Federal Task Force Releases ‘Roadmap’ to Treat Pain Crisis

By Pat Anson, PNN Editor

A federal advisory panel has released its final report on recommended best practices for acute and chronic pain management, calling for a balanced approach to pain treatment that focuses on individualized patient care – not rigid guidelines that triggered a pain crisis for millions of Americans.

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

Unlike previous federal efforts that focused primarily on limiting access to opioid medication while expanding access to addiction treatment, the 116-page report by the Pain Management Best Practices Inter-Agency Task Force took a more comprehensive approach to pain management that focused on the needs of patients, improving their quality of life, and establishing a “therapeutic alliance” between patient and clinician.   

The panel sought and received feedback from over 5,000 patients, advocates and healthcare providers on issues such as suicide, patient abandonment and the stigma associated with chronic pain. Several patient stories were incorporated into the final report.

Even longtime critics of federal pain care policies were impressed.

HHS+Task+Force.png

“This report from the HHS Pain Management Task Force is exceptional, in my view. Rarely have I seen a report that is of such high quality, with such reasonable, common-sense recommendations,” said Bob Twillman, PhD, former Executive Director of the Academy of Integrative Pain Management. “The willingness to recognize concerns expressed by people with pain and by healthcare providers is not something we have often seen, and it is refreshing to see those comments play an important role here.”

“I truly hope this is a huge step forward,” said Andrea Anderson, a pain sufferer and patient advocate. “I think there was much to be praised, such as the focus on individualized patient care, the need for multi-disciplinary treatment teams with care-coordination, a more robust focus on post-surgical pain management, an emphasis on moving complementary and integrative health approaches into the main stream of pain treatment, and the need for further education and research  on a number of important topics.”

No Repeal of CDC Guideline

The task force did not call for a repeal of the CDC’s controversial opioid prescribing guideline, but said the guideline should be clarified and updated with better evidence to supports its recommendations..

“The Task Force recognizes the utility of the 2016 CDC Guideline for many aspects of pain management and its value in mitigating adverse outcomes of opioid exposure. Unfortunately, misinterpretation, in addition to gaps in the guideline, has led to unintended adverse consequences. Our report documented widespread misinterpretation of the CDC Guideline — specifically, the recommendation regarding the 90 morphine milligram equivalents (MME) dose,” the report found.

“Educating stakeholders about the intent and optimal application of this guideline and re-emphasis of its core beneficial aspects are essential. Instances have been reported where the CDC Guideline was misapplied to the palliative care and cancer populations with pain and to providers who care for these patient populations.”

The task force called for a more “even-handed approach” to opioid prescriptions that allows doctors to use their own clinical judgement on how to treat patients.

“Various health insurance plans, retail pharmacies, and local and state governments are implementing the CDC Guideline as policy, limiting the number of days a patient can receive prescription opioids even when the seriousness of the injury or surgery may require opioids for adequate pain management for a longer period. A more even-handed approach would balance addressing opioid overuse with the need to protect the patient-provider relationship by preserving access to medically necessary drug regimens and reducing the potential for unintended consequences,” the task force said.

That kind of thinking is heresy to anti-opioid crusaders and politicians who consider the CDC guideline a cornerstone of the government’s war on drugs. Even before the task force report was finalized, 39 state and territory attorney generals wrote a letter of protest.   

“As a matter of public safety, there is simply no justification to move away from the CDC Guideline to encourage more liberal use of an ineffective treatment that causes nearly 50,000 deaths annually,” the letter warns. “It is incomprehensible that officials would consider moving away from key components of the CDC Guideline.”

Critics have also claimed that some task force members have a conflict-of-interest because of their financial ties to pharmaceutical companies. Oregon Sen. Ron Wyden (D) — who has received millions of dollars in campaign donations from healthcare companies and insurers — recently told Mother Jones that the task force was “being used as part of the industry’s broader effort to water down the CDC’s recommendations on opioid prescribing.”

The 29 members who served on the task force included representatives from the FDA, CDC, VA and Office of National Drug Control Policy; as well as academic and medical experts in pain management, addiction treatment, pharmacy, oncology, psychiatry and interventional medicine. There was only one patient advocate, Cindy Steinberg of the U.S. Pain Foundation.

Interestingly, Harold Tu, MD, the lone dentist on the panel, is the father-in-law of Andrew Kolodny, MD, the founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that played a key role in drafting the CDC guideline. Tu voted in favor of the task force’s final report.

The report’s recommendations are voluntary and not binding on the Department of Health and Human Services or anyone else. The task force was created in 2016 by the Comprehensive Addiction and Recovery Act to “determine whether there are gaps in or inconsistencies between best practices for pain management.”

Those gaps have been identified. Whether anyone will get to work and fill them is unclear.

“I think the task force provided a very good analysis of the problem with recommendations that if implemented should help millions of Americans with pain and reduce the problem with opioids,” says Lynn Webster, MD, past president of the American Academy of Pain Medicine and a PNN columnist.

