Lessons from ‘Prescription Drug Diversion and Pain’

Lessons from ‘Prescription Drug Diversion and Pain’ — Pain News Network – September 28, 2018 – By Roger Chris

The new book“Prescription Drug Diversion and Pain” is a textbook treatment of pain management and drug policy amid the opioid crisis.

Written and edited by experts, the book is a scholarly, rigorous and evenhanded examination of the benefits and burdens of opioid pain medication.

Each chapter is written by specialists who address a particular aspect of the opioid crisis, with extensive footnotes justifying every statistic and claim. Much of that data, however, is admittedly flawed.

“As we show in this book, essential data about opioid abuse, morbidity, and mortality are lacking and what little data we have are derived from flawed and obsolete government databases,” the authors note in the preface.

See also: The CDC’s Math Doesn’t Add Up: Exaggerating Death Toll and The CDC Is Publishing Unreliable Data

“Yet, these resources are relied upon for public policy development, resource allocation, and lawmaking.

In the absence of sound data, ingrained cultural feelings about addiction can become a powerful driver of attitudes, even among pain specialists who, despite their professional training and experience, may be influenced by such bias in their prescribing practices.”

The first chapters look at the history, regulation and monitoring of opioid prescriptions, and attempts to defuse the bias often associated with them:

“These medications are neither good nor bad absent context, despite the public tendency to oversimplify their use and mischaracterize their utility.”

The origins of the opioid crisis are given due consideration. Rising rates of opioid prescribing are recognized as one factor, but drug diversion in the supply chain is also acknowledged:

“There is evidence that thefts from hospital and pharmacy drug supplies, as well as in-transit thefts from manufacturers and distributors, may also be a significant source of diverted opioids.”

It’s impossible to have so many prescription opioids available illicitly if the only source is filled presciptions, even if many of those were fraudulent. The availability is far greater than can be explained by individual prescriptions of 60, 120, or even hundreds of pills, for multiple people for multiple months. Those numbers still don’t correlate with how many are sold on the black market.

I’m certain that the greatest numbers of pills are diverted long before they reach a patient.

While individual patient prescription pills are carefully rationed out, counted, and recorded in the PDMP, there are no such controls for

• the folks transporting huge batches of pills from manufacturers  to their warehouses
• the folks working at warehouses where these pills are stored in bulk
• the folks transporting the pills to the distribution centers of the buyers (drug store chains)
• the folks unpacking and repacking bulk quantities into shipments to individual stores

I don’t understand why these folks haven’t come under greater scrutiny and why the media shys away from reporting such huge thefts. This can partly be explained by the distributers’ reluctance to publicly admit to thefts under their watch.

I wonder how many times such cases have been hidden from our view as the false narrative about pain patients causing the “opioid crisis” goes on and on.

Close attention is given to the issue of overprescribing and doctors who are “careless, corrupt, and compromised by impairment.”

But the book is also critical of the theory – expounded by the CDC opioid guideline – that reducing the number of prescriptions will help solve the opioid crisis:

“Government databases for tracking nonmedical drug use and related health consequences are obsolete and lack the sensitivity to show which drugs, by chemical name and product formulation, licit or illicit, are responsible for the increasing overdose deaths.”

Later chapters explore opioid prescribing in detail and echo many of the themes of the CDC guideline:

“Not every patient who complains of pain needs an opioid or is a candidate for opioid therapy. Opioids should be prescribed only when the benefit outweighs the risks. Functional improvement should be a primary goal, along with improved sleep and mood, regardless of the therapy used.”

I agree that functional improvement is the most important factor in pain management. When pain is reduced, function normally increases, but the amount of pain reductions is obviously not always correlated to the amount of functional improvement.

For instance,

• if pain is reduced from an incapacitating 9 to an almost equally incapacitating 8, there will be little outward improvement, even though the patient’s suffering will decrease.
•  If pain is reduced from 7 to 6, a person might be able to more of their physical therapy exercises.
• If pain is reduced from a 5 to 4, a person might not be more active but also not be as exhausted at the end of the day and be more pleasant to family members.

The book laments the loss of interdisciplinary pain management programs, starting in the 1980s. These programs provided “a safer and clinically more effective alternative to opioids [and] have also been empirically associated with reducing patients’ reliance on opioids.”

But the programs were costly to insurers and not profitable for medical facilities. Their disappearance “should be considered a contributory factor in the crisis of diversion and abuse and the associated destruction of lives.”

Here again, financial factors have an outsized influence on our medical treatment. If there’s no profit involved in a treatment, it will simply no longer be offered. In its place, we get profitable, but ineffective, schemes for non-opioid pain management like injections and surgeries.

Because misuse of prescription drugs and use of illicit drugs is not uncommon among chronic pain patients, such monitoring is recommended. But the book cautions: “Other clinical indicators are needed before determining if a patient is nonadherent.”

I take issue with the idea that the “use of illicit drugs is not uncommon among pain patients”.

Perhaps this would be the case when patients add unaproved therapies to their opioid regimen, like marijuana in states where it’s still illegal or illiciit opioids when a doctor isn’t prescribing enough. But I doubt this could be labeled as “common”.

The book concludes with its key idea, that there are no easy solutions:

“Given the complexity of the practice of pain management, the ‘opioid crisis’ cannot be solved, nor can conditions for pain patients be improved, using only simple and direct approaches: one medication, one regulatory policy, one law, or one injection will not be the answer for our chronic pain patients.

The government’s crackdown on drug companies and others in the pharmaceutical industry has had a negligible effect on reducing the morbidity and mortality resulting from the abuse of opioids.”

In other words, the opioid crisis and pain management are sufficiently complex that simple approaches are bound to fail. We need smart approaches.

Author: Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of theEhlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.