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The opioid epidemic

Skeptic Ginger said:
The creeps that made the Epipen version of Narcan cost $3000/dose should be drawn and quartered.

Back in the day when there was an amphetamine epidemic, Nixon made the legal versions of the drug near impossible to get. The epidemic subsided.

The DEA/FDA have cracked down on pain med prescriptions. I have prescriptive authority for class 3 to 5 drugs but I've never used it. It's not something I use in my practice. But I am familiar with changes in the law. Not long ago a new law was passed in WA State but I think it might be federal. If I prescribe any scheduled drugs, including class 5 drugs I think, I have to send in a monthly report of the patients I prescribed them for. Pharmacies have to do the same for patients they dispensed any scheduled drugs to.

Then the pharmacy board cross checks the list to find any patient getting drugs from more than one doctor. They will also be monitoring patient drug use.

It's a good first step.

The new additions to the problem are the designer drugs coming in from other countries like the altered versions of fentanyl. That is not something I am familiar with so I defer to other forumites.

I agree with cresent about evidence based, not religious based treatment with one exception, if there is evidence it is successful, keep it, religion based or not. Having worked with drug addicted persons in the past, I know there is no one size fits all.
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My stupid state is having trouble with this most basic first step!!!
http://www.govtech.com/policy/Missouri-Statewide-Prescription-Drug-Monitoring-Bill-Founders.html

With regard to heroin and Fentanyl, according to this data:

https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

...4 out of 5 iv drug addicts started out using prescription painkillers and "94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”9"

In other words you are probably correct, stopping the flow of prescription pain pills from the pharmacies would likely go a long way to stemming the epidemic.

Of course the current addicts will still need treatment.
 
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MuDPhuD said:
Fortunately, narcotics turn out to be a crappy treatment for chronic pain.
After chronic opioid use, tolerance makes the effective dose ever increasing until some unfortunate patients end up on unbelievably huge daily doses (lethal for an opioid naive person). The nervous system adapts to the opioid saturation by essentially turning up the gain in the pain pathways, making these people extremely sensitive to small painful stimuli. As you can imagine this ends up making their chronic pain ever more difficult to manage.
Its really not a good situation, although in a few cases there are no other good options.


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Have to ask "evidence for this"?

I'm asking because it is totally outside my experience with chronic pain. I've been taking opiate based painkillers for the majority of my life (going on 35 years now). My dosage has not needed to be increased over that time, I do now use another drug for pain relief as well but that is for a different kind of chronic pain (neuropathic caused by the deterioration in my spine) for which opiate based painkillers are not very good at treating.

The problem seems to be more based on people not getting the right type of treatment in the first place and their conditions being badly managed by their primary medical treatment giver.
 
Darat said:
Have to ask "evidence for this"?

I'm asking because it is totally outside my experience with chronic pain. I've been taking opiate based painkillers for the majority of my life (going on 35 years now). My dosage has not needed to be increased over that time, I do now use another drug for pain relief as well but that is for a different kind of chronic pain (neuropathic caused by the deterioration in my spine) for which opiate based painkillers are not very good at treating.

The problem seems to be more based on people not getting the right type of treatment in the first place and their conditions being badly managed by their primary medical treatment giver.
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Yes, I agree, and I am happy to here that you are not having these difficulties. It sounds like your pain is being well managed.

The evidence that opioids are effective for managing chronic pain is poor, because there are no long term controlled studies.
The evidence of potential for harm from opioids is robust.
http://annals.org/aim/article/20893...opioid-therapy-chronic-pain-systematic-review
"Conclusion:
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms."

http://jamanetwork.com/journals/jama/fullarticle/2503508
"Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks."

In this study "We found that 49% of patients taking opioids continued to report severe pain (≥ 7/10)."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960717/

Opioid induced hyperalgesia is a documented phenomenon.
http://www.sciencedirect.com/science/article/pii/S1526590008008018

My own experience comes from managing patients with chronic pain who come for repeat back surgery, etc. These patients may already take 60, 90, or 120 mg of Morphine equivalents per day. I am able to dose these individuals with enough IV Fentanyl (500-1500mcg) to kill an opioid naive patient while they remain awake, talking, with very little effect. These same individuals are paradoxically extremely sensitive to painful stimuli, and present a very difficult problem in post operative pain management. They may require 10 times the standard opioid dose to manage, and most nurses and physicians are not comfortable administering or prescribing those dosages.