“My concern is that there doesn't appear to be any teeth to the recommendations. I would like to have seen some specifics but that may have been too much to expect at this stage.”

Fibromyalgia Stole My Life, Kratom Gave It Back

By Mary Ann Dunkel, Guest Columnist

Fibromyalgia stole my life more than 28 years ago. I have severe chronic pain and fatigue that limits my activities of daily living. Unless you have experienced unrelenting severe pain 24 hours a day, you cannot know the horror of it.

I have been prescribed more pharmaceuticals than I can remember and suffered damaging side effects from them. I've participated in psychotherapy, aqua therapy, multiple pain management programs, acupuncture and hypnosis. None of these modalities brought me relief and for quite some time I was bedridden and dependent on family for care.

My doctors have prescribed me morphine, fentanyl, oxycodone, tramadol and other medications to control the pain. None of them worked for very long and I could see these prescriptions were going to lead to addiction. Often, I weaned myself off them and suffered through terrible withdrawal because the small amount of relief they gave was not worth the risk of addiction or overdose death. Bottom line is these narcotics were not effective in treating my chronic pain.

There were times when I thought about taking my life because I just couldn't get a break from the pain and didn't think I could take it any longer.

Then a friend introduced me to kratom. She had been consuming it for more than 10 years without side effects or becoming addicted to it. I started my own journey consuming kratom.

Kratom is not a drug. It is a dietary supplement. It does not heal any disease, but it has certainly improved my quality of life. I am having pain free days and my energy level is greatly improved. Kratom has restored my ability to have a normal life and I can enjoy all sorts of activities that make my life rich and full.

Kratom does not make me high, nor do I experience side effects. I am now clear minded without the sedation caused by narcotics. And I am devastated that the FDA is working to ban the only thing that has helped me in the past 28 years.

MARY ANN DUNKEL

MARY ANN DUNKEL

I am sick to death of reporters parroting the lies from the FDA and CDC. I implore you. The studies they have done are full of inaccuracies and half-truths. Independent studies of the autopsies in the so called kratom deaths have shown the victims had multiple medications in their systems. They also included a death caused by gunshot.

Eight leading scientists have studied kratom and found it to be safe. It has been used for hundreds of years without problem. It is not an opioid; it is related to the coffee plant. It does attach to the same receptors in the brain as opioids, but so do many other substances such as chocolate and milk.

I would suggest to you that the FDA wants it banned because it is cutting into Big Pharma's financial bottom line. People are finding the help they need without costly and deadly pharmaceuticals. I fear that if kratom is banned this country will see an epidemic of self-inflicted deaths by people who have no hope. Kratom would become a black market substance due to overreach by the government to protect the monies they get from pharmaceutical lobbies.

Please investigate these facts and do the right thing. Do a story on the positives of kratom.

bigstock-Tell-Us-Your-Story-card-with-c-78557009.jpg

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.

39 Attorneys General Practicing Medicine Without a License

By Pat Anson, PNN Editor

Over 5,000 healthcare providers, patients, caretakers and advocacy organizations have left comments in the Federal Register on a draft report by a federal advisory panel known as the Pain Management Best Practices Inter-Agency Task Force. The comment period ended April 1.

Most of the comments – which you can see by clicking here – are supportive of the report, which recommends that pain management be balanced, multimodal and focused on individualized patient care. Opioid pain medication should be prescribed cautiously, if prescribed at all, according to the task force.

Those may sound like reasonable and prudent goals, but one aspect of the draft report has stirred controversy and it’s a familiar one: the CDC’s 2016 opioid prescribing guideline.

While commending its “useful general guidance,” the report found that that guideline has had many unintended consequences, including forced opioid tapering, patient abandonment and suicide. The task force said the guideline was never meant to be mandatory or to be used as a model by states, insurers and pharmacies, and better evidence was needed to support its recommendations.

The task force stopped short of recommending a wholesale revision of the guideline, but suggested a “more even-handed approach” to pain care was needed.  

“In essence, clinicians should be able to use their clinical judgement to determine opioid duration for their patients,” the report concludes.

bigstock-Health-Care-Challenge-39408331.jpg

Those were fighting words to some anti-opioid crusaders and politicians who consider the CDC guideline a cornerstone of the government’s war on drugs.

“As a matter of public safety, there is simply no justification to move away from the CDC Guideline to encourage more liberal use of an ineffective treatment that causes nearly 50,000 deaths annually,” warns a letter signed by 39 state and territory attorney generals.  “It is incomprehensible that officials would consider moving away from key components of the CDC Guideline.”

‘They Have Overreached’

The AG’s letter shows a fundamental and perhaps willful ignorance of what the guideline is – a voluntary set of recommendations intended only for primary care physicians. The letter also demonstrates how politicians have grown accustomed to inserting themselves into pain management decisions normally left between patients and their doctors. In essence, the AG’s are saying that doctors should not be allowed to use their own clinical judgement and should rely instead on treatment guidelines.  

