In Reply—The Importance of Educational Interventions and Regional Analgesia in Tackling the Opioid Crisis in the United StatesOverprescribing opioids has true risks for our patients. A study by Sanger et al1 found that more than half of patients in a methadone maintenance treatment program were introduced to opioids through a prescription. This carries particular relevance for surgeons, who prescribe a significant portion of all opioids, including many for patients without a history of exposure.2,3 Optimal prescribing practices therefore toe the delicate line between providing adequate pain control and minimizing the risk of medication misuse and abuse.
The Importance of Educational Interventions and Regional Analgesia in Tackling the Opioid Crisis in the United StatesZiegelmann et al1 recently published an interesting report titled “Wide variation in opioid prescribing after urological surgery in tertiary care centers” that strives to shed light on the mounting opioid crisis in the United States. In accordance with previous studies, the analysis revealed a considerable variation in postoperative opioid prescribing patterns both for a given procedure and among procedures. This was ascribed to patient-related factors such as younger age, male sex, cancer diagnosis, and prolonged hospital stay and more importantly to lack of standardization and physician and patient expectations.
In Reply II—Root Causes of Opioid CrisisDr Pendyal highlights an important point that the opioid crisis is much bigger than just the “supply side” of the problem. It is truly a biological-psychological-social-spiritual problem that impacts both the “supply side” and the “demand side.”1 However, in his description of the social factors, of which there are many, he too fails to acknowledge many of the drivers of the opioid crisis. Many of the drivers go beyond “unemployment, poverty, and wealth inequality,” with an increasing number of those dying from opioids being employed, middle- and upper-class individuals.
The Root Causes of the Current Opioid CrisisI read with a great deal of interest the article by Rummans et al1 and the accompanying editorial by Srivastava and Gold2 in the March 2018 issue of the Mayo Clinic Proceedings.
In Reply I—Root Causes of the Opioid CrisisWe thank Dr. Pendyal for the thoughtful and articulate response to our article.1 We agree that a thorough examination of opioid use disorders and overdoses includes evaluation of structural- and societal-level factors. Indeed, income inequality, social disparities, and other structural inequities are important considerations in chronic illnesses, disease management, premature deaths, infant mortality, maternal illness, and all epidemics past and present, not just the current opioid epidemic. Similarly, depression, despair, hopelessness, and suicide are not exclusively linked to the current opioid crisis but are reflective of the state of health and wellness in our society.
CAREFUL: A Practical Guide for Improving the Clinical Surveillance of Long-Term Opioid TherapyTo the Editor: National prescribing guidelines for opioid use provide recommendations for clinical surveillance aimed at enhancing the safe use of these medications in patients with chronic pain.1 However, despite the widespread availability of these guidelines, most clinicians do not follow recommendations for clinical surveillance.2 The purpose of this letter was to describe an acronym that provides a summary of many key components of clinical surveillance that have been recommended for patients receiving long-term opioid therapy.
In Reply—Additional Safety Considerations Before Prescribing Opioids to Manage Restless Legs SyndromeWe thank Dr Geller for his interest in our article on the appropriate use of opioids in refractory restless legs syndrome (RLS).
Additional Safety Considerations Before Prescribing Opioids to Manage Restless Legs SyndromeSilber et al1 are commended for espousing the merit of low and stable dose opioid treatment of refractory restless legs syndrome (RLS) given the risks of suicide and severely compromised quality of life if untreated. Opioid agreements reduce risks of RLS treatment with opioids as agreements mandate drug testing as well as frequent query of prescription drug monitoring programs.
Interpreting Urine Drug Screen Results in the Context of Poppy Seed UseThe abuse of home opiate preparations derived from poppy seeds (PSs) is gaining popularity in the United States,1 and clinicians may increasingly encounter these patients in their practice. At least 5 American men have died after consuming poppy-based tea, most often in the context of urine drug screens (UDSs) positive for other illicit substances.1 Clinicians may find that their patients using PS tea are also using other opioids, which may present a challenge when interpreting UDSs.
The Contribution of Patient Satisfaction to the Opiate Abuse EpidemicIn their editorial on opiate overdose, Berge and Burkle1 list the release of new opioid drugs, the aggressive marketing to physicians, the declaration of pain as “the fifth vital sign,” and the increased willingness of physicians to treat noncancer pain with opioids as the measures that led to the explosion of sales of prescription opioid pain relievers. It is imperative that 3 others be added to this list: the patient satisfaction survey industry, the Centers for Medicare and Medicaid Services (CMS), and hospital administrators.
Benzodiazepine Oncogenesis as Mediated via Diminished Restorative Sleep Effected Sympathoadrenal ActivationThe valuable cohort contribution by Kao et al1 associating narcotic zolpidem consumption with heightened iatrogenic malignancy risks would be considerably more compelling if accompanied by proposition of a distinct plausible pathophysiologic mechanism. The most favorably received mechanism would define associations between the physiologic effects of zolpidem that are common to other pharmacologic agents and diagnoses that effect similar intermediary stepwise events epidemiologically linked to oncogenesis.
Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical PracticeHamza and Bryson1 argue against health care professionals returning to clinical practice while taking buprenorphine, based on purported neurocognitive effects. Their argument is based on weak science and flawed assumptions. Studies examining neurocognitive effects associated with buprenorphine are mostly based on small, selected samples and frequently fail to account for preexisting neurocognitive function or to distinguish between short- and long-term effects (after development of full tolerance) of the drug.
Opioid Substitution Therapy for Dependent Health Care Practitioners: Approach With CautionIn a recent article in Mayo Clinic Proceedings, Hamza and Bryson visit the difficult decisions involved in returning addicted health care practitioners (HCPs) back to work; their article focuses on maintenance therapy of addiction disorders with opioid maintenance therapy. Specifically, they propose that “abstinence-based recovery should be recommended until studies demonstrate that it is safe to allow this population to practice while undergoing opioid substitution therapy.”1 They review the current (and limited) research on the cognitive effects of opioid medications, including buprenorphine.
Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care ProfessionalsIn their article entitled “Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals,”1 Hamza and Bryson draw a distinction between a “harm reduction and damage control model” of opioid-addiction management and treatment for which abstinence (including, very specifically, abstinence from prescribed agonists) defines both the treatment process and its therapeutic objective. The authors' notion that there is an inherent contradiction between continued prescribing of medication and a patient's “recovery” and the suggestion that reducing harm and controlling damage are not part and parcel of any practice of medicine are extraordinary.
Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden ControversyThe article by Hamza and Bryson1 cites several studies to support their opinion that health care professionals should not be returned to practice if their treatment includes opioid agonist therapy. The quality of the evidence cited is poor. Three of the studies2-4 evaluate the effects of buprenorphine in “healthy volunteers” rather than in patients after careful dose titration. Other studies are small and poorly controlled for the duration of therapy and other drug use. The most relevant study5 compares patients taking buprenorphine with those taking naltrexone.
Safe Use of Opioids to Manage Pain in Patients With CirrhosisTo the Editor: The duty to relieve symptoms, safely, is a preeminent one of health care professionals. We appreciate the concerns of Chandok and Watt1 about the need for cautious use of opioids, particularly in patients with advanced liver disease. Indeed, we concur that caution should be exercised by all health care experts in use of therapeutics. However, we have concerns with the recommendations by Chandok and Watt1 regarding opioid use. Although the fear of precipitating encephalopathy or causing excessive sedation is real, an equally cogent concern is that this fear may result in less-experienced practitioners thinking that pain must be experienced regardless, or that opioids are not safe to be used in patients with cirrhosis.
Safe Use of Opioids to Manage Pain in Patients With Cirrhosis–Reply–IWe thank Swetz et al for their insightful comments. They bring forth valuable contributions to pain management in a subset of patients with liver disease who require palliative care, which we did not differentiate adequately. Because our article was intended to be an overview of outpatient (and/or transient inpatient) pain management, admittedly we did not address the extremes of pain management discussed in the letter by Swetz et al. Our goal was to provide clinicians with a broad approach to cirrhotic patients with pain (patients with abdominal pain, headaches, and joint pain, as well as those with more severe chronic pain).
“Practical Guide” to Urine Drug Screening ClarifiedTo the Editor: Moeller et al1 recently provided a timely and important review of urine drug screening. Drug abuse is a serious medical and social problem in the United States. Urine drug testing (UDT) to detect abuse and diversion of prescription controlled medications, as well as abuse of illicit substances, is increasingly important in clinical medicine. Physicians' ability to accurately interpret UDT results, however, is poor.2–4 Education is critical; equally critical is the dissemination of accurate information.
The Sickle Cell Crisis: A Dilemma in Pain ReliefSickle cell anemia is a progressive hemoglobinopathy producing chronic hemolytic anemia, microvascular thrombosis, ischemic pain, tissue infarction, decreased quality of life, and ultimately shortened life expectancy.1,2 In sickle cell anemia, valine is substituted for glutamic acid in the sixth amino acid of the β-globin chain. In a person who is homozygous, all hemoglobin is of the abnormal HbS type, and repeated episodes of sickling result in a less malleable molecule even at sites of normal atmospheric pressures of oxygen.
Fibromyalgia and Pain Management: In replyIn reply: I am sure Dr Sartin's letter embodies many of the concerns and prejudices of other physicians involved in treating patients with chronic pain problems. My article does not conclude that all fibromyalgia patients should be treated with narcotics. To quote: “Opiates are seldom the first choice of analgesics in chronic pain states, but they should not be withheld if less powerful analgesics have failed.”1
Approaches for Management of Postoperative Pain: The authors replyWe appreciate the opportunity to reply to Dr. Wang's letter. He asserts that, in our recent review, we failed to mention the common practice of administering analgesic medication to the patient with postoperative pain. In the opening paragraph of our article, we mentioned conventional parenterally administered opioid analgesia by describing a study in which 75% of patients were inadequately controlled with this treatment.1 We also pointed out other studies that had similar results.2,3 A discussion of patient-controlled analgesia was included, and, as mentioned, many studies have proved the superiority of this method over conventional intermittent intramuscular administration of analgesia.