The Other Opioid Crisis: Hospital Shortages Lead To Patient Pain, Medical Error

I came across this public-accesss story, and wanted to share the perspective:

Even as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.
The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.
As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.
In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which can be up to 10 times more powerful than fentanyl, the ideal medication for that situation.
In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Other patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.
The American Society of Anesthesiologists confirmed that some elective surgeries, which can include gall bladder removal and hernia repair, have been postponed.
Even as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.
The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.
As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.
In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which can be up to 10 times more powerful than fentanyl, the ideal medication for that situation.
In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Other patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.
The American Society of Anesthesiologists confirmed that some elective surgeries, which can include gall bladder removal and hernia repair, have been postponed.
In a Feb. 27 letter to the U.S. Drug Enforcement Administration, a coalition of professional medical groups — including the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists — said the shortages “increase the risk of medical errors” and are “potentially life-threatening.”
In addition, “having diminished supply of these critical drugs, or no supply at all, can cause suboptimal pain control or sedation for patients,” the group wrote.
The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.
Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.
Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.
Marchelle Bernell (Courtesy of Marchelle Bernell)
Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.
Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.
“The system has been set up safely for the drugs and the care processes that we ordinarily use,” said Dr. Beverly Philip, a Harvard University professor of anesthesiology who practices at Brigham and Women’s Hospital in Boston. “You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”
Dr. Beverly Philip (Courtesy of the American Society of Anesthesiologists)
Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.
“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.”
During the last major opioid shortage in 2010, two patients died from overdoses when a more powerful opioid was mistakenly prescribed, according to the institute. Other patients had to be revived after receiving inaccurate doses.
The shortage of the three medications, which is being tracked by the FDA, became critical last year as a result of manufacturing problems at Pfizer, which controls at least 60 percent of the market of injectable opioids, said Erin Fox, a drug shortage expert at the University of Utah.
A Pfizer spokesman, Steve Danehy, said its shortage started in June 2017 when the company cut back production while upgrading its plant in McPherson, Kan. The company is not currently distributing prefilled syringes “to ensure patient safety,” it said, because of problems with a third-party supplier it declined to name.
That followed a February 2017 report by the U.S. Food and Drug Administration that found significant violations at the McPherson plant. The agency cited “visible particulates” floating in the liquid medications and a “significant loss of control in your manufacturing process [that] represents a severe risk of harm to patients.” Pfizer said, however, that the FDA report wasn’t the impetus for the factory upgrades.
Other liquid-opioid manufacturers, including West-Ward Pharmaceuticals and Fresenius Kabi, are deluged with back orders, Fox said. Importing these heavily regulated narcotics from other countries is unprecedented and unlikely, she added, in part because it would require federal approval.
At the same time, in an attempt to reduce the misuse of opioid painkillers, the Drug Enforcement Administration called for a 25 percent reduction of all opioid manufacturing last year, and an additional 20 percent this year.
“DEA must balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances,” the agency said in August.
When the coalition of health groups penned its letter to the DEA last month, it asked the agency to loosen the restrictions for liquid opioids to ease the strain on hospitals.
The shortages are not being felt evenly across all hospitals. Dr. Melissa Dillmon, medical oncologist at the Harbin Clinic in Rome, Ga., said that by shopping around for other suppliers and using pill forms of the painkillers, her cancer patients are getting the pain relief they need.
Dr. Shalini Shah, the head of pain medicine at the University of California-Irvine health system, pulled together a team of 20 people in January to figure out how to meet patients’ needs. The group meets for an hour twice a week.
Dr. Shalini Shah (Courtesy of University of California-Irvine)
The group has established workarounds, such as giving tablet forms of the opioids to patients who can swallow, using local anesthetics like nerve blocks and substituting opiates with acetaminophen, ketamine and muscle relaxants.
“We essentially have to ration to patients that are most vulnerable,” Shah said.
Two other California hospital systems, Kaiser Permanente and Dignity Health in Sacramento, confirmed they’re experiencing shortages, and that staff are being judicious with their supplies and using alternative medications when necessary. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
At Helen Keller Hospital’s emergency department in Sheffield, Ala., earlier this month, a 20-year-old showed up with second-degree burns. Dr. Hamad Husainy said he didn’t have what he needed to keep her out of pain.
Sometime in January, the hospital ran out of Dilaudid, a drug seven times more potent than morphine, and has been low on other injectable opioids, he said.
Because Husainy’s patient was a former opioid user, she had a higher tolerance to the drugs. She needed something strong like Dilaudid to keep her out of pain during a two-hour ride to a burn center, he said.
“It really posed a problem,” said Husainy, who was certain she was in pain even after giving her several doses of the less potent morphine. “We did what we could, the best that we could,” he said.
Bernell, the St. Louis nurse, said some trauma patients have had to wait 30 minutes before getting pain relief because of the shortages.
Dr. Howie Mell (Courtesy of Howie Mell)
“That’s too long,” said Bernell, a former intensive care nurse who now works in radiology.
Dr. Howie Mell, an emergency physician in Chicago, said his large hospital system, which he declined to name, hasn’t had Dilaudid since January. Morphine is being set aside for patients who need surgery, he said, and the facility has about a week’s supply of fentanyl.
Mell, who is also a spokesman for the American College of Emergency Physicians, said some emergency departments are considering using nitrous oxide, or “laughing gas,” to manage patient pain, he said.
When Mell first heard about the shortage six months ago, he thought a nationwide scarcity of the widely used drugs would force policymakers to “come up with a solution” before it became dire.
“But they didn’t,” he said.



