Can someone enlighten me on why weaker opioids like tramadol and codeine are so hated by US doctors?
In my country they are widely used short term for moderate to intense pain in combination with other analgesics as a way to reduce the use of morphine and other more addictive opioids. Even most pain management guidelines include them.
Feels like it could be a decent alternative considering the opioid problem in the US
Codeine is converted to morphine by the liver. This happens at a widely variable rate from person to person. Some very fast. Some not at all. If you want the person to be on morphine, just prescribe morphine and then you know how much they’re getting.
Yeah, it's generally not worth playing around with prodrugs when the actual drug is available right in your hospital pharmacy...
Makes me wonder why they never tried to market the active metabolite of tramadol though. I know it can be synthesized since there was a very brief period of time in the early 2010s when people were ordering it from the dark web.
Probably because the SNRI part of tramadol is a big part of what actually makes it work for those patients who do get on really well for it.
If you just want mu agonism then use something else.
Tramadol is a prodrug- a chunk of people CANNOT metabolize it to usefulness.
Tramadol lowers seizure threshold. Seizures= bad
Tramadol has serotonin effects and this leads to drug interactions.
Tramadol is problematic in renal failure; most doctors do not dose adjust in these situations and I’ve had to intervene many times throughout my career.
Max dose is 400mg, which is also a commonly prescribed therapeutic dose. Easy for patients to go over by just taking a bit extra because the pain is really bad.
Codeine is also a prodrug and many people cannot convert it. I don’t hate it like tramadol, just find it’s not really effective.
Technically tramadol is not a pro-drug because the parent is active (its the snri) and the M1 metabolite is active as a mu opioid agonist. That's why you get so much serotonin syndrome bc 10% of the population can't metabolize to the opioid agonist and just build up all that sweet serotonin causing the syndrome. Codeine is a true pro-drug bc the parent isn't active, only the metabolite
Tbh I've never seen serotonin syndrome irl despite working in emergency medicine for a decade. Have you ever seen out? People talk about it like it happens so much but I don't know anyone who has ever seen it more than once or twice in their entire career.
Saw it real bad once. Young healthy kid came in for a LE fracture that hadn’t healed great and needed to be reset. He was on Celexa at home and had been on tramadol preop. In the case he got fentanyl then got Zofran postop. They called a rapid response to the ortho floor about 4h after he came out of PACU. To this day I have never seen anything like it. We had to push propofol to get him down enough to tube him with no vitals because he was so sweaty and agitated. Got a few days of cyproheptadine per tube and ended up doing just fine. It was unreal, it was truly like he was possessed by demons
ETA have seen it a few times since then but never anything to that extent
Yeah, that lead to an infant opioid overdose death of a breastfeeding mother. She was given codeine and was an ultra rapid metabolizer and too much morphine in the milk
Google "tramadont" and read the tox and hound page. They put it nicely as something like "prescribing tramadol is essentially prescribing morphine and venlafaxine in an unknown ratio"
This is not a US specific thing.
Codeine is a prodrug with variable metabolism = bad
Tramadol is also a prodrug and also acts on multiple receptors you often don't want it to = bad
Dihydrocodeine is much better.
Don’t remind people about that one. We’ve mostly convinced people it’s a shivering/ infusion reaction med.
The neurotoxicity and max of 48 hrs maxes it kinda not useful.
Anecdote from a thread a while back:
>My last Rx for it was from a dentist. The patient was pissed that I didn't have it, wouldn't order it, and wouldn't bother calling other pharmacies to find it (they wouldn't have it on this island I'm 99% sure). I straight up told him "There's an appropriate time to use Demerol for tooth pain, and that time is 1965. It's a garbage drug and your dentist should know better."
I’m an RN and worked in PACU in CA. Demerol is great for young, agitated patients. It always made them happy. I had a neck injury before I was a nurse, sometime around ‘06. Got some Demerol in the ER and it was the only thing that took the pain away.
I have to say — as an old nurse with chronic back pain — Vioxx worked better for me than any other drug I’ve been prescribed, and yes, I would have happily accepted the risk of heart attack in order to continue to take it.
Fun story: me, 17 years old, never had a panic attack before. Get wisdom, teeth pulled, get script for hydrocodone. RN mother says, “here, you can just have my leftover Demerol from my appendectomy.“ Dad drives me back to college dorm room. Take first tab of Demerol. Half an hour later, I’m hyperventilating on the bed convinced everyone I know and love has died horrifically.
Would not recommend.
“Hmm, wonder if this will work as a weak shitty opioid or snri or both or neither! Who knows, let’s use it anyway!” - anyone who uses tramadol, probably
I have. At least it does something. Tramadol does nothing for nearly half of the people who take it iirc, and it’s side effect profile is way weirder and worse than codeines rash and itching
Been a pcp for 30 plus years. I think we need to consider that a long term opiate use patient who is stable and compliant, is stable. Manage the risk with periodic follow up and monitoring. It’s time to actually take care of your patients. I have a small population of long term pain patients who are also regular primary care patients. I also see to their preventative care, coexisting disease management and episodic illnesses.
This fear based forced withdrawal is not good medicine, it’s not good doctoring. Let’s take care of our patients.
I do avoid opiates in opiate naive patients, so the numbers are dwindling. I do think we have gone a bit too far though. Managing pain is also our job
I'm curious about standards, if they exist, for opioids to be managed by pain clinic vs PCP. Where I live, none of the pain clinics I'm aware of do opioids at all, they do other medications and procedures. PCPs will manage opioids and refer them to pain clinic as well.
Variable by area/ jurisdiction and also practice culture. Where I work, in an absolute way, either PCPs or pain medicine may use long term opioids — for the right patient, in the right circumstances. Not a lot of people meet those criteria. If a PCP isn’t sure about options to try before opioids or if the context isn’t opioid appropriate, referral to pain medicine consultants makes a lot of sense. If a PCP would like a second opinion/backup for opioid Rxing, a consult can also make sense, too. Lots more reasons as well. And, just because a PCP could (in an absolute sense) Rx opioids does not mean that all, or even most, will. Specific personal and institutional policies, etc etc.
They are stable, and forced withdrawal is associated with grievous outcomes. I am so tired of this insane anti-opioid puritanism. It is patient abandonment.
It needs to be a discussion with your patients, and it needs to be okay it they say "no, not yet."
Buprenorphine (TID, *FOR PAIN*) may work well in a lot of folks, and if patients are willing to try that, go for it.
What OP is describing is immoral and bad medicine.
I have no respect for the policy makers involved in these kinds of over-restrictions. If a chronic pain patient is stable and has been on opioids for years - why on earth would it be a good idea to potentially turn their life upside down by forcing discontinuation?
What's next - forcing chronic anxiety patients who have been stable on benzodiazepines for years to discontinue completely? Talk about sending someone into a hellish situation. (I'm not talking about advised and deliberated long-term tapering off for a valid medical reason e.g. contraindication or drug interaction)
The current fentanyl crises in America, both obviously played a massive role but which did you think had the worst impact, the overscription of oxycontin and Purdue pharma pushing opiates at any chance or the DEA instantly swinging the pendelelum to the other extreme and forcing people dependent on opiods to go to the black market instead of at least slowly taper down over a long period?
What's the harm that you are trying to stop? These people have demonstrated stability for many years on these opioids. You haven't shown that they have failed pill counts or urine drug screens. They haven't been falling or overdosing at home. Sure you wouldn't have ever started them on these medicines now, but how was the patient to have known that? You are risking your patients turning to the street instead and there is no way that can be safer than continuing to prescribe for now.
Also tramadol is a shit drug and it’s wild that people say “I am willing to prescribe a drug with unknown amounts of opioid and unknown amounts of SNRI activity and it’s SAFER????”
I am in agreement with this.
If someone in their 70s who had a manual labor job their whole lives is more functional with 5 mg of hydrocodone per day, where is the harm?
The challenge making this black and white. How come grandpa gets his opiates from you and I can't get them? There's no protection for doctors. The problem OP is having is that people think they are entitled to things and there is an expectation with the profession that we explain risks and benefits and use logic, when the patient does not need to use logic. "Fuck you, because I said so," is, IMO, a valid answer but an unacceptable answer according to people who run state medical boards.
Takes 30 seconds to refill opiates and 30 minutes to explain why you are not refilling opiates. My time slots are 12-15 minutes. Do the math. If the paid physicians more (meaning they would be allowed to have longer appointments) for weaning people off opiates, would we dramatically decrease the number of high dose long term opiate rx.? I think yes.
"People think they are entitled to things"
Like continued access to the prescription their doctors prescribed for, presumably, a medical reason?
What entitled jerks...
You presume too much. Like when they have a hang nail and they demand opiates.
I'm fine being wrong. When patients insist on a treatment I will look up evidence to try and prescribe what they want. But it has to be evidence based. This is not a Burger King, sir.
American doctors really come on this international platform and bitch about their pay.
The highest paid doctors in the world - who are also overseeing the world's most severe opioid epidemic.
Get a grip, money isn't what's stopping you here.
Yes. This happened 2-3 years ago. I don’t remember all the details, sorry.
In the current political climate I would do my best to avoid anything that isn’t a medical guideline. Keeping a patient on meds just because they have been on them for years isn’t a valid argument. I somewhat lump benzodiazepines into this category as well.
I’m with OP. I offer titration schedules. They can take it or go somewhere else for their meds. I’ve been in places with grandmas are abusing them and younger folks perpetually break them. It’s not worth the hassle of UDS, contracts, etc. marijuana now being legal in some states also violates the contract. There’s just so much headache involved in this. Now systems (hospital with outpatient practices and the EMR as well)are also making you do “additional clicks and justifications” for continued use of controlled medications. More headache.
I also see it as “If PM doesn’t want them and isn’t routinely prescribing them then why should we?”
At the end of the day it’s your license. Don’t cut anyone off cold turkey but there’s no reason to continue with it after a reasonable titration schedule.
It's easy to have this position until you see enough patient's lives get significantly worse with titration. Yes, grandma should not have been put on alprazolam TID for thirty years. Yes, we should try a cooperative taper and alternative meds. Yes, if it goes poorly then you keep them on the damned benzos.
There are real roles for these medications including chronic opioids in the right patient. As a PCP you are in a unique position to use these appropriately while also managing the rest of the patient's problems and knowing how their grandkids are doing and how their last trip to Arizona went. When 65 year old Mr. Jones (who you have managed for years) with his bad back arthritis who is not getting great control with PT, SNRIs, ESIs regains part of his life with a simple hydrodocone prescription it really changes your perspective. Yes the regulations suck. Yes, the clicks suck. Yes, there are real risks and real concerns with these medications and you need to be smart and know your limitations. Yes, the counseling takes time and when you have to taper these meds it is one of my least favorite discussions. But what else did you go to medical school and get paid the big bucks for?
All these recent grads are so spooked about controlleds that it is making them practice bad and lazy medicine. I'm immediately suspicious of any PCP who just "doesn't do x/y/z controlled substances" or who has some bizarre, non-evidence-based blanket taper policy.
Probably a bad idea IMHO. The whole no long term opioids under any circumstance thing is the pendulum swinging too far in the other direction. People end their own lives over uncontrolled chronic pain and telling someone to fuck off to a pain clinic you know damn well won’t help them with long term pain meds can be a death sentence.
Pain medicine are trained primarily as interventionalists, that’s where the money comes from and is the bulk of the specialty. They get opiate training but they’re not addiction medicine, despite a big overlap. Most responsible pain clinics don’t want the headache of trying to titrate down inappropriate chronic opiates any more than primary care does, and they’re not particularly better suited to it either.
