The prescription opioid epidemic in a nutshell

[Orin]

Looks like pharma companies are good at spending money

In reality the data is driven by the top 5-10% of folks, but the air must not stink up on that high horse...

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[drusso]

 

[Painted]

https://www.cdc.gov/nchs/images/databriefs/251-300/db294_fig1.png

 

[emd123]

The DEA and federal government have successfully gotten the amount of opiate prescriptions, plummeting. I think that's a good thing and I hope it continues. But overdose deaths are still increasing. As this trend becomes more obvious, what's their next move? Jail more doctors?
Clearly, when you've stemmed the tide of over-prescribing, yet the problem worsening, there needs to be a different plan. And when it becomes obvious that physician overprescribing is no longer driving the problem, and there's no longer an easy scapegoat (US doctors, US drug companies) then what do they do?

Look at the blue line, in the second graph. You know what that is?
It's fentanyl, mostly from China, and it bypasses any and all legitimate pathways. And you can't even call it "diversion" from normal pharmaceutical pathways because it's illicit from day 1. It starts overseas in an illegal drug lab, comes to USA often through known commercial pathways - (using google, bitcoin and USPS) and goes right to the streets, never passing through a legit US drug manufacturing plant, warehouse, pharmacy, doctor or pain patient.

is

 

[244913]

The answer is directing more money into addiction services, rehab, psych. These deaths are predominantly in addicts who- denied rx's- go to the street. Some of them are starting on the street.

 

[drusso]

The answer is directing more money into addiction services, rehab, psych. These deaths are predominantly in addicts who- denied rx's- go to the street. Some of them are starting on the street.

In the real world, tried to get paid doing that.

 

[Ducttape]

Again we gloss over the fact that there are 2 issues related to opioids and the chain effect.

Reducing doctor prescribing reduces many individuals from becoming addicted, as the most common pathway to addiction is through prescription opioids. This needs to continue not necessarily to reduce prescribing but to change social expectations regarding opioids.

The main portion of people dying from opioids are due in no small part to our actions and direct Big Pharma meddling changing societal expectations on opioids and directly causing addiction.

The other issue is illicit drug use, much now not tied directly to prescription opioids but due to illegal fentanyl. That requires societal change in addition to addiction care.

 

[emd123]

The answer is directing more money into addiction services, rehab, psych. These deaths are predominantly in addicts who- denied rx's- go to the street. Some of them are starting on the street.

I agree that would help. But is that what the response is going to be, or just more "enforcement"?

 

[lobelsteve]

Again we gloss over the fact that there are 2 issues related to opioids and the chain effect.

Reducing doctor prescribing reduces many individuals from becoming addicted, as the most common pathway to addiction is through prescription opioids. This needs to continue not necessarily to reduce prescribing but to change social expectations regarding opioids.

The main portion of people dying from opioids are due in no small part to our actions and direct Big Pharma meddling changing societal expectations on opioids and directly causing addiction.

The other issue is illicit drug use, much now not tied directly to prescription opioids but due to illegal fentanyl. That requires societal change in addition to addiction care.

Besides media talking points and essential lies, is there any data to support your statements?

 

[Ducttape]

Just go back and review this entire thread. It’s all there.

 

[Ducttape]

to summarize, i looked at the first 10 pages, and the last 3 pages of this thread. i got bored at that point.

how it started:


A Pain-Drug Champion Has Second Thoughts

Pharmaceutical lies:
Amazon product
Health Care Renewal: The "King of Pain" Recants - Pharmaceutical Paid Key Opinion Leader Admits It Was All "Misinformation"
oxycontin:


algosdoc's summary in 2012, apropos today: "Addiction level of 1%? Probably TRUE based on most of the literature using the DSM4 definitions of chemical dependency. Not habit forming? Absolutely FALSE. Rates of addiction of 20-40% and equating aberrant behavior in and of itself to addiction? FALSE. The rate of aberrant drug behavior is 20-40% and exists because of inadequate monitoring and safeguards by physician practices (who falsely make the assumption the use of opioids are inherently a safe therapy). Did drug companies and doctors overpromote these medications? Absolutely. Do we need changes from past practices? Absolutely"

