Pharmakonis
Greenlighter
- Joined
- Jun 10, 2016
- Messages
- 12
A documentary released widely in January 2017 entitled Dr. Feelgood: Dealer or Healer? chronicles the explosion of prescription opioid analgesics onto the scene in the mid 1990's and the misapplication of information known regarding opioids in chronic pain conditions.
This documentary is currently available on Netflix, as well as other outlets after being selected for several film festivals of 2016. While the whole film is an interesting look into what we already know, at least anecdotally, about long-term opioid use, there is a specific aspect I would like to address and was brought up in the films, but not focused on adequately in my opinion. This aspect is the lack of an absolute maximum dose for pure opioid agonists. It seems that the idea that there is indeed no hindrance to use of increasing doses of pure (mu-) agonists is given little credence. While it is obvious that addicts exploited this belief to their own detriment and the Dr. Hurwitz, this is what I saw to be the only focus of the idea (of ever-escalating doses). Indeed, the only absolute reason why dose escalation AKA titration-to-effect is the development of respiratory drive depression and other attendant complications of CNS depression. However, taking a look at a patient's documented medication regimen displayed during the film reveals what can only be looked at as clear misapplication of the principle. The patient is a chronic back pain patient who did not have their vertebrae properly stabilized during surgery, and had subsequently more severe pain than was anticipated following the surgical procedure. Even though the regimen shown would normally be expected to develop over a period of decades of opioid use, in reality several (3-5 years) had elapsed at most. The regimen displayed on screen was as follows (these are at most 15 day supplies given the signatura [sig] line):
–Klonopin 2.0mg Disp #30 Sig 2 tabs Q HS No Refills > Total of 60mg of the controlled API clonazepam per Rx, 4mg per day at bedtime...
–OxyContin 80.0mg Disp #200 Sig 5 tabs TID > Total of 16,000mg (16g) of the controlled API oxycodone HCl per Rx, 1,200mg (1.2g) per day, 400mg per dose (!)
–Dilaudid 4.0mg Disp #400 Sig 10 tabs Q 4-5h > Total of 1,600mg (1.6g) of the controlled API hydromorphone HCl per Rx, 240mg per day, 40mg per dose 6x daily.
–Oxycodone 5.0mg Disp #1500 Sig 20 tabs Q 3-4h PRN breakthrough pain > Total of 7,500 (7.5g) of the controlled API oxycodone HCl per Rx, 600mg per day if taken every 4h, and a total now of 1800mg of oxycodone between the CR form present in OxyContin® and the IR form present in Oxycodone HCl IR tablets (generic) (!)
–Methadone 10.0mg Disp #60 Sig 4 tabs Q HS > Total of 600mg of the controlled API methadone HCl per Rx, 40mg per day taken as a single 40mg dose at the "hour of sleep..."
Now, I have seen some aggressive pain management control regimens in my time, especially with severe chronic pain associated with malignancy. As we now know, chronic pain not associated with malignancy can be just as severe and warrant properly tailored treatments as that pain associated with malignancy. All that said, this is a incredible dosing regiment! I have difficulty believing the patient would need any benzodiazepine or related sedative-hypnotic to assist in sleep as the steady intake throughout the day of three different narcotic analgesics, oxycodone, hydromorphone & methadone, with the last agonist being administered entirely at bedtime, its long half-life means it will still be at work well through the next day. The neuroexcitatory properties of both hydromorphone and methadone along with metabolites thereof, contribute to the lowering of the seizure threshold and possible development of an excited delirium may be the indicator used to warrant the administration of a benzodiazepine like clonazepam which is particularly effective in controlling seizures.
This patient was also receiving S.L. buprenorphine 0.3mg after formal treatments. The patient was monitored particularly closely as they had endorsed a history of cocaine use. Additionally, the amounts of medication being prescribed were such that no drug was prescribed with supply for more than 15 days so the patient was being seen at least bi-monthly.
