Opinion: Once Again Congress Practices “Burn Before Reading”

Opinion: Once Again Congress Practices “Burn Before Reading”

By Richard A Lawhern, PhD.

News from last week highlights President Trump signing into law, the “Veterans Administration Mission Act”.  Much is being made of the provisions of this Act which allow veterans to seek insured medical care outside of Veterans Health Administration hospitals.  But most reporters have missed a “poison pill” in the legislation that places the lives of thousands of veterans at risk.

Section 131 of the Act reads as follows:

Section 131 would ensure that contracted providers have reviewed the evidence-based guidelines for prescribing opioids set forth in the Opioid Safety Initiative before providing care through the community care program. This section would also require VA to implement a process to make certain that community care providers have access to available and relevant medical history of the patient, including a list of all medication prescribed to the veteran as known by VA.

This section would require that contracted providers submit medical records of any care or services furnished, including records of any prescriptions for opioids, to VA in a time frame and format specified by VA. VA would be responsible for the recording those prescriptions in the electronic health record and enable other monitoring of the prescription as outlined in the Opioid Safety Initiative.

This section would require a report each year evaluating the compliance of contracted providers with the requirements of this subsection. If VA determines that a community provider is not complying with the Opioid Safety Initiative, VA is authorized to refuse authorization of care by such provider and direct their removal from the community care network.

Richard “Red” Lawhern

It all sounds pretty innocent, doesn’t it?  But it’s not.  The so-called Safety Initiative is anything but safe.  It is a prescription for medical disaster.

The Initiative is built around a 191-page monster Clinical Practice Guideline [https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf]  with four complex and confusing flow charts that physicians must implement.  But there is a bottom line in this confusion.  Even if non-opioid therapy has been ineffective in managing pain, VA doctors must now “manage with non-opioid modalities”.  Legacy patients long treated with high-dose opioids must be tapered to below 90 Morphine Milligram Equivalent per day – even if assessed risks of opioids are outweighed by benefits.  And any doctor in private practice who treats veterans must do the same.

Ninety MME is the magical mystery number invented out of thin air and unsupported opinion by writers of the 2016 CDC Guidelines.  CDC publicly proclaims that their guideline was intended to be voluntary for General Practitioners.   But patients know it is not.  CDC Guidelines have caused tens of thousands, many of them veterans, to be deserted by their doctors or forced into coerced tapering of medications to below useful levels.   Possibly hundreds have committed suicide to escape overwhelming agony.  The Veterans Administration Mission Act has doubled down on the carnage.

Congress has once again passed healthcare legislation that it doesn’t understand and cannot possibly have read in detail.  Pain management specialists know that the optimum therapeutic dose range for opioid pain relievers is about 50-1000 MME per day – far exceeding CDC limits.  Opioid dependence can occur when opioids are used for long periods.  But the Director of the National Institute on Drug Abuse informs us that dependence is not addiction.  Addiction is rare in pain patients [http://www.nejm.org/doi/full/10.1056/NEJMra1507771], despite the ignorant hype spread by hysterical anti-opioid zealots and ill informed reporters.

It is time to repeal Section 131 of the VA Mission Act and revise VA Practice Guidelines.  Call your legislators and tell them so.

Richard “Red” Lawhern Ph.D. is Co-Founder and Corresponding Secretary of the Alliance for the Treatment of Intractable Pain

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Bill Chaffee

The standard is ambiguous. Does it refer to injected morphine or oral morphine? Injected morphine is reportedly three to six times as potent as oral morphine. If it refers to oral morphine then it is of course totally inadequate for almost anyone with severe chronic pain.

jimweda

I’m really appreciative you brought this up because no one else is pointing out the flaws.

Bottom line if Vets who suffer from CP and are not allowed the pain meds that work for them AND end up committing suicide the government no longer need to pay their monthly compensation.

They view PTSD, injured personnel or disabled/retired Vets as weak and have no use for them anymore. That’s the bottom line. Usefulness and profitability are the only reasons they would do anything for any of us.

And yes, I am a Veteran and chronic pain sufferer.

Terri McFarland

Sure let’s make sure no one in the private sector will treat our vets. That’s what this will amount to.

Kathleen Kaiser

I saw this while it was still a bill and contacted my reps but they all voted for it from the house to the senate to President Trump. Very disheartening to say the least. I feel badly for all the vets that are being treated worse then we treat our pets.

