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Letters to The Editor: Guidelines for Opioid Prescribing, Drug Legislation

July 2013
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Guidelines for Short- or Long- Acting Opioids

Are there any written guidelines with dosages for short-acting and long-acting opioids other than generalizations, such as in the Physicians Desk Reference, American Academy of Pain Medicine, and American Academy of Pain Management? I would appreciate any information you had or any links you can suggest to getting an exact answer. I have explored those three options previously stated, and obviously I am aware of variations and dosages, but I need something in print that gives specific guidelines.

—Barry M. Kotler, MD
Boynton Beach, Florida

Dear Dr. Kotler,

Unfortunately, there are no specific guidelines for either short- or long-acting opioids.

Here are some of my personal guidelines for chronic (not acute or short-term) patients. I only use short-acting opioids AFTER the patient has tried and failed anti-inflammatory and one or more of these neuropathic agents:

  • Milnacipran (Savella)
  • Duloxetine (Cymbalta)
  • Pregabalin (Lyrica)
  • Gabapentin (Gralise, Neurontin)

My first choice for short-acting opioids are the weakest, in this order:

  • Tramadol (Ultram)
  • Codeine
  • Buprenorphine (Butrans)
  • Hydrocodone compounds

The more potent short-acting opioids are not used until the above have been tried. Long-acting schedule II opioids are labeled for moderate to severe pain when “around-the-clock” dosing is necessary. I make this determination by two basic, historical findings:

  • Patient has constant (24 hours unless asleep) pain
  • Patient can’t control their pain with anti-inflammatory, neuropathic, and short-acting opioids

I hope this is helpful.

—Forest Tennant, MD, DrPH

Up to the present, there have been no position papers or specific guidelines about when to use short-acting opioids. In my recent Ask the Expert column, I reviewed the research.1

Once I decide that the patient can benefit from opioids, I use them as follows:

  1. For acute pain, ie, pain that can be expected to be short term.
  2. In cases of chronic pain, I use immediate-release (IR) opioids initially to determine the appropriate opioid dose while paying attention to the patient’s reaction to this class of drugs (ie, nausea, sedation). I then usually transition them to equivalent doses of sustained-release (SR) opioids.

For breakthrough pain, given that chronic pain isn’t uniform and that there are times when the pain is greater than at others, I like to use the same molecule, ie, morphine sulfate (MS) IR for a patient who’s on MS ER, or oxycodone IR or Percocet for a patient on an SR oxycodone. Because buprenorphine is a partial agonist, it’s not a good choice when the patient is also getting a pure µ opioid agonist, ie, most other opioids. Also, I rarely use codeine.

—Jennifer Schneider, MD, PhD


Avoiding Legal/Legislative Microscopes

I just finished reading the June 2013 PPM article by Erin M. Timpe Behnen, PharmD, BCPS, and Jennifer Bolen, JD.2 Clearly, the majority of your readers reside in the United States and, thus, come under the intense scrutiny of state and federal authorities concerning the treatment of opioid addiction and the use of opioid agonists. However, I was hoping that some discussion might have been raised concerning the use of Suboxone for pain, as it is something used in other countries, such as in Canada where I live.

I recently attended the International Conference on Opioids in Boston, and currently am attending the Harvard Medical School continuing medical education course on “Principles and Practice of Pain Management.” I am amazed that as physicians we cannot hold such conferences without the majority (or at least perceived majority) of the time being spent on considering this or that regulation, federal act, and the role of the DEA and/or FDA, none of which have to do with clinical/treatment issues per se.

While clearly there need to be appropriate best treatment consensus guidelines to help direct out practice, we should not be under the electron microscope of lawyers and legislators eagerly searching us out to pounce on us. Most of these people have no idea what it is like to be “in the trenches” and deal with our chronic pain patients day in and day out. It seems to me that until physicians stop cow-towing to these agencies and, as a body, stand up in opposition, we will see more and more of our autonomy eroded. The requirement for ongoing physician education should be with state medical boards or, as in Canada, with our Colleges of Physicians and Surgeons, and not with police, lawyers, or judges.

—Ian M. Postnikoff, MD
Central Alberta Methadone Program
Calgary, Alberta, Canada

Dear Dr. Postnikoff,

You have an excellent point. Our pain conferences are sadly forced to spend inordinate amounts of time on regulatory rather than clinical issues. At this time, I see little change in the near future.

I offer my personal opinions as to why we will continue to do this. There are multiple factors. First, there is a tendency for government agencies to over-regulate. Second, there have been many criminal practitioners, pharmacies, and wholesalers who have showered the country with illegal prescription opioids and they must be eliminated. Third, the movement to provide opioids for non-malignant chronic pain has proved extremely successful and brought relief of suffering to millions of people. This development, however, has interfered with the income of many parties as pain patients no longer have to frequent emergency rooms, enter hospitals, undergo unnecessary procedures, or use undesirable or ineffective drugs including alcohol and illegal substances. Consequently, the parties that have seen their income reduce due to opioid pain treatment now lobby government agencies to restrict opioids. Put simply, some parties put money over misery.

The issues of overdose, abuse, and diversion are real and must be curbed, but these problems are controllable and they are currently being controlled. This problem is grossly overstated compared to the good and benefits that opioids have brought to millions. The complications of opioids such as hormone suppression and constipation are easily managed and not an excuse to stop their use any more than the complications of hypertensive, anti-lipid, insulin, or carcinogenic agents should be restricted due to their complications.

You are certainly correct that physicians must continue to band together, advocate, and make a public case for opioids in patients who fail non-opioid therapies. Also, pain patients must vigorously contact their elected and appointed government officials and advocate for their right to obtain opioids and escape misery. Most physicians never think to educate their patients about this need, and I encourage them to do so.

Thank you for your thoughtful letter. You rightfully point out that the right to opioid treatment is one that physicians (and patients) must protect and fight for from now on.

Last updated on: October 28, 2014
First published on: July 1, 2013