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Thread: Abnormally high dosages of prescribed opioids does not automatically equal Pill Mill

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    Abnormally high dosages of prescribed opioids does not automatically equal Pill Mill 
    #1
    Hello,

    Ive ghosted the forum for years with only the occasional post, but the past year or so it seems that Im reading more and more stories in the media regarding doctors getting in trouble with the DEA for prescribing what would to the general public seem to be abnormally high dosages of opioids to a large portion of their patients, and even reading in this and other drug-related forums that people who's PM doc is prescribing these abnormally high dosages of opioids to are being almost automatically dismissed as pill mill docs, in it for the money, or easy tickets for getting high. Im not saying everybody is assuming this, but it seems to be at minimum an upward rising trend almost everywhere I turn to scrutinize without fail the higher dosing of these medications for non-cancer related illnesses. As if living a life in excruciating pain isn't somehow on the same level as having a terminal illness such as cancer pain-wise physically.

    My close friend has been a pain patient for the past 3 years or so after going years suffering because he was considered too young (was only 27 at the time) to be suffering, as if age had anything to do with it. He is a Type 1 Diabetic, and has been since he was 7 years old, and suffers not only from diabetic neuropathy ( a really tough problem to alleviate), but has two severely herniated discs from an exercise accident in his lower lumbar that cannot be fixed without surgery that his neurosurgeon has recommended against at least for the time being.

    He also happens to be highly deficient in his CYP350 chromosome that metabolizes many opioids, as he was given a test by his PM doc (who is excellent btw) because higher than normal doses of opioids were not giving him sufficient pain relief, and now with technology advancements, we can now see that a very large portion of the population, especially of Northern European descent are deficient in this or another enzyme responsible for the metabolization of various opioids, causing a need for increase, sometimes to very large levels... .as we now know that there really is no ceiling for pain relief for most opioid medications...

    He has received criticism and down right condescending lectures from other docs regarding his large opioid tolerance, but this just goes to show how little most PCP's know about pain management.

    I dont know his exact dosing, but I know its approximately 3 x 80mg OP's spaced evenly daily, times daily and 8mg Dilaudid 2-3 times per day as needed, and 10 mg Opana IR for breakthru pain....along with 60mg Adderall in the morning.

    That is a lot by almost anybodies standards, but for him it works well keeping his pain around a 3/4 out of 10 nearly all day.

    Here are some articles of studies done by one of the most well known and respected PM docs in the country on this very issue...http://http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/genetic-screening-defects-opioid-metabolism-historical

    http://www.practicalpainmanagement.c...h-opioid-doses

    Actually, here is the list of all his written studies, all very good reads for those interested...

    http://foresttennant.com/pain_management_articles.html

    I just felt that it was not spoken of enough and too many people were being labeled as drug seekers and good, responsible, caring doctors were losing their careers over something hardly anybody in the medical establishment talks about outside of pain doctors, especially not the morons at the DEA.

    Take Care and God Bless.
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    #2
    Bluelighter ro4eva's Avatar
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    I had no idea there was no commercial test available yet for possible CYP3A4 deficiency.
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    #3
    Bluelighter Rybee's Avatar
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    I can somewhat relate to this scenario. I'm 24 and had a slipped disc since I was 18 but was often told I was too young to be on potent opioids that 'should only be used in palliative care for cancer patients.' I often get the feeling that most doctors think I'm just after some painkillers for a quick high, though I have MRI's scans that clearly demonstrate I have a quite a severely herniated disc. It's taken me 3 years to be taken seriously and given sufficient pain medication (100mg MS Contin) and 20mg Oramorph for break-through pain. Previous to this I was prescribed 30mg Codeine Phosphate tabs and a bit of Naproxen, it was a joke.

    When my GP asked me what I wanted and I was honest, I said I wanted to try Oramorph because, politely, Codeine was a joke. I got 'that look' and 'that talk' about abuse and addiction. I've not been tested for enzyme levels but have been on max dose (375mg) of Venlafaxine for 2 years so it's a possibility that it was inhibiting CYP2D6 for metabolism, when I raised this issue I was informed that I'd 'obviously been reading up on abusing opioids' which was just a complete joke if anything.