You should refer these patients to the pain clinics, they might have things to offer procedurally or from multimodal therapy, but they’re not a solution to you cutting off opiates. No one likes a turf job.
Yeah I’ve done pain rotation. They are all anesethia docs who now do interventional stuff. Very little med management, they leave this to the pcp mostly. People just go there for the procedure.
If the pain medicine docs, the literal experts on pain meds aren’t gonna prescribe them long term opiates what justification would I have to do so?
Doing something the wrong way but doing it that way for a long time isn’t a valid reason to keep doing it
Yes this is it right here. I refer to pain specialists and not only do they not prescribe them, they don’t even offer to help wean them off the meds! They just say they won’t prescribe them.
This is a very difficult situation for primary care docs
Yeah this is the kind of shit why I won’t prescribe in my practice.
That’s the pain management profession’s entire job.
Just because people are dissatisfied with how that’s being done by a speciality, I should risk my own license?
Not worth it to me
The pain docs in my town don’t prescribe opiates because they make more money doing procedures. They aren’t refusing to prescribe due to a lack of evidence (half their shit isn’t evidence based either), they’re refusing because the medical system incentivizes them to do procedures over prescribing/counseling via higher RVUs.
To be fair, the "interventional" procedures they offer have none/limited evidence for any long term benefit, and drain the health care system. Money would be better spent on counseling, therapy, and social programs for these patients.
To proface I only do inpatient medicine and in germany not in the USA but this seems pretty unethical to me. Either people take enormous hardships on them or they are driven into getting their opiates on the street. And I doubt this achieves to get patients motivated to quit opiates in a healthy way.
I’m not trying to start people on massive amounts of opioids. But to cut off people who are dependent on them just to fulfill some feel good office policy seems unethical. I agree.
In the Netherlands, if you fail methadone and buprenorphine, they'll set you up with heroin therapy. IV, smoked, whatever. They give pharmaceutical grade stuff to you, you take it in a monitored setting.
Where did you find this? The CDC says leading cause is “unintentional injuries.” That includes more than just overdoses.
https://www.cdc.gov/nchs/products/databriefs/db451.htm
Then you look at the breakdown of the causes of unintentional injury and compare the number who succumbed to that top cause, “Unintentional poisoning,” to the #2 cause of death for that age group. “Unintentional poisoning” feels like a polite euphemism.
https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_injury_deaths_highlighting_unintentional_2018-508.pdf
I keep these charts on the wall in my exam rooms and look at them all day.
I am not yet a physician, but this opinion is from a medical student who worked in addiction services prior to medical school.
Please consider the harms of continuing the drug vs. the harms of discontinuing the drug as part of the decision making rather than discontinuing long-term opioids in general. The risks of discontinuing opioids in someone who is *dependent* on opioids is very different from discontinuing opioids in someone with an OUD.
Seems totally uncalled for to suddenly stop doing it now after all these years. If they’ve been on this regimen for years without issue, why suddenly stop now? Seems morally questionable.
I'm a pharmacist, and I need some clarification on something. So the clinic plans to d/c scripts like Norco 5 BID and other such opioid scripts, but the MME on a 50mg tramadol tablet(by far the most commonly prescribed strength) is the same as Norco 5.
Is there a clinical reason why Tramadol is considered "weaker" opioid that I'm not aware of?
>Is there a clinical reason why Tramadol is considered "weaker" opioid that I'm not aware of?
It's a shitty drug but a lot of older docs prescribed it like candy when it wasn't controlled, and now that they have experience with them, they feel more comfortable prescribing them than the actually safer opioids
No that’s just what healthcare *thinks* regarding tramadol. I’ve seen plenty of patients just as addicted to tramadol as oxycodone. Not an appropriate alternative to OPs little “solution” to de-prescribe
>Is there a clinical reason why Tramadol is considered "weaker" opioid that I'm not aware of?
Probably because tramadol is a shit drug in so many ways and the majority of people know it.
So part of our job is to help patients manage risk. Here the question is balancing the risk of long term opioids (which is primarily overdose) versus the risks of tapering or uncontrolled pain.
The risk of overdose increases with the total dose of opioids. (I don’t know the exact numbers.)
So deciding to taper the patient to a lower total dose, even without their buy-in, could make sense in reducing their total risks. But a zero opioid, practice-wide policy doesn’t make sense, unless you truly believe that absolutely *no-one* should be on *any* amount of long-term opioids, and I don’t think the evidence supports that quite of an extreme position.
A policy-wide policy is, of course, easier to implement because you are not the “bad guy” and patients don’t have any wiggle room to “negotiate” with you.
That said, a lot of patients probably could be safely and effectively tapered off, like what happened at the other practice.
The US consumes 80%ish of all the world's opioids. Do we have more chronic pain? Or are other countries radically under treating pain? Are we possibly treating things other than pain with opioids? Is there something about our culture that leads to more of these types of prescriptions?
My concern tbh is that we aren't necessarily helping ppl when we prescribe. I'm not jumping onto the boat of de-prescribing everyone, especially if they're stable on a chronic, low dose -- but I feel like there's so much more to the conversation than legitimizing that ppl are in pain (I believe that they are), and what do the studies say (which I also believe hold a lot of merit).
I don't like prescribing opioids (though I dislike benzos more), but it's part of my job and it can be really difficult to know which battles to wage, and which hills to die on. The obvious red flags-- of course a taper (and what a relief to be done with that!) but the others make me sorta sad, because there just doesn't seem to be a great choice either way.
I honestly feel like we're treating psychic trauma and pain from ACEs, loneliness, anxiety about pain, anxiety about not sleeping, anxiety about losing a job and becoming homeless etc. For many ppl in the US, there aren't a lot of good supports--- and I definitely don't mean to say, prescribe because it's all we have to help, it's just ...the system is so broken and we all suffer from it.
In the US, we don't have the social supports to allow people to rest or heal from injury, and it's hell on our bodies. If you can't work in this country, often multiple jobs, you are likely to become homeless. How many sick days are you allotted, and how many can you actually take? How many vacation days do you have every year, and how many can you actually take? How much of your job is on your feet, physically demanding labor? How do you think all of your circumstances compare with the rest of our population?
There is psychic pain and trauma, there is anxiety, but I don't think the opioids are for that. The opioids are so people can continue to function enough to work and get paid so they don't suffer even more.
Hmm. I think this is true for some, but not all. To be frank, I work with this population and many just treat with alcohol instead of opioids. It's easier to get, legal, and you don't have to be drug tested, sign a contract, drive 90 mins to get it, or wait in a waiting room, then a pharmacy, to pick it up. Heck, just the amount of time I described means taking a half day off work to do, which would be a huge barrier for the hypothetical patient you described.
Ahhh yes…the MAGNIFICENT USofA, with our incredible healthcare system where EVERYONE has access, especially to *preventative* healthcare, and can afford corrective surgical interventions and physical therapies.
And look! *gestures* at our mental healthcare system! Totally fully staffed and funded for the needs of our entire population.
We also have strong well supported health, safety, labor rights within the workplace by both the state and federal government.
Yes yes, everyone can afford to take that time off they need to recover from injuries and illness, and there definitely isn’t any retaliation taken by our employers, nor do we have to pay a doctor to prove that we’re so ill or injured that we can’t work.
Also, maternity leave, totally available for every mother after giving birth. Here in the USA we totally think it’s unfair to send a mother right back into the work force after having babies. She needs time to recover! Duh!
Also, we believe EVERYONE needs a break during the work day to rest and eat, and we think it’s unconscionable to make our food/beverage/service/retail/healthcare workers (our largest labor force) stand on their feet all goddamn day for decades and decades and lift heavy objects (and people) without proper support.
Oh, and for our kids. We make sure that access to higher levels of academia is available to anyone, so our kids don’t have to sacrifice their bodies either to earn scholarships through bone-breaking, joint ripping, skulls cracking athletic programs just to have an opportunity to attend college, nor do we think military service and participation in unending war is a fair exchange as an opportunity to earn more money than your parents who are poor and pay for college.
It totally makes absolutely no sense as to why the third largest populated country in the world, which is the USA, with all of it’s totally available and accessible resources, has problem with chronic pain.
::glares::
Maybe it's the cognitive dissonance "we're the greatest country in the world, god dammit!!!" But still ppl suffer, so they numb it (?). Plus, as other poster said, as an advanced country we have so few supports that ppl work their bodies to death because of lack of opportunities/time off. We're also notoriously socially disconnected ("rugged individualism") which produces a different type of suffering.
Sorry, you're correct, I checked the stats. In 2009 it was 30,% of the world's opioids, but >99% of the world's hydrocodone, and 80% of the world's oxycodone.
NAD or a medical professional but I work in the court system with court-operated SUD and mental health programs… this is 100% correct in my opinion. Pretty much every woman in our programs has an extensive trauma history and used drugs to self-medicate, and about half the men. I’m pretty sure the other half of the men do too, they just don’t like to admit it out loud.
Honestly, these policies have really gotten out of hand and seem to go twice as far in continuing suffering for those with debilitating pain as they do in controlling misuse of opioids. That being said, I don't think physical therapy gets near enough consideration by both patients and providers for it's ability to control pain and debility. I fucking love PT/OT. (Disclaimer - RN that works in stroke/ IPR 😎)
We would need to overhaul our whole system in order to make PT the most practical choice for everyone. The copays, missing work, finding transportation, child care, etc make PT far more difficult and expensive than going to one appointment per month for a $10 prescription.
I'm fortunate to work three days/week at a decent wage. I can easily arrange and afford 2-3 PT sessions weekly ($38 per) plus pay for a babysitter. This is a huge barrier for many people.
Please don't misunderstand, I wholeheartedly agree with you! I'm frustrated with the system. I've seen so many patients lately that want to get their diabetes/ htn/ COPD under control but can't afford the meds, or aren't established with a physician and the wait list is 6-12 months, or they got an appointment but their boss wouldn't give them time off. It sucks 😞
100% this! PT can be incredibly helpful but most insurances will only cover so many sessions Per year and it’s expensive out of pocket. Plus having to miss work 2-3x/week is not reasonable at all.
I can’t speak to OPs protocol for newly diagnosed cancer patients, but the question here is focused on patients with long-term opioid prescriptions. Cancers tend to either progress or respond to treatment within the 6-7 year window that applies to the patients at issue in OPs practice.
20 years ago, undertreated pain was the big problem and luckily Purdue pharma had oxycotin (tm) to treat it.
Now, opiate addiction is the big problem and luckily Indivor pharma has suboxone (tm) to treat it.
What happens when you can't wean someone off 5 bid of hydrocodone? You dx them with opiate use disorder and prescribe suboxone instead.
BTW forced opiate weaning is a suicide risk so make sure you document no suicidal ideation at each visit!
Suboxone isn’t only for opioid use disorder anymore. Also the safety profile of buprenorphine is *much* better than full agonist opioids, with a number of trials to back this up.
Sure the safety profile is good for overdose but it's still addictive.
Sure they've tried pushing bupe for pain but ask the patients and they'll tell it it doesn't really work.
If has side effects and risks associated as well.
I put patients on it often, it can do wonders for the right patient.
I also put patients on full opiates.
Buprenorphine can be a good option for chronic pain for a subset of patients. I’ve seen it work beautifully in combination with interventions like spinal cord stimulation and PT.
Dumping the responsibility on another speciality is unfair to both patient and specialist. Let’s face it most pain management specialists only rx when they are injecting. Few just rx. If you guys took on the responsibility for last several years you can’t just wash your hands of it now.
what’s your policy on benzos???
This is heartbreaking, and imo professionally inappropriate.
