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Methadone: Public Enemy No. 1

The opioid class painkiller, methadone, is the cause of one in 3 prescription painkiller overdose deaths, despite accounting for only 2 percent of painkiller prescriptions written, reports Kristina Fiore for MedPage Today.

Methadone took center stage in a recent CDC report.  Approximately 5,000 patients died from methadone overdose in 2009, about six times more than 10 years ago.

“Methadone is riskier than other prescription painkillers … and we don’t think it has a role in the treatment of acute pain,” said Thomas Frieden, director of the CDC.

Frieden explained that the proportion of methadone to other painkiller prescriptions is on the rise because insurers have increasingly made it a top-tier drug for chronic pain since it has such a low cost.  Evidence suggests that the increase in methadone overdoses is directly related to the increased use of methadone to treat chronic pain.

It’s  “penny wise and pound foolish …with higher societal costs in terms of death and other problems that can be avoided” Frieden said adding that there are other, safer opiates that should be used for pain.

Frieden cautioned that there’s limited evidence for the efficacy of opiates on chronic pain that is not related to cancer.

I suppose this is simply another example of insurance companies using a cost/benefit analysis on human life.


Marijuana mouth spray seeks FDA approval for pain

sativex spaySativex, is a cannabinoid medicine for the treatment of multiple sclerosis (MS) symptoms, cancer pain, and neuropathic pain developed by GW Pharmaceuticals.  Sativex could be approved in the U.S. as a treatment for pain relief in the next few years.

The British pharmaceutical company is currently testing the drug, which is delivered as a mouth spray, in clinical trials.  The company plans to seek FDA approval of the drug for the treatment of cancer pain when the trails conclude in 2014, according to myhealthnewsdaily.  Currently, Sativex is approved in the U.K., Spain, Germany, Denmark, New Zealand and Canada.

Sativex has a low risk for abuse, according to experts, because any “high” that a patient could receive is delayed compared to traditional smoking methods of marijuana ingestion on the street.  Cultural norms that take place in stoner circles may demand the smoking method.  Although some may consider this naive conjecture, the assumption is based on the low abuse rate of similar synthetic cannabinoids that have been on the market in the U.S. for several decades.

Sativex is the first marijuana-based drug to be made by extracting the compounds from the plant, rather than synthesizing them, which is the case in two other drugs, Marinol and Cesamet that were approved by the FDA in the 1980s.  These two drugs have had low rates of abuse in the past.

Patients can adjust the dose of Sativex to prevent it from entering the blood steam too rapidly, allowing them to experience symptom relief without the high, says GW Pharmaceuticals.  Furthermore, the drug is made up mostly of two ingredients: THC and another cannabinoid called CBD, the latter of which is known to meliorate some of the side effects of THC, such as the high that marijuana users feel.

Opioids and Alternatives according to Dr. Torregiani

Dr. Seth Torregiani wrote a somewhat useful essay today about the state of opioid treatments in the medical marketplace and their viable alternatives.  He argues that while pain pills have a place in treating chronic pain, their usage has ballooned, screening other treatments that could be even more effective.

The original purpose of opioid medicines was for the treatment of pain related to cancer, or for the short-term treatment of moderate to severe pain from injury or following a medical procedure. They have since become the “go-to” medication for pain of all kinds, including chronic pain.

In my opinion, opioids, while they may have a role in chronic pain treatment and may be necessary at times, are not a great choice for the long-term treatment of pain.

…I think it has become incumbent upon the medical community, patients and their advocates as well as insurers and the government to seriously rethink the approach we have adopted as a society to the treatment of pain.



vicoOpioids have become the most prescribed class of drugs in the U.S. despite being potentially dangerous and very easily abused.  Recent studies have shed new light on the dangerous qualities of these drugs.

