The prescription opioid epidemic in a nutshell

IPSIS: Formerly the Spine Intervention Society
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
emd123 said:
This may be an unpopular opinion, but personally I like the CDC guidelines. It's given me a concrete guideline to follow, and backing to lower opioid prescribing in my practice as well as reducing patients co-prescribed benzos. Honestly, I hope they go lower next year to 60, or say, "No schedule II's for CNP; only tram/butrans/non-opiates or sub from addiction psych."

Okay, come at me now.
Click to expand...

I only worry about ideological conflicts of interests on the CDC Core Expert Group, Transparency, and the vetting of good public policy...these will be addressed in the 2020 revision. Do you think that you'll stick with the 2016 or go the 2020 when they are released? If you don't agree with the 2020 guidelines, then what? How important is it to follow *ANY* guidelines versus only guidelines you agree with?

Opinion | Opioid Overreaction

Many doctors, Heubusch writes, “have turned away from their patients in chronic pain.” The real problem, he says, is not excess pills that happen to be prescribed by well-meaning doctors. It is “the illegal trafficking of opioids on the street where you live.” He continues: “The C.D.C.’s intended audience should have been small; a limited number of bad actors and a minority of doctors overprescribing for short-term pain were the C.D.C.’s real target. But the guidelines were ambiguous and short-sighted. The immediate result: confusion at major medical conferences, inside hospital boardrooms and, most troubling, in just about every doctor’s office.”
Members don't see this ad.
 
drusso said:
I only worry about ideological conflicts of interests on the CDC Core Expert Group, Transparency, and the vetting of good public policy...these will be addressed in the 2020 revision. Do you think that you'll stick with the 2016 or go the 2020 when they are released? If you don't agree with the 2020 guidelines, then what? How important is it to follow *ANY* guidelines versus only guidelines you agree with?

Opinion | Opioid Overreaction

Many doctors, Heubusch writes, “have turned away from their patients in chronic pain.” The real problem, he says, is not excess pills that happen to be prescribed by well-meaning doctors. It is “the illegal trafficking of opioids on the street where you live.” He continues: “The C.D.C.’s intended audience should have been small; a limited number of bad actors and a minority of doctors overprescribing for short-term pain were the C.D.C.’s real target. But the guidelines were ambiguous and short-sighted. The immediate result: confusion at major medical conferences, inside hospital boardrooms and, most troubling, in just about every doctor’s office.”
Click to expand...
I don't agree with Heubusch. He seems to imply that, generally speaking, opioids prescribed in excess of the guidelines have a positive benefit/harm ratio and that only a small subset of "bad actors" need to be reformed. We all hear this from our patients, that "some guys have ruined it for everyone".

The guidelines were not designed to target opioid aberrations. They target mainstream use, which I fully agree should not include opioids in excess of 90 med. These would be the EXCEPTIONS to the guidelines, which of course exist.

I think the guidelines are helpful to both us and PCPs, especially with respect to NEW STARTS and increases. And finally, helpful to patients.

I would not follow guidelines I don't agree with. If, for example the new guidelines say that every pain patient should be titrated up on opioids until their pain score is zero, most of us would dismiss these even if we felt it was risking our license.
 
  • Like
Reactions: 1 users
drusso said:
I only worry about ideological conflicts of interests on the CDC Core Expert Group, Transparency, and the vetting of good public policy...
Click to expand...
I am concerned about this and think we need to address it, also.

drusso said:
Do you think that you'll stick with the 2016 or go the 2020 when they are released?
Click to expand...
It depends what it is. Assuming the 2020 guidelines are reasonable, chances are, I'll follow them. On the other hand, if they're crazy, and there's a multi-Pain society revolt, then I suppose I'd have to see where that goes. But at the end of the day, chances are that I'll follow them, assuming they're reasonable.

Ultimately, I am biased towards the realization that if the guys that allow me to work (the Feds) draw a box for me to work within, it's best for my survival to work within it, for better or for worse. But it's all hypothetical at this point. I'll have to see how it goes and assess the situation at the time and chart a course based on the facts, and environment, at that time.
 
Members don't see this ad :)
drusso said:
I only worry about ideological conflicts of interests on the CDC Core Expert Group, Transparency, and the vetting of good public policy...these will be addressed in the 2020 revision. Do you think that you'll stick with the 2016 or go the 2020 when they are released? If you don't agree with the 2020 guidelines, then what? How important is it to follow *ANY* guidelines versus only guidelines you agree with?

