Reduce Opioids – Then What?

Reduce Opioids – Then What?

By Ed Coghlan

When we read that opioid prescriptions are not only being reduced, but also Cigna, a major health plan, was committing to reduce opioid prescriptions by another 25% in the next three years, it again brought up a question that has been asked but seldom answered by government regulators (or insurers like Cigna).

“If opioids are going to be reduced, then why aren’t we talking about the alternatives to them for patients who use them responsibly?”

We turned to Beth Darnall, PhD from Stanford University. Beth is Clinical Associate Professor in the Division of Pain Medicine at Stanford University and author of Less Pain, Fewer Pills. She writes about using less medication—but also talks about alternatives.

She thinks we have to do more than simply reduce opioid prescriptions:

This is a great question. First, we need individualized pain care- one size does not fit all. Broadly speaking we need 3 things:

(1)   Alternatives. It’s shortsighted to simply take something away: we have to give alternatives, ideally make them available before medications get started.

Beth Darnall - PhD

Beth Darnall, PhD

(2)   Understanding that the patient experience is critical. Simply taking away opioids can engender anxiety, anger, and feelings of injustice—especially in those who believe the medications are working well.  In all of the conversation about whether opioids are good or bad, there is not enough focus on how to ease the emotional distress of patients on this issue. We need to acknowledge the emotional distress and deliver treatment approaches to reduce it. Give them access to alternatives. Then, if opioids must be tapered, help patients feel more in control of the process.  Tapering works best when anxiety and stress are low. I write a lot on the underappreciated importance of this topic.

(3)   Recognize that most patients take opioids responsibly. The issues of whether opioids are good for chronic pain (on average) and addiction have been conflated. In my experience, the vast majority of patients taking opioids take them responsibly and exactly as prescribed. They are doing nothing wrong!  Whether or not they work well, improve function, and have low side effects and low risks is a separate issue, and this is where most patients find that opioids are no panacea. The problems they experience have nothing to do with addiction or so-called “aberrant behaviors”. Patients are doing everything right, taking medications as prescribed, and they are having problems caused by the medications.  In these cases – and I have seen many—tapering opioids helps reduce problems. They get better. They still have chronic pain, but they had it before on the opioids, too. Granted, when I work with patients I help connect them to those alternatives so that the focus is on managing pain differently with key lifestyle changes and use of skills. They may begin other non-opioid pain medications that may have lower risk profiles.

There’s no perfect solution here because each patient is different. Opioids do work well for some people with chronic pain, and even with the CDC guidelines in place prescribers have discretion to prescribe the medications long term. Ideally, there will be less of a focus on treating pain with opioids ONLY, as has been the case in the past. 

The second question that bothered us in the wake of Cigna’s announcement was the fact that many insurers simply don’t cover alternatives.

Now, we have a new problem:  insurance companies do not provide good access to the opioid alternatives so desperately needed by patients.  How about providing free chronic pain self-management classes to patients?  Free or low cost pain psychology classes? We need scalable solutions to meet the treatment needs of millions of Americans. In an ideal world the U.S. would have put these solutions in place before issuing edicts on prescription limits.

Here’s last week’s story on Cigna’s decision to reduce opioid prescriptions.

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Authored by: Ed Coghlan

There are 46 comments for this article
  1. Dooney at 4:00 pm

    Thanks matt! Glad you didn’t think that 98% pain patients abuse their meds.

  2. Matt at 1:35 pm

    Hello Dooney,
    My Mistake! If you read the entire context of my comments, I am a total advocate for chronic pain patient’s rights.

    I meant to say that 98% DO NOT abuse their medications. I apologize for the typo, and forgive me for not noticing the error of my statement.

    You may wish to read my comments on another one of topics.

    http://nationalpainreport.com/opinion-stop-the-war-on-chronic-pain-patients-8830555.html#comments

    Thank you Dooney for bringing it to my attention.

  3. Dooney at 7:22 pm

    Matt, I would like to know where you got the information that 98% of pain patients abuse their medications. The statistics I have seen from this site as well as the book A Nation in Pain state the there is a small percentage of pain patients who abuse meds. That is what the media would like everyone to believe and the addiction centers that moat patients abuse their meds but it’s not true. That is why what is happening to pain patients across the country is both sickening and sad.

  4. scott michaels at 10:58 pm

    Go find a real pain mgt doctor. IF YOUR IN A MESSED UP STATE LIKE MA, WA etc. I would move.
    If i couldnt get my paineds i would be in terrible pain too This means the govt and medical assoc, forced me to go to the street. I guess heroin in very small doses would help and i would actually feel euphoric. God know the 3 oxy 80mg and 6 15 mg morph a day only take my pain away up to 80%.
    i couldnt do nothing or i would be like you.NO THANKS
    FEEL BETTER!.

  5. Em Raven at 12:05 pm

    So people only “think” the medications are working well? You are a complete hypocrite. Preaching individualized care, but not seeing the individual when it comes to a certain class of medications. A month ago I was about to return to work, was taking care of the house, seeing friends, working on cars, gardening, etc… Now that one of you self righteous doctors with your woo “medicine” plan got a hold of me I can’t even go outside and personal hygiene is becoming difficult. These alternative treatments are not a new thing like you act they are either. I’ve already spent thousands of my own money on all of it. People like you are destroying lives because of your ego ie the patient doesn’t know what they feel/improvement and function doesn’t matter if YOU don’t like something. Please tell me how yoga and smiles are going to help when I’m on my way to the ER with high blood pressure and a resting pulse of over 200 due to uncontrolled pain… I’d really love to know

  6. scott michaels at 8:57 pm

    Yep. Me too
    Are you willing to picket and fight or are you going to do nothing

  7. HJ at 8:17 am

    Without Opiods, I wouldn’t be able to work. Period.

    Also, those free classes you’re talking about? How does that work for people who are employed? They’ll be held during working hours, right? And how am I going to explain to my boss that I need time off to go?

