A Government In Disarray Over Opioid Therapeutic Use vs. Addiction

A Government In Disarray Over Opioid Therapeutic Use vs. Addiction

By Richard A. (Red) Lawhern, Ph.D.

Most readers of National Pain Report will be aware of the many shouting voices of government Agencies trying to get in on the action concerning the so-called “opioid crisis” in the US.  As pharmacist Steve Ariens pointed out to me recently, it seems like everybody wants to pursue their own agendas.  And none of the agendas match up.

Richard A. (Red) Lawhern, Ph.D.

The recently fired and replaced Surgeon General Vivek H. Murthy has stated that addiction is a mental health disease rather than a moral failing.  That didn’t keep him from writing every General Practitioner in America to advocate for restriction of opioid prescribing to pain patients, in favor of non-opioid medications or behavioral therapies.   The unfortunate reality of such “alternatives” is that for the great majority of people in severe pain, they simply don’t work and should never be regarded as a replacement for opioid analgesics.  When NSAIDs are part of the mix, they also increase risk of death by sudden cardiac arrest or liver toxicity.  More people die from Tylenol and Ibuprofen every year than from opioid prescriptions under active management by a physician.

The CDC issued prescription guidelines in March 2016 which advocated for a threshold of risk at 90 Morphine Milligram Equivalent Daily Dose (MMEDD).  When prescribing above that level, doctors were advised to evaluate risks and benefits before continuing opioid therapy.  Unmentioned in the Guidelines are serious problems of consistency in computing MMED for some medications.  Likewise, because of natural genetic variability, there are tens of thousands of pain patients in the US who need dose levels above 200-400 MMED in order to get any pain relief at all.  And although the Guideline was phrased as voluntary, Congress made compliance mandatory for the Department of Veterans Affairs a full four months before CDC published.  Multiple US States have legislated limits on prescribing.  Tens of thousands of patients are being plunged into agony, unsupervised opioid withdrawal and disability as their doctors are driven out of practice or choose to deny them the medications they need.

The FDA in its turn held a Workshop in May 2017 to plot a way forward on educating physicians in pain management and safe prescription of opioids.  Unfortunately for their good intentions and unknown to most of the bureaucrats who attended, there is effectively no accepted standard of practice in which doctors can  be educated.  The CDC guidelines are widely understood by medical professionals to be unscientifically biased against opioids, grounded upon very weak science or personal opinions, egregiously incomplete and actively dangerous to patient health and welfare.  Hundreds of published papers and articles reveal the guidelines to be, in the words of one title, “simple, plausible, and generally wrong”.

Insurance companies have also gotten in on the act.  In a transparent effort to reduce their costs, companies lobbied the US Centers for Medicare and Medicaid to impose payment restrictions on pharmacies which dispense opioid analgesics, using what are called “soft” and “hard’ audits.  Pharmacists will be forced to contact the prescribing doctor to confirm any prescription above 90 MMED as medically necessary, before dispensing.  A lengthy and contentious process of back and forth argument will be imposed for doses over 200 MMED.  At the very least, this will result in many patients facing days of delay after they have run out of their prescriptions.  Predictably, it will drive even more pharmacies to stop carrying these drugs than have already.

Now comes the most recent insult to intelligence and common sense.  Attorney General Sessions is lobbying Congress not to renew the Rohrabacher-Farr Amendment which restricts DEA from spending money to prosecute marijuana cases in States where medical marijuana is legal.  Sessions wants to prosecute marijuana dispensaries and harass them out of business.

Contrast this initiative against recent published findings of the US National Institute on Drug Abuse  in “Is Marijuana Safe and Effective as Medicine?” (April 2017). As NIDA reports, an analysis  by the RAND Corporation, has shown that

“legally protected access to medical marijuana dispensaries is associated with lower levels of opioid prescribing, lower self-report of nonmedical prescription opioid use, lower treatment admissions for prescription opioid use disorders, and reduction in prescription opioid overdose deaths. Notably, the reduction in deaths was present only in states with dispensaries (not just medical marijuana laws) and was greater in states with active dispensaries.”

