Pursuant to the Migraine thread.....narcotics....

[physasst]

This was a great article in the NY Times today. I have to confess, I prescribe probably about a 1/3rd the number of narcotics now, compared to when I first started in practice. I see a lot of chronic pain people, particularly in Fast Track, and they generally leave unhappy. We have a hospital policy that we DO NOT administer Methadone in the ED. Like EVER. Additionally, I am very restrictive with refilling narcotics. I've had patients tell me "What if I go into withdrawal?" I always answer, "Yep, you probably will, and it won't be fun, but I'm still not going to refill your pain meds, you need to always get your pain medication from ONE provider, and ONE provider only". I had one recently leave threatening me and my family. Narcotics are not the answer, and we (collectively, cause I have been guilty as well) have created this monster. I once heard an attending answer a patient who said...."What happens if I go into withdrawal...man?" with "It's okay, no one has ever died from narcotic withdrawal". I do actually care, and I try to also have a conversation with chronic pain patients about learning to live with the pain. It's okay to have pain. It really is. We have this ridiculous cultural expectation that everyone should always be pain free, and that pain is "never okay"......BULLSH*T.

I have chronic pain issues myself. I have Crohns and Ankylosing Spondylitis. I wake up every morning (for the last 14 years at least) with moderate back pain (occasionally more than moderate). My wife calls me "grandpa" cause I move like that at first. It wakes me up at night too. When my crohn's is flaring it can really hurt. I never really take anything for this pain (occasionally tylenol). In fact, I don't even normally think about it, and I refuse to allow it to keep from doing things or letting it control me. I did a triathlon 10 months after my last abdominal surgery.....

BTW- Benzos are almost as big a problem, but unfortunately you cannot withhold them as they need to taper. SO, I reluctantly refill benzo requests, but never more than 4-6 tablets.

I do use narcotics for acute pathologies. Fractures, Trauma, Abdominal pathology, etc.etc...but chronic pain....rarely. Anyway, thought the article was apropos.

http://www.nytimes.com/2012/04/09/he...nt&tntemail0=y

Some snippets:
High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States. And over the last decade, the number of prescriptions for the strongest opioids has increased nearly fourfold, with only limited evidence of their long-term effectiveness or risks, federal data shows.

“Doctors are prescribing like crazy,” said Dr. C. Richard Chapman, the director of the Pain Research Center at the University of Utah.

In 2006, a state official here, Dr. Gary Franklin, called together 15 medical experts to discuss some troubling data found in the records. Thirty-two injured workers who were prescribed opioids for pain had died of overdoses involving the drugs. In addition, in just a few years, the strength of the average daily dose of the most powerful opioids prescribed to patients treated through the workers’ compensation program had shot up by more than 50 percent. The number of patients taking the drugs in large quantities had grown to 10,000.


Doctors often increase opioid dosages because patients can adjust, or develop tolerance, to the drugs and need greater amounts to get the same effect. Pain specialists, including Dr. Portenoy of Beth Israel, had argued that it was safe to increase dosages so long as doctors made sure that patients were improving.
But the Washington data suggested that doctors were not monitoring patients; they were simply prescribing more and more. Such practices are common, said Dr. Trescott, the official at Group Health in Seattle, because treating pain patients, who are often also depressed or anxious, is time-consuming and difficult.
“Doctors end up chasing pain” instead of focusing on treating the underlying condition, she said.

The system is now examining how those changes have affected patients. Studies elsewhere suggest the benefits of lower opioid use may be significant for many patients. For example, Danish researchers have published a study indicating that chronic pain patients getting nondrug treatments recover at a rate four times as high as those on opioids.
“These drugs don’t seem to be even doing what they are supposed,” said Dr. Per Sjogren, a pain expert in Copenhagen who led the study.

[winterallsummer]

Unfortunately it's a double edged sword. While many people abuse pain pills there are also those who need them and cannot get them because people suspect them of abuse. I think you having a pain condition yourself probably helps a lot in explaining to patients how to handle chronic pain. You can always tell them to go to a detox center if they withdraw very badly.