In a Feb. 27 letter to the U.S. Drug Enforcement Administration, a coalition of professional medical groups — including the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists — said the shortages “increase the risk of medical errors” and are “potentially life-threatening.”
In addition, “having diminished supply of these critical drugs, or no supply at all, can cause suboptimal pain control or sedation for patients,” the group wrote.
The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.
Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.
Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.
Marchelle Bernell (Courtesy of Marchelle Bernell)
Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.
Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.
“The system has been set up safely for the drugs and the care processes that we ordinarily use,” said Dr. Beverly Philip, a Harvard University professor of anesthesiology who practices at Brigham and Women’s Hospital in Boston. “You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”
Dr. Beverly Philip (Courtesy of the American Society of Anesthesiologists)
Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.
“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.”
During the last major opioid shortage in 2010, two patients died from overdoses when a more powerful opioid was mistakenly prescribed, according to the institute. Other patients had to be revived after receiving inaccurate doses.
The shortage of the three medications, which is being tracked by the FDA, became critical last year as a result of manufacturing problems at Pfizer, which controls at least 60 percent of the market of injectable opioids, said Erin Fox, a drug shortage expert at the University of Utah.
A Pfizer spokesman, Steve Danehy, said its shortage started in June 2017 when the company cut back production while upgrading its plant in McPherson, Kan. The company is not currently distributing prefilled syringes “to ensure patient safety,” it said, because of problems with a third-party supplier it declined to name.
That followed a February 2017 report by the U.S. Food and Drug Administration that found significant violations at the McPherson plant. The agency cited “visible particulates” floating in the liquid medications and a “significant loss of control in your manufacturing process [that] represents a severe risk of harm to patients.” Pfizer said, however, that the FDA report wasn’t the impetus for the factory upgrades.
Other liquid-opioid manufacturers, including West-Ward Pharmaceuticals and Fresenius Kabi, are deluged with back orders, Fox said. Importing these heavily regulated narcotics from other countries is unprecedented and unlikely, she added, in part because it would require federal approval.
At the same time, in an attempt to reduce the misuse of opioid painkillers, the Drug Enforcement Administration called for a 25 percent reduction of all opioid manufacturing last year, and an additional 20 percent this year.
“DEA must balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances,” the agency said in August.
When the coalition of health groups penned its letter to the DEA last month, it asked the agency to loosen the restrictions for liquid opioids to ease the strain on hospitals.
The shortages are not being felt evenly across all hospitals. Dr. Melissa Dillmon, medical oncologist at the Harbin Clinic in Rome, Ga., said that by shopping around for other suppliers and using pill forms of the painkillers, her cancer patients are getting the pain relief they need.
Dr. Shalini Shah, the head of pain medicine at the University of California-Irvine health system, pulled together a team of 20 people in January to figure out how to meet patients’ needs. The group meets for an hour twice a week.
Dr. Shalini Shah (Courtesy of University of California-Irvine)
The group has established workarounds, such as giving tablet forms of the opioids to patients who can swallow, using local anesthetics like nerve blocks and substituting opiates with acetaminophen, ketamine and muscle relaxants.
“We essentially have to ration to patients that are most vulnerable,” Shah said.
Two other California hospital systems, Kaiser Permanente and Dignity Health in Sacramento, confirmed they’re experiencing shortages, and that staff are being judicious with their supplies and using alternative medications when necessary. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
At Helen Keller Hospital’s emergency department in Sheffield, Ala., earlier this month, a 20-year-old showed up with second-degree burns. Dr. Hamad Husainy said he didn’t have what he needed to keep her out of pain.
Sometime in January, the hospital ran out of Dilaudid, a drug seven times more potent than morphine, and has been low on other injectable opioids, he said.
Because Husainy’s patient was a former opioid user, she had a higher tolerance to the drugs. She needed something strong like Dilaudid to keep her out of pain during a two-hour ride to a burn center, he said.
“It really posed a problem,” said Husainy, who was certain she was in pain even after giving her several doses of the less potent morphine. “We did what we could, the best that we could,” he said.
Bernell, the St. Louis nurse, said some trauma patients have had to wait 30 minutes before getting pain relief because of the shortages.
Dr. Howie Mell (Courtesy of Howie Mell)
“That’s too long,” said Bernell, a former intensive care nurse who now works in radiology.
Dr. Howie Mell, an emergency physician in Chicago, said his large hospital system, which he declined to name, hasn’t had Dilaudid since January. Morphine is being set aside for patients who need surgery, he said, and the facility has about a week’s supply of fentanyl.
Mell, who is also a spokesman for the American College of Emergency Physicians, said some emergency departments are considering using nitrous oxide, or “laughing gas,” to manage patient pain, he said.
When Mell first heard about the shortage six months ago, he thought a nationwide scarcity of the widely used drugs would force policymakers to “come up with a solution” before it became dire.
“But they didn’t,” he said.

Ten Gripes of Buprenorphine Doctors

I recently gave a lecture to medical students about opioid dependence and medication assisted treatment using buprenorphine, methadone, or naltrexone. I was happy to see their interest in the topic, in contrast to the utter lack of interest in learning about buprenorphine shown by practicing physicians. In case someone from the latter group comes across this page, I’ll list a few things to do or to avoid when caring for someone on buprenorphine (e.g. Suboxone).
1. Buprenorphine does NOT treat acute pain, so don’t assume that it will. Patients are fully tolerant to the mu-opioid effects of buprenorphine, so they do not walk around in a state of constant analgesia. Acute pain that you would typically treat with opioids should be treated with opioids in buprenorphine patients. Patients on buprenorphine need higher doses of agonist, usually 2-3 times greater than other patients. Reduce risk of overuse/overdose by providing multiple scripts with ‘fill after’ dates. For example if someone needs opioid analgesia for 6 days, use three prescriptions that each cover two days, each with the notation ‘fill on or after’ the date each will be needed.
2. Don’t say ‘since you’re an opioid addict I can’t give you anything’. There are ways to provide analgesia safely. If you do not provide analgesia when indicated, your patient will only crave opioids more, and may seek out illicit opioids for relief. Unfortunately nobody will criticize you for leaving your patient in pain, but they should!
3. Don’t blame the lack of pain control on laws that don’t exist, for example “I’d like to help you but the law won’t let me.” Patients deserve honesty, even when the truth makes us uncomfortable. We get paid ‘the big bucks’ for tolerating the discomfort that sometimes comes from frank discussions with our patients.
4. Don’t assume your patient can or cannot control pain medications. If a patient has been stable on buprenorphine for years, he/she may have a partner or family member who you can trust to control pain medications. Some patients stable on buprenorphine can control agonists used for acute pain, but I wouldn’t stake my life, or theirs, on that ability. A useful compromise is to prescribe enough pain medication to cover 1-2 days of analgesia on each of several prescriptions, each with a ‘fill after’ date, to reduce the amount of agonist controlled by the patient at one time.
5. Don’t tell your patients that ‘opioids don’t work for chronic pain.’ I see stories on such great medical sources as the ‘Huffington Post’ explaining that ‘opioids never help chronic pain’. In reality, your patients know that opioids DO treat chronic pain, so they will consider you a liar or an idiot if you clam they don’t. The challenge is explaining the risk/reward equation to your patients, and explaining why treating chronic pain with opioids often leads to greater problems, as the risk/benefit equation is changed by tolerance.
6. I know this will cause heads to explode, but don’t assume that chronic pain is always less severe than acute pain. What if your patient’s chronic pain is worse than the typical pain after cholecystectomy or ACL repair? Most doctors would gasp at the idea of recovering from major surgery without opioids. What if the pain from failed back syndrome is worse?! I have had a few patients who, I’m certain, experience a great deal of suffering, and have gone so far as to have brain or spinal cord implants to get relief. I’m not arguing that we treat chronic pain in the same way as acute pain. But we shouldn’t jump to the conclusion that chronic pain isn’t severe enough to warrant opioids in order to dismiss those complaints more easily.
7. Don’t tell your patient to stop taking buprenorphine unless you’ve talked with the doctor who is prescribing that medication, and realize that the doctor you are calling knows more about buprenorphine and addiction than you do.
8. Don’t ask patients ‘how long are you going to take that stuff’ or criticize patients’ use of buprenorphine medications. Likewise psychiatrists shouldn’t tell patients scheduled for knee arthroscopy that the procedure is controversial, or talk patients out of hernia surgery.
9. Don’t assume that the doctor prescribing buprenorphine knows what YOU are doing. Too often patients will tell me about surgery that they failed to discuss in advance, even calling about pain hours after getting home from a procedure they failed to mention. Some people seem to believe that doctors regularly collaborate on their care, even though the opposite is closer to the truth.
10. Don’t assume that unusual or atypical symptoms come fromo buprenorphine. One truism of medicine is that doctors tend to blame unexplained symptoms on whatever medication they know the least about. Fevers of unknown origin, mental status changes, or double vision are not ‘from the buprenorphine!’
Those are the gripes at the top of my list. Did I miss one of yours? Or for patients, have you suffered from breakdowns in the system?
Addendum: 11. When treating post-surgical pain in buprenorphine patients, choose one opioid and stick with it. What often happens is that doctors will use one opioid, say morphine… and when nurses call a few hours later to say the patient is still screaming, they change to a different opioid, then another after that. As a result, the patient is placed on insufficient doses of several opioids, rather than an adequate dose of one medication.
There are two critical issues in treating such patients effectively. First, providing pain relief comes down to competition at the mu receptor. A certain concentration of agonist in the brain and spinal fluid will out-compete buprenorphine and provide analgesia. You cannot get there by adding other opioids together. If you use oxycodone for an hour and then change to dilaudid, you are starting over. Instead, choose one drug, preferably something that can be given intravenously, and stick with it. Morphine is not a good option btw, because of the low potency and histamine releasing properties of that drug.
Second, remember that analgesia and respiratory depression travel together, both mediated by the mu receptor. Anesthesiologists know this principle well… opioid medication can be titrated to respiratory rate, providing that the medication is given IM or IV. If a patient is breathing 28 times per minute, he/she is in pain. If the patient is breathing 6 times per minute, pain is not a problem, and the patient should be monitored for respiratory depression and possible overdose. When treating pain, doctors should aim for a respiratory rate of 14-18 breaths per minute, making sure that the medication is actually getting into the bloodstream (the risk comes when patients are given SQ injections or oral doses of narcotic that enter the bloodstream later, causing toxic blood levels).