    I don’t go to a pain clinic, because they had this wonderful one-size-fits-all approach of enrolling people into a fibromyalgia class that met three times a week for three hours a day. I would have lost my job to attend class! They had nothing else they were willing to offer to me. It was the “class or else.”

    No. No thank you. Offer weekend classes and then we’ll talk. Why weekends? Well… after an 8 hour workday, I’m not going to have the energy to attend a class. I’d do my darnedest… don’t get me wrong, but I’m not sure what I’d actually GET out of trying to put more into my day when I’m already wiped out.

  8. Jill at 5:44 pm

    Dr. Darnell, I’ve reread your article a few times and frankly am unsure you really”get” the issues of chronic pain patients . You probably think you do and perhaps you are a very kind lady trying to help, but you don’t seem to understand that we are in emotional distress when you talk about reducing the medications that we KNOW help us manage pain because we don’t want more PAIN! It is beyond me that you would find that difficult to understand. Alternative treatments are not new. I’ve had back pain for thirty years and of course I’ve tried everything. All chronic pain patients try everything. We are in pain, that doesn’t make us stupid! We take opioids because that’s what works best and we take them responsibly. It’s not hard to quit. It’s out of your system quickly and withdrawal symptoms are no worse than the other nightmares we go through. But we want to live a functional life and why shouldn’t we. We’re as removed from street addicts as you are, Dr. I am stressed,angry and anxious regarding the CDC protocols because I have been in pain for so long and will be every day until I die. If the opiods go the pain will be worse. It’s just that simple.

  9. Dave at 5:20 pm

    Pain- and the suffering from pain has proven more then a match for Stanford University and our society.
    Dr Darnall- like most professionals overestimates the ability of her intervention programs to meet the needs of people suffering from pain and undrstimates th complexity and challnge of suffering from pain. The science and thinking behind such programs stems from efforts to simplify treatment for all people in pain to a relatively small combination of treatmnts that is based largely on population studies that arent designed to provide for individual needs of people in pain. Moreover their is a lack of appreciation by professionals and government in understanding just how underpowered approachs to pain currently are. They live in a state of blissful denialism.
    If we are to make much progress in pain care then continuing on the same path of new and improved medications and combining them with some alternative treatments isnt going to make much of a difference for many people suffering pain. Professionals need to do what they might claim is walking on water. They must let go of cherished assumptions about treatments and be bold and caring enough to give markedly different treatments and treatment approachs a chance. But to continue to believe that antipathic approaches combined with psychotherapy and eating a good diet will make things right for those in pain is terribly flawed.
    Just treating pain is, to me like Yoda said- ” do or do not” Lets fix the suffering and not merely “treat” pain with dated approaches and treatment regimens that dont even attempt to cure pain or renew the individual suffering pain.
    Its time America get out of its reinforcement loop- a viscious circle of underpowered and dated approaches to pain and suffering and lets, with sinceritas, humilitas, caritas move toward a much different and better future for people suffering pain or any other condition.

  10. LouisVA at 2:38 pm

    Like many others that have commented, I started using opioids as a LAST RESORT at age 60 (I’m currently 66) and have suffered chronic, severe pain since childhood. Through these many years, I’ve tried virtually every possible treatment known to science, and NOTHING would stop the pain. For the last 6 years on opioid therapy I have had the best quality of life ever and can do things that I have not been able to do in many, many years. I’ve also used my meds in accordance with my doctor’s orders and have not had to increase my dosage. Now it looks as if I am facing being house-bound once again if my dose is lowered (or even worse if it is stopped). I fear the future now instead of feeling of the joyous feeling of good pain relief. The decision to use opioids should be between doctor and patient, not the patient and government or patient and insurance company (neither of which have a license to practice medicine). Isn’t it great living in a wonderful country that was formed as a democratic republic?

  11. Cathy M at 10:14 am

    Dr. Lawhern, good luck with that speech, and let us know how it turned out!!

    Carolyn S. – I would like to know how it turns out, too. I’m in OR, and I find it surprisingly (ominous?) that our OR tv station is advertising it as a “live town hall” – even though it’s in MD… I don’t have tv, but I’m gonna try to tune-in online. If I can stomach it.

  12. Richard A. Lawhern, Ph.D. at 6:11 am

    On June 5th, I will be a webinar participant in an FDA Public Meeting on Patient-Focused Drug Development for Peripheral Neuropathic Pain. I hope to make the following points:

    (1) For the long term, significant increases in funding are needed for the timely evaluation of selective Sodium channel blockers such as Convergence Pharmaceuticals experimental drug CNV10140802, and peptide compounds produced in spider venom.

    (2) In the intermediate term, funding is needed for the evaluation of Marijuana and its components in treatment of chronic neuropathic pain. There is a large body of patient reports of efficacy in a wide variety of pain conditions including neuropathy. Failure to explore this avenue should be viewed as medical malpractice.

    (3) In the near term, the single most important recommendation that can be generated by the FDA public meeting, is for the immediate withdrawal and rewriting of the CDC voluntary guidelines for prescription of opioids in chronic pain of all kinds. The guidelines have already resulted in withdrawal of multiple pain management physicians from practice, and the plunging of their patients into unsustainable agony.

    I may only have two minutes during the webinar to make these points. Hopefully I won’t be cut off before I’m allowed to speak.

  13. Richard A. Lawhern, Ph.D. at 5:55 am

    Llinda, when you talk with lawyers, may I suggest that you raise two questions:

    (a) What specific grounds might be used in such a lawsuit? (My instinct is that the central question if denial of care due to imposition of unreasonably restrictive practice standards)

    (b) What should be our expectation of the time and cost to win such a lawsuit, based on other successful class actions?

    These questions may have direct bearing on the charter and structure of any non profit organization that will be involved in raising funds to hire and sustain the law firm which prosecutes the suit.