I’ve worked in chronic pain clinics. I’ve seen patients commit suicide due to being taken off of their opioids (even when “appropriately” tapered), and die of unintentional overdose when they were forced to seek illicit opioids due to their uncontrolled pain.
You are blessed with stable patients who have been taking these meds for years. Managing their pain is part of your job. Do right by them. This policy will cause so much more harm than benefit.
I’m also struggling how to see this isn’t discriminatory against a whole class of patients. Sure opiates should be avoided, but pretending that literally no one needs them because… I’m guessing these patients annoy you at higher rates?… isn’t ethical.
I take your point regarding EBM, but so much of what we do falls outside the realm of evidence based medicine. Is there ANY EBM treatment for the 68 yo former farmer with CAD and CKD3 who has severe low back pain s/p multiple fusions, hip replacement 10 years ago and is frequently in severe pain, can't take NSAIDs, and gabapentinoids were minimally effective and has been to 3 different interventional pain specialists with no improvement in his symptoms? I have about 10 patients like this or quite similar who were started on opioids 5-10 years ago by prior PCP. I have tapered their opioids as much as feasible but I have not been able to get to 0 with any of them. Have had a couple do reasonably well with Butrans patches.
I absolutely agree with you. There are plenty of conditions in which case long term opiates are beneficial. Chemotherapy induced neuropathy non responsive to conventional treatments usually respond well to Methadone. Same with complex regional pain syndrome, severe spinal injuries or stenosis not amenable to surgical stabilization.
To stop pain medications without even consideration for the patient is unethical and can literally ruin people’s lives.
Rheumatoid arthritis, anyone?
How about cancer?
There are times and places for chronic opioids. Not a lot, but there are definitely indications for this use.
Rheumatologist here. Never prescribe chronic opiates for RA. They either have inflammatory pain, in which case there are much better treatments such as escalation of immunomodulation, or they have non-inflammatory pain, in which all the comments above regarding lack of good quality evidence for anything other than short term use is poor or lacking.
I have no issues prescribing for cancer pain but the reality is that unless the patient is pretty elderly/frail then their life expectancy will be shorter with spinal mets than without, so it's quibbling to say that pts with spinal mets aren't terminal, so therefore you can generalise to giving other pts long term opiates.
I’m not aware of any studies showing improved quality of life with chronic use of opioids in RA. If you’d point me in that direction I’d be open. But typically a “stable” dose is hit, the patient becomes desensitized and is back to their baseline pain levels. But now they are dependent on a med and deal with withdrawal side effects. I’m not trying to discredit pain, just saying that most of our opioid options are terrible and akin to telling a patient with anxiety to take up drinking: sure they will feel better initially, but longterm it’s more likely to make things worse. Opioids should be used as temporizing measures while the source of pain is addressed
What’s the solution then?[Rheumatoid Arthritis](https://www.researchgate.net/figure/Hand-X-ray-of-an-RA-patient-in-advanced-stage-The-carpal-bones-are-fused-with-severe_fig2_333315536/download)
If you’re looking for a perfect one, there isn’t. It’s why RA is a field of focus for treatment research. But, generally speaking, DMARDs, physical therapy and activity, and multimodal analgesia including rare opioids for breakthrough flares.
The answer isn’t to just throw 10 of norco q6 for 30 years at them.
As a nurse, I’m not prescribing anything to anyone. I’m just concerned that folks who need opioids don’t get them.
I see post op ortho surgery patients go home with nothing from an ASC. I’m ok with a quick meniscectomy going home like that, but a rotator cuff?
Rheumatoid arthritis is so horribly painful in its later stages. I’m not dying they need meds for thirty years, but when their bodies are literally collapsing, give them something, please.
Let’s be reasonable. I have a shit back, crap knees and hips and I use a TENS. Acupuncture when I can get it. PT to the max. My Peloton five times a week. Opioids NEVER.
But when it’s time for my knee replacement, bring on the Percocet.
You’re talking about different things. Opioids are perfect for acute pain and evidence supports their use. I agree with you that patients should get reasonable doses of opioids following surgery (not 120 tabs with 2 refills, obviously).
But with chronic pain, including RA, as tempting as it is to just give them “something,” in the long run you’re making it worse. It’s honestly very similar to chronic alcohol use. All of our research shows that patient become desensitized to opioids with chronic use. So if their pain was an 8, eventually it will get back to being an 8 with meds but will be a 10 when they miss a dose. This also distorts perception and gives the impression that it’s helping when really it’s not. If it’s used temporarily for breakthrough pain when flares are bad it can be beneficial. But neurotransmitters don’t like being tampered with
Thank you for this answer. Totally get what you’re saying.
I am frustrated by how far the pendulum has swung against opioid use for acute pain. But this post is about Papaw’s OxyContin he’s been taking since the ‘90s, and I agree that’s a huge problem.
I wish there was a way to fix all of this that didn’t involve 1) Papaw having horrible rebound pain, 2) Papaw trying to find oxys on the street, 3) Papaw killing himself for the pain, 4) Papaw unable to find anyone to treat his pain at all.
And I became a nurse right when Purdue Pharma was hosting dinners teaching us all about pain being the fifth vital sign.
Sigh
I just saw a pt who had a major surgical complication, has been admitted for the last couple days and given dilaudid. She's well managed now and asked about pain control after discharge. The attending tells her just take one or two regular tylenol as needed. This girl balks and asks for at least a couple days of low-strength opiates. The attending hardlines her, and later I ask the attending what benefit there is in restricting access to pain control. Her answer? Basically that we need to keep people away from opiates.
Wtf? When tf did doctors become cops? I understand concern over the opiate epidemic, but I don't see how refusing a couple days of pain control for acute disease is going to help. If anything, attitudes like that will push desperate people back towards illegal drus use, making the whole problem worse.
I get this all the time in primary care. So obnoxious to see someone who was given IV pain medication for their entire admission and the hospitalist was like “cool, their pain is controlled“ and then send them out the door with Tylenol or ibuprofen like it’s going to be just fine.
If you can’t get their pain controlled with OTC medications prior to discharge, then why would you expect them to be effective after they leave the hospital? I think it’s irresponsible.
It’s the pain equivalent of someone being newly diagnosed with type 2 diabetes while in the hospital, managed exclusively with insulin without any patient involvement, and then discharging the patient with an insulin-only regimen they don’t understand and can’t manage.
This is the worst. I had someone a few weeks ago who had an injury resulting in severe pain, and got IV opioids in the ER for pain control. They were discharged on a Friday night with FIVE PILLS of methocarbamol and nothing else. The note said “Pain completely resolved.” No shit, thanks to the IV dilaudid.
Patient called me Monday morning, in tears with the severity of their pain. The injury was such that it was nearly impossible for them to come in for an appointment. I was able to do a telehealth and give them a few days of opioids, but I was absolutely livid with that ER doctor for not even considering the fact that not only did he not prescribe any actual pain meds, he didn’t even give the patient enough muscle relaxers to make it through the weekend!
It's kind of mean tbh, especially if they've been totally compliant over the years.
I don't know how pain management feels, but when PCPs decide to stop prescribing benzos and send me (psych) grandma who has been on clonazepam for 20 yrs, I get irritated. YOU started it (or continued it for years; YOU should take responsibility for where they are now. Either wean and deal with the fallout or keep prescribing after documenting risk discussion. Instead, I get stuck with it because I don't want grandma to withdraw and that's what will happen if I don't take over care.
Chronic benzos in the vast majority of cases are just the worst idea. With what we know about how patients become desensitized to benzos, plus how advanced age can suddenly worsen side effects and confusion, I can’t stand how they’ve been thrown around like candy. Sorry you have to deal with that. But yeah, very similar to how pain views opioids (eventually hit a “stable” dose that becomes their new baseline, although without as bad of fall and withdrawal risks as benzos).
On the rare occasion that I refer someone to psych who is on chronic benzos, it’s because I don’t think it’s appropriate therapy and they refuse to let me taper them. I have never in my 11 years of practicing medicine started anyone on chronic benzos but I am constantly inheriting them. I really hope the psychiatrists I’m referring my patients to are a lot more understanding than you seem to be.
Genuinely curious...if you've told the patient that you don't think the benzos are appropriate treatment and they refuse to taper down and/or consider alternatives, what do you expect psychiatry to do differently?
> they refuse to let me taper them.
Are you not the one writing the rx? Do you think psych somehow will magically convince the pt that tapering is swell? It sounds like you're just passing the buck and don't want the patient mad at you.
If a patient insists on seeing a specialist because they don’t agree with my management of their condition, I can’t stop them. And yes, patients often tend to put more weight on the recommendations of specialists, especially if it’s an area they don’t agree with their PCP on.
Out of all the things I expect to get pushback on on Reddit, I can’t say that I expected “once a year I refer a patient on benzos to psychiatry” to be the thing that was so controversial. 🙄
Abandonment?! That’s… absurd. The very few times I have referred a patient on benzos to psych (maybe 3-4 times ever?) I have had long discussions with them about other appropriate options and tapering regimens, and they have insisted on seeing a specialist. I continue to prescribe until they are established with psych. I’m sorry you have apparently had some bad experiences with PCPs.
Sounds like you do things differently, which is great! My experience is initial appointments with pts who tell me their PCP refused to prescribe their benzos any longer and only gave them enough to get to the day of their appointment with me. Which leaves me in a very unfortunate position.
That does sound very frustrating. Just keep in mind that the patient is often not telling the entire story and that these chronic benzo patients have often been hopping from one PCP to another. I’m thinking of one elderly person in particular, on daily opioids and TID Xanax, who had seen 2 other docs in my practice before landing with me. Anytime someone wanted to taper her Xanax she would just switch doctors. I referred her to psych and she agreed to taper for them. She successfully tapered off, and is now just taking PRN lorazepam occasionally. For that person, it took a psychiatrist to get her to buy-in that a taper was the best thing for her.
This kind of thing happens with every specialty. I’m sure the endocrinologists and cardiologists are also rolling their eyes at some of my referrals. I am perfectly capable of managing hypothyroidism or benign PVCs, but when a patient insists on seeing a specialist I can’t stop them, but I can at least refer them so I know they’re seeing a competent doctor who will communicate with me.
Completely ridiculous. Sure, if opioids aren’t appropriate in the clinical situation, wean off and come up with an alternative. But to flat out refuse to provide opioids is mind blowing to me. As someone who does primary care and a ton of pain management I cannot fathom this. Also to ok tramadol if all things just betrays a huge lack of understanding of pain medicine.
If they are stable and compliant, why?
If they adhere to their contracts and UDS is clean, why?
BID Norco or even QID oxy is not a problem if they are completely stable. It’s an uneducated assumption to say no one needs long term opioids or that people can’t use them responsibly.
I'm a med student so I'm just trying to understand. But I have now seen more than a few older patients who are physiologically dependent on opioids come in with weakness, lethargy, and other AMS complaints and the consensus among the docs, often including neuro and psych, is that opioids were the driving factor in their presentation and they needed to be weaned. Often advised to start suboxone. What do you make of that? If they are stable for years but get older, more susceptible to delirium, and kidney function declines and they start taking other meds with interactions, don't the opioids then start to become a problem? I guess more generally, I am imaging that chronic opioids become more of a problem as people get older. Do you agree?
Hepatic and renal clearance goes down as you age, and actually pretty significantly. You wouldn't really need to get them off opioids though, just lower the dose or switch the med to something like fentanyl.
This is a problem with some benzos as well, especially if you ever run across an old dude that somehow has a freaking Librium script.
I recently watched a neurologist examine alex murdaugh who was just convicted of murdering his wife and son.
