Fluoroquinolone Antibiotics Warning For Neuropathy Patients

Today's post from zedie.wordpress.com (see link below) is a very short one but is none the less important for that. Depending on the infection in your body from whatever cause, you may be prescribed antibiotics. Some of these antibiotics are called fluoroquinolones and are notorious for causing neuropathic symptoms. Very often it will be difficult to spot the name fluoroquinolone on the box because the brand and pharmaceutical names will be most prominent. If you already have neuropathy, it may be worth asking your doctor if the antibiotics he/she is prescribing belong to the fluoroquinolone family. If so, it may be worth changing them - there are plenty of alternatives. This short post talks about the American FDA requiring that drug companies place a neuropathy warning on fluoroquinolone packaging. This is of benefit to neuropathy sufferers but also patients who may be at risk of getting neuropathy.

Fluoroquinolone Labels Updated to Reflect Heightened Risk for Peripheral Neuropathy.
Author Zedie: US Virgin Islands August 16th 2013


The FDA is requiring that the labels of fluoroquinolone antibiotics warn of the drugs’ increased risk for peripheral neuropathy.

The risk has been observed with oral and injectable fluoroquinolones, but not topical agents. Patients could experience peripheral neuropathy any time during their treatment, and it could persist for months or years or be permanent.

Patients should contact their healthcare providers if they develop symptoms consistent with peripheral neuropathy in the arms and legs, including pain, burning, numbness, or weakness; change in sensation to touch, pain, or temperature; or change in the sense of body position.

Patients who develop these symptoms should stop taking the antibiotic and receive alternative therapies unless the benefit of the fluoroquinolone outweighs the risk.

Source: FDA MedWatch safety alert

http://zedie.wordpress.com/2013/08/16/fluoroquinolone-labels-updated-to-reflect-heightened-risk-for-peripheral-neuropathy/

Weight Bearing Exercise Can Be Dangerous For Neuropathy Patients

Today's post from huffingtonpost.com (see link below) looks at the problems that certain forms of exercise may bring the neuropathy patient who has lost most of the feeling in their feet. These problems are not to be underestimated but it's important to say here that the vast majority of neuropathy patients have some feeling in their feet, despite the numbness that can affect the toes and pads of the foot. These patients are unlikely to step on a nail and not feel something. That said, many people living with neuropathy feel very little and this can certainly lead to serious accidents. When this is the case, load-bearing exercises can be more dangerous than helpful. Nevertheless the article recommends exercise as being essential, as long as this is controlled and the feet are carefully and regularly monitored. The article is aimed at diabetic neuropathy patients but applies to all people living with neuropathy and foot problems.

Type 2 Diabetes and Peripheral Neuropathy: To Walk or Not to Walk?
 
Milt Bedingfield Posted: 05/11/2015 

It is now well known that engaging in light to moderate physical activity on a regular basis is of significant value for most people that have either Type 1 or Type 2 diabetes. In fact the American Diabetes Association recommends that people with diabetes should get a minimum of 150 minutes of light to moderate exercise per week including aerobic and resistance training.

What the ADA says...

It has also been recommended that people with peripheral diabetic neuropathy that have reduced or absent feeling in their feet should not engage in any form of weight bearing exercise activity. The American Diabetes Association recommends that people with diabetes-related peripheral neuropathy should limit the amount of weight-bearing physical activity they perform due to their increased risk of foot ulcers and amputation (1, 2). This is based on the fact that with peripheral neuropathy there is either a decreased ability or total inability in the feet to feel pain or discomfort.

As an example, standing barefoot on hot asphalt maybe in a parking lot in the middle of the summer would be very uncomfortable for someone with normal sensation in their feet, however go unnoticed for someone with peripheral neuropathy. Similarly, the person with peripheral neuropathy may develop a painful nickel-sized blister after walking too far or when wearing new shoes and not even feel it. Without daily inspection of the ankles and feet (which a lot of people do not do) this blister could go unnoticed for days resulting in a potentially infected, slow to heal, or non-healing wound. In the worst case this could lead to an amputation. All of this is the result of losing what is called the protective sensation in the feet.

