Dr. Hypocrisy

Here we have another one-sided article from the New York Times, this one about the abuse of drugs used to treat addiction.

http://www.edsinfo.wordpress.com/2016/06/28/addicted-to-a-treatment-for-addiction/

http://www.nytimes.com/2016/05/29/opinion/sunday/addicted-to-a-treatment-for-addiction.html?_r=0

“Let’s be clear,” said Dr. Andrew Kolodny, a longtime Suboxone prescriber in New York and executive director of Physicians for Responsible Opioid Prescribing. “The real crisis is the severe epidemic of opioid addiction and overdose deaths that’s devastating families across the country.”

And here we have Mr. Kolodny, still trying to convince everyone that drugs like Suboxone aren’t part of the opioid family. As if there aren’t any families that have been devastated by deaths related to the use of bupe, methadone, and Suboxone.

It says a lot about how lazy the media is that it uses “experts” like Kolodny. And they never include important facts about Kolodny, like the criminal investigations into some of his Phoenix Houses. Like how Kolodny started his work with addiction in the New York prison system, specifically with bupe.

And before Kolodny began his work in the prison system, in 1996, France approved bupe (Suboxone) for the treatment of addiction. The current situation in France is that, along with methadone, buprenorphine is the opioid that’s causing the most damage:

https://painkills2.wordpress.com/2014/12/02/whats-the-drugopioid-epidemic-look-like-in-france/

Dr. Kolodny ranks anti-Suboxone judges like Judge Moore in a category with climate-change deniers and people who believe vaccines cause autism. “When there’s really dangerous heroin on the streets, I’d rather see Suboxone out there, even if it is being prescribed irresponsibly or is being sold by drug dealers,” he said…

And here we have Mr. Kolodny advocating for the underground Suboxone market, which really makes him look like a drug dealer. I wonder if he gets a percentage of all Suboxone sales… Or maybe he’s been promised a better job with the government or Big Pharma.

Hey, Kolodny, don’t you understand that doctors are drug dealers, too? Do you think the drugs that doctors prescribe never do any damage, never kill anyone? Perhaps you should change your name to Dr. Hypocrisy.

Under comments:

Steven A. King, M.D., Philadelphia, May 29, 2016

The issues of using buprenorphine for opioid use disorders are not as clear cut as the author appears to be making them.

Some of what Judge Moore believes is true and some of what Drs. Volkow and Kolodny say is misleading.

As a physician who specializes in pain management, I know that there are a not insignificant number patients prescribed opioids for legitimate pain complaints who end up abusing and becoming addicted to these, and although it is often reported that we’ve only become recently aware of this in fact there is research going back 25 years demonstrating this.

However, there are no studies showing that either buprenorphine or methadone are appropriate treatments for these patients. As these both provide analgesia equal to the other opioids, if these were the proper treatment for these patients then it would make sense to make them the first line opioids for pain as we would be prescribing the appropriate treatment for the problem at the same time we were prescribing the cause of the problem.

Sorry, bupe and methadone do NOT provide analgesia equal to other opioids. Yes, they help some pain patients, but their strength is more in line with, say, codeine, if that.

I’m not exactly sure what this pain doctor is trying to say, but I think pain patients will increasingly be offered bupe and methadone, whether they’ve been red-flagged for addiction or not.

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Chili Peppers Could Free Us From Opioids

Sometimes the media cracks me up, like with this headline. Do you know how long the medical industry has been promising a breakthrough for the treatment of pain with chili peppers? I can’t be sure, but I think it’s decades.

http://www.bloomberg.com/news/articles/2016-06-27/chili-peppers-could-free-us-from-opioids

“When we talk about chronic pain, like chronic low-back pain, physicians feel like they only have one bullet in their toolbox that works for many, many patients,” says Michael Oshinsky, program director for pain and migraine at the National Institutes of Health, about opioids.

Do you think doctors feel that way because it’s true? Like, duh.