Opioid Analgesia Without Addiction

I don’t have pull with the addiction-related organizations out there.  I’m never been a joiner, and I tend to notice the problems caused by medical societies over the good things that they supposedly accomplish.    For example PROP, or ‘Physicians for Responsible Opioid Prescribing’, have a specific mission.  Once a group has a mission, any considerations about individual patients go out the window.  PROP has propagated the message that opioids are NEVER beneficial for patients with chronic pain.

Legislators with no knowledge of clinical medicine hear that message, and respond by passing draconian laws that interfere with any considerations of individual patients.  I would guess that the people of PROP pat themselves on the back for encouraging laws that remove physician autonomy.  I’m sure they figure that they are smarter than all the family practice docs out there.  But in reality, they are only destroying the control of doctors over patient care, and handing that care over to politicians.  Way to go, PROP.

In the same way, the societies that hold meetings about meetings, that elect Secretaries who become Vice Presidents who become Presidents, get to publish the articles that describe clinical protocols.  The doc who spends every day talking with patients has no access to these sources, and little ability to influence those protocols.  Sometimes the societies and organizations get things right… and sometimes they get things wrong.  The latter is the case with post-op pain control in patients on buprenorphine products.

I’ve written about this before, as regular readers know.  Over the past 8 years I’ve had dozens, if not hundreds, of patients on buprenorphine undergo surgery.  The surgeries include coronary bypass, thoracotomy, rotator cuff repair, C-section, nephrectomy, total knee or hip replacement… and a host of minor surgeries with scopes and lasers.  I’ve treated these patients in a number of ways, in part because hospitals that provide emergency care have different ways of dealing with post-op analgesia.  I rarely have control over what they do acutely– but I almost-always take over pain control when patients are discharged.

In the past few months there have been several ‘articles’ stating that the best way to handle surgery, in people on buprenorphine products, is to stop the buprenorphine before surgery, and treat pain using opioid agonists.  This opinion is not supported by any data.  It is someone’s opinion– usually someone who has a title, i.e. someone who spends at least some of his/her time in society meetings.  That time is removed from the amount of time that could be spent treating and speaking with patients.  Frankly, the ‘higher’ a doctor is in society circles, the less time they spend in patient care.  That comment will anger the docs who it applies to.  I can hear them now– saying I’m only full of ‘sour grapes’. But maybe those same docs should look in the mirror, and wonder how they ended up as ‘President’ of a society.

I’ve used the approach claimed as best practice in the society journals– i.e stopping buprenorphine before surgery– and the same thing always happens.  Tolerance to opioid agonists rises very rapidly in the post-op period.  Patients are discharged on huge doses of opioid agonists.  And at some point, agonists must be discontinued for 24 hours to allow for re-induction with buprenorphine agents.  I’ve had several recent patients go through this exact process– and my frustration motivates this post.  One guy shot himself in the femur, and the bullet also passed through his lower leg.  He needed fasciotomy to avoid losing the leg. His Suboxone was discontinued at admission, and ten days later he was discharged on 30 mg of oxycodone every 2-3 hours– i.e. over 200 mg per day.  The other person was in a serious car accident, and had multiple fractures—  femur, pelvis, ribs, wrist– as well as internal injuries.  After 3 weeks he was released on over 300 mg of oxycodone per day!

On the other hand, I’ve had many patients go through the surgeries listed earlier while maintained on buprenorphine, 4-8 mg per day.  In ALL cases, they had excellent analgesia with lower doses of oxycodone than in the people who stopped buprenorphine.  Most patients did well on 15 mg of oxycodone every 3-4 hours– a max of 120 mg of oxycodone per day.  In a few cases– i.e. in the most painful operations, in the most sensitive patients– I had to use 30 mg of oxycodone every 4 hours.

The most amazing thing about the combination of buprenorphine and opioid agonists is the absence of tolerance to agonists, when buprenorphine is present.  I’ve had patients with recurrent injuries that required repeated surgeries, including a woman who tore her rotator cuff and the surgical repair THREE times over three months.  She took the same amount of opioid agonist for three months, with no noticeable decrease in efficacy.  After the final operation, after three months on significant amounts of opioid agonist, she simply stopped the agonist and resumed her full dose (16 mg) of buprenorphine.  She had no withdrawal, and not other complications.  She simply stopped the agonist and resumed buprenorphine treatment.