In the absence of peripheral neuropathy whenever there is insult to the foot or feet such as a blister, a cut or scrape or stepping on a small piece of glass or nail, there would be pain which would cause you to notice the injury and hopefully treat the wound accordingly.

There are also painful stages of neuropathy that can precede lack of sensation which are characterized by frequent but intermittent pain in the feet throughout the day, having pain only in the evening while in bed to constant pain. This stage of neuropathy can result in changing the way you walk, that is your stride length, which part of your feet you strike the ground with first and ultimately what part of your feet support your body weight.

Because of everything I have just mentioned above this leads to the unfortunately recommendation that discourages walking for a great many people with diabetes.

To Walk or Not to Walk?

So where does that leave us? Exercise is arguably the best treatment there is, particularly in controlling Type 2 diabetes, and preventing diabetes related complications, such as peripheral neuropathy, however once you have peripheral neuropathy in your feet you should avoid doing any weight bearing exercise.

I have wrestled with the dilemma for years about how to guide my patients that would benefit immensely from starting to exercise or increasing their exercise however have various stages of neuropathy.

According to the Centers for Disease Control and Prevention, from 2000-2002, approximately 60 percent of lower-extremity amputations in the United States were diabetes-related, with the majority of those amputations being preceded by a foot ulcer (3). Almost all diabetic foot ulcers occur in those people that have lost feeling in their feet due to diabetic peripheral neuropathy (4, 5).

On the other hand poorly controlled blood glucose control contributes greatly to peripheral neuropathy.

Eight-year cardiovascular mortality is 34 percent lower among people with diabetes who walk two hours per week compared with non-walkers (6).

Feet First Randomized Controlled Trial

The Feet First Randomized Controlled Trial was designed to look at the effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy. The study, conducted over a 12-month period by Lemaster and colleagues, showed that participants in the Feet First intervention group achieved a modest increase in activity, with no increase in foot lesions, compared with those in the control group. The group also recommended additional research be conducted in this area to investigate the current guidelines and close supervision for patients with diabetes and peripheral neuropathy (7).

Tuttle and colleagues found that people with Type 2 diabetes and peripheral neuropathy experienced no negative consequences when performing moderate-intensity, weight-bearing exercise in their study (2).

Dr. Sheri Colberg reports in her article "Exercising with Peripheral Neuropathy" that recent descriptive studies suggest that patients with a lack of feeling in their feet who participate in daily weight-bearing activity are at decreased risk of foot ulceration compared with those who are less active (8, 9), especially if their daily routine is very similar with little variation from day to day regarding their physical activity (9, 10).

As a result of the above information, I am going to continue evaluating each of my class participants on a case by case basis, however, for those patients with peripheral neuropathy that I believe will be prudent in checking their feet and following the recommended foot care guidelines and stand to gain significant benefit from performing some weight bearing exercise, I will be more likely to recommend it to them.

References:

1. Singh, N., D. G. Armstrong, and B. A. Lipsky: Preventing foot ulcers in patients with diabetes. JAMA 293 (2):217-228, 2005

2. Tuttle, L. J., M. K. Hastings, and M. J. Mueller: A moderate-intensity weight-bearing exercise program for a person with Type 2 diabetes and peripheral neuropathy. Phys Ther 92 (1):133-141, 2012

3. Centers for Disease Control and Prevention. History of foot ulcer among persons with diabetes -- United States, 2000-2002. MMWR. 2003;52:1098-1102. Medline

4. Pham H, Armstrong DG, Harvey C, et al. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000;23:606-611.

5. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA. 2002;287:2552-2558. CrossRefMedline

6. Gregg EW, Gerzoff RB, Caspersen CJ, et al. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med. 2003;163:1440-1447. CrossRefMedline

