How Would Opioid Prescription Guidelines Read if Pain Patients Wrote Them?

How Would Opioid Prescription Guidelines Read if Pain Patients Wrote Them?

By Richard A. Lawhern, Ph.D.

Introduction

A CDC Guideline for prescribing opioids in chronic pain was published in March 2016.  It has become clear that this Guideline is generating horrendously negative results for both chronic pain patients and their doctors.  Many doctors are choosing to leave pain management rather than face possible prosecution by State or Drug Enforcement Agency authorities for over-prescription of pain relieving opioids.  Tens (if not hundreds) of thousands of patients are being summarily discharged without referral and sometimes without management of opioid withdrawal.  There are increasing reports of patient suicides.

Richard “Red” Lawhern, Ph.D.

Many professionals in medicine have published sharply critical reviews of the problems of the CDC Guideline.  Also of deep concern are proposals by the US Centers for Medicare and Medicaid to make the Guideline a mandatory standard for insurance reimbursement.   Many believe that the Guideline was deeply influenced by an anti-opioid bias on the part of key writers on the CDC Working Group which authored it.  Even more damaging have been revelations that medical evidence assembled in support of the work was manipulated to discredit opioid reliability and over-magnify risks.  As one group of medical professionals phrased the issues, the CDC Guidelines are “neat, plausible, and generally wrong.”   Inarguably, so also is most of the dominant public narrative on opioids and chronic pain.  As remarked in a widely viewed TED talk  on U-Tube, “Most of What You Think You Know About Addiction is Wrong.”

It is now clear that CDC Guidelines must soon be withdrawn for a major rewrite.  This is the only ethically and morally sound way forward.  The public narrative has become mired in an avalanche of hype, conflicting claims and financially self-interested posturing on the part of addiction treatment specialists, insurance company partisans and pharmaceutical company marketers.  Especially important in any rewriting process must be the inclusion of stakeholder voices that were largely unheard in the first writing of the Guidelines.  Chronic pain patients themselves should be among this list, as should board certified pain management specialists active in community practice outside hospitals.

It is thus appropriate to ask what pain patients might write if they were tasked to revise prescription guidelines themselves.  The following is not a “standard” of medical practice. The present state of validated medical evidence is inadequate to produce such a standard with reliability.  This summary of principles is instead, a good faith effort to capture both the state of medical evidence and the experience of many thousands of patients who support each other online and in social media — too often in the absence of support from medical professionals and government policy communities.

