“the opioid lunatic fringe” #OLF!

https://edsinfo.wordpress.com/2015/10/16/outrageous-conflict-of-interest-in-the-debate-over-opioids/

http://www.insidesources.com/dysfunction-lobbying-and-conflict-of-interest-in-the-debate-over-opioids/

Another health care provider noted the fear that many pain clinics have of being investigated and shut down. In Ohio, a local pain clinic had been overprescribing. It was raided by police and closed. Its patients have not been welcomed to other pain clinics for fear that triggers an investigation against them. One man with terminal throat cancer has been unable to find any clinics to provide pain relief because he had been a customer at the overprescribing clinic…

After my pain doctor of 8 years passed away, the only doctor I could find who would agree to see me was in another state. I found out that my doctor was a little infamous within the pain doctor community and the majority of his patients could not find another doctor within the State of Texas. The doctor’s office shut down immediately after his death, and refused to provide copies of our medical files, so that was part of the problem, too. What a freaking nightmare…

“I’m sure everyone on the committee is an expert, but you need to have a variety of opinions, otherwise why even bother having the meeting in the first place,” said Pitts, whose responsibilities at the FDA included overseeing the formation of FDA’s advisory committees. Referring to PROP’s role in creating the guidelines, Pitts said, “When you basically take one group that is considered the opioid lunatic fringe and allow them to create the basis of your policy almost verbatim is inexcusable. It’s bad policy. It’s bad science. It’s poorly serving the public health.”

The “opioid lunatic fringe,” that’s hilarious. Dr. Pitts needs to trademark that phrase. (Now trending on Twitter, #OLF!) 🙂

Dr. Roger Chou of Oregon Health and Sciences University served both as one of the contributing authors and as a member of the Core Expert Group… Chou’s decision to alter course is unclear. He did not respond to a request for an interview…

Isn’t it fun to so easily go back to the past and find out what OLF! has been doing? Dr. Chou, an “interventional pain physician,” is a busy bee:

https://painkills2.wordpress.com/2015/01/13/fck-here-we-go-again/

https://painkills2.wordpress.com/2015/06/04/interventional-pain-physicians/

https://painkills2.wordpress.com/2015/07/21/the-effectiveness-and-risks-of-long-term-opioid-therapy-for-chronic-pain/

My comment:

What a great article! While I don’t agree with 100% of it, the article clearly details both sides, which is certainly a difficult thing to find in the small amount of media reporting on the opioid war. The only thing I would add is that there should also be a place at the table for pain patients. And not anyone affiliated with so-called patient groups, as I’ve found that many of them also have conflicts of interest.

The suicide epidemic is a lot worse than the opioid “epidemic,” even though the CDC spends very little time on the prevention of suicides. The increase in suicides in the U.S. is just one of the results of the war against the pain community, but it will continue to get worse because of anti-drug and hypocritical groups like PFROP (bupe for drug addicts, but no opioids to treat pain, right Mr. Kolodny?).

While the increase in overdoses is mainly affecting those who suffer from addiction, one of the reasons for that is that there probably won’t be many chronic pain patients with the courage to commit suicide. We suffer in silence because we’ve become accustomed to it. For some it’s apathy, and for many, it’s just plain fear. When your survival depends on drugs that are now part of the drug war, what does your future look like?

Monsters

“Monsters are real, and ghosts are real too. They live inside us, and sometimes, they win.” Stephen King

“Everyone carries around his own monsters.”  Richard Pryor

“Whoever fights monsters should see to it that in the process he does not become a monster.” Friedrich Nietzsche

“There are very few monsters who warrant the fear we have of them.”  Andre Gide

0DSC05450 (2) - Copy

Pain patients on worker’s comp are screwed

http://dwd.wisconsin.gov/wc/medical/pdf/CHRONIC%20OPIOID%20CLINICAL

%20MANAGEMENT%20GUIDELINES%20.pdf

Chronic Opioid Clinical Management Guidelines for Wisconsin Worker’s Compensation Patient Care

Emerging medical evidence shows that the previously pursued practice patterns of using higher dose chronic opioids rarely results in sustained improvements in pain control and function, but has resulted in increased addiction and death nationally over the last 10 years. These Clinical guidelines will assist you in managing your patients with chronic pain…

The following steps for patients who require chronic opioid treatment for a worker’s compensation injury should be followed:

1. The Pain Generator Must be Adequately Evaluated

-A clear etiology and diagnosis of the pain should be identified and documented at every visit.
“Chronic Back/Neck Pain” is a symptom, not a diagnosis.

-Not all pain conditions are opioid responsive; therefore, not all diagnoses that cause pain are appropriate for chronic opioids. Chronic headaches and fibromyalgia would be examples of diagnoses that are not appropriate to be treated with chronic opioids.

-If you are not able to identify (a) specific medical diagnosis(es) responsible for the patient’s pain, then consider that the patient has not been properly worked up for a pain generator or the patient does not have a medical diagnosis that warrants the use of chronic opioid therapy…

-Opioid therapy truly needs to be considered a last resort…

3. Patient Criteria for Long Term Opioid Therapy?

-Patients must have persistent (i.e. daily) moderate to severe pain (pain 5 and over on the
10 point scale).

-Patients must have daily, describable functional limitations due to pain.

-Identifiable medical diagnosis, known to be appropriate for chronic opioids therapy (i.e. the
pain generator/Diagnosis is not chronic pain syndrome, pain, or headache etc).

-Minimum risk profile as identified by standard screening (SOAPP recommended)…

For patients with high SOAPP scores and unclear clinical conditions, consideration can be given to not offering chronic opioid therapy because the risks outweigh benefits. If the patient is already on them, they could be appropriately discontinued…

Chronic opioid therapy is a goal-directed therapy, and goals must be stated so that if they are not met, the medications can be appropriately discontinued. Goals of chronic opioid therapy include:

Sustained pain reduction (at least 30% as compared to pre-treatment).
-Sustained functional improvement.
-Strict compliance with the opioid treatment agreement

Consider explaining to patients on higher doses of opioids that newer clinical evidence demonstrates that lower doses of opioids are just as effective in maintaining sustained functional improvements and pain reductions…

Where’s this evidence? Sounds like something PFROP made up.

