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Coroner letters changed habits of doctors whose patients died of overdoses

latimes.com

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Re: Coroner letters changed habits of doctors whose patients died of overdoses

#51

Post by justinjlynn »

DanBC wrote: post #47
cm2012 wrote: post #25

Earlier quoted context omitted.

There's almost no chance of you developing an opiate addiction from a prescribed dose if you don't already have a history of addiction: https://www.google.com/amp/s/fivethirtyeight.com/features/wh... This is a false narrative that needs to go away.

You're pushing a narrative created by opioid manufacturers: "These meds aren't addictive if used to treat pain". That's only true (if it is true) if they're used short term. People in this thread aren't talking about acute pain, they're talking about chronic (long term) pain. It's likely that opioids are addictive if used long term to treat long term pain. Here's what actual doctors say: https://www.rcoa.ac.uk/facult…

Physiological dependence is a treatment complication to be managed. Corticosteroids, hormones, and other nonpsychoactive medications feature this issue too. It is part of the risk/benefit calculation.

What's important is the psychological addiction. You can taper off of a medication on which you are physiologically dependent. However, if it makes you psychologically dependent, you can never forget the high.

Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew?

It's when people take more than they need to to address their physical pain, that they experience psychological addiction, that they chase the high, that a problem develops.

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#52

Post by DanBC »

ewjordan wrote: post #37

Opiods have been around forever; pardon my ignorance, but what is different now that makes so many more people get hooked on them? Presumably people felt the same levels of pain in the past as they do now, given the same maladies. Is the situation: A) More surgeries with extremely painful and long recovery periods are happening, where these meds are truly necessary B) Doctors are prescribing opiods more freely for lo…

Opioid sales quadrupled between 1999 and 2014.

> but what is different now that makes so many more people get hooked on them?

The US VA noticed that pain was not being adequately treated. They created a campaign to make every HCP ask patients about pain. They looked at the science of the time which seemed to be saying that opioids were not addictive if you use them to treat pain. (they're less addictive if used short term for short term pain (post surgery, for example) but more addictive if used long term.) Drug companies put out new formulations that they claimed were less addictive - turns out they were more addictive. US doctors prescribe huge amounts of opioids.

The tragedy is that pain is still left untreated. The VA campaign meant people got opioids (cheap, but not particularly effective for long term pain) but didn't get access to pain management clinics.

https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/

> Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.

https://www.cdc.gov/drugoverdose/data/prescribing.html

> Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014,1 but there has not been an overall change in the amount of pain Americans report.2,3 During this time period, prescription opioid overdose deaths increased similarly.

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#53

Post by DanBC »

justinjlynn wrote: post #50
DanBC wrote: post #44

Earlier quoted context omitted.

People think that opioids are an effective treatment for long term pain. They aren't. They don't work to treat the pain and the patient develops a tolerance and so ends up taking large quantities putting their health at risk. > Patients are seeing their medication reduced without tapering, they are given no other option than to "suck it up," These are both bad, but these are both symptoms of the sometimes terrible he…

> They don't work to treat the pain and the patient develops a tolerance and so ends up taking large quantities putting their health at risk. As you've already asserted in your other comments here and I've asked elsewhere, could you expand on this assertion?

https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...

> 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.

> 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation)

> 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit.

> 4. If a patient is using opioids but is still in pain, the opioids are not effective and should be discontinued, even if no other treatment is available.

> 5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detail assessment of the many emotional influences on their pain is essential.

https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...

> The experience of pain is complex and influenced by the degree of tissue injury, current mood, previous experience of pain and understanding of the cause and significance of pain. Previous unpleasant thoughts, emotions and experiences can also contribute to the current perception of pain and, if unresolved, can act as a barrier to treatment. The assessment of chronic pain needs to be wide-ranging and comprehensive. The persistence of symptoms is particularly relevant in relation to prescribing where patients may be exposed to cumulative harms of drugs over prolonged periods. If a patient continues to have pain despite taking a number of medications, drugs should be sequentially tapered or stopped to establish continued utility. Similarly, if a patient reports reasonable pain relief from a medication regimen in the longer term, it is also necessary to taper medications intermittently to assess whether the symptoms have resolved spontaneously or whether the patient is relatively pain free because of continued efficacy of medication.

https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...

> Medicines are generally less effective for persistent pain than for other types of pain. When medicines are prescribed they should be used in combination with other treatment approaches to support improved physical, psychological and social functioning.

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#54

Post by Broken_Hippo »

cm2012 wrote: post #24
justinjlynn wrote: post #22

It had a direct impact on several doctor's prescription habits. This is a good thing. Now, did it do so while ensuring doctors maintained the same pain management outcomes for their patients? I am dubious and concerned this doesn't appear to have been addressed in their studies.

