opioids

1 September 2021

Is This Why Aimovig Won’t Work For You?

James Discoveries & Stats, Medications 0

Aimovig (erenumab) has been a great help for many migraine patients, but not all. Do we know of any reasons why it doesn’t work with some people?

Different medications - problems together?

A good doctor doesn’t want to randomly throw medications in your direction, trying on after the other. A good doctor knows which drugs have good scientific evidence behind them, and if possible which seem to work best for a patient like you – perhaps someone with your symptoms, or your lifestyle, or your medical history.

Now we all know that each person is very different and complex, so we will never type in “10 facts about Me” and have the computer spit out the perfect treatment. But we do have some clues once in a while that help us choose one treatment over the other.

Last year at the 62nd Annual Scientific Meeting of the American Headache Society, a report was presented entitled “CGRP Monoclonals: Efficacy, Side Effects, and Switching”. It attempted to start answering questions about which CGRP related medications were good for whom, and whether or not a patient should consider switching. Another concern is that more side effects were showing up in the real world than had shown up in clinical trials (not uncommon, but something to watch).

There were a couple of interesting notes in particular regarding erenumab, brand name Aimogvig.

First, and not surprisingly, patients with “moderate or severe refractory chronic migraine” were less likely to be helped. That is, those with significant chronic migraine that has not responded to several other common treatments. However, if patients had “mild refractory chronic migraine”, the medication may help.

The second predictor that Aimovig may not work was that the patient was taking opioids.

Opioid medications have helped many migraine patients, but must be used with extreme care because they are notorious for making the migraine condition worse. Occasional or very temporary use may be helpful for pain, but there are usually better options.

So for some reason, patients taking opioids were less likely to benefit from erenumab. This raises an interesting question – if patients stopped taking opioid medications for several months, might they be able get more benefit from Aimovig? Or, if they stopped taking opioids upon starting Aimovig, would symptoms improve several months later?

For the average patient, the study found that most patients could tell after a couple of months if Aimovig was going to be worth it for them. (A good rule of thumb for most treatments is to try them for three months.)

And what about trying a different but similar medication? In this small study, there did not seem to be a general benefit – but remember, for an individual, it may be worth it. The study did note that some patients did switch because of financial reasons, and “more than half of the patients did well”.

7 May 2019

Doctors too “abrupt” as they apply Opioid Restrictions?

James Medications, News 0

In 2016, the Centers for Disease Control and Prevention (CDC) in the USA implemented new guidelines for restrictions of opioid medications. Now, as the results of the restrictions are coming to light, the CDC is expressing concern that doctors may be taking the restrictions too far.

It’s not surprising that the media attention on opioids has led to a bit of an overreaction. Although the evidence generally does suggest that prescriptions of opioids could be cut down drastically, it’s also true that they’ve helped a lot of people. Prescribing them when they’re helpful, and not rushing to get people off them, are two important concerns.

Three of the original authors of the restrictions published an article in the New England Journal of Medicine explaining:

Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations. A consensus panel has highlighted these inconsistencies,⁵ which include inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice. The panel also noted the potential for misapplication of the recommendations to populations outside the scope of the guideline.
No Shortcuts to Safer Opioid Prescribing

Although it’s certainly important to encourage patients to change when there are better treatment options, even the changes need to be done wisely. Dr. Patrice A. Harris, President-elect of the AMA and chair of the AMA Opioid Task Force, pointed out that the guidelines have been “wrongly treated as hard-and-fast rules, leaving physicians unable to offer the best care for their patients.” (source How the CDC’s opioid prescribing guidance went astray)

In the midst of all the concern about opioid overuse and overdose, doctors need to remember to put their patients first, and take a long term view.

For more information: CDC Admits Its Opioid Prescribing Guidelines Have Hurt Chronic Pain Patients

27 April 2015

More Concerns About Narcotics in a Migraine Emergency

James Discoveries & Stats, Medications 0

New studies are reinforcing concerns about hospitals that are still giving narcotics, otherwise known as opioids, for treatment of migraine in the emergency room. Common examples include hydromorphone and meperidine (Demerol).

Many years ago, when we didn’t have the migraine treatments that are available today, treatment with opioids was common. But today, after much more research and having many more options, these types of medications are a long way down the list of recommended treatments.

A study published this past November in the journal Cephalalgia illustrates some of that research. The study, out of Stanford University in the USA, reviewed the charts of 574 patients who visited the ER/ED with some kind of headache disorder, such as migraine accompanied by headache. You can see the results below
Opioids in the ER/ED
Patients who were given opioids/narcotics tended to stay in the ER/ED more than an hour longer (5 hours as opposed to almost 4). In the next seven days, patients who were given opioids were more than twice as likely to return.