Guidelines on Prescription of Opioids in Chronic Pain

  1. There should be no distinction in principle between the objectives of treating pain which is acute, chronic, or associated with advanced medical conditions assessed to be terminal. The objectives in all three cases are to alleviate suffering, promote patient functioning and improve quality of life.  In this sense, treatment of pain is always “palliative”.  To deny treatment of pain when effective means exist to manage it, is a fundamental violation of human rights.
  2. In the practice of general medicine, prescription opioids are not considered to be drugs of first choice in the control of long term pain. Opioids are more frequently used with moderate to severe acute (short term) pain associated with injury, surgery or dental procedures, where pain is expected to resolve in a few days. When prescribed for periods over 60 days, opioids are most often used for pain that is found by a physician to be unresponsive or intractable to other therapies. In the context of chronic pain and palliative care for terminal conditions, managed access to opioid prescriptions is indispensible at the current state of medical knowledge.
  3. Insurance organizations and some State legislatures have placed increasing emphasis on STEP (fail first) therapy as an alternative to opioids or surgical interventions and as a measure of cost control. However, the potential benefits of such therapy must be explicitly weighed in each patient, against the risks of disease progression and development of more intractable pain.  Likewise needed is a thorough review of the outcomes of interventional spinal surgeries and injections, to establish for what conditions such procedures are most likely to be effective and with what long term medical risks to patients.
  4. In opioids as with any other medications, best medical practice is that treatment should be accomplished with the minimum dose that is effective and for the minimum duration appropriate for the intended purpose. In acute pain associated with injury, surgical or dental procedure, this may mean that a maximum of seven days medication is initially prescribed, in doses and of types deemed adequate for the patient to sleep and to function in daily life.
  5. The experience and training of individual physicians are centrally important in determining appropriate types and strength of medications. However, provision must also be made for integrating patient reports, particularly when pain control is experienced as inadequate. Extension of an opioid prescription for acute pain must be founded upon the prognosis for full resolution of the medical issues which prompted the prescription.
  6. Treatment of pain in America takes place in a social environment where addiction to opioids and overdose deaths involving them as contributing factors are a major public health issue. There is widespread concern that unmanaged or casual availability of opioids may lead many people to become addicted, no matter what the “source” of such drugs may be.  While ready availability of prescription opioids before 2010 may have contributed to their diversion by adolescents or by addicts shamming pain, evidence from a Cochrane Review in 2008 suggests that risk of addiction in patients who have no previous history of opioid use is very small – possibly less than one percent.  Opioid overdose deaths in 2016 were dominated by street drugs (heroin, fentanil illegally imported from China and Mexico, methadone diverted from treatment programs).  Public policy on opioid prescriptions must acknowledge this context.
  7. The most reliable risk factors associated with addiction are status as an adolescent, a history of family trauma, and/or long term unemployment. None of these factors is addressed by restriction of opioids prescribed to patients in pain.  Education of patients to control others’ access to drugs at home and to turn in or destroy unused medications may help at the margins to reduce exposure of non-patients to potentially addicting drugs.  But there is no evidence that restriction of opioid medications reduces overdose deaths.  To the contrary, it is clear that reformulation of Oxycontin in 2009 to reduce its abuse potential was accompanied by a sustained increase in overdose deaths involving street drugs.
  8. Before starting opioid treatment for chronic pain, clinicians and patients should mutually establish treatment goals and expectations for pain and function. Criteria and a transition plan should be established for how opioid therapy will be discontinued if observed benefits do not appear to justify risks or untoward side effects.  However, opioid therapy should not be discontinued in the absence of evidence that the underlying disorder is resolving, or that effects and side effects of treatment outweigh the benefits in the individual patient.
  9. Before starting and periodically during opioid therapy for chronic conditions, clinicians should discuss with patients known risks and realistic benefits of opioid therapy as well as patient and clinician responsibilities for managing therapy. Patients should be reminded of their responsibility for controlling access to powerful opioid drugs by friends or family members who have not been prescribed them.
  10. Clinicians should not dismiss patients from their practice solely because of a substance use disorder. Such action can adversely affect patient safety and could represent patient abandonment. Identification of substance use disorder represents an opportunity to initiate potentially life-saving interventions.   It is important for the clinician to collaborate with the patient regarding their safety, to increase the likelihood of successful treatment. Although identification of an opioid use disorder can alter the expected benefits and risks of opioid therapy for pain, patients with both pain and substance use issues require ongoing pain management that maximizes benefits relative to risks.  Consultation with an addiction treatment specialist is in order for general practitioners and others who lack current training in the specialty or who are not appropriately licensed.
  11. Multiple physiological and genetic factors should influence physician prescription of opioid types and doses to the individual patient. These factors include the patient’s history of previous opioid exposure, any history of alcoholism or drug abuse, the types and causes of pain being treated, the physical weight of the patient, and the individual’s ability to metabolize opioids or non-opioid medications. When pain is unresponsive to initial prescription of opioids, genomic testing should be considered to establish whether the patient is a poor metabolizer of opioids or other medications.  Long term medication management should integrate the findings of such testing.  Research is needed to assess the reliability of opioid-related genomic testing and to reduce its costs.
  12. Although it seems plausible that higher opioid dose levels might be associated with higher risk of dependency or addiction in some patients, medical evidence is presently inadequate to generalize numerical thresholds on opioid dose levels considered dangerous. An important criterion for evaluating risks and benefits to long-established patients is whether the patient has been on a stable opioid dose, without progression of the underlying medical conditions which generate pain.  When the patient is stable — even on doses over 400 MMED — there should be no reason to change opioid dose levels, absent indications of progression in the underlying medical disease or disorder, or identification of an alternative treatment with fewer potential side effects.  Physical dependence on opioids is not a sufficient criterion for forced withdrawal of these medications in stable chronic pain patients, regardless of dose.
  13. It must be recognized that established addicts may attempt to doctor-shop for physicians who are incautious in prescribing opioids to patients with a history of either medical or non-medical use. To reduce hazards from diversion or misuse of prescribed opioids, doctors and pharmacists must have timely access to a US national opioid prescription database, cross-referenced to reliable real-time identity data. Online use of such a database must be optimized for rapid access by physician and pharmacy office staff, with a goal of completing data entry and system response in a maximum of 60 seconds online.
  14. When there are indications that a patient has requested treatment by three or more doctors in a year, the patient’s medical records should be reviewed to assess circumstantial factors beyond the patient’s control, before taking action to more closely monitor opioid access, alter treatment plans, or engage a substance abuse management specialist in coordinated treatment.
  15. US Government authorization for production and distribution of opioid medications should be optimized to ensure that all patients with legitimate medical needs receive their prescriptions in a timely manner. Measures must also be implemented to detect drug diversion before, during or after distribution. Pharmacists who believe that a prescription exceeds accepted medical practice should contact the prescribing physician’s office immediately, to confirm the appropriateness of the prescription.  In no instance should a patient be refused refill on a valid prescription solely on the basis of pharmacy corporate policy or the individual “comfort levels” of the pharmacist.
  16. Urine testing should be implemented in initial and periodic follow-up physician appointments, to assess whether patients are using medications other than those prescribed or in quantities different than prescribed. When a patient must travel more than one hour to attend medical appointments, use of short-notice urine testing should be implemented by public health nurses or local clinics in the communities where patients live. There is presently no conclusive evidence that drug use “contracts” between patients and doctors actually reduce the number of hospitalizations for opioid toxicity or the number of overdose deaths. Research investment may be needed to lower costs and improve reliability (reduce false positive rates) of such testing.
  17. Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear.  For example, experts have noted that there may be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC). In addition, costs of urine testing can be reduced by restricting confirmatory testing to situations and substances for which results can reasonably be expected to affect patient management.  Before ordering urine drug testing, clinicians should have a plan for responding to unexpected results.
  18. Just as there is a potential for opioid misuse among patients, there is valid concern that some physicians licensed to dispense opioids may do so inappropriately or with inadequate patient oversight. However, the volume of opioids prescribed in a medical practice is not a one-size-fits-all criterion to justify confiscation of a doctor’s medical records or imposition of sanctions prior to review by State medical boards or courts. Prescribing patterns must be assessed in the context of the numbers of patients served, the nature of their underlying medical issues, and the area availability of practitioners and centers formally accredited to prescribe.
  19. A careful and non-stigmatizing distinction must be applied in the assessment of opioid risks and side effects among long-term pain patients. It is established that many if not most chronic pain patients do not get a euphoric “high” from opioid use. Nor do these patients commonly display the spectrum of compulsive and self-destructive drug seeking and escalating dose levels displayed by addicts. Some pain management specialists believe that neurochemical and genetic markers exist which identify patients in whom chronic pain has produced permanent changes in the brain. Such markers might in principle offer means of differentiating some addicts from chronic pain patients. Further research may be needed to confirm the science and reduce such testing to common and affordable practice.
  20. Physical dependency on opioids for pain control may cause withdrawal symptoms when medications are suddenly reduced. However, drug dependency is not the same medical entity as addiction. In patients for whom resolution (“cure”) of underlying medical conditions is deemed unlikely, dependency may be an acceptable and manageable side effect in maintaining the best possible quality of life, in the absence of effective alternative means.   When dependent patients are withdrawn from opioids for whatever reason, physicians are ethically required to provide assistance with withdrawal symptoms.
  21. Despite many articles in popular press and medical literature, there is little validated medical evidence for what is called “opioid-induced hyperalgesia” (increasing sensitivity to pain over time, requiring sharply increasing doses of opioids for effective pain control). There are no documented diagnostic protocols for this supposed medical entity, and there is no generally accepted protocol for treatment, other than tapering down present medications and tapering up others. Some pain management specialists go so far as to suggest that if opioid-induced hyperalgesia exists at all, it may be associated primarily with constant exposure of the brain to opioids delivered by intrathecal pain pumps.  Given these observations, when drug tolerance or increased pain are reported by patients, medical assessment is warranted for progression in the underlying processes believed to have produced pain. Development of opioid abuse disorder should not be a default assumption. It is also well established that initial diagnosis of many chronic pain conditions is complex and frequently incorrect.
  22. Opioids have both short and long term side effects which must be actively managed by the prescribing physician. These may include constipation, dry mouth, nausea, confusion, lethargy, sedation, suppression of sexual libido, situational or chronic depression, and anxiety.  Drug interactions are also of concern in developing a pain management plan for the long term.  It is known that a significant fraction of patients who die from opioid-related overdose have also been prescribed Benzodiazepine drugs.  Physicians should avoid dual prescription of Benzodiazepine drugs and opioids wherever possible.  When benzodiazepines are deemed medically necessary, drug metabolism and interactions should be monitored frequently to avoid accidental death by respiratory suppression.  Alcohol is also a major contributor in drug overdose and patients should be counseled on its dangers.
  23. There is much public discussion of Naloxone as an interventional drug to counter the immediate effects of opioid overdose. The CDC has proposed to make this drug widely available to emergency medical technicians and police as an aid in saving the lives of drug overdose victims. However, there seems to be little medical evidence that Naloxone can be used similarly to Methadone, to suppress cravings for other opioids over the long term.  A few published reports have suggested that Naloxone therapy may merely postpone the decline and death of addicts who do not enter a more sustained program of community based non-drug treatment.  Investment will continue to be needed in community programs of addiction treatment. There is no easy one-size-fits-all solution for addiction.
  24. There is also much public and professional discussion of non-opioid medications (e.g. steroids, NSAIDS, anti-seizure medications, anti-depressants) and behavioral therapies (rational cognitive therapy, operant behavioral therapy, creative visualization, acceptance therapy) as alternatives in chronic pain management. The present state of medical evidence is not sufficiently developed to generalize practice standards for the use of such therapies in preference to opioids.  Based on published papers and tens of thousands of patient reports in social media, it is clear that these non-opioid approaches to pain control do help some patients, some of the time.  But no patient should be coerced to accept such therapies as replacements for opioids, particularly if the patient hasn’t experienced improvement in pain during trial of the therapy.
  25. Due to its status as a Schedule I “narcotic”, marijuana-related research has largely been stifled in the US even as it continues elsewhere. In recent years, there has been an increasing trend toward legalization of medical uses and in some US States, of recreational use. While much remains to be learned about the mechanisms and reliability of marijuana and its components (e.g. CBD oil, THC) as medical treatments, one fact is entirely clear: there is no valid evidence supporting the designation of marijuana or its component products as a “gateway” drug for opioids or other addictive drugs.  Moreover, data are emerging from States where medical marijuana has been legalized, suggesting that where marijuana is available, opioids are less often used both medically and recreationally.  Immediate rescheduling of marijuana is warranted to facilitate further medical research to investigate and quantify its potential benefits,  reported by tens of thousands of chronic pain patients in social media.

About the Author:  Richard A (“Red”) Lawhern, Ph.D.  is a non-physician writer, research analyst, patient advocate, and website moderator for chronic pain patients, families, and physicians.  His wife and daughter are chronic pain patients.  His 20 years of experience has produced articles and critical commentaries at the US Trigeminal Neuralgia Association, Ben’s Friends online communities for patients with rare disorders, US National Institutes for Neurologic Disorder and Stroke, Wikipedia, WebMD, Mad in America, Pain News Network, National Pain Report, the American Council on Science and Health, the Global Summit for Diagnostic Alternatives of the Society for Humanistic Psychology, Psychiatric News and Psychology Today.

This article has benefitted from review and input by a correspondence group of 25 chronic pain patients and by medical professionals qualified in pain management.  However, responsibility for content remains solely that of the author.

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There are 57 comments for this article
  1. connie at 4:23 am

    It’s hard e enough for cpp with issues that show up on tests but even harder for those patients who have severe chronic pain where most of their issues don’t show on tests that are currently available yet to get relief require large doses of strong opiates! Fibromyalgia doesn’t show up, a syrinx in the spinal cord does but “isn’t big enough to cause any problems, the lump under the right ribs that can be seen with the naked eye isn’t anything on tests. How about the issues that have yet to be diagnosed? For 15 years I was told that the horrible abdominal pain I had was all in my head, I wanted drugs, I hated being a woman, I just wanted attention, etc turned out to be the worst case of endometriosis the surgeon had ever seen! After recovering from surgery the opiates I had finally been given were no longer needed! It seems that almost every PAINFUL health issue I’ve had doesn’t present in the “normal” way and has taken years to diagnose yet in the meantime I am suffering! Right now I have multiple issues, the only thing that shows on tests are the multiple bulging discs affecting all but three. To get the most relief with the fewest side effects I was on 125 mcg fentanyl changed every 48 hours, 4 mg dilauded every 3hours along with heating pads (the big one known to most as an electric blanket lol), an herbal lotion and anything else that I try that might work! I was stable on this regimen for 8 years until the stupid cdc guidelines came out! Now I get minimal relief with 25 mcg fentanyl, 1mg dilauded twice a day and 30 mgs oxycontin twice a day. Yes it is a lot of medication and I would rather not have to take it but I toO need relief! I keep looking for the causes of such pain but recently moved to a new state where I have yet to find a doctor and now haveno insurance so as of near the end of June fully expect to receive no more pain relief. I have tried every kind of alternative to opiates with little success. I’ll try most anything once and if it seems to work I’ll try it again! I can no longer use ofc medication since my stomach has been destroyed on them. I don’t think it’s too much to ask that my pain level be low enough to allow my wonderful husband of forty years to hold me without crying from the severe pain!

