What’s good for the goose is good for the gander

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While I can barely muster up the chutzpah to write this blog, I’ve finally reached the end of my rope in tiptoeing around the subject. 

Call me a TURKEY if you must, but everybody is entitled to pain management.

Not everybody is entitled to opioids if they are non-compliant or the risks are shown to outweigh the benefits.

And here it is if you’re ready….

Cancer patients, and their “caregivers” are NOT entitled to a free pass. What possible reason could there be to think that cancer patients or their caregivers are less likely to have a personal or family problem with opioid and/or alcohol abuse?

What, you ask???

I get it. I began my career in hematology/oncology over 30 years ago, and I was involved in building one of the first hospice and palliative care units in our entire region. So, I understand the mindset when colleagues tell me, “No we are not going to have our dying patients sign an opioid consent and no, we are not going to test their urine.”

Fast forward three decades, and we are in the midst of a presumed opioid epidemic. State after state is capping the quantity of opioids, prescribers are running scared especially following the recently release CDC guidelines, and chronic non-cancer patients requiring long-term opioid therapy are being discharged often for no good reason with nowhere to turn.

Report after report talks about the increase in prescription opioid deaths. The CDC reports that in 2014, prescription opioid related deaths rose to almost 19,000. But the statistic that is often left out is that the far majority of deaths also involve combined alcohol and/or benzodiazepines. In fact, Dasgupta and colleagues pointed out that of 2,182,374 patients prescribed opioids, the attributable death total was 0.022%.1 His group further revealed that in 80% of mortality cases attributable to opioid-related deaths, 80% were also receiving benzodiazepines. And, about half of the patients that died from opioids did not have an active legal prescription.  So realistically, chronic opioid therapy in the absence of benzodiazepines and at reasonable doses is quite low for compliant patients.

Here’s a big question in my mind?  Where did the prescription opioids come from for those other 50%?  Most pain patients won’t part with them; hell, they’re lucky these days if they can even find a prescriber.  Yes, some come from medicine cabinets when teens or other non-suspecting persons steal opioids.  Yes, opioid quantities have often been overprescribed.  And yes, there are other places to illegally find opioids.

But, God forbid that we even think for a minute that a patient with cancer, or worse yet, their caregiver is diverting drug.  Do you suppose it’s possible that when an unsuspecting cancer patient keeps complaining of pain, perhaps they aren’t actually receiving their opioid?  Is it even possible that their dose keeps getting increased because they have pain in the absence of their prescribed opioid?  Do you think that if a savvy diverting caregiver knew that urine screens were being done that they’d give a few doses to the dying patient to make it look legit?  Is it possible that the urine would be opiate positive after a single 15mg oral dose of morphine (the answer is yes) even though a dose of 200mg was prescribed? A serum morphine level would answer this question.

Another population that seems to get a free pass are dialysis patients.  “Oh, well we can’t do a urine analysis because the patient doesn’t make urine.” Hello people, does the patient have blood?

In the last several years I have been referred patients on mega-doses of opioids as single agents or 2-3 different opioids combined.  Additionally, I frequently receive emails and phone calls from colleagues asking for advice on how to treat a patient that is dying from cancer and the opioid doses are so high, they don’t know what to do.  Sure, there are situations where this is possible but it is at least equally or more possible that the patient is not taking or not given the drug.

Here are some real examples:

  1. Morphine 200mg oral every 8 hours and oxycodone 10mg oral four times daily as needed for breakthrough pain. Family keeps asking for higher doses – dad is in severe pain.  Urine screen is opiate positive, no oxycodone in urine even though prescription is filled monthly, and serum shows a miniscule amount of morphine – enough for a mouse.  WHERE’S THE MORPHINE AND OXYCODONE GOING?
  2. Fentanyl 500mcg/hour transdermal patch (5 x 100mcg/hour patches) every 48 hours, plus methadone 40mg oral four times daily and morphine 60mg oral four times daily as needed. Urine is opiate negative which we’d expect from fentanyl and methadone, but the morphine is filled regularly which should cause a positive urine. This prompted a serum analysis which showed no fentanyl and enough methadone to treat a rat. WHERE’S THE FENTANYL, METHADONE, AND MORPHINE GOING?
  3. I could give 50 more examples with varying opioid combinations and doses.

