The End of Narcotic Pain Medication?

The LA Times ran a very interesting story a few days ago about deaths from overdose of narcotic pain medications.  I strongly encourage readers of this blog to read the story, which discusses the issue from the perspectives of doctors, patients, and family members. The story reports that a small number of Southern-California doctors wrote […]

The post The End of Narcotic Pain Medication? appeared first on Suboxone Talk Zone: A Suboxone Blog.

Treatment? Or Murder?

I subscribe to Google news alerts for the phrase ‘overdose deaths.’  Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.

Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.

I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.

In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts.  On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even if we tattooed the letter A across their chests, there are addicts who are in need of pain treatment. Are we to decide that every person who has become addicted to pain medication gives up the right to pain treatment?  And we know that many of the patients addicted to opioids became addicted through the course of pain treatment from their physician— so I would expect that on average, patients addicted to opioids would have a higher incidence of chronic pain, and vice versa.

I do not find it reasonable to make patients with addiction histories endure pain that would be treated in other patients.  Father than singling out some patients for ‘special non-treatment,’ we should prepare for the risks from opioids in ALL patients—a set of ‘universal precautions for opioid treatment,’ similar to the way we use a different set of universal precautions to avoid transmission of blood-borne infections.

There are times when doctors have to tolerate being the bad guys.  Some patients have been taught, through careless prescribing, that all pain should be treated with narcotics. Those patients are not happy when told, after paying several hundred dollars, that they do not ‘need’ narcotic pain medication– and so many of their doctors have a hard time saying ‘no.’ After all, doctors studied hard to do well in school, and usually receive praise for what they do. It is much easier to write a prescription and hear ‘thank you’ than to be called an unsympathetic jerk! But doctors are paid the big bucks to tolerate such things, and to keep the long-term health of patients in mind. And for many people with chronic pain, opioids will provide a good month or two, but for the price of many years of misery.

I’ve been told by patients “I don’t care about the risks, doc– I’d rather have three good months and then die, then have twenty years in pain.” I reply, “that’s why these medications require a doctor to consider things very carefully, and a good doctor would not allow someone to make that decision.” I’m sure that some people will be angered by that attitude. But the approach is similar to how we handle many other illnesses, where we encourage patients to tolerate short-term misery for long-term benefits. Many patients would refuse chemotherapy and give up on life if not pushed to move forward. And to depressed patients, suicide can appear a reasonable option. I’m a fan of free will, but I recognize that we don’t always choose our paths through life with full insight.

Even with full knowledge of the reasons to avoid narcotics, some doctors really struggle over withholding opioids.  I find it somewhat ironic that the doctors who are too ‘kind-hearted’—i.e. who want to please patients so much that they cannot deny even that which is bad for them—are the ones who end up getting into trouble.  The Iowa doctor is being sued over several of the deaths, likely by relatives of the patients who pled the hardest for pain pills!  Talk about good deeds not going unpunished!

But there are aspects of the case in Iowa that do not argue well for the doctor. Several of the patients who died were only seen once, but treated with narcotics for years. The DEA requires that patients are prescribed no more than 90 days of narcotic medication at one time (divided on three monthly prescriptions). I presume that patients were picking up scripts every three months, without having appointments each time. Such a practice is not strictly illegal (not that I am aware of, anyway), but the standard of care would be to evaluate patients on potent opioids every three months, or even more frequently. And one news article stated that the doctor had tens of thousands of pain patients. As a full-time practitioner with less than 1000 patients, I wonder how so many patients could be managed by one physician.

When I write about this topic I receive angry comments from some readers. Some attack me personally with comments like “I’m glad I’m not YOUR patient!” or “I hope YOU have to suffer with horrible pain some day!” I realize that this is a very hot topic, and my only intent is to educate and inform, to help people understand what is happening in the minds of physicians. Of course, the care of patients should not be determined by the need for doctors to protect their own interests. But at the same time, it is understandable that doctors are affected by headlines announcing the imprisonment of other doctors facing the same treatment decisions.

