WTF are ya doin ?

[ghost dog]

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Here's a keeper:

Came across a paper review recently:

Pt taking 10 x80 mg Oxycodone AM / 8 x 80 mg Oxcodone PM

Pt has a Hx of

1. alcohol abuse
2. Drug abuse
3. run ins with the law / imprisonment
4. suicide attempt - with PILLS !!

The "doctor" ( and I use the term very loosely) who started him on the above regimen was disciplined for prescribing narcs " too enthusiastically " - has lost narc license due to above such insanity. Pt runs to another doc, who is now prescribing this wackadoo dose. I am unable to get in touch with her, as she doesn't seem too eager to speak to me.

Anyone else thinkin diversion ????

Unfriggin believable.

 

[Aether2000]

When doctors place no limits on their prescribing maximums and follow the manufacturer's propaganda of the 1995-2005 era that there are no ceilings on pain medication, nonsense like this results. A local doc (gastroenterologist) is prescribing 320mg methadone per day plus xanax for chronic abdominal pain....the family has pleaded with him to cut back on the prescribing due to the patient being gorked all day long, stumbles and falls frequently, and is incoherent, but the doctor continues massive overprescribing.
What we really need is a national maximum dosage for our practices that should only be exceeded in extraordinary circumstances....

 

[lobelsteve]

When doctors place no limits on their prescribing maximums and follow the manufacturer's propaganda of the 1995-2005 era that there are no ceilings on pain medication, nonsense like this results. A local doc (gastroenterologist) is prescribing 320mg methadone per day plus xanax for chronic abdominal pain....the family has pleaded with him to cut back on the prescribing due to the patient being gorked all day long, stumbles and falls frequently, and is incoherent, but the doctor continues massive overprescribing.
What we really need is a national maximum dosage for our practices that should only be exceeded in extraordinary circumstances....

All family has to do is file complaint with medical board.

Failure to address family's concerns is biggest reason that a report will be filed.
The patient will unlikey file any complaint related to opiates.

 

[Birdstrike]

when doctors place no limits on their prescribing maximums and follow the manufacturer's propaganda of the 1995-2005 era that there are no ceilings on pain medication, nonsense like this results. A local doc (gastroenterologist) is prescribing 320mg methadone per day plus xanax for chronic abdominal pain....the family has pleaded with him to cut back on the prescribing due to the patient being gorked all day long, stumbles and falls frequently, and is incoherent, but the doctor continues massive overprescribing.
What we really need is a national maximum dosage for our practices that should only be exceeded in extraordinary circumstances....

.

 

[101N]

When doctors place no limits on their prescribing maximums and follow the manufacturer's propaganda of the 1995-2005 era that there are no ceilings on pain medication, nonsense like this results. A local doc (gastroenterologist) is prescribing 320mg methadone per day plus xanax for chronic abdominal pain....the family has pleaded with him to cut back on the prescribing due to the patient being gorked all day long, stumbles and falls frequently, and is incoherent, but the doctor continues massive overprescribing.
What we really need is a national maximum dosage for our practices that should only be exceeded in extraordinary circumstances....

Don't forget our colleagues who happily sold out to PHARM during the same era. They are still the 'thought leaders' in all of our major pain societies. Everyone involved in Hurwitz defense team should called out for special attention.

 

[Aether2000]

There are no anonymous complaints with our board....whoever files the complaint, their identity becomes known. In this situation the family that makes trouble for the doc makes trouble for themselves since they would become homeless. The social entanglements sometimes make rational choices impossible.

 

[PinchandBurn]

When doctors place no limits on their prescribing maximums and follow the manufacturer's propaganda of the 1995-2005 era that there are no ceilings on pain medication, nonsense like this results. A local doc (gastroenterologist) is prescribing 320mg methadone per day plus xanax for chronic abdominal pain....the family has pleaded with him to cut back on the prescribing due to the patient being gorked all day long, stumbles and falls frequently, and is incoherent, but the doctor continues massive overprescribing.
What we really need is a national maximum dosage for our practices that should only be exceeded in extraordinary circumstances....

Do you think the patients are really telling you the truth?

What doc would not go DOWN on the meds if the patient/family request it? There's no difference in terms of billing ......sounds fishy..

 

[Ducttape]

very few docs would be daft enough to go that high...

but im willing to hazard that very few docs would go down, if the patient disagreed and threatened legal action, etc.


i am not in favor of limitations on dosages, because who decides? and setting a max limit does encourage many to think that going up to but not exceeding that limit is safe...

REMS are not that great, but they are a start...

 

[emd123]

When doctors place no limits on their prescribing maximums and follow the manufacturer's propaganda of the 1995-2005 era that there are no ceilings on pain medication, nonsense like this results. A local doc (gastroenterologist) is prescribing 320mg methadone per day plus xanax for chronic abdominal pain....the family has pleaded with him to cut back on the prescribing due to the patient being gorked all day long, stumbles and falls frequently, and is incoherent, but the doctor continues massive overprescribing.
What we really need is a national maximum dosage for our practices that should only be exceeded in extraordinary circumstances....

What would you pick that dose to be? The number I keep seen being thrown around is 120 mg of Morphine equivalents per day. In the current climate, it would be nice to have a dose, that if you are under it and the patient is not showing aberrant behavior otherwise and has a legitimate medical need, that it's considered okay. That would at least get rid of this, "Doses like this are only seen in cancer patients and drug dealers!" stuff.

The days of titrating up indefinitely, with no ceiling are over in chronic non-cancer pain. If you started at dose X, and you're still no better at dose 10 times X, why would I think that 11 times X will be the magic number? Regardless of whether a few outliers may do well on very high doses, the regulators just aren't going to tolerate it any longer. Unless you can invent a drug with no tolerance.

 

[lobelsteve]

What would you pick that dose to be? The number I keep seen being thrown around is 120 mg of Morphine equivalents per day. In the current climate, it would be nice to have a dose, that if you are under it and the patient is not showing aberrant behavior otherwise and has a legitimate medical need, that it's considered okay. That would at least get rid of this, "Doses like this are only seen in cancer patients and drug dealers!" stuff.