Not only are health professionals and patients interested in these numbers, so are the people who are crunching the numbers – that’s quite an economic impact when migraine is such a common disability around the world.

There are some limitations in this study. It would be helpful to know why patients were prescribed opioids. Were the opioids causing the longer stays in every case, or were the headaches worse, or of a different type? However, this study isn’t alone. Even back in 2008 we talked about a study involving Demerol, which showed that it tended to be less helpful for patients than other options. To put it simply, there are other medications that tend to do a better job at fighting the headache.

Although we should be careful not to go to an extreme and say that all opioids are evil and should never be an option, the evidence is showing that they should be used rarely. And the problem right now is that they’re being used far more often than they should be, based on the research.

But this is important if you’re a patient: If you are in emergency with a headache, and you aren’t given a narcotic, don’t assume that they think you’re a drug-seeker. Don’t assume they’re not listening to you, or not taking you seriously. And don’t even assume they’re trying to save money at your expense.

More likely, they have found that there are other treatments that will probably work better for you, in both the short term and long term, with fewer side effects.

And if you’re working in the ER/ED as a health professional, and your department is still giving a high number of opioids to migraine patients, review some of the latest evidence and recommendations to find the best treatment for your patients.

For more information:

6 April 2015

Child Migraine: Time to Fight for Better Treatment

James Discoveries & Stats, Medications 1

We’ve talked in the past about how far behind we are in the field of migraine treatment for children. Far behind where we should be, and far behind where we are in treatment for adults.

A new study sponsored by the Migraine Research Foundation has brought the discussion to the forefront yet again. Child Migraine: Better treatment, please.

The study used Electronic Health Record data to see how 40,000 teens and children with migraine were treated. The news was generally not good.

First, of those who were actually prescribed medication, 15.8% were prescribed an opioid. Considering the wide range of treatments available today, and the many problems with using opioids as treatment for migraine, this number is very high. (Note: This is not to suggest that opioid treatments are never appropriate. Only that the evidence increasingly shows that they should be way down the list of things to try. Prescribing so much of this type of medication indicates that treating children and teens with migraine is many years, even decades, behind where it should be.)

It should be noted that opioids were far more likely to be given in the emergency room. Emergency room health care workers may still not be aware of some of the other options available to quickly treat a severe migraine attack.

Next, only 16.1% were prescribed an “evidence based” medication. Again, we’re talking about medication that has good scientific evidence behind it.

Now at first glance, I’m not quite as worried about this statistic. There are many excellent non-drug treatments for children, including biofeedback and supplements. I would not necessarily want doctors to jump to medication first-thing.

However, if I’m reading the numbers correctly, this actually represents 35% of children and adolescents who were prescribed medication.

In other words, the vast majority were not being prescribed the best medication to fight migraine.

Finally, only 46% were prescribed medication at all.

Again, I’m not necessarily worried that doctors are not going to drugs as the first and best option. However, these numbers and years of experience in this field tell me that a good number of doctors are probably telling patients to “just live with it”, when better options are available.

An interesting side note to the study. The researchers compared treatment in metropolitan and non-metropolitan areas, and discovered to their surprise that the doctors in the non-metropolitan areas were doing a better job at prescribing medications with good evidence behind them. So just because you’re in the city doesn’t mean you have better options – that small-town doctor seems to be doing a great job.

It is very difficult for doctors to stay up with the latest research in every area. All right, impossible. This is not an anti-doctor study by any means (and again, there is a lot this study doesn’t tell us).

However, it is a reminder that migraine in children and teens is a serious issue which needs to get more attention. If you’re a doctor, this is certainly something to think about. If you’re a parent, you can focus on your child and take responsibility to make make sure they are getting good treatment.

16 December 2013

Headache: Five Things Physicians and Patients Should Question

James Information, News 0

Neuroimaging Studies: These scans rarely diagnose the problem, and can actually pose risks.
CT Scans: MRI scans should almost always be used in place of CT scans, but both in rare cases.
Trigger Point Surgery: Surgical deactivation of migraine trigger points doesn’t yet have enough research behind it.
Butalbital and Opioids: Risk > Benefit
OTC Pain Meds: Prolonged or frequent can make things worse.

Bonus: EEGs: The American Academy of Neurology version of the list includes “Don’t perform electroencephalography (EEG) for headaches.“

This list (the first five items) was the result of surveys and recommendations discussed through the AHS. For more information from the Choosing Wisely initiative: