Are opioids any less safe or effective in non cancer patients?

by Drew Rosielle, MD

Recently, the New York Times reported of the movement in Washington State to officially do something about prescription opioid abuse, coming on the heels of course of the FDA rejecting the current risk evaluation and mitigation strategy plan as, essentially, not going far enough.

The article basically discusses the discussion in Washington about what to do; no formal new plans have been officially proposed as far as I can tell from the article.

This is what they mention that is being discussed:

The regulations would not affect how narcotics are used to treat patients with cancer or those at the end of life because experts agree that such patients should receive as much pain medication as necessary.

The panel is expected to require that, among other things, doctors refer patients to a pain specialist for review when their daily medication increases to a specified dosage level and they do not show improvement. The specialist can then determine whether to continue the drug, reduce it or use other treatments like physical therapy.

This is an exemplary quote from the article:

“This is not just about addicts but little old ladies with arthritis starting to die because of this kind of medical practice,” said Dr. Alex Cahana, a pain specialist involved in devising the regulations in Washington State.

As a clinician, and really just a policy dabbler (I have my opinions; I acknowledge I haven’t done the homework to really support many of them), here are my responses to this.

This is part of an ongoing attempt to make moral/ethical and legal/policy distinctions between pain experienced by people with cancer and those without.  I am not convinced that many of my patients with severe peripheral vascular disease and rest pain, decubiti, or arthritis have less pain or are less deserving of opioid analgesics than patients with cancer.  And, indeed, cancer patients can misuse opioids, or can get addicted.

The discussion should be had in strictly therapeutic terms and the real question is are opioids any less safe or effective in non-cancer patients than in cancer patients?  What drives me nuts about this is that ‘non-cancer’ patients are such a heterogeneous group and extrapolating from studies of, say, fibromyalgia patients that opioids are ineffective for ‘non-cancer’ pain is ridiculous.  The quality and extent of the research about this is dismal.  There are very few well controlled trials that study patients for longer than a few months.  I worry, deeply, that the research is just not there to make any sort of sound decisions.

Where is the data suggesting that iatrogenic overdosing is a significant contributor to opioid related deaths?  That is, where are the bodies piling up of little old ladies dying because they took an opioid as prescribed by their doctor?  I want to be clear: I have no doubt this happens, but none of the data I’ve seen about the very real epidemic of prescription drug abuse suggests a major contributor is people taking their pills as prescribed.

Instead it’s via diversion, recreational use, and mixing with other substances (diverted benzodiazepines, booze, other opioids, etc.).  There’s no doubt that pain and opioid management is terrible out there — we all see the crazy stuff people are put on everyday — but that this is contributing to the epidemic of opioid related deaths in a major way I have yet to see any data to convince me.

Anecdotes about little old ladies dying are alarmist.  If the policy decision is one of “we’ve just got to reduce the volume of prescription opioids available to get them off the street by any means” and the way it’s decided to do that is by drastically restricting clinicians’ ability to prescribe them, then this makes sense, whether or not you think it’s the right thing to do.

I’d at least appreciate people saying that straight-up and not hiding behind the idea that these deaths are related to iatragenic overdosing.

Drew Rosielle is a palliative care physician who blogs at Pallimed.

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  • http://somebodyhealme.dianalee.net Diana Lee

    It makes me incredibly angry that there is so little discussion about under treatment of pain and so much fixation on abuse. Abuse has nothing to do with chronic pain patients and to be frank, as a chronic pain patient I could care less about abuse. People who want to overindulge will always find something to fuel their needs/wants. I read an article a few minutes ago from the World Congress on Pain estimating that 80 of pain patients across the world are under treated. I know I am one of them. I’m frustrated and tired of having to beg for help.

    Thank you for writing about this. Hopefully if we keep sending this message we can increase awareness.