I’ve come to realize that buprenorphine effectively ‘anchors’ tolerance when patients take opioid agonists, as long as the buprenorphine is continued.  Patients always say the same thing:  that the pain was reduced by the agonist, but that it didn’t ‘feel’ like the agonist they used to take.  In fact, patients who could never control pain pills found that they COULD control agonists if they stayed on buprenorphine.

A couple years ago I presented these findings at an annual meeting of ASAM.  The slides can be found here.  I believe that some day, combinations of buprenorphine and opioid agonists will be the standard approach to pain treatment.  The combination allows for opioid analgesia without tolerance, without euphoria, and with little or no risk of addiction.  If THAT doesn’t piqué your interest, you have no business reading about opioid dependence!

I picture combinations of buprenorphine and fentanyl… especially since both are now FDA-approved as transdermal patches.  Or perhaps a combination of fentanyl lozenges and sublingual buprenorphine.  The possibilities are endless.  Throughout history, the miracle of opioid analgesia has been cursed by the attachment to tolerance, dependence, and addiction.

Imagine if that curse was lifted from opioid analgesia.    Can you even dare to imagine that world?  I’m telling you… it is closer than you think—- and there for the taking.

Short-Timers

Another question from a reader:
The current blog brings up the notion of long term use of Bupe or short term detox.  You say you are a fan of long term use, and that is clearly a good thing when the patient is one headed back to a drug culture of life of crime or is obsessed with the drug.  But-  what about patients like me and I think many others who have zero contact with the drug world, have never taken an illegal drug, and yet have taken Ocy C over the years for pain and find it all but impossible to stop the Ocy C.  
 The Suboxone helps with the W/D and just getting through with that is all we want.  NA meetings and the like are like being on Mars, it makes no sense.  There are no drug cravings at all and the goal is just normal.  Or rather, the goal is to make it through the W/D which is so harsh with Oxy C as to be dangerous for older people, whose only source of drugs indeed is the doctors Rx for them  And now that too is unavailable.  This group does not need Suboxone to become a new problem for them.  They just want the help.  It is not critically  important to determine “who” is being treated.  The certification training materials seem to brush over this so lightly that there is only one induction method allowed.  One that a drug company would love, but not always a patient —  pleading, do no harm.
My Thoughts:
I hear you, and watch for those patients.  Frankly I wish I had more of them, so that I could get some movement through my practice—- instead of being stuck with 100 chronic patients and a long wait list.   The financial motivation for the DOCTOR is to push people through, for that same reason.  Of course the drug company gets paid in either case.
The first question is whether buprenorphine even helps in the case you describe.   It is easier, in many ways, to taper with methadone than with buprenorphine, as you don’t have to divide such tiny pills.  It has been suggested that it is easier to taper off a partial agonist than an agonist—and I believe that to be true, simply because I have seen people do the former and not the latter.  But I don’t know HOW much easier it is—or if psychological aspects of the taper were more responsible than the person’s state of misery.
There were several studies a few years ago that showed relapse rates of 100% in people treated with Suboxone for less than a year;  those findings, it seems to me, put a damper on the idea that buprenorphine could be useful for short-term detox.  But I don’t know where those people would have fallen on the spectrum that you are presenting.  I do know that they were people with a primary diagnosis of ADDICTION— NOT chronic pain– so maybe they are not relevant here.
My caveat would be that I HAVE met many people over the years who are convinced that they fall in the pain camp you describe, but who turn out to be just as ‘addicted’ as anyone else.  They describe the process in different terms;  instead of admitting to ‘relapsing on opioids’, they describe ‘deciding the pain was worse than they expected, and that it was a mistake to go off opioids.’  They will claim to be different…. But an objective observer would see the same growing attachment to opioids, the same gradual dose escalation, the same excitement and activity when opioids are ‘on board’, and the same depression and misery if a day passes without using.
I agree with your thoughts, and get your point.  I just don’t know if very many people are as clearly-defined as you describe. One reason is because there are few conditions that cause pain severe enough to require high-dose opioid agonists for an extended period of time– say, a few months– that then go away.  Most pain conditions have residual symptoms—- from chronic inflammation, or even from the set-up of central pain circuits.  In a sense the pain is remembered, even after the original injury is repaired.  The severity of that residual pain is affected by the person’s emotional state, dependency, motivation, genetics…..  and the residual pain becomes a expressway back to using opioids— an expressway that is used often by many people.
Thanks for your comments!

Uncoupling of analgesia, tolerance, and euphoria from mu-agonists using buprenorphine

I presented this topic at the Atlanta meeting of ASAM a couple weeks ago.  There are too many slides, but the historical stuff was just too fascinating to leave out.  I wanted to demonstrate,  by lining it up on the side, how time has compressed the most critical discoveries to a very short period of time.  In other words, it wasn’t until thousands of years of opium use that the general concept of endorphines and opioid receptors came along.  We can only hope that similar understandings of the biological basis of tolerance and withdrawal will be comparatively soon.
My study shows something truly fascinating– that a partial agonist seems to anchor tolerance at a lower level, still allowing for potent analgesia, but preventing euphoria and dose escalation.  I have used this combination in people with very major surgeries, that are known to be quite painful– i.e. knee and hip replacements, dental surgeries, gallbladder surgery, and median sternotomy.

