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Tag Archives: pain
If you’re a prescriber or pharmacist, you owe it to yourself to check out the Atlantic Mentorship Network’s Prescribing Course – Safe Opioid Prescribing for Chronic Non-Cancer Pain. I had the pleasure of attending this course this weekend in Halifax, Nova Scotia. Although I had been trying to get to this amazing course for quite some time, my schedule finally permitted me to get there this year. In fact it was such an incredible learning experience I felt I should share it with you. As a disclaimer: I am a pharmacist, I have presented for the Mentorship program before, I have no financial interest in the program although I am involved with the planning of the program’s Fall Conference in Inverness Cape Breton this year. Other than that I’m just a fan of the Network.
Chaired by Dr. Peter MacDougall and Dr. John Fraser, this day-long event goes through pearls on what best practices are to deal with the average person with pain. This is not end of life pain or cancer pain, where boundaries are much wider. It is the tough world of dealing with pain at a time that threatens the potential of addiction more than we were aware of at any other time. It threatens safety of prescriber, patient, and the public. Even Dr. MacDougall claimed what many of us were told years back when dealing with narcotics: that we used to think that as long as there was still pain, the chance of addiction was extremely rare. The Nova Scotia College of Physicians and Surgeons are quite active now in reducing the narcotic load in our patients, as are the other provinces in Canada as the wave of overdoses washes eastward. They have adopted the CDC guidelines for treating this type of pain, which includes more of an emphasis on non-narcotic and non-drug.
As someone who feels the burn of the “online” world of alternative treatments and skeptics’ treatment of them, believe me it was refreshing to be in an entire room full of 40 legitimate practitioners embrace whatever works for their patients. I have commented on this phenomenon before and it was evident here again. Terms like physiotherapy, chiropractic, massage, TENS, acupuncture, qigong, yoga and other terms used side by side are embraced by physicians as treatments that have clinical results that they may or may not have success with. I have been working as a pharmacist for almost 24 years and the most important clinical pearls I picked up were:
-If someone claims to be travelling away and needs their Narcotics early ask them when, how are they getting there and where are they staying. This allows you to call contacts (landline) while the patient is sitting in front of you in the office and gives an opportunity to ask (demand) to see plane/bus/train tickets.
– There are many Addiction Risk Assessment tools that really don’t have any evidence to back them up but they can be clinically effective tools in seeing who might be at the highest risk for addiction in the future and who may require special attention going forward with their therapy.
– Although many patients in our patient records claim to be allergic to morphine, this “allergy” may actually be a normal pruritis side effect from the morphine and not an allergy at all.
-An increased request for more narcotic dosing may occur after a previous increase in dose for many reasons. It may be from hyperalgesia from the narcotic causing more pain. It may be from the increased activity that the pain relief allowed – which causes more pain. The concepts of pseudoaddiction, tolerance, pseudotolerance, opioid withdrawal, failed opioid trial and chemical coping are all important factors to consider.
-One way to realize if an aberrant behavior more serious or less serious is to ask yourself, “I would never think to do that” or “I wouldn’t even know how to do that”. If the answer is “yes”, then it is most likely a more serious behavior.
– Safety of the prescriber is paramount
– UDT or Urine drug testing (preferably onsite) and a patient contract should be a standard practice for your opioid patients. It should be kept in mind that not only is UDT an important piece to the overall puzzle, its limitations should be kept in mind.
– “It is the information and not the story” that should be considered with abberant behavior. Why you ran out early is less important than the fact that you ran out early.
– Evidence on opioid rotation is primarily anecdotal but it can be an important method to reduce narcotic load after a failed opioid trial.
– As much as the goal of no narcotics beyond 3 months for this pain is ideal, we will always see these medications given. The goal of “no pain” is not a concept we entertain, and function should always come before pain relief. PRN doses of narcotics on top of long acting narcotics only focuses on the pain relief and not the function. Long acting narcotics are perfectly ok for initiation of narcotics rather than the tried and tested method of “start with short acting meds then convert to long acting”. Patients will not feel the same on these two types of meds and it might be counter productive to have the patient switch to long acting and not feel as well as the short acting med made them feel.
