The Problem with Surrogate Endpoints

The Problem with Surrogate Endpoints – Alex Gertner – Twitter stream from @setmoreoff – Feb 2019

Mr. Gertner shows why you cannot measure drug use by counting various “surrogate outcomes” like those listed below and expect to get a realistic number.  Measurements can be dramatically skewed and lead to wildly inaccurate results when invalid surrogate endpoints are chosen.

1/ If you’d like to research the effect of a policy or program on drug use rates then you need to measure drug use.

  • ED overdose visits,
  • drug related arrests, and
  • overdose deaths

are not good measures of drug use rates. Thoughts from >10 years working in drug policy & research   Continue reading

Since when does the government write prescriptions?

Opioid crisis — Since when does the government write prescriptions?By Dr. Henry I. Miller, Josh Bloom | Fox NewsMar 2019

federal and state agencies are focusing on the wrong target – legitimate prescribing of opioids – and have insinuated themselves into the doctor-patient relationship as never before.

Our governments are taking prescription pads out of the hands of physicians and dictating which, and how much, prescription pain medication may be prescribed for patients. This is chilling and unprecedented.

And nationwide, millions of pain patients, even those who were functioning well with long-term opioid therapy, are being forcibly tapered or having their medicines stopped outright, regardless of their wishes or those of their physicians.   Continue reading

Diagnosing Hyperalgesia to Limit Care

Misuse of Hyperalgesia to Limit Care | Practical Pain Mgmt | By Donald C. Harper, MD, BSc March 2011

John (not his real name) is a 51-year-old chronic pain patient that I have been seeing since 2003. I had begun carefully titrating him on oxycodone, Oxycontin® and Dilaudid®, which had been started by another doctor and, ultimately, settled on a dose of Oxycontin 640mg B.I.D., 32mg hydromorphone q 4 hrs prn breakthrough pain and Xanax® 1 to 1.5mg q.i.d. prn muscle spasms and anxiety. On these medicines, he was content and functional and denied any deficits or side-effects due to his medicine.

His insurance company was concerned about the expenses of his medicine and asked me to arrange for a second opinion. Given the complicating factor of his end-stage lung cancer, I arranged for an evaluation by the pain clinic of a major cancer center.   Continue reading

Opioid Use, Misuse, and Suicidal Behaviors

Opioid Use, Misuse, and Suicidal Behaviors in a Nationally Representative Sample of U.S. Adults. – PubMed – NCBI – just the abstract available – Mar 2019

This study proves that simply using opioids to treat a medical condition does not lead to increases in suicidal thoughts and behaviors.

Prior research has shown associations between opioid misuse and suicidal behaviors, but the relationship between medical opioid use and suicidal behaviors is not known.

We assessed associations between opioid use and misuse to suicidal ideation, suicide plans, and suicide attempts among adults 18-64 years old (n=86,186) using nationally representative cross-sectional data from the 2015-2016 National Survey on Drug Use and Health.   Continue reading

Low rates of dependence/addiction from opioids for pain relief

I edited the title because it’s been pointed out that “dependence” isn’t the right word. I knew this but was paraphrasing the article title, which uses that word instead of addiction, even though they are clearly talking about opioid misuse. We can thank the DSM-5 for this confusion.

Development of dependence following treatment with opioid analgesics for pain relief: a systematic view – June 2012

Aims: To assess the incidence or prevalence of opioid dependence syndrome in adults (with and without previous history of substance abuse) following treatment with opioid analgesics for pain relief.

Spoiler alert from the happy conclusion:

The available evidence suggests that opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence.    Continue reading

The Truth About Hyperalgesia

Demystifying Opioid-Induced Hyperalgesia – By Jennifer P. Schneider, MD, PhD Feb 2019

Some insurance companies have declined to continue paying for opioid medications, citing OIH. Here’s why.

In cases like these, many insurance companies state that patients should have their doses tapered in order to decrease their pain.

Now, we’re really living in a fun-house mirror world, where taking a pain reliever increases pain and taking away opioid pain relief decreases it.

However, clinicians may find that attempts to reduce the opioid dose often result in increased pain.

Ya think?  Continue reading

California’s probe of opioid deaths

Doctors call California’s probe of opioid deaths a ‘witch hunt’by Cheryl Clark – Jan 2019

The Medical Board of California has launched investigations into doctors who prescribed opioids to patients who suffered fatal overdoses, in some cases months or even years later.

The effort, dubbed “the Death Certificate Project,” has angered physicians in California and beyond, in part because the doctors being investigated did not necessarily write the prescriptions that led to a death.

That makes it the most comprehensive [and perverse] project of its kind in the country.   Continue reading

Pain Management Best Practices draft report toolkit

Pain Management Best Practices draft report toolkit – U.S. Pain Foundation

Comments on new federal recommendations on pain are
due April 1.

A high-ranking federal task force has released its much-anticipated draft report with recommendations for improving the management of chronic and acute pain. The public is being asked to provide feedback on the report by April 1.

In this toolkit, you’ll find information about:

  • The task force
  • The report
  • How to submit comments
  • Tips for submitting comments

Continue reading

60 Minutes Fails to Represent Pain Patient Perspective

60 Minutes Fails to Represent Pain Patient Perspective By Laura Mills, Kate M. Nicholson, and Lindsay Baran – Mar 2019

CBS heaved out another stigmatizing and inaccurate media “story” (didn’t qualify to be called a “report”) about opioids and those who must take them. Here is the response, which points out the “pain” side of opioids (instead of just the “addiction” side).

In a Feb. 24 segment, CBS’s 60 Minutes accused the Food and Drug Administration (FDA) of igniting the overdose epidemic in the United States with its “illegal approval of opioids for the treatment of chronic pain.”

While the program highlighted the adverse consequences of misleading pharmaceutical marketing and lax government oversight, this segment failed to consider the perspective of patients who legitimately use opioids for pain, stigmatized them as drug-seekers, and propagated misconceptions about the overdose crisis, such as the idea that opioid treatment for chronic pain is indisputably illegitimate and is driving overdose deaths in the US.   Continue reading

Impact of High-Dose Opioids on Overdoses

Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality | Pain Medicine | Oxford AcademicJanuary 2016

Objective.

Previous studies examining opioid dose and overdose risk provide limited granularity by milligram strength and instead rely on thresholds.

We quantify dose-dependent overdose.

Spoiler: there is no linear or incremental increase in overdose risk by dosage.  The 90MME limit proposed by the CDC Guideline isn’t based on science, but more like a consensus “best guess” by addiction doctors.  Continue reading