Ketamine’s antidepressive effects
tied to opioid system in brain
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The New England Journal of Medicine published a report from Harvard researchers on March 14, 2019, entitled
“Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012–2017.”
They found a “29% reduction in the number of providers who initiated opioid therapy in any patient who had not used opioids, from 114,043 in July 2012 to 80,462 in December 2017.”
Two of my own physicians, both distinguished, outstanding – an internist and a specialty cardiologist who does painful procedures – have said they will never prescribe opioids again. If I ever need an opioid for pain, it is possible I may never be able to get a prescription.
One of my pain management colleagues has defended 6 colleagues in the last 6 months before the Medical Board.
This is just the beginning of Opioid Intimidation perpetuated by government and CDC. It is deeply worrisome and it is getting worse.
We have a shortage of pain management specialists and those that have survived mostly do procedures, delegating prescription writing to PA’s and NP’s because it is time consuming and does not pay. There is a formidable barrier of denials by insurers for nonopioid medications, physical therapy, acupuncture, yoga, Pilates, cognitive behavioral therapy, and all compounded medications. Denials have become voluminous for at least 10 years. The process is not only time consuming, it is expensive, it wears us all down, inflicts horrific cruelty on patients, and to top it all off the appeals system is a joke.
Who would want to go into the pain management field ever again?
Stay tuned for more stories to come.
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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.
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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.
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For My Home Page, click here:
Welcome to my Weblog on Pain Management!
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HHS Inter-Agency Task Force Urges New Ways to Limit Opioid Use and Addiction
In related news, pain patients everywhere rejoiced when Cindy Steinberg, National Director of Policy and Advocacy for the US Pain Foundation, spoke in front of the Senate Committee on Health, Education, Labor, and Pensions (HELP) on February 12, 2019.2 Steinberg, an advocate for the betterment of care for members of the pain community, lives with chronic back pain as a result of a workplace accident.
In her testimony, she urged Congress to restore more balance to opioid prescribing and improve pain care overall by funding and implementing measures outlined in the Pain Management Best Practices draft report released by the above-noted Inter-Agency Task Force, emphasizing the importance of investing in research on safer, more effective treatment options ranging from medical devices to medical cannabis.
In particular, Steinberg, who spoke to the Senators while lying in a cot due to her own chronic pain condition, brought up two points that counteract the current opioid climate, including the fact that:
She added, “It is essential that treating clinicians be permitted to evaluate individual benefits and risks for each patient and that all appropriate pharmacological, interventional and complementary therapies remain available.”
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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.
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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.
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For My Home Page, click here:
Welcome to my Weblog on Pain Management!
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The CMS opioid overutilization criteria may not accurately identify patients at risk for opioid use disorder or overdose, according to a research letter published in JAMA.
“Based on the CMS opioid overutilization criteria, the majority of the Medicare Part D patients diagnosed with opioid use disorder or overdose were not identified as ‘opioid overutilizers,’ and more than half of ‘opioid overutilizers’ did not develop opioid use disorder or overdose during the study period,” Yu-Jung Jenny Wei, PhD, Msc, assistant professor of pharmaceutical outcomes and policy at the College of Pharmacy, University of Florida, told Healio Primary Care Today. “The CMS criteria seem not to be a good clinical marker for identifying patients at risk for opioid-related adverse events.”
To estimate the predictive value of the CMS opioid overutilization criteria in correctly identifying prescription opioid users at risk for opioid use disorder or overdose, researchers used the 5% Medicare sample from 2011 through 2014 from which they identified between 142,036 and 190,320 beneficiaries who had at least one opioid prescription filled every 6 months, were continuously enrolled in Parts A, B and D and who met the CMS criteria as opioid overutilizers. Opioid utilization was defined as receiving prescription opioids with a mean daily morphine equivalent dose 90 mg from more than three prescribers and pharmacists or receiving a mean daily morphine equivalent dose of 90 mg by more than four prescribers.
Breaking the study period into three 6-month cycles, researchers examined the performance measures over time to assess if accuracy changed with increasing efforts to combat the opioid crisis.
During any 6-month cycle, the proportion of beneficiaries who met CMS overutilization criteria ranged from 0.37% to 0.58%.
Throughout the entire 18-month follow-up, researchers found that the proportion of patients who had a diagnosis of opioid use disorder or overdose increased from 3.91% in the first cycle to 7.55% in the last.
In addition, researchers observed low sensitivity of the criteria which ranged from 4.96% (95% CI, 4.42-5.58) at the beginning of the study period to 2.52% (95% CI, 2.26-2.81) at the end (P < .001).