Opinion | Opioid Overreaction

Many doctors, Heubusch writes, “have turned away from their patients in chronic pain.” The real problem, he says, is not excess pills that happen to be prescribed by well-meaning doctors. It is “the illegal trafficking of opioids on the street where you live.” He continues: “The C.D.C.’s intended audience should have been small; a limited number of bad actors and a minority of doctors overprescribing for short-term pain were the C.D.C.’s real target. But the guidelines were ambiguous and short-sighted. The immediate result: confusion at major medical conferences, inside hospital boardrooms and, most troubling, in just about every doctor’s office.”
Click to expand...
how well did it work when we didn't have guidelines to follow and followed "expert opinion"?


fwiw, these many doctors should never have gotten so involved in their patients with high dose COT in the first place. the guidelines are about exposing the limits of what a PCP should be doing. no FM doc would be condoned for performing a cardiac cath, or IM doc for doing an appendectomy, or pain doc for doing an ACDF. imo, its the similar to allowing a PCP to prescribe over 100 MED.
 
  • Like
Reactions: 1 user
Ducttape said:
how well did it work when we didn't have guidelines to follow and followed "expert opinion"?


fwiw, these many doctors should never have gotten so involved in their patients with high dose COT in the first place. the guidelines are about exposing the limits of what a PCP should be doing. no FM doc would be condoned for performing a cardiac cath, or IM doc for doing an appendectomy, or pain doc for doing an ACDF. imo, its the similar to allowing a PCP to prescribe over 100 MED.
Click to expand...
Honestly I'd be fine with limiting us PCPs to 60 MED. That will still allow q4h Norco 10 or QID Percocet 10. We have no business doing more than that.
 
  • Like
Reactions: 1 users
lobelsteve said:
Make it 30meq and not for more than 3 months total in a year.
Click to expand...
40 and no dice on the length. Us younger PCP types generally speaking are very cautious about this and I don't think limiting duration is going to make a huge difference going forward once the older generation retires.

So I checked a few weeks ago. I have 3 patients on chronic opioids that I manage. 2 of them are over 70 with bad OA who aren't surgical candidates (one is norco 7.5 TID, the other Norco 10 BID), I don't think I need a pain management consult for those 2 (and yes, UDS every refill, state database check, no benzos, all the usual stuff). The third is a women who got polio from the vaccine in the 60s with pretty significant contractures. Local neuro wouldn't see her since its a chronic pain issue. Local pain management wouldn't see her since its a neuro issue. A prescription of 60 Norco 7.5 lasts her on average about 45 days.

I don't think I'm causing any problems with those 3.
 
  • Like
Reactions: 1 users
  • Like
Reactions: 1 user
i hate this article for 1 reason....

PCPs will use this to justify continuing opioids on patients using illicits. ive had this convo already.

PCP: "but i have to keep prescribing, to taper him. he says hes having bad withdrawal already."
me: "what did you do?"
PCP: "I went from 8 oxy IR 15 to 7."
me: "oh, and what are you worried about?"
PCP: "he might turn to heroin."
me: "dude.... his UDS was + already for heroin."
PCP: "he might use again..."
me: "he will use again....."
 
Ducttape said:
i hate this article for 1 reason....

PCPs will use this to justify continuing opioids on patients using illicits. ive had this convo already.

PCP: "but i have to keep prescribing, to taper him. he says hes having bad withdrawal already."
me: "what did you do?"
PCP: "I went from 8 oxy IR 15 to 7."
me: "oh, and what are you worried about?"
PCP: "he might turn to heroin."
me: "dude.... his UDS was + already for heroin."
PCP: "he might use again..."
me: "he will use again....."
Click to expand...

No problem, easy fix.

PM me the PCPs name I can have the DEA drop by and snatch his registration. If this is not knowingly assisting in diversion....

One idiot at a time. Not the patient's fault based on dx of heroin addiction. Offer help with detox or inpatient. Nothing else can be done. No Rx ever indicated.for oxy again. Suboxone from DEAx addictionologist.
 
  • Like
Reactions: 2 users
And just in time! we have the government, the same government telling us not to prescribe opiates, telling us not to stop opiates, "cuz hurt feelings." They're telling us not to prescribe opiates because according to them, they kill people, but don't stop them, because they'll kill themselves. and either way, it's 'your fault.' Get ready for all the 'undue psychological distress and you made uncle Jim kill himself" lawsuits. You couldn't make up anything this farcical, if you tried.






FDA press release, 4 days ago:

"FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering


4-9-2019] The U.S. Food and Drug Administration (FDA) has received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.

