The Other Opioid Crisis: Hospital Shortages Lead To Patient Pain, Medical Error

I came across this public-accesss story, and wanted to share the perspective:

Even as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.

The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.

As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.

In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which can be up to 10 times more powerful than fentanyl, the ideal medication for that situation.

In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Other patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.

The American Society of Anesthesiologists confirmed that some elective surgeries, which can include gall bladder removal and hernia repair, have been postponed.

Even as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.

The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.

As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.

In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which can be up to 10 times more powerful than fentanyl, the ideal medication for that situation.

In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Other patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.

The American Society of Anesthesiologists confirmed that some elective surgeries, which can include gall bladder removal and hernia repair, have been postponed.

In a Feb. 27 letter to the U.S. Drug Enforcement Administration, a coalition of professional medical groups — including the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists — said the shortages “increase the risk of medical errors” and are “potentially life-threatening.”

In addition, “having diminished supply of these critical drugs, or no supply at all, can cause suboptimal pain control or sedation for patients,” the group wrote.

The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.

Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.

Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.

Marchelle Bernell (Courtesy of Marchelle Bernell)

Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.

Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.

“The system has been set up safely for the drugs and the care processes that we ordinarily use,” said Dr. Beverly Philip, a Harvard University professor of anesthesiology who practices at Brigham and Women’s Hospital in Boston. “You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”

Dr. Beverly Philip (Courtesy of the American Society of Anesthesiologists)

Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.

“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.”

During the last major opioid shortage in 2010, two patients died from overdoses when a more powerful opioid was mistakenly prescribed, according to the institute. Other patients had to be revived after receiving inaccurate doses.

The shortage of the three medications, which is being tracked by the FDA, became critical last year as a result of manufacturing problems at Pfizer, which controls at least 60 percent of the market of injectable opioids, said Erin Fox, a drug shortage expert at the University of Utah.

A Pfizer spokesman, Steve Danehy, said its shortage started in June 2017 when the company cut back production while upgrading its plant in McPherson, Kan. The company is not currently distributing prefilled syringes “to ensure patient safety,” it said, because of problems with a third-party supplier it declined to name.

That followed a February 2017 report by the U.S. Food and Drug Administration that found significant violations at the McPherson plant. The agency cited “visible particulates” floating in the liquid medications and a “significant loss of control in your manufacturing process [that] represents a severe risk of harm to patients.” Pfizer said, however, that the FDA report wasn’t the impetus for the factory upgrades.

Other liquid-opioid manufacturers, including West-Ward Pharmaceuticals and Fresenius Kabi, are deluged with back orders, Fox said. Importing these heavily regulated narcotics from other countries is unprecedented and unlikely, she added, in part because it would require federal approval.

At the same time, in an attempt to reduce the misuse of opioid painkillers, the Drug Enforcement Administration called for a 25 percent reduction of all opioid manufacturing last year, and an additional 20 percent this year.

“DEA must balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances,” the agency said in August.

When the coalition of health groups penned its letter to the DEA last month, it asked the agency to loosen the restrictions for liquid opioids to ease the strain on hospitals.

The shortages are not being felt evenly across all hospitals. Dr. Melissa Dillmon, medical oncologist at the Harbin Clinic in Rome, Ga., said that by shopping around for other suppliers and using pill forms of the painkillers, her cancer patients are getting the pain relief they need.

Dr. Shalini Shah, the head of pain medicine at the University of California-Irvine health system, pulled together a team of 20 people in January to figure out how to meet patients’ needs. The group meets for an hour twice a week.

Dr. Shalini Shah (Courtesy of University of California-Irvine)

The group has established workarounds, such as giving tablet forms of the opioids to patients who can swallow, using local anesthetics like nerve blocks and substituting opiates with acetaminophen, ketamine and muscle relaxants.

“We essentially have to ration to patients that are most vulnerable,” Shah said.

Two other California hospital systems, Kaiser Permanente and Dignity Health in Sacramento, confirmed they’re experiencing shortages, and that staff are being judicious with their supplies and using alternative medications when necessary. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

At Helen Keller Hospital’s emergency department in Sheffield, Ala., earlier this month, a 20-year-old showed up with second-degree burns. Dr. Hamad Husainy said he didn’t have what he needed to keep her out of pain.

Sometime in January, the hospital ran out of Dilaudid, a drug seven times more potent than morphine, and has been low on other injectable opioids, he said.

