How the government creates criminals

The Centers for Disease Control and Prevention issued a broad set of recommendations in March for physicians and treatment facilities that dispense opiate medications. The same week Massachusetts Gov. Charlie Baker signed into law some of the most restrictive regulations ever governing the therapeutic use of narcotic drugs—including limiting first-time prescriptions for opioid pain medication to seven days worth of pills. At least six states have passed similar measures restricting the amount and potency of narcotic medications doctors can prescribe…

[Christopher] Baltz was in his third year of treatment for chronic pain resulting from a severe motorcycle accident and was being prescribed a high dose of oxycodone when Florida Gov. Rick Scott declared war on the state’s robust pain management industry in 2011…

Scott’s crackdown led to the closure of some 400 pain management clinics almost overnight, while a coordinated effort by the Drug Enforcement Administration targeted pharmacies suspected of over-dispensing controlled substances.

This took the form of more aggressive enforcement of a decades-old federal mandate known as “corresponding responsibility” that holds pharmacies legally accountable for ensuring the drugs they dispense are being used for a “legitimate medical purpose.”

In theory, the policy is designed to add another check in the process of preventing drug abuse and diversion. In practice, it places pharmacists in the unwarranted position of policing doctors, and discriminating against patients on the basis of often arbitrary red flags (for instance, paying for their prescriptions in cash).

The net effect of the crackdown in Florida was profound and acute. Prescription drug deaths dropped precipitously within the first year-—but heroin deaths rose 39 percent, as patients cut off from legal opioids turned to illegal drugs for relief…

In spring 2013—two days after receiving a courtesy call confirming his monthly appointment—Baltz showed up at his pain management clinic only to find it had been closed down. Within weeks he was making regular trips to Miami to buy heroin.

“The government wants to prevent people abusing pain medication, but there’s no exit strategy,” said Baltz. “I never even saw heroin until this happened.” …

According to the United Nations, 5.5 billion people around the world already suffer from inadequate pain treatment. This includes roughly a third of all cancer patients in the U.S.

Dr. Webster is one of hundreds of doctors and pharmacies that have been investigated by the DEA since it launched its OxyContin Action Plan in 2001. The plan signaled a shift in federal enforcement tactics away from a focus on illicit street drugs and toward preventing controlled pharmaceuticals from falling into the wrong hands. Over the next 13 years the DEA added more than 1,500 personnel and more than doubled its budget. It also significantly ramped up administrative audits of registrants authorized to dispense controlled substances. (As The Daily Beast reported last year, over the same period the DEA was increasing its quotas of Schedule II pharmaceuticals approved for commercial sale).

During one year alone (2009-2010) the number of regulatory investigations conducted by the DEA’s Office of Diversion Control (responsible for policing prescription drugs) more than tripled, according to the Government Accountability Office…

Federal law requires that all prescriptions for controlled substances be for a “legitimate medical purpose,” but it doesn’t define the term…

Ironically, there is evidence that restricting patient access to pain medicine could actually lead to more overdoses, not fewer. Medical examiners are already unsure of how many deaths attributed to “unintentional overdose” are actually suicides. Chronic pain patients frequently suffer from ancillary mental health problems—including depression, anxiety and insomnia—and are at least twice as likely to commit suicide.

In 2013, when the Department of Veterans Affairs responded to a runaway painkiller problem with a new Opioid Safety Initiative, reports surfaced of patients being cut off their medication without proper dose reductions. Within months the agency came under fire for its new policy when a 52-year-old Navy veteran shot himself in the head in front of an outpatient clinic in Virginia after he was forced off his pain meds.

“The medications were the only thing that was helping him, and when they took that away from him, his life just went downhill,” a friend of the dead man told a local paper…

Meanwhile, there is evidence that the majority of prescription opioids that are diverted for illicit use come from the acute care setting, not the treatment of chronic pain.

I’m not sure that makes sense, if this is also true:

From the New York Times:  “And so although emergency physicians write not quite 5 percent of opioid prescriptions, E.R.s have been identified as a starting point on a patient’s path to opioid and even heroin addiction…”

But perhaps it just shows how small the diversion problem really is, even though we’ve spent so much money (and ruined so many lives) in the effort to combat it.

