Re: Interesting Pain Articles

I saw this... good guidelines. Have you seen the crap that is about
to be published regarding methadone prescribing guidelines in the
Annals of Internal Medicine.
They are very labor intensive for the providers and pts. It seems
they are trying to clamp down on the prescribing of methadone even
though its a safe, effective pain medicine if prescribed properly. I
think you can find them on medscape if you search "methadone
guidelines". They were presented at the Internal Medicine annual
conference within the past 2 weeks. Its going to really suck for all
of us.


On 13 Feb 2009 21:18:29 GMT, Top <top@xxxxxxxxxxxxxx> wrote:

Here is a more recent article for you. I read it to be the same thing
we've known for a long time.

Title: American Academy of Pain Publishes Guidelines for Prescribing
Opioids
"American Academy of Pain Publishes Guidelines for Prescribing
Opioids"


NEW YORK -- February 9, 2009 -- The American Pain Society (APS) and
the American Academy of Pain Medicine (AAPM) has published the first
comprehensive, evidence-based clinical practice guideline to assist
clinicians in prescribing potent opioid pain medications for patients
with chronic non-cancer pain. The guideline appears in the February
issue of [The Journal of Pain.

To create this guideline, researchers reviewed more than 8,000
published abstracts and nonpublished studies to assess clinical
evidence on which the new recommendations are based.

"This guideline was a true multidisciplinary effort that sought
to address in a balanced manner the many challenging issues that
clinicians face with regard to when and how to prescribe opioids for
chronic noncancer pain," said principal investigator Roger Chou, MD,
Oregon Evidence-Based Practice Center, Oregon Health & Science
University, Portland, Oregon.

"A key part of this process was performing a comprehensive
literature review to inform the recommendations -- though an
important take-home message is that even though the recommendations
represent the best judgment of the panel based on the currently
available literature, there is still a lot of research that needs to
be done."

The expert panel concluded that opioid pain medications are
safe and effective for carefully selected, well-monitored patients
with chronic non-cancer pain. They made 25 specific recommendations
and achieved unanimous consensus on nearly all.

Prior to initiating chronic opioid therapy, the guideline
advises clinicians to determine if the pain can be treated with other
medications. If opioids are appropriate, the clinician should conduct
a thorough medical history and examination, and assess potential risk
for substance abuse, misuse or addiction.

A key recommendation urges clinicians to continuously assess
patients on chronic opioid therapy by monitoring pain intensity,
level of functioning, and adherence to prescribed treatments.
Periodic drug screens should be ordered for patients at risk for
aberrant drug behaviour.

Other recommendations in the practice guideline include:
· Methadone: Use of methadone for pain management has increased
dramatically but few trials have evaluated its benefits and harms for
treatment of chronic non-cancer pain. Methadone, therefore, should be
started at low doses and titrated slowly. Because of its long half-
life and variable pharmacokinetics, the panel recommends methadone
not be used to treat breakthrough pain or as an as-needed medication.
· Abusers: Chronic opioid therapy must be discontinued in
patients known to be diverting their medication or in those engaging
in serious aberrant behaviours.
· Breakthrough Pain: As-needed opioids can be prescribed based
on initial and ongoing analysis of therapeutic benefit versus risk.
· High Doses: Patients who need high doses of opioids should be
evaluated for adverse events on an ongoing basis, and clinicians
should consider rotating pain medications when patients experience
intolerable side effects or inadequate benefit despite appropriate
dose increases.
· Pregnancy: Clinicians should counsel women about risks of
opioids in pregnancy and encourage minimal or no use of chronic
opioid therapy unless potential benefits outweigh risks.