Cheri Furr

This is such bull! Chronic Pain patients are being made to pay for the oipoid crisis, when we are not the culprits! If I have had CRPS for 18 years and have gone to one neurologist and one pharmacy that entire time, what makes them thing I am going to overdose NOW??? In fact, most people who overdose have three or more drugs in their system! When will the DEA go after the smugglers of illegal heroin and powdered fentanyl from China that is much more potent than a controlled fentanyl patch, and is cut with God knows what??!! Congress is going to be responsible for MORE deaths—the suicides committed by vets and chronic pain patient civilians who can find no pain relief from their doctors!!! I tried every alternative treatment possible in the first year I had CRPS. Nothing worked, not even five nerve blocks. After having one per month for five months, the Pain Clinic was the one who told me they couldn’t help me and to see a neurologist, who tried even MORE alternative patients. CPP’s should be exempt from these guidelines, and vets in this situation should be warned to stay with the VA!!!

Randy

Hear, hear!!!!!!

Howard Techau

I urge everyone to contact their U.S. Senators, U.S. Representatives, and State Senators and Representatives. I have done so on both levels and I believe I and a few others in my pack of friends have made some inroads in getting them to understand our position. It is not hard to do. The amount of time is only a few hours. Writing to them is fine, but phone calls and meeting in person, are more influential.

Since when did the goverment have the right to right to intervene in the doctor-patient relationship? This government does not care about children being shot and killed in our schools because the right to bear arms is a higher right than the rights of children to be safe in public schools.

Does anybody remember Prohibition? We laugh about it now. What a stupid idea and it didn’t last long. Who benefited? The underworld and the Mafia families. And that is what is happening and going to happen here.

Economics 101: Where there is demand , there will be supply. The world is full of corruption; we hear about it everyday on the news.

A group of good people have been unjustly targeted to be the recipients of cruel and unusual punishment and denied a group of drugs that have worked like no other to kill pain for millenia.

We have a violation of equal protection under the US Constitution here.

This is dictatorial power at play. Those of you that promulgated these rules are torturing good people who have had bad luck already by getting a disease, being born with a defect, or having been in a horrible accident for which there is no cure or likelihood of relief without opiate pain medication.

And for those brave men and women who served this country in war zones, have lost limbs and suffered other horrible injuries for you and your families, or have been the victims of a horrible crime, or medical malpractice, and are now in excruciating physical pain and mental pain, you have left them high and dry too.

Whether you believe in God or evolution or whatever, there is a reason the opium poppy grows on the earth. There is a reason man has the intelligence to duplicate it synthetically.

And the opiate crisis: fake news, folks; fake news.

YOU MR. FDA MAN, MR. CDC, NIH, YOU ARE OUR SERVANTS ;WE ARE NOT YOUR’S YOU ARE OUR’$. YOU ARE THE CAUSE OF ANXIETY, DEPRESSION AND A SURGING SUICIDE RATE.

YOU ARE NOT WALKING IN OUR SHOES!!! DON’T FIX WHAT AIN’T BROKE.

RESCIND THESE RIDICULOUS, ARBITRARY AND CAPRICIOUS LAWS, RULES AND REGULATIONS AND NO LATER THAN SEPTEMBER 10,2018 BY MIDNIGHT.

THINK ABOUT IT OVER YOUR WHISKEY AND CIGARS .

Rich Reifsnyder

Hello,Well there is 100 million of us CPP,S and Veterans suffering tremendous pain and really ******* pissed off.How can you Justify leaving a 100 million CPP,S and Veterans suffer inhumanly from severe pain from being under prescribed or cut off pain medication.Then you have illegal Heroin,safe injection sites,free clean new needles,and a guardian with Narcan to bring back someone who OD,s.And on top of that our military who are also deprived of pain meds If wounded are guarding the Poppy Fields in Afghanistan.This is exactly what a lot of our people wrote,the government cant afford to pay us Baby Boomers SS,Medicare because they kept taping the SS funds for years.Iam nauseas and disgusted that 1/3 of our population are being told about a fictitious Opiod Epedemic when before our eyes we are seeing a Suicide Epedemic.I have a lot of respect for Canada,they are smart enough to figure the OD Deaths are being caused by Heroin and Fentanyl,not Opiod Medication used by responsible CPP,S.Canada is letting their doctors treat CPP,S and letting them give the dosage that helps the CPP,S.Dont Pee on my leg and tell me it’s raining out.This strongarm approach is like someone got a DUI in Ohio and the government takes away 100 million of our driver licenses.God Bless All our Brothers & Sisters.

Remember the last line of the article, folks: On Monday CALL YOUR REPRESENTATIVE AND SENATORS IN DC and give them an earful. And go on doing so every day until they capitulate!