  2. Lisa Osborne at 10:13 am

    Gather as many records as you can about your medical condition: CT Scans, MRIs, EMGs, Dr reports, anything. Call your old Dr who moved and request a letter that you had been a patient there x years, followed all the rules, never displayed drug-seeking behavior, etc. If you can get most recent urine tests, get those. Build a case file for yourself. I have found it helps to have this every time you see a doctor. Drug addicts do not keep years of organized records proving they are not drug addicts. Find a picture of a body on the internet and color in the places that hurt. Use different colors for different kinds of pains. Make several color copies so you can provide one to the Dr. They can copy your paperwork but may not have a color copier for that. Take as much as you can find now and go to the emergency room anyway. Take contact info for your old Dr. They may help you or they may not but don’t depend on the word of the clinic. The ER might be able to call your old Dr. Crying is okay but try to stay calm. I have been through what you are going through. I am in Washington State. I am sorry–I understand your pain, fear, and anger. This is my best stab at a solution.

  3. Danstheman at 7:27 am

    YOUR CHANCE TO MAKE A DIFFERENCE!

    Call for Comments to the President’s Commission on Combating Drug Addiction and the Opioid Crisis.

    This is a chance to make your voices heard. The President’s Commission is accepting comments by email until June 15th. Please help us FLOOD their mail with complaints from chronic pain patients. The address is commission@ondcp.eop.gov

    You may clip and edit from the following outline as you write your mail. Delete any of the material that doesn’t apply. PLEASE don’t let this opportunity pass us by. Administrators please pin this post until June 15th

    ========================

    Dear Staff, Presidential Commission on Combating Drug Addiction and the Opioid Crisis.

    I am a chronic pain patient diagnosed with [———————— names of disorders]. I have been managed on opioid medications for __ years, with major improvement to my function and quality of life. I have some pain every day. But without opioids I would be totally disabled and the pain would be unbearable. Nothing else has worked for me and my doctor has tried almost everything.

    I live in daily fear that my doctor will be forced out of pain management practice by the arbitrary and ill-founded policies of our government and the CDC, enforced by the bogus drug war witch hunt conducted by the DEA. Patients like me are committing suicide in increasing numbers because of denial of effective medical care.

    DO NOT MAKE ME ONE OF THEM!

    If the US government is to deal with the opioid epidemic, the first thing you must realize is that managed prescriptions to chronic pain patients didn’t cause the problem. And torturing us by denial of care will only make the mess worse when we must go into the street to get pain relief.

    I am not an addict, even if I must depend on opioids just to live with my pain. The most reliable predictors for addiction are status as an adolescent (an age when few people are treated for pain), a history of family trauma, or a period of prolonged unemployment. These are social problems, not medical ones.

    Please take action to require withdrawal of the March 2016 CDC guidelines for prescription of opioids. The guidelines are biased, scientifically invalid, and actively dangerous to patients and as public policy.

    Sincerely,

    [Your name, City and State]

  4. Bev at 5:13 am

    So it’s june 8. I’m finding this out the hard way. I’ve been in pain mgt 8 years with absolutely no infractions. Monthly udi’s. All perfect and unchanging. My pain level used to be 8-9-10 even and with experimenting with what worked for me my doctor get my level down to 3 and I could get out of bed. The as i said 8 years of the same doctor who grew to know me and my condition well. He knew my name and even my grandchildren a names, as they sometimes were with me. I didn’t care to have a urine screen at all. Big deal. The office was clean and professional and friendly at that. One day last year I walk in to hear he was moving away. He referred me to the only other pain mgt doctor in town. It’s a clinic and it’s filthy. The patients there stink and have no teeth. All of them. There are three doctors but you will only see one on Your first visit. He is a spine specialist and gives epidurals all day. Suddenly my neuroapathy becomes a spine issue I need an epidural for. ???????
    The next month I see a nurse practitioner. She’s not friendly and she’s tired. The women who give the urine cups have an egg timer they spin for five minutes. You better go in those five minutes or you must leave and call in for another appointment. I call them the pee nazi’s.
    Every month it’s a new face asking the same questions. Same questions. Same questions. They have my records and test reports. They can see plainly the severe nerve damage I have. They always push me into an injection into my spine. There is no way those people are sticking a needle in my back when it’s not my back that hurts. I’ve asked to the the doctor again but no. Last month I walk in and guess what….?
    A new face and this face is angry and has an agenda. After eight years of perfect urine screens and zero complaints she informs me they will no longer give me the one medication that relieves my pain and gives me life. They offer no reason but they are all angry today more then usual. I’m sorry but I flip out. Why? What did I do? Is there no weaning? I’m 60 years old and ha e taken this drug eight years and I think there will be some discomfort in just not taking it tomorrow.
    Too bad.
    I go to my primary doctor. She also says too bad. I ask should I go to er if I get too sick? She says you can go to er but they won’t help you and neither can I. So im out. I gather eight years of medical records and read them looking for what did I do wrong. What are they not telling me and why are they so mean today. My medical records are perfect. I was just abandoned by this pain mgt clinic because they became afraid to prescribe my medication anymore. I suppose explanations to me would give me time to melt down there in the office. As it was it was a quick flip out and I was released. Now what?
    Nerves do not repair theirselves.
    My pain is coming back as the medication leaves my system. This morning my feet and legs are on fire and im in tears. My heart rate is over 100 and my blood pressure was very high last night. My head is throbbing so I take two asprin but I can’t call a doctor this morning. I’ve called doctors within a 50 mile radius and im getting no luck so far. I Google the medication and it looks as if the company who makes it is being forced to stop making it.
    There are zillions of articles about how the stocks in that company have plumated. Zillions. I only find one about the patients. This one. My head hurts. And I’m just getting started on the withdrawl part of this not to mention the pain coming back.

  5. Trish at 11:58 am

    To me it seems that the supposed balancing of pain control and potential harm is not about potential harm to the patient, but potential harm to others who use the drugs for pleasure. If it were about preventing harm to pain patients the drugs that would be hard to get would be things like gabapentin and elavil.

  6. John S at 2:28 pm

    It’s unfortunate but the medication we are talking about is an Opiate. Yes, I know how you feel and I’m in the same boat as most Pain patients- my I R meds are now cut 85% with the Dr’s goal for me ; completely weaned off all Opiates. Once off Opiates I’m required to have a Pain Pump installed and then filled with an Opiate medication.

    Our group takes what is now considered the same as HEROIN – we know that’s not true but the government and the media are telling the public that it is. So we are now told to ” Learn to live with the pain ”

    My Surgeon told me that a Pain Pump isn’t an option because my Spinal cord has sustained too much damage and is compressed at the point where the lead wire would be attached. So now my only hope is medical cannabis and that is still a year away in my state, Pennsylvania.

    We aren’t in any way like sick people with a disease that requires a medication like insulin. We Are Special !

    Like my PM Dr. said ” don’t blame me blame the government ”

    Thanks,

    John S

  7. connie at 5:37 am

    To Emily Raven, Personally I compare the the medicating of diabetes with chronic pain because it’s a disease that is commonly known to require long term treatment with medication not to “throw them under the bus”. Both chronic pain and diabetes often require long term medication, sometimes at high doses. Understand?

  8. Emily Raven at 2:06 pm

    “Don’t compare pain patients to diabetics, it’s wrong, you’re throwing them under the bus, etc.”

    *Sigh*

    Okay. ANY OTHER PATIENT WITH ANY OTHER CHRONIC DISEASE THAT WILL BE ON MEDICINE THE REST OF THEIR LIFE WOULDN’T BE TAKEN OFF MEDS THAT HAVE WORKED LONG TERM BECAUSE OF DOCTOR PREFERENCE.

