Survey Finds Doctors Need More Addiction Education

By Pat Anson, Editor

Many primary care physicians -- the top prescribers of opioid pain medication in the United States – lack a basic understanding of how the drugs can lead to abuse and addiction, according to a new survey by the Johns Hopkins Bloomberg School of Public Health. The survey was conducted by several longtime critics of opioid prescribing practices who advocate tighter restrictions on painkillers.

The survey of over 500 practicing internists, family physicians, and general practitioners was conducted by mail in early 2014. Primary care physicians treat over half of the chronic pain patients in the U.S. and prescribe most of the pain medication.

The survey results, reported in the Clinical Journal of Pain, found that nearly half the physicians incorrectly believe that abuse-deterrent pills – which are harder to crush or liquefy for snorting or injecting – are less addictive than their standard counterparts. .

"Physicians and patients may mistakenly view these medicines as safe in one form and dangerous in another, but these products are addictive no matter how you take them," says study leader G. Caleb Alexander, MD, an associate professor in the Bloomberg School's Department of Epidemiology and co-director of the school's Center for Drug Safety and Effectiveness.

“Opioids serve an important role in the treatment of some patients. However, our findings highlight the importance of patient and provider education regarding what abuse-deterrent products can and cannot do. When it comes to the opioid epidemic, we must be cautious about overreliance on technological fixes for what is first and foremost a problem of overprescribing."

Every primary care physician who was surveyed thought that prescription drug abuse was a problem in their communities. Large majorities also supported efforts to reduce abuse, including patient contracts, urine drug testing, databases that monitor opioid prescribing, and greater restrictions on the marketing and promotion of opioids.

About a third of the doctors incorrectly reported that the most common route of prescription drug abuse is by means other than swallowing pills. Numerous studies have shown that most drug abuse is through oral ingestion, followed by snorting and injection.

Interestingly, one third of the physicians (33%) believed that efforts to reduce opioid abuse have had a chilling effect on pain management practices, and were preventing legitimate pain patients from gaining access to appropriate treatment.

Despite that finding, Alexander said further efforts are needed to combat opioid abuse, saying “doctors continue to overestimate the effectiveness of prescription pain medications and underestimate their risks.”

"For the sake of making a dent in an epidemic of injuries and deaths, we have to find ways to make changes. Too many lives are at stake to stick with the status quo," he said.

Two of the co-authors of the study are Andrew Kolodny, MD, and Stefan Kruszewski, MD. Kolodny is president of Physicians for Responsible Opioid Prescribing, a group that has lobbied Congress and petitioned the Food and Drug Administration to limit access to opioids. Kruszewski has served as an expert witness in multiple lawsuits against pharmaceutical companies.

Their research was supported by the Robert Wood Johnson Public Health Law Research Program and the Lipitz Public Health Policy Award at Johns Hopkins Bloomberg School of Public Health.

The Centers for Disease Control says over 16,000 Americans die annually from painkiller overdoses, an estimate that dates back to 2010. Most of those deaths also involved alcohol or other drugs.

Several recent studies suggest the tide of opioid abuse has turned in the U.S.

Dispensing of opioid pain medication and painkiller overdoses have declined substantially since 2010, according to a recent study published in JAMA Internal Medicine.

The number of prescriptions filled in the U.S. for hydrocodone has also declined, the first concrete evidence that restrictions on hydrocodone prescribing that were adopted in 2014 are starting to have an impact. Hydrocodone is no longer the most widely filled prescription in the U.S.

The National Institutes of Health estimates that only about 5 percent of pain patients become addicted to opioids after using them as directed for a year.

Opioid Abuse Takes Back Seat to Cost at Medicare

By Pat Anson, Editor

The U.S. Food and Drug Administration calls the development of abuse deterrent opioids a “priority” in combatting the so-called epidemic of prescription painkiller overdoses.

But when it comes to Medicare coverage of opioids, new research shows that lowering the cost of painkillers is a bigger priority for the federal government than discouraging abuse.

The study by Avalere, a health analytics research firm, found that Medicare Part D coverage of abuse deterrent OxyContin is falling rapidly. From 2012 to 2015, OxyContin coverage fell from 61% to 33% of Medicare Part D plans. In addition, one quarter of Part D plans now require prior authorization for OxyContin. 

In contrast, a generic version of OxyContin (oxycodone hydrochloride) that has no abuse-deterrent properties is covered by all Medicare Part D plans – and prior approval for it is only needed in 0.3% of Part D plans.

“While prescription opioid abuse continues to be a priority for public health experts and lawmakers, coverage for these products by Part D plans is limited and plans are increasingly favoring lower-cost generic products on their formularies,” said Caroline Pearson, senior vice president at Avalere.

“Policymakers seeking to limit opioid abuse will have to balance the desire for greater access to abuse-deterrent opioids with the increased costs of such medications to public programs and private payers.”

OxyConin was reformulated by Purdue Pharma in 2010 to make it harder for addicts to crush or liquefy for snorting and injecting. In 2014, the FDA approved three other opioids with abuse deterrent properties and in April of this year issued guidance to drug makers strongly encouraging them to develop more.  

“The science of abuse-deterrent medication is rapidly evolving, and the FDA is eager to engage with manufacturers to help make these medications available to patients who need them,” said FDA Commissioner Margaret Hamburg, MD. “We feel this is a key part of combating opioid abuse.”

But combating opioid abuse apparently takes a back seat to price, not only for Medicare but private insurers and the drug makers that developed abuse deterrent formulations.

According to the Healthcare Bluebook, a website that estimates the market price of medications, the “fair price” for a 60-day supply of OxyContin 20mg is $316.

A 60-day generic version of oxycodone -- without abuse deterrence -- retails for just $78.

“It will be important for policymakers to monitor and consider the implications of these trends,” the Avalere study says, warning that abuse-deterrence formulations may be pricing themselves out of the market.