Inconvenient Truth

Next month I will be presenting a paper at the annual meeting of ASAM, the American Society of Addiction Medicine. The paper discusses a new method for treating chronic pain, using a combination of buprenorphine and opioid agonists. In my experience, the combination works very well, providing excellent analgesia and at the same time reducing—even eliminating– the euphoria from opioids.
Ten years ago, I would have really been onto something. Back then there were calls from all corners to improve the pain control for patients. The popular belief regarding pain control was that some unfortunate patients were being denied adequate doses of opioid medications. I remember our hospital administrators, in advance of the next JCAHO visit, worried about pain relief in patients who for one or another reason couldn’t describe or report their pain. Posters were put up in each patient room, showing simple drawings of facial expressions ranging from smiles to frowns, so that patients in pain could simply point at the face that exhibited their own level of misery.
What a difference a decade makes! Purdue Pharma, the manufacturer of Oxycontin, was fined over $600 million for claims that their medication was less addictive than other, immediate-release pain-killers. Thousands of young Americans have died from overdoses of pain medications, many that came from their parents’ medicine cabinets. Physician members of PROP, Physicians for Responsible Opioid Prescribing, have called out physicians at the University of Wisconsin School of Medicine and Public Health for having ties to Purdue while arguing against added regulations for potent narcotics.
I have tried to present both sides of the pain pill debate, without disclosing my OWN opinions on the issue—at least until today. And I must be at least somewhat ‘fair and balanced,’ because I’ve received angry messages from both sides—from people telling me I’m evil for not understanding their need for pain medications, and from people telling me I’m evil for not respecting the danger of the medications.
By the way… I have a policy of not printing messages that simply call me names, or that tell me how bad a doctor I must be for writing what I do. I love a good argument, so please feel free to comment on ANY points that I’m trying to make. But I don’t think that making efforts to lead a discussion warrants personal attacks—so please, stick to the issues!
Today, though, I would like to share a couple thoughts on the issue. The thoughts came after a discussion with one of my patients with chronic pain. I have been presenting one side, then the other side, and back again, trying to remain neutral… but from all that I’ve seen as a psychiatrist and as an anesthesiologist, some things cannot be denied.
1. Some people do have chronic pain that responds to opioids. Many doctors—including the doctors who are afraid of the DEA, or the doctors who don’t want to deal with the hard work of prescribing opioids, or the doctors who want a simple world where ‘pain pills are always bad’—don’t want to admit the truth of this statement. This is, with apologies to Al Gore, a very inconvenient truth.
I find it interesting that doctors who don’t want to prescribe pain pills act as if chronic pain does not exist– as if the suffering of people with painful disorders is less important in some way, if it lasts too long. Every prescriber is aware of the need to treat acute pain, but when it comes to chronic pain, the difficulties that arise with treatment (e.g. abuse, diversion, tolerance) lead some doctors to act as if something magical happens on the road from acute to chronic. The phenomenon is the exact opposite of the old saying, ‘to a man with a hammer, everything looks like a nail.’ In this case, ‘to doctors who don’t want to use hammers, there ARE NO NAILS.’ But in truth, there ARE nails; some patients have lots of them. And we doctors have a duty to hammer away at them… (OK, enough with the analogy already!).
2. Just because some people divert opioids does not mean that other people shouldn’t have necessary pain relief. Treating pain is about as fundamental as medicine can be. I do not understand the doctors who say ‘I do not treat pain—you’ll have to see someone else’—especially when there are no doctors available to fill that role. More and more ‘health systems’ are adopting this position, at least in my area. What gives?!
3. At the same time, there is no such thing as ‘complete pain control.’ Tolerance removes the power of narcotics, and chasing tolerance always ends badly. Patients with chronic pain must use ALL tools available, including non-narcotic techniques.
4. Being prescribed pain medications comes with certain responsibilities; the responsibility to use the medications appropriately, to communicate openly and truthfully with the prescriber, to avoid ‘doctor-shopping,’ etc. At some point, patients who refuse to honor these responsibilities will lose access to pain medications—at least to some extent. Is this humane or fair? I think so, as access to pain relief for these patients is balanced against the lives of those killed by illicit use of these medications.
I’m sure I could go on… but for now, this is enough food for thought. Besides, it’s almost time for dinner! Feel free to comment—but please, be nice!
 

The Downside of Methadone

An Article by Mike Berens and Ken Armstrong, Seattle Times, discusses some of the problems with using methadone as a first-line treatment for pain:
When it comes to battling pain, Washington health officials have encouraged doctors to reach for methadone, a powerful and inexpensive prescription drug. For the past decade, the state has declared methadone to be as safe and effective as any other narcotic painkiller.

Methadone

But in a striking reversal that has gained momentum this week, doctors are receiving stark warnings that methadone is riskier and more dangerous — a drug of last resort — because it’s unpredictable and poses a heightened risk of accidental death.
“It’s a dangerous drug because it accumulates in the body and people die in their sleep,” Dr. Jane Ballantyne, a pain specialist at the University of Washington, said Friday. “It’s very tricky and difficult to use safely.”
Ballantyne and the university are helping spearhead a series of state-sponsored training programs to educate physicians, pharmacists and advanced nurse practitioners about the risks of pain drugs.
Earlier this week, while delivering a continuing medical education course for dozens of physicians and other medical professionals at the university, Ballantyne presented a slideshow in which she cautioned that methadone “should be considered a last option opioid, never a first line opioid.”
The state’s effort is a response to a Seattle Times series, “Methadone and the Politics of Pain.” The investigation, published in December, detailed that at least 2,173 people in Washington have died from accidental overdoses of the drug since 2003.
The Times found that year after year, a committee of state-appointed medical experts sanctioned methadone, empowering the state to designate it a “preferred drug” and steer people with state-subsidized health care — most notably, Medicaid patients — to the drug in order to save money.
The state has included only two drugs, methadone and morphine, on its preferred list of long-acting pain drugs.
During the committee’s meetings, officials from state agencies that have a financial stake in methadone’s selection consistently deflected concerns about the drug.
Methadone’s death toll has hit the hardest among low-income patients. Medicaid recipients account for about 8 percent of Washington’s adult population but 48 percent of methadone fatalities.
After the series, the state sent out an emergency public-health advisory that singled out the unique risks of methadone.
Medicaid officials faxed a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as about oxycodone, fentanyl and morphine. The state Department of Health mailed advisories to about 17,000 licensed health-care professionals.
The health advisory confirmed that Washington ranks among states with the highest rates of opioid-related deaths, exceeding the number of deaths each year involving motor vehicles.
Most painkillers, such as oxycodone, dissipate from the body within hours. Methadone can linger for days, pool into a toxic reservoir and depress breathing. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.
Ballantyne noted that methadone is an indispensable drug and plays an important role in the treatment of many patients. However, due to the heightened risks, methadone should be prescribed only by those with extensive training and experience — and only after every other option has been exhausted.
Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, now readily agrees that methadone use carries unique risks and that it should not be the first choice if other drugs are equally suitable.
He said physicians are stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription drugs now that Washington’s new pain-management law has gone into full force beginning this month.
The groundbreaking law requires practitioners to follow new standards for treatment and record-keeping. It also requires prescribers to consult with state-certified pain experts when narcotic dosages reach higher thresholds.
While the law’s goal is to lower doses and, if possible, wean patients from narcotic pain drugs, doctors are finding the task more difficult than hoped, Thompson said.
For instance, methadone patients can suffer prolonged withdrawal symptoms, like nausea and depression. With most pain drugs, withdrawal subsides within a week. Methadone’s grip can last for months, even years, he said.
State officials will review methadone’s role on the state’s preferred drug list during a meeting next month.
“I think we’re going back and relearning how to treat pain,” Thompson said.