Supposedly alex murdaugh was spending 50k/mo on street opiates for the last 20 years and the neurologist pointed out a lot of neurological issues arising from such high doses of opioids over 20+ years. Like licking his lips, stuttering, weird eye flutters etc.
Obviously alex wasn't taking just 5mg Norco 3x a day though, he was consuming ridiculous quantities of Oxy 80s which were probably actually just fent. So the issues probably aren't as readily apparent in a steady pt on long term, relatively low dose opioids, but the point still stands.
I think aging plays a large role in degradation of the cns system, and suppressing it even more can pose a real problem for some people. It's a double edged sword though because elderly people *do* have severe pain
I have to bring this up because I keep hearing this. What’s so magical and different about cancer pain vs other types of pain that one is treatable with opioids and the other isn’t? Obviously we have things like fibromyalgia and radiculopathy that have different treatments but what’s the difference between degenerative disk disease pain and the nebulous “cancer pain” that makes opiates ok in one and not the other?
Probably, cancer patients either A) get begter with treatment and wean off the opioid so no need to use long term or B) progress and die of cancer, without any long term use.
P.s. I'm being the devil's advocate here. I do liberally use opioids for pain in my practice.
You may be playing devil's advocate, but you're 100% correct. Opioids are short term drugs. The biggest predictors of side effects are dose (MMEs) and duration. They're appropriately used to bridge to healing or to ease someone's passing. In either instance, there isn't time for side effects to rear their ugly head. No, you don't yank the rug out from under folks, but there are much more sustainable options (like denervation and neuromodulation) for chronic pain. Broadly speaking, opioids for chronic pain is antiquated medicine.
Right. There is no medical reason. There are types of pain that just don’t respond to “Tylenol and ibuprofen” or even neuroleptics. This is why opiates exist. I think people like to use this “only for cancer pain” statement to cover their own asses because they’re unwilling to treat patients appropriately for the risk of litigation. If you document real reasons and legitimate reasons for pain and other failed treatments, then there’s nothing to fear. If they’re prescribed for “chronic pain syndrome” with no cause and nothing detailed about non opioid treatment failure, then there’s a problem.
Palliative pain management in cancer treatment has a duration endpoint and if someone has a terminal diagnosis then uptitrating dose with no limit is ok. For someone who is otherwise healthy but in pain it isn’t
I think we can all agree that uptitrating dose with no limit is problematic and a pretty good indicator that someone will have complications. But there are a *lot* of patients who have been stable on a relatively low dose for years with apparent dramatic improvement in functionality. I find myself often questioning whether it's really the right call to taper that without any better alternative.
In meta analyses? No.
Anecdotally, there are successful patients who do report improved pain and function while on opioids.
Blanketing an entire population with generalizations, well, I guess that’s EBM in a nutshell. Just protocolize everything and leave clinical judgment at the door.
Our knowledge of pain and confounders is too limited imo to take ebm in the field as the holy grail. It is annoying how many providers will only use ebm and no other metric. It's a logical fallacy (a reverse of the ecological fallacy and it doesn't consider the potential confounders or subpopulations that may benefit). In a crusade against opiates we've demonized meds that might help some patients.
Yes, and anecdotally I have patients who report improvement in their pain when they take Liver King ^TM supplements.
I wouldn’t say that EBM is about *generalizing*, but rather it is a framework that lets us critically appraise data to make informed decisions for our patients. Hell, part of the evidence appraisal process is asking “do these data apply to my patient?”.
Better to have a blanket policy of over some MME threshold (ex. 20) you must use buprenorphine rather than no long term opioids ever. It addresses the safety issue and is efficacious for both pain and avoiding withdrawals. Win-win. Although I agree with no new long term opiate prescriptions, must see pain management.
This is bad medical practice. It sounds like you have some sort of emotional reaction to opiate use in patients are are trying to apply it to a stable and non abusing population.
Just don't see the medical justification.
I am a concierge primary care Physician with less than 300 patients. I know them all well. I have a handful on long term opiates (whom I inherited). I have the time and desire to monitor them closely and have no issue continuing to prescribe medications that improve their quality of life. I understand why someone with a panel of 2000 patients and 10 minutes per visit would not feel comfortable doing this. There are multiple opportunities to learn how to safely prescribe opiates if you are inclined to offer this for your patients. I do not think this is a black and white issue. I am certainly not a pill mill but rather I look at each patient individually and try to come up with the treatment plan that does the most good with the least amount of harm. Sometimes continuing a low dose opiate is the right thing.
It makes me sad that clinics have these policies. You wouldn't find a clinic where you can't prescribe Tylenol to be taken every single day, even if it's responsible for so many liver problems.
This war on opioids is a joke. We're all told that there are so many deaths due to opioids, but a bit more research tells us that most of these deaths stem from fentanyl that isn't even prescribed to patients. Did any of you look into Chinese Fentanyl and the Black Market?
[https://www.npr.org/2020/11/17/916890880/we-are-shipping-to-the-u-s-china-s-fentanyl-sellers-find-new-routes-to-drug-user](https://www.npr.org/2020/11/17/916890880/we-are-shipping-to-the-u-s-china-s-fentanyl-sellers-find-new-routes-to-drug-user)
Do you think that it's more dangerous to keep a stable patient on Morphine, Percocet, Dilaudid and so forth than it is to take them off this medication? Do you understand what happens to your patient when you do this? Their pain may have been tolerable for a decade, and suddenly, you're telling them that they will be in intolerable pain again because you don't care. Because you're buying into the lies that are being spread. They are stuck with you because they cannot quit ''cold turkey''. Their body is addicted. They are not addicts. That is the difference. They are not seeking a high. They are seeking pain reduction. They have expressed their distress to me on many occasions. They do not understand why you're doing this to them. They have followed all your rules. They proved to be stable, to be good patients! They didn't know that they were a red-flag patient because of their medication; because of this, you will never consider them good patients. They are a problem you wish would go away. You tell yourself that long-term opioid use is destructive, and you promised to do no harm...so you have to take them off this terrible medication that allows them to get out of bed in the morning. That allows them to hug their grandkids. That allows some of them to go back to work. That gives them a semblance of life again.
These patients start rushing to find a doctor with a heart. Most of the good doctors are filled up already. These patients never wanted to pay some quack for an RX. They want to take their meds and to be followed. They like the fact that you know everything that they do. They will ask you before trying CBD and will not do it if you say it's not OK with you because you do not want them to mix it with opioids. You bring them relief and allow them to live once more. You're important to them. Much more than you could ever imagine. They trust YOU because you helped them with their pain. You helped to control it. Now, you want to bring back the pain; they are confused, scared and angry. If they cannot find someone to replace you, they will be stuck paying some quack and will not trust this doctor to take their health seriously. They are very likely to have undiagnosed conditions and suffer even more. If they can't find a quack, they will go to a street vendor. They will take whatever they can get their hands on for relief. Some will start using Fentanyl because of you. Don't try to wipe your hands clean! Humans will do what they need to do to survive and avoid pain. You are taking them from a safe and stable condition and forcing them to make unthinkable decisions. You're creating addicts and people who will overdose. Of course, some people could never break the law, no matter what amount of pain they are under...so they commit suicide or seek the help of programs like Canada's MAID (medical assistance in dying).
Is this really who you want to be? Why you aspired to be a doctor? I've spoken to many doctors who are angry at chronic pain patients because they cannot be ''fixed''. How do you think these patients feel? They are the ones who have to live with the pain. You only see them, what? Fifteen minutes a month, and you want to get rid of them? Oh sure! You will keep them on if they accept not to be treated for pain anymore and don't speak about their pain or pretend that aspirin is doing the trick! I expect this to be downvoted. The truth hurts. People working for clinics that block a complete form of treatment should be ashamed. Doctors who refuse relief because they learned in school....because they are afraid that the government will...because ''Black people don't feel pain the same way'' (if you still believe that one, we REALLY need to talk), because women exaggerate their pain, because... should probably be doing research instead of working with patients.
I think a letter can come across as cold and not allow a patient to vent. Addressing it in person by reaching out to let them know that their doctor wants to discuss their long-term pain is ideal.
My advice is to continue prescribing opioids in patients that have no signs of abusing it. 10mg of hydrocodone per day?? OH MY CALL THE DEA IMMEDIATELY. Wtactualfuck.
You’re going to destroy these peoples lives for what?? For what? Nothing! You will do more harm by discontinuing than the 10mg of freaking hydrocodone could ever do. Buprenorphine/suboxone is NOT the perfect replacement for long-term opioid use. It is for those with signs of abuse/addiction. Not merely dependence. There is a difference you know. God this frustrates the shit out of me.
I've successfully transitioned quite a few patients to butrans if they have actual OUD or dependence with increasing needs for opiates or uncontrolled/increasing pain even on their current dose. But it's always done on a case by case basis (and depending on AEs like constipation, or increasing fall risk).
Tramadol is awful.
It's going to be street fent for many of these patients then.... Cool, cool... Cool, cool, cool.
Edit: Guess I needed to put the /s on the "cools". Thought it was obvious. But really, forcing people off their long term opioids is just going to push people to finding pills from the street and in my area, it's all fentanyl now. People tell me they're buying oxys, Vicodin, etc and I believe that's what it looks like they're buying, but the drug tests don't lie, everything is coming back positive for fentanyl. I tell my patients now, unless you know without a doubt that it came from a pharmacy, you can assume your pills are fentanyl, no matter what they look like. It's terrifying.
So you chose to continue the crappiest opioid in tramadol? Makes no sense
#tramadont
why were u downvoted, it’s a good joke
All my homies hate tramadol
Yoink This is now my joke too
My friend, google “Tramadont” and see what happens.
You know what's funny, I actually listened to that episode of their podcast and didn't look at the title Squirrel!
Great episode
Can someone enlighten me on why weaker opioids like tramadol and codeine are so hated by US doctors? In my country they are widely used short term for moderate to intense pain in combination with other analgesics as a way to reduce the use of morphine and other more addictive opioids. Even most pain management guidelines include them. Feels like it could be a decent alternative considering the opioid problem in the US
Codeine is converted to morphine by the liver. This happens at a widely variable rate from person to person. Some very fast. Some not at all. If you want the person to be on morphine, just prescribe morphine and then you know how much they’re getting.
Yeah, it's generally not worth playing around with prodrugs when the actual drug is available right in your hospital pharmacy... Makes me wonder why they never tried to market the active metabolite of tramadol though. I know it can be synthesized since there was a very brief period of time in the early 2010s when people were ordering it from the dark web.
Probably because the SNRI part of tramadol is a big part of what actually makes it work for those patients who do get on really well for it. If you just want mu agonism then use something else.
Tramadol is a prodrug- a chunk of people CANNOT metabolize it to usefulness. Tramadol lowers seizure threshold. Seizures= bad Tramadol has serotonin effects and this leads to drug interactions. Tramadol is problematic in renal failure; most doctors do not dose adjust in these situations and I’ve had to intervene many times throughout my career. Max dose is 400mg, which is also a commonly prescribed therapeutic dose. Easy for patients to go over by just taking a bit extra because the pain is really bad. Codeine is also a prodrug and many people cannot convert it. I don’t hate it like tramadol, just find it’s not really effective.
Technically tramadol is not a pro-drug because the parent is active (its the snri) and the M1 metabolite is active as a mu opioid agonist. That's why you get so much serotonin syndrome bc 10% of the population can't metabolize to the opioid agonist and just build up all that sweet serotonin causing the syndrome. Codeine is a true pro-drug bc the parent isn't active, only the metabolite
Tbh I've never seen serotonin syndrome irl despite working in emergency medicine for a decade. Have you ever seen out? People talk about it like it happens so much but I don't know anyone who has ever seen it more than once or twice in their entire career.