“The Draft Report proposes to rely solely on the judgment of providers regarding the dose and duration of opioid treatment. With annual overdose deaths in the tens of thousands, evidence-based recommendations, such as documentation and consultation, are necessary,” the AG letter states. “Similarly, the Draft Report states that duration of opioid treatment for acute pain, including trauma and surgery, is best determined by providers without the need for guidelines to inform appropriate decision-making.”

Critics say the AG’s are essentially practicing medicine without a license.

“The foxes watching the hen house want more hens to watch, more justification for their existence,” says Mark Ibsen, MD, a Montana doctor all too familiar with government intrusion into pain care. Ibsen’s medical license was suspended in 2016 over allegations that he overprescribed opioids, a decision later reversed by a judge.

“They have overreached. I hope someone else notices, and takes law enforcement out of the practice of medicine, where they’ve been screwing up medical care since 1914. Abolish the DEA. Let law enforcement catch criminals, not make them up out of thin air,” Ibsen said.

This isn’t the first time the National Association of Attorneys General has tried to meddle in pain care. In 2017, the organization sent a letter to health insurers asking them to take steps to reduce the prescribing of opioid medication.

Reducing the frequency with which opioids are prescribed will not leave patients without effective pain management options.
— National Assn. of Attorneys General

“Reducing the frequency with which opioids are prescribed will not leave patients without effective pain management options,” the 2017 letter states. “When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care.”

In their latest letter, it’s no longer a matter of “should.” The AG’s say doctors “must be encouraged” to reduce opioid prescriptions and to recognize that opioids have “well established risks.”  

“The Draft Report should be revised to clearly state that there is no completely safe opioid dose, and that higher doses are particularly – and predictably – risky,” the AG’s wrote.

But most opioid medications are not particularly risky, as PNN reported in a recent study of over half a million Medicare patients who were prescribed the drugs. Over 90 percent had a negligible risk of an overdose. Even among “high risk” patients on high opioid doses, the risk of an overdose is less than two percent.

‘Too Much Money On the Line’

Critics also point out the AG’s have a political and financial interest in demonizing opioid medication. Most have signed on as plaintiffs in over 1,600 class action lawsuits filed by states, cities and counties seeking billions of dollars in damages from opioid manufacturers and distributors. Oklahoma Attorney General Mike Hunter – one of the AG’s who signed the letter criticizing the task force report --  recently reached an out-of-court settlement with Purdue Pharma for $270 million.  

“There is just too much potential money on the line. This is not an argument about truth, or evidence, or anything except money," says Andrea Anderson, Executive Director of the Alliance for the Treatment of Intractable Pain (ATIP).  

“Since the Purdue/Oklahoma settlement of $270 million, all the AG’s of every state involved in this opioid litigation will focus solely on their potential financial gains until they get their piece of settlement pie. This will come at the cost of needed revisions to the flawed CDC Guidelines and a return to clinical common sense. People can remember these AG’s when they vote.” 

According to OpenSecrets.org, the law firm of Simmons Hanly Conroy donated over $1 million to congressional candidates during the 2018 election cycle. Simmons Hanly Conroy represents dozens of states and local governments that are suing drug makers over their marketing of opioids, and would pocket one-third of the proceeds from any settlements, according to reports.

A recent PNN survey found the CDC guideline was having a harmful effect on both patients and healthcare providers. Over 85 percent of patients say the guideline has made their pain and quality of life worse. Nearly half have considered suicide. Over two-thirds of practitioners are worried about being sanctioned or prosecuted for prescribing opioids. Rather than risk going to prison, many have stopped treating pain, closed their practice or retired.  

Pain Management Association Shutting Down

By Pat Anson, PNN Editor

An association of pain management providers that was a leading advocate for patient access to pain care is closing its doors. The board of directors of the Academy of Integrative Pain Management (AIPM) voted unanimously this week to cease operations, largely due to financial problems.  

“This is an incredibly difficult and sad decision,” said Bob Twillman, PhD, AIPM’s Executive Director. “Our message has never been more relevant than now, amid the nation’s opioid crisis, yet we have found it increasingly difficult to maintain the resources needed to sustain our efforts.”

For over three decades, AIPM promoted an “integrative model” of pain care that utilizes a variety of different treatments, including both drug and non-drug therapies.

Although that model has become a standard of pain care, AIPM’s membership has steadily declined due to demographic and other industry trends. With doctors under increasing scrutiny for opioid prescribing, pain management is not an attractive specialty for recent medical school graduates.

lastslider.jpg

“Joining associations like ours just is not a high priority for younger health care providers, and decreased interest in attending in-person educational events has contributed to significantly decreased conference revenues for AIPM,” said W. Clay Jackson, MD, President of the Board of Directors.

The demonization of opioid medication by policymakers and politicians also played a major role, causing many drug makers to limit or drop their support for medical associations and patient advocacy groups.

