The prescription opioid epidemic in a nutshell

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The "opioid epidemic" will not be solved with sound bytes. I am cynical but practical. IMO, the solution involves the following:

1. Never start COT for non-malignant pain unless patient is end of life and non-interventional candidate.

2. Those already on COT need to be risk optimized by testing for sleep apnea, minimizing MED, no concomitant EtOh/benzos, and strict compliance.

3. Offer OUD patients that are truly motivated resources and treatments to come off COT.

4. Wait for the generation of current COT patients to die.

I remember clearly when I read the first publication expounding the fact that opioids for non-malignant pain were not addicting. Sitting in the holding room, I announced to my partners that this was the biggest load of horse **** I had ever seen. Never did I anticipate the sad situation that we are in today.

Like nicotine, the substance that these patients are dependent on was legal when they were started on it. Prohibition doesn't work. While forced taper/discontinuation advances #4 it is not the best thing for society to promote.The COT patients have just migrated to heroin and the overdose death rates parallel MED reduction rates. There are ancillary costs such as the legal system, family services, EMS expenses etc. I see no easy fix for the problem despite what all of the talking heads expound. The above steps would fix the problem but it will be decades.
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Ducttape said:
Agree, but there are some patients in which a forced taper is indicated. Particularly those endangering others...
Click to expand...

That is not a forced taper. That is forced withdrawal. If a patient runs out of meds 1 week early: forced withdrawal. If a patient is suspected of diverting: forced withdrawal while gathering data.

Treat withdrawal aggressively with what we've got, but don't continue to Rx when it does not make sense.
 
David A Fishbain, Aditya Pulikal; Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review, Pain Medicine, , pny231, Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review

Abstract
Objective
To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.

Methods
Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.

Results
No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.

Conclusions
There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
 
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"Alternative medicine had garnered significant support in the state of Oregon in recent years. It had been lobbied extensively as a desired modality in medicine. However, Oregonians had not realized they were fighting for the avenue that would eventually be explored as the cause of their healthcare demise. They fought for the right to additional medicinal access, not a means of limiting their existing treatment plans. Instead, once they won the right to alternative means, they began to lose their right to traditional medicine."
 
Not entirely sure how that relates to opioids?

Do you have a link to the article?

Or are you trying to whitewash the prior opioid taper post?
 
Ducttape said:
Not entirely sure how that relates to opioids?

Do you have a link to the article?

Or are you trying to whitewash the prior opioid taper post?
Click to expand...

If you click on it the link it opens up to an article. I thought it was interesting because it highlight a lack of consensus about tapering policies.
 
it didn't work yesterday when I tried that. its working now. thanks.

the article is not the best written, and it is as biased as she purports the Oregon Chronic Pain Task Force is, which is understandable as she is a chronic pain patient.
 
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Prescription Opioid Misuse and Projected Overdose Deaths in the United States

Key points - things will get worse and decreasing prescription opioids will have an effect, but expect it to be a modest one. we need a multipronged approach.

people who say reducing prescribing will not cure the epidemic are right, because it is too late. still, any positive effect should be encouraged.



Prevention of Prescription Opioid Misuse and Projected Overdose Deaths in the United States
Qiushi Chen, PhD1,2,3; Marc R. Larochelle, MD, MPH4; Davis T. Weaver, BS2,5; et al Anna P. Lietz, BA2; Peter P. Mueller, PhD2,3; Sarah Mercaldo, PhD2,3; Sarah E. Wakeman, MD3,6; Kenneth A. Freedberg, MD, MSc3,6,7,8; Tiana J. Raphel, BA9; Amy B. Knudsen, PhD2,3; Pari V. Pandharipande, MD, MPH2,3; Jagpreet Chhatwal, PhD2,3
Author Affiliations Article Information
JAMA Netw Open. 2019;2(2):e187621. doi:10.1001/jamanetworkopen.2018.7621


Key Points español 中文 (chinese)
Question What is the projected effect of lowering incident nonmedical prescription opioid use on the future trajectory of the opioid overdose crisis in the United States?

Findings In this system dynamics model study, under current conditions, the opioid overdose crisis is expected to worsen—with the annual number of opioid overdose deaths projected to reach nearly 82 000 by 2025, resulting in approximately 700 000 deaths from 2016 to 2025. Interventions focused on lowering the incidence of prescription opioid misuse were projected to result in a 3.0% to 5.3% decrease in opioid overdose deaths over this period.

