As published by National Pain Report.

By Richard “Red” Lawhern, PhD

You Need to Hear a Tenth Voice

This article is edited from correspondence sent to the Office of National Drug Control Policy on June 17th, 2017.  Others who wish to make their voices heard may also do so by email to [email protected] .

With many others, I listened and watched for two hours of the first working meeting of the Commission on Friday June 16, 2017.  The Commission was addressed by leaders of nine Non Profit Organizations engaged with various aspects of addiction treatment.  Much of the input seemed quite apropos.  But one voice was missing from the session that is vital if the Commission is to arrive at safe and supportable recommendations on this important public health issue.

Speakers failed to include even one practicing physician or advocate for pain patients who have largely and unfairly been blamed for the so-called “opioid epidemic”.  I urge the Commission to remedy this exclusion by inviting participation in an additional session by organizations such as the American Academy of Pain Medicine, the American Academy of Integrative Pain Management,  the National College of Physicians, PAINWeek, Pain News Network, National Pain Report, and/or the US Pain Foundation.  Commission staff should be able to identify other physicians who are deeply trained in this field.

In the absence of such input, I offer my own insights as a 20-year volunteer advocate who daily interacts with more than 20,000 chronic pain patients, among the estimated 100 million Americans affected by persistent, long-lasting pain (by the American Academies of Medicine). Within this group, an estimated 16 million are treated in any given year for recurrent persistent pain, and on the order of 3 million are treated for more than 90 days with opioid analgesics. [See “Neat, Plausible, and Generally Wrong — A Response to the CDC Recommendations for Chronic Use” by Stephen A. Martin, MD, EdM; Ruth A. Potee, MD, DABAM; and Andrew Lazris, MD]

I am myself neither a physician nor an expert in addiction. My training is in systems engineering, experimental design and technology analysis. My wife and daughter are the pain patients in my family.  But I talk with and read the work of many medical and pharmacy professionals, including several who were originally copied on this letter — all of whom have published in this field.

I believe I can lend support or amplification to several points made by speakers in the first session of the Commission. Certain aspects of the discussion stand out.

  1. A large number of addiction treatment and recovery programs now operating in the US are funded by Medicare.  To address the “opioid crisis,” the Commission must be prepared to advise President Trump to expand the scope of conditions treated under Medicare, not reduce it.
  2. As several speakers suggested, effective programs to reduce the death and destruction wrought by illicit drugs must be multi-dimensional.  Five aspects must be addressed.  None is adequate to stand alone, or will be effective standing alone.  There are no simple solutions here.

a.  Prevention in kids, beginning in Middle School, continuing through High School and beyond.

b.  Prevention in adults, focusing on employment development and the creation of hope.  Addiction in adults is not primarily a disorder created by drug exposure.  It is created by social disintegration and hopelessness that leave people vulnerable.

c.  Initial recognition of addiction by properly trained community medical professionals.

d.  Ongoing community engagement and support for recovering addicts over periods of at least 3-5 years and possibly longer.  Relapse is an ongoing issue for which there are no simple, one-size-fits-all solutions.

e.  Diversion of addicted kids and adults out of the prison system and into community treatment and re-integration programs.

As noted by Governor Christie, overshadowing all of these dimensions is the reality that we must reduce the moral condemnation and stigma now assigned to addicts in order to be able to engage them, their families, and their communities in corrective initiatives.   Not mentioned in the proceedings, the same is true of the stigma and abuse which are regularly experienced by long term pain patients and by doctors who attempt to treat their pain.

  1. As several speakers suggested, any program recommendations must be evidence-based and reinforced by sustained observation of outcomes.  We should not be wasting limited resources on measures that don’t work.  Some of the statements of participants stand out in flashing lights.  These can be readily confirmed by even minimal research on the part of Commission staff.

a.  90% of drug addicts first encounter opioids or other intoxicants as adolescents, either on the street or by diversion or theft from family members.  Not explicit in the proceedings is the reality that it is unusual for adolescents to have medical encounters which require treatment with opioid analgesics.  Thus this statistic makes clear that prescription drugs under active physician management are NOT the primary cause of the opioid epidemic and likely never were.  Further restriction of prescriptions to people in agony will not be a solution for this essentially “social” problem.

b.  The most effective interventions for confirmed addiction are medication-assisted.  This means programs like Methadone maintenance.  We have multiple international examples of maintenance programs which work.  For the politically bravest of the brave, we should also examine the experience of Portugal, where possession of drugs has been decriminalized for 14 years — and where overdose deaths have dropped to near zero as rates of addiction are dropping.

c.  Although community-based therapy in the 12-Step model might be a supporting element in recovery, this model is clearly inadequate by itself.  Relapse rates into addiction by 12-step attendees are abysmally high.

d.  As one speaker noted, “more beds are not the answer.” 28-day detox programs — including those used in the Phoenix House chain of addiction treatment centers, on the Board of which one of the speakers participates — are ineffective when not backed by ongoing community interventions. Media are littered with stories of addicts whose first act after leaving a treatment center is to find a dealer and shoot up. Some published figures on relapse rates for discharged addicts approach 95% within one year. This too can be confirmed by Commission staff.