“The potential increase in costs due to new innovations may be a barrier to policies that increase the coverage of abuse-deterrent opioids, especially in public programs, despite potential long-term public health savings associated with lower levels of opioid abuse. While the greater number and quality of abuse-deterrent options—both brand and generic—can support competition, reduce cost, and increase plan coverage, the potential of abuse-deterrent technologies may not be fully realized as long as non–abuse deterrent alternatives have less restrictive insurance coverage.”

Funding for the Avalere study came from Pfizer. Avalere says it maintained “full editorial control” over its content.

Over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010, according to the CDC. The government estimates that over 400,000 seniors are  “misusing” pain medication.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.

Five Ways TIME Gets Pain Pills So Wrong

By Crystal Lindell, Columnist

Access to pain pills is not a cause I chose. I didn’t wake up one day and think, “Gee, more people need opioids.”

No, access to pain pills is a cause that chose me. Because I really did wake up one day two and half years ago, and say, “What is wrong with me? Why do I suddenly have insane pain in my ribs?”

It’s a pain that never went away. And for months, the doctors didn’t take me seriously. They gave me prescription-strength Advil, Lidoderm patches, and told me to wear looser bras.

None of that worked.

So, for weeks on end, the pain got worse and worse, while I tried multiple doctors, trying to find someone who could help.

I was in so much pain that I would often lay down on the ground mid-sentence because I didn’t have it in me to keep standing. The pain was just that overwhelming.

And at night, after trying to survive the day, I would lay in bed and plan ways to commit suicide. I wish I was exaggerating.

Finally, I found a pain specialist who put me on hydrocodone. At the time I had no idea that opioids were controversial. I was just happy to finally have found something that gave me relief.

The problem with hydrocodone though is that it comes with these crazy spikes. So you take a pill, it relieves the pain and then it completely wears off within a couple hours — and you to wait six hours for your next dose. It’s a horrible way to live.

I’m also on a time-released morphine that lasts about 8 hours. I take it three times a day — so I am always on an opioid, 24 hours a day. And then, on top of that, I also take hydrocodone as needed.

I pretty much always need it.

The pain still gets bad. But now, because of the pain pills, I have times when I am nearly pain free. Times when I can catch my breath and remember that life is worth living.

Opioids have literally saved my life.

Which is why I’m so upset about TIME magazine’s cover story about the “worst addiction crisis America has ever seen.” 

I realized when I read the article that I am spoiled by my Facebook news feed. I tend to follow chronic pain groups, so most of the information I see is about how chronic pain patients need access to these drugs. As a result, I’ve been lulled into thinking that the chronic pain community is actually making progress on this issue.

Apparently, we aren’t.

And it is articles like this that make it that much harder for pain patients like me to get the relief they need.

Let’s break down what it gets so wrong, with some quotes from the report:

1.    It implies time-released morphine is basically heroin.

“The longer patients stay on the drugs, which are chemically related to heroin and trigger a similar biological response, including euphoria, the higher the chances users will become addicted.”

Aside from the excessive number of commas, there are so many infuriating things about this sentence. 

While the drugs can give you a “high” feeling when you first start taking them, I can promise you — after being on morphine all day, every day for over a year — that the “high” is only a short-term side effect.

Also, comparing the drugs I take to heroin is like saying that both TIME and US Weekly are similar because they both require reading. Yes, that’s true. But that’s about all they have in common.

2. The article focuses on how much the drug companies are supposedly making on these meds.

“The total annual sales for opioids in the U.S. has grown over 20 years to more than $8 billion.”

While there have been some new meds on the market, like Zohydro, the pills that I take and the pills most of the people I know take, are generic. Morphine isn’t exactly a brand name.

Giving people relief from horrific, daily pain is not part of some drug company conspiracy. It’s called compassion.

3. It devalues how horrible pain can be.

“The standard-setting Joint Commission on Accreditation of Health Care Organizations in 1999 required doctors to measure pain as part of their basic assessment of a patient’s health, which had the effect of elevating pain the same level of importance as objective measurements like temperature and heart rate.”

The author writes that like it’s a bad thing. I’m here to tell you, it’s not. Pain is such a huge part of your health. And managing it is just as important as managing your blood pressure or your insulin level.

Having too much pain will ruin your life and your body just like any other health issue.

Living with chronic pain is like living every day of your life with the same amount of pain you would wake up with after an extensive surgery, or a horrific car accident, or a stabbing.

Anyone in those situations would be given adequate pain relief. And, just because people with chronic pain have that same pain every day, all day, doesn’t mean they don’t deserve the same relief.

4. It implies that anyone on long-term pain medications is an “addict.”

“With America awash in opioids for the foreseeable future, health care providers and public officials are searching for ways to help addicts get clean.”

I don’t need to “get clean.” I need a cure, but there isn’t one for what I have. The next best thing is daily pain relief. Going off all my meds would be catastrophic for me, not because I’m addicted, but because I would end up stuck on the couch for the rest of my life in too much pain to shower.

Also, we need to take a second to talk about the word “addicted.” It is very different from what’s actually happening for most people, which is “dependence.”

Dependence is what happens when you take lots of different types of drugs long-term. Your body becomes dependent, so going off them cold turkey would be hell. However, if you taper off it, you’re good. Just like anti-depressants. And nobody ever says people are “addicted to anti-depressants.”

Addiction is when you start to crave that high feeling you get the first few times you take the drug, so you start taking higher and higher doses seeking it out. Sort of like how all of us are dependent on food, while a select few are addicted.

5. The authors don’t mention any alternatives.

For those enduring chronic pain, the real-life alternative to not having adequate pain pills is suicide.

Articles like this just make it that much harder for people with chronic pain to get the medications they need. If you want to see the suicide rate jump, just take away the medications that so many people rely on to do even simple things, like make dinner or do a load of laundry.

Look, I’m not saying everyone with a cold should get a prescription for morphine. I’m just saying that there are millions of people out there who need these drugs. And more regulation just gets in the way of decisions that doctors and patients should make together to help those who are suffering cope with their pain. The government should never be in anyone’s doctor’s appointment.

At the end of the day, I guess I just wish that TIME had talked to even one chronic pain patient for the article. There are millions of us out here, responsibly using opioids long-term, and we would have loved to chat with TIME.

If only they had asked.