Bottom line– there are very good reasons to avoid using opioids for nonmalignant chronic pain. Just giving patients what they want, and ignoring the danger of opioids, will likely result in criminal and civil prosecution. But that reason is secondary to the most important thing– the promise all doctors make to first, do no harm. And patients should realize that their doctors may be withholding narcotics for that reason alone.

Short-Timers

Another question from a reader:

The current blog brings up the notion of long term use of Bupe or short term detox.  You say you are a fan of long term use, and that is clearly a good thing when the patient is one headed back to a drug culture of life of crime or is obsessed with the drug.  But-  what about patients like me and I think many others who have zero contact with the drug world, have never taken an illegal drug, and yet have taken Ocy C over the years for pain and find it all but impossible to stop the Ocy C.  

 The Suboxone helps with the W/D and just getting through with that is all we want.  NA meetings and the like are like being on Mars, it makes no sense.  There are no drug cravings at all and the goal is just normal.  Or rather, the goal is to make it through the W/D which is so harsh with Oxy C as to be dangerous for older people, whose only source of drugs indeed is the doctors Rx for them  And now that too is unavailable.  This group does not need Suboxone to become a new problem for them.  They just want the help.  It is not critically  important to determine “who” is being treated.  The certification training materials seem to brush over this so lightly that there is only one induction method allowed.  One that a drug company would love, but not always a patient –  pleading, do no harm.

My Thoughts:

I hear you, and watch for those patients.  Frankly I wish I had more of them, so that I could get some movement through my practice—- instead of being stuck with 100 chronic patients and a long wait list.   The financial motivation for the DOCTOR is to push people through, for that same reason.  Of course the drug company gets paid in either case.

The first question is whether buprenorphine even helps in the case you describe.   It is easier, in many ways, to taper with methadone than with buprenorphine, as you don’t have to divide such tiny pills.  It has been suggested that it is easier to taper off a partial agonist than an agonist—and I believe that to be true, simply because I have seen people do the former and not the latter.  But I don’t know HOW much easier it is—or if psychological aspects of the taper were more responsible than the person’s state of misery.

There were several studies a few years ago that showed relapse rates of 100% in people treated with Suboxone for less than a year;  those findings, it seems to me, put a damper on the idea that buprenorphine could be useful for short-term detox.  But I don’t know where those people would have fallen on the spectrum that you are presenting.  I do know that they were people with a primary diagnosis of ADDICTION— NOT chronic pain– so maybe they are not relevant here.

My caveat would be that I HAVE met many people over the years who are convinced that they fall in the pain camp you describe, but who turn out to be just as ‘addicted’ as anyone else.  They describe the process in different terms;  instead of admitting to ‘relapsing on opioids’, they describe ‘deciding the pain was worse than they expected, and that it was a mistake to go off opioids.’  They will claim to be different…. But an objective observer would see the same growing attachment to opioids, the same gradual dose escalation, the same excitement and activity when opioids are ‘on board’, and the same depression and misery if a day passes without using.

I agree with your thoughts, and get your point.  I just don’t know if very many people are as clearly-defined as you describe. One reason is because there are few conditions that cause pain severe enough to require high-dose opioid agonists for an extended period of time– say, a few months– that then go away.  Most pain conditions have residual symptoms—- from chronic inflammation, or even from the set-up of central pain circuits.  In a sense the pain is remembered, even after the original injury is repaired.  The severity of that residual pain is affected by the person’s emotional state, dependency, motivation, genetics…..  and the residual pain becomes a expressway back to using opioids— an expressway that is used often by many people.

Thanks for your comments!

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

I presented this topic at the Atlanta meeting of ASAM a couple weeks ago.  There are too many slides, but the historical stuff was just too fascinating to leave out.  I wanted to demonstrate,  by lining it up on the side, how time has compressed the most critical discoveries to a very short period of time.  In other words, it wasn’t until thousands of years of opium use that the general concept of endorphines and opioid receptors came along.  We can only hope that similar understandings of the biological basis of tolerance and withdrawal will be comparatively soon.

