Wednesday, February 1, 2012

Pt. 3: Tales From the Trenches in the War on Pain

War On Pain Clueless in Seattle by correspondent Thomas Sachy, MD, MSc

I had been working on another article for this ongoing War on Pain (and pain medication) series when I came across a rather disturbing article in the January 27, 2012 edition of the Seattle Times [here]. I knew that I had to comment on it as soon as possible.

Under the headline, “‘Preferred’ pain drug now called last resort,” the gist of this article is that doctors who treat pain in the State of Washington are now being warned that methadone is “riskier and more dangerous” than previously thought, and that it should be only rarely used since it is “unpredictable and poses a heightened risk of death.” Judging by these comments, methadone may soon go the way in Washington State of now-discontinued propoxyphene in the U.S.

To be sure, I realize that newspaper articles can reflect sensationalism and hyperbole, so I want to note that I am not being confrontational with any physicians or opinion-leaders mentioned in the article. Nevertheless I am going to bluntly address several of the more incendiary statements made in this article that could eventually affect the public’s ability to obtain methadone in Washington State, and in the rest of the country for that matter.

The article explains that Washington health officials previously encouraged physicians to prescribe methadone because it was as “safe and effective” as any other “narcotic” pain reliever, and because of its low cost, especially for those patients on Washington State’s version of Medicaid. Apparently, officials had “consistently deflected” concerns about Methadone’s dangers in the past, especially when it came to the state’s lower income patients.

It seems that, in response to a Seattle Times expose detailing the accidental overdose deaths of nearly 2,200 patients prescribed methadone since 2003, state officials recently made an abrupt about face regarding the drug’s use as an opioid analgesic. Now, physicians in Washington are receiving warnings that methadone is a riskier and more dangerous analgesic than the rest of the opioid family, and it should only be used as a “drug of last resort.”

First, I hate the word “narcotic,” as used in the news article. It is a legal term, not a medical one. From the DEA’s own web site [here]: “In a legal context, narcotic refers to opium, opium derivitives [sic], and their semi-synthetic substitutes. Cocaine and coca leaves… are also classified as ‘narcotics’ in the Controlled Substances Act (CSA).”

Second, I do not know what a “derivitive” is, but I do know that methadone is an opioid analgesic. I know that it has the longest half-life of any currently marketed opioid. I also realize that there is medical literature (including a black box warning by the manufacturer) suggesting that methadone and its major metabolite, EDDP, may prolong the cardiac QTc interval and result in the serious arrhythmia torsade de pointes.

I further know that methadone binds to the glutamatergic NMDA (N-methyl-D-aspartate) receptor, thus modulating glutamate, a primary excitatory neurotransmitter in the central nervous system. As such, methadone mediates, among other things, peripheral pain sensitization and visceral pain; beneficial effects that no other opioid is known to produce in a significant way. Although methadone is now deemed a last-resort drug in Washington State, the article also states contradictorily, “methadone is an indispensable drug and plays an important role in the treatment of many patients.”

Why? Well, besides being an NMDA modulator, the main reason methadone is indispensable in the world of pain management is that, due to individual genetic polymorphisms, each and every patient with pain will respond differently to each and every opioid analgesic. This fact should be evident to anyone who takes the time to read the medical literature; however, it would appear that many pain physicians and other medical specialists fail to appreciate this unassailable fact.

This further means that any particular opioid analgesic medication will not work equally well, or at all, for every patient with pain. THAT’S IT! DONE! And so, those who claim to be pain management practitioners, and those in the press who report on this topic, must get it out of their heads that the various opioid analgesics are interchangeable in the context of pain-management. For example, morphine is not a substitute for methadone, as the article seems to suggest.

Therefore, pain patients and pain physicians need to have methadone in their armamentarium. For examples, to most people, drinking only cola is not sufficient — we need grape, orange, and other flavors to stimulate our taste sensors. Similarly, we also need a panoply of opioids to work on our individual pain control systems that rely on our individual repertoires of opioid receptors.

As such, no ethical or competent pain management physician would dare force a patient with pain to take a particular opioid analgesic merely because (1) it is that physician’s “favorite” due to his/her familiarity/comfort level with it, (2) it is cheap, (3) it is allegedly “safer,” or (4) it is or is not a “last resort.”

The truth is that all opioids are unsafe if improperly taken. All opioids also act differently in different patients; so, there can be no room in ethical pain management for “favorite opioids,” “comfortable choices,” “cheap” alternatives for the poor, or “last resorts.”

Opioid analgesics should always be prescribed to patients based on what works best for them. This entails getting a detailed history from patients about the various pain medications they have been prescribed in the past and what their responses to those analgesics have been. If a patient is seeking chronic pain management for the first time, then the most scientifically valid, yet most simplistic algorithm for choice of opioid pain management should be employed — that is, start low and go slow. And, a note to pain specialists: listen to your patients — they know about their pain and its treatment history far better than you do.

One final thought: according to the Seattle Times article, the chief medical officer of Washington State’s Medicaid program states that physicians in the state are “stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription [opioid] drugs.” My humble recommendation to him would be to begin by…

  1. reviewing the detailed 5,000-year-old history of opioid use by mankind,

  2. researching the effects that the ubiquitous, endogenous opioids have on human beings, and

  3. openly publishing his findings regarding the long term impact on the body from prescription opioid analgesics, apart from abuse-related overdose, the neurological disease of addiction, and perhaps some other neuro-hormonal effects that opioids may have in select patients.

About the Guest Author: Thomas Sachy has Bachelor’s Degrees in electrical engineering and in general studies, and graduate degrees in medicine [MD] and biology [MSc]. His post-graduate medical training was in psychiatry, forensic psychiatry, and behavioral neurology. Dr. Sachy practices in the state of Georgia and has completed numerous ongoing continuing medical education activities in the field of pain management and the neurosciences, and has been featured on national TV on several occasions. He is a Diplomate of the American Board of Psychiatry and Neurology.

Proviso: All observations, opinions, advice, or facts expressed above are those of the guest author, and do not necessarily reflect the positions of Pain Treatment Topics, our staff and advisors, or our educational supporters.

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