physician practice might have introduced risk of addiction:
Physician Introduction to Opioids for Pain Among Patients with Opioid Dependence and Depressive Symptoms

in 2013, in one study, meds implicated in opioid deaths were probably from prescriptions:
Unintentional prescription opioid-related overdose deaths: description of decedents by next of kin or best contact, Utah, 2008-2009. - PubMed - NCBI

discussion on increase in opioid deaths, causes (ie implicating prescription opioids):
Opioid Analgesics—Risky Drugs, Not Risky Patients

opioids dont work long term:
Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety? - PubMed - NCBI
Opioid vs Nonopioid Medications on Pain-Related Function

in fact long term opioid use increases risks of ER visit for OD:
Emergency department visits among recipients of chronic opioid therapy. - PubMed - NCBI

dose does matter:
Opioid prescriptions for chronic pain and overdose: a cohort study. - PubMed - NCBI
https://www.ncbi.nlm.nih.gov/pubmed/21467284

illicit drug use does commonly start with prescription meds:
https://archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf

it may seem we arent having an impact (though i disagree with the conclusion that we arent having impact - the numbers from illicit substances now overwhelm prescription effects)
https://www.acsh.org/news/2018/05/14/one-opioid-crisis-or-many-12956

but this is why we should be "taking" opioids off the streets so it is not readily available to initiates (note this is only link that is not from the first 10 or last 2 pages of this thread):
https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm

basis for my stance (italics are my statements):
https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end
1) Prevent new generations of opioid users (ie CDC guidelines)
2) Make addiction treatment easier to access than opioid painkillers and heroin (improve availability of buprenorphine, addiction resources)
3) If we can’t stop people from doing drugs, we can make it less dangerous (curb illicit fentanyl - which will drastically reduce OD incidence, but not alter addiction or prescription OD, which is still huge compared to 1998)
4) Address the other problems that lead to addiction

Take home message:
From 101N, thread #1319
The way out of the overdose epidemic with thanks to Andrew Kolodny, where
this tread began many years ago.

1. Prevent new cases of addiction: for us applying CDC guidelines.
2. Treat the addicted: for us getting and using our x-waivers.
3. Reduce the supply: again apply CDC for legacy patients and
moving forward keeping the opioid naive, naive.

 

[lobelsteve]

We, legitimate pain physicians are not to blame.

When they say 75% of addicts started on rx meds, they fail to disclose the very few % that were given an rx. Almost all were taking meds from family and friends.

When applying screening tools and doing due diligence, the risk of de novo addiction is not more than 2%. Genetics, social situation, past history can screen out those at risk. Its the person and not the drug.

 

[Ducttape]

Your stats are still dated.

Even if I agree with your position - I do to a degree, beyond yours - eliminating the “meds from family and friends” will be beneficial in the long run

 

[drusso]

We, legitimate pain physicians are not to blame.

When they say 75% of addicts started on rx meds, they fail to disclose the very few % that were given an rx. Almost all were taking meds from family and friends.

When applying screening tools and doing due diligence, the risk of de novo addiction is not more than 2%. Genetics, social situation, past history can screen out those at risk. Its the person and not the drug.

What is a legitimate pain doctor?

 

[pastafan]

What is a legitimate pain doctor?

like pornography, you know it when you see one

 

[Ducttape]

What is a legitimate pain doctor?

Portenoy

no wait.
Passik.

um...
Fine?

no no, wait,
Webster.

grr...

 

[lonelobo]

Ya, our " legitimate Pain Doctor" at hospital does injections and passes patients on to PMR for chronic narcotics

 

[lobelsteve]

1. Me
2. DRusso
3. Ligament
4. SSDoc
5. Hyperalgesia
6. Doctodd
7. Ductape
8. Taus
9. Lonelobo
10. axm (come back)
11. Algos
12. RInoo
13. AMPA
14. pastafan
15. Tenesma
16. many, many others.