[physasst]

Unfortunately it's a double edged sword. While many people abuse pain pills there are also those who need them and cannot get them because people suspect them of abuse. I think you having a pain condition yourself probably helps a lot in explaining to patients how to handle chronic pain. You can always tell them to go to a detox center if they withdraw very badly.

What was interesting from that article was, the evidence that patients who by all criteria NEED pain medications, but taking four times longer to recover. I would need to look at the source study more, and methodologies etc., but it was an interesting point.

[ventana]

You don't need to refill benzo's on the threat of wihdrawl. Take some vitals and see if their is any evidence of withdrawl and if not then they can follow up with their original prescriber. No need to provide more drugs to an addict that is threatening withdrawl when their is no evidence of such.

[jmj11]

I agree with the premise that one issue in today's culture is the expectation and entitlement of pain freedom. I have patients call all the time and say, "Something must be done now, I'm in pain!" This is after we've done heroic things without pain freedom. I tell them, you must do the same thing that people have done for tens of thousands of years . . . bear with it.

[physasst]

Benzo withdrawal is much more serious than narcotic withdrawal. Benzo withdrawal can be life threatening, and can induce seizures and convulsions. I tend to have a lower threshold to refill these in an ED. One should always taper off of chronic benzo use, unless they are already on the lowest dose possible. Additionally, IIRC, it can induce people to commit suicide.

Narcotic withdrawal sucks, but it doesn't have the serious potentially life threatening complications like benzo withdrawal does.

[Contrarian]

Sort of...

In the inpatient setting, If a patient shows up with a reasonable story and verifiable history of and reason for continued opiate/opiod use... most of the time, I will give them what they were on as a outpatient. Sometimes I will "adjust" their regimen to something more reasonable with adjunctive meds as the "stars of the show." Thus far, I have RARELY prescribed Schedule II (C) pain medications in the outpatient setting... Maybe 20 times.
But then again, I don't work in emergency medicine.

Often, when they leave... they expect me to write a script for outpatient med refills. I do write for the adjuctive meds that I added... just NOT for the "candy." They usually get PISSED, and then I smile, and remind them that if indeed they were on the pain meds prior to coming to my facility like they told me... after spending 5-15 days with us supplying them these medications... surely they have 5-15 days worth of these meds sitting at home awaiting their return. So they should have enough to get them to their next appointment with the prescriber of these meds, or simply enough to get them to their next refill time...


The "service lines" in my private practice are: Addiction Medicine (Tobacco, Etoh and Opiates), Non-Invasive Pain Management and Internal Medicine House calls.

For the Addiction Medicine piece, I use:

Varenicline, Buproprion, Clonidine, Acamprosate, Buprenorphine, Naltrexone, Baclofen, Chlordiazepoxide (max 5 days for Etoh W/Ds), Disulfiram, Nicotine Replacement, propranolol.

For the Non-Invasive Chronic Pain Mangement Piece, (I prescribe very few/ little opiates/opioids) I use a LOT of:

Muscle Relaxants: Cyclobenzaprine, Methocarbamol, Tizanidine, Carisoprodol, Metaxalone, Chlorzoxazone, Orphenadrine

NSAIDS: Ibuprophen, Naproxen, Flubiprofen, Diclofenac, Ketoprofen, Celecoxib, Sulindac, Oxaprozin, Etodolac, Piroxicam, Indomethacin, Keterolac, Meloxicam, Nabumetone,

Topical/Local: Diclofenac Gel, Salonpas Patch, Lidoderm patch, Flector Patch, Salicylate Cream,

Duloxetine, Amitriptyline, Imiprimine, Pregabalin, Milnacipran

Withdrawal Syndromes:

The only withdrawal syndromes that kill is Etoh and Benzo...
This is typically thought to be due to Glutamate and GABA receptor remodeling/homeostasis/Neuroadaptation (up/down regulation).

Thing is... You don't really have to refill the benzos either... all you have to do is prescrib prophalactically to prevent benzo seizures.

I use one of two strategies in the Crisis Respite:

1.) If I do prescribe benzos... its ONLY Clonazepam and NEVER more than 0.5mg po TID.

