A Doctors Advice Regarding Opioid Prescription

Today's post from painnewsnetwork.org (see link below) is advice from one doctor to other medical practitioners regarding the prescription of opioids to chronic pain patients. It's directly applicable to many hundreds of thousands of neuropathy patients who have ended up on opioid management because there's literally been no other option. It's full of common sense and reinforces what this blog has believed from the beginning of this (primarily) USA row and that is that existing chronic patients should never be denied the medication they need to reduce their pain but should be carefully monitored and guided, so that the chances of addiction and over-prescription are minimised. Pain control must be the priority. At the moment, many doctors are refusing to issue new opioid prescriptions because of the fear that they will end up in a law court, or at best, be castigated by their local health authorities. In the meantime, the patient suffers from cold-turkey withdrawal and searches the internet or the black market to find the drugs they need, leading to more criminality and a dangerous and much bigger problem. As I said, this is currently a North American issue but as we all know, what happens in America, happens in the rest of the world shortly after. Panic law-giving and lack of understanding of medical nuances has led to a hysterical media campaign and a profession afraid of its own shadow - this can't be healthy, for patient or professional and needs to be addressed urgently. Definitely worth a read.

Don't Flinch From Prescribing Pain Medications By Forest Tennant, MD, Guest Columnist April 21, 2016

By now chronic pain patients and practitioners are well aware of the new Center for Disease Control and Prevention (CDC) “Guidelines for Opioids for Chronic Pain” released on March 15, 2016. Although these guidelines have been, and will continue to be, strongly criticized for the process by which they were created, they are now published.

One of the often stated goals of CDC, despite widespread skepticism from many pain specialists, is that they did not want to limit access to pain care. Let’s take them at their word.

A major “bone of contention” regarding the guidelines is the recommendation that a daily dose of opioid should seldom go over 90 mg equivalents of morphine a day. In the CDC’s words:

“Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day.”

Thankfully, few chronic pain patients require more than 90 MME for pain management. Be alert, however, to the fact that 90 MME in the guidelines is not a maximum ceiling dose but a “trigger” or “call” for a medical-necessity evaluation, including a possible consultation or referral to a pain specialist.

My personal objection about all the new opioid prescribing guidelines, including CDC’s, is that they seem to want all patients on high-dose opioids to be managed by pain specialists rather than primary care physicians (PCPs).

Unfortunately we don’t have enough pain specialists to medically manage these legitimate, suffering patients who can’t function or leave the couch without an opioid dosage above 90 MME.

While the intent of the CDC to have the most serious pain patients managed strictly by pain specialists may be laudable, this won’t solve our nation’s epidemic of untreated and undertreated chronic pain. Incidentally, the new guidelines rightfully mention all the risks of high-dose opioids, such as addiction, diversion, and overdose; but they wrongfully fail to mention all the serious, life-shortening, and physiologic impairments that are the risks of under treated, severe, chronic pain.

Sadly, without opioids, some of these unfortunate individuals will suffer immense physical dysfunction, endocrine failure (see Hormone Testing and Replacement), cardiovascular collapse, immune dysfunction, dementia, and premature death.

This memo is a plea to not discharge severe pain patients who are currently taking over 90 MME or avoid and deny patients who may need this level of opioid in the future. Be aware that the CDC guidelines do not prohibit dosages over 90 MME—what they rightly recommend is that physicians do an assessment and document medical necessity for dosages above that level.

Here are my personal practice policies and recommendations for dealing with past, current, and future patients who require over 90 MME:

The pain practitioner has to clearly state, in the patient’s chart, that the patient has severe chronic pain due to a specific underlying cause. For a patient to receive high-dosages of opioids, the physician must obtain and document the history, relevant physical exam, laboratory data, informed consent, and past records of treatments that have been tried.

Opioids should not be prescribed in isolation. Rather than just continuing to increase the dose, the physician needs to revisit what other modalities are being used or have been tried. These include: non-opioid medications such as an anticonvulsant if the pain has neuropathic elements, (being certain to titrate up to an effective dose); a topical medication such as Lidoderm patch, Voltaren gel, etc.; a physical therapist-guided home exercise program and other physical activities, including massage; consultation with an interventionist if appropriate; assessment and treatment of co-occurring anxiety or depression.

The new guidelines, in my opinion, could worsen a growing problem of access to medication. Already, in some locales, patients can’t obtain prescriptions and insurance companies don’t want to pay for opioids (or much else!!). If patients need a high, costly opioid dosage, they must personally determine the limits of their insurance coverage and identify pharmacies that will supply opioid medications.

We physicians can help but none of us has the time or influence to help every pain patient with his or her personal supply of medication and insurance issues. Simply stated, a patient must be an active rather than traditional, passive patient: pain patients must now join advocacy groups and begin to lobby for their right to obtain opioids and avoid an agonizing existence and premature death.

Millions of chronic pain patients now take opioids responsibly and constructively. While opioids aren’t for everybody, many pain patients who are taking high-dose opioids have enhanced their overall health, achieved a decent quality of life, and have likely extended their life span. These patients don’t abuse, divert, or overdose on their opioids, and they don’t develop hyperalgesia or the need to continually escalate their dosage. Isn’t it time we pay as much attention to these worthy folks as those who non-comply, abuse, and overdose?