Dr. Lawhern, can u refer me to any articles that explain WHY the CDC , DEA, and other govt agencies are doing this? Why would they cut production of pain meds 45%? Who is making money on the (opioid)fentanyl crusade? I can’t figure out why they are so draconian. Do they want people to die? Population getting too large? I don’t get it

Jill

As upsetting as it is to me personally to have the meds that I need to be active and function denied to me, when I read that they are denying our veterans their pain meds, I am nauseous and livid and depressed all at the same time. How ungrateful our government is. How do these administrators sleep at night? The VA is an embarrassment to our country and the CDC who started it all a disgrace. Thank you Dr.Lawhern for fighting for all CPP. Thank you.

Steven

Do they just not believe us? We are real people dying. I can only speak for myself I spent 40 years paying Social Security 20th of the highest rate possible. So it’s 60 years old I get sick and they tossed me in the dumpster? How can they possibly call this Healthcare. It’s care denied! That’s what I see and that’s what it is. The only people this is benefiting is the Undertaker’s. The United States has become worse than a third world country. I never dream this would be possible in a so-called civilized country. Suicide is genocide for the chronic pain patient.

Notasheep

Another apt quote:

“Those who give up freedom for safety, deserve neither.”

Perhaps our founding fathers knew what was coming.

Dr. Lawhern, I read the entirety of the article you referred us to here. It’s very intelligently presented, gives many explanations for many things, BUT IT IS NEGATIVE toward the use of opioids beyond 8 weeks. So it’s just another professional lowering another sledgehammer on pain patients. These short timeframes are everywhere now. In some states, only a few days. The article urges More research on pain, obviously a good thing (altho animals will suffer with that research). …”more research” isn’t going to help people suffering in pain NOW. ..my question is this….if the biggest part of the so-called opioid problem is coming from >90 mg morphine equivalence, why are so many pain patients below that having their meds cut or taken away? I recently had my ambien taken away, after twenty yrs. also small amount of ativan cut…Also cut in Percocet, after ten yrs. it is cruel and bad medicine, I think, to pull stability away from pain patients who work hard to find some semblance of living by using medications we have been given for years. How can it be good medicine to disrupt people’s lives so violently.?? I guess the population of USA is so large now that losing thousands to suicide doesn’t really matter. …I want to see CDC publsh numbers of overdose deaths that were chronic pain patients. When will that come out?

Granny

Hmmmmm, … You know how police officers in training are both maced and tazed so they will *personally* understand what they are about to inflict on another human being before they do it??

Well, how about if we modify a taser to deliver ‘pain spikes’ (as only 1 simple to recreate example) like RSD (at the top of the McGill pain scale, above childbirth, nonsedated amputation, cancer pain, etx.) and then line up the Pharma, Insurance, CDC, DEA Execs and all voting/decision-making politicians and then give them each a 30 second *ZAP* .. then tell them we are gonna continue to zap them for 30 second stretches, every day, all day, for the rest of their lives … and while we do it, we are going to place a vial of opiate/opioid pain meds just out of their reach. We can give each one of them a single therapeutic dose of meds so they can feel the difference for a few brief hours .. but after that one dose, no more..ever. They can see it, and KNOW what a difference it would make, but not have any, just because we say so… because we ‘know’ that tazing is indicated for behavioral modification and the meds are contraindicated for their long term health… and just keep tazing away… hour after hour, day after day, month after month, year after year… all the while they can see the tool for their relief but never reach it.

Do you think that then, maybe, a few would begin to realize what the *&$% they are doing to us? Willfully, ignorantly, torturously doing to us day after day so they can line their pockets while we die in agony?!?

I have learned that people almost *never* understand a thing until it is personal… Maybe we need a way to make this personal so the fools ‘in charge’ can begin to understand the reality of our daily lives…

Kathleen Kaiser

I think it sounds horrible for the veterans. Apparently the VA does not trust civilian medical doctors to treat their patients in the right way when it comes to opiates. I think the government is way over reaching this. the doctor has the ability to report his prescriptions to any statewide reporting system. They don’t need the VA to do that for them.

Sue

At the same time the government is so cruel as to deny opioids to those who need them; they appeal the compassionate right to die law with dignity in California. A legal process that was already approved in June of 2016 but made difficult to achieve, yet an option. Also costly because after Governor Brown signed the bill approving the law, the cost of the medication increased from $300 to $3,000 plus. Gallop polls show that the majority of US adults supported the law “when a person has a disease that cannot be cured and they are suffering.” As a cancer patient I had done the research and felt some relief that it was an option. Hospice is not for everyone; especially now that hospice and palliative doctors are having a difficult time getting patients medication for pain.