Dr. Daniel del Portal, who teaches emergency medicine at Temple University’s Lewis Katz School of Medicine, says the modern health care system often incentivizes doctors in acute care settings to find a quick fix for patient complaints. “The pressure is on physicians to make patients happy at any costs,” he told The Daily Beast…

Really? How many doctors have you known that made an effort to make you happy? I don’t ever recall feeling happy after leaving the doctor’s office.

Finally, doctors say there is little use in recommending alternative treatments for patients if they can’t afford them. Pain pills are cheap, and usually fully covered by insurance; physical therapy, chiropractic care, and yoga are expensive, and almost always include co-pays (if they are covered at all)…

Sure, the only reason pain patients don’t use alternative treatments is because of the cost. That really flies in the face of how many pain patients pay out-of-pocket for these alternative treatments, as many are forced to do before they are even given access to opioids.

The fact is that alternative treatments have not proven to be very successful, and their gains are extremely short-lived. This is about treating constant, daily pain, not an injury that will improve over time. For instance, I’m sure there are plenty of pain patients who would welcome a daily massage (if they could afford it), but I would need painkillers before I agreed to let someone work on my body. It would be a treatment that caused more pain, just like so many others I’ve tried. Seems to me that most of the treatments which cause more pain don’t provide as much benefit as their practitioners would have you believe. “No pain, no gain” doesn’t really work when we’re talking about chronic pain.

Another problem is that many of these alternative treatments can be practiced at home, but unless you’re being seen by a doctor, disability insurance companies will question if you’re really suffering from chronic pain. And what’s the point of paying for a doctor if all she can prescribe are these alternative treatments? Because you really don’t need a prescription for yoga, meditation, stretching and exercise, and many other alternative treatments. (Doctors suck.)

Is it time to legalize marijuana in sports?

Kyle Turley was watching one of those commercials earlier this year when he decided enough was enough. He was done with synthetic drugs.

A decade-long NFL career left the former San Diego State All-American offensive tackle with a multitude of health issues. Turley’s football injuries broke his body, but he’s also convinced that football did irreparable damage to his brain. He’s struggled with anxiety, headaches, depression and rage issues. In an interview with the Union-Tribune in 2013, he even admitted to having entertained suicide.

To help him deal with his ailments, Turley’s doctors have prescribed a multitude of painkillers, psych meds and muscle relaxants over the years.

Depakote. Wellbutrin. Zoloft. Flexeril. Percocet. Vicodin. Toradol. Vioxx.

You don’t need to know what each of these drugs is designed to do. The point is that dating back to when he blew out his knee at SDSU in 1996, Turley has been on them all at some point, often in different prescribed combinations, over a period that spans almost 20 years.

That ended in February when Turley decided to free himself of all prescription medications and use only marijuana – a move he credits with saving his life…

With California’s liberal medical marijuana policies, access to marijuana was one of the reasons Turley uprooted his family from Nashville, Tenn. back to his hometown of Riverside last April.

Since weaning himself off all prescription drugs three months ago and transitioning solely to medicinal marijuana, Turley has noticed a “night and day difference in his psyche.” He no longer suffers from low testosterone, his libido is back, and his anxiety issues have improved.

“I don’t have as bad depression any more, that’s getting better. The cognitive impairment seems to be getting a little bit better. Life is more manageable, I have more energy and feel more alive,” Turley said. “I don’t think about killing myself any more. Suicidal thoughts and tendencies were part of my daily living.

“At the end of the day, I was losing hope with the synthetic drugs and now I feel better. It’s giving me hope again, helping with depression and anxiety.” …

Who’s side are you on?

