Information on chronic pain and addicton

Christopher Frandrup, M.D., DABPM, FIPP

Category: Opioids

FDA requiring boxed warning about serious risks and death when opioid pain or cough medicines combined with benzodiazepines

FDA review has found that the growing combined use of opioid medicines with benzodiazepines or other drugs that depress the central nervous system (CNS) has resulted in serious side effects, including slowed or difficult breathing and deaths.  Therefore the FDA is adding Boxed Warnings, its strongest warnings, to the drug labeling of prescription opioid pain and prescription opioid cough medicines, and benzodiazepines.

The agency issued a Safety Alert noting that it has conducted and reviewed several studies showing that serious risks are associated with the combined use of those drugs, other CNS depressants, or alcohol.

If these medicines are prescribed together, it recommends limiting the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect.  Further, prescribers should warn patients and caregivers about the risks of slowed or difficult breathing and/or sedation, and the associated signs and symptoms. 7619349538_25d476aa12_o

If you or someone you know is taking a benzodiazepine and an opioid, schedule an appointment with us to discuss your options.

Sorry, opioids probably aren’t helping your back pain

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It’s time to really talk about opioid use. Chronic pain is no laughing matter, and it’s nothing to be flippant about. We see thousands of patients a year who suffer terribly from lower back pain and other conditions. The struggles that they face in their daily lives, and the challenges that their chronic pain presents to their friends and family, are very real. We take them very seriously. We live our mission of helping patients get their lives back every day, and we want them to know that we consider them like our own family. And as with our own family, it’s time for some tough talk: opioids are probably not helping your lower back pain. In fact, opioids may be making your lower back pain worse.

Research on opioids for lower back pain comes up short

For years now researchers have been looking deeply into opioids for chronic pain of all types. They have amassed hundreds of studies over decades looking at opioids for both short- and long-term use.

Again and again, the evidence shows that opioids have limited effectiveness in treating lower back pain. The most recent findings come just weeks before this post. In a meta-analysis of 20 trials looking at the safety and side effects of opioids for lower back pain with no clear identifiable cause, researchers found that opioids had about half the effectiveness for pain relief as that of an inactive placebo. In addition, many of the study participants were unable to handle the side effects of opioids, with over 50% experiencing side effects so severe that they withdrew from the studies.

So why are doctors and patients alike still working under the assumption that opioids are effective?

A brief history of opioids and lower back pain

Opioids have been around in some form since 3400 BCE (in the form of poppies). Fast forward thousands of years to the 1990s when undertreatment of pain became a rallying cry for more aggressive interventions and pain management.

One of these interventions was the development of extended release opioids, including morphine, oxycodone, and fentanyl. Pain lobbyists pushed for wide release and prescription of opioids for all types of pain beyond non-cancer pain, which has generally always been the standard of care.

These slow-release medications produced in pain patients an overwhelming feeling of euphoria and a perception of pain relief. It stands to reason that a person suffering for years from chronic pain would embrace this feeling, but there was one huge caveat: the body’s adaptability to this type of medication.

Doctors began prescribing these miracle drugs to excess, with patients understandably clamoring for relief.

We want to note again that we truly understand why patients and their doctors adopted opioid prescription practices so readily. To see patients who had been suffering for decades report pain-free days and a restored hope for the future is what every doctor hopes for.

But in the ten-year period from 1998 to 2008, opioid prescriptions doubled. Along with that prescription doubling came over 730,000 visits to the emergency room due to misuse or abuse of prescription opioids, doubling in just five years. In 2002, over six million people in the U.S. were abusing prescription drugs.

The changing face of addiction

The vast majority of those with opioid dependence are not who you might think they are. Many people who begin taking opioids for acute pain find themselves physically dependent on them in a short time. In fact, many patients leave the hospital physically dependent on opioids after an operation, suffering minor withdrawal symptoms that they may believe is a cold or a virus contracted at the hospital.

It should be noted that physical dependence is not the same as addiction. Physical dependence on opioids is the same as physical dependence on insulin for Type 1 diabetics. The body becomes used to functioning in a certain way with their medications and struggles to acclimate after those medications are withdrawn. Addiction is characterized as a behavioral component that usually accompanies a physical dependence.

That being said, it is remarkably easy to become dependent on opioids, and the longer you take them, the more likely you are to develop both physical dependence and an increased tolerance to their effects. Patients may find that previous prescriptions may no longer help with their pain, and they may begin to suffer withdrawal symptoms such as nausea, fatigue, muscle pain and weakness, and irritability or anger.

The person who finds themselves “addicted” to opioids may still be able to function in daily life, but the longer they take opioids, the more dangerous they become. Long-term use is associated with disruption to the menstrual cycle, a weakened immune system, and affected sex hormones. Additionally, side effects may include nausea, constipation, and difficulty concentrating, problems which worsen as time goes on.