It is highly unusual for a patient who is compliant with taking chronic opioids to not have constipation; therefore, all patients should be on appropriate medication (Senna or Miralax are good choices)…

I didn’t have a problem with constipation while taking oipioids and it was not because I wasn’t “compliant.” And I doubt that I’m highly unusual as a pain patient. Forcing unneeded medication on patients is an expense we can’t afford, and alleging that we aren’t compliant because we don’t want to take Miralax is just plain wrong.

-Oxycodone is highly desirable on the street and there are many other opioid alternatives;
oxycodone products should be considered the last line opioid.

-It is becoming increasingly popular to treat patients with very high doses of immediate release
opioid without the use of an extended release opioid. There is absolutely no physiological/ pharmacological reason that immediate release products work fine but extended release products “don’t work for me.” Generally, this is because the immediate release opioids are much easier to abuse and divert than the extended release opioids, not because the extended release opioids “don’t work.”

Immediate release opioids worked better for me than extended release, but that must be because all I wanted to do is abuse and divert them. I mean, why would I want to treat my pain when I can become a millionaire by selling the drugs that help me survive?

See, when you add the potential for addiction to any treatment, then doctors will have to read your mind to figure out what your true intentions are. I’m telling you, the next step will be polygraphs for all pain patients.

-Once a patient reaches an opioid dose of 50 mg MDE, then the patient should be placed on an
extended release opioid product…

Because there are many other chemical systems that participate in maintaining pain, it is perfectly reasonable to start other adjunctive medications (tricyclics, SSRI’s, gabapentin, tizanidine, other anticonvulsants, duloxetine, etc.) to help with chronic pain management at any point in the patient’s treatment. Such adjunct medications should be used in conjunction with taking advantage of side effects they may have that are beneficial (sleep induction for tricyclics and trazadone, for example).

And if those medications don’t help, or if we don’t want to take them because of their side effects, then we must not be in too much pain, right? In other words, if you don’t take these pills, you can’t have these other pills that actually work.

-Daily dosing of “muscle relaxers” is not indicated for the treatment of chronic pain but may be
helpful in treating their disordered sleep. Carisoprodol specifically is NOT recommended for this purpose (oxycodone + diazepam + carisoprodol = “the holy trinity” on the street).

Because what’s happening on the “street” is more important than what works for the patient.

-If benzodiazepines have been prescribed specifically as part of the patient’s pain reduction
treatment, then consideration should be given to discontinuing via a taper. There is no
evidence that this class of medication helps with pain reduction and adverse medication effects are many times more likely when patients are on benzodiazepines and opioids together. If benzodiazepines and opioids are necessary, then consultation with psychiatry is recommended to assist with whatever condition for which the benzodiazepines are needed since they are not indicated for management of chronic pain.

Who wrote these “guidelines”?  It doesn’t say, but PFROP is mentioned in the references. I don’t see why anyone needs to see a doctor anymore, as the DEA has already decided how to treat patients.

The epidemic of grief-stricken parents

http://www.startribune.com/rosenblum-parents-pain-helps-shift-prescription-drug-awareness/189749261/

Steve Rummler died in 2011 of an accidental drug overdose, after a long, frantic battle to manage chronic pain from a back injury. His death at age 43 ended the life of a popular Edina athlete and musician who was planning to marry his high school sweetheart.

Life is a whirlwind for [Steve’s mother] Judy, with luncheon speaking engagements at Rotary clubs, visits to local churches and colleges and, on Thursday and Friday, a presentation at a Food and Drug Administration public hearing in Bethesda, Md., regarding drug labeling…

Judy is not opposed to opioids used appropriately and responsibly. For end-of-life issues, palliative care and, even in some acute situations, they can be a godsend. But she refers to a note Steve left, which has become the tragic sound-bite for their foundation: A lifeline, he wrote, became “a noose around my neck.” …

In 1996, Steve suffered a severe back injury, “and life was never the same again for him,” Bill, 72, said. “I don’t know if he ever had a good night’s sleep after that.”

Steve sought help immediately but never got a treatable diagnosis. Depressed, he started taking antidepressants. “He reached the critical fork in the road,” Bill said. “The antidepressants gave him a little relief, so, gee, let’s keep going down this road.”

In 2005, Steve was prescribed narcotic painkillers and the anti-anxiety drug clonazepam. His family watched their gregarious son and brother start slipping away. In 2010, he checked into the Pain Rehabilitation Center at the Mayo Clinic in Rochester for three weeks, where he was weaned off his medications…

Knowing that he might lose Holtum, Steve completed 28 days of treatment at Hazelden in May of 2011. He relapsed shortly afterward. In unbearable pain one desperate night, he sought out illegal drugs. He died on July 1, 2011.

The Rummlers, who split their time between Edina and Bonita Springs, Fla., began sharing their story soon after, winning respect from many physicians. “They’re really helping with awareness,” said New York-based psychiatrist Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing (PROP)…

Click to access Spoke2015_05_13Int.pdf

Bill and Judy Rummler spoke to us about this growing problem…. Their son Steve died in 2011 from an overdose. Steve had become addicted to opioid painkillers as the result of a chronic back pain problem that could not be solved by doctors. The Rummlers were determined that Steve’s death would not be in vain. They formed a foundation with the mission “to heighten awareness of the dilemma of chronic pain and the disease of addiction and to improve the associated care process”. The motto is, “Providing HOPE for those with Chronic Pain and Addiction.” 

Rotary clubs in Minnesota have provided support for the organization…

http://creatingnewnormal.com/2011/12/01/the-myth-of-the-five-stages-of-grief/

Judy Rummler
December 4, 2011 at 5:48 pm
Hi Emily,
I sponke with your Dad again today at church… We lost our 43-year old son Steve in July to a drug overdose. He had suffered with chronic pain for 15 years and had been prescribed narcotic pain killers to which he became addicted. Our ministry is to make a difference for others with these same struggles…

http://blog.illumen.org/healthways/?p=77038

The FDA’s decision to more tightly control prescription pain medications surely will save lives… “Wow!” said Judy Rummler who, with husband, Bill, was back east visiting family when she learned of the FDA’s long-awaited decision. “This is the most exciting news we’ve had since we started this effort.”