    Regards, Red

  14. Carolyn S. at 5:00 am

    Cathy M., I would be interested in knowing how the meeting went in Maryland at the Town Hall about the Heroin Epidemic. We had a chronic pain crisis in Buffalo, NY and surrounding areas when a pain management facility was abruptly closed due to government interference, leaving 10,000 patients to fend for themselves. A handful of patients went to a similar meeting. After patiently waiting 3.5 hours, a few questions were asked about the comparison of addicts and people suffering chronic pain. The keynote speaker dropped the mic and walked off the stage. The next day, the media reported that the meeting was hijacked. It seems that those addicted to heroin have more places to get help than the chronic pain sufferers, as we were being turned away by the entire medical community. PCP’s, ER’s and outpatient clinics refused to do ANYTHING. After a little more than 2 weeks, the crisis has temporarily been averted, but a lot of damage had already been done.

  15. Matt at 11:18 pm

    First, there are no alternatives to a pain medication that’s origin comes from a plant which has been used to alleviate pain since the beginning of time.
    Fossil remains of poppy-seed cake and poppy-pods have been found in Neolithic Swiss lake-dwellings dating from over 4,000 years ago.
    Virtually every society through out history has used the poppy plant without harm until the British Empire decided to use it to purposely enslave the Chinese in the 19th century.
    No other analgesic has less side effects, or safer for the human body. 98% of all people in legitimate chronic pain abuse their prescriptions.
    I am in the same boat as the rest of you. My doctor had a visceral response to the CDC March guidelines until my wife who works in a Michigan hospital talked to the person in charge of implementing all the information coming from Washington and our State’s capital.
    Here is the bottom line;
    The CDC guidelines are just that, guidelines. There is no law on the books that makes this mandatory. The doctor still retains complete and total autonomy to prescribe opiates to patients that demonstrate cause for it’s use. The doctor’s responsibility is to document that all alternates have been exhausted.
    The problem is in the way the government sends intimidating letters to doctor’s implying that their license to practice will be in jeopardy if they do. Here’s a hard pill to swallow…..THE GOVERNMENT IS LYING. I know, hard to believe.

    There is an agenda that they have, some is difficult to believe. One of them is the money Big Pharma is making pushing new drugs with side effects you hear as they advertise them on TV. Remember that most opiod based drugs are generic.
    Pain clinics don’t make money prescribing what you need, they make money on all the severe torture they put you through. 2/3 rd’s of the population are baby boomers that are ready to start receiving social security from a system that is bankrupt. Where is the money going to come from?
    I live in a very small rural area that looks like Mayberry RFD and the police busted 3 Heroin dealers last month.
    On a PBS special series called “Drugs Inc” a border sheriff stated that the government has only been able to stop 1% of all illegal drugs coming across the southern border. That’s 99% that’s getting through.

    Imagine if you will that a drug responsible for over 500,000 deaths a year was the target. Imagine if the government intervened and ordered that all addicts of this drug were going to be cut off immediately, or that they had to go to a Nicotine clinic. If they are currently smoking two packs a day, the doctor cut them down to 5 cigarettes a day. But I forgot to mention, the government makes millions on tobacco taxes.
    Just like Marijuana, once taxed it’s now legal. But what about the propaganda movie “Refer Madness”? Legalized Marijuana? Didn’t the government pound into our heads that it was a gateway drug that leads to Heroin?

    If we want to save our Constitutional right to Life, Liberty and the pursuit of Happiness, we better start fighting before it’s too late.

  16. Sara B at 9:28 pm

    Great post – opioids are not a panacea, but these changes are being made in a vacuum, as you both know. Alternatives are the only answer – we need to lobby for large increases in research for new pain treatments! Now! But until these alternatives are available, everything else needs to remain “in the table”. In the long run, educating docs & patients about the problems with opioids is great. Too bad they’re doing such a poor job of it…,

  17. G. Depaolo at 7:43 pm

    Help! After being a responsible Percoset user for level years, when every other treatment and surgery has failed, my doctor just stopped writing these scripts for me with no alternative remedy for my chronic pain.

    This is sadism. American government has got us in its grip and there is nothing we can do as sufferers. Free country, my a**!

  18. Cynthia at 7:27 pm

    I am totally confused. Last week, there was an article on NPR about Obama signing something and making a statement that indicated doctors should not be interfered with when it comes to prescribing pain meds. Did I misread that? Can someone clarify? THis article about CIGNA contradicts what I thought I read.

  19. Cathy M at 7:00 pm

    This is it! This is the smoking gun!! This is why they have done the rabble rousing so that America is terrified of this “opioid epidemic”:

    https://braeburnpharmaceuticals.com/titan-pharmaceuticals-and-braeburn-pharmaceuticals-announce-fda-advisory-committee-recommends-approval-of-probuphine-first-6-month-implant-to-treat-opioid-addiction/

    Titan Pharmaceuticals and Braeburn Pharmaceuticals Announce FDA Advisory Committee Recommends Approval of Probuphine, First 6-Month Implant to Treat Opioid Addiction
    SOUTH SAN FRANCISCO, CA and PRINCETON, NJ – January 12, 2016 –Titan Pharmaceuticals, Inc. (NASDAQ:TTNP) and partner Braeburn Pharmaceuticals today announced that the Psychopharmacologic Drugs Advisory Committee (PDAC) of the U.S. Food and Drug Administration (FDA) voted 12 to 5 in favor of approving Probuphine, the first long-acting, subdermal buprenorphine implant for the maintenance treatment of opioid addiction, in stable patients receiving 8mg or less per day of buprenorphine.

