The prescription opioid epidemic in a nutshell

[bedrock]

As a final comment regarding mixing benzos and opioids, I inquired on the SDN psych board regarding BZD practices taught in contemporary psych residencies and several points were driven home by those practicing pyschiatrists.

1- absolutely no one should ever ever be written xanax bid, tid, qid!
1a- no one should be on chronic Xanax, period
2- most pysch only use daily benzos as part of induction until they are stable on a non addicting anxiety medication, and even that is fairly rare.
3- # of patients which truly require daily benzo are extremely small, and if daily BZD it should be long acting like klonopin and very low dose.
4- Some patients do benefit from 3-5 benzos a month for true emergencies, but again, not daily usage and certainly not TID usage, and not xanax!
5- weaning benzos is a huge pain, just like weaning high dose COT patients

So basically 98% of the patients send to us for pain consults who are also on chronic daily benzos shouldn't be on BZD, so I feel quite justified in telling these chemical copers, they don't get both opioids and benzos, and really most of those patients should not be written for either med.

Benzo vs other options for anxiety

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[lobelsteve]

As a final comment regarding mixing benzos and opioids, I inquired on the SDN psych board regarding BZD practices taught in contemporary psych residencies and several points were driven home by those practicing pyschiatrists.

1- absolutely no one should ever ever be written xanax bid, tid, qid!
1a- no one should be on chronic Xanax, period
2- most pysch only use daily benzos as part of induction until they are stable on a non addicting anxiety medication, and even that is fairly rare.
3- # of patients which truly require daily benzo are extremely small, and if daily BZD it should be long acting like klonopin and very low dose.
4- Some patients do benefit from 3-5 benzos a month for true emergencies, but again, not daily usage and certainly not TID usage, and not xanax!
5- weaning benzos is a huge pain, just like weaning high dose COT patients

So basically 98% of the patients send to us for pain consults who are also on chronic daily benzos shouldn't be on BZD, so I feel quite justified in telling these chemical copers, they don't get both opioids and benzos, and really most of those patients should not be written for either med.

Benzo vs other options for anxiety

How about a sticky?

 

[Agast]

Hm I don’t know, there were some psychiatrists who didn’t see the value in taking chronic stable benzo patients off their benzos in other to fit our metrics. I suspect the real life answer is somewhere in between, and not everyone is willing to admit they still prescribe Xanax to select patients. Just as a lot of pain physicians will say they don’t prescribe high dose opioids but if you went through their panel there’s probably a few who “don’t count” for one reason or another. My friend who practices psychiatry did tell me she would try to convert them to clonazepam which is longer acting and more stabilizing.

 

[Pain Applicant1]

I don't prescribe any opiates/opioids if someone is concomitantly on a BZD, tramadol, or Lunesta/Ambien. I just tell them something along the lines of I'm not saying it's not indicated but I don't want to red flag myself and trigger an audit. In a sense, they must choose which one they want to be on. It's rare that I would even start an opioid/opiate. I prescribe a good amount of opioids but I don't usually start them. I'm fortunate as I'm not desperate for patients and I work for myself so I can cherry-pick my patient population.

I think benzos can be helpful if used very sparingly as anxiety can be crippling for some people. They kind of help reset things in a scrambled brain. The problem with them, like all controlled substances, is that people get too used to taking the easy way out of dealing with life. That's when things backfire.

 

[Analgesia108]

Good read re: CDC ''Guidelines''

https://www.painmedicinenews.com/Online-First/Article/04-22/CDC-Revised-Opioid-Prescribing-Guideline-Falls-Short-of-What-People-in-Pain-Need/66758?sub=&enl=true&dgid=U080942274&utm_source=enl&utm_content=1&utm_campaign=20220420&pos=1&utm_medium=button

 

[Ducttape]

Written by someone who has “skin“ in the game. Webster is well known for contributing to the vast use of opioids prior to 2010, and has been a strong advocate in same vein of Passik and Portenoy.

I read the entire article, and he makes some minor points that i can agree with, in particular that some of the guidelines have been used legallly in a manner not seemingly intended by the CDC. However, he does manipulate some of his comments in a manner that is untoward.