The Rummlers, of Edina, can be credited with influencing the dramatic policy shift. Judy and Bill are founders of the Steve Rummler Hope Foundation, named for their son, a gifted musician and financial adviser…

She also had no idea how reluctant the FDA would be to recommend stricter controls on popular pain medicines, despite support for tighter oversight from the Drug Enforcement Administration and Centers for Disease Control and Prevention

So Rummler, joining leaders of other similarly focused organizations, has been pushing back, testifying before congressional committees, speaking to Rotary clubs and attending drug summits. Earlier this year, she met with FDA Commissioner Margaret Hamburg…

The turning point, Rummler believes, occurred on Oct. 1, when 600 people from several states protested on Capitol Hill during their “Fed-Up Rally.” The rally, chaired by Rummler, demanded a federal response to the opioid epidemic…

Steve’s parents are very selective in how they choose to remember their son and what details about his story they choose to tell. But even with the small amount of information available on this 43-year old pain patient — who had been suffering from chronic pain for 15 years — it doesn’t sound like he died from an “unintentional” overdose. Was it suicide?

I’d say the first thing that led to his death was unmanageable and under-treated chronic pain. It was the unrelenting pain that killed him, not the drugs. Unfortunately, even though the antidepressants appeared to help him initially, they didn’t work for long. And in the end, he was only being treated for addiction, not depression or chronic pain.

The other thing that contributed to Steve’s death were his efforts at abstinence. These kinds of abstinence-related deaths — closely following a stint in rehab (or a visit to the doctor) — are seen in both chronic pain patients and those suffering from drug addiction. You can’t stop treating either pain or addiction with drugs and replace that treatment with essentially nothing, which is how I describe all these “alternative” treatments that everyone is forcing on pain patients (especially veterans). As we have seen with injections, the available non-opioid treatments are doing more harm than good, creating even more pain. And all the other alternative treatments only help a small percentage of patients.

As a chronic pain patient, I can understand Steve’s feeling of the drugs being a noose around his neck, especially considering all the expense, regulation, and shame involved in being treated with opioids. But he was wrong — the drugs are not the noose. It’s the unmanageable pain that strangles the life out of you. I’d say it’s possible that the drugs kept him alive longer than if he didn’t have access to them, which is what his parents now want for all pain patients.

I don’t know how Steve’s parents expected him to treat his chronic pain — with religion? His parents have no comprehension of what their son’s life in pain was like, so their advocacy efforts in his name are very misguided (a familiar story). They have based their opinions on feelings of grief, not facts or science. And these grieving parents have a lot of money to support themselves while they travel and talk to universities, rotary clubs, and agencies like PFROP and the FDA.

As every American knows, money equals speech in this country. The voices of pain patients are not being heard, but the voices of well-to-do and middle-class grieving parents have been heard loud and clear. The voices of the drug war have always been those of the privileged and powerful, and I don’t know any pain patients who are a part of that exclusive group.

Steve didn’t start taking painkillers until 9 years after his pain started, so it’s not like he didn’t try to do it mostly on his own. Unable to manage the pain, he slid into a depression, although I can’t say he was adequately treated for either. Seems like he tried to get help, but eventually the only advice he got was to stop the treatment for pain, only focusing on treating his addiction with abstinence.

I think Steve gave up on the hope of achieving any real pain relief. He knew his pain would just continue to get worse, but with abstinence, he had no way to manage it. I know exactly how he felt. After my last pain doctor abandoned me, I couldn’t come up with any way to manage my pain except suicide. Steve had the courage to do it, but I didn’t. Now he’s at peace — and I’m envious of a dead man.

The foundation’s motto is:  “Providing HOPE for those with Chronic Pain and Addiction.”

Hey Judy, you and your anti-drug advocacy groups are actually doing the very opposite of what your motto claims to be. You and yours are causing pain patients to lose hope that their voices will ever be heard. In fact, I hold you and your groups partially responsible for the death of every pain patient who overdoses — including your adult son.

Whiny Kolodny Bullies the Senate

http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/53579?xid=nl_mpt_DHE_2015-09-17&eun=g875301d0r

FedUP, a coalition of organizations and doctors concerned about the overuse of prescription narcotics, wants the U.S. Senate to release records it obtained 3 years ago as part of an investigation into financial ties between the opioid industry and nonprofit groups that advocated for use of the drugs in treating pain…

Narcotics? Wow, Medpage Today, way to show discrimination in your reporting.

“Recent investigative reporting from the Milwaukee Journal Sentinel/MedPage Today and ProPublica revealed extensive ties between companies that manufacture and market opioids and nonprofit organizations such as the American Pain Foundation, the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the University of Wisconsin Pain and Policy Studies Group, and the Joint Commission,” Grassley and Baucus wrote…

In addition to the pain organizations, the committee also sought records from three leading drug companies: Purdue Pharma, Johnson & Johnson, and Endo Pharmaceuticals. It also requested records from the Center for Practical Bioethics, a Kansas City, Mo., organization that has advocated for pain treatment…

You know, the United Nations also advocates for pain treatment. Anyone want to request records from that agency? Seems to me it’s more important to expose the records of those who are working for the drug war, not against it. That means we need to see PFROP’s records, too, Mr. Kolodny.

And who is supposed to fund the groups that advocate for patients? The patients themselves? Certainly not doctors, the medical industry, or the government. Corporations are allowed to fund breast cancer but not chronic pain? Discrimination and hypocrisy, hand-in-hand.

The FedUP coalition said their goal in seeking release of the records is to bring the nation’s opioid epidemic to an end. 

Yes, I’m sure that will do it. Those addicted to drugs have been awaiting the release of these records so they can recover. Please, don’t confuse the political goals of FedUP with those of the “nation.” I assure you, they are quite different.

“This goal will be difficult to achieve if opioid makers, and the groups they fund, continue to promote aggressive and inappropriate prescribing,” the group said. “We urge you to release the findings from the Committee’s investigation of their activities.”

Another goal is to expose the financial connections before new guidelines on the treatment of chronic pain are finalized, said Andrew Kolodny, MD, executive director of the Physicians for Responsible Opioid Prescribing. Kolodny said the CDC is working on the guidelines and he expects that pain groups will oppose them.

“By making the findings of the investigation public and exposing the financial relationships between pain organizations and opioid makers it will be harder for them to claim that it is the interests of pain patients they are lobbying for,” he said.

“By exposing the financial relationships between the government and the addiction industry, it will be harder for them to claim that it is in the public interest they are lobbying for,” said everyone else.

