Before you succumb to the newest opioid epidemic, you may want to visit #OpioidIQ. Allow me to explain.
According to Wikipedia, Collective intelligence is shared or group intelligence that emerges from the collaboration, collective efforts, and competition of many individuals and appears in consensus decision making.
As I navigate through some of the political rhetoric, I can’t help but ponder the time and energy that is variously spent by countless printed and Internet media sources with misleading information about opioids. It makes me want to develop a new IQ scale specific to opioids. The perfect name for this would be Collective Ignorance, or cIQ (collective ignorance quotient). There is no doubt that consensus decision making is alive and well with opioids, as seen by the recent release of CDC Guidelines and the fallout that has occurred.
And so it has happened. Lawmakers and media muckrakers, the lay public, and even clinicians within various specialty groups are collectively lobbying against legitimate opioid use at the expense of patient safety and increased suicide risk. And why? Because they are victims to the newest epidemic, a high Opioid Collective Ignorance Quotient (Opioid cIQ), which of course is inversely proportional to what we all know as IQ. It’s of particular interest that the CDC’s job is to monitor dangerous epidemics, but they have actually been part of the virus that created this. Apparently the CDC has been infected with a smart little bug capable of dodging intelligent treatment by pain scholars and good science. Perhaps the CDC has been spoofed by this virus, as the resistance to treatment is incredible. Isn’t it CDC’s job to squelch such bugs instead of promoting mitosis and growth?
Rather than dwell on the misconceptions of the CDC Guidelines, the move by various states to limit opioids for legitimate patients, the unintelligible use of opioid equivalent doses without consideration to individualized therapy, the expectation that in order to continue opioids chronically one must see “clinically meaningful improvement in pain and function” in all patients when we know that won’t happen with a spinal cord injury or Parkinson’s patient, and, blah, blah, blah…
I’ve asked our prolific guest blogger Dr. Mena Raouf to work with me so we could get this Opioid cIQ blog out in time for #PainWeek2016. And once again, he was up to the task. Here’s what Dr. Raouf has to contribute…
In the midst of the opioid crisis and policy changes, an important problem that is often overlooked by policy makers, is lack of education and intelligence quotient (IQ) on opioid use. Part of the problem is lack of emphasis on opioid education across healthcare professional schools leading to subsequent deficiency in patient and lawmaker education. In fact, this week some of our pharmacy colleagues, Carroll J, Cleary, JP, Strassels S, and of course Fudin J will be presenting a poster at #PainWeek2016 entitled Analysis of Pain Education Deficiencies Among Student and Recent Graduate US Pharmacists which should be a wake-up call to Colleges of Pharmacy.
Approximately 85% of opioid overdoses are unintentional.1 Therefore, there is a dire need for improving education and awareness on proper use and risk mitigation strategies. A renowned group of clinicians developed educational videos to improve Opioid IQ, reduce cIQ, promote appropriate opioid use, and increase awareness of accidental and purposeful misuse. As a Clinical Pharmacy Specialist, Dr. Fudin expressed his gratitude for another opportunity to work with renowned physician pain specialists having different but overlapping backgrounds, to produce the Opioid IQ series.
But first, let’s tease out the terminology:
Abuse, misuse, dependence, addiction, and pseudoaddiction are distinct phenomena that are accidentally grouped together due to variability and confusion in definition.
Definitions:2,3
- Abuse: taking a medication for recreational purpose (ex. to get high) different from the intended use.
- Misuse: taking a medication for the appropriate indication it being prescribed for, but not following the prescribed directions.
- Dependence: physical dependence occur as a result of adaptation to chronic drug exposure where abrupt discontinuation may precipitate withdrawal symptoms.
- Addiction: may include physical dependence but is distinguished by compulsive drug seeking and continued use despite harm or negative consequences and lack of indication.
- Pseudoaddiction: is an iatrogenic syndrome defined as “drug-seeking behavior that simulates true addiction, which occurs in patients with legitimate pain who are receiving inadequate pain medication.”