    I do understand hesitation in prescribing opiates/opioids because I guess a lot of patients start out with genuine pain and end up as pill-poppers and doctors do have to be cautious about this, but the reluctance to prescribe me with sufficient painkillers has severely hindered my care and put my life on hold. I had to leave my job in November and have temporarily withdrawn from my masters degree because I'm bed bound most days - even these 2 major life happenings weren't enough to convince doctors that my case was genuine.
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    #4
    Not many people do...I think the more people aware of it can possibly utilize it with their PM doc to adjust needed dosages....
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    #5
    If he was highly deficient in the enzyme a low dose would be very powerful since it wouldn't be metabolized very well. He probably has an incredibly Efficient enzyme, therefore breaking down opioids far more quickly than the average person and needing higher doses.
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    #6
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    My heart goes out to the chronic pain patients. The dea is only making a bad situation worse.
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    Bluelighter ro4eva's Avatar
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    Quote Originally Posted by bukweat View Post
    My heart goes out to the chronic pain patients. The dea is only making a bad situation worse.
    The feeling is mutual.
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    #8
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    Quote Originally Posted by _DankOpiAmp_ View Post
    If he was highly deficient in the enzyme a low dose would be very powerful since it wouldn't be metabolized very well. He probably has an incredibly Efficient enzyme, therefore breaking down opioids far more quickly than the average person and needing higher doses.
    hmmm some things need to be metabolised to stronger compounds ( e.g.tramadol/oxycodone/codeine). surely the way around it is to give the patient an opiate that doesn't need metabolism to be fully effective
    Last edited by pofacedhoe; 25-12-2013 at 22:27.
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    #9
    I want to start by saying how much I feel for those in chronic pain, whom are inadequately treated for their ailments due to the decade long trend of opiates being the "in" drug. I would certainly surmise that due to this phenomenon there is a reluctance by doctors to prescribe opiates for fear that the DEA will come knocking on their door. If you think about it opiate medications have changed so much over the past 15 years, with the introduction of OxyContin being a pivotal event. In Pre-OxyContin days, (this is my recollection) I believe the strongest oxycodone product contained 10 mgs. Hydromorphone capped at 8 mgs, I believe that fentanyl patches were not available until about a decade ago. oxymorphone was capped at 10 mgs ( the infamous blues from drugstore cowboy) however, I believe those were discontinued many many years ago. Methadone has always been available in 10 mg dosages. Not sure about morphine sulfate in those days. Fast forward to mid 1990's and the DEA wanted the pharma companies to develop a painkiller that was longer acting. They did not like the sheer number of pills being prescribed. Imagine how many 10 mg Percocet had to be prescribed for a long-term chronic pain patient. OxyContin was marketed to provide pain relief for 12 hours. This is just speculation, but I'm guessing the expectation was each pain patient would receive two pills per day plus breakthrough meds. The increase in tolerance associated with opiates would be handled by the variety of strengths offered by OC not in the number of pills. I believe it was a change in strategy. For whatever reason many more than two pills per day were prescribed. Once it was discovered that the time release control feature (what a joke) could be broken and the so called genie was out of the bottle it created a generation of opiate addicts.
    Another force was at play as well, which contributed to the current state of affairs. This had to do with the premise that pain should be controlled at all costs. Not sure if this directive came from the AMA or whom, but there was definately a change in philosophy when it came to pain.
    As a result, I think this created a stigma, which is so unfortunate. As the OP points out, it seems like there are misconceptions attached to opiate dosage. It truly is unfortunate, as I don't believe there is a correlation between dosage and addiction. Dosage and dependence, yes, but not addiction.
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    #10
    Quote Originally Posted by pofacedhoe View Post
    hmmm some things need to be metabolised to stronger compounds ( e.g.tramadol/oxycodone/codeine). surely the way around it is to give the patient an opiate that doesn't need metabolism to be fully effective
    The hydromorphone and oxymorphone would not be susceptible to that; also oxycodone is not simply a prodrug as you imply. According to a cited wiki page, oxycodone is metabolized by cytochrome p450 and FAST metabolizers suffer from a reduced analgesic effect.
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    #11
    Bluelighter ro4eva's Avatar
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    Quote Originally Posted by _DankOpiAmp_ View Post
    The hydromorphone and oxymorphone would not be susceptible to that; also oxycodone is not simply a prodrug as you imply. According to a cited wiki page, oxycodone is metabolized by cytochrome p450 and FAST metabolizers suffer from a reduced analgesic effect.
    That's how I've always understood it as well.

    As a poor metabolizer of 2D6 substrates, opiates/opioids such as codeine and tramadol never did provide much analgesia, regardless of my tolerance level, and also the dosage. Doses of codeine ranging from 8mg to 300mg didn't feel like such a big difference.

    In contrast, when I first used oxycodone, it was in the form of one Percocet pill. I couldn't believe how blissfully stoned I was. And, the high lasted about 5 hours (some decent mileage for such a low dose). I'd imagine my poorly performing 2D6 pathway was responsible for the dramatic difference in effect. Then I take a look at a few opioid dosage conversion charts, and they all state that 5mg of oxycodone (orally ingested) is equal to about 60mg of codeine (orally ingested). Difficult to agree with that, even if comparing only the analgesic effect.
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