Surge in Fake Painkillers as Opioid Prescribing Drops

By Pat Anson, Editor

A decline in the abuse and diversion of prescription pain medication is being offset by a “massive surge” in the use of heroin and counterfeit painkillers, according to a comprehensive new report by the U.S. Drug Enforcement Administration.

The DEA’s 2016 National Drug Threat Assessment paints a stark picture of the illicit drug trade in prescription medication, fentanyl, heroin, marijuana, methamphetamine and cocaine.  Interestingly, the 194-page report doesn’t even mention kratom, the herbal supplement the DEA attempted to ban in August before postponing its decision after a public outcry.

"Sadly, this report reconfirms that opioids such as heroin and fentanyl - and diverted prescription pain pills - are killing people in this country at a horrifying rate," said DEA Acting Administrator Chuck Rosenberg. "We face a public health crisis of historic proportions. Countering it requires a comprehensive approach that includes law enforcement, education, and treatment." 

The diversion of prescription opioids has fallen dramatically, according to the DEA report, from 19.5 million dosage units in 2011 to 9.1 million in 2015. Less than one percent of the opioids legally prescribed are being diverted to the black market.

The agency says the prescribing and abuse of opioid medication is also dropping, along with the number of admissions to treatment centers for painkiller addiction.

“With the slightly declining abuse levels of CPDs (controlled prescription drugs), data indicates there is an increase in heroin use, as some CPD abusers have begun using heroin as a cheaper alternative to the high price of illicit CPDs or when they are unable to obtain prescription drugs,” the report states.

The increased use of heroin coincided with federal and state efforts to reduce the prescribing of opioids. So did the appearance of counterfeit pain medication made with illicit fentanyl – a synthetic opioid that is 50 to 100 times more potent than morphine.  

“In 2015, there was a marked surge in the availability of illicit fentanyl pressed into counterfeit prescription opioids, such as oxycodone. In many cases, the shape, colorings, and markings were consistent with authentic prescription medications and the presence of fentanyl was only detected after laboratory analysis,” the DEA said. “The rise of fentanyl in counterfeit pill form exacerbates the fentanyl epidemic. Prescription pill abuse has fewer stigmas and can attract new, inexperienced drug users, creating more fentanyl-dependent individuals.”

As Pain News Network has reported, the number of fentanyl related deaths has surged around the country. In Massachusetts – where there has been a marked effort to reduce opioid prescribing -- three out of four opioid overdoses are now being linked to illicit fentanyl.

In Ohio’s Cuyahoga County, the problem is even worse. The medical examiner there estimates 770 people will die from either fentanyl or heroin overdoses by the end of the year, ten times the number of overdose deaths from prescription opioids.

The DEA predicts the problem will only grow worse.

“Fentanyl will remain an extremely dangerous public safety threat while the current production of non-pharmaceutical fentanyl continues,” the agency warns. “In 2015 traffickers expanded the historical fentanyl markets as evidenced by a massive surge in the production of counterfeit tablets containing the drug, and manipulating it to appear as black tar heroin. The fentanyl market will continue to expand in the future as new fentanyl products attract additional users.”

Those who do manage to get their hands on prescription painkillers for recreational use are mostly getting them from friends or relatives. Less than 25% of the painkillers that are used non-medically are obtained directly from doctors.

Over two-thirds of the painkillers that are abused are bought, stolen or obtained for free from friends and relatives.

Despite the shifting nature of the opioid epidemic, government efforts to stop it continue to focus on punishing doctors who overprescribe and reducing patient access to opioids.

“I have several chronic pain conditions that I was managing with a doctor’s care and Norco,” one reader recently emailed Pain News Network. “The DEA closed his office out of the blue. I was left with no doctor, no medical records, and the responsibility of weaning myself off what meds I had left on my own. 

SOURCE OF PAINKILLERS USED NONMEDICALLY

SOURCE: DEA

“My life is in shambles and I live in constant pain with no mercy. How much medical proof of real pain does it take? They just run me around to see different doctors. All the money and time wasted. I can't imagine living the rest of my life like this.”

The Centers for Disease Control and Prevention says 52 Americans die every day from overdoses of prescription opioids, although the accuracy of its estimates has been questioned. Some deaths caused by heroin and illicit fentanyl are wrongly reported as prescription drug overdoses. Other deaths may have been counted twice.

‘Opioid Vaccine’ Could Revolutionize Addiction Treatment

By Pat Anson, Editor

Scientists at The Scripps Research Institute have developed an experimental vaccine that appears to significantly lower the risk of an overdose from prescription opioids and could someday revolutionize opioid addiction treatment. The vaccine also blocks the pain-relieving effects of opioid medication.

“We saw both blunting of the drug’s effects and, remarkably, prevention of drug lethality,” said co-author Kim Janda, PhD, a professor of chemistry at Scripps. “The protection against overdose death was unforeseen but clearly of enormous potential clinical benefit.”

Vaccines typically take advantage of the immune system’s ability to recognize and neutralize foreign invaders such as bacteria.