The days of titrating up indefinitely, with no ceiling are over in chronic non-cancer pain. If you started at dose X, and you're still no better at dose 10 times X, why would I think that 11 times X will be the magic number? Regardless of whether a few outliers may do well on very high doses, the regulators just aren't going to tolerate it any longer. Unless you can invent a drug with no tolerance.

200mg is the ceiling. Above that, increased documentation, increased frequency of visits, and multimodal approach required.

Documentation: UDS 3+ times per year, calls to pharmacy or check database and document. Functional status must be included and detailed in every note.

 

[101N]

100mg is the ceiling...

Ann Intern Med. 2010 Jan 19;152(2):85-92.
Opioid prescriptions for chronic pain and overdose: a cohort study.
Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M.
Source
Group Health Research Institute, Seattle, Washington 98101, USA.
Abstract
BACKGROUND:
Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown.
OBJECTIVE:
To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy.
DESIGN:
Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose.
SETTING:
HMO.
PATIENTS:
9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005.
MEASUREMENTS:
Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes--nonfatal and fatal overdoses--were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review.
RESULTS:
51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate.
LIMITATIONS:
Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation.
CONCLUSION:
Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients.
PRIMARY FUNDING SOURCE:
National Institute of Drug Abuse.

 

[ghost dog]

very few docs would be daft enough to go that high...

but im willing to hazard that very few docs would go down, if the patient disagreed and threatened legal action, etc.


i am not in favor of limitations on dosages, because who decides? and setting a max limit does encourage many to think that going up to but not exceeding that limit is safe...

REMS are not that great, but they are a start...

The doc in the initial post is a gas passer, which goes to show you that the road to hell is paved with good intentions.

Almost without exception, chats I have with other docs in regards to paper reviews are very collegial. However, considering her reluctance to call me back, I don't think that this would have been one of those times. 😎

I strongly believe that she hasn't done her howework in regards to this patient's background story ( which neither the medical licensing board or the drugs squad will care about ) . It is pretty much guaranteed this situation will blow up in her face... sooner or later. And in a big way.

 

[lonelobo]

A ceiling dose is a theoretical number which is different for each person, obviously you see disagreement with this on this board of pain specialists....just think what it is like with PCP's

 

[Aether2000]

Ours is a somewhat higher ceiling for the vast majority of patients is 300mg/day, but we have only a handful in my practice at that dosage level. The problem with the Ann Int Med study is that it did not identify co-drug variables that would have caused overdose. Frequently there are multiple sedating medications prescribed by several physicians to the same patient simultaneously without a thought as to the implications. The other problem with the Ann Int Med is that it was assumed the patient took the medications as prescribed. That is rarely the case when there is overdose. Frequently patients will take far more than prescribed. Also the article assumes the patient acquired their opioid narcotics only through the insurance system. This is also frequently not the case as shown in data regarding drug sharing published by the CDC. I suspect the milligrams of opioid involved with overdose actually taken was much much higher than the 100-120mg a day.

 

[Ducttape]

so... we have 4 board certified pain docs on this forum who postulate a ceiling dose... and there are 4 different doses.

no wonder PCPs dont know how high to go, let alone how to stop going up...

 

[101N]

so... we have 4 board certified pain docs on this forum who postulate a ceiling dose... and there are 4 different doses.

no wonder PCPs dont know how high to go, let alone how to stop going up...

Ah, ask the 4 for data to support their positions and then ask them for their disclosures, i.e., have you received $ from PHARMA.

Recommended maximum dose 100mg-MS04 equiv/day, disclosures: $0.00.

There is bias here.

 

[Aether2000]

The ceilings are based on our own extensive clinical experience, the degree of infrastructure and monitoring that is used in our own practice, patient selection, and the ability to withdraw opioids (sometimes suddenly if necessary) without trepidation. They have nothing to do with pharma monetary support or money since I have received none in over a decade.

 

[lobelsteve]

The ceilings are based on our own extensive clinical experience, the degree of infrastructure and monitoring that is used in our own practice, patient selection, and the ability to withdraw opioids (sometimes suddenly if necessary) without trepidation. They have nothing to do with pharma monetary support or money since I have received none in over a decade.

Agree with above.

One crappy study from 101N's post is useless.

I believe my 200mg is based on clinical experience as per Algos above as well as prior data suggesting adverse events at 192mg+ from another study.

DIsclosure: Savella speaker (4 talks in 3 years), Opiate pharma lectures: None since 2007
DEA: $5000+ per year
Medical Boards: $5,000+ per year
Independent review company: $5000+ per year

I like using my rules based on exhaustive reviews from multiple states from 100's of physicians and 1000's of charts. I have gleaned the standard of care and opined for DEA and medical boards what is and is not acceptable based on documentation.

Disagree with my review, appeal. My testimony has helped take many a license from drug dealers and helped find appropriate folks appropriate jailing.

I'm the guy who represents us, and you (PCP's, Peds, Neuro so far) do not want to be on the other side of the table. I believe in a reasonable approach to opiates, am not opiophobic, and that we have a greater obligation to society when we Rx. It is not just a doctor patient relationship when prescribing.

 

[101N]

The ceilings are based on our own extensive clinical experience, the degree of infrastructure and monitoring that is used in our own practice, patient selection, and the ability to withdraw opioids (sometimes suddenly if necessary) without trepidation. They have nothing to do with pharma monetary support or money since I have received none in over a decade.

Disclaimer: the 100mg equiv is what I use for PMD's as their ceiling. You, I, and others here often inherit folks who exceed this dose. IMO, they are better followed by a specialist.

 

[powermd]

It is not just a doctor patient relationship when prescribing.

Wise words.