Meaning Prevention of prescription opioid misuse alone is projected to have a modest effect on lowering opioid overdose deaths in the near future, and multipronged approach is needed to dramatically change the course of the epidemic.

Abstract
Importance Deaths due to opioid overdose have tripled in the last decade. Efforts to curb this trend have focused on restricting the prescription opioid supply; however, the near-term effects of such efforts are unknown.

Objective To project effects of interventions to lower prescription opioid misuse on opioid overdose deaths from 2016 to 2025.

Design, Setting, and Participants This system dynamics (mathematical) model of the US opioid epidemic projected outcomes of simulated individuals who engage in nonmedical prescription or illicit opioid use from 2016 to 2025. The analysis was performed in 2018 by retrospectively calibrating the model from 2002 to 2015 data from the National Survey on Drug Use and Health and the Centers for Disease Control and Prevention.

Interventions Comparison of interventions that would lower the incidence of prescription opioid misuse from 2016 to 2025 based on historical trends (a 7.5% reduction per year) and 50% faster than historical trends (an 11.3% reduction per year), vs a circumstance in which the incidence of misuse remained constant after 2015.

Main Outcomes and Measures Opioid overdose deaths from prescription and illicit opioids from 2016 to 2025 under each intervention.

Results Under the status quo, the annual number of opioid overdose deaths is projected to increase from 33 100 in 2015 to 81 700 (95% uncertainty interval [UI], 63 600-101 700) in 2025 (a 147% increase from 2015). From 2016 to 2025, 700 400 (95% UI, 590 200-817 100) individuals in the United States are projected to die from opioid overdose, with 80% of the deaths attributable to illicit opioids. The number of individuals using illicit opioids is projected to increase by 61%—from 0.93 million (95% UI, 0.83-1.03 million) in 2015 to 1.50 million (95% UI, 0.98-2.22 million) by 2025. Across all interventions tested, further lowering the incidence of prescription opioid misuse from 2015 levels is projected to decrease overdose deaths by only 3.0% to 5.3%.

Conclusions and Relevance This study’s findings suggest that interventions targeting prescription opioid misuse such as prescription monitoring programs may have a modest effect, at best, on the number of opioid overdose deaths in the near future. Additional policy interventions are urgently needed to change the course of the epidemic.
Click to expand...
 
lobelsteve said:
https://center4si.com/wp-content/uploads/2018/05/Opioid-Overdose-Deaths-MA-Residents-0218.pdf

20% of opiate deaths related to Rx. But less than that if you add in polypharmacy.
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I'm actually surprised that cocaine was seen more often in those toxicology reports than benzos (41% to 38% respectively), but I guess I shouldn't be surprised considering the overwhelming majority of overdose deaths have nothing to do with prescription opiates and anyone abusing street fentanyl of course is doing whatever they can get their hands on...cocaine, heroin, etc...
 
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Ducttape said:
Prescription Opioid Misuse and Projected Overdose Deaths in the United States

Key points - things will get worse and decreasing prescription opioids will have an effect, but expect it to be a modest one. we need a multipronged approach.

people who say reducing prescribing will not cure the epidemic are right, because it is too late. still, any positive effect should be encouraged.
Click to expand...

Nothing can be done, except Addiction specialists covered and readily available. That will save some. All doctors need to be willing to stage the intervention with patients. Not sweep it under the rug by pushing it off on “pain management”.

Then, when the death rate has leveled off, no more routine opioids for chronic non malignant pain. GME programs need to be on board, and older physicians need to be rehabilitated through their professional societies.
 
Disciple said:
Nothing can be done, except Addiction specialists covered and readily available. That will save some. All doctors need to be willing to stage the intervention with patients. Not sweep it under the rug by pushing it off on “pain management”.

Then, when the death rate has leveled off, no more routine opioids for chronic non malignant pain. GME programs need to be on board, and older physicians need to be rehabilitated through their professional societies.
Click to expand...

I read that article and I don't see where one comes up with a blanket "no opiates for non malignant pain" conclusion.

