The next instant narcotic

in Uncategorized | 7 responses

Following in the footsteps of the candy Fentanyl, comes Fentora: transmucosal fentanyl.

Comments

RJS
Actually candy Fentanyl/Actiq/OTFC is transmucosal fentanyl, so it’s not a new thing. What is new is that Fentora is absorbed by the buccal mucosa, whereas Actiq is not.
Buccal absorbtion has a onset of analgesia.
Just a minor nitpick :p
WilliamManginoMD
Dear RJS-and others:
You made the comment ‘Blame it on the doctors if they are using it …for purposes other than intended’
Are you serious?
First of all-this drug has NO PLACE in out patient pain management. It doesn’t offer any appreciable advantage over standard pill-type breakthrough medications.
Your comment about doctors using it other than intended beles the fact that the production and marketing of this buccal preparation is specifically designed to increase, not decrease, the incidence of misuse in a general population of patients who have a subset of people prone to misuse if not carefully monitored–so why introduce this type of preparation?
Clearly-your understanding of the nature of the dynamic in treating chronic pain patients leaves much to be desired if you even momentarily contemplate using this drug in any manner-when other less inviting drugs get the job done just as well.
The regulatory agencies will crucify the first doctor who prescribes this drug-as packaged- to a patient who fails to protect his or her medications – and allows it to fall into the hands of some unsuspecting teenager on the way to a weekend party; who subsequently overdoses.
You don’t need a whole lot of breakthrough medications if you prescribe long acting opioids the way they should be prescribed-through careful titration.
Trust me when I tell you-this medication presents more problems than solutions.
It should never be prescribed outside the OR or hospital. Neither should Actiq.
RJS
“Clearly-your understanding of the nature of the dynamic in treating chronic pain patients leaves much to be desired if you even momentarily contemplate using this drug in any manner-when other less inviting drugs get the job done just as well.”
Please elaborate on what you mean by “get the job done just as well” and why are these phantom meds preferable? (I’m genuinely curious because there’s no other analgesic out there with kinetics like Fentora.)
If baseline pain is being managed effectively, and a patient has a low risk for opioid abuse, there’s no reason Fentora should be avoided. Extremely rapid absorbtion and a pleasant taste (presumably) aren’t good reasons to avoid this med. Unless you have some other reasons that aren’t “what if” scenarios in mind?
“The regulatory agencies will crucify the first doctor who prescribes this drug-as packaged- to a patient who fails to protect his or her medications – and allows it to fall into the hands of some unsuspecting teenager on the way to a weekend party; who subsequently overdoses.”
That’s a fairly spurious reason to not use a drug. I suppose we should avoid fentanyl patches because a child might pick one out of the trash and stick it on?
“You don’t need a whole lot of breakthrough medications if you prescribe long acting opioids the way they should be prescribed-through careful titration.”
Oh I absolutely agree with you there. But I think that Fentora *does* have a place in a tightly-controlled regimen where baseline pain is mostly stable and a patient experiences very few episodes of breakthrough pain.
But I do think Fentora will be prescribed (often) for conditions that fall outside this criteria, which is too bad, really. And yes, the doctors are to blame for it, if this happens, not the drug company.
I would imagine that any pain specialist worth his/her title, however, will be familiar with the pros and cons of a drug like Fentora, and use it appropriately. I’d be more worried about people who aren’t intimately familiar with the physical and psychological aspects of pain management.
WilliamManginoMD
Dear RJS:
You and I might be able to discuss these issues rationally – but regulators cannot. Your questions are great – and I admit my own bias on this subject-remember that I am being prosecuted; so I’ve examined this issue in depth.
If you look at the studies done by David Joransson [ sp.] at The University of Wisconsin, he [ and others ] will readily admit that EVEN IN A LEGITIMATE PAIN PRACTICE WITH LEGITIMATE PAIN PATIENTS a good number of these people are prone to exhibit psychological traits consistent with pseudoaddictive behavior.
One can infer from this data that members of patient’s families may also have similar genetic propensity to act out manifestations of behavior akin to drug-seeking; even though these people have bona fide pain which deserves to be treated with opioids.
Add to this scenario the pain specialist’s absolute obligation to practice “Due diligence.”
This is often interpreted by courts as meaning that if you do not practice due diligence then you are “Willfully blind.”
If the child of one of THESE patients pilfers a drug from his parent – which subsequently results in a respiratory depression death – YOU WILL BE ACCUSED of not practicing “Due diligence.”
This means that your argument in your paragraph three will fall on very deaf ears-because YOU KNEW that there was a slight chance that this COULD HAVE ocurred; and YOU did not take EVERY conceivable precaution to prevent this third party tragedy from happening-by allowing yourself to be UNDULY impressed by fancy packaging of a product wich offers no advantage over OXY-IR, or NORCO 5mgs. Not as “Tasty” -but every bit as effective.
Even moreso-DOCTOR- [ as the prosecutor singles you out before the very disturbed jurors ] you failed to properly titrate the original medication [ OxyContin or MS-Contin ] to effect-thereby demonstrating that you have no “Real” knowledge about what you are doing-and should spend time in jail for your manslaughterous approach to practicing opioid prescribing.
Beginning to get the picture? I’m only trying to help-so don’t get upset.
