11th Commandment: Thou Shalt Not Prescribe Short-Acting Opioids for Chronic Pain!
Pain clinicians and scientists worldwide have come to recognize that chronic pain is a disease of the central nervous system resulting from nerve cell reconfiguration known as neuroplasticity. In essence, chronic pain (generally defined as pain lasting 6 months or longer; not consistent with the normal healing processes, potential unidentifiable pathology, and decreased function) is a disease that in many ways is similar to other chronic disorders. Why then do we treat it differently when prescribing medication, especially opioids?
No matter how you slice it, all immediate release (IR) opioids have a short half-life which averages around 4 hours. The translation is that a person taking IR opioids should not expect pain relief for greater than 3-6 hours per dose. Comparatively speaking, imagine prescribing an antihypertensive that lasts 4 hours, the patient is to measure the BP each 4 hours, and with a pressure exceeding certain parameters, “pop a pill”.
Hydrocodone/APAP 5/500mg, Take 1-2 tablets PO Q4-6H PRN pain. This is the typical pain prescription.
According to a recent interview with Dr. Steve Passik, “…8.8 million people are on chronic opioid therapy and 5.5 million of them are on hydrocodone. Now, putting aside the fact that hydrocodone and other short acting opioids are not considered right for every person along the spectrum of pain and risk for addiction, could we possibly be doing things right if more than 60 some odd percent of patients are on the same drug?”.
Imagine for a minute that you are the patient. You’re already feeling embarrassed and shady because the prescriber questions you, the pharmacist questions you, and really, you don’t want to be dependent on these drugs for intractable pain anyway…you would rather not have pain! You go to bed at night, take one tablet; after three hours of tossing and turning you take another; 3 hours later you wake up…can I take one tablet, has enough time gone by to take two tablets, I need to sleep because of a job interview tomorrow, etc. This cycle goes on for a month taking short-acting opioids throughout the day, an extra for walking the dogs, grocery shopping, cutting the lawn. Now it’s Friday afternoon on Labor Day weekend, and “just two tablets left”. You are in a panic, your doctor doesn’t want to speak with you at the nth hour regarding a hydrocodone refill on the Friday before a holiday weekend, and so the story goes. Who is really at fault here; is it the patient or the prescriber?
By way of example, the following is a partial list of hyperlipidemia risk factors in a patient receiving statins:
- Smoking
- High-fat/high-cholesterol diet
- Obesity
- Lack of physical activity
- Age and gender (Male)
- Age and Gender (Female)
- Liver disease
- High blood pressure due to sedentary lifestyle
- Family history of [heart disease]
What are some risk factors associated with chronic acetaminophen-containing short-acting opioids?
- See above, substitute [heart disease] with [substance abuse]
But do we ask these questions to our chronic pain patients?
I liken short-acting PRN chronic opioids to the following:
- Regular insulin 2U SQ Q4-6H PRN for high sugar (glucose test not necessary); see you in 6 months.
- Dopamine 500mg 1-2 tabs PO Q4-6H PRN for Parkinson rigidity, frequent falls and drooling; see you in 6 months.
- Warfarin 5mg PO Q4H PRN for atrial fib (INR not necessary); see you in 6 months
- Nifedipine 10mg 1-2 PO Q4-6H PRN if you think your BP is high (no monitoring necessary); see you in 6 months
- Simvastatin 20mg 1-3 tablets PO daily PRN for anticipated high cholesterol, depending on meals (no LFTs or lipid monitoring necessary); see you in 6 months
Chronic opioids for chronic pain should include extended release formulations, initial risk stratification (similar to diet, exercise, baseline LFTs & lipids with ongoing monitoring for statins), functional assessment, baseline urine analysis, controlled substance agreement, counseling if indicated, occasional serum monitoring, physical therapy, attempt at healthy lifestyle, monitoring of functional improvement, etc.
You don’t have time to do these things in your practice? Do you have time to treat diabetes, depression, hypercholesterolemia, sleep disorders, hypertension, and more? Unless we are prepared to pay specialists for every disorder, a new model needs to be established that encourages and assists primary care providers in the treatment of chronic pain disorders.
