Do Doctors Care?

By Katie Burge, Guest Columnist

Tell me... exactly when did it become acceptable for physicians to not only harm, but to actually contribute to a patient's demise by denying adequate, necessary medical care? 

I'm referring to the rising death rate among chronic pain patients, whose doctors have yielded to political pressure and reduced their patients’ doses of pain medication to the point that they are virtually useless or refused to continue prescribing pain medication at all -- regardless of diagnosis or need -- because they fear regulatory action if they continue treating pain with opioids.  

Am I missing something? Under the Hippocratic Oath, aren't physicians supposed to strive to do no harm?  Or should we just start calling it the Hypocritical Oath when it comes to people in pain?

You might think that denying opioids to folks can only be a positive thing, but for those of us who suffer from severe, round-the-clock pain that only responds to opioids, this scenario is a nightmare.  Losing access to the only thing that lessens your pain can feel like a death sentence. And in some cases, it is.

Being forcibly tapered off opioids and then having to cope with the full brunt of your pain causes extreme stress, which can lead to heart attack and stroke.  Even worse, it causes some patients to lose hope of ever attaining help and commit suicide.

This almost happened to me last year. The really shocking thing is when I told a couple of my doctors that I was becoming increasingly suicidal because of pain, they just ignored me.

I guess they felt like if they acknowledged the reasons for my depression, they might have to address my pain. That is unacceptable to many physicians nowadays. I call this the "Ostrich" School of Medicine — where the doctors bury their heads in the sand whenever the topic of chronic pain comes up.

Many doctors have become so desensitized to pain and suffering that they seem to believe they're absolved of any responsibility when presented with a patient whose chronic pain is so severe that it only responds to opioids. They'll fall all over themselves trying to get away from us.

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My longtime family doctor refuses to even discuss my chronic pain. And when pain management specialists see the catalog of all my conditions, they visibly cringe. It’s as though I make them feel threatened, when the real threat comes from bumbling bureaucrats attempting to prove that they aren't completely impotent when it comes to dealing with the opioid epidemic.

A major truth about the opioid epidemic is that these bureaucrats can't do a damn thing about recreational drug use, but they want their constituents to believe they can. So in a lame attempt at proving their political prowess, they put the squeeze on pain management physicians and blame vulnerable pain patients for other people's opioid abuse.

What really makes my jaw drop in astonishment is the fact that most doctors simply kowtow to this bureaucratic lunacy without even trying to advocate for their patients or their own right to treat patients to the full extent of their education and experience. Doctors should never be put in the position of having to choose between incarceration and providing compassionate medical care.

There aren't many courageous physicians left who will help somebody like me.  I did eventually find one who gives me about half the medication I need to get through a month and be able to function. This enabled me to survive my “suicidal” level of pain, but I wouldn't actually call it living. 

My round-the-clock pain is being treated with a short-acting opioid that I'm only allowed to take once every 8 hours, because the doctor says he's not "allowed" to prescribed the long-acting, time released opioids anymore. These extended relief medications provide much better, more even relief -- often at a lower dose than the immediate release, short-acting opioids.

My current drug regimen creates kind of an evil roller coaster effect, where I'm okay for 3 or 4 hours and then the pain spikes for the next 4 hours until I can take another dose. And then the roller coaster takes off all over again.

Over the past 20 years, I've tried every traditional and alternative treatment known to medical science. Some have been beneficial and some have not, but I've learned what is safe and effective for me. I just wish my doctor would take my word for it. I know I'll never be pain free and surgeons say they're unable to "fix" me, so pain management is the only option I have left.

I am alive today due to a combination of God's grace and the adrenaline created by a combination of righteous indignation and an intense passion to help other pain patients and educate the public about chronic pain.

If you are a pain patient or you love a pain patient, please speak up and be counted if you're not getting the treatment you deserve. Never give up!

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Katie Burge lives in Mississippi. Katie has degenerative disc disease, spinal stenosis, spondylolisthesis, failed back syndrome, stenosis, osteoarthritis and fibromyalgia. 

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org. 

The information in this column is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

The Visible Few Pain Patients

By Dr. Lynn Webster, PNN Columnist

I receive several emails a week from people who ask for help because their treatment options have been limited or eliminated. They are in terrible pain, and they don’t know what to do.

One such person, Sharon Berenfeld, MD, recently shared an experience she had visiting her doctor.