 

[244913]

Take the random pill count/2 wk quant UDS challenge

See how many of your "stable" "within CDC guidelines < 90 MME" patients are truly compliant and not diverting, misusing, etc. etc.

or go back and re-read Algos' posts on the matter...

 

[drrosenrosen]

1. Me
2. DRusso
3. Ligament
4. SSDoc
5. Hyperalgesia
6. Doctodd
7. Ductape
8. Taus
9. Lonelobo
10. axm (come back)
11. Algos
12. RInoo
13. AMPA
14. pastafan
15. Tenesma
16. many, many others.

Sad to see I didn't make your list, Steve. I'll keep trying...

 

[emd123]

1. Me
2. DRusso
3. Ligament
4. SSDoc
5. Hyperalgesia
6. Doctodd
7. Ductape
8. Taus
9. Lonelobo
10. axm (come back)
11. Algos
12. RInoo
13. AMPA
14. pastafan
15. Tenesma
16. many, many others.

Hello?

 

[Ducttape]

How many Oxy’s did you have to take to put me 7th on the list??

 

[lobelsteve]

How many Oxy’s did you have to take to put me 7th on the list??

Just 1. Old 80mg i been saving....

 

[lobelsteve]

An Open Letter to Dr. Andrew Kolodny

Well written and researched. Dont completely discount the letter because it was written by a patient.

 

[drusso]

An Open Letter to Dr. Andrew Kolodny

Well written and researched. Dont completely discount the letter because it was written by a patient.

Don't
Even
kNow
I
Am
Lying

 

[lobelsteve]

Don't
Even
kNow
I
Am
Lying

Nope, that is the stem cell salesman talking.

 

[drusso]

Nope, that is the stem cell salesman talking.

I think that the patient who wrote this letter would score high on the Pain Catastrophizing Scale (PSC). Also, likely meets DSM-V criteria for Mild Opioid Use Disorder given her obsession and intense focus on opioids and their effects on her (#3) and her resistance (#4) to learn PROP's message (#9). I would screen for fibromyalgia.

1. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
**3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
**4. Craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.
**9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of an opioid. Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
11. Withdrawal, as manifested by either of the following: a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal). b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

 

[Ducttape]

unfortunately she uses her limited knowledge to reach some unjustifiable positions, even when the obvious is presented to her.

for example, railing about the 30 patient limit for addiction care. by every account other than her own, 30 patients max never came close to "managing" addiction before the opioid epidemic was even known to us, let alone now. think... 1200 addiction specialists in the US x30 patients means that not even all the addicts that live in the boundaries of, say, Boston would be able to access MAT. right now, <2% of all US physicians have X registration. even at 100 patients a doctor, thats still short of the number of known heroin and prescription opioid addicts...

and there is a huge difference between oxycodone/oxycontin and buprenorphine. the molecules and their effects on the human body are significantly different. they cannot be equated, a point she misses by a mile.

 

[melodic minor]

unfortunately she uses her limited knowledge to reach some unjustifiable positions, even when the obvious is presented to her.

for example, railing about the 30 patient limit for addiction care. by every account other than her own, 30 patients max never came close to "managing" addiction before the opioid epidemic was even known to us, let alone now. think... 1200 addiction specialists in the US x30 patients means that not even all the addicts that live in the boundaries of, say, Boston would be able to access MAT. right now, <2% of all US physicians have X registration. even at 100 patients a doctor, thats still short of the number of known heroin and prescription opioid addicts...

and there is a huge difference between oxycodone/oxycontin and buprenorphine. the molecules and their effects on the human body are significantly different. they cannot be equated, a point she misses by a mile.

Agree with you. I am in no way a fan of Kolodny, but if you dig deeper, you find out that you've seen patients like her all the time.

