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.  

Misperceptions about ‘Opioid Epidemic:’ Exploring Facts

Misperceptions about the ‘Opioid Epidemic:’ Exploring the Facts – ScienceDirect – Pain Management Nursing – Feb 2020

Here is the full article I posted about yesterday:

A plethora of statistics and claims exist concerning the rise in prescription opioid use and the increase in opioid-related deaths.

Eleven misperceptions were identified that underlie some of the growing national concern and backlash against opioid use.

Misperceptions include

• the number of opioid overdose deaths,
• the quality of government-sponsored data and guidelines,
• the impact of opioid dose escalation on overdose risk,
• postoperative opioid use associated with long-term use, and
• the link between prescription opioid use and heroin initiation.

Tapentadol (Nucynta) Prolonged Release: A Review

Tapentadol Prolonged Release: A Review in Pain Management – free full-text /PMC6422986/ – 2018 Nov

Tapentadol prolonged release (tapentadol PR) [Palexia® SR in EU] is a long-acting tablet formulation of the strong central analgesic tapentadol, which acts as both a μ-opioid receptor (MOR) agonist and a noradrenaline reuptake inhibitor.

Tapentadol PR is approved for chronic pain in various countries, with its EU indication (severe chronic pain manageable only with opioid analgesics) being the focus here.

Well-designed trials and clinical practice data support tapentadol PR use in this setting.   

Study Shows Surgery Reduces Chronic Opioid Use

Surprising Finding: Study Shows Surgery Reduces Chronic Opioid Use – Pain Medicine News – by Michael Vlessides – May 2020

Among chronic opioid users, having surgery seems to be associated with a faster time to opioid discontinuation—contrary to popular belief.

I’m very curious about what they consider “contrary to popular belief”. It doesn’t make much sense to believe that having surgery leads to a “longer time to opioid discontinuation.”

“Of patients coming to our operating rooms, 23% will already be on an opioid by the time they see you on the day of surgery, and 3% will be chronic opioid users,” said Naheed Jivraj, MD.  

EBM only works for the mythical “average patient”

Pain-Topics.org News/Research UPDATES: Expect Analgesic Failure But Seek Success – this website is dead, but my post from 2013 still feels pertinent as corporate profit-driven healthcare companies continue their push to standardize our healthcare.

Evidence-Based Medicine (EBM) figures prominently in these efforts and is vigorously pursued and implemented by corporate healthcare (whose prime directive is to create profit for shareholders).

As our healthcare system tries to move toward EBM (evidence-based medicine), it’s critical to remember that there’s no such thing as an “average patient”.

New standards will be created based on statistical evidence – like means and averages – which can be misleading in medicine. This article points out how such statistics may not make sense in the real world (where not one single family has the statistical average of 2.2 children). 

HHS Guide for Clinicians on Opioid Dosage Reduction

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics.pdf – September 2019

This is the federal document mentioned in the previous post.

This HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-T erm Opioid Analgesics provides advice to clinicians who are contemplating or initiating a reduction in opioid dosage or discontinuation of long-term opioid therapy for chronic pain.

More judicious opioid analgesic prescribing can benefit individual patients as well as public health when opioid analgesic use is limited to situations where benefits of opioids are likely to outweigh risks.

This guide reiterates that benefit/risk calculation over and over as though it’s a special procedure for opioids when it’s what doctors have always been doing. 

A new opioid crisis: beware lest you get what you asked for

America’s new opioid crisis, Politico – By SARAH OWERMOHLE – Apr 2020

This story definitely falls into the category of “beware lest you get what you asked for”.

The DEA has restricted the production of opioids by 50% over the last four years without concern for their medical use. They seemed to believe that all opioids are the same, whether bought, cooked, and injected in the street or prescribed by a doctor.

In their opinion, there were “too many” legitimate opioids being manufactured, so they set out to curtail that by cutting production quotas.

They were successful. They got what they asked for, and now we don’t have enough medication during a crisis.  And people are still overdosing just like before, with illicit opioids. 

Opioids Have Little Effect on Cognition

The Effects of Opioids on Cognition in Older Adults With Cancer and Chronic Noncancer Pain: A Systematic Review – Oct 2019

I’m only able to access the abstract here, but it says pretty much what pain patients already know: unless we’re also taking other non-opioid medications, like Gabapentin or antidepressants, there is “no effect of opioid use on cognitive domains”.

Context

Opioids are prescribed to manage moderate-to-severe pain and can be used with older adults; however, they may lead to several adverse effects, including cognitive impairment.

This is purely conjecture since it has NOT been proven.  

Opium, Opioids And A Pendulum Of Pain

Opium, Opioids And A Pendulum Of Pain – by Hayley Sperling  Wisconsin Public Television – Feb 2019

The story of opioids in the 21st century is one fraught with urgency, pain and heartbreak. To understand how opioids came by their contemporary and often-negative reputation, it’s crucial to examine their history.

The earliest reference to opium use was in about 3500 B.C.E., Dahl said. By 1300 B.C.E., the Egyptians cultivated the opium poppy plant, and its use spread when in 330 B.C.E., Alexander the Great introduced it to Persia and India.

Because they’ve been used for millennia, we know more about opioids than any pharmaceuticals developed by modern science. In some ways, this makes them much “safer” than any of the alternatives suggested. 

Chronic Pain After Cancer: The Role of Opioids – part 2

Chronic Pain Following Treatment for Cancer: The Role of Opioids – Ballantyne – 2003 – The Oncologist – Wiley Online Library – Jane C. Ballantyne –  Dec 2003

This is part 2 of a long article (part 1 here) making very reasonable arguments for using opioids after cancer treatment when chronic pain persists. Her views used to be reasonable, but now she’s one of the most adamant anti-opioid zealots.

Stable Pain Treatment

Ideal chronic opioid therapy, assuming the pain and disease are stable, uses a stable dose of opioid medication

Often, chronic pain is constant and unremitting, and in that case, long‐acting drugs and formulations given round the clock are useful. Round‐the‐clock dosing allows many patients to achieve maximum functionality, without the need to focus on the next dose of drug and without the swings in analgesic level associated with as‐required dosing.