Rick Perry’s pain, and mine

It isn’t necessary to choose between pain relief and altertness: small doses of stimulants can restore alertness and potentiate opiate analgesia. But drug enforcement has made physicians afraid to practice textbook medicine.

Keith offers some acute reflections on the story that Rick Perry’s disastrous debate performances resulted from adding big doses of opiate pain relievers to his built-in dumbitude.

As a former sufferer both from long-term, severe back pain and from the haziness produced by oxycodone, I’d like to add an additional thought: if the story is true, it reflects badly not just on Perry’s political advisers, but on his physicians, who neglected a simple step that could have kept him alert.

The drowsiness produced by the opiates is a basic problem in treating chronic pain. For that problem there turns out to be a straightforward solution: reduce the dose of opiates, and add a little bit of amphetamine-type stimulant (ATS). The ATS potentiates opiate pain relief, enabling the lower dose, and directly counteracts the drowsiness.

I discovered this in reading Dan Perrine’s Chemistry of Mind-Altering Drugs. Having spent twenty years deciding almost every day between pain and drowsiness, I was surprised by this, and checked it out with my friend Jerry Jaffe, who writes the section on opiates for Goodman and Gilman. His response? “Yes, of course. Everybody knows that.”

My next question – asked with some asperity – was why, if “everybody knows that,” no doctor had ever given my a little bit of amphetamine along with my oxycodone. Jerry answered, “Think about it. If you take a script for Percodan and a script for Desoxyn down to your corner pharmacy, what’s the first thing the pharmacist does? He calls either the medical board or the DEA and says, ‘Dr. X is writing uppers and downers.’ Then the doctor spends two years trying to keep his license and stay out of jail.”

As a result, I had two decades of needless pain and disability (until I finally let Dr. Gregory Brick fix the underlying problem with his magic scalpel). And, as Keith points out, the people of Texas have an impaired governor, and the Republican Party is about to nominate the Ken doll for President.

The only person I know whose chronic pain was treated according to the textbooks was Lew Seiden. There are advantages of being the chairman of pharmacology at the University of Chicago. But really, should that be a necessary precondition to getting the right treatment?

Seems to me to be about time for (1) the DEA to exercise some self-restraint (or for enforcement against diversion to move from DEA to FDA) and (2) a few doctors to learn some medicine and grow a pair.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

11 thoughts on “Rick Perry’s pain, and mine”

  1. Or (3) some enterprising pharmaceutical manufacturer to develop a potentiated version of an opiate.

  2. Interesting assertion that everyone knows this. Often it turns out that “everyone” effectively means “me and this other guy I know.”

    A PubMed search for randomized clinical trials on “methylphenidate and narcotics” yields only six articles, three of which are germane to this question; they were published in 1987, 1992, and 1995. In the past 17 years, no new randomized trials are showing up.

    A European palliative care guideline (Stone P and Minton O, Palliative Medicine 2010;25(5):431-441) for management of central nervous system side effects of narcotics cited these three studies and concluded that the current evidence was of low quality, and that only a weak recommendation could be made for the use of methylphenidate for the relief of opiate-associated sedation when other measures have failed.

    This means that a major problem in pain management is not being studied as it deserves to be studied; all three clinical trials above were on cancer patients and none were in nonmalignant pain. This is not acceptable.

    Parenthetically, it is noteworthy that PubMed searches for practice guidelines on “psychostimulants and narcotics” produce zero articles, even though the European guideline ought to have qualified for inclusion in such a search. The dissemination of information to the medical profession can be made more difficult by the vagaries of how well the National Library of Medicine indexes the thousands of articles it has to deal with every day.

    So, getting “everyone” informed about the possible usefulness of an unused intervention for a difficult problem is itself a problem. The example of psychostimulants for narcotic-associated sedation is not an isolated problem.

    Makes you think, “Gosh, I wish there some government agency which could conduct studies of drugs which have gone off patent and whose use would generate few if any profits for Big Pharma.”

    1. When it’s in one of the standard reference works (Perrine’s book is published by Oxford University Press and the American Chemical Society) and the guy making the reference is the author of the relevant chapter in the gold-standard reference work (Goodman & Gilman’s The Pharmacological Basis of Therapeutics is now in its twelfth edition) “everyone knows” means “everyone who knows anything about the topic knows.” Alas, that doesn’t seem to include most of the people actually practicing medicine. Maybe there’s no recent research because there isn’t an open research question.