My study shows something truly fascinating– that a partial agonist seems to anchor tolerance at a lower level, still allowing for potent analgesia, but preventing euphoria and dose escalation.  I have used this combination in people with very major surgeries, that are known to be quite painful– i.e. knee and hip replacements, dental surgeries, gallbladder surgery, and median sternotomy.

Inconvenient Truth

Next month I will be presenting a paper at the annual meeting of ASAM, the American Society of Addiction Medicine. The paper discusses a new method for treating chronic pain, using a combination of buprenorphine and opioid agonists. In my experience, the combination works very well, providing excellent analgesia and at the same time reducing—even eliminating– the euphoria from opioids.

Ten years ago, I would have really been onto something. Back then there were calls from all corners to improve the pain control for patients. The popular belief regarding pain control was that some unfortunate patients were being denied adequate doses of opioid medications. I remember our hospital administrators, in advance of the next JCAHO visit, worried about pain relief in patients who for one or another reason couldn’t describe or report their pain. Posters were put up in each patient room, showing simple drawings of facial expressions ranging from smiles to frowns, so that patients in pain could simply point at the face that exhibited their own level of misery.

What a difference a decade makes! Purdue Pharma, the manufacturer of Oxycontin, was fined over $600 million for claims that their medication was less addictive than other, immediate-release pain-killers. Thousands of young Americans have died from overdoses of pain medications, many that came from their parents’ medicine cabinets. Physician members of PROP, Physicians for Responsible Opioid Prescribing, have called out physicians at the University of Wisconsin School of Medicine and Public Health for having ties to Purdue while arguing against added regulations for potent narcotics.

I have tried to present both sides of the pain pill debate, without disclosing my OWN opinions on the issue—at least until today. And I must be at least somewhat ‘fair and balanced,’ because I’ve received angry messages from both sides—from people telling me I’m evil for not understanding their need for pain medications, and from people telling me I’m evil for not respecting the danger of the medications.

By the way… I have a policy of not printing messages that simply call me names, or that tell me how bad a doctor I must be for writing what I do. I love a good argument, so please feel free to comment on ANY points that I’m trying to make. But I don’t think that making efforts to lead a discussion warrants personal attacks—so please, stick to the issues!

Today, though, I would like to share a couple thoughts on the issue. The thoughts came after a discussion with one of my patients with chronic pain. I have been presenting one side, then the other side, and back again, trying to remain neutral… but from all that I’ve seen as a psychiatrist and as an anesthesiologist, some things cannot be denied.

1. Some people do have chronic pain that responds to opioids. Many doctors—including the doctors who are afraid of the DEA, or the doctors who don’t want to deal with the hard work of prescribing opioids, or the doctors who want a simple world where ‘pain pills are always bad’—don’t want to admit the truth of this statement. This is, with apologies to Al Gore, a very inconvenient truth.

I find it interesting that doctors who don’t want to prescribe pain pills act as if chronic pain does not exist– as if the suffering of people with painful disorders is less important in some way, if it lasts too long. Every prescriber is aware of the need to treat acute pain, but when it comes to chronic pain, the difficulties that arise with treatment (e.g. abuse, diversion, tolerance) lead some doctors to act as if something magical happens on the road from acute to chronic. The phenomenon is the exact opposite of the old saying, ‘to a man with a hammer, everything looks like a nail.’ In this case, ‘to doctors who don’t want to use hammers, there ARE NO NAILS.’ But in truth, there ARE nails; some patients have lots of them. And we doctors have a duty to hammer away at them… (OK, enough with the analogy already!).

2. Just because some people divert opioids does not mean that other people shouldn’t have necessary pain relief. Treating pain is about as fundamental as medicine can be. I do not understand the doctors who say ‘I do not treat pain—you’ll have to see someone else’—especially when there are no doctors available to fill that role. More and more ‘health systems’ are adopting this position, at least in my area. What gives?!

3. At the same time, there is no such thing as ‘complete pain control.’ Tolerance removes the power of narcotics, and chasing tolerance always ends badly. Patients with chronic pain must use ALL tools available, including non-narcotic techniques.