  • ATC

    I wholeheartedly concur both with the article and with Ms. Lee’s post. As someone who has suffered chronic pain for more than 20 years, mostly undertreated, I can tell you that the corrosive, destructive effect it has had on my emotional and physical health is extensive. And it is completely avoidable. But the “just say no” simpletons of drug policy want to win brownie points for being “tough on drugs” and so pluck the low hanging fruit—prescription drugs. Easier to track and identify, a few quick headlines, and presto, you’ve made little old ladies and children safe from the demon narcotic. No attention is paid whatsoever to patients with genuine need for the pain relief these drugs afford.Too often mindless regulation deters physicians from prescribing strictly on the basis of a patient’s need—he must keep an eye both on what the FDA says is reasonable and often on what the health insurance nannies will pay for. I recently had to go nearly eight weeks without even the minimal pain relief afforded by the medication my physician prescribes because my insurance co refused to cover it. Their excuse was that because I had refilled the prescription more often than they deemed safe, that I was “engaging in classic drug seeking behavior” and likely to become addicted. This is in spite of the fact that the drug in question is not a narcotic and in spite of the fact that my MD spent literally hours on the phone and on paperwork to reverse their decision. And let’s not get started about sleep meds…When non-medical personnel unfamiliar with a patient’s needs and medical history have the power to dictate drug policy, the patient ALWAYS suffers. True addicts (who suffer from a real disease) will find a way to get what they need, and the unscrupulous who prey upon the needs of these sick people are very enterprising and determined and far better funded than either the FDA or the average patient. Guess who wins?

  • ErnieG

    What about little old ladies dying for GI bleeds from NSAIDS? Or “therapeutic misadventures” from acetaminophen? Or depression from undertreated pain?

    I agree the at the distinction made between cancer and non-cancer pain is artificial. I also agree that the problem with opioids is diversion. The question of addiction to pain killers is less relevant than the abuse and diversion of opioids. After all, isn’t a heart failure patient “addicted” to ACE-I, beta-blockers, loop diuretics, etc because without them he/she would not function or live? If a chronic pain patient needs a daily steady dose of opioids to function, and they are not abusing or diverting the opioids, what does it matter? In reality, the trick is identifying who will benefit and who will not (the latter being those who need escalating doses to chase pain, those in whom it triggers impulsive behavior, and those who abuse it for the high)

  • Dr. J

    This is a good article because it points out the difficulties in painting all patients with the same brush. I think it is helpful to try to group patients when we talk about narcotic use. Determining which group a patient is part of requires a skilled assessment. There is always a lot of angry posting in response to pain articles because people assume they are all being painted with the same brush.
    1) Patients with addiction: These patients are misusing narcotics for the purpose of euphoria. They can be offered addiction treatment +- structured opioid maintenance (methadone/bupenorpherine).
    2) Patients with behaviour that resembles addiction. These patients may have addiction or may have pseudo-addiction because of uncontrolled symptoms. They require a carefully monitored trial of rational pain therapy usually including opiates to see if symptoms improve or if underlying addiction is unmasked.
    3) Patients with chronic pain who achieve some improvement with opioid therapy. These patients have a painful condition and their quality of life and function is improved with these medicines. These patients should have intensive management to find an acceptable med regime and then should receive prescriptions of similar length to other chronic illnesses (like hypertension).
    4) Patients with chronic pain who do not benefit from therapy with opioids. These patients show no improvement in pain or function and are often on high doses of narcotics and experiencing side effects. These patients should be gradually tapered off of narcotics (often in hospital because they are often on astronomical doses), reassessed and possibly retried on an alternative narcotic with clear monitoring for functional and pain benefit. If they do not derive benefit from a second opiate, they likely have pain that is not responsive to opiates and they should be engaged in other forms of pain management (other meds, therapy, CBT etc.).

    Most patients are in group 3 and require management as a patient with a long term illness that will periodically improve and exacerbate. Most of these patients can easily be managed by a PCP.

    Patients in the other groups really require careful and intensive treatment and often a referral to a pain practice equipped for such intensity can be helpful and once the patient is stabilized they can be referred back to the PCP.

  • http://offwhitecoat.wordpress.com The Scrivener

    I’m confused. First you say that pain is pain, no matter the disease process. Then you say that “non-cancer patients” are too heterogenous a group to compare their pain to each other. Could you clarify, please?