“Dr. Webster, I came across a publication of yours. It struck a nerve with me. My pain is intractable. I have tried everything,” she wrote. “Before the exam room door even closed, [my doctor] announced to me, ‘If you think I’m just here to refill your pills, you can leave now.'

"I left in tears. I was being judged and punished for having a complication from cancer treatment. I completely understand the opioid crisis. But I feel impotent to do anything."

Who Are the Visible Few?

Earlier this year, Fox News' three-part series, Treating America's Pain: Unintended Victims of the Opioid Crackdown, showed the terrifying circumstances of people in pain and doctors under siege. One individual’s decision to commit suicide as a result of the crackdown on opioid prescribing embodies the struggles of people in pain and their providers' inability to meet their needs.

The visible few are the small number of people whose stories have been heard by journalists, media consumers and government officials. Their stories reflect millions of Americans suffering from chronic pain who live in the shadows and are invisible to most of us. 

The needs of people in pain and the challenges providers face when treating them have been overshadowed by the government's attempts to deal with the opioid crisis. The well-intentioned CDC Guideline for Prescribing Opioids for Chronic Pain has affected 20 million Americans with severe disabling pain.

It also is having consequences for everyone else in the healthcare system. Prescription opioids have been demonized and blamed for our current drug crisis.

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Unintended Consequences

The CDC guideline was supposed to be voluntary. However, in practice, the guideline has been treated as a policy with the strength of a law, and it has had severe unintended consequences. Many people are worse off in its wake. Here is a summary of the most substantial effects of the guideline.

  • Providers feel pressured to reduce the amount of opioids that they prescribe, regardless of their patients' individual needs. About 70% of physicians have reduced their opioid prescribing or stopped it completely.

  • Insurance companies set prescription limits based on the guideline. In some cases, they override physicians' recommendations. That means insurers, rather than doctors, are making decisions about how to treat pain.

  • Pharmacy chains are also limiting the amount of opioids they dispense, based on the guideline rather than on doctors' prescriptions..

  • The Centers for Medicare & Medicaid Services and the U.S. Department of Health and Human Services have set dosage limits. Providers advocating for patients who need higher amounts must navigate a complicated appeals process.

  • State attorneys general have used the guideline to evaluate whether a doctor is prescribing for a legitimate medical purpose. Deviation from the guideline has been used to accuse doctors of criminal conduct.

  • In a desperate search for pain relief, some patients have turned to street drugs.

Where We Are Now

The CDC guideline has left a trail of misunderstanding in its path. Its authors acknowledged misapplication of the guideline in the New England Journal of Medicine, emphasizing that their intention was to provide guidance rather than to establish a mandate.

"Difficulties faced by clinicians in prescribing opioids safely and effectively, growing awareness of opioid-associated risks, and a public health imperative to address opioid overdose underscored the need for the guidance,” they wrote.

In a separate article in the JAMA Network, the guideline's authors said, “The number of people experiencing chronic pain is substantial, with U.S. prevalence estimated at 11.2% of the adult population. Patients should receive appropriate pain treatment based on careful considerations of the benefits and risks of treatment options.”

There are other signs of recognition that the guideline has been misinterpreted. For example, CDC Director Robert Redfield, MD, wrote in a letter to Health Professionals for Patients in Pain (HP3), “The CDC is working diligently to evaluate the impact of the guideline and clarify its recommendations to reduce unintended harm.”

The American Medical Association's House of Delegates passed a series of resolutions on the guideline at an interim meeting in November 2018.

“Physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the morphine milligram level thresholds found in the CDC guidelines for prescribing opioids,” the AMA delegates said.

There is also some light being shined on the issue in a report by The Pain Management Best Practices Inter-Agency Task Force.

“There is no one-size-fits-all approach when treating and managing patients with painful conditions. Individuals who live with pain are suffering and need compassionate, individualized and effective approaches to improving pain and clinical outcomes. This is a roadmap that is desperately needed to treat our nation’s pain crisis,” said Vanila Singh, MD, task force chair and chief medical officer of the HHS Office of the Assistant Secretary for Health.

As the opioid odyssey continues, there are signs that the visible few are beginning to be heard. This is an important step to helping the invisible millions with chronic pain receive the care they deserve.

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Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, The Painful Truth,” and co-producer of the documentary,It Hurts Until You Die.” You can find him on Twitter: @LynnRWebsterMD.

The information in this column is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

A Pained Life: Stop Terrorizing Doctors

By Carol Levy, PNN Columnist

When I visit chronic pain support groups online, it is almost astounding how often posters turn to talking about the “opioid crisis,” no matter the subject of the initial post. One person wrote that she lives in a town where there is not one doctor who will prescribe opioids, no matter what the diagnosis.

