Tag Archives: opioids

Prescribing opioids: An ethical dilemma

An ethical dilemma for doctors: When is it OK to prescribe opioids? – KevinMD | Travis N. Rieder, PhD | October 3, 2017

The National Academies of Science, Engineering and Medicine released an official report on the crisis earlier this year. And, on September 21, the National Academy of Medicine released a special publication calling clinicians to help combat the crisis.

As a bioethicist working on the ethical and policy issues regarding prescription opioids, I am grateful to the National Academy of Medicine for inviting me to serve on this publication’s authorship team, and for taking seriously the ethical component of the prescription opioid crisis.

The opioid epidemic is shot through with ethical challenges.   Continue reading

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Just How Responsible is PROP?

Just How Responsible is PROP? – Dec 2012 – Eliot Cole, MD, MPA

Though this article is from 2012, Dr. Cole shows the holes in PROP’s arguments for opioid restrictions. 

Physicians for Responsible Opioid Prescribing (PROP) is an organization of medical doctors whose mission is to “reduce morbidity and mortality resulting from prescribing of opioids and to promote cautious, safe and responsible opioid prescribing practices.” At first blush, this is a worthy goal that few would challenge.

In an opinion piece Kolodny published in The New York Timesin February 2012, he wrote that “opioids are rarely the answer” for the management of chronic pain, and that “doctors have contributed to an epidemic of overdose deaths and addiction by overprescribing opioids” for chronic pain.  Continue reading

Opioids for Restless Leg Syndrome

Mayo Clinic Proceedings: Restless legs syndrome – Jan 2018

Restless legs syndrome (RLS) is a distinct disorder, differing from chronic pain in many ways.

Refractory RLS is characterized by unresponsiveness to dopamine agonists or alpha-2-delta ligands due to inadequate efficacy, augmentation, or adverse effects.  This may result in severely impaired quality of life, profound insomnia, and suicidal depression.

Opioid therapy is a mainstay in the management of these patients. 

I find it outrageous that opioids are considered appropriate for restless leg syndrome, but not for chronic pain. Continue reading

Little evidence that opioids work for cancer pain

Opioids for cancer pain – an overview of Cochrane reviews. – PubMed – NCBI– Jul 2017

It turns out that there’s not much evidence that opioids are effective for cancer pain either. 

I wonder how research can be so blind: we all know opioids are effective pain relievers for almost everyone, yet studies show so little benefit. This is because current research looks only for harms from opioids, not benefits.

Pain is a common symptom with cancer, and 30% to 50% of all people with cancer will experience moderate to severe pain that can have a major negative impact on their quality of life. Continue reading

Absolutes in Chronic Pain Treatment Can Backfire

Absolutes in Chronic Pain Treatment Can Backfire – National Pain Report – Oct 2017 by Ed Coghlan

Beth Darnall PhD is a pain psychologist, noted researcher and Clinical Professor at the Stanford University as well as successful author on chronic pain.

She and her research team have just landed a major grant to study chronic pain. We interviewed her on the grant, the opioid controversy and the National Pain Strategy

Beth Darnall is the main proponent of the “catastrophizing” theory about chronic pain, which is that the patient’s fears of pain supposedly cause most of chronic pain’s amplification.   Continue reading

Genetic Testing for Opioid Pain Management: A Primer

Genetic Testing for Opioid Pain Management: A Primer – April 2017 – free full-text article /PMC5447546/

An increased use of prescription medications (especially opioids) has led to an increase in adverse drug reactions and has heightened our awareness of the variability in response to medications.

Pharmacogenetics has improved our understanding of drug efficacy and response, opened doors to individual tailoring of medical management, and created a series of ethical and economic considerations.

Since it is a relatively new field, genetic testing has not been fully integrated into the primary care setting.   Continue reading

Pain Patients Denied Needed Opioids in Palliative Care

Rehab Expert: Pain Patients Denied Needed Opioids in Palliative Care – Dec 2017

David, a 38-year-old father of four and five-year survivor of fungal meningitis, experiences the long-term effects of contaminated epidural injections that have left him with headaches, visual disturbances, tinnitus, adhesive arachnoiditis and fibromyalgia.

His story exemplifies the gap between state and federal health care laws and treatment protocols for those with chronic pain requiring high-dose opioid therapy, wrote Terri Lewis, PhD, in “States of Pain: Part II. The Influence of Regulations” in National Pain Report.   Continue reading

Opioids restricted even for cancer pain

Opioid Epidemic Response May Restrict Cancer-Related Pain Management – January 2018 by Leah Lawrence

In response to what many are calling an opioid epidemic, the CDC issued guidelines for limiting prescribing of opioids and many state legislatures have passed or are in the process of passing laws limiting opioid prescriptions.

Although much of the response to the opioid epidemic exempts treatment for cancer-related pain, a recent Oncology Nurse Advisor online survey showed that more than 80% of respondents were concerned about how current restrictions set up to manage the opioid crisis are affecting cancer patient pain management.

