geoffrey modest medical blogs

Two important articles were just published in NEJM which I think should stimulate a change in clinical practice regarding prescribed opiates. ------------------------------------------------------------------------------------ One article assessed the relative importance of physician prescribed opiates and the subsequent development of opioid use disorders in the elderly (see  opiate prescribing in elderly and dependence nejm2017  in dropbox, or Barnett ML. N Engl J Med 2017; 376: 663). Details: -- retrospective analysis of a random 20% sample of continuously-enrolled Medicare beneficiaries who had an emergency department (ED) visit from 2008-2011, and had not received opioid prescription for the prior six months -- mean age 69, 65% female, 76% white, 50% also on Medicaid, 37% disabled, mean of 3.5 chronic conditions (most commonly hypertension in 78%, hyperlipidemia in 70%, acute MI in 50%, depression 40%, diabetes 38%, COPD 28%), with 38% from...

a couple of brief reports on opiates in the community. 1. MMWR reported that there was an outbreak of poisonings in people in San Francisco taking a counterfeit​  Norco  (a combo of hydrocodone and acetaminophen, but with a sinister name)  -- see  http://www.cdc.gov/mmwr/volumes/65/wr/mm6516e1.htm?s_cid=mm6516e1 . 7 cases were reported, with some differences in the apparent composition of the counterfeit drug: all had fentanyl (a potent synthetic opioid, 100x that of morphine, and a full m-opioid receptor agonist. fentanyl has high lipophilicity, allowing it to enter the CNS rapidly. it is not marketed as an oral pill, so its presence in pill form confirms its being illicit); some had promethazine (used for nausea/vomiting, motion sickness, and it may potentiate the opiate high), some trace amounts of cocaine and several with no detectable hydrocodone. details: --the illicit drugs appeared very similar to the real thing, including ...