However, it’s one thing to claim what we all know to be the case—that the potential for overdose and abuse has skyrocketed—but it’s quite another to claim there are treatments out there that are as effective as opioids.  I remain skeptical, especially for cases involving chronic neuropathic pain.  Dr. Torregiani lays out the “wide variety of techniques and therapies that are now available”:

  • “Don’t take a percocet when acetimenophen (Tylenol) will do.”  Tylenol and NSAIDs (non-steroidal anti-inflammatory drugs) like Advil and Aspirin work very well with lower doses of opioid drugs and can reduce the need for higher or more frequent doses of opioids, he argues.  Do people really have opioids stashed away in the medicine cabinet reserved for headaches and minor aches and pain?  I find this bit of advice useless, and somewhat irrational.
  • “Don’t be stoic.”  Really?  Dr. Torregiani encourages patients to not “tough it out” and to always have their pain meds in their system.  I find this to be a useless point.  Usually people suffering from chronic pain want nothing more than to have relief, right?
  • “Honesty is the best policy.”  He makes the superfluous argument that people suffering from chronic pain shouldn’t see the complete eradication of pain as an ultimate goal.  I agree, but would like to add that after many years of suffering from chronic pain, most people wouldn’t be so delusional. “…[A] long-term strategy to manage pain, one that involves the patient, family and friends, employers as well as caregivers, is often the best approach, if a complete cure is unlikely.”  This just seems obvious to me, and unhelpful.
  • “Consider bodywork.”  Now this is some useful advice, and actually relates to the topic of alternative treatment that he originally set out to write about.  The idea is that chronic pain, whether it’s musculoskeletal related or neuropathic, causes additional somatic symptoms such as trigger points and muscle spasms that can be alleviated with some types of manual bodywork.  He specifically cites massage, myofascial release (vigorous massage), Rolfing, chiropractic manipulation, osteopathic manipulation, craniosacral therapy.
  • “Keep moving.”  This is also good advice.  Research suggests that activity is good for chronic pain.  Exercise increases endorphin release, improves blood flow, decreases muscle tension, improves moods, etc.. “I regularly advise my patients to keep moving — whether walking, tai chi, yoga, gardening, stretching.”

Overall, I found Dr. Torregiani’s advice to be well intentioned and out of touch.  I guess perhaps I could be the one who’s out of touch, but I’d be willing to bet that he’s never suffered from chronic pain, nor spent more than a few minutes at a time with his patients.  I think this is an all too common problem in the medical profession based on personal experience as well as a reading of How Doctors Think by Dr. Jerome Groopman.  This book is excellent and makes the case that communication needs to be restored between doctors and their patients in order to optimize care.  Any way, what do you folks think of Dr. Torrengiani’s column?  Could I have overlooked something?

Congress hesitates to impose austere regulations on painkillers

800px-Pills_MC_inverseThe New York Times did a piece today on a bill that would have handed down stricter controls on drugs such as hydrocodone and oxycodone.  Efforts by Congress to pass the bipartisan bill were apparently impeded by a massive wave of lobbying from pharmacists and drugstore chains.  The bill ultimately fell flat yesterday.

Everyone knows about the rampant abuse of pain killers, but what struck me were some of the facts that Congress was looking at.  Apparently abuse has spiked over the past ten years.  A recent report by the federal Centers for Disease Control and Preventions said that lethal overdoses involving prescription painkillers are at “epidemic levels” and currently kill more Americans than heroin and cocaine combined.  “The death toll from overdose of prescription painkillers has more than tripled in the past decade.”  Wow!  Please everyone, be very careful with your medications!

I guess what the pharmacists and drugstores objected to was the high cost that it would take to comply with tightened security, e.g. storage would require more substantial safes, etc.  They also claimed that it would be harder for us, the patients, to get out meds, but there seems to be some contention on that point.

I personally understand the need to address the out-of-control abuse of these drugs, but I’m not sure these measures would be the best angle to attack it from.  I feel like it’s already a pain to get narcotic medications, and placing more hoops in front of people isn’t going to solve the problem.  Perhaps pain management doctors are  prescribing recklessly.  I know there aren’t really any viable alternatives, but passing the buck onto the drugstores is rather unfair.  It’s a very difficult and concerning issue to take on, and I can’t imagine many easy answers. 

I guess the moral of the story is to be careful with your meds.  Does anyone have any thoughtful comments on the issue?