The FDA recently released a Drug Safety Announcement regarding the use of codeine in young children after tonsillectomy/adenoidectomy surgery for obstructive sleep apnea.  I was somewhat surprised to see a safety announcement on a medication that has been in use for decades, but the release underscores our improved knowledge of drug metabolism, and the broadening demographics of the United States.

Codeine has little activity at opioid receptors.  The analgesic effects of codeine are actually caused by morphine, after the conversion of codeine to morphine at the liver.  The conversion is catalyzed by an enzyme called CYP2D6, part of the cytochrome system of enzymes that are involved in the breakdown of a number of compounds.

I have written about the addictiveness of narcotic pain medications.  People addicted to opioids often go to significant lengths to obtain prescriptions for narcotic pain relievers from healthcare practitioners.  Emergency room physicians and nurses become aware of the efforts of ‘narcotic-seekers’, which range from faking pain symptoms or dental injuries to self-catheterization and instilling blood into the bladder to fake kidney stones.  Distinguishing those with real pain from those who are addicted and not experiencing pain is a serious situation, but doctors roll their eyes at some of the more-typical presentations.  One such situation is the patient who reports an ‘allergy’ to all of the weaker narcotics, and claims that ‘the only drug that works is (insert Dilaudid, morphine, oxycodone, or another potent opioid here).

Codeine is one drug that is commonly rejected as ‘ineffective’ as part of a request for something stronger.  When I was a medical student, we assumed that requests for something other than codeine were disingenuous.  But at some point, maybe 15 years ago, I remember reading an article that described the conversion of codeine to morphine by the liver.  The article reported that the enzyme that performs the conversion exists in varying forms across the population, with some ethnic groups having more active forms of the enzyme than others.  Some people have very low levels of CYP2D6, and therefore get very little analgesia from codeine.  In …

I’ve described the ongoing debate over the use of opioids to treat chronic pain.  To catch new readers up to speed, the country is in the midst of an epidemic of deaths due to overdose on pain medications or heroin.  The epidemic is evident to anyone who spends even a few minutes searching the internet using the keywords ‘overdose deaths.’   Another increasing phenomenon is the prosecution of physicians whose patients have died from overdose.  Physicians have been found guilty of manslaughter, even when people used the prescribed medication inappropriately, far outside of prescribed guidelines.  It is no surprise that in response, many doctors have stopped treating pain with opioids altogether.

I’ve described one group of physicians, Physicians for Responsible Opioid Prescribing or PROP, who have taken a position seen as extreme by some other physician groups, particularly groups involved in advocating for pain relief.  The latest efforts by PROP have resulted in a direct conflict with pain advocacy groups.  Readers of this blog who are interested in the issue can have a direct impact on the outcome of the situation.

Medications approved by the FDA have been shown through scientific study to be effective and safe enough to justify their use.  At present, opioid pain medications are indicated for moderate or severe pain.  There are no other restrictions on the use of pain medications from the FDA, but use of all medications, including opioids, must be within the ‘standard of care,’ a general pattern of practice in a given area that is sometimes difficult to pinpoint.

PROP has asked the FDA to change the indications to state that opioid pain medications are to be used only for severe pain.  They also asked that opioids be recommended for use for a maximum of 90 days, and never in doses greater than the equivalent of 100 mg of morphine.  They base their request on studies that have shown that some patients develop a condition of increased pain, when maintained on opioids for a prolonged period of time.  They are also concerned about the large numbers of deaths from opioids, …

I subscribe to Google news alerts for the phrase ‘overdose deaths.’  Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.

Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.

I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.

In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts.  On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even …

I hope that people recognize the tongue-in-cheek nature of the title.  After working as a physician in various roles over a period of 20 years, I can state with absolute confidence that the answer to the question is ‘yes’.

I’ve written numerous times about the writer/activist for the Salem-News.com website, Marianne Skolek.  I don’t know if she writes for the print edition as well, but at any rate I somehow was planted on a mailing list that provides constant updates on what she calls the battle against Purdue and ‘big pharma’.

People with a stake in the outcome of this battle may want to stay current, and even see if their Senators are involved in the process.  The investigation was launched in early May, by the Senate Committee on Finance, and at this point has asked for documents from several pharmaceutical companies, including Purdue, the manufacturer of oxycontin– a medication that has become the focus for most of the wrath of those affected by opioid dependence.

The investigation will include a number of groups whose missions are (or in some cases, were) to advocate for pain relief, including the American Pain Foundation, the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the University of Wisconsin Pain and Policy Studies Group and the Joint Commission.

I’ve written about the Pain Relief Network in prior posts — one side of the battle between those trying to limit access to schedule II opioids (led by PROP, or Physicians for Responsible Opioid Prescribing), and until recently, the Pain Relief Network, or PRN.