  9. G.D.B. MD at 11:42 am

    WOW WOW WOW!
    Thank you so much Dr. Lawhern.
    I have practiced pain management since 1982. I have seen the evolution of pain management come full circle from restricted prescribing to permissive prescribing and finally back to restrictive prescribing. And now I am witnessing the vilification of patients suffering with intractable chronic pain and the physicians who DARE to treat them. The pharmaceutical industry has done little to find newer treatment options other than the manipulation of the opioid molecules to maintain their patent protections and profits. I have witnessed the Federal Government maintain tight control over the medical investigation of the known 60 different cannnabinoids for medical uses. I have witnessed the CDC demand physicians perform meaningless exercises to promote safe prescribing of opioids while at the same time admitting that there is absolutely NO evidence that ANY of these measures reduce the risk of addition and death among chronic pain patients. I have witnessed the failure of our socioeconomic policies that under-employ our population while listening to the government brag about full employment and all the while wonder why there is such frustration hopelessness among our youth. Is it no wonder that the disenchanted turn to pharmaceutical means to find solace? And how does the government explain the worldwide incidence of opioid addiction and death due to opioids? Can we blame this worldwide plague on American doctors and the chronic pain sufferer as well? Yes, it’s time to listen to our patients. It’s time to demand that the pharmaceutical companies perform REAL research and development of alternative means of pain control. It’s time we demand our government to allow more research into the medical uses of cannabinoids. It’s time we develop rational approaches to the safe prescription of opioids to the chronic pain patient following evidence based guidelines. Shut down the pill mills and the illegal trafficking of drugs but permit well trained, well meaning physicians who care about their patients practice medicine without the fear of being accused of murder and drug trafficking.

  10. Lynda at 10:30 am

    What frustrates me is the DEA knows everyone getting opioids how much & for how long so that means the CDC knows how many people have been on long term high doses of opioids without any problems but they claim to not know about all the patients like myself that have been stable at the same dose for more then a decade without even one problem? They lie & harm patients that were living better lives. Pain patients are dying while they are playing games with our lives! While we are having our medications reduced down to the CDC “One Size Fits All Doses” our pain increasing our lives are being stolen from us as we become more crippled by debilitating pain! The prejudice discriminating drug r doctors of P.R.O.P. are banking their profits from government money to fill their drug rehabs no wonder the drug rehab industry calls this the “Gold Mine”! Then with the Politicians investments growing they push for more laws to improve their profits. The media that goes along for their share of the profits leaves the chronic pain patients with no one that will even listen to us let alone speak up for the injustice of the entire thing. The public is inundated with their horror stories of drug abuse & only see us as the drug addicts our government & media has painted us to be. Except for the few doctors willing to fight for our care most of our own doctors won’t even stand up for the treatment the have provided us for decades! The excuse to save the drug addicts that didn’t ask or want to be saved is used to justify the elimination of the chronically ill pain patients they see as useless eaters taxing the S.S. system. As the largest generation is getting older & needing S.S. & becoming ill in old age taxing the system the government have stolen from for years. The veteran & civilian chronic pain sufferersre being left to do exactly that suffer & die thrown away by our own country & they did with the publics support!

  11. Danstheman at 9:36 am

    I do want to add, yes, lets not let UDT take us off course. If that is the only thing we have to debate, then it would be a welcome debate. But Sadly, it is much worse than that.

    To answer the question:” what would you do to identify addicts who are shamming a doctor or doctors, to obtain their drugs of choice under prescription? It seems to me that we cannot claim to be responsible as citizens if we try to push that question under the rug. ”

    Short Answer – If someone is “shamming” their Dr. they will find a way to pass the UDT, Criminals are criminals, period. it will circle back to the good patient, who for one reason or another, gets a wrong test result. I am a Scientist and an Engineer. Errors are made in all fields, the problem is when you add in pass or fail test and the Dr. gets suspicious, all trust is lost and the patient will ALWAYS lose. Personal, trusting, Dr.-Patient Relationships with the Dr. unhindered by fear of prosecution, will be the only way pain patients will be treated properly.

    Not once have I heard a Dr. tell my wife, I want to do a UDT “because I fear you might have compromised your health by taking other medication,” or “because I fear you have other health issues that need to be investigated.” It has only been, “so I can see if you are taking your medications as prescribed” or because, “I have to protect myself and you from the DEA” I would ask, where is the health science in that?

    Thank you all again..

    PS.to RAE – I agree, my wife and I will not even watch the Tucker Carlson shows on Opioids, the adverts alone on that piece infuriated us.

  12. Lisa T Osborne at 12:52 am

    Thank you for this article!

    Last summer in Washington State, the pain clinic chain that served most Medicaid patients (at 8 locations across 3 counties) was abruptly shut down with no warning to patients or area providers. The director is accused of alleged patient deaths and alleged insurance fraud. There are no longer ANY pain management doctors in ANY of the 4 ACA Medicaid plans in these 3 counties. None. There were an estimated 25,000 patients suddenly without care last summer and over half of them were in life-threatening situations due to the nature of their medications.

    Patients were told to ask their primary care doctor to take over medication management. Patients were told that if they had “psychological distress”, they should call the crisis line. The newspapers made it sound as though primary care doctors jumped to offer supportive patient care. I am not sure where they got such an idea. An estimated 18,000 of the 25,000 were on some form of medication that they were physically dependent on. They had no care, no follow up, and the best they could do was call the care crisis line.

    My pain management doctor was not part of the clinics that closed but his practice merged with a company that does not accept Medicaid–several other pain specialists merged at the same time. I spent 9-1/2 hours on the phone trying to find a doctor who would take me because my primary care doctor was convinced she would lose her license if she treated me. No primary care doctors would take me as a patient because I was a chronic pain patient. My former pain specialist would not see me after his merger, even though the insurance agency offerred to pay him his rate. He told me to let him know how the transition to a new provider went; when it fell apart, he would not take my phone call. By policy, I could not pay cash to see him. He wouldn’t work with my insurance company. After 3 years where I followed every rule, never was in any trouble, and was a model patient, he just abandoned me. I don’t understand how that fits with “do no harm”.

    My primary care doctor finally agreed to keep me. Even though I was stable on my medications, she changed the meds I was on, cut them by half, and did not support me when I went into withdrawal. The way she documented my office visits was misleading and I was not permitted to fill out my own pain reports–I had to dictate them to her. After 33 years of chronic pain, of which the last 18 have been on opioid medications, I went through withdrawal for the first time…by myself. When I asked for help, my sickness was minimized and invalidated.

    I eventually was able to change my medicaid plan, and because I was employed in social services before becoming disabled, am resourceful, and know how to keep good records, I was able to get a new primary care doctor and begin returning to my old meds and stability. However, the insurance company moved very slowly and prior authorization took so long, that for the second time in 3 months I went through withdrawal–by myself.

    There are no words for the panic and despair that you feel when you realize you are about to spend at least a week doing that again.

    It is not hard for me to understand why patients commit suicide. I will not go through withdrawal by myself a third time.

    I am finally stable again. It has taken ONE YEAR. I still do not have a pain specialist because there aren’t any. My prior doctor violated her oath to “do no harm”. She thought I was an addict and spent my appointments talking to me about addiction and her fear.

    My new doctor is very good and I thank God for him. I try not to worry about what will happen if he retires in 5 years.

    I often think that pain patients need to unite and bring a class action lawsuit. It may be the only way that we can fight back against big pharma, the lobbyists, politicians with agendas, poorly done research, lack of support by doctors (for any reason), and the DEA. As a group, we are poor. We do not have stamina and energy to fight, no matter how much we want to. And we face the stigma of taking opioids, which makes us guilty until proven innocent. How do we oveecome those things to even begin a lawsuit? And who would be crazy enough to represent us–it would probably be pro bono and a lot of work.

    I loved what you wrote. It would have saved me last summer. Like another woman wrote, you are my hero. Thank you. Thank you so much.

  13. I. Hollis at 5:24 pm

    Richard,
    This is excellent! One point I would add, in regard to urine testing, is that for those patients with unusual metabolism, such as ultra rapid, or poor metabolizing, blood level tests for the medications they are taking would be a much more accurate assessment. Urine tests can be highly inaccurate for these patients.
    Along the same note, as mentioned in #11, all physicians and pharmacists should be taught pharmacogenomics, and become well aware of ultra-rapid and poor metabolizers as they make up perhaps as much as 10-30 percent of patients they will be treating. They respond very differently to opioids, often reporting “no-analgesia” with standard levels of medication, and often require higher doses for adequate analgesia than what is currently espoused by the CDC Guidelines…

  14. RAE at 12:00 pm

    “Fair & Balanced” media (?) ie: *Tucker Carlson* has jumped on the opioid crisis bandwagon & has vowed to beat that drum till the cows come home! We’re in deep…..!!!! Ive wrote my state senator & he responded promptly: adding not only he but his wife is a physician. He hasn’t made a decision on which side of the controversy he stands, but encouraged me to keep in touch. Why (?) I’m recovering from orthopedic corrective surgery–ranks right up there as one of the most painful! I’m maintaining as of now on a chronic pain regimen (2 weeks post-op) & not acute pain control up to a therapeutic level. Surgeon gave CP Dr. The go-ahead to manage pain because his prior patients were dropped from CP clinics after surgery! It’s that bad my friends! That bad!!!!!

