Pain Treatment Becomes More Rational

I’ve spent 15 years treating addiction, mostly to opioids. I’ve worked in residential treatments, methadone programs. I have testified in cases related to overdose deaths. I know the harm that is possible from excess opioid precribing or use.

But I also hope that some day, pain treatment becomes more rational. I have worked for over ten years as an anesthesiologist treating chronic pain. Patients with severe chronic pain are some of the bravest people I know. Imagine waking up each morning to another day of suffering, knowing that things will only get worse as each day passes. Imagine waking up that way while knowing that some of your suffering could be relieved, if only the politics of opioid prescribing wasn’t stacked as strongly against you as it has been for the past 10 years.

The CDC published guidelines about the use of opioids in 2016. Many people and agencies fought those guidelines, including the American Society for Anesthesiology and psychologists who work with patients with severe chronic pain. But the guidelines were pushed very heavily, and somewhat secretly, by study authors and PROP, or ‘Physicians for Responsible Opioid Prescribing’. The guidelines were eventually adopted and had a chilling effect on the prescribing of opioids.

Hopes for rational pain treatments might be answered now that the CDC has reversed many of the 2016 guidelines. The CDC now says that they never intended to tell doctors how to practice; they were just giving ‘advice’. Some of the 2016 guidelines were grossly inappropriate such as limiting the appropriate morphine-equivalent dose to be used for pain. Even a first-year medical student understands the basic principles of drug tolerance, and knows that a dose that could kill one person may not be enough to reduce pain at all in another person. The 2016 guidelines also placed ‘recommended’ limits on duration of treatment. I say ‘recommended’ because that’s what the CDC is now claiming after years of civil and criminal prosecutions of doctors who didn’t follow those ‘suggestions.’ Thanks for the advice, CDC!

Under the new guidelines, the CDC acknowledges that doctors may know best in some situations, and treatment should be individualized. What a concept!

My anger over this issue stems from my experiences treating addiction after the 2016 guidelines came out. Almost every new addiction patient had the same history: “my doctor said he had to stop prescribing pain pills and I was so sick that I started buying them on the street.”

“He didn’t taper you??” I would ask.

“No, he just stopped them at my appointment. I was so sick, plus my (back, knee, shoulder, etc) hurt so bad I lost my job.” Lucky for those iatrogenic addicts most methadone treatment programs accept medicaid! Most of them are still patients there 6 years later, but that’s for another blog post.

We have learned some things since 2016. One of the study’s coauthors, Roger Chou, failed to disclose conflicts of interests that may have impacted his opinions. And the PROP docs had their own biases and conflicts. Did any of the PROP guys make the rounds on the opioid lawsuit circuit? Shaping anti-opioid guidelines in a way that might lead to a good paycheck… isn’t that the definition of a conflict?

The last time I paid attention to PROP was when the group was trying to push hydrocodone — a relatively weak opioid that doctors used to call in for people with, say, a kidney stone or a severe toothache– to Schedule II status, removing if from the doctors phone-call armamentarium for moderate to severe acute pain. I once considered joining the group but then learned of their severe positions and impact on practices.

Now the bias and conflicts in 2016 appear even worse than we thought. A recent article described how PROP was invited by Roger Chou to stack the deck during public hearings related to 2016 CDC guidelines about opioids. Organizations were each allowed one speaker, but Chou helped PROP get at least four speakers on the list, stepping over patients who wanted to describe the reality of living in pain. The panel heard repeated opinions in a coordinated effort to sway their votes, using time that could have been used by others with different opinions.

Why is an addiction specialist like me not on the side of the anti-opioid zealots? Many reasons. Just like generals always fight the last war, so do governments and government-funded societies. I haven’t admitted an opioid-addicted patient for years who described using oxycone, let alone hydrocodone. Pharmaceutical opioids disappeared 5-10 years ago, replaced by heroin and then fentanyl. Anyone who considers oxycodone diversion to be a threat has no understanding of what his going on out there.

And as I mentioned, I saw the sudden discontinuation of opioids after 2016 as the biggest reason for illicit opioid use and overdose deaths. Yes, there are always a few bad docs who prescribe for the wrong reasons. But we live in a big country. People in NY read about crimes in Dallas. Heck, I’ve seen cannabilism in the news (I live near Milwaukee) – but we don’t try to regulate it away!

I also disagree with the state prosecutions of pharmaceutical opioid manufacturers. It was great for the pension funds that politicians never funded. But people who watched a movie about Purdue blame them for all of the opioid deaths out there. Purdue sold about 6% of the oxycodone ever manufactured, and the rest came from generic companies. And while the general public thinks Purdue got all those doctors to mistakenly prescribe Oxycontin, most doctors know that pharmaceutical reps have very little impact on what they do. Addictiveness of opioids is related to the speed of onset and offset, and Oxycontin actually was less addictive. Just not after you hit it with a hammer!

I blame the doctors for overprescribing, not the companies that make the drug. Almost every company out there makes something that can be misused, from firearms to axes to automobiles. We don’t sue Chevrolet because the Corvette can go real fast. We go after the idiot who drives it incorrectly.

Largest on my mind are the people I’ve known who suffer from severe pain. The people I’m referring to have inflammatory arthritis, failed back, ankylosing spondylitis, or horrible accidental injuries. They have been on all of the usual meds like gabapentin, Lyrica, clonidine, muscle relaxants, Cymbalta, SSRIs and SNRIs, and what I consider the biggest fraud drug for pain, amitryptilline. They have been through injections and have implanted dorsal column stimulators, and they are still suffering. Opioids will not relieve all of their pain, but appropriate use will reduce the severity of the worse episodes. I try to help where I can, but the prescription drug database follows every controlled substance that a doctor prescribes, and warns if the provider is in a high percentile. The message is clear: prescribe too much and you’ll hear from us.

Almost as miserable are patients on buprenorphine after major surgery. I hear, over and over, from patients who were told ‘there is nothing I can do, you’re on Suboxone’. Now I try to take over the prescribing in those situations. It IS possible to provide analgesia after major surgery. If your doctors says it isn’t, ask him to look it up on my blog.

Finally, I know that there are better ways to treat pain, using opioids, that from my experience can greatly reduce the risk of addiction or overdose. I don’t have the time or energy to write case reports, but I’ve had dozens of patients do well after surgery with combinations of buprenorphine and oxycodone. In another era, pharmaceutical manufacturers would race to create a patch that weds buprenorphine and fentanyl, creating opioid analgesia without euphoric or addictive effects and less risk of addiction. Twenty years ago, an invention that spared millions of Americans from suffering might win a Nobel Prize. Now, it might bankrupt your family if people start sticking it in the wrong orifice.

Happy Saturday everyone. Don’t forget to vote.