While we continue to track this safety concern as part of our ongoing monitoring of risks associated with opioid pain medicines, we are requiring changes to the prescribing information for these medicines that are intended for use in the outpatient setting. These changes will provide expanded guidance to health care professionals on how to safely decrease the dose in patients who are physically dependent on opioid pain medicines when the dose is to be decreased or the medicine is to be discontinued.

Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. In turn, these symptoms can lead patients to seek other sources of opioid pain medicines, which may be confused with drug-seeking for abuse. Patients may attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substances.

Opioids are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. They have serious risks, including abuse, addiction, overdose, and death. Examples of common opioids include codeine, fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, and oxymorphone.

Health care professionals should not abruptly discontinue opioids in a patient who is physically dependent. When you and your patient have agreed to taper the dose of opioid analgesic, consider a variety of factors, including the dose of the drug, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient. No standard opioid tapering schedule exists that is suitable for all patients. Create a patient-specific plan to gradually taper the dose of the opioid and ensure ongoing monitoring and support, as needed, to avoid serious withdrawal symptoms, worsening of the patient’s pain, or psychological distress (For tapering and additional recommendations, see Additional Information for Health Care Professionals).

Patients taking opioid pain medicines long-term should not suddenly stop taking your medicine without first discussing with your health care professional a plan for how to slowly decrease the dose of the opioid and continue to manage your pain. Even when the opioid dose is decreased gradually, you may experience symptoms of withdrawal (See Additional Information for Patients). Contact your health care professional if you experience increased pain, withdrawal symptoms, changes in your mood, or thoughts of suicide.

We are continuing to monitor this safety concern and will update the public if we have new information. Because we are constantly monitoring the safety of opioid pain medicines, we are also including new prescribing information on other side effects including central sleep apnea and drug interactions. We are also updating information on proper storage and disposal of these medicines that is currently available on our
Disposal of Unused Medicines webpage.

To help FDA track safety issues with medicines, we urge patients and health care professionals to report side effects involving opioids or other medicines to the FDA MedWatch program, using the information in the “Contact FDA” box at the bottom of the page."

FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering
 
So what would be a reasonable tapering course for a patient who is on a total of 80mg methadone daily and 40mg Norco daily?
 
Members don't see this ad :)
check EKG now - to see if methadone dose needs to be dropped faster initially due to prolonged QT interval.

10 mg per week seems reasonable, which would about in 3 months. if this is self-initiated and patient requests, consider decreasing by only 5 mg per week so you decrease the patients fears and regrets that might surface while going through withdrawal.

if you plan on continuing some form of long term opioid still, think about rotating to butrans or belbuca when patient is off methadone, and stop norco when doing so.
 
Roger Chou's mea culpa... (I still can't figure out why they keep calling him a pain specialist)


"Often in medicine, it’s difficult to get clinicians to adopt new guidelines. This is the rare case where they take a guideline too far.
“This puts the CDC in an awkward position,” Chou said. “People are taking actions based on something they say the agency put out but it’s a misinterpretation or overzealous application of it.”

I think he knows that he **** the bed on this one. It will be interesting to see how the Plaintiff's attorneys identify classes of people/patients with damages (pain and suffering of course), suss out who (the Government or Guideline authors) is responsible for making sure that appropriate measures were taken to ensure that the Guidelines wouldn't be abused, etc.

Right now the dominant narrative is that the DOCTORS are responsible for misapplying the Guidelines and the CDC and the Authors are just walking away from any responsibility in telling doctors to rely on them for clinical decision making.
 
It’s no different than how they handled it coming out of the “pain is the fifth vital sign” era - issue new guidelines saying “wait wait, don’t do all that stuff we forced you to do before (Joint commission guidelines, pain control on patient satisfaction surveys, etc),” and leave doctors who followed the guidelines holding the check (and the liability).
 
except... the guidelines had 1. more evidence to back it up 2. is accompanied by legal enforcement with respect to inappropriate prescribing tactics.

don't tell me that it has ever been appropriate for primary care physicians and noctors who have no knowledge at all about opioid medications to prescribe mega doses of narcotics, combined with benzos and soma.
 
  • Like
Reactions: 3 users
Ducttape said:
except... the guidelines had 1. more evidence to back it up 2. is accompanied by legal enforcement with respect to inappropriate prescribing tactics.

don't tell me that it has ever been appropriate for primary care physicians and noctors who have no knowledge at all about opioid medications to prescribe mega doses of narcotics, combined with benzos and soma.
Click to expand...