  15. Steven at 8:40 am

    I agree with urine testing. I personally have nothing to hide and don’t mind my once a year urine testing. I also think that testing should occur more often in order to root out people not taking their meds (ie, people who may sell their meds) and those using other substances. I too suffer with pain 24/7 and have taken my meds exactly as prescribed for many years but something strange happened right after the new guidelines were put in place last year. I gave my yearly urine sample and the test came back far different than all years prior. I had tested positive for substances I had never taken in my life. How could that have happened. I think the testing company had changed because of the new CDC Guidelines and my tests we messed up or were someone else’s results. I questioned my doctor about my results but I wonder if he brushed me off thinking I was not being honest. Testing must be 100% accurate if it’s going to be done. Mine were not, conveniently for the first time after the new guidelines were put in place, so I understand peoples frustration with urine testing but I still think it needs to be done to root out people who are ruing pain management for many others.

  16. Richard A. Lawhern, Ph.D. at 1:38 pm

    I realize that there is strong sentiment among chronic pain patients against urine testing. And false positives are an on-going source of actual harms to patients. However, on this issue I must speak from years of observation of patients and talking with doctors. I’ve lost count of the number of times I’ve heard the phrase “addicts have ruined it for us.” And I believe that observation may be accurate. But I must also ask you: what would you do to identify addicts who are shamming a doctor or doctors, to obtain their drugs of choice under prescription? It seems to me that we cannot claim to be responsible as citizens if we try to push that question under the rug.

    I’m not a chronic pain patient (my wife and daughter are). But I am given a urine test every time I do a yearly physical exam. And that test may have saved my life three years ago when it turned up positive for red blood cells. Further investigation found an 18 millimeter Stage 1 A renal cell carcinoma (cancer) on my right kidney. At this stage it could be removed by a simple overnight procedure at a local hospital. I’m free of cancer now.

    I also find the comparison between chronic pain patients and diabetics to be a bit off-target. Many diabetics are first identified by routine blood testing for sugar. So indeed, we do “require” testing before initiating treatment.

    Ultimately the purpose of this article is to start a National conversation with the medical and policy establishments. We have to understand that we’re not going to get everything we want from that conversation. But it is still one we must have.

  17. jon morgan-parker at 9:44 am

    What an amazing suggestion!
    I would like to give these manufacturers a small piece of my mind…because their description is nothing like I have…very addictive and severe withdrawal symptoms for the Opioids…scary stuff!

  18. Danstheman at 7:38 am

    Dr. Lawhern, a BIG THANK YOU!

    I would add a comment from a great neurologist. “Doctor-Patient” relationships are built on trust, when there is no trust, a relationship cannot exist.” I am a caretaker of a chronic pain patient stable of 437MED daily for the last 2 years(15 prior years of looking for the Doctor who could take the risk to actually treat the pain and the patient). The problem is in todays world that 15 years would have stigmatized us as “Doctor Shopping” Pharmacy shopping and any other drug seeking criminal label one would apply to a patient desperately seeking relief. Walking into Doctors with 4″ stack of Neurologist and lawyer reports.

    On the subject of Urine Drug Testing. It is demeaning and shows that the Doctor has no trust in their patient. Quite frankly my “patient” has only taken one Urine Drug test in the last 17 years and it was the first and last one. So demeaning, so humiliating. There are other ways to document and treat patients, other than by policing them. Your argument that the patient might be taking something that combined with the opioids might hurt them would say that we should take UDT to ALL Patients taking prescription drugs. For example what is someone is taking high blood pressure meds or insulin and they consume a substance that would trigger a stroke? What about Xarelto and NSAIDS? etc etc…. Lets face it the UDT is a form of a Doctor not trusting their patient, so I refer you to my original comment above.

    Dr. Lawhern, you are one of my hero’s and the hero of many pain patients. One day I would like to meet you and have you meet my “patient.” I think it would be beneficial to yours, hers and all of our mission.

  19. Mary at 10:42 pm

    I moved to Pa 2 yrs ago bc brother had leukemia & single parent of 3 kids. VA took me off pain meds i had taken for 7 years. Now, i van no longer work and hav a semi normal life. VA hurts veterans. Civilian dr would not keep me on same meds either. Put me on fentanyl which did not work. It wasnt being absorbed into my body. Drug test proved i had no fentanyl in my system even tho i was wearing patch. Dr then suspected me of something, not sure what, but his attitude changed. Still would not take me off it. After another month i quit. I hav no hope in doctors. I simply wanted to remain on the same medicine i had neen taking for 7 years. 50mg of nuycenta and 200mg extended release tramadol. Dr wouldnt automatically change a diabetic’s drug if it worked, but they will change a pain patients for no good reason.

  20. Robert Dean Rose Jr. at 7:58 pm

    Why do Big Pharmaceuticals support the lies?

    Why do Big Pharmaceuticals support the lies and propaganda of the “opioid epidemic?” Simple greed! Here’s how it works; they get elected officials to pass laws limiting or flat out denying opioid based medications and/or medical marijuana (paying over $5000,000 to keep it illegal while pushing their own synthetic THC drugs through the FDA). Drugs with a proven track record unlike the “designer” poisons they are marketing.

    Once accomplished, they force people to turn to the synthetic designer crap they have developed which have a two-fold objective. First, the can claim high prices because of all the R&D that went into making these miracle drugs. Second, these miracle drugs, such as Lyrica, Ibuprofen, Gabapentin, Meloxicam, and all the other NSAIDs cause long term health problems. Just read the warning labels – may cause bleeding ulcers, perforated bowels, lymphoma, heart damage, liver & kidney damage, multiple forms of cancer and the list goes on and on. With all these new health problems, the Big Pharmaceuticals, besides killing millions of people, have also created a whole new client base for other expensive designer drugs to treat these new patients. Just think about how much a round of chemo costs. WOW. With this in mind, why on earth would they support medical marijuana or opioid pain medications which have fewer adverse side-effects?

    There are more than 18,000 deaths annually as a result of NSAID-induced GI bleeding. Additionally NSAID use has been found to be associated with an increased risk of heart failure in several randomized clinical trials and observational studies. Where is the NSAIDs epidemic considering they are responsible for over 12,000 (that we know of) deaths more than medically prescribed and monitored opioid medications?

    Obviously Big Pharmaceuticals motivation in spreading the lies and propaganda is pure greed. All those extra ailments bothering you from these alternative treatments have them rolling in the dough…

    Teufelshunde

    Robert D. Rose Jr.
    BSW, MEd. USMC
    Semper Fidelis

  21. Robert Dean Rose Jr. at 7:52 pm

    America the Hypocrite!!! Genocidal Policies Worse than Syria Against Her Own Citizens.. Murdering Veterans, the Elderly & Chronic Pain Patients by the Tens of Thousands.

    Our government, the VA, CDC and DEA are losing the war on drugs by their own mistakes. So they have decided to grab the “headlines” by creating a make-believe epidemic about opioids. ignoring expert medical professional testimony about what happens to people with intractable pain and cancer without these lifesaving medications. Based on my and other’s research it is all about greed as the policies continue to kill more Americans, civilians and veterans in far greater numbers than the chemical attacks in Syria.

    If McCain with his new bill seriously wants to help veterans and the American people maybe he should expose the lies and cover-ups and wasted millions as these agencies use veterans as guinea pigs to best deliver their lies. He can start by adding these modifications to his bill…

    1) The toxicology report needs to be in-depth and not just your basic drug screen to see exactly what drugs are present and amounts. With these tests, just because a drug is present does not mean it was an opioid related death. IE: A guy using pain medications get’s hit by a drunk driver while walking down a sidewalk (legally) and dies, DO NOT list it as an opioid related death as the CDC did for their guidelines.

    2) Why just five years? Why not go back to 2008 when Dr. Alec DeLucca made his first report on chronic pain and the implications of what would happen if patients were denied pain medications. Then compare that data with data collected after 2013 when the VA first implemented the policy to deny pain meds to 90% of all veterans.

    3) Why only suicide, accidental and traumatic deaths? Why not include “natural causes” of those veterans on a forced taper or being denied pain medications outright because of their asinine policies?

    4) Why not be all inclusive of every veteran; some were injuries in training accidents or became ill in peacetime and we cannot forget the damaged done by Agent Orange or the drinking water at Camp Lejuene. Some of those illnesses have also led to intractable pain conditions leading to the prescription of opioid type medications.