I did some further reading on her site. She is 33 years old. There is an entry entitled "Strangulation On Medicine: My life as a pain patient". I can't post the link, but if you go read it, you will see some really interesting things, not the least of which is that at age 31, she suddenly developed intractable back pain and "sciatica" leading to a fusion . This was because in her words, " your lowest vertebrae are separated, and have been for years and years; that this has allowed a spinal disc to slide out of place, forcefully compressing a nerve". Needless to say, the surgery didn't work. Normally I would have some sympathy for her, but as a another pain patient wrote on one of the sites she posts on, her tone is so confrontational it actually is counter productive. If you read the entry I mentioned, she sounds like a very typical chronic pain patient who thinks she is an expert, knows everything, and constantly insults physicians.

 

[bedrock]

1. Me
2. DRusso
3. Ligament
4. SSDoc
5. Hyperalgesia
6. Doctodd
7. Ductape
8. Taus
9. Lonelobo
10. axm (come back)
11. Algos
12. RInoo
13. AMPA
14. pastafan
15. Tenesma
16. many, many others.

Been on the site for 13 years......and I didn’t make the cut.

 

[lobelsteve]

Been on the site for 13 years......and I didn’t make the cut.

On my secret special list. Hugs.
I just did a list of top of my head.
You guys are more hypersensitive then I am.
Post PCS score.

 

[cara susanna]

Hi all, long time listener, first time caller (I like to read this forum because I work in the VA and see a lot of patients with chronic pain). That letter and the comments on it make it me sad, because it seems like they all would benefit so much from cognitive-behavioral treatment for chronic pain. Assuming, of course, that they were willing to engage and could accept the idea that their pain is impacted by their thoughts and behaviors. I see so much fear and avoidance of pain that are probably making things a lot worse in the long run.

 

[drrosenrosen]

Hi all, long time listener, first time caller (I like to read this forum because I work in the VA and see a lot of patients with chronic pain). That letter and the comments on it make it me sad, because it seems like they all would benefit so much from cognitive-behavioral treatment for chronic pain. Assuming, of course, that they were willing to engage and could accept the idea that their pain is impacted by their thoughts and behaviors. I see so much fear and avoidance of pain that are probably making things a lot worse in the long run.

That, sadly, in my experience, is the big if. Many people who fall into this category are simply unwilling to participate actively in a healing process, be it psychological or physical.

 

[cara susanna]

That, sadly, in my experience, is the big if. Many people who fall into this category are simply unwilling to participate actively in a healing process, be it psychological or physical.

Yes, and that's why I find chronic pain so difficult to work with in my clinical role.

 

[lobelsteve]

Chronic pain patients, overlooked in opioid crisis, getting new attention from top at FDA

 

[lobelsteve]

More good news:
Drink up: Coffee is good for you, research shows

 

[Ducttape]

first article - an opinion piece. adds nothing to the discussion.

second article - good to know about coffee. drink up!

 

[lobelsteve]

first article - an opinion piece. adds nothing to the discussion.

second article - good to know about coffee. drink up!

It seems everything to support your side of the argument is hardened fact and well supported in the literature.
But everything on the other side is hearsay, heresy, nonsense.

As pain physicians, we have no adequate voice in the whole subject. The guys who are talking are ****** of industry for both sides. Thre is no physician who appears to advocate for the patients who are able to do well on medications without developing an addiction, OUD, or overdose.

 

[Ducttape]

It seems everything to support your side of the argument is hardened fact and well supported in the literature.
But everything on the other side is hearsay, heresy, nonsense.

As pain physicians, we have no adequate voice in the whole subject. The guys who are talking are ****** of industry for both sides. Thre is no physician who appears to advocate for the patients who are able to do well on medications without developing an addiction, OUD, or overdose.

I like to think that my opinions on topics are informed by the search for facts (too much Perry Mason as a kid).
unfortunately, that does make a lot of what is said from the other side as hearsay....

that's why I think kudos are given for the second article. and I read the first article, and it is an opinion piece. in fact, I read it again just now.



fwiw, what pray tell does the FDA have to do with what the DEA decides?

 

[lobelsteve]

Congress assisting illegal distribution.