I don’t know what you’re so afraid of, Kolodny. That the right side will win? You know that the CDC is completely on your side (the side of the drug war), so why are you being so whiny?

Some of the groups continue to promote aggressive opioid use and continue to block federal and state interventions that could reduce overprescribing, Michael Carome, director of Public Citizen’s Health Research Group, said in a statement…

Is there a group promoting aggressive opioid use? Where the heck are they? I’d like to meet them. What about the groups funded by the federal government that advocate for the drug war? It’s time to expose who’s funding all sides working against patients, don’t you think?

Thinking of you, Martin Szczupak

http://www.reuters.com/article/2015/09/02/us-usa-rehab-phoenixhouse-specialreport-idUSKCN0R21PY20150902

(9/2/2015) Special Report: Renowned U.S. drug-rehab program spun out of control

Martin Szczupak had already been in and out of rehab when, for a misdemeanor possession charge, a judge sent the 21-year-old heroin addict to a century-old estate in the wooded hills of upstate New York for another chance to clean up…

By December 2012, he had given up on the treatment program. He felt he would be stuck going from “dead end job and rehab and jail until I eventually drop dead,” he wrote in a letter to his fiancée. “You deserve better than that.” He didn’t want to use drugs anymore, he wrote, “but realistically the odds are against me.”

Szczupak never sent the letter. Three weeks later, he walked out of Belle Terre without permission. One day after that, police visited Szczupak’s mother, Inez, at her Staten Island home to tell her that her son had been found dead from a drug overdose…

In 2012, the U.S. criminal justice system sent 580,000 people to drug treatment…

At Belle Terre, criminal-justice referrals account for the majority of residents. The facility is run by Phoenix Houses of New York, whose parent foundation is one of the nation’s largest drug treatment nonprofits, operating in 10 states and the District of Columbia. In the year ended June 20, 2014, the Phoenix House Foundation and its affiliates reported operating revenue of $141 million.

Phoenix Houses of New York is 95 percent publicly funded and enjoys star-studded endorsements. Beyonce donated a cosmetology center at a Brooklyn facility. Financier Pete Peterson chaired a summer fundraiser in 2013 in the posh Hamptons on New York’s Long Island…

The closures that preceded Szczupak’s arrival weren’t the last. And nor is Belle Terre an anomaly. In November last year, OASAS suspended admissions to Belle Terre and four other Phoenix Houses of New York facilities. In a letter to Phoenix House’s then-chief executive in November 2014, OASAS said Phoenix House had “persistent regulatory violations and resident/patient care concerns dating back several years.”

An OASAS site report on the five facilities went into graphic detail. The regulator’s findings at some or all of the facilities included use of marijuana, cocaine, heroin and other illegal drugs; sexual activity among residents; reports of violence and sexual assault; insufficient, inadequately trained or abusive staff; dirty premises; and lax security, with residents coming and going as they wished…

In November 2014, regulators again suspended admissions at Belle Terre, as well as four other Phoenix House facilities. State regulators noted high staff turnover and need for improved clinical practices at Belle Terre. They also warned the facility to let clients speak to their attorneys without staff present.

OASAS let Belle Terre reopen in January 2015. Three of the other centers were reopened with limited admissions in late 2014 and early 2015. The Shrub Oak teen residential treatment facility was closed permanently in June 2015.

In March, OASAS inspected Belle Terre again, prompted by unspecified complaints against director Alan Hargrove, OASAS reported. Phoenix House then fired Hargrove, based on OASAS’s feedback.

Hargrove declined to comment.

Phoenix House announced on Aug. 19 it would be closing Belle Terre and the 185th Street facility…

Perhaps Mr. Kolodny should attend to his own affairs, instead of fighting the war against pain patients.

Kolodny gets air time at the Financial Times

This guy is really boring.  He says the same stuff over and over again — it’s like he’s stuck on one channel.  But what makes this particular video interesting is how much blame is being shoveled on doctors, including doctors who don’t use the PDMPs.  Time to shame doctors into distrusting their patients and viewing each and every one as a potential drug addict…

http://video.ft.com/4385493799001/The-rise-of-opioid-addiction-in-the-US/Companies

I support Planned Parenthood

I support women’s rights, but I just don’t have the mental energy to keep up with the abortion fight.  Keeping up with the war against pain patients and mental health care is about all I can handle.

But you can’t escape the news about the latest “attacks” against Planned Parenthood.

The link is to a graphic that shows connections between all the political and religious groups advocating against women’s (not men’s) reproductive rights.  It so reminds me of trying to figure out who is funding each anti-drug “expert” or group.  And you won’t be surprised to learn of all the religious groups that are funding the war against pain patients and drugs, or their connections to politicians, both in state and federal government.  And their connections to Big Pharma, law enforcement, and agencies like the DEA and FDA, along with very supportive, powerful and rich donors, like Sheldon Adelson.

Sometimes it seems like Republicans haven’t arrived in the internet age yet, where information is freely accessible online.  You can name your group “The Center for Medical Progress” and expect a few people to be misled by the generic (and anonymous) name, or too lazy to search for the intent of the group. But that you expect most people and the media to be fooled — and be so blatant about how dumb you think we are — makes me question the weak strategy behind such groups.

You can name your group “Physicians For Responsible Opioid Prescribing” and expect a few people to be fooled, but keep in mind that the addiction and pain management industries are really fooling no one. And no one is fooled by being unable to completely see into the dark corners of political machinations, where religious groups like to hide.

I suggest that religious groups come out of the closet.  Just like gay people who couldn’t and shouldn’t have to pretend to be heterosexual, religious groups should stop pretending and hiding behind generic labels, funding “anti” groups of every stripe and flavor — from the war against drugs to fighting against the rights of women, voters, immigrants, pain patients, the disabled, and poor people.

Just like pain patients who should have access to every available treatment option, women who require reproductive health care should have access to every service.  And that’s why I support Planned Parenthood.

http://rhrealitycheck.org/a-network-of-lies/

(7/17/2015) VA must strike better balance in managing veterans’ pain.

http://www.startribune.com/va-must-strike-better-balance-in-managing-veterans-pain/316371311/

The two-part Star Tribune series, which ran Sunday and Monday, documented a different though equally disturbing facet of pain medication mismanagement. The series’ findings suggest that the VA system swung too suddenly in the other direction after the national spotlight on overprescribing. Veterans with a legitimate need for powerful pain medications aren’t getting them or are facing unacceptable delays in getting refills. The VA also appears to have been ill-prepared to help veterans access alternative therapies — such as acupuncture — during pain medication tapering.