    THIS IS A SIX-MONTH IMPLANT – you can imagine how expensive it’s gonna be. There is no way the insurance or govt. would pay for it, unless there was a “crisis of epic proportions”… sorry to be a cynic, but this is the kind of shoe I was waiting to drop — the huge financial incentive to cause people to try anything to deal with something that suddenly has become a crisis (even though numbers show the prescriptions have been dropping since 2013)… here’s another article that talks about it, and has some people expressing reservations, considering the results of the few tests done:

    http://www.mcclatchydc.com/news/nation-world/national/article79588787.html#storylink=mainstage

    Dang, I hate it when my cynicism proves to be not cynical enough…

  20. LINDA LENTINE at 6:11 pm

    I think we should file a class action law suit for all the pain , suffering & yes suicides that are caused from taking away our pain management medications . I am going to begin calling lawyers . Thank You , In chronic pain all the time

  21. Pharmacist Steve at 3:00 pm

    I think that this is GREAT… Cigna has reached the pinnacle of arrogance… up until this point insurance companies have attempted to practice medicine and denying care by hiding behind quantity limits and required prior authorizations. A insurance company does not have a license to practice medicine and it is ILLEGAL for a prescriber – like their medical director – to treat/prescribe one of their policy holders without doing a personal exam.
    I can sense the attorneys circling … because Cigna has publicly stated that it is going to determine what is medically necessary (practicing medicine) on a particular group of patients that are covered by the Americans with Disability Act.

  22. Won't tell at 1:50 pm

    I already have been screwed by this BS.
    I wish these people would have to endure all this chronic pain for awhile.
    I just pray that I die in my sleep every single night.

    There’s a chance I have cancer, maybe it’ll kill me, and I’ll not have to suffer anymore.

    SCREW OUR HEALTHCARE SYSTEM!

    Hell, I’m currently praying for death. Anything to end this suffering.
    Dogs are treated better.

  23. KIP at 1:25 pm

    Hi Tracy,

    Without knowing your exact scenario, I can only offer my experience. I too had pseudarthrosis (failed fusion/non-union) at L5-S1 from a level 2 posterior minimally invasive (?) L4-S1 fusion. About 6 months into my recovery, I began experiencing excruciating pain. CT revealed loose screws and non-union at L5-S1. Revision surgery involved going in from my back, removing the hardware, and ensuring the L4-L5 was fused/fusing properly, then going in anteriorly (invasive) and fusing the L5-S1 with a plate. Unfortunately, I was still in unbearable pain. 2nd and 3rd opinions revealed that the L4-L5 was in fact, NOT fused. I was virtually walking around with an unsupported broken back.

    If you are not already aware, the more levels fused, the greater the risk for a failed fusion.

    BTW – I opened a claim with DORA (Colorado Medical Board), and after 18 months of investigation, my case was disposed.

    Best of luck to you!

  24. scott michaels at 1:05 pm

    thanks ed
    are they just that stupid. dont they understand for us the opioid therapy is the vest of 2 evils. As long as taken as direvted and not abused opioids therapy is fine.
    If taken away, yes the widthdrawls will be aweful, but tey will ho away. OUR PAIN WONT AND IN MANY CASES BE WORSE THEN IS WAS BEFORE THE THERAPY.
    WHY IS OUR COUNTRY PANDERING TO PEOPLE THAT BREAL THE LAW, MIX DRUGS AND ACLCOHOL, USE AND STEAL OUR TYPE OF MEDICATION TO GET LOADED. THE JUNKIES OF THE WORLD ARE NOT VICTIMS. Anybody who has gone thru the 12 steps of recovery know this. Why dont these so called addiction specialists andinsurance companies.
    MARK MY WORDS IF CIGNA WAS FORCED TO PAY FOR 30 TO 90 DAY INPATIENT REHAB AND THEN CONTINUED CARE FOR US. THEY WOULD CHANGE THEIR TUNE IN A MINUTE.
    PRESCTIPTION OPIOID USE IS BACK TO THE LEVEL IT WAS IN 2002. THIS IS BECAUSE ALL OF THE BEW RULES WORKED, DEA list, URINE TESTS, CONTRACTS etc.
    It took the criminal element out of prescription pain pill, except the few with no conscience that steel them from grandparents or parents.
    Its like our country needs something else to focus on, other then us

  25. Danny at 1:01 pm

    Cathy M, I appreciate your suggestion, probably more than you can imagine. I was thinking of taking your idea a step farther and using an attempt at humor to help get it BIG attention. Sadly, I don’t want to offend anyone, so I’m just gonna suggest, tongue firmly in cheek, that we all become LGBT, too…

  26. Cathy M at 11:41 am

    I posted this on the original CIGNA post, but wanted this group to see it. Here’s my idea: Let’s push through a federal bill that requires all insurance companies to PAY DOUBLE if someone commits suicide and there’s evidence that it was due to untreated pain. I am not being sarcastic – hitting them in the pocket book is the ONLY way to make them pay attention! If they are held responsible for double life insurance payments (instead of none, with suicide, as they have now), they would have a huge incentive to change the pain relief laws – and I bet they’d do it. Let’s make them put their money where their mouth is!! What do you think?

  27. KIP at 10:50 am

    In short, before 2 failed spinal fusions (L4-S1) in 2011, 2012, I was an avid/accomplished marathoner residing in Colorado. I should add that I have degenerative disc disease, warranting an additional C4-C7 fusion…NOT! In order to give me any quality of life, I was placed on opiates, muscle relaxers, and neuropathic medications, and unfortunately am self-insured by CIGNA. Perhaps coincidental, but I just received my EOB, and they refused to cover my last PM appointment, stating that he was out of network. They had no explanation, however said that they would take care of it. I hope/pray this is not an indication of what is to come. First it was King Sooper/Kroger who had implemented their own regulations to supersede DEA/FDA – 120 opioid tabs per month, regardless of type oxy/hydro, ER/breakthrough. Colorado has been using a PDMP (Prescription Drug Monitoring Program) for numerous years. This should provide doctors with possible ‘doctor shopping’, early refills, etc. This, in conjunction with the random UDTs (urine drug tests) given by PM doctors, should provide preliminary and sufficient information for any patient misuse/abuse. My doctor goes over his report at every visit. Thankfully, living in CO provides me the opportunity to ‘experiment’ with various strains of cannabis as an alternative.