 

[NEPain]

It's hard for me to believe that anyone would embrace a ceiling dose. Who is going to decide on the dose? The "thought leaders" in whom we don't have faith?
All these attempts to control the practice of medicine are counterproductive. It's clear that there is a wide range of pharmacokinetics/dynamics among patients. So, outliers have to suffer while we get permission to prescribe?
If the goal is to control diversion or incompetent docs, then this is not the solution. IMHO.
It's like applying "evidence based medicine" to Pain Medicine. It makes no sense. Education is likely to be more successful than trying to objectify something that is totally subjective.
Are we professionals or kindergarten students?

 

[101N]

It's hard for me to believe that anyone would embrace a ceiling dose. Who is going to decide on the dose? The "thought leaders" in whom we don't have faith?
All these attempts to control the practice of medicine are counterproductive. It's clear that there is a wide range of pharmacokinetics/dynamics among patients. So, outliers have to suffer while we get permission to prescribe?
If the goal is to control diversion or incompetent docs, then this is not the solution. IMHO.
It's like applying "evidence based medicine" to Pain Medicine. It makes no sense. Education is likely to be more successful than trying to objectify something that is totally subjective.
Are we professionals or kindergarten students?

Here is a experiment to test your hypothesis. Ask Alex Cahana and Mike VonKorff for stats are on overdose in WA pre and post implementation of the 120mg/day requirements. My bet is that there will have been a BIG decrease in prescription deaths and other adverse events.

 

[ghost dog]

It's hard for me to believe that anyone would embrace a ceiling dose. Who is going to decide on the dose? The "thought leaders" in whom we don't have faith?
All these attempts to control the practice of medicine are counterproductive. It's clear that there is a wide range of pharmacokinetics/dynamics among patients. So, outliers have to suffer while we get permission to prescribe?
If the goal is to control diversion or incompetent docs, then this is not the solution. IMHO.
It's like applying "evidence based medicine" to Pain Medicine. It makes no sense. Education is likely to be more successful than trying to objectify something that is totally subjective.
Are we professionals or kindergarten students?

Problem : education typically doesn't work with the lazy and incompetents MDs you refer to; as such, we are left with watchful doses.

I am continually amazed by some of the doses I see in my community. Every time I see a stupid high dose, I think to myself : no one can top that. Needless to say, somebody comes along, and shows me their lack of education / insight into pharmacology and concern for patient safety.

Pharma disclosure: big fat zero.

However, I am paid reasonably well for providing my opinion in respect if opioids are appropriate in various settings.

 

[NEPain]

Ghost dog, your comments are sad but true. Ultimately, though, we should be responsible for our profession. Sheesh, if you can get through college and med school, how can you not learn to prescribe opiates responsibly? But, I do realize that many do NOT do that. So, I will assume we are not talking about caps for pain specialists. I may have misunderstood the reference by algos to a ceiling dose. Would this be a maximum dose that can be prescribed by NON pain docs? Any dose higher would require consultation with a pain doc?
I remember an article in the last few years that suggested we have specialized opiate management clinics. Seems like it was prescient.
101N, whether there was a decrease in deaths and adverse effects is not really relevant by itself. If I eliminated highways and put a maximum speed of 30 mph on all cars I could decrease traffic deaths. What price do you pay for this? Are people suffering who need higher doses? What other meds are found in overdose deaths? Alcohol? BZD's? Why not limit them instead? A maximum dose makes no sense with a class of medications that has such a range of tolerances among patients. It sounds like a ceiling would not treat outliers. I still think education is the answer. And maybe opiate clinics.

 

[Aether2000]

The dosage I quoted was my ceiling in my clinic for my prescribing. If a non-pain doc prescribed this much and referred the patient to me, I would not accept the patient since they are already way above my comfort zone for prescribing. I think the Washington experience is probably a valid method of controlling medication prescribing. The maximum for patients is not 120mg, but that is the usual maximum dosage that is permitted until a pain consult is obtained, or tried to be obtained. Most PCPs and non-pain specialists are not cavalier enough to be prescribing more than this amount for most patients, but a few will, and it is these outliers that need to be capped. For pain physicians, there may be an internal cap that is self imposed.
One of the main problems in Washington was the state pushing doctors to prescribe cheap drugs (ie methadone) via their Medicaid rules, and predictably people ODd on the methadone. BTW, I have just completed a comparison of the ARCOS data for sales plotted against death for semisynthetics/morphine and for methadone. It turns out methadone had a 10:1 ratio of potency causing death compared to semisynthetics/morphine. This is much higher than the generally accepted potency of 1.5-3 times the semisynthetics/morphine. This shows methadone to be a much more dangerous drug than most of us appreciate.

 

[ghost dog]

Ghost dog, your comments are sad but true. Ultimately, though, we should be responsible for our profession. Sheesh, if you can get through college and med school, how can you not learn to prescribe opiates responsibly? But, I do realize that many do NOT do that. So, I will assume we are not talking about caps for pain specialists. I may have misunderstood the reference by algos to a ceiling dose. Would this be a maximum dose that can be prescribed by NON pain docs? Any dose higher would require consultation with a pain doc?
I remember an article in the last few years that suggested we have specialized opiate management clinics. Seems like it was prescient.
101N, whether there was a decrease in deaths and adverse effects is not really relevant by itself. If I eliminated highways and put a maximum speed of 30 mph on all cars I could decrease traffic deaths. What price do you pay for this? Are people suffering who need higher doses? What other meds are found in overdose deaths? Alcohol? BZD's? Why not limit them instead? A maximum dose makes no sense with a class of medications that has such a range of tolerances among patients. It sounds like a ceiling would not treat outliers. I still think education is the answer. And maybe opiate clinics.

I would most definitely not want to run an opiate clinic / day or what have you... this would not be a rewarding endeavor.

I have noticed a trend with high dose opioid referrals : it does appear that this patient population is more likely to have high risk characteristics , such as : a history of substance abuse + family hx of substance abuse compared to my own opioid pt population. I am more likely to believe that they are looking for an opioid derived high / diverting ( unfortunately I'm a cynic) than believe they are "opioid resistant."