The pharma industry has struggled to come up with alternatives. No fewer than 33 experimental medicines for chronic pain went into clinical trials from 2009 to 2015, and all failed, Oshinsky says…

You can’t search for an alternative treatment for pain by trying to circumvent another problem, addiction. (Some people even believe that the quickest way between two points is a straight line.)

It appears that Big Pharma (working with the medical industry) is looking in the wrong direction. Don’t ask me what the right direction is, because I don’t know. But I do know that looking for ways to beat addiction during the treatment of pain is not a direct route to finding new ways to manage pain. Because 90% of people who suffer from pain do not need treatment for addiction.

A brain on chronic pain is not the same as a brain that suffers from addiction and some level of pain. Those who suffer from addiction have different wires crossed. Their brains react differently to opioids. Treating pain with drugs that focus on addiction will only help a very small percentage of pain patients. I think methadone and bupe have been around long enough to prove that fact.

The problem with narcotics is that in treating pain they affect an area of the brain that registers intense pleasure…

What’s the opposite of pleasure? Pain. And just like there are two sides of a coin, the areas of the brain that deal with pleasure and pain are the same ones — the same coin. These areas of the brain do the same work. They work so closely together that some people feel pain just like it’s pleasure, and vice versa. Even the very few people who are unable to feel pain don’t live a life of pleasure.

Centrexion’s drugs are designed to target pain directly, without triggering the brain’s reward system…

So, yeah, try to target pain without going through the pleasure/reward system of the brain… I’m no expert, but I don’t think it’s possible. Well, perhaps it would be more accurate to say that we already have these drugs, like aspirin and NSAIDs, which come with their own risks and lack of effectiveness.

You should eat chili peppers. Not only do they taste good, but they’re good for you. Because they work as an anti-inflammatory, they can relieve pain. Just like aspirin. And by the way, just like decongestants and antihistamines. But these drugs do not target pain directly — they’re not really painkillers.

Progress?

What would progress in the opioid war look like? For the government, progress is a decrease in the supply of opioids, along with the number of doctors prescribing (treating pain). And of course it means a decrease in the number of drug overdoses and deaths. In this Bloomberg article, New Mexico is highlighted as a state that’s making progress, but that’s not the reality.

Unfortunately, any “progress” in the opioid war is bad news for patients.

http://www.bloomberg.com/news/articles/2016-06-23/opioid-crisis-draws-failed-response-from-most-states-group-says

Kentucky, New Mexico, Vermont among states making progress

States were evaluated on six criteria, including the availability of treatment; mandatory education for doctors who prescribe opioids; and access to naloxone, which can reverse the effect of opioids. Michigan, Missouri and Nebraska didn’t meet a single one of the standards, according to a report from the council. Twenty-four other states were labeled as “failing” because they meet just one or two of the six objectives. While Kentucky, New Mexico, Tennessee and Vermont passed at least five, no state had a perfect score…

Does this look like progress to you?

https://nmhealth.org/publication/view/marketing/2117/

In 2014, there were 540 deaths to drug overdose in New Mexico.

New Mexico has the 2nd highest drug overdose death rate in the U.S.

https://nmhealth.org/publication/view/help/1832/

In 2014, 450 New Mexicans died by suicide (21.1 deaths per 100,000 residents)

The New Mexico suicide rate is more than 50% higher than the United States rate

http://www.practicalpainmanagement.com/resources/ethics/new-mexico-approach-improving-pain-addiction-management

However, New Mexico decided not to establish a “trigger” dosage threshold because of concern that such a policy would interfere with the patient-provider relationship. Instead, the state requires a mandatory continuing medical education course covering both prescription drug abuse prevention and the treatment of pain…

Opioid prescribers are mandated to sign up with the New Mexico Board of Pharmacy prescription monitoring program (PMP) and obtain a patient PMP report for the preceding 12 months when initially prescribing chronic opioid therapy (ie, ≥10 days) and every 6 months thereafter…

https://painkills2.wordpress.com/2015/09/06/unm-project-echo-bites-the-dust/

New Mexico is one of 16 states that successfully competed for the four-year grant from the U.S. Centers for Disease Control and Prevention. The grant is from a new program called Prescription Drug Overdose: Prevention for States that helps states address the ongoing prescription drug overdose epidemic.

