Opioid Moderation

Opioid moderatism and the imperative of rapprochement in pain medicine – free full-text /PMC6388760/ – byMichael E Schatman, Alexis Vasciannie, and Ronald J Kulich –  J Pain Res. Feb 2019

A brief history of the “prescription opioid crisis”

Although many have attempted to blame this crisis on a single cause, more thoughtful analysis has yielded numerous contributors to the onset and maintenance of the abuse crisis.

health insurance carriers’ decision to discontinue coverage of interdisciplinary pain management programs left physicians without the most effective means of treating chronic pain, resulting in the consequence of turning to increased opioid prescribing.

There are many in the pain community who will not acknowledge this dubious conjecture. I don’t really believe it either but will concede the point if it allows us to initiate a dialog with the “opposition”.  

safety issues associated with non-opioid pain medications such as non-steroidal anti-inflammatory drugs and acetaminophen may have further fueled opioid prescribing.

I’m glad he’s acknowledging that the non-opioid medications could have more hazardous side effects than opioids.

questionable industry behaviors such as kickback schemes, lucrative compensation for speaking as an incentive to prescribe, and promotion of off-label use have also been implicated as contributing to the prescription opioid conflict.

Other causes to which the prescription opioid crisis has been attributed include

  • unscrupulous physicians operating “pill mills”,
  • unrealistic expectations of patients regarding complete relief of pain,
  • state medical boards curtailing restrictions on prescribing opioids for noncancer pain.

I don’t know of any pain patient that expects complete pain relief. Over the course of years of pain, we learn this is impossible and are happy with anything that can reduce it by a few pain level points.

However, despite a lack of consensus, a recent analysis concluded that the prescription opioid crisis is over, replaced by an even more deadly epidemic of overdose deaths from heroin and illicit fentanyl and its analogs.

This is consistent with the United States Food and Drug Administration’s data, which demonstrate a decrease in total opioid sales (as measured by morphine milligram equivalents [MME]) every year since 2010.

Similar to the lack of consensus regarding the root cause(s) of the prescription opioid epidemic is that regarding the cause(s) of the precipitous decline in overall opioid prescribing over the past 8 years.

Efforts to curb the “prescription opioid crisis”

However, as the decade progressed, the published literature became progressively less balanced, and the pendulum began to swing more strongly toward opiophobia.

Prescribing guidelines of questionable quality were released by interventional pain societies, as they recognized an opportunity to increase their own market share of chronic pain patients by demonizing opioid analgesia.

Washington State’s Medical Director of workers compensation began his war on opioids in 2005, publishing a retrospective study in which he and his colleagues found a positive correlation between high-dosage opioids and overdose death in workers compensation patients.

In 2007, a group that he led developed an “educational” opioid prescribing guideline, followed by a “recommended” guideline in 2010 and an updated guideline in 2015.

Each iteration was more restrictive regarding its recommended arbitrary opioid limits or “triggers” than the previous one, and was based on “consensus” rather than “evidence”.

This is exactly what I noticed too: there was so little data and what data there was, was of  low quality – not enough evidence to make

Although these guidelines were promoted as “voluntary”, their “chilling effect” resulted in widespread fear among Washington physicians, thereby reducing prescribing

As soon as the 2015 Washington State guideline was published, many of its authors began working with the United States Centers for Disease Control and Prevention (CDC) on its 2016 guideline, which was also touted as “voluntary”.

However,“In fact, the CDC imprimatur makes it more likely that these guidelines become de facto requirements through adoption by state health departments, professional licensing bodies or insurers.”

Tragically, this is what appears to have happened, in state legislatures, state medical boards, and among both private and public insurers. State legislatures have already passed draconian legislation mandatorily limiting opioid dosing for acute pain, with no evidence of societal benefit.

All these opioid restrictions are completely without any evidence of benefit to anyone… and outcomes for patients are being ignored because all policy is focused only on milligrams prescribed.

This type of overreaching legislation may discourage some physicians from prescribing controlled substances altogether.

states are writing guidelines and laws that require prescribers to consult with a “pain specialist” in order to prescribe MME well below those recommended by the CDC guideline.

Perhaps one of the best known of such laws is that of Indiana, stipulating that after 3 months of a mere 15 MME, a “trigger” necessitating that prescribers alter their standard prescribing practices goes into effect

Unfortunately, anecdotally, patients in numerous states are being told by their physicians that they have to cut back their opioid dosages due to state laws requiring them to do so, which is inaccurate and disingenuous.

