Doctors and pain patients: Conflict and collaboration

It seems more folks are starting to see that our current medical system and its methods have made doctors and patients into adversaries. Both initially assume the other isn’t truthful, is either maximizing (patient) or minimizing (doctors) pain.

It’s become a contest: patients want the pain relief opioids provide and doctors want to avoid prescribing them. Both parties have valid reasons for their views and both have valid reasons to distrust the other, a sorry situation for all fo us.

Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care – PubMed – free full-text /25261714/ – Dec 2014 

Forced Tapering of Opioids Ethically Impermissible

Is Nonconsensual Tapering of High-Dose Opioid Therapy Justifiable? | Journal of Ethics | American Medical Association – by Travis N. Rieder, PhD – Aug 2020

This case considers a so-called legacy patient, one whose behaviors and symptoms express a legacy of past, aggressive opioid prescribing by a clinician.

Some prescribers might feel pressured to taper doses of opioids for such patients, but this article argues that nonconsensual dose reductions for stable opioid therapy patients is impermissible because it both puts a patient at risk and wrongs an individual in a misdirected attempt to ameliorate a systemic wrong.

Although perhaps surprising, this argument is supported by current evidence and recommendations for patient-centered pain care. 

Pharmacies Sued for Discrimination Against Pain Patients

Pharmacies Sued for Discrimination Against Pain Patients — Pain News Network – by Pat Anson – Aug 2020

This is wonderful news, to finally push back against the anti-opioid forces aligned against us.

Class action complaints against Walgreens, Costco and CVS Pharmacy were filed in California and Rhode Island on behalf of two women seeking legal relief that will allow them to get their opioid prescriptions filled without delays or restrictions, and without the fear that their prescriptions will be denied. 

Pain patients in the U.S. have complained for years about pharmacists refusing to fill their opioid prescriptions or reducing them to lower doses. It’s also not uncommon for patients to encounter delays and excuses, such as a pharmacy claiming it was out of stock of a particular medication.  

DOJ Tricks Used in Prescribing Prosecution

DOJ Tricks Used in Healthcare Fraud and Prescribing Prosecution – by Ron Chapman II on twitter: @HealthcareDef – June 2020

This is a sickening view into the murky drug-war tactics that our doctors have to face any time they prescribe opioids for chronic, ongoing pain.

I have had the opportunity to represent hundreds of healthcare professionals facing scrutiny from the federal government for healthcare fraud and drug trafficking. From this perspective I have been able to see the evolving playbook utilized by the DOJ to prosecute physicians.

Here are ten tricks used by the DOJ to convict physicians and other healthcare professionals for charges of healthcare fraud and unlawful prescribing.  

Maximum Opioid Doses are an Abomination

Maximum Opioid Doses: A Pharmacological Abomination – By Josh Bloom — June 22, 2020

Despite irrefutable pharmacological evidence of the wide range in individuals’ metabolism of opioid drugs, states continue to impose “one-size-fits-none” laws.

It’s safe to say that no one is really paying attention to the science. So, here it is. Again.

The American Medical Association was two years late to the party when it issued its first statement (1) about the inappropriate use of CDC Guidelines to establish, among other things, laws that define a dose and duration limits for opioid analgesics. No one was listening. Since then things have gotten worse, not better, for pain patients.  

Congressional Letter Builder

Welcome to the Congressional Letter Builder Survey –  from “Your Voice Matters: make chronic pain visible” – 2020

Here’s a good idea to help us write the letters we want to write our legislators. It leads you through a series of statements about your pain and its treatment (or lack thereof) and you can use their 5 choices of “Strongly Agree” to “Strongly Disagree”, sand/or you can write about your thoughts or experiences in the text box below each statement.

We’re so glad you’re here! You are affecting policy decisions and influencing new areas of research. Your voice matters! Your responses will be combined with others and delivered to legislators.  Submissions… will be delivered on bi-monthly intervals.

To be effective, we estimate that 10,000 responses will be representative of how chronic pain affects people’s lives in the United States. Together we make a difference!  

Pain Patients Angry and Fearful about Govt. Interference

Charges against pain doctor reveal undercurrent of anger, angst among patients at federal government – cleveland.com – By John Caniglia, The Plain Dealer – Jul 2020

For more than 25 years, patients suffering in pain sought out Dr. William Bauer. They had crippling injuries from car crashes and work accidents, chronic headaches and debilitating spine issues. At 83, Bauer had a practice in Sandusky that cared for many of the same patients for 10 to 20 years.

Federal prosecutors have accused the neurologist of illegally prescribing thousands of opioid pills between 2015 and 2018. 

But realistically, “prescribing thousands of opioid pills” for pain patients is medically appropriate. These drug-warriors should do the math before they toss around meaningless phrases like this just to create drama.

Neuropathic Pain & Wind-Up Phenomenon

Managing Difficult Pain Cases: Neuropathic Pain & Wind-Up Phenomenon – WSAVA2013 – VIN – 2013

I was looking for information on the “pain wind-up” phenomenon and found this veterinary paper that explains it well – and without any special fuss about opioids, treating them the same as any other pain-relieving medication. What a refreshing change!

And with animals, there are no “biopsychosocial” factors to blame for increasing pain, so vets take it seriously and don’t just discount it as an attitude problem.

The options for analgesia are ever increasing as our understanding of pain physiology improves.

Yet for humans, there is still little understanding of chronic pain and few new treatments significantly different from the old. 

Illicit opioid use after loss of access to opioids for pain

Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLOS ONE. May 4, 2020.

Here’s a finally a study showing the potentially hazardous actions taken by pain patients when their pain relief is cut off. I’m surprised they found the same thing with increasing the dose – if anyone can think of an explanation, please let me know.

In a retrospective study of more than 600 patients in San Francisco receiving opioid pain relievers (OPR) for chronic, non-cancer pain, the researchers found that

• “[l]oss of access to prescribed OPRs was associated with more frequent use of non-prescribed opioids and heroin, and
• increased OPR dose was associated with more frequent heroin use.

In addition to being cautious with increasing OPR dose, care providers should consider the potential unintended consequences of stopping OPR therapy when developing opioid prescribing guidelines and managing practice.”

AMA recommends specific changes to CDC guideline

The full AMA letter and each recommendation to revise the CDC guideline – (continued from yesterday’s post)

…the CDC Guideline could be substantially improved in three overarching ways.

1. First, by incorporating some fundamental revisions that acknowledge that many patients experience pain that is not well controlled, substantially impairs their quality of life and/or functional status, stigmatizes them, and could be managed with more compassionate patient care.
2. Second, by using the revised CDC Guideline as part of a coordinated federal strategy to help ensure patients with pain receive comprehensive care delivered in a patient-centric approach. And
3. Third, by urging state legislatures, payers, pharmacy chains, pharmacy benefit management companies, and all other stakeholders to immediately suspend use of the CDC Guideline as an arbitrary policy to limit, discontinue or taper a patient’s opioid therapy.