    My understanding was that it’s not prescribing opioids to just cancer patients, but to terminally ill cancer patients. That’s a big difference. The logic is that while they may indeed become addicted, and the opioids may hasten their death by a few months, the benefit of NOT treating their pain is minimal. It’s the principle of double effect. Non-terminal diagnoses don’t fall into this category, and thus the use of opioids becomes less justifiable given the not-insigificant risk of addiction, respiratory depression, etc.

  • ErnieG

    Dr. J’s distinction is thoughtful and helps me think about the treatment of pain better.

    As far as the Scrivener’s confusion regarding Dr. Rosielle’s unclear message- I think there are certain chronic pain conditions that do not respond well to opioids- primary fibromyalgia syndrome being the most common one. (That is not to say that secondary fibromyalgia won’t improve if opioids help the primay condition, or that opioids can’t be use for primary fibromyalgia, but that chronic pain that primarily involves dysfunction of central pain centers is very commonly refractory to opioids; chasing this pain leads to large ineffective doses of opioids).

    Treating pain is difficult to approach- not only are no objective labs or objective thermometers for pain, but how pain affects one’s life has to do with any number of psychological and personality traits that affect how an individual responds to pain.

  • ninguem

    Washington State is doing what they are doing, because of practices like this one.

    http://www.oregonlive.com/news/index.ssf/2009/03/complaints_against_vancouver_p.html

    Actually, this is an all-nurse-practitioner clinic, no physicians involved. This is allowed in Washington, and many other states.

    Doses of a thousand mg oxycodone, for flimsy diagnoses, minimal to no monitoring, obvious diversion with death from the diverted drug. A reputation bad enough in southwest Washington, that entire drug store chains refuse to dispense narcotic prescribed from this clinic.

  • Michael F. Mirochna, MD

    Part of the problem is that we can’t see chronic pain. We do not get a solid education on it either, residency or medical school.

    State databases, like ours in Indiana, Inspect, are very helpful in the “war on drugs.” We get to see all of the prescriptions that a patient fills for narcotics.

    I’m also not sure how many people are made more functional with pain medications, it could be a lot, it could be not many, I just don’t know. Finally, what did people do before pain medications?

  • ATC

    Well, Dr. Mirochna, “before pain medication” would take you a long way back. Do you mean only manufactured pain meds? Or to Native Americans chewing the bark of the willow, or the Chinese or Afghan elders smoking opium? I can tell you what people without access to adequate relief of chronic pain do: they live with it as best they can, as long as they can. They watch the quality of their lives decline as every decision, from whether to take a shower or go for a walk or pour a cup of coffee is based on how much will it hurt, how much pain can I take. It’s like living on a very, very, very small budget, except what you’re spending is your energy, your endurance. Spend it on a shower, and that might be it for the day. You watch your life become smaller and smaller. Some decide not to live with it and either end their lives or turn to “illegal” or “diverted” manufactured drugs to ease their pain. This endangers them further because narcotics, to be effective and safe need to be carefully monitored, but not denied to people in need of them. But you’re a doctor. I guess you know that.

  • http://paynehertz.blogspot.com Payne Hertz

    Thanks for an informative and accurate article. It seems as a society we are more concerned with the handful of people who abuse pain meds than with the 70 million Americans who suffer from chronic pain. The DEA would certainly like to eliminate prescription pain meds altogether making the street the sole source of pain relievers that actually work. The people whose only source of pain relief is suicide are apparently no concern for regulators, nor those who die from self-medicating with lethal over the counter drugs like NSAIDS and alcohol.

    I am sure the people of Ciudad Juarez appreciate the DEA’s efforts to protect Mr Escobar’s monopoly.