What we think means nothing. There were individuals who went through the long process and had the medication before this law was appealed recently. If they were to use it now, it would be considered suicide. The doctors could be prosecuted and they are likely to loose their life insurance benefits. We are faced with being denied comfort care and death with dignity. Im not really in pain right now and hopeful but if my situation changes I know what my only option is at the present time.

Steven

Thank you for putting together the pre ultimate article culminating with the torture and death of the pain patient over the last five years. Although there probably will be small changes no doubt to this mandate they will result and even less medicine maybe even the elimination of Medicine for pain. I can’t get by on the present 190 mme I take . I know from personal experience that 90 m m e e won’t treat anyone for anything. At least not for long. This simply is the elimination of the prescription of pain medication as we knew it. It kept me well treated for 15 years but the last 5 of been hell on Earth. The future is the end of a lot of us. God can can only be the final cure for us. God bless us all.

Nancy

I totally agree with Dr. Lawhern and this applies to all Chronic Pain patients and the Veterans. I see things like this written all the time and I am in agreement with others who are responding. WE NEED HELP. William Dorn (see his comment) has the right approach. We need to be represented by someone with medical knowledge who will go directly to the top. This effects 100 million people. Surely there is someone who can help. How many lives do we have to lose? Look at what the Parkland students have accomplished. They got a meeting with the President and they haven’t given up.

The very simplest solution would be for the CDC to admit voluntarily that it never wrote the “CDC Opioid Prescribing Guidelines”, but simply invited a group of PROP members to visit Atlanta, meet in a room, and borrow CDC’s letterhead on which to publish the Guidelines.

That would give the VA a reason to suspend their 191-page opioid policy document, which was written at the order of President Obama to implement the CDC Guidelines, and create something that makes good medical and scientific sense to replace it.

Congress could motivate this voluntary administrative process, if one of the oversight committees decided to hold hearings into just exactly how PROP came to dominate the national conversation about opioids. Administrative bureaucrats would see the subpoenas coming out, and will quickly jump out of the way of the investigative bulldozer rather than be buried in the debris pile with Dr Andrew Kolodny, whose malpractice insurance company PRI appears to finance PROP as a front for it’s lobbying activity to keep bad doctors in practice and endanger patients, so that it makes profits selling malpractice insurance to bad doctors.

Earlier this week, the Canadian Province of British Columbia’s regulatory body, called in Canadian law the “Provincial College of Physicians and Surgeons”, ruled that discrimination against pain patients violates Canada’s Charter of Human Rights, and scrapped a policy document written in 2016 that had been based on the US CDC Opioid Prescribing Guidelines. The story was reported in Canada’s national newspaper, “The Globe and Mail” and can be read here: http://www.theglobeandmail.com/canada/article-bc-doctors-cant-limit-opioids-or-discriminate-against-pain-patients-2/

If your Congressman or US Senator sits on any of the Oversight or Investigation committees that have jurisdiction of the VA, HHS, Judiciary, Energy and Commerce, or the Armed Forces, invite them to hold hearings on how PROP created this dangerous problem. A bill to repeal or modify §131 would be assigned to one of those committees for hearings, so why not start with the hearings immediately? And why not immediately ask the question that really needs to be asked, which is “How did a shill for an insurance company pretend to be the world’s leading authority on opioids, and why did an Obama CDC appointee believe him?”. Policy reform can start with the truth.

Hayden

Every comment made here has validity to their point. A simple “magic” number of milligrams of morphine equivalent is not even rational. Dr. Nelson, who was on the CDC committee, behind closed doors that helped author the CDC “policy” for opioid prescribing physicians states that 90 mme, is still TOO MUCH! How in the hell could he possibly “know” what milligram of medication is sufficiently effective for an individual? Might be wrong but, I would not care if EVERY author AND those that agree with the maximum dosage gets a realistic experience into un managed pain. THEN and only then can the non cancer, intractable pain be realized for how devastating it is and what little pain management patients are requesting from our “protective” health agencies. Feel the pain you……….’s.

CRPS patient.

My PM doctor is getting out of managing chronic patients because of these “Guidelines”. What’s going to happen to those is us who suffer with CRPS? I’m really worried for the future because I cannot live in this pain

90MME was studied on OA which is nothing in comparison to CRPS, I don’t even notice mine.

When will it stop?
The Cartels are to blame for the drug addicts, NOT compliant pain patients. How many of us have to die?

So much for serving your country and then being left in pain. Leaders of the free world is a joke.