I see comments like, “My doctor won't prescribe them for me anymore even though they were helping,” or “My doctor reduced what I was taking without any effort to ask how I was doing.”

Often they’ll add, “My doctor said he has changed his prescribing practices because of the CDC guidelines.”

Human Rights Watch recommended last year that the CDC guideline be revised because too many doctors were using it as an excuse to abruptly cutoff or taper patients.

“Even when medical providers understood that the Guideline was voluntary, they believed they risked punishment or unwanted attention from law enforcement agencies or state medical boards if they maintained patients at high doses,” Human Rights Watch found.

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How does this fear, engendered by political institutions like the CDC and DEA, not fall under the definition of terrorism? This is how Miriam-Webster defines terrorism: 

“The unlawful use or threat of violence especially against the state or the public as a politically motivated means of attack or coercion.”

Granted, the guidelines are not unlawful, but they have had the exact effect of being coercive on many in the medical community. I would also contend that the threat of being arrested and going to prison is a threat of violence.

The guidelines were engendered by the public outcry and governmental concern over the level of opioid overdoses and deaths. The CDC said the guidelines are voluntary, but to many doctors, pharmacies and insurance companies they are enshrined in stone as commandments. They were promulgated as a political response. They were not based on the medical model or the realities of patients in pain.

The point of terrorism is to instill fear. Terrorize one and others will fall in line. The guidelines have had exactly that effect. Accuse one doctor of overprescribing or running a pill mill – even if no charges are actually filed -- and other doctors will change their practices by reducing or refusing to prescribe opioids out of fear of being falsely accused, even when they know doing so will hurt their patients.

And how are patients hurt? Attorney Mark Rothstein, Director of the Institute for Bioethics at the University of Louisville School of Medicine, answers that question.

“Many physicians who previously prescribed opioids now have reduced or discontinued such prescriptions, even for established patients with chronic pain. In some cases, the change in policy was adopted literally overnight,” Rothstein wrote in the American Journal of Public Health.

“With no alternatives for pain control... and the physical and mental pressure of unremitting pain, many patients turned to illicit drugs, especially heroin. The result has been greater addiction, more deaths from overdoses, and an increase in cases of HIV/AIDS and hepatitis from contaminated syringes.”

It is long past time to end what has been interpreted as policy, a policy that hurts patients and the community. It’s time for the terrorism to stop.

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Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Lawyer Calls for DOJ to End ‘Indiscriminate Raids’ on Doctors

By Pat Anson, PNN Editor

In recent years, hundreds of physicians, pharmacists and addiction treatment doctors have had their offices raided and searched by DEA agents.

Many of the raids were orchestrated by the Justice Department’s Opioid Fraud and Abuse Detection Unit, a special team of investigators created in 2017 to mine opioid prescribing data to identify suspicious orders and practices. The investigations have resulted in the high-profile arrests of healthcare providers for fraud and risky opioid prescribing.

"If you're a doctor and you want to act like a drug dealer, we're going to treat you like one. And sometimes the only difference between a doctor and a drug dealer is a white coat," U.S. Attorney Jay Town said about a federal takedown in April that resulted in charges against 60 practitioners in seven states.

Rarely publicized are the cases where criminal charges are never filed because the evidence against doctors is weak or non-existent.

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“It’s quite frustrating to see how their careers were ruined even though they never faced criminal charges. That’s because the government was incapable of bringing credible charges against them,” says attorney Michael Barnes, who is managing partner at DCBA Law & Policy, a law firm that advises healthcare providers. “When I read a criminal complaint, what I would see as ‘best practices’ is construed as criminal exploitative behavior on the part of the prosecutors.

“There’s a heavy bias against medications to treat pain and opioid use disorder that is driving some of the aggressive enforcement actions. Also, an overzealousness combined with a lack of understanding of the practice of medicine.”

Barnes recently wrote an op/ed, published online by American University’s Washington College of Law, calling for an end to the DOJ’s “indiscriminate raids” on doctors.

“DOJ raids and searches of professionals’ homes and medical clinics interrupt the delivery of health care, put patients’ lives at risk, and unjustly destroy careers and livelihoods. They also create confusion and fear,” wrote Barnes. “Not all health care professionals subject to the DOJ’s searches and seizures are ‘dirty docs.’ In fact, some of them are nationally recognized leaders not just in pain management, but also in addiction medicine.” 

