The prescription opioid epidemic in a nutshell

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lonelobo said:
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You have a face for Radio:happy:
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Dear Colleague:
The Substance Abuse and Mental Health Services Administration (SAMHSA) has partnered with the National Institute on Drug Abuse (NIDA) to provide guidance for the use of medication assisted treatment (MAT) with extended-release injectable naltrexone for treatment of an opioid use disorder.

Federal data for 2013 indicate that approximately 4.5 million people in the United States reported nonmedical use of prescription pain relievers in the past month and 289,000 reported use of heroin in the past month.1 Recent data published by the CDC indicates that overdose fatalities due to heroin are increasing in at least some states.2 Despite the dimensions of the problem, many people with an opioid use disorder do not receive MAT because of limited treatment capacity, financial obstacles, social bias, and other barriers to care.3

Integration of MAT with extended-release injectable naltrexone into existing substance use treatment programs as well as primary care and community mental health care settings represent a significant opportunity to address the unmet need for treatment of opioid use disorder. In fact, many studies show that the treatment of an opioid use disorder can be successfully integrated into general office practice by physicians and healthcare providers who are not addiction specialists.4-12
SAMHSA and NIDA jointly convened the Consensus Panel on New Pharmacotherapies for Opioid Use Disorders and Related Comorbidities. Composed of experts research, clinical care, medical education, and public policy, the panel reviewed current evidence on the effectiveness of available medications for the treatment of an opioid use disorder.5 Their guidance is now available as Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide. This brief guide includes a summary of the key differences between extended-release injectable naltrexone, methadone, and buprenorphine. It covers key information on assessing the patient's need for treatment, initiating MAT, monitoring patient progress and adjusting the treatment plan, and deciding whether and when to end MAT. A separate new guidance document will be available soon to address the use of pharmacotherapies for alcohol use.
SAMHSA encourages you to review the brief guide and begin to integrate the information into your daily practice. Please also share it with colleagues, local opinion leaders and other stakeholders to expand the effective treatment of opioid use disorder.
For further information and questions please contact Dr. Melinda Campopiano, MD here at SAMHSA. You may call her directly at 240-276-2701 or email her at [email protected].
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References

1Substance Abuse and Mental Health Services Administration (SAMHSA). Center for Behavioral Health Statistics and Quality. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of national findings (HHS Publication No. 14-4863, NSDUH Series H-48). Rockville, MD: Substance Abuse and Mental Services Administration.

2Centers for Disease Control and Prevention (CDC). Center for Surveillance, Epidemiology, and Laboratory Service. (2014). Increases in Heroin Overdose Deaths 28 States, 2010 to 2012. (MMWR, 63(39):849-854). Atlanta, GA: Centers for Disease Control and Prevention.
3Arfken CL, Johanson CE, diMenza S, et al. Expanding treatment capacity opioid dependence with buprenorphine: National surveys of physicians. J Subst Abuse Treat. 2010 Sep; 39(2):96-104.
4Barry DT, Irwin KS, Jones ES, et al. Integrating buprenorphine treatment into office-based practice: A qualitative study. J Gen Intern Med. 2009 Feb; 24(2):218-225.
5Bruce Medical interventions for addictions in the primary care setting. Topics HIV Med. 2010 Feb-Mar; 18(1):8-12.
6Fiellin DA, Moore BA, Sullivan et al. Long-term treatment with buprenorphine/naloxone primary care: Results at 2-5 years. Am J Addict. 2008 Mar-Apr; 17(2): 116-120.
7Finch JW, Kamien JB, Amass Two-year experience with buprenorphine/naloxone (Suboxone) for maintenance treatment of opioid dependence within a private practice setting. J Addict Med. 2007Jun; l(2):104-l10.
8Jones ES, Moore Sindelar JL, et al. Cost analysis of clinic and office-based treatment opioid dependence: Results with methadone and buprenorphine in clinically stable patients. Drug Alcohol Depend. 2009 Jan 1; 99(1-3):132-1340.
9Magura S, SJ, Salsitz EA, et al. Outcomes of buprenorphine maintenance in office-based practice. J Addict Dis. 2007; 26(2): 13-23.
10Sullivan Fiellin DA. Narrative review: Buprenorphine for opioid-dependent patients office practice. Ann Intern Med. 2008 May 6; 148(9):662-670. Review.
11Torrington M, Dornier CP, Hillhouse M, et al. Buprenorphine l 01 : Treating opioid dependence with buprenorphine in an office-based setting. J Addict Dis. 2007; 26(3):93-99.
12Walley AY, Alperen JK, Cheng DM, et al. Office-based management of opioid dependence with buprenorphine: Clinical practices and barriers. J Gen Intern Med. 2008 Sep; 23(9):l1398.
Please follow link to view the Press Release.
 
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101N said:
http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/49536

PUBLIC HEALTH & POLICY01.14.2015
No Easing in Opioid Death Toll
Action Points
Despite years of policy changes and increasing awareness of abuse and addiction, deaths due to poisoning from prescription opioids rose in 2013 as did heroin deaths, federal researchers reported.
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I've had two patients test positive for 6-MAM in clinic this week---one worker's comp and one MEDICARE. If you don't think that heroin addiction is in our communities and affecting our patients and their families, then you're not paying attention.
 
Yet another home run by John Fauber.

http://m.jsonline.com/watchdog/watc...ng-term-opioid-use-b99421747z1-288307521.html
Studies find little proof of help from long-term opioid use
(26)
By John Fauber of the Journal Sentinel
Updated Jan. 12, 2015

Despite more than a decade of booming use of narcotic painkillers for chronic pain conditions, solid evidence of the long-term safety and effectiveness of the drugs is scant to nonexistent, research published Monday concluded.

One group of researchers noted there have been only short-term studies — and none extending a year or more — evaluating opioids on pain, function or quality of life. Another group noted that data supporting long-term use of opioids for chronic pain is extremely limited.

The two papers, published in the Annals of Internal Medicine, highlight a key issue in one of the major medical controversies of the last decade: how America got thrust into an opioid epidemic.

For years, doctors regularly prescribed opioids for chronic, non-cancer pain conditions such as low-back pain, fibromyalgia and migraines.

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By 2010, enough of the drugs were being dispensed to medicate every U.S. adult round-the-clock for a month. The United States was consuming 99% of the world's hydrocodone, the narcotic in the drug Vicodin.

Yet, unlike many other prescription drugs that were approved based on rigorous studies showing safety and effectiveness, such long-term studies have not been done with opioids.

Investigations by the Milwaukee Journal Sentinel and MedPage Today have documented the lack of evidence supporting use of narcotic painkillers for chronic, non-cancer pain.

The stories also revealed that behind that surge in opioid prescribing was a network of pain organizations, doctors and researchers that pushed for expanded use of the drugs while taking in millions of dollars from the companies that made them.


One of the research papers published Monday stemmed from a National Institutes of Health workshop on the role of opioids in treating chronic pain. The other was a review of long-term opioid therapy funded by the U.S. Department of Health and Human Services.

"This federal government-sponsored review makes clear that opioids are a lousy choice for most patients with chronic pain," said Andrew Kolodny, chief medical officer at Phoenix House, an addiction treatment organization in New York City, who was not a part of the study.

Kolodny, an advocate of tighter controls on opioids, said the best available evidence suggests that opioids are not safe and probably ineffective when used long term.

"I hope the FDA pays close attention and puts an end to pharma marketing of opioids as safe and effective for long-term use," he said.



A shift to long-term use


David Reuben, lead author of the NIH workshop paper, said part of the reason opioids became popular for chronic pain is that the drugs had been useful in short-term pain.

"That happens a lot in medicine," said Reuben, a geriatric medicine specialist at the UCLA School of Medicine.

The research noted that most clinical trials of opioids don't extend beyond six weeks. It also found a lack of randomized trials, the gold-standard in medical research, evaluating the potential harms of opioids, such as abuse and addiction.

"We continue to be disappointed that there is not the kind of randomized trial evidence," said study co-author Richard Deyo, a professor of evidence-based medicine at Oregon Health and Science University.

It is doubtful whether that kind of research will ever be done, he said. Among the reasons: the high number of people who drop of such trials, either because of a lack of benefit or side effects from the drugs.

In addition, Deyo said, patients who are most at risk of being harmed by the drugs such as those who have had past substance abuse problems or depression often are excluded from the trials.

In a separate paper published last week, Deyo and others found that opioid prescriptions in the United States for low-back pain had increased and that rates of such use in North America were two to three times greater than in most European countries.

"However, the effectiveness of long-term opioid therapy for back pain remains unclear and surveillance data have shown markedly increased rates of opioid overdose and addiction," they wrote in BMJ, formerly the British Medical Journal.

Other long-term problems include falls, fractures, motor vehicle crashes, cognitive and mood effects and sexual dysfunction, they said.