    Bottom line: should chronic pain patients be deprived of their ONLY means to relieve their pain, they may very well turn to alternatives. However, since insurers do not cover, or cover limited options, we may see an increase in alcoholism, illicit drug use, and worst case, suicide.

  28. Jill at 10:41 am

    Danny, I agree. Most of us would love to lessen our pain without opiods. But that is all pain meds do, lessen the pain. It never goes away completely! If I make lifestyle changes such as staying on the couch all day doing cognitive therapy my pain is reduced. But what quality of life is that! How will your heart and bones and digestion deal with the inactivity? I hate that I have to defend taking pain meds to anyone. If I didn’t need them I wouldn’t take them!!!

  29. Renee Mace at 10:33 am

    To Beth Darnall, PhD:

    I read your letter and I wish you knew more about different kinds of Pain Disorders because as you stated, One dose doesn’t fit all, what I am saying is please tell me in your educated opinion, how to you treat Central Pain Syndrome, I have tried all and I mean all of the different “alternative treatments” and not one of them helped me. So please tell me other than pain medication what treatment will help my chronic throbbing pain in both my legs that worsens with my legs hanging down while sitting or by walking even to the bathroom. I lay in bed with my legs elevated and with my pain medications, I can get my pain on a 5 on the pain scale, but when I get up to move then it flares to a 9. So if you reduce my pain medication I will have nothing left to distract my pain from when I use the Biofeedback and Relaxation technique, which I am doing right now by writing this to you to distract my brain from the intense pain. If I didn’t have my medications, it would never work for me. You see there is nothing wrong with my legs but my brain says different, my brain was injured from being unconscious and now it miss fires that I am in the most savage pain that makes having labor pain be a cake walk. So again tell me why lowering my dose on pain medication with CPS, how that will enrich my life and help me to live???? TELL ME PLEASE, I AM LISTENING??????? I know that there are thousands of pain disorders so I can’t vouch on all of them, but I can say that you can’t treat us the same as doctor’s like Richard A. Lawhern, Ph.D. or Dr. Merle Janes who by the way saved my life, would. They work with each individual trying to find out what’s wrong with you and trying everything under the sun to help you and in some cases the only thing that works is pain medications. At present, there are no cures for Central Pain Syndrome and it only gets worse every year, so how is lowering my medications going to help?????

  30. Chris at 10:31 am

    Some of the problems are w/ the controlled release, or all the different ways the say “release.” The old med WORKED and gave me back to my family. I was able to take my meds responsibility. To help addicts at our expense shows a lack of knowledge. Two different; almost opposite to one another. After the changes are made, we Chronic Pain survivors, are left holding the bill. Meds no longer as effective, restrictions coming in between Drs. and patients, how is this even legal???? We don’t get a buzz, we get some relief. People w/ addictions just move to another high.

  31. Danny at 10:22 am

    Dr. Lawhern,
    Your comments always add a great deal to whatever issue is being discussed. I want you to know that I appreciate your input.
    When I referred to the “alternative treatments” I’d been thru, your list of nin-opiod treatments could’ve been copied from my medical records. Almost every single thingyyou wrote, my Drs tried on me before narcotics were introduced. I felt that my comment was too long, already, to write out that info. Just mention that to prove that most Drs, even 25 years ago, are hesitant to start with narcotic medications. The relief I felt, after about 3 years of those alternative treatments, was LITERALLY a life saver.
    Again, thank you for your attention to this situation and your informative comments.

  32. Elizabeth at 9:52 am

    Oh and PS:

    You may now cease accusing us Chronic Psin patients of experiencing “fear and anxiety” of losing our treatment , when you know very well that what you are getting in feedback is unbelievable frustration from not only Chronic Sufferers with incurable diseases, but frustration and disbelief from Scientific professionals who also know better .

    You do not need to address our fear and anxiety. You have yet again been unable and uneducated enough to understand what we are going through. We are at a disbelief of the archaic nonsense of these suggestions , the assumption that we’ve never tried them and the absurd audacity at making the ridiculous stretch to compare us with perfectly healthy street heroin users who endanger themselves out of choice!

    The sheer amount of ignorance and hubris is astounding. Be certain you are not fooling anyone but the average and nearly illiterate Anerican who never leaves their TV sets nor suffer any pain.

  33. Tracy at 9:41 am

    This is clearly an over reach of authority by the DEA, HHS, CDC. I have loose SI screws that need to be replaced but too am told recovery from pain and capacity to walk is a 50/50% chance . I cannot sit in hot water all day for relief. I do not tolerate physical therapy because of two herniated discs and one disc prolapse in the neck. I have gone from an active productive nurse in society to a home bound disabled person who is unable to walk without pain. Don’t tell me I need alternative treatments if you take away my pain mgmt. Do you have any idea to the ramifications of steroid injections, well thank you but no thank you. Do some research. I also have Leiden factor 5 and cannot take Asa, NSAIDS because of high blood clot risk. Is there a purpose for targeting law abiding citizens who are responsible. I am appalled at these liberal, quick fixes who are aware of the consequences but fail to yield to the common good.

  34. Elizabeth at 9:33 am

    Please help us. While this may be a new issue for these shiny, happy, bribe able useful tools…we have been living with a wide array of various incurable diseases, that the general populace only occasionally experiences, their “average” pain due to an accident or routine surgery, does not ever mimic or compare to the severe, intense and debilitating pain experienced by those of us with chronic pain who are simply trying to live.

    We just want to try and have half the life the average person is fortunate enough to have. On opiod a some of us can work, paint, be a good spouse, rescue animals, help communities .

    We are not new or uninformed of these proposed alternative treatments. It’s simply not new to us. We’ve experienced far more in this area than all the Policy Wonks put together.

