pharmacyA blog written by Charlie P. Reznikoff, MD was shared by Medscape on March 16, 2015 titled 10 Scripts Never to Write. It gave me pause, enough so that I shared it with respected colleagues in the pain management field for their perspectives. It was suggested to me that those of you who live with pain might like to weigh in. I urge you to read Reznikoff’s blog for yourself to see what you think. I will share some thoughts with you to mull over before you do. Here goes.

First of all, I did find there were some interesting points of wisdom, such as with the current state of pain science “there is no biomarker for pain.” I wholeheartedly agree that to effectively assess pain–skillful and open communication between the patient and their healthcare provider is key.

I also agree that:

  • “Pain is not one thing but many, and all are in interplay.”
  • Opioids may “complicate, not simplify, the treatment of pain.” Sometimes, they offer people their lives back, too.
  • I would suspect that opioids could “powerfully relieve some psychiatric symptoms, which are not indicated for such conditions.” I would like to see that evidence cited.
  • When people have co-existing conditions of substance use disorder, behavioral health disorders and pain disorders, “the picture does becomes muddier which could challenge any clinician’s ability to deliver safe and compassionate care.” That makes the work harder, not impossible. There are some great clinicians out there doing wonderful work in this arena—independently or in collaborative practices. Clearly, we need more of this.
  • There does need to be clear and easy tools to guide healthcare professionals “through the quagmire of opioids, addictive disease, mental health disorders, and pain.”

Reznikoff goes on and recommends this:

Ten Prescriptions Never to Write:

  1. Alprazolam (Xanax®) (lorazepam [Ativan®] is safer)
  2. Methadone for pain, unless very experienced
  3. Opioids greater than 100 mg morphine equivalents daily
  4. Carisoprodol (Soma®) or butalbital, which are short-acting barbiturates
  5. Tramadol; it is not a safer option for high-risk patients
  6. Short-acting psychostimulants (amphetamine, methylphenidate)
  7. Meperidine (Demerol®)
  8. Long-acting hydrocodone (Zohydro®)
  9. Any opioid until you’ve assessed the patient’s addiction and mental health background
  10. Any prescription while the patient is under duress.

The list of “nevers” that are recommended above, seems flawed and not backed up with quality research (though definitely more is needed to demonstrate efficacious prescribing in all conditions referenced). Here are some shared thoughts to challenge his recommendations, or shall I say modify them.

  1. There is an agreement that most benzodiazepines (BZD), which includes alprazolam (Xanax®), (lorazepam [Ativan®] and diazepam [Valium®) can be problematic. Great caution should be used with BZD’s when used as a sole agent and especially when combined with other medications that can cause sedation, like opioids. Then there is the problem when alcohol is introduced into the picture.
  2. Methadone for pain, should not be prescribed unless from the very experienced. It can be a great choice in the right patient, with the right dose by the right provider, though.
  3. It is incorrect to say that prescriptions for opioids greater than 100 mg morphine equivalents daily should “never” be written as there are occasions when this is appropriate. “Rarely” might be a more accurate statement.
  4. Carisoprodal {Soma®) is a muscle relaxant that breaks down into a barbiturate and butalbital which is found in Fiorcet® or Fiorinol®. All are sedating. It is common knowledge in the pharmacy world to watch out for the “holy trinity” which is considered a red flag—the combination of three prescriptions—an opioid, a BZD and Soma. Taken together, they are highly sedating and an overdose waiting to happen.
  5. Disagree, yet could be in agreement if “never” was changed to “rarely.” Tramadol has been useful in some cases. There are some patients who do well with it while others may experience the disassociation effects from the serotonin-like additive.
  6. Short-acting psychostimulants have been very helpful in moribund, depressed patients with advanced disease and in treating opioid-related sedation.
  7. High five and wholeheartedly agree about Meperidine. Why in the world it is still being ordered for pain is beyond me.
  8. Disagree about Zohydro®. This is a long-acting form of hydrocodone and has the same risks and benefit profile as most long-acting opioids. See Policy Statement from the American Academy of Pain Management.
  9. Agree unless this is not a case of acute pain, such as surgery, trauma/emergency care (then treat first and evaluate later)—prescribing any opioid should require a risk assessment for substance use and mental health disorder or family history.
  10. This one is problematic—do not write any prescription while the patient is under duress. How do you define “duress”? Suffering because of pain? Then there is disagreement. Psychosocial distress or duress from another party, then the consensus is in agreement.

Overall, one wise and respected colleague said it best. I find any list of ‘rules’ like this to be of great concern; both as a patient, as an individual, and as a researcher/writer in the pain and addiction fields for the past 23 years. I would not want to have as my physician or any other practitioner one who is [so] biased and under-educated that they would even subconsciously adhere to such a list. It is de-personalized medicine at the extreme and potentially more harmful than helpful; in my opinion.”

I must concur. Effective and quality care can only be achieved when the healthcare professional develops treatment using patient-centric and relationship based principles. The best pain care is derived from these principles while multi-modal, integrative care is offered. I support the same for those dealing with substance misuse/abuse and mental health challenges as well.

So, I say “Never, say never.” Providing lists as absolutes does a disservice to all of us—clinicians and patients alike. What’s your opinion?

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