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Unintended and neglected consequences of the opioid epidemic

Posted: 07 Nov, 2016   Recommendation: 1   Replies: 5

Any discussion of ways to address the current opioid epidemic must also focus some attention on solutions to ensure/increase access in LMICs.

Currently 150 countries don't have routine access to morphine and the vast majority of opiates are consumed by a minority of the world's population in HICs. To date, most effort has been put into preventing abuse with relatively little energy put toward increasing access in LMICs. Although simultaneously ensuring these two goals was the dual purpose of the UN Single Convention, in many ways it has failed. As we discuss ways to prevent abuse we must carefully evaluate if any solutions impact access to opiates to patients in LMICs and also actively discuss ways to improve pain care outside HICs.

Replies

 

Jim Cleary Respondent Replied at 10:40 AM, 7 Nov 2016

Michael,
Very perceptive. Data on Opioid access (six main opioids; morphine, oxycodone, hydromorphone, fentanyl, pethidine (demerol) and methadone) for all countries can be found at the Pain and Policy Studies Group Web site, http://www.painpolicy.wisc.edu). Over 80% of the world lack access to these medicines.
Agree with you have the 1961 single convention was to ensure access to these essential medicines while reducing the risk of diversion and abuse. While access to medicines has been neglected, there is increasing focus on it. The UN Commission of Narcotic Drugs had resolutions in 2009 and 2010; the 2014 WHA Palliative Care resolution addressed it; and one of the central pillars of the UN General Assembly Special Session (UNGASS) on Drugs included access to medicines.
I think one of our major challenges in addressing this, is our lack of proper understanding of the problem in the US. To create a public health solution you need to understand the problem. Again in the US we are seeing hospice patients struggling to access opioids for pain relief at the end of life.
Balance is critical

A/Prof. Terry HANNAN Replied at 3:22 PM, 10 Nov 2016

This was posted within the last 24 hours from the New England Journal of Medicine. As a Perspective article it may be free.
Perspective

Ending the Opioid Epidemic — A Call to Action

Vivek H. Murthy, M.D., M.B.A.

November 9, 2016DOI: 10.1056/NEJMp1612578
http://www.nejm.org/doi/full/10.1056/NEJMp1612578?query=featured_home

Gary Parkes Replied at 3:08 AM, 11 Nov 2016

Many inventions can have both good and bad uses. Many drugs intended for good can have unintended uses. In Nepal we see plenty of alcohol abuse but so far I have not knowingly seen any Morphine abuse. In many ways our problem is the converse of many developed health systems where Morphine abuse is rife. We need this drug for palliative care but need to balance the dispensing with safety measures to make sure that abuse does not arise. This needs country specific regulation and control but not at the expense of Pain control for those who desperately need it. Our hospital is seeing a rise of attention to palliative care and so we are keen not to make the drug inaccessible. However it must not go the way of antibiotics where you can buy any kind of antibiotic from a local medical store without any kind of meaningful regulation.

Jim Cleary Respondent Replied at 12:41 PM, 11 Nov 2016

Gary,
Totally agree.
We have had an International Pain Policy Fellow in Nepal, Dr Bishnu Paudel, a medical oncologist.
http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/Paudel_0.pdf

Opioid consumption data for Nepal can be found here.
http://www.painpolicy.wisc.edu/country/profile/nepal

Balance is the strategy. The WHO document Ensuring Balance in Controlled Substances is a great resource!
http://www.who.int/medicines/areas/quality_safety/guide_nocp_sanend/en/

jim

A/Prof. Terry HANNAN Replied at 7:07 PM, 14 Nov 2016

This discussion reaffirms just how difficult the problem of opioid management has become.
In my former role as a director of a chronic pain centre (distant past) I was significantly influenced by the work of Dr Loser from the University of Washington in Seattle.
Some crucial points I learnt.
• Chronic pain syndrome (CPS) is defined as a pain syndrome for which there is no surgical remedial cause and has been present for more than 3 months.
• Based on the neurophysiological understanding of the changes in the spinal cord pain pathways with chronic pain (neurooncogenesis) the following can be stated.
o Opioid therapy is inappropriate for the CPS
o Stress is the major propagating factor (not causative) for the CPS
o Activation of proprioception through exercise and cognitive behavioural therapy is the most effective management. Not analgesics.
• The protocol implemented based on this knowledge is as follows:
MANAGEMENT OF CHRONIC PAIN SYNDROME (CPS)-for patients and carers
 Patient education in the principals and mechanisms of CPS
 Patient must take responsibility for “their pain”
 No one can guarantee the pain will ever be eliminated-it is similar to all other chronic illnesses
 NARCOTICS (Morphine, Endone, Codeine, DiGesic, etc.) are contraindicated-dependency, tolerance
 BENZODIAZEPINES are contraindicated-dependency, tolerance
 NO PRN (as required) medications
 All medications are to be taken “by the clock”
 Management includes “by the clock” or regular exercise
 Initially exercise and physiotherapy INCREASES the pain response. This has to be ‘TRAINED’ through as with sport training.
 Patient is not to be assisted with daily tasks as this ‘perpetuates’ the pain syndrome-increases dependency on others
 Disregard patients complaints of pain-‘it will always be there’.
 TIME FRAME for ‘functional’ recovery is 18-24 months.
 NON-COMPLIANCE WITH MEDICATION PROTOCOL ELIMINATES PATIENT FROM PROTOCOL
Another important factor is get the “pain history” correct. A patient of mine this week is an example.
Middle-aged female with a CPS based on a background of severe domestic violence including traumatic pancreatitis. She has classic manipulative opioid dependent behaviour based on management by ‘experts’’.
A review of her admission history and overcoming her attempts to manipulate the interview and demanding to see the other ‘expert’ doctor it is discovered that her pain syndrome had changed significantly and she has a major stenosis of the distal pancreatic-biliary ducts. She is undergoing an ERCP as I write.
The other lesson from Dr Lower’s group is that the modern radiology of CPS shows “what is not there” as the cause of the pain.
I hope this dissertation helps this discussion which I have found illuminating.

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