A Presidential Commission on “Combating Drug Addiction and the Opioid Crisis” was scheduled to meet on Friday June 16th, to add its voice to the general clamor.  Led by Governor Christie, and lacking any sitting members with medical background as practitioners, the Commission has already published its intended schedule for generating a report to President Trump.  The draft report is to be reviewed on June 26th, 2017 — ten days after the first working meeting!

On such a schedule, I’d give 100 to 1 odds that the fix is already in. We should anticipate more of the “war on drugs” mentality from politicians who don’t have a CLUE! Despite having been allowed to comment by email to the National Office of Drug Control Policy, pain patients will have no effective voice in the outcomes, whatever they turn out to be and however many people are carelessly harmed.

Richard A. “Red” Lawhern has 20 years of experience as a chronic pain patient advocate, with published work in several venues including the National Pain Report and the Journal of Medicine of the National College of Physicians.

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There are 17 comments for this article
  1. Melly at 8:03 pm

    I was diagnosed with Parkinson’s disease a year ago at the age of 68. For several months I had noticed tremors in my right hand and the shaking of my right foot when I was sitting. My normally beautiful cursive writing was now small cramped printing. And I tended to lose my balance. Neurologist had me walk down the hall and said I didn’t swing my right arm. I had never noticed! I was in denial for a while as there is no history in my family of parents and five older siblings, but now accept I had classic symptoms. I was taking pramipexole (Sifrol), carbidopa/levodopa and Biperiden, 2 mg. and started physical therapy to strengthen muscles. nothing was really working to help my condition.I went off the Siferol (with the doctor’s knowledge) and started on parkinson’s herbal formula i ordered from Health Herbal Clinic, my symptoms totally declined over a 5 weeks use of the Parkinsons disease natural herbal formula. i am now almost 70 and doing very well, the disease is totally reversed!! Visit there website www. healthherbalclinic. net

  2. M at 11:06 am

    Thank you, Doctor, for a well written and cohesive article on what many of us in the patient pool have come to believe is the real information on this “opioid epidemic.” It is tantamount to the Salem Witch trials.

    The numbers and studies being thrown around just can’t be supported.

    The “epidemic” isn’t patient related. It is not from prescriptions. It is black market.
    Without humane and necessary treatment, many more will consider suicide.

    The Doctors are retiring in fear and disgust. They are being force fed instructions to leave their patients in incredible pain. Their life work can get them hunted down and prosecuted. The time and money spent on their preparation to be Doctors nets them a practice where the government makes their choices for them instead of good medical judgement.

    Even accepted practices for treatments like denervation/ablation are being considered unhelpful and Medicare and insurance won’t have to pay if pending bills are passed. These treatments for relief of lower back pain really do work. I can attest 18-20 months of walking upright instead of a wheelchair will be out of my reach. At $14,000 a treatment I won’t get them anymore. Who can afford them? Sometimes I think some in “control” are enjoying our discomfort too much.

    You really need to consider making the circuit on TV and written news. **We need you to.**

  3. Carla Cheshire at 6:53 am

    Yesterday after reading that the Office of National Drug Control Policy had it’s first meeting with President Trump in attendance. It was all about parents who have lost children and addicts who have lost everything telling the story of opioid addiction. There was nothing on the helpful and life-saving uses of opioid medications. I wrote an email to the President telling my story and asking him to consider those of us who are using opioids to fight chronic pain. How they are the only thing giving us a better quality of life. We’ll see if I receive a reply.

  4. Dale Masters at 7:57 pm

    The intrusion of the DEA into states with protocols in place for treating pain patients (and Federal legislation into cutting down opioid use in those states) is a blatant violation of the Constitution, in its enumeration of States’ rights. Same for medical marijuana.
    The States need to file suit with the Supreme Court for violation of their Constitutional rights.

    The Attorneys General need to look into this.

  5. Sonya Rodrigue at 7:03 pm

    Good for all you patients who stay aware and educated on these issues! There are providers out there who care. Excellent writing and insight.