“My understanding is that the decreased industry support is not limited to the pain space, but it is especially acute here because for many years it was the opioid manufacturers who were the greatest source of funding,” Twillman wrote in an email to PNN. “As recently as five years ago, it would not be unusual for a company to drop nearly $100,000 at a single conference, between big exhibit hall booths, grants for continuing education programs, sponsored meal programs, and items such as bags, lanyards, key cards, etc.

“But when the lawsuits against opioid manufacturers started to ramp up, the logical response from the manufacturers was to withdraw support. After all, if they are being accused of using groups like ours as ‘front organizations,’ then it is completely logical for them to stop any behavior that might be perceived that way.”

A 2018 report by Sen. Claire McCaskill (D-MO) even accused the AIPM and other industry supported groups of playing “a significant role” in starting the opioid epidemic.

“These financial relationships were insidious, lacked transparency, and are one of the many factors that have resulted in arguably the most deadly drug epidemic in American history,” McCaskill's report alleged.

"Sen. McCaskill and the others haven’t spent the necessary time talking to us to understand how we do things and what we have to offer," Twillman said at the time. "It appears that they’ve simply looked at how much money we got from a set of pharma companies, constructed a narrative about what that means, and published it."

Over a five-year period, McCaskill’s report found that AIPM received over $1.25 million in support from opioid makers. But the report failed to mention that AIPM also accepted funding from chiropractors, yoga therapists, acupuncturists and massage therapists.

We’re all very sad at this turn of events, but we’re also very proud of what we accomplished.
— Dr. Bob Twillman

Among other things, those donations helped AIPM host the 2017 Integrative Pain Care Policy Congress, a meeting that united dozens of providers, insurers, patients, researchers and policymakers.

The Congress adopted a consensus definition of integrative pain management that is “person-centered and focuses on maximizing function and wellness.”

Twillman says AIPM — formerly known as the American Academy of Pain Management — had less of a financial cushion than other pain organizations and was not able to adjust to changing times or the backlash against pain management.

“I fear for the future of those organizations, because I'm not sure this set of problems is going to get better, and I don't see the other organizations adapting as quickly as perhaps they should,” said Twillman, who has long stood up for patient rights and been a reliable source of common sense for PNN.

“I very much want to remain in a pain policy position if possible, because that is my real passion,” he said. “We're all very sad at this turn of events, but we're also very proud of what we accomplished, and can only hope that others will pick up the baton and continue the race while we look for ways to keep pursuing our passion.”

Fed Panel Releases Draft Report on Pain Management

By Roger Chriss, PNN Columnist

A federal advisory panel known as the Pain Management Best Practices Inter-Agency Task Force has released a draft report listing its recommendations for improving pain care in the United States. The content is both revealing and promising, because its recognizes the complex nature of chronic pain and the difficulty in treating it effectively.

The task force was formed as a result of the Comprehensive Addiction and Recovery Act (CARA) of 2016. Its mission is to identify gaps and inconsistencies in acute and chronic pain management and to propose possible solutions.

The 29 members who serve on the task force include representatives from the FDA, CDC, VA and Office of National Drug Control Policy; as well as academic and medical experts in pain management, addiction treatment, pharmacy, oncology, psychiatry and interventional medicine.

Interestingly, Harold Tu, MD, the lone dentist on the panel, is the father-in-law of Andrew Kolodny, MD, the founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP). Only one pain patient and advocate was appointed to the task force, Cindy Steinberg of the U.S. Pain Foundation.

PAIN MANAGEMENT INTER-AGENCY TASK FORCE

PAIN MANAGEMENT INTER-AGENCY TASK FORCE

The key findings of the task force are that pain management should be balanced, individualized, multidisciplinary and multi-modal. Pharmacological pain management requires careful screening and monitoring of patients to minimize risks, while non-pharmacological modalities, in particular physical therapy, also have a significant role to play. The needs of special populations such as children, women, older adults, and military personnel and veterans must also be recognized, according to the draft report.

The task force introduces a new term: “chronic relapsing pain conditions.” These conditions include a lengthy list of degenerative, inflammatory and neurologic conditions, such as multiple sclerosis, cancer, trigeminal neuralgia, lupus, Parkinson’s disease, postherpetic neuralgia, CRPS, porphyria, lupus, lumbar radicular pain, migraines and cluster headaches.

In other words, the draft report recognizes that pain is heterogeneous and the umbrella term of “chronic pain” is problematic. The report notes: “There are multiple potential causes of worsening pain that are often not recognized or considered. Non-tolerance-related factors include iatrogenic (medical related) causes such as surgery, flares of the underlying disease or injury, and increased ergonomic demands or emotional distress.”

The draft report gives considerable attention to the risks associated with high opioid doses and the use of benzodiazepines, but doesn’t entirely dismiss their use:

“Dose-dependent opioid overdose risk among patients increased gradually and did not show evidence of a distinct risk threshold. Much of the risk at higher doses appears to be associated with co-prescribed benzodiazepines.”

“Although the risk of overdose by benzodiazepine co-prescription with opioids is well established, this combination may still have clinical value in patients who have chronic pain and comorbid anxiety, which commonly accompanies pain, and in patients who have chronic pain and spasticity.”

