What’s your goal

Chronic pain pts are often advised never to ask the practitioner for a particular medication or strength  for fear that they will be viewed as a “drug seeker”.  When a pt goes to a doc’s office – regardless if it is a PCP or some specialist…  If the pt’s labs are outside of normal ranges, the prescriber should automatically have a “goal” to prescribe some sort of therapy to enable the pt to get their labs back into what is considered a “normal range”

Maybe it should be suggested to chronic pain pts to their pain doc… what on the 1-10 pain scale is his/her goal for you.  After all you are seeing a PAIN SPECIALIST… does this specialist believe that he/she is comfortable with their pts having to LIVE or EXIST in a pain level > 5 most all of the time ?   Some believe that level of pain is – or should be considered – a torturous level of pain.

Opiates are one very few meds that doesn’t have a relative predictable LD50 – LD50 is a dose when given to a number of pts, 50% will die. One of the first thing that the body becomes tolerate to when a pt takes a opiate every day – and that is respiratory suppression.

This explains why opiate naive people that take some illegal fentanyl, they DIE FROM RESPIRATORY SUPPRESSION.

I would suspect that any pt asking a pain doc what level of pain was his/her goal for the pt and gets a very vague or gets something like…  we will have to see how things progress… would strongly suggest that the pt’s therapy and pain management outcomes will be more dependent on the pt’s opiate doses reach some MME/day limit that the physician believes is a hard daily limit.

If the prescriber has not done any testing for opiate metabolism rates using the CYP-450 opiate metabolism test or the PGx (pharmacogenomics) test… both of these tests are simple cheek swab or “spit in a tube” test.  If the pt is given the choice, I would chose the latter, it is a much more comprehensive test and will give the prescriber much more information about the pt’s metabolism.

If the prescriber has reached his/her daily MME limit and the pt’s pain intensity is still >5, then the pt has to either accept living in a torturous level of pain or if the practitioner has not ran one of the DNA metabolism tests – the pt might want to ask as to why not ?  ask the practitioner if they had the DNA test run, and the pt was shown to be a fast/ultra fast metabolizer… would the prescriber even increase the pt’s dose ?   If the answer is NO… then the pt has to decide if they wish to continue to live in a torturous level of pain or have the DNA test run themselves and if it demonstrates that they are a fast/ultra fast metabolizer.  Attempt to find a practitioner that will take those DNA test in consideration when determining how much opiates they would be willing to prescriber for you.

3 Responses

  1. Before entering palliative care, I asked my doctor to run a test to look at how I metabolize my opiates. She insisted that it would definitely show that I was a fast metabolizer and all high dose opiate patients are. Otherwise, “All high dose patients would have overdosed years ago.” Am I mistaken, or did she mix tolerance with rapid metabolizers in an effort to end the conversation? I wanted to ask you what you thought about her comment.

    • Fast/ultra fast metabolizers will require higher single dose or more frequent doses – OR BOTH… A ultra fast metabolizer can ‘burn thru” a “12 hr dose”- sometimes in 3-4 hrs.. Fast metabolizer is real obvious when the pt is using Fentanyl patches, because they will start having break-thru pain or symptoms of withdrawal in 48-60 hrs after the patch is put on… instead of the 72 hrs that would be the recommended replacing a patch. IMO, tolerance is not as much of a problem than some people believe. Some practitioners jump directly to “tolerance” when a pt needs higher doses… when in reality, the pt’s health issues that is causing pain – is progressing- getting worse, aging typically has some increased pain issues and pain pts tend to try to keep up doing- what they use to do – and in turn causes more activity induced pain, and after all those increased pain issues – there MAY BE some tolerance. A couple of decades ago, rotating opiates – was in vogue – to deal with pt’s perceived increased tolerance… but I don’t hear much about opiate rotation any more.. maybe because tolerance was never that much of a issue to begin with.

  2. The DEA makes the decisions, at least in Ohio. I found a PM Doctor that would but can’t prescribe what I had for 13+ years because it would flag the DEA. We’ve got a dirty AG and I’m sure he benefited from the opioid litigation of 2019. I believe if we could get rid of him, things would get better here.

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