Because Husainy’s patient was a former opioid user, she had a higher tolerance to the drugs. She needed something strong like Dilaudid to keep her out of pain during a two-hour ride to a burn center, he said.

“It really posed a problem,” said Husainy, who was certain she was in pain even after giving her several doses of the less potent morphine. “We did what we could, the best that we could,” he said.

Bernell, the St. Louis nurse, said some trauma patients have had to wait 30 minutes before getting pain relief because of the shortages.

Dr. Howie Mell (Courtesy of Howie Mell)

“That’s too long,” said Bernell, a former intensive care nurse who now works in radiology.

Dr. Howie Mell, an emergency physician in Chicago, said his large hospital system, which he declined to name, hasn’t had Dilaudid since January. Morphine is being set aside for patients who need surgery, he said, and the facility has about a week’s supply of fentanyl.

Mell, who is also a spokesman for the American College of Emergency Physicians, said some emergency departments are considering using nitrous oxide, or “laughing gas,” to manage patient pain, he said.

When Mell first heard about the shortage six months ago, he thought a nationwide scarcity of the widely used drugs would force policymakers to “come up with a solution” before it became dire.

“But they didn’t,” he said.

In a Feb. 27 letter to the U.S. Drug Enforcement Administration, a coalition of professional medical groups — including the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists — said the shortages “increase the risk of medical errors” and are “potentially life-threatening.”

In addition, “having diminished supply of these critical drugs, or no supply at all, can cause suboptimal pain control or sedation for patients,” the group wrote.

The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.

Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.

Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.

Marchelle Bernell (Courtesy of Marchelle Bernell)

Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.

Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.

“The system has been set up safely for the drugs and the care processes that we ordinarily use,” said Dr. Beverly Philip, a Harvard University professor of anesthesiology who practices at Brigham and Women’s Hospital in Boston. “You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”

Dr. Beverly Philip (Courtesy of the American Society of Anesthesiologists)

Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.

“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.”

During the last major opioid shortage in 2010, two patients died from overdoses when a more powerful opioid was mistakenly prescribed, according to the institute. Other patients had to be revived after receiving inaccurate doses.

The shortage of the three medications, which is being tracked by the FDA, became critical last year as a result of manufacturing problems at Pfizer, which controls at least 60 percent of the market of injectable opioids, said Erin Fox, a drug shortage expert at the University of Utah.

A Pfizer spokesman, Steve Danehy, said its shortage started in June 2017 when the company cut back production while upgrading its plant in McPherson, Kan. The company is not currently distributing prefilled syringes “to ensure patient safety,” it said, because of problems with a third-party supplier it declined to name.

That followed a February 2017 report by the U.S. Food and Drug Administration that found significant violations at the McPherson plant. The agency cited “visible particulates” floating in the liquid medications and a “significant loss of control in your manufacturing process [that] represents a severe risk of harm to patients.” Pfizer said, however, that the FDA report wasn’t the impetus for the factory upgrades.

Other liquid-opioid manufacturers, including West-Ward Pharmaceuticals and Fresenius Kabi, are deluged with back orders, Fox said. Importing these heavily regulated narcotics from other countries is unprecedented and unlikely, she added, in part because it would require federal approval.

At the same time, in an attempt to reduce the misuse of opioid painkillers, the Drug Enforcement Administration called for a 25 percent reduction of all opioid manufacturing last year, and an additional 20 percent this year.

“DEA must balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances,” the agency said in August.

When the coalition of health groups penned its letter to the DEA last month, it asked the agency to loosen the restrictions for liquid opioids to ease the strain on hospitals.

The shortages are not being felt evenly across all hospitals. Dr. Melissa Dillmon, medical oncologist at the Harbin Clinic in Rome, Ga., said that by shopping around for other suppliers and using pill forms of the painkillers, her cancer patients are getting the pain relief they need.

Dr. Shalini Shah, the head of pain medicine at the University of California-Irvine health system, pulled together a team of 20 people in January to figure out how to meet patients’ needs. The group meets for an hour twice a week.

Dr. Shalini Shah (Courtesy of University of California-Irvine)

The group has established workarounds, such as giving tablet forms of the opioids to patients who can swallow, using local anesthetics like nerve blocks and substituting opiates with acetaminophen, ketamine and muscle relaxants.

“We essentially have to ration to patients that are most vulnerable,” Shah said.