Now, for your question about fentanyl patches-which HAVE been innocently and purposefully sucked upon and licked enough times in the history of our great republic to prompt me to say-NEVER USE THESE PATCHES FOR OUTPATIENTS. Once again-”Willful blindness.” In the hands of the innocent and uneducated these patches are killers-so why open yourself to criticism?
Do you watch football? Do you think you always have to outfox the opponent in order to get a first down? NO – you can just simply run at the defense with power and effectiveness.
We have the less exciting drugs OxyContin, Methadone, and MS-Contin.
We don’t need the fancy-tasty stuff. Trust me even if you hate me–don’t use that stuff-you’ll be in trouble enough if someone complicates from standard opioid therapy- why add to your risk and add risk to your patients?
Anonymous
Sorry bill,
I have little doubt you know more than I about chronic pain. But as an oncologist I have found fentanyl patches in certain patient’s necessary.
JThompson311@msn.com
Sorry guys, I am not a doctor like you but I am a pain patient who takes both Fentora for breakthrough pain and Methadone as a long acting drug. Dr. William, with the methadone, because of the long half life of the drug, it is impossible to find break through meds that have any appreciable pain relieving effect. Actiq/Fentora were life savers for me because I was able to recieve short, severe pain relief in between oral doses of ten milligram methadone, two tablets every six hours, 24 hour dosing. These two drugs are the first true rapid onset pain relievers for severe pain. (my onset is five minutes or less, lasting about 45 minutes) Why would you deny such an effective drug to people going through such excruciating pain? Thank God truly that my pain doctor does not share the same point of view. The one major flaw with the pain profession is that so very few physicians have ever truly had suicidal type pain. You lack the empathy and sympathy to go to whatever length to give truly effective relief. Now, you might say, “the incidence of addiction is just too high.” In my clinic, my physician uses a pain contract and serum and urine testing to control abusive patients. If a patient is truly in severe pain, that pain relief is too precious to jeopardize by self adjusting medication dosages. Also, if a patient is terminal, what difference does addiction make?
I do agree, however, that blaming a doctor for a patients actions is ridiculous. The patient-doctor relationship has an implicit contract that the patient will be active in their treatment, and will be as educated as possible about their treatment and illness. I have a hard time believing that any person in America does not know that narcotics are by their very nature, addictive. Any person that fills a pain medicine prescription is making a choice; they are weighing pain perception against the ills of opiates. That is a conscious choice for all patients. To blame a doctor for addiction to a medication, is, well, irresponsible and pathetic. In a free society, we have the choice to adhere to a doctors advice or to leave and ignore that advice. It is the patients choice, and with choice comes responsibility.
Anonymous
hi,
im a chronic pain patient.
interesting read,,
im taking 2 100mcg patches every 2 days and fentora 400mcg 3day. im just now at the point of some pain relief. its funny,the 100 and 50 patch left me in allot of pain. i really didnt think the jump to the 100 from 50 making 200 total would be a huge deal,but it was like night and day.
now im being titrated on fentora for breakthrough pain.,,or rather i should say,,i want to be titrated on fentora,,but the dr.s assistant,,she might be a doc,,i dont know. anyway,,she wanted to argue with me about addiction and overdosing and therefor we shouldnt go to the 400 and instead stay on the 200 4 a day. she went up to the 400s,, but what about next month?? and the next?? this fighting just to be NOT be in pain is getting old. i guess ill find out in a month.
when the dr sets a predetermined amount in their head,,titration stops.
so i insisted on being titrated up to an effective dose,,well she got real huffy and left the room to speak with the doc. came back and changed them to 400s 3 a d ay.
heres the thing, i read and read the pamphlet that comes with the fentora,,and according to it, im under dosed. because i can take the one,wait the 30 mins and take another,, and though i feel something,, the pain isnt touched at all, certainly nothing close to “fast acting”.
i thought it might have to do with the fact that im taking 200mcg an hour from the patches,,and that is why the fentora isnt “breaking through” my normal meds,therefor me needing a much higher dose than presently getting.
the thing is,,i hate the conflict in the office with the doc.
does a diabetic have to beg for titration?
what if the dr didnt prescribe enough insulin for them and something bad happened??
use that or ANY other medical condition. maybe you have an infection and your under prescribed and lose your leg? ,,this country wouldnt stand for it.
but with pain,, tough crap for you, ” i dont have to nor will i titrate your narcotic pain medication,ill give you enough to take care of your pain(same as i give everyone),and thats all im prescribing.if you “need” a higher dose,to bad,it aint coming from me.” so we take their shit and smile. cant change drs,wouldnt want to look like were dr. shopping,,would we?
WTF?
unfortunately the only way out i can see is to bring suit and have a handful of drs cough up a bunch of cash a few times,, then maybe we will get proper pain treatment.
it seems like malpractice to me when the doc dosent prescribe enough medicine to treat my condition. meanwhile i suffer and have no life at all. i could go on and on,,,
this began for me in 99,, and im still being titrated to get relief. the only time i ever was titrated,, was just last month with the upping of my patch. as far as breakthrough meds, the way it feels now ,,her dose of fentora,,should double or triple to begin titration.giving some relief.