  • lynda harring

    I to have chronic pain. IPMN, a pre pancreas cancer,50/50 chance of the cysts turning to cancer. I also have acute chronic pancreatitis, 3 bulging discs in my back, alot of scar tissue that accumulated at the site where I had back surgery, ddd, foraminal and centralstenosis, bursitis. Do you know what I receive for this? 4 percocet a day. Atleast a portion of my day is pain free as long as I don’t do anything but lie on the couch.
    l.harring

  • gzuckier

    Oh, I must have missed the memo. Are we done with that nice Mr. Bush’s “War on Steroid Abuse”, then?

  • Carolyn Smith

    I think that this topic needs MUCH more study as well. A 92 y/o male family member (retired clergy) suffered from pain in hip this past spring. (Story line is about 6 weeks.) He was active, (getting wood for fire, driving) and alert, but having increasing L hip pain. He saw his MD who suggested the only cure was a hip replacement. Due to hx of heart and valvular disease, he had to get cardiac clearance pre-op. This lead to planned heart cath which was cancelled due to high CR. This lead to nephrology appt, and stopping of all cardiac nephrotoxic drugs to get CR down to a level where the Cardiologist would cath and stent. (This stage involved 4 trips with SOB to ER.) This lead to a cath with a CR at 3.4. MD was unable to stent and actually caused an MI. MD gave lots of contrast which lead to confusion/kidney failure and CR of 6.8, and after 2 weeks, a miserable, confused, skin-scratching death. First Appt: June. Death: July 18.

    So, all you doctors who say that opoids are a terrible thing, what is so wrong with an elderly man with arthritis getting a low-dose narcotic that will allow ADL’s with decreased pain until a natural death can occur? I would like to see fentanyl patches brought down to a very low dose- say 5 mcg- with a 5 day delivery time, and offered to folks like this. They will not be taking pills, and the patches will be so low dose they will not be diverted. I especially would like to see the stigma removed for legitimate prescription and use of narcotics. This man should NOT have been taking high dose NSAIDS. He should have had a reasonable discussion with his family practice MD, and received a long-acting, low dose narcotic, and remained on his cardiac regime.

  • Russell B

    So many good points brought up in this discussion.
    I myself think the first thing that needs to be done is the DEA taken out of the medical profession an back from Columbia and all these other foreign countries where they are supposedly doing so much good on stopping the drug flow into America. If they are doing anything some of them are getting rich by helping get the drugs into America and the rest of the money is just being wasted when it could be used protecting our borders where the illegals come in with the drugs.
    Second I think doctors should have to take additional pain training yearly with so many advances being made in pain care so quickly. I’ve taken articles to my pain doctor from the American medical journals well documented I might add that he said he new nothing of. I’ve brought up things to doctors as a diagnosis I’ve read about to be told there no such thing. I know you doctors can’t keep up on everything you are busy men that also have lives to lead. BUT, Do me a big favor and don’t act like you know everything when you don’t have a clue about some things.
    I have so many things wrong with me it would fill a sheet of paper some doctors have stated opioids will not help that type of pain, you ever stop to think you may not be using a high enough dose. Addition, Addiction, Addiction, that’s all I here anymore the doctors say I probably have 12 to 15 years left to live if all goes well. I’m going to tell you the truth I don’t care if I’m addicted to 25 different kinds of paid meds if it will stop this excruciating pain that has made me put a gun to my head more than once. But then I remember what my Lord God tells me He shall not heap more on me than I can bare.
    God made Poppies from which our opiates come from. God made Marijuana from which nothing comes from because our government knows more than God. God new these old raggedy bodies were going to have injuries and things that would wear out in our life time and he put something on this earth to help us bare those burdens. It’s a shame the government, doctors, pharmacist, DEA, FDA and who ever else wants to get involved want to tell a grown man or woman that have raised and provided for their families and most did a darn good job, now just to be treated like children again, do this don’t do that.
    Then last but not least are these people wanting to get a buzz rather than take their meds like they should if you could remove all the drugs out of the world I know you have heard of the glue sniffers and the paint huffers,etc,etc. I have harped long enough I am a very sick man and I am darn sick and tired of doctors telling me that is to high of a dose for you to take. I am not stupid nor do I wish to die BUT, HAVE YOU NOT HEARD PAIN KILLS!!!!!