I want to give cancer patients and everyone the benefit of the doubt, but seriously people, use your brains!   

Here’s some food for thought…

  1. It is just as demoralizing for noncancer chronic pain patients requiring long-term opioid therapy to give a urine sample as it is for cancer patients.
  2. It is simple to take a blood  from someone already hooked up for hemodialysis.
  3. Monitoring cancer patients similarly to non-cancer patients, especially when high dose opioids have limited or no effect on pain, may actually be doing the patient a great service if they aren’t receiving their drug(s).
  4. If the two cases above had been identified earlier, perhaps we could have prevented several deaths in people that bought these drugs on the street.

ASCO recently published practice guidelines, Management of Chronic Pain in Survivors of Adult Cancers.  Here they talk about reasonable and universal precautions. Since cancer survivors are more commonplace these days, we need to be cognizant of these guidelines.2

Believe me when I say that I have a big heart for hospice and palliative care patients and I do support their entitlement to receive pain medicines, which should also be the case for non-cancer patients when opioids are clinically indicated.  But what possible reason could there be for trusting cancer patients and their caregivers more than noncancer chronic pain sufferers that wish they had cancer so they could get their medicine, or so their prescribers believed them, or so their prescribers had an allayed fear for writing their opioid prescription?

In closing on the cusp of this Thanksgiving Holiday, I wish to remind clinicians from every specialty area that if you have a Turkey that’s diverting drugs, perhaps when assessing risk and monitoring patients universally we should remember, what’s good for the goose is good for the gander!

As always, questions and comments are enthusiastically welcomed!


References

  1. Dasgupta, N., Funk, M. J., Proescholdbell, S., Hirsch, A., Ribisl, K. M., & Marshall, S. (2016). Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain medicine, 17(1), 85-98.
  2. Paice, J. A., Portenoy, R., Lacchetti, C., Campbell, T., Cheville, A., Citron, M., … & Koyyalagunta, L. (2016). Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. Journal of Clinical Oncology, 34(27), 3325-3345.

 

 

12 thoughts on “What’s good for the goose is good for the gander

  1. From the arrival of the pilgrims until 1914 Americans had the right to self-medicate without government interference. They commonly used opioids, just has people have been for thousands of years.

    No right is more fundamental or important than self-owernship. What you do with your body is your business, and the crisis is pain control is a direct result of Americans being deprived of self-ownership.

    Government, and its licenses physician agents, should have no power to decide who is permitted access to medications. Free people do not need permission to relieve their suffering.

    1. True. But: It is Not Just “You” that is involved. If ‘You’ are getting Px’s for pain meds and other controlled meds from a Dr., it is that Dr, and ‘Your’ Pharmacy, therefore ‘Your’ Pharmacist whose *Livelihoods & Licences are on the line to be suspended or revoked. (Which ultimately affects ‘Your’ taxes). Aside from those potentially ruined lives, it is ‘Your’ Family and/or ‘Your’ loved ones who will both cry With ‘You’ when ‘You’ are suffering, AND cry For ‘You’ when you are abusing drugs (or alcohol), therefore lying/cheating/even stealing to/from Them.
      ‘Your’ actions have a direct link to ‘Your” ability to perform ‘Your’ job, even menial tasks and ‘Your’ ability to drive ‘Your’ car when impaired — even if the people ‘You’ hit and permanently maim or Kill are not ‘Your’ friends. If ‘You’ don’t have a spouse, ‘You’ have parents. They continue to be parents long after ‘You’ turn 18 or 21.
      So, while this may be true, unless ‘You’ live Alone, on Privately owned land, travel Only on privately owned and maintained roads, and also live in an area with both fresh water, and a year-round food supply, supply Your own heat and petrol/oil ‘Your’ actions DO have an impact on Other’s lives.
      BTW, I DO live with (chronic, unforgiving) pain that I would not wish on Anyone!! I would absolutely rather drop a sample of urine for a Dr. ANY day than need a loved one or nurse clean My bodily waste out of My bed after feeding Me.
      just a thought…

  2. I’ve been shouting this into medical mouthpieces for over two years now as a 30 year senior staff physician at a large city/county hospital recently disabled from a long history of painful psoriatic arthritis with numerous complications.