After reviewing this list and the frankly outrageously large quantities of drugs being dispensed, I was hoping to get the feedback of other users on such a regimen.
~Pharmakonis
This documentary is currently available on Netflix, as well as other outlets after being selected for several film festivals of 2016. While the whole film is an interesting look into what we already know, at least anecdotally, about long-term opioid use, there is a specific aspect I would like to address and was brought up in the films, but not focused on adequately in my opinion. This aspect is the lack of an absolute maximum dose for pure opioid agonists. It seems that the idea that there is indeed no hindrance to use of increasing doses of pure (mu-) agonists is given little credence. While it is obvious that addicts exploited this belief to their own detriment and the Dr. Hurwitz, this is what I saw to be the only focus of the idea (of ever-escalating doses). Indeed, the only absolute reason why dose escalation AKA titration-to-effect is the development of respiratory drive depression and other attendant complications of CNS depression. However, taking a look at a patient's documented medication regimen displayed during the film reveals what can only be looked at as clear misapplication of the principle. The patient is a chronic back pain patient who did not have their vertebrae properly stabilized during surgery, and had subsequently more severe pain than was anticipated following the surgical procedure. Even though the regimen shown would normally be expected to develop over a period of decades of opioid use, in reality several (3-5 years) had elapsed at most. The regimen displayed on screen was as follows (these are at most 15 day supplies given the signatura [sig] line):
–Klonopin 2.0mg Disp #30 Sig 2 tabs Q HS No Refills > Total of 60mg of the controlled API clonazepam per Rx, 4mg per day at bedtime...
–OxyContin 80.0mg Disp #200 Sig 5 tabs TID > Total of 16,000mg (16g) of the controlled API oxycodone HCl per Rx, 1,200mg (1.2g) per day, 400mg per dose (!)
–Dilaudid 4.0mg Disp #400 Sig 10 tabs Q 4-5h > Total of 1,600mg (1.6g) of the controlled API hydromorphone HCl per Rx, 240mg per day, 40mg per dose 6x daily.
–Oxycodone 5.0mg Disp #1500 Sig 20 tabs Q 3-4h PRN breakthrough pain > Total of 7,500 (7.5g) of the controlled API oxycodone HCl per Rx, 600mg per day if taken every 4h, and a total now of 1800mg of oxycodone between the CR form present in OxyContin® and the IR form present in Oxycodone HCl IR tablets (generic) (!)
–Methadone 10.0mg Disp #60 Sig 4 tabs Q HS > Total of 600mg of the controlled API methadone HCl per Rx, 40mg per day taken as a single 40mg dose at the "hour of sleep..."
Now, I have seen some aggressive pain management control regimens in my time, especially with severe chronic pain associated with malignancy. As we now know, chronic pain not associated with malignancy can be just as severe and warrant properly tailored treatments as that pain associated with malignancy. All that said, this is a incredible dosing regiment! I have difficulty believing the patient would need any benzodiazepine or related sedative-hypnotic to assist in sleep as the steady intake throughout the day of three different narcotic analgesics, oxycodone, hydromorphone & methadone, with the last agonist being administered entirely at bedtime, its long half-life means it will still be at work well through the next day. The neuroexcitatory properties of both hydromorphone and methadone along with metabolites thereof, contribute to the lowering of the seizure threshold and possible development of an excited delirium may be the indicator used to warrant the administration of a benzodiazepine like clonazepam which is particularly effective in controlling seizures.
This patient was also receiving S.L. buprenorphine 0.3mg after formal treatments. The patient was monitored particularly closely as they had endorsed a history of cocaine use. Additionally, the amounts of medication being prescribed were such that no drug was prescribed with supply for more than 15 days so the patient was being seen at least bi-monthly.
After reviewing this list and the frankly outrageously large quantities of drugs being dispensed, I was hoping to get the feedback of other users on such a regimen.
~Pharmakonis