Accidental Misuse: An honest mistake
It is reported that up to 1 in 4 patient misuse their opioid medications where misuse was defined “as opioid use contrary to the directed or prescribed pattern of use, regardless of the presence or absence of harm or adverse effects”.3 The study did not report whether opioid misuse is intentional or unintentional. Contrary to the belief that misuse is more common with immediate-release (IR) opioids where patients take more “as needed” tablets for pain control, unintentional misuse with extended-release (ER) opioids is a major problem that is often overlooked. ER opioids are designed to deliver a medication over a prolonged period of time. Chewing, dissolving, or crushing the tablets defeats the ER profile and results in dose dumping.4
There have been instances where ER formulations were unexpectedly crushed or cut with no intention for abuse, such as in elderly patients who may crush their medication for ease of ingestion. In an online survey of 1021 chronic pain patients, 65% of the patients reported that they are unaware that crushing, cutting, or grinding the opioid medication can alter the way it works.5 Noted the man age of the participants is 56 years old.
It is not uncommon for patients to split, crush, or grind medications and this may lead to generalization that ER opioid can be handled similar. Consider patients who put all their medications in a pill box and may crush them all for ease of swallowing.
A Population at-risk
Approximately 6 million US patients experience swallowing difficulties, and with the increase in the older adult population and growing prevalence of chronic pain, this poses a serious safety concern.
Role of Communication
An important conversation to have with patients is “how they are taking their medication”. NOT “how many times a day are you taking it” or “when do you take it”, rather discussing how they are ingesting it and whether are they swallowing it whole or crushing it. Approximately 81% of patients reported that they never discussed swallowing difficulties with their physicians.5
Abuse Deterrent Formulations
Abuse-deterrent formulations (ADF) have been supported by the Food and Drug administration (FDA) developed to encourage proper opioid use. A comprehensive review of ADF can be viewed HERE. The name may carry stigma some stigma to it for some patients, and it is an opportunity for the clinician to educate patients. In patients with swallowing difficulties, ADF may represent a safer viable option.
You don’t need to have a high Opioid cIQ forever – there is a cure! We encourage everyone to treat their high Opioid Collective Ignorance Quotient (Opioid cIQ) with a visit to opioid IQ. And of course, as always, comments are welcome and encouraged.
Dr. Raouf is a PGY-1 Pharmacy Resident at the VA Tennessee Valley Healthcare System. He received his PharmD from Albany College of Pharmacy and Health Sciences, with a concentration in nephrology. He completed an advance practice rotation in pain management under the mentorship of Dr. Jeffrey Fudin at the Stratton VA Medical Center, where he developed a strong interest in pain management and continued to volunteer thereafter as a student pharmacist. He has been involved in developing an automated software platform to assess pre-validated risk for opioid-induced respiratory depression to qualify patients for in-home naloxone. Following his PGY-1 residency training, Dr. Raouf hopes to pursue a PGY-2 in Pain Management.
References:
- Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2015;64(1):32. National Vital Statistics Reports. 2015;64(2). www.cdc.gov/nchs/.
- Volkow ND1, McLellan AT1.Opioid Abuse in Chronic Pain–Misconceptions and Mitigation Strategies. N Engl J Med. 2016 Mar 31;374(13):1253-63
- Weissman DE, Haddox JD. Opioid pseudoaddiction–an iatrogenic syndrome. Pain. 1989 Mar;36(3):363-
- Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576.
- Katz N, Dart RC, Bailey E, Trudeau J, Osgood E, Paillard F. Tampering with prescription opioids: nature and extent of the problem, health consequences, and solutions. Am J Drug Alcohol Abuse. 2011;37(4):205-217.
- Pergolizzi JV Jr, Taylor R Jr, Nalamachu S, et al. Challenges of treating patients with chronic pain with dysphagia (CPD): physician and patient perspectives. Curr Med Res Opin. 2014;30(2):191-202.
Thank you! How do we get out of this horrific situation is a brain-drainer for me and others.
The quality of my life is horrible and I’m a human pin cushion for corticosteroids which I must agree to receive the minimal medications I’ve been cut down to because if Legislation by ignorants. We are many who live this way.
Well-written explanatory information devoid of opinion. Again, thank you!
