How the Fed Used Opioids as Scapegoat

Games without Frontiers: How the Fed Used Opioids as Scapegoat & Diversion for the Nation’s True Crises – by Matthew Giarmo, Ph.D. – Sept 2018

Here’s a guy who lays it out as he sees it, remarkably similar to the view of pain patients. This could be because he took time off to take care of a family member with cancer – he saw firsthand the full destructive force of their pain.

EXECUTIVE SUMMARY

• The problem is not opioids. It’s heroin.
• The problem is not painkillers. It’s pain.
• The problem is not prescription. It’s diversion.

To all those sanctimonious crusaders, self-aggrandizing careerists, and shameless opportunists looking for a piece of the opioid pie, I say that you are more addicted to the opioid crisis than we are to opioids. 

Only 46 lives per day are lost to the class of opioids used to treat pain (CDC data).

Not 115.

When you factor out heroin, fentanyl, & methadone, it’s 46.

And 50% of these died because they took the painkiller with another substance.

Possibly alcohol. Actually, it’s usually alcohol. But it might also be a sedative like Ambien or a benzodiazepine like Xanax.

At this depth you are less likely to blame opioids and more likely to blame polysubstance use.

Right about now that 46 is looking a whole lot more like 23.

Now you are ready to know that an estimated 25-45% of those 23 people took opioids as a means to suicide. You know this — *I* know this — because the former President of the American Psychiatric Association knows this. Her guestimare comes from an extensive review of the literature. Oquendo is her name.

And we’ll blame depression.

Life in 21st Century America is a much better — much more efficient — explanation for the rise in overdose fatalities.

I’m talking about the fact some people get hooked on substances that relieve a broader socioeconomic brand of pain. Anxiety. Stress. Resentment.  Disappointment.

Some dose recklessly out of frustration with intractable pain. So now you’re thinking — why not blame the pain itself? Lord only knows what our number — at last count 17 — looks like now.

The Lord also knows that some of these painkillers were obtained by diversion, not by prescription.

Of those addicted to Oxycontin, 79% never had a valid script. So how can we blame the pain management and compassionate care enterprise for this.

So now you know. The real epidemic here is MASS HYSTERIA. The real CRISIS is STREET DRUGS, DIVERSION, CURRENT EVENTS, and PAIN.

Of those prescribed painkillers,

• only 8-12% develop a use disorder &
• OF THOSE only 4-6% turn to heroin.

THE FACTS MAKE A MOCKERY OF FEDERAL MEDDLING IN PHYSICIAN TREATMENT OF PAIN.

While scripts were declining 30%, heroin overdoses were busy rising 19%, as doctors forced to abandon patients drove them into the Street. To suicide. Or to clinics where the methadone is more deadly than the Rx painkillers

Our response to this “issue” constitutes a mental illness on a national scale.

PART I

Opioid crusaders (led by the attorney generals / FDA, CDC, and DOJ/DEA) overreached when they shifted their strategy from attacking SUPPLY (to the Street) to attacking DEMAND. Pharmaceutical houses are portrayed as cartels. Doctors as dealers. Chronic pain patients as addicts.

Over 4,000 physicians lost their licenses for over-prescribing. Many were able to reinstate them after gaining access to due process too late to salvage their careers.

An estimated 71% of pain patients had their meds reduced or suspended, some of whom have suicided or succuumbed to overdoses on what they procured on the Street. The Government & the doctors made it THAT clear they would never find anyone to write these scripts.

But the Fed had no choice. Politicians running for office or re-election promised grieving families no one else would have to suffer their fate, but the DEA has never been able to sufficiently disrupt the supply chain that floods the streets with narcotics.

The new tactic is a psychological defense mechanism of sorts. By going after domestic professionals and institutions, the Fed can appear in control for a change.

DEA officials also want to punish Americans for desiring narcotics and giving foreign natiomals the power they have over their agency.

The DEA feels it is finally targeting the real source of the drug problem … you.

Disingenuous also describes the lumping of all opioid casualties into one dumb sum designed to make a minnow of a problem look like a whale of a crisis.

60% of opioid deaths are heroin overdoses — and many of these involve heroin surreptitiously adulterated by counterfeit fentanyl.

