STOP THE WAR AGAINST PAIN PATIENTS! – A Point Paper for Lobbying Legislators

STOP THE WAR AGAINST PAIN PATIENTS! - A Point Paper for Lobbying Legislators

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

STOP THE WAR AGAINST PAIN PATIENTS! State and Federal law-makers must introduce legislation and hold public hearings to force recall and rewriting of 2016 CDC Opioid Prescription Guidelines, and repeal State laws that limit treatment of chronic pain patients.

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  • An estimated 100 -120 Million people in America will experience long-lasting pain at some point in their lives due to injury, disease, or medical error.
    • About 18 million people have pain lasting longer than 90 days in any given year.
    • 2.7 to 3.3 million will be prescribed an opioid for longer than 90 days.
    • Fewer than 10% will continue their prescription longer than one year. [Ref 1]
  • By Richard A. (Red) Lawhern, Ph.D.

    Faulty public policy on prescription of opioids is damaging hundreds of thousands of people whose only offense is that they hurt. Some are dying.  Many more are being forced into disability. [Ref 2]

    • Pain patients who have been stable and well managed on opioid analgesics for years are being forcibly tapered down or outright denied the only medicines which make their pain bearable.
      • The widespread result is a wave of agony and disability as patients become bed-ridden and lose function.
      • Some patients are forced into unmanaged opioid withdrawal because of too-rapid tapering or outright cold-turkey desertion.
      • Some who are unable to bear their agony are dying by suicide.
    • Scores of doctors are deserting their patients and leaving pain management practice for fear of losing their medical licenses.
    • In a larger context, enough physicians commit suicide every year to fill a class of medical students, and 50% of doctors suffer from burnout syndrome. [Ref 2A]
      • No one can now predict the future effects of the resulting shortage of doctors on chronic pain patients - even before large numbers have stopped prescribing opioids to patients in pain. [Ref 2B]
    • The US Drug Enforcement Administration is using extra-judicial persecution to drive pain doctors out of practice. [Ref 3]
      • Confiscation of doctor assets and patient records without a judicial trial or verdict
      • Public announcements intended to destroy doctors practices
      • Coercion of prosecution witnesses using plea bargains
      • Prolonged delays in court cases to increase financial pressure and force consent decrees.
    • A key enabling element in denial of pain treatment is the US Centers for Disease Control and Prevention 2016 Guidelines on prescription of opioids to adult non-cancer pain patients. [Ref 4]
      • Although written as voluntary, the Guidelines are widely being used to justify mandatory limits on opioid dosing.
      • The US Veterans Administration was directed by Congress in December 2015 to make adherence to the Guidelines mandatory, not voluntary (four months before publication).
      • Several US States have enacted arbitrary restrictions on opioid prescribing, referencing the CDC guidelines as a standard.
      • Even where not required by State laws, many medical practices are denying renewal of patient prescriptions or discharging patients.
    • The CDC opioid guidelines are fatally flawed by a combination of uncritical anti-opioid bias, weak medical evidence, cherry picking of research and dangerously incomplete analysis. [Ref 1, 5]
      • The “core experts group” selected by CDC was unduly influenced by anti-opioid partisans from “Physicians for Responsible Opioid Prescribing” (PROP).
        • PROP had previously lobbied FDA against opioids but major elements of their proposals were rejected. [Ref 6]
        • Congress directed CDC to open its deliberations to public review, following complaints of violations of transparency laws. [Ref 7]
        • None of the core experts group had ever worked in community pain management outside a hospital. [Ref 8].
        • Although available in CDC, medical ethics experts were not invited. [ibid Ref 8]
      • Research was selected in a manner calculated to disqualify opioid analgesics in favor of non-opioid medication or behavioral therapies - neither of which were better supported by medical evidence or studied longer than opioids. [Ref 10]
        • Research on opioids is mostly in studies of less than one year duration.
        • Guidelines falsely state there is no long term benefit from opioids. [ibid Ref 1, Ref 9]
      • CDC Guidelines drew “strong” conclusions from “weak” evidence and personal opinion, omitting many confounding factors and reservations and ignoring contradictions between studies. [ibid Ref 1, 11]
      • Particularly disqualifying, the Guidelines make no mention of the natural genetic variations (polymorphism) between individual patients which affect ability to metabolize opioids and benefit from their effects. [Ref 12 - 14]