 

[Ducttape]

algos, you qstate the "generally accepted potency of 1.5-3 times the semisynthetics/morphine".

are you specifically referring to mortality or pain equivalence? if the latter, i dont think you can correctly draw the conclusion that potency with regards to mortality can be equated to potency with regards to pain relief.

unequivocally, though, this evidence should be used to reinforce the opinion that methadone should not be prescribed by PCPs.

and i do disagree with your comment about most PCPs being cavalier enough to prescribe more than 120mg per patient. After all, thats "only 2" 60 mg MS ER, or "only 8" Percocet 10/325s or "only 1" Fentanyl 25-50 mcg/hr patch, doses that most PCPs have no concerns about prescribing.

 

[NEPain]

ducttape's points about methadone are the same I would make. Methadone is a complex drug that is poorly understood by most prescribers, even pain docs, if only for the huge variation in bioavailability among individuals. Add that to the long respiratory depression half life compared to the much shorter analgesic half life and you get OD's. How are drug OD's defined? Someone ?MSK mentioned that a patient who died in an mva after having a stroke was found to have methadone in his blood. Cause of death? drug overdose. So statistics don't mean much to me unless I understand how they are arrived at.
I'm sure we're all cynical. I assume most of my patients are lying to me, but I don't act on these feelings other than to get pill counts, urine tests, etc.
Clearly, high dose opiates are not for most patients, but they are for some. Injections are not for everyone.
I seldom prescribe high doses of opioids but I don't want that option controlled. We are already controlled enough. I'd rather see an attempt at eduction.

Our pain clinic receives many referrals of patients who have been gradually placed on higher and higher doses of opioids until the pcp is uncomfortable. YES, Ghost Dog, these are usually "HIGH RISK" patients. Those are the ones that ask for opioids. Among them are patients with severe arthritis, crps, undiagnosed cancer, high tolerance from long use with good results (pain and function). Why should those patients be denied treatment, even for a single day?
I accept that part of my practice is weeding out the screwups that convinced someone to put them on high dose narcs. I also see it as part of a social and genetic disease, so I don't feel anger towards the patients, even though I might not like them at all. I wean the FM patients on high methadone doses and try to educate the referring docs. Another issue is that it's not always docs. In some places we have other disciplines who can prescribe and may not have the experience to do it properly.
And I don't refuse to see a patient. I may refuse to prescribe what they've been getting, but I'll see them and usually have other things to offer. It would be nice if addiction treatment were more readily available instead of just 12 steps. Finally, I would not want to run the opiate clinics either, but someone would and they would handle it better than it's handled now.

 

[101N]

"Those are the ones that ask for opioids. Among them are patients with severe arthritis, crps, undiagnosed cancer, high tolerance from long use with good results (pain and function)."

I'm calling your bluff, Publish demographic data on the patients in your clinic so we can see the average ages, comorbidities, work histories, welfare rates, diagnoses, BMI's, smoking histories, illicit drug histories, DUI's, criminal histories, etc. These are not productive members of society who just happen to need their oxy/MS04/Metadone to allow them to work and carry on, raise their families, pay taxes, contribute.Don't try
to 'sell' what you are doing to a group of your peers who live in this specialty.

That said, most of us recognize that there is a cohort of opioid users who should never have started in the first place, and will never get off. Ballentine mentioned this in her recent NYT article. In a time of opioid pull backs how do we handle these folks. Maybe your clinic is the answer for these people. I do not want to work there.

The answer to the prescription epidemic is prevention: stop writing the scripts.

 

[NEPain]

Well, 101, you have an antagonistic style. There is no bluff. We're not playing poker. You may have misunderstood me. I was agreeing with Ghost Dog that most of the patients on high dose opioids are also high risk patients. I was, however, suggesting that we be careful not to throw out the baby with the bathwater.
You can stop writing prescriptions if you want. Of course, that's not fair to your patients and it makes you an incomplete pain doctor. Don't know what you mean by "my clinic". If you're referring to my actual pain clinic, you probably would not want to work here because we run a multi-disciplinary clinic and prescribe meds appropriately as part of the treatment.
If you're referring to the "opiate clinic", that is not "my clinic". It was a suggestion in one of the major journals a few years back. I would not want to work in that type of clinic either, but I do think it would be a good idea. I do take care of addicts since they are sick and I'm a doctor.

I'm not trying to "sell" anything. I thought we were discussing an issue here, but if I don't follow your dogma, I'm trying to sell you something? You say "stop writing scrips". To me, that's practicing poor medicine and definitely unethical. You're typical of the docs that attack each other anonymously while everyone else is giving it to us per rectum. I ain't publishing jack for you. As we prescribe less, more heroin has begun to appear for our kids to use. Not writing won't help.

 

[101N]

As we prescribe less, more heroin has begun to appear for our kids to use. Not writing won't help.

This is precisely my point. I am not a surrogate for a street pusher. But in my clinical experience- most - of the people you describe as "High Risk" are looking for just that. That is the roll that Hurwitz carved out for himself. These - High Risk - are dysfunctional people who use opioids to cope with their dysfuction lives. Are they suffering, have they been dealt a bad hand, are their lives tragic, yes to all. Are you really helping them by mollifying them with opioids and addicting them: no.

Most of us - people in the field - won't start opioids on these folks because we see where it's going. Typically they are started by primary providers, with no exit strategy, and then when they reach some crazy crescendo dose they are punted to us. We become the sheppards of the flock that we did not create.

This is not a 'pain' problem, it's a subset of people with societal coping problems. But society needs to look elsewhere than pain medicine for coping problems. There is NO RATIONAL WAY TO JUSTIFY THE AMOUNT OF OPIOID PAIN MEDICINE USED IN THE US WHEN COMPARED INTERNATIONALLY. The model you are advocating for has been tried and failed. Our society's appite for opioids is NOT a medical problem and I won't participate in making it so.