The series’ findings merit the same kind of scrutiny that overprescribing did. Veterans should not be imprisoned by pain because doctors are unwilling or unable to prescribe the medications they need…

http://www.startribune.com/cut-off-veterans-struggle-to-live-with-va-s-new-painkiller-policy/311225761/

Part 1

Williams eased the chronic pain with the help of narcotics prescribed for years by the Minneapolis Veterans Medical Center. Then the VA made a stark and sudden shift: Instead of doling out pills to thousands of veterans like him — a policy facing mounting criticism — they began cutting dosages or canceling prescriptions, and, instead, began referring many vets to alternative therapies such as acupuncture and yoga.

At first, the change seemed to work: Worrisome signs of prescription drug addiction among a generation of vets appeared to ebb. But the well-intentioned change in prescription policy has come with a heavy cost. Vets cut off from their meds say they feel abandoned, left to endure crippling pain on their own, or to seek other sources of relief.

Or worse.

On Sept. 20, 2013, police were called to Williams’ Apple Valley home, donated to him by a veterans group grateful for his sacrifice. Williams, 35, lay dead in an upstairs bedroom. He had overdosed on a cocktail of pills obtained from a variety of doctors.

Authorities ruled his death an accident, officially “mixed drug toxicity.” Advocates for veterans and some treatment counselors angrily call it something else: the tragic result of the VA’s failure to provide support and services for vets in the wake of the national move away from prescription pain pills.

At the VA’s Medical Center in Minneapolis, for instance, there is one chiropractor on staff for the more than 90,000 patients it sees a year…

Before alternative therapies can work, Kolodny said, the VA needs to better tend to the addicts it has created…

The Minneapolis VA, which had one of the highest rates of high-dosage prescription pain medications, has embraced the new directive to reduce painkiller use among its patients. It pioneered a program that emphasized education and alternative therapies like yoga, chiropractic treatment and acupuncture. In a three-year period from 2011 to 2014, it reduced the number of veterans on long-term high-dose opioids by 78 percent…

In their published findings, Marshall and his colleagues wrote that there were fewer complaints than expected. “Patients mostly appreciated what we were doing,” said Marshall, who now directs pain management programs at the Minneapolis VA and the VA’s Upper Midwest region. While the paper recommended further research into patient satisfaction, the study surveyed only providers and pharmacists…

Although statistics aren’t available, deaths of vets linked to the VA’s pain policy are showing up in headlines around the country.

Last July, Navy veteran Kevin Keller drove himself to a drugstore parking lot next to a VA community clinic in Wytheville, Va., late at night, walked to the door of the clinic and shot himself in the head.

In recent years Keller had complained that VA doctors were reducing his pain medication. Keller had scribbled a note to a friend. In capital letters it read: “SORRY I BROKE INTO YOUR HOUSE AND TOOK YOUR GUN TO END THE PAIN! FU VA!!! CAN’T TAKE IT ANYMORE.”

In October 2013, Todd Roy, a 45-year-old Persian Gulf veteran, shot himself in the head with a shotgun in friend Charlie Bollman’s garage in Watkins, Minn. In 2008, the VA, citing alcohol and drug abuse, had cut off Roy’s Vicodin for pain in his arm and shoulder…

For more than 40 years, Vietnam vet Peter Ingravallo has suffered back pain after being hit with shrapnel during an ambush. With a 100 percent disability rating, Ingravallo took 25 milligrams of oxycodone every four hours until the Minneapolis VA sent him a letter telling him it was reducing his medications by 70 percent. It also warned that he would lose his benefits if he got meds from somewhere else…

Some vets have been warned that if they don’t take part in educational programs, they won’t get prescriptions. Failure to submit urine samples could result in expulsion from the program.

Vets also complain of being kicked out of programs for failing “pain contracts” they were ordered to sign. The contracts require the vets to agree to submit to urine screenings and to take one of several VA opioid safety classes or risk being denied their medications…

Ryan Trunzo’s descent from promising soldier to drug addict is detailed in more than 500 pages of medical files and Army reports…  Trunzo, who was 19 when he joined the Army, served in Iraq from February to November 2008 and was injured when his convoy was hit by a roadside bomb. He suffered several small fractures in his back and was given some painkillers.

There were other traumas: the death of a close friend, the shooting death of an Iraqi boy and an incident in which he said he was ordered to stand guard while a superior officer sexually assaulted an Iraqi woman…

But, because of a history of addiction during his military service and the change in VA policy, for the pain Trunzo got tablets of nothing stronger than over-the-counter-strength ibuprofen…

http://www.startribune.com/the-new-goal-at-the-va-treating-the-root-causes-of-veterans-pain/311225971/

Part 2

The Minneapolis VA hired its first chiropractor in 2014 and was overwhelmed by the response, with more than 850 visits in less than five months. Because of the demand, 23 veterans have been allowed to make appointments with chiropractors outside the VA. The Minneapolis VA said it hopes to have its second chiropractor in place this summer.

Dr. Carolyn Clancy, then the interim VA undersecretary of health, told a congressional committee in June that the VA is conducting research to identify predictors for veterans who abuse opioids and which veterans might respond best to nonnarcotic treatments…

DEA Creates New Task Force For Chicken Farms

The Drug Enforcement Agency has been working closely with the medical industry for years in trying to combat the use and abuse of any kind of prescription drug that can make a patient feel good. This would include drugs like opioids, antidepressants, muscle relaxers, anti-anxieties, and stimulants like Ritalin.

In conjunction with that goal, the DEA and medical researchers have been testing wastewater for drugs, mostly around university campuses and economically distressed cities, because it’s a fact that the young and the poor take more drugs than any other population.

But this kind of testing doesn’t address the drugs that we consume through the food chain. In order to expand the drug testing of waste, the DEA has created a new task force to look for drugs found on farms. This new task force, called Operation Cock-a-doodle-doo (COCK), will begin with testing the waste found on chicken farms.