    Everyone in the US knows that whatever politician is behind this is doing so at the monetary behest of Cigna, Anthem and others who have had their bean counters decide that not covering this miracle medication, they can boost their bottom line … at the expense of our lives. The expense of our only journey on planet earth. How can these people look themselves in the mirror? How do they sleep at night?

    They over commited themselves when they jumped in bed with political movements.

    It’s time for this country to separate healthcare from state. As we separate religion and state this too must happen between healthcare and state.

    Policy Wonks and sorry, but medical quackery does not trump all the research and science that had been discovered by brilliant Anesthesiologists, Medicsl Drs and Scientists to help humanity .

    Why are Americans going back to the day of leeches and quackery?

    We already know. We live this every minute of every day. We know what works. We have been guinie pigs to every new medication that hits the market .

    We go through experiencing all the horrific side effects every single time. Opiod a are so close to nature and chronic constipation is a joke to the patient who is accustomed to, their physiology creates a symbiotic stasis with the medication.

    It’s easy to mislead the average joe and the inexperienced social worker and policy wonk, but know that the scientist, Anesthesiologists, pain specialists and Drs DO know what we chronic patients know and we see right through this and will always see through this low integrity campaign .

    You may be able to convince I tell risky limited people of the VDC Guidelines to accomplish your ends, but the truth will not be silenced and will emerge louder than ever, and all of you who’ve jumped on board this lunatic, hyperbolic, anti -scientific , crazy – train , by lumping street heroin users with poor chronic pain patients with incurable diseases , will have your day .

    You will have your day because karma is real by any name. And no matter what verbiage you choose to alter , remember a rose is a rise by any other name . Science is science even when you try to make it into hyperbolic emotional issues over facts.

  35. HAZZY at 9:17 am

    Im in pain management at the moment, Ive had two Back Surgeries, one a Fusion and they both failed !!!! Ive been in pain since 1992. Pain Management cut my Meds down to a 28 Day Supply so, when i go back to the Paim Management Doctor, i have to fight for my Prescriptions. These people that get Pain Meds just to get High are the problem, Oh i forgot the Government also, they need to keep their noses out of our bussines. I take my Meds as Prescribed, my wife gives them to me everyday and they are locked up in two Safes.

  36. Geo Sims at 8:47 am

    Hi Kris –

    We kept the longer, more inclusive (2nd) comment; however, when reading this 3rd comment, I did have a good laugh – so thank you! And thank you for your continued readership and contributions.

  37. Patricia Charles at 8:40 am

    I am a 67 year old female with multiple pain and mental problems. Because of you I am losing all my help to live as a fairly decent life. I will be back in bed ,using a cane or walker. My life will die. How do you feel about people like me and what is being done for us.

  38. Kris at 8:33 am

    oh well would you look at that! my computer died and I lost it..it said 0 comments so I wrote again ..Now I see I have 2 comments…

    oh if you could see me laughing right now!! wonderful..I feel good enough for that shower now

    Remember keep laughing even when your computer dies just when you hit send……just laugh

    and I guess the moderators can pick which story they like best but I hope they are all laughing too!! as I post this 3rd one…this is just for laughter I mean really?? icing on the cake..I had no idea the 1st comment made it…when I went back it did not say I had any comment waiting for review….LOL…hugs and laughter to everyone! and I hope you all pick the best and at least get a good office laugh on this one

  39. Cathy M at 8:29 am

    Firstly, I want to thank Dr. Darnall for at least understanding that most of us are responsible medicine consumers. A couple points on her assumptions though: 1) no one seems to want to admit there are NO studies done on longterm benefits of opioids for chronic pain. None. Bupkis. They talk as if it’s settled that they “don’t really help” – and we have to keep fighting that!! (Note – she says, “MOST patients find they are no panacea” – what exactly is she saying, and where is her data?)

    And she (and others) shift the dialogue, to chronic pain patients who are “having problems” – well, duh – yes, they need to explore other avenues. WE are talking about those of us who take the meds, have had no problems or side effects and want to continue to use them to have a functional (as much as possible) life – and are being denied them “because rules” – even though, she claims, doctors “have discretion”. I say they don’t have discretion anymore due to the pressure, either overt or covert, on them to stop! Let there be oversight of these oversight committees by a third party who doesn’t believe (as they seem to) that opioids “are not helpful for longterm chronic pain” – when I hear spokesdoctors saying it’s been misguided to give pain sufferers narcotic relief, I totally doubt their objectivity!

    2) She says: “We need to acknowledge the emotional distress and deliver treatment approaches to reduce it. Give them access to alternatives. Then, if opioids must be tapered, help patients feel more in control of the process.” – Again – listen to the underlying assumptions: a) pain is really their emotional distress and their fear – if we “ease” that (with psychiatric meds – which have intense side effects!) then they won’t mind getting rid of the opioids b) which we’ve already decided they must do. When I hear doctors talking like that I know they are already not listening to me! And no where does she mention that if the pain persists, the patient will be allowed back to using a dosage that provided relief – I want someone to say that out loud, or I call BS.

    I have explored other alternatives to opioids, and they did not work as well (though I still use several as adjunctives). I would love to explore something like medical marijuana (note, not WITH the opioids – otherwise, how does one test it?), with the option of switching back to my usual low-dose norco if they didn’t work. But you note she’s not saying that anywhere! She’s saying she can “be nice” while taking people off meds – but she’s still saying she “knows better” about their pain relief!

    I am glad she mentions alternatives (I shudder when she says “ideally they should be available before”- that sounds like the new barriers in some states, where you have to try several alternatives before you are issued opioids, meaning you’re in pain for months if not years as those things are scheduled!) I totally agree that alternatives like massage, chiropractic, acupuncture and physical therapy should be more available. (I’ve been to some of those “manage your pain” seminars and they’re bunk – unless they are run by someone who has chronic pain! Each time, it’s some well-meaning clueless medical staffer who doesn’t understand pain at all. Like at the first session, she wants all of us to lie flat on the linoleum tile for half hour “to relax” – I can’t even get onto the floor!) But even more, insurance companies need to be pressured to allow primary doctors sufficient time to actually work with a patient in chronic pain!! It’s inevitable that the solution is forced when one has only 10-15 minutes to deal with all the chronic and acute conditions since the last 3 months!! And thus the ball of misunderstanding, assumptions and ‘bandaids’ get rolling.