“What we are seeing is more and more difficulty for our patients in getting their pain medicine,” said Ann Brady, MSN, RN-BC, CHPN, a symptom management care coordinator at Cancer Center Huntington Hospital in Pasadena, California. “In the past, a physician could write an order for an opioid and the patient could fill it. Now there are a lot more hoops to jump through.”

Cancer-Related Pain

As the number of people with cancer increases so too will the number of people living with cancer-related pain. An estimated 4 in 10 cancer survivors live in some degree of pain, and 5% to 10% have severe chronic pain.

Pain related to cancer is dynamic. Patients with cancer can experience pain related to the tumor itself. A tumor growing in an organ may stretch the part of the organ, causing pain. Tumors that metastasize to bone or to the spinal cord or a nerve can also cause pain.

However, cancer-related pain can also be due to cancer treatment. Patients undergoing surgery, radiation therapy, chemotherapy, bone marrow transplant, or hormonal therapy can experience a variety of types and degrees of pain that may be long-lasting.

According to Dr. Conway, opioids may be considered for cancer-related pain in several settings including short-term use in patients with pain due to treatment, and for the treatment of patients with advanced disease who are experiencing significant pain.

Unfortunately, since the recognition of and response to the growing opioid epidemic, both Dr. Conway and Ms. Brady have begun to face difficulties in getting their patients their pain medication.  

Opioid Epidemic Response

“These opioid restrictions are supposed to carve out for cancer pain, and I think technically they do, but on a practical level it does not always work that way,” Ms. Brady said.

Most people’s understanding of opioids is related to the crisis and often doesn’t distinguish between cancer pain and other pain.”

Ms. Brady has seen these effects in her day-to-day care for patients. For example, some insurance companies and pharmacies are responding to the opioid crisis by being more restrictive with pain medications, she said. Brady will often have to call insurance companies and speak with several rounds of representatives in order to obtain insurance coverage for a patient to receive the type, strength, or length of opioid prescription necessary for their pain.

“This can be very frustrating and time-consuming because sometimes we are making changes to pain management treatment on a day-to-day basis,” she said.

Dr. Conway has also encountered these issues, adding that some insurance carriers will not authorize coverage beyond emergency 3-day or 7-day prescriptions.

Ms. Brady has also heard from patients that even once an opioid prescription is approved by their insurance carrier, they may still run into issues when they go to a pharmacy to fill the prescription.

“If a physician writes for 90 pills and the pharmacy says they only have 30 pills in stock, the patient may only get 30 pills and will not be able to come back to get the remainder of those pills,” she said.

“That is inadequate pain control,” Dr. Conway points out. “This can lead to patients rationing out their pain medication, and in between pills they are suffering.”

He speaks as though only cancer patients suffer from untreated pain. What about all the rest of chronic pain patients now desperately rationing out their own pain medication? Why is it OK for them to suffer between pills?

Ms. Brady said she has also heard of pharmacies requiring that opioid prescriptions be picked up in person by the patient. “For some patients with cancer that is a huge burden.”

Opioid Addiction

Opioid addiction is still a concern in patients with cancer, especially as more and more patients continue to survive beyond 10 years. According to Dr. Conway, that means the prescribers must carefully weigh the pros and cons of these medications.

“If I am treating a patient with advanced, terminal disease, and I know that patient is likely addicted to the medication, am I going to fight the patient knowing that their time is limited and they have no other way to survive but on pain medication? No,” Dr. Conway said.

Non-Opioid Pain Management

Ms. Brady is also a big proponent of integrative therapy. “The clinic where I work has an acupuncturist, a massage therapist, and someone who does classes on mindfulness, and while patients are in the hospital there is music therapy, pet therapy, and a variety of other things available,” she said.

“However, a lot of times these things may help, but will not be a complete fix.”

According to Dr. Conway, oncology nurses, advanced practitioners, and physicians have a responsibility to provide all types of supportive services for patients with cancer experiencing pain.

“That starts with assessing patients individually and not grouping everyone into one category,” Dr Conway said.

“An individualized approach to care means

  • understanding what type of pain they have,
  • their goal of management, and
  • what long-term outcomes we are seeking.”

 

Clinical non-biased opioid guideline from doctors

I found this extremely sensible opioid guideline from 2009. It was developed by doctors and other professionals in pain management, not addiction specialists.

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain – ScienceDirect – February 2009,

Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.   Continue reading

Report in Lancet Calls for Needed Pain Relief

Report in Lancet Calls for Needed Pain Relief | Human Rights Watch

Poor people around the world live and die with little or no pain relief or palliative care, a report published today in the medical journal, Lancet, said, calling the fact a “medical, public health, and moral failing and a travesty of justice.”

And they are trying to make this happen in the US too.   Continue reading