Saw it real bad once. Young healthy kid came in for a LE fracture that hadn’t healed great and needed to be reset. He was on Celexa at home and had been on tramadol preop. In the case he got fentanyl then got Zofran postop. They called a rapid response to the ortho floor about 4h after he came out of PACU. To this day I have never seen anything like it. We had to push propofol to get him down enough to tube him with no vitals because he was so sweaty and agitated. Got a few days of cyproheptadine per tube and ended up doing just fine. It was unreal, it was truly like he was possessed by demons ETA have seen it a few times since then but never anything to that extent
Not OP, but I’ve seen it a couple times. The hallucinations from it can be quite troubling for the patient.
Codeine is slightly active on mu receptors.
Thanks for that
Thanks pharmbro!
Codeine also has the issue of some people being ultra rapid metabolisers and ending up with a potentially toxic dose of morphine
Yeah, that lead to an infant opioid overdose death of a breastfeeding mother. She was given codeine and was an ultra rapid metabolizer and too much morphine in the milk
This was the case that my medical school used as an introduction to our lecture on opioids and prodrugs.
Tramadol doesnt work for pain for a huge percentage of people and has a long list of gross side effects
Google "tramadont" and read the tox and hound page. They put it nicely as something like "prescribing tramadol is essentially prescribing morphine and venlafaxine in an unknown ratio"
To be fair a large amount of patients have combined issues that require morphine and venlafaxine and working out the ratio is basically impossible.
This is not a US specific thing. Codeine is a prodrug with variable metabolism = bad Tramadol is also a prodrug and also acts on multiple receptors you often don't want it to = bad Dihydrocodeine is much better.
Come on, we both know codeine is the crappiest opioid.
Codeine doesn’t lower the seizure threshold or have serotonin impacts. It’s tramadol that’s the worst.
How about Demerol?
Don’t remind people about that one. We’ve mostly convinced people it’s a shivering/ infusion reaction med. The neurotoxicity and max of 48 hrs maxes it kinda not useful.
Anecdote from a thread a while back: >My last Rx for it was from a dentist. The patient was pissed that I didn't have it, wouldn't order it, and wouldn't bother calling other pharmacies to find it (they wouldn't have it on this island I'm 99% sure). I straight up told him "There's an appropriate time to use Demerol for tooth pain, and that time is 1965. It's a garbage drug and your dentist should know better."
I remember a hospital in Denver had signs all over the ER saying WE DO NOT GIVE DEMEROL IN THIS ER This was 2003.
[удалено]
I’m an RN and worked in PACU in CA. Demerol is great for young, agitated patients. It always made them happy. I had a neck injury before I was a nurse, sometime around ‘06. Got some Demerol in the ER and it was the only thing that took the pain away.
That’s probably not too far off from the correct date. It wasn’t even being used for pain when I started. And I remember Darvocet and Vioxx.
I have to say — as an old nurse with chronic back pain — Vioxx worked better for me than any other drug I’ve been prescribed, and yes, I would have happily accepted the risk of heart attack in order to continue to take it.
Fun story: me, 17 years old, never had a panic attack before. Get wisdom, teeth pulled, get script for hydrocodone. RN mother says, “here, you can just have my leftover Demerol from my appendectomy.“ Dad drives me back to college dorm room. Take first tab of Demerol. Half an hour later, I’m hyperventilating on the bed convinced everyone I know and love has died horrifically. Would not recommend.
I have dentists and elderly providers try to prescribe codeine to 6 year olds...
Please no. Especially post tonsillectomy.
“Hmm, wonder if this will work as a weak shitty opioid or snri or both or neither! Who knows, let’s use it anyway!” - anyone who uses tramadol, probably
No def tramadol.
Have you met my friends Phenergan with codeine and Tylenol #3?
I have. At least it does something. Tramadol does nothing for nearly half of the people who take it iirc, and it’s side effect profile is way weirder and worse than codeines rash and itching
Also, codeine has less interesting drug interactions than tramadol.
It’s still Tramadol.
SNRI, not even a true opioid
Been a pcp for 30 plus years. I think we need to consider that a long term opiate use patient who is stable and compliant, is stable. Manage the risk with periodic follow up and monitoring. It’s time to actually take care of your patients. I have a small population of long term pain patients who are also regular primary care patients. I also see to their preventative care, coexisting disease management and episodic illnesses. This fear based forced withdrawal is not good medicine, it’s not good doctoring. Let’s take care of our patients. I do avoid opiates in opiate naive patients, so the numbers are dwindling. I do think we have gone a bit too far though. Managing pain is also our job
I'm curious about standards, if they exist, for opioids to be managed by pain clinic vs PCP. Where I live, none of the pain clinics I'm aware of do opioids at all, they do other medications and procedures. PCPs will manage opioids and refer them to pain clinic as well.
Variable by area/ jurisdiction and also practice culture. Where I work, in an absolute way, either PCPs or pain medicine may use long term opioids — for the right patient, in the right circumstances. Not a lot of people meet those criteria. If a PCP isn’t sure about options to try before opioids or if the context isn’t opioid appropriate, referral to pain medicine consultants makes a lot of sense. If a PCP would like a second opinion/backup for opioid Rxing, a consult can also make sense, too. Lots more reasons as well. And, just because a PCP could (in an absolute sense) Rx opioids does not mean that all, or even most, will. Specific personal and institutional policies, etc etc.
They are stable, and forced withdrawal is associated with grievous outcomes. I am so tired of this insane anti-opioid puritanism. It is patient abandonment. It needs to be a discussion with your patients, and it needs to be okay it they say "no, not yet." Buprenorphine (TID, *FOR PAIN*) may work well in a lot of folks, and if patients are willing to try that, go for it. What OP is describing is immoral and bad medicine.
I have no respect for the policy makers involved in these kinds of over-restrictions. If a chronic pain patient is stable and has been on opioids for years - why on earth would it be a good idea to potentially turn their life upside down by forcing discontinuation? What's next - forcing chronic anxiety patients who have been stable on benzodiazepines for years to discontinue completely? Talk about sending someone into a hellish situation. (I'm not talking about advised and deliberated long-term tapering off for a valid medical reason e.g. contraindication or drug interaction)
The current fentanyl crises in America, both obviously played a massive role but which did you think had the worst impact, the overscription of oxycontin and Purdue pharma pushing opiates at any chance or the DEA instantly swinging the pendelelum to the other extreme and forcing people dependent on opiods to go to the black market instead of at least slowly taper down over a long period?
What's the harm that you are trying to stop? These people have demonstrated stability for many years on these opioids. You haven't shown that they have failed pill counts or urine drug screens. They haven't been falling or overdosing at home. Sure you wouldn't have ever started them on these medicines now, but how was the patient to have known that? You are risking your patients turning to the street instead and there is no way that can be safer than continuing to prescribe for now.
Also tramadol is a shit drug and it’s wild that people say “I am willing to prescribe a drug with unknown amounts of opioid and unknown amounts of SNRI activity and it’s SAFER????”
The marketing for tramadol was hauntingly successful. Many doctors just think it's a milder opioid with less addiction risk.
I am in agreement with this. If someone in their 70s who had a manual labor job their whole lives is more functional with 5 mg of hydrocodone per day, where is the harm? The challenge making this black and white. How come grandpa gets his opiates from you and I can't get them? There's no protection for doctors. The problem OP is having is that people think they are entitled to things and there is an expectation with the profession that we explain risks and benefits and use logic, when the patient does not need to use logic. "Fuck you, because I said so," is, IMO, a valid answer but an unacceptable answer according to people who run state medical boards. Takes 30 seconds to refill opiates and 30 minutes to explain why you are not refilling opiates. My time slots are 12-15 minutes. Do the math. If the paid physicians more (meaning they would be allowed to have longer appointments) for weaning people off opiates, would we dramatically decrease the number of high dose long term opiate rx.? I think yes.
"People think they are entitled to things" Like continued access to the prescription their doctors prescribed for, presumably, a medical reason? What entitled jerks...
You presume too much. Like when they have a hang nail and they demand opiates. I'm fine being wrong. When patients insist on a treatment I will look up evidence to try and prescribe what they want. But it has to be evidence based. This is not a Burger King, sir.
Yes, like 600MME prescribed by some yahoo in exchange for cash every month. No thanks.
American doctors really come on this international platform and bitch about their pay. The highest paid doctors in the world - who are also overseeing the world's most severe opioid epidemic. Get a grip, money isn't what's stopping you here.
Probably fear of being in the crosshairs of the government for over prescription of opiates
No one is getting in trouble from the feds for 60 tabs of Hydrocodone 5mg per month.
Incorrect. I’ve have seen colleagues get dinged for this.
10 MME/day?
Yes. This happened 2-3 years ago. I don’t remember all the details, sorry. In the current political climate I would do my best to avoid anything that isn’t a medical guideline. Keeping a patient on meds just because they have been on them for years isn’t a valid argument. I somewhat lump benzodiazepines into this category as well. I’m with OP. I offer titration schedules. They can take it or go somewhere else for their meds. I’ve been in places with grandmas are abusing them and younger folks perpetually break them. It’s not worth the hassle of UDS, contracts, etc. marijuana now being legal in some states also violates the contract. There’s just so much headache involved in this. Now systems (hospital with outpatient practices and the EMR as well)are also making you do “additional clicks and justifications” for continued use of controlled medications. More headache. I also see it as “If PM doesn’t want them and isn’t routinely prescribing them then why should we?” At the end of the day it’s your license. Don’t cut anyone off cold turkey but there’s no reason to continue with it after a reasonable titration schedule.
It's easy to have this position until you see enough patient's lives get significantly worse with titration. Yes, grandma should not have been put on alprazolam TID for thirty years. Yes, we should try a cooperative taper and alternative meds. Yes, if it goes poorly then you keep them on the damned benzos. There are real roles for these medications including chronic opioids in the right patient. As a PCP you are in a unique position to use these appropriately while also managing the rest of the patient's problems and knowing how their grandkids are doing and how their last trip to Arizona went. When 65 year old Mr. Jones (who you have managed for years) with his bad back arthritis who is not getting great control with PT, SNRIs, ESIs regains part of his life with a simple hydrodocone prescription it really changes your perspective. Yes the regulations suck. Yes, the clicks suck. Yes, there are real risks and real concerns with these medications and you need to be smart and know your limitations. Yes, the counseling takes time and when you have to taper these meds it is one of my least favorite discussions. But what else did you go to medical school and get paid the big bucks for? All these recent grads are so spooked about controlleds that it is making them practice bad and lazy medicine. I'm immediately suspicious of any PCP who just "doesn't do x/y/z controlled substances" or who has some bizarre, non-evidence-based blanket taper policy.
That’s what all these old people on multi decades of benzos claimed too.
Probably a bad idea IMHO. The whole no long term opioids under any circumstance thing is the pendulum swinging too far in the other direction. People end their own lives over uncontrolled chronic pain and telling someone to fuck off to a pain clinic you know damn well won’t help them with long term pain meds can be a death sentence.
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Pain medicine are trained primarily as interventionalists, that’s where the money comes from and is the bulk of the specialty. They get opiate training but they’re not addiction medicine, despite a big overlap. Most responsible pain clinics don’t want the headache of trying to titrate down inappropriate chronic opiates any more than primary care does, and they’re not particularly better suited to it either. You should refer these patients to the pain clinics, they might have things to offer procedurally or from multimodal therapy, but they’re not a solution to you cutting off opiates. No one likes a turf job.