It appears that a bucket load of education and the PDMP were not enough to make a real difference in the number of overdoses in New Mexico. In fact, after a few years of seeing a small decrease in overdoses, the latest statistics show an increase.

Which leaves me to wonder what is being taught in these continuing education classes and seminars on chronic pain and addiction. Since this education is being funded by the government — and disseminated with the help of the medical industry — I assume everyone is learning to comply with the new CDC rules. And treating pain according to the CDC rules is not going to work for very many patients.

http://amarillo.com/news/2016-02-04/new-mexico-lawmakers-look-curb-opioid-addiction

More New Mexicans died in 2014 of drug overdoses than in any other year on record…

Neurologist Joanna Katzman, president of the American Academy of Pain Management and head of the University of New Mexico’s Pain Consultation and Treatment Center, said continued education for medical professionals who prescribe opioids as well as better access to care for patients dealing with chronic pain must still be part of the equation.

“Chronic pain overlaps with addiction. Chronic pain overlaps with mental health,” she said, pointing to higher incidences of depression, anxiety and even suicide. “We need to really think about increasing treatment for chronic pain, increasing access to treatment.”

Dr. Katzman can talk a good game, making it seem like she could be on the side of pain patients. But I can’t imagine that too many pain patients would agree with her view of what constitutes treatment:

https://painkills2.wordpress.com/2016/03/18/addiction-clinics-masquerading-as-pain-clinics/

http://santafepreventionalliance.com/wp-content/uploads/2016/05/Michael-Landen-Prescribing-and-Drug-Overdose-Deaths-in-NM-May-7-2016.pdf

Council leading joint process to develop common language for the 7 licensing boards to use in developing their chronic pain management rules by 1/1/17

If you’re a pain patient in New Mexico, you should keep a watch out for these new rules. I assume they will mostly be in line with the new CDC rules, but I also assume that they will include a lot more restrictions on what doctors can prescribe.

I’m sorry, but I think things are about to get a lot worse, not only for patients in New Mexico, but in every state.

Facebook comments that disappear

I use Facebook to make comments, but I’m not that familiar with how the software works. When I made a comment on this Consumer Affairs article through my Facebook account, I expected it to show up in my activity log. But my comment was deleted by Consumer Affairs, so it doesn’t appear in my Facebook account. (I guess everybody hates — and prefers to silence — a critic.)

That doesn’t seem right, but I guess it’s just another reason to dislike Facebook. After all, why would I want to use the same blogging platform as Mark Zuckerberg?

https://www.consumeraffairs.com/news/study-most-patients-getting-opioids-have-leftover-pills-061516.html

My censored comment:

Most deaths related to an opioid overdose are due to a combination of drugs, not just the opioid. If Consumer Affairs would like to see responsible reporting on the drug war, here’s one (lonely) example:

http://www.theguardian.com/us-news/commentisfree/2016/jun/08/opioid-epidemic-drug-mix-overdose-death

“Opioid use on its own is not dangerous, and it’s time we stop demonizing it.”

New York (with Bloomberg at the helm) is the poster state for how not to fight the drug war. That state (with help from Kolodny and PFROP) has been at the forefront of restricting access to prescription pain medications and increasing the amount of addiction clinics (along with the use of drugs like methadone, bupe, and Narcan).

http://www.huffingtonpost.com/2013/01/11/new-victims-in-the-war-on_n_2455917.html

And look where New York is at now — they’ve gone from bad to worse.

This study is a day late and a dollar short. The problems with diversion aren’t being caused by patients anymore, and it was only a small percentage of patients who were responsible for diversion anyway. If Consumer Affairs is going to “report” on the drug war, it should include other stories about diversion, like from DEA agents, pharmacies, hospitals, and nurses. The longer the medical industry blames patients, the more guilty it looks.

