The nonsense of dosing opiates to treat chronic pain

Morning Mr. Steve,

I hope you’re and Barb are fairing well with the cold. It’s freezing here
After explaining to my “Pain Management“ doctor yesterday  that all I’ve tried all his recommendations in terms of injections and oral medications without success in lowering my pain. I went on to further explain it’s impossible to find a doctor in locally who wants to manage someone’s pain if someone else implanted a pain pump. I explained if my exploration  with Palliative Care doesn’t help my pain, I’ll have to fly to NY to find a compassionate doctor to control my pain. It annoyed him so much he explained his feeling of oral opiates. 
Regardless of how he feels or even hospital policy, how can it be legal to not prescribe opiates when a patient is a “pain management” doctor working with intractable pain patients? Below is his response and the oral medications he’s referring to are Cymbalta and Remeron to treat my pain. 
“With respect to oral medications, I am sorry you feel those were inadequate – we actually are following best practices according to state health dept and CDC guidelines. Opioids are really important and useful but we also have to make sure we are not creating new problems, which if you read the news you can see can cause really bad problems, and so again we go by data. I am actually less restrictive than many doctors.“
As always I love hearing your thoughts and am always extremely thankful. Stay well Sir. 
My response/recommendation to this pt:

My first thoughts is can the doc show you the DATA as to the intensity of your pain ?  Has anyone done a CYP-450 opiate metabolism test or a PGx DNA test – to see if you are a ultra fast metabolizer or which opiate YOUR SYSTEM metabolizes the best or utilizes the best ? It is well known that CRPS causes higher intensity of pain – it is known as the “suicide disease” and if you have someone with CRPS and a ultra metabolizers… they will need higher and more frequent doses of opiates to even attempt to get the pt <5 on the pain scale.

Here is four quotes from the CDC opiates guidelines:  – are these CDC guidelines being followed ?

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”

Clinicians should consider the circumstances and unique needs of each patient when providing care.”

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”

I would have to  dig it up, but it was well distributed back in 2016 after the CDC guidelines were published that the studies that the CDC committee used to come to their recommendations… in regards to the quality of the data used in the studies… most were rated 3-4 on a scale of 4… where “1′ is excellent and “4” is CRAP.

If your blood pressure is above what is consider a normal range of 135/85 and no amount of blood pressure meds will get it down or your high blood pressure is being ignored…  high blood pressure is called the “silent killer”…   high blood pressure will cause strokes, heart attack, eye & kidney damage. and a premature death…

Under/uncontrolled pain may cause anxiety, depression and suicide.  This chart may have been published before 2011 – but this one has been around for 10 yrs..

how many different different health issues do you have that are a separate and distinct sources of pain ?  A implanted pump will not always “hit” all the sources of pain and some sources of pain – within the body – will cause higher intensity of pain than others.. so a specific concentration of a pain med – may or may not put a “dent” in the intensity of pain from one or more pain generators.

There is no or a very high LD50 or upper dose limits for opiates and a pt that has been on them for a long time not many meds share that characteristic.

I would ask your doc… what level of pain does the CDC and state health dept guidelines suggest is an acceptable level of a pain that a pt should be expected to live or EXIST with ?

How many other chronic diseases does the state health dept and/or CDC have no target test/lab value that should be the goal in treating a pt ?

The headlines that your doc is referring to 2021 – 100,000 deaths – and that is OD’s from ALL DRUGS… it is estimated that within those numbers is 15,000 bleed out deaths from the use/abuse of NSAIDS… and 75,000 is from illegal fentanyl coming from China via Mexico

Depending on which study you wish to believe those pts that end up being addicted after getting a legal opiate prescribed is somewhere between 0.6% -2%.  So we should deny 98%+ of chronic pain pts from adequate treatment to MAYBE prevent <2% from becoming addicted ..  and probably those in that <2% are already using/abusing alcohol & Nicotine…they have a addictive personality … they will at some point find some substance that they “like the way that it makes them feel”… silences the demons in their head and/or monkeys on their backs.

That 100,000 number does not include the 100,000/yr deaths from the use/abuse of the drug alcohol and the 450,000/yr deaths from the use/abuse of the drug Nicotine

Second chart is from when the Decade of Pain law expired and was not renewed… OD’s from Pharma opiates is virtually FLAT FOR 10 YRS.. – what we don’t know, if the CDC knew and did not disclose – how many of those OD’s had a legal rx for the pharma opiate found in their toxicology –  if they would have disclosed that number – would have suggested SUICIDES…  the toxicology of the typical OD’s contains 4-7 different substances/drugs – with one typically being the drug ALCOHOL .

3 Responses

  1. This has to be the most disgusting sad thing I have read in quite some time beside the fact that we have lost three patients recently. I cannot believe that there are doctors out there that do not research this information. I believe it may be a blessing in disguise that this doctor is ignorant because hopefully she finds a doctor that is not. I would certainly utilize the information you have provided her with and send it back to that doctor for his response that is egregious behavior from a professional. I hope she utilizes every entity to defame this ignorant fool

  2. yes Jen ,my doctor said the exact same thing. It’s like thy have a script. Do no harm is no longer in the script .

  3. I had the drug metabolism test done on me to see how I metabolize medications. Even knowing I was a rapid metabolizer of hydrocodone she continues to give it to me because other pain meds are to controversial apparently. Not only do I rapidly metabolize but I also take Paxil which according to my testing makes the hydrocodone less affective. Knowing these things my doctor still gives me the same medication because it’s safest for her.

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