Wednesday, July 28, 2010
A couple of recent NY Times articles.
The most salient one is a discussion of the movement in Washington State to officially DO SOMETHING about prescription opioid abuse, coming on the heels of course of the FDA rejecting the current REMS plan as, essentially, not going far enough. The article basically discusses the discussion in Washington about what to do; no formal new plans have been offically proposed as far as I can tell from the article. This is what they mention that is being discussed:
The regulations would not affect how narcotics are used to treat patients with cancer or those at the end of life because experts agree that such patients should receive as much pain medication as necessary.This is an exemplary quote from the article:
The panel is expected to require that, among other things, doctors refer patients to a pain specialist for review when their daily medication increases to a specified dosage level and they do not show improvement. The specialist can then determine whether to continue the drug, reduce it or use other treatments like physical therapy.
“This is not just about addicts but little old ladies with arthritis starting to die because of this kind of medical practice,” said Dr. Alex Cahana, a pain specialist involved in devising the regulations in Washington State.I know policy-minded individuals read the blog. If anyone is following what is occuring in Washington in more detail - please let us know in the comments.
As a clinician, and really just a policy dabbler (I have my opinions; I acknowledge I haven't done the homework to really support many of them), here are my responses to this:
- This is part of an ongoing attempt to make moral/ethical and legal/policy distinctions between pain experienced by people with cancer and those without. I am not convinced that many of my patients with severe PVD and rest pain, decubiti, or arthritis have less pain or are less deserving of opioid analgesics than patients with cancer. And, indeed, cancer patients can mis-use opioids, can be addicted, etc. The discussion should be had in strictly therapeutic terms and the real question is are opioids any less safe or effective in non-cancer patients than in cancer patients? What drives me nuts about this is that 'noncancer' patients are such a heterogeneous group and extrapolating from studies of, say, fibromyalgia patients that opioids are ineffective for 'noncancer' pain is ridiculous. The quality and extent of the research about this is dismal. There are very few well controlled trials that study patients for longer than a few months. I worry, deeply, that the research is just not there to make any sort of sound decisions.
- Where is the data suggesting that iatrogenic overdosing is a significant contributor to opioid related deaths? That is, where are the bodies piling up of little old ladies dying because they took an opioid as prescirbed by their doctor? I want to be clear: I have no doubt this happens, but none of the data I've seen about the very real epidemic of prescription drug abuse suggests a major contributor is people taking their pills as prescribed. Instead it's via diversion, recreational use, and mixing with other substances (diverted benzodiazepines, booze, other opioids, etc.). There's no doubt that pain and opioid management is terrible out there - we all see the crazy stuff people are put on everyday - but that this is contributing to the epidemic of opioid related deaths in a major way I have yet to see any data to convince me. Anecdotes about little old ladies dying are alarmist. If the policy decision is one of 'we've just got to reduce the volume of prescription opioids available to get them off the street by any means' and the way it's decided to do that is by drastically restricting clinicians' ability to prescribe them, then this makes sense, whether or not you think it's the right thing to do. I'd at least appreciate people saying that straight-up and not hiding behind the idea that these deaths are related to iatragenic overdosing.
- I'd really appreciate readers' thoughts about this.