– Determining the goals of the patient and the expectations of treatment are important.
If you can’t make it to this annual event (now in its 18th presentation), you should get to a similar program in your area. This one gets definite kudos from me. Well done!
Graham MacKenzie Ph.C.
When I graduated from Pharmacy school in 1993, topically applied preparations for pain relief were limited to lidocaine and capsaicin, or so I was told up to that point. I was also taught that narcotics were safe not only for short term pain relief but also for long term pain that was non palliative and non cancer related and that addiction was rare in cases where total pain relief had not been reached yet. Medication is a constantly evolving and changing world. 23 years has passed and all of this has changed in a drastic manner.
It’s difficult to know exactly how it all started, but many in the medical community like to lay blame on the shoulders of a company called Purdue that had its beginnings in New York City as a relatively small pharmaceutical firm in the early 1950’s when it was purchased by two psychiatrist brothers, Mortimer and Raymond Sackler. The success of OxyContin from this company generated billions of dollars in revenue and made the Sacklers one of the wealthiest families in the country. Unfortunately, we began to see a trend happening where claims of this company and the aggressive and inappropriate marketing practices resulted in the alarming abuse and trafficking of this medication over decades of use. The company had to pay 635 million dollars after executives plead guilty.
You’d think that would have been the end of it. However the Mundipharma associated foreign corporations are agressively marketing this same medication worldwide with no plans to scale back. They also are running training programs to physicians in these countries urging them to overcome “opiophobia” and to just go ahead and write for these painkillers. They also have campaigns urging patients to take what their doctors prescribe to them.
The issue now is we have created an entire continent of addicts who would not normally have been there without these recommendations. For example, Jane Doe gets in a car accident. She has undeniable pain from this and it is not handled with NSAIDS. She is given a narcotic based on the recommendations from companies like Purdue who claim their studies show this is a safe medication to prescribe in this patient. In a little while Jane needs a higher dose of the medication and after not too long, despite her repeated denials, is addicted to painkillers. She then is unable to get a continuous supply of the drug from her doctor who now recognizes the problem. She starts to purchase the medication off the street. Her addiction becomes stronger as her supply and quality of the medication becomes more and more questionable. She then finds herself injecting to keep up with her addiction. In the last number of years, she has lost her job, her husband, her children, her home, car, money, friends, and everything she owns is in a small bag that she uses as a pillow because she lives on the streets with a sole purpose of seeking her next supply of fentanyl.
Is this scenario typical of everyone on narcotics? Of course not. If you walked down Vancouver’s downtown Eastside and asked random passersby what their story is, you might hear this one. Canada has recognized this in a west – east manner this year. Canada’s largest mental-health/addictions hospital, the Centre for Addiction and Mental Health in Toronto called on Ottawa in November to remove these high dose opioids from the market and to launch a review of prescription painkillers across Canada.
In fact, in the last 4 years, the number of opioid prescriptions dispensed per 1000 population has decreased in the United States whereas in Canada the number has more or less remained the same over that time frame. The provinces in Canada have been steadily spending more and more each year on opioid addiction. Not surprisingly, BC has lead this spending. PEI and NB are 2nd and 3rd behind them surprisingly. NS is near the bottom of the list. Towards the end of the year, Nova Scotia’s chief medical officer, Dr. Robert Strang, made a statement where he wanted the provinces’ physicians to ween patients back from current prescribed levels of narcotics exceeding the 90 mg per day of morphine and to keep to max of 50 mg if possible. He also wants long-term fentanyl patients backed off this drug in an effort to fit in with upcoming guidelines. The Nova Scotia College of Physicians and Surgeons is endorsing the CDC guidelines for prescribing opioids.
Lately in the news on the west coast we had a story in the news of 13 overdose deaths in one day making emergency kits a necessity. Nova Scotia Pharmacists are now able to dispense rescue kits of naloxone for overdose and these kits are becoming more available as the awareness of the antidote and education spreads.