4. Being prescribed pain medications comes with certain responsibilities; the responsibility to use the medications appropriately, to communicate openly and truthfully with the prescriber, to avoid ‘doctor-shopping,’ etc. At some point, patients who refuse to honor these responsibilities will lose access to pain medications—at least to some extent. Is this humane or fair? I think so, as access to pain relief for these patients is balanced against the lives of those killed by illicit use of these medications.

I’m sure I could go on… but for now, this is enough food for thought. Besides, it’s almost time for dinner! Feel free to comment—but please, be nice!

 

Do Interventions Work?

It has been a while, it seems, since I’ve checked in.  I’m at the point in the life cycle of a ‘blogger’ where I feel like I’ve said most of what I came here to say… so help me out by sending your questions, particularly those with broad implications, and I’ll chime in with an opinion.

In the meantime, check out the ‘best of’ page;  I have links there to some of the more popular post.   And for now, I’ll answer a question I received today on ‘TheFix.com’:

Do you believe in intervention of someone who does not ask or desire (to be clean)?

It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions.  But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within. 

Grandma needs an intervention

More common than you think!

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option. 

For example… let’s say that grandma has a problem with pain pills, taking more than what is prescribed, going to multiple doctors, going to the ER for pain pills, etc.  Her children don’t like her behavior, so they stage an intervention, to show her the problems her behavior is causing.  At the intervention, they tell her how hurt her grandchildren are by her absence at their functions, and they explain the risks of her behavior.  They set her up at a treatment center, and she is shipped off for 30 days.

She may go to all of the groups and meetings in treatment, agreeing politely in every setting that she has a serious problem, and that she really ‘gets it.’  And that would be great for the treatment center; they would collect their $30K, and everyone there would congratulate each other on how compassionate and bright they are. And later, when grandma is doing the exact thing she was doing before treatment, the counselors would put the blame on HER, acting as if SHE has a problem for not sticking to plan—even though almost all of their patients end up the same.

I used to be a bigger fan of residential treatment. But at some point I let go of the fantasy of residential treatment as the ‘gold standard’, and accepted the real numbers.  It is easy to clean a person up for a month in a closed environment.  But in regard to long-term sobriety… residential treatment rarely works.  Sorry to say something so horrible—but that emperor, sadly, has no clothes.

So back to grandma… I would expect her to go back to the same behavior after treatment. Why, after hearing from all the family, would she do that?

Because true change is very, very difficult. 

Besides, she has plenty of reasons to keep things the same.  She will likely think that the problem isn’t the use of pain pills, but rather that she didn’t hide things well enough.  Or she will assume that other people simply don’t understand what it is like to be 70 years old, trying to live with pain. She used to change the smelly diapers of these kids;  what could they possibly tell her that she doesn’t know?

And the major reason she won’t change?  For her to truly realize that her behavior is a problem, she would have to endure the shame for what was going on—and shame is a very strong motivator for denial.

In treatment, the team will try to try to break through that denial and have her admit, to herself, that she has a problem.  But that type of admission is rare, and only comes out when a person is desperate—and when there is no choice but to change.

But there are other ways to manage an intervention.  It would be best if grandma herself decides, at some point, that things must change.  How does that happen?  First, everyone has to stop enabling her.  If the grandchildren are angry that grandma didn’t show up at their birthdays, they should be allowed to express that anger—and when grandma protests, she is forced to hear why people are mad.  If grandma runs into problems with the doctor or pharmacist, nobody should help her sort things out;  she is left to juggle excuses on her own.  If she needs the ER for pain pills, she drives herself—or waits for a cab.

I chose ‘grandma,’ by the way, because I wanted to present the challenge of dealing with a person who deserves sympathy.  Nobody does her a favor by keeping her miserable.  Realize, though, that we are discussing addiction here;  I’m not suggesting that people abandon loved ones struggling with painful conditions!