Crystal Lindell is a journalist who lives in Illinois. She loves Taco Bell, watching "Burn Notice" episodes on Netflix and Snicker's Bites. She has had intercostal neuralgia since February 2013.

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

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.

Many Doctors Not Confident Prescribing Opioids

By Pat Anson, Editor

Nearly two-thirds of physicians who prescribe opioids say they are not confident or only somewhat confident about managing patients on opioid painkillers, according to the results of a new survey that found widespread gaps in education about opioid safety.

"This indicates a critical need for provider education addressing this issue. It is important our medical community is given the training it needs to confidently manage chronic pain while significantly reducing prescription opioid misuse, overdose and diversion," said Daniel Alford, MD, of Boston University School of Medicine.

Boston University and Haymarket Medical Education conducted an online survey of nearly 800 physicians who are registered with the Drug Enforcement Administration to prescribe Schedule II and III controlled substances.

Over a quarter (28%) said they had not completed certified medical education (CME) in safe opioid prescribing. Many also said they lacked the time or staff to implement an opioid monitoring system for patients, such as drug testing and pill counts.

"It's troubling that so many physicians say implementing safe opioid prescribing systems is not a priority, even though this is an acute issue. We've created a situation where some physicians are comfortable not doing anything about it,” said Alford.

Only a quarter of the doctors surveyed said they were very confident about their ability to safely manage chronic pain with opioid pain medication. Four out of ten said they don’t even prescribe opioids.

 “Lack of knowledge regarding some narcotics. Concerns of dealing with patients who appear to be drug seeking. Lack of time to follow some of these patients closely,” said one doctor who was not confident about prescribing opioids.

“Lack of training. Fear of providing access to patients who might abuse opioids,” said another.

Pain education for doctors – or the lack of it – is such a concern that the recently released National Pain Strategy considers it a top priority.

“Many health professionals, especially physicians, are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain,” a draft version of the report states. “Core competencies in pain care are not fully developed and generally do not inform undergraduate curricula in health professions schools or graduate training programs, even those in pain medicine.”

A 2012 study published in the Journal of Pain  called pain education in the U.S. and Canada “lackluster” and warned that unless steps were taken to improve the training of pain physicians, “the crisis in pain care and resultant deaths from opioid abuse will only spiral upwards.”

The study of 117 U.S. and Canadian medical schools found that less than 4% required a course in pain education and only one in six schools offered a pain elective. A large number of U.S. medical schools do not have any pain courses and many of those that do have less than five hours of classes.

Tramadol ER Visits Soar as Prescriptions Rise

By Pat Anson, Editor

Emergency room visits in the U.S. involving tramadol have nearly tripled in the last decade, coinciding with a sharp increase in the number of prescriptions for the opioid pain reliever.

According to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA), emergency room visits involving adverse reactions to tramadol rose from 10,901 visits in 2005 to 27,421 visits in 2011. A second SAMHSA report  found a similar increase in the number of ER visits related to the abuse or misuse of tramadol. The vast majority of patients were treated and released.

Ironically, tramadol is considered less risky than other opioid painkillers and doctors have been increasingly prescribing it. The IMS Institute recently reported the number of tramadol prescriptions in the U.S. nearly doubled from 28 million in 2010 to over 44.2 million in 2014.

Tramadol is the active ingredient in brand name pain relievers such as Ultram, Ultracet, Ryzolt and Rybix.

“Tramadol is not abused as much as most pain medication, but it is often overtaken in an effort to obtain additional pain relief.  Like with all pain medication, excessive amounts can cause serious harm,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine and vice president of scientific affairs at PRA Health Sciences.

Webster predicted that tramadol would be prescribed even more often when hydrocodone was reclassified in 2014 by the Drug Enforcement Administration from a Schedule III drug to a more restrictive Schedule II medication. Tramadol is a Schedule IV drug, meaning it has less potential for abuse than other narcotic pain relievers.

“In the past several years there has been tremendous pressure to reduce prescribing strong opioids. Tramadol has been used in place of other opioids. But it is not without risks as well,” said Webster in an email to Pain News Network.

“The rise in problems associated with tramadol underscores the larger problem of an unmet need to effectively treat pain. Most people, including policymakers, don't realize how many people are desperate to have their pain treated.”

About two-thirds of the ER visits related to misuse or abuse involved tramadol that was taken with other opioid pain relievers or anti-anxiety drugs (benzodiazepines). When tramadol is combined with other drugs that depress the central nervous system its sedative effects can be enhanced, causing seizures and a potentially fatal drug reaction known as serotonin syndrome.

Women were far more likely to have a tramadol-related trip to the ER than men, according to SAMHSA.

The greatest increase in tramadol-related misuse or abuse occurred in patients aged 55 and older. A SAMHSA spokesman said the higher number of older adults was not surprising because seniors are more likely to combine tramadol with other medication.

"Tramadol and other pain relievers can help to alleviate pain, but they must be used carefully and in close consultation with a physician," said SAMHSA Chief Medical Officer Elinore McCance-Katz, MD. "Like all medications tramadol can cause adverse reactions, which can be even more severe if the drug is misused. We must all work to lower the risks of taking prescription drugs.”

Readers Sound Off on Urine Drug Tests

By Pat Anson, Editor

Our recent series of stories on urine drugs screens – and how they are often unreliable or misinterpreted by doctors – struck a note with several readers who said they were falsely accused of abusing or misusing drugs.

Timmi Jernigan is a 54-year old retired educator in South Carolina who says she was “fired” last month by her doctor after a single drug test. Timmi has a prescription for Adderall – a drug used to treat attention deficit disorder – but the amount detected in her system was low.

A week after the test, she received a registered letter from the doctor discharging her.

"On 4/23/15 a drug test was performed which shows you are not taking the controlled substance prescribed. This in in violation of your drug agreement and we will no longer continue your care. We will see you for an emergency only for the next thirty days. During this time we will not prescribe any controlled substances. If you feel you need drug rehabilitation please contact our office for a referral,” the letter said.