7. Lemaster, J. W., M. J. Mueller, G. E. Reiber, D. R. Mehr, R. W. Madsen, and V. S. Conn: Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. Phys Ther 88 (11):1385-1398, 2008

8. Richerson, S., and K. Rosendale: Does tai chi improve plantar sensory ability? A pilot study. Diabetes Tech Ther 9(3):276-286, 2007

9. Ko, S. U., S. Stenholm, C. W. Chia, E. M. Simonsick, and L. Ferrucci: Gait pattern alterations in older adults associated with type 2 diabetes in the absence of peripheral neuropathy--results from the Baltimore Longitudinal Study of Aging. Gait Posture 34 (4):548-552, 2011

10. Kanade, R. V., R. W. van Deursen, K. Harding, and P. Price: Walking performance in people with diabetic neuropathy: benefits and threats. Diabetologia 49 (8):1747-1754, 2006

http://www.huffingtonpost.com/milt-bedingfield/post_9394_b_7188266.html

Lung Cancer Patients Who Also Have Neuropathy

Today's post from cancergrace.org (see link below) is very useful if you have lung cancer or lung problems in general and have contracted neuropathy as a result of the cancer drugs you're taking. It explains the issue simply and highlights the chemotherapy drugs most likely to cause neuropathic symptoms. Whatever your medical history, there is always a possibility that  you may end up with a form of cancer and neuropathy is a fairly common side effects of cancer treatment drugs. It's important that you discuss the options with your doctor or specialist.
 

What about treating patients who have medical problems? Treating lung cancer in patients with kidney issues or neuropathy.
Published March 2, 2014 | By Dr West 
Download PDF

One of the challenges of cancer care is that we guide our treatments by what clinical trial evidence tells us is best for particular patient populations. However, trials exclude patients who have significant medical issues other than cancer. So what do you do for patients who have lung cancer but also have common medical problems like compromised kidney function or pre-existing numbness and tingling (neuropathy) from diabetes or vascular disease? A purist in evidence-based medicine would say that patients who don’t have good kidney function or who have other medical problems that would exclude them from the trials of our standard treatments can’t get treated, but fortunately most oncologists are more flexible than that. What’s the right way to proceed? The answer is that it falls to best medical judgment. But can we be more specific than that?

In the setting of renal insufficiency, which is common as patients get older, as well as being a result of years of high blood pressure or diabetes, we need to substitute out the treatments that are most threatening to kidney function worsening. Specifically, this means avoiding the particularly kidney-threatening cisplatin, considering avoiding carboplatin (or perhaps giving it and carefully monitoring kidney function and dropping if it kidney function worsens, and then substituting non-kidney damaging agents instead). If kidney function is only minimally impaired, it may be very acceptable to give carboplatin plus a taxane: Taxol (paclitaxel), Abraxane (nab-paclitaxel), or Taxotere (docetaxel)), Gemzar (gemcitabine), Navelbine (vinorelbine), or Alimta (pemetrexed). An alternative, and the leading one if kidney function is quite compromised or gets worse on carboplatin-based chemo, is to give a nonplatinum doublet, which basically means pairing two drugs for lung cancer that are more commonly partners for cisplatin or carboplatin. Common nonplatinum doublets include Gemzar/Navelbine or Gemzar with one of the taxanes. About 15 years ago, there was a significant hope that these agents might turn out to be an improvement from platinum-based doublets, with comparable or slightly superior efficacy and improved tolerability. That didn’t turn out to be the case: the nonplatinum doublets were typically of the same or very slightly lower efficacy, and the same or slightly better tolerability. Overall, they were a lateral move and never took hold as a leading choice, but they are certainly a fine choice and arguably the ideal one for people with limited kidney function.