Sheldon Nierman

Please someone tell me what to do before more lives are lost or as my doctor said that in one of his meetings “thinning out the heard”. Everyone that needs opiods to just survive or even have a life needs to know a direction to go before they either lose there lives or lose what little quality of life this provides. Our government is trying to kill us and make us suffer. Our veterans, the ones who risked there lives for us cannot get the medical care they need. This is nothing short of killing off the weak and unneeded in the eyes of our government and until everyone that’s able marches on D.C with the notion that they won’t leave until carted off or heard the abuse of our citizens and the right of the pursuit of happiness and healthcare are at risk. Why is government involved in the healthcare of individuals? The simple answer in my opinion is exactly what my doctor said, ” they want to thin out the heard”. For you that don’t understand those words, it simply means they would rather you take your own lives than to help. That way they don’t have to spend the money through Medicare or in this situation through the VA. Once your dead and many choose to die painless through opiods so they can at least die without as much pain as possible they will then continue to strengthen their absurd view by saying that ” that another overdose death. They are creating ways to push the patients to extremes that they will take their own lives and many choose a pill over a gun. Can’t say that isn’t a good choice but what I can say is that all who suffer in pain that most don’t understand much less care about needs to ALL stand up and organize against these atrocities. Yes I will be happy to lead the charge on the Whitehouse and the institutions that are suppose to protect our rights not kill our citizens

Will no one listen to us!

William Dorn

Sir can you and others that are on pain patient rights try to get a meeting with president trump. If you could get the true facts to the president maybe he would listen. We have contacted our legislators and get form letters so we know they are not listening. Also why are the veterans groups like the American legion not speaking out. If we can not get our message to the top we will never have a chance.

jimweda

I am a service connected disabled veteran. My experience has shown me the system is a joke when it comes to chronic pain patients.

First, the government should not involve themselves in the medical field for lack of expertise and no desire for the truths regarding pain.

What really upsets me is if you ask our representatives about the bills they pass “in our best interest” most will tell you they don’t have time to read them all. This is ludacris! If you can’t read the whole thing don’t vote until you understand it completely! They are not doing their job!

Next, DEA needs to stop filling their pockets with big pharma cash. Think about this… Not long ago they wanted to put Kratom in the Schedule 1 category. This is a plant in the coffee family used for thousands of years. Like Marijuana no one has ever overdosed on this substance. You can get nauseated or vomit but it won’t kill you!

There has been a spike in Americans using it to ween off of opiates and/or pain relief successfully. Big pharma knocked on their door and said this can’t happen. Luckily it didn’t get the Schedule 1 tag but that could be temporary.

VA pain management, I’m not sure about outside practices state this: if Marijuana or Kratom is found in your regularly scheduled urine test not only will you be dropped as a patient but also lose all of your VA medical and monetary compensation benefits for life!

Both Marijuana (non-lethal) and Kratom (non-lethal) are not illegal in California and, in most states!

When do we say enough is enough! How many more rights do we have to lose before we put a stop to all this nonsense! We barely have anything left of a constitution.

One last note. The Bayer/Monsanto merger. Oh boy, we are now in serious trouble. There goes the nutrition in our foods. There’s barely any now. Wait til you see what they do next.

I bring them up because the lack of good nutritious food aids in many who suffer chronic pain to many levels. Think about what they are doing to us and overwhelm your reps with phone calls and emails letting them know that this is not acceptable anymore. Stand for something or fall for anything. Bless America!

Audrey Lynn

👏

Dian

I’m sick of non medical critters deciding what we feel experience and need, actually I’m sick of medical critters doing the same, I don’t care how many degrees you have, if you don’t have what I have, don’t experience what I do, don’t try and tell me out of some book! How dare you tell me “you can’t be in pain all the time” or throw that stupid pain gauge 1 thru 10 at me, each person reacts to their pain differently, just because because I can still smile or talk to you doesn’t make my pain a 2, whereas someone else may be muted by far less, it also makes a big difference depending on how long you have dealt with your specific problem. Dr’s who look down on us would be the first one’s to grab the prescription pad if they or a loved one had even a fraction of what we deal with.

Karl Zaremba

The addiction component quickly becomes a self fullfilling prophecy. As they wean the patient down to the mandated level and the patient begins to complain of inadequate relief they become easy to label as being an addict. Then as suicide numbers begin to rise that number also goes into the harm from opiates category and is used to bolster the anti opioid strategy. It seems rather circular and I suppose it is a cant lose strategy. I am not anti politician per se but this whole thing falls right into a politicians wheelhouse. Unfortunately the result is a lot of unnecessary suffering.