 “Just like that. No follow-up appointment to discuss this test. I called and they would not let me see the doctor,” Timmi wrote to Pain News Network.

Timmi wanted to remind the doctor that a month earlier they had agreed to lower the amount of Adderall she was taking because it might worsen her high blood pressure.

“To suggest (per the letter) that I need drug rehabilitation because there is not enough amphetamine in my system is ludicrous at best,” she wrote.

Now Timmi is worried that the discharge letter in her medical files will damage her reputation and prevent her from finding another doctor.  Adding insult to injury, she received a bill for $1,300 from Ameritox, the drug screening company that performed the test – which is not covered by her insurance.

"I was not made aware of the huge cost involved in this ‘not medically necessary’ test. I was not even given a choice,” Timmi said.

"Anytime you are tested to this degree, you are convicted before being charged,” wrote Kim Miller, advocacy director of the Kentuckiana Fibromyalgia Support Group. “If you are the patient testing with a false positive for marijuana or a drug you are not prescribed, it can mean your last prescription of pain medication for a crime you didn't commit! Yes, I said ‘crime’ because that's the way chronic pain patients are treated anymore.”

False Negatives

Sometimes it’s not a false positive that gets a patient in trouble, but a false negative that indicates they may not be taking a prescribed medication – a red flag that could indicate the drug is being diverted.

That’s what happened to another woman – we’ll call her “Kathryn” -- who prefers to remain anonymous. Kathryn was accused of not taking klonopin, a prescribed medication for anxiety, after it didn’t show up in her drug screen.

“I was taking it as prescribed but no one listened. I was treated horribly,” Kathryn wrote. “After a lot of calls, the support of my husband, primary care doctor, insistence with staff (who made me feel like a criminal) and a revisit with doctor, Doc agreed med was at low enough level it wouldn't necessarily show up.”

“It's a shame though that patients have to pay literally and figuratively for the urine tests and revisits,” said Kathryn, who suffers from back pain, osteoarthritis, fibromyalgia and carpal tunnel syndrome.

Some readers did their own detective work to find out why they tested positive for a drug they weren’t taking. One shared with us a website called AskDocWeb that keeps a list of hundreds of medications, over-the-counter drugs, foods and even household products that can trigger a false positive. Poppy seeds in a muffin, for example, can trigger a false positive for opiates. And the pain reliever ibuprofen could get you flagged for marijuana.

“All this, and there is no scientific evidence to support that urine drug screens are curbing addiction. Would our money be better spent on programs to help those with addiction, which would not interfere with people who use their medications responsibly? Is a middle man once again driving up the costs of healthcare?” asked Celeste Cooper, a retired nurse and fibromyalgia advocate.

For more information about the $4 billion dollar a year drug screening industry, the Milwaukee Journal Sentinel has a story about the "Hidden Errors" found at drug testing laboratories.

Half of Americans Say Painkiller Abuse 'Serious Problem'

By Pat Anson, Editor

Over half of all Americans believe the abuse of a prescription painkillers is an extremely or very serious problem, according to a new poll by the Boston Globe and Harvard School of Public Health that documents the widespread concern – and misconceptions – the public has about opioid pain medication.

While nearly half (45%) believe painkillers are prescribed too often or in doses that are bigger than necessary, a majority (51%) believe that current regulations on the prescribing and availability of opioid pain medication are about right.  

Less than a third (29%) believe that regulations make prescription painkillers too easy for people to get.

The telephone poll of over 1,000 adults, which was conducted in mid-April, found that most Americans were more concerned about prescription painkiller abuse than they were about heroin.

Nearly one in four (39%) said they knew someone who had abused pain medication.

"For much of the public, the issue of prescription painkiller abuse is not just a remote concern; it's a problem they see in their personal lives," said Robert J. Blendon, a professor of Health Policy and Political Analysis at Harvard T.H. Chan School of Public Health.

People who know someone who has abused prescription painkillers hold different views about the problem than those who do not. They are significantly more likely to think painkiller abuse is an extremely or very serious problem (64% vs. 43%) and that the problem has gotten worse over the past five years (56% vs. 28%).

Of those who have known someone who has had an abuse problem, a majority say it has had a major harmful effect on the user's family life (67%), work life (58%), and health (55%). In addition, 21% say that the person's abuse of prescription painkillers led to their death.

Although studies have found that only a small percentage of pain patients become addicted to opioids, many Americans believe it is easy to get hooked on them. Nearly half of those surveyed (44%) say it is “very likely” that a person taking prescription painkillers will become addicted.

About one in five (21%) of the survey respondents said they had taken a prescription painkiller in the past two years. Of those, one in four (26%) reported they had been very or somewhat concerned that they could become addicted. Nearly two-thirds (61%) said they had talked to their doctor about the risk of addiction.

You can view the complete poll findings here.

While many respondents (39%) believe prescription painkiller abuse has gotten worse over the last five years, there are signs it has been abating.

Hydrocodone prescriptions fell by 8% last year and it is no longer the most widely prescribed medication in the U.S.

A recent report by a large national health insurer found that total opioid dispensing declined by 19% from 2010 to 2012 and the overdose rate dropped by 20 percent.

Using Marijuana and Opioids Doesn't Raise Risk of Abuse

By Pat Anson, Editor

As more and more states legalize medical marijuana, many chronic pain patients are turning to cannabis for pain relief. Some are also continuing to use opioid pain medication – raising concern that the combination could increase their risk of substance abuse.

But a new study at the University of Michigan found that patients who use marijuana and opioids are not at higher risk for alcohol and drug abuse. Researchers studied 273 patients at a marijuana clinic in Michigan and found that more than 60% were also using prescription opioids.

"We expected that persons receiving both cannabis and prescription opioids would have greater levels of involvement with alcohol and other drugs," said Brian Perron, PhD, of the School of Social Work at the University of Michigan.

"However, that wasn't the case -- although persons who were receiving both medical cannabis and prescription opioids reported higher levels of pain, they showed very few differences in their use of alcohol and other drugs compared to those receiving medical cannabis only."