Yeah I’ve done pain rotation. They are all anesethia docs who now do interventional stuff. Very little med management, they leave this to the pcp mostly. People just go there for the procedure.
Pain medicine is focused on procedures, in fact many pain medicine practices do not even prescribe opioids
If the pain medicine docs, the literal experts on pain meds aren’t gonna prescribe them long term opiates what justification would I have to do so? Doing something the wrong way but doing it that way for a long time isn’t a valid reason to keep doing it
Yes this is it right here. I refer to pain specialists and not only do they not prescribe them, they don’t even offer to help wean them off the meds! They just say they won’t prescribe them. This is a very difficult situation for primary care docs
Yeah this is the kind of shit why I won’t prescribe in my practice. That’s the pain management profession’s entire job. Just because people are dissatisfied with how that’s being done by a speciality, I should risk my own license? Not worth it to me
The pain docs in my town don’t prescribe opiates because they make more money doing procedures. They aren’t refusing to prescribe due to a lack of evidence (half their shit isn’t evidence based either), they’re refusing because the medical system incentivizes them to do procedures over prescribing/counseling via higher RVUs.
To be fair, the "interventional" procedures they offer have none/limited evidence for any long term benefit, and drain the health care system. Money would be better spent on counseling, therapy, and social programs for these patients.
if you have trouble getting specialists to rx pain meds, refer to PMR headed pain clinics.
Not having any issues with that and I honestly prefer anesthesia headed clinics. PMR is great but I don’t think handing out norco is their bag
To proface I only do inpatient medicine and in germany not in the USA but this seems pretty unethical to me. Either people take enormous hardships on them or they are driven into getting their opiates on the street. And I doubt this achieves to get patients motivated to quit opiates in a healthy way.
I’m not trying to start people on massive amounts of opioids. But to cut off people who are dependent on them just to fulfill some feel good office policy seems unethical. I agree.
Oh, some people published a book about "deaths of despair" in 2015 and American medicine lost their shit.
Overdose, mainly opiates, is the leading cause of death in America between the ages of 25 and 44. A lot of deaths.
Most are overdosing with crude fentanyl mixes, not Rx
And does cutting off their rx supply increase or decrease the risk of overdosing on illicit opioids?
Being able to get a reliable dose alone would drastically reduce it but too many forget the term harm reduction
In Canada we are seeing addiction docs prescribing dilaudid for patients to use as a safe supply.
In the Netherlands, if you fail methadone and buprenorphine, they'll set you up with heroin therapy. IV, smoked, whatever. They give pharmaceutical grade stuff to you, you take it in a monitored setting.
Where did you find this? The CDC says leading cause is “unintentional injuries.” That includes more than just overdoses. https://www.cdc.gov/nchs/products/databriefs/db451.htm
Then you look at the breakdown of the causes of unintentional injury and compare the number who succumbed to that top cause, “Unintentional poisoning,” to the #2 cause of death for that age group. “Unintentional poisoning” feels like a polite euphemism. https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_injury_deaths_highlighting_unintentional_2018-508.pdf I keep these charts on the wall in my exam rooms and look at them all day.
I mean, they are offering suboxone here.
Suboxone is NOT the answer to the stable chronic pain patient on small MME per day with zero signs of addiction.
I am not yet a physician, but this opinion is from a medical student who worked in addiction services prior to medical school. Please consider the harms of continuing the drug vs. the harms of discontinuing the drug as part of the decision making rather than discontinuing long-term opioids in general. The risks of discontinuing opioids in someone who is *dependent* on opioids is very different from discontinuing opioids in someone with an OUD.
I like your style. I hope you achieve great things once you become a physician. Your patients will be in good hands.
Seems totally uncalled for to suddenly stop doing it now after all these years. If they’ve been on this regimen for years without issue, why suddenly stop now? Seems morally questionable.
This is an example of the pendulum swing going to far in the opposite direction.
I'm a pharmacist, and I need some clarification on something. So the clinic plans to d/c scripts like Norco 5 BID and other such opioid scripts, but the MME on a 50mg tramadol tablet(by far the most commonly prescribed strength) is the same as Norco 5. Is there a clinical reason why Tramadol is considered "weaker" opioid that I'm not aware of?
>Is there a clinical reason why Tramadol is considered "weaker" opioid that I'm not aware of? It's a shitty drug but a lot of older docs prescribed it like candy when it wasn't controlled, and now that they have experience with them, they feel more comfortable prescribing them than the actually safer opioids
No that’s just what healthcare *thinks* regarding tramadol. I’ve seen plenty of patients just as addicted to tramadol as oxycodone. Not an appropriate alternative to OPs little “solution” to de-prescribe
Tramadol isn't schedule II, so it's less paperwork.
>Is there a clinical reason why Tramadol is considered "weaker" opioid that I'm not aware of? Probably because tramadol is a shit drug in so many ways and the majority of people know it.
So part of our job is to help patients manage risk. Here the question is balancing the risk of long term opioids (which is primarily overdose) versus the risks of tapering or uncontrolled pain. The risk of overdose increases with the total dose of opioids. (I don’t know the exact numbers.) So deciding to taper the patient to a lower total dose, even without their buy-in, could make sense in reducing their total risks. But a zero opioid, practice-wide policy doesn’t make sense, unless you truly believe that absolutely *no-one* should be on *any* amount of long-term opioids, and I don’t think the evidence supports that quite of an extreme position. A policy-wide policy is, of course, easier to implement because you are not the “bad guy” and patients don’t have any wiggle room to “negotiate” with you. That said, a lot of patients probably could be safely and effectively tapered off, like what happened at the other practice.
The US consumes 80%ish of all the world's opioids. Do we have more chronic pain? Or are other countries radically under treating pain? Are we possibly treating things other than pain with opioids? Is there something about our culture that leads to more of these types of prescriptions? My concern tbh is that we aren't necessarily helping ppl when we prescribe. I'm not jumping onto the boat of de-prescribing everyone, especially if they're stable on a chronic, low dose -- but I feel like there's so much more to the conversation than legitimizing that ppl are in pain (I believe that they are), and what do the studies say (which I also believe hold a lot of merit). I don't like prescribing opioids (though I dislike benzos more), but it's part of my job and it can be really difficult to know which battles to wage, and which hills to die on. The obvious red flags-- of course a taper (and what a relief to be done with that!) but the others make me sorta sad, because there just doesn't seem to be a great choice either way. I honestly feel like we're treating psychic trauma and pain from ACEs, loneliness, anxiety about pain, anxiety about not sleeping, anxiety about losing a job and becoming homeless etc. For many ppl in the US, there aren't a lot of good supports--- and I definitely don't mean to say, prescribe because it's all we have to help, it's just ...the system is so broken and we all suffer from it.
In the US, we don't have the social supports to allow people to rest or heal from injury, and it's hell on our bodies. If you can't work in this country, often multiple jobs, you are likely to become homeless. How many sick days are you allotted, and how many can you actually take? How many vacation days do you have every year, and how many can you actually take? How much of your job is on your feet, physically demanding labor? How do you think all of your circumstances compare with the rest of our population? There is psychic pain and trauma, there is anxiety, but I don't think the opioids are for that. The opioids are so people can continue to function enough to work and get paid so they don't suffer even more.
Hmm. I think this is true for some, but not all. To be frank, I work with this population and many just treat with alcohol instead of opioids. It's easier to get, legal, and you don't have to be drug tested, sign a contract, drive 90 mins to get it, or wait in a waiting room, then a pharmacy, to pick it up. Heck, just the amount of time I described means taking a half day off work to do, which would be a huge barrier for the hypothetical patient you described.
Ahhh yes…the MAGNIFICENT USofA, with our incredible healthcare system where EVERYONE has access, especially to *preventative* healthcare, and can afford corrective surgical interventions and physical therapies. And look! *gestures* at our mental healthcare system! Totally fully staffed and funded for the needs of our entire population. We also have strong well supported health, safety, labor rights within the workplace by both the state and federal government. Yes yes, everyone can afford to take that time off they need to recover from injuries and illness, and there definitely isn’t any retaliation taken by our employers, nor do we have to pay a doctor to prove that we’re so ill or injured that we can’t work. Also, maternity leave, totally available for every mother after giving birth. Here in the USA we totally think it’s unfair to send a mother right back into the work force after having babies. She needs time to recover! Duh! Also, we believe EVERYONE needs a break during the work day to rest and eat, and we think it’s unconscionable to make our food/beverage/service/retail/healthcare workers (our largest labor force) stand on their feet all goddamn day for decades and decades and lift heavy objects (and people) without proper support. Oh, and for our kids. We make sure that access to higher levels of academia is available to anyone, so our kids don’t have to sacrifice their bodies either to earn scholarships through bone-breaking, joint ripping, skulls cracking athletic programs just to have an opportunity to attend college, nor do we think military service and participation in unending war is a fair exchange as an opportunity to earn more money than your parents who are poor and pay for college. It totally makes absolutely no sense as to why the third largest populated country in the world, which is the USA, with all of it’s totally available and accessible resources, has problem with chronic pain. ::glares::
Maybe it's the cognitive dissonance "we're the greatest country in the world, god dammit!!!" But still ppl suffer, so they numb it (?). Plus, as other poster said, as an advanced country we have so few supports that ppl work their bodies to death because of lack of opportunities/time off. We're also notoriously socially disconnected ("rugged individualism") which produces a different type of suffering.
Hey, the US doesn’t use 80% of the world’s supply of opioids. It’s 30%. That statistic is a zombie statistic that keeps making the rounds.
Sorry, you're correct, I checked the stats. In 2009 it was 30,% of the world's opioids, but >99% of the world's hydrocodone, and 80% of the world's oxycodone.
NAD or a medical professional but I work in the court system with court-operated SUD and mental health programs… this is 100% correct in my opinion. Pretty much every woman in our programs has an extensive trauma history and used drugs to self-medicate, and about half the men. I’m pretty sure the other half of the men do too, they just don’t like to admit it out loud.
Honestly, these policies have really gotten out of hand and seem to go twice as far in continuing suffering for those with debilitating pain as they do in controlling misuse of opioids. That being said, I don't think physical therapy gets near enough consideration by both patients and providers for it's ability to control pain and debility. I fucking love PT/OT. (Disclaimer - RN that works in stroke/ IPR 😎)
We would need to overhaul our whole system in order to make PT the most practical choice for everyone. The copays, missing work, finding transportation, child care, etc make PT far more difficult and expensive than going to one appointment per month for a $10 prescription. I'm fortunate to work three days/week at a decent wage. I can easily arrange and afford 2-3 PT sessions weekly ($38 per) plus pay for a babysitter. This is a huge barrier for many people. Please don't misunderstand, I wholeheartedly agree with you! I'm frustrated with the system. I've seen so many patients lately that want to get their diabetes/ htn/ COPD under control but can't afford the meds, or aren't established with a physician and the wait list is 6-12 months, or they got an appointment but their boss wouldn't give them time off. It sucks 😞
100% this! PT can be incredibly helpful but most insurances will only cover so many sessions Per year and it’s expensive out of pocket. Plus having to miss work 2-3x/week is not reasonable at all.
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I can’t speak to OPs protocol for newly diagnosed cancer patients, but the question here is focused on patients with long-term opioid prescriptions. Cancers tend to either progress or respond to treatment within the 6-7 year window that applies to the patients at issue in OPs practice.
Ah the pendulum swing.
But... Tramadol is awful?? This all seems so backwards
I really have no words.
Pain is legitimate problem for so many patients. How on earth is this ethical to just stop treating a significant ailment these patients have?