2.) If I do NOT prescribe benzos to someone who obviously has/had issues with them and/or Etoh.... I use other things to prevent seizures. Since we know that the seizures are a result of Glutamate unopposed by GABA:

A.) Neurontin 300mg po TID (max 3600/24hrs)
B.) Tiagabine, 4mg po qd x 1wk then BID x 1wk then TID x 1wk then 8mg BID W/other anticonvulsant
C.) Depakote 250mg po TID
D.) Dilantin 100mg po TID-QID

MY POINT...

There are LOTS of things you can prescribe LOOOONG before you think about writing for Opiates/Opioids and Benzos.

When the patient tries to "guilt" you into prescribing to avoid withdrawal... you CAN and should empathize with them... then explain that you will NOT prescribe controlled substances but that you WILL Rx them symptomatic meds to ease their withdrawal.

Clonidine blunts the catacholemine effects (tachycardia, diaphoresis, hypertension, etc.) associated with withdrawal.

Robaxin or Baclofen or Flexeril blunts the spaticity (muscle cramps) associated with withdrawal.

Librium or Vistaril or Meprobamate will decrease the anxiety associated with withdrawal.

Trazadone, Doxepin, Benedryl, Melatonin, Valerian for insomnia associated with withdrawal.

Gabatril is a GABA reuptake inhibitor. Tiagabine, Acamprosate and Baclofen all act as GABA agonists. A lack of GABA in the synapse is part of the problem associated with withdrawal seizures. It is usually these seizures that kill.

[Contrarian]

Dr. Elliot Krane gives a great short talk on chronic Pain: here

[CAdamsPAC]

Thanks "C" x 2. @Phyasst I concur with your position and practice along the same lines in the ED. Physicians!!!! remain the greatest offenders of giving "percodoodles candy" to "get them out of here" ignoring the good rule of "never feeding stray cats"!!

[True Anomaly]

jmj definitely touched on a point that I've noticed in my short time practicing- there is a significant population out there that feels they should never have pain at any time...ever. As a result, some of them who aren't even on any kind of opiate show up to the ER for a minor problem and expect opiates to treat their minor pain, because they've been "taught" to think that way. This may even be two or three generations deep in the mentality. The classic response, to when I tell them I'm going to prescribe Motrin or Tylenol, is that "But I'm in pain"....as if I'm just giving them candy. My favorite so far is a 60 year old woman who had a paper cut....a PAPER CUT...who wanted opiates for the pain from it.

For those of you who were at SEMPA this year, there was an EXCELLENT lecture on acute management of the chronic pain patient by James Ducharme, who's the editor in chief of the Canadian Journal of Emergency Medicine and also is a medical director for several pain management clinics, basically made the case for pretty much never giving short-acting opioids in the ER for chronic pain. You give short-acting opioids to those people when you give them to otherwise "healthy" patients....fractures, etc.

[ventana]

MY POINT...

There are LOTS of things you can prescribe LOOOONG before you think about writing for Opiates/Opioids and Benzos.

When the patient tries to "guilt" you into prescribing to avoid withdrawal... you CAN and should empathize with them... then explain that you will NOT prescribe controlled substances but that you WILL Rx them symptomatic meds to ease their withdrawal.

Clonidine blunts the catacholemine effects (tachycardia, diaphoresis, hypertension, etc.) associated with withdrawal.

Robaxin or Baclofen or Flexeril blunts the spaticity (muscle cramps) associated with withdrawal.

Librium or Vistaril or Meprobamate will decrease the anxiety associated with withdrawal.

Trazadone, Doxepin, Benedryl, Melatonin, Valerian for insomnia associated with withdrawal.

Gabatril is a GABA reuptake inhibitor. Tiagabine, Acamprosate and Baclofen all act as GABA agonists. A lack of GABA in the synapse is part of the problem associated with withdrawal seizures. It is usually these seizures that kill.

one of the top 10 posts of all time!!! a logical thought out response to the ER provider that merely focus's on dispo instead of what is right for the patient and not setting up all the other ER providers to deal with the ongoing requests for controlled substances "because last time they refilled them for me in the ER!"

[xxbowiexx]

Great posts. I will try hard to implement opiate alternatives in the treatment of chronic pain in my practice.