        • “Hyper”-metabolizers may over-dose on some medications (e.g., codeine, tramadol) or so rapidly process other meds that pain is relieved only for minutes rather than hours.
        • “Poor” metabolizers need far higher dose levels to get the same pain management as “normal” metabolizers.
        • Published case reports ignored by CDC indicate that tens of thousands of US patients are well managed on ultra doses over 2500 MMED, with little risk of addiction.
      • Genetic polymorphism means there can be no “one size fits all” threshold of risk or maximum safe dose applied to all patients.
        • Patients must be evaluated and managed individually.
        • This reality was completely missed or deliberately ignored in the CDC guidelines.
      • The US has a real opioid crisis, but it wasn’t created by prescriptions managed by doctors — and it won’t be solved by restricting treatment of patients in agony. [Ref 15]
        • ~90% of all addicts first begin abusing alcohol or drugs in their teens - long before they are ever seen by a doctor for any pain condition. [Ref 16]
        • A second reliable predictor for addiction is a history of sustained unemployment or family trauma. [Ibid Ref 15]
        • Although some sources assert that 75% of addicts may “begin with prescription drugs”, the source isn’t a doctor’s prescription to a genuine pain patient. [Ref 17]
          • Most drugs first abused by addicts are stolen from a family medicine cabinet or diverted by a family member who hasn’t used up a previous prescription.
          • Millions of doses hit the street every year from pharmacy and hospital thefts. [Ref 18]
          • Among deaths which involve an opioid drug of any kind, less than a quarter of the victims have a current prescription. Many deaths involve alcohol or an anti-anxiety agent. Some “accidental” deaths are likely suicides by under-treated patients. [Ref 19]
        • Addiction is not primarily a disorder of drug exposure. It is a “disease” of social disintegration and alienation among people at the margins of failing social and family systems.
          • Addiction is not deterred by fear of prison or other punishment. [Ref 20]
          • Yet our prisons contain millions of non-violent drug offenders who consume tens of billions in resources.
        • Finding solutions for addiction and for the management of intractable pain will not be cheap or easy - but this is not an either/or issue.
          • Pain patients can become dependent on pain killers when used for long periods (weeks or longer). But they rarely become addicts. Dependency and addiction are different medical entities calling for different medical practice standards. [Ref 21]
          • Opioids should not be prescribed carelessly or casually, and for the most part they aren’t.
            • Pain patients are tried on opioids only after other therapies have failed.
            • For the most severe pain, behavioral therapy is never a substitute for opioid or non-opioid analgesics.
            • Non-opioid analgesics also have risks - 30,000+ hospital admissions per year for Tylenol toxicity, with 1500 deaths [Ref 22].
            • Clearly, additional research is needed on safer medications for chronic pain, and cures for many underlying conditions which cause it.
          • Pill counting and limitations on prescribing opioids will not “solve” a crisis created by aggressive marketing of street drugs to kids and compounded by adult unemployment. [Ref 23]
        • The purpose of all pain treatment is to relieve suffering and promote function. Denial of effective treatment for chronic pain is a fundamental abuse of human rights and a violation of the principle “First Do No Harm”.
        • To correct the harms now being done to pain patients, a first step must be withdrawal and rewriting of the CDC opioid prescription guidelines to correct the biased and unbalanced policy and implement known best practices of pain management. Several initiatives are also needed to better educate physicians and patients.
          • The central role of physicians and patients in selecting and managing care must be restored, with appropriate and prudent oversight of prescribers and patients, to detect drug diversion and “pill mills”.
          • Increased medical education and research funding must better delineate chronic pain, opioid therapy and co-therapies, and the risks and benefits of both opioids and alternative therapies for chronic pain.
          • Educate patients on risk of stomach ulcer and bleeds, heart attack and stroke from NSAIDs and aspirin.
          • Educate patients on risk of liver toxicity, liver failure, and death with acetaminophen or Tylenol.
          • State laws fixing maximum dose rate limits must be immediately repealed as unscientific and abusive of patients.
        • It is time to STOP THE WAR AGAINST PAIN PATIENTS!