Dear NY Times: You Suck

I used to think that the New York Times was a liberal paper. When did they go over to the dark side? Maybe it all started with Maureen Dowd and the cannabis candy bar:

http://www.nytimes.com/2014/06/04/opinion/dowd-dont-harsh-our-mellow-dude.html

And the Times is known for lending its credibility to the opioid war. This article is the latest proof that the Times is running away from science. And so one has to wonder, how many white, middle-class employees at the Times have known and/or lost someone to drug addiction and the drug war? Or maybe they’re just choosing to be ignorant.

http://www.nytimes.com/2016/06/14/health/pain-treatment-er-alternative-opioids.html

Since Jan. 4, St. Joseph’s Regional Medical Center’s emergency department, one of the country’s busiest, has been using opioids only as a last resort. For patients with common types of acute pain — migraines, kidney stones, sciatica, fractures — doctors first try alternative regimens that include nonnarcotic infusions and injections, ultrasound guided nerve blocks, laughing gas, even “energy healing” and a wandering harpist…

St. Joe’s is even cautiously trying therapies not typically taught in medical school. A nurse practitioner is studying acupuncture for pain. And another nurse, Lauren Khalifeh, the hospital’s holistic coordinator, does a treatment called “pranic healing.” …

On a recent weekday in the E.R., John Schiraldi, 25, a recovering heroin addict, was grateful that his merciless kidney stone pain was ebbing not because of intravenous morphine — a conventional E.R. protocol — but because of a regimen that included intravenous lidocaine, a non-opioid analgesic…

St. Joe’s pediatricians used a non-opioid protocol including a nasal spray of ketamine, a powerful drug which, in low doses, has analgesic and sedative properties…

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…

The E.R. staff is beginning to embrace the non-opioid options. “I’m thrilled,” said Allison Walker, a nurse. “I’d hate to be the first to give Percocet to a teenager who dislocated his knee at hockey practice. And then he comes back a year later, addicted to opioids? I don’t want that on my conscience.” …

“St. Joe’s is on the leading edge,” said Dr. Lewis S. Nelson, a professor of emergency medicine at New York University School of Medicine, who sat on a panel that recommended recent opioid guidelines for the Centers for Disease Control and Prevention…

The Centers for Disease Control and Prevention calculated that in 2014 there were 10,574 heroin overdose deaths and 14,838 for prescription opioids…

This article from 2013 shows the progression of how hospitals deal with painkillers:

https://painkills2.wordpress.com/2014/11/20/3132013-new-victims-in-the-war-on-painkillers/

Under the new city policy, most public hospital patients will no longer be able to get more than three days’ worth of narcotic painkillers like Vicodin and Percocet. Long-acting painkillers, including OxyContin, a familiar remedy for chronic backache and arthritis, as well as Fentanyl patches and methadone, will not be dispensed at all. And lost, stolen or destroyed prescriptions will not be refilled. It only applies to the city’s public hospitals. Which means it will largely be poor people who are forced to suffer pain that can easily be treated.”

I’m not going to say that alternative treatments for pain don’t work, just that they only work for a very small percentage of the patient population — like the stories depicted in the Times article. And their benefits don’t appear to last very long. A true investigative reporter would follow up with these patients, see how they’re doing in a year or two. Of course, a real reporter would have shown all sides to this story.

I find it odd that I have a better understanding of addiction than these “professionals” who work in a hospital. Treating acute pain with a painkiller, like a teenager with a dislocated knee, rarely puts the patient on a path to addiction. However, ignoring acute pain can most definitely cause a chronic pain condition for that patient in the future. Unfortunately for patients, after your pain goes from acute to chronic, you no longer deserve treatment. And even if your pain is acute, you still may be refused treatment.

Under comments:

Cindy, NJ, June 10, 2016
Beyond frustrated that addiction is now treated as a disease but chronic pain disorders treated like a lifestyle decision.