Participants in the study, which is being published in the Journal of Studies on Alcohol and Drugs, did report higher rates of drug use than the general population. But their use of other drugs -- including alcohol, cocaine, sedatives, heroin, and amphetamines – was similar whether they used opioids or not.

“I am thrilled this research is now happening so others will also gain the confidence in trying medical marijuana,” said Ellen Lenox Smith, a medical marijuana advocate and columnist for Pain News Network.

“People who have addictive personalities will have issues weather it is alcohol, marijuana, smoking, or opioids. Those of us without that tendency do not have to be concerned. We have patients that have been using both medications successfully, but most of them have eventually chosen to wean away from the opioids due to the annoying side effects. But while using both, they have seemed to cope fine and metabolize both.”

A noted medical marijuana researcher says cannabis may actually make opioids more effective – enabling some patients to take lower doses.

“We’ve seen it in patients who started using cannabis successfully and they were able to reduce their other medications,” said Mark Ware, MD, an associate professor in Family Medicine and Anesthesia at McGill University in Montreal.

“In some cases they find that the dose of opioids that they were taking, they can lower it and get a similar effect at much lower doses. In others, they don’t need the opioids any longer and they’re able to taper off and stop it completely.”

Ware and other researchers believe medical marijuana may be a safer alternative to opioids, which have a higher risk of addiction and overdose. But they stress that communication between doctors and patients is important – since some doctors may have no idea if a patient is using marijuana.

"Physicians do not actually 'prescribe' medical cannabis -- they only certify whether the patient has a qualifying condition, which allows the patient to gain access to medical cannabis,” said Perron.

“The system of dispensing medical cannabis is completely separate from prescription medications, so physicians may not know whether a given patient is using medical cannabis, how much, and in what form."

CDC Social Media Campaign Backfires

By Pat Anson, Editor

A social media campaign by the Centers for Disease Control aimed at raising awareness about the  "epidemic" of painkiller abuse had the unintended effect of launching another campaign about the "pandemic" of untreated chronic pain -- and how the agency was failing to address it.

Last month the CDC encouraged people to "help us tell stories of the many people whose lives have been affected by prescription painkiller addiction or the death of a loved one."

The agency, which estimates that over 16,000 Americans die annually from painkiller overdoses, asked for stories to be posted on Facebook, Instagram and Twitter with the hashtag #RxProblem.

“Prescription drug overdose devastates individuals, families and communities,” said Erin Connelly, associate director for Communication at the CDC. “We’d like to get everyone talking and thinking about the risks involved with opioid painkillers.”

While painkiller addiction and overdoses are undoubtedly a public health issue, the #RxProblem campaign rubbed some activists in the pain community the wrong way.

"There are really two problems with prescription drugs. One is the problem of abuse. But the other problem is patients who have pain and have a legitimate medical need for these drugs and can't access them," said Bob Twillman, PhD, Executive Director of the American Academy of Pain Management.

"I think they (the CDC) know what the problems are, but for some reason they don't want to deal with the chronic pain problem. I've criticized them for calling the problem of prescription drug overdoses and prescription drug abuse an 'epidemic' and taking a much, much bigger problem like chronic pain and not saying anything about it.  Because to me, if 16,000 people a year dying from overdoses is an epidemic, then 100  million people with chronic pain must be a pandemic."

It was Twillman's idea to launch a rival social media campaign to draw more attention to the chronic pain problem.

"What we came up with was the idea of the hashtag #AnotherRxProblem, and have people who have trouble getting their medications write in about that experience and the impact that's had on them," Twillman told Pain News Network.

Write in they did, with hundreds of people complaining about the one-sided approach the CDC was taking to prescription pain medication.

"We need to live a quality life. Don't punish us. Find better pain control," posted Teri Daniel on Twitter.

"When will we take untreated pain seriously?" asked Melissa VanHouten.

"We have 2 public health crises: RxDrugAbuse & UnrelievedPain. Stop blaming. Work together," wrote Barby Ingle.

"We got a tremendous response. If you look at the Twitter feed for #RxProblem, about half of the posts are #AnotherRxProblem posts. We started another campaign on Facebook and the Facebook response absolutely blew up," said Twillman.

Dozens of pain patients also shared their stories on Dr. Jeffrey Fudin's blog.

"I’m going to get right to the point. PAIN AND OPIOIDS. They do help us. Yes, they’re in every group abusers and non-abusers. Those that it helps for medical necessity should not have to be punished, denied, etc. for those who choose to disregard the contract they signed," wrote Gina. "CDC there are alternatives, to wean out drug abusers. Utilize the resources you have vs. taking the easy way and punishing all."

The CDC's #RxProblem campaign officially ended May 15th. Did they get the message from #AnotherRxProblem get through?

"I'm not optimistic that it's going to make a change in what they're doing. But if it raises someone's awareness, then it was worth it," said Twillman. 

Study: Painkiller Abuse Costs Employers $25 Billion

By Pat Anson, Editor

Painkiller abuse is costing U.S. employers over $25 billion a year in lost productivity and missed work days, according to a new analysis by a healthcare consulting firm that also found that the vast majority of patients who are prescribed opioids do not have an abuse problem.

The “white paper” was produced by Healthentic, a Seattle-based company that helps employers identify health savings to reduce the cost of employee healthcare. You can download a copy of the report, called “Painkiller Abuse Is Costing Your Company” by clicking here.

"Opioid misuse costs employers in multiple ways including more medical costs and productivity loss," said Jeff O'Mara, CEO of Healthentic. "Employers have a unique opportunity to help people get more productivity for less money by identifying and engaging the people at risk."

Healthentic reviewed four years of health insurance claims data from 2011 to 2014 and found that only a small percentage of pain patients were misusing or abusing opioids.

"It was remarkably consistent that most people with an opioid prescription do not have a chronic or abuse problem. In fact, 87% of those prescribed an opioid in those four years didn’t show a cause for concern in the claims data,” the report states.

And what about the other 13 percent?