SOURCE: Oregon Health & Science University



noone@xxxxxxxxx has brought this to us :
I'm not talking about when it was written... thats a publication
date, not a citation. The information for the article was pulled
from dated material ie: (Musto 1987) at the end of the first
sentence. Something written 20 years ago is history, not current
scientific knowledge. The most recent literature cited by the
author was published almost 16 years ago.... so nothing has changed
in 16 years? Clinton had just entered the White House, the
internet was just beginning to catch on with the the tech geeks,
but certainly wasn't mainstream by any means. Google didn't exist,
Yahoo was around, but very limited, a small group up north was
working on something called the Mosaic web browser. and Microsoft
had just released Windows 3.1. If I were writing an article on the
state of computer technology using only information published up to
1993 how accurate would it be? Think critically when reading
internet crap. Don't be a lemming.



noone@xxxxxxxxx wrote in
news:et3ap45d48e00ip87511l0b6o24rje4enu@xxxxxxx:

I'm not talking about when it was written... thats a publication
date, not a citation. The information for the article was pulled
from dated material ie: (Musto 1987) at the end of the first
sentence. Something written 20 years ago is history, not current
scientific knowledge. The most recent literature cited by the
author was published almost 16 years ago.... so nothing has
changed in 16 years? Clinton had just entered the White House,
the internet was just beginning to catch on with the the tech
geeks, but certainly wasn't mainstream by any means. Google didn't
exist, Yahoo was around, but very limited, a small group up north
was working on something called the Mosaic web browser. and
Microsoft had just released Windows 3.1. If I were writing an
article on the state of computer technology using only information
published up to 1993 how accurate would it be?
Think critically when reading internet crap. Don't be a lemming.



On Thu, 12 Feb 2009 10:48:32 -0800 (PST), "LoriB.o.B."
<banjobabe@xxxxxxxxxxx> wrote:

Thanks (((Top)))!
Exactly!
Kindly,
LoriBoB
(who appreciates what the person who won't post name says but
needs to look at the larger pic, informing ppts!, jmo)


On Feb 11, 8:14?pm, Top <t...@xxxxxxxxxxxxxxxxxx> wrote:
Here is the date info taken dirrectly from the referenced
article:

Author: Mark Barletta (---.lightspeed.hstntx.sbcglobal.net)
Date: ? 02-05-09 16:34

Not sure what you consider current.

Top

no...@xxxxxxxxx was thinking very hard :



The citations are very dated.... look for information that is
more current. ?Things have come a long way in the last 20 yrs.

On Sun, 8 Feb 2009 11:35:19 -0800 (PST), "LoriB.o.B."
<banjob...@xxxxxxxxxxx> wrote:

Hi (((all))) again!
Found some more very interesting (to me) pain articles I
thought I'd share. ?This one's from the National Foundation
for the Treatment of Pain:
http://www.paincare.org/phorum-3.4.8a/read.php?f=1&i=21726&t=21
726
They seem to be tackling the problems from a # of angles.
?See what u think!
Kindly,
LoriBoB
****************

Controlled Substances, Medical Practice, and the Law
Author: Mark Barletta (---.lightspeed.hstntx.sbcglobal.net)
Date: ? 02-05-09 16:34

David E. Joranson, M.S.S.W.
Aaron Gilson, M.S.

The development of drug control policy in the United States
has been characterized by vacillation between tolerance and
intolerance toward drugs (Musto 1987). Today's war on drugs
is distinguished by intense media coverage of drug-related
crime, new antidrug laws, and efforts to educate
schoolchildren and the public to "just say no" to drugs. The
message is clear: Drugs are dangerous and must be avoided.
The United States continues to have significant drug abuse
problems that must be addressed, but we should be careful not
to reject the medical benefits of drugs or restrict the
ability of physicians to care for patients.

Antidrug efforts are directed not only at the illegal
controlled substances such as marijuana, heroin, and cocaine,
but also at the legal controlled substances that have
important medical uses: the opioids (narcotics), stimulants,
and sedative hypnotics. These efforts involve media campaigns
against perceived overprescribing (Safer and Krager 1992),
vigorous enforcement efforts against suspect prescribers
(Benton 1993; Hill 1989; McIntosh 1991a, 1991b; Nowak 1992),
regulations to increase restrictions on prescribing
(Weintraub et al. 1991), and federal proposals to monitor all
prescribing to patients of all controlled substances (Stark
1990).

When controlled substances are used for medical purposes,
they can provide great improvements in the quality of life
for millions of people with debilitating diseases and
conditions, including pain, severe anxiety, narcolepsy, and
epilepsy. However, when diverted from the legitimate
distribution system, the nonmedical use of controlled
substances can lead to serious public health problems.
For example, there are a small percentage of practitioners
who abuse their privilege to prescribe and are a source of
drugs for addicts and the illicit market. Consequently, it is
in the public interest to protect the medical uses of
controlled substances while at the same time preventing their
diversion and abuse. Public policy should recognize the dual
effect of controlled substances on public health to obtain
the broadest medical benefit while reducing the risks of
diversion and abuse.

