Long-term benefit from low-dose opioids?

[UCIZotMD]

Hi all,

As a psychiatrist, I have several patients with anxiety disorders who seem to experience ongoing benefit with benzodiazepine treatment despite long-term use. It makes me wonder if there can be some sort of differential tolerance—where tolerance to euphoria occurs but not the central therapeutic effect of the medication.

In your clinical experience with chronic pain patients refractory to first-line medications, could you share whether patients started on low-dose opiates inevitably require higher and higher dosages? Or have you observed a subset that respond well at a relatively low dose and find lasting benefit?

Thanks guys.

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[Baron Samedi]

They always require higher doses.
They always demonstrate aberrant behavior.

The only variable is whether or not they die before that happens. The likelihood of them dying beforehand is what determines whether or not they are candidates for opioid therapy for non-malignant pain.

 

[painfree23]

No one ever flushed down their blood pressure or depression pills down the toilet on accident.

 

[Ferrismonk]

I'm not a psychiatrist, but aren't benzodiazepines only indicated for short term use? There is all kinds of negatives when used long term.

That being said, with regards to opioids, there are a subset of people who say they are doing well on long term on low-dose opioids. You'll notice, however, that if you stop the patient will report they are in terrible pain. What happens is the body gets used to the opioid and any withdrawal of that medication will cause worsening pain, usually worse than if you never gave the opioid to begin with. Any stable, long term, low-dose opioid use is not treating pain anymore, it's treating iatrogenic dependence.

 

[Ducttape]

opioids also should be for short term use. unfortunately, the development of dependence even at low doses ultimately necessitates long term treatment, which ultimately increases risk of tolerance and need for higher doses.



that being said, there is a subset of patients who will not escalate their dose regimen or request escalation.

in my experience, it is almost invariably those 80-90 year old patients with severe debilitating incurable arthritic conditions who are deathly afraid of becoming addicted. ie the ones in which chronic opioid use is appropriate...

 

[deleted875186]

Yes there seems to be some patients that will not need to escalate their dose and are ok with low dose opioids.

As stated above, it’s older patients, with predominantly osteoarthritis or joint pain from having no joint left. In my experience, almost every other type of pain patient is as stated above, dependent, their brain is changed from the opioids, and they truly beleive the opioid is treating pin, and that they need higher doses.

 

[deleted875186]

So OP, while we’re at it, I get referrals from PCPsin the area and a bunch have psychiatrists that have them in multiple benzos per day, like Ativan 60 or 90 tabs per month, or clonazepam 90 per month. Have a few also on stimulants like Adderall with this benzo combination.

What’s the deal? Why is psychiatry not being critiqued more harshly about this type of stuff?

 

[Ferrismonk]

So OP, while we’re at it, I get referrals from PCPsin the area and a bunch have psychiatrists that have them in multiple benzos per day, like Ativan 60 or 90 tabs per month, or clonazepam 90 per month. Have a few also on stimulants like Adderall with this benzo combination.

What’s the deal? Why is psychiatry not being critiqued more harshly about this type of stuff?

Also interested in this question. I really don't understand how someone can logically be on a controlled-substance stimulant and a controlled-substance depressant.

 

[UCIZotMD]

So OP, while we’re at it, I get referrals from PCPsin the area and a bunch have psychiatrists that have them in multiple benzos per day, like Ativan 60 or 90 tabs per month, or clonazepam 90 per month. Have a few also on stimulants like Adderall with this benzo combination.

What’s the deal? Why is psychiatry not being critiqued more harshly about this type of stuff?

No, I completely agree. I’m describing patients that I inherit who were mismanaged, commonly by psychiatric nurse practitioners or just bad psychiatrists, with combination stimulant-benzos or extreme doses of short-acting benzos (e.g. Xanax).

Still, the patient with severe anxiety refractory to the standard SRIs and therapy and some second line agents (e.g. pregabalin, buspirone), I do wonder if there’s a role for low-dose long acting benzos like clonazepam (e.g 0.25-0.5mg BID), even long term.

The panic disorder data indicates that benzo users do not escalate their doses over time, yet many still benefit.

And the larger question—given the previously unrecognized risks of SSRIs (sexual dysfunction, emotional numbing, withdrawal syndromes akin to benzos, tolerance, bleeds, hyponatremia, etc) can we really say for certain that the risk-benefit profile does not favor something like clonazepam?

These are active questions in psychiatry, and was wondering about parallels with pain medicine.

 

[lobelsteve]

Also interested in this question. I really don't understand how someone can logically be on a controlled-substance stimulant and a controlled-substance depressant.

DEA keenly aware and red flags this. Would strongly recommend against rx of opioids to these patients. Or taper now.

 

[lobelsteve]

No, I completely agree. I’m describing patients that I inherit who were mismanaged, commonly by psychiatric nurse practitioners or just bad psychiatrists, with combination stimulant-benzos or extreme doses of short-acting benzos (e.g. Xanax).

Still, the patient with severe anxiety refractory to the standard SRIs and therapy and some second line agents (e.g. pregabalin, buspirone), I do wonder if there’s a role for low-dose long acting benzos like clonazepam (e.g 0.25-0.5mg BID), even long term.

The panic disorder data indicates that benzo users do not escalate their doses over time, yet many still benefit.

And the larger question—given the previously unrecognized risks of SSRIs (sexual dysfunction, emotional numbing, withdrawal syndromes akin to benzos, tolerance, bleeds, hyponatremia, etc) can we really say for certain that the risk-benefit profile does not favor something like clonazepam?

These are active questions in psychiatry, and was wondering about parallels with pain medicine.

Show us a study showing benefit to BZD therapy for any dx over any time period. Treating substance use or dependence is more likely, akin to opiates.

 

[Laryngospasm]

IMHO there is an underlying benzo overprescribing issue that is totally overlooked.. yes some patients do well on low dose opioids especially when taken sparingly prn. As stated usually older patients.
The young people who expect to never have any pain ever ever ever will not do well.

 

[deleted875186]

No, I completely agree. I’m describing patients that I inherit who were mismanaged, commonly by psychiatric nurse practitioners or just bad psychiatrists, with combination stimulant-benzos or extreme doses of short-acting benzos (e.g. Xanax).

Still, the patient with severe anxiety refractory to the standard SRIs and therapy and some second line agents (e.g. pregabalin, buspirone), I do wonder if there’s a role for low-dose long acting benzos like clonazepam (e.g 0.25-0.5mg BID), even long term.

The panic disorder data indicates that benzo users do not escalate their doses over time, yet many still benefit.

And the larger question—given the previously unrecognized risks of SSRIs (sexual dysfunction, emotional numbing, withdrawal syndromes akin to benzos, tolerance, bleeds, hyponatremia, etc) can we really say for certain that the risk-benefit profile does not favor something like clonazepam?

These are active questions in psychiatry, and was wondering about parallels with pain medicine.

Yes, I have the same thoughts about elderly patients at times. Many can be managed with a low dose opioid. In my mind this may have less risk than gabapentin/pregabalin which in this population can be very intolerable.