 

[Aether2000]

If opioids universally created substance abuse and drug diversion problems or were associated with such, then the barring of the use of opioids in chronic pain could be justified. But they do not. There are indeed far too many opioids prescribed in our society, and the PCPs are at the forefront of the problem, escalating doses based on vague complaints of pain without any other meaningful interventions. Yet, opioids do work for some chronic pain patients when other avenues have failed. Those that do not want to deal with the nastiness of prescribing opioids in a population that overlaps appropriate use, drug diversion(non medical use), drug dealers, and substance abuse, I agree should not feel compelled to do so. But it is a quantum leap to say no patients should receive such medications because of physicians that are unwilling to apply monitoring and detection techniques for substance abuse and diversion. We have only 6 studies supporting significantly long term use of opioids. And we have studies showing the substance abuse rates are 35%. And we have studies showing significant sharing of drugs in the population. And studies that demonstrate under highly controlled circumstances with inpatient long term rehab) some patients may have nearly equivalent pain control without opioids. But what we do not have are studies that find opioids ineffective for the treatment of most chronic pain. When those studies become prevalent , then the US should indeed consider a ban on opioids for the treatment of pain.
Prescribing opioids for this population is not easy. It takes work.....and is not nearly as easy as performing a RF neurotomy or transforaminal epidural steroid injection. It requires street smarts, detective work, rules of steel in your practice, and exit strategies that are tried and tested. For those that accept this challenge for the greater good of parsing out the subset of patients that could benefit from chronic opioids and commit to the vigilance and education of patients needed to avoid substance abuse issues, it can be a lifesaver for those patients. But I grant you it is certainly not for everyone.

 

[emd123]

If opioids universally created substance abuse and drug diversion problems or were associated with such, then the barring of the use of opioids in chronic pain could be justified. But they do not. There are indeed far too many opioids prescribed in our society, and the PCPs are at the forefront of the problem, escalating doses based on vague complaints of pain without any other meaningful interventions. Yet, opioids do work for some chronic pain patients when other avenues have failed. Those that do not want to deal with the nastiness of prescribing opioids in a population that overlaps appropriate use, drug diversion(non medical use), drug dealers, and substance abuse, I agree should not feel compelled to do so. But it is a quantum leap to say no patients should receive such medications because of physicians that are unwilling to apply monitoring and detection techniques for substance abuse and diversion. We have only 6 studies supporting significantly long term use of opioids. And we have studies showing the substance abuse rates are 35%. And we have studies showing significant sharing of drugs in the population. And studies that demonstrate under highly controlled circumstances with inpatient long term rehab) some patients may have nearly equivalent pain control without opioids. But what we do not have are studies that find opioids ineffective for the treatment of most chronic pain. When those studies become prevalent , then the US should indeed consider a ban on opioids for the treatment of pain.
Prescribing opioids for this population is not easy. It takes work.....and is not nearly as easy as performing a RF neurotomy or transforaminal epidural steroid injection. It requires street smarts, detective work, rules of steel in your practice, and exit strategies that are tried and tested. For those that accept this challenge for the greater good of parsing out the subset of patients that could benefit from chronic opioids and commit to the vigilance and education of patients needed to avoid substance abuse issues, it can be a lifesaver for those patients. But I grant you it is certainly not for everyone.

Another great post by Algos. Couldn't have said it better.

 

[Ducttape]

But what we do not have are studies that find opioids ineffective for the treatment of most chronic pain. When those studies become prevalent , then the US should indeed consider a ban on opioids for the treatment of pain.

Not to take you to task or to be too argumentative, but there does not have to be the requirement that we have to declare that opioids are ineffective for treatment of chronic pain for a ban or limitations to be placed on their use for chronic pain.

To use analogies, which i do a lot, a similar example might be with cigarette smoking. We have more than enough information that cigarette smoking has almost no beneficial effects, yet cigarettes are not banned. They are highly taxed, and people who use them should be penalized from a cost side because their utilization of health care dollars far exceeds those who do not smoke.

Likewise, i personally dont think opioids should be banned, and their use is highly effective for postsurgical pain, palliative care/end of life situations, etc. but i do not believe that we have to have studies to "ban" opioids from chronic pain. There is enough evidence of the potential for harm to say that opioids should be used in only very few, limited chronic pain patients, and the doctors to determine who these patients are are not PCPs or nonpain physicians.

 

[101N]

The problem in a nutshell. And yet he is still considered a thought leader in pain management and is on multiple speaker's bureaus. His influence is still visible here, and in clinical practice.

Congress should investigate his relationship to PHARMA and Propublica should post his PHARMA income.

http://www.nytimes.com/1987/12/31/u...-ignoring-evidence.html?pagewanted=all&src=pm

Health: Patient Care; Physicians Said to Persist in Undertreating Pain and Ignoring the Evidence
By DANIEL GOLEMAN
Published: December 31, 1987
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Despite studies of more than a decade ago that showed many physicians were undertreating pain in hospital patients, new research indicates that the undertreatment persists, causing millions of patients needless suffering.

The physicians are concerned about the addictive dangers of the painkilling drugs. But those dangers are a myth, said Dr. Russell Portnoy, director of analgesic studies in the Pain Service at Sloan-Kettering Memorial Hospital. He said the myth persists, at least in part, because of a lack of education about the treatment of pain in many medical schools. 'Undertreatment Is Medieval'

''The undertreatment of pain in hospitals is absolutely medieval,'' Dr. Portnoy said.

A new survey shows that 65 percent of the hospital patients who were in pain were undertreated for it.