The CDC promotes the prescreening of patients to avoid addiction. Overdose concerns are more prevalent with those over 65 years of age, history of overdose, substance abuse disorder (including alcohol), history of depression, renal or hepatic impairment and sleep-disordered breathing. Any patient may be considered at risk for overdose if they combine opioids with benzodiazepines, on a longterm formulation or especially just starting this medication, on an opioid for longer than 3 months, or on more than 100 morphine mg equivalents. Addiction is more prevalent with this level of morphine equivalents as well as being on the opioid longer than 3 months.
Nova Scotia’s Dr. Mary Lynch has gone on the record as not being in favour with these strict guidelines and claims that there are many of her patients where there simply is no alternative drug for them. Many physicians are unclear as to what they are supposed to use to control the pain of their patients.
Unfortunately later this year we heard of a list of Doctors flagged by Ontario’s Ministry of health because they were prescribing the equivalent opioid dose of 150 Tylenol 3’s daily for some patients. 86 physicians were the target of this probe.
The recommendations include such non pharmacologic modalities as cognitive-behavioral therapy, exercise therapy, complimentary medicine (like yoga, meditation and acupuncture). Nonopioid analgesics recommended include acetaminophen, NSAIDS, Cox-2 inhibitors, anticonvulsants like gabapentin or pregabalin, and antidepressants like tricyclics and serotonin and norepinephrine reuptake inhibitors. Other therapies involve epidural injection and biofeedback.
With such a sense of urgency and recommendations of treatments not normally seen by physicians in general medicine, one would expect that physicians would be open to topical pain relief. In speaking to physicians I have found a friendly acceptance but a definite hesitance in writing for these compounds. These compounds are new to them and contain such familiar oral ingredients as ketamine, ketoprofen, clonidine, gabapentin, and lidocaine. They may also use lorazepam, carbamazepine, baclofen, cyclobenzaprine, dextromethorphan, and others. A recent article written by myself and a local palliative care doctor covers these ingredients. Check it out here.
This is a tremendous opportunity to reduce opioid use and improve pain relief. As I have seen from physicians that have tried this and seen it working in their patients, confidence comes with numbers and experience. The lack of side effects, interactions and lowered dose is something they like. Contact a compounding pharmacy and ask them more.
I had a conversation with our local palliative care and pain clinic doctor the other day. As a disclaimer, this physician is open to treating patients with the safety of the patient first in mind and he also has what I refer to as an “open mind” when it comes to doing whatever we can to alleviate pain and suffering. A lot of the time it involves using medications and therapies that most physicians would prescribe. It also involves therapies that are safe and effective but are shunned by other physicians either because of lack of knowledge or experience with them or because they claim it is an off label use or one that lacks either a firm recommendation from a governing body or has not been recommended at a recent conference they attended.
Off label prescription writing is certainly not a stranger to my daily dispensing of drugs. Some reviews put this practice as high as 10% of prescriptions written in Canada. A May 2012 MacLean’s article discusses this as a major issue and a huge gamble for the physicians writing these prescriptions. As a pharmacists, I can assure you that this practice is the norm and for the most part doesn’t land people in the hospital any more often than officially approved writing of any other prescription medication such as NSAIDS, narcotics, blood pressure or heart meds, or antibiotics, to name a few. There are hundreds of examples of off label uses of drugs now being written for. A few common ones listed by the Lexicomp Facts and Comparisons Off Label are:
ASA for high risk coronary artery disease
Clonidine for hot flashes
Erythromycin for acne vulgaris
Folic acid for neural tube defects
Gabapentin for diabetic neuropathy
Nifedipine topical for anal fissures
Trazodone for insomnia in the elderly
Amitriptyline (oral or topical) for neuropathic pain
Childhood and adolescent uses of many medications
Note the use of the amitriptyline topically. Topical compounds are notoriously listed here although there are studies showing they work for various types of pain when used correctly at the right strength. Granted many of these studies are small but many are well designed and like I always say, nothing beats the experience of the first patient a physician tries and sees the topical preparation working and the lack of side effects compared to oral medications is an added bonus.