If you RELIED on defective guidelines or guidelines that were created from a defective process, and the plan of care for a patient was INFLUENCED by those guidelines, and that patient was damaged (avoidable pain or suffering) from the care rendered---who's accountable? The doctor or the author/agency of the guidelines upon which the doctor relied upon? This is going to put MD/DO's in the awkward position of claiming the "Nazi Guard" defense---I didn't know what was going on; I was just following orders...that is why they are saying the guidelines were "misapplied" and not intrinsically defective. It's just like saying "guns don't kill people; people kill people." The doctors are being scape-goated.

Chou and the other authors have to be crapping their drawers. Who is going to indemnify and defend them?
 
you are willing to say that it is okay and fine to render treatment such as certain stem cell injections on the basis of level 4 or 5 evidence, yet a consensus statement of clinical practice already established under the CSA is fallacy? i dont get it. its okay to stick a needle in an eye with stem cells, or put in a breast implant that is linked to lymphoma, but a statement that one should do standard of care with regards to narcotics is wrong... hmmm

read the guidelines and tell me, what in the guidelines specifically states THOU SHALT NOT.... what is in the guidelines that you dont do?

interpretation of the guidelines are at fault. that is on the doctor. i hate to say it, but look at them again and they provide a lot of leeway.


fwiw, im willing to bet Big Pharma has a role in attempts to discredit the guidelines. who benefits from this false narrative that "many many people are committing suicide" due to the guidelines? or the current one - "never discontinue opioids on patients without their approval"?

here is the link: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf
 
lobelsteve said:
Not just people. Not just opioids.


apple.news

Scientists discover cocaine in every shrimp tested from English rivers, study says — Miami Herald

University of Suffolk and King’s College London researchers found cocaine, ketamine and pesticides in shrimp in English rivers, British scientists’ Environment International study said. But chemical levels were low.
apple.news apple.news
Click to expand...

Today i worry about the non opioids from the PCPs since PCPs won’t write for the dangerous Tramadol , or even a few who won’t touch gabapentin. But they have no problem with benzos, soma, sleeping meds. Usually in combination.

Step one, take soma off the market. I don’t know why it is on other than cost. I catch so much grief when I take patients off their beloved soma. “My last Doctor was allowed to write for it, why can’t you?”

Don’t get me started on ambien.

Or when patients are on two benzos, one for sleep and one for anxiety
 
  • Like
Reactions: 4 users
lobelsteve said:
Not just people. Not just opioids.


apple.news

Scientists discover cocaine in every shrimp tested from English rivers, study says — Miami Herald

University of Suffolk and King’s College London researchers found cocaine, ketamine and pesticides in shrimp in English rivers, British scientists’ Environment International study said. But chemical levels were low.
apple.news apple.news
Click to expand...
Man. Are we gonna have to start doing drug screens, pill counts & PMP checks on shrimp now, too? Geez. Shoulda known something was up the last time I ordered shrimp and they were hummin’ Casey Jones by the Grateful Dead.
 
www.acsh.org

Heroin Pills Are Now A Reality - Is Andrew Kolodny Finally Happy?

Kolodny, the self-appointed (but thoroughly unqualified) opioid czar, repeatedly uses the made-up phrase "heroin pills." It's an apparent attempt to demonize opioids like oxycodone. In a way, he's succeeded. To fill the void left by the oxycodone shortage, the Southwestern U.S. is being flooded...
www.acsh.org www.acsh.org
 
Statements like "heroin pills" remind me of that absurd claim from the surgeon general in 2016 about "every person in America having their own bottle of pills."

Stupid and politically motivated.
 
  • Like
Reactions: 1 user
yes...

but at that point, he was probably looking at 2012 data, and there were 81.3 opioid prescriptions per 100 Americans. 255 million prescriptions were dispensed that year.

we are down to 58.7 prescriptions per 100 Americans, which is good for the future, but we still have to improve resources for people to get help with addiction and try to reduce access to illicit fentanyl and derivatives.
 
lobelsteve said:
www.ncbi.nlm.nih.gov

Nonopioid Overdose Death Rates Rose Almost As Fast As Those Involving Opioids, 1999-2016 - PubMed

The number of Americans dying from drug overdoses has risen rapidly, but the contribution of nonopioid drugs to this growth is not well understood. Using vital statistics data from the universe of deaths among US residents in the period 1999-2016, I calculated levels of and increases in overall...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Oops. Not opioids. All deaths increased over same time period.
Click to expand...

