By Richard A. Lawhern, Ph.D. as published in iPain Living, the magazine of the International Pain Foundation.
We hear and read the glaring headlines every morning and evening from National media: America is in an opioid overdose crisis and prescription drugs are the supposed cause. The same messages are being shouted in Canada with equally dire consequences. We hear the truth far less often. National media and public policy are naming the wrong culprits in a repeat performance of the failed “war on drugs” of the 1980s.
It is time for Congress and States legislators to hear a very different message. Restrictions and persecutions imposed on doctors and their patients are destroying the lives of millions of people. Doctors are leaving pain management m droves. Patients are spiraling into disability. Some are committing suicide, unable to bear their pain after being denied pain treatment or coerced to give up treatment that has worked for years. This atrocity is being committed for no good purpose because lawmakers have their facts and assumptions wrong. In the words attributed to humorist, Will Rogers, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”
Doctors and healthcare writers are beginning to speak up to contradict a sorry record of malpractice, misdirection and sometimes outright deceit. None of the following have given their permission for the use of their names here, but all are on public record calling the current war against pain patients what it is – a massive and needlessly destructive mistake.
- Maia Szalavitz is a highly regarded neuroscience journalist whose work appears in Scientific American among other venues.
- Carl Hart, Ph.D., Chairman of the Department of Psychology at Columbia University, has also written in Scientific American.
- Jacob Sullum, Senior Editor at Reason Magazine, is a nationally syndicated columnist in the New York Post and other media.
- Jeffrey Singer, MD at the Cato Institute, writes of common opioid myths.
- George Knapp, twice recipient of the Peabody Award and 22 times Emmy Award winner, is investigative lead reporter for “The Other Side of Opioids” on Las Vegas Now television and Coast to Coast AM radio (hashtag #OurPain)
- Lynn Webster MD is the expert author of books and documentaries on “The Painful Truth.”
- Michael E Schatrnan, Ph.D. and Stephen J Ziegler Ph.D. have written about CDC distortions of overdose data, in Journal of Pain Research.
There are many more.
Mine is a lesser voice in this chorus of contradiction. My wife and daughter are chronic pain patients. I am a technically trained nonphysician, patient advocate, and healthcare writer. My Ph.D. is in Engineering Systems and much of my two careers was devoted to assessing advanced military technologies. However, I have been active for over 20 years in social media, supporting people like my family. I interact weekly with over 25,000 pain patients, affected family members, and doctors.
An estimated three million people are now treated long-term with opioid medications, out of the l 00-million plus Americans and several million Canadians who experience daily moderate to severe pain. Unlike US and Canadian legislators and policymakers, I talk to people every week whose lives are being destroyed by public policy which arbitrarily restricts the use of opioid pain relievers in people for whom these medications are the only effective management for incurable medical conditions.
From this background, I feel that I must speak truth to power: legislators and policymakers are wrong about almost the entire narrative on prescription opioids, chronic pain, and drug abuse. And their errors are killing people.
Doctor prescriptions for pain-relieving drugs to actual patients are only a minor contributor to the current casualty toll in opioid-related overdose deaths. A much more prevalent problem is drugs diverted to the street by theft from homes or pharmacies, or by being given by family members to people who never saw a doctor. Drying up the supply of pain relief to valid patients won’t “solve” this problem.
Overdose related deaths continue to climb despite significant reductions in prescriptions during the past five years.
For 2015, the State of Massachu- setts traced opioid-related deaths to State prescription monitoring databases. Fewer than 8% of overdose victims had a recent prescription for an opioid pain reliever. We have no reason to expect different outcomes in other States. Prescriptions made to patients aren’t causing the great majority of drugrelated overdose deaths. According to the CDC itself, that distinction belongs to heroin, illegally imported fentanyl, morphine stolen from hospital dispensaries, and methadone diverted from community treatment centers.
Although physical dependence on opioids for pain control does occur in some long-term patients, addiction – which is a different medical entity — is uncommon in those who are properly worked-up and monitored. A 20 l O Cochrane Review on long-term benefits and risks of opioid pain relievers found that fewer than ½ of one percent of patients who had never before used opioids were diagnosed with opioid abuse disorder within one year. Other reports indicate lower than 3% risk over longer periods. The risk may be higher in people who have a history of drug use or abuse.