Dr. Forest Tennant is pain management specialist in West Covina, California who has treated chronic pain patients for over 40 years. He has authored over 300 scientific articles and books, and is Editor Emeritus of Practical Pain Management.

This column is republished with permission by Practical Pain Management, which featured the opinions of several other practitioners on the CDC guidelines this month. You can see them all by clicking here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

http://www.painnewsnetwork.org/stories/2016/4/21/dont-flinch-from-prescribing-pain-medications

FDA Advice For Doctors About Nerve Damage From Antibiotics

Today's post from topclassactions.com (see link below) is the latest article warning of the dangers of nerve damage from fluoroquinolone antibiotics. This time the warning comes from the FDA themselves. Last year they instructed the pharmaceutical companies to put warning labels on the boxes of these drugs and now they are advising doctors who prescribe these antibiotics, to be especially alert to symptoms of nerve damage in their patients (at which point of course, it could be too late). There's no doubt that this has been the hot topic in neuropathy circles for some time now but with good reason. If your doctor prescribes antibiotics for you, ask him or her if they belong to the fluoroquinolone group and if they do, don't leave the surgery until you have had a serious discussion as to whether they're going to harm you or not. There are alternatives but successful marketing campaigns have made these drugs the most popular antibiotics around. However, if you're prone to neuropathic problems or have them already you really need to question their value for you.

FDA Advises Doctors to Monitor Antibiotic Users for Nerve Damage 
By Amanda Antell January 13, 2015

Due to the mass concern of fluoroquinolone side effects, the FDA recently announced that it wants healthcare professionals to watch for the risk of peripheral neuropathy in patients prescribed these antibiotics.

As of Aug. 15, 2013, fluoroquinolones had become a major concern for the FDA for a number of reasons, but this particular warning surrounded the devastating side effect peripheral neuropathy, which can cause nerve damage, burning pain, paralysis and more.

The agency advises prescribing physicians to closely monitor patients who are prescribed any members of the fluoroquinolone family, which include the antibiotics levofloxacin (Levaquin), ciprofloxacin (Cipro), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin), and gemifloxacin (Factive).

In its announcement, the FDA reiterated its requirement for manufacturing companies to have their medications’ labels include peripheral neuropathy on their list of side effects, and emphasized the danger with a recent toll of injuries. If not diagnosed in time, this condition can cause severe to permanent damage.

According the FDA’s Center for Drug Evaluation and Research Trade press team, the agency made the decision to update the warning for fluoroquinolone peripheral neuropathy due to the number of injury reports the agency had received. While the agency decided against withdrawing fluoroquinolones from the market, the FDA did revise its systemic benefit and risk evaluations regarding these antibiotics.

A recent review of the FDA’s Adverse Event Reporting System (AERS) Database had identified 83 cases of fluoroquinolone peripheral neuropathy between Jan. 01, 2003 and Aug. 01, 2012; this was the report discussed in the Aug. 15, 2013 FDA warning. Each of these patients had become disabled due to some degree of antibiotic nerve damage, which furthered the FDA’s concern of this possible correlation.

Antibiotic Nerve Damage a Concern for Years

The concern of peripheral neuropathy being associated with fluoroquinolones started in 2004, when the FDA required all fluoroquinolones to carry this risk on their list of side effects.

While the complication of antibiotic nerve damage is a frightening thought, it’s the fact that the injury reports indicate that the condition could start within a few days of starting the medication, and continue for years after stopping it, that has many so concerned. Even in 2015, the FDA and other medical institutes have not managed to identify what exactly causes peripheral neuropathy from antibiotics, but it appears not to be related to age or duration of medication use.

Additionally, during their August 2013 warning, FDA MedWatch stated that physicians should give patients a medication guide for every fluoroquinolone prescription, and patients should be instructed to contact their physicians if they show signs of peripheral neuropathy. While suddenly ceasing medication is not advisable without a physician’s consultation, the FDA generally recommends that the medication should be switched with a non-fluoroquinolone antibiotic, unless the risks of the new antibiotic outweigh the benefits.

Medical experts state that a majority of peripheral neuropathy reports indicate that it is not linked with diabetes, thyroid conditions, vitamin deficiencies, or environmental factors. It is important to note that the risk of peripheral neuropathy is still a relatively recent concern, but remains prevalent because there are no known prevention methods.

Overview of Quinolone Peripheral Neuropathy

Fluoroquinolones are among the most popularly prescribed antibiotics in the United States, and are used to treat a variety of bacterial infections. In 2011, over 23 million patients were prescribed a member from this antibiotic family to treat their conditions. As mentioned before, peripheral neuropathy has been listed as a side effect for fluoroquinolones since 2004, with patients reporting long-lasting or permanent disability, allegedly in direct consequence of using this medication.

Peripheral neuropathy is a condition where the nerves that send signals from the brain and spinal cord become damaged, which disrupts communication with the rest of the body. Symptoms of peripheral neuropathy will vary depending on which nerves are affected. Generally speaking, the symptoms are in the arms and legs and include numbness, tingling, burning, or shooting pain.

It is important to note that peripheral neuropathy symptoms start quickly, and spread just as fast, so it is vital that patients see their physicians immediately.

 http://topclassactions.com/lawsuit-settlements/lawsuit-news/47255-fluoroquinolone-peripheral-neuropathy/