Dr. ----
Hope all is well.
I am a bit surprised that you would challenge the 50 mg morphine
equivalent dose (MED) threshold supported in the updated ACOEM guidelines. We are in a CDC-declared opioid epidemic. People are dying needlessly. It is difficult to dissent against ACOEM’s 50
MED threshold when the reported death rate is 3 to 5 times greater in patients prescribed 50 mg MEDs and
above than in patients prescribed
49 mg MEDs and below. For context the
current CDC VitalSign report shows that, nationally, 46 opioid overdose deaths
occur each day.
Furthermore the ACOEM guidelines are – contrary to your
suggestion – both applicable to and directed toward chronic cases. As the most recently updated standards for
the practice of occupational medicine, ACOEM further reveals our developing understanding
of opioid best-practices. There is simply
no credible evidence to support long term opioid use for chronic non-cancer
pain. Conversely a Cochrane review
demonstrated that back pain patients taking opioids for more than a week, when
compared with a similar cohort taking opioids for a week or less, were twice as
likely not to return to work within a year.
A related review contradicted the practice of escalating doses. High doses of opioids were shown to be no
more effective than lower doses of opioids, supporting the intuitive notion
that once opioid receptors are saturated, increasing the dose does not yield
additionally beneficial results. If you
have not yet read the two studies used to confirm the new ACOEM morphine
equivalent dose (MED) level, you should.
Another concerning issue that pain management physicians
among others are not taking into account?
Up to 30% of patients can’t properly metabolize approximately 25% of
drugs currently used clinically due to inherent pharmacogenetic deficiencies (Wang et al., 2009). Drugs in this grouping include codeine,
tramadol, oxycodone, hydrocodone and many synthetic and semisynthetic opioids
which are not adequately metabolized by other CYP450 isoenzymes. As result many patients are building up
levels of the parent drug causing cascading effects such as hyperalgesia, which
in turn often causes the treating physician to further increase dosage. Dose escalation is often pursued instead of
weaning without documenting either improved function or reduced pain.
Following a psychosocial evaluation, most patients feel
better once weaning starts in conjunction with pain management and mind-body
therapies (e.g. cognitive behavioral therapy, motivational interviewing,
etc.). However, only about 4-7% of
patients are ever evaluated for these potential treatment options despite
prolonged treatment and a history of attenuated improvement. Similarly medically indicated evaluations for
dependence and addiction or interventions for smoking cessation are often left
unaddressed.
My feeling is that a number of clinicians still practice
based on an outdated biomedical model instead of utilizing a growing body of
evidence supporting a psychosocial model of pain and its correlation to
impairment and disability. It is ignored
that psychologically and/or socially distressed people seek medical treatment
for psychosocial conditions. Due to this
lack of recognition, many psychosocial conditions are being managed through
inappropriate modalities and passed off as anatomically diagnosed biomedical pain. These inappropriate modalities (e.g. opioids,
surgery, and interventional treatment) share complicit complications and side
effects that further exacerbate long term disability and failed syndromes.
Consider that in October 2010, the CDC published a report
indicating that over 60% of US children had suffered some form of traumatic
abuse prior to the age of 18. These same
children grow up and enter the work force.
Some of them eventually file claims because of unresolved, unaddressed
issues amplified by a work related injury, leaving the worker feeling
victimized by a supervisor, a poor work environment, or low wages. Injecting opioid treatment into this
psychosocial complexity without addressing the underlying issues leads to long
term disability and frequent social isolation due to unsympathetic family,
friends, and coworkers.
I hope that this will help clarify why the decision was made
that, when people are dying daily, we cannot apologize for taking action to
ensure patient safety. While we realize
guidelines take time to be updated (MTUS is being rewritten currently), an
epidemic exists at this moment which can be controlled by removing the cause.
We do not want to be downstream catching bodies but upstream
saving lives.
Thank you for your understanding.
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