Chronic pain patients having been screaming to get the attention of our leaders at every level city, state, & federal but we are outright ignored every level. Our leaders are no longer operating with common sense. Our leaders act & respond as if there is not a single legitimate responsible chronic pain patient in our country. All pain patients have been neatly tucked into the box of drug abuser & are now denied treatment. As the crack down on legitimate pain patients continues the death rate among pain patients & veteran pain patients continues to rise daily! The suicide rate continues to grow but nothing is done. The legitimate pain patients are being systematically eliminated by the simple lack of common sense in dealing with this entire situation. The very simple review of patients records provides the necessary proof of care with opioids is needed along with proof of patient responsibility with opioid care at high & low doses. All of this proof sits ignored all proof needed is within each medical record. But no one even considers to trust & go by the patients medical records. Instead everyone has jumped on the opioid prohibition train with complete & total neglect of all of these innocent patients. The result is this epidemic will continue & it will turn into a pandemic of death among pain patients. If the innocent chronic pain patients continue to not be addressed & their medications not restored to the doses that are successful & tailored to each individual patient per their own medical care needs more will suffer & die. We are not all the same with the same health problems all are individual with individual health issues that can not will not be resolved by a one size fits all medication dose & you know it. Even in the most basic of terms using alcohol. The common understanding is people get drunk all depending on weight & prior exposure to alcohol. No one person is the same or equal. Every person is different & the amount of alcohol it takes to become drunk is different. The more exposed to alcohol the more can be drank before getting drunk. It works the same with opioids the more exposed to opioids the high the dose can rise to reach a pain relieving dose. It does not mean abuse it is simple exposure. But breaking this issue down to the basics seems impossible. It is the blind leading the blind & no one wants to listen to the fact the blind are walking off a cliff but refuse to be enlightened of the danger.
Please join the chronic pain community on Oct 22nd from 10-5 in Washington DC for the Rallyagainstpain.com march. All info can be found on the website. I’m sure your knowledge will be greeted with open arms. There are going to be many guest speakers including doctors, caregivers, patients, pain advocates, etc. The pain community really needs to come together on that very important day. Our one chance to show the country that there is a huge population of people being neglected and discriminated against with the war on drugs, we need to show the citizens of this country the truth, and the human sacrificing being done at the hands of the government, DEA and CDC. People in pain deserve to be treated with respect and dignity and imo, to have a dr that shows compassion and offers hope, a dr that makes you feel that you are safe, that putting your life in your drs hands, entrusting that dr to take care of you to the best of his ability and when suffering from severly debilitating incurable conditions to a make you as comfortible as possible to allow for a quality of life. Terrifyingly, the doctors out there that continue to put thier pts first, and continue to prescribe opiods are being taken down one by one. The DEA and our government along with the CDC are killing off the pain community and are taking down any dr in thier way. We are being left with two choices, turn to the streets for relief getting God knows what or SUICIDE, !! This should NEVER be happening to innocent law abiding chronically ill citizens!!
This was a refreshing article after being bombarded constantly and consistently with all the reasons being a chronic pain patient just means you need to suffer. I’m fortunate enough to have a pain management doctor that actually cares about his patients. I think this is becoming a rare event and consider myself extremely lucky for the time being.
I also have been through the process of having my medications taken away for no good reason other than a legislative decision. I was swept up in the great pill mill crackdown in Kentucky, where my doctors of thirty plus years were located. I know how “things” can change, causing unnecessary harm to patients because of the very type of ignorance spoke of in this piece.
Thanks, Dr. Rapid, for explaining the current issues that threaten to again and still adversely affect chronic pain patients for no good reason. We’re always on someone’s radar because our medications are responsible for killing people, not the people, who took them for no reason and continued to do so until they overdosed. Not the fake, fentanyl-laced opioids the CDC, DEA and media continuously label as prescription drugs. No, it’s chronic pain patients and their doctors who have caused all of it. My pills in my possession have never killed a soul and never will! It’s a scary time to be in pain.
Great article! One point missing from all the discussions of late is, and a very important point for increasing opioid IQ is: News flash!!!! We are all different !! The new guidelines were written for 70 percent of the population that metabolizes medicine in a “standard” way. For them the “suggested ” MEDD is more than adequate. In the new policies developed and issued by HHS, and the CDC, specifically the CDC guidelines for opioid prescribing, one third of patients with genetic anomalies were left out of the discussion! One third! Every doctor in America should know this fact. To not include these patients with defects of Cytochrome (CYP450) including those with ultra-rapid metabolism, intermediate metabolism, and poor metabolism proven by a simple genetic test, in which 25 percent of all medications are metabolized is discriminatory. Medications are developed for the 70 percent of those with normal metabolizing who have a standard reaction to these medications. This science was ignored in the writing of the new CDC guidelines. Now the guideline is being used by the VA, CMS, Medicaid Services, and State Medical Boards and other agencies, to target overutilizers and over-prescribers! No provision is being made for long-term treatment of chronic and intractable pain patients, OR for those patients with genetic defects of metabolizing medications who need a higher dose of medication to achieve analgesia than the “standard” seventy percent of patients for which these guidelines were based on. That’s a recipe for therapeutic failure and under-treatment of pain. Through no fault of their own, and because of genetics, people have been stricken with painful conditions that are often incurable at this time, and are progressive, and standard medication protocols don’t work for them. The “inconvenient truth” of these “outlier” patients is real, and they were blatantly ignored in the writing of these CDC guidelines. With the new policies in place the doctors who treat them will now be looked at as over-prescribers!
