The civil war over prescription opioids – by Lynn Webster, MD – Dec 2018
The war is between science and fact versus PROPaganda and media hype.
Over the past 10 to 15 years, attitudes towards opioid use for pain have shifted dramatically. In the 1990s and early 2000s, pain relief was front and center on the newsstands and in medical literature.
During that time, compassion for people in pain increased and permeated our culture and opioids became standard therapy for chronic pain, because few affordable and effective treatment alternatives existed.
This is the factor too often ignored: there are few other effective options for chronic pain except opioids.
By the middle of the first decade of the 21st century, however, opioid-related casualties started to rise. When these deaths were attributed to increased opioid prescriptions for pain, tragic stories of ordinary citizens dying of opioid overdoses grabbed the headlines. Predictably, the United States public demanded a quick and easy solution.
Accordingly, many medical professionals changed their attitudes towards opioids.
They replaced their compassion for people in pain with a concern for those being harmed by opioids. It was reasonable to be concerned about people who were harmed by opioids. However, it shouldn’t be a binary choice.
If people want to harm themselves with opioids, they can turn to the street where opioids are cheap and plentiful.
Reports about opioids routinely focused on the people who overdosed, but they ignored why opioids had been prescribed in the first place.
This has been driving me crazy in all the research on opioids: opioids doses are measured and counted in isolation and the pain they were prescribed to treat weren’t mentioned. (see Opioids Blamed for Side-Effects of Chronic Pain)
In so many of those studies, you won’t even find the word “pain” anywhere.
People in chronic pain were mostly forgotten.
the Journal of the American Medical Association published an article last March titled, “Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial.” Subsequently, a firestorm of media articles appeared that misinterpreted the study and supported the anti-opioid narrative.
The Washington Post joined the fray when its Editorial Board responded to the JAMA article with a column titled, “Another harsh truth about opioids: They’re not a better way to manage pain.”
With this editorial, one more prestigious newspaper got the story wrong and hundreds of reports followed that continued to misrepresent the science about opioids. (I explained why these conclusions to the JAMA article are flawed in a Pain Medicine commentary).
A veritable war now exists between the needs of people in pain on one side and the popular crusade to limit — and even ban — opioid use on the other.
With the zeal of moral crusaders, most clinicians and policymakers fall into one of the two camps.
The Centers for Medicare and Medicaid Services (CMS) issued new opioid prescribing policies for Medicare drug plans that will take effect in January 2019. These policies were developed to curb over-prescribing, because some believe that overprescribing is the main contributing factor in opioid-related overdose deaths.
And they continue to believe this no matter what the actual evidence shows. Their public persona is based on “fake data” and so deeply invested in untruths, that they cannot correct their wrong-headed course.
The CMS policies are based on the CDC opioid prescribing guideline, which itself is based on weak research. Nevertheless, governmental agencies are experiencing enormous pressure to do something about the opioid crisis while ignoring those in severe pain.
Even worse is the proposal by the Oregon Chronic Pain Task Force to drastically limit access to opioids for Medicaid patients who have been in severe pain. This proposal would force doctors to reduce dose levels, regardless of the patients’ needs or the effect on their quality of life.
The proposed changes are inconsistent with multiple guidelines, including the CDC Guideline for Prescribing Opioids for Chronic Pain and the new CMS opioid prescribing policies.
Medical professionals have started to voice their concern.
Yes, they are finally starting to speak up after remaining silent as this shit storm brewed and grew for 2.5 years. If they’d spoken up right away when this biased and unscientific CDC guideline was released, these restrictions may not have been legislated.
I blame them, as the most intimately involved group, for their acquiescence and sometimes even collaboration with virulent anti-opioid zealots.
The scientific literature, media reporting and policymakers are all responsible for analyzing two things without bias:
- the root causes of the opioid crisis and
- the consequences any corrective policy might have on people in pain.
American drug policy is always reactive and shortsighted.
Unfortunately, none of the governmental interventions have turned the tide on overdose deaths.
In fact, evidence suggests that interventions, like the dose limits imposed by payers and legislators, have actually pushed abusers and patients to the street where the most dangerous drugs are found.
We can’t solve the war over prescription opioids by failing to treat the millions of Americans who suffer from chronic pain.
Unfortunately, by focusing only on the supply of opioids while ignoring those in pain, we will actually worsen a public health crisis that began when we, inspired by compassion, attempted to relieve pain.
Author: Lynn R. Webster M.D., is a vice president of scientific affairs for PRA Health Sciences and consults with pharmaceutical companies. Webster is a former president of the American Academy of Pain Medicine and author of “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.” You can find him on Twitter: @LynnRWebsterMD.