  6. Richard A. Lawhern, Ph.D. at 10:47 am

    While nobody truly understands the causes or cures of Schitzophrenia as a mental health diagnosis, I understand the concerns expressed in my use of the term in this context. I believe the government’s response to the so-called opioid “crisis” is indeed irrational and disordered. But I had no intention of further stigmatizing people going through life crisis with severely disordered cognition and perception.

    Ed Coghlan, if you care to change the title while leaving the link definition unaltered, you may substitute “A Government In Disarray Over Opioid Therapeutic Use vs. Addiction”.

    For all other readers: I have just emailed a long letter to the President’s Commission on Combating Addiction and the Opioid Crisis. I will offer that letter to the editors of National Pain Report as a further article for publication here. An archive of my recent published work on opioid policy may be found at http://www.face-facts.org/Lawhern, including other articles which have appeared here.

  7. Joe Benotz at 1:44 pm

    All the anti-opioid rhetoric would be over in a heartbeat………………
    if each and everyone of these $%#$@%#$ physicians, politicians,
    insurance CEO’s etc etc etc had to live our lives in long term persistent pain.
    Not a week, not a day,
    would go by before they’d be grabbing at their momma’s
    skirt writhing in agony crying their eyes out. Every day I look for karma in these anti-opioid zealots.
    Please walk out in front of a bus………and then live or try to live in daily unrelenting pain.
    They all need to walk into a doctors office and be scorned as drug seekers.
    I especially seethe in anger over these “experts” WHO ARE NOT IN PERSISTENT PAIN
    telling we people who ARE in persistent pain that they know what works best for us.
    I hope someday their blindness to compassion and empathy will be restored………
    but I don’t hold my breath. Only when they are in pain will the tide turn.

  8. William Dorn at 11:42 am

    Dr Lawhern can you get your letters in some newspapers so the public can hear the truth.If the truth gets out politicians wont be able to ignore us.Sir you know how many people will suffer and die if the truth doesnt get out.Please find a way to let the public know. I Thought torture was illegal in America how do they get away with tortureing millions of Americans.Thank you sir and find a way.

  9. Linda Godowsky-Bilka at 10:03 am

    Thank you. You said it so perfectly. This article is chocked full of common sense, and what has always seemed to me to be information that’s so hard to miss yet it’s missed by the masses. That’s the part I don’t grasp – how this “pact” mentality set in so darn easily. And I mean EVERYONE has bought into that surgeon generals narrative without a second thought. So many lines have been crossed that it blows my very simple mind. Yet all of these people, who I held in such high regard because of their education and positions, I realized real quick it was such a farse. I just don’t trust anyone anymore. How can I. It’s dug in so deep now. I mean between these new commissions where you know the agenda for the outcome is pre determined, the new group to determine, basically more of the same and how incredibly fast that one is moving should be obvious to all. To the new fast tracking of drugs that, if one really knew just HOW the FDA approves new drugs they would find it shocking, – I come to the same belief that I don’t have any trust any more in anyone.

    People who let other people suffer needlessly and can do something about it – what on earth has happened to people that they would let this happen in America?

    Once again, thanks for listening and, my prayers to all of you who are hurting and suffering.

  10. Pip at 8:45 am

    Dear Dr. Lawhern

    This is a fabulous essay on the knee-jerk “war on drugs” response to and restrictions of opioid prescribing and access that will leave many people in agony, their pain treated with suspicion, and they themselves treated like drug addicts without any thought to the complexities of being a chronic pain patient.

    Unfortunately the title of this piece is completely stigmatising towards mental illness. Many people who live with mental illness live not only with physical pain brought on by physical conditions and disability, but with mental pain that manifests as physical, bodily pain.

    The title implies that the government is irrational and deluded, enacting violence on it’s chronic pain citizens. The government is enacting violence on citizens with mental health issues, too. To use mental illness to imply there is some distinction, or that mental illness is somehow less severe than physical illness and bodily pain, is unsettling.

    Were it not for the stigmatising title I would share this article with all my chronic pain friends. But the title implies I and my friends are separate parts of the Disability and Chronic Illness community. We are not. My mental illness has caused me extreme bodily pain in the past, and while I may not have been a candidate for opiate based pain relief, I did take some form of pain relief to alleviate my physical pain symptoms.