I'm hoping the doctors just got better at finding out which patients were going to multiple doctors for opiates at the same time, since that was the case for almost all of the deceased. The average decrease was only 10% less new subscriptiona. But I wish they studied that also.

I think this could be partially solved by changing the pharmacy systems and moving them to robust electronic systems.

In the US, when I'd get an electronic prescription, I'd have to specify which branch of which pharmacy I was picking it up on. They don't allow electronic prescriptions for opiods, however. (I worked at a pharmacy). Other pharmacies, even in the same chain, could not see my prescriptions without the pharmacy transferring it over to the other physical location. If the pharmacist or doctor suspects something, they basically have to keep the patient waiting to investigate - and if they deny, hope they are getting something wrong instead of someone just getting bad luck.

I now live in Norway. The doctor just does the electronic prescription. I can go to any pharmacy in any location to pick it up. Including the things that aren't allowed to be electronic in the US. This makes such things much easier to be noticed - doctors and pharmacists can get access to this information when filling a prescription.

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#55

Post by [deleted] »

cm2012 wrote: post #25
kelnos wrote: post #23

Earlier quoted context omitted.

As a potential patient, I'm pretty sure I'd prefer to endure a little extra pain if the alternative is an increased likelihood of painkiller addiction that could lead to death.

There's almost no chance of you developing an opiate addiction from a prescribed dose if you don't already have a history of addiction: https://www.google.com/amp/s/fivethirtyeight.com/features/wh... This is a false narrative that needs to go away.

[deleted]

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#56

Post by mmt »

justinjlynn wrote: post #50
DanBC wrote: post #44

Earlier quoted context omitted.

People think that opioids are an effective treatment for long term pain. They aren't. They don't work to treat the pain and the patient develops a tolerance and so ends up taking large quantities putting their health at risk. > Patients are seeing their medication reduced without tapering, they are given no other option than to "suck it up," These are both bad, but these are both symptoms of the sometimes terrible he…

> They don't work to treat the pain and the patient develops a tolerance and so ends up taking large quantities putting their health at risk. As you've already asserted in your other comments here and I've asked elsewhere, could you expand on this assertion?

I'm pretty sure this is generally accepted to be true in the medical/scientific community (and I suspect isn't new, considering how long opium and its derivatives have been in use). Using "opioid long term pain" or "opioid chronic pain" as search terms for Google or Google Scholar should bring up plenty of reviews and meta-studies that elaborate on this concept.

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#57

Post by justinjlynn »

DanBC wrote: post #53
justinjlynn wrote: post #50

Earlier quoted context omitted.

> They don't work to treat the pain and the patient develops a tolerance and so ends up taking large quantities putting their health at risk. As you've already asserted in your other comments here and I've asked elsewhere, could you expand on this assertion?

https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar... > 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain. > 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify…

Well, that's a far more nuanced argument than yours. Frankly, you'd be better off quoting that than making veridical statements such as 'does not' when your own evidence indicates it 'sometimes' does. Certainly opioids are not a front line treatment, and never were, but I would avoid going around saying they 'do not work' when clearly sometimes they do and it's a highly contextual decision. You may want to say instead that there is little evidence supporting their widespread use in long term pain management as a primary strategy. That would be supported by what you've posted and I'd take no issue with that statement.

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#58

Post by ehnto »

I have a condition that meant that until my late teens, I was in incredible pain daily. My parents asked about painkillers, but my doctor at the time strongly cautioned against them, citing dependence and eventual ineffectiveness. His decision and my parents bravery to listen, when all signs pointed toward the need for relief, is likely why I am a fully functional adult today. That was an insight he had over two decades ago, which is why I find the opioid crisis so damning toward the prescribers.

Re: Coroner letters changed habits of doctors whose patients died of overdoses

#60

Post by jazoom »

justinjlynn wrote: post #49
DanBC wrote: post #46

Earlier quoted context omitted.

> Now, did it do so while ensuring doctors maintained the same pain management outcomes for their patients? Opioids are not effective at treating long term pain, so these doctors were probably maintaining the same pain management outcomes for most patients and avoiding addiction on top.

> Opioids are not effective at treating long term pain OK, so, please expand on this asssertion. Also, what does then?

Not GP but I can expand. Over long periods of use the body develops tolerance to opioids and to get the same level of relief the dose must be increased. This seems to go on forever. Last year I had a patient on 10x what would probably be lethal for me (about 200 times a basic starting dose) and they didn't affect him much at all. He had been on the opiate train for about 30 years.
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