An overstated figure


The NIH workshop paper also clarified a controversial figure that has been a central part of the chronic pain-opioid debate.

In 2011, the Institute of Medicine issued a report saying that 100 million Americans, the equivalent of more than 40% of the adult population, suffered from chronic pain.

In a Journal Sentinel/MedPage Today investigation last year, pain experts familiar with how the number was derived criticized it as exaggerated and misleading.

The 100 million figure is problematic in part because it includes everyone who reports chronic pain, which is defined as lasting three to six months — from those with persistent but manageable back pain to those recovering from surgery or battling cancer.

It includes those who may not even seek medical help or those who treat their pain with over-the-counter products.

The investigation also found that nine of the 19 experts on the panel that produced the number had financial connections to companies that manufacture narcotic painkillers within three years of their work on the report.

The NIH workshop paper published Monday mentioned the 100 million figure, but noted that a much smaller number of people — 25 million — have moderate to severe chronic pain that limits activities and diminishes quality of life.

"This report took the opportunity to clarify this estimate in a way that I think most experts would agree with," said Michael Von Korff, senior investigator with Group Health Research Institute in Seattle, who was not part of the study.

Many of the 100 million are those with bothersome aches and pain that do not necessarily result in work disability or substantially impaired quality of life, he said.

Von Korff said the long-term use of opioids is concentrated among the 25 million adults who have these more severe and disabling chronic pain conditions. Of those, he said, perhaps 5 to 8 million use opioids long term.
 
So much for the "Trust me I'm an expert approach to opioid Rx'ing for CNP"...

J Pain. 2013 Feb;14(2):103-13. doi: 10.1016/j.jpain.2012.10.016.
Personalized medicine and opioid analgesic prescribing for chronic pain: opportunities and challenges.
Bruehl S1, Apkarian AV, Ballantyne JC, Berger A, Borsook D, Chen WG, Farrar JT, Haythornthwaite JA, Horn SD, Iadarola MJ, Inturrisi CE, Lao L, Mackey S,Mao J, Sawczuk A, Uhl GR, Witter J, Woolf CJ, Zubieta JK, Lin Y.
Author information

Abstract
Use of opioid analgesics for pain management has increased dramatically over the past decade, with corresponding increases in negative sequelae including overdose and death. There is currently no well-validated objective means of accurately identifying patients likely to experience good analgesia with low side effects and abuse risk prior to initiating opioid therapy. This paper discusses the concept of data-based personalized prescribing of opioid analgesics as a means to achieve this goal. Strengths, weaknesses, and potential synergism of traditional randomized placebo-controlled trial (RCT) and practice-based evidence (PBE) methodologies as means to acquire the clinical data necessary to develop validated personalized analgesic-prescribing algorithms are overviewed. Several predictive factors that might be incorporated into such algorithms are briefly discussed, including genetic factors, differences in brain structure and function, differences in neurotransmitter pathways, and patient phenotypic variables such as negative affect, sex, and pain sensitivity. Currently available research is insufficient to inform development of quantitative analgesic-prescribing algorithms. However, responder subtype analyses made practical by the large numbers of chronic pain patients in proposed collaborative PBE pain registries, in conjunction with follow-up validation RCTs, may eventually permit development of clinically useful analgesic-prescribing algorithms.

PERSPECTIVE:
Current research is insufficient to base opioid analgesic prescribing on patient characteristics. Collaborative PBE studies in large, diverse pain patient samples in conjunction with follow-up RCTs may permit development of quantitative analgesic-prescribing algorithms that could optimize opioid analgesic effectiveness and mitigate risks of opioid-related abuse and mortality.

Copyright © 2013 American Pain Society. All rights reserved.
 
Is anyone contributing data to the collaboratoe practice-based evidence registries to establish responder sub-groups?

I heard that NIH was very interested in funding these projects. Apparently, RCT's are "out" and registries are "in."
 
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The Ethics of Patient Selection for Opioid Management for Pain
Feb 4, 2015
Moral change in social behavior only comes when we are able to see the ethical implications of the behavior in a new light and as a consequence we are moved to act differently. This general statement seems especially true when the ethical implications of a social behavior have been heretofore under-appreciated. In such situations, a change in ethics requires that we first raise awareness of the implications of our behavior. In so doing, we foster an understanding that our behavior has ethical consequences when, perhaps, we had previously thought that our behavior had no such ethical implications at all.

A recent example in our everyday life is the movement to ‘go green.’ We now have the opportunity to make a variety of choices about home goods, office products, the cars and food we buy, and even our choice of office buildings to lease. We may or may not make such ‘green’ choices, depending on different circumstances, but we do so in the knowledge that our choices make some difference to our environment and climate, whether for good or ill. Few among us had previously considered the ethical dimensions of such goods and services, but we do now because we have come to see the ethical implications of our consumer choices in a new light. In other words, once we have come to understand the ethical implications of our previous consumer choices, we now have the opportunity to change our behavior and foster positive ethical change.

For those of us who are either providers or patients in the field of chronic pain management, we face a similar newfound appreciation of the ethical implications of long-term opioid management, one which leads us to an opportunity for positive ethical change. We might safely assume that for many years the field considered the alleviation of pain and suffering as a social good and by extension had considered the practice of long-term opioid management as something that brings about this social good. Indeed, it has been commonplace to consider the practice of long-term opioid management for chronic pain as unquestionably the ethically right thing to do. This understanding is now, however, giving way to a re-conceptualization of the practice, particularly in light of the present epidemics of prescription opioid addiction and overdose (Compton & Volkow, 2006; Sullivan & Howe, 2013).

The last decade and a half of research on the practice of long-term opioid management has shed light on how the epidemics of addiction and overdose has arisen. What the research shows is that we have not been providing long-term opioid management to all patients with chronic pain, but only to a select few, and these few, as it turns out, are the most vulnerable to the adverse consequences of addiction and overdose. Dubbed “adverse selection” (Sullivan & Howe, 2013), long-term opioid management has settled into a practice of providing the most addictive medications to those who are most vulnerable to addiction and emotional distress: those patients with chronic pain who also have had past or present histories of either mental health problems or substance dependence or both.

This finding brings with it the opportunity to raise our consciousness about the ethical implications of this practice: in our intentions to bring about a social good – the alleviation of pain and suffering, we have in fact brought about an altogether different form of pain and suffering in the form of addiction and overdose. We must therefore re-evaluate the practice of long-term opioid management.

This realization will no doubt be difficult to achieve on a wide-scale basis. The practice of long-term opioid management has for so long been unquestionably assumed to be a social good. It continues to have many proponents to this day. Let us therefore review the research in some detail to determine for ourselves how we might arrive at a newfound appreciation of its adverse ethical implications.

Who receives long-term opioid management for chronic pain?
Providers and patients who advocate for the practice of long-term opioid management are often surprised to learn that most people with chronic pain do not manage their pain with opioid medications. Breivek, et al, (2006) found in an epidemiological study of European countries that 19% of the general population had chronic pain. In further follow-up interviews of those with chronic pain, they found that 5% take long-acting opioids and 23% take short-acting opioids. In a later study, Fredheim, et al., (2014) found that only 15% of people with chronic pain used opioids to manage their pain. Among those reporting their pain as severe or very severe, 11% used opioids. In the United States, the rate of opioid use among patients with chronic pain is similar. Toblin, et al., (2011) found that a quarter of the population has chronic pain. Among people with chronic pain, they found only 15% using prescription opioids to manage their pain. Importantly, a very large majority of all those with chronic pain, even the 85% of them who were not taking opioids, were satisfied with the way they were managing their pain (Toblin, et al., 2011).

Even among patients who are readily offered opioid management on a long-term basis, most of them will voluntarily stop using opioids even though they remain in pain (Fredheim, et al., 2013; Gustavsson, et al., 2012).

What these studies show is that the vast majority of people with chronic pain do not take opioid medications to manage their pain.

Numerous studies consistently show that patients who remain on long-term opioid management are those who, on average, have significantly higher rates of mental health and substance abuse problems (Breckenridge & Clark, 2003; Hojsted, et al., 2013; Jensen, Thomsen, & Hojsted, 2006; Mallen, et al., 2007; Sullivan, et al., 2006; Thomas, et al., 1999). As the data above suggests, this subset of people with chronic pain is small and is not representative of all people with chronic pain. Their co-occurrence of chronic pain with mental health or substance dependence problems suggests that they have struggled to cope with different aspects of life prior to or concurrent with the onset of pain. As such, they now struggle to cope with the additional problem of chronic pain and come to rely on opioids at a much higher rate than those people with chronic pain who do not have such additional problems.