Companies shipped 1.6 billion opioids to Missouri from 2012 to 2017, report says

 

[Ducttape]

Despite the huge fines, the report said that DEA enforcement efforts have declined since 2011, and the DEA issued just 12 immediate suspension orders to distributors between fiscal 2007 and 2017. Former DEA officials reported that the “revolving door between the agency and the distribution industry created an institutional resistance to issuing immediate suspension orders,” according to the report. The DEA did not respond to a request for comment Wednesday.

The report also cites a Washington Post report about how members of Congress allied with drug distributors to pass a law — the Ensuring Patient Access and Effective Drug Enforcement Act — that bowed to industry and undermined efforts to slow the flow of pain pills nationwide.


thanks for posting, but this seems to go counter to your "its the patient not the drug" position.

 

[lobelsteve]

Despite the huge fines, the report said that DEA enforcement efforts have declined since 2011, and the DEA issued just 12 immediate suspension orders to distributors between fiscal 2007 and 2017. Former DEA officials reported that the “revolving door between the agency and the distribution industry created an institutional resistance to issuing immediate suspension orders,” according to the report. The DEA did not respond to a request for comment Wednesday.

The report also cites a Washington Post report about how members of Congress allied with drug distributors to pass a law — the Ensuring Patient Access and Effective Drug Enforcement Act — that bowed to industry and undermined efforts to slow the flow of pain pills nationwide.


thanks for posting, but this seems to go counter to your "its the patient not the drug" position.

Nothing to do with it. Not even a stretch. Preconceived notions. Closed mind. Liberal. Laws ensuring profits despite harm is not a person/drug thing. It is a tit for tat corrupt government thing.

 

[Ducttape]

drug distributors Cardinal Health, McKesson Corp. and Amerisource Bergen funneled the equivalent of about 260 opioid pills for every person in Missouri in the six-year period

and that's not a problem.

huh.

 

[lobelsteve]

drug distributors Cardinal Health, McKesson Corp. and Amerisource Bergen funneled the equivalent of about 260 opioid pills for every person in Missouri in the six-year period

and that's not a problem.

huh.

Pill mills pushing drugs and distributors not performing their due diligence (specifically neglecting the clear and present danger of ludicrous quantities of opiates flowing). With the approval of law makers. Who are getting paid off to do so.

 

[lobelsteve]

Medscape: Medscape Access

@Ducttape

Here is the drug and not the person.

 

[lobelsteve]

Why Are We Abandoning Those Living in Chronic Pain During the Opiate Crisis?

 

[bizdr]

Interesting Prop-aganda. I actually agree with much of the presentation except their conclusions and some of their assertions that opioids result in addiction in 25%. There are few studies that would support that allegation or perhaps the authors did not understand the definition of addiction. Substance abuse is definitely present in 25% but not addiction. Ballantyne's quote needs to be further delineated as to what she was referring....
Overall the presentation is very similar to mine presented to our state legislature.

I think there should be a much wider acceptance of maintence therapy - but even many knowledgeable physicians look down upon it. We can change the guidelines to help reduce improper opioid use going forward, but something better has to be done with all the people who have been heavily prescribed opiates for years.

 

[emd123]

I think there should be a much wider acceptance of maintence therapy - but even many knowledgeable physicians look down upon it. We can change the guidelines to help reduce improper opioid use going forward, but something better has to be done with all the people who have been heavily prescribed opiates for years.

For the legacy people:

1-Don't prescribe above 90 MME/day (or whatever the CDC/Feds dose-limit du jour of the week happens to be)
2-Don't dose escalate
3-Look for reasons to reduce dose, when indicated
4-Look for reasons to stop opiates, when indicated
5-Once stopped, don't restart opiates, including by doctors downstream

Over time, this will minimize harm for the legacy generation. It creates a ceiling and downward pressure on doses, as opposed to no ceiling and upward pressure on dose.