Two other California hospital systems, Kaiser Permanente and Dignity Health in Sacramento, confirmed they’re experiencing shortages, and that staff are being judicious with their supplies and using alternative medications when necessary. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

At Helen Keller Hospital’s emergency department in Sheffield, Ala., earlier this month, a 20-year-old showed up with second-degree burns. Dr. Hamad Husainy said he didn’t have what he needed to keep her out of pain.

Sometime in January, the hospital ran out of Dilaudid, a drug seven times more potent than morphine, and has been low on other injectable opioids, he said.

Because Husainy’s patient was a former opioid user, she had a higher tolerance to the drugs. She needed something strong like Dilaudid to keep her out of pain during a two-hour ride to a burn center, he said.

“It really posed a problem,” said Husainy, who was certain she was in pain even after giving her several doses of the less potent morphine. “We did what we could, the best that we could,” he said.

Bernell, the St. Louis nurse, said some trauma patients have had to wait 30 minutes before getting pain relief because of the shortages.

Dr. Howie Mell (Courtesy of Howie Mell)

“That’s too long,” said Bernell, a former intensive care nurse who now works in radiology.

Dr. Howie Mell, an emergency physician in Chicago, said his large hospital system, which he declined to name, hasn’t had Dilaudid since January. Morphine is being set aside for patients who need surgery, he said, and the facility has about a week’s supply of fentanyl.

Mell, who is also a spokesman for the American College of Emergency Physicians, said some emergency departments are considering using nitrous oxide, or “laughing gas,” to manage patient pain, he said.

When Mell first heard about the shortage six months ago, he thought a nationwide scarcity of the widely used drugs would force policymakers to “come up with a solution” before it became dire.

“But they didn’t,” he said.

Opioid Analgesia Without Addiction

I don’t have pull with the addiction-related organizations out there.  I’m never been a joiner, and I tend to notice the problems caused by medical societies over the good things that they supposedly accomplish.    For example PROP, or ‘Physicians for Responsible Opioid Prescribing’, have a specific mission.  Once a group has a mission, any considerations about individual patients go out the window.  PROP has propagated the message that opioids are NEVER beneficial for patients with chronic pain.  Legislators with no knowledge of clinical medicine hear that message, and respond by passing draconian laws that interfere with any considerations of individual patients.  I would guess that the people of PROP pat themselves on the back for encouraging laws that remove physician autonomy.  I’m sure they figure that they are smarter than all the family practice docs out there.  But in reality, they are only destroying the control of doctors over patient care, and handing that care over to politicians.  Way to go, PROP!!

But I digress…

In the same way, the societies that hold meetings about meetings, that elect Secretaries who become Vice Presidents who become Presidents, get to publish the articles that describe clinical protocols.  The doc who spends every day talking with patients has no access to these sources, and little ability to influence those protocols.  Sometimes the societies and organizations get things right… and sometimes they get things wrong.  The latter is the case with post-op pain control in patients on buprenorphine products.

I’ve written about this before, as regular readers know.  Over the past 8 years I’ve had dozens, if not hundreds, of patients on buprenorphine undergo surgery.  The surgeries include coronary bypass, thoracotomy, rotator cuff repair, C-section, nephrectomy, total knee or hip replacement… and a host of minor surgeries with scopes and lasers.  I’ve treated these patients in a number of ways, in part because hospitals that provide emergency care have different ways of dealing with post-op analgesia.  I rarely have control over what they do acutely– but I almost-always take over pain control when patients are discharged.

In the past few months there have been several ‘articles’ stating that the best way to handle surgery, in people on buprenorphine products, is to stop the buprenorphine before surgery, and treat pain using opioid agonists.  This opinion is not supported by any data.  It is someone’s opinion– usually someone who has a title, i.e. someone who spends at least some of his/her time in society meetings.  That time is removed from the amount of time that could be spent treating and speaking with patients.  Frankly, the ‘higher’ a doctor is in society circles, the less time they spend in patient care.  That comment will anger the docs who it applies to.  I can hear them now– saying I’m only full of ‘sour grapes’. But maybe those same docs should look in the mirror, and wonder how they ended up as ‘President’ of a society.