Then there’s the case of patients with peripheral neuropathy. The taxanes and especially Taxol are the worst offenders here, as is cisplatin, and Navelbine can also worsen neuropathy. Here, we commonly favor carboplatin with a less neuropathy-inducing partner drug, so Gemzar is often a leading choice, or Alimta for a non-squamous lung cancer.

It’s also reasonable to consider single agent chemotherapy, though several recent trials have shown that carboplatin doublet chemotherapy is associated with better outcomes as first line treatment than single agent chemo, even in patients with a marginal performance status. But it’s certainly reasonable to consider single agent chemo in individual patients with significant organ compromise, or simply in patients who are particularly wary about significant side effects.

Though there are certainly other problems that merit individual treatment recommendations, these are among the most common ones. In the end, it still comes down to individualized judgments and considerations of the circumstances of the particular patient.

http://cancergrace.org/lung/2014/03/02/treating-patients-with-other-med-problems/#more-14241

Suspect Drug Interactions for HIV and Neuropathy Patients

Today's post from Aidsmeds.com (see link below) concerns the somewhat controversial view that older anti-seizure drugs can clash with HIV anti retroviral drugs to such a degree that the HIV meds can fail, with all the ensuing consequences. Underneath the article are comments which dispute that view but for HIV-patients who take Carbamazepine amongst others, in combination with Prezista amongst others, for their neuropathy problems, this is a very important question which needs to be resolved. Your neurologist and/or hiv-specialist may not be aware of the potential clash between the drugs so you should certainly discuss the issue with them perhaps with a photocopy of this article to back up your concerns. The article explains why the clash occurs.

Certain Anti-Seizure Drugs Up the Risk of HIV Treatment Failure
June 14, 2011

People taking older anti-seizure medications that are broken down by the same liver enzyme (CYP3A4) as many common antiretroviral (ARV) drugs were more likely to experience treatment failure than people taking seizure medications that aren’t broken down by that liver enzyme. These data were published online May 16 in the journal AIDS Research and Therapy.

A significant minority of people with HIV use anti-seizure medications. Roughly 11 percent of all HIV-positive individuals are diagnosed with a seizure disorder, and a substantial number of additional people use the same class of drugs for other disorders, including neuropathic pain, bipolar disorder and depression.

Though FDA guidelines recommend against combining—or urge caution when combining—some of the older anti-seizure drugs with ARV therapy, not all people have the option of the newer medications. For some people this is because the new medications don’t control their seizure disorders well, or because they can’t tolerate the newer drugs. The lack of available alternative drugs in resource-poor settings is another common reason why people with HIV still use them.

The problem with these older anti-seizure drugs is that they are broken down by the liver enzyme CYP3A4. This enzyme is also required to break down protease inhibitors such as Prezista (darunavir) as well as non-nucleoside reverse transcriptase inhibitors such as Sustiva (efavirenz) and the entry inhibitor Selzentry (maraviroc). This means that people who combine the anti-seizure drugs with their HIV therapy might be at higher risk of HIV treatment failure.

To study how a group of older anti-seizure drugs—including Dilantin (phenytoin), Tegretol (carbamazepine) and Luminal (Phenobarbital)—affects ARV treatment, Jason Okulicz, MD, from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and his colleagues studied the medical records of a group of HIV-positive people enrolled in the U.S. Military HIV Natural History Study.

Okulicz and his colleagues compared the rates of treatment success in 19 HIV-positive people taking the older anti-seizure drugs, with 85 people taking new anti-seizure drugs and 190 people taking no seizure medication. The research team only included people taking anti-seizure medication for either a seizure disorder or neuropathy.

The groups were similar in most respects, except that those taking the older anti-seizure medications were more likely to have a seizure disorder and those taking the newer medications were more likely to have neuropathy. The criteria for a person to be defined as having treatment failure included having no viral load measures under 400 copies within the first six months after starting ARV therapy, or having at least two measurements above 400 copies after the first six months of therapy.