    Sadly no one cares including most treating physicians who should know better. For my entire career (and most of my disease which I suffered through while in full time practice) I’ve listened to the risk-averse co-dependent physician positions of what ‘might’ happen to them if X, Y, or Z happened (one of those is always a malpractice lawsuit when physicians in my state never get sued for much of anything).

    I watch as government entities physicians always despise – in this case the CDC – tells them how to practice and they sit idly by. Were this about Medicare reimbursements every physician subspecialty organization would be howling bloody mad and ‘fixing’ it and no one outside of medicine would ever know. But for their patients….. NADA. Sorry, we just can’t help you.

    If anyone thinks someone who requires even low dose opioids on a chronic basis – and happens to be a well-respected physician – is in any better position than anyone else you would be wrong. If you’re ill and become ‘a patient’ your voice and experience counts for ZIP.

    Our state officials say the state guidelines don’t stop any physician from scripting for opioids up to 100mme and they don’t (one told me any physician who wouldn’t script for my low dose opioids would be a ‘bad’ physician) and yet they never question the majority of those who won’t script for them. Nor do they go after hospital systems that stop outpatient physician scripting for them – I know this first hand.

    Until physicians are made to do their jobs (all of them – not just a few who then become ‘outliers’) nothing’s going to change. I wrote a post about this at the Pain News Network which should tell anyone what’s wrong with all of this. I appreciate chronic pain advocacy efforts but respectfully think they’re chasing the wrong people not unlike a dog chasing a parked car. Until medical specialties are confronted directly about why their member physicians are willing to throw their patients under the bus nothing’s going to change.

    1. Richard,

      Thank you for your voice!!

      Frankly, I don’t know how much longer I’ll make it under the bus.

      Please, keep fighting for thr rights of chronic pain patients.

  3. Thank you Dr. Fudin from the bottom of my “non-malignant pain” patient’s heart for the statistics I wish were published every time this terrifying subject is misrepresented in the media. All we hear at this point is how many people die from opiod use every minute…if the deceased consumed opioids from a prescription not their own, or not as prescribed (which includes combination with alcohol, other medication, or at a different dose than prescribed), surely that should not be part of the oft-quoted statistic, as you point out. My medication containers are covered with 3-6 brightly-colored stickers warning me not to combine with alcohol, not to combine with specified other medication, not to operate heavy machinery, not to leave medication in an unsecured location, not to take in quantity or manner other than directed. If I disregard these stickers, PLUS the conditions in my pain contract, PLUS the warnings of my physicians, PLUS those in the patient leaflet, PLUS the verbal consultation with my pharmacist, my death should not be attributed to opioids any more than death from hanging myself should be attributed to the rope I use.

    Most importantly, if we are to accurately determine the danger associated with opioid use, we need the *real* statistics. Thank you for providing those.

  4. Family depriving the patient of meds and diverting them is an example where urine drug screening can truly help the patient. I have several friends in nursing homes who are younger and in wheelchairs like me. NONE get their full dose. Some get none. Some are forced to do “favors” to get even part of their meds. I experienced the same thing myself when I wound up in a nursing home for five days (and eloped out the door in my power chair during shift change – probably the smartest decision I have ever made!). They repeatedly told me that their medical director wouldn’t allow me to have my full dose yet I wasn’t allowed to speak with him and my cell phone was confiscated. I had another good friend admitted to the hospital and she was feeling found in respiratory arrest 12 hours later. The nurses in the hospital were actually giving her the morphine that was being increased monthly due to the horrible pain she had but hair testing proved she was getting none of it. She didn’t even know she was ordered morphine In the first place! That’s because the medical director says almost nothing to his patients. He naturally has a large portion with advanced dementia, buy unfortunately he seems to act as though ALL his patients have advanced dementia. Just talking to my friend, the rather than running in and out of her room faster than Secretariat dare dream, would have revealed the problem soon after It started and saved her many miserable months. Thanks for bringing up this important issue!

    1. Anne,

      Wow!! What a horrible story and one I am certain has taken place and continues to take place all around the world.

      We need better doctor education and doctors need to better educate their patients.

      Frankly, these days every day is filled with gut wrenching anxiety… as if I’ve been diagnosed with a terminal illness that has a known expiration date… which in Maine is July 1st.

  5. Jeff- Insightful and well written. Your critical thinking skills and compassion will help to reverse the mass hysteria over opioids for chronic nncancer pain.

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