I’ve used the approach claimed as best practice in the society journals– i.e stopping buprenorphine before surgery– and the same thing always happens.  Tolerance to opioid agonists rises very rapidly in the post-op period.  Patients are discharged on huge doses of opioid agonists.  And at some point, agonists must be discontinued for 24 hours to allow for re-induction with buprenorphine agents.  I’ve had several recent patients go through this exact process– and my frustration motivates this post.  One guy shot himself in the femur, and the bullet also passed through his lower leg.  He needed fasciotomy to avoid losing the leg. His Suboxone was discontinued at admission, and ten days later he was discharged on 30 mg of oxycodone every 2-3 hours– i.e. over 200 mg per day.  The other person was in a serious car accident, and had multiple fractures—  femur, pelvis, ribs, wrist– as well as internal injuries.  After 3 weeks he was released on over 300 mg of oxycodone per day!

On the other hand, I’ve had many patients go through the surgeries listed earlier while maintained on buprenorphine, 4-8 mg per day.  In ALL cases, they had excellent analgesia with lower doses of oxycodone than in the people who stopped buprenorphine.  Most patients did well on 15 mg of oxycodone every 3-4 hours– a max of 120 mg of oxycodone per day.  In a few cases– i.e. in the most painful operations, in the most sensitive patients– I had to use 30 mg of oxycodone every 4 hours.

The most amazing thing about the combination of buprenorphine and opioid agonists is the absence of tolerance to agonists, when buprenorphine is present.  I’ve had patients with recurrent injuries that required repeated surgeries, including a woman who tore her rotator cuff and the surgical repair THREE times over three months.  She took the same amount of opioid agonist for three months, with no noticeable decrease in efficacy.  After the final operation, after three months on significant amounts of opioid agonist, she simply stopped the agonist and resumed her full dose (16 mg) of buprenorphine.  She had no withdrawal, and not other complications.  She simply stopped the agonist and resumed buprenorphine treatment.

I’ve come to realize that buprenorphine effectively ‘anchors’ tolerance when patients take opioid agonists, as long as the buprenorphine is continued.  Patients always say the same thing:  that the pain was reduced by the agonist, but that it didn’t ‘feel’ like the agonist they used to take.  In fact, patients who could never control pain pills found that they COULD control agonists if they stayed on buprenorphine(!)

A couple years ago I presented these findings at an annual meeting of ASAM.  The slides can be found here.  I believe that some day, combinations of buprenorphine and opioid agonists will be the standard approach to pain treatment.  The combination allows for opioid analgesia without tolerance, without euphoria, and with little or no risk of addiction.  If THAT doesn’t piqué your interest, you have no business reading about opioid dependence!!

I picture combinations of buprenorphine and fentanyl… especially since both are now FDA-approved as transdermal patches.  Or perhaps a combination of fentanyl lozenges and sublingual buprenorphine.  The possibilities are endless.  Throughout history, the miracle of opioid analgesia has been cursed by the attachment to tolerance, dependence, and addiction.

Imagine if that curse was lifted from opioid analgesia.    Can you even dare to imagine that world?  I’m telling you… it is closer than you think—- and there for the taking.

Chronic, Nonmalignant Pain: Why Opiates Aren't the Answer

I answered a post today that is similar to many prior posts– a patient with significant pain is no longer getting good pain relief from the pain pills he has taken for the past three years, and he asked whether it was a good idea to change from one narcotic– let’s say oxycodone– to another narcotic– let’s say Duragesic, the fentanyl skin patch.
I often come across this question in one form or another.  For a person in pain, opiate pain medications are wonderful– at least initially.  The problem is that the medications lose their potency over time through a process called ‘tolerance’.  In order to continue to get relief, the person with pain has to keep increasing the dose of the medication.  This leads to problems; often the doctor prescribing the medication becomes uncomfortable with the dose but wants to avoid confrontation, and the doctor/patient relationship becomes more and more strained… the patient goes to the ER for pain relief and nothing works, and the nurses and doctors treat the person like a criminal…  Read on for one writer’s experience, followed by my comments:
As I mentioned in your forum, it’s refreshing to see someone preaching the realities of non-acute opiate use. This happened to me to a certain degree, with opiate hyperalgesia (which you didn’t address in this post but have mentioned elsewhere) thrown in. Doctor doesn’t explain the limitations of opiates and tolerance, things spin out of control (in my case, thankfully no doctor shopping and only a couple of instances of upping the dose myself slightly and no more out of fear of overdose), I end up on Suboxone to taper off after the source of the pain was finally discovered and properly treated (with my pain receptors still firing improperly for the first few months, albeit not nearly as badly as they did while on the painkillers and during withdrawal. Plus, being ill-informed, after my relationship with my doctor soured for various reasons and I knew that even if it hadn’t, my dose had gotten much too high, I didn’t know that tolerance too high = withdrawal, for WEEKS in spite of visits to ERs, other neurologists, and psychiatrists who, in hindsight, seemed to be playing dumb in some cases so as not to second-guess the original prescribing doctor while I lied there screaming in the worst pain of my life from a combination of opiate hyperalgesia and withdrawal. This was actually the second time that this happened though it was slightly less bad the other time (and for those of you who absolutely have to take opiates while recovering from surgery or for cancer pain, AVOID OPANA ER LIKE THE PLAGUE. The time release doesn’t work properly for many people, including me).
I often see patients who have been destroyed by pain medications. I hear you– you are in pain, and need a way to reduce the pain. But all opiates have the same severe limitation– tolerance.