Opioids for Chronic Pain – An Interview with Dr. Webster, Pain Guru

To develop an addiction, a person must be exposed to the drug. Avoiding the use of opioids whenever possible decreases exposure. Decreasing exposure reduces the chance for the disease of addiction to be expressed…

If an opioid is to be prescribed, an assessment for risk factors should be performed followed by close monitoring for aberrant behavior. Addiction can be triggered with the first dose or develop after prolonged exposure. People with a “loaded” genome may express an addiction earlier than those who are spared many of the genetic risks. People who develop an addiction later may have less of a genetic vulnerability, but the stress associated with chronic pain can tip toward destructive use behaviors. Using urine drug testing and prescription drug monitoring is essential to detecting non-adherence, which could be a sign of addiction.

For more on how to prevent opioid addiction see my book, Avoiding Opioid Abuse While Managing Pain…

I personally believe that the FDA should set a deadline for when all ER formulations must meet a minimum standard of abuse-deterrent properties to remain on the market. If this were to occur, the cost of ER formulations would likely increase, but this may be a reasonable trade-off for potentially safer products. Of course, this move will not eliminate all dangers; people can still overdose if they take multiple pills of an abuse-deterrent formulation…

It is important that prescribers have access to interstate data sharing because patients can easily move from one area to another if they intend to deceive the prescriber. In some cases, physicians can access data from prescription monitoring programs in surrounding states by contacting those states, but this takes more time and work than is desirable. For years there has been a push for a nationally centralized database of prescriptions. However, funding has been lacking to make that happen…

Pain Guru or Addiction Guru?

The Stanford Opioid Management Model

First published on June 1, 2014

It is important to clearly address these responsibilities and expectations at the onset of establishing a treating relationship, particularly when the increasingly controversial subject of opiate medications is involved.

 Risk Identification and Stratification

Patients should be notified prior to their visit that medications will not be prescribed during their first appointment. The purpose of the initial evaluation is to obtain a thorough history and physical examination to ascertain the most appropriate treatment course. The history should include information relevant to the pain condition, past medical history, and psychiatric functioning. A risk assessment tool for substance abuse should be administered in the event that opioid prescribing will be a part of the treatment plan…

Low-Risk Individuals

Patients who are categorized as “Low Risk” on the ORT, present a medication history that corresponds with the CURES [PDMP] report, have a UDS result that is consistent with their prescribed medications, and do not have untreated or undertreated mental health issues are considered at low risk for opioid abuse. Prescribing of opioids may be initiated if it is clinically indicated. Before opioids are prescribed, the patient should sign written documents that explain the risks of opioid therapy and the parameters of treatment…

Consistent UDS results, CURES reports, and appropriate responses in the above areas suggest a lack of contraindications for continued opioid use. However, any deviations in the above parameters would result in the patient being recategorized as being “At Risk” and would prompt a switch to the pathway described in the next section.

At-Risk Individuals

Patients are considered “At Risk” for opioid abuse due to any combination of the following:

-Moderate- or high-risk result on the ORT
-Medication history that does not correspond to the CURES report
-UDS result that is inconsistent with prescribed medications
-Untreated or undertreated mental health issues

An evaluation by a pain psychologist should be obtained for all at-risk patients to identify the nature and extent to which psychological factors may be influencing the patient’s predicament. An additional consultation with an addiction medicine specialist should be obtained for patients at moderate or high risk based on the ORT, incongruent CURES, or inconsistent UDS results.

Upon completion of the additional evaluations, the information should be integrated to identify whether the patient should be recategorized as low risk or if an active substance abuse disorder is present that necessitates formal addiction treatment…

Reasons to Consider Opioid Cessation

It is critical for prescribing providers to actively monitor patients to ensure that use of opioid therapy remains appropriate. The parameters surrounding the number and type(s) of infractions that would result in medication discontinuation should be specified clearly in the agreement. Once the threshold for discontinuation has been reached, providers should initiate a taper. Contraindications for continued prescribing include (but are not limited to) aberrant behavior, lack of functional improvement, and medical complications…

Lack of Functional Improvement

One of the hallmark differences between acute and chronic pain is the fact that the latter lacks a definitive cure; thus, treatment approaches focus on management of the condition. It can be tempting to focus solely on pain palliation when prescribing medication, but optimal pain management treatment should encompass a wider range of factors, including functional status and emotional well-being. Use of activity diaries (documents in which patients track daily activity), monitoring of work absenteeism due to pain, and obtaining corroborating information from family members may facilitate assessment of functioning…