Chronic, short-acting, as needed opioids prescribed regularly without continuous thoughtful monitoring are counter-intuitive. Are chronic opioids only appropriate for cancer pain as suggested by some adversaries? No… Why you ask? We are all terminal, but some of us are more terminal than others.
Enjoy your holiday weekends, and as always, comments are welcome!
Hey there, I’ve really enjoyed reading everyone’s posts and comments here. I would like to say coming from a 16 year year addiction to opiods, the utter potential for a devastating loss of self, and death of many close friends, and my own husband, that there is a horribly miscalculated judgement in either the medical professionals or more likely and my favorite, the pharmaceutical companies who are paying these Dr’s thousands just to promote and prescribe these medications.
Now understand I’m in SFL pain clinic capital. And for 16 years I watched first hand how these old Dr’s , close to retirement or just not very good, coming to work in these pain clinics packed with over 15 Dr’s, and at least 100 patients sitting in their waiting rooms and standing on sidewalks outside at any time of day. And if you know the right people they’ll tell you which Dr’s have they’re own pharmacy and will sell out they’re back Door… “NO PRESCRIPTION OR HASSLE NEEDED COME ALL! ”
The very first couple years my prescriptions consisted of this:
300 30mg oxycodone,
120 15mg oxycodone
120 2mg Xanax bars …
And a partridge in a pair tree…
All in one 30 day prescription.
After 16 years of that,.. well 7 our 8 doing that, the rest chasing them on the street at $30 a pop after the DEA thought that it might be finally time to regulate. HMMM ya think? But at the same time driving cost sky high…
… I started the grueling process of trying to get clean. Methadone first which was worse, and destroyed my teeth in less than 2 years. Then finally Suboxone, Which with Care Resource, a new MAT program, finally saved my life.
I was never an addict before my accident (which did not warrant the amount of pain meds they shell out) and I had a beautiful life. Married with 2 beautiful kids, bought my first house at 20 in the Firefighter/Paramedic program set to make my career and had everything I could ever want. By 26 I had only the kids (4 now) and my husband left, what was left of him, and by 35 he was dead and my life was in complete shambles. Even first finding Suboxone didn’t work at first because the Dr’s kept charging pain clinic prices at $200 to $250 per visit and the films costing $10 apop when you have a 60 film prescription? Do that math being now a single mom of four. The saving grace was the MAT programs set up which are currently only about 4 years old I believe.
I am only just now these past 2 years and at 43 , finally feeling back to the best version of myself. And I’m one of the lucky ones. For my kids and because of my core self, I had to find a way out. But I was extremely lucky I did so before my babies were left orphans.
The worst part… even when your finally ready to, and able to get help…is when you start getting sober and reflecting on those years and all the disappointments you caused and all the loss and utter destruction of self worth and Self and a destroyed family and social life, the depression and time it takes to walk that very long road thru it all, is so discouraging and unbelievabley difficult, that most would rather die high then find worth in their life enough to make the jump.
Listen I have never even posted online like this before, not my Forte, but I hear all of your professional and kind words, but what happened with those medications then and still now, granted somewhat more regulated, has nothing to do with what a Doctor does or doesn’t understand about prescribing, or even to who or for what ailment your prescribing. Sorry guys but I lived it. And the whole world shunned us and blamed us for being addicts, treating us like rejects for what they themselves caused. None of your prescribing methods will fix the problem. Because the original problem was that a medication like this was ever released to the public in the first place, when it was very obvious that the pharmaceutical companies were well aware of what would happen when they did their own drug trials before being released at all. And how is it even legal that a drug like this can be pushed by paying off Dr’s thousands to promote and prescribe? What else could happen with a highly addictive opioid and all that money being shelled out? Exactly what they wanted. Their billions… I’m not bitter, I could never be a bitter person because I love my own life too much to give it anymore of my time. But there is an unbelievable amount of passifying (but well intentioned) information being spoken here. And really I understand why, because the amount of time and attention the pain clinc fiasco received in any media outlet, was so limited and so downplayed that it seemed like just a small blip of issues ensued. And then everyone moved on… but just look at the deaths, look at the VERY YOUNG DEATHS, and then see the numbers for addiction and recovery. My own MAT program, Care Resource, has had to expand exponentially over the last year because of their own admitted underestimate of how many Suboxone and Counsling/Psych patients they would receive.. It needed to be said. At least I needed to say it. My heart breaks for everyone of the people still caught in that trap. It’s one of the most painful journeys a soul can take on this earth. Yet we still want to prescribe it to patients with anything less than a terminal and unbearably painful existence left? Because they are the only people who should ever need to see a 15 or 30mg Roxy or 20, 40, 60, 80 and even the banned 120mg ER OXYS! There is some serious negligence on part of our country regulating these pharmaceutical giants, and in our entire Healthcare system, when our real 1st Pandemic was the unfamously mentioned pain clinic boom and unfathomable amount of money made, at the pre-known cost of lives to be lost and destroyed over a bottom dollar..I do so apologize if I’ve insulted anyone, but actually I’m just not sorry. Because the debt they made in lives is still being paid in droves. So I thank your for reading and hope that you might better understand the seriousness of what your really discussing. And I hope you truly understand that everything I’ve stated here happened in just that way. You can look into the DEA arrests in Ft. Lauderdale and Hollywood FL. and see the records of what those clinics were prescribing, as well as the sad statistics of continued fallout for yourselves, and then tell me it’s about prescribing or educating patients…I don’t think you really can if your honest with yourself. All I hope is too at least have enlightened your grasp of the situation. And hope I’ve even swayed even just one medical professional to not misuse their script pads! Thanks for your ears!!
Wishing everyone a Beautiful Holiday!
“It’s just me, myself, I … and all I am”
-Spread joy, love, hope and understanding so we can all live better together! Don’t embrace ignorance only to ignore your better nature! –
Michelle B. South Florida
Fortunately or unfortunately, we live in a world of instant gratification. Everyone wants to receive their desires immediately. Unfortunately for chronic pain and most every other common condition such as hypertension, hyperlipidemia, and diabetes, we don’t have a quick cure. What we do have, however, are medication that MANAGE these diseases. Managing a disease means that we as healthcare professionals need to continuously monitor and assess these patients to make sure we are properly treating them.
Dr. Fudin’s scenario described above is just another presentation of a lack of understanding and management that exists for short acting opioid medications. How much blame can we really put on the patient for taking these medications as they are prescribed? Most patients that seek out the help of medical professionals come because they trust in us; we have a duty to “first, do no harm.” By carelessly prescribing and dispensing short acting opioids we are creating our own worst nightmare. By carelessly prescribing and dispensing these substances we may increase the likelihood of abuse and addiction. Proper monitoring and assessment of these patients before and during treatment will take us a long way in combating the poor stigma that’s associated with this specific drug class, and opioids as a whole.
PROP seeks to do this by changing the labeling of opioids, what I believe is another attempt at a quick fix for a multi-dimensional problem. They believe that limiting the approved indications of opioids and placing a time and dosage cap on their usage is going to solve the problem of overprescribing. They do not even address the importance of professional education, and will leave multitudes of patients with non-cancer pain to suffer unnecessarily. It’s almost insulting to think that PROP feels that medical professionals are so incompetent in the prescription of opioids that they are no longer going to allow us to use our medical judgment in prescribing and dispensing these prescriptions. The answer is not limiting the prescribed use of these drugs or prescribing them off-label, but instead eliminating the lack of proper understanding that surrounds them. Opioids can be a wonderful drug for patients that suffer from moderate to severe pain in which other medication classes are either contraindicated or offer minimal or no relief. As we all know, however, they can also be drugs that lead to devastating consequences if not used properly. These drugs should be respected by prescribers, pharmacists, and patients. The first step to respecting these substances requires proper professional education and diligence; in both the doctor’s office and each side of the pharmacy counter.
Comical, but so true!! It seems our patients requiring pain management have little, if any, follow-up. These are the only patients that are not being asked “How is it working?” and “How do you feel?”. From the pharmacists’ point-of-view early refills come across as abuse, we should recognize this as a potentially failed drug regimen for a patient in pain. -Justine
Thank you Dr. Marryott. It’s always enlightening to see your comments here. Keep up the good work in Florida and patient advocacy!