Duragesic (which is fentanyl), morphine, oxycodone, hydrocodone, hydromorphone (dilaudid)… they all work through the exact same receptor site, and they are all ‘cross tolerant’– meaning that if you are tolerant to one of them, you are tolerant to all of them.

The problem with tolerance is that if you increase your dose, or (as you are suggesting) change to a different medication at a dose that is essentially higher than what you are taking now, your receptors will change to match the increase, and very soon you will have exactly the pain you are having now– only while on a higher dose of medication. I typically see patients who have chased tolerance to extreme levels– people who are taking 600 mg of oxycodone per day or more, and who get nothing from it, because of tolerance.

If you chase tolerance and end up on high doses of pain meds, you face many problems– most doctors will refuse to even consider taking on a patient in that position; if you have surgery it is very difficult to treat the pain, as even higher doses are required; and if you miss a dose, or run out of medication, you are in deep trouble from withdrawal.


The ONLY solution is to avoid chasing tolerance. Don’t interpret this as ‘not caring’ or ‘not believing you’– that is not the issue. Assuming you are having bad pain, and from a standpoint of wanting to help, increasing the narcotic simply does not work.

Some day– maybe soon– we will have a way to prevent tolerance. Studies suggest that tolerance requires actions through glutamate receptors, and so there have been attempts to limit tolerance by using drugs that block those receptors– such as dextromethorphan. Studies that looked at a combination drug called ‘morphidex’ did not show reduced tolerance in humans, but dextromethorphan has been demonstrated to reduce tolerance in animals. There are ‘compounding pharmacies’ out there that make and dispense pills containing oxycodone and dextromethorphan, in an attempt to limit tolerance.

So if you don’t increase the opiate medication, what can you do? I don’t know– maybe nothing! My point is that an increase is ultimately not helpful, and is actually setting you up for worse pain. So keep the opiate dose constant and focus your efforts on every non-opiate pain-reduction technique you can find. Exercise as much as you are able– that will have the greatest effect on your level of disability. Use an SNRI antidepressant. Try the anti-convulsant medications for ‘burning’ pain– medications like ypregabalin (Lyrica), gabapentin, tegretol, or topiramate (Topamax). Use locally-applied heat for tight muscles, and use muscle-relaxants sparingly– medications like cyclobenzaprine (Flexeril), metaxolone (Skelaxin), tizanidine, or baclofen. Benzodiazepines like diazepam (Valium) are potent muscle relaxants, but are limited by sedation and tolerance, and can be addictive in some patients– particularly those with other substance issues including alcoholism. As for pain clinics, be careful. I am Board Certified in Anesthesiology and worked in pain treatment for ten years as an anesthesiologist, so I understand what pain docs can and cannot do. Pain treatment is a huge draw for hospitals, and pain clinics are often a bit misleading (trying not to use the word ‘scam’ here!). Blocks that eliminate your pain for a few hours are fun for the anesthesiologist, and they bring in a grand or two for the hospital… but if your pain returns in six hours, were they worth it?

As prior posts have suggested, the important thing is to find a doc who listens. I would add, look for someone who doesn’t just keep increasing your narcotic dose. That is a fine approach for a person who has a terminal illness, but is a disaster for a person with years to live.