Barnes cites the case of Dr. Stuart Gitlow, an addiction psychiatrist whose Rhode Island home and office were raided by FBI agents in March 2018. Sixteen months later, the reasons for the raid remain unclear and Gitlow, the former president of the American Society of Addiction Medicine, has not been charged with a crime.  

MICHAEL BARNES

MICHAEL BARNES

Neither has Dr. Forest Tennant. In November 2017, DEA agents raided the office and home of Tennant, a prominent California pain physician who was flagged for “very suspicious prescribing patterns.” In a search warrant, the 76-year old Tennant was depicted as the kingpin of a drug trafficking organization that spanned several states.

“I know based on my training and experience that patients traveling long distances to obtain controlled substance prescriptions is another ‘red flag’ of drug abuse and addiction,” wrote DEA investigator Stephanie Kolb, who led a two-year investigation of Tennant.

But Kolb, who was self-employed as a dog walker and pet groomer before she started working for the DEA in 2012, failed to note that Tennant only treated intractable pain patients, many from out-of-state, and often prescribed high doses of opioids because of their chronically poor health. Some patients were in palliative care and near death, and one committed suicide after learning of the raid, fearing she would lose access to opioid medication.

Tennant denies any wrongdoing and was never formally charged, but retired from clinical practice a few months after the raid.

“It’s hard to continue operating when they never closed my case, and so I’m going to retire and move on,” Tennant told PNN at the time. “That’s on the advice of both my lawyers and my doctors."

(Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.)  

Biased Investigations

Barnes says the biases of some prosecutors extends to the expert witnesses they hire to help build their cases. The role of these witnesses is important because they help DOJ persuade judges to sign off on search warrants that are key to gathering evidence. It’s a lucrative sideline for some paid witnesses, who charge the government hundreds of dollars an hour for their time and expertise.

“Expert witnesses are eager to give DOJ business to get the expert witness fees, and they of course will help to spin the facts in a way that is prejudicial to the defendant,” Barnes said. “What we’re seeing here is people who are really not qualified to be making assessments of other practices serving as experts for the government.” 

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Dr. Timothy Munzing, a Kaiser Permanente family practice physician in California, has worked as a medical consultant for the DEA, FBI and DOJ on over 100 investigations, most of which involve prescriptions for opioids and other controlled substances.

According to GovTribe.com, which tracks payments to federal contractors, Munzing has been awarded nearly $1 million in DOJ contracts since 2017 and is currently working on nearly two dozen DEA investigations, mostly reviewing patient files and data from prescription drug monitoring programs.

It would be unusual for a family practice physician to treat an intractable pain patient without making a referral to a pain or palliative care specialist. But Munzing was one of the expert witnesses hired by the DEA to analyze Tennant’s prescribing.

“I find to a high level of certainty that after review of the medical records… that Dr. Tennant failed to meet the requirements in prescribing these dangerous medications,” Munzing wrote in an affidavit. “These prescribing patterns are highly suspicious for medication abuse/and or diversion. If the patients are actually using all the medications prescribed, they are at high risk for addiction, overdose, and death.”  

Munzing’s affidavit and the DEA search warrant identified no patients who were actually harmed while under Tennant’s care. As PNN reported, some patients found the allegation that they were selling their medication and funneling the profits back to Tennant laughable.      

“It’s like everything else they do. They don’t talk to any patients. They don’t talk to any doctors. They just go and throw all this stuff out there and making all these incriminations against people. They don’t have any evidence that I’ve sold anything. It’s just ludicrous,” said Ryle Holder, a Tennant patient who lives in Georgia.  

Barnes says the bias against opioid prescribing “is inherent in the work of many of the investigators and prosecutors.”

“Then there is the incompetence as it relates to many of the law enforcement officers not having the medical expertise to make judgements of a medical nature. And then, when they do consult with the experts, those experts are typically trying to please their clients and getting repeat business as a result,” he told PNN. 

State Medical Boards

To bring more expertise into investigations of healthcare providers, Barnes is proposing that state medical boards play a more prominent role. He wants Congress to amend federal law to require DOJ investigators and prosecutors to get a referral from a state licensing board before investigating a practitioner for misconduct. Similar laws at the state level would also need to be changed to require state and local law enforcement to get a referral from a medical licensing board.

To make sure complaints are handled in a timely manner, Barnes says federal funds should be used to bolster the budgets of state licensing boards so they can investigate allegations of misconduct.  