The co-occurrence between chronic pain and mental health or substance dependence problems are highly associated with addiction to prescription opioids (Ives, et al., 2006; Turk, Swanson, & Gatchel, 2008; Wasan, et al., 2007). With an empathetic view, we can see why: the field of chronic pain management has settled into a pattern of providing the most addictive medications to the most vulnerable subset of people with chronic pain – those who also have mental health and/or substance dependence problems.

(Now, to be sure, any aggregate data admits of counter examples. So, the reader, here, might readily be able to acknowledge someone in their life, either personally or professionally, who may have chronic pain, take opioids on a long-term basis, and have no history of a mental health or substance dependence problem. However, the occurrence of a counter-example does not disprove the more general finding that, on average, those who come to rely on the long-term use of opioids to manage chronic pain have higher rates of mental health and/or substance dependence problems than the majority of people with chronic pain who cope with their pain well and without opioids.)

The field has thus fallen into a pattern of providing long-term opioid management to only a select minority of people with chronic pain. This select minority are those people with chronic pain who are most susceptible to addiction and emotional distress. Meanwhile, we are witnessing epidemics of prescription opioid addiction and overdose. While correlation, of course, does not prove causality, it seems against any reasonable odds that the addiction and overdose epidemics are coincidental to the rise of long-term opioid management as it is practiced today.

A false dilemma
In the debate over the practice of long-term opioid management for chronic pain, many commonly assume that large-scale pain and suffering will result if the field curtails the practice. The assumption leads to a seemingly impassable dilemma: with the practice of long-term opioid management, we have epidemic levels of prescription opioid addiction and overdose; without the practice of opioid management, we will have large-scale pain and suffering.

Here is where the epidemiological data cited above is so important. The data shows that the majority of people with chronic pain, even moderate to severe chronic pain, do not use opioids to manage their pain. We know that they are not suffering because the vast majority of these people report that they are satisfied with the ways they are managing pain. In other words, the norm for those with chronic pain is not one of wide-scale suffering. The norm is that people with chronic pain cope well without long-term opioid management. Thus, the dilemma is really a false dilemma.

The ethics of long-term opioid management in a new light
We might therefore assert that it’s unethical that we relegate long-term opioid management to the most vulnerable subset of those with chronic pain – those people with chronic pain who have comorbid mental health and substance abuse problems. These patients are the most susceptible to prescription opioid addiction and overdose. We do not alleviate their pain and suffering through the use of long-term opioid management. Indeed, we may just be adding to their pain and suffering.

Our field of chronic pain management thus needs a new moral calling for the alleviation of pain and suffering (at least as it regards what is truly incurable, chronic pain). We must recognize that the majority of people with chronic pain do not manage their pain with opioid medications on a long-term basis. They are not suffering, for they cope well with their pain and are satisfied with their pain management. This recognition puts into a new light the nature of the problem of those who are suffering. They are the people with chronic pain and co-occurring mental health and substance dependence problems. They are the people with chronic pain who have struggled to cope and as a result have come to be reliant on the long-term use of opioids as a substitute for effective coping. Our new moral calling should be to help them learn how to cope well with chronic pain – in the ways that those who self-manage pain already do. This therapeutic goal – what is essentially a rehabilitation goal – is the ethically right thing to do. What’s not the right thing to do is to continue the widespread practice of maintaining the most vulnerable subset of people with chronic pain on a poor substitute for good coping -- the most addictive pain medications available.

Author
Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. Dr. McAllister also blogs at theInstitute for Chronic Pain Blog.

References

Breckenridge, J. & Clark, J. D. (2003). Patient characteristics associated with opioid versus non-steroidal anti inflammatory drug management of chronic low back pain.Journal of Pain, 4(6), 344-350.

Breivek, H., Collett, B., Ventafridda, V., Cohen R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10, 287-333.

Fredheim, O. M., Borchgrevink, P. C., Mahic, M., & Skurtveit, S. (2013). A pharmacoepidemiological cohort study of subjects starting strong opioids for nonmalignant pain: A study from the Norwegian Prescription Database. Pain, 154, 2487-2493.

Fredheim, A. M., Mahic, M., Skurtveit, S., Dale, O., Romundstadt, P., & Borchgrevink, P. C. (2014). Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian Prescription Database and the Nord-Trondelag Health Study. Pain, 155, 1213-1221.

Gustavsson, A., Bjorkman, J., Ljungcrantz, C., Rhodin, A., Rivano-Fischer, M., Sjolund, K.-F., & Mannheimer, C. (2012). Pharmaceutical treatment patterns for patients with a diagnosis related to chronic pain initiating a slow-release strong opioid treatment in Sweden. Pain, 153, 2325-2331.

Hojsted, J., Ekholm, O., Kurita G. P., Juel, K., & Sjogren, P. (2013). Addictive behaviors related to opioid use for chronic pain: A population-based study. Pain, 154, 2677-2683.

Ives, T. J., Chelminski, P. R., Hammett-Stabler, C. A., Malone, R. M., Perhac, J. S., Potisek, S. M., Shilliday, B. B., DeWalt, D. A., & Pignone, P. M. (2006). Predictors of opioid misuse in patients with chronic pain: A prospective cohort study. BMC Health Services Research, 6, 46.

Jensen, M. K., Thomsen, A. B., & Hojsted, J. (2006). 10-year follow-up of chronic non-malignant pain patients: Opioid use, health-related quality of life and healthcare utilization. European Journal of Pain, 10(5), 423.

Mallen, C. D., Peat, G., Thomas, E., Dunn, K. M., & Croft, P. R. (2007). Prognostic factors of musculoskeletal pain in primary care: A systematic review. British Journal of General Practice, 57(541), 655-661.

Sullivan, M. D., Edlund, M. J., Zhang, L., Unutzer, J., & Wells, K. B. (2006). Association between mental health disorders, problem drug use, and regular prescription opioid use. Archives of Internal Medicine, 166(19), 2087-2093.

Sullivan, M. D. & Howe, C. Q. (2013). Opioid therapy for chronic pain in the United States: Promises and perils. Pain, 154, S94-S100.

Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

Thomas, E., Silman, A. J., Croft, P. R., Papageorgiou, A. C., Jayson, M. I., & Macfarlane, G. J. (1999). Predicting who develops chronic low back pain in primary care: A prospective study. British Medical Journal, 318, 1662-1667.

Turk, D. C., Swanson, K. S., & Gatchel, R. J. (2008). Predicting opioid misuse by chronic pain patients: A systematic review and literature synthesis. Clinical Journal of Pain, 24(6), 497-508.

Compton, W. M. & Volkow, N. D. (2006). Major increase in opioid analgesic abuse in the United States: Concerns and strategies. Drug and Alcohol Dependence, 81, 103-107.

Wasan, A. D., Butler, S. F., Budman, S. H., Benoit, C., Fernandez, K., & Jamison, R. N. (2007). Psychiatric history and psychological adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clinical Journal of Pain, 23, (4), 307-315.
 
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How do you trim demand? Stigmatize demand.
 
101N said:
How do you trim demand? Stigmatize demand.
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I think that would be enormously harmful to patients and a shameful approach to embrace---especially as a public policy. Those of us serving in the public policy arena recognize that enormous stigma that patients with chronic pain, mental illness, and addiction face.

I can't think of any data for any other condition that supports that stigmatizing a health condition encourages treatment.

J Pain. 2014 May;15(5):550.e1-10. doi: 10.1016/j.jpain.2014.02.001. Epub 2014 Feb 15.
Internalized stigma in people living with chronic pain.
Waugh OC1, Byrne DG2, Nicholas MK3.
Author information

Abstract
Although persistent pain occurs in a sociocultural context, the influence of personal devaluation and invalidation is often neglected. As such, the present study sought to consider whether individuals' experience, perception, or anticipation of negative social reactions to their pain may become internalized and affect the self. To examine this issue, 92 adults with chronic pain responded to a questionnaire exploring the presence of internalized stigma and its association with a range of psychological consequences. As predicted, a large percentage of people with chronic pain (38%) endorsed the experience of internalized stigma. The results showed that internalized stigma has a negative relationship with self-esteem and pain self-efficacy, after controlling for depression. Internalized stigma was also associated with cognitive functioning in relation to pain, in terms of a greater tendency to catastrophize about pain and a reduced sense of personal control over pain. Overall, this study presents a new finding regarding the application of internalized stigma to a chronic pain population. It offers a means of extending our understanding of chronic pain's psychosocial domain. Implications are discussed in terms of the potential to inform clinical treatment and resiliency into the future.

PERSPECTIVE:
This article presents a novel finding regarding the presence of internalized stigma among people living with chronic pain. Internalized stigma is strongly associated with indicators of patient outcome. It presents an area for future work with the aim to improve our understanding and treatment of people living with pain.

Copyright © 2014 American Pain Society. Published by Elsevier Inc. All rights reserved.
 