Pill Mill Prosecution and the Pain Relief Network

Wow. I just read an email about a story that I was vaguely aware of– about a doctor in Kansas and his wife, who were together linked to scores of overdose deaths. But that is just the beginning. The doctor was supported, during his trial, by Siobhan Reynolds, founder of a nonprofit advocacy group called ‘Pain Relief Network.’  She started the group back in 2003, when her ex-husband was suffering from severe pain from a congenital connective tissue disorder.Reynold's Billboard
He (the ex-husband) found relief in combinations of high-dose opioids and benzodiazepines, at least until his doctor, Virginia pain specialist William Hurwitz, was convicted on 16 counts of drug trafficking.  The ex died, by the way, in 2006.  Are you still with me?
The trial of the Kansas doctor, Stephen Schneider, went on for years.  During the trial, Ms. Reynolds apparently helped support what she considered to be a ‘dream team’ of attorneys.  She used the case as an opportunity to increase her visibility, encouraging the Schneiders to aggressively fight the charges against them on the basis of ‘patient rights.’  Ms. Reynolds, through the Schneiders, argued that suffering patients are being denied appropriate care because of a war, waged by overly-aggressive prosecutors, against doctors who prescribe pain medication.
Ms. Reynolds even paid for a billboard adjacent to the road to the courthouse, so that jurors could see, en route, the statement “Dr. Schneider Never Killed Anyone.”  Some might see the billboard as ‘free speech’, but the judge presiding over the case was not amused.  At the eventual sentencing, the judge gave both Dr. Schneider and his wife over 30 years in prison, hoping that the sentences would “curtail or stop the activities of the Bozo the Clown outfit known as the Pain [Relief] Network, a ship of fools if there ever was one.”
We already have enough drama for a made for TV movie.  Actually there already is one, made by Ms. Reynolds, about her ex’s struggle over finding appropriate pain treatment.  The hour-long film is called ‘The Chilling Effect,’ and can be found here— along with a number of vignettes about the efforts of the Pain Relief Network.
Make that the former Pain Relief Network.  Ms. Reynolds was investigated by a Grand Jury, led by the same prosecutor who led the efforts against Dr. Schneider.  After years of what she considered to be ‘vindictive efforts,’ she closed down Pain Relief Network, saying that the organization’s finances ‘were in shambles.’
Within weeks of closing PRN, Ms. Reynolds lost her life in a plane crash.  Piloting the plane, and also killed, was Kevin Byers– Ms. Reynold’s romantic partner and also– get this attorney for the wife of Dr. Schneider.
Our story ends in typical, made for TV fashion, with all of the loose ends tied up.  The Pain Relief Network is gone, tragically missed by some, and considered ‘good riddance’ by others.  Ms. Reynolds, tireless advocate or misguided fanatic, has left this world for the next.  Left behind are the story-tellers;  I will provide links to both sides, so that readers can have a true, balanced perspective.  From the PRN side, simply go to their former web site, and you will find links to the archives.  The archives contain links to stories in a number of publications, including Slate and the NYT– places where David and Goliath stories are repeated without much challenge, particularly for the Davids.
On the other side is a woman named Marianne Skolek, writer for the Salem News online site, who has little positive to say about Ms. Reynolds and PRN.  For years she has chronicled the epidemic of deaths from Oxycontin, and she has also written a number of articles about the Schneiders, Reynolds, and PRN.  One of the most chilling points in a story by M. Skolek is a a list of the patients who saw Dr. Schneider and who died shortly afterward.  The pattern is clear; people in sudden possession of large numbers of pain pills, who took amounts sufficient to end their lives:

Name

Age

On or about 1st Office Visit

On or about Last Office Visit

On or about Date of Death

Heather M 28 Aug. 27, 2001 Feb. 8, 2002 Feb. 9, 2002
Billie R 45 Oct. 19, 2001 May 2, 2002 May 4, 2002
William M 36 Nov. 12, 2002 Jan. 28, 2003 Feb. 4, 2003
Leslie C 49 April 9, 1996 Feb. 9, 2003 Feb. 14, 2003
David B 47 Nov. 18, 2002 March 12, 2003 March 15, 2003
Terry C 48 Oct. 12, 2001 April 8, 2003 April 14, 2003
Lynnise G 35 May 23, 2002 April 23, 2003 April 30, 2003
Mary S 52 Feb. 6, 2003 June 11, 2003 June 16, 2003
Dustin L 18 June 26, 2003 June 26, 2003 June 27, 2003
Marie H 43 Dec. 24, 2002 May 28, 2003 June 30, 2003
Jessie D 21 March 4, 2003 June 27, 2003 July 11, 2003
Boyce B 59 June 29, 2003 July 23, 2003 July 25, 2003
Kandace B 43 July 10, 2003 Nov. 12, 2003 Nov. 14, 2003
Katherine S 46 July 9, 2003 Nov. 19, 2003 Nov. 25, 2003
Robert S 31 June 2, 2003 Dec. 7, 2003 Dec. 8, 2003
Deborah S 44 Jan. 3, 2003 May 5, 2003 Feb. 5, 2004
Shannon Mi 38 July 27, 2003 Dec. 9, 2003 Feb. 23, 2004
Danny C 35 April 21, 2003 March 5, 2004 March 6, 2004
Vickie H 53 June 26, 2003 March 16, 2004 April 11, 2004
James C 33 March 3, 2004 June 8, 2004 June 9, 2004
Shannon Me 25 July 24, 2003 June 4, 2004 June 22, 2004
Ancira W 45 Sept. 25, 2002 June 15, 2004 July 12, 2004
Darrell H 24 Nov. 12, 2002 July 15, 2004 July 17, 2004
Michael H 37 March 9, 2004 Aug. 26, 2004 Sept. 12, 2004
Patricia C 43 Nov. 8, 2001 Oct. 4, 2004 Oct. 6, 2004
Jon P 36 April 23, 2004 Oct. 8, 2004 Oct. 20, 2004
Tresa W 43 Sept. 15, 2003 Nov. 29, 2004 Dec. 16, 2004
Jeff H 45 Jan. 10, 2003 Dec. 8, 2004 Dec. 29, 2004
Russell H 24 Aug. 23, 2003 Jan. 12, 2005 Jan. 19, 2005
Michael B 48 Sept. 30, 2004 Jan. 28, 2005 Feb. 2, 2005
Amber G 22 Aug. 13, 2003 Jan. 3, 2005 Feb. 26, 2005
Christine B 45 Dec. 11, 2001 Dec. 3, 2004 April 7, 2005
Victor J 48 Jan. 24, 2005 April 15, 2004 April 22, 2005
Randall P 44 March 10, 2005 April 22, 2005 May 3, 2005
Michael F 49 Jan. 10, 2005 May 9, 2005 May 11, 2005
Deborah M 52 Feb. 23, 2005 May 4, 2005 May 15, 2005
Patricia G 49 Feb. 1, 2003 June 18, 2005 June 20, 2005
Dustin B 22 Jan. 20, 2005 Feb. 27, 2005 June 21, 2005
Jerad M 24 July 9, 2004 June 13, 2005 June 22, 2005
Earl A 29 Sept. 22, 2004 June 29, 2005 July 3, 2005
Brad S 53 Oct. 15, 2004 June 30, 2005 July 11, 2005
Clifford C 39 July 23, 2003 June 29, 2005 July 27, 2005
Sue B 38 Oct. 21, 2002 May 12, 2005 Aug. 1, 2005
Jason P 21 Aug. 19, 2003 June 29, 2005 Sept. 4, 2005
Randall S 52 April 27, 2005 Nov. 12, 2005 Nov. 19, 2005
Thomas F 46 Feb. 15, 2005 Jan. 5, 2006 Jan. 9, 2006
Toni W 37 Dec. 30, 1999 Feb. 16, 2006 Feb. 18, 2006
Marilyn R 39 Aug. 16, 2004 March 16, 2006 April 5, 2006
Dalene C 45 Aug. 25, 2003 April 19, 2006 April 21, 2006
Eric T 46 June 2, 2003 April 19, 2006 April 23, 2006
Jo Jo R 46 Feb. 26, 2005 June 5, 2006 June 7, 2006
Mary Sue L 55 Jan. 30, 2002 June 13, 2006 June 14, 2006
Pamela F 42 March 31, 2003 July 21, 2006 July 22, 2006
Deborah W 53 July 18, 2003 Sept. 7, 2006 Sept. 9, 2006
Jeffrey J 39 May 5, 2004 Oct. 23, 2006 Oct. 24, 2006
Ronald W 56 June 29, 2004 March 20, 2007 March 23, 2007
Evelyn S 50 Dec. 12, 2004 April 16, 2007 April 17, 2007
Robin G 45 July 13, 2004 May 11, 2007 May 15, 2007
Ralph S 44 Jan. 16, 2003 May 15, 2007 July 23, 2007
Patsy W 49 Dec. 2, 1999 July 16, 2007 July 26, 2007
Donna D 48 Dec. 27, 2005 July 19, 2007 Aug. 16, 2007
Lucy S. 61 Aug. 29, 2003 Aug. 23, 2007 Aug. 28, 2007
Gyna G 33 Feb. 10, 2004 Oct. 4, 2007 Oct. 7, 2007
Casey G 28 Sept. 4, 2007 Sept. 13, 2007 Oct. 23, 2007
Julia F 50 June 20, 2007 Nov. 20, 2007 Nov. 28, 2007
Rebecca T 54 May 2, 2006 Nov. 17, 2007 Dec. 24, 2007
Jane E 40 Jan. 8, 2003 Jan. 12, 2008 Jan. 26, 2008
John D 52 June 23, 2003 Jan. 3, 2008 Feb. 10, 2008