“There are some detractors who say medical boards didn’t do an adequate job leading up to the overdose crisis. But the reality is neither did law enforcement,” Barnes says. “The medical boards could get up to speed and make these assessments on medical needs and patient care to make sure that healthcare providers can be assessed with medical expertise, rather than law enforcement trying to guess about standard of care and best practices.”

“Making it more difficult for law enforcement to investigate potential diversion of dangerous and addictive controlled substances, including powerful painkillers, is probably not going to happen right now,” says DEA spokesman Rusty Payne.

This idea that people need to worry about the DEA hiding in the bushes if they write an oxycodone prescription is ridiculous.
— Rusty Payne, DEA spokesman

Payne points out the DEA is both a law enforcement and regulatory agency, one that oversees 1.3 million practitioners licensed to prescribe controlled substances. He says enforcement actions are relatively rare and not “indiscriminate” as Barnes suggests.

“The numbers are incredibly low. It is a very, very, very small number.  So this idea that people need to worry about the DEA hiding in the bushes if they write an oxycodone prescription is ridiculous,” he told PNN. “We don’t have the resources. We don’t track individual prescriptions. We look for patterns and large-scale significant diversion.”  

Getting state medical boards involved, according to Payne, is not a good idea.

“I don’t think making it harder for us to scrutinize those that are acting outside the law is in anyone’s best interest,” he said.

But Barnes’ proposal makes sense, according to Dr. Lynn Webster, a PNN columnist and former president of the American Academy of Pain Medicine. 

“Barnes makes a sensible recommendation. If the law enforcement suspects a provider is not complying with the law, then the first step should be a referral to the medical board where the provider can be evaluated by their peers,” Webster said. “If a doctor goes to trial, they will not be evaluated by their peers. That is not the way the justice system is supposed to work.” 

Webster was once the target of a federal investigation of his opioid prescribing practices and DEA agents raided his Utah pain clinic in 2010. Four years later, the DOJ said it would not prosecute Webster, who said his “reputation was tarnished forever.”  

“DEA investigations are often designed to entrap a provider on technicalities.  Even if an investigation never leads to any charges the doctor's reputation is damaged.  In the court of public opinion an investigation must mean something was wrong,” Webster said. 

Doctors Prosecuted for Opioid Prescribing Should Fight Back

(Editor’s note: In 2016, Dr. Mark Ibsen’s medical license was suspended by the Montana Board of Medical Examiners for his opioid prescribing practices. Two years later, the suspension was overturned by a judge who ruled that the board made numerous errors and deprived Ibsen of his legal right to due process.)

By Mark Ibsen, MD, Guest Columnist

The headlines are pretty typical: “60 Doctors Charged in Federal Opioid Sting.” The story that follows will include multiple damning allegations and innuendos, including a claim by prosecutors that they are “targeting the worst of the worst doctors.”

Sometimes there is a trial, but often the doctors plead guilty to lesser charges and give up their license rather than mount a lengthy and costly legal defense.

Why are doctors losing every case to their medical boards and DEA? Are there that many criminal doctors? If so, what happened to our profession?

I see a pattern emerging: A doctor sees patients and treats pain in the course of their practice. As other doctors give up prescribing opiates for fear of going to prison or losing their license, the ones left end up seeing more and more patients.

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They soon become the leading prescribers of opioids in their state and become suspect just based on the volume of opioids they prescribe.

Given that law enforcement and medical board investigators usually don’t have training in statistics (or medicine), they are unable to see that the number of pain patients remains the same, but there are fewer practitioners willing to treat them.

“The Criminalization of Medicine: America’s War on Doctors” was published in 2007, but is even more relevant today.   

“Physicians have been tried and given longer prison sentences than convicted murderers; many have lost their practices, their licenses to practice medicine, their homes, their savings and everything they own,” wrote author Ronald Libby. “Some have even committed suicide rather than face the public humiliation of being treated as criminals.”

Libby wrote over a decade ago about doctors’ homes and offices being raided, DEA agents posing as pain patients to entrap them, and law enforcement task forces being created to target doctors for fraud, kickbacks and drug diversion.

Sound familiar?

I was reviewing a case about a nurse practitioner in Michigan who recently had her license suspended because she prescribed opioids “contrary to CDC guidelines” and “ranked among Michigan’s highest-volume prescribers of commonly abused and diverted controlled substances.”

This unsubstantiated crap put out by the Michigan Board of Nursing and its investigator is unethical and immoral. It should lead to a mistrial in court or dismissal at hearings. 

