A Delicate Dance Between Pain and Prescription
Ivanka Trump presumably has the president’s ear. So when Massachusetts Governor Charlie Baker found himself seated with her at a National Governors Association dinner Sunday, he took the opportunity to talk about America’s opioid crisis. Baker noted their discussion on CBS This Morning Tuesday.
The Bay State leader explained how his state legislature’s Democrats and Republicans collaborated to develop a 2016 state law that governors of 46 other states now have “signed on to” as a way to address the epidemic in their regions.
The law has “a lot of elements to it,” Baker told the CBS program, “but it’s basically prevention and education on the front end. Better training of prescribers. I mean, until very really recently you could practice medicine, you could be a dentist, you could be a nurse, you could be a physician’s assistant, and never take a course in pain management or opioid therapy. In Massachusetts anyway, you gotta actually take a course and pass it now to graduate from any of those schools.”
Acknowledgment of pain management needs in the midst of public concern about rising use of prescription opioids likely provides some psychological relief to the approximately 100 million Americans who suffer from chronic pain — the constant companion of people with arthritis, some cancers, back damage, migraines and other conditions.
In 2014, more than 28,000 people fatally overdosed on opioids, including heroin. Increases in heroin use are tied to the misuse of and dependence on opioid pain relievers. Nevertheless, the vast majority of prescriptions for opioids reportedly go to people who do not develop addictions, a fact that can get lost in discussions of the current crisis. And policy crackdowns are already having an effect: the proliferation of opioid prescriptions in the U.S. peaked around 2012 and then dropped in 2013, 2014 and 2015.
The need for more effective pain management stands out clearly in a new statistical analysis based on a nationally representative sample of nearly 20,000 adults over the age of 50 who were surveyed repeatedly from 1998 to 2010. At the start of the study, more than a quarter of respondents reported chronic non-cancer pain. But by 2010, that figure rose to more than one third, according to research published in the February issue of the journal Pain.
And while middle-aged people (ages 45 to 64) are the most likely age group to have pain lasting more than 24 hours, a quarter of people between ages 20 and 44 also reported such pain, according to data from the 1999 to 2002 National Health and Nutrition Examination Survey.
In the longitudinal study, levels of pain rose for each age group over time; in other words, new cohorts entering each age group in the study experienced more pain than did the group they replaced for that age interval.
Pain is more than discomfort — it’s a condition unto itself. And higher levels of chronic pain are associated with earlier death on average, the research reveals. Most striking: social disparities in chronic pain apparently mirror social disparities in health care. People of lower socioeconomic means report significantly more pain than people of higher socioeconomic means. Also associated with higher levels of pain: lower levels of education.
“For instance, if you’re just looking at severe pain, someone who doesn’t have a high school degree is 370 percent more likely to have severe pain than someone who has a graduate degree,” says study author Hanna Grol-Prokopczyk, a medical sociologist at the University at Buffalo. “That is really big. That is something that previous studies haven’t shown because they don’t break pain down into mild versus moderate versus severe.”
Unfortunately, some of our federal policy aimed at reducing prescription opioid overdoses and addiction has little to no basis in evidence and may have become so cautious that it forces doctors to either risk professional suicide by prescribing, or deny pain medications to patients who need them, two physicians wrote last week in the online publication STAT.
A draft policy released last month by the Centers for Medicare and Medicaid Services ratchets down the dosage threshold at which pharmacies can be blocked from dispensing opioid painkillers. This limit could provoke withdrawal and dysfunction among people currently on higher doses for pain relief.
Many research questions surround who suffers from differing pain levels, why they do, how they are treated and the implications for overall health. For instance, Grol-Prokopczyk was surprised to find in her analysis that pain levels among Americans over 50 actually went up as opioid analgesics use rose in the first decade of the 21st century.
“There’s growing evidence that when used in long-term, opioids can increase pain,” she says. “It’s possible that the pain profile of the country was made worse by the widespread use of opioids.”