Subtract those. Also subtract deaths in which the Rx painkiller was taken with another substance like alcohol or a benzodiazepine. Then subtract deaths in which the Rx opioid was used as the premeditated means to suicide. Subtract cases in which the decedent dosed recklessly out of frustration with intractable pain … or obtained the product by way of diversion rather than prescription.

…the Rx opioid cannot be blamed for deaths caused by an unregulated street drug, polysubstance use (another drug), depression, and pain itself.

Rx painkillers are not even gateway drugs to heroin. Not when only 8-12% of patients prescribed an opioid develop a use disorder and, of those, only 4-6% go on to eventually try heroin. But the gateway theory is critical to the Federal strategy. Without it, the Fed cannot justify its surveillance and meddling in doctor-patient affairs.

Truth be told, opioids are safer than most OTC products.

The FDA issued a black box warning alerting to widespread liver damage caused by chronic use of Tylenol in 1,000 mg doses.

Chronic use of ibuprofen causes stomach & kidney toxicity.

So imagine how disingenuous it must have been for the media to throw its support behind research showing that opioids are no more effective than OTC medication.

The study diabolically compared the MINIMUM dose of Percocet (5 mg) — seldom prescribed for severe or chronic pain — with the MAXIMUM dose of ibuprofen (800 mg) and acetaminphen (1,000 mg) that we know is unsustainable for chronic pain due to organ toxicity.

I described this study and found an unheralded conclusion: “Krebs Study” Shows Opioids are Safe

It’s easy to insist on a point of view when you and those you care about are not adversely affected by it. I imagine all these Senators who voted to move forward with the 71-bill anti-opioid package do not count any chronic pain sufferers among those in their inner circle — or for that matter their voting constituency. Then again, if and when the nation is sanitized of every last filthy Percocet, I suspect these Senators believe they’d be able to finagle a script for just about anything they want or need. They are the only people who don’t have to live with the consequences of their own votes.

There are quite a number of references to lawmakers needing to “get off their asses and do something.”

What HAVEN’T WE DONE? What MORE is there LEFT to do? Are you not aware the Fed sued 47 states for the right to install a database they can use to surveill doctors in real time and challenge their scripts?

My family member’s doctor tells her every time the DEA phones to complain about a script he’d written her. They complain about every one.

Are you unaware the DEA, armed with network TV camera crews, arrested and suspended the licenses of 4,000 doctors for “overprescribing” without due process or standards for what constitutes a “reasonable quantity”?

Are you unaware the FDA is trolling chat rooms and comment boards in search of the drugs patients plan to use when they can no longer get their scripts? Kratom, gabapentin, lamotil, and all benzodiazepines are on the hit list.

Are you unaware the DEA placed severe restrictions on what hospitals & pharmacies can stock.

Pain management contracts, up to 3 pages from 1, now stipulate a patient must use the same pharmacy to fill all opioids.

When the pharmacy is out of stock, it is prohibited from

(a) telling the patient over the phone,
(b) earmarking a new order for the patient,
(c) phoning the patient to signal arrival,
(d) transferring the script to another pharmacy, &
(e) splitting the script so the patient can claim the balance at a later date.

Are you unaware States have passed laws limiting new patients with acute injury diagnoses to 3 day supplies?

Are you unaware that the Fed is treating opioid manufacturers like cartels, physicians like dealers, and patients like addicts?

Are you unaware Federal guidelines recommend periodic and random urine screens by physicians of patients prescribed an opioid?

Are you unaware about the package of laws passed on every state? The 52 bills proposed by the Federal Committee on Commerce & Energy? The competing guidelines disseminated by the FDA and CDC and the efforts of State legislatures to vote on making the Federal agency guidelines State law? Are you aware the U.S. Senate is due to pass its own opioid legislative package within days?

Are you unaware physicians are required by law to review before each patient encounter that patient’s past opioid prescriptions in the prescription monitoring database?

Are you unaware hospitals have complained of morphine shortages after the DEA placed limits on the distribution and stocking of opioids?

Are you unaware there are plans to regulate the OTC anti-diahhreal Immodium like Sudafed because a few people have died while exceeding the recommended dose so the opiate will spill out of the intestine and into the CNS?