Well, that's nice. But if you are an American with cLBP, HA/Migraine, or FMS, aged 18-55, you shouldn't be receiving opioids, or disability for those diagnoses.
 
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101N said:
Well, that's nice. But if you are an American with cLBP, HA/Migraine, or FMS, aged 18-55, you shouldn't be receiving opioids, or disability.
Click to expand...

Stigmatizing social ills generally just drives the problem underground.

If you want to change attitudes around frivolous disability, then the effective public health message to promote is that "pain doesn't equal disability." The Australians have been incredibly successful in doing this:

http://www.abs.gov.au/ausstats/[email protected]/Lookup/4446.0main+features52009
 
I'm ok with underground back pain, FMS, and HA.
 
drusso said:
Except these patients don't really go away. They just become someone else's problem. They go to naturopaths, etc...
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No, cLBP, cHA/Migraine, FMS are life's foibles, not medical problems. Hangnails that we all run into along the way.
Opioid use and disability related to these problems are, more often than not, cover for psychological/addiction problems. Are
the psychological and addiction problems real, absolutely, and even a cause for disability at times. But we 'pain doctors' need to stop
preying on these patients by calling them 'chronic pain' and doing patients the disservice of narcotizing them and injectionizing them
ad infinitum. We are not doing this for the betterment of the patient.

In the US today here is what the 'pain management specialist' moniker typically means. Either a pill mill, or a procedure mill.
Pill mills don't need explanation. Procedure mills do. A procedure mill is an 'IPM specialist' who limits him/herself injections
and has one or more mid-level providers performing his/her refills. Every few weeks/months the mid-level tosses a patient back to the
'pain specialist' for another injection/series. The glue that holds this fraud together is opioid prescribing, often high dose, by
the mid-level provider. This sham is not the making of the mid-level provider, it's the result of the current training of the IMP specialist.
 
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101N said:
No, cLBP, cHA/Migraine, FMS are life's foibles, not medical problems. Hangnails that we all run into along the way.
Click to expand...

Wrong: Widespread pain, migraine headache, chronic (transformed) migraine, even chronic low back have ample neurophysiological, genetic, and functional imaging data to support the notion that they are bonafide medical conditions. They are not character flaws nor foibles. You're conflating the patient's problem (diagnosis) with the doctor's problem (treatment).

Here's a more effective message: Treating chronic pain is resource intensive, labor intensive, and expensive work. Payer MUST expect that proper treatment of chronic pain and related disorders will be costly. Effective professional preparation for work in this field requires a broad and deep understanding of neurology, musculoskeletal medicine, pharmacology, neurophysiology, radiology, rehabilitation, and psychiatry. It necessitates being able to work in coordinated care teams and demonstrated competency in interdisciplinary settings.

https://prevention.nih.gov/docs/programs/p2p/ODPPainPanelStatementFinal_10-02-14.pdf

"Health care providers, often poorly trained in management of chronic pain, are sometimes quick to label patients as “drug-seeking” or as “addicts” who overestimate their pain. Some doctors “fire” patients for increasing their dose or merely for continuing to voice concerns about their pain management. Some patients have had similarly negative interactions with pharmacists. These experiences may make patients feel stigmatized, or feel as if others view them as criminals. These experiences may heighten fears that pain-relieving medications will be “taken away,” leaving the patient in chronic, disabling pain. In addition, negative perceptions by clinicians can create a rupture in the therapeutic alliance, which some studies have identified as impeding successful opioid treatment."

....

"Chronic pain is a complex clinical issue requiring an individualized, multifaceted approach.
Contributing to the complexity is the fact that chronic pain is not limited to a particular disease
state but rather spans a multitude of conditions, with varied etiologies and presentations. Yet,
traditionally, persons living with chronic pain are “lumped” into a single category, and treatment
approaches have been generalized with little evidence to support this practice. In addition,
although pain is a dynamic phenomenon, waxing and waning and changing in nature over time,
it is often viewed and managed with a static approach. For a number of reasons—including lack
of knowledge, practice settings, resource availability, and reimbursement structure—clinicians
are often ill-prepared to diagnose, appropriately assess, treat, and monitor patients with chronic
pain. "

...

As noted above, different types of pain—peripheral nocioceptive,
peripheral neuropathic, and centralized pain—appear to have different profiles of response to
such treatments. Furthermore, the use of a more effective chronic disease care model may have
implications for reducing the potential of a new generation of chronic opioid users as the
continued first-line use of opioids for chronic pain treatment is generally suboptimal and has the
potential for addiction. Although the team composition may vary, members might include the
primary care provider, case or care managers, nurses, pharmacists, psychologists, psychiatrists,
social workers, and other pain specialists.

...

Current reimbursement for
evaluation and management may be inadequate to reflect the time and team-based approaches
needed for integrative treatment. In some instances, payment structures place barriers to nonopioid
therapy, such as formulary restrictions that require evidence of failure of multiple
therapies before covering non-opioid alternatives (e.g., pregabalin).

...

The rise in the number of Americans with chronic pain and the concurrent increase in the use of
opioids to treat this pain have created a situation where large numbers of Americans are
receiving suboptimal care. Patients who are in pain are often denied the most effective
comprehensive treatments; conversely, many patients are inappropriately prescribed medications
that may be ineffective and potentially harmful. At the root of the problem is the inadequate
knowledge about the best approaches to treat various types of pain, balancing the effectiveness
with the potential for harm, as well as a dysfunctional health care delivery system that
encourages clinicians to prescribe the easiest rather than the best approach for addressing pain.
 
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Reactions: 2 users
drusso said:
Wrong: Widespread pain, migraine headache, chronic (transformed) migraine, even chronic low back have ample neurophysiological, genetic, and functional imaging data to support the notion that they are bonafide medical conditions. They are not character flaws nor foibles. You're conflating the patient's problem (diagnosis) with the doctor's problem (treatment).

Here's a more effective message: Treating chronic pain is resource intensive, labor intensive, and expensive work. Payer MUST expect that proper treatment of chronic pain and related disorders will be costly. Effective professional preparation for work in this field requires a broad and deep understanding of neurology, musculoskeletal medicine, pharmacology, neurophysiology, radiology, rehabilitation, and psychiatry. It necessitates being able to work in coordinated care teams and demonstrated competency in interdisciplinary settings.

https://prevention.nih.gov/docs/programs/p2p/ODPPainPanelStatementFinal_10-02-14.pdf

"Health care providers, often poorly trained in management of chronic pain, are sometimes quick to label patients as “drug-seeking” or as “addicts” who overestimate their pain. Some doctors “fire” patients for increasing their dose or merely for continuing to voice concerns about their pain management. Some patients have had similarly negative interactions with pharmacists. These experiences may make patients feel stigmatized, or feel as if others view them as criminals. These experiences may heighten fears that pain-relieving medications will be “taken away,” leaving the patient in chronic, disabling pain. In addition, negative perceptions by clinicians can create a rupture in the therapeutic alliance, which some studies have identified as impeding successful opioid treatment."

....

"Chronic pain is a complex clinical issue requiring an individualized, multifaceted approach.
Contributing to the complexity is the fact that chronic pain is not limited to a particular disease
state but rather spans a multitude of conditions, with varied etiologies and presentations. Yet,
traditionally, persons living with chronic pain are “lumped” into a single category, and treatment
approaches have been generalized with little evidence to support this practice. In addition,
although pain is a dynamic phenomenon, waxing and waning and changing in nature over time,
it is often viewed and managed with a static approach. For a number of reasons—including lack
of knowledge, practice settings, resource availability, and reimbursement structure—clinicians
are often ill-prepared to diagnose, appropriately assess, treat, and monitor patients with chronic
pain. "

...

As noted above, different types of pain—peripheral nocioceptive,
peripheral neuropathic, and centralized pain—appear to have different profiles of response to
such treatments. Furthermore, the use of a more effective chronic disease care model may have
implications for reducing the potential of a new generation of chronic opioid users as the
continued first-line use of opioids for chronic pain treatment is generally suboptimal and has the
potential for addiction. Although the team composition may vary, members might include the
primary care provider, case or care managers, nurses, pharmacists, psychologists, psychiatrists,
social workers, and other pain specialists.

...

Current reimbursement for
evaluation and management may be inadequate to reflect the time and team-based approaches
needed for integrative treatment. In some instances, payment structures place barriers to nonopioid
therapy, such as formulary restrictions that require evidence of failure of multiple
therapies before covering non-opioid alternatives (e.g., pregabalin).

...

