2017: The Year of Thinking Magically

2017: The Year of Thinking Magically

By Ed Coghlan

1.1 Billion dollars has been set aside by the Obama administration for the purpose of addressing the abuse of heroin and prescription drugs which have contributed to an ‘epidemic of overdoses and deaths.  Data from the Centers for Disease Control and Prevention (CDC) indicates that opioids — a class of drugs which include prescription pain medications and heroin — were involved in 28,648 deaths in 2014, an increase from 2013.  Drugs of abuse include heroin, synthetic opioids such as fentanyl, and prescription drugs that have flooded streets through illicit and aftermarket sales.  These statistics are muddied by CDCs acknowledgment that counts in some cases are duplicated, and that sources of supplies are not always attributable to prescriptions written by physicians.

The President’s FY 2017 budget takes a multi-pronged approach to address this epidemic.  First, it includes new mandatory funding over two years to expand access to treatment for prescription drug abuse and heroin use.  This will be used for expansion of state programs designed to address opioid use disorders which have a specific diagnostic code in DSM-V-TR that excludes persons receiving treatment for chronic pain from this definition; expansion of the National Health Services Corp to support persons with substance abuse disorders; funds to reduce barriers to entry into services, and, funds for analysis of program effectiveness.

What is missing from this approach? Funds to address the distinct need for research into effective continuation of treatment protocols for persons who suffer from the more than 200 readily identifiable health conditions that generate chronic pain syndromes are strikingly omitted from this budget.  While a mention of CDC’s effort to implement guidelines for primary care support to persons with chronic pain is given a nod, in fact there is no mention of funding for the need for medical education of health care professionals, continuing education for practitioners currently in place, and no mention of the fact that skilled treating providers with broad skills across disciplines are needed particularly in rural areas where integrated services are largely absent.  CDC’s proposed guidelines offer no force of regulation to mobilize funding for the expansion of alternative approaches to include technology, telemedicine or integrated alternative medicine.  Counseling and complementary approaches to care remain unaddressed despite their potential complementary effectiveness for persons who are disabled by chronic pain syndromes, the elderly, or those who lack transportation to care.  This is a serious oversight of the needs of this population which the addiction and diversion model fails to support.

According to the National Institutes of Health (NIH), one in five adults over the age of  45 sustains a diagnosis of 2 or more serious health conditions, and after the age of 55, the number of health related conditions increases to an average of 5 or more.  ‘Safe communities’ means not only removal of illicit drugs from the streets – it also means health prevention services, and assurance of the appropriate patient selection and treatment of patients who require a continuum of integrated care supports.  These supports include the medication management of chronic pain, which may be co-morbid with other health conditions.  While this population may be ‘at risk’ for substance abuse disorders, they are far more vulnerable to the effects of polypharmacy, drug-drug interactions, predatory pain management practices, and poorly designed medical interventions in communities that lack providers.  Placing the focus entirely on opiates ignores the forest for the trees and misses a large opportunity to understand the nature of the problem we can readily observe – which is not limited to opiates, but is rooted in a reaction approach to health care.

There is no evidence that the proposed guidelines under development will improve the way opioids are prescribed or help providers offer safer, more effective chronic pain treatment, while reducing opioid misuse, abuse and overdose.  We seem to have fallen victim to the notion that doing something, anything, is better than nothing.  But, given the current state of advancing state legislation which incorporates these proposed guidelines, we may well continue to see a large treatment gap continue to grow.  Without federally directed intervention in the training and support of primary care and specialty physicians and oversight through evaluation of outcomes, we may be hard pressed to understand how effective these guidelines actually are.

Persons with chronic pain are generally responsible users of medications.  All of the statistics available indicate that fewer than 3% of the more than 100 million persons who rely on opiates graduate to abuse of their medications.  The majority of physicians strive to be responsible in their conduct – there is no reliable indication that physicians are abusing their obligations for stewardship.  Throwing all of the nation’s resources into expanding a model that emphasizes addiction reduction fails to account for one very simple fact –  that addiction is largely rooted in conditions associated with culture and the social indicators of health care.  The 2017 budgeted interventions attack personal behavior, not the root causes of addiction or the injury and disease processes that install chronic pain disorders.  Regulating personal behavior is unlikely to result in cultural change – it never has, and it is unlikely that it ever will.

Santayana said, “those who fail to learn from history are doomed to repeat it.”  Are we really still so incapable of learning that we are engaging in the same conduct and logic over and over again – expecting a different outcome?  Isn’t that a form of “magical thinking”?

I guess it’s an election year.

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Authored by: Ed Coghlan

There are 11 comments for this article
  1. Red at 1:04 am

    “The President’s FY 2017 budget takes a multi-pronged approach…” When I first read that sentence, it took me a while to understand that “FY” meant “fiscal year.” I thought it stood for…something else, because I feel that is what the federal government is saying to pain patients generally.

  2. Richard Oberg M.D. at 5:43 pm

    Excellent response Carla Cheshire! You have a right to be confused!! The ‘muddled statistics’ Ed mentions from the CDC have been challenged multiple times by me for almost two years now and I’m glad they’re finally being acknowledged. Someone there has been playing games to inflate negative prescription drug stats for obvious purposes. I take exception to the first paragraph which includes heroin to inflate numbers from 16,235 to 28,648 and may be an opioid but most definitely is not a prescription drug. Media sources then take and embellish them further and before you know it wow – we have the most non-existent ‘epidemic’ no one’s ever experienced outside of media/government sources. Rest assured there will be plenty of hands out for that gov. money and none of it will benefit we that need help with our prescription meds. This is magical thinking just like prohibition was and it’ll have the same outcome. Unfortunately, the majority of us are just casualties along the way. As a physician I find it all repugnant.