I’ve heard about many people whose doctors have told them the opioid reductions are due to “the law”, which is either a lie, a gross misunderstanding, what they were told by their employers, and/or a way to deflect blame for going against medical ethics and leaving patients to suffer.

Health insurers, on the other hand, are indeed mandating hard limits on MMEs for chronic pain, and this is causing considerable distress.

Although initially, some states’ Medicaid programs focused on limiting short-acting opioid units, the recently proposed law in Oregon essentially eliminating Medicaid coverage for any chronic opioid therapy for chronic noncancer pain is particularly oppressive.

Another health insurer/health care system that has mandated harsh decreases in opioid use over the past year is Veterans Affairs (VA) Medical Centers.Between 2012 and 2017, 99% of all VA facilities reduced their percentage of patients to whom opioids were prescribed.

While the VA has attempted to counteract the impact of this substantial reduction by developing interdisciplinary chronic pain management programs, limited funding has allowed for the development of only a small number of them, resulting in numerous veterans receiving inadequate analgesia with no adequate substitute treatment available.

a 2018 formulary change by Cigna has demonstrated that private insurers are now in the “business” of reducing opioid prescribing. Cigna switched its “preferred” brand of abuse-deterrent extended-release opioid to a newer drug, with a deal with the new manufacturer to encourage physicians to prescribe lower dosages of the medication that became a preferred drug on the formulary.

A primary result of what has been both an evolution and a devolution in America’s opioid policy has been increased suffering for many for whom there are no other accessible options for their chronic pain other than opioid analgesia. For many years, the plight of these patients was ignored, with an emphasis on the far “sexier” “opioid epidemic”.

However, well-respected academicians have been exposing the impact of the “opioid pendulum” on pain patient well-being over the past several years, with progressively more papers on the “new opioid crisis” of opiophobia being published.

numerous articles on the topic have been written not only by pain specialists but by other health care professionals, including addiction medicine specialists and bioethicists.

 Mainstream media has finally begun to recognize the plight of patients with pain, with the number of articles written on the gravity of the situation progressively increasing.

It’s been encouraging to see more mainstream media covering the horrendous fallout of these brutal and ineffective restrictions.

Elizabeth Llorente at Fox News wrote a 4-part series about our plight in 2019:

  1. Without pain relief, patients driven to despair and suicide
  2. Doctors struggling with crackdown on prescriptions
  3. Solutions for Consequences of Opioid Rules
  4. Leg Amputation and No Opioids Afterward

She also wrote:

I didn’t expect to find an ally at Fox News.

However, opiophobia – as practiced in academic and community medical centers – continues to increase in scope and severity, thus promoting the passage of even more draconian legislation and the insurance industry’s further limitation of access to opioid analgesia to patients for whom there is no other adequate and accessible option.

As a result, the plight of patients with chronic pain is at a modern-era height of severity, with no sign of the end of the “war on opioids” in which patients are the “collateral damage”.

Solving the dilemma

The remainder of this essay will focus on several strategies that will be imperative if the plight of the patient with chronic pain is to be eased. Doing so will require a widespread acceptance of “opioid moderatism”, which seems to be a stance that few in the pain world (patients, physicians, insurers, and legislators) are willing to consider.

Rapprochement

As has been discussed above, the “opioid wars” between those who are “anti-opioid” and those who are equally “pro-opioid” have resulted in patients with intractable chronic pain becoming the collateral damage in the conflict,

with the extent of the damage seemingly devolving from patient suffering to the tragedy of overdose deaths due to patients involuntarily tapered from prescription opioids seeking stronger, illicit opioids.

A review of social media, particularly Twitter, indicates a progressively harsher level of discourse between patients with pain along with pain patient advocates and those that they perceive to be the cause of their suffering.

I don’t know why he doesn’t just come out and say it: all these restrictions are due to people who abuse opioids (usually illicit, not prescribed) and overdose. That’s just a fact.

Pain patients are being forced to give up their opioid pain relief. That’s also a fact.

When you’re in so much pain so consistently that it impacts every aspect of your life so severely that you’re considering suicide, it’s perfectly understandable that you’d have little sympathy, empathy, or compassion for the kind of person who’s behavior started the chain of events that resulted in your misery.

Key opinion leaders can be found on both sides of the “opioid argument”, and seeking a middle-ground together will likely to be essential in creating a national opioid policy that focuses on opioids not as a first-line treatment of chronic pain, yet as a tool that society cannot afford to eradicate from providers’ pain management armamentaria.