REFERENCES:

      1. Stephen A. Martin, MD, EdM; Ruth A. Potee, MD, DABAM; and Andrew Lazris, MD, Neat, Plausible, and Generally Wrong: A Response to the CDC Recommendations for Chronic Opioid Use
      2. Pat Anson, Survey Finds CDC Opioid Guidelines Harming PatientsPain News Network, March 15, 2017. [Observations reinforced by hundreds of postings in Facebook groups focused on chronic pain patients, families, and medical professionals]. Also revealing: Bob Tedeschi, “A ‘civil war’ over painkillers rips apart the medical community - and leaves patients in fear”  STAT News, January 17, 2017, https://www.statnews.com/2017/01/17/chronic-pain-management-opioids/
        Ref 2a: Association of American Medical Colleges. Physician shortage and projections. Data and Reports. Workforce. Data and Analysis. AAMC. The 2017 update: complexities of physician supply and demand. Projections from 2015 to 2030. 2017. https://www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.html
        Ref 2b: BC Government News. “#BC is committed to listening to all voices in order to save lives and overcome the #opioid crisis.” July 28, 2017. Accessed August 9, 2017. https://twitter.com/BCGovNews/status/892151820394606592
      3. Funtony47 The War On Doctors: How The DEA is Scaring Doctors from Prescribing Pain Medications  Daily Kos, Apr 15, 2015  https://www.dailykos.com/stories/2015/4/15/1375189/-The-War-On-Doctors-How-The-DEA-is-Scaring-Doctors-from-Prescribing-Pain-Medications
      4. “CDC Guideline for Prescribing Opioids for Chronic Pain” - United States, 2016 https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
      5. Richard A. Lawhern, Ph.D. “Warning to the FDA: Beware of Simple Solutions In Chronic Pain and Addiction”. National Pain Report, June 1, 2017, https://nationalpainreport.com/warning-to-the-fda-beware-of-simple-solutions-in-chronic-pain-and-addiction-8833744.html
      6. Mark Maginn, “Living with Pain: FDA Ruling a Victory for Pain Patients and PROP” National Pain Report [Opinion], September 10, 2013, https://nationalpainreport.com/living-pain-fda-ruling-victory-pain-patients-prop-8821625.html
      7. Congress of the United States, House of Representatives Committee on Government Reform, Letter to Thomas Frieden, MD, Director CDC, December 18, 2015
      8. Christina Porucznik, PhD MSPH, “Observations presented to the National Center for Injury Prevention and Control’s Board of Scientific Counselors on behalf of the Opioid Guideline Workgroup”  [CDC Briefing, Spring 2016]
      9. Baraa O. Tayeb, MD Ana E. Barreiro, MPH Ylisabyth S. Bradshaw, DO, MS Kenneth K. H. Chui, PhD, Daniel B. Carr, AM, MD, DABPM, FFPMANZCA (Hon) Durations of Opioid, Nonopioid Drug, and Behavioral Clinical Trials for Chronic Pain: Adequate or Inadequate?  Pain Med. 2016 Nov; 17(11):2036-2046
      10. Richard A. Lawhern, Ph.D. “The CDC Opioid Guidelines Violate Standards of Scientific Research” - American Council for Science and Health, March 25, 2017. https://www.acsh.org/news/2017/03/25/cdc-opioid-guidelines-violate-standards-science-research-11050 Â
      11. Richard A. Lawhern, Ph.D. Tracking Down the ‘Research’ Behind the CDC’s Opioid Prescribing Guidelines, National Pain Report, August 10, 2016
      12. Steven H. Richeimer, MD and John J. Lee, MD Genetic Testing in Pain Medicine—The Future Is Coming, Practical Pain Management, October 17, 2016.
      13. Tom Lynch, PharmD and Amy Price MD, The Effect of Cytochrome P450 Metabolism on Drug Response, Interactions, and Adverse Events, American Family Physician,  August 1, 2007.
      14. Jennifer Schneider, MD; Alfred Anderson, MD; and Forest Tennant MD, Dr PH, “Patients Who Require Ultra-High Opioid Doses”, Practical Pain Management,  September 2009
      15. Maia Szlavavitz, Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause - Cracking down on highly effective pain medications will make patients suffer for no good reason, Scientific American, May 10, 2016
      16. Podcast of the President’s Commission on Combating Addiction and the Opiod Crisis - Observations by a subject matter expert from the National Institute on Drug Abuse, June 2017.
      17. Pat Anson, Editor, Pennsylvania Overdoses Soar, But Not from Painkillers Pain News Network, July 27, 2017
      18. David E. Joranson, MSSW, Aaron M. Gilson, PhD, Pain & Policy Studies Group,University of Wisconsin - Madison Comprehensive Cancer Center; and World Health Organization Collaborating Center for Policy and Communications Madison, Wisconsin, USA “Drug Crime Is a Source of Abused Pain Medication in the United States”  Letters, Journal of Pain and Symptom Management , Vol. 30 No. 4 October 2005, Response to “How Prescription Drugs Get Onto the Street”.
      19. Roger Chriss, “The Myth of the Opioid Addicted Chronic Pain Patient” Pain News Network, July 25, 2017, https://www.painnewsnetwork.org/stories/2017/7/25/the-myth-of-the-opioid-addicted-chronic-pain-patient?rq=25%25
      20. Pew Charitable Trusts / Research and Analysis, “Pew Analysis Finds No Relationship Between Drug Imprisonment and Drug Problems”, June 19, 2017, https://www.pewtrusts.org/en/research-and-analysis/speeches-and-testimony/2017/06/pew-analysis-finds-no-relationship-between-drug-imprisonment-and-drug-problems
      21. Silvia Minozzi, Laura Amato & Marina Davoli, Department of Epidemiology, Lazio Regional Health Service, Cochrane Drugs and Alcohol Group, Rome, Italy “Development of dependence following treatment with opioid analgesics for pain relief: a systematic review” Addiction Review, pp1360-0443.2012. March 5 2012 Main points of this paper are reinforced by a 2010 Cochrane Review.
      22. Eric Yoon, Arooj Babar, Moaz Choudhary, Matthew Kutner, and Nikolaos Pyrsopoulos “Acetaminophen-Induced Hepatotoxicity: a Comprehensive Update” Journal of Clinical and Translational Hepatology, June 28, 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913076/
      23. Mallika L. Mundur, MD, MPH, Adam J. Gordon , MD, MPH & Stefan G. Kertesz, MD, MSc “Will strict limits on opioid prescription duration prevent addiction? advocating for evidence-based policymaking” 20 Jun 2017, https://www.tandfonline.com/doi/full/10.1080/08897077.2017.1345194