The doctor should prescribe medications on a tight schedule, with strict refill dates that are maintained without exception.  Doctors are sometimes afraid to let people go into withdrawal, so they order ‘a few extra pills’ to get to the next refill;  medications should be long-lasting, so that withdrawal is uncomfortable, but not dangerous.  A short period of the medication- i.e. a one-week supply—will reduce the period of withdrawal.  If a person struggles to follow limits, the prescribing period is shortened until the person CAN follow it—even to the point of 3-day prescriptions with multiple refills.  If grandma complains about the multiple trips to the pharmacy, she is told that period will be lengthened if she sticks to the schedule— and shortened if she doesn’t.

The point of all of this is to make the person with the problem feel the consequences of their problem.  Too often, everyone else is aware of the need for an intervention, because everyone else feels the consequences—everyone but the addict.  The trick is to make the consequences hit the person who has the problem—and for everyone else to get on with life, until the person with the problem is sick and tired of those consequences.

Of course, every now and then an intervention turns out to be meaningful enough to get a person’s attention, and to spur change.  But in my experience those types of outcomes—the things we see on TV and in movies—are not the norm.

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The Downside of Methadone

An Article by Mike Berens and Ken Armstrong, Seattle Times, discusses some of the problems with using methadone as a first-line treatment for pain:

When it comes to battling pain, Washington health officials have encouraged doctors to reach for methadone, a powerful and inexpensive prescription drug. For the past decade, the state has declared methadone to be as safe and effective as any other narcotic painkiller.

Methadone

But in a striking reversal that has gained momentum this week, doctors are receiving stark warnings that methadone is riskier and more dangerous — a drug of last resort — because it’s unpredictable and poses a heightened risk of accidental death.

“It’s a dangerous drug because it accumulates in the body and people die in their sleep,” Dr. Jane Ballantyne, a pain specialist at the University of Washington, said Friday. “It’s very tricky and difficult to use safely.”

Ballantyne and the university are helping spearhead a series of state-sponsored training programs to educate physicians, pharmacists and advanced nurse practitioners about the risks of pain drugs.

Earlier this week, while delivering a continuing medical education course for dozens of physicians and other medical professionals at the university, Ballantyne presented a slideshow in which she cautioned that methadone “should be considered a last option opioid, never a first line opioid.”

The state’s effort is a response to a Seattle Times series, “Methadone and the Politics of Pain.” The investigation, published in December, detailed that at least 2,173 people in Washington have died from accidental overdoses of the drug since 2003.

The Times found that year after year, a committee of state-appointed medical experts sanctioned methadone, empowering the state to designate it a “preferred drug” and steer people with state-subsidized health care — most notably, Medicaid patients — to the drug in order to save money.

The state has included only two drugs, methadone and morphine, on its preferred list of long-acting pain drugs.

During the committee’s meetings, officials from state agencies that have a financial stake in methadone’s selection consistently deflected concerns about the drug.

Methadone’s death toll has hit the hardest among low-income patients. Medicaid recipients account for about 8 percent of Washington’s adult population but 48 percent of methadone fatalities.

After the series, the state sent out an emergency public-health advisory that singled out the unique risks of methadone.

Medicaid officials faxed a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as about oxycodone, fentanyl and morphine. The state Department of Health mailed advisories to about 17,000 licensed health-care professionals.

The health advisory confirmed that Washington ranks among states with the highest rates of opioid-related deaths, exceeding the number of deaths each year involving motor vehicles.

Most painkillers, such as oxycodone, dissipate from the body within hours. Methadone can linger for days, pool into a toxic reservoir and depress breathing. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.

Ballantyne noted that methadone is an indispensable drug and plays an important role in the treatment of many patients. However, due to the heightened risks, methadone should be prescribed only by those with extensive training and experience — and only after every other option has been exhausted.

Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, now readily agrees that methadone use carries unique risks and that it should not be the first choice if other drugs are equally suitable.

He said physicians are stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription drugs now that Washington’s new pain-management law has gone into full force beginning this month.

The groundbreaking law requires practitioners to follow new standards for treatment and record-keeping. It also requires prescribers to consult with state-certified pain experts when narcotic dosages reach higher thresholds.