The reluctance of doctors to give adequate doses of painkilling drugs is, in large part, a result of widely publicized studies in the 1940's and 1950's that seemed to show many people had become addicted to morphine and other drugs that were given them while they were undergoing medical treatment. More recent studies, however, have found that the danger of such addiction is minuscule under current guidelines for the use of painkilling drugs and that the dangers had been greatly exaggerated. 'Physicians Fear Sanctions'

http://www.nytimes.com/2007/03/27/science/27tier.html?pagewanted=print

“Half of pain patients would have to stop taking their medicine if the rule went out that every so-called red-flag behavior meant you couldn’t prescribe,” Dr. Portenoy says. He and researchers like Dr. Steven D. Passik, a psychologist at the Memorial Sloan-Kettering Cancer Center, have found that about half of pain patients exhibit at least a couple of the warning signs, and that even veteran physicians cannot agree on which signs are the most important to look for.

 

[Aether2000]

The supply chain for opioids that are abused or diverted is almost solely due to physicians prescribing opioids to patients in pain without having sufficient monitoring of those patients and failing to take definitive action to stop substance abuse/diversion. So I absolutely agree the medications are overprescribed. But I also believe that they are frequently prescribed by physicians that do not have the infrastructure, training, or interest in proper monitoring. Several states have adopted laws recently that have the effect of curtailing prescribing of opioids, but do not go far enough in giving guidelines for prescribing opioids and monitoring. Kentucky, Tennessee, Florida, Washington, and Oklahoma have recently adopted new rules/laws, with many more to come. But they miss the point- with the legislatures believing pain clinic registration, ownership by physicians, elimination of in office dispensing of opioid scripts, and mandatory pain physician referral or treatment make assumptions that the problem is coming primarily from pill mills. It is not in every state...and in some is coming from PCPs. Many pain physicians do not want to prescribe opioids nor should be required to do so. But with continued restriction of availability, the remaining pain physicians that do prescribe these medications find themselves completely overwhelmed by state mandated referrals. And some pain physicians should also not be prescribing the medications since they may demonstrate the same knowledge and training deficits as the PCPs. So we work towards more coherent solutions.....

 

[Ducttape]

Most PCPs are not the enemy. they want to do what is best for themselves and for their patients. also, they dont have the time given the way they are paid to spend with each patient going over diversion, functionality, tolerance, dependence, addiction, appropriate safe storage, compliance, and limitations towards use. it is much easier to make the patient happy, and continue coming, and stay on time.

Overprescribing also has nothing to do with many American's perspective on drugs (think of THC), and appropriate use. A great proportion of opioids are consumed recreationally. That is not due to physicians poor prescribing practice. Without the willingness of the average American to abuse these drugs, it would be highly unlikely that the vast volume of drugs out there would be abused.

The time it took me to type that paragraph was probably close to the amount of time a PCP has for an office visit, if he wants to be profitable...


My suggestion, a multitiered approach:

1. Mandate that pills be limited in strength.
2. Mandate that amount of pills be limited per month (i.e. 90 a month)
3. Mandate that insurance companies do not cover for scripts that exceed 90 a month.

 

[NEPain]

Clearly I disagree with the approach, but it is a "duct tape" type of solution. It does not address the real problem-why is addiction such a problem in our country? But I won't suggest we discuss that.

Algos, I've been curious about how the source of recreational drugs is determined. What's the basis for the belief that abused drugs are almost solely from prescription diversion? What about pharmacy theft, theft during shipping, etc. Is there some research available on this? Thanks.

And I agree with you that some pain docs should not prescribe opiates. Just as some pain docs should not be doing discograms, cervical epidurals, etc. One must have proficiency in any treatment they offer.

As far as efficacy of opiates, as a separate issue from addiction and diversion, I don't think we should quote an evidence base for this unless we are willing to compare it to the evidence base for our interventions. In my opinion, Pain Medicine is really not an appropriate field in which to apply evidence since there is really no objective measurement of pain, as compared to blood sugar, blood pressure, MI's, strokes, etc.

 

[facets]

Physicians have nothing to gain and everything to lose by prescribing opoids. We have so much paperwork, review of drug screens, pharmacy boards, criminal data bases, narcotic agreements, opoid risk screens and at the end of the day, we use our best clinical judgment. If we guess wrong, there are plenty of people to pick our carcasses. Things are fine as long as they they are fine, their are no maximums on opoid doses. When the patient diverts, mixes opoids with drugs from another doctor or takes a whole month's worth of medication in 1 week, the world is quick to say that you are incompetent or worse, a greedy "pill mill" doctor. No it is much easier and more lucrative to just say no and perform procedures only. At least half the medical board disciplinary actions are for "over-prescribing narcotics"
But, medicine is not to be practiced for the sole benefit of the doctor. Do you really think that society is better served by denying opoids to an 82 year old patients with severe arthritis? Really? I think that denying narcotics to all people in chronic pain is self serving, cowardly, and inhumane. These pendulums tend to swing every 10 years or so. In the late 1990s there was no limit on opoid prescribing, now it is swinging the other way, similar to the 1980s when pain was very undertreated. I was trained in the 80's and am still haunted by some of the faces I saw. People with severe untreated pain. I am not talking about 40 year olds with fibromyalgia, these were elderly people suffering because narcotics were "too dangerous and addictive"
This is not to make light of the substance abuse problem that exists. I can't stand to think that a medication that I prescribed will be diverted to young people, bought with taxpayer money and sold on the streets to subsidize an illicit lifestyle, or used in a suicide. But at the end of the day I can only make human judgments. I use the pharmacy board, do drug screening and psychological assessments, can't figure out how to get on the criminal database, use narcotics agreements but can I say that I have never prescribed medication in good faith that was diverted or denied medication to a patient who could have benefited? Of course not, none of us can say that, we err both ways.
My fear is that well meaning and innocent doctors are being made examples of to the point that physicians are afraid to treat patients in pain with appropriate medications. As a result patients who could be managed medically are being shunned. Practicing medicine from a fear basis is poor medicine. We need to give the doctor the benefit of a doubt. Doses that in retrospect seem excessive may be the result of a gradual escalation that seemed appropriate at the time. We can all look back at decisions we have made that "seemed like a good idea at the time. " Pain physicians don't make money off of prescribing, don't be so ready to crucify another doctor who most likely was acting in good faith. Put your stones down, you have done the same thing