Roger Chou, M.D., associate professor of medicine at Oregon Health and Science University in Portland points out that new research has utterly debunked opioids’ effectiveness against lower back pain, noting:

“The old perception about opioids is that they are reasonably effective and safe for chronic pain, but what we’ve come to realize is for many types of pain they don’t work all that well and are actually associated with significant harm.”
Gary Franklin, M.D., research professor of environmental and occupational health sciences at University of Washington in Seattle believes that the evidence has become overwhelming against prescribing opioids for chronic pain:

“What concerns me is that there is no clear evidence that people who take opioids over the long term can do more or get around more easily. But we do know that the higher the dose of the drug and the longer you take it, the greater your risk.”
Opioids – what are they good for?

In specific, controlled instances, opioids work well for pain management. End-stage cancer pain and pain as a result of surgery or in the acute, short-term stage of an injury are two times when opioids are recommended and are the standard of care.

But for chronic lower back pain? There is no evidence that the benefits from opioids outweigh the risks. Indeed, it does not seem that opioids have any more affect on chronic lower back pain than a placebo.

Opioids and chronic lower back pain – the bottom line

The bottom line for opioids and chronic lower back pain is this: there is no evidence that opioids are effective in treating chronic lower back pain, and the risk of side effects, dependence, and death increase the longer a patient takes them.

If you are currently taking opioids for chronic lower back pain, it’s time to talk to your doctor about other options. It is never too late to make changes in your health, and a conversation with your pain management specialist is a great place to start.

Prince’s death triggered the FDA to mandate physician training.

Even though Prince will be only one of over 100,000 to die this year from prescription drug abuse this year he has brought public attention to the opioid epidemic facing America.  Additional physician training requirements have been proposed in the past by the FDA but were essentially made voluntary at the behest of the pharmaceutical companies.  However, the new FDA commissioner stated in a speech earlier this year he specifically addressed the opioid problem and the role of the FDA in combating the epidemic.  He also spoke at length about opioid specific physician education programs developed through the Risk Evaluation Mitigation Strategies (REMS) programs promoted by the FDA.  So far, 100,000 physicians have “voluntarily” participated in these programs.  Many of which were required by the states licensing them.  I too have completed some of these programs and I can attest to their length.  Sure enough, shortly after it was revealed Prince died of an opioid overdose, an FDA panel recommended mandatory REMS training for all physicians with DEA registrations.

DEA COLLECTS RECORD-SETTING AMOUNT OF MEDS AT LATEST NATIONAL R/X TAKE-BACK DAY

 

  FOR IMMEDIATE RELEASE

 Contact: DEA Public Affairs

Press Release

DEA COLLECTS RECORD-SETTING AMOUNT OF MEDS AT 

LATEST NATIONAL R/X TAKE-BACK DAY 

WASHINGTON, D.C. – Americans turned in more unused prescription drugs at the most recent DEA National Prescription Drug Take-Back Day than on any of the previous ten events since it began in 2010, demonstrating their understanding of the value of this service. 

 

Last weekend the DEA and over 4,200 of its state, local, and tribal law enforcement partners collected 893,498 pounds of unwanted medicines—about 447 tons—at almost 5,400 sites spread through all 50 states, beating its previous high of 390 tons in the spring of 2014 by 57 tons, or more than 114,000 pounds.  The top five states with the largest collections, in order, were Texas (almost 40 tons); California (32 tons); Wisconsin (31 tons); Illinois (24 tons); and Massachusetts (24 tons). 

 

The majority of prescription drug abusers report in surveys that they get their drugs from friends and family.  Americans understand that cleaning out old prescription drugs from medicine cabinets, kitchen drawers, and bedside tables reduces accidents, thefts, and the misuse and abuse of these medicines, including the opioid painkillers that accounted for 20,808 drug overdoses—78 a day—in 2014 (the most recent statistics from the Centers for Disease Control and Prevention).  Eight out of 10 new heroin users began by abusing prescription painkillers and moved to heroin when they could no longer obtain or afford those painkillers.

 

“These results show that more Americans than ever are taking the important step of cleaning out their medicine cabinets and making homes safe from potential prescription drug abuse or theft,” said DEA Acting Administrator Chuck Rosenberg.  “Unwanted, expired or unused prescription medications are often an unintended catalyst for addiction.  Take-Back events like these raise awareness of the opioid epidemic and offer the public a safe and anonymous way to help prevent substance abuse.”

OxyContin in the news again…

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I remember when OxyContin was released by Purdue Pharmaceuticals in 1996.  It was heralded as the best treatment for chronic pain.  With millions spent on marketing, it became a very popular and very deadly drug.

The NY Times just published a great article on OxyContin titled “‘You want a description of hell?’ OxyContins 12 hour problem“.

I have had many patients complain that it doesn’t last the advertised 8 hours.  It turns out, they were right, and Purdue knew as well.  They hired an army of sales reps to convince doctors to never prescribe the drug every 8 hours (as it should be), only every 12 hours as their patent stipulated.  Purdue has made 30 billion dollars on this drug and if they admitted it doesn’t last the 12 hours promised….  That would be the end of their patent.

Instead, they convinced doctors to increase the dose to cover the 4 hour gap.  If you are a patient, it means an “excessive dose” followed by an excruciating return of pain hours before the next dose.  Does this sound like a recipe for addiction?  Some experts have called OxyContin an “addiction factory”.  If you are on this drug and not getting the results you expected, talk to your doctor.

National Geographic also did a video on this highly abused drug.

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