For opiate naive, chronic non-cancer/non-palliative pain patients:

1-Don't start opiates
2-Don't start opiates
3-Don't start opiates
4-Maximize non-opiate pain treatment options
5-When fails, go back to #1

 

[Ducttape]

I think there should be a much wider acceptance of maintence therapy - but even many knowledgeable physicians look down upon it. We can change the guidelines to help reduce improper opioid use going forward, but something better has to be done with all the people who have been heavily prescribed opiates for years.

bizdr, I think it is disingenuous to post algosdoc's comment dated 2012. I would hazard a guess that his opinion as to chronic opioid prescribing has changed in the past 6 years.

 

[244913]

I began believing in the late 1990s my patients were compliant since they self reported no aberrations, and had 3 month visits. I began UDS testing without confirmatory testing initially and found many aberrancies, but part of these could be explained by inaccuracy in the testing. Out of concerns from this I moved to bimonthly visits. Then I started asking about specifics such as any hospital visits, falls, use of alcohol, cocaine, marijuana or other illicits ANY TIME DURING THE MONTH. It was eye opening. I then lowered my prescribing interval from two months to monthly and instituted UDS with confirmatory testing. Even with all our rules and regulations, 20% of the patients each month were abusing drugs. Jettisoned more and more patients, while tightening up my requirements to accept any patient, and would not accept anyone out of state, then eventually anyone outside of the area. PMP access eventually became available and was initially checked once a year, then later once every 3 months, then once a month. Added mandatory direct fax of prior prescribers history and progress notes before I would even make an appointment for those wanting to see me, and screened out over 50% of those who would have otherwise been given an initial appointment. There were some doozies of doctor shoppers that were caught in this manner and they were quickly kicked out of the practice. Instead of rare UDS, I increased this to targeted UDS plus at least yearly UDS. Kicked out more patients. Began working with local police departments notifying them of diversion of drugs and some departments reciprocated notifying me about patients that were running off the road DUI, crashing, injuring others, and in rare cases about those who were known to be selling drugs. Then I added alcohol testing- found 25% of my patients were actively drinking alcohol in spite of clinic rules specifically stating possible discharge under such conditions- they did not care. Patients will do whatever they damned well please despite all the clinic rules, all the CDC guidelines, and regardless of the risk to your medical license and medical practice. They may use cocaine in week one or two after being seen in your clinic. They may have sold most of the drug by the end of the first week, as I found out when I instituted mandatory pill counts between visits discovering only 30% had at least as many pills as expected. Jettison more patients. Finally I had enough and jettisoned all patients receiving opioids.

So........no, I am no longer helping the chronic pain population by being a "compassionate" doctor any longer, nor am I fulfilling my desire to help people with chronic pain by using all means necessary or available. The upside is that I have selected out treatment options that do not require me to herd cats or involve myself with unsavory, potentially dangerous chemically dependent patients (re: addicts). There is just too much overlap in the Venn diagrams of the legitimate compliant pain population that would benefit from opioids, those who are out of control with their use of opioids or engage in illicits/alcohol use at the same time as opioids, and the population diverting opioids. My time as a physician is better spent helping those I can help rather than trying to determine who is scamming me, who may overdose, and who may become violent if they don't get their candy. When added to the pressures from state attorney generals, threats of litigation from families should a patient die while taking opioids, medical board actions, county civil suite actions, and push back by every branch of government, I found it impossible to continue prescribing opioids. My conclusion is that whereas opioids are a viable option for a few patients, at least 80% of those being prescribed opioids should not be receiving them since they pose a threat to themselves and to society. In order to prescribe opioids, an elaborate screening and compliance program is needed, requiring significant number of hours and effort to keep the practice clean, but even then if we look hard enough (alcohol testing of urine, pill counts throughout the month) we find we are being scammed. The majority of the general population who would seek opioids from pain doctors are indeed addicts, engage in dangerous practices with drugs, or are diverting drugs for sale or trade. I haven't the patience nor the time left in my career trying to weed out the majority those seeking opioids that could easily end my career through no fault of my own. The risks of opioid prescribing are far too high to many patients and the benefits are too low for even a few patients to continue this dangerous game of roulette.

Re-posted for everyone's viewing pleasure- the greatest comment of all time from the great one himself, Algos. His thoughts on opioids from spring, 2018