To locate these farms, the members of COCK will be looking for any chickens that are suspected of having drugs in their system. Because chickens aren’t known to be happy animals, COCK will be looking for roosters and hens that appear to be in a good mood.

Andrew Kolodny of Physicians For Responsible Opioid Prescribing (PFROP) will be the medical “expert” working with COCK to help identify the chickens that are using or abusing drugs.

“Drug addiction in chickens is easy to spot,” says Mr. Kolodny. “We look for signs of the munchies, along with chickens that are dancing or strutting.”

When asked about the crisis of antibiotic resistance in our food chain, and if COCK will be testing for these drugs, a DEA spokesperson explained that antibiotics are not part of the Drug War. “We’re only interested in drugs that can have the side effect of making people feel high or happy.” The DEA spokesperson indicated that along with prescription drugs, COCK will also be looking for signs of marijuana use in chickens.

The COCK task force submitted the above photo as an example of what a chicken on drugs looks like. The DEA asks that the public be on the look out for dancing chickens or farm animals that are only interested in eating, and to report these sightings immediately to COCK at 1-800-COCKADOO or HappyChickens.com.

After receiving a reported sighting of happy chickens, Mr. Kolodny’s job will be to collect samples of chicken poop and test them for certain drugs. If these drugs are found, the DEA will arrest the owners of the farm, and the land and animals will be sold at auction to the highest bidder in order to fund the work of COCK.

(Photo taken on 7/4/2015.)

Insurance companies and the war against pain patients

http://www.managedcaremag.com/archives/2015/6/confronting-epidemic-opioid-overdoses

Meanwhile, the Coalition Against Insurance Fraud, a group that includes insurers, government regulators, and consumer groups, estimates opioid abuse costs over $70 billion each year…

There are some bright spots in this otherwise grim picture. The rate of increase in opioid overdoses has notably slowed in recent years; in fact, the number of deaths from opioid overdose declined by 5% from 2011 to 2012. Many states have implemented polices that require providers to check databases of prescriptions for controlled substances before they prescribe certain medications…

Most of the blame for the opioid abuse epidemic has been directed at the companies that make and market the drugs. But private and government payers have also been criticized for, at the very least, not doing enough to stop it. Stingy coverage of a more integrated approach to chronic pain management means doctors are more apt to depend on opioid prescriptions, say the critics. There’s also been some finger pointing at formularies that put tamper-resistant opioids on more expensive tiers and impede access to the buprenorphine–naloxone combination (Suboxone) used to treat opioid addiction. The GAO and Pro Publica, the not-for-profit investigative journalism organization, have published reports critical of the CMS and its Medicare Part D program for allowing dangerous prescribing practices, including excessive prescription of opioids.

But if you are part of the problem, you can also be part of the solution, and health plans have been taking steps to rein in rampant opioid prescribing. For instance, Aetna implemented a misuse, waste, and abuse program involving clinical pharmacists, care managers, and behavioral health clinicians. The program coordinates efforts across departments to encourage safe prescribing, identify members at risk, and provide appropriate support to fight addiction.

“When an opioid pharmacy claim overlaps with a buprenorphine pharmacy claim, we notify the prescriber within 48 to 72 hours by fax,” explains Celynda Tadlock, PharmD, vice president of Aetna Pharmacy Management. “An Aetna pharmacist then calls the provider three days following the fax notification. Ultimately, we want the provider to contact the member to stop continued opioid use.”

Anthem identifies members who have filled 10 or more prescriptions for controlled substances within a three-month period. (Members with cancer or multiple sclerosis are excluded.) Over 61% of the members identified had a reduction in the number of opioids after the intervention.

CeltiCare Health Plan in Massachusetts looks at providers’ prescribing practices and the percentage of their prescriptions that are controlled substances. Outliers are flagged for educational outreach, typically starting with a letter or phone call sharing the data that compares their prescribing practices to those of their peers.

“We can and do refer them to our behavioral component for face-to-face education,” says Robert LoNigro, MD, CeltiCare’s chief medical officer. Of course, physicians are given a chance to explain their prescribing patterns. CeltiCare is exploring additional programs, including a hot line for providers to obtain real-time information about opioid prescribing and risk-modeling tools to help them identify which of their patients might be at a higher risk for misusing opioid medications.

Blue Cross and Blue Shield of Massachusetts spotted a problem in its claims data about three years ago when it became clear that a small percentage of its members were being prescribed a disproportionate share of opioid analgesics, says Tony Dodek, MD, the plan’s associate chief medical officer. The insurer introduced a program—developed with an outside panel of physicians, pain experts, and addiction specialists—to reduce the volume of opioid prescribing while protecting those members with legitimate treatment needs. Steps include limiting the supply of short-acting opioid analgesics to two 15-day periods over two months (with some well-defined exceptions) and requiring providers who prescribe long-acting opioids to start with short-acting medications. Dodek says his company also began sending prescribers reports that list their patients for whom they have prescribed opioids. During the first 18 months of this effort, called the Prescription Pain Medication Safety Program, prescriptions for short-acting opioids fell by 20%, and prescriptions for long-acting ones fell by 50%…

PBMs and the national drugstore chains are also talking up their efforts to quell opioid abuse. For example, on its website Express Scripts describes a program designed to limit opioid abuse among those getting prescriptions through worker compensation. When an injured worker presents a prescription at the pharmacy, the company’s claims processing system calculates its morphine equivalent dose (MED). If the prescription dose is over certain MED limits, it is submitted to the payer for a special review and the prescribing physician is sent a reminder about the guidelines for prescribing opioids. The company also uses a pharmacy “lock in” program for some claimants. Their prescriptions for drugs likely to be abused can be filled at just one pharmacy and sometimes the script can be written by just one prescriber.

Two years ago, CVS Health executives announced in the pages of the New England Journal of Medicine that the company had identified physicians with unusual patterns of prescribing high-risk drugs (alprazolam, a benzodiazepine, and carisoprodol, a muscle relaxant, as well as hydrocodone, oxycodone, and methadone) by combing through its huge cache of claims data. The company discovered 42 outliers and banned 36 from fulfilling prescriptions at their stores.