    Teufelshunde

    Robert D. Rose Jr.
    BSW, MEd. USMC
    Semper Fidelis

  22. Mark Ibsen MD at 5:32 pm

    John Sandherr:

    See my comment April 10:

    We could put a marker Or tracer on each pill manufactured under DEA regulation.
    Then
    If a person dies, we seek data from blood urine and tissue samples.
    Then we track that pill to its origin.
    And
    I suggest we will prove what Massachusetts found:
    Most opiate OD are counterfeit
    Or
    Imported drugs
    No marker would be found.
    Then
    We can at least start barking up the right tree….

  23. scott michaels at 1:01 pm

    Aftr years of following this situation. A solution that satisfies patient 1st, Doctor second and Insurance company should be devised. I believe those with acute short there pain should be started with Tylenol unless a fracture or stitches were needed. Thenjoy, low dose opioid can be prescribed. Do not exceed a 5 day supply. Patient must see doctor for refill and drug test. THESE PEOPLE ARE GENERALLY THE CULPRITS OF RECREATIONAL USE OR PERSECUTED HARDER DRUGS. IF PATIENT IS HEELED AND STILL REQUESTS OPIOIDS THEY MUST BE WEANED COMPLETELY OFF. IF THERE IS PERMANENT DAMAGE THEY MUST GO TO PAIN MANAGEMENT AND physicalTHERAPY in order to justify future prescriptions.
    FOR THOSE THAT HAVE BEEN IN CHRONIC PAIN FOR OVER TWO YEARS AND ARE DISABLED WITH PROOF VIA MRI THAT THEY HAVE A CHRONIC CONDITIONS THAT CAUSES MODERATE TO SEVERE PAIN AND HAVE BEEN TAKING HIGH DOSES OF PAIN RELIEVERS 360 MORPHENE EQ OR MORE PROOVEN TOLERANCE TO OPIOIDS THEY SHOULD CONTINUE WITH NO DISRUPTION UNLESS, THEY DO NOT PASS random DRUG TEST, been caught doctor shopping within the last 2 years more then once. MANY PEOPLE NEED BREAK THRU.MEDICATION DURING THE DAY. SOMETIMES IT’S JUST FROM BAD WEATHER OR NEW PAIN. They also can not fill thier refill more then 3 days in advance unless a weekend or holiday causes them to run out of said precription.
    THESE PATIENTS DO NOT FEEL ANY EUPHORIA FROM THIER MEDICATION. IT IS 100% PROOVEN IT REDUCES THE PAIN LEVEL FROM AN 8 TO 10, DOWN TO A 2 TO 3. THAT IS A DRAMATIC INCREASE IN QUALITY OF LIFE.
    IF FEAST LE, A 30 DAY TIMED DISPENSER SHOULD BE CREATED SO THE PHARMACIST CAN FILL THE DISPENSER AS TO WHICH ONLY 1 DAY CAN BE OPENED AT A TIME. THIS WILL ELIMINATE THE CHANCE MOST OF OUR CONCERNS REGARDING SAFEGUARDS.
    LASTLY NEW CHRONIC PAIN PATIENTS ONCE PROOVEN BY 2 DOCTORS THAT OPIOID THERAPY IS MEDICALLY NECESSARY AFTER OTHER METHODS HAVE BEEN TRIED TO NO AVAIL, THEN AND ONLY THEN OPIOIDS SHOULD BE USED. WITHIN THE 1ST YEAR PATIENTS SHOULD NOT EXCEED 180 MG EQ. THIS AMOUNT SHOULD BE GRADUATED BY 15 MG UNTIL ACHIEVED. WITH EVERY DOSAGE INCREASE, THE PATIENT SHOULD BE WARNED OF ADDICTION POSSIBILITIES AND BE WITNESSED TAKING THE INCREASED DOSE. IF DR OR NURSE OBSERVES PATIENT BECOMING LOOPY, THEN THEY HAVE GONE ABOVE THEIR TOLERANCE LEVEL.
    I WRITE THIS FROM BED. SINCE MY MEDICATIONS HAVE BEEN CUT IN HALF, I CAN NO LONGER LIFT MY HEAD WITHOUT ASSISTANCE. THE PAIN IN MY NECK FEELS AS THOUGH I’VE BEEN HIT WITH A SLEDGE HAMMER. I AM MORE THEN WILLING TO BE INCONVENIENCED SO I COULD GET MY PAIN MEDICATION BACK. KAISER REFUSES. I AM NOW IN TALKS WITH DEPT OF HEALTH AND HUMAN SERVICES. I HAVE NO EXPECTATIONS. I HAVE NOT HAD ALCOHOL IN OVER 15 YEARS. I MUST NOW DRINK TO SLEEP. THC WOULD ALLOW THEM TO COMPLETELY CUT ME OFF

  24. connie at 10:05 am

    Urine testing wouldn’t be needed if government agencies weren’t allowed to practice medicine without a license. The cost is often prohibitive to pain patients who are struggling to survive financially. I realize that the government, once it gets a toehold in something isn’t going to back off but it remains a fact that urine testing is putting yet another burden on people who can’t afford it.

  25. Heather at 7:19 am

    Great article and oh so true!! Just read an article from Pain network where the CDC is actually finally awakening to the fact that the opioid epidemic is not from the REAL PAIN PATIENTS but the heroin addicts using with fentanyl which we all knew. They are now placing it in a new category. I hope those that jumped the gun lost their precious jobs for causing such havoc on pain patients and patients to have meds decreased or cut altogether which in itself is dangerous. Also those poor innocent people who lost their lives to suicide when they could have been treated properly instead of been treated like an addict. So so sad at the number of lives we have lost in just the past y months alone. 8 I believe and this breaks my heart. AS a health care professional myself I would never refuse a patient pain medicine, laughing or not. We learn to cope over the years and we know our bodies more than anyone. We have researched and researched and know so much about our disorders and diseases that I believe it scares the Drs. We are and always will be a challenge to them because we are chronic and can’t be fixed like an acute patient but try to figure it out. We have to be our own advocates…….I personally just ask my Dr or offer advice and they usually listen. I thank goodness my pain Dr caught something abnormal on an MRI he ordered of my hip and pelvic and referred me to oncology. Oh all the Drs I have seen from pcp, rheumatologist x 3, orthopedic, neurologist, OB/GYN, and more the pain Dr did it. So now I’m in the most of a ton of blood work being ran which are all abnormal So far explaining a lot of why my immune is in the toilet and I stay sick. My IGg is low as well as IGG 1,2,&4 as well. Soooo getting answers. I still stay in constant pain due to all my other diagnosis and autoimmune disorders but I’m getting furtjer2 and others would too if Drs would think outside the box with us. I’m thankful to have good Drs all the way around. Hoping the CDC makes and changes restrictions very very soon before more Drs leave and more patients suffer or worst end their lives.
    Thanks again. Great article!!!

  26. misjudged at 7:06 am

    No kidding thought out and well written.

  27. Richard A. Lawhern, Ph.D. at 5:29 am

    A few follow-up comments, if I may.

    (1) I realize that urine testing seems demeaning to some chronic pain patients. But doctors need the protection that such testing provides them. If a patient is prescribed opioids and diverts them to the street, the doctor can be prosecuted by DEA for running a pill mill. Ultimately, the patient ALSO needs this protection, to detect drugs that they may not have disclosed to the doctor, which in combination with opioids could kill them.

    (2) Abolishment of all opioid guidelines doesn’t help patients, doctors or pharmacists. Anti-opioid forces will win by propaganda and fraud if we take that approach. Standards of care are an absolute must in establishing the ongoing training of physicians who are expected to diagnose and treat pain. Many have been mis-educated, and this article is in part an effort to begin correcting that reality.

    (3) I would reiterate that in order to begin a national conversation about chronic pain and addiction, this article (and others such as Steve Ariens publishes, of course) needs to be made VISIBLE in widely read media. I’ve offered a short letter in this comments thread. I urge all readers to copy that letter, edit it as needed, and send it to the editors of your local newspapers, and to consumer advocates in local radio stations.

    I will do as much as I can to be available for media discussions or legislative hearings. But I can’t do this work alone!

    Regards, Red

  28. connie at 3:35 am

    I totally agree that we shouldn’t be required to have urine testing any more than people with other maladies have to. I’ve never seen a diabetic or heart patient that was required to take a piss test In order to continue their treatment!

  29. Carol at 10:44 pm

    I think it would be beneficial to do a study and ‘follow the money’. I read somewhere that several doctors on the advisory board to the CDC have financial interests in drug rehab centers and at least one other doctor had lost a son to overdose of drugs (conflict of interest in all cases). And how much of these new standards issued by the CDC are being pushed by the drug manufacturers because their patents have expired on the standard pain medications and their interest now is pushing the new more expensive drugs that don’t really work (i.e., Lyrica, Gabapentin, etc.)???