  1. I note in passing, that the Commission must also wrestle with a contentious reality:  not all sources of advice are equally credible. My sense of the working session was that some of those who addressed the Commission were financially or professionally self-interested. I personally have particular reservations concerning the helpfulness of psychiatric care, given that the entire field of psychiatry is now experiencing a crisis in public confidence due to scientific corruption and over-medication promoted by pharmaceutical companies.

While we know that many addicts also deal with life crisis problems called “mental disorder,” there is legitimate doubt that psychiatry presently has reliable remedies to offer. More basically, use of anti-psychotic drugs has been associated with a marked drop in life expectancy and function among patients who are medicated involuntarily.  For further on this subject, a useful resource is “Psychiatry Under the Influence – Institutional Corruption, Social Harms, and Prescriptions for Change” by Whittaker and Cosgrove, available on Amazon. I would advise the Commission to apply the same standards of evidence to psychiatric programs as to all others considered.

  1. If the Commission is to seek solutions to the addiction crisis, then it seems to me that they must first be able to separate out hype from facts in understanding what is going on. I offer the following in my role as an advocate for people in agony who stand to be grievously harmed if the Commission gets this narrative wrong.

a.  Origins of the rising tide of opioid-related deaths are frequently attributed to careless prescribing practices of the 1990s, encouraged by pharmaceutical companies who touted “Pain as the 5th Vital Sign”.   It is certainly evident that prescribing practices were greatly liberalized during that period.  What is not so obvious is that ill-trained physicians not only over-prescribed to patients whose pain might have been managed by other means, but also to undetected addicts who shammed pain to get safe and regulated drugs of choice.

b.  The impact of over-prescribing was arguably and primarily NOT on legitimate pain patients themselves.  A Cochrane Review of 2010 of long term effectiveness and risks of opioids, found that among patients who were previously opioid-naive, the number who later presented with opioid abuse disorder was fewer than 1%.  Other and later studies have placed abuse rates at 5-10%. [See also Warning to the FDA: Beware of “Simple” Solutions in Chronic Pain and Addiction,  R.A. Lawhern, Ph.D. This article has since been featured in PAINWeek with a short introduction, as “What If Prescribing Standards Were Patient Centered?”]

c.  Much of the present “crisis” in opioid related deaths can  be laid at the feet of the FDA, when they forced the reformulation of OxyContin into “abuse resistant” form in 2010.  In the next three years, deaths attributed to heroin increased by more than 200% while prescriptions of Oxycontin dropped by 66%.

[“Have Opioid Restrictions Made Things Better or Worse?” by Josh Bloom, Ph.D.]  Heroin deaths continued to skyrocket in 2014-2015.  A plausible explanation for these statistics is that addicts who previously used Oxycontin found that they no longer got high on it, and were forced into unsafe street drugs.

d.  Whatever we may believe concerning how the “opioid epidemic” got started, there is ample evidence that it is no longer sustained by prescribed analgesics if it ever was.  Mortality statistics of the CDC itself reveal that in 2015, deaths attributed to overdose were dominated by heroin, imported fentanyl, diverted or stolen morphine and methadone.  Co-prescription of anti-anxiety medications (Benzodiazepine) was observed in about half of the 33,000 estimated accidental overdose deaths in 2015, and alcohol played a role in more than half.

[“New CDC Overdose Study Reduces Role of Pain Meds” – Pain News Network, December 26, 2016.]

In States like Massachusetts where mortality statistics have been compared with prescription databases, it is found that fewer than a quarter of the deaths attributed to opioids occurred among people who had a current prescription for them.  It also seems likely that many deaths reported as accidental were in fact suicides or sudden cardiac arrests caused by unsupervised sudden withdrawal of opioids by physicians leaving pain management.   Veteran suicide due to denial of pain relief is an even more evident trend.

e.  One of the speakers to the Commission asserted that simple “enforcement” of the March 2016 CDC Guidelines might reduce overdose deaths by half.  The implication was that a 90 MMED dose limit should become a standard of practice for all pain management physicians.  Unfortunately, I believe that speaker was grievously wrong.

I would assert from wide reading and direct observation of social media, that CDC guidelines have already been directly responsible for at least hundreds of patient deaths in the past year.  In their present form, they are deeply and unfairly biased against opioid pain relief, scientifically unsupported, and vastly incomplete.  Of particular concern is that natural genetic variability of patient responses to opioids was utterly ignored by those who wrote the Guidelines.   Any physician training that is based on these Guidelines may be responsible for deaths among patients who hyper-metabolize opioid analgesics, and therapy failure among many more who are poor metabolizers due to polymorphisms in the expression of key liver enzymes.

[See “Warning to the FDA: Beware of “Simple” Solutions in Chronic Pain and Addiction.”]  These errors and omissions are well known among pain management physicians.  The Commission should consider recommending that the CDC Guidelines be totally rewritten by a qualified consultants group led by pain management physicians and supported by patient advocates and medical ethicists.  In their present form, the Guidelines are “unsafe at any speed.”

Thank you for accepting this input.