The rise in the number of Americans with chronic pain and the concurrent increase in the use of
opioids to treat this pain have created a situation where large numbers of Americans are
receiving suboptimal care. Patients who are in pain are often denied the most effective
comprehensive treatments; conversely, many patients are inappropriately prescribed medications
that may be ineffective and potentially harmful. At the root of the problem is the inadequate
knowledge about the best approaches to treat various types of pain, balancing the effectiveness
with the potential for harm, as well as a dysfunctional health care delivery system that
encourages clinicians to prescribe the easiest rather than the best approach for addressing pain.
Click to expand...
Agree. Migraines in particular are completely physiologic. That's undeniable. You can even see vascular changes on routine mRI in migraine patients. That's not saying they need OPIATES or don't have psychosocial triggers, but they're physiologic and 100% real. They respond to a specific subclass of medications (tryptans) that don't work for other headache types, etc. To lump vague undiagnosed "widespread pain" in with migraine, is way off track as far as I'm concerned. To take opiates off the table? Fine. But to lump those all together as psychogenic and not distinct entities is a step backwards as far as I'm concerned.
 
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Reactions: 1 users
drusso said:
Wrong: Widespread pain, migraine headache, chronic (transformed) migraine, even chronic low back have ample neurophysiological, genetic, and functional imaging data to support the notion that they are bonafide medical conditions. They are not character flaws nor foibles. You're conflating the patient's problem (diagnosis) with the doctor's problem (treatment).

Here's a more effective message: Treating chronic pain is resource intensive, labor intensive, and expensive work. Payer MUST expect that proper treatment of chronic pain and related disorders will be costly. Effective professional preparation for work in this field requires a broad and deep understanding of neurology, musculoskeletal medicine, pharmacology, neurophysiology, radiology, rehabilitation, and psychiatry. It necessitates being able to work in coordinated care teams and demonstrated competency in interdisciplinary settings.

https://prevention.nih.gov/docs/programs/p2p/ODPPainPanelStatementFinal_10-02-14.pdf

"Health care providers, often poorly trained in management of chronic pain, are sometimes quick to label patients as “drug-seeking” or as “addicts” who overestimate their pain. Some doctors “fire” patients for increasing their dose or merely for continuing to voice concerns about their pain management. Some patients have had similarly negative interactions with pharmacists. These experiences may make patients feel stigmatized, or feel as if others view them as criminals. These experiences may heighten fears that pain-relieving medications will be “taken away,” leaving the patient in chronic, disabling pain. In addition, negative perceptions by clinicians can create a rupture in the therapeutic alliance, which some studies have identified as impeding successful opioid treatment."

....

"Chronic pain is a complex clinical issue requiring an individualized, multifaceted approach.
Contributing to the complexity is the fact that chronic pain is not limited to a particular disease
state but rather spans a multitude of conditions, with varied etiologies and presentations. Yet,
traditionally, persons living with chronic pain are “lumped” into a single category, and treatment
approaches have been generalized with little evidence to support this practice. In addition,
although pain is a dynamic phenomenon, waxing and waning and changing in nature over time,
it is often viewed and managed with a static approach. For a number of reasons—including lack
of knowledge, practice settings, resource availability, and reimbursement structure—clinicians
are often ill-prepared to diagnose, appropriately assess, treat, and monitor patients with chronic
pain. "

...

As noted above, different types of pain—peripheral nocioceptive,
peripheral neuropathic, and centralized pain—appear to have different profiles of response to
such treatments. Furthermore, the use of a more effective chronic disease care model may have
implications for reducing the potential of a new generation of chronic opioid users as the
continued first-line use of opioids for chronic pain treatment is generally suboptimal and has the
potential for addiction. Although the team composition may vary, members might include the
primary care provider, case or care managers, nurses, pharmacists, psychologists, psychiatrists,
social workers, and other pain specialists.

...

Current reimbursement for
evaluation and management may be inadequate to reflect the time and team-based approaches
needed for integrative treatment. In some instances, payment structures place barriers to nonopioid
therapy, such as formulary restrictions that require evidence of failure of multiple
therapies before covering non-opioid alternatives (e.g., pregabalin).

...

The rise in the number of Americans with chronic pain and the concurrent increase in the use of
opioids to treat this pain have created a situation where large numbers of Americans are
receiving suboptimal care. Patients who are in pain are often denied the most effective
comprehensive treatments; conversely, many patients are inappropriately prescribed medications
that may be ineffective and potentially harmful. At the root of the problem is the inadequate
knowledge about the best approaches to treat various types of pain, balancing the effectiveness
with the potential for harm, as well as a dysfunctional health care delivery system that
encourages clinicians to prescribe the easiest rather than the best approach for addressing pain.
Click to expand...

It’s not possible to reconcile the rate of opioid consumption for chronic non-cancer pain (CNP) in the US based upon burden of disease because our per capita consumption vastly exceeds every other industrialized country except Canada.(1) So if disease isn’t driving prescribing, something else must be.

The pain advocates here - and PHARMA - are quick to quote the IOM has estimated of 100 million Americans in pain as a defense for their views on liberal opioid use for CNP. This estimate is based upon work by Mike Von Korff. But, Dr. Von Korff - who is a member of PROP - has publicly distanced himself from the IOM’s estimate, suggesting it exaggerates the number of individuals with severe pain or work disability, i.e., those who might benefit from opioid treatment. (3) Dr. Von Korff - and others - have since estimated the number of American’s with severe chronic non-cancer pain to be on the order of 15-25 million. (4)

So who are the 75 or so million Americans with chronic non-cancer pain who would not require chronic opioids if they lived in most other developed countries? By and large these are working aged adults with chronic back ache, chronic head ache, and fibromyalgia syndrome. These are the big three chronic non-cancer pain diagnoses for which opioids are prescribed in the US and Canada. If we take chronic low back pain as case in point - this is valid because it is the most common chronic pain condition in the US (1)- recent functional MRI data indicates that as LBP goes from acute to chronic it’s interpretive center in the brain moves from the acute pain center to an emotional/reward area that also houses phenomena such as emotional rejection, PTSD, and catastrophizing.(5) This area - a center of suffering without pain - is not responsive to acute pain, but it’s activity is reinforced by opioid use. This may explain why so many individuals on disability are also on chronic opioids in the US. Thus, it's safe to say the use of opioids for most CNP in the US merely reinforces it’s persistence by rewarding it. (6,7)

I'll close this with a quote from Mark Sullivan, a prominent pain researcher, that is apropos to this discussion:

"Sullivan told me that in poor, rural regions doctors are using opioids to treat a “complex mixture of physical and emotional distress.” He said, “It’s much more convenient for both patient and physician to speak in the language of physical pain, which is less stigmatized than psychological pain.” Some of these patients could be said to be suffering from what his colleague calls “terribly-sad-life syndrome.” “These patients are at a dead end, life has stymied them, they are hurting,” he said. “They want to be numb.” He believes that doctors are inappropriately adopting a “palliative-care mentality” to “relieve the suffering of people who have had very tough lives.” (8)




REFERENCES:


1. BMJ. 2015 Jan 5;350:g6380. doi: 10.1136/bmj.g6380. Opioids for low back pain. Deyo RA1, Von Korff M2, Duhrkoop D3.

2. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, Borges GL, Bromet EJ, Demytteneare K, de Girolamo G, de Graaf R, Gureje O, Lepine JP, Haro JM, Levinson D, Oakley Browne MA, Posada-Villa J, Seedat S, Watanabe M. J Pain. 2008 Oct;9(10):883-91. doi: 10.1016/j.jpain.2008.05.005. Epub 2008 Jul 7. Erratum in: J Pain. 2009 May;10(5):553.

3. http://www.medpagetoday.com/PainManagement/PainManagement/46482J Pain.

4. 2014 Oct;15(10):979-84. doi: 10.1016/j.jpain.2014.05.009.Prevalence of persistent pain in the U.S. Adult population: new data from the 2010 national health interview survey. Kennedy J1, Roll JM2, Schraudner T3, Murphy S3, McPherson S

5. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Hashmi JA, Baliki MN, Huang L, Baria AT, Torbey S, Hermann KM, Schnitzer TJ, Apkarian AV. Brain. 2013 Sep;136(Pt 9):2751-68.

6. Pain. 2013 Jul;154(7):1038-44. doi: 10.1016/j.pain.2013.03.011. Epub 2013 Mar 26. Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up? Ashworth J1, Green DJ, Dunn KM, Jordan KP.

7. Med Care. 2014 Sep;52(9):852-9. doi: 10.1097/MLR.0000000000000183. Prescription opioid use among disabled Medicare beneficiaries: intensity, trends, and regional variation. Morden NE1, Munson JC, Colla CH, Skinner JS, Bynum JP, Zhou W, Meara E.

8. http://www.newyorker.com/magazine/2014/05/05/prescription-for-disaster
 
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drusso said:
Stigmatizing social ills generally just drives the problem underground.

If you want to change attitudes around frivolous disability, then the effective public health message to promote is that "pain doesn't equal disability."
Click to expand...