 
  • Like
Reactions: 1 user
don't get too excited.

read the article.

essentially, he "guessed" and used multiple assumptions to come up with the idea that a bunch of deaths were not opioid related.

in addition, his "results" do not correlate with his reported findings. yes both rates increased, but the opioid rate increased much more. also,read and review his data.

here is an excerpt:
Drug overdose deaths involving nonopioids rose 274 percent between 1999 and 2016, from 10,466 to 39,121 per year. This compares to 371 percent growth, from 10,663 to 50,222, for opioid-involved overdoses. See appendix exhibit 1 for additional details on the numbers of nonopioid- and opioid-involved overdoses.15 The nonopioid mortality rate increased by 223 percent, from 3.75 to 12.11 per 100,000, while opioid death rates rose 307 percent, from 3.82 to 15.54 per 100,000. Both rates grew fairly steadily over time (exhibit 1). Much of the increase in nonopioid fatalities reflected combined involvement with opioids. However, the numbers and rates of nonopioid deaths that did not simultaneously involve opioids rose by 122 percent and 92 percent—from 5,931 to 13,192 (appendix exhibit 1)15 and from 2.13 to 4.08 per 100,000, respectively (exhibit 1 and appendix exhibit 1).15
Click to expand...
 
  • Like
Reactions: 1 user
This discussion resembles the firearm discussions going on. What are needed are some good studies.
 
New Bern doctor Sanjay Kumar receives 31 counts of federal charges:

"Conspiracy to unlawfully dispense and distribute Oxycodone, Oxymorphone, Hydromorphone and Alprazolam.

● Distribution of Oxycodone and Alprazolam.

● Possession of a firearm in furtherance of a drug trafficking crime.

● Engaging in monetary transactions in property derived from specified unlawful activity.

● Laundering of monetary instruments...

Kumar was also previously charged on five misdemeanor counts of stalking his neighbors.

A search warrant issued at his home turned up trafficking levels of opium the same day, according to authorities."
 
lobelsteve said:
www.medpagetoday.org

PRIME® Continuing Medical Education

PRIME Education is an accredited provider of continuing medical education
www.medpagetoday.org
Click to expand...

We've been doing this for years...it's amazing what you pick up especially when you combine it with regular urine toxicology. I've uncovered all kinds of little "tincture parties" and drug swapping rings at the assisted living centers...
 
  • Like
Reactions: 1 user
this is written by Jeffrey Singer from the CATO institute, who has rehashed this same position supporting opioid use in multiple articles in the past..

business as usual.
 
speaking of business as usual:

apnews.com

Mundipharma is promoting OxyContin in China with claims its U.S. affiliate, Purdue Pharma, admitted in court were false

SHANGHAI (AP) — Mundipharma is promoting OxyContin in China with claims its U.S. affiliate, Purdue Pharma, admitted in court were false.
apnews.com apnews.com

apnews.com

Fake doctors, misleading claims drive OxyContin China sales

SHANGHAI (AP) — OxyContin is a dying business in the United States. Purdue Pharma, owned by the billionaire Sackler family, is collapsing under an avalanche of lawsuits that accuse the company of using false claims to push its blockbuster painkiller in the U.S., profiting as an unsuspecting nation s
apnews.com apnews.com
 
  • Like
Reactions: 1 user
Ducttape said:
speaking of business as usual:

apnews.com

Mundipharma is promoting OxyContin in China with claims its U.S. affiliate, Purdue Pharma, admitted in court were false

SHANGHAI (AP) — Mundipharma is promoting OxyContin in China with claims its U.S. affiliate, Purdue Pharma, admitted in court were false.
apnews.com apnews.com

apnews.com

Fake doctors, misleading claims drive OxyContin China sales

SHANGHAI (AP) — OxyContin is a dying business in the United States. Purdue Pharma, owned by the billionaire Sackler family, is collapsing under an avalanche of lawsuits that accuse the company of using false claims to push its blockbuster painkiller in the U.S., profiting as an unsuspecting nation s
apnews.com apnews.com
Click to expand...

The real mu-shu.
 
  • Like
Reactions: 1 users
You must log in or register to reply here.
Next unread thread

Similar threads

drusso
The Economist: Opioid Epidemic May Given Republicans Upper Hand
Replies
2
Views
614
Ducttape
D
TheLoneWolf
Opioid Agonist Therapy Underused, Data Suggest
Replies
27
Views
2K
Pain Applicant1
Pain Applicant1
lobelsteve
Lobel 4.5 CME event. Meeting the Challenge of Pain Management in an Ever-Evolving Opioid Epidemic
Replies
22
Views
1K
buddababa
B
P
Question about Opioid Prescribing Practices
2
Replies
73
Views
4K
lobelsteve
lobelsteve
lobelsteve
Opioid CME 4.5hrs for free (Lobel back at it Nov-Dec 2023)
Replies
29
Views
2K
lobelsteve
lobelsteve
Top