Tag Archives: opioids

Fentanyl: Separating Fact from Fiction

Fentanyl: Separating Fact from FictionPractical Pain ManagementLast updated on: April 12, 2019

The US Centers for Disease Control and Prevention continue to report increasing opioid-related deaths despite declining rates of opioid prescribing.

Dramatically on the rise is the role of illicit synthetic fentanyl derivatives. These potent Schedule I drugs have dwarfed deaths from prescription-opioid overdose deaths, even among those that possess prescription opioids from a nonmedical source

Part of the discrepancy is that overdose deaths are frequently reported through ICD-10 codes, based on the International Statistical Classification of Diseases and Related Health Problems, which do not allow for delineation of overdoses by

  • a legitimately prescribed opioid versus
  • an illicit opioid, versus
  • a combination of these and/or other non-opioid sedative hypnotics.

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Novel Opioid Receptor Agonist Found Effective[?]

Novel Opioid Receptor Agonist Found Effective for Chronic Low Back Pain – Clinical Pain Advisorby Amit Akirov, MD – Aug 2019

The main appeal of this very mild opioid pain reliever is that it enters the nervous system very slowly compared to current opioids, which supposedly makes it less addictive.

NKTR-181 was found to be a safe, effective, and well tolerated treatment over the long term in patients with moderate to severe chronic low back pain (CLBP), according to results from a phase 3 trial published in Pain Medicine.

NKTR-181, a novel μ-opioid receptor agonist, has several advantages compared with conventional opioid drugs, including

  • a slower entry into the central nervous system,
  • delayed receptor binding, and [why would a delay of pain relief be desireable?]
  • long duration of effect.

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The complexity of opioid receptor function

Untangling the complexity of opioid receptor function – by Rita J. Valentino & Nora D. Volkow – Sept 2018for science nerds

This is a technical article explaining the differences between different opioid receptors, which turn out to have further layers of complexity. Finding the molecular paths or signals that create and/or transmit pain signals, researchers hope to find new ways to interrupt that process to alleviate pain.

Evidence that opioid receptors form and can function as heteromers suggests another layer of complexity and another route for manipulating opioid receptor function

Mu opioid receptor agonists are among the most powerful analgesic medications but also among the most addictive.   Continue reading

Opioid Taper Associated with Termination of Care

Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study. – Pub Med – J Gen Intern Med. – Aug 2019

This study exposes the horrific aftermath of forced opioid tapers when patients are expelled from medical care because doctors have a reasonable fear of losing their livelihoods if treating pain with opioids.

BACKGROUND

Opioid tapering is increasingly utilized by providers to decrease risks of chronic opioid therapy, but it is unknown whether tapering is associated with termination of care.

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DSM-5 Criteria for Opioid Use Disorder

DSM-5 Criteria for Diagnosis of Opioid Use Disorder– from American Psychiatric Association

These are the latest diagnostic criteria for what used to be called addiction. They make it seem like everyone on opioid therapy for chronic pain has “opioid use disorder” (OUD).

The writers of this new version of the manual thought the term “addiction” would be stigmatizing, so they created this new disorder as a continuum of “dependence”, further erasing the line between “use of opioids” and “addiction to opioids”.

It makes me think they themselves can’t see the difference that’s so obvious to us. Or perhaps they relied on addiction specialists, most of whom see any use of opioids beyond 90 days as an “opioid use disorder”.   Continue reading

Patient Perspectives on Opioids

Patient Perspectives on Opioids: Views of Inpatient Veterans with Chronic Pain | Pain Medicine | Oxford Academic – July 2018

Objective: To elucidate perspectives on opioids and opioid use from hospitalized veterans with comorbid chronic pain using qualitative methods.

Design:

This was an analysis of individual qualitative interviews.

The semistructured interview guide was developed by a hospitalist with clinical expertise in pain treatment with guidance from a medical anthropologist.   

I’m surprised and baffled to see that a “medical anthropologist” was involved. With just this abstract available, I have no idea why or what for.  Continue reading

Opioid Tapering: Less, Same, or Worse Pain?

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 – PubMed – NCBI – Pain Med. 2018 Dec

This study’s bizarre findings can be explained by the same flaws I pointed out in a previous post of another study on tapering: Opioid cessation and chronic pain

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.

Here’s the first problem I see: the inclusion of only 5% of the references. This would allow for considerable bias, especially since the quality of the chosen studies was so low.  Continue reading

Are WHO Pain Tx Guidelines just Purdue Marketing?

Lawmakers contend WHO pain treatment guidelines are really Purdue ‘marketing materials – By ED SILVERMAN @Pharmalot MAY 22, 2019 – (article athttps://www.statnews.com/pharmalot/2019/05/22/purdue-opioids-world-health-guidelines/” accessible only through subscription to StatPlus)

Just the two first paragraphs of visible preview are astonishing and so infuriating that I’ll just leave you with these two:

Two  lawmakers are urging the World Health Organization to rescind guidelines issued nearly a decade ago for treating pain because they contain “dangerously misleading” and sometimes “outright false claims” about the safety and effectiveness that were orchestrated by Purdue Pharma.

In a new report, the lawmakers contend that the WHO guidelines, which were released in 2011 and 2012, are “serving as marketing materials for Purdue.” And they pointed to efforts by the company to create and fund front groups that participated in research that shaped WHO decision making – and dovetailed with corporate goals to boost use of opioids, such as its own OxyContin pill.

FDA warns against sudden discontinuation of opioids

FDA identifies sudden discontinuation of opioid pain medicinesfda.gov – Apr 2019

I don’t know how I missed this until now. If your doctor is trying to force you into a taper, you can let them know that the FDA warns against taking opioids away from pain patients without a medical reason and then only in a carefully planned extremely gradual taper.

The U.S. Food and Drug Administration (FDA) has received reports of  serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased.

These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.    Continue reading