Okulicz’s team found that treatment failure was more than four and a half times more common in people taking the older anti-seizure medication. This difference held up even when the team accounted for differences in viral load before starting therapy and the year in which people started therapy. The difference between people on the older anti-seizure drugs and those taking no anti-seizure medication was less meaningful, however. People on the older anti-seizure medications were only significantly more likely to experience treatment failure than those taking no anti-seizure medication when pre-treatment viral loads were taken into account.

“[Older anti-seizure medications] should be avoided in favor of [newer medications] in patients requiring concurrent [ARV treatment] and [anti-seizure] therapy due to the higher potential of virologic failure and reduced efficacy,” conclude the authors, who added, “In areas where [older anti-seizure medication] use cannot be avoided, closer and more frequent monitoring of HIV and seizure control is warranted.”

Previous Comments:
comments 1 - 3 (of 3 total)

David Evans, AIDSmeds, New York, NY, 2011-06-23 15:55:37
While there was a difference in the risk of treatment failure between those on older versus newer anti-seizure meds, there was less difference between those NOT taking seizure meds and those taking older-seizure meds. The authors don't provide an explanation, but argue that there may have been more significant differences in terms of baseline viral load and and adherence between those on and off seizure meds compared with the two groups that were both taking seizure meds.

Steven McLaughlin, Washington, DC, 2011-06-17 12:55:25
This article is poorly written and provides no meaningful data. In the 8th paragraph the author states that the individuals taking the older seisure meds were 4.5X more likely to have treatment failure and then in went on to say,"The difference between people on the older anti-seizure drugs and those taking no anti-seizure medication was less meaningful, however." The author tried to identify patterns but did not clearly establish a causal relationship between the 3 groups of test subjects.

jjbearphx, Phoenix, 2011-06-16 11:37:22
I have HIV induced eplepsy. My experience is not failure to maintain viral suppression, but failure of the anti seizure meds Dilantin then Zonigram was added and that has causes exacerbation of neuropathy. Hideous AM Med Hang over, that doubles after my AM antiviral pass as liver dumps toxins to work on HIV meds. Anti Epileptics aren't covered on ADAP formularies end up o o pocket, new anti seiz drugs are expensive. Lack of access to epileptologists makes things harder all around. not covered


http://www.aidsmeds.com/articles/hiv_seizure_protease_1667_20615.shtml

A Patients View Of Small Fibre Neuropathy Vid

While watching today's video (see link below) you may want to switch the sound off (depending on your musical tastes) but it's the message and visuals that count and I'm sure if you're having an off-day and feeling like you're the only one with nerve problems, this video will help. It's 8 minutes of protest against a largely uncaring world, when the power of positive thinking just doesn't seem to be working for you.

Small Fiber Neuropathy SFN From A Patient's View
Terra Tufts Published on 16 Jan 2015

SFN has many affects on our lives and the lives of our families and friends. For the first time Our Voices are heard through this powerful and video from SFN Warriors on Facebook who courageously volunteered their thoughts and pictures, without them this video could not have been made...I love you all Some Memes and the songs DO NOT belong to me but to the talents of those who sing them and write them


 

https://www.youtube.com/watch?v=5z0Ery6SCTo

Inconsistent Opioid Prescription Confusing For Patients

Today's post from the ever consistent pain-topics.org (see link below) looks once again at the problems surrounding opioids, especially in North America. More and more people who are genuinely in need of opioids as the only way of controlling their pain, are finding their supplies cut off because of severe legislation meant to tackle drug abuse and crime. Somehow the legislators haven't found a way to separate the genuine need from the addiction which feeds criminality, so are using a 'cover all' approach which means thousands of people are being unfairly treated. It's a growing problem as more and more doctors and pharmacies are reluctant to issue opioid prescriptions for fear of running foul of the law.