Clearly, little of what is known about pain and public health inspires confidence in new policy directions regarding prescription opioids. But educating the president’s adult daughter about policies already making a difference was more constructive than demonizing people in need of medical attention.
This is no longer a war on drugs this has become a war on pain patients. Who is here to help us with this chronic incurable debilitating condition. We are being targeted because of medications available to us? We are being looked at as lower class citizens with less education because of a disease? As we get older our conditions worsen because of a medication we take, so it’s somehow proven to worsen our conditions? That’s ridiculous. … maybe our conditions worsen due to we are all subjected to useless procedures (injections, physical therapy etc), that exasperate our conditions. This just proves our conditions are incurable and worsen over time, it has nothing to do with a medication “making our disease worse!”. What other chronic disease patient is denied medication that helps control that condition? NONE…
I am mentally, emotionally and physically exhausted! The war on drugs has turned inti a full blown attack on innocent law abiding chronically ill citizens whose bodies are ridden with debilitating incurable diseases that cause severe pain every minute, of every hour of their lives!! Intractable pain pts are NOT addicts! We are patients that deserve to be treated with dignity and respect!! The CDC used FALSIFIED statistics to fit the corrupt governments addiction driven agenda! Why are you jsing studies from ten years ago!!?? Why are intractable pain pts being left out of the equation, continue to be silenced, abused, neglected, mistreated, stigmatized as drug addicts, degraded and discriminated!?!? I have had enough of this fictious opiod epidemic!! The CDC. DEA, PROP AND FDA have devastated the pain community with the barbaric and INHUMANE guidelines that are killing legitimate pain pts daily! Where are the stories about the many suicides caused by inadequate pain relief!?’n The corrupt lawmakers continue to silence people in pain. Every other day it seems as if these scumbag lawmakers come up with another barbaric and inhumane law pertaining to opiods, to further the witchhunt. They know dam well that by denying legitimate pain pts our lifeline, that many will turn to the streets for relief or worse SUICIDE!! They are intentionally inflicting pain and suffering on the chronically ill until we kill ourselves to escape the pain!! We treat animals better! If I were to alow my dog to suffer, I’d be arrested on animal cruelty charges, please enlighten me and tell me why it is acceptable to allow humans to suffer!?!? Why are these so called BS studies leaving out the most important people – CHRONIC INTRACTABLE PAIN PTS!!! Many have been on high doses of opiods and had a quality of life!! Chronic pain pts do NOT GET ANY HIGH, I REPEAT, WE DO NOT GET HIGH!!! WE GET MUCH NEEDED PAIN RELIEF!! In steps the corrupt government and thier sidekicks and just like that they are being discharged thru no fault of the pt. How is what the corrupt government doing to the chronically ill even legal!?!! When will the media start reporting on the genocide being done to the chronically ill!?!! Insurance companies are denying filling a pts lifesaving meds, pharmacies are turning pts away, lying to them and saying its not in stock, or are allowing them to deny filling scripts bas d on the way a pain pt looks, I can go on and on but im exhausted?
I feel like as successful long term opioid treated patients we are deliberately ignored. Can anyone answer why this is? Why hasn’t the government or anyone for that matter ever spoken with any of the long term opioid treated pain patients all across this country? The DEA keeps track of who gets what, how much,how often & for how long of opioid medications so they know who is on long term treatment & if they are on high doses so doesn’t all the government know? So why haven’t patients ever been contacted for studies? Or Is it they don’t want to acknowledge the patients that have been stable on long term opioid treatment? It seems like everyone ignores the fact that there are so many successful long term opioid treated chronic pain patients all over the country. Not only that but pain patients that have not only been on long term opioid therapy but are stable on high dose opioids for more then a decade successfully without any problems with medical records to back it up. Did all of these patients suddenly become addicted and are no longer benefiting? Still they continue to claim there is no evidence that long term opioids work. I find it incredibly frustrating it’s like we don’t exist or maybe we are so discriminated that they don’t believe it I just don’t know but I do know patients are suffering & dying because of being returned to pain levels they haven’t lived with in so long it is just over whelming on every level & the body & mind can’t live like that.