The CMS opioid overutilization criteria may not accurately identify patients at risk for opioid use disorder or overdose.Source: Adobe Stock
Positive predictive values ranged from 35.2% (95% CI, 32.14-38.38) to 50.95% (95% CI, 47-54.86) and specificity was greater than 99% in all cycles.
“CMS has required their Medicare Part D plans to implement the criteria,” Wei said. “It’s unclear the effectiveness of such criteria in stopping our national opioid epidemic and whether there are unintended consequences of such implementation. As we are developing solutions to the opioid crisis, it’s important for policymakers, health care providers, hospitals and health insurance companies to be aware that solely relying on opioid prescription data is likely to be ineffective in identifying the high-risk populations for interventions.” – by Melissa J. Webb
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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.
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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.
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For My Home Page, click here: Welcome to my Weblog on Pain Management!
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CLIMATE OF FEAR
WASHINGTON — Patients with chronic pain are suffering from ham-handed efforts to curb opioid overdoses, a series of witnesses told the Senate Health, Education, Labor and Pensions (HELP) Committee on Tuesday.
In particular, the CDC’s 2016 guidelines for opioid prescribing came under heavy fire, as even a self-described supporter of its recommendations admitted the evidence base was weak.
In 2018, Congress passed the SUPPORT for Patients and Communities Act, which included billions of dollars in funding aimed at curbing the overdose epidemic and expanding access to treatment for those with substance use disorders.
About 50 million Americans suffer from chronic pain and almost 20 million have high-impact chronic pain. At the same time, more than 70,000 people died from drug overdoses in 2018, often involving opioids, said HELP Committee Chairman Lamar Alexander (R-Tenn.) at the start of Monday’s hearing.
Even as Congress tries to dramatically curb the supply and the use of opioids, “we want to make sure … that we keep in mind those people who are hurting,” said Alexander.
Cindy Steinberg, national director of policy and advocacy for the U.S. Pain Foundation, argued that well-intentioned efforts to address the epidemic — particularly strategies to tamp down overprescribing — have stoked a “climate of fear” among doctors.
Thousands of patients with chronic pain have been forcibly tapered off their medications or dropped from care by their physicians, said Steinberg. (Physicians in California, under threat of medical-board sanction if patients die from overdoses, have reported similar reactions.)
Such decisions are “inhumane and morally reprehensible,” she said.
Steinberg, herself a pain patient, said she takes opioids in order to function. Eighteen years ago, Steinberg was injured when a set of cabinets fell on her. Since her accident, she experiences constant pain, she said, and throughout the hearing she took breaks from testifying to recline on a cot and pillow.
She was especially critical of the CDC’s opioid guidelines, which included recommendations regarding the number of days and dosage limits for certain pain patients.
“When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed,” notes a CDC fact sheet.
These recommendations have been “taken as law,” she said.
In 2016, Massachusetts set a 7-day limit on first-time opioid prescriptions, according to the National Conference of State Legislatures, which counted 33 states with laws limiting opioid scripts as of October 2018.
Steinberg said the guidelines should be rewritten.
Because of the CDC’s reputation, “people think that those [guidelines] are based on strong science and they’re not,” Steinberg said. Pain consultants were not involved in the development of the guidelines, she said.
(Voicing similar concerns in November, the American Medical Association passed a resolution opposing blanket limits on the amount and dosage of opioids that physicians can prescribe.)
Steinberg pointed instead to the Pain Management Best Practices Inter-Agency Task Force, a group appointed by Congress of which she is a member, which issued its own draft recommendations in December.
Alternatively, the NIH (which she noted has an office dedicated to pain policy) could be asked to make recommendations, she suggested.
Halena Gazelka, MD, chair of the Mayo Clinic Opioid Stewardship Program in Rochester, Minnesota, pointed out that the guidelines were “intended to advise primary care providers” and not to provide “hard and fast rules.”
“I actually like the CDC guidelines,” Gazelka said. Mayo’s own guidelines are based on the CDC’s. However, “the doses that are mentioned, probably are not scientifically-based, as we would prefer that they would be,” she acknowledged.
Another challenge for some pain patients are situations that pit prescribers against pharmacists, said Sen. Lisa Murkowski (R-Alaska).
“It’s the pharmacists that are refusing to fill the prescription the doctor has prescribed,” she said, blaming the CDC guidance. Pharmacists are following it out of “an abundance of caution,” including in cases where abuse is not suspected, she suggested.
Steinberg said, “I think we need public education about pain and the fact that pain is a disease itself. … Pharmacists are not getting proper training in that, I don’t think anyone is getting proper training in pain.” She asserted that veterinarians get nearly 10 times as many hours of pain management training as do medical students.
Andrew Coop, PhD, of the University of Maryland School of Pharmacy in Baltimore, returned to the CDC guideline. “I think those guidances on the quotas, I think they’ve been taken too far and that needs to be rolled back.”