Opioid Risk Tool (ORT) Assessment Instrument

Reprinted With Permission from Lynn Webster, MD

I took the test and scored in the “high risk” category.  In fact, I can’t imagine that too many pain patients would score in the low or moderate risk categories, as you (and your family) would have to be saints (or devout Mormons) to do so.  And if you have a large family, then you’ll have a higher risk for family members who have abused drugs or alcohol.

For instance, who doesn’t have a family member that has abused alcohol?  And if you’re an older pain patient, who hasn’t abused alcohol in their youth?  I know I did — not to the point of addiction, but I did some wild partying in my younger days.  Of course, I quit drinking (and partying) a very long time ago.  I can’t remember the last time I had any alcohol, including wine. Still, I’d be penalized for stuff that happened over 25 years ago.

And the test appears to discriminate against men, who get a higher score than women if they’ve ever abused alcohol and/or illegal drugs.  And if you’re a woman who’s been a victim of preadolescent sexual abuse, you get high marks used against you — but if you’re a man, you get no marks at all.

My high risk score just confirms that if I were to see a pain doctor, I would be denied any kind of treatment that included pain medication.  Of course, this test is self-reported by patients, so I could always lie on the questionnaire, as I’m sure many patients do.

Jennifer Aniston nails her role in ‘Cake,’ living with chronic pain

I was the medical director of an ambulatory surgical center when “Philadelphia” came out, and I recall the executive director of the facility telling me at the time that we were not equipped to accept people with AIDS. Instead, she said, we should shovel them to a nearby hospital. This type of fear fueled prejudices and discrimination for years until “Philadelphia” and icons like Magic Johnson helped to change the discussion surrounding AIDS. The commitment to research and treatment that followed has culminated with an HIV-positive diagnosis’s no longer equating to a death sentence.

Today, we face another epidemic that has degraded lives within a huge swath of our society and another movie portraying how people suffer because of it. Jennifer Aniston will not receive the Oscar, lacking even a nomination for her performance in “Cake,” a movie about living with chronic pain, but in my opinion she deserves recognition. As a physician who has treated people suffering with chronic pain and addiction for 30 years, I can attest that Aniston, in the role of Claire, did an outstanding job and that her behavior and appearance in the movie ring true for a person in severe chronic pain.

Few people realize that the Institute of Medicine has documented 100 million Americans with chronic pain, more than those with heart disease, cancer and diabetes combined. People in pain are often stigmatized as people with AIDS were in an earlier era, dismissed as malingerers, mistakenly judged to be addicted, even labeled as lowlifes. The difficulty is that there is no cure for most severe chronic pain…

Hoping for a movie that could serve as a cultural touchstone to talk about these issues, I saw “Cake” on opening night at 7:00 pm. There were only 24 people in our 300-seat auditorium in my hometown of Salt Lake City, Utah. Granted, the Sundance Film Festival was in town, perhaps pulling potential viewers away, but I feared the low response mirrored the public’s lack of interest in the topic of chronic pain. This is supported by a recent survey by ResearchAmerica that reported only about 18% of Americans think chronic pain is a significant health problem.

Unfortunately, despite Aniston’s fine performance, “Cake” is no “Philadelphia” and is unlikely to spur the same sort of social movement for change. The movie’s primary lack is the context of the bigger story. It does little to portray the heroism of people who struggle daily with pain, their dignity routinely assaulted by family members and doctors who don’t believe them, friends who abandon them, and public and private insurance policies that will not pay for the interdisciplinary care that could help them. Perhaps another movie about a lawsuit demanding justice for pain sufferers who have been denied care could reach “Philadelphia” stature.

“Cake” does have its strengths, though. Claire’s alcohol use, pill overuse and eventual overdose are, unfortunately, accurately portrayed and far too typical of many people in severe pain.

