COVID worsens shortage of hospital opioids

Special Report: COVID deepens the other opioid crisis – a shortage of hospital painkillers – Reuters – Lisa Girion, Dan Levine, Robin Respaut – June 2020 

The DEA, an agency of law enforcement without a medical purpose, controls the amount of opioid medication manufactured by giving several companies strict quotas to produce each year. Because the DEA has no ties to or knowledge of medicine, they react purely to police agency reports of illicit opioids.

They still don’t understand that overdoses are from street opioids, not medication, so they want to keep reducing the opioid medication supply in a misdirected effort to reduce overdoses from street drugs.

As opioid pills and patches fueled a two-decade epidemic of overdoses in the United States, hospitals faced chronic shortages of the same painkillers in injectable form – narcotics vital to patients on breathing machines.  

Genetic Polymorphisms and Pain

Genetic Polymorphisms: Understanding Their Relationship With Cancer Pain – Clinical Pain Advisor – by Vicki Moore, PhD – June 2020

Cancer pain is no different than any other pain and this article explains why and how genetic factors are critical in determining opioid doses.

The Genetic Connection

In addition to genetic polymorphisms associated with the experience of pain, several SNPs have been linked to responses to pain analgesia, such as with opioid therapy.

Although opioids are often an efficacious therapy for pain related to cancer, patients may show varying responses to opioid treatment in association with SNPs in OPRM1, COMT, ABCB1 and other genes.  

Maximum Opioid Doses are an Abomination

Maximum Opioid Doses: A Pharmacological Abomination – By Josh Bloom — June 22, 2020

Despite irrefutable pharmacological evidence of the wide range in individuals’ metabolism of opioid drugs, states continue to impose “one-size-fits-none” laws.

It’s safe to say that no one is really paying attention to the science. So, here it is. Again.

The American Medical Association was two years late to the party when it issued its first statement (1) about the inappropriate use of CDC Guidelines to establish, among other things, laws that define a dose and duration limits for opioid analgesics. No one was listening. Since then things have gotten worse, not better, for pain patients.  

N.H. Bill supports doctors treating pain with opioids

Here’s a very positive development in New Hampshire:

HOUSE BILL 1639-FN – AN ACT relative to healthcare.

Section 5
Requires that boards regulating practitioners prescribing, administering, and dispensing controlled substances adopt rules for management of chronic pain.

Section 6:
defines chronic pain for the purposes of the controlled drug prescription health and safety program.  

Neuropathic Pain & Wind-Up Phenomenon

Managing Difficult Pain Cases: Neuropathic Pain & Wind-Up Phenomenon – WSAVA2013 – VIN – 2013

I was looking for information on the “pain wind-up” phenomenon and found this veterinary paper that explains it well – and without any special fuss about opioids, treating them the same as any other pain-relieving medication. What a refreshing change!

And with animals, there are no “biopsychosocial” factors to blame for increasing pain, so vets take it seriously and don’t just discount it as an attitude problem.

The options for analgesia are ever increasing as our understanding of pain physiology improves.

Yet for humans, there is still little understanding of chronic pain and few new treatments significantly different from the old. 

Self-administration of Hydrocortisone for Pain

General theory of inflammation: patient self-administration of hydrocortisone safely achieves superior control of hydrocortisone-responding disorders by matching dosage with symptom intensity – free full-text /PMC6581742/ – J Inflamm Res. 2019;

Objective: To determine if patient self-administration of hydrocortisone will safely achieve superior symptom control for all hydrocortisone-responding disorders as it does for Addison’s disease and rheumatoid arthritis.

Methods: 2,480 participants with hydrocortisone-responding disorders were brought to a minimum symptom state using daily administered hydrocortisone tablets in a 24-week, open study.

Thereafter, participants used 5-day, low-dose hydrocortisone regimens to quench subsequent disorder exacerbations (flares) to maintain the minimum symptom state. Stressors such as emotional traumas, infections, allergies, and injuries were minimized to reduce disorder intensity, hydrocortisone consumption, and participant discomfort.  

Illicit opioid use after loss of access to opioids for pain

Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLOS ONE. May 4, 2020.

Here’s a finally a study showing the potentially hazardous actions taken by pain patients when their pain relief is cut off. I’m surprised they found the same thing with increasing the dose – if anyone can think of an explanation, please let me know.

In a retrospective study of more than 600 patients in San Francisco receiving opioid pain relievers (OPR) for chronic, non-cancer pain, the researchers found that

• “[l]oss of access to prescribed OPRs was associated with more frequent use of non-prescribed opioids and heroin, and
• increased OPR dose was associated with more frequent heroin use.

In addition to being cautious with increasing OPR dose, care providers should consider the potential unintended consequences of stopping OPR therapy when developing opioid prescribing guidelines and managing practice.”

AMA recommends specific changes to CDC guideline

The full AMA letter and each recommendation to revise the CDC guideline – (continued from yesterday’s post)

…the CDC Guideline could be substantially improved in three overarching ways.

1. First, by incorporating some fundamental revisions that acknowledge that many patients experience pain that is not well controlled, substantially impairs their quality of life and/or functional status, stigmatizes them, and could be managed with more compassionate patient care.
2. Second, by using the revised CDC Guideline as part of a coordinated federal strategy to help ensure patients with pain receive comprehensive care delivered in a patient-centric approach. And
3. Third, by urging state legislatures, payers, pharmacy chains, pharmacy benefit management companies, and all other stakeholders to immediately suspend use of the CDC Guideline as an arbitrary policy to limit, discontinue or taper a patient’s opioid therapy.

AMA urges CDC to revise opioid prescribing guideline

AMA urges CDC to revise opioid prescribing guideline | American Medical Association – Jun 18, 2020

Finally! I’m still outraged that the AMA stood by silently for 5 long years as more and more pain patients were deprived of legitimate medical opioid treatment.

They remained silent as law enforcement second-guessed doctors’ decisions and essentially dictated our treatment. I didn’t hear a peep of protest when appropriate medical care was decided by the DEA and enforced by SWAT teams.

So pardon me if I’m not giving the AMA adulation or kudos or praise for doing what they should have done 5 years ago. Their inaction led directly to the suicides of so many pain patients who were deprived of pain relief on the basis of these appallingly arbitrary and misapplied CDC guidelines. 

Doctor Fights State Over Opioid Tapering Ethics

Doctor Declines State’s Offer In Battle Over Opioid Tapering Ethics – Redheaded Blackbelt

Here’s another courageous doctor fighting back for us, staring down the medical board, refusing to taper her patients faster than medically appropriate, no matter what the medical board or the DEA says.

In an update with Humboldt Last Week, Arcata doctor Connie Basch said she’s declined an offer from the Medical Board of California to receive probation in exchange for an admittance of guilt in her case involving the overprescription of opioids.

The complaint against Basch surrounds what she would call five “legacy” patients that came to her several years ago on high doses of opioids and anti-anxiety meds.