 

[deleted875186]

“The AMA even cited data that enforcement of an MME-threshold dose in Ohio had lowered prescription quantities and doses but also coincided with a rise in opioid death rates. This scenario has played out nationally in recent years as prescriptions written for opioids have dropped in every state; yet opioid deaths continued to rise.”

this arguement is often made and is completely ridiculous. Just because america has a drug problem and opioid deaths are increasing despite decreasing opioid prescriptions does not mean prescription opioids must be safe. Complete logically fall icy.

 

[Ducttape]

It also ignores the growth of illicit fentanyl as a primary cause of death in the last 6 years.

interesting how he comments that fentanyl deaths are being counted as prescription deaths but he doesn’t attribute opioid deaths going up due to those same fentanyl deaths. Selective reasoning there.

 

[deleted875186]

Just saw a patient of my colleagues the other week, on chrinic opioids for failed back surgery, happens to be on Xanax 2mg TID for years from their primary care 😬. I see lots of people in benzos in my area, but this is a record dose.

 

[Chrish]

Question regarding NSAIDs vs low dose opioids from risk vs benefit perspective..

If someone is on celebrex 200 mg qd-bid for chronic arthritis and it’s working fine for them, would you continue them on it indefinitely? Or at some point would it make sense to d/c it and put them on a low dose opioid (tramadol/ norco 5 # 30 tabs a month etc.). Does benefit of low dose opioid ever outweigh the risk associated with long-term nsaids (bp, glucose, kidney, stomach harm etc.)? I am just curious from a pharmacy perspective.

 

[Ferrismonk]

Question regarding NSAIDs vs low dose opioids from risk vs benefit perspective..

If someone is on celebrex 200 mg qd-bid for chronic arthritis and it’s working fine for them, would you continue them on it indefinitely? Or at some point would it make sense to d/c it and put them on a low dose opioid (tramadol/ norco 5 # 30 tabs a month etc.). Does benefit of low dose opioid ever outweigh the risk associated with long-term nsaids (bp, glucose, kidney, stomach harm etc.)? I am just curious from a pharmacy perspective.

I personally would not change. Celebrex is anti-inflammatory and actually doing something for the problem. Opioids, even low-dose, only mask the pain and tolerance will develop over time.

 

[lobelsteve]

Question regarding NSAIDs vs low dose opioids from risk vs benefit perspective..

If someone is on celebrex 200 mg qd-bid for chronic arthritis and it’s working fine for them, would you continue them on it indefinitely? Or at some point would it make sense to d/c it and put them on a low dose opioid (tramadol/ norco 5 # 30 tabs a month etc.). Does benefit of low dose opioid ever outweigh the risk associated with long-term nsaids (bp, glucose, kidney, stomach harm etc.)? I am just curious from a pharmacy perspective.

Treat the patient. You listed BP, glucose, kidney, GI. You left off liver. Meh. Cardio and cerebrovascular risks are the problem. My patients are older. Daily nsaid increases risk of mi or cva 31-50%. So I choose tramadol over nsaids several times per day.

 

[Chrish]

Yeah that’s what I lean toward too. Despite lack of abuse potential, nsaids have very undesirable long-term side effects. So, if you need something for chronic pain such as arthritis, low dose opioids make most sense to me personally.

Saw prescription for Eliquis and Celebrex sent in by the same doctor once.. LOL! I mean come on!!

 

[deleted875186]

Yeah that’s what I lean toward too. Despite lack of abuse potential, nsaids have very undesirable long-term side effects. So, if you need something for chronic pain such as arthritis, low dose opioids make most sense to me personally.

Saw prescription for Eliquis and Celebrex sent in by the same doctor once.. LOL! I mean come on!!

I see it go both ways though. Patient started on opioids for knee OA because they had a gastric bypass and can’t take NSAIDS, and when I ask if they’ve tried voltaren they tell me they can’t use it.

 

[MitchLevi]

No issues with Eliquis and an occasional NSAID assuming the latter is genuinely helpful and the doses are kept low and infrequent.

I allow NSAIDs in low doses in geriatric pts. I tell them they can use 4 doses per week, so take 4 Aleve tabs and put them in your weekly pill box. That's your limit.

 

[Baron Samedi]

I personally would not change. Celebrex is anti-inflammatory and actually doing something for the problem. Opioids, even low-dose, only mask the pain and tolerance will develop over time.

Most arthritis is non-inflammatory, though. I agree COX inhibition makes sense in those with true inflammatory OA.