Lilikoi, Hawaii, June 10, 2016
As a practicing Emergency physician, I would love to have access to more non-narcotic therapies for my patients. Are opiates the first line of therapy for severe acute pain? Yes, much of the time they are, though there are some conditions such as migraines and kidney stones that will often respond better to non-opiate meds. Unfortunately, only a fraction of the patients I see with pain have acute conditions like broken bones or freshly ruptured spinal discs. A majority of the patients requesting pain killers in the ER have chronic pain syndromes like fibromyalgia, cyclic vomiting syndrome, chronic migraine, and chronic low back pain. They’re in the ER because they’ve through the opiates prescribed them in other settings, and need a fix for more. They will swear loudly, like many commenters here, that only opiates will do anything for their pain. This is partly because they are addicted to a tremendously addictive class of medications that in long term use cause heightened sensation of pain – opioid induced hyperalgesia. But it’s also partly because they’ve never really been offered pain remedies other than opiates or over the counter pills like Tylenol and Ibuprofen.

It’s good to know how ER doctors feel about chronic pain patients, although I find it hard to believe that many pain patients seek help at the ER these days. This doctor appears to blame addiction on hyperalgesia, which I guess could happen. But it seems to me that doctors find it easy to place blame on a lot of things that don’t apply to most patients, mainly to switch the blame from doctors onto patients.

And if this doctor is talking about chronic pain patients, then believing that we’ve only been offered pills to treat pain is just a flat-out lie. More likely, he’s talking about those who suffer from drug addiction. And I’m sitting here wondering, what would be so bad about treating drug addiction with opioids? For ERs, I guess it’s about drug addicts coming back for more drugs, and the possibility of diversion. But if there wasn’t a drug war, what would be the problem with treating drug addiction? If drug addicts had easy and affordable access to their drug of choice, what harm would they do to the public?

Maggie Chin, NJ, June 10, 2016
“And so although emergency physicians write not quite 5 percent of opioid prescriptions, ERs have been identified as a starting point on a patient’s path to opioid and even heroin addiction”

As an EM physician, I write a fair amount of very limited (10 pills) opioid prescriptions for painful conditions such as renal colic or severe back pain. It doesn’t make sense to me to say that ED’s are a “starting point” if we prescribe small amounts. I have NEVER, in 11 years of practice, met an EM physician who would prescribe a month’s worth of an opioid as noted in the article. However, I look up patients in the state database before prescribing, and we often see patients who have been prescribed 120 pills or more by “pain management” physicians yet still come to the ED trying to get more.

A true drug-seeker will continue to complain of pain no matter what “alternative” you attempt (and I have tried nerve blocks on some of these patients), say they have allergies to all other pain medications, and dramatically complain of severe pain for all the ED to hear. Compound all this with patient satisfaction surveys and you have a no-win situation for docs who are already trying to take care of multiple very sick patients…

So, these drug-seekers (pain patients) aren’t considered to be “sick”? More of a nuisance than anything for this doctor, probably because doctors are refusing to treat them. It’s like, what are you doing here, in a hospital with sick people? Yes, I’m a doctor, I help sick people, but I can’t help you.

As a pain patient, it’s good to know what behaviors are considered red flags to doctors. Unfortunately, these red flags are also very real medical conditions, like an allergy to medications. I find it sad that this doctor believes that nerve blocks should actually work for most patients, when that’s just not true. And if the nerve block doesn’t work, it’s the patient’s fault? If the injection doesn’t work, the patient is a drug addict because she wants her pain to be treated?

Should doctors dismiss science because of the fear of addiction and the drug war? Too late, it’s already happened.

Finally, a sane voice in the opioid war

http://www.theguardian.com/us-news/commentisfree/2016/jun/08/opioid-epidemic-drug-mix-overdose-death

Our current obsession with opioids is just the latest trend in a long history of scapegoating single drugs: alcohol in 1830s and 40s, opium in 1870s, marijuana in the 1950s and 60s, crack cocaine in the 1980s and 90s, methamphetamine in the 1990s and early 2000s and now, opioids like heroin, Oxycontin and Fentanyl. The problem of multiple-substance use has remained absent from much of this conversation – and from the education of users and health practitioners – despite the fact that drug mixing is both dangerous and pervasive…

By fixating on fearing opioids, we are missing the more culpable factors that lead some people to keep using drugs despite negative consequences. Opioid use on its own is not dangerous, and it’s time we stop demonizing it. Instead, we must implement a national overdose education strategy targeting the immediate factors of opioid-related overdose: drug mixing and tolerance changes.