Demographics of chronic pam treatment and addiction do not support the prevailing public narrative. Chronic pam treatment rarely “leads to” addiction, and almost never on short exposure. The typical new addict is a white male with a history of family trauma, unemployment and/or mental health issues, who begins to abuse drugs and alcohol as an adolescent or young adult. Young males from economically distressed areas are rarely seen by doctors for pain severe enough to justify the use of opioids. But the typical chronic pain patient (by a female/male ratio of 60/40 or higher) is a woman in her 40s or older, who suffers from traumatic injury, failed back surgery, chronic face pain, migraine headaches, fibromyalgia or Complex Regional Pain Syndrome. Women of this age rarely become addicts.
Restriction of prescription drugs and FDA mandated reformulation of Oxycontin into “abuse-resistant” form have directly contributed to tripling the number of deaths due to heroin and fentanyl overdose since 20 l 0. Addicts who shammed pain prior to 20 l O were denied safe prescription drugs that they could abuse, and driven into the street where heroin is cheap and plentiful. There is evidence that patients in agony are also being driven into the same horrid choices by the desertions of doctors afraid of being persecuted by the DEA or State authorities.
Much is made in news media concerning doctors who operate “pill mills” and divert large volumes of opioid pain pills to people who resell them. Doubtless, some drug dependent or careless doctors have been guilty of such abuses. However, DEA enforcement actions have long since devolved into a campaign of terror against any doctor who dares to attempt treatment of people in agony who need and benefit from high dose opioids. A celebrated recent case has been opened with DEA confiscation of the office records of one of America’s most prominent and honored pain management doctors, Forest Tennant MD. Alarmingly, DEA has yet to demonstrate that its investigators can discriminate reliably between pill mill operators versus pain management physicians who are being called to serve patients of other doctors whom the DEA has driven out of practice.
New laws and regulations are being enacted in several States, to restrict the amount or duration of opioids that a doctor may prescribe for new or existing patients. Such restrictions are sometimes claimed to reflect the 2016 CDC prescription “guidelines”. What is not acknowledged in these laws is the growing consensus among medical professionals that CDC standards are deeply misdirected, unfairly biased against opioid therapy, poorly supported by research, and actively dangerous to patient health. I call them “standards” because Congress made the supposedly “voluntary” guidelines mandatory for the Department of Veterans Affairs, three full months before publication. But CDC published them without change.
The largest error in the CDC opioid guidelines may have been their failure even to consider the natural variability between individuals’ ability to metabolize (break down) opioid pain relievers into byproducts that cross the brain-blood barrier to relieve pain in the brain. 90% of all medications are broken down by six enzymes in the human liver. Polymorphism in the genes which control the expression of these enzymes causes millions of people to poorly process particular medications, or to so rapidly process them that breakdown products pass out of the blood system too rapidly to sustain pain relief for more than minutes. In consequence, millions of people who might be helped by opioid pain relievers will fail any therapy that places arbitrary restrictions on maximum dose.
Combined with very weak science pertaining to “Morphine Milligram Equivalent Daily Dose”, genetic polymorphism creates a reality which must be absolutely horrifying to government bureaucrats who seek a one-size-fits-all “solution to the overdose crisis”. There literally cannot BE a one-size-fits-all threshold of addiction risk or a standard dose for adequate pain relief. Medications must be tailored to each individual patient, based on drug responses and side effects.
The CDC opioid prescription guidelines recommend that opioids should be deemphasized in favor of non-opioid analgesics, behavioral therapies like Rational Cognitive Therapy, or noninvas1ve, nonpharmacological interventions like exercise, massage, chiropractic, or acupuncture. However in December 2017, the US Agency for Healthcare Research Quality circulated a draft report of a major systematic review for thousands of trials for such interventions. The review reveals that the trust invested by CDC Guideline writers in socalled “alternative” therapies was hugely naive. A fair reading of the AHRQ draft report suggests that the state of medical evidence for non-opioid pain therapies is simply abysmal. We literally don’t know if they work or how well and for which categories of patients. And we certainly cannot have confidence that non-opioid therapies offer any real alternative to opioid medication for the great majority of people in long-term severe pain.
Pain patients aren’t the only ones being injured by the misdirection of government policy on drug abuse and pain treatment. Addicts and their families are also victims. We must recognize that addiction is a much more complex and expensive problem than many legislators have been willing to ap.Qroach – or perhaps, to fund.