    I would respectfully request that you replace the title of this piece with a more inclusive, less stigmatising one, so that I can share this amazing piece of writing with as many of my chronic pain friends that I can reach.

    Thankyou for your time.

  11. Tim Mason at 8:17 am

    I am fortunate to have an excellent pain management doctor. I have a neurosurgeon and many diagnostic images that confirm my painful joints and back. This is real pain and not just aches or soreness. I am at that 90 mg equivalent but that amount does not increase my mobility. I have post laminectomy syndrome (a.k.a. Failed Back surgery) mainly caused by descending nerve roots being encased in scar tissue. The right nerve coming off the spinal column is almost all black on contrast MRI and an extruded disc above the ALIF 360 done in 2015.
    My employer noticed my inability to walk far, poor gait, and use of the prescribed cane. An ergonomic evaluation was ordered for my work station and desk. I got a new chair and laser jet printer next to my desk. A follow-up stated no improvement and my employer has asked me to consider disability. My boss will be down from NY next week to go over the details. Perhaps in most people 90 MED is about all one can take and still function 8 hours. Leg tremor has started to develop and with a family history of Parkinson’s disease I am being referred to neurologist.
    My point is this: Although my pain is well managed the result back from SS said I have 8 qualifying codes that will disable me on first pass and the representative for my LTD insurance contact said the same thing.
    It may be time to enjoy the last 10 years of my life with my dogs, shade tree and iced tea.
    The positive aspect is that disability will afford me the time to fight for others not being treated fairly. The CDC is only 119 miles south of me and a ticket to FDA in Maryland is fairly inexpensive.
    I will fight those under my code name Mad Mason, similar to Mad Max (Beyond the Thunder dome)

  12. Reed at 7:54 am

    Well, the “Despite having been allowed to comment by email to the National Office of Drug Control Policy”, al came back mailer Daemon, Starting June 13th, It spooled for 48 hrs. The server was alive, I checked the address. Several attempts to e-mail comments. This happened to others I know. The SMTP server refused to connect, yet the address verified existing. Here’s and example:

    Abstract from Mailer Daemon header:

    “Final-Recipient: rfc822; commission@ondcp.gov
    Action: delayed
    Status: 4.4.1
    Diagnostic-Code: smtp; The recipient server did not accept our requests to connect. Learn more at https://support.google.com/mail/answer/7720
    [ondcp.gov 2a02:26f0:d800:19d::2add: timed out]
    [ondcp.gov 2a02:26f0:d800:18b::2add: timed out]
    [ondcp.gov 23.217.246.249: timed out]
    Last-Attempt-Date: Sat, 17 Jun 2017 04:49:49 -0700 (PDT)
    Will-Retry-Until: Mon, 19 Jun 2017 03:57:34 -0700 (PDT)”

    Note: Ping to the ipv4 23.217.246.249 resulted in ICMP echo, and 0% packet loss.

    Hmmm. Anyone else experience?

  13. Owl at 7:18 am

    I just cannot understand how these fools are getting away with trying to kill us?? We are human beings, we are fellow Americans and I’m told, we are one in three!! What happened to “representation”? Are we not being loud enough? I watched http://www.pbs.org/video/2365977432/ last night and it is wonderful! It appeared to me as a very accurate portrayal of the chronic pain/opioid scandal that is being perpetrated on our chronic pain citizens. One thing missing though is “WHY?” There almost has to be a very deep pocketed force behind this witch hunt. Are the drug companies really sitting on new therapies so that after they have brought us to our knees, they can force us to pay ridiculous prices for their “non dangerous” new alternatives? Is our government trying to kill us off as a way to reduce healthcare costs? I don’t know the answer but my gut tells me that there is something very sinister about all this. There are too many other substances that are so much more deadly that are being completely ignored and there is too great a preponderance of evidence that this “war” was ill conceived and based on incorrect information. IDK, maybe the American public just ‘needed’ to be distracted for a while??? I’m there. It’s hard to focus on much of anything with all this horrible, PAIN!!! I’m 53 and, right now, my greatest hope is to die young!