But yes, by all means, LET’S DO “SO MUCH MORE” BECAUSE CLEARLY WE HAVEN’T DONE ENOUGH.

The problem is that the Fed committed itself to reducing prescriptions by 30% per annum.

When you set public goals like this and make jobs and promotions dependent on this, you create a Wells Fargo like culture in which DEA agents are harassing doctors over the phone to into reducing scripts — and it does not matter to these agents whose scripts are reduced

The Fed is under pressure to develop Guidelines, to sell these Guidelines, and to enforce these Guidelines.

The problem is that the Guidelines are not evidence based.

They neglect the nuances and complexities of patients, patient care, and patient care financing.

The Fed immediately attempted to persuade assemblies to turn these Federal Guidelines into State laws. And with thess Guidelines still shy of legal status, the DEA is engaging prescribers whose scripts exceed these Guidelines as criminals.

Physicians will tell you there is no one-to-one correlation between the subjective perception of pain and objective conditions in the body.

In reality, this is due to individual differences in genetic sensitivity to pain and pain medication and to less than perfect technologies for measuring pain or identifying pain sources in a morass of bone, muscle, cartilage, & nerve fibers. But the McCarthyists view this statement as evidence of fraud (malingering, drug seeking) or mental illness.

We have all sorts of issues here they don’t have in Europe. Much of it boils down to a strange blend of what we are raised to believe as Americans. Like hedonists, we are taught that happiness is everything but as puritans we are also taught to shame and guilt ourselves for being happy. From birth we’re encouraged to dream big — to believe the sky is the limit here in the greatest nation on earth – and that we’ve no one to blame but ourselves for not achieving these dreams or living up to expectations.

The Calvinist in us tells us there are rules to living that decide who is entitled to happiness and when it really isn’t earned. These core beliefs / cultural underpinnings are a recipe for neurosis. Much has been made of the role of drugs and alcohol in self-handicapping so there is something other than oneself to blame for failure.

This is a Regulatory Age marked by the pursuit of best practices, protocols, SOPs, benchmarks, and compliance.

We have even set aside a week to celebrate it: National Regulatory Compliance Week. There isn’t a problem we don’t believe can be solved with a set of new laws, regulations, and authorities

For many persons, Rx painkillers are part of nature’s system of checks and balances. You get sick, well, the silver lining is temporary access to that wonderful cough syrup w codeine or hydrocodone. You get a terminal diagnosis like cancer, the silver lining is access to drugs that not only kill the pain but help salvage your normal life by restoring your energy and boosting your mood. Opioids are far more effective than antidepressants or antianxiety drugs at enhancing your mood — and they do so without sedation.

But opioids keep you happy & alert, which is why McCarthyists view it in the same negative light as sports purists view anabolic steroids. Conceptual pragmatism, Calvinism, and Puritanism are a large part of our American “DNA,” which explains why drugs are regarded as inherently evil.

They allow people to “steal” happiness who did not earn it within the rule structure. Feeling good is something we earn through building a respectable resume and being productive contributors to the “bottom line.” If we can feel good merely by popping a pill — there’s no incentive to live “the right way.”

Policies affecting vulnerable populations like chronic pain sufferers are created by hardy Type A personalities with robust constitutions — self-aggrandizing careerists who climbed into their current positions by burning more midnight oil than the next guy and by more stridently modeling / embodying the ideology of their department.

This is why you’ll never see an FDA/DEA/CDC Chief with a balanced philosophical view that accounts for the needs of pain patients. It’s systemically impossible

Are we in too deep to pull ourselves out? America is addicted to the opioid crisis. The Federal government is committed to defending billions in investments, which it does by making sure no one changes or adjusts the Narrative in any meaningful way.

Once the community of businesses and entrepreneurs catches wind of the Government-sponsored, Narrative-supported, emergency declaration (“Crisis” / “Epidemic”)-inspired pot of funds, it isn’t long before these venturers are hawking their socially conscientious innovations in venues like LinkedIn.

Journalists love to report on the latest company to “do battle with the opioid epidemic.” The promise of Federal contracts and insurance money has new mercenaries marching into the noble war.

