Treating America’s Pain: Unintended Victims of the Opioid Crackdown, Part 3 – The Solutions
Solutions are obvious (rewrite CDC Opioid Guideline), but there’s just no political will to reverse course.
It looks like this Titanic will have to sink before anyone dares make corrections. Pain patients (like passengers on the Titanic) will just be sacrificed before we eventually see progress.
The government has addressed the overdose epidemic with an aggressive focus on reducing prescribing practices, which has unintentionally led many doctors to cut down or cut off their patients’ pain medications altogether.
This tactic has left many chronic pain sufferers undertreated, with some even contemplating taking their own life.
The government response to the epidemic… has also set off alarm bells for many of the millions of Americans with chronic pain who legally take opioids, under their doctor’s supervision, and are suffering a range of unintended consequences that have left them undertreated, ignored, and desperate for alternatives.
The root of the problem, according to dozens of pain patients, doctors, scholars, and others who spoke to Fox News for this story, are the Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing that were issued in 2016.
This makes me think of the phrase “the root of all evil…” and it seems appropriate here, considering the horrific consequences for all the suffering and suicides of pain patients.
While the guidelines are credited with focusing attention on prescribing practices, critics say they’ve been adopted by too many as hard and fast rules that must be enforced across the board, rather than serve their intended advisory purposes.
“We’re targeting the most vulnerable and sickest people who have been on opioids a long time,” said Dr. Stefan Kertesz, an addiction specialist and professor at the University of Alabama at Birmingham School of Medicine.
Striking the right balance between getting control of the overdose epidemic and protecting access to treatment that brings relief to pain sufferers is a public health imperative.
The failure to do so threatens to exact a heavy price on the tens of millions of Americans whose pain is severe and disabling, and who are not driving the drug overdose epidemic. [!!!]
It’s no longer about “threats”, but about an increasingly desperate situation of thousands of pain patients cut off from the medication that has made their lives bearable for years and decades (like me).
So what’s the solution? Medical professionals, patients and others familiar with the opioid crisis and the fallout from the government crackdown have offered a variety of ideas.
RESETTING CDC GUIDELINES
Many believe the most urgent need is to address misunderstandings about the CDC guidelines. Clinicians and health experts say the CDC needs to make clear, in a high-profile way, what the guidelines were – and were not – meant to address.
A letter signed by more than 300 health professionals, including former drug czars in the Clinton, Nixon and Obama administrations, calls on the CDC to examine the impact of the guidelines and publicly clarify them.
When hard-core experts, even those involved in the “drug war” all agree that the CDC guidelines were inappropriately written, publicized, and then weaponized, it’s time for the recent self-appointed “experts” to shut up and listen.
The letter said that because the guidelines do not offer alternative pain care options, “patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use. Others have experienced preventable hospitalizations or medical deterioration.”
CLARITY ON LEGAL PAINKILLERS
Many have acknowledged the need for better data about opioid use, on everything from the precise role that legal vs. illicit drugs have played in the national overdose crisis to more accurate information on the effect of dosage changes.
Over the summer, a U.S. Health and Human Services special task force on pain management formulated a draft report of recommendations for the guidelines and noted muddled data on deaths involving illegal opioids vs. prescribed drugs.
This is our worst problem: the CDC has been overcounting Rx opioid overdoses since the beginning, by lumping them together with heroin and other street drugs.
Additionally, they often counted an overdose multiple times, once for each drug found in the dead body. (See CDC Over-Counting Rx Opioid Overdose Deaths)
“The national crisis of illicit drug use along with overdose deaths are confused with the appropriate therapy of patients who are being treated for pain,” the draft report said. “This confusion has created a stigma that contributes to barriers to proper access to care.”
Federal data on overdose deaths generally do not offer specific statistics on how many involved patients who were prescribed opioids, though other data – such those compiled by states – indicate they account for a small minority.
In November, a data and software company serving emergency medical services, fire departments and hospitals, released national opioid overdose data based on approximately 15,000 records collected between January and October of this year, and found that 94 percent of opioid overdoses involved illicit drugs, with only 4 percent being prescribed.
But that hasn’t stopped political leaders from developing policies and initiatives around cutting prescriptions as well as the supply of opioids. Trump vowed to cut opioid prescriptions by 30 percent over three years.
And many state and government officials are boasting about opioid prescription reductions, giving a misleading impression, Kertesz said, that progress is taking place in the drug overdose epidemic.
Many medical groups and health researchers also are calling for the CDC to address the fallout – such as reports of pain patients suffering withdrawals — from misguided implementation of its guidelines.
There’s absolutely no reason the CDC cannot amend their corrupted guidelines now that the damage to pain patients has been clear for over 2 years.
I cannot understand why the agency is maintaining such a long silence after such a regressive policy disaster. Could they really be so afraid of admitting a mistake? Are they afraid of being sued for the fallout of suicides?
The American Medical Association (AMA) recently released a resolution critical of the CDC guidelines that said: “We urge the CDC to follow through with its commitment to evaluate the impact by consulting directly with a wide range of patients and caregivers, and by engaging epidemiologic experts to investigate reported suicides, increases in illicit opioid use and, to the extent possible, expressions of suicidal ideation following involuntary opioid taper or discontinuation.”
Richard Baum, then-acting director of the Office of National Drug Control Policy, said the dialogue about the opioid epidemic has been misleading.
