Opioids, spines, and dead people

Friend and colleague David Deitz, MD, PhD, was kind enough to provide his perspective on two seemingly-unconnected items in the current issue of the New England Journal of Medicine that are highly relevant for medical providers treating occupational injuries.  Here’s his view:

Deitz – The first is an editorial by Drs. Thomas Frieden and Debra Houry from the Centers for Disease Control (CDC) reviewing the new CDC opioid prescribing guideline. It’s a concise review of what led the CDC to develop the guideline, as well as a clear statement of what CDC hopes to achieve. The money quote is this one: “We know of no other medication routinely used for a non-fatal condition that kills patients so frequently.”

Included in the same issue is one of a regular series of Images in Clinical Medicine – this one entitled Resolution of Lumbar Disc Herniation without Surgery. You don’t need a medical education of any kind to interpret this one – the pair of MRI images beautifully demonstrates a large disc herniation which resolves over a 5-month period. Nothing surprising to students of low back pain, there is abundant literature demonstrating that the best care for the majority of patients with lumbar disc herniation is conservative – maintaining physical activity as much as possible while waiting for the natural resolution demonstrated again in this case.

While I don’t think the Journal editors intended the irony, it’s sobering to think about how many opioids have been prescribed to injured workers over the last 20 years for this condition, and its (often unnecessary) surgical consequences. One of the most common conditions in WC, and a routinely-prescribed medication with potentially fatal consequences. Hopefully, we’re starting to do better.

Paduda – In a related piece, Michael Van Korff ScD andGary Franklin MD MPH summarize the iatrogenic disaster driven by opioid over-prescribing.  Over the last fifteen years, almost 200,000 prescription opioid overdose deaths have occurred in the US, with most deaths from medically-prescribed opioids.

Doctors prescribed opioids that killed well over a hundred thousand people.

Here’s one

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Today, about 10 million Americans are using doctor-prescribed opioids; somewhere between 10% – 40% may have prescription opioid use disorder – they may well be addicted.

Van Korff and Franklin note that 60% of overdose fatalities were prescribed dosages greater than a 50 mg morphine equivalent.

This despite evidence suggesting “neither high opioid dose nor dose escalation improves patient outcomes.”

The authors suggest three immediate steps we can take:

  1. Avoid ill-advised and unplanned initiation of COT (chronic opioid therapy). Don’t prescribe more than 10 pills initially, check the Prescription Drug Monitoring Program database, educate the patient.
  2. Regulators and legislators need to change policies and regulations to reflect what we KNOW about COT and its inherent dangers.
  3. Considerably enhance population surveillance of opioid prescribing and safety.  The FDA should expand its postmarketing surveillance program for long-acting opioids to patients using short-acting versions.

What should you do about this?

  1. Do NOT allow opioids for “herniated” disks.  (I know, easier said than done…)
  2. Require a pre-auth for ALL acting opioid scripts, and all increases in dosage above 50 mg MED.
  3. Wherever and whenever possible, ensure prescribing docs check PDMPs, educate patients, limit initial scripts, complete an opioid agreement.
  4. Educate patients – for those already on excessive dosages, have your nurses contact the patient to educate them on the potentially fatal risk inherent in long-term use of opioids.

11 thoughts on “Opioids, spines, and dead people

    • Agree! Educate the providers. When they\’re resistant, use your IME to stop the prescribing. Opioids are a huge money maker for docs so their incentive to prescribe is huge. Patient safety seems to not be the most important factor, so countering that with another doctor\’s opinion can be the best way to \’just say no\’.

  1. How simple it all sounds until you have to live with chronic pain with nothing to help. Spine injections? Expensive and temporary at best. I have dealt with chronic pain for several years now, and nothing is helping. Been through all kinds of therapies and endless tests for lyme, lupus and etc.

    Chronic pain is awful and sucks the life out of you. Because so many folks have abused these drugs it hurts those of us that don’t abuse. Instead, I have to live with chronic pain. I no longer have any choices left. Unless I head towards street drugs or just plain commit suicide.

  2. The use of appropriate medications within a structured program is still available to chronic pain patients. The issue remains that many patients with acute pain end up with unnecessary surgeries or addiction to pain meds with all the bad consequences that come with that. Ongoing physician education, policy development and enforcement and awareness are the keys to changing their behavior.

      • Mark – unfortunately that is not necessarily an option and not necessarily true. I have suffered from chronic pain for over 9 years with very little support and understanding after 2 neck fusions and a serious situation after the 1st one – became paralyzed temporarily – ended up in rehab for a month – they worked with me for about 4 months. I tried to get more help but the medical community does not really listen to those of us who deal with chronic pain. May be you do and have been lucky but I sure have not.

  3. Angie J – There is a way for you to find out what is truly causing your chronic pain experience, and then using that information to help yourself resolve your pain, possibly with non-aggressive treatments or opioids. You may have a physical-sensory cause (which needs to be addressed), or you may just have a neural-biological cause [real pain] that if addressed, can significantly reduce or eliminate most of your pain. You need to know the real factors causing your pain, so that you can address them, and get back your life.

    Check out our website, or have a primary care doctor you trust do so. I’m confident there is a good chance we can help you.

  4. I know why I have pain – my history explains itself yet very little help after the initial 4 months. It is not that easy.

  5. It would be nice if “IME doctors” occasionally backed adequate alternative treatment. Generally they just announce that the patient’s “subjective symptoms” are not backed by “significant findings”, cut off their only source of income and order them back to cleaning thirty hotel rooms per shift, or cutting up hog carcasses on a high speed assembly line. The latest fashion — declaring the patient a “drug seeker” and recommending he be “weaned” from opioids over a three-to-four week period with no support and no alternate treatment.

    The worst part? The same adjuster who kicks a chronic pain patient off his “inappropriate narcotics” then hangs up the phone and cheerfully signs off on second-rate, Norco-intensive care for the guy with the brand-new back injury! Because, you see, it’s cheaper than physical therapy or adequate time off.

    We need serious answers to the opioid crisis. Sadly, I have learned not to expect them from the workers-comp insurance profiteers.

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