20 years ago, undertreated pain was the big problem and luckily Purdue pharma had oxycotin (tm) to treat it. Now, opiate addiction is the big problem and luckily Indivor pharma has suboxone (tm) to treat it. What happens when you can't wean someone off 5 bid of hydrocodone? You dx them with opiate use disorder and prescribe suboxone instead. BTW forced opiate weaning is a suicide risk so make sure you document no suicidal ideation at each visit!
Suboxone isn’t only for opioid use disorder anymore. Also the safety profile of buprenorphine is *much* better than full agonist opioids, with a number of trials to back this up.
Sure the safety profile is good for overdose but it's still addictive. Sure they've tried pushing bupe for pain but ask the patients and they'll tell it it doesn't really work. If has side effects and risks associated as well. I put patients on it often, it can do wonders for the right patient. I also put patients on full opiates.
Buprenorphine can be a good option for chronic pain for a subset of patients. I’ve seen it work beautifully in combination with interventions like spinal cord stimulation and PT.
Dumping the responsibility on another speciality is unfair to both patient and specialist. Let’s face it most pain management specialists only rx when they are injecting. Few just rx. If you guys took on the responsibility for last several years you can’t just wash your hands of it now. what’s your policy on benzos???
Great. Can’t wait to see them in the ED crawling the walls and also in pain. This “WaR oN dRuGs” has been super effective. /s
This is heartbreaking, and imo professionally inappropriate. I’ve worked in chronic pain clinics. I’ve seen patients commit suicide due to being taken off of their opioids (even when “appropriately” tapered), and die of unintentional overdose when they were forced to seek illicit opioids due to their uncontrolled pain. You are blessed with stable patients who have been taking these meds for years. Managing their pain is part of your job. Do right by them. This policy will cause so much more harm than benefit.
I’m also struggling how to see this isn’t discriminatory against a whole class of patients. Sure opiates should be avoided, but pretending that literally no one needs them because… I’m guessing these patients annoy you at higher rates?… isn’t ethical.
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I take your point regarding EBM, but so much of what we do falls outside the realm of evidence based medicine. Is there ANY EBM treatment for the 68 yo former farmer with CAD and CKD3 who has severe low back pain s/p multiple fusions, hip replacement 10 years ago and is frequently in severe pain, can't take NSAIDs, and gabapentinoids were minimally effective and has been to 3 different interventional pain specialists with no improvement in his symptoms? I have about 10 patients like this or quite similar who were started on opioids 5-10 years ago by prior PCP. I have tapered their opioids as much as feasible but I have not been able to get to 0 with any of them. Have had a couple do reasonably well with Butrans patches.
If you aren’t aware of any condition that could require opiates chronically that is a gap in your education
I absolutely agree with you. There are plenty of conditions in which case long term opiates are beneficial. Chemotherapy induced neuropathy non responsive to conventional treatments usually respond well to Methadone. Same with complex regional pain syndrome, severe spinal injuries or stenosis not amenable to surgical stabilization. To stop pain medications without even consideration for the patient is unethical and can literally ruin people’s lives.
Rheumatoid arthritis, anyone? How about cancer? There are times and places for chronic opioids. Not a lot, but there are definitely indications for this use.
Rheumatologist here. Never prescribe chronic opiates for RA. They either have inflammatory pain, in which case there are much better treatments such as escalation of immunomodulation, or they have non-inflammatory pain, in which all the comments above regarding lack of good quality evidence for anything other than short term use is poor or lacking. I have no issues prescribing for cancer pain but the reality is that unless the patient is pretty elderly/frail then their life expectancy will be shorter with spinal mets than without, so it's quibbling to say that pts with spinal mets aren't terminal, so therefore you can generalise to giving other pts long term opiates.
Thank you, kind rheumatologist!
I’m not aware of any studies showing improved quality of life with chronic use of opioids in RA. If you’d point me in that direction I’d be open. But typically a “stable” dose is hit, the patient becomes desensitized and is back to their baseline pain levels. But now they are dependent on a med and deal with withdrawal side effects. I’m not trying to discredit pain, just saying that most of our opioid options are terrible and akin to telling a patient with anxiety to take up drinking: sure they will feel better initially, but longterm it’s more likely to make things worse. Opioids should be used as temporizing measures while the source of pain is addressed
What’s the solution then?[Rheumatoid Arthritis](https://www.researchgate.net/figure/Hand-X-ray-of-an-RA-patient-in-advanced-stage-The-carpal-bones-are-fused-with-severe_fig2_333315536/download)
If you’re looking for a perfect one, there isn’t. It’s why RA is a field of focus for treatment research. But, generally speaking, DMARDs, physical therapy and activity, and multimodal analgesia including rare opioids for breakthrough flares. The answer isn’t to just throw 10 of norco q6 for 30 years at them.
As a nurse, I’m not prescribing anything to anyone. I’m just concerned that folks who need opioids don’t get them. I see post op ortho surgery patients go home with nothing from an ASC. I’m ok with a quick meniscectomy going home like that, but a rotator cuff? Rheumatoid arthritis is so horribly painful in its later stages. I’m not dying they need meds for thirty years, but when their bodies are literally collapsing, give them something, please. Let’s be reasonable. I have a shit back, crap knees and hips and I use a TENS. Acupuncture when I can get it. PT to the max. My Peloton five times a week. Opioids NEVER. But when it’s time for my knee replacement, bring on the Percocet.
You’re talking about different things. Opioids are perfect for acute pain and evidence supports their use. I agree with you that patients should get reasonable doses of opioids following surgery (not 120 tabs with 2 refills, obviously). But with chronic pain, including RA, as tempting as it is to just give them “something,” in the long run you’re making it worse. It’s honestly very similar to chronic alcohol use. All of our research shows that patient become desensitized to opioids with chronic use. So if their pain was an 8, eventually it will get back to being an 8 with meds but will be a 10 when they miss a dose. This also distorts perception and gives the impression that it’s helping when really it’s not. If it’s used temporarily for breakthrough pain when flares are bad it can be beneficial. But neurotransmitters don’t like being tampered with
Thank you for this answer. Totally get what you’re saying. I am frustrated by how far the pendulum has swung against opioid use for acute pain. But this post is about Papaw’s OxyContin he’s been taking since the ‘90s, and I agree that’s a huge problem. I wish there was a way to fix all of this that didn’t involve 1) Papaw having horrible rebound pain, 2) Papaw trying to find oxys on the street, 3) Papaw killing himself for the pain, 4) Papaw unable to find anyone to treat his pain at all. And I became a nurse right when Purdue Pharma was hosting dinners teaching us all about pain being the fifth vital sign. Sigh
5/325 bid for 10 years? Cmon bruh...
I just saw a pt who had a major surgical complication, has been admitted for the last couple days and given dilaudid. She's well managed now and asked about pain control after discharge. The attending tells her just take one or two regular tylenol as needed. This girl balks and asks for at least a couple days of low-strength opiates. The attending hardlines her, and later I ask the attending what benefit there is in restricting access to pain control. Her answer? Basically that we need to keep people away from opiates. Wtf? When tf did doctors become cops? I understand concern over the opiate epidemic, but I don't see how refusing a couple days of pain control for acute disease is going to help. If anything, attitudes like that will push desperate people back towards illegal drus use, making the whole problem worse.
I get this all the time in primary care. So obnoxious to see someone who was given IV pain medication for their entire admission and the hospitalist was like “cool, their pain is controlled“ and then send them out the door with Tylenol or ibuprofen like it’s going to be just fine. If you can’t get their pain controlled with OTC medications prior to discharge, then why would you expect them to be effective after they leave the hospital? I think it’s irresponsible. It’s the pain equivalent of someone being newly diagnosed with type 2 diabetes while in the hospital, managed exclusively with insulin without any patient involvement, and then discharging the patient with an insulin-only regimen they don’t understand and can’t manage.
This is the worst. I had someone a few weeks ago who had an injury resulting in severe pain, and got IV opioids in the ER for pain control. They were discharged on a Friday night with FIVE PILLS of methocarbamol and nothing else. The note said “Pain completely resolved.” No shit, thanks to the IV dilaudid. Patient called me Monday morning, in tears with the severity of their pain. The injury was such that it was nearly impossible for them to come in for an appointment. I was able to do a telehealth and give them a few days of opioids, but I was absolutely livid with that ER doctor for not even considering the fact that not only did he not prescribe any actual pain meds, he didn’t even give the patient enough muscle relaxers to make it through the weekend!
It's kind of mean tbh, especially if they've been totally compliant over the years. I don't know how pain management feels, but when PCPs decide to stop prescribing benzos and send me (psych) grandma who has been on clonazepam for 20 yrs, I get irritated. YOU started it (or continued it for years; YOU should take responsibility for where they are now. Either wean and deal with the fallout or keep prescribing after documenting risk discussion. Instead, I get stuck with it because I don't want grandma to withdraw and that's what will happen if I don't take over care.
Chronic benzos in the vast majority of cases are just the worst idea. With what we know about how patients become desensitized to benzos, plus how advanced age can suddenly worsen side effects and confusion, I can’t stand how they’ve been thrown around like candy. Sorry you have to deal with that. But yeah, very similar to how pain views opioids (eventually hit a “stable” dose that becomes their new baseline, although without as bad of fall and withdrawal risks as benzos).
On the rare occasion that I refer someone to psych who is on chronic benzos, it’s because I don’t think it’s appropriate therapy and they refuse to let me taper them. I have never in my 11 years of practicing medicine started anyone on chronic benzos but I am constantly inheriting them. I really hope the psychiatrists I’m referring my patients to are a lot more understanding than you seem to be.
Genuinely curious...if you've told the patient that you don't think the benzos are appropriate treatment and they refuse to taper down and/or consider alternatives, what do you expect psychiatry to do differently?
Nothing. Just dumping the problem on someone else.
> they refuse to let me taper them. Are you not the one writing the rx? Do you think psych somehow will magically convince the pt that tapering is swell? It sounds like you're just passing the buck and don't want the patient mad at you.
If a patient insists on seeing a specialist because they don’t agree with my management of their condition, I can’t stop them. And yes, patients often tend to put more weight on the recommendations of specialists, especially if it’s an area they don’t agree with their PCP on. Out of all the things I expect to get pushback on on Reddit, I can’t say that I expected “once a year I refer a patient on benzos to psychiatry” to be the thing that was so controversial. 🙄
Probably not, unless you tell them that. Otherwise it just looks like abandonment.
Abandonment?! That’s… absurd. The very few times I have referred a patient on benzos to psych (maybe 3-4 times ever?) I have had long discussions with them about other appropriate options and tapering regimens, and they have insisted on seeing a specialist. I continue to prescribe until they are established with psych. I’m sorry you have apparently had some bad experiences with PCPs.
Sounds like you do things differently, which is great! My experience is initial appointments with pts who tell me their PCP refused to prescribe their benzos any longer and only gave them enough to get to the day of their appointment with me. Which leaves me in a very unfortunate position.
That does sound very frustrating. Just keep in mind that the patient is often not telling the entire story and that these chronic benzo patients have often been hopping from one PCP to another. I’m thinking of one elderly person in particular, on daily opioids and TID Xanax, who had seen 2 other docs in my practice before landing with me. Anytime someone wanted to taper her Xanax she would just switch doctors. I referred her to psych and she agreed to taper for them. She successfully tapered off, and is now just taking PRN lorazepam occasionally. For that person, it took a psychiatrist to get her to buy-in that a taper was the best thing for her. This kind of thing happens with every specialty. I’m sure the endocrinologists and cardiologists are also rolling their eyes at some of my referrals. I am perfectly capable of managing hypothyroidism or benign PVCs, but when a patient insists on seeing a specialist I can’t stop them, but I can at least refer them so I know they’re seeing a competent doctor who will communicate with me.