Summary and conclusion

As is far too common in American society, efforts to identify the primary culprit for the crisis of the past have focused on individual players and policies rather than recognizing that it was due to an unfortunate confluence of factors.

As the perhaps unintended consequence of the 2016 CDC guideline, opioid analgesia runs the risk of essentially being legislated away.

Even this respected doctor knows the consequences of the guideline were quite intentional, but he can’t say that so he just writes “perhaps”. Still, this validates what we’ve suspected all along.

Furthermore, the process has contributed to the illicit opioid crisis that is resulting in considerably more mortality than was ever due to prescription opioids.

Accordingly, we posit that draconian laws and policies of legislative and regulatory agencies need to be replaced by increased prescriber responsibility.

But prescriber responsibility, as it pertains to opioids, has been expanded to include the future overdoses of their present patients.

In California, if a patient for whom they wrote even a single opioid prescription ends up overdosing on any opioid up to 5 years after being treated, the doctor is considered responsible.

See California’s Death (of Sanity) Certificate Project

3 thoughts on “Opioid Moderation

  1. Kathy C

    Cui Bono, Who Benefits, is the big question.

    Our local media turned to in content marketing or alternative treatments. They also in content advertising for pain clinics, including one at a university. At the same time they continued to stigmatize and .demean not only people with pain, but people with addiction problems. The reason we don not have affordable housing, even though the homeless are on every street corner, panhandling, is “drugs.”

    Since day one they viewed this societal problem as a marketing opportunity. Our state legalized medical marijuana, and the marijuana industry used the same deceptive marketing techniques to market their expensive products. Marijuana sounds a lot more palatable, when compared to the horrors of opioid addiction. In order to sell more marijuana, and give the public the idea that marijuana should be legalized, they attacked people with chronic pain. It was more attention getting and increased sales of medical marijuana. https://marijuanastocks.com/scientists-believe-that-legalizing-marijuana-may-end-the-opioid-crisis-in-america/ Of course science is a little more complicated than this.

    “In this study, researchers Jacob Miguel Vigil and Sarah See Stith saw how patients that were hooked on their pain medications slowly left them behind.”

    In their view all pain patients are addicts or users, and marijuana is safer than opiates. They refer to a small studies of self selected participants, who either were already using marijuana or open to it. Science tell us that it is more complicated than that, but the quest for funding and need for attention, require over stating the findings. Each of these articles has to re iterate the number of deaths, conflating prescription opioids with illegal street drugs. They include the scary opioid narrative. The researcher also forgot to mention that people enrolled in the study would have been shamed for refilling their opioid prescriptions or told by their physician they need to cut back or taper. At ever office visit, required in this state, they would have been Gas Lighted about their pain.

    The FDA and FTC were supposed to protect the public from deceptive health advertising, now as long as there is a “public health message” such as “opiates are bad” or “patients are addicted” they can make any kind of false claim. Due to this misleading marijuana advertising, state policy makers , with no background in science or medicine, believe that marijuana is a replacement for opioids. The state allowed marijuana for Opioid Use Disorder, which according to these “researchers” is any patients with intractable chronic pain, and any random person addicted to street drugs, like heroin and fentanyl.

    We live in the land of alternate facts, where marketing lies and propaganda are more important than facts and science. This state had a serious heroin addiction problem, even before the so called opioid crisis. 22 years out and they are no closer to an answer. The media is complicit, creating false narratives about both pain and addiction as they avoid any information on outcomes. They used the so called opioid epidemic to not only market false cures, but to hide the reasons behind the American epidemic of despair.

    Liked by 2 people

    Reply
    1. Zyp Czyk Post author

      I agree with you about marijuana because it never helped my pain either. Sure, it helps with some of the mood problems chronic pain causes, like the hypersensitivity and irritability that can make my life miserable, but has no effect on my pain levels. I’ve heard from a few pain patients that it really does work for them, but that certainly doesn’t apply to everyone. Ideally, we should all be allowed to experiment with anything that has a chance of helping our pain and then pick what’s effective for *us* – no mater what is helpful for *other* people or, worse yet, the mythical “average patient”.

      Liked by 1 person

      Reply
  2. GZB

    So much talk about *new* alternative therapy! I’ve said it before, but it’s worth saying again. None of these therapies are new. Those of us who have been dealing with intractable pain know full well that they don’t work. After at least 100 injections I think I’m knowledgeable on their effectiveness. I’ve had all the other alternate therapies with no meaningful success. I’m willing to try new treatment, but for heavens sakes, don’t take away the only thing that works!

    Liked by 1 person

    Reply

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