The draft report also warns that medication shortages are worsening the quality of pain care: "Recurrent shortages in opioid and nonopioid medications have created barriers to the proper continuity of treatment in acute and chronic pain patients. This creates the unintended consequence of poor patient care.”

Importantly, the report devotes an entire section to the impact of the 2016 CDC opioid prescribing guideline. While recognizing the “useful general guidance” in it, the report notes that “an unintended consequence of the guideline is the forced tapering or patient abandonment that many patients with chronic pain on stable long-term doses of opioids have experienced."

The report concludes that the “CDC guideline was not intended to be model legislation for state legislators to enact,” but stops short of recommending that the guideline be revised. Instead, the task force recommends “educating stakeholders” about the intent of the guideline and its “core beneficial aspects.”

The depth of analysis in the draft report is clear from the 446 footnoted references, which includes the familiar names of Beth Darnall, PhD, Roger Chou, MD, and Lynn Webster, MD. Pain News Network is even cited as one reference.

The task force held two public hearings in May and September 2018. The task force will be accepting comments on its draft report by mail, email and online. After a 90-day public comment period, the report will be finalized and submitted to Congress.

Roger Chriss.jpg

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

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.

Don’t Take Away Our Medicine

By Lynn Joyce, Guest Columnist

I am a 62-year-old woman who -- aside from my intensely painful back --- enjoyed a full life of work, swimming, going to the gym, outings to various places with my husband and friends, and running my household.

A few years ago, my back pain became so severe I had to move from my primary care doctor to pain management after all the solutions we tried, including physical therapy, various pain treatments, x-rays and MRIs could not diagnose or in the end treat me. I went to a doctor in Sarasota who gave me pain medicine. which helped a little. I also had several procedures under anesthetic, which again did not totally relieve the pain.

I was desperate, as I spent much of the day and night with ice packs on my back to ease the pain. My ordinary life went down the drain, my husband got fed up with me not being able to accompany him and looking after my home went downhill.

I cried as I went to bed early with a sleeping pill to take away the pain -- though this did not always work as the pain woke me up. I tried various types of pain medicine and the one that worked best was oxycodone.

Nearly a year ago my doctors finally found a combination of drugs that made me pain free and able to resume my normal life. I was ecstatic to be able to do all the things I enjoyed again and to be able to run my home and look after my family.

I then had a shock a month ago when my doctor told me that my medicine would have to be reduced. I had two tearful visits to his office, where he told me that starting July 1st I would receive only one oxycodone a day.  

LYNN JOYCE

LYNN JOYCE

My doctor knows that this is not even a therapeutic dose and yet is being forced to break his sacred oath to "First do no harm." After getting my life back, I was so upset that I would have to go back to my previous existence, where every day is full of pain and there is very little joy.

I am not a drug addict. I am a person that needs medication for a condition that curtails my enjoyment of life, just as much as another person who needs a drug to alleviate their condition or keep them alive. My doctor should be allowed and supported in the care of his patients, not vilified by government and media alike.

There are legitimate people who are truly suffering and need the medication that is being taken from them. I am one of these people -- the other side of this so-called crisis – and we are being ignored and used as scapegoats by the government.

I do not understand how such arbitrary, draconian laws can be passed in a modern society. This government’s heavy-handed solution to the "opioid crisis" is targeting the wrong people. We are not the ones selling drugs like fentanyl and heroin, we are just people with an illness. We are not lawbreakers, although some of us may be driven to escape the pain with illegal drugs or, in some tragic cases, suicide.

There are studies that totally refute the reasoning behind these opioid laws and guidelines, doctors who have tried to stop this from happening to their patients, and those who know the science and social reasons that show we are not the cause. We are not out there selling our drugs or "doctor shopping."

I see and read daily about politicians and stores that are jumping onto the false bandwagon to further their own careers and profits. Pharmacies that are too afraid or are taking a false moral stance about the prescriptions they will or won't fill.

There has been mishandling of prescriptions in the past, but systems have been put in place to remedy that. Yet the media screams about this person or that who has overdosed and stores like Walmart that will limit a person’s medication to seven days. I hope there are the few that get opioids for short term use if they need it, but they are not long-term pain sufferers who need their therapeutic doses daily to ameliorate their pain.

I have read that companies are being forced by the DEA to reduce their drug production so much that there are worries about hospitals not having enough to treat patients or with surgeries being delayed.

Those of us that need long term drug treatment are your family member, a friend, or a familiar stranger like the postal worker who you see every day. We are not the archetypal addict that people think of when the words “drug user” comes up. Think of a time in your life when you or someone you care about was in pain and were helped by medication to make it go away.

We have that pain every day and it doesn't go away without our medicine. The government or anyone else in a position of power who keeps on pushing this inhumane agenda should walk in our shoes for a day.

bigstock-Tell-Us-Your-Story-card-with-c-78557009.jpg

Lynn Joyce lives in Florida.

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.