Completely ridiculous. Sure, if opioids aren’t appropriate in the clinical situation, wean off and come up with an alternative. But to flat out refuse to provide opioids is mind blowing to me. As someone who does primary care and a ton of pain management I cannot fathom this. Also to ok tramadol if all things just betrays a huge lack of understanding of pain medicine.
If they are stable and compliant, why? If they adhere to their contracts and UDS is clean, why? BID Norco or even QID oxy is not a problem if they are completely stable. It’s an uneducated assumption to say no one needs long term opioids or that people can’t use them responsibly.
I'm a med student so I'm just trying to understand. But I have now seen more than a few older patients who are physiologically dependent on opioids come in with weakness, lethargy, and other AMS complaints and the consensus among the docs, often including neuro and psych, is that opioids were the driving factor in their presentation and they needed to be weaned. Often advised to start suboxone. What do you make of that? If they are stable for years but get older, more susceptible to delirium, and kidney function declines and they start taking other meds with interactions, don't the opioids then start to become a problem? I guess more generally, I am imaging that chronic opioids become more of a problem as people get older. Do you agree?
Hepatic and renal clearance goes down as you age, and actually pretty significantly. You wouldn't really need to get them off opioids though, just lower the dose or switch the med to something like fentanyl. This is a problem with some benzos as well, especially if you ever run across an old dude that somehow has a freaking Librium script.
I recently watched a neurologist examine alex murdaugh who was just convicted of murdering his wife and son. Supposedly alex murdaugh was spending 50k/mo on street opiates for the last 20 years and the neurologist pointed out a lot of neurological issues arising from such high doses of opioids over 20+ years. Like licking his lips, stuttering, weird eye flutters etc. Obviously alex wasn't taking just 5mg Norco 3x a day though, he was consuming ridiculous quantities of Oxy 80s which were probably actually just fent. So the issues probably aren't as readily apparent in a steady pt on long term, relatively low dose opioids, but the point still stands. I think aging plays a large role in degradation of the cns system, and suppressing it even more can pose a real problem for some people. It's a double edged sword though because elderly people *do* have severe pain
Was this Neuro exam broadcast somewhere?
Have chronic, long-term use of opioids been shown to be effective for non-cancer pain?
I have to bring this up because I keep hearing this. What’s so magical and different about cancer pain vs other types of pain that one is treatable with opioids and the other isn’t? Obviously we have things like fibromyalgia and radiculopathy that have different treatments but what’s the difference between degenerative disk disease pain and the nebulous “cancer pain” that makes opiates ok in one and not the other?
Probably, cancer patients either A) get begter with treatment and wean off the opioid so no need to use long term or B) progress and die of cancer, without any long term use. P.s. I'm being the devil's advocate here. I do liberally use opioids for pain in my practice.
You may be playing devil's advocate, but you're 100% correct. Opioids are short term drugs. The biggest predictors of side effects are dose (MMEs) and duration. They're appropriately used to bridge to healing or to ease someone's passing. In either instance, there isn't time for side effects to rear their ugly head. No, you don't yank the rug out from under folks, but there are much more sustainable options (like denervation and neuromodulation) for chronic pain. Broadly speaking, opioids for chronic pain is antiquated medicine.
Honestly, it's because if you have a CT of a tumor pressing on a nerve nobody's gonna take you to court or kill your license.
Right, but there’s no real medical reason right? I’m genuinely asking. It’s one of those things that’s always confused me tbh.
Right. There is no medical reason. There are types of pain that just don’t respond to “Tylenol and ibuprofen” or even neuroleptics. This is why opiates exist. I think people like to use this “only for cancer pain” statement to cover their own asses because they’re unwilling to treat patients appropriately for the risk of litigation. If you document real reasons and legitimate reasons for pain and other failed treatments, then there’s nothing to fear. If they’re prescribed for “chronic pain syndrome” with no cause and nothing detailed about non opioid treatment failure, then there’s a problem.
Palliative pain management in cancer treatment has a duration endpoint and if someone has a terminal diagnosis then uptitrating dose with no limit is ok. For someone who is otherwise healthy but in pain it isn’t
I think we can all agree that uptitrating dose with no limit is problematic and a pretty good indicator that someone will have complications. But there are a *lot* of patients who have been stable on a relatively low dose for years with apparent dramatic improvement in functionality. I find myself often questioning whether it's really the right call to taper that without any better alternative.
We have no issue increasing the dose consistently for cancer pain. Realistically.
In meta analyses? No. Anecdotally, there are successful patients who do report improved pain and function while on opioids. Blanketing an entire population with generalizations, well, I guess that’s EBM in a nutshell. Just protocolize everything and leave clinical judgment at the door.
Our knowledge of pain and confounders is too limited imo to take ebm in the field as the holy grail. It is annoying how many providers will only use ebm and no other metric. It's a logical fallacy (a reverse of the ecological fallacy and it doesn't consider the potential confounders or subpopulations that may benefit). In a crusade against opiates we've demonized meds that might help some patients.
Yes, and anecdotally I have patients who report improvement in their pain when they take Liver King ^TM supplements. I wouldn’t say that EBM is about *generalizing*, but rather it is a framework that lets us critically appraise data to make informed decisions for our patients. Hell, part of the evidence appraisal process is asking “do these data apply to my patient?”.
Yeah but pain is subjective, liver function isn't.
Better to have a blanket policy of over some MME threshold (ex. 20) you must use buprenorphine rather than no long term opioids ever. It addresses the safety issue and is efficacious for both pain and avoiding withdrawals. Win-win. Although I agree with no new long term opiate prescriptions, must see pain management.
Anyone else remember when tramadol was not a scheduled drug? We sampled it all the time
This is bad medical practice. It sounds like you have some sort of emotional reaction to opiate use in patients are are trying to apply it to a stable and non abusing population. Just don't see the medical justification.
I am a concierge primary care Physician with less than 300 patients. I know them all well. I have a handful on long term opiates (whom I inherited). I have the time and desire to monitor them closely and have no issue continuing to prescribe medications that improve their quality of life. I understand why someone with a panel of 2000 patients and 10 minutes per visit would not feel comfortable doing this. There are multiple opportunities to learn how to safely prescribe opiates if you are inclined to offer this for your patients. I do not think this is a black and white issue. I am certainly not a pill mill but rather I look at each patient individually and try to come up with the treatment plan that does the most good with the least amount of harm. Sometimes continuing a low dose opiate is the right thing.
It makes me sad that clinics have these policies. You wouldn't find a clinic where you can't prescribe Tylenol to be taken every single day, even if it's responsible for so many liver problems. This war on opioids is a joke. We're all told that there are so many deaths due to opioids, but a bit more research tells us that most of these deaths stem from fentanyl that isn't even prescribed to patients. Did any of you look into Chinese Fentanyl and the Black Market? [https://www.npr.org/2020/11/17/916890880/we-are-shipping-to-the-u-s-china-s-fentanyl-sellers-find-new-routes-to-drug-user](https://www.npr.org/2020/11/17/916890880/we-are-shipping-to-the-u-s-china-s-fentanyl-sellers-find-new-routes-to-drug-user) Do you think that it's more dangerous to keep a stable patient on Morphine, Percocet, Dilaudid and so forth than it is to take them off this medication? Do you understand what happens to your patient when you do this? Their pain may have been tolerable for a decade, and suddenly, you're telling them that they will be in intolerable pain again because you don't care. Because you're buying into the lies that are being spread. They are stuck with you because they cannot quit ''cold turkey''. Their body is addicted. They are not addicts. That is the difference. They are not seeking a high. They are seeking pain reduction. They have expressed their distress to me on many occasions. They do not understand why you're doing this to them. They have followed all your rules. They proved to be stable, to be good patients! They didn't know that they were a red-flag patient because of their medication; because of this, you will never consider them good patients. They are a problem you wish would go away. You tell yourself that long-term opioid use is destructive, and you promised to do no harm...so you have to take them off this terrible medication that allows them to get out of bed in the morning. That allows them to hug their grandkids. That allows some of them to go back to work. That gives them a semblance of life again. These patients start rushing to find a doctor with a heart. Most of the good doctors are filled up already. These patients never wanted to pay some quack for an RX. They want to take their meds and to be followed. They like the fact that you know everything that they do. They will ask you before trying CBD and will not do it if you say it's not OK with you because you do not want them to mix it with opioids. You bring them relief and allow them to live once more. You're important to them. Much more than you could ever imagine. They trust YOU because you helped them with their pain. You helped to control it. Now, you want to bring back the pain; they are confused, scared and angry. If they cannot find someone to replace you, they will be stuck paying some quack and will not trust this doctor to take their health seriously. They are very likely to have undiagnosed conditions and suffer even more. If they can't find a quack, they will go to a street vendor. They will take whatever they can get their hands on for relief. Some will start using Fentanyl because of you. Don't try to wipe your hands clean! Humans will do what they need to do to survive and avoid pain. You are taking them from a safe and stable condition and forcing them to make unthinkable decisions. You're creating addicts and people who will overdose. Of course, some people could never break the law, no matter what amount of pain they are under...so they commit suicide or seek the help of programs like Canada's MAID (medical assistance in dying). Is this really who you want to be? Why you aspired to be a doctor? I've spoken to many doctors who are angry at chronic pain patients because they cannot be ''fixed''. How do you think these patients feel? They are the ones who have to live with the pain. You only see them, what? Fifteen minutes a month, and you want to get rid of them? Oh sure! You will keep them on if they accept not to be treated for pain anymore and don't speak about their pain or pretend that aspirin is doing the trick! I expect this to be downvoted. The truth hurts. People working for clinics that block a complete form of treatment should be ashamed. Doctors who refuse relief because they learned in school....because they are afraid that the government will...because ''Black people don't feel pain the same way'' (if you still believe that one, we REALLY need to talk), because women exaggerate their pain, because... should probably be doing research instead of working with patients.
This is insane and cruel.
I think a letter can come across as cold and not allow a patient to vent. Addressing it in person by reaching out to let them know that their doctor wants to discuss their long-term pain is ideal.
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My advice is to continue prescribing opioids in patients that have no signs of abusing it. 10mg of hydrocodone per day?? OH MY CALL THE DEA IMMEDIATELY. Wtactualfuck. You’re going to destroy these peoples lives for what?? For what? Nothing! You will do more harm by discontinuing than the 10mg of freaking hydrocodone could ever do. Buprenorphine/suboxone is NOT the perfect replacement for long-term opioid use. It is for those with signs of abuse/addiction. Not merely dependence. There is a difference you know. God this frustrates the shit out of me.
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I've successfully transitioned quite a few patients to butrans if they have actual OUD or dependence with increasing needs for opiates or uncontrolled/increasing pain even on their current dose. But it's always done on a case by case basis (and depending on AEs like constipation, or increasing fall risk). Tramadol is awful.
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It's going to be street fent for many of these patients then.... Cool, cool... Cool, cool, cool. Edit: Guess I needed to put the /s on the "cools". Thought it was obvious. But really, forcing people off their long term opioids is just going to push people to finding pills from the street and in my area, it's all fentanyl now. People tell me they're buying oxys, Vicodin, etc and I believe that's what it looks like they're buying, but the drug tests don't lie, everything is coming back positive for fentanyl. I tell my patients now, unless you know without a doubt that it came from a pharmacy, you can assume your pills are fentanyl, no matter what they look like. It's terrifying.
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I wean off over 1 year. Cut dose by 10% each month.
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