Healthentic identified three red flags in those patients that raised potential cause for concern:

1. Ten or more opioid prescriptions
2. A prescribed opioid supply for 120 days or more
3. A week or more of overlapping prescriptions for opioids and benzodiazepine, a sedative used to treat anxiety, depression and insomnia

“These people – just 13% -- are responsible for 92% of employer’s costs. And if you break it down even further, the 7% of the population with an opioid prescription that have two or more issues account for over 80% of the cost,” the report states.

Healthentic said opioid abusers used significantly more healthcare resources than non-opioid users, and cited a study that estimated the cost of their healthcare at $10,627 annually. In addition, opioid abusers cost employers $1,244 more in lost work days compared to non-abusers.

The company advised employers that opioids “should not be the first line of treatment” for back pain and other common workplace injuries, and said over-the-counter pain relievers like Tylenol and ibuprofen are “a more affordable and safer option.”

Healthentic recommended four actions to employers to address opioid abuse:

1. Understand and insist upon conservative prescribing guidelines for pain treatment for all participating providers.
2. Evaluate and know which employees are at risk by reviewing their insurance claims.
3. Educate employees about the risks of opioid drug use.
4. Increase and ensure access to treatment programs for employees with an abuse problem.

"Our hope is this analysis provides further insight into the societal and financial issue of prescription painkillers, and helps employers take strides in alleviating the problem to ensure the well-being of their people," said O'Mara.

Healthentic provides healthcare data and analytic services to nearly 11,000 corporate clients in 19 states.

Survey: Most Pain Patients Don't Abuse Painkillers

By Pat Anson, Editor

Only a small percentage of chronic pain patients misuse or abuse their opioid painkillers, according to a wide ranging survey by the Partnership for Drug-Free Kids that also found a “disconnect” between patients and their doctors about opioid prescribing.

About one in ten pain patients (7% of chronic pain patients and 13% of acute pain patients) admitted misusing their opioid medications. Nearly half took longer to finish their prescriptions than directed – which was usually an effort to save the pain medication for another time.

More than one in ten (13% of chronic pain patients and 15% of acute pain patients) admitted using someone else's opiate prescription.

The online survey of 705 pain patients and 360 prescribing physicians was conducted by the research firm Whitman Insight Strategies (WINS) earlier this year.

About two-thirds of the opioid prescribers said they “always” warned their patients about the risk of addiction and dependency.

But when patients were asked who, if anyone, explained to them the potential for becoming dependent or addicted to painkillers, 19% of chronic pain patients and 40% of acute pain patients said "no one."

The survey also found that most patients pay little attention to the proper storage and disposal of pain medication. Only 11% of chronic pain patients and 13% of acute pain patients said they were concerned that someone else in their household might use their medications.

Less than half of chronic pain patients (42%) who have children said they store their medication somewhere their kids can’t reach. Most patients said their doctors never discussed the proper storage and disposal of painkillers.

"This research highlights key opportunities for prescribers of Rx opiates and their patients to have better communication around proper use and disposal of prescribed painkillers," said Marcia Lee Taylor, Interim President and CEO of the Partnership for Drug-Free Kids.

"The Centers for Disease Control has deemed abuse of prescription painkillers an 'epidemic,' and we can all do our part to help turn the tide on this critical health issue. Prescribers and patients can become more aware of the repercussions surrounding the improper storage and disposal of Rx pain medications and talk more at length in order to improve doctor-patient communication and help curb abuse."

The survey also found that many physicians are concerned about patients misusing their pain medication – by either taking too little or taking too much.

The majority of prescribers (77% of primary care physicians and 75% of pain management specialists) believe their patients do not always use their prescribed opiates in accordance with instructions. Twenty percent of the primary care physicians said they don’t feel comfortable prescribing opiates at all.

"This research suggests to us that prescribers need to feel more confident in assessing the potential risk of misuse or abuse of the Rx medicines, but unfortunately many of them feel they have not received proper training to assess those risks. There is a lot more we can do to help prescribers feel they have the proper tools they need to feel comfortable prescribing these medicines and taking action if a patient is abusing them," Taylor said.

The survey also found that most pain patients would prefer alternatives to opioids. About 9 in 10 chronic pain patients have tried an alternative treatment such as physical therapy and massage. Many were hindered in their use of alternative therapies by restrictions on insurance coverage.

Doctor Defends Use of Urine Drug Tests

By Pat Anson, Editor

A prominent pain doctor is disputing reports that a widely used urine drug test often gives faulty results.

“They are reasonably reliable and highly cost effective for use in a pain management practice. I would strongly recommend the practitioners use this,” said Laxmaiah Manchikanti, MD, chairman and CEO of the American Society of Interventional Pain Physicians.

Dr. LAXMAIAH MANCHIKANTI

Dr. Manchikanti, who is medical director of a pain clinic in Paducah, Kentucky, was the lead author of a study published in the journal Pain Physician in 2011, which looked at the reliability of immunoassay “point-of-care” (POC) tests. The urine tests are inexpensive and give immediate results, and doctors often use them to monitor their patients for opioid or illicit drug use.

“The UDT (urine drug test) with immunoassay in an office setting is appropriate, convenient and cost effective. Compared with laboratory testing for opioids and illicit drugs, immunoassay office testing had high specificity and agreement,” Manchikanti's study found.

Pain News Network recently reported on the results of a second study conducted by Millennium Health, a San Diego-based drug testing laboratory, which found that POC tests were wrong about half the time – frequently giving false positive and false negatives results for drugs like marijuana and oxycodone. The Millennium study advocates the use of chromatography-mass-spectrometry – a more complex laboratory test that costs thousands of dollars – to confirm POC test results.

“Following the advice from companies in reference to numerous expensive tests and also income generating avenues will only lead to time in the slammer and will not improve patient care at all,” said Manchikanti.

“(The) Millennium study is performed by the company which makes a living by testing. The more samples that are sent to them, the better off they are. Further, they are not even a practical setting. From our practice we send approximately only 2% of the samples for confirmation testing. Even then, the patients can’t pay their bills.”

Manchikanti’s study found false negative and false positive rates for POC tests that were far below the rates reported by Millennium.

For example, Millennium’s false positive rate for oxycodone was 41.3 percent. For Manchikanti, it was only 7.7 percent.