 
The story is not quite over.  The Schneiders are now appealing their convictions, claiming insufficient counsel– namely that the romantic involvement of one of their attorneys with Ms. Reynolds created a conflict that led to poor counsel.  In other words, they may have asked for mercy, had Ms. Reynolds not been cheering them and their attorney to place everything on the line.
As I’ve written many times, the use of opioids for chronic pain is a complicated issue, with no clear ‘good’ or ‘bad’ side. As in most of life’s challenges, the extremes of each position appear…. extreme.  Ms. Reynolds believed that the Controlled Substances Act should be repealed;  I find it difficult to understand how any educated person would adopt such an approach.  But the extreme opposite side leads to enough fear, in physicians, to stifle the use of narcotic pain relievers in people who truly need such relief.  As for me, I keep trying to straddle the wide middle.

Narcissism, Celebrity Rehab, and Another Overdose Death

On May 27th, 2011, actor Jeff Conaway died from complications of opioid dependence. His death has been attributed to several causes—sepsis, pneumonia, and aspiration among them— but there is little debate over the ultimate cause of his death at the age of 60 years, that being addiction to opioid pain medications.
Mr. Conaway reportedly struggled with chronic pain and addiction to pain medications for a number of years. His situation was particularly tragic—living with severe pain that was relieved by nothing save for a substance with the power to destroy him. Such situations are, unfortunately, not uncommon.
It is easy to take the position that Mr. Conaway should have avoided pain pills; that his addiction essentially disqualified him from even considering them. I will take that attitude myself from time to time, after a series of appointments with patients who are clearly worsening their situation by using opioids for pain that appears ‘tolerable.’ But about the time I start to become confident in my position, I always seem to develop a painful condition of my own—minor sciatica, plantar fasciitis, or lumbar strain, far less severe than the condition of the patients who I have decided should ‘tolerate’ their pain. Whenever that happens I realize, very quickly, something that I had forgotten– pain hurts! Funny how easy it is to ‘tolerate’ pain that is being experienced by someone else!
Most studies that follow patients with chronic pain over periods of years show that people are more ‘functional’ if they never use opioids for chronic pain. But there is considerable debate among the medical community over this issue, with each side finding little to appreciate in the other side’s position. Through my 25 years as a physician I’ve seen the pendulum swing back, and forth, and back again over the issue of opioid treatment for nonmalignant chronic pain. At present, science suggests that opioids are grossly overprescribed. But patients who are taking pain medications for severe pain have a hard time accepting the results of those studies.
There is also considerable confusion among people with addictive disorders about the proper treatment of addiction. I read that Mr. Conaway tried to recover from addiction using methods based in Scientology, as well as ‘traditional’ treatment methods. When he appeared on ‘Celebrity Rehab’, he had every reason to trust his treatment team, and to believe that the advice that he received was sound. But was he told that the success rate for the type of treatment offered in that silly, exploitative TV show is perhaps 5%—and that the presence of TV cameras probably made the success rate even lower?
And am I the only person who finds it bizarre that the doctor behind that TV show has a new book coming out about the harmful effects of narcissism on society– a book that he wrote after building his career off putting movie cameras in the treatment sessions of people who were dying from the end-stages of fatal disease?
I watched the same guy—the doctor writing about all those darn narcissists— do family ‘sex therapy’ on another TV show, offering 15 minutes of fame for teens who would talk about the most intimate details of their young lives, again providing one more step up the career ladder for the guy who is supposedly critical of narcissism.
Wow.
That same doc who is fuzzy on narcissism has made statements about buprenorphine that have done little to clarify the science of treating addiction. He was often on record on his celebrity show stating that buprenorphine should only be used short term, because otherwise people would become ‘dependent’ on it. Those comments surprised me, as I used to think that anyone with a TV show was at least up on the literature in his supposed field of expertise—and the literature has shown quite clearly, for several years now, that opioid addicts LIVE when they are on buprenorphine, and often DIE when they are not.
I can state without reservation that every patient I have treated with buprenorphine has remained alive while taking the medication—the vast majority of them feeling entirely normal, with no side effects save for constipation—which was a problem when they were using opioid agonists as well. I tell patients on buprenorphine that I’m sorry that they need medication, but they have a fatal illness after all—and that yes, they are dependent on buprenorphine—just as diabetics are ‘dependent’ on insulin.
We will never know for certain, but I strongly suspect that had Mr. Conaway received THAT recommendation—that he had a chronic illness, and that he deserved chronic treatment with a chronic medication—then I would have had to find a different topic for this blog post.
And that would have been fine with me.
Rest in Peace, Jeff Conaway.