       

    1. About the Author: Richard A. Lawhern, Ph.D. is a technically trained non-physician with 20 years of experience in peer-to-peer patient support groups for chronic pain patients. His work and commentaries have been published or featured at the US Trigeminal Neuralgia Association, National Pain Report, Pain News Network, The American Council on Science and Health, The Journal of Medicine of the National College of Physicians, the National Institutes for Neurological Disorder and Stroke, Wikipedia, Mad in America, Psychiatric News and other online venues.

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You CANT …allow for the continued ‘pain shamming’ and short sighted Govt sanctioned torture.

I have full body CRPS 2 and CAN NOT get medication to help me function. Opioids are not the silver bullet but contribute to my ability to take care of myself. I am in too much pain to argue.

CRPS has been revealed as the most painful disease. Pain exceeds amputation.

You are killing those like me.

Richard

—sent to all the primary contacts as suggested. We ALL need to get together before it becomes standard practice!!!!!

Janet Groth

I sent this to commission@ondcp.eop.gov I hope everyone does .But there you have to leave your name and email/

C daily

Dr. Lawhern, you are the BEST! What’s happening in our country with chronic pain patients is cruel. I have been a RN for 30 and 5 years ago was diagnosed with rheumatoid arthritis. I’m fortunate to have a MD that will work with me. I was referred to pain Manangement by a Ortho spine specialist for two epidural. Being a patient in that setting can be humiliating.
Thanks for what you do.

Renee E Mace

Please Richard A. (Red) Lawhern, Ph.D. write it out as a petition, I and many of my friends would sign it right away. We need people such as yourself to keep sending out petitions out to everyone everyday until someone hears us. I am very bad on writing out my pains and aches, but with educated people such as yourself, you can be our Champion.

HAZZY

I’ve been on Opioids for over 18 Years !!! What i have seen 90% of Chronic Pain Patients are not the ones Abusing their opioid meds, it is the people that just want to get HIGH and make it bad for us Chronic-Pain Patient’s. Doctors now have a site where they can key in your Name, Date of Birth and see all the Medications that have been prescribed. So, Doctors need to cut a little slack on Chronic-Pain Patients that do not ABUSE their PAIN MEDS !!!!! THANKS

Sue Woodruff

Great article & appreciate someone on our side!
What can we do ?

connie

Everyone needs to share this and suggest that non chronic pain sufferers write or call their senators, congressman, the cdc,dea,fda and the news media! Their voices might be heard more than ours since we’re seen as a bunch of drug addicts!

Denise Bault

AMEN!

Marna Parker

Brava!!!!

Bette

This is an important message.

Bette

I would be in horrible shape from this mess if I had not just moved to Arizona. I can now be prescribed medical marijuana for my long term pain. It’s better than opioids, so I want to suggest that the Federal govt make marijuana legal. It would take care of the whole problem. It’s NOT addictive, you can not over dose on it. Problem solved.

M.Billeaudeaux

Thank you Dr. Lawhern for your article. It was very informative and educational. Thank you also for standing for the pain patient’s rights. We cannot allow those in government to restrict our physicians who help us live somewhat normal lives.