This says nothing about what percentage opioid treated chronic pain patients have these difficulties. I only see the people with ongoing problems serious enough to warrant surgery, so it is a biased sample, for sure.
 
I have limited knowledge and understanding of the present opioid epidemic. But something vaguely relevant to keep in mind: Untreated pain itself causes significant adverse health effects. My understanding is that the mortality associated with the present epidemic has been partly due to the flooding of street markets with fentayl and carfentanil - particularly powerful and lethal opioids; which are particularly dangerous when obtained in unpredictable concentrations. (And in at least one case, fentanyl being passed off on the street as the much less potent and dangerous Norco).
 
rjh01 said:
As to opioids, many abusers got that way because they were prescribed them for pain. So they then get prosecuted because of what was done to them (made them adicts)....
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For the record, having worked with drug users in the past and admitting I don't have current information, almost every narcotic drug abuser will tell you this whether it is true or not.

They also tend to blame PTSD. We had a saying, that guy was born in Vietnam. It meant that the person denied anything prior had anything to do with their alcoholism or drug abuse. But statistics don't corroborate the claims.

Not saying over-prescribing hasn't contributed, mind you, just that the numbers are probably inflated.
 
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MuDPhuD said:
Yes, I agree, and I am happy to here that you are not having these difficulties. It sounds like your pain is being well managed.

The evidence that opioids are effective for managing chronic pain is poor, because there are no long term controlled studies.
The evidence of potential for harm from opioids is robust.
http://annals.org/aim/article/20893...opioid-therapy-chronic-pain-systematic-review
"Conclusion:
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms."

http://jamanetwork.com/journals/jama/fullarticle/2503508
"Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks."

In this study "We found that 49% of patients taking opioids continued to report severe pain (≥ 7/10)."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960717/

Opioid induced hyperalgesia is a documented phenomenon.
http://www.sciencedirect.com/science/article/pii/S1526590008008018

My own experience comes from managing patients with chronic pain who come for repeat back surgery, etc. These patients may already take 60, 90, or 120 mg of Morphine equivalents per day. I am able to dose these individuals with enough IV Fentanyl (500-1500mcg) to kill an opioid naive patient while they remain awake, talking, with very little effect. These same individuals are paradoxically extremely sensitive to painful stimuli, and present a very difficult problem in post operative pain management. They may require 10 times the standard opioid dose to manage, and most nurses and physicians are not comfortable administering or prescribing those dosages.

This says nothing about what percentage opioid treated chronic pain patients have these difficulties. I only see the people with ongoing problems serious enough to warrant surgery, so it is a biased sample, for sure.
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Chronic pain management has a lot of issues, anticipatory pain being a well known phenom that is consistent with self reported pain being high despite treatment. It's a function of addiction, not necessarily of the lack of effectiveness of narcotics for pain relief.

I don't disagree, narcotics for chronic pain is not the best choice. Chronic pain needs to be managed by specialists that understand anticipatory pain and drug seeking behavior and they need to use other treatment modes. But that's no reason to quit using narcotics altogether.
 
MuDPhuD said:
When I trained in medicine in the late 1990's we were all taught that pain was being inadequately treated across the board, and were encouraged to be generous with the meds to make sure patients pain was adequately controlled. I was also taught that when used for an acute painful condition (a broken arm for instance) that potential opioid addiction should not be a big concern and it was more important to adequately treat the pain.
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That was when Pharma Purdue was pushing the line that OxyContin was less addictive than immediate-release oxycodone. Eventually it was found guilty of criminal charges.
MuDPhuD said:
Interestingly, a family member of mine in Japan has recently had surgery on his fractured wrist, involving a titanium plate and screws, and he was prescribed NO opioids whatsoever, because the Japanese physicians do worry about addiction, and do NOT use opioids for acute pain.
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I have heard opioids are not great for bone pain.

Also knew a doc who considered opioids horrible choices for treating chronic pain. He felt they inevitably made the problem worse.
 
Darat said:
The problem seems to be more based on people not getting the right type of treatment in the first place and their conditions being badly managed by their primary medical treatment giver.
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I suspect the UK's prescribing practices are much more rational than those in the U.S.
 
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