Influences on Opioid Rx for Chronic Pain Studied

Posted by SB. Leavitt, MA, PhD Friday, August 9, 2013

Opioids are still among the most commonly prescribed analgesics for treating moderate-to-severe pain. Overall, their use has been increasing even though prescribers are becoming concerned about adverse effects, misuse and abuse, morbidity and mortality, and scrutiny by federal and state regulatory agencies. Two recently published surveys of healthcare providers show that some have stopped prescribing opioids entirely for chronic noncancer pain while others, having more experience with opioids and positive attitudes, continue to prescribe these essential drugs without reluctance.

Opioid Prescribing Changes in Washington State Surveyed

In the first study, researchers in Washington State conducted a survey of primary care physicians and advanced registered nurse practitioners (ARNPs) in the state to understand changes in practice patterns regarding the prescription of opioids for treating chronic noncancer pain (CNCP) [Franklin et al. 2013]. Data were gathered via a web-based anonymous survey conducted during March-August 2011. Participants included a convenience sample of healthcare providers in Washington representing diverse geographic regions and healthcare organizations.

Writing in the July/August 2013 edition of the Journal of the American Board of Family Medicine the researchers report that 623 of 856 provider respondents (73%) claimed to treat patients with CNCP, and these practitioners served as the analysis sample. Most of these providers (72%) reported concerns about opioid overdose, addiction, dependence, or diversion, while only 25% indicated concern about regulatory scrutiny.

Only a small proportion of providers overall (3.3%) said that they had stopped prescribing opioids for CNCP, but twice as many ARNPs (5.8%) as physicians —MDs or osteopaths — (2.1%) reported opioid discontinuation. At the same time, a greater proportion of physicians (71%) than ARNPs (40%) reported familiarity with the Washington State opioid dosing guidelines then in existence.

Of interest, physicians in a large health plan serving 400,000 members in Washington (Group Health), which has substantial infrastructure support, reported less concern about problems with opioids compared with providers in other settings. For example, no providers with Group Health had stopped prescribing opioids; whereas, of providers in Spokane (the largest city in Eastern Washington), 45% reported very low capacity to access pain specialty consultation or other support and consequently were less frequent prescribers of opioids at any dose.

The vast majority of providers reported a need for more efficient, innovative means of support and education related to treating patients with CNCP. Overall, prescribers in Washington reported ongoing concerns regarding opioid use for CNCP, but those affiliated with a large healthcare organization and having access to pain consultation were less likely to report being concerned about opioid-related problems or to have discontinued prescribing opioids.

Opioid Rx Rates Influenced by Prescribers’ Attitudes and Experience

The second study was industry-sponsored (Janssen Scientific Affairs) and published in the June 2013 edition of the Journal of Pain. Researchers found that practitioners’ attitudes about pain drugs closely affect how often they prescribe opioids for CNCP (chronic noncancer pain) [Wilson et al. 2013]. As might be expected, negative physician attitudes about opioid medications appear to be associated with lower rates of prescribing and more favorable attitudes are linked with higher prescribing levels.

This study, conducted by University of Washington researchers and collaborators, used a 38-item questionnaire to assess present-day attitudes reflecting impediments and concerns regarding opioid prescribing, perceived efficacy of opioids, medical education, and benefits of tamper resistant formulations (TRFs). Of 1,535 physicians assessed in the final survey more than 70% reported using opioids in fewer than 30% of their patients with CNCP.

Of particular interest, those physicians who treated higher volumes of patients experiencing CNCP were more likely to prescribe opioids and said that they were less concerned with impediments surrounding opioids, were not worried about or avoidant of prescribing Schedule II vs. Schedule III drugs, believed in the benefits of TRFs, and thought that they were adequately trained to treat chronic pain.

According to the researchers, these results are consistent with other studies showing that physician uneasiness with prescribing long-term opioids for chronic pain is linked with inexperience in using the medications. There were no differences evident in overall physician attitudes about opioids in various areas of the country; however, the researchers noted that orthopedists expressed the most negative views of opioids, showed the lowest level of confidence in opioid efficacy, and had the highest average levels of concern about opioid addiction, tolerance, and dependence.