Fight Fire With Fire

This is an Amber alert for physicians. While pejorative headlines contaminate the discourse, the prescriber’s reputation bleeds away. The Montana Board of Medical Examiners did this in my case, and since I knew that the board was relentlessly after my license for “overprescribing” opioids, I gave up any hope of fairness.

My proposal: Lawyers representing doctors must counter the negative headlines with their own, and doctors should use whatever goodwill is left to rally their staff and patients, counteracting the pressure to testify against the doctor. 

I used what was left of my bully pulpit to save my own license and freedom. How? My assistant assembled my patients in large crowds at my hearings. I also made myself available to the media to counter the narrative put out by Mike Fanning, the board’s attorney, who went so far as to publicly question my sanity.

Fanning’s title was special assistant Attorney General, which told me the medical board works for DOJ in my state. I knew this for sure when DEA agents came to my office and tried to intimidate me.

“Doctor Ibsen, you are risking your license and your freedom by treating patients like these.”

Patients like what?

“Patients who might divert their medicine.”

Might? Isn’t that everyone? What would you have me do?

“We can’t tell you, we’re not doctors.”

My plea to doctors: Let’s reinvent our defense. The DEA and medical boards have a formula. It’s winning. 

We need a new response: Fight back and hold on. Just like with any bully, reveal their game and fight fire with fire.

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Dr. Mark Ibsen continues to practice medicine in Montana, but focuses on medical marijuana as a treatment. He no longer prescribes opioids. Six of his former patients have died after losing access to Dr. Ibsen’s care, three by suicide.

Do you have a story you want to share on PNN? Send it to: editor@painnewsnetwork.org.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

What Doctors Say About CDC Opioid Guideline

By Pat Anson, PNN Editor

Over two-thirds of healthcare providers are worried about being prosecuted for prescribing opioid medication and many have stopped treating chronic pain, according to a new survey by Pain News Network on the impact of the CDC’s opioid prescribing guideline. One in four providers say they’ve lost a pain patient to suicide since the guideline was released in 2016.

A total of 68 doctors and 89 healthcare providers participated in the online survey. While that’s a relatively small sample size in comparison to the nearly 6,000 patients who took the survey, the providers come from a broad spectrum of healthcare, including pain management, primary care, palliative care, surgery, pharmacy, nursing and addiction treatment.

The CDC guideline discourages the prescribing of opioids for chronic pain and cautions doctors not to exceed a daily dose of 90 morphine milligram equivalents (MME) because of the risk of addiction and overdose. Although voluntary and only intended for primary care physicians, the guideline has been widely implemented as mandatory throughout the U.S. healthcare system.

Many doctors believe the guideline limits their ability to treat patients and has not improved the quality of pain care in the United States.  

“There are reasonable elements to the guidelines which should be preserved. However, setting an upper dose limit, especially one so low, severely interferes with titrating the opioids to their most effective doses, which is often much higher than 90 MME,” said a pain management doctor.

“The guidelines became hard rules for many insurance companies and pharmacies. Patients with pain have suffered in consequence,” said a palliative care doctor. 

“I see chronic pain patients all day that do not have their pain well controlled. It is heart breaking,” said another provider.

HAS CDC GUIDELINE IMPROVED QUALITY OF PAIN CARE?

“They are horribly ill-conceived. If we thought our previous approach to pain management was flawed, we surely will soon realize that these guidelines are worse,” said a pain management physician. “A patient told me two weeks ago that his friend needs repeated (coronary bypass) surgery, but now the hospital system treats post-surgical pain with Tylenol. This is barbaric.” 

An addiction treatment doctor summed up his feelings about the guideline with two words: “Misguided and draconian.”

Pain Contracts and Drug Tests

Nearly two-thirds of providers surveyed require patients to sign a “pain contract” before they get opioids. Over half have discharged a patient for failing a drug test or not following the rules. And nearly one in five mistakenly believe the guideline is mandatory.

  • 64% require patients to sign a pain contract or take drug tests

  • 52% have discharged patients for failing drug test or not following rules

  • 45% use more non-opioid therapies

  • 18% believe CDC guideline is mandatory

  • 17% refer more patients to addiction treatment

  • 10% stopped treating chronic pain patients

  •   7% closed practice or retired due to concerns about opioids

“I feel like the blow-back to the CDC guideline is just as misplaced as the misuse of it. The recommendations are good science,” said a pharmacy provider. “There are lots of people - prescribers, pharmacists, insurance companies, law enforcement - who have misapplied the guidelines and are practicing poorly with them as an excuse. That is not the fault of the guidelines themselves, but the fault of poor education and dissemination.”