I tend to use low dose PRN tramadol in geriatric patients. Far too many of them have cardiac, GI, and renal comorbities or a baseline increased bleeding risk.

 

[lobelsteve]

Thousands of Colorado patients put in peril due to risky prescribing of psych medicineThousands of Colorado patients put in peril due to risky prescribing of psych medicine

Benzo

 

[lobelsteve]

https://www.empr.com/home/news/experts-say-new-street-drug-is-as-deadly-as-fentanyl/

Experts Say New Street Drug Is ‘as Deadly as Fentanyl’​

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"Naloxone has been effective in reversing nitazene-involved overdoses, but multiple doses might be needed." Credit: Shutterstock.

HealthDay News — Nitazenes, powerful illicit synthetic opioids, are increasingly being added into heroin and street versions of opioid pills and triggering fatal overdoses, according to research published in the September 16 issue of the US Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report.
“Laboratory test results indicate that the potency of certain nitazene analogs (e.g., isotonitazene, protonitazene, and etonitazene) greatly exceeds that of fentanyl, whereas the potency of the analog metonitazene is similar to fentanyl,” explained a team of researchers from the Tennessee Department of Health.
Deaths linked to drugs are on the rise. In their report issued September 16, Jessica Korona-Bailey and colleagues said that “four times as many nitazene-involved overdoses were identified in Tennessee in 2021 than in 2020, and this number could be underestimated because of low testing frequency.”
Overall, deaths in Tennessee known to be linked to the synthetic opioids rose from 10 in 2020 to 42 one year later, with a majority of those killed being young men (average age 40 years). Unfortunately, naloxone may not help if given in a single dose in cases involving nitazenes. “Naloxone has been effective in reversing nitazene-involved overdoses, but multiple doses might be needed,” the Tennessee researchers advised.
The growing danger of nitazene-tainted opioids in illicit drug supply is not specific to Tennessee, of course. In June, the Washington, D.C.-based branch of the US Drug Enforcement Agency issued an alert on the same class of drugs being spotted in that area. “A drug that was never approved for medical use, nitazenes are being sourced from China and being mixed into other drugs,” the DEA explained in a statement.
So far, the spread of nitazenes remains relatively low, but “we want to get this info out and warn people,” said Jarod Forget, special agent in charge of the DEA Washington Division. “If we can educate and inform our communities about the dangers of taking counterfeit prescription pills or other drugs, we stem the proliferation of these deadly opioids, stop all of these senseless deaths, and help keep our neighbors and loved ones safe.”
Abstract/Full Text

 

[MitchLevi]

WTH is that?

 

[Ducttape]

new synthetic opioid. tho apparently identified in the 1950s initially

https://www.deadiversion.usdoj.gov/drug_chem_info/benzimidazole-opioids.pdf

addendum: mu receptor agonist.

 

[willabeast]

The only way to lessen deaths is to offer free analysis of illegal drugs by the guv. They used to do that in the seventies at LAC/USC (LA County paid for it). It was anonymous, you dropped off a little of your illegal drug and they would tell you what was in it and how much. It also enabled the E.R. and Public Health know what was circulating on the street. Had they still been doing that the word on rainbow fentanyl would have gotten out much sooner.

 

[lobelsteve]

https://www.practicalpainmanagement.com/resources/clinical-practice-guidelines/cdc-2022-opioid-prescribing-guideline-tapering

 

[MitchLevi]

I'll stick with my 40 MED ceiling.

 

[lobelsteve]

I will start by not accepting anyone over 50meq. Will keep my existing 50-90 where they are, and no longer escalate above 50.

 

[MitchLevi]

I had one Friday who is attempting to negotiate with me from 22.5 to "something stronger." Norco 7.5 TID.

Her and husband. I told them I may increase it slightly at some point, and while my ceiling is 40 she probably won't get there with me.

I clearly explained to her I've seen no difference in efficacy from 20-40 MED other than worsening side effects with no added pain relief.

Further, in my experience the tolerance that develops in that window between 20-40 MED rapidly outpaces the tolerance seen at lower MEDs...Despite no clear increase in efficacy.

I don't play that game and I don't recommend any of my colleagues play it either.

The only way we fix this BS is by not taking part in it.