Sounds like the AAPMR should be the one pushing this stance. In the US anyway.
 
drusso said:
Here's a more effective message: Treating chronic pain is resource intensive, labor intensive, and expensive work. Payer MUST expect that proper treatment of chronic pain and related disorders will be costly. Effective professional preparation for work in this field requires a broad and deep understanding of neurology, musculoskeletal medicine, pharmacology, neurophysiology, radiology, rehabilitation, and psychiatry. It necessitates being able to work in coordinated care teams and demonstrated competency in interdisciplinary settings.
Click to expand...

Opportunities for a directorship/consulting position for large hospital/health systems or large employers.

Needs an MBA?
 
101N said:
It’s not possible to reconcile the rate of opioid consumption for chronic non-cancer pain (CNP) in the US based upon burden of disease because our per capita consumption vastly exceeds every other industrialized country except Canada.(1) So if disease isn’t driving prescribing, something else must be.

The pain advocates here - and PHARMA - are quick to quote the IOM has estimated of 100 million Americans in pain as a defense for their views on liberal opioid use for CNP. This estimate is based upon work by Mike Von Korff. But, Dr. Von Korff - who is a member of PROP - has publicly distanced himself from the IOM’s estimate, suggesting it exaggerates the number of individuals with severe pain or work disability, i.e., those who might benefit from opioid treatment. (3) Dr. Von Korff - and others - have since estimated the number of American’s with severe chronic non-cancer pain to be on the order of 15-25 million. (4)

So who are the 75 or so million Americans with chronic non-cancer pain who would not require chronic opioids if they lived in most other developed countries? By and large these are working aged adults with chronic back ache, chronic head ache, and fibromyalgia syndrome. These are the big three chronic non-cancer pain diagnoses for which opioids are prescribed in the US and Canada. If we take chronic low back pain as case in point - this is valid because it is the most common chronic pain condition in the US (1)- recent functional MRI data indicates that as LBP goes from acute to chronic it’s interpretive center in the brain moves from the acute pain center to an emotional/reward area that also houses phenomena such as emotional rejection, PTSD, and catastrophizing.(5) This area - a center of suffering without pain - is not responsive to acute pain, but it’s activity is reinforced by opioid use. This may explain why so many individuals on disability are also on chronic opioids in the US. Thus, it's safe to say the use of opioids for most CNP in the US merely reinforces it’s persistence by rewarding it. (6,7)

I'll close this with a quote from Mark Sullivan, a prominent pain researcher, that is apropos to this discussion:

"Sullivan told me that in poor, rural regions doctors are using opioids to treat a “complex mixture of physical and emotional distress.” He said, “It’s much more convenient for both patient and physician to speak in the language of physical pain, which is less stigmatized than psychological pain.” Some of these patients could be said to be suffering from what his colleague calls “terribly-sad-life syndrome.” “These patients are at a dead end, life has stymied them, they are hurting,” he said. “They want to be numb.” He believes that doctors are inappropriately adopting a “palliative-care mentality” to “relieve the suffering of people who have had very tough lives.” (8)




REFERENCES:


1. BMJ. 2015 Jan 5;350:g6380. doi: 10.1136/bmj.g6380. Opioids for low back pain. Deyo RA1, Von Korff M2, Duhrkoop D3.

2. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, Borges GL, Bromet EJ, Demytteneare K, de Girolamo G, de Graaf R, Gureje O, Lepine JP, Haro JM, Levinson D, Oakley Browne MA, Posada-Villa J, Seedat S, Watanabe M. J Pain. 2008 Oct;9(10):883-91. doi: 10.1016/j.jpain.2008.05.005. Epub 2008 Jul 7. Erratum in: J Pain. 2009 May;10(5):553.

3. http://www.medpagetoday.com/PainManagement/PainManagement/46482J Pain.

4. 2014 Oct;15(10):979-84. doi: 10.1016/j.jpain.2014.05.009.Prevalence of persistent pain in the U.S. Adult population: new data from the 2010 national health interview survey. Kennedy J1, Roll JM2, Schraudner T3, Murphy S3, McPherson S

5. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Hashmi JA, Baliki MN, Huang L, Baria AT, Torbey S, Hermann KM, Schnitzer TJ, Apkarian AV. Brain. 2013 Sep;136(Pt 9):2751-68.

6. Pain. 2013 Jul;154(7):1038-44. doi: 10.1016/j.pain.2013.03.011. Epub 2013 Mar 26. Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up? Ashworth J1, Green DJ, Dunn KM, Jordan KP.

7. Med Care. 2014 Sep;52(9):852-9. doi: 10.1097/MLR.0000000000000183. Prescription opioid use among disabled Medicare beneficiaries: intensity, trends, and regional variation. Morden NE1, Munson JC, Colla CH, Skinner JS, Bynum JP, Zhou W, Meara E.

8. http://www.newyorker.com/magazine/2014/05/05/prescription-for-disaster
Click to expand...



You have to stop equating pain as an opiate deficiency. Pain and opiates do not go hand in hand. Our message needs to be we will treat your pain no matter what. What we use has to be reasonably based in sound science. Opiates for palliative care is a no brainer. Opiates for post-op pain is a no brainer. Opiates for FMS is also a no brainer but it's a no go this time.
 
101N said:
It’s not possible to reconcile the rate of opioid consumption for chronic non-cancer pain (CNP) in the US based upon burden of disease because our per capita consumption vastly exceeds every other industrialized country except Canada.(1) So if disease isn’t driving prescribing, something else must be.

The pain advocates here - and PHARMA - are quick to quote the IOM has estimated of 100 million Americans in pain as a defense for their views on liberal opioid use for CNP. This estimate is based upon work by Mike Von Korff. But, Dr. Von Korff - who is a member of PROP - has publicly distanced himself from the IOM’s estimate, suggesting it exaggerates the number of individuals with severe pain or work disability, i.e., those who might benefit from opioid treatment. (3) Dr. Von Korff - and others - have since estimated the number of American’s with severe chronic non-cancer pain to be on the order of 15-25 million. (4)

So who are the 75 or so million Americans with chronic non-cancer pain who would not require chronic opioids if they lived in most other developed countries? By and large these are working aged adults with chronic back ache, chronic head ache, and fibromyalgia syndrome. These are the big three chronic non-cancer pain diagnoses for which opioids are prescribed in the US and Canada. If we take chronic low back pain as case in point - this is valid because it is the most common chronic pain condition in the US (1)- recent functional MRI data indicates that as LBP goes from acute to chronic it’s interpretive center in the brain moves from the acute pain center to an emotional/reward area that also houses phenomena such as emotional rejection, PTSD, and catastrophizing.(5) This area - a center of suffering without pain - is not responsive to acute pain, but it’s activity is reinforced by opioid use. This may explain why so many individuals on disability are also on chronic opioids in the US. Thus, it's safe to say the use of opioids for most CNP in the US merely reinforces it’s persistence by rewarding it. (6,7)

I'll close this with a quote from Mark Sullivan, a prominent pain researcher, that is apropos to this discussion:

"Sullivan told me that in poor, rural regions doctors are using opioids to treat a “complex mixture of physical and emotional distress.” He said, “It’s much more convenient for both patient and physician to speak in the language of physical pain, which is less stigmatized than psychological pain.” Some of these patients could be said to be suffering from what his colleague calls “terribly-sad-life syndrome.” “These patients are at a dead end, life has stymied them, they are hurting,” he said. “They want to be numb.” He believes that doctors are inappropriately adopting a “palliative-care mentality” to “relieve the suffering of people who have had very tough lives.” (8)




REFERENCES:


1. BMJ. 2015 Jan 5;350:g6380. doi: 10.1136/bmj.g6380. Opioids for low back pain. Deyo RA1, Von Korff M2, Duhrkoop D3.

2. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, Borges GL, Bromet EJ, Demytteneare K, de Girolamo G, de Graaf R, Gureje O, Lepine JP, Haro JM, Levinson D, Oakley Browne MA, Posada-Villa J, Seedat S, Watanabe M. J Pain. 2008 Oct;9(10):883-91. doi: 10.1016/j.jpain.2008.05.005. Epub 2008 Jul 7. Erratum in: J Pain. 2009 May;10(5):553.

3. http://www.medpagetoday.com/PainManagement/PainManagement/46482J Pain.

4. 2014 Oct;15(10):979-84. doi: 10.1016/j.jpain.2014.05.009.Prevalence of persistent pain in the U.S. Adult population: new data from the 2010 national health interview survey. Kennedy J1, Roll JM2, Schraudner T3, Murphy S3, McPherson S

5. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Hashmi JA, Baliki MN, Huang L, Baria AT, Torbey S, Hermann KM, Schnitzer TJ, Apkarian AV. Brain. 2013 Sep;136(Pt 9):2751-68.