Most consider topical pain therapy to be limited to capsaicin, lidocaine and camphor menthol combinations. There is an entire universe out there of other ingredients used in these preparations. And for those who like a few references here you go.
Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004;63(6):959-965.[PubMed 15452284]
Ho KY, Huh BK, White WD, Yeh CC, Miller EJ. Topical amitriptyline versus lidocaine in the treatment of neuropathic pain. Clin J Pain. 2008;24(1):51-55.[PubMed 18180637]
Lynch ME, Clark AJ, Sawynok J, Sullivan MJ. Topical 2% amitriptyline and 1% ketamine in neuropathic pain syndromes: a randomized, double-blind, placebo-controlled trial. Anesthesiology. 2005;103(1):140-146.[PubMed 15983466]
Lockhart E. Topical combination of amitriptyline and ketamine for post herpetic neuralgia. Poster presented at: American Pain Society Annual Meeting; May 6-9, 2004; Vancouver, BC. http://www.ampainsoc.org/db2/abstract/view?poster_id=2185#893. Accessed November 4, 2008.
Now a common complaint is that I supply studies that cherry pick what I am trying to prove, although I assume that whomever is asking has plenty of studies to favour something against my side. The point is, when you know something works, and it’s safe, you tend to care more about potential patients and less about converting non believers. Topical pain relief is just one of those “alternative” therapies. Many would consider off label use to be alternative therapy by definition. If alternative therapy is something that wanders past a monograph or official indication, then many practice alternative medicine. If that therapy is “recommended” by a medical group then for most it becomes accepted therapy and therefore not alternative. Although this may make them more comfortable with prescribing choices, alternative therapy’s definition is one that changes based on the one defining it.
With the recent talk of p-values and their value in scientific journals it brings to light an important interpretive tool in efficacy of therapies, clinical experience. P value is the chance of getting a positive response in a scientific study when there is no real effect after all, also known as a false positive. The smaller this number, the better the certainty that what you are observing is truly an effect of what you are studying. This number often is given as p .05 meaning that only 5% of the time would you see this happen by chance, the rest of the time it is a true effect of what you are studying. Put another way, you can say that you are rejecting the “no effect” assumption, and come to the conclusion that drug A has effect B on the body and claim that your results are statistically significant.
This has been the backbone of science forever to determine if what you are seeing is not a fluke. On closer examination though this value may not be as strong as we first thought. Don’t get me wrong, it is an awesome way to reduce bias in a study and the best we have to weed this out as long as we don’t play around with this p value after our calculations are done. What if we applied this 5% theory to a supplement that was being tested for a certain condition. If we wanted to try 100 supplements for a given condition and only one of these supplements actually did something to improve the condition, we would find 5 supplements that appeared to help (false positives) and one extra that actually did, the one effective supplement in the bunch. Of the six supplements you came away with thinking worked for the condition, really only one worked. This means that out of those six conclusions that claim to help the problem, only 1 in truth really does. You are incorrect 83% of the time in your determination of effective products even though you successfully eliminated 94 ineffective products! Imagine, a randomized, placebo controlled trial with a p value of 0.05 with this kind of result.
Retractions of published papers also appear to be on the rise and after being involved myself this past year in a scientific study, there really is a lot of pressure felt by the authors to get published in a scientific journal. It’s almost like a final approval by the cool kids in class and seems to psychologically give a stamp of approval on your work not only to the authors that did the study, but by the public and scientific community that will read or hear about the study. If you aren’t published, there is almost a sense of failure felt towards the whole project, regardless of how astounding the results are.