 

[deleted875186]

I had one Friday who is attempting to negotiate with me from 22.5 to "something stronger." Norco 7.5 TID.

Her and husband. I told them I may increase it slightly at some point, and while my ceiling is 40 she probably won't get there with me.

I clearly explained to her I've seen no difference in efficacy from 20-40 MED other than worsening side effects with no added pain relief.

Further, in my experience the tolerance that develops in that window between 20-40 MED rapidly outpaces the tolerance seen at lower MEDs...Despite no clear increase in efficacy.

I don't play that game and I don't recommend any of my colleagues play it either.

The only way we fix this BS is by not taking part in it.

Absolutely. Negotiating is always a bad sign.

 

[GoBeers]

I had one Friday who is attempting to negotiate with me from 22.5 to "something stronger." Norco 7.5 TID.

Her and husband. I told them I may increase it slightly at some point, and while my ceiling is 40 she probably won't get there with me.

I clearly explained to her I've seen no difference in efficacy from 20-40 MED other than worsening side effects with no added pain relief.

Further, in my experience the tolerance that develops in that window between 20-40 MED rapidly outpaces the tolerance seen at lower MEDs...Despite no clear increase in efficacy.

I don't play that game and I don't recommend any of my colleagues play it either.

The only way we fix this BS is by not taking part in it.

In these negotiation scenarios, I'm happy to increase dose but decrease frequency to maintain med 20 .

 

[Ducttape]

butrans.

but no going back to norco if butrans fails.

 

[Chrish]

Have someone at my pharmacy who is on 240 MME (120 ME Oxy and 120 ME of ER Morphine). Called to verify the diagnosis and was told pt has wegener's granulomatosis. Pretty young person.

Any opinion on this? I don’t have experience with these rare genetic conditions.

 

[MitchLevi]

Have someone at my pharmacy who is on 240 MME (120 ME Oxy and 120 ME of ER Morphine). Called to verify the diagnosis and was told pt has wegener's granulomatosis. Pretty young person.

Any opinion on this? I don’t have experience with these rare genetic conditions.

Terrible disease.

Not sure I have any experience with it that I recall, but I'd probably treat them like malignant pain TBH. I'm sure there's ischemia right? Probably sucks really bad.

 

[Ducttape]

severe wegeners shouldnt indicate need for high dose opioid use.

you can get joint pain. you can have pain from chronic kidney disease. apparently there have been case reports of back pain. you get chronic lung disease and pulmonary symptoms.

because of the latter, high dose opioids are probably not a safe nor a good option for these patients.

 

[Ferrismonk]

The thing to remember is that the actual disease process and the dose of opioid medication has almost nothing to do with each other. The dose escalation (of course assuming its being used legitimately and as directed) has more to do with medication tolerance than pain level from the disease.

 

[MitchLevi]

severe wegeners shouldnt indicate need for high dose opioid use.

you can get joint pain. you can have pain from chronic kidney disease. apparently there have been case reports of back pain. you get chronic lung disease and pulmonary symptoms.

because of the latter, high dose opioids are probably not a safe nor a good option for these patients.

Does WG not cause ischemia? I would think that hurts, but I guess that's probably chronic ischemia and slowly progressing?

 

[Ducttape]

ischemia in the lungs. not specifically painful but causes respiratory difficulties.

remember that lung lesions from cancer often dont present with pain as primary complaint. and PEs may or may not be painful - sometimes presents as shortness of breath or hemoptysis only.

 

[MitchLevi]

ischemia in the lungs. not specifically painful but causes respiratory difficulties.

remember that lung lesions from cancer often dont present with pain as primary complaint. and PEs may or may not be painful - sometimes presents as shortness of breath or hemoptysis only.

I thought they got it in the extremities and commonly became gangrenous and required amputations. Not that dead tissue necessarily hurts I guess.

 

[lobelsteve]

WG can be painful. He must ignore everyone on this forum who hasn’t examine the patient and documented what is going on. Conjecture and ego.