RE: 1 February, 2017
NOTE TO: Medicare Advantage Organizations, Prescription Drug Plan Sponsors, and Other Interested Parties
SUBJECT: Advance Notice of Methodological Changes for Calendar Year (CY) 2018 for
Medicare Advantage (MA) Capitation Rates, Part C a
nd Part D Payment Policies and 2018 Call Letter and,
ATTN: Cynthia G. Tudor, Ph.D.
Acting Director, Center for Medicare
I wish to register my objection to the proposed “Opioid High Dosage” HEDIS measure, focused on minimizing the number patients receiving greater than 120 morphine milligram equivalents. This measure violates the principles in the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.
1. Patient centered care. Patients have the right to appropriate effective treatment for their unique needs and characteristics without stigma.
2. Risk of harm. The measure will pose a serious risk to some patients currently receiving opioids appropriately prescribed in doses constructed for their health history and disease characteristics. The adoption of a threshold conflates the needs of multiple patient groups (addiction, chronic pain, dual diagnosis).
3. Faulty heuristics. The inappropriate application of these heuristics may result in under or wrong treatment, and drug switching based on regulations and insurance plan payment behavior.
4. Nonexpert physicians. The under/over application of guidelines by clinicians is a training issue, not a medication issue. Harm results from patients inappropriately matched to treatment protocols constructed by clinicians who lack expertise relying on algorithms for decision criteria to treat patients of specific complexity.
5. Violation of CDC Guidelines recommendations. The proposed measure offers no ability to address clinical differences in etiology. The CDC Guideline insists on “individual assessment of risk and benefit” as the primary basis for decision making and that “clinicians should discuss their safety concerns with the patient, consider tapering to a safer dosage (Recommendations 5 and 7)…”
6. Perverse incentive. Nonexpert physicians will be incentivized to rapidly reduce the number of community located patients whose current opioid dose exceeds 120 MME, a standard for which there is only indirect clinical evidence, as a function of physican limitations, prohibition, and license safeguarding.
7. Patient loss to followup. We want to keep these patients in stable in safe clinical protocols.
8. Untested theory. The measure will accelerate a reconfiguration of care that has never been clinically trialed, violates patient autonomy and informed consent for treatment, and can be predicted to actually force some patients to choose between treatment protocols that treat disease OR intractable pain.
9. Systematic error and bias. As designed we will be managing a threshhold instead of managing the patient. Institutional embrace of binary quality measures installs systemmatic error and bias into the data, damaging clinical decision making. Neither patient nor physician will have recourse in the case of error.
10. Impaired datasets. Systematic error harms effectiveness research and policy management.
11. Harmful effects. Forcing patients to adhere may contribute to rising injuries and death associated with medical switching and polypharmacy.
Dr. Terri A. Lewis
Silver Point, TN (Congressional District 6)
Look up Arachnoiditis and you will understand that this is a very rare disease that is in the NORD. We need the opioids to control the pain. If the doctors are not allowed to prescribe them the CDC and DEA are signing our death certificates. We are NOT drugies! All we want is to have a chance at some quality of life.
I am regrettably one of those positions who has suffered from the hostile regulatory environment around pain management. In 2013 a complaint was filed against me regarding nine patients who had come to me for help when they were dropped by their positions. Seven of these nine patients headwind off opiates entirely at the time of the complaint. Nevertheless, the state Board of medical examiners had evidence, scrambled my documentation, then perjured themselves in the hearings themselves.
I was ultimately exonerated by and administrative law judge, then my state board over ruled that ruling and suspended my license. This suspension intern was stayed by a temporary restraining order in District Court 12 months ago.