  3. Cynthia at 7:13 pm

    Thank you for writing this, Ed. I have been writing to all my politicians for quite a while…I hope your article gets read by them. Especially President Obama. I just read the FDA article posted online today. It definitely has some hidden threats in it. And today, on CNN, a map was shown of the “heroin epidemic”. Half of the country, starting on east coast, was shown as being seriously affected. What a shame that responsible pain patients are caught-up in this national hysteria. I will keep reading and writing, not sure hat else to do.

  4. BL at 4:50 pm

    Has anyone read “FDA Unveils Sweeping Changes to Opioid Policies” that was in Medscape today (Feb 4, 2016) ? It does not look good for chronic pain patients. You have to read between the lines and not just the words that are said/printed, but what isn’t said/printed.

  5. Terri lewis at 4:46 pm

    At Carla, the Medicare drug database and pharmacy drug sales data bases indicate that many more than 8 mil opiate prescriptions were written in 2013 for persons with acute and chronic pain.some estimates are as high as 227 mil. The real numbers remain an estimate as there is variety in sales dAta collections from state to state. There are roughly 100 mil persons with chronic pain based on the IOM report in 1999. This population reported the use of analgesics of all types that incorporated opiates at least once. The actuals are unclear.

  6. Carla Cheshire at 3:46 pm

    I’m confused. You write: “All of the statistics available indicate that fewer than 3% of the more than 100 million persons who rely on opiates graduate to abuse of their medications.” Where did this 100 million come from? There are 350 million people in US, so this means that almost 28% of population are/were opioid users? 3% of the 100 million that rely on opioids are said to abuse them so that’s 3 million people.

    Then this is from: The Man-Made Opioid Epidemic: A 5 Part Series, by Mike Magee
    In 2013, opioid analgesics were involved in 16,235 deaths — far exceeding deaths from any other drug or drug class, licit or illicit. According to the National Survey on Drug Use and Health (NSDUH), in 2012 an estimated 2.1 million Americans were addicted to opioid pain relievers and 467,000 were addicted to heroin. These estimates do not include an additional 2.5 million or more pain patients who may be suffering from an opioid use disorder because the NSDUH excludes individuals receiving legitimate opioid prescriptions.”

    Statistics. What to believe. If indeed 100m used opioids and 16,235 died, I’d say that is very low. If 2.1m Americans are addicted out of 100m that’s low too, in my opinion. NSDUH claims opioids have little to no effect on relieving chronic pain. I wonder how many chronic pain patients they have interviewed? Since there are virtually no studies on opioid use >1year I’m uncertain how they make this claim. In my own situation opioids are the most effective way to live a more normal life with the pain I have– every day. Nothing else has worked as well and believe me I’ve tried many approaches. I add that I am on the same dosage for 10+ years. I know many other chronic pain sufferers that agree.

    On another note: In 2013 there were 21,175 suicides by gun. That’s more deaths than by opioid overdoses yet where is the outcry about this? I just don’t understand.

  7. BL at 2:56 pm

    The Affordable Care Act has a section that addresses research into chronic pain, but nothing is said about funding. Without funding, words mean nothing. It can be written into the law. as it is with ACA, but without a way to pay for it, it won’t become a reality.

  8. DAve at 1:40 pm

    Ed- well written and insightful article. I know it must be a challenge to continue to follow news in pain care as it is often not pleasant news.
    I hope people in pain will realize that it is up to them to call for needed reforms as it is clear our institutions cannot get pain care right.

  9. Kristine (Krissy) at 1:19 pm

    This “missing” part that doesn’t even acknowledging the number of people in pain (many of whom include that opioids are the only armor of defense they have against their pain), is getting quite tiring. Everything I read, every candidate for President says, the same thing. It’s almost as if there is a script up there in the cloud that is quoted without thought or research. Patients such as me and my patient friends online are really isolated from this wall that has been built by the government and the anti-opioid groups. Look around and it’s easy to see that people are simply suffering! Our healthcare system has been brutally interrupted by a one-sided mindset.

  10. Celeste Cooper at 12:42 pm

    While this population may be ‘at risk’ for substance abuse disorders, they are far more vulnerable to the effects of polypharmacy, drug-drug interactions, predatory pain management practices, and poorly designed medical interventions in communities that lack providers. Placing the focus entirely on opiates ignores the forest for the trees and misses a large opportunity to understand the nature of the problem we can readily observe – which is not limited to opiates, but is rooted in a reaction approach to health care.

    I couldn’t agree more. Why are these folks not reading the drug-to-drug interactions on the “new designer” drugs used to treat pain – alternatives to NOT prescribe opioids can come at a much higher cost. How many unintentional deaths are due to this exact thing? Why isn’t this equally important? Great article Ed. Thanks for keeping us enlightened regarding how our tax dollars are being spent.

  11. LouisVA at 9:27 am

    People, such as myself, that have tried everything and failed sometimes need access to opioids. My life is being lived now but if doses are capped, I’ll be back to a couch bound state. It’s my feeling that humans and the opium poppy evolved together for a reason.