 

[Ducttape]

Upper limb ischemia in a patient with Wegener's granulomatosis - PubMed

Classic Wegener's granulomatosis is a form of vasculitis that primarily involves the upper and/or lower respiratory tract and kidney. The amount of clinical symptoms is enormous and the diagnosis, arduous. In the literature there are only a few clinical cases referring to limb ischemia in a...

pubmed.ncbi.nlm.nih.gov

A Rare Case of Digital Ischemia and Gangrene in ANCA-Associated Vasculitis with Review of the Literature

This paper describes one patient with Antineutrophil Cytoplasmic Antibody- (ANCA-) associated vasculitis who initially presented with multiple ischemic fingers and toes. On further evaluation, the patient was also found to have pulmonary-renal involvement and episcleritis. The diagnosis was...

www.hindawi.com

Based on our review of the English literature, to the best of our knowledge, only 16 cases have been previously reported describing adult patients with GPA who presented with digital ischemia and gangrene [7–20] (see Table 1). Given the paucity of cases reported, we suspect the prevalence with digital ischemia and gangrene in the GPA population to be <1%.

 

[SSdoc33]

WG can be painful. He must ignore everyone on this forum who hasn’t examine the patient and documented what is going on. Conjecture and ego.

LOL. thats rich. Lobel calling out someone for their ego.

could it possibly be that he actually knows more than you? the horror!! last time i checked, you weren't an internist as well.

 

[lobelsteve]

LOL. thats rich. Lobel calling out someone for their ego.

could it possibly be that he actually knows more than you? the horror!! last time i checked, you weren't an internist as well.

So M15.8 isn't a thing?
Advocating treatment or lack of treatment based on no exam or history?
You are as smart as you are a conservative.

 

[SSdoc33]

So M15.8 isn't a thing?
Advocating treatment or lack of treatment based on no exam or history?
You are as smart as you are a conservative.

we dont have a sample Wegeners patient in front of us right now. i could probably come up with maybe 100 instances when you have advocated for or against treatment on other's patients based on the history given here.

lets see if you can accept your hypocrisy and admit that you might have a tad bit of an ego problem yourself. the board is watching......

 

[lobelsteve]

we dont have a sample Wegeners patient in front of us right now. i could probably come up with maybe 100 instances when you have advocated for or against treatment on other's patients based on the history given here.

lets see if you can accept your hypocrisy and admit that you might have a tad bit of an ego problem yourself. the board is watching......

No ego problem. I am that good.

 

[Ducttape]

er... you are advocating for 240 MED for Wegeners?

what happened to your prior words about hard caps and limited use for nonmalignant pain processes.....

i postulate that someone with compromised lung function needs to be carefully considered when using opioid medications, particularly doses about 5 times the CDC suggested levels.

 

[SSdoc33]

No ego problem. I am that good.

you are. but your ego prevents you from being great. even the best need to have an open mind and admit their shortcomings

 

[lobelsteve]

er... you are advocating for 240 MED for Wegeners?

what happened to your prior words about hard caps and limited use for nonmalignant pain processes.....

i postulate that someone with compromised lung function needs to be carefully considered when using opioid medications, particularly doses about 5 times the CDC suggested levels.

Nope. But what if it is terminal and palliative care? Having a chart handy would be helpful. I do not have anyone currently on those MEQ that is not palliative. One of them is Scleroderma. Would I testify against that doctor? Depends on documentation.

 

[MitchLevi]

...poking my head in real quick to say I don't Rx 240 MED...

I'd refer out for that, and now I'll back out slowly before I get hit with a bottle.

 

[lobelsteve]

you are. but your ego prevents you from being great. even the best need to have an open mind and admit their shortcomings

 

[Ducttape]

to that end, and to take liberty and paraphrase:

"But what if the fibromyalgia is terminal and palliative care?"

 

[Chrish]

Thanks everyone for their $0.02. Your responses have been helpful.

 

[lobelsteve]

to that end, and to take liberty and paraphrase:

"But what if the fibromyalgia is terminal and palliative care?"

The actuarial probability of survival for these patients was 97% at one year and 71% at ten years. Only three CP treated patients (10%) progressed to end-stage renal disease. The case fatality rate was 26% (eight patients) and sepsis was the cause of death in five. WG and not FMS.

 

[deleted875186]

There are many diseases like this that could be considered “terminal” or “palliative”.

ESRD on HD with various pain complaints. Some types of inflammatory lung disease. Some PVD patients.

Not sure if always justifies opioid therapy, especially high dose, but I too would need to see thorough documentation of therapies tried, symptoms, monitoring, etc. I personally wouldn’t do it, but to each their own.