Millennium’s false positive rate for marijuana was 21.3 percent. For Manchikanti, it was just 2 percent.

There were discrepancies between the two studies for several other drugs, including methadone, cocaine and methamphetamine.

Millennium Sponsored Both Studies

How could two studies come to such different conclusions?

There were some differences in their design. Urine samples in the Millennium study came from nearly 4,300 patients in addiction treatment clinics, while the urine samples in Manchikanti’s study came from 1,000 patients in pain management programs. Millennium maintains the patients in its study were younger and more likely to be drug users.

Ironically, the laboratory tests for both studies were conducted by Millennium – which collected samples and provided chromatography-mass-spectrometry testing at no cost to Manchikanti. Millennium is identified as the “sponsor” of Manchikanti’s study, but he says the company had “no influence or interference” in his and his three co-authors’ findings.

“We had our agreement in the beginning itself that they will not be involved in any way in writing the manuscript or publishing the results. Consequently, they really did not have much input into the publication. The publication was as it is and without any bias from the industry,” Manchikanti wrote in an email to Pain News Network.

Millennium’s study, which was published last year in the Journal of Opioid Management, had six co-authors. All but one were employees of the company. The lone exception is a pain management doctor who frequently testifies as a legal expert for Millennium in court cases.

A source with broad experience in the drug testing industry told Pain News Network the data in Millennium’s study was “skewed toward exaggeration.”

“It does not surprise me that Millennium would show a high rate of inconsistencies with the POC test. Remember, their business is to sell confirmation testing, so they will skew the way they present data to try to influence the market to do more confirmation testing.  In most cases, that’s how it works in any study conducted or funded by a device or pharmaceutical company,” the source said.

Millennium bristles at the notion that its study was biased.

“Millennium Health strongly disagrees with the characterization… that the study was skewed or biased in any way,” the company said in a statement to Pain News Network.

“The study was accepted and published by a well-respected, peer-reviewed publication. Millennium Research Institute is committed to the highest ethical and research science standards, and we stand by the results of our study. The study was based on random samples from addiction treatment clients. The data clearly indicated that immunoassay, or point-of-care, tests have a high rate of false positives and false negatives when used to screen patients for illicit drug use.

“Millennium is committed to providing data that helps clinicians evaluate the best course of treatment for patients with pain and addiction issues. Millennium Health performs only the tests ordered by clinicians.”

In recent years a growing number of doctors who treat addicts and pain patients have required them to submit to drug tests. The competition between Millennium and other laboratories for this business is intense. According to one estimate, drug testing has grown into a lucrative $4 billion dollar a year industry.

But Manchikanti maintains that a single inexpensive urine test that costs about $20 is often the only one that’s needed.

“If a proper (patient) history is provided which matches with the test, there is no need for further testing,” he said.

When Drug Tests Go Wrong

By Pat Anson, Editor

Robin Haas was driving to Disneyworld with her husband and three children in 2008 when their vehicle was rear-ended by a truck on a Florida highway. The accident left Robin with chronic back pain, and she had 17 surgeries over the next 11 months to repair her damaged spine.

It was only the beginning of her problems.

Last year Robin was kicked out of a pain management practice after two office urine tests failed to find any trace of the fentanyl patch she was wearing for pain relief – a red flag for physicians that a patient may be diverting a drug.

Initially, Robin says her doctor didn’t seem too concerned.

“When it happened the second time, he said ‘Don’t worry about it. It’s happened with several of my patients with the fentanyl patches,’” Robin said

About a week later, she was shocked to get a certified letter from the doctor discharging her.

“I don’t know what happened. I really don’t,” Robin told Pain News Network. “I was just mortified. I never did anything wrong in pain management. Ever.”

What happened to Robin is not uncommon. According to a recent study, immunoassay urine tests widely used by pain management doctors to screen patients for drug use are wrong about half the time – frequently giving false positive or false negative results.

“Clearly, people don’t know how to interpret these tests,” said Jeffrey Fudin, a pharmacist and patient advocate, who says most physicians have no idea how inaccurate immunoassay testing is.

“I’m positive that they don’t. I get probably 50 emails a week from all over the country from concerned physicians and nurse practitioners who want to make the right decision, but they’re not sure what to do,” said Fudin.

"The other problem is there are no standards. You can go to five different providers and be treated five different ways for the same results.”

Fudin says fentanyl may not show up on an opiate screen because it has a  different chemical structure compared to most commonly prescribed opioids. There can also be false negatives because an opioid is simply prescribed in too low of a dose to be detected.

Some medications can also trigger false positives for an illicit drug. Widely used pain relievers like naproxen and ibuprofen, for example, can trigger a false positive for marijuana. 

To help doctors correctly interpret immunoassay results, Fudin is developing an online app called Urintel that can help them decide whether to take a negative or positive drug screen seriously – and whether to order more reliable and more expensive confirmation testing in a laboratory.

“Basically, it’s educational and it’s not punitive to the patient,” said Fudin about his app.

“My goal is to make opioid therapy as safe as possible and to make it individualized for each patient. And also to be fair, not only to patients, but providers because it’s not their fault that they don’t have training in pharmacokinetics or biochemistry. It takes a lot of things to understand the complexity of this.”

Fudin’s app may be too late to help pain patients like Robin Haas. She just hopes more patients aren’t wrongly accused of diverting or abusing drugs because of a test that is so often wrong.

“I guarantee not one of my pills has ever hit the street,” says Robin.

The 43-year old Florida resident says the pain clinic told her that her urine samples were re-tested in a laboratory – at a cost of $18,000 – but the results came back the same. She’s still not sure what went wrong. The  clinic has refused to identify the laboratory it used or provide her with the lab results. She had to find a new doctor.

“It’s a horrible thing to happen to people. And when you’re having to deal with chronic pain to begin with, nobody should have to go through it,” she says.

Have you been wrongly accused of failing a drug test?

Tell us your story. Send an email to editor@PainNewsNetwork.org.