“Cake” also gets the link between chronic pain and suicide right: fully half of people with chronic pain consider suicide, making Claire’s preoccupation with it frighteningly accurate. The CDC reports that about 40,000 deaths per year are from suicides. These, doubtless, include many people trying to escape pain…

Doctors usually have a different perspective than pain patients, but I haven’t been able to find any reviews for this movie from a pain patient.  And I haven’t seen this movie, so I can’t offer one.

Medication monitoring company performs biased study on pot

Study Shows Marijuana Use May Be Linked to Opioid Noncompliance (2013)

Ft. Lauderdale, Fla.—As medical marijuana use continues to grow, pain practitioners are beginning to ask what effect, if any, its use has on the issue of potential nonadherence to existing pain treatment. Now, a study by a private corporation has revealed that marijuana use is, indeed, associated with potential nonadherence in chronic pain patients prescribed hydrocodone…

No, not indeed, not really at all.

“Physicians have different opinions on whether to test their patients for THC [a compound in marijuana],” said Michael K. DeGeorge, PharmD, associate director of medical affairs at Ameritox, a medication monitoring company based in Baltimore. “Either way, we thought it would be interesting to see if there was an association between marijuana use and nonadherence in patients, to give clinicians some information when implementing urine drug testing as part of their practice.”

You mean, you thought it would be interesting to pay for a study which the company could use to market its services to doctors who treat pain patients.

“I wasn’t really surprised that we found marijuana use to be associated with medication misuse,” Dr. Dawson said in an interview with Pain Medicine News. “But I was very surprised that it rivaled cocaine in terms of its association to other nonprescribed medications.”

Could it be because cocaine isn’t very good at relieving pain?  Can even make pain worse?  For a company that sells drug monitoring services, I’m surprised that ya’ll didn’t know that.

Lynn R. Webster, MD, cautioned against drawing broad-based conclusions from the retrospective study. “The analysis is based on information reported to the company at the time the tests were ordered,” said Dr. Webster, medical director at CRI Lifetree in Salt Lake City, and president of the American Academy of Pain Medicine. “It is therefore difficult to know how accurate the information is. More importantly, almost all hydrocodone is immediate release, and may not be detected if the urine sample is taken outside the detection window. For example, if a patient is prescribed hydrocodone 7.5 mg and the last dose ingested was 12 or more hours before the urine was collected, hydrocodone may not be present. Similarly, we don’t know the dose and we don’t know when the urine samples were collected for the cocaine and THC groups.”

Whether or not physicians should consider regular marijuana testing is a complicated issue given the rift between state and federal laws. “In states where marijuana is illegal, I would recommend testing,” Dr. Webster noted. “I’d also recommend that physicians counsel patients to discontinue use if they find it in their system, since physicians must advocate for legal use of all medications.

Obviously, Dr. Webster is advocating for physicians, not pain patients.

“In states that have legalized marijuana, it’s still probably wise to test for it,” Dr. Webster added. “Here, too, I would recommend physicians advise their patients to discontinue use if they are planning to prescribe a scheduled drug, particularly an opioid. Prescribing an opioid to someone using marijuana—even in states that have legalized it—may present additional legal issues due to federal laws.”

Well, Dr. Webster, if I didn’t know where you stand on treating pain patients as drug addicts, with all the monitoring that entails, I do now.

DEA should not interfere with physicians and pain patients

My comment:

“The DEA can continue to enforce policies that prevent overuse and overdoses. But it must not interfere in the appropriate relationship between physician and patient.”

Seems like the DEA is actually one of the causes of a lot of drug abuse and overdoses, directly or indirectly. The agency is definitely the cause of who knows how many deaths at the hands of law enforcement, not to mention all the victims (and their families) locked up for nonviolent drug offenses.

And then there’s all the pain patients, doctors, and pharmacists who are now victims of the drug war, too.

It’s too late to stop the DEA’s interference in the medical industry — that’d be like trying to, I dunno, stop the drug war.

Dr. Webster, unless you look realistically at why pain patients are drowning, your arguments are just treading water in this fight (if that).