The problem is street fentanyl and other illicits, not opiate Rx. That article even says measures to curb opiate misuse only reduces OD rates by 3-5.3%...

It's not 75 yo Mrs Jones with a 4mm lumbar canal and golf ball facets who can't have back surgery so I give her Norco 5 BID. That's nonmalignant pain but I guess I shouldn't give her that little tiny drop of opiate bc there are thousands of addicts running around using street fentanyl and cocaine...

What about the spinal cord injury pts with severe neuropathic pain...Again not cancer.

Individuals treated as individuals not herds.

I avoid opiates like the plague, but the fact remains there are individuals who benefit from them in certain circumstances.
 
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No, missing the sociological point.

What introduces future addicts to opioids are the prescription opioids - mostly through the over abundant supply of opioids out there. Some of this is coming from seemingly innocent scripts to elderly patients.

I hate anecdotes, but in my few years I have seen at least 10 elderly patients who were there to get meds for relatives (they admitted as much).


Once addicted, it’s too late for us doctors to change behavior. At that point, addictionologists, narcan, counseling, suboxone, changing societal mores regarding opioid use, limiting illegal drug entry in to the US, etc. multipronged...


That’s not to say we need to stop prescribing. But PCPs, other specialists, even our own colleagues - who are trading shots for pills - could learn. And we need to continue to be very careful and thoroughly vet who and how much we prescribe and use less addicting meds when possible
 
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I don't know why it is ethical to give a pt with cancer pain hydrocodone but not someone with symptomatic severe stenosis (in certain circumstances).

Last paragraph I agree with completely.
 
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Ducttape said:
one will only live a few months, and unlikely to suffer the ill side effects of COT.

the other will have side effects, have no functional benefit, and more disabled use opioids... Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study

at the very least, opioid use does not improve disability: Increases in the Use of Prescription Opioid Analgesics and the Lack of Improvement in Disability Metrics Among Users
Click to expand...

I rarely see a cancer patient live only a few months. The ones that are quicker to pass skip us and go from Onc to grave or brief stop with hospice.
 
Ducttape said:
one will only live a few months, and unlikely to suffer the ill side effects of COT.

the other will have side effects, have no functional benefit, and more disabled use opioids... Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study

at the very least, opioid use does not improve disability: Increases in the Use of Prescription Opioid Analgesics and the Lack of Improvement in Disability Metrics Among Users
Click to expand...

...but in certain individuals...
 
Why is the border an emergency and not the opioid crisis? Trump can't answer that question

Why is the border an emergency and not the opioid crisis? Trump can't answer that question

By Ross Rosenfeld
Jan 08, 2019 | 6:35 AM


ny-1546894755-btfq64ol5m-snap-image

President Donald Trump speaks during an event on the opioid crisis, in the East Room of the White House on Oct. 24 in Washington. (Evan Vucci / AP)

We’re 17 days into Donald Trump’s temper-tantrum-induced shutdown, and the President is threatening to declare a national emergency at our southern border if he doesn’t get funding for his dream wall. Trump says the wall is necessary to keep drugs out of our country. Yet, interestingly enough, he refused to declare the opioid crisis a national emergency, despite an estimated 72,000 drug overdose deaths in 2017, including 49,000 from opioids alone.

In early 2017, Trump created a commission made up of experts to study the epidemic and offer advice to combat it. By the end of the year, they had come out with 56 recommendations, many of which the President ignored. One of their recommendations was to declare the crisis a national emergency in order to devote to it the funds and attention it deserves. Trump declined, opting rather to call it a “national public health emergency,” which resulted in essentially no new funding being provided.



In October 2017, just before the commission’s final report was issued, Trump told a gathering of families at the White House who had lost loved ones to the crisis that he believed it could all be solved with “really great advertising.” He said we could simply teach young people not to take them. “It’s really, really easy not to take them,” he said. That was the extent of his concern.

The administration did go along with some reasonable steps, including agreeing to $3.8 billion of spending to combat the crisis through 2018 via the Cures Act, plus $8 billion over five years through other legislation. It has also expanded access for drug addicts through Medicaid.



Yet experts contend that these steps aren’t nearly enough to address the tens of thousands of deaths we’re witnessing every year. Democrats like Elizabeth Warren and Elijah Cummings, meanwhile, have proposed much more expansive bills with considerably more funding, yet Trump has refused to take them up.