There is troubling evidence that some controlled substances
laws and regulations and their enforcement interfere with
medical practice and patient care. In this chapter we explore
whether controlled substances laws and regulations achieve an
appropriate balance between controlling abuse and protecting
medical use. The primary focus is on the opioids (narcotics)
that are used in the somatic treatment of pain, in particular
pain due to cancer.

Tragically, cancer pain is often undertreated. Several
factors impede pain management, including inadequate
preparation of health care professionals, the low priority
given to pain management, and the effects of antidrug
policies. Although most, if not all, cancer pain can be
relieved (Foley 1985; Takeda 1987), it is estimated that
one- half to three-quarters of cancer patients with pain are
inadequately treated and that nearly 25% die with severe
unrelieved pain (Daut and Cleeland 1982). The mainstay of
cancer pain management is opioid therapy (World Health
Organization 1986). Efforts to improve pain management and
eradicate misuse and abuse of prescription controlled
substances take place in a medical and regulatory environment
characterized by misinformation about opioids. Misinformation
about opioids and exaggerated fears of addiction are
prevalent among the professions and medical regulators
and are partly responsible for the undertreatment of pain
(Ferrell et al. 1992; Jaffe 1989; Jasinski 1989; Joranson et
al. 1992; Morgan 1986).

The Framework of Controlled Substances Policy
Three tiers of law establish the policy framework that
governs the medical use and diversion of controlled
substances: 1) international treaties, 2) federal laws and
regulations, and 3) state laws and regulations. As will be
seen, international and federal laws clearly recognize the
principle that a balance should be maintained between
controlling drug abuse and ensuring that controlled
substances are available for medical use. However, most state
laws do not achieve this balance and, in some instances,
interfere with medical practice.

International Treaties, Drug Control, and Medical Use
Treaties provide the basic legal framework for controlling
international and domestic production and distribution of
drugs that have been determined to have an abuse liability.
The principal treaties recognize that many controlled
substances are indispensable to public health and that their
availability for legitimate medical and scientific purposes
must be ensured. These treaties are the Single Convention on
Narcotic Drugs, 1961 (United Nations 1977b), and the
Convention on Psychotropic Substances, 1971 (United Nations
1977a). In becoming a party to a treaty, a government agrees
to ensure the availability of controlled substances for
medical purposes. Most, but not all, of the governments of
the world have acceded to these treaties (International
Narcotics Control Board 1991).

The International Narcotics Control Board, the United Nations
agency responsible for monitoring governments' compliance
with the treaties, has reported that opioids are not
sufficiently available for legitimate medical purposes
throughout the world and that this is due in part to antidrug
abuse laws and regulations that unduly restrict the
availability of opioids for medical use (International
Narcotics Control Board 1989).

A World Health Organization expert committee has also
expressed concern that the fear of drug abuse has curtailed
appropriate medical use of opioids, particularly for the
treatment of cancer pain (World Health Organization 1990);
laws are so strict in some countries that physicians cannot
prescribe morphine for cancer pain. The expert committee
commented on "multiple copy prescription programs" that are
used in several countries as well as in several states in the
United States.

The extent to which these programmes restrict or inhibit the
prescribing of opioids to patients who need them should be
questioned.... Health care workers may be reluctant to
prescribe, stock or dispense opioids if they feel that there
is a possibility of their professional licenses being
suspended or revoked by the governing authority in cases
where large quantifies of opioids are provided to an
individual, even though the medical need for such drugs can
be proved. (World Health Organization 1990, p. 39) Thus,
although the purpose of the international treaties is to
ensure availability of drugs for medical use, restrictive
laws in some countries limit the use of opioids for the
treatment of pain. To what extent do laws and regulations in
the United States maintain a balance between the control of
drug abuse and the appropriate medical use of opioid
analgesics or other controlled substances?

Federal Law and Medical Practice

--
Conceit is just as natural a thing to muman minds as a center is
to a circle. - Dr. O. W. Holmes

.