COMMENTARY: The survey by Franklin and colleagues [2013] may be conveying false perceptions that are contrary to current realities in Washington State. For one thing, the survey depicts a point in time that may no longer be relevant; that is, data collection was concluded in August 2011, but the study was not even submitted for publication until 14 months later in October 2012 and was just recently published in summer 2013.

Meanwhile, aggressive new laws (as opposed to mere guideline recommendations) for the management of CNCP — intended to curb opioid-related problems in Washington State — had gone into effect in January 2012 [see discussion in UPDATE here]. In advance of enactment of the new rules, some reports noted that as many as 70% of community health clinics in the state had stopped treating patients with chronic pain, and most of those that still did treat such patients would not provide opioid analgesia. Therefore, the out-of-date survey by Franklin et al. may grossly understate the extent to which prescribing practices negatively changed in the state.

Furthermore, the survey by Franklin et al. used a convenience sample, with a low response rate, that was slanted toward physicians in the large and highly supportive Group Health system. These respondents were less intimidated by opioid-dosing guidelines than other prescribers in the state — eg, none in Group Health had completely discontinued opioid prescribing — but this may or may not hold true today, more than 2 years after the survey. Meanwhile, all indications are that problems have grown worse rather than better for patients who might benefit from opioid therapy for chronic pain in Washington State; and, there have been other unintended consequences.

For example, according to newly reported research, heroin use is on the rise in Washington State and the upsurge can be traced to the new laws that made it more difficult to obtain prescriptions for opioid analgesics [see June 12, 2013 U.S. News & World Report article here]. Implementation of the new opioid-Rx laws decreased the numbers of people abusing opioid analgesics, but also increased the demand for heroin in the state.

As noted by study author Caleb Banta-Green of the University of Washington, “We were either progressive or regressive with that aggressive effort to reign in opiate prescribing before a lot of the country.” He conceded, “It shows if you enact these laws, you get some of the intended effects — high school sophomores have significantly decreased the rate at which they’re abusing prescription opiates — but people are also diverted to heroin.” This increase in heroin use is not new, and has been occurring nationwide as regulators and legislators have tried unsuccessfully to grapple with opioid-related problems [see most recent UPDATE on this topic here].

The second study noted above, by Wilson et al. 2013, appears to confirm general assumptions that prescriber attitudes toward opioid prescribing are favorably influenced by their education and experiences in using the drugs and by treating more patients with CNCP. It seems to be a case of familiarity with opioids and their effectiveness builds comfort that overcomes other concerns.

Among the various speciality groups surveyed, orthopedists were most troubled by impediments/concerns relating to long-term opioid use and had the least confidence in opioid efficacy, whereas pain medicine specialists and physical medicine and rehabilitation specialists were the most confident in opioid use and effectiveness. However, it must be considered that orthopedists most often treat patients with acute pain conditions and have less familiarity with CNCP.

The survey revealed additional factors that may influence attitudes and prescribing practices; although, the significance and universal applicability of these should be circumspectly considered. For example, male physicians on average believed more strongly in the efficacy of opioids for CNCP than females; physicians less than 45 years of age were slightly less confident in prescribing opioids compared with those between 45 and 60 years; and physicians with less than 10% of their patients having chronic pain believed significantly less in opioid efficacy compared with those having greater percentages of patients with CNCP.

Taken together, the two studies appear to emphasize practitioners’ needs for evidence-based guidance, tools and resources, as well as ongoing education regarding benefits and risks of opioid analgesics for CNCP. As might be expected with any medical therapy, practitioner confidence and expertise increase as opioid prescribing experience accumulates. This further suggests that generalizations about successes or failures of opioids for treating CNCP conditions should take into account differential qualifications, attitudes, and beliefs of the prescribing healthcare providers.