But the DEA has gone after CVS—and its rival, Walgreens—as part of a crackdown on prescription drug abuse. Last month, CVS agreed to pay a $22 million settlement after a DEA investigation found that employees at two of its pharmacies in Sanford, Fla., dispensed controlled substances without legitimate prescriptions. In 2013, Walgreens reached an $80 million settlement after the DEA found problems with record keeping and prescribing practices at a distribution center and six of its retail outlets in Florida…

Andrew Kolodny, MD, praises payers who are getting involved in fighting the opioid abuse epidemic. Kolodny, the chief medical officer of Phoenix House, a New York City drug and alcohol rehabilitation program, and president of Physicians for Responsible Opioid Prescribing, calls Blue Cross and Blue Shield of Massachusetts’s program “very smart.” It is important, he says, for payers to work on reducing the number of Americans starting opioid therapy for chronic pain because once they are on it, stopping is often difficult. Kolodny spreads blame for the opioid addiction epidemic around: “The FDA has been awful on this issue,” and he mentions a “well-financed misinformation campaign” by pharmaceutical companies. But he would also like to see state medical boards and the medical community get more involved. Tamper-resistance opioids might be helpful but because most people get addicted to the oral formulations he expects them to make “only a very small dent in this problem.” It comes down to this for Kolodny: “Opioids are lousy drugs for most people with chronic pain,” and we have to come up with better ways for helping people suffering with pain that won’t go away.

Let me make this one fact very clear:  Andrew Kolodny is not an expert on the treatment of chronic pain.

Andrew Kolodny: Enemy #1 of All Pain Patients

http://www.jhsph.edu/news/news-releases/2015/survey-many-doctors-misunderstand-key-facets-of-opioid-abuse.html

Many primary care physicians – the top prescribers of prescription pain pills in the United States – don’t understand basic facts about how people may abuse the drugs or how addictive different formulations of the medications can be, new Johns Hopkins Bloomberg School of Public Health research suggests.

This lack of understanding may be contributing to the ongoing epidemic of prescription opioid abuse and addiction in the U.S.

If opioid abuse and addiction is an epidemic, pray tell, what would you call the ever-increasing suicide rate?  More people die from suicide and guns than opioids, and neither of those issues are called epidemics.

Reporting online June 23 in the Clinical Journal of Pain, the researchers found that nearly half of the internists, family physicians and general practitioners surveyed incorrectly thought that abuse-deterrent pills – such as those formulated with physical barriers to prevent their being crushed and snorted or injected – were actually less addictive than their standard counterparts. In fact, the pills are equally addictive…

Another finding from the new research: One-third of the doctors erroneously said they believed that most prescription drug abuse is by means other than swallowing the pills as intended. Numerous studies have shown that the most common route by which drugs of abuse are administered is ingestion, followed by snorting and injection, with the percentage of those ingesting the drugs ranging from 64 percent to 97 percent, depending on the population studied. Certain medications are more likely than others to be snorted or injected…

“Primary Care Physicians and Prescription Opioid Abuse: A National Survey” was written by Catherine S. Hwang, MSPH; Lydia W. Turner, MHS; Stefan P. Kruszewski, MD; Andrew Kolodny, MD; and G. Caleb Alexander, MD, MS…

http://protomag.com/articles/world-of-pain

http://www.bgsu.edu/news/2015/06/conference-looks-at-history-of-alcohol-and-drug-use.html

The opening session on June 18 will discuss “The Heroin/Opioid Epidemic in Northwest Ohio.” The panel discussion, from 7-9 p.m. in 201A Bowen-Thompson Student Union on BGSU’s campus, is free and open to the public. Panel participants include Dr. Andrew Kolodny, chief medical officer for Phoenix House Foundation in New York and executive director of Physicians for Responsible Opioid Prescription…

——-

2015 Summer Conference
Indiana Prosecuting Attorneys Council and Office of Indiana Attorney General

OPIOID EPIDEMIC
Dr. Andrew Kolodny
Chief Medical Officer, Phoenix House
President, Physicians for Responsible Opioid Prescribing
Brooklyn, NY

(6/12/2015) As VA cuts narcotic prescriptions, veterans with chronic pain cry foul

http://newsok.com/as-va-cuts-narcotic-prescriptions-veterans-with-chronic-pain-cry-foul/article/feed/851253

For nearly four decades, the Department of Veterans Affairs had prescribed James Andrews narcotic painkillers for back pain. But last year, the VA sent the Vietnam veteran a terse letter informing him that it had canceled his prescription for hydrocodone.

His doctor told him he’d tested negative for opioids — a sign that patients might be hoarding and selling their pills — but Andrews said he had no hydrocodone in his system because he took the medication only when his pain was unbearable.

“I was extremely upset. You can’t do that to somebody, especially someone with a failed spinal fusion,” he said. “Ask me how I’m taking them rather than cutting me off and assuming I’m doing something illegal, because I’m not.” …

The complaints have grown so loud that Disabled American Veterans, an influential advocacy group, has called for more “humane” pain management treatment as the VA seeks a balance between giving the painkillers to those who need them to function and reducing or discontinuing them for those who don’t.

The VA’s new guidelines and policies on opioids look good on paper. They call for exploration of alternative therapies and gradual tapering of veterans on long-term painkillers to avoid painful withdrawal symptoms. They call for conversations with veterans about options such as acupuncture and spinal cord stimulators before doctors discontinue narcotics. And they call for reducing the amount of narcotic painkillers given to individual veterans to safer levels…

Replacing opioids with acupuncture and spinal cord stimulators?  Do these “treatments” have a better success rate than opioids?  How many pain patients does acupuncture help — something like 10%, if that?  How many VA doctors know anything about acupuncture? It’s not even a recognized medical specialty.  And how many patients are harmed by stimulators?

At the heart of many complaints is a more robust painkiller contract, known as an informed consent agreement, that the VA requires veterans to sign, pledging to take their opioids as prescribed and to avoid alcohol and recreational drugs…

One of those patients was San Marcos resident Ezekiel Enriquez, 68, a Marine veteran who fought in Vietnam. The VA had prescribed him opioids, including hydrocodone, off and on for nearly a decade for herniated discs.

Like Andrews, Enriquez tested negative for opioids late last year and was abruptly cut off of his painkillers. Enriquez says flare-ups and dental pain caused him to sometimes finish his prescription early, meaning the medications were out of his system by the time he went to the Austin VA clinic to see his doctor. “They said, ‘We can’t give it to you any more, you broke the contract,'” he said…

While Central Texas officials have introduced such alternatives as aquatic therapy and chiropractic care, Enriquez said his doctor didn’t discuss such treatments with him, and suggested in a meeting that he might be selling his pills.