Improving Care
In exploring other ways to improve care for patients with chronic pain, Gazelka recalled the pain clinics that existed 30 years ago, which included a physician, a psychologist, and a physical therapist.
“It would be ideal to return to a situation where people could have all of that care in one place,” Gazelka told MedPage Today after the hearing. But most small practices and even institutions may not have the same blend of clinicians, and the cost could be “prohibitive,” she said.
Access to specialists also poses a problem, noted witnesses as well as senators.
In her own pain group, it takes patients more than a year to get an appointment with pain specialists, Steinberg said. She encouraged Congress to “incentivize” pain management as a specialty.
Gazelka agreed and suggested leveraging telemedicine and electronic health records to extend the reach of existing specialists.
Telemedicine can allow primary care physicians to consult with pain management specialists, she said. Also, in Mayo’s own controlled substances advisory group, she and other specialists review cases submitted by primary care clinicians and provide advice directly into the patient’s medical record. However, Gazelka noted that privacy protections in some states might disallow that.
Gazelka noted that insurance coverage can be a barrier to non-opioid alternatives. For example, the Mayo Clinic has a Pain Rehabilitation Center staffed by specialists in pain medicine, physical therapy, occupational therapy, biofeedback, and nursing that aims to treat pain without opioids. But Medicaid won’t pay for it, she testified.
Witnesses also spoke of efforts to develop non-addictive painkillers, such as NIH’s Helping to End Addiction Long-term program.
Steinberg called these efforts “a great start” but noted that only 2% of the NIH’s budget is directed towards pain research. Funding should be “commensurate with the burden of pain,” she said.
Finally, Coop pressed the committee to take seriously the potential of medical marijuana.
Acknowledging that it’s a controversial area, he stressed the need for “good consistent, well-designed clinical studies with good consistent material,” referring to the type of marijuana used.
But speaking to reporters after the hearing, Alexander was cautious. “I’ve supported giving states the right to make decisions about medical marijuana. That’s about as far as I’m willing to go right now.”
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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.
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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.
~~~~~
For My Home Page, click here: Welcome to my Weblog on Pain Management!
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Please ignore the ads below. They are not from me.
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Please ignore the Advertising – has nothing to do with me.
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Your participation in HelloMD studies is invaluable as it takes us one big step closer to showing healthcare professionals, elected officials and the public at large the potential for cannabis to alleviate the opioid crisis our nation is experiencing.
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Finally, we highlight Dr. Gary Richter, the ‘Cannabis Pet Vet’, who has made it his mission to help animals and their owners lead happy, healthy lives.
Be happy & healthy,
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One of the study’s leaders, UVA anesthesiologist Marcel Durieux, MD, PhD, said the impetus behind the pain score improvements is likely attributable to several factors. One, previous research has indicated opioids can ultimately make people more sensitive to pain. And two, the increased use of non-opioid painkillers like lidocaine and acetaminophen during surgeries at UVA was likely effective.
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….”There is very clear evidence that people can become opioid-dependent because of the drugs they get during and after surgery,” said Dr. Durieux. “I think that by substantially limiting opioids during surgery, we’ve made an important step in addressing that problem.”
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Tools |
# of Items |
Administered |
Patients considered for long-term opioid therapy: |
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ORT Opioid Risk Tool |
5 |
By patient |
SOAPP® Screener & Opioid Assessment for Patients w/ Pain |
24, 14, & 5 |
By patient |
DIRE Diagnosis, Intractability, Risk, & Efficacy Score |
7 |
By clinician |
Characterize misuse once opioid treatments begins: |
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PMQ Pain Medication Questionnaire |
26 |
By patient |
COMM Current Opioid Misuse Measure |
17 |
By patient |
PDUQ Prescription Drug Use Questionnaire |
40 |
By clinician |
Not specific to pain populations: |
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CAGE-AID Cut Down, Annoyed, Guilty, Eye-Opener Tool, Adjusted to Include Drugs |
4 |
By clinician |
RAFFT Relax, Alone, Friends, Family, Trouble |
5 |
By patient |
DAST Drug Abuse Screening Test |
28 |
By patient |
SBIRT Screening, Brief Intervention, & Referral to Treatment |
Varies |
By clinician
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By 2014, the price was almost $19 a vial.”
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“Peter Grace, a neuroscientist at the University of Colorado (CU), Boulder, and his team has been trying to trace hyperalgesia to the way opioids affect the immune system.”
© 2016 American Association for the Advancement of Science
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Do they live in your neighborhood?
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It would be unAmerican to publish their names and addresses.
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With the world’s eyes on this nationwide experiment, they allow Rectal suppository morphine. That’s all folks.
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Head to my front page if you want
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