“These guidelines came from people that do not serve as clinicians to patients,” said one provider. “I have witnessed patients being abruptly cut off from medications they've been on for years and without any notice. Some have gone through extreme withdrawal to the point of death from the complications of withdrawal.”

Disparity in Prescribing

The survey found a wide disparity in how providers have adjusted to the guideline’s recommendations.

Nearly half still prescribe opioids above 90 MME when they feel it’s appropriate, while 20 percent only prescribe at or below the 90 MME threshold. Fourteen percent have stopped prescribing opioids altogether.

“We are getting dumped on by all the PCP’s (primary care providers). They no longer want anything to do with patients on opioids,” said a pain management doctor. “What is medicine coming to that the number of opioids is more important than a patient’s well-being?”

“Acute pain is now being undertreated, as well as many who have been denied pain control with opiates. These patients are being harmed. All of us prescribers know that the majority of overdoses are from illegal opiates from other countries. We are not stupid,” wrote a provider who works in urgent care.

HOW HAS CDC GUIDELINE AFFECTED YOUR OPIOID PRESCRIBING?

Chilling Effect

Doctors are well aware they are under scrutiny. The Drug Enforcement Administration and other law enforcement agencies monitor prescription drug databases (PDMPs) to track opioid prescriptions. While PDMPs were initially promoted as a way to protect physicians from “doctor shopping” patients, they are now routinely used by the DEA to identify, threaten and raid the offices of doctors who prescribe high doses – even when there is no evidence of a patient being harmed by the drugs.       

“PDMPs are tracking prescribing based upon CDC guidelines. That has an adverse effect upon prescribers who end up being profiled and in jeopardy of arrest and prosecution,” a doctor wrote.

“They have weaponized the political and legal manifestations of appropriately treating chronic pain,“ said a pain management doctor.

“They have shamed high dose long term opioid patients and treat the prescriber like a bad guy. They are clueless to the fact that majority of deaths have always been street addicts and not legit pain patients. The guidelines embolden medical regulators to come after doctors, resulting in chilling effect on prescribers,” said an addiction treatment doctor.

The crackdown has also had a chilling effect on pharmacies and insurers, who are just as eager to stay out of trouble. Nearly three out of four providers (73%) say they’ve had a pharmacy refuse to fill an opioid prescription and 70 percent say an insurer has refused to pay for a pain treatment.

“Why does CVS, a drug store that sells NSAIDs without restriction, have control of how I treat my patient?” asked one provider.

“The insurance companies are acting beyond the CDC guidelines with their hard limits on dosing, even sending threatening letters to doctors,” said a physician. 

“Pharmacies and insurances are dictating how we treat our patients without the medical ability or authority to make diagnosis or treatment plans. Each patient is different,” wrote one provider. 

“The guideline is extremely narrow-minded and reactionary. Yes, opioid addiction has become a huge problem, and yes, some physicians are partially to blame because of inappropriate prescribing, but plenty more physicians prescribe opioids appropriately. Now many of those doctors are scared to do their job, leaving patients in unnecessary pain,” said a doctor.

Biased CDC Advisors

Many providers believe the guideline advisors assembled by the CDC were biased and unqualified to make recommendations for pain management. Their initial meetings were closed to the public and the agency refused to disclose who the advisors were. Later it was revealed that five board members of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group, were involved in developing the guideline, including two that belonged to a key committee that helped draft it.

“They are an abomination that has been foisted on the world by PROP via the CDC and have no real clinical or evidence based background, yet are carried forward by political and bureaucratic purveyors of untruth,” said a pain management doctor.

“I believe this guideline was made by a panel without any pain doctors. How can they know what is best? They have contributed to stigma, and now patients instead of safely being monitored by pain clinics are turning to the streets and dying from illegal opioids. The CDC then uses that data to inflate the so-called epidemic,” said another provider.

“The CDC never weighed the information from the pain treating community. The consequences were predictable. Poor quality of life for the pain patients and continuation of the opiate epidemic from imported fentanyl. The guidelines were a travesty,” a pain management doctor wrote.

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“The CDC did not have the legal authority to issue the guidelines in the first place. They should be declared unconstitutional and burned. Dosing should be following the FDA published guidelines for a particular medication,” said a pharmacy provider.

‘Where Are the Followup Studies?’

