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Tag Archives: narcotics
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.