Needing, Wanting, and Taking Narcotics: Do opiate addicts need more or less?

Today I received a call from a patient who has been taking Suboxone for about six months, asking for help with a pain issue.  Before getting into the specific details I’ll mention something that I have mentioned many times before; some people do very well on Suboxone maintenance for opiate dependence, and others do less well.  Some people take their daily morning dose of Suboxone and then live life almost as non-addicts, rarely even thinking about opiates as they go about the business of life.  But others will remain in an addictive relationship with opiates.  The Suboxone bails them out of jams, or even prevents the jams from happening in the first place.  They don’t spend all of their money on oxycodone or heroin, and in most cases they will manage to avoid taking opiate agonists most of the time.  But they clearly think about opiates much more than would be ideal.   They dose Suboxone more than once per day, even while admitting that they are probably only getting a ‘placebo effect’ when they take that second dose late in the day.  Some are even worse off, taking little chunks of Suboxone at times because they think it gives them a ‘lift’ of energy or mood.  This type of behavior doesn’t necessarily end in disaster (although it sometimes does), but people stuck in this pattern don’t seem to benefit near as much as do those who dose once and forget opiate for the rest of the day.
The patient who called today wanted something ‘i.e. something narcotic’ for ‘severe throat pain that felt like a hole in his throat’—or as my kids would call it, a sore throat.  He didn’t have a diagnosis, but playing the odds he probably has a virus, or perhaps strep throat.  I’ve had strep throat many times, as have most people, including all of my kids.  I’m a pretty compassionate guy as far as my kids go, and I can’t think of a single time I considered treating their sore throats with a narcotic.  I did not provide narcotic for this patient either; doing so would have been unprofessional for multiple reasons, including the fact that he first needed to know what was using the sore throat, before simply masking the pain with narcotics.  But even after a diagnosis has been made, it is not appropriate to treat a sore throat with narcotics even in a person without addiction, let alone in a person with an addiction to opiates.
I have had a number of similar cases; people on Suboxone requesting narcotics for back pain, hand pain, carpal tunnel pain, fibromyalgia, a sore tooth, a sebaceous cyst… things that ‘normal’ people would never seek narcotics for!  I usually get into a discussion, and sometimes an argument, where I try to make the point that most people go through their entire life without taking a schedule II narcotic.  If they did have a schedule II narcotic prescribed it was almost always for severe pain from kidney stones, major surgery, or perhaps from an acute spinal disc herniation; NOT for a sore throat.
There are several issues at stake here and I’ll try to avoid getting them confused with each other.  First, people with opiate dependence who take or don’t take Suboxone must remember that they cannot control their use of opiates.  In the days before Suboxone, opiate addicts were scared to death about needing to take narcotics for surgery.  I remember cases I had as an anesthesiologist where addicts made me promise to withhold narcotics even if they begged for them during the post-op period.  I usually tried to convince those people that they simply HAD to take narcotic in some cases, as there are risks associated with untreated severe pain such as pneumonia from failure to expand the lungs after gallbladder surgery or heart attack from hypertension after abdominal aneurysm surgery.  To summarize, addicts could take their fear too far and avoid narcotics that were necessary to their surgical recovery, but the bottom line was that the smart addict avoided narcotics whenever possible, and was quick to recognize and admit the thought all addicts have after stumbling on a sidewalk crack:  ‘good- maybe I’ll break my leg and need some Percocet!’
Suboxone allows some degree of carelessness because taking Suboxone prevents a free-fall into compulsive opiate use.  But I see too much complacency, and it is important for addicts to realize that not everybody on Suboxone does well.  I have seen cases where an addict on Suboxone believes he/she is safe lightening the dose of Suboxone now and then and taking a couple ‘80s’ for a weekend of pain relief, only to end up back on oxycodone ‘full-time’, no longer able to benefit from buprenorphine. Opiate addiction is a ‘crafty MF’ to borrow a phrase.  We are lucky to have a tool to help some escape the misery of addiction.  But those who take sobriety for granted and abuse the opportunity provided by Suboxone are asking for a heap of misery, and there may be no respite the next time around.
A separate issue is whether opiate addicts DESERVE pain treatment, and I don’t want to be misunderstood on this issue because of my comments above.  There are times in life where a person may need potent schedule II narcotics to treat pain, and in these situations an opiate addict is as deserving of pain relief as any other patient.  I have seen MANY times over the years where a doctor will take note of an addict’s high opiate tolerance, and instead of prescribing a higher dose of narcotic will prescribe a lower-than-normal dose or none at all!  I have heard doctors say ‘out loud’ things like ‘I’m sick of these people, and I’m not giving him anything!’  When a person with a high opiate tolerance (often because of a carelessly- prescribing physician) goes to the local pain clinic for relief of genuine pain, the pain docs will look for a lucrative injection that can be performed, and in the absence of an injection they will look at the patient with a blank expression and say ‘I’m sorry but I can’t help you—I’m not giving you anything.’  They don’t want to do the hard work, and don’t want to take on the trouble of a person who has been damaged by other narcotic prescribers.  Why bother trying to help that person when the next guy has insurance that pays $700 for the 20 minutes of time it takes to do an epidural steroid injection?  If you have a high opiate tolerance and you are refused adequate pain treatment, you have rights.  If you are in that position, send me an e-mail and I will hook you up with a group that advocates for such patients– a group with many lawyers!
I hope that you can differentiate between the two situations described above.  There will always be a gray area between the two types of situations, but the ideas behind each of the two extremes are clearly different.  Opiate addicts learn to see every pain as deserving of treatment with narcotics regardless of whether the pain is coming from a viral cold, a migraine headache, or major surgery.  Addicts who do well are those who recognize that narcotics are rarely necessary and rarely if ever taken by non-addicts.  On the other hand, in the rare cases where narcotics are clearly indicated, addicts have as much right to pain treatment as does anyone else.
JJ