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Opioid Dispensing and Overdoses Down Sharply

By Pat Anson, Editor

Dispensing of opioid pain relievers and painkiller overdoses both declined substantially after an abuse-deterrent formula of OxyContin was introduced and the painkiller propoxyphene was withdrawn from the U.S. market in 2010, according to a new study published online in JAMA Internal Medicine.

The study is another indication there has been a reversal in the growth of opioid prescribing – which has long been blamed for the so-called “epidemic” of prescription drug abuse. Last week another study was released showing that the painkiller hydrocodone was no longer the most-widely prescribed drug in the U.S. 

Researchers analyzed claims from over 31 million members of a large national health insurer, and estimated that by 2012 total opioid dispensing declined by 19% and the overdose rate dropped by 20 percent. The drop in prescription opioid overdoses was partially offset by a 23% increase in overdoses due to heroin.

“Our results have significant implications for policymakers and health care professions grappling with the epidemic of opioid abuse and overdose,” said lead author Marc Larochelle, MD, of the Harvard Medical School and Boston University School of Medicine.

"Changes imposed through regulatory mandates or voluntary company actions may be a viable approach to stemming prescription abuse. However, identifying interventions that reduce opioid supply without affecting access to individuals who benefit from opioid therapy remains a challenge.”

Propoxyphene (also known as Darvon) was voluntarily withdrawn from the U.S. market after data emerged about its cardiac toxic effects.

The abuse-deterrent formula of OxyContin introduced by Purdue Pharma in 2010 is harder for drug abusers to crush or dissolve for snorting or injecting. Researchers said the prescribing of OxyContin and other extended released oxycodone products dropped by 39% in the two years after the formulation change.

They noted there was “minimal” evidence that people switched to other pain medications because of the formulation change – an indication they weren’t taking OxyContin for pain relief.

"These results suggest that many people who were prescribed OxyContin before it was reformulated may have been diverting or misusing the drug," said Larochelle. "Given the decreased supply of prescription opioids, those seeking out an opioid could be turning to heroin, which may partially explain the tremendous increase in heroin overdose deaths over the past few years both locally and nationally."

“This study parallels other independent and internal research that shows reformulated OxyContin is associated with a reduction in abuse,” Purdue Pharma said in a statement.

“We agree with the FDA, the U.S. Drug Enforcement Administration, The White House Office of National Drug Control Policy and many federal and state policymakers that abuse-deterrent formulations are a valuable public health tool that must be part of any comprehensive approach to combatting prescription drug abuse.”

The study also suggests that legitimate pain patients were not the ones abusing opioids.

“Most overdoses do not occur among patients who are receiving daily prescribed opioids or among those receiving the highest doses,” said Hillary Kunins, MD, of the New York City Department of Health and Mental Hygiene in an editorial also published in JAMA Internal Medicine.

"Recasting the often-maligned 'doctor-shopper' instead as a patient with a substance use disorder reminds us that using public health strategies to promote judicious opioid prescribing, including via pharmaceutical market change to reduce overdose risk, needs to be accompanied by similar policy approaches to provide accessible and effective services for people who use drugs.”

U.S. Hydrocodone Prescriptions Dropping

By Pat Anson, Editor

The number of prescriptions filled in the U.S. for hydrocodone declined in 2014, the first concrete evidence that restrictions on the widely used opioid painkiller are starting to have an impact.   

According to the IMS Institute, 119.2 million prescriptions for hydrocodone pain medications were dispensed by pharmacies last year -- down from 129.5 million the year before – a decline of 8 percent. Hydrocodone is typically combined with acetaminophen in Vicodin, Lortab, Lorcet, Norco, and other hydrocodone products.

The IMS report also found that levothyroxine – a synthetic hormone used to treat thyroid deficiency -- has replaced hydrocodone as the #1 most widely filled prescription in the U.S.

The decline in hydrocodone prescriptions is striking because it was only in the last three months of 2014 that the painkiller was reclassified by the U.S. Drug Enforcement Administration from a Schedule III drug to a more restrictive Schedule II medication.

The DEA and Food and Drug Administration have been under pressure to restrict access to opioids because of the so-called epidemic of prescription drug abuse. Over 16,000 Americans die annually from painkiller overdoses, although most of those deaths involve other drugs or alcohol.

“The rise in opioid prescribing, which led to an opioid becoming America’s most prescribed medication, resulted in a public health catastrophe,” said Andrew Kolodny, MD, director of Physicians for Responsible Opioid Prescribing (PROP), which played an instrumental role in getting hydrocodone rescheduled.

“The trend is clearly moving in the right direction. I’d predict that up-scheduling will accelerate the decline in prescriptions. This will go a long way toward bringing the opioid crisis under control because with more cautious prescribing we are likely to see less new cases of opioid addiction.”

The rescheduling of hydrocodone limits pain patients to an initial 90-day supply of hydrocodone — and also requires them to see a doctor for a new prescription each time they need a refill. Prescriptions for Schedule II drugs also cannot be phoned or faxed in by physicians.

Since the rescheduling, many patients have complained that their doctors were no longer willing to prescribe hydrocodone and that pharmacists were unwilling to fill valid prescriptions. A recent survey found that many pain patients had suicidal thoughts after being denied a prescription. Others said that rescheduling hard been harmful to their relationship with their doctor.

Hydrocodone prescriptions were dropping even before the rescheduling took effect. They peaked in 2011 with nearly 137 million prescriptions filled by pharmacies.

The IMS report found that prescriptions of tramadol, a weaker Schedule IV opioid, rose by over 5% in 2014 – a possible sign that tramadol is being used as a substitute for hydrocodone. The number of tramadol prescriptions being dispensed has nearly doubled since 2010 from 28 million to over 44.2 million in 2014.

“I predicted tramadol prescriptions would increase,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine and vice president of scientific affairs at PRA Health Sciences.

“I think the overall amount of opioids has declined a little.  Physicians are prescribing less because of publicity, and fear of regulatory interventions. Payers are also limiting what patients can receive. Seems inappropriate that payers have so much control.”

Total spending on all prescription medications in the U.S. rose over 10% to $373.9 billion in 2014, according to IMS, with a record volume of 4.3 billion prescriptions filled.