    2. The opiate chapter in the 12th edition of G&G mentions sedation only in passing and says it will resolve on its own without specific treatment. Yes, there actually are lots of people who know about Ritalin for opiate sedation, but the trouble appears to be that there are too few studies to establish it as a standard of care.

      Part of the dilemma appears to be related to what has to happen for a practice pattern to become generally accepted in the era of “evidence-based medicine.” Dr. Jaffe is a walking encyclopedia who hangs out with other walking encyclopedias. I think that rather than saying “everyone who knows anything about the topic knows,” it would be more precise to say “everyone who knows everything about the topic knows.” This would be “eminence-based medicine” whose glory days are in the past. Perhaps that is a loss which has not sufficiently been appreciated when the Cochrane Meta-analysis stands as King of the Evidence.

      It would be of great interest to get Dr. Jaffe’s insights about what has to happen for practice to change in the current culture of medicine. Not an easy problem by any means.

      1. It must be very difficult to set up double-blind, informed-consent trials on patients in severe pain. Would you sign up? On the other side of the relationship, any doctor has the strongest ethical obligation to prescribe the pain-relief medication she thinks most effective. That said, since doctors have different views, you could easily do other if less conclusive forms of trials, following matched cohorts. Wouldn’t the white-coat effects cancel out?

      2. Dissemination of information seems to be a key part of the problem here. It often occurs that people confuse the appropriateness of an intervention with the level of evidence supporting it.

        The “weak” recommendations of published guidelines are still recognitions of the legitimacy of using Ritalin for the sedative and cognitive side effects of opiates. They want better evidence before making a stronger endorsement of its use, but this is not the same thing as saying that it is inappropriate to prescribe it.

        The Massachusetts General Hospital pain management manual mentions Ritalin only in an appendix, with no discussion about its usefulness. Wall and Melzac Textbook of Pain also mentions it in passing in just one sentence, with no discussion about its use in potentiating the effect of narcotics. And the lack of any mention of treatment of opioid-induced cognitive side effects in G&G 12th edition is a real omission which does not help the situation. And of course the PDR, being limited to listing FDA approved indications for drugs, is pretty hopeless.

        I will ask on Wednesday morning at a weekly spine conference I go to what the practice is among spine specialists locally. I am especially interested in finding out if they are prevented from combining stimulants and narcotics because of fear of the DEA coming after them.

      3. Update: I did ask at spine conference this morning (seven very good spine surgeons in attendance), and none of them has ever used or considered Ritalin for opioid-related sedation and cognitive problems. The physical medicine docs were not there this morning, and they would be a better bet to know this stuff, but a lot of their practice is concerned with things that they get patients referred to them for, like injections and electrodiagnostics rather than clinical pharmacology. The anesthesiologists were also not there today, and they would be the best bet to shed light on this topic.

        I am getting the feeling that this is something that the pain guys would know about, but a potentially very valuable pain intervention is not part of routine practice. This is a problem worth pursuing. The fragmentation of knowledge that accompanies specialization has been deplored for decades, with patients paying the price for the way that knowledge is disseminated or sequestered. This is a systemic and not a localized issue.

  3. Well, why is a Democratic administration hassling pot growers in California? I’m sure marijuana helps a lot of sick people too. I don’t think a simple switch to the FDA would solve the problem, which is we’re still a bunch of Puritans.

  4. Few physicians know of this literature. And single dose studies hardly support the chronic co-use of opioids and amphetamines. And their use for a couple of months in cancer patients does not really support ongoing treatment in those without cancer for what usually turns out to be years. There are many therapies like this with a little bit of evidence that never get integrated with the mainstream. Hard to imagine a more addictive mix in terms of dopamine release.

    1. I expect that the published guidelines were very cautious and lukewarm in their endorsement of Ritalin for this and other reasons having to due with lack of data for long-term use and with the fact that you cannot get the information you need from two or three small crossover trials. That is one reason to lament the lack of research in this area.

      But the best clinicians consider the whole landscape of information, which includes the pharmacology (receptors and kinases and second messengers and volumes of distribution all that), the pathophysiology of the condition they are treating, and, above all, the patient they are dealing with and the setting in which the patient is living and working. All those Osler aphorisms about it being more important to know what kind of patient has a disease than to know what kind of disease the patient has, have been overlooked when every patient must be approached with the assumption that the worst-case scenario is to be the default scenario.

      The interaction of drug, set, and setting, in other words, jointly determine the shape of the whole landscape in which a good general will plan a strategy.

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