While the law’s goal is to lower doses and, if possible, wean patients from narcotic pain drugs, doctors are finding the task more difficult than hoped, Thompson said.

For instance, methadone patients can suffer prolonged withdrawal symptoms, like nausea and depression. With most pain drugs, withdrawal subsides within a week. Methadone’s grip can last for months, even years, he said.

State officials will review methadone’s role on the state’s preferred drug list during a meeting next month.

“I think we’re going back and relearning how to treat pain,” Thompson said.

Pill Mill Prosecution and the Pain Relief Network

Wow. I just read an email about a story that I was vaguely aware of– about a doctor in Kansas and his wife, who were together linked to scores of overdose deaths. But that is just the beginning. The doctor was supported, during his trial, by Siobhan Reynolds, founder of a nonprofit advocacy group called ‘Pain Relief Network.’  She started the group back in 2003, when her ex-husband was suffering from severe pain from a congenital connective tissue disorder.Reynold's Billboard

He (the ex-husband) found relief in combinations of high-dose opioids and benzodiazepines, at least until his doctor, Virginia pain specialist William Hurwitz, was convicted on 16 counts of drug trafficking.  The ex died, by the way, in 2006.  Are you still with me?

The trial of the Kansas doctor, Stephen Schneider, went on for years.  During the trial, Ms. Reynolds apparently helped support what she considered to be a ‘dream team’ of attorneys.  She used the case as an opportunity to increase her visibility, encouraging the Schneiders to aggressively fight the charges against them on the basis of ‘patient rights.’  Ms. Reynolds, through the Schneiders, argued that suffering patients are being denied appropriate care because of a war, waged by overly-aggressive prosecutors, against doctors who prescribe pain medication.

Ms. Reynolds even paid for a billboard adjacent to the road to the courthouse, so that jurors could see, en route, the statement “Dr. Schneider Never Killed Anyone.”  Some might see the billboard as ‘free speech’, but the judge presiding over the case was not amused.  At the eventual sentencing, the judge gave both Dr. Schneider and his wife over 30 years in prison, hoping that the sentences would “curtail or stop the activities of the Bozo the Clown outfit known as the Pain [Relief] Network, a ship of fools if there ever was one.”

We already have enough drama for a made for TV movie.  Actually there already is one, made by Ms. Reynolds, about her ex’s struggle over finding appropriate pain treatment.  The hour-long film is called ‘The Chilling Effect,’ and can be found here– along with a number of vignettes about the efforts of the Pain Relief Network.

Make that the former Pain Relief Network.  Ms. Reynolds was investigated by a Grand Jury, led by the same prosecutor who led the efforts against Dr. Schneider.  After years of what she considered to be ‘vindictive efforts,’ she closed down Pain Relief Network, saying that the organization’s finances ‘were in shambles.’

Within weeks of closing PRN, Ms. Reynolds lost her life in a plane crash.  Piloting the plane, and also killed, was Kevin Byers– Ms. Reynold’s romantic partner and also– get this attorney for the wife of Dr. Schneider.

Our story ends in typical, made for TV fashion, with all of the loose ends tied up.  The Pain Relief Network is gone, tragically missed by some, and considered ‘good riddance’ by others.  Ms. Reynolds, tireless advocate or misguided fanatic, has left this world for the next.  Left behind are the story-tellers;  I will provide links to both sides, so that readers can have a true, balanced perspective.  From the PRN side, simply go to their former web site, and you will find links to the archives.  The archives contain links to stories in a number of publications, including Slate and the NYT– places where David and Goliath stories are repeated without much challenge, particularly for the Davids.

On the other side is a woman named Marianne Skolek, writer for the Salem News online site, who has little positive to say about Ms. Reynolds and PRN.  For years she has chronicled the epidemic of deaths from Oxycontin, and she has also written a number of articles about the Schneiders, Reynolds, and PRN.  One of the most chilling points in a story by M. Skolek is a a list of the patients who saw Dr. Schneider and who died shortly afterward.  The pattern is clear; people in sudden possession of large numbers of pain pills, who took amounts sufficient to end their lives:

Name

Age

On or about 1st Office Visit

On or about Last Office Visit

On or about Date of Death

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

 

The story is not quite over.  The Schneiders are now appealing their convictions, claiming insufficient counsel– namely that the romantic involvement of one of their attorneys with Ms. Reynolds created a conflict that led to poor counsel.  In other words, they may have asked for mercy, had Ms. Reynolds not been cheering them and their attorney to place everything on the line.

