Crash Course for Submitting Comments to CMS

#HPM Crash Course in Submitting Comments to CMS | Matthew Cortland on Patreon – Feb 2018 – by Matthew Cortland

Mr. Cortland gives excellent advice for the best way to write your comments on opioid policy. Though his words are aimed at Hospice & Palliative Medicine (HPM) clinicians, I believe many of us chronic pain patients have just as much knowledge and experience with this subject.

CMS has published their proposed changes to Medicare for 2019.

Here are the changes that, in my view, may be the most concerning to Hospice & Palliative Medicine (HPM) clinicians:  

1. Starting to crack down on opioid ‘potentiator’ drugs – like gabapentin and pregabalin.
2. Limiting opioids to 90 MME per day.
3. Making it more difficult for patients to fill two or more long-acting opioids.   

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DEA Raids Dr. Forest Tennant’s Pain Clinic

DEA Raids Dr. Forest Tennant’s Pain Clinic — Pain News Network  – November 16, 2017 By Pat Anson, Editor

Agents with the Drug Enforcement Administration have raided the offices and home of Dr. Forest Tennant, a prominent California pain physician, confiscating patient records, appointment books and financial documents.

In a lengthy search warrant, the DEA alleges that Tennant prescribed such high doses of opioid pain medication that his patients must be selling them.

So, the DEA got a search warrant based on their assumptions about his patients’ medical needs and their assumptions about what his patients are doing with their medication – no proof, no evidence, just assumptions. 

Opioid dose reductions have no effect on OUD rate

Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives. – PubMed – NCBI – August 2017

I found this evidence that opioid dose reductions are failing in their stated purpose of reducing the rate of Opioid Use Disorder (used to be addiction).

No studies have assessed the comparative effectiveness of guideline-recommended interventions to reduce risk of prescription opioid use disorder among chronic opioid therapy (COT) patients.

We compared the prevalence of prescription opioid use disorder among COT patients from intervention clinics that had implemented opioid dose and risk reduction initiatives for more than 4 years relative to control clinics that had not. 

Chronic Cancer versus Non-Cancer Pain

Chronic Cancer versus Non-Cancer Pain: A Distinction without a Difference? | GeriPal – Geriatrics and Palliative Care Blog – March 2016 – by Eric Widera, MD (@ewidera)

In 1824, Jeremy Bentham published the “Book of Fallacies” in which he criticized fifty arguments used in political debate and explained the sinister interests that led politicians to use them.

One of these fallacies he describes as the “sham distinction”, now known better as a “distinction without a difference“.

This logical fallacy appeals to a distinction between two two things that ultimately cannot be explained or defended in a meaningful way.    

Opioid Epidemic: 6 Charts Designed To Deceive

The Opioid Epidemic in 6 Charts Designed To Deceive You – By Josh Bloom — October 12, 2017

In this article, Josh Bloom eviscerates Kolodny’s arguments showing the unrelenting anti-opioid bias and disregard for opposing evidence.

Dr. Kolodny, a psychiatrist, is the executive director of Physicians for Responsible Opioid Prescribing (PROP)—a group that played a significant role in creating the disastrous CDC Guideline for Prescribing Opioids for Chronic Pain (2016).

The CDC ended up incorporating much of PROP’s recommendations, which were supposedly designed to help the US mitigate the damage done by opioid drugs, despite the fact that the “evidence” contained in the recommendations had been carefully scrutinized and found unsupportable by FDA scientists.  

From Cancer or Not, the Pain is the Same

Terminology of chronic pain: the need to “level the playing field” – Free full-text /PMC4734783/ –  Jan 2016 – John F Peppin and Michael E Schatman

This article, published in the Journal of Pain Research, makes it clear that there is NO biological/medical/physical difference between “chronic cancer pain” and “chronic noncancer pain”.

Pain medicine as a separate subspecialty is in its infancy, only fairly recently being recognized as such by the American Board of Medical Specialities. As it continues to find its way in the ever-changing world of medicine, terminology becomes an important consideration.

Terms carry tremendous impact: 

Suicides due to Opioid Restrictions

Perhaps you thought the warnings about abandoned pain patients committing suicide were hyperbole, but this phenomenon is  very real:

Partial List of Suicides, as of 9–10-17 , revised, related I personally believe, to CDC and “Physicians for Responsible Opioid Prescribing” who suggest responsible prescribing is no prescribing or reductions in prescribing pain medicines in 25 million non addicted medical patients in daily pain, all for a good reason they say, to prevent heroin addiction and death from heroin overdose. You decide.

I’ve only picked out a few from this long, sad list of patients who could not tolerate their painful lives without effective opioid relief. 

Less than 5% Risk of Opioid Use Disorder in Patients

Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain. – PubMed – NCBI –  2017 Mar

Here’s the main finding of this study:

Less than 5% of our study population
revealed any evidence of substance use disorder.

Objective. :

To examine the risk of developing aberrant behaviors that might lead to a substance use disorder (addiction) when prescribing opioids for the relief of chronic noncancer pain in primary care settings. 

People With Chronic Pain May Die Earlier

Why People With Chronic Pain May Die Earlier – Korin Miller – June 8, 2017

More than one in 10 Americans, or 25.3 million adults, suffer from pain every day, according to NIH data released in 2015.

Chronic pain seems to be just that—a serious pain—but new research has found that ongoing pain is associated with an increased risk of dying early.

For the analysis, which was published in Arthritis Care & Research, researchers looked at data from two large population cohorts of 50-year-olds.

They discovered that people who reported suffering from chronic pain had a nearly 30 percent increased risk of dying during the study.

It got worse as the pain became more intense:

People who said they had “quite a bit” of pain were 38 percent likely to die during the study, while those who were in “extreme” pain regularly had an 88 percent increased risk. 

Chronic pain linked to increased risk of dementia

Chronic pain linked to increased risk of dementia in study of older adults – Medical News Today – June 2017

This study gives us good reason to demand effective treatment for our pain.

Treat us for our pain now or for our dementia later.

Allowing a patient to remain in pain causes real physical and cognitive damage.

Opioid restrictions are hazardous to patients’ health

Researchers at UC San Francisco have found that older people with persistent pain show quicker declines in memory as they age and are more likely to have dementia years later, an indication that chronic pain could somehow be related to changes in the brain that contribute to dementia.