    I’ll end this long comment by mentioning a Town Hall on the “Heroin Epidemic” coming up this Wednesday in Maryland: http://katu.com/your-voice-your-future-town-hall-the-heroin-epidemic
    I hope that someone from this organization, or at someone with our perspective, can get into the audience there!!

    Also, I have written a rather long blog piece on pain, the mind and the new CDC rules, and it will be posted on Daily Kos, in the KosAbility forum at 4pm on 5/29 – anyone is welcome to come over and comment; I know there are many here who have cogent information.

  40. Kris at 8:24 am

    wow..spent half an hour and my computer died LOL…

    Well I guess I will start over but…I need a shower

    so I take norco 5 for my back and neck..great! YAY okay I have many other painful problems no one not even my pain doctor will treat me for with a higher dose

    interstitial cystitis
    endometriosis
    Atypical facial pain
    burning to death privates

    now he does necks and backs and fine….insurance used to pay for injections that got my neck out of pain for a year!! they do not cover those injections for me anymore because on my X ray my neck looks nice!!! isn’t that special….LOL..now I am going to keep laughing because this is a self taught tool I use to get me through life as I am stuck on my couch not able to function with a heating pad on my privates

    Oh yes I do exit my couch in major pain to go to doctors to try and fix me…..

    So I have been in counseling for years…with many counselors..I do have the best right now

    and I have self help tools of distraction,,meditation, biofeedback learned relaxation..and physical therapy tools…I have a whole TOOL box……

    THESE DO NOT WORK … when your pain is so great..and I gave birth to 2 babies 1 c-cection and 1 vaginal so okay I know pain…….

    Now enter me stuck on my couch with my heat pad so hot that I have purple veins coming out on my thighs……yep they are there for life I am told..why?? because a doctor will not give me something so I can function…hmm….when it gets really really bad and it does…I sit in a bath as hot as you can imagine just to take that burning feeling away..so my life could be stuck in a bath life…..that gets boring….

    So I have my tools …I have my pain..I have my illness’s that are not curable..no none of them are…

    so what do I do??? I laugh…oh and I rip out body parts! oh this is fun…I had a complete and total hysterectomy because more than 1 doctor said…this will fix you right up!! no more pain!! boy did I fall into that one …..nope….still same pain…less parts …I do not care I was done with those parts I am 45

    so yesterday I ripped out 1 more tooth..hey why not? it can not hurt …right? to keep looking praying some doctor is wrong because I do not respond to the anti depressants and anti seizure meds and muscle relaxers

    in fact my dumb bladder flares to just about anything these days….I just laughed again

    I thought put their head on my body for a week…and see how they feel about the need of pain meds in the world….no most people would be dead by now

    oh and I may too someday chose to take my self off this earth
    because I WILL NOT spend the rest of my life stuck on a couch with a heating pad or in a hot bath not able to function

    oh but not yet ….see I am a fighter…so now I am going to extreme diet change…and oh I better be careful because I am only 90 lbs now…well that might put a damper in my all raw food juicing plan…..dang!

    yep I have been dealing with ongoing infections for 3 years..in my bladder and vaginal area..I have been on antibiotics everyday month for the past 3 years…so I am sick on top of this

    but no one can stop the infections and I have been thrown from this specialist to that one
    my blood is good..I have no autoimmune disorder …no reason why I keep getting infections.But infectious disease after 3 referrals still will not help because oh..they say I am not contagious……………………………………………………………………..okay…..than how bout a pain med to get me off my couch.??????

    but I am dying regardless it seems….and I would really like to live my last time on earth OFF MY COUCH and maybe at a movie!!!

    well..I think you got 1 person’s picture and if I did not paint it clear enough it is because this is the 2nd time I wrote lol

    so I say Keep laughing because that is all we can do and with every tool any one ever gave me …no one gave me my sense of humor that I taught myself….laugh laugh and laugh you will distract your self for as long as you laugh…when you stop the pain will return and you will cry and sometimes it hurts more when you laugh……………but…………I ……….still…laugh

  41. Amy Frank at 7:20 am

    I spoke to the lady this last week who did the (yes, I take my medicine) drug test. She told me that the government doesn’t care about us who suffer from chronic pain. She told me they could make a pill that had the component of Cannabis that stops pain with out the part that is a narcotic. That means I would have a drug that would not make me high or make me addicted but would treat my pain. As it stands the doctor was forced to take me off one pain pill a day so now I have only three per day instead of four per day. It means I never sleep at night. I got on the opiods because over the years nothing else worked. I had done everything else. And I use more than one method to keep on surviving with this serious pain.

  42. Richard A. Lawhern, Ph.D. at 7:17 am

    Thanks for Beth Darnall’s thoughtful comments. If I may, I would add one footnote. Among the thousands of chronic face pain patients whom I’ve supported for 20 years, there may be a few hundred who are prescribed opioid medications. Among those few hundred, opioids were almost always offered as a LAST alternative, after nothing else worked well enough to give them a quality of life.

    As parts of “nothing else”, I include a wide range of both medication and non-medication therapies. Some patients resort to surgeries such as RF Rhizotomy (creating a controlled lesion on a nerve) or Neurectomy (severing a nerve). Peripheral neuro-stimulators are also beginning to come into wider use, though they are still considered experimental and reliability seems to be in the range of 50% and lower.

