Allegations of Medical Malpractice in Chronic Opioid Analgesic Therapy Possibly Related to Collaborative/Split Treatment and the P-450 Enzyme System: Forensic Case Report

Migraine and the Risk of Suicide

Rarely and tragically, migraineurs commit suicide or overdose on medications we prescribe.

The clinical implications of cytochrome p450 interactions with opioids and strategies for pain management

Pharmacokinetic differences among opioids influence a patient's response to opioid treatment. An important element affecting a drug's pharmacokinetics, its metabolism, may be altered under various circumstances, thereby enhancing or mitigating a patient's response to opioids. The genetic background of the metabolic enzymes involved in opioid metabolism, comorbid medical conditions, older age, and the presence of other drugs that influence metabolism are such factors that can cause the response to opioid therapy to vary greatly from the expected response to a standard dose. As a result of the variability in individual responses to opioids, clinical management of pain with opioids must be empirical.

Is smoking associated with alcohol-drug dependence in patients with pain and chronic pain patients? An evidence-based structured review

OBJECTIVE

The objective of this study was to determine if there is consistent evidence for smoking to be considered a red flag for development of opioid dependence during opioid exposure in patients with pain and chronic pain patients (CPPs).

METHODS

Six hundred and twenty-three references were found that addressed the areas of smoking, pain, and drug-alcohol dependence. Fifteen studies remained after exclusion criteria were applied and sorted into four groupings addressing four hypotheses: patients with pain and CPPs who smoke are more likely than their nonsmoking counterparts to use opioids, require higher opioid doses, be drug-alcohol dependent, and demonstrate aberrant drug-taking behaviors (ADTBs). Each study was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 13 quality criteria to generate a quality score. The percentage of studies in each grouping supporting/not supporting each hypothesis was calculated. The strength and consistency of the evidence in each grouping was rated by the AHCPR guidelines.

RESULTS

In each grouping, 100% of the studies supported the hypothesis for that grouping. The strength and consistency of the evidence was rated as A (consistent multiple studies) for the first hypothesis and as B (generally consistent) for the other.

CONCLUSIONS

There is limited consistent indirect evidence that smoking status in patients with pain and CPPs is associated with alcohol-drug and opioid dependence. Smoking status could be a red flag for opioid-dependence development on opioid exposure.