Why I Am Closing My Pain Practice

(Editor’s note: Patient abandonment is a serious and growing problem in the pain community. Thousands of patients have been discharged by doctors who have grown fearful of treating chronic pain and losing their medical licenses for prescribing opioid medication. We were recently contacted by a nurse practitioner, who offered her perspective on this disturbing trend. The author asked to remain anonymous.)

I am a nurse practitioner who has been in the field of pain management for the past 4 years. Prior to that, I spent years as an intensive care unit nurse and in primary care as an advanced registered nurse practitioner (ARNP).

Working with chronic pain patients has been the highlight of my professional career. I absolutely love my job and about 99% of my patients. I have had two complaints about me made to the Washington State Department of Health, both of which accused me of prescribing too much opioid medication to my patients. Both complaints were investigated by the state and I was found to be practicing within the standards of care -- and essentially told to continue. Which I did.

Then the Seattle Pain Centers closed in 2016, leaving thousands of untreated pain patients in the Puget Sound area. I inherited some of their patients. I felt like I had been "vetted" by the state, and believed that if I continued to do everything according to the law, I would be safe from any legal action.

bigstock-Portrait-Female-Doctor-Nurse-W-212922889.jpg

In my practice, we fight ALL THE TIME for our patients, against the state, insurance companies, pharmacies and even the patient's families sometimes (when they don't understand). I'm not afraid of a good fight, because I have seen patients’ lives turned around when they are finally given the correct amount of opioids. I believe in opioid therapy.

Of course, all the tools in the box should be used, and I refer routinely to physical therapy, interventional pain specialists, surgeons, acupuncturists, chiropractors and others, in addition to prescribing opioids for pain.

Now I find how naive I have been. I have been to national conferences to learn more about pain management, and have heard the top doctors and researchers talk. One of these giants, Dr. Forest Tennant, was recently raided by the DEA. With Jeff Sessions as Attorney General, there is apparently more money being allotted to these raids and more are promised in the future. I also went to a website called "Doctors of Courage" and learned more about the DEA.

My interpretation of the facts is that it doesn't matter if I practice legally anymore. The DEA will look at my prescribing patterns, and tell me that I MUST have known that the ONLY reason any patient would get that much medication is if they are selling it on the street. And therefore, I am a "drug trafficking organization.” The Justice Department takes over the case and the provider is prosecuted.

If convicted, which seems to be the case recently, the provider becomes a felon and serves a prison term. Medical license is lost, time is served and because it is a "drug crime," asset forfeiture law may be used to confiscate everything I own.

'My Fear Is Very Real'

I am married, with a daughter still at home. I cannot do this to my family. So I am joining the legions of others who are closing their pain practices. I have just begun to tell my patients, and have had many, many tears, thoughts of both suicide and homicide, and one very special patient who told me that she will no longer be able to keep her service dog because she will be unable to care for him.

This whole thing is making me literally sick to my stomach. I've cried a million tears for my patients already, and I'm just beginning. I will be carefully weaning them all down to 90 MED per day over the next 6 months, or arranging transfer of care to anywhere the patient would like. What a joke that is -- there is no one else prescribing effective doses of opioids for chronic pain patients. If I am to be thrown in prison, it should be for that -- not for keeping them on therapy that enriches their lives.

I keep asking my husband to tell me that I am overreacting, but as wonderful and encouraging as he has always been, he is scared too.

Please tell all patients that what may have started merely as a provider being paranoid about his or her license has recently morphed into something truly dangerous for us. I will be absolutely no good to anyone, once locked up. If I can stay clear of the DEA's witch hunt, perhaps I can remain a voice of advocacy for pain patients. God help us all.

Please don't use my name if you post this. I can tell you, my fear is VERY real, and I don't want to call any attention to my practice right now. Thank you for understanding.

bigstock-Tell-Us-Your-Story-card-with-c-78557009.jpg

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.

The Death of Pain Management

By Janice Reynolds, Columnist

The art and science of pain management is more than just opioids.  It is knowing what pain is and how pain works, the harmful effects of pain, different reasons for pain, how individuals react differently to pain, which medications may work and how they work, what non-pharmacological interventions may be appropriate, the difference between “acute” and “chronic” pain, understanding that guidelines are not written in stone, and the importance of listening to the patient and treating the whole patient.

While many physicians, nurses and pharmacists may not know all of this, they should be willing to research it or ask for help from someone who is knowledgeable.  Above all, it requires compassion, belief and faith in the patient.  It’s complicated, but that is why I call it an art and a science.

There have always been those who are bigoted against people in pain, do not believe pain is all that important, and that people need to gut it out. They’d rather 1,000 people suffer in pain than be fooled by one. They see pain management as a money-making endeavor.

Others take the values of beneficence (doing good), non-maleficence (not doing harm), veracity (truth telling), and equable justice (all are treated fairly) seriously, and don’t try to warp these ethical values to support their own beliefs.

Unfortunately, the tide has turned against pain sufferers and pain management providers, and they are being overwhelmed with falsifications and even hate. Some would cite the so-called “opioid epidemic” as the cause, and while it has certainly acerbated the problem, the seeds were planted long ago.