 

[101N]

But, medicine is not to be practiced for the sole benefit of the doctor. Do you really think that society is better served by denying opoids to an 82 year old patients with severe arthritis? Really? I think that denying narcotics to all people in chronic pain is self serving, cowardly, and inhumane. These pendulums tend to swing every 10 years or so. In the late 1990s there was no limit on opoid prescribing, now it is swinging the other way, similar to the 1980s when pain was very undertreated. I was trained in the 80's and am still haunted by some of the faces I saw. People with severe untreated pain. I am not talking about 40 year olds with fibromyalgia, these were elderly people suffering because narcotics were "too dangerous and addictive"

1+

But, we have to acknowledge that some of our tribe have lost the plot and created an epidemic of opioid overuse. We need to be contrite, admit our mistakes and step back. Opioids are like debt, too much of a good thing causes a lot of problems. In my estimation their use ought to be restricted to acute pain, malignant, post-op pain, trauma, and an agree upon, albeit narrow, subset of chronic pain.

We need to throw out the principles of malignant pain when discussing non-malignant pain: pseudo-addiction,
"pain is whatever the patient says it is and occurs whenever the patient says it does", and opioids have "no ceiling". These principles don't hold water when treating chronic, non-malignant pain. Pain is not a vital sign, and in the vast majority of cases, it's not a disease.

I think the IASP needs to go back to the drawing board with their squishy definition and come up with something less artistic and more scientific.

 

[NEPain]

101n, your naivete is disturbing. The days of the giants are surely gone. It's just a business now. Very sad.

Algos, can you provide support for your statement? It would be very helpful.

 

[Aether2000]

My source for that piece of data was the Office of National Drug Control Policy document published April 25, 2012. I for one would be ecstatic to not prescribe opioids to anyone if we had alternatives that were viable and without significant side effects of their own. Interventional pain medicine has its place as a treatment, but is very expensive, and is not a curative profession for the most part. Radiofrequency neurotomy must be repeated over and over again for those with significant zygapophyseal arthrosis, the primary cause of facet pain. Epidural steroids are band aids with significant increases in weight gain, hypertension, hyperglycemia, and psychological manifestations with long term effects of osteoporosis. Sacroiliac joint injections are temporary treatments and SI fusion simply transfers the pathology to the hip or the lumbar spine, although it is beneficial short term. MILD is not covered by insurance and neither is IDET, pulsed RF, biacuplasty, SInergy, fluoro guided percutaneous discectomy using any technique, endoscopic discectomy, annuloplasty, or facet fusion. Virtually everything introduced in the past 10 years has been blocked by insurance and Medicare. The current interventions fate balances on the head of a pin due to lack of significant randomized placebo controlled trials, and physiotherapy with physical therapists at $150 per hour is covered less and less. Massage is usually not covered and neither is acupuncture. Psych therapy is covered at such a low rate that most psychologists are out of network. Non-opioid medications are covered but with increasing limitations on quantity, dose, and at a very high tier for medications such as Lyrica or Cymbalta. Antidepressants and anticonvulsants have an entire array of side effects, many unknown to pain physicians. Transdermal treatments with compounded medications are largely ineffective or have a complete lack of efficacy, and increasingly insurances are denying this therapy. TENS units and back braces have been a racket for years with many docs pocketing tens to a hundred thousand dollars a year by selling these devices out of their office, and with back bracing there is little evidence of efficacy in controlled trials.
So you tell me.....what is left. It is rapidly approaching the time to either close down pain medicine as a subspecialty or fight the insurers via litigation. But that is all that can be done. Insurers have closed the door to many potentially effective therapies and those that we do offer that are non-narcotic are either too expensive or are marginally effective. I don't think I would rush so fast to torpedo one of the few therapies we have remaining.......

 

[101N]

My source for that piece of data was the Office of National Drug Control Policy document published April 25, 2012. I for one would be ecstatic to not prescribe opioids to anyone if we had alternatives that were viable and without significant side effects of their own. Interventional pain medicine has its place as a treatment, but is very expensive, and is not a curative profession for the most part. Radiofrequency neurotomy must be repeated over and over again for those with significant zygapophyseal arthrosis, the primary cause of facet pain. Epidural steroids are band aids with significant increases in weight gain, hypertension, hyperglycemia, and psychological manifestations with long term effects of osteoporosis. Sacroiliac joint injections are temporary treatments and SI fusion simply transfers the pathology to the hip or the lumbar spine, although it is beneficial short term. MILD is not covered by insurance and neither is IDET, pulsed RF, biacuplasty, SInergy, fluoro guided percutaneous discectomy using any technique, endoscopic discectomy, annuloplasty, or facet fusion. Virtually everything introduced in the past 10 years has been blocked by insurance and Medicare. The current interventions fate balances on the head of a pin due to lack of significant randomized placebo controlled trials, and physiotherapy with physical therapists at $150 per hour is covered less and less. Massage is usually not covered and neither is acupuncture. Psych therapy is covered at such a low rate that most psychologists are out of network. Non-opioid medications are covered but with increasing limitations on quantity, dose, and at a very high tier for medications such as Lyrica or Cymbalta. Antidepressants and anticonvulsants have an entire array of side effects, many unknown to pain physicians. Transdermal treatments with compounded medications are largely ineffective or have a complete lack of efficacy, and increasingly insurances are denying this therapy. TENS units and back braces have been a racket for years with many docs pocketing tens to a hundred thousand dollars a year by selling these devices out of their office, and with back bracing there is little evidence of efficacy in controlled trials.
So you tell me.....what is left. It is rapidly approaching the time to either close down pain medicine as a subspecialty or fight the insurers via litigation. But that is all that can be done. Insurers have closed the door to many potentially effective therapies and those that we do offer that are non-narcotic are either too expensive or are marginally effective. I don't think I would rush so fast to torpedo one of the few therapies we have remaining.......

