By Dr. Jay Joshi.
Editor: When the National Institutes of Health announced recently that it is launching a joint initiative with pharmaceutical companies to spur the development of drugs to address the opioid epidemic, we reached out to an occasional contributor to the National Pain Report, Dr. Jay Joshi.
Dr. Joshi is CEO/Medical Director – National Pain Centers in Chicago. We’ve been attracted to his patient-centered common-sense approach to dealing with current approaches to treating pain.
He provided the following thoughts:
The NIH outreach will start with a series of private workshops over the next six weeks and focus on three areas:
- Developing interventions for reversing overdoses, including medicines and wearable devices.
- New treatments for opioid addiction, including medications and even vaccines.
- Non-addictive treatments for chronic pain, including new compounds.
On a positive note, I am very happy that steps are being taken to ensure safety for patients nationwide. There are many talented people at both the NIH and in the pharmaceutical industry and I sincerely hope the best and brightest find solutions quickly. How can anyone dispute the altruistic goals of developing technologies that saves lives, medications that are safer, and non-addictive options for chronic pain?
On the other hand, substance abuse and overdose deaths are nothing new. I have been cautioning about the dangers of opioids, and Oxycontin specifically, since the late 1990’s prior to my medical training. Having worked at the World Health Organization’s Department of Substance Abuse in Geneva, Switzerland, I participated in the development of international substance abuse education while my professors and other physician in America thought that I was wasting my time! When other physicians, especially in the university setting, were prescribing “opiates for everyone”, “there are no dose limits”, and “opiates are not addictive as long as you have pain”, I felt compelled to stand up for logic and common sense. Those physicians are still considered “experts” and are interviewed by the media all the time. What a joke! The hypocrisy and bandwagon jumping is shameful. Some of those experts are now the physicians who think that all opiates are the same and that they are all unnecessary regardless of pathology. Opioids have been used responsibly for thousands of years for painful conditions (with the keyword being responsible).
Is the NIH outreach really going to address this epidemic that we are currently experiencing? What are the realistic timelines for their fairly ambitious objectives? Has anyone accurately defined this epidemic? Many real pain physicians and pain patients do not think so because it is not an opioid epidemic, it is a Stupidity Epidemic. Have you noticed that after all of these high-level meetings, recommendations, guidelines, and warnings, the following set of questions are never asked together?
- Is the patient a legitimate pain patient?
- Has the patient been prescribed legitimate molecules?
- Does the medication have a legitimate formulation technology?
- Is the medication prescribed by a legitimate pain physician?
- Have the medications been legitimately manufactured (non-counterfeit and non-substandard)?
- Is the treatment part of a legitimate multi-modal pain strategy?
The Stupidity Epidemic has caused more suicides because of inappropriate pain management than prescription opioid deaths, even from illegitimate patients and illegitimate medical care. If that figure doesn’t put this epidemic into perspective, I don’t know what will. Allowing chronic pain patients to suffer because of stereotypes, insurance denials, discrimination, and a fundamental lack of understanding of the complexities of pain is just plain ignorant, inhumane, and anti-American. Chronic pain is torture and it terrorizes the patient’s brain. That condition is called central sensitization. For more information about central sensitization, please watch my lectures online.
We are still seeing illegitimate patients who are trying to get high. We are still seeing prescriptions for “illegitimate” pain management molecules that are less safe, dangerous, and very addictive (here’s looking at you oxycodone, alprazolam, carisoprodol, zolpidem, etc). We are absolutely seeing prescriptions with illegitimate formulation technologies, for example, the infamous 12-hour extended release medication that really releases over 4-6 hours. The scourge of prescriptions by illegitimate pain physicians still exists as well, such as the prescription from “Doctor I-have-no-training-in-pain-management” or “Doctor I-prescribe-oxycodone-so-I-must-be-a-pain-doctor”.