As I’ve written many times, the use of opioids for chronic pain is a complicated issue, with no clear ‘good’ or ‘bad’ side. As in most of life’s challenges, the extremes of each position appear…. extreme.  Ms. Reynolds believed that the Controlled Substances Act should be repealed;  I find it difficult to understand how any educated person would adopt such an approach.  But the extreme opposite side leads to enough fear, in physicians, to stifle the use of narcotic pain relievers in people who truly need such relief.  As for me, I keep trying to straddle the wide middle.

Weezer Ex-Bassist Dies, Suspected Overdose

Written by Daniel Gordon at ThirdAge.com:

Former Weezer bassist Mikey Welsh was found dead in a Chicago hotel room Saturday afternoon, the Chicago Tribune reports.

Raffaello Hotel staff reportedly found the 40-year-old ex-musician on the floor of his room around 1 p.m. Saturday. The Chicago Tribune reported that narcotics are the suspected cause of death.

Chicago Police News Affairs Officer Laura Kubiak told reporters that police are currently conducting a death investigation. An autopsy was scheduled for Sunday, according to the Tribune.

Weezer Former Bassist Mikey Welsh

Weezer Former Bassist Mikey Welsh

Welsh performed with Weezer from 1998-2001. According to Weezer’s Website, he left the band after having a nervous breakdown and reinvented himself as a painter.

In 2002, shortly after leaving Weezer, he told the MetroWest Daily News that he felt the need to move on from music, adding that he was much happier as a painter.

“Music is still an important part of my life, but I really have no desire to actually play it,” he told the Daily News.

A tribute to Welsh on the band’s Website says, “It saddens me and the guys in Weezer so much to say that our beautiful, creative, hilarious and sweet friend Mikey Welsh has passed away at the very young age of 40. A unique talent, a deeply loving friend and father, and a great artist is gone, but we will never forget him. His chapter in the Weezer story (’98 – ’01)
was vital, essential, wild, and amazing.”

Current Weezer bassist Scott Shriner posted a note on his Twitter account saying, “Really bummed about Mikey. My heart goes out to his family and friends. Such a talent… he made a special mark on the world with his art.”

Weezer is playing at the Chicago Riot Fest Sunday, a show Welsh was expected to attend.

The post on Weezer’s site ends by saying, “Mikey was planning on attending this show and we were looking forward to seeing him again. As sad as it is to think about, we know Mikey would never want the rock stopped on his account – quite the contrary in fact. While we wont see him, we know he will be there rocking out with us!”

Long-term opioid analgesia without tolerance, respiratory depression, or euphoria

I have been kicking these observations around for the past year, and have been unable to find a big fish willing to ‘bite’.  I truly believe that the observations below have the potential to dramatically change the approach to opioid treatment of chronic pain.  Since I have a blog, I have a soapbox– so I’ll share the idea, and welcome comments in return.  I do ask that proper attribution be provided if this article is shared.

Introduction:

Long-term opioid analgesia without tolerance, respiratory depression, or euphoria?  Introducing the Holy Grail for chronic pain treatment!

Premise:

The miracle of opioid pain relief is fatally limited by tolerance, addiction and respiratory depression.  Buprenorphine, when combined with a mu agonist, results in game-changing effects.  Patients experience potent, dose-related analgesia from the agonist, but have NO euphoria.  The therapeutic window is widened.  Patients unable to control their use of a mu agonist alone gain that control when on buprenorphine. And most exciting, buprenorphine indefinitely anchors tolerance, maintaining analgesia WITHOUT DOSE ESCALATION. This finding offers huge implications for pain management.