“This is framed as an opioid epidemic. But when you look under the hood at the report of people who overdose on fentanyl and heroin, they often have other drugs on board – cocaine, methamphetamine, other pharmaceuticals,” Baum said. “So we have a multi-drug threat that’s complicated. It means people often aren’t using [just] heroin, fentanyl, they’re also using cocaine.”
LOOKING BEYOND DOSAGES
Health experts say the Drug Enforcement Administration (DEA) and state authorities must not be so narrowly focused on quantity and dosage when looking at prescribers who might require disciplinary action.
“No entity should use [morphine milligram equivalent] – thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guidelines for Prescribing Opioids,” according to the AMA.
when prescribers are targeted by authorities, sometimes they lose access to their patients’ medical records, and either are forced to stop treating them because they lose their controlled substance prescribing rights or their medical license through suspension or revocation. Often, their patients are left to scramble, with nothing to fill the void of a doctor taken out of commission, and an abrupt loss of a medical treatment plan.
Pain patient advocacy groups, and health care experts, say that authorities undertaking an investigation or disciplinary action must have a plan in place for patients who are under the care of such health care providers.
Health professionals also argue that regulators and law enforcement authoritiesmust stay in their lane, so to speak, and not interfere in the doctor-patient relationship in an effort to address the largely illegal opioid crisis.
“The key is to get the government out of medicine entirely,” said Dr. Kenneth W. Fogelberg, who specializes in obstetrics and gyneacology.
I’m surprised how long it took the AMA to protest this incursion on the medical domain that has been regulated to be treated only by medical doctors.
“Let the politicians and lawyers do what they do and let us practice medicine. We have licenses and DEA certificates and most of us know what we’re doing.”
MORE RESEARCH ON RISKS – AND BENEFITS
Most health experts agree more studies are needed on the effectiveness and dangers of opioid use.
Other agencies, such as the Department of Health and Human Services (HHS) and the Food and Drug Administration (FDA), are moving ahead with their own guidelines on opioid prescribing and pain management.
In August, FDA Commissioner Scott Gottlieb referred to the CDC guidelines as a commendable initial step, and said that his agency was working on developing evidence-based guidelines that would look at opioid prescribing.
In a rare acknowledgment of the depth of desperation among pain patients whose long-time opioid treatment had been abruptly cut down or cut off, Gottlieb expressed concern about suicides.
“In select patients and for certain medical conditions, opioids may be the only drugs that provide relief from devastating pain,” Gottlieb said in a statement on the agency’s website.
“We’ve heard from some of these patients, and listened carefully to their concerns about having continued access to necessary pain medication. We’ve heard their fear of being stigmatized as a person with addiction, and the challenges they face in finding health care professionals willing to work with patients with chronic pain.”
“Tragically, we know that for some patients, loss of quality of life due to crushing pain has resulted in increased thoughts of or actual suicide,” Gottlieb said. “This is unacceptable.”
So now the FDA says the use of the guidelines to take away pain medication is “unacceptable”, but he’s still not DOING anything about it.
RESEARCH INTO NON-OPIOID ALTERNATIVES
Stricter pre-authorization policies for prescription and non-opioid treatments, such as physical therapy, many times mean delays that leave patients in pain.
Several physicians told Fox News they’ve had to wait several days, or longer, for prescription pre-authorization.
They also said there is much more paperwork required now in connection to pain management, leaving more room for error and, by extension, more potential for red flags that could lead to disciplinary action.
Most people interviewed by Fox News agreed there should be a concerted move toward a multi-faceted, more comprehensive way to treat pain. And, they stressed, because severe, unrelenting pain can lead to anxiety and depression, mental health must be an important part of treating the condition.
Among the AMA recommendations was “Expand graduate medical residency positions to train in pain specialties including adult pain specialists, pediatric pain specialists, behavioral health providers, pain psychologists, and addiction psychiatrists,” and “expand availability of non-physician specialists including, but not limited to, physical therapists, psychologists, and behavioral health specialists.”
Dr. Daniel Alford, the associate dean at Boston University’s School of Medicine’s Office of Continuing Medical Education, is on a mission to ensure that the next generation of doctors are better equipped to make decisions about safe opioid prescribing.
A prioirty, Alford said, is to improve the patient’s quality of life.
But the approach won’t go very far if insurers won’t cover non-opioid or multidisciplinary treatments, health experts said.
“Insurance won’t pay for many evidence-based treatments,” said Michael Schatman, a clinical psychologist who runs Boston Pain Care, which uses an array of programs – including exercise, psychotherapy as well as prescription painkillers—to treat pain. “My program loses money every year.”
At Boston Pain Care, patients go through multiple treatments simultaneously.
Shatman claims it is more effective than the status quo approach, which often involves trying one treatment, perhaps two, which may not work. Often, patients are pressed to try different therapies, one at a time, until one offers some improvement.
And meanwhile the pain continues unabated, leading to more pain chronification.
“Sequential pain management is an incredible failure,” Schatman said.
This what step-therapy is, and it is designed to fail, and fail, and fail again, before an effective method is found.
“As long as we have a for-profit insurance agency, it’s not going to get much better.
We’re seeing the devolution of the profession of pain medicine to the business of pain medicine.”
This is a big part of the problem with healthcare in general: it’s all guided by profit seeing.
Capitalism may not be the best way for our country to manage the health of its citizenry (you know, the ones who are working themselves to the bone to create more “productivity” and boost the corporation’s bottom line.)