As for the wall, we know that such a barrier at the southern border would do little to curb the drug trade. Most drugs are smuggled through ports of entry, and a wall would do nothing to stop that. Drug cartels have even used subterranean tunnels to get drugs into the country. Basically, we’re there is demand, they will find a way. Properly addressing the opioid crisis could help reduce that demand.

So why is Trump ready to declare a national emergency if he doesn’t get $5 billion for his wall, yet not willing to do the same for the opioid crisis?

The answer is that Trump isn’t truly concerned with drugs or the deaths caused by them; he’s concerned about his own political future. Trump made a promise to his base that he would not only build a giant wall at the southern border — a very symbolic wall, mind you — but that he would also get Mexico to pay for it.


Well, Mexico certainly isn’t going to pay for it, though Trump and his surrogates are already trying to spin the renegotiated NAFTA deal into Mexican remuneration.

Either way, Trump needs the wall — not because it would actually keep us safer, but because it would keep him safer. Without the wall, he would’ve failed to deliver on one of his key promises, which is why Democrats can never give in to that symbol of hate.

If Donald Trump is serious about declaring a national emergency over drugs, how about he takes the recommendations of his own commission and does so regarding opioids? Or do the tens of thousands of lives lost every year not matter enough?


Rosenfeld is a writer on Long Island
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https://psmag.com/news/one-year-aft...ction-a-public-health-emergency-whats-changed

Trump declared an emergency over opioids. A new report finds it led to very little.

and to be "fairly biased" i mean "fair and unbiased"...
Hope amid the opioid crisis? Glimmers of progress since Trump declared national emergency
Psychiatrist Sally Satel, with the American Enterprise Institute, predicted that most opioid-addiction trendlines “will continue to go down as they’ve been going down” this year.

But she said the progress that’s being made is happening on local levels. While the Trump declaration redirected federal money and cleared red tape for state and local officials -- including demanding each Cabinet department claim a role in tackling this epidemic -- many health experts believe the declaration will have limited effect without major new sources of funding.
Click to expand...

and most recently:
The opioid epidemic is a crisis, but Trump isn’t treating it like one
 
"Doctor gets life in prison after patient’s fatal opioid overdose"

https://nypost.com/2019/03/11/doctor-gets-life-in-prison-after-patients-fatal-opioid-overdose/?

One informant said Henson “would have a glass of scotch during their visits.”

On May 4, 2015, a female undercover DEA agent made an appointment with Henson by phone. She got to his Men’s Clinic at 8:15 a.m., “before the posted operating hours,” and stood outside until Henson let her in.

“What is your story?” he asked her, according to the document. He didn’t have her fill out paperwork on allergies or medical history. He only took a copy of her undercover driver’s license, which listed an Olathe address. She put $300 on the counter before leaving. There was no receipt.
What feds found when they investigated Wichita pain-med doctor


DOJ Statement:
Wichita Doctor Sentenced to Life For Diverting Rx Drugs to the Streets
 
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The above examples are of drug dealers playing doctor.
 
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This is 1 state.

How many states have sued, you ask?

(36 in case you were curious. Similar amounts of settlement would be, um... $9.72 billion...)
 
Written by a chronic pain patient on long term oxy. Nice. Objective. not biased. Etc.

FWIW, the government already penalizes ppl they catch with illicits. We have also spent the last 60 + years trying to stop illicit drug use. I don’t see that having any effect. That and pain medicine’s embrace of opioids in late 90s has made our current situation the worst ever.

Here’s an idea, let’s listen to these naysayers and do nothing. Let them have their drugs.

Oh wait that’s what we had done. up to the last 3 years, too early to make any difference...
 
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actually, not really. article has a fair amount of balance. not saying that we need to start prescribing or ignoring CDC guidelines...

interestingly, this ad was present every single page of the article. : Medscape: Medscape Access

INDICATIONS AND USAGE
Xtampza® ER (oxycodone) is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.

Limitations of Use
  • Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve Xtampza ER for use in patients for whom alternative treatment options (eg, non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain
  • Xtampza ER is not indicated as an as-needed (prn) analgesic
Click to expand...
 
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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.
 
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