Some advocates claim that drug addiction is a brain disease and should be approached as a public health issue rather than a problem for law enforcement. While there might be merit in this redefinition, it ultimately may not matter. At the present state of medical knowledge, we have no medical “cure” for addiction, however we characterize it. Given the complexity of human biochemistry and behavior, we might never discover such a cure. The best we can reasonably hope for in the near term is better prevention among young people and long-term harm reduction in those who have already become addicts.
Policy makers cannot say that they don’t know what is needed. Authorities at the National Institutes on Drug Abuse have long known what works and what doesn’t.
Though “Just Say No” was an ineffective disaster in the I 980s, other programs of intensive early education down to grade school level have better records. Nobody who understands drug abuse would say that our community doctors and school nurses already know enough about recognizing or managing addiction when they see it. Training of community practitioners will be an essential element of any solution.
Beyond education, we also know what works to reduce harm in confirmed addicts. As an emergency intervention to save lives, suboxone may play a temporary role – though there is doubt that repeated administration does more than postpone death by overdose. The most effective harm reductions are in ongoing Medication Assisted Therapy (MAT) – community methadone or buprenorphine clinics. But even such clinics are not a solution when standing alone.
We also know what clearly doesn’t work. As a senior MD stated during the June 2017 meeting of the President’s Commission on Combating Addiction and the Opioid Crisis, ”we don’t need more beds.” People discharged from 28-day detox facilities have horrendously high relapse rates when returning to the same communities and conditions where they first became vulnerable to drug abuse, without ongoing active support. Abstinence-based programs like Narcotics Anonymous are similarly ineffective when used alone.
The m1ssmg elements in reducing harms of addiction must revolve around community reintegration. This means safe and sober housing for people who are often homeless, combined with meaningful job training, community based counseling for mental health issues and ongoing support following relapse (which will frequently occur).
We know from organizations such as the Pew Charitable Trusts, that law enforcement policy and punitive measures have no effect whatever on addiction, overdose or recovery rates. Diversion of non-violent drug offenders out of the prison system is one of the few recommendations that the President’s Commission got unequivocally right.
Going much further, the State of Portugal has already pointed the way toward effective policy. In the 12 years since Portugal decriminalized drug possession, drug related overdose deaths have dropped to near zero and heroin addiction is down by 75%. In US States where medical marijuana is legal, prescription rates for opioids are also down. Yet the US Attorney General is on record as determined to continue prosecuting mar1Juana growers even in States where the substance is legal.
We know that to truly deal with America’s addiction crisis, legislators must be prepared to spend billions of dollars every year – for the foreseeable future. What remains to be demonstrated is that they have the will and the human courage to do so in the face of demands for down-sizing the reach and cost of government. Existing treatment programs are mostly ad- ministered by Medicare and Medicaid – programs under attack by US political conservatives.
For chronic pam patients, the issues of public policy are clearer and potentially cheaper. Congress and State legislators can save thousands of lives literally overnight by the stroke of a pen, and without new legislation. All that is needed is for Representatives and Senators to sign or co-sign a letter to the Director of the CDC stating that Federal appropriations will be reduced by 10% per year until CDC publicly withdraws the 2016 opioid guidelines for a major rewrite to correct horrendous unintended outcomes, errors and omissions. On this round, all stakeholders need to be represented among the consultants group that does the writing. Pain patients or advocates should be voting members along with pain management specialists experienced in community practice.
For Veterans and at State level, legislation may be needed to repeal draconian and scientifically unfounded restrictions on opioid pain relief, and interference in doctor-patient relationships. The CDC opioid prescription guidelines should no longer be mandated as a requirement for the Department of Veterans Affairs, when we know that the guidelines are so poorly constructed and that they have caused a toll of deaths among Vets denied effective pain management.
Pain is the number one reason why people see a doctor. Over time, we need to double the number of trained pain management doctors, not further reduce this resource by a hostile regulatory environment. Doctors, pain patients and their families know that few patients are addicts or at risk for addiction. Solutions for America’s addiction crisis cannot be built upon the broken backs of people forced into agony and disability by government policy.
It is time for legislators to listen up and stop the phony war against pain patients and their doctors.