    Non-opioid drug examples include SSRI meds, steroids, anti-anxiety meds, anti-convulsant meds like Tegretol and Trileptal, tri-cyclic antidepressants like Amitriptyline and Nortriptyline (used off-label, but widely recognized as effective for neuropathic pain in many people), and homeopathy remedies. Non-drug alternatives include acupuncture and accupressure, myo-fascial release, osteopathic massage, cervical chiropractic, aroma therapy, vitamin B-12 shots or capsules, Cognitive Behavior Therapy, conventional psychotherapy for anxiety, meditation, mind-body centering techniques, and Tai Chi Chuan.

    Each of these modalities has their advocates, and each appears to help a few people some of the time. But my reading of hundreds of patient reports is that none of these techniques is uniformly effective, and many of them help only a small minority. Thus my observation is that opioids are very often a solution of last resort after many other therapies have been tried and failed. Placing people back on these previously failed therapies is NOT an appropriate step for most chronic pain patients, nearly all of the time.

    Nobody should be taking opioids casually — and I firmly believe that the days are largely over when pill mills could pass out opioids like candy, without drug screening or appropriate follow-up oversight. Caution is also much needed in over-prescribing opioids for acute post-surgical pain when other analgesics may have an acceptable and reliable record of pain relief. And finally, I believe that patients in chronic pain should be educated and prepared to store opioids under lock and key when used at home, to cut off a major avenue for drug diversion into street markets. When there is an adolescent at home, this step is especially vital, as the majority of drug abusers start in their teens.

    It is time for mainstream medicine to stop the war against chronic pain patients!

  43. Danny at 7:15 am

    As far as I’m concerned, this is a case of deja vu, all over again. Since the beginning of this attack on opiod medications, the use of the phrase “alternative treatments” has been bandied about, over and over again. What isn’t being plainly stated is what I believe Associate Clinical Professor Beth Darnell, PhD, and many others, are specifically referring to. And what frightens me is the possibility that many chronic pain sufferers, fearful of what the future holds with the opioid medication they KNOW is working well (as opposed to “they ‘BELIEVE’ is WORKING well”, as is written in this article) will cling onto these “alternative treatments” as a legitimate replacement for the medicine that’s working but is possibly going to be taken away. My experience with alternative treatments proves otherwise.
    I was sent to highly reputable Pain Clinics when my doctors realized that my chronic, severe head pain wasn’t going to be “cured” and it wasn’t going away on its own. At these clinics, I was intensively trained how to use Biofeedback and Relaxation techniques. That was my first exposure to the phrase “alternative treatments”.
    Dr. Darnall refers to the “anxiety, anger and feelings of injustice” as well as “the emotional distress” resulting from opioid medication being taken away and how there need to be “treatment approaches to reduce IT”. The “it” isn’t pain, it’s the emotional upset. THAT’S where Biofeedback and Relaxation techniques are quite useful! Not in reducing pain. Not in my experience, at least.
    These alternative treatments can be successful when used IN CONJUNCTION with opioid medications. While my pain is a 24/7/365 presence in my life, I have episodes of severe, #10 pain (you know what that means) that last, uninterrupted, for 4 to 14 days. It’s during these episodes that my body tenses against the pain. My teeth grind, my facial muscles become rigid and I can get extremely angry/frustrated/hopeless. This is when my training in Biofeedback and Relaxation is extremely valuable. I focus and use it to reduce the physical tension and emotional distress caused by the pain. And, it works! By relaxing my muscles, reducing the tension, lowering my heart rate and reducing the emotional distress, it helps me to endure, whether by falling asleep (the greatest escape from my pain) and/or by experiencing a sense of empowerment – actually doing something, other than taking medicine, to fight back against the pain. But, IT DOESN’T reduce the actual pain. It only helps me to handle things that the pain causes.
    I’ll finish by saying that I’ve also tried other “alternative treatments”, such as acupuncture, deep tissue massage and chiropracture. None did anything for my pain. However, I’ve heard of people who do get pain relief using these treatments, so I know it CAN work. Also, I’m sure there are other treatments that I am not familiar with and haven’t tried. But, until someone discusses them, in detail, and informs us of the specific ways they actually REDUCE PAIN (selfishly, my specific pain), how are we to know if they are actual alternatives to our medications? Dr. Darnall mentions that she’s “seen many” cases where people tapering opiods “reduces problems… They get better”. They get better because the side effects of the opiods were as difficult as their pain? What I want is for my pain to “get better”! Yes, I had the pain before I was started on narcotic pain medication, but I can’t live with that pain. That’s why I need the medicine. If it can be reduced without medicine, I’m all for it! I think all chronic pain sufferers would choose pain relief without opioids. I just haven’t been shown how it can be accomplished for me. Please… SHOW ME! Be specific in explaining alternative treatments, how they work and what types of pain they’re effective in treating.

  44. Carla Cheshire at 6:22 am

    Very well put doctor! You cannot take medication away and leave people trying to survive with pain with nothing to help them. It is a recipe for disaster.

  45. Bill Mill at 5:52 am

    Once again we have so-called leaders in the forefront of pain treatment spouting off opinions and not giving examples of real alternatives. That’s because there aren’ t any. I have been a physical rehabilitation therapist for 35 years and have worked with thousands of patients with a variety of diseases and injuries, to include “pain management”. There is nothing new about patients being treated with epidural steroid injections, massage, tens, exercise, pain pychology groups, or OTC meds. The fact is that medicine or the governmental powers that be proclaim to have treatments that fail to provide a long- term cure. This is why we call them palliative treatments. Spend one week in hospital burn unit, a nursing home, a children’s cancer ward , or a veterans rehab unit and you will see pain. We have no new treatments. We just like to keep billing insurance and Medicare because medicine is a business. It pays to keep patients coming back for years.
    There is no incentive for doctors or clinicians to make the right diagnoses. So, I am lying here in my bed with an inoperable brain tumor. I will live a fairly long while. My doctor is afraid to prescribe narcotics. Do you think OTC Adil will help my unbearable pain?
    Do you think that exercising will make me feel better?
    Stop in to your local rehab or pain unit. You will see nothing new on the menu. We have gone from Pill Mills to Bill Mills.