I’m still awaiting the permanent ruling on that order, I indeed have a license to practice medicine still however I cannot seek licensure in another state or get credentialing at a hospital or insurance company until my case is completely cleared up.
This case has tortured me and my patients for four years now. Unfortunately there is no guarantee of a speedy resolution for doctors. There are no protections for doctors in this environment. My clinic has been closed for 16 months now.
At one point I completely stopped prescribing to all of the opiate refugees in my practice, then several patients died of suicide or their chronic pain.
These are human rights violations happening right under our noses.
Thank you so much for this reasonable article about it the “opioid crisis”. It’s refreshing to see the subject explored rationally without the usual hype and propaganda.
Most of what I see written about this crisis wrongly suggests that opioids cause addiction and ignores the issue of pain entirely. So it’s gratifying to see the acknowledgement that some pain patients need opioids and have no problems with them.
Scientific research has become just as anti-opioid as the media with studies that are designed only to find more negative effects of opioids.
In their overzealous efforts to demonize opioids, researchers are confusing the effects of opioids with the detrimental effects of pain:
I have written widely on the current “crisis” in forced reduction of prescription opioid use for people in chronic pain. From 20 years of intensive study and support to chronic pain communities, I challenge Dr. Grol-Prokopczyk on the unsupported and unscientific assumption that prolonged use of opioids in any way “causes” increases in pain levels among Americans over 50. The cause-effect relationship is actually in quite the opposite direction. Opioid prescription levels increase because underlying medical conditions which cause pain are very often progressive in nature, and are more often diagnosed in recent years than formerly. Likewise, chronic pain is most commonly under-treated by physicians who are unaware of the wide variability in natural opioid metabolism in the chronic pain patient population as a whole. These are facts, not suppositions, well supported by published medical literature.
In this context, the March 2016 opioid prescription guidelines released by the US Centers for Disease Control and Prevention have proven to be an unmitigated disaster for chronic pain patients, and in fact contribute NOTHING to reducing overdose deaths. Doctors are being driven out of pain management practice all over the US. Thousands of chronic pain patients have been dumped “in the street” without referral and often without support for opioid withdrawal symptoms and greatly increased levels of agony. Whole areas of several US States (notably but not exclusively Montana, Tennessee and Kentucky) now lack any pain management center. Published stats from the CDC reveal that as numbers of prescriptions have dropped, deaths from street drugs like heroin, diverted methadone, and synthetic fentanyl have risen — an effect which is not accidental.
Compounding this debacle, we now know that the methodology used by the CDC guidelines consultants writing team was deeply influenced by unacknowledged anti-opioid professional biases among the writers. When literature was reviewed to assess the effectiveness of opioids, non-opoid medications, and behavioral therapies, the reviewers cherry picked the studies allowed to contribute as “evidence”. They rejected any study of opioids that lasted for less than a year — but did NOT similarly reject studies of alternatives.
As noted in the journal Pain Medicine, [ref: Pain Med (2016) 17 (11): 2036-2046], “To dismiss trials as “inadequate” if their observation period is a year or less is inconsistent with current regulatory standards… Considering only duration of active treatment in efficacy or effectiveness trials, published evidence is no stronger for any major drug category or behavioral therapy than for opioids.”
The only ethically and medically sound way forward from the present horrid misdirection of US government policy on opioids is to immediately withdraw the restrictive CDC guidelines and stop their implementation as mandatory in medicare and medicaid reimbursement standards. Rewriting should be led by board certified pain management specialists rather than addiction psychiatrists, and chronic pain patients or advocates should be voting members of the writing team.
I would love to see someone in the DEA and CDC have Arachnoiditis and not given the right medication and correct dosage to control the pain this wicked disease gives you. There are very very few doctors that know how to treat this disease because it crosses multidisciplinary areas. So we end up going to a pain mgmt. doctor who is afraid to give me the high dose of medication(s) to control the pain. We are NOT drugies! The pain is so severe, if I(we) can’t get the medication the suicide rate WILL go UP.