  14. Rebecca Fraley at 7:02 am

    My 31 year old daughter struggles to live, already disabled from genetic EDS, Ehlers Danlos Syndrome, a connective tissue disease and undiagnosed Lyme, Bartonella, Babesia, Rocky Mountain Spotted Fever, Dengue fever, to name a few.
    Due to the EDS and brain/bone damage from Lyme her body needs more pain medicine to function. Unfortunately, she cannot get that due to government limitations. She wants to work part time, at the minimum. She wants to be a contributing member of society. She wants to be able to take care of herself, go to grocery, shower daily, do dishes, etc.

    Without her 2 Opana ER, and 2 Percocets a day, she would be best to end her life. Even now, her pain is never lower than a solid 8 on a pain scale. In winter it is 9, and passes out, collapses at the 10. She lives with constant pain, 24×7 since age 23. I give her great amounts of NSAIDS which we know will damage greatly. There is no choice but to do this. My daughter’s pain doctor will not prescribe above this level due to the government guidelines. What do we do?

    Both parents have EDS. Bad news for just this genes to inherit. We would not have had her if we knew why we both had daily pain, which was not disabling for one parent, her Mother, me.

    Then came the Lyme. No idea how she got it. It is worth saying due to uneducated doctors, it took two years to find the EDS. After still having bone pain and swelling, I searched again for answers. An LLMD found the Lyme and other bacteria. He said she was colonized. She nearly died twice. Once from the Lyme, and once from the antibiotics to kill it.

    My question is why do we allow those that suffer, who want to contribute to society to make a positive difference to suffer at the hands of decision makers who have had zero personal of familial debilitating pain experience?

    My daughter graduated with top honors in Interior Architecture. Her senior thesis was the entire interior design, and architectural plans for a Holistic Healing Center because she had seen me, her Mother fight aggresive breast cancer for years, without a such place to help.

    She wants greatly to be able to see this dream come true for others. She would like to speak at conferences for disabled people to encourage them to fight to live.

    We as a nation do not care for our disabled who did not choose to be in their position. Government is pressured by families to control their members who make a free choice to stay addicted to whatever substance.

    I chance to say, some of these folks who are forcing decisions to send critical pain patients into abandonment and likely suicide, have imbibed with alcohol and encouraged alcohol consumption at personal or company events. Alcohol deaths occur and alcohol addiction is rampant. Alcohol will not help my daughter to function, nor me to take care of her.

    Government has turned their backs on disabled, chronically ill pain patients, coldly, without a care.

  15. Ibin at 6:46 am

    It seems to me after reading a great deal on the drug use and overdose situation in this country, that a younger majority of people but , not all, after being exposed to drugs, illicit and prescribed, “choose” to use one substance, one or another, as early as age 12, 13?. This defiant act against the “establishment” in the rush to be an adult, is causing future harm to those that do not develop into responsible adults.Maybe abuse or misuse is the only way to escape the reality of responsibility. Many millions of people choose to use alcohol in the quest of a “break” with the realities of responsibility that we ALL have. Alcohol use does not work well for continuous pain but, can become problematic. Alcoholism. The sale of alcohol is regulated and taxed by .gov and the choice to abuse, is yours.

    Not only is drug abuse a psychological disorder, it is a social disorder. If our children are “reared” in an environment where drug abuse is not present, abstention IS taught while very young, would the risk of misuse of any drug be deterred?. I would say the risk of misuse will be lowered. Regardless if agreed with this thought or not, the possibility of drug abuse, illicit and prescribed will become an “opportunity” to all.

    There is an abounding testimony from people in pain, from disease, accidental injury that have used pain medication FOR the intended effect that 90mmedd is CAUSING more harm than “good” for the “intended” populous. Simple as that. To ease pain to a tolerable level so that life, a more bountiful life, even to the extent that the daily necessities of life, can be realized has been an absolute, documented fact, with people that need in excess of 90mmedd. Absolute necessities. Child rearing ability, food gathering, food preparation, social interaction with family., and DOCTOR appointments. ALL necessary.