M.Billeaudeaux

Email the commission who is starting to hurt us. The email address is commission@ondcp.eop.gov
I cannot emphasize enough the importance of contacting your congressmen, the president, Senator Price, etc. And keep on writing. They cannot be allowed to tie the hands of our pain physicians by not allowing them to write prescriptions for certain drugs, that help us maintain a somewhat normal lifestyle by working and spending time with our families.

Please write.

Barrow

Thank you Dr. Lawhern for saying this in no uncertain terms. I hope someone with the power to change things hears it. I hope the suffering of CCPs and our doctors ends soon. But it probably will be too late for me. Last month my doctor, who’s seen me for 10 years, was denied the right to continue practicing until a replacement can be found for his clinic partner who passed away. My doctor’s record is impeccable. So is mine. But because of the “opioid hysteria” the State of Georgia is requiring him to jump through hoops; and, finding a doctor willing to risk what’s happening to so many pain management doctors could take months or years, if one can be found at all. I am almost out of my medication. I’m taking tiny bits at a time. I’m already suffering withdrawal and it’s about to get much worse. I’m too weak and ill to go running from one office to another trying to find a doctor who will write my prescriptions until my doctor returns, or take me on as a patient if he never comes back. I’m an author in my 60s, writing a book I hope to finish. It almost certainly will be my last unless an absolute miracle occurs. I live alone. I am highly functional on my medications. Sick, in awful withdrawal with no medical support, and in pain, I am worthless. I’ll be happy if I can finish this book. If I can’t, I can’t. I never imagined my life ending this way. God bless you doctor, and God bless everyone out there in the same mess I’m in.

Richard Dobson

All very good points, Mr. Lawhern. I think you have missed one vital issue. The mushrooming death toll in the past few years has been fueled by illegal poisons and NOT by prescription opioids. The deaths are fueled by NON-MEDICINAL fentanyl derivatives (e.g. carfentanil and furanylfentanyl) that are manufactured in China and shipped to the US, often via the US Post Office. Heroin and these fentanyl-poisons CANNOT be obtained via any medical mechanism….no doctor can prescribe them; no pharmacist can stock them; no pharmaceutical company can produce them for sale. The problem of addiction would still be there without them but the death toll would be far lower without this poisons that have such rapidly lethal effects.

Bruce

Red - your hotmail account would not receive an email from me, perhaps your mailbox is full. I would like to volunteer my services, as requested by your previous post.
Thanks,
Bruce Stewart
Bste111@yahoo.com

This was one of the best post I have had the pleasure of reading. It was certainly well researched and without a doubt publicized how the twisted minds of the CDC,the FDA and the damn federal government operate. The only way it could have been any better is if it would have ended with mass hanging, after a short trial of course, with the dirty bastards at the FDA & the CDC that have chosen to torture for no reason cronic pain patients. THE ONLY REASON FOR THEIR ACTIONS COULD BE TO GET NEW DRUGS WITH NEW PATENTS REPLACING OPIODS SO THE DRUG COMPANIES CAN RAPE THE PUBLIC WITH RIDICULOUSLY HIGH PRICES. My thanks and appreciation to the author.

JoAnn Kulaski

Wonderful, informative article! I am very concerned that after being on opioid painkillers for 15 years, the government will force pain management doctors to cease writing all prescriptions for those of us who cannot function due to the physical pain in our lives. I am not addicted to my medication, but I do not tolerate horrific pain due to chronic illnesses.

Tim Mason

Dr. Lawhern has brought us out of our “Fox Holes” and is leading the charge. I will follow. My copies are printed and will be mailed out beginning tomorrow.
News agencies as well as many others will find out that misinformation and Inaccuracy in Media will no longer go in answered,
People have simply stopped thinking for themselves.
Even the major networks are misleading the people in their broadcasts and even have the president quoting misinformation and misdirecting taxpayer dollars to fix a false epidemic.
The Government agencies at the highest level even know the information being fed the president is false.

https://www.healthnewsreview.org/2016/01/the-opioid-crisis-facts-that-news-coverage-is-missing/

Lying Statistics https://www.thefix.com/opioid-epidemic-exaggerated

Drug abuse by age. https://www.samhsa.gov/prescription-drug-misuse-abuse/specific-populations

They admit it is heroin not prescription drugs that is a problem. https://www.yahoo.com/news/the-campaign-heats-up-to-make-overdose-fighting-naloxone-available-everywhere-135455251.html

Right now the TRUTH cannot be stated enough.