If you haven’t read my earlier posts on the subject, I encourage you to do so;  the final chapter, including the death of PRN’s founder in a plane crash, had all of the drama of a made-for-TV movie.  PRN suffered a number of consecutive blows, including the founder’s death, the loss of a major case against a ‘pill-pushing’ doctor, and investigations into PRN’s finances by the prosecutors of the doctor’s case.

PRN did things that angered too many people, including placing a billboard for jurors to see on the way to the doctor’s case; a deliberate ‘spit in the eye’ of the judge and prosecutors in the case.  At some point, I think PRN went too far, and discovered that they didn’t have quite as much power as they thought. PRN no longer exists.

My dad used to tell a joke about a bunch of soldiers sitting around the barracks.

One old guy yelled 31! – and the place broke out in laughter.  After a moment or two, another guy yelled 52! – and more laughter erupted.  Then a depressed-looking guy in the corner yelled 29! — followed by silence.  He yelled again, 68!—and again, the room was silent.

The new recruit asked the guy in the next bunk what was going on.  The guy answered, “we’ve been together so long that we know each others’ jokes too well—we decided to just number ‘em and save us the time.”

The new guy asked again, “but what about that guy in the corner?”

“Oh—that’s just Slim—he never could tell a joke.”

I recently exchanged emails with a patient about his complaints of back pain.  After reading about his symptoms and history by email, I told him– prior to his first visit– that I would consider treating his back pain and his use of opioids using buprenorphine, but I would not prescribe opioid agonists.

We met and started buprenorphine, but after the second or third visit, he began asking for opioid agonists.

Next month I will be presenting a paper at the annual meeting of ASAM, the American Society of Addiction Medicine.  The paper discusses a new method for treating chronic pain, using a combination of buprenorphine and opioid agonists.  In my experience, the combination works very well, providing excellent analgesia and at the same time reducing—even eliminating– the euphoria from opioids.

Ten years ago, I would have really been onto something. Back then there were calls from all corners to improve the pain control for patients.  The popular belief regarding pain control was that some unfortunate patients were being denied adequate doses of opioid medications. I remember our hospital administrators, in advance of the next JCAHO visit, worried about pain relief in patients who for one or another reason couldn’t describe or report their pain. Posters were put up in each patient room, showing simple drawings of facial expressions ranging from smiles to frowns, so that patients in pain could simply point at the face that exhibited their own level of misery.

What a difference a decade makes!  Purdue Pharma, the manufacturer of Oxycontin, was fined over $600 million for claims that their medication was less addictive than other, immediate-release pain-killers. Thousands of young Americans have died from overdoses of pain medications, many that came from their parents’ medicine cabinets.  Physician members of PROP, Physicians for Responsible Opioid Prescribing, have called out physicians at the University of Wisconsin School of Medicine and Public Health for having ties to Purdue while arguing against added regulations for potent narcotics.

A reader sent a link to a recent NYT editorial about the lack of pain medications in some countries.  The writer of the editorial injured his leg while traveling in Africa, and was dismayed to find that opioid pain medications were in limited supply, with only enough for patients admitted to the hospital.

The writer went on to describe a number of developing countries where pain medications are in short supply, and in some cases totally unavailable.  He described hospitals and clinics where he was visited, where patients await treatment for horrible injuries without so much as a tablet of Tylenol.

I don’t want to rewrite the editorial, and I cannot copy it, for obvious copyright reasons– so you’ll have to follow the link.  The story mentions the efforts of a group called ‘GAPRI’, for Global Access to Pain Relief, that tries to reduce barriers to effect pain relief measures in developing countries.

Wow. I just read an email about a story that I was vaguely aware of– about a doctor in Kansas and his wife, who were together linked to scores of overdose deaths. But that is just the beginning. The doctor was supported, during his trial, by Siobhan Reynolds, founder of a nonprofit advocacy group called ‘Pain Relief Network.’ She started the group back in 2003, when her ex-husband was suffering from severe pain from a congenital connective tissue disorder.

He (the ex-husband) found relief in combinations of high-dose opioids and benzodiazepines, at least until his doctor, Virginia pain specialist William Hurwitz, was convicted on 16 counts of drug trafficking. The ex died, by the way, in 2006. Are you still with me?

The trial of the Kansas doctor, Stephen Schneider, went on for years. During the trial, Ms. Reynolds apparently helped support what she considered to be a ‘dream team’ of attorneys. She used the case as an opportunity to increase her visibility, encouraging the Schneiders to aggressively fight the charges against them on the basis of ‘patient rights.’ Ms. Reynolds, through the Schneiders, argued that suffering patients are being denied appropriate care because of a war, waged by overly-aggressive prosecutors, against doctors who prescribe pain medication.

I’ve described the ongoing debate over use of opioids for chronic pain, and shared information about a group of physicians who are attempting to reduce the damage caused by careless over-prescribing.  Their attempts have created some backlash, as described here.

Feel free to comment in response — here or there, or both!

http://seattletimes.nwsource.com/html/localnews/2012873602_drugs12m.html

Pills photo available from Shutterstock.