    The “opioid crisis”, is not a true “war” on drug abuse, it is a simple minded, mis-guided authoritative limitation on all opiate based medication in the attempt to incur “social” reform. Otherwise known as “commune-ism”. The people afflicted with everlasting pain that the body can NOT cope with are seemingly being pacified with 90mmedd. The problem is just as Dr. Lawhern has stated.The variables, physiological properties,of the pain patient, requiring and have been using in excess of 90mmedd have been reduced so drastically that it IS causing pain and suffering. The patient has been told to adapt and survive…..or not.

    No other resource to control pain has been more carefully monitored by “substance control ,gov, than a personally, licensed, physician or facility staff member who also falls under the due diligence in prescribing under the physician. The patient has no recourse to “counsel”, no other realistic means of pain reduction method, no access to an effective dose of medication. Their homes, with the inability to stay employed become in jeopardy of foreclosure loss, their personal vehicle payments can not be met, the marital alliance has become in jeopardy, the social interaction with children that the parent “had” is no longer possible, the self sufficiency that EVERY human being possesses had, is dissolving. These are REAL conditions that are happening with enforced maximum dosage of medication prescribed without regard to any history that is documented with the provider.

    In the struggle for life, the pain patient will realize that the only way to survive is either to use illicit drugs for pain relief, and or file for the necessary funds to meet minimum obligations for their debt recurrence, food needs, utility needs, and shelter needs. All these requirements will be sought after through the “state”, .gov. Is the “state” (.gov) prepared for the influx of “applications” from our people who are simply requesting life? I doubt it. Then the worst of what is happening, the realization that self sufficiency, in any capacity can not be achieved. The psychological reasoning that if a tolerable pain level can not be achieved by the absolute reality that 90mmedd is here to stay, the inevitable last “choice” that a pain patient has is self termination.

    Dr. Lawhern has the best, realistic, commentary of what is, and what will continue to happen with 90mmedd. The “pill mills” in this nation MUST be able to be identified with a better accuracy rate of identification and subsequintly dealt with as opposed to the national policy that is casing more harm and death than the current CDC mis-guide-line. A guideline that make no exceptions for any and all documented people that use opiate based medication. A “guideline” that even before subsequent policy changes are made or enforced, and their WILL be more, is causing death, property loss, negative psychological problems including more burden upon compassionate family members and friends that will attempt to help those who can’t help themselves for a little while. I can not BELIEVE the total negligence, the realized problematic conditions, the suffering placed upon a large populous of American people by and through .GOV in the effort to change the thinking, through reduction of medication, beneficial to millions in the effort to thwart the use of illicit, illegal substances in an entirely DIFFERENT populous of folks that choose to be irresponsible.

    The pain patients needs OR concerns are being deliberately ignored, regarless of any type documentation with the us of opiate medication but, we are being reported to that new, non opioid medications and methods of treatment for pain are…..on the way. What is next, all “over weight” folks will be denied food? All pet owners will be subjected to a pet tax? The prescribing of a maximum amount of “high” or “low” blood pressure medication. 90mmedd is a social damnation placed upon people in lifetime pain with the only result of comply, turn to illegal/illicit substances, or die.

  16. Carla Cheshire at 6:15 am

    These politicians all seem to talk the talk. They’ve finally found something they can agree on– “Opioids are a scourge on society and opioid addiction is an epidemic!” I still can’t figure out how it’s an epidemic when supposedly there were enough opioid prescriptions written in a year that equaled the population of the US, like 360,000,000. The statistics say there were 32,000 overdoses in 2016. Doesn’t seem like like an epidemic to me. If I could do equations well enough I’d tell you what percentage 32,000 is to 360,000,000 Somebody help me out!

    But when it comes down to funding to help addicts get rehabilitated President Trump’s budget would cut 95% of the funding for the Office of National Drug Control Policy, the agency leading the effort to stem opioid use disorder. This, despite his campaign promises to end the opioid epidemic. It appears it’s all talk and no substance. In my research I’ve found there is little political will to expand funding to help addicts. Most seem to feel it is their own fault and why should they have to pay for their care. Others think it is a criminal offense and they should be in jail where they’d be forced off opioids “cold turkey” as punishment. Most Americans still have not accepted the fact that addiction is a disease and should be treated as one.

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