Discussion:

Use of opioids for chronic pain has severe limitations.  Tolerance removes the benefits of opioid analgesics over time.  Worse, tolerance is associated with dependence and withdrawal.  Many patients use additional doses of their prescription early in the month, then suffer through withdrawal while awaiting refills.  Others find opioids through less-reliable, non-clinical sources.

At the same time, addiction to mu opioids is a nationwide epidemic.  Reformulation Oxycontin has pushed many opioid users toward diacetylmorphine—brand name Heroin.  Some physicians recommend avoiding mu opioids altogether for chronic pain (e.g. Physicians for Responsible Opioid Prescribing), while pain treatment advocates argue to ease narcotic restrictions.

Over the past six years I have treated over 500 patients using buprenorphine, mostly for opioid dependence.  Buprenorphine, a partial mu agonist, is the active ingredient in Suboxone, a medication used for treating opioid dependence. The majority of my patients began their addictions with narcotics prescribed by doctors for back pain, knee pain, shoulder pain, fibromyalgia, chronic headaches, and other conditions.

Many of my patients found their pain reduced or gone after stopping mu agonists and substituting buprenorphine.  Buprenorphine has the mu activity of 40 mg of daily methadone, but this activity is unlikely responsible for significant analgesia, since patients rapidly become tolerant to the agonist actions of buprenorphine. Instead, their pain while on mu agonists was likely maintained by psychological forces.

Patients on buprenorphine occasionally need opioid analgesia, just like other patients.  My patients have had knees replaced, gallbladders removed, hysterectomies and c-sections, rotator cuff repairs, and in two cases, cardiac surgery.  In all cases, sufficient analgesia was provided by maintaining daily buprenorphine at 4-8 mg per day, and using potent mu agonists, usually oxycodone, in doses ranging from 15-45 mg every 4-6 hours as needed.

Several patients have severe chronic pain from avulsion of the brachial plexus, failed spinal fusion, or other conditions, where prior opioid use resulted in rapid tolerance that prevented effective analgesia. These patients are now successfully maintained on combinations of buprenorphine plus mu agonists.

The combination of buprenorphine plus mu agonists has provided perioperative analgesia for patients on buprenorphine.  Patients universally describe adequate pain relief, even after major surgeries.  They also described the absence of euphoria, and to their surprise, the ability to control their use of pain medication—something impossible before taking buprenorphine.

But it is the effects on chronic pain that suggest a ‘game-changer’ for pain treatment.  Even after over a year on combination buprenorphine/oxycodone, my patients 1. have no euphoria;  2. are often able to manage their own narcotic medication; and most important, 3. describe stable analgesia WITHOUT agonist dose escalation.

The ability to treat pain long-term without tolerance or dose-escalation is as exciting a development as was the initial discovery of opioids for pain relief!

Properties of a combination agent

Buprenorphine is administered sublingually, and could be prescribed as a separate medication, and use verified through urine monitoring.   But greater safety benefits would come through regulations requiring buprenorphine (or a similar partial agonist) to be an inseparable part of every opioid prescription.  Such a policy would dramatically lower the addictiveness and reduce the respiratory depression of mu agonists WITHOUT removing efficacy.  The most obvious formulation would be a transdermal system that delivers buprenorphine and fentanyl, since both are already available in separate transdermal systems.

There may be situations, for example hospice care, where euphoria would be a desirable part of opioid treatment.  But for other cases, analgesia without euphoria has obvious benefits.

I have written to several pharmaceutical companies with this idea, and have heard back that while the idea is interesting and scientifically sound, the generic nature of the component medications reduce the potential for profit that would motivate development.  But given the potential value of this approach for multiple problems– addiction and chronic pain among them—I have to think that there is money to be made—not to mention the advances in treatment that the approach offers.

Reference:

Some supporting background information can be found in:  Alford, D., P Compton, and J Samet, Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy.  Ann Intern Med. 2006 January 17; 144(2): 127–134.

I also discuss this approach to pain treatment in my ‘Users Guide to Suboxone’, sold on Amazon and at bupeguide.com

Jeffrey T Junig MD PhD

Please do not reproduce without attribution.