What this “crisis” has done is escalate the terrorism of the DEA by driving providers out of pain management or punishing those who still treat pain. There has been a lack of due process, with providers found guilty until they can prove themselves innocent, damned by innuendo, and with no thought or care for the collateral damage to their patients.

The media and anti-opioid zealots have also made claims that pain management experts are all tools of the pharmaceutical industry and anyone who advocates for appropriate pain management is spreading lies.

bigstock-Health-Care-Challenge-39408331.jpg

The crisis in pain management can be traced back, in part, to the Joint Commission’s accreditation standards for pain.  Healthcare organizations were first held accountable to them in 2001.  My friend, Dr. June Dahl (a professor of pharmacology) and Dr. Patricia Berry (a nurse) wrote the initial standards.  Our belief was these standards would “make pain visible” and pain would no longer be ignored.

The standards essentially said that healthcare organizations should have a plan to assess the presence of pain, that pain should be treated, and that providers should be educated on pain and pain management. This turned out to be wishful thinking.  Negative comments we heard included variations of “If you ask them about pain they will have it” or “People will only exaggerate their pain.” My favorite one (asked by an emergency room doctor) was “Do you really think this pain thing is all that important?”

Dr. Andrew Kolodny and Physicians for Responsible Opioid Prescribing (PROP) have also had a huge impact on pain management. Seldom mentioned is the fact that PROP is a small group with only a handful of practicing physicians. Many, like Kolodny, have links to addiction treatment centers.

When the FDA wouldn’t go along with a PROP petition to change opioid warning labels, PROP found a home at the Centers for Disease Control and Prevention, where they helped draft the CDC’s opioid prescribing guideline. The guideline has severely damaged pain management by forcing providers to essentially ignore pain and commit malpractice. PROP has done more to murder pain management than any other entity.

Another large contributor to the death of pain management is the use of McCarthyism to spread fear and innuendo.  Doctors are afraid to provide appropriate pain management either because of the CDC guideline or a realistic fear of the DEA.  Providers are abandoning pain management or leaving practices entirely. Nor can they be faulted, as there is little support for them by politicians, the government or the media.  Even professional medical organizations, such as the American Pain Society, American Society of Anesthesiologists and American Academy of Neurology, have abandoned them.

Now we are seeing a bastardization of pain education, as well as a debasing of pain management itself. Education in medical schools and continuing education for providers should center on pain syndromes, pharmaceutical interventions, non-pharmaceutical therapy, and the consequences of poorly managed pain.  It should be evidence based, as well as ethical, and should not include the CDC guideline, which is neither. It should not just focus on addiction or the evils of opioids. 

There are now efforts to standardize pain management through the development of “best practices.”  President Trump’s opioid commission, the VA, Medicare, and other government agencies are creating them with input from addiction treatment advocates and insurance payers, without input from pain management experts or people in pain.

Will the art and science of pain management survive these assaults? I certainly want it to. But it will be difficult to re-educate providers and bring back into practice those who have been persecuted by the DEA and the media.

The narrative needs to change. We need to refocus on the harmful effects of inadequate pain management, the maltreatment of people in pain, and what forces are behind this butchery of adequate pain management.

Pain management, according to the World Health Organization, is a human right.  What kind of world and country do we live in when this right is blatantly ignored and the health of many placed in jeopardy by the death of pain management?  

Janice Reynolds - Copy.jpg

Janice Reynolds is a retired nurse who specialized in pain management, oncology, and palliative care. She has lectured across the country at medical conferences on pain management, and is co-author of several articles in peer reviewed medical journals. Janice has lived with persistent post craniotomy pain since 2009. 

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.

The Importance of Pain Management in Wound Care

By Janice Reynolds, Guest Columnist

A recent article by Kaiser Health News on the difficulty of healing chronic wounds caught my attention.  After reading it several times, I was concerned with the message it was sending -- it seemed much like the misleading articles we see on the evils of opioids or how pain management is not being done right.

One of the red flags was the lack of any mention of skin and wound nurses. Or the important relationship pain management has in wound healing.

In the world of wound care, skin and wound nurses are the experts.  They are usually asked to consult by physicians and surgeons in managing wounds. Wound clinics may be run by them or in partnership with a physician. Our local clinic is managed by a skin and wound nurse and a foot physician.

While I never did the certification for Skin, Ostomy and Wound Care, I did manage my hospital’s wound team for a couple of years, so I studied as much as I could.  I also presented at several medical conferences on pain management in wound care. Those are my qualifications for this input.

bigstock-Medical-Team-Working-On-Patien-55984199.jpg

Like pain management, wound care is very difficult, as there are so many different types of wounds and different ways patients respond to them.

There are wounds from bites (I saw one where a pig took a chunk out of a kid’s calf), diabetic ulcers, peripheral ulcers caused by poor circulation, pressure sores, burns, trauma, and cancer. Some surgical wounds get infected and have to be reopened, or just don’t heal correctly to start with. 