Under comments:

cowboy335 2d ago
The thing politicians and others don’t understand. We have a pain epidemic not a drug epidemic. People are in mental and physical pain from life and the controllers of medicene say no. What do you do . Heroin, methadone, vicodan. I am a 64yr old combat Vietnam Vet. I take what I need for pain. I do believe I am old enough and don’t need others to decide for me. That happened when I went to serve in Vietnam. Freedom even if they don’t decide to free me. I have freed myself.

panamadave 2d ago
I am 70 years old and in pain. I really don’t give a damn what some politician wants me to do

Samson151 2d ago
I think the author may have misinterpreted what happens in an OD situation. The user combines an opioid with other CNS depressants in order to overcome his or her greatly elevated tolerance and once again get high. It’s the same motivation that drives addicts to seek out new varieties of heroin laced with fentanyl. It’d be wrong to assume that if we could just convince them to stick to opioids only they’d be fine — they’re not going to do that. From the addict perspective, the opioid is no longer enough…

There are many reasons that pain patients take more than just painkillers, including drugs like muscle relaxers, anti-anxiety meds, antidepressants, anticonvulsants, and blood pressure meds. Suffering from chronic pain is not just about the pain and many patients have comorbid conditions. And all of these additional meds can work in conjunction with painkillers, increasing their effectiveness. Because, let’s face it, opioids can only do so much. And remember, even though opioids work for most people, there are still millions of people who can’t take them.

One of the shortcomings of an opioid is that it treats pain and that’s it. And when there’s pain, there’s usually more to treat than just the pain. But then, most drugs are focused on treating only one condition, just like opioids. Then some people end up taking a bucket full of different drugs to treat each symptom, on the advice of doctors. And this can result in overdose and death, even if it’s only in a very small portion of most patient populations (with the exception of those who suffer from addiction).

When the drug war ends, the overdose and death rate will decrease significantly, but it will never be zero. We’re humans, not robots, and mistakes will be made, both by patients and doctors. But keep in mind that more mistakes are made by doctors — the so-called professionals — than by patients themselves.

This would be a good time to point out one of the benefits of cannabis, in that it treats more than one symptom, no matter what your medical condition. For some patients, it will be able to replace that bucket full of pills, but not for all.

They’re coming for your Oxy

This was an interesting article about the history of Oxy, but I’m not sure it told me anything I don’t already know.

http://static.latimes.com/oxycontin-part1/#nt=oft12aH-1gp2

But OxyContin’s stunning success masked a fundamental problem: The drug wears off hours early in many people, a Los Angeles Times investigation found. OxyContin is a chemical cousin of heroin, and when it doesn’t last, patients can experience excruciating symptoms of withdrawal, including an intense craving for the drug.

The problem offers new insight into why so many people have become addicted to OxyContin, one of the most abused pharmaceuticals in U.S. history…

“What was happening was that they were taking more than they were prescribed because the pain medication wasn’t working,” Hughes recalled in an interview…

The doctor kept raising the dose, eventually putting Bodie on 400 milligrams a day…

Holy cow, that’s a high dose. And it’s probably very rare.

Anyone who has taken Oxy knows that it doesn’t last for 12 hours, even though our doctors have tried to convince us otherwise.

https://painkills2.wordpress.com/2016/01/24/the-effectiveness-of-pills/

I understand that some patients experienced the symptoms of withdrawal as described in this article, but that didn’t happen to me. I had to convince my pain doctor to lower my dosage of Oxy, as the main side effect I experienced was nausea. Yuck. And the nausea wasn’t worth the very small amount of pain relief I obtained from Oxy.

I don’t have proof that my doctor accepted bribes from Big Pharma, but he didn’t pay for all those international vacations on his own. So, I had to keep taking the Oxy, because the medical industry decided that short-acting pain medication could only be used for breakthrough pain. As the article details, breakthrough pain only happens because the stupid pills don’t last as long as they’re supposed to. (Doctors suck.)