This brings us to the world of the front line where these products are actually handed out to the public, the Pharmacy. Many times I see products written on prescription that work exactly the way they are supposed to but sometimes they fail miserably. Regardless of how many studies were done on a drug, if a patient paid $100 for it and it didn’t work, they really don’t care how many studies were done or what the p value was; they are out $100 and they now need to fork over more money for another product. This doesn’t mean the studies that brought this to market were bad, it’s just that they were some of the outliers in the results that didn’t respond to the drug.
When you deal with supplements you often are labeled and dare I say it with “alternative therapy”, you are always searching for these studies. They are often small studies but you still look for them. The same is true for pain compounding. It is not difficult to be labeled a quack or a charlatan when you try to help someone that doesn’t seem to fit into the regular modern medicine model or wants to try another way first. Nothing replaces clinical experience in determination of a product’s net worth and if studies are done correctly your results should mimic the studies you originally read. Keep in mind that this may mean a 70% success rate as determined by the studies. It is only when you see something work before your own eye(s) that makes you comfortable suggesting it more. Those products that showed promise in studies and it doesn’t pan out with your patients, these products fall away rather quickly. When you deal with people that are paying out of pocket for something, you know it is working when they come back for more to spend more money on. I have had physicians steer away from a product because of one or two bad experiences with it with their own patients. As always, patient safety is key with any product. Will this therapy harm this patient based on their existing meds, allergies or medical condition? Will it cause a dangerous delay in treatment with another more proven product? These are important questions to as when a patient looks for an alternative medication.
Clinical experience with pain compounding creams has completely change the thinking of a lot of physicians I deal with at the pharmacy level. Many of these doctors haven’t read even one of the studies I have on the response rate of this type of therapy but when they took a leap of faith with just one patient, then another and another, they realized the value of a therapy they were not taught in school. When I get in my car and turn the key, a lot goes on to start the car and keep it running. I haven’t read any studies on car engines but I do it because it seemed to work for others and it works for me for the most part as well.
False positives and subjective results can happen this way as well, but when a patient that was previously addicted to hydromorphone prefers a pain cream or an addition of omega-3 with their pain medication, it helps to alleviate thoughts that they are pretending the pain went away. As one palliative care physician said to me, “If the placebo effect is 30% on drug X, I’ll take that kind of response rate”. When there are doubts as to the effectiveness of a well-designed trial, clinical experience acts as an effective filter to refine one’s beliefs.
There are few medical issues that bring about a “must deal with” mentality than pain. Acute or chronic, it can have various causes: nerve pain, muscle pain, trauma, cancer, visceral, bone, various organ pain…it can be described as shooting, stabbing, dull, throbbing, aching, excruciating, and debilitating. Whatever the cause or description, when you have it you want it gone.
Most of us automatically think of a medication when we need something for pain. Certainly for a sudden onset acute type of pain that occurs infrequently, I recommend an NSAID or Acetaminophen to our patients who need some safe and quick relief for themselves to get on with their day or night. Most of the patients we see at Stone’s have no idea that nutrition (and diet) drastically influence pain management.
The standard American Diet drives people to a low omega3:omega6 ratio. The higher this ratio, the better outcome for just about any medical issue you can think of. Psychiatric, cardiovascular, dermatological, neurological and a myriad of other issues are helped or even cured it seems by increasing this omega-3 to our diet. The anti-inflammatory diet helps with this ratio.
Vitamin D. What a surprise. Vitamin D is good for something else. Shown time and time again to help with pain, vitamin D supplementation into target ranges is helpful to keep pain away. Overdoing it with the higher doses of vitamin D seem to very rarely cause adverse effects, but it helps to get your levels checked.
Magnesium. This quickly emerging star in the supplement world has shown several benefits, including pain relief from migraine, fibromyalgia, sciatica, muscle cramps, back pain, dysmenorrhea issues and more.
B vitamins are important for pain relief. Especially, a mixture of pyridoxine, B12 and thiamine have been used in patients with vertebral pain and nerve related pain with much success.
What else deserves mention, boswellia, curcumin, green tea, gamma linoleic acid, 5-hydroxytryptophan, zinc/copper, and bromelain have shown promise for antiinflammatory and pain relief.