Replacing opioids with aquatic therapy and chiropractic care?  How’s that working for you, VA?

Eventually another VA doctor put him on Tramadol, a less powerful painkiller that he says doesn’t relieve his pain as well as hydrocodone and makes him drowsy.

Some pain medicine experts warn against using urine drug tests as evidence that a patient isn’t taking painkillers because synthetic opioids such as hydrocodone stay in the bloodstream for only a couple of days.

“Testing the urine does not tell you if the patient took the medicine,” said pain specialist Dr. C.M. Schade, director emeritus of the Texas Pain Society. And urine tests are especially poor tools for detecting opioids in a patient taking painkillers on an as-needed basis, which many doctors recommend for chronic conditions.

Cutting patients off of painkillers cold turkey “is unsafe medicine,” Schade said…

But several patients say they weren’t given a Plan B. Bill Williams, a 62-year-old Vietnam veteran from Brackettville, had his longtime hydrocodone prescription canceled earlier this year after he tested positive for marijuana. But he said his doctor didn’t discuss the situation with him as spelled out in the guidelines.

“I would have thought they would give me the courtesy of a phone call rather than shoot me a letter,” he said. “I thought we had a little better relationship than that.”

And Enriquez said he learned of his doctor’s decision when he called the VA to ask why he hadn’t received his monthly prescription…

“We are in our last years already, where you don’t know if you are going wake up or not,” he said. “If we take the medications responsibly and it’s helping, why do you take it away from us?

Not only, why do you take away something that works, but what the hell are you going to replace it with?  Cruelty and suffering?

Interventional Pain Physicians

http://www.pharmaciststeve.com/?p=10663#comment-10928

The Interventional Pain Physicians group has grown out of control in their political influence and their ability to use the system for their own gain in my opinion. Working to obtain higher reimbursements for their procedures and adding new codes for reimbursement of procedures.

But you don’t need to look very far to find them. Many are regular visitors to our nation’s Capitol where you will most likely be able to find these doctors at breakfasts, lunches, dinners and fundraisers meeting with our politicians in Washington DC, where they hold their annual meeting each year so that all of their members can meet with their legislators as well. Making more than 500 legislative visits, meeting with congressional members each year during Capitol Hill visits to discuss healthcare issues of concern to interventional pain physicians.

Obtaining almost 40 letters of congressional support on various issues. Multiple meetings with, and presentations to, CMS officials. Having sent over 18,000 letters to legislators and to the Health Care Financing Administration (HCFA) on a variety of issues. Several meetings between their group’s leadership and former Secretary of Health and Human Services Tommy Thompson. They proudly proclaim it online on their website as part of their list of accomplishments along with their own PAC – Political Action Committee…

Click to access 2014;17;E1-E10.pdf

As we say goodbye to 2013, 2014 brings in the global epidemic of opioid use, inappropriate use, and abuse with related fatalities, which along with the global epidemic of chronic pain with its related disability continue to be major issues for the public, officials, and physician community. After much controversy with pendulums swinging in different directions over the last 3 decades, it appears that we have reached the boiling point, with disagreements and colliding opinions finally resulting in definitive action with the publication of a policy position paper from the American College of Physicians (ACP) in December 2013 which in our opinion further validates as it is largely in keeping with the philosophy and policies that the American Society of Interventional Pain Physicians (ASIPP) initiated in 2000 (6,10). Starting in 2014, the Medicare participating provider program…

Under References (Page 8):

46. Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med 2011; 155:325-328.

Kolodny and the VA speak at Georgetown University conference

It’s so sad that even a place like Georgetown University is hosting a quack like Kolodny.

https://blogs.commons.georgetown.edu/medthread/

Click to access R3D%20Abstracts.pdf

Also speaking at the conference:

Managing chronic pain: A case study of the potential of comparative effectiveness research
Carolyn Clancy MD, Department of Veterans Affairs

http://www.news8000.com/news/va-to-release-opiate-management-tool-ahead-of-tomah-results/31691556

Dr. Carolyn Clancy, interim secretary for health for the Department of Veterans Affairs, announced the new Opioid Therapy Risk Report on Monday. Clancy said it will allow doctors to better monitor their patients’ opiate prescriptions, as the report allows VA providers to review all pertinent clinical data related to pain treatment in one place…

Clancy said since the VA established the Opioid Safety Initiative (OSI) in 2012, there are currently:

91,614 fewer patients receiving opioids;
29,281 fewer patients receiving opioids and benzodiazepines together;
71,255 more patients on opioids that have had a urine drug screen to help guide treatment decisions;
67,466 fewer patients on long-term opioid therapy

I can see that there are a lot of veterans out there who are now suffering and part of the war against pain patients.  Funny that these statistics say nothing about how veterans in pain are handling this change in treatments, just highlighting decreases in the use of prescription medications.

http://wuwm.com/post/congressional-hearing-alleged-painkiller-abuse-tomah-va-starts-monday

Carolyn Clancy, Interim Under Secretary for Health for the U.S. Dept. of Veterans Affairs, recently told the Senate Veterans Committee that the number of veterans who suffer from chronic pain appears daunting. She put the rate, among those returning from service in the Middle East, at 60 percent…

“Here is an instance of excessive quantities of a particular drug doing absolutely horrific damage to our nation’s heroes,” according to Connecticut Sen. Richard Blumenthal, who serves on the Senate Veterans Affairs Committee… “We know that 22 veterans everyday commit suicide, and many of them have suffered from over-prescription of opioids.

Blaming the suicide rate on opioids doesn’t really address the fact that veterans are suffering because politicians sent them to war in the first place.  They’ve returned broken and damaged, both physically and mentally, and to deny them treatment is just plain cruel.  Once again, the problem is not drugs.

Dr. G. Caleb Alexander says some VAs have been leaning away from the use of narcotics to control pain, when possible. “Things such as physical therapy or biofeedback or acupuncture and the like. To some degree, it depends on the type of pain,” Alexander said.

Tell me, Dr. Alexander, how successful are these treatments compared to pain medications? Sounds like you’re just asking for an increase in the suicide rate for veterans, especially since the VA refuses to prescribe medical cannabis.