Most, if not all people on them have tried many different modalities and medications before starting opioid medications. Many have been injured further BY medical interventions such as epidural injections, and failed back surgeries to treat painful conditions. These medications are often a last and lifesaving resort along with other life-supporting medications and modalities. These people aren’t abusing their medications.
They left out one very important point -we are all different and one size fits all medicine doesn’t work for approximately 30% of the population! Patients vary.
One third of all pain patients are being ignored, in ER’s, in hospitals, post-surgically and in chronic pain treatment.
Great article. I plan to share at our patient leadership group meeting. I have also added a link on my website as additional reading. http://www.celestecooper.com/pain-vs.-addiction-behavior.html
Excellent
Thanks Dr. Raouf. We certainly don’t want unintended harm from our medicines, even when those medications contain opioids.
Monthly, I receive 4 or more prescriptions from my physician. My medical regimen hasn’t changed by more than a pill or two a day using these same 4 medications in over two years, yet each month, my pharmacy presents me with 3-5 sheets containing “patient information” about these medications.
The bottles containing my medication come with preprinted labels typical of today’s automated pharmacy.
(What I find odd is that, according to these labels, both my soporific and stimulant medications can make me drowsy.)
I have read all about these meds, as some of them have been a daily part of my medical regimen for over 15 years. I’ve rotated through most of the opiate – based meds and have read the FDA required inserts at one time or another in my 35 years living with chronic illness that cause intractable pain.
Having some medical training, I am familiar with the indications, action, dosing, contraindications, side effects, and other information available in the PDR.
Yet I receive a paperback book’s worth of “patient information” inserts every year. I’ve asked pharmacists to stop wasting the paper — don’t print these inserts for me.
I’ve been told that they just “come” out of the printers when an Rx is filled.
Psychology has demonstrated that the human mind is designed to filter repetitive stimuli from our cognitive awareness so that we may respond to new, more informative inputs.
May I suggest that most human beings ignore the carefully prepared patient information written by a well meaning pharmacologist at great expense to the manufacturer.
Do these patient information inserts that fill the bags of medical consumers each month protect anyone from unintended harm, or are they being ignored and (hopefully) recycled each month, as they are at my home?
I have never read a patient information sheet that has advised the patient keep their medications in a safe, yet we are told by high (and low) authority that many who die from prescription poisoning are believed to have stolen their drugs from the medicine cabinet of a friend or relative.
I have never read a patient information sheet that has advised me to use pill dividers to manage daily dosing of baseline or breakthrough opioids, benzodiazepenes, and other medications that when taken daily for extended periods, can cause confusion that has lead some to forget the number of doses taken daily.
I have never read a patient information sheet that has advised me on how and when to use my breakthrough opioids, when commom remedies, like ice, heat, excercize, manipulation, or behavioral interventions, like those taught by a pain psychologist in CBT may help that patient lower their breakthrough pain without resorting to medical means.
In the same spirit, I have never read a patient information sheet that has explained the simple principle of saving a rescue dose as a last resort to controlling pain in order to delay the inevitable result of COT — opioid tolerance and all that physiological change it implies to lowering analgesic efficacy and dose escalation — in a medical enviroment where standards of practice are based on the myth that lowering Maximum Equivalent Daily Dose will reduce the “harm” caused by opioids.
I have never read a patient information sheet that has advised me of the deadly combination of one of America’s most harmful yet widely accessible substances — ethyl alcohol — when used in conjunction with opioids, anxiolytics, hypnotics, and the panaloply of other popular medications that act on CNS recptors.
Lowering MEDD on people living in pain creates more alcohol use, because many of the millions of under medicated patients also understand that although alcohol increases risk of harm, they are left with no other choice by their physicians, as directed by the “experts” who set guidelines and standards of care that ignore pain as an important sign in the holistic assessment of the patient with intractable pain.
Let’s increase opioidIQ, by all means, so that American physicians can again aggressively treat pain with confidence, and without fear of censure and sanction by the ignorant, opiophobic, and profiteering factions in today’s medical establishment that are attempting to cut themselves a larger piece of the $600B / year spent by American’s on pain management.
@kwgmatthies
Love it.