REFERENCES: > Franklin GM, Fulton-Kehoe D, Turner JA, et al. Changes in Opioid Prescribing for Chronic Pain in Washington State. J Am Board Fam Med. 2013;26:394–400 [access here].
> Wilson HD, Dansie EJ, Kim MS, et al. Clinicians' Attitudes and Beliefs About Opioids Survey (CAOS): Instrument Development and Results of a National Physician Survey. J Pain. 2013(Jun);14(6):613-627 [abstract].

http://updates.pain-topics.org/2013/08/influences-on-opioid-rx-for-chronic.html

Codeine And Chronic Pain Patients

Today's post from the always interesting sciencedaily.com (see link below) talks about how over use of codeine as a pain killer may actually worsen the original problem in the long term. This is due to the increased sensitivity to pain that long term codeine use can cause. It then works in much the same way as opioids, in that it increases dependence on the drug to achieve the same effects. Codeine can be said to be part of the opioid family anyway because it converts 10% of the codeine to morphine which then acts as a pain killer. It should be said that reasonable codeine use is not harmful but large doses over a long period of time can make the source problem worse. Because of its over-the-counter availability, many neuropathy sufferers use codeine as a matter of course and often alongside other analgesic medications they may have been prescribed. Being aware of the dangers should help you put your drug use into perspective.

Codeine Could Increase Users' Sensitivity to Pain
The above story is based on materials provided by University of Adelaide. Sep. 12, 2013 

— Using large and frequent doses of the pain-killer codeine may actually produce heightened sensitivity to pain, without the same level of relief offered by morphine, according to new research from the University of Adelaide.

Researchers in the Discipline of Pharmacology have conducted what is believed to be the world's first experimental study comparing the pain relieving and pain worsening effects of both codeine and morphine.

The University's Professor Paul Rolan, who is also a headache specialist at the Royal Adelaide Hospital, says codeine has been widely used as pain relief for more than 100 years but its effectiveness has not been tested in this way before.

"In the clinical setting, patients have complained that their headaches became worse after using regular codeine, not better," Professor Rolan says.

"Codeine use is not controlled in the same way as morphine, and as it is the most widely used strong pain reliever medication in the world, we thought it was about time we looked into how effective it really is."

In laboratory studies, University of Adelaide PhD student Jacinta Johnson found that codeine provided much less pain relief than morphine, but resulted in the same level of increased sensitivity to pain.

"Pain sensitivity is a major issue for users of opioid drugs because the more you take, the more the drug can increase your sensitivity to pain, so you may never quite get the level of relief you need. In the long term it has the effect of worsening the problem rather than making it better. We think that this is a particular problem in headache patients, who seem more sensitive to this effect," Ms Johnson says.

"Both codeine and morphine are opioids but codeine is a kind of 'Trojan horse' drug -- 10% of it is converted to morphine, which is how it helps to provide pain relief. However, despite not offering the same level of pain relief, we found that codeine increased pain sensitivity just as much as morphine."

Professor Rolan says while more research is needed, these laboratory findings suggest a potential problem for anyone suffering from chronic pain who needs ongoing medication.

"People who take codeine every now and then should have nothing to worry about, but heavy and ongoing codeine use could be detrimental for those patients who have chronic pain and headache," Professor Rolan says. "This can be a very difficult issue for many people experiencing pain, and it creates difficulties for clinicians who are trying to find strategies to improve people's pain."

Ms Johnson presented this research at the 2013 International Headache Congress in Boston, and her work is featured in this month's issue of Neurology Reviews.

A clinical trial testing a new approach to treating codeine-related headache is now being run by Professor Rolan.

The review itself can be found online at: http://www.neurologyreviews.com/the-publication/issue-single-view/codeine-and-morphine-may-increase-pain-sensitivity-equally/382d2c385b5e3154bbed15156f33e46c.html
  
http://www.sciencedaily.com/releases/2013/09/130912092251.htm