When it released the guideline in 2016, CDC said it was “committed to evaluating the guideline” and would make revisions if there were unintended consequences. A CDC spokesperson recently told PNN several studies are underway evaluating the guideline, but gave no indication that any changes are imminent.

“Where are the followup studies to monitor the incidence of patients committing suicide, looking for illicit drugs on the streets, overuse of NSAIDs, (acetaminophen) with organ damage and death, increased disability, loss of quality of life, overuse of alcohol and tobacco, worsening of co-morbid conditions due to weight gain, inability to exercise or sleep, adverse effects on relationships?” asked a pain management doctor. “The guidelines are effective at saving money for the payors. That, I fear, is why there is no serious effort to revise the guidelines.”

For a breakdown of some of the other key findings from our survey, click here. To see what patients had to say about the guideline, click here. Our sincere thanks to everyone who took the time to participate.

Is My Life Worth Anything to Doctors and Politicians?

By Beth Sweet, Guest Columnist

I keep a journal and usually write about my symptoms and medical appointments. But today I vented and afterwards realized this might be something I should share.

I'm doing really bad with writing lately. It's just so hard to find the motivation to do anything. Between pain, exhaustion, migraines and IBS every day, I feel like crap! I'm so sick of feeling like this. I just want to feel like a normal human being again and not wake up every day realizing that isn't going to happen.

Lately I've been wondering if I even have fibromyalgia or if I was misdiagnosed. We have tried so many treatments for it and none of them work. I feel like a guinea pig half the time. Do doctors even know what they are doing?

I've tried over 19 medications and treatments. So far, the only thing that helps is what all the doctors say isn't recommended for fibro and that's oxycodone. I'm in my own body, know what I feel, and what works. But I'm too afraid to ask my doctor for a therapeutic dose instead of a bare minimum dose that only gets me a few hours of relief a day.

All because of this damned opioid epidemic!

They freak out about addicts overdosing on opioid medication, but addicts will find a fix even without prescriptions. What about chronic pain patients who are killing themselves because they can't get treatment for their pain?

I wish the politicians and lawmakers could suffer from chronic pain for a while and get treated like we are. I bet then the laws would change! I don't think they could survive it.

BETH SWEET

BETH SWEET

I'M SICK OF PAIN! Sick of crushing, aching, searing, cramping, stabbing, stiff, radiating, grinding, burning, tingling, constant pain. When I sit, stand, walk or lay in one position for too long. Headaches and migraines over half the month. PAIN ALL THE TIME!

But I can't ask a doctor for what I know works because everyone is in a panic about opioids. I am on the lowest possible dose. I get just enough for 4-6 hours of relief a day! God forbid I have a flare that makes it nearly impossible to move and lasts for days. It's not fair!

I want to go to church.

I want to go to my kids’ events

I want to be able to earn an income and be a functioning member of society

I want to not have my kids feel like they must take care of me. It's supposed to be the other way around!

I want to get well, but that's never going to happen. I must live with the fact that I am going to feel like crap on varying levels for the rest of my life.

Think about that. If someone told you that from this moment until the day you die you are going to be in pain, exhausted and unable to lead a normal life. That we don't know how to cure you or even if there is a cure. We aren't even sure what's wrong with you. We've tried everything and none of it has worked. Maybe it's all in your head.

How would that make you feel? Frustrated? Hopeless? Pissed? Sad?

And what if those same people who told you they don't fully understand your illness will not give you the one drug that gives you relief because "it's not an approved treatment for your diagnosis." They’ve already admitted knowing very little about it anyway!

What if they treated you like a drug addict because you asked for a medication that finally gives you some pain relief?  I have no problem getting medication for my thyroid, insulin resistance, anemia, IBS or any of my other health issues. But God forbid I ask for treatment for chronic pain.

I don't take those meds to get high. I don't even understand how people do, they don't affect me that way. I take them to get some of my life back. Is my life worth anything to these doctors and politicians?  I'm 38 and a hermit because of my pain and health issues. I've been sick for years and getting worse.  

I want to make something clear. I'm not going to kill myself. I have my family to live for. Even when my life feels worthless, I think of them. But not every chronic pain paint has that because this illness causes isolation and hopelessness. And no, we aren't in pain because we are depressed. We are depressed because we are in pain. There is a difference, so please stop giving us antidepressants to use as pain meds!

Stop ignoring chronic pain patients. Some are at the point where they can't take the pain anymore and the doctors that could save their lives are too concerned with the opioid epidemic to help!

I hope to find a doctor someday that thinks my life is worth living.

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Beth Sweet lives in Michigan.

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.