6. Pain. 2013 Jul;154(7):1038-44. doi: 10.1016/j.pain.2013.03.011. Epub 2013 Mar 26. Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up? Ashworth J1, Green DJ, Dunn KM, Jordan KP.

7. Med Care. 2014 Sep;52(9):852-9. doi: 10.1097/MLR.0000000000000183. Prescription opioid use among disabled Medicare beneficiaries: intensity, trends, and regional variation. Morden NE1, Munson JC, Colla CH, Skinner JS, Bynum JP, Zhou W, Meara E.

8. http://www.newyorker.com/magazine/2014/05/05/prescription-for-disaster
Click to expand...

I don't understand who you're trying to convince: I'm still trying to understand how stigmatizing the problem helps it.

Mark Sullivan's quote is a distinction without a difference; it says nothing new. One can just change the language a little and say, "Reversing the "chronification" (I would say the detection, diagnosis, treatment, and rehabilitation) of pain is labor, resource, and time-intensive work. Payers can expect it will be costly. Practitioners in this field will need to have broad and deep knowledge of neurology, musculoskeletal medicine, pharmacology, psychiatry, and rehabilitation. They will also need demonstrated competence and skill in working in collaborative care teams and interdisciplinary treatment settings."
 
lobelsteve said:
You have to stop equating pain as an opiate deficiency. Pain and opiates do not go hand in hand. Our message needs to be we will treat your pain no matter what. What we use has to be reasonably based in sound science. Opiates for palliative care is a no brainer. Opiates for post-op pain is a no brainer. Opiates for FMS is also a no brainer but it's a no go this time.
Click to expand...

My point is that most "chronic pain" in the US - the majority of the IOMs 100m- are likely 'central' pain syndromes. The fMRI signatures in these folks are c/w Sullivan's SLS comments. These people - the majority of them working aged - don't need either IPM or opioids, ie, us. But most IPM practices are built on them: 724.8, 722.52, 723.1. 723.3, 722.83, 337.xx, 784, 339, 729.1

Some may benefit from behavioral interventions, but the EBM jury is still out on those. Pubic health and behavioral economics approaches - prevention & removing incentives - probably holds as much or more promise.

And yes, stigma plays a beneficial role in helping to minimize behavior. If guilt happens as a byproduct of accepting responsibility it's a good thing.

http://online.wsj.com/articles/guil...er-isnt-and-how-to-tell-them-apart-1415038844
 
Last edited:
101N said:
My point is that most "chronic pain" in the US - the majority of the IOMs 100m- are likely 'central' pain syndromes. The fMRI signatures in these folks are c/w Sullivan's SLS comments. These people - the majority of them working aged - don't need either IPM or opioids, ie, us. But most IPM practices are built on them: 724.8, 722.52, 723.1. 723.3, 722.83, 337.xx, 784, 339, 729.1

Some may benefit from behavioral interventions, but the EBM jury is still out on those. Pubic health and behavioral economics approaches - prevention & removing incentives - probably holds as much or more promise.

And yes, stigma plays a beneficial role in helping to minimize behavior. If guilt happens as a byproduct of accepting responsibility it's a good thing.

http://online.wsj.com/articles/guil...er-isnt-and-how-to-tell-them-apart-1415038844
Click to expand...

When you're treated poorly, it doesn't make you want to get help there, and while a lot of people do get help, the reality is they are in the minority,” Child said. "There's still enough stigma around mental health issues. Until we can talk about mental health problems, we have a lot of work to do."

In addressing the stigma, Geels said it starts with reducing the distinction in health conditions.
"We really need to emphasize there is no difference between having mental health and physical health conditions," Geels said. "A long time ago, these medical conditions were separated and classified as mental, but they're still just as important and relevant."

Oregon State and county officials committed to bridging mental health gap
Health care leaders working to rid mental health stigma, emphasize no difference between mental, physical health

http://theworldlink.com/news/local/...cle_cbc38a3d-34c7-5791-96c1-e1d8e25e0e19.html
 
This is a thread about opioid overprescribing for CNP nested within an IPM forum. I'm all for more funding for mental health and addiction Tx.

When I recently posted a thread about screening instruments to detect mental health concerns and catastrophizing - the very diagnoses that are
germain to the article just posted - several respondants basically said: why? Here is why: to better direct treatment at the underlying disease or
condition. Not screening for mental illness and catastrophizing in CNP leaves chronic pain patients vulerable to both unnecessary and harmful COT as well
as unnecessary, costly, and potentionally harmful IPM procedures.

The tacit understanding amongst many IPM folks is that there is a financial incentive not to ask "Is this a centralized pain problem, or un/undertreated depression/anxiety,
or addiction masquerading as CNP?" Thus: Would this patient be better served in behavioral health/addiction medicine, etc? Is treating this patient really beyond my scope of
practice. Am I just checking a box by prescribing an opioid or doing a procedure that I know really isn't going to get anywhere near addressing the underlying issues.
 
Last edited:
101N said:
This is a thread about opioid overprescribing for CNP nested within an IPM forum. I'm all for more funding for mental health and addiction Tx.

When I recently posted a thread about screening instruments to detect mental health concerns and catastrophizing - the very diagnoses that are
germain to the article just posted - several respondants basically said: why? Here is why: to better direct treatment at the underlying disease or
condition. Not screening for mental illness and catastrophizing in CNP leaves chronic pain patients vulerable to both unnecessary and harmful COT as well
as unnecessary, costly, and potentionally harmful IPM procedures.

The tacit understanding amongst many IPM folks is that there is a financial incentive not to ask "Is this a centralized pain problem, or un/undertreated depression/anxiety, or addiction masquerading as CNP?" Thus: Would this patient be better served in behavioral health/addiction medicine, etc? Is treating this patient really beyond my scope of practice. Am I just checking a box by prescribing an opioid or doing a procedure that I know really isn't going to get anywhere near addressing the underlying issues.
Click to expand...

What should be considered a community standard of care for a IPM specialist? I think that the broader problem is the idea of the specialty of IPM viewed in isolation. An interventional cardiologist would not eschew medical or lifestyle management of HTN, CAD, PVD, etc.

I'm an interventionalist, but I treat pain in the broader sense: Peripheral pain, central pain, cancer pain, headaches, pelvic pain, any unpleasant sensory or emotional experience described in actual or potential tissue damge, etc. Each kind of problem requires a different kind of "intervention." Sometimes that's a behaviorally-oriented one.

If you're interventionalist, but haven't invested the resources into developing behavioral support in-house, or formed relationships in your community with those supports, you're probably not practicing at a recognized standard of care. Similarly, if you're an interventionalist, but don't demonstrate a basic competency at recognizing somatization disorders, central pain disorders, substance use disorders, etc then similarly you're not practicing at a standard most similarly trained specialists would recognize as acceptable.

The problem becomes that patients often have more than one problem: Peripheral nociceptive pain and central pain disorders.

Still, the bar should be low for patients to access treatment for pain as most pain problems reflect a combination of psychiatric and physical problems.
 
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US Pain Foundation (receives the majority of it's funding from PHARMA)

If you are someone with fibromyalgia and/or chronic pain who has taken prescription hydrocodone medications (Vicodin®, Lortab®, Lortab ASA®, Hycomine®, and Vicoprofen®) to alleviate your suffering, please consider taking part in this very important survey. Your voice matters. Along with several other patient advocate organizations, the National Fibromyalgia & Chronic Pain Association (NFMCPA) is interested in how new government opioid medication regulations are affecting people with chronic pain. Deterring illegal and illicit use of prescription drugs is an important and mandatory campaign led by the Drug Enforcement Administration (DEA) to help stop criminal drug abuse and illegal drug prescriptions from infiltrating into mainstream American society.

However, during their strong efforts to create new laws limiting access to these medications to deter illegal activities, the DEA and law enforcement agencies have not heard from the many people with chronic pain conditions who need these pain medications. This has resulted in unintended, negative consequences to chronic pain patients legitimately seeking pain relief. On October 6, 2014, hydrocodone was moved from a Schedule III medication to a more tightly restricted Schedule II opioid medication. This means that a person who is prescribed one of these drugs is now required to:

1. Sign a contract with their doctor for their prescription hydrocodone medications
2. Fill a 30-day hydrocodone medication with only a hand-signed prescription from their doctor, which ordinarily requires a monthly medical appointment. These prescriptions can no longer be called into the pharmacy, emailed or faxed, nor can prescriptions for hydrocodone drugs be refilled from an original prescription.
3. Designate which pharmacy will be used to fill the prescription.

To give chronic pain patients a voice about this new law, the National Fibromyalgia & Chronic Pain Association created a survey with a group of medical experts for people who have been impacted by hydrocodone rescheduling. The goal of the survey is to collect data to publish an accurate assessment of the rescheduling impact to help counterbalance stigma or limited access to care issues that people with chronic pain face.