Chronic Pain Treatment Approaches

I write for a couple of medical sites– not the ones I have mentioned here, but sites where they actually allow doctors to identify themselves so that the person asking the question knows the credentials of the person providing the reply.  Oh, what the heck– I think it is OK to name them…  I answer questions ‘formally’ for MedHelp.com and for DoctorsLounge.com.  Go ahead and check them out if you like– if you do, be sure to give me good feedback!!  They are unpaid positions–  as I have whined about many times, I cannot find a way to make money as a doctor on the internet!  But I do them for the publicity– although what the publicity does for me, I’m not really sure…

Here is something I wrote recently about chronic pain;  I figure that the readers of this blog might find my basic approach useful.  The question was a generic request for help with chronic pain in a family member.

My Reply:

When treating pain, physicians generally separate acute pain from chronic pain in order to decide upon proper strategies for treatment.  We then tend to separate cancer pain from non-cancer pain; perhaps a more useful approach is to separate pain in the presence of limited life expectancy vs pain in a person with years of life ahead.  The reason for these distinctions relates to the problems with narcotic pain medications, namely tolerance, physical dependence, and addiction.  If a person has pain but has only months to life, the tolerance and addiction issues are unimportant;  the person can be treated with narcotics without much concern about addiction.  Likewise, ‘acute’ pain is pain that is time-limited;  narcotics can be used without a great deal of concern, providing the patient is monitored for signs of developing an addiction to the medications, and provided that the medications are discontinued as soon as possible.

The big challenge is dealing with chronic, nonmalignant pain.  I recommend anyone with this type of pain do an internet search using the terms ‘chronic’ and ‘nonmalignant pain’ and read up on the concerns and options.

The problem with any narcotic, including morphine, is tolerance and dependence.  The dose that works today will be ineffective in a month or two.  If the doctor or patient keeps increasing the dose, eventually there will be significant problems related to dependence and withdrawal– the patient will be on a huge dose of narcotic that no longer works.  So caution must be taken to prevent dose escalation;  many doctors are guilty of giving in to requests for ‘more, more, more’ until they eventually get scared of the dose, throw up their hands and say ‘I can’t treat you anymore’.  Ouch!    It is a difficult spot for the doctor, but of course worse for the patient–  it seems that more medication is the answer… but it simply isn’t.  There MUST be a reasonable limit.

OK, back to the question… there are many alternatives to morphine; some narcotic, some non-narcotic.  For narcotic medications, the general approach is to combine a long-acting narcotic, say a once per day or twice per day medication, with a short-acting medication for ‘breakthrough pain’.  There are many long-acting narcotics out there– oxycontin, opana ER, the fentanyl patch, once-per-day morphine preparations… but again, they all have the danger of tolerance and dependence.

Non-narcotic options require an understanding of the cause of the pain;  pain from nerves (damaged or compressed nerves) will often respond to anticonvulsant-related meds like gabapentin, tegretol, or lyrica; inflammation-related pain responds to NSAIDS like ibuprofen or naprosyn; and acetominophen often adds some relief to any other medication.  Depression makes pain worse, and antidepressants that might help include mainly the SNRI’s like Cymbalta, Effexor, and Pristiq.  The older tricyclics like amitriptyline, in small doses, have proven helpful– particularly taken at night, as they are quite sedating.

For many patients, non-narcotic medications don’t seem to be enough, and there is strong temptation to take narcotics.  That is a huge step;  once a person moves to narcotics for chronic pain it is VERY difficult to ever go back to life without them.  Narcotics usually affect the personality over time;  the person taking them becomes more and more focused on the pain, and on the narcotic, until both become the center of the person’s life.  Hobbies disappear.  Relationships suffer.  Through ‘denial’, the patient doesn’t see this happen, but simply thinks that more medication is the answer.

Because of this problem, there is growing attention to the use of buprenorphine for chronic pain.  The medication has been around for 30 years, but more recently has been developed as an oral preparation used to treat opiate dependence, called Suboxone.  A search for buprenorphine at clinicaltrials.gov will show the growing interest in the medication for pain.  I talk about buprenorphine extensively on my blog Suboxone Talk Zone so I won’t go on and on here, but basically buprenorphine is a ‘partial agonist’ that has strong opiate properties– as potent as about 60 mg of oxycodone– but it has a completely different effect on the patient’s psyche.  When given to opiate addicts, the medication virtually eliminates interest in opiates;  when taken by pain patients there is much less desire or urge to take more than prescribed.  The medication has a ‘ceiling effect’ that helps reduce (but not eliminate!) the risk of overdose.