    I personally read the latest CDC guidelines and it even says that if a person suffers from intractable pain 24/7 for which no other modality works, he/she should not be denied appropriate pain medications (no limits stated).

    So something smells awful fishy about this whole thing and innocent people like all of those who have commented here (as well as myself) are suffering needlessly and getting blamed for something we’re not doing and we didn’t cause in the first place!

  30. Kim at 8:42 pm

    Thha k you for a timely, welll written article. It is soo very immportant to have the voice of painn patients be heard, loud andcllear as this very scary issue is kicked around in soo many forums. Adequate meds allter our quality of life .. daily .. for the better or worse.

  31. Christinetaylor at 8:38 pm

    I agree with everything except the urine testing. Patients should not have their urine tested unless there is a reason. Not only is this costly but it is also humiliating and lumps everyone as an addict or dealer.

  32. Susan Domokos at 6:30 pm

    I was verbally assaulted by my pain management Dr… April 5 2017….I have tested positive for marijuana since I began seeing him a year and​a half ago…I was honest about it from day 1…He began screaming about my positive tests and accused me of selling my meds to obtain the mj… Questioned me about how I afford it…What $$ do I use… Accused me of lying “like everyone else”..Sooo…He took away my 3 a day tramadol…And cut my Norco from 3 to 2…He told me I had to quit the mj by May or I was out…I am devestated bc I am broke like a vase and those meds only take me to bearable…I really need someone to talk to…I sent my story to Cleveland Fox 8 and got stupid replies…Is there anyway to share that message with national pain report?? I really need to forward to you.. Please….

  33. Caryn Abrams at 6:28 pm

    I read these ” Guidlines” and said to myself, the CDC needs to be taken to task and even if it takes a filing up to the Supreme Court, the data used to Promote an Criteria of incorrect data, misinformation, money, Political Power grabs, and worst of all now the DENIAL Of ACUTELY NEEDED CRITICAL CARE” must be challenged. Via Petition or lawsuit, this Line in the sand that has been crossed and motivated by Political Agendas must be stopped!
    In my State, I fought a difficult and frustrating battle when Govenor Christy declared war on me, as I felt everyone else was scared to speak up. I was actively involved, I called both State and Federal Politicians and I fought hard. Still Gov. Christy won his 5 day Oppoid Law in N.J. And made my State a record and signed the 5 day prescription law. As Christy continues to run his misdirected shameful tv ads, telling how a young girl from a stolen bottle of pain pills led her right to Street Drugs, i.e.: Heroin. I have been under pain management for years and at my age have never seen a chronic pain patient convert to street drugs, TILL NOW!!
    We MUST fight back against these insane laws as now it is becoming very apparent their facts to support this FACTUALLY INCORRECT ASSAULT on Chronic Pain Doctors and Patients, MUST BE reversed.
    RIGHT NOW, it’s becoming very clear that the Heroin flowing into our Country along with counterfeit narcotics is now killing more Americans including Pain Patients who previously were under close care and getting safe drugs from the Pharmacies companies. Now it’s all bets off and pain patient horror stories are not being played on tv. No one is telling the intended consequences of this war on Opoids.
    I feel as a United front we as not victims, but as a large group of well educated, smart, college educated people, we can form a United Front and fight like hell to make the CDC reverse the 2016 Guidelines and every other law than has been passed based on its false data.
    No one else will fight for us and we will pay a terrible price if we do not unite and raise our voices against this war on the sickest People in the medical community.
    We are disabled, we are sick, we are in chronic pain and suffering, and NO ONE HAS THE RIGHT TO INCUR MORE PAIN & SUFFERING ON OUR COMMUNITY!
    This is not an option. Our lives depend on this fight.
    We need leaders and we must united even if we must march to tell them how wrong they got this.
    Speak truth to Power or we will all suffer & possibly die.
    That is not acceistsble.
    And The CDC KNOWS THEY GOT IT WRONG AND ITS UP TO US TO REGAIN WHAT THEY TOOK. Our lives.

  34. jimmy moyes at 6:07 pm

    I got a friend who they changed his meds now he is in the bed sick it’s not helping his pain do any body care about is chronic pain ppl any more .pain is not funny when your up late at night .we didn’t cause all this a buse or addiction

  35. al newman at 5:39 pm

    can anyone help-called 150 plus MD’s pain MD replacement needed. Dumped for calling my MD and nurse morons. I needed prescription 2 days early, pills fell in toilet, I fished them out for proof but it did not matter to Doctor. Hence morons. Out in 2 days and PCP tired of writing temporary scripts, Please, been though withdrawl before and do not want again.

    Cedar Grove NJ patient

  36. Emily Ullrich at 4:54 pm

    This is arguably one of the most intelligent, most important, most accurate and unbiased yet thoughtful on behalf of the so downtrodden patients. Thank you. This gives me hope, and reinforces a critical point I’ve been preaching for years-patients and pain doctors MUST be a part of this discussion. I’ve felt increasingly defeated since the guidelines came out. Thank you for letting me know there are people who are willing to fight for us, and haven’t all been brainwashed by the nationwide opiophobia!

  37. Pharmacist Steve at 3:56 pm

    We don’t have a opiate epidemic.. we have a mental health epidemic… 45 million alcoholics, 35 million Nicotine epidemic… which kills 550,000/yr from the use/abuse… We have 40 K – 50K suicides and ONE MILLION ATTEMPTS.
    Our Surgeon General recently stated that addiction is a “mental health disease” not a moral failing yet Our Judicial system/DEA, FDA, CDC continues to treat it as a crime.
    When a Oxcodone or Opana dose can be worth up to $150 on the street.. until we start treating addiction – like all other disease – this illegal market will continue.
    If we universally treat addiction as a disease… will make the illegal street drug trade UNPROFITABLE for those in that “business”.
    The only guidelines we need is to let doctors treat pts’ disease state and for the politicians and bureaucrats to keep their well meaning opinions out of the practice of medicine.
    It has been proven time and again.. that prohibition or restriction on a product only produces a thriving “black market”.. which the bureaucracy then created another agency to deal with the black market that they created.

  38. John Sandherr at 11:35 am

    As Pain patients I think we would be too bias to even attempt to come up with Opiate guidelines. Just like the folks that wrote them, they to were using only their fear and lack of knowledge about Opiates and their need in the treatment of severe, chronic, acute, and progressive pain. These guidelines influence the lives of millions of patients.

    Get rid of the guidelines.

    Mandatory education for all Dr’s with a DEA #

    Mandatory education for all patients that use or might use Opiates

    Find a way to keep OUR PAIN MEDS out of the hands of addicts. I’m quite sure if they put their minds to it they can come up with an answer. Our technology has no limits.

    For the drug seeking addicts, decriminalize drugs and provide safe drugs that will stop the Over Dose deaths that plague our country.

    The Media needs to stop misinforming the public about Pain medication. Last week in Pittsburgh the local news hosted a show about addiction that featured Wrestler Kurt Engle. Kurt broke his neck in an accident and was given Vicodin upon discharge. Kurt said ” I was hooked after just 1 pill and within a month I was taking 65 pills a day” I’m no chemist but 65 Vicodin pills will destroy the human liver very quickly. And who gets addicted from taking a single pill ?

    So I don’t want to write any guidelines BUT, I wouldn’t mind having those that do just ask long term pain patients that use Opiates how they felt about the issue and how Opiates have made a positive difference in our lives. Cookie cutter medicine has failed and it’s killed people.

    Thanks,

    John S

  39. Geralynn M. Gillogly at 11:19 am

    Could any of this drama about opiates be connected to the legalization of marijuana?

    People that may be making
    Marijuana. Exc….

    GIGI

  40. Rhonda at 10:20 am

    Thank You Richard. Hopefully common sense will provail.

  41. Denise Bault at 10:04 am

    What an excellent article! Informative and exactly what SHOULD be happening…versus the demonizing of those of us who use opioids just to get through each and every pain filled day! Now, if only the families of those who committed suicide could find comfort in prosecuting those who did not / could not / would not listen to them…

  42. Lisa A Smith at 9:40 am

    If only the CDC had doctors like you helping them write up their guidelines. Instead it seems none of them had worked or lived in the chronic pain community. Please send this to all the individuals who participated in the original writing.

  43. Tracy Bryan at 9:34 am

    Great article. “Red”, our government cannot be trusted for they only rely on those out to make a profit. I say let’s go after the heroin and fentynal coming in from other countries. Then we will see a decrease in overdose.