Hydrocodone Rescheduling: The First 100 Days is the first in a series of three hydrocodone-specific surveys that will be conducted over this first year of rescheduling. These anonymous surveys are hosted on Survey Monkey, and all collected data results will be used for the sole purpose of this survey. Confidentiality will be promised to the extent allowed by law. Data will be reported without any personal identifiers and in aggregate form. It will be available online at the link below February 6 – March 9, 2015.

https://www.surveymonkey.com/r/Hydrocodone100Days
 
talk about a bunch of loaded questions.

there is even the jist that a patient's thought of suicide is due to changes in the law.


 
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lobelsteve said:
You have to stop equating pain as an opiate deficiency. Pain and opiates do not go hand in hand. Our message needs to be we will treat your pain no matter what. What we use has to be reasonably based in sound science. Opiates for palliative care is a no brainer. Opiates for post-op pain is a no brainer. Opiates for FMS is also a no brainer but it's a no go this time.
Click to expand...


Pain. 2015 Feb;156(2):231-42. doi: 10.1097/01.j.pain.0000460303.63948.8e.

The Pain and Opioids IN Treatment study: characteristics of a cohort using opioids to manage chronic non-cancer pain.

Campbell G1, Nielsen S, Bruno R, Lintzeris N, Cohen M, Hall W, Larance B, Mattick RP, Degenhardt L.

Author information

  • 1aNational Drug and Alcohol Research Centre, School of Medicine, University of New South Wales, Sydney, Australia bThe Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Surry Hills, Australia cSchool of Medicine, University of Tasmania, Sandy Bay Campus, Hobart, Australia dUniversity of Sydney, Addiction Medicine, Central Clinical School, Camperdown, Australia eSt Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia fCentre for Youth Substance Abuse Research, Royal Brisbane and Women's Hospital, University of Queensland, Herston, Australia gSchool of Population and Global Health, The University of Melbourne, Melbourne, Australia hMurdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Australia iDepartment of Global Health, School of Public Health, University of Washington, Seattle, WA, USA.
Abstract

There has been a recent increase in public and professional concern about the prescription of strong prescription opioids for pain. Despite this concern, research to date has been limited because of a number of factors such as small sample sizes, exclusion of people with complex comorbidities, and studies of short duration. The Pain and Opioids IN Treatment is a 2-year prospective cohort study of 1500 people prescribed with pharmaceutical opioids for their chronic pain. This article provides an overview of the demographic and clinical characteristics of the cohort using the baseline data of 1514 community-based people across Australia. Participants had been in pain for a period of 10 years and had been on prescription opioids for approximately 4 years. One in 10 was on a daily morphine equivalent dose of ≥200 mg. Employment and income levels were low, and two-thirds of the sample reported that their pain had impacted on their employment status. Approximately 50% screened positive for current moderate-to-severe depression, and 1 in 5 had made a lifetime suicide attempt. There were a number of age-related differences. The younger groups experienced higher levels of pain and pain interference, more mental health and substance use issues, and barriers to treatment, compared with the older group. This study found that the people who have been prescribed strong opioids for chronic pain have very complex demographic and clinical profiles. Major age-related differences in the experiences of pain, coping, mental health, and substance use suggest the necessity of differential approaches to treatment.

Policymakers in the USA have taken a "wait to fail approach" in addressing the opioid epidemic in our country. Literally we're counting ED overdoses and body bags. In part, this faulty and muddle-headed approach is grounded in the fallacy that the problem is **ONE** problem. Pain specialists need to inform policymakers that a simple-minded "one-size fits all" approach to the problem won't work. Pain specialists need to inform the discussion moving forward--not meta-analyticians, not insurance companies, not politicians.

Given what we know about the characteristics of patients with chronic pain, the longitudinal treatment of chronic pain is EXPECTED to be resource intensive, complex, high risk work requiring the expertise of multiple professionals (medical, behavioral, and addiction) working in concert. When our state and federal governments throw good money after bad on useless quackery (acupuncture, nutritional supplements, homeopathy, massage, chiropractic) and calls it "pain management" our patients suffer and our resources are drained.
 
http://www.kevinmd.com/blog/2015/02/ask-dilaudid-get-dilaudid-no-questions-asked.html
Ask for Dilaudid, get Dilaudid. No questions asked.
GOMERBLOG | MEDS | FEBRUARY 28, 2015

A local hospital is trying a new, controversial but more efficient approach to medical care. “We have changed our guidelines, if you want Dilaudid you get Dilaudid, if you want Valium, you get Valium. No questions asked,” CEO Michael Shoemaker told reporters Wednesday.

In what experts are calling pure genius, emergency department utilization has never been better, costs have been severely cut down, and patient satisfaction scores are through the roof: a national high.


“I didn’t have to fake my seizure just to get that Xanax that I love so much!” read one comment card. “The new policy saved me hours of the day, I didn’t have to describe my abdominal pain and go through hours of tests, scans, and experts coming in to see me. I got my drug that starts with a ‘D’ [winks] and then I could go out and get things done,” said a smiling patient leaving the emergency department with pin-point pupils.

The hospital is now saving thousands of dollars on avoiding abdominal CT scans and MRIs. “Our radiology costs were out of control, as a ten-year supply of Percocet is still cheaper than an MRI. Simple economics,” Hospital CFO Charlie Daniels stated.

ED physician Jennifer Hillgis is very happy with the new rules saying, “America has the highest opioid use in the whole world, it’s time to just accept it and move on. Plus these drug seekers don’t take up any of my beds anymore. They come in, get their drugs, and go home. No more spitting at my staff or cussing me out because I deny them medication by looking out for their safety.” Dr. Hillgis was surprised that some patient’s allergies have literally disappeared overnight. “If we are out of Dilaudid then many people are ‘willing to try something else,’ even if they have a documented allergy to it!”

“If a patient asks for a medication, we now advise health care providers to not to ask why, or figure out the medical reason, we now suggest they ask what dose,” said administrator Shoemaker. “We keep the lawyers away by having patients sign a couple documents saying they probably will die taking medication without medical advice.”

The new program removes any liability from health care providers as patients are required to sign a consent that they have been counseled about the risks.

“Everyone is happy. I get the drug seekers out of my ED quickly and with what they want. We can ethically wash our hands clean and move on to patients with real disease.”

The hospitals hired a manager from local fast-food chain Burger King whose motto is “Have it your way” to facilitate this new style of medicine.

“It really is easier,” Nurse Samantha told reporters. “Now when a patient comes in they just tell me ‘I want some Lortab please’ and I give them the dose and quantity they want.” She continued, “No need to lie or come up with excuses anymore. I just show them the package insert that says they might overdose and die if they take too much, and after showing them the warnings, I give them what they want. Done.”

Hospital personnel in Columbus are floored by the sudden memory gain of all their patients. “Everyone now knows what medication starts with a D.”

Founded by an emergency physician, GomerBlog is Earth’s finest medical satire news site.
 
101N said:
It’s not possible to reconcile the rate of opioid consumption for chronic non-cancer pain (CNP) in the US based upon burden of disease because our per capita consumption vastly exceeds every other industrialized country except Canada.(1) So if disease isn’t driving prescribing, something else must be.
Click to expand...

The problem is nothing to do with disease or patients. This problem is solely the fault of doctors. Have not seen a patient start themselves on narcotics via Rx. Taking the pens away from those who don't know what they are doing will fix this side of the equation. Setting expectations that life has pain as part of it needs to be the public health arena.
 
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I have ignored this thread since it appeared since it was too long to start - now it is 14 pages long.

Will this thread ever die? Please let it die....

It makes me feel guilty every time I see it in the list of posts because i haven't partaken.
 
It's meant to make you feel guilty. This is our wailing wall. This is us paying for the sins of our fathers.
 
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I know I feel obligated to read it and keep up... ugh pain in the ass ;)
 
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kind of a waste of a study. key finding - decrease in VAS over 6 month period of time.

clearly not a long term study. they may be determining QoL based on VAS??

cant read whole article, but it was interesting to note the following comment:
Opioids are generally considered the most effective analgesics and are preferred to NSAID for chronic use, due to their pharmacologic profile. Although opioids may cause addiction, it is infrequently seen in pain patients, even in those affected by CNCP.
Click to expand...
seems a little biased?
 
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drusso said:
Mexican drug cartels doubling down on Heroin. Seeing more of this show up in rural areas of the country...

http://www.9news.com.au/world/2015/...-forces-business-rethink-from-mexican-cartels

"Opiate-dependent drug users are increasingly turning to heroin, which is typically easier to source and cheaper than prescription opioids," the board's report says."
Click to expand...

A DEA agent recently told me that 80% of heroine users now-a-days started with prescription use. That is in start contrast to 20 years ago.
 
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