I agree that there is a role for opioids in our practices. I continue to prescribe and I am willing to consult and help on VERY difficult cases. However, I think that the role of opioids in non-malignant pain has been expanded way, way beyond reason or science. The prescription epidemic - that we caused - was identified by physicians - Dunn, VonKorff, Chou, Deyo - outside our specialties. And still there is reticence and foot dragging in our membership about the magnitude of the problem. We appear clueless, or worse pandering to our constituency. IMO, we need to get in front of this faux pas quickly.

It's particularly aggravating to me that many of those within our ranks who advocate for liberal prescribing do so because of their speakerships or because 'opioids are good business'. Enough about the 'art' of pain medicine. Pain doctors aren't Albert Schweitzer treating lepers in Gabon. If this 'subspecialty' is to survive it needs to move toward a nosological approach to pain just like the rest of medicine.

 

[NEPain]

"it needs to move toward a nosological approach"

I, for one, don't want to start treating noses.

Agree with everything said, although I don't believe we created the disease of addiction. We may have fed it, but I do believe that opioids can be used effectively and carefully as part of the treatment for certain patients. A supply will always be present for those who choose to abuse.

Algos, it can be a depressing field. Thanks for making me feel good...

 

[lobelsteve]

My source for that piece of data was the Office of National Drug Control Policy document published April 25, 2012. I for one would be ecstatic to not prescribe opioids to anyone if we had alternatives that were viable and without significant side effects of their own. Interventional pain medicine has its place as a treatment, but is very expensive, and is not a curative profession for the most part. Radiofrequency neurotomy must be repeated over and over again for those with significant zygapophyseal arthrosis, the primary cause of facet pain. Epidural steroids are band aids with significant increases in weight gain, hypertension, hyperglycemia, and psychological manifestations with long term effects of osteoporosis. Sacroiliac joint injections are temporary treatments and SI fusion simply transfers the pathology to the hip or the lumbar spine, although it is beneficial short term. MILD is not covered by insurance and neither is IDET, pulsed RF, biacuplasty, SInergy, fluoro guided percutaneous discectomy using any technique, endoscopic discectomy, annuloplasty, or facet fusion. Virtually everything introduced in the past 10 years has been blocked by insurance and Medicare. The current interventions fate balances on the head of a pin due to lack of significant randomized placebo controlled trials, and physiotherapy with physical therapists at $150 per hour is covered less and less. Massage is usually not covered and neither is acupuncture. Psych therapy is covered at such a low rate that most psychologists are out of network. Non-opioid medications are covered but with increasing limitations on quantity, dose, and at a very high tier for medications such as Lyrica or Cymbalta. Antidepressants and anticonvulsants have an entire array of side effects, many unknown to pain physicians. Transdermal treatments with compounded medications are largely ineffective or have a complete lack of efficacy, and increasingly insurances are denying this therapy. TENS units and back braces have been a racket for years with many docs pocketing tens to a hundred thousand dollars a year by selling these devices out of their office, and with back bracing there is little evidence of efficacy in controlled trials.
So you tell me.....what is left. It is rapidly approaching the time to either close down pain medicine as a subspecialty or fight the insurers via litigation. But that is all that can be done. Insurers have closed the door to many potentially effective therapies and those that we do offer that are non-narcotic are either too expensive or are marginally effective. I don't think I would rush so fast to torpedo one of the few therapies we have remaining.......

Thank you very much. I was about to get a runner's high and now I'm not sure. I appreciate the knowledge, candor, and willingness to share. I'l consider it a great day when I get to 50% Algos knowledge. (Look ma, no darkorchid). Algos: we need your leadership in these times to at least slow the swing of the pendulum and soften the blow.


SML

 

[facets]

Unfortunately, physicians with the experience and depth of knowledge of algos are fading into the sunset. Probably fed up with the system.
Blaming physicians for the drug problem is like blaming McDonalds for the obesity epidemic. What type of society do we have when 65% of the population is obese? Yet millions drive by McDonalds everyday and are not obese because they have what seems to be in short supply in this current population-self control. Alcoholism kills millions yet anyone can buy it if they are over 21. The majority of Americans are not punished for the excess of some. A simple analogy but the point is- I don't know 🙂. The point is we had a drug problem in the 70's and physicians were not prescribing opoids because we had addicts in the 70's and addicts have a genetic disease, environmental influence but genetic. They lack impulse control, are dysphoric and don't know how to find comfort. There will always be people who want to alter their mental status and will do with whatever, bath salts. alcohol. If opoids are severely restricted they will drink themselves to death. Addicts are a breed that cross addicts, when they can't get drugs they start smoking. You are not going to solve their problem by restricting one drug, they simply go to another. My concern is that people who are responsible should not be denied treatment with opoids because addicts do, always have and always will exist.

 

[NEPain]

Well said, Facets.
Controlling the prescribing of opiates not only 1) deprives those patients who benefit from them, 2) does nothing to stop the disease of addiction, but 3) makes the practice of medicine more cookbook, less complex, and more easily done by a (fill in your choice).

 

[PMR 4 MSK]

It is one thing to say opioids should never be given to anyone with chronic pain. That is a ridiculous statement and should result in public beatings. Of course some patients will benefit.

The opposite end of the spectrum is that championed by Dr. Portnoy - "Opioids for EVERYONE. Really, they're safe! No Worries!"

The truth lies somewhere in the middle, but we all have the place on that continuum where we draw the line. I feel very few people who want opioids for chronic pain should be on them, and the majority who would likely benefit and do well do not want them.

 

[Tenesma]

i can count one 2 hands the number of patients under the age of 65 who have truly benefted from narcotics .... out of >6000 new patients.

 

[lobelsteve]

i can count one 2 hands the number of patients under the age of 65 who have truly benefted from narcotics .... out of >6000 new patients.

You really gotta get out more often. I say more like 50/50 in my practice.
If I am being lax you are being cruel.

Happy medium.