Prescriptions that are manufactured illegitimately, such as counterfeit and substandard medications, is a major problem. I have been the national pain management physician leader on both education and solutions to this “Silent Epidemic” of counterfeit and substandard medications. Please watch my national presentations for more information. Finally, many patients are still a part of an illegitimate pain strategies where a complete lack of a multimodal approach, a lack of basic and complex conceptual understanding of pain management, a lack of quality, and a lack of interventional skills exist.
So yes, we are witnessing the Stupidity Epidemic.
All of these NIH advances will be meaningless until we have a society of patients and physicians that recognize that they may be victims of the Stupidity Epidemic. Swinging pendulums from one extreme to the other is useless and unintelligent. I have held steadfast in my belief about the problem with substance abuse since the late 1990’s when it was not a sexy thing to do and, as it turns out, I was correct the entire time. When I decided to never write a prescription for Oxycontin almost 2 decades ago, physicians and professors at universities and training programs thought I didn’t know how to manage pain because Oxycontin was all they knew. When I said that medical cannabis in a pharmaceutical-like delivery format can help with pain, they looked at me as though I was being blasphemous. When I discussed how properly administered ketamine infusions could reverse central sensitization, their heads short circuited like a bunch of Fembots from Austin Powers International Man of Mystery (one of the best documentaries about the human condition of all time).
The Stupidity Epidemic has caused the media and the so-called experts to lambaste safer medications all while promoting more dangerous medications. Case in point is Zohydro, which is a true 12 hour extended-release hydrocodone without acetaminophen. Before this medication was released on the market in 2014, multiple physicians and media outlets said that it would cause more deaths than heroin and other opiates. Even some of the major pain societies chastised it. Ironically, these societies are filled with pain physicians that STILL prescribe high doses of oxycodone, alprazolam, zolpidem, etc! In the last three years, to my knowledge, there have been no documented overdose deaths from Zohydro, but we do have about a 100,000 deaths from other opioids! Nice call, so-called experts.
The Stupidity Epidemic has caused insurance companies to force physicians to prescribe and pharmacies to dispense dangerous counterfeit, substandard, and generic medicines with variable bioavailability, efficacy, fillers, and pharmacokinetics. These insurance companies have denied safer molecules in favor of highly addictive molecules like oxycodone and fentanyl. They have also denied more stable extended release and abuse deterrent technologies. They have also denied appropriate and safer treatments such as Interventional Pain Management options.
In order to curb the Stupidity Epidemic, we have to make sure the patient is legitimate through a variety of screening tools. We have developed proprietary technologies that can help us identify illegitimate pain patient trends. That is the kind of progress we need. If the patient is truly addicted, they need to see an addictionologist. We need to focus on more legitimate molecules. The NIH outreach is trying to address that. But for now, that means we need to stop using the more dangerous molecules. We need to continue to encourage safer, legitimate formulation technology. Some of these technologies are available now and can allow us to lower dosage, lower side effects, and maintain or improve efficacy. We need to really start calling out illegitimate pain physicians and “Pain Practitioners”. I met a nurse recently who recently started practicing independently as a “Pain Practitioner” because she “knows how to prescribe Oxycontin” since she gave it in the hospital as a floor nurse…no joke.
We will really start curbing the Opioid Epidemic and the Stupidity Epidemic if we start authenticating medications that can be counterfeited and diverted. Unfortunately, pharmaceutical companies have been complacent in authenticating their products. People die because of counterfeits and complacency. If patients are part of a legitimate multi-modal pain strategy, you will see organic reduction of medications and improvements in function.
Chronic pain and substance abuse are completely different diseases but they sometimes overlap. They are not politically correct discussions and therefore this article isn’t either. We need leaders that understand these important points and don’t just huddle up in a conference room handing out participation trophies to each other for showing up. People are dying, both literally and figuratively, because of the Stupidity Epidemic. If we want to start having real solutions, we need to start being honest and call out what the real problems are.
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