, no more opiates.
    If patient is absolutely known to us to be selling drugs or alters a prescription or steals prescriptions, discharge at once and report to both DEA and local police in addition to their PCP.
    If patient runs out early of meds, we will prescribe tizanidine for withdrawal until their next script time is due, and for 6 months revert to monthly or biweekly scripts. Repeatedly running out early requires reassessment of the patient and at times withdrawal from all opiates if the patient does not have control over their use of the drugs.

    Our policy of no more opiates is not discharging the patient from our practice (since we would be required to give an additional 30 day supply to abuse or sell). We don't discharge- we simply change their therapy. We are happy to prescribe all the PT, psych, injections, acupuncture, yoga, non-controlled substances the patient needs but will never again prescribe opiates.
     
  52. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Identical policy here.

    I have not used Tizanidine for withdrawal. I typically use Clonidine 01.mg bid prn or the Catapres patch. Rarely I have used Klonopin (on the fence because it is a BZD with the same risk of abuse/misuse) in very selected patients who had lost or stolen meds and policy dictates no more opioids, or no opioids until the next visit. I think it helps reinforce the serious nature in which we handle these situations while trying to do the right thing for patients.
     

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