As I guessed would happen, other companies are jumping onto the R and D bandwagon;  I wrote about a couple other meds in testing in one of my last posts.  Time will tell which meds will make it all the way to the market– a very long trip in the US.

Acute pain e.g. surgery while taking Suboxone

From a patient looking at having surgery:

I’ve been on Suboxone sucessfully for three full years, after ten years on everything up to 100mg fentanyl patches every 48 hours for chronic pain. However, it doesn’t work for acute pain, like having teeth pulled. I’ve been on Lortab 10/650 tabs briefly (1 week) twice in that three years. Pain was not suppressed adequately because of the suboxone. These were painful and no notice extractions. I now know I will lose 7 teeth for dentures in about 10 days. I can cut back on suboxone use (currently 8mg x 2 a day), but without a month or so cannot decrease to the point of total elimination. What level of pain medication will make me comfortable during the 3 to 4 days of initial oral surgical pain and how in the world do I get a dentist / doctor to understand my situation and concern. “Obviously I taking Suboxone because I am an addict and am just asking for drugs” right?

The two times I used Lortab as stated above, I started feeling withdrawl symptoms after just a couple days without any suboxone. My life works on Suboxone, no cravings, much less pain, a lot less burning, exercise daily. I no longer take antidepressants and feel like I can make it, even with the degree of pain I still have. I just have to be carefull and not over do it. Is this all just unecessary worry, or is there something realistic I can do?

Sincerely,
XXXX

My Response:

Surgery is a tough situation for Suboxone patients. I have had a number of patients go through surgery for one thing or another and have settled on the following procedure: if the person is not having significant pain and needs elective surgery, I have them stop the suboxone three days before the surgery, and I give them clonidine and ativan to help with the withdrawal they will have on the second or third day without suboxone. After the surgery they will still be partially blocked, and even those who are not blocked will have a high tolerance, so I usually augment their pain control. I will add to the opiate agonists that they need after surgery, and stop the augmentation at the point where the surgeon usually stops narcotics– my rationale is that a higher dose is needed, but a longer period of time should not be needed.

If a person has a condition that is causing an increase in pain and that also requires surgery, such as an abscessed tooth, I will do the same but instead of giving clonidine and ativan I will give an opiate of some type to treat the pain. It usually takes high doses, as the person is highly blocked for the first couple days off Suboxone.

The problem from my perspective is that I cannot give a bunch of methadone or oxycodone to a person who has ‘street connections’ unless I trust the person absolutely. Every person who has had problems with opiates, myself included, should recognize and acknowledge that the situation is a dangerous one– if I have a patient say ‘what, you don’t trust me?’ red flags go up! Of course I don’t trust you!! I don’t even trust myself!!

Unfortunately, there is tremendous social stigma against addiction and against people who ‘look like addicts’ for one reason or another– and I feel for you, because yes, you will be ‘judged’ by your doctor. The thing that really stinks is that if a person tells their surgeon the truth, explaining why they need more narcotic than usual, the surgeon often responds by giving less narcotic— or giving none at all!! So I have to step in for my patients and try to help as best I can. I cannot do the same for people I don’t know, even though I recognize the tough spot they are in– if I started trying to treat pain in people I hardly knew I would quickly lose my license, and that wouldn’t help anybody.

I would hope that any doc prescribing Suboxone would recognize the tough spot that patients on Suboxone are in when it comes to surgery, and would help them during that period of time. The medication (Suboxone) that the doc is providing you has problems that come with it– namely the blockade that occurs when a real narcotic is needed– and that problem falls squarely on the shoulders of the doc who prescribes Suboxone. At least it should fall there– there are docs who seem to have no shoulders… and shame on them!

I hope your doc will help–there are good docs out there, and the tricky thing is finding them. Thanks for reading and for your question.

SD

PS:  I will add one more thing…  most people take about 16 mg of Suboxone per day to get maximum relief from opiate cravings.  If taken correctly, doses much lower will easily provide full block of their opiate receptors.  The possible need for surgery is the main reason for taking lower doses of Suboxone– because of the ceiling effect there is no real difference in the tolerance level for people on different doses of Suboxone, but the people on lower doses have less buprenorphine in their system and so require less narcotic to overcome the block of their receptors.  The decision over proper dose involves balancing that issue, the cost issue, the amount of cravings, etc to arrive at the proper dose for an individual patient.