  44. Richard A. Lawhern, Ph.D. at 9:34 am

    Connie, you and I agree: this article needs to be placed in the hands of legislators at all levels by thousands of patients demanding change. Will you commit today to finding out who your State and Federal legislators are, and sending them a link through their online gateways? I’ll even help you write a short letter:

    Dear (legislator by name).

    I am a chronic pain patient and I vote. Are you truly on my side? Or have pharmaceutical companies and insurance corporations paid you off and bought your vote? Please have one of your staff read the following link and brief you on how wrong it is to deny effective treatment to chronic pain patients. The US CDC opioid prescription guidelines and many very restrictive State laws MUST be withdrawn immediately for a total re-write. And this link offers a starting point for doing just that. See http://nationalpainreport.com/how-would-opioid-prescription-guidelines-read-if-pain-patients-wrote-them-8833330.html

    Sincerely,
    (your name and address).

  45. Mark Ibsen MD at 9:11 am

    Great, sensible summary of what would restore workability to a failing policy with no accountability to it.

    Good people have been harmed.
    I have seen it.
    Preventable Suicides are especially
    Gut-wrenching.

    One of the problems is poor data or no data about cause of death,
    Which is fashionable to blame on doctors and patients.

    It would be scientific to discern cause.
    This could be done by placing a marker on each opiate,
    Tracing each adverse event, like a VIN on a car,
    Bullet rifling patterns
    Or
    Fingerprint.
    The other thing to note:
    The treatment of each individual patient requires use of the scientific method. This is truly science to determine what is benefiting the patient measured by function as well as pain relief.

  46. Steven at 9:02 am

    The New Form Of Genocide.

    It seems to me that the CDC Guidelines are in fact a new form of Genocide proposed by the federal government on behalf of Corporate America. I firmly believe this to be fact. Why? Well, if we simply take a look at the way insurance company’s have routinely lobbied over recent years to remove some of the most used medicines from prescribed to over the counter, you will see that their reasoning is motivated in whole by profit and not for the increase of their accessibility. Prescription medicines are routinely being removed in whole as cost cutting measures by insurance company’s and not for increased public access but rather to increase their bottom line. Pain meds could never be removed by insurance company’s in the same manner as, for instance allergy meds as a cost cutting measure, simply because this class of medicine still needs to be more closely monitored for efficacy and treatment. Public outcry would also be swift and tremendous. What happened to overcome that barrier? A false report filed by the CDC as a way to lower the increasing Medicare and Medicaid costs associated with the aging baby-boomer population and the many others who suffer from real and debilitating pain issues. We, as people who suffer in pain are completely unrelated to the overdose and deaths being reported in the news. The facts are now starting to come out to show that the new guidelines are hurting lots of people in the name of corporate profits. This is reprehensible. We, as people suffering in pain, much more often than not, do not abuse or sell our medicines. We, as baby-boomers and others suffering from real and otherwise untreatable pain issues are simply being made scapegoats for corporate greed and a corrupt government hell bent on paying for the industrial war machine to keep rolling at the cost of its most vulnerable citizens. We must stand up against this and fight for our right to live with dignity and not allow this new form of genocide to continue. I’m not alone in my understanding of the new CDC Guidelines. It’s time the general public knows the truth behind the government’s decision to limit and or stop treatments that have proven effective for so many people who’ve shown no misuse or abuse after years of successful treatment. “To stop medically needed treatments purely in the name of profit is otherwise known as Genocide.”

  47. M.C. at 8:23 am

    Great guidelines that make sense. Let’s hope they actually read them & consider them.
    Thank you Richard Lawhern, Ph.D.

  48. Brad at 8:09 am

    This article is spot on, and to add to it The Workers Compensation Courts have also added “Tapering Off” to their System. I was found to be Permanently Totally Disabled a couple years ago and was awarded to have all treatments including my Medications covered by my Ex-Employer for the rest of my life. Well now with this new Tapering off non-sense they have sent my records to a Doctor who has never seen me face to face, and he came up with a Tapering down program that I had to follow for months. Even though I am currently under care of my OWN Pain Management Specialist for over the last 6 years now and have tried numerous times over those years to change Medications and lower doses with no relief. You name it, we have tried it over the last few years. Im in my late 30’s, so the last thing I want is to be chained to Meds the rest of my life, Ive gone through Epidural shots, nerve blocks, 2 Failed Back Surgeries, even had a Spinal Stimulator implanted to try and relieve some pain and come off these pills. The last thing I want in my life is to have to take these Meds to live my life the little Im able to. But now with all this Opioid stuff in the news it has come down on all of us that have Chronic pain and it just isnt fair. I’ve gone through all the Urine tests, both from my Doctor and from the Insurance Company for over 6 years and it’s never once come back abnormal. Now Ive had to change my Medications to what this Doctor no show wants and Ive been in pain that I havent felt in years ever since. All because they dont think a young man should be taking medications. Even took it to the point of the Adjuster offering to pay for me to go to Rehab over paying for the Medications that I’ve been taking for years that they no longer want to pay for.
    So I thank you for writing about this subject, something has to be done, all I heard the last time I was in court waiting for my hearing was people complaining about this same issue. But noone knows how to handle it because its so new to the System. Something needs to be done and soon.

  49. Konnie at 8:07 am

    Thank you Richard.
    I would like to add language to address:
    1. Insurance coverage and referrals for less invasive therapies as a treatment option. Drugs should not always be the default first option.
    2. Comprehensive coordination of care between physician’s and specialists.
    3. Initial and periodic testing for possible contributing factors including tests for organ damage caused by medication prescribed long term.

    Teatment modalities such as physical therapy, hydrotheapy, massage therapy, nutritional consults, etc. should be offered in addition to or in lieu of medication. My experience personally and professionally show little or no coverage for less invasive therapies to help reduce pain and increase function, especially long term.

    Ideally, the patient should be looked at in a holistic manner-looking at and addressing possible contributing factors such as an autoimmune disease, electrolyte imbalance or vitamin deficiency. For those who must take medication long term, periodic tests for liver and kidney functions should be conducted.

    Western medicine has fractured into treatment specialities. Once upon a time a patient had a primary care doc who looked at the whole picture. We now have to see several “specialists” who will address only what lies within their field of specialty. Realistically, we most likely see a nurse practitioner (NP) or physicians assistant (PA). I once saw my pain specialist monthly who was well informed about my condition and new me well. I must now see one of 3 NPs who are only vaguely aware of my condition and don’t know me. I can only see the physician if I need a highly reinbursable procedure.
    It is not uncommon for a patient to have 4 or 5 doctors – none of whom speak to each other to coordinate care.

    I have requested a position on our state public health advisory board on opiate abuse. I would appreciate links to studies and data on these issues in order to present an informed and articulate point from the eyes if those who suffer chronic pain.

  50. Mel at 7:50 am

    Mine would be moved up from four 10/325 4 a day to six 10/325 hydro a day.

  51. HJ at 7:40 am

    It would be nice if the folks who authored the guidelines didn’t hate pain patients and think we should just go away and quietly commit suicide.

    A genuine thank-you to advocates and pain specialists who are fighting for appropriate treatment.

    There ought to be a way to objectively measure the impact of changes in guidelines on the pain patient community. It’s too bad that medical examiners see that someone has opiods in their system and freely say that the opiod contributed to death. Medical examiners are generally poorly-trained, from what I’ve come to understand.

    There are just so, so many ways in which the wider community, public officials and even some doctors have communicated to pain patients that we are not valued members of society.

  52. Joan Hamm at 6:01 am

    The best answer is the people who receive opiods as medicines that was tested and proven for correct meds with approval by Drs. Who specializes in whatever Disease that requires pain medicines. These patients can tell you their story and how the medicines help them to ease their pain and live a normal ( somewhat) life. Many of these patients help others.. Volunteer.. Advocate..when they can get exercise and do contribute to Society!!! This study should be done and advertised properly so all can contribute. This information will be valuable to American citizens rather than government make decisions they know nothing about. So get it going on social medias!!!! Many people can volunteer and go through all the written mail. Patients can pay for envelope and stamps. You can put this program together without any outrageous costs. The reward of knowledge and similar stories you will receive will also save government money instead of every stupid cure or help you come up with that don’t help and you end up trashing it. We still need scientists but make sure you have good ones and not as many.

  53. jimmy mote at 5:47 am

    this affecting innocent ppl like me .punishing me for somebody elese,wrong.my med help me that I get now.why punish all the kids in the bus only 1showed out
    chronic pain is not fun had,half my foot taken off .that is pain my friend

  54. Connie at 3:54 am

    Very well thought out and written! The key now is to get it into the hands of the powers that be and hope to God they read them! Sadly I fear that even that would not open the minds of most of them nor would it change the abuse of current or future chronic pain patients who will only respond to opiates.

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