For their CHRONIC pain patients, physicians will notate the script “PRN” or “as needed,” which means patients can safely within limits adjust the dose to match the intensity of the pain (e.g., 10 -> 12.5 mg). Unlike other medication, pain meds do not have a regular schedule because the timing, frequency, duration, & intensity of pain does not follow a schedule.

If you are a chronic pain patient, the whole notion of programming your medicine cabinet like the timers on your light switches seems absurd.

Even those for whom pot is the recreational drug of choice want a piece of the action. In the “Opioid Crisis” they see an opportunity to present cannabis as the “exit drug.” Some states are so gripped with fear over the new and somewhat doctored CDC statistics that they have bought in, introducing legislation that would actually substitute marijuana for Percocet.

This development offers the most poignant evidence to date of our mass hysteria.

The McCarthy Era tactics drove wedges between stakeholders across the health care enterprise. Doctors learned to fear their patients as well as the DEA.

I was able to get one doctor investigated by the State Department of Public Health for patient abandonment (withholding medication) even as this same doctor was being investigated by the DEA for over-prescribing. Sucks to be a doctor these days.

So why did the AMA go AWOL rather than defend its members against the modern day McCarthy Threat? Why do AMA executives act like Stockholm Syndrome cases?

I, too, would like to know why the AMA has allowed this erosion of medical care, allowing bureaucrats and politicians to override doctors’ medical decisions.

Pharmacists felt opioid prescriptions exposed them to risk and refused to fill until doctors made adjustments to the scripts or provided the pharmacist with additional information. Naturally the physician felt hassled and squeezed by these requests, often abandoning the scripts altogether (“fine don’t fill it”) or resenting the patient.

The exercise in alarmist hyperbole began when all these overdose casualties were lumped into one disgusting Auchwitz-style pile. Let’s review the bodies we piled in 2016.

On the pile we cast decedents that succuumbed to heroin (15,469) (29%), methadone (3,373) (6%), “opioids other than methadone” (a hotdog of a category that includes fentanyl & tramadol) (19,413) (37%), and finally the “natural/semisynthetic opioids” (e.g., hydrocodone, oxycodone, oxycontin) prescribed by doctors for pain (14,487) (27%).

The pills our doctors give us for pain account for less than 30% of all overdose deaths.

how many of you (still reading) still believe we should be throwing billions of dollars, Federal lawsuits against 47 states, stigmatization and intimidation of physicians and patients, and a whole lot of tension / antagonism among principals in the health care enterprise — to take granny’s vicodin away?

The headlines are dominated by 3 problematic drugs.

Heroin. Fentanyl. Methadone.

BUT THERE’S NOTHING WRONG WITH HYDROCODONE, OXYCODONE, & HYDROMORPHONE.

In the Fed’s Universe, the original target was the international drug cartel. When the DEA and the Fed became frustrated — distressed that for all the battles they appeared to win — all the drug busts and seizures — statistically the war remained at best a standoff for decades. People were dying. So without giving up on the idea of saving the People, the Fed decided it was high time to place the blame for the resilience of the cartels squarely on the shoulders of the People themselves

But recreational drug users proved as hard to neutralize as the cartels themselves, so the Fed needed another way to get to them — so they exaggerated and embellished the link between heroin and prior prescription painkiller use.

So the Fed harassed

• the community of chronic pain patients and the physicians who supplied them.
• And the pharmacists who supplied the physicians.
• And the distributors (e.g., McKesson) which supplied the pharmacists.
• And the pharmaceutical houses which supplied the distributors.

It’s a high reward, low risk strategy.

doctors would seem to have no voice in this crisis even as the nation’s cops made the crisis about prescription painkillers and the doctors who over-prescribe them ostensibly, if you believe the tin-foil wrapped conspiracy theories, in exchange for kickbacks from Big Pharma. And where is the AMA?

The Feds have traditionally tried to keep substancs use issues away from thought leaders in the health care mission space. As far as the Feds are concerned this is not a health care issue. This empowers Feds to censure medical professionals for their role in the crisis. As far as the Fed is concerned, this is a law enforcement issue.

If the Fed follows through on its intentions to replace my doctors with cops, I need to know now so I can brace myself for a less-than-stellar bedside manner