As mentioned in the article, necrotizing fasciitis is difficult to heal and, in extreme cases, amputation is used to stop it. Radiation therapy can cause severe irritation and lead to a skin breakdown. Thrush, fungus, and moist desquamation caused by constant moisture can also cause a skin breakdown. There are so many more.

Pain is a huge issue in the management of wounds.  Entire chapters on pain are included in textbooks on Skin and Wound Care.  Pain inhibits wound healing, increases the likelihood of infection, and creates stress and anxiety.  This all effects quality of life. This is fact, not opinion.

There is pain related to the wound itself and what is called incidental pain – pain that is caused by dressing changes, debridement or other types of medical care. Of course, some patients are unfortunate enough to already have acute or chronic pain from another condition, in addition to the wound itself.

Opioids have always been the core of wound pain management, whether they’re delivered intravenously, orally (pills), or even topically.

I was once expressing frustration to my airline seat partner, who was a physician, on the difficulty I had trying to get my hospital to allow me to try a morphine gel compound which went directly in the wound. There had been several studies which had good results.  He looked at me in surprise and said, “I usually just drip morphine into the wound.”

Providers in wound care are like those in pain management. Some are very good, some adequate, some just barely make an attempt, and then there are those who deny the pain exists, blame the patient, say it only lasts for a minute, and so on.  This unfortunately has changed for the worse.

There are two large issues effecting the healing of chronic wounds and neither are the development of better dressings.  The first, but not the greatest problem, is money. Wound care is expensive.  It can be the cost of the dressing material or the expense of treating a patient at home.  Many insurers are selective about what they will pay for, and patients without insurance are tremendously lacking in adequate treatment.

The hysteria over opioids and pain management in general has greatly affected wound care. Opiophobia, fearmongering, McCarthyism, and my personal favorite -- yellow journalism -- have changed the way some providers look at and treat pain. In the War on Drugs, patients with wounds have also been causalities.    

Janice Reynolds.jpg

Janice Reynolds is a retired nurse who specialized in pain management, oncology, and palliative care. She has lectured across the country at medical conferences on different aspects of pain and pain management, and is co-author of several articles in peer reviewed journals. 

Janice has lived with persistent post craniotomy pain since 2009.  She is active with The Pain Community and writes several blogs for them. 

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.

Pain Clinic Settles Discrimination Case

By Pat Anson, Editor

An Indiana pain management clinic has agreed to pay $30,000 to settle a federal claim that it discriminated against a pain patient by refusing to treat him.

In an unusual twist, the discrimination case filed by the U.S. Justice Department against Pain Management Care of South Bend was not based on the man’s rights as a pain patient – but because of his HIV status. The Americans with Disabilities Act (ADA) is intended to protect all people from being discriminated against because of physical or mental disability.

According to the Justice Department, the patient was referred to Pain Management Care (PMC) in November, 2014 after the closure of another pain clinic where he had been treated. The patient sought bi-monthly cortisone injections, which he had been receiving for pain management from his previous doctor.

After sending the results of an MRI exam and other medical records to PMC, the patient received a voicemail message from a clinic employee stating that Dr. Joseph Glazier would not treat him “due to the risks involved with needles and blood due to (his) condition of being HIV positive.”    

The patient asked PMC to change its position but was still refused treatment. He was not able to find another pain management doctor willing to treat him until several months later.

“PMC’s discriminatory denial caused (the patient) to endure six months without needed pain management care and to experience emotional distress,” federal prosecutors said.

The case against PMC was filed on April 7th and quickly settled out-of-court, with Dr. Glazier agreeing to pay the patient $20,000 and a $10,000 civil penalty. PMC must also develop a non-discrimination policy, provide ADA training to its staff, and submit annual reports to the government. The consent decree still needs a judge’s approval.

PMC’s website now contains this notice: “Pain Management Care, P.C., does not discriminate on the basis of disability, including HIV. All individuals, including persons with HIV, have an equal opportunity to treatment from Pain Management Care, P.C.”

“The Justice Department is committed to eradicating discrimination resulting from the unfounded fear and dangerous stereotype that someone with HIV would pose a threat to a medical provider,” said Principal Deputy Assistant Attorney General Vanita Gupta, head of the Justice Department’s Civil Rights Division.  “Discrimination by those in the medical profession breaks a trust critical to ensuring access to appropriate treatment for all.”

This settlement is part of the department’s Barrier-Free Health Care Initiative, a partnership of the Civil Rights Division and U.S. Attorney’s Offices to target enforcement efforts on access to healthcare for individuals with disabilities. 

The Americans with Disabilities Act was signed into law by President H. W. Bush in 1990. It is intended to protect against discrimination based on “physical or mental impairment that substantially limits one or more major life activities.”

For more information on the obligations of healthcare providers under the ADA, you can call the Justice Department’s toll-free hotline at 800-514-0301. ADA complaints may be filed by email to ada.complaint@usdoj.gov or by clicking here.