When injected, the opioid vaccine triggers an immune system response when two widely used painkillers -- hydrocodone and oxycodone -- are detected. Antibodies released by the immune system seek out the opioids and bind to the drugs' molecules, preventing them from reaching the brain.

“The vaccine approach stops the drug before it even gets to the brain,” said study co-author Cody Wenthur, PhD, a research associate at Scripps. “It’s like a preemptive strike.”

In tests on laboratory mice, scientists found that the opioid vaccine blocked the pain relieving effects of oxycodone and hydrocodone, as well as any euphoria. The vaccinated mice also appeared less susceptible to a fatal overdose.

“Our goal was to create a vaccine that mirrored the drug’s natural structure. Clearly this tactic provided a broadly useful opioid deterrent,” said study first author Atsushi Kimishima, a research associate at Scripps.

Currently, opioid addiction treatment relies on other opioids – such as methadone and buprenorphine (Suboxone) – to stifle cravings for opioids. But those drugs can be abused as well.  

Although some of the vaccinated mice succumbed to an opioid overdose, researchers found that that it took much longer for the drug to impart its toxicity. If this effect holds true in humans, the opioid vaccine could extend the window of time for emergency treatment if an overdose occurs.

The next step for researchers is to refine the dose and injection schedule for the opioid vaccine. It may also be possible to make the vaccine more effective. Scripps researchers are already working on vaccines to block the effects of heroin, fentanyl and other synthetic opioids.

The Scripps study has been published in the journal ACS Chemical Biology. The study was supported by the National Institute on Drug Abuse of the National Institutes of Health.

Heroin Vaccine

California-based Opiant Pharmaceuticals is developing a similar vaccine designed to treat heroin addiction. The company recently announced that it has obtained exclusive development and commercialization rights to an experimental heroin vaccine invented by scientists at the Walter Reed Army Institute of Research and the National Institute on Drug Abuse.   

“Aggressively addressing heroin addiction is part of Opiant’s mission,” Roger Crystal, MD, CEO of Opiant said in a news release. “In our view, this vaccine fits our plan to develop innovative treatments for this condition. The vaccine has promising preclinical data.”

Opiant’s first commercial product was Narcan, an emergency nasal spray that rapidly reverses the effects of an opioid overdose.

“Whilst our development of Narcan Nasal Spray to reverse opioid overdose has been a significant effort to address the unfortunate consequences of heroin addiction, we see the vaccine as having potential in addressing the disease itself,” said Crystal.

The Addict is Not Our Enemy

By Fred Kaeser, Guest Columnist

A number of people in chronic pain support the plight of those with addiction. Yet, over the past year and a half, I have read any number of derogatory statements and comments here on Pain News Network and on its corresponding Facebook page about people who are dealing and struggling with addiction.

Even a cursory review of the comment section on different articles will reveal rather quickly any number of folks who are dismissive of those dealing with addiction. Some express a real hatred.

One person actually suggested letting “all the druggies overdose, one by one.”

Another laments that “addicts can't die quick enough for me.”

Some express a sort of jealousy over addicts getting better treatment than they: “It's good to be an addict" and "Maybe I'd be better off being an addict.”

And then there are those who got all shook up over Prince's overdose, not so much from his death, but because it was linked to an opioid and that it might make it harder for them to obtain their own opioid medications.

And to think these comments come from the same people who beg others to better understand and accept their own need for better pain care!

It wasn't very long ago that the "drug addict" was scorned and forgotten: the druggie on the dark-lit street corner or the drunk in the back-alley. Pretty much neglected and left to fend for themselves.

But that started to change in the '70s and '80s, and nowadays the person suffering from addiction is recognized as someone who suffers from a very complex disease, is quite sick, and struggles to access the necessary care in order to recover. Societal attitudes towards those with an addiction now reflect empathy and a desire to help, as opposed to denunciation and dismissiveness.

We chronic pain patients are looking for the same acceptance and understanding that addicts were desperately seeking just a few short years ago. And that struggle took many, many decades, one might say centuries, to achieve. Our struggle is similar, and my guess is if we keep our eyes and focus on reasonable and rational argument, we too will achieve success in our struggle to obtain acceptable pain care and understanding.

But if some of us continue to see the enemy as the person who has an addiction, our fight for justice will suffer and be delayed.

Why? Because the addict is not very different from us.  Irrespective of the reason why a drug or substance user becomes addicted, the addict just wants to feel better, just like us. The addict is sick, just like us. The addict wants relief from pain, just like us. Perhaps not from physical pain, but emotional and psychic pain. The addict wants proper medication, just like us. The addict needs help and assistance, just like us.

And sometimes the pain patient is the addict. Sometimes we are one in the same. A recent review of 38 research reports pegs the addiction rate among chronic pain patients at 10 percent. From a genetic predisposition standpoint, we must presume that some addicts have become addicted just because of their genes, just like some of us.

No one with an addiction started out wanting to become addicted, just like none of us wanted chronic pain. And while our government is trying to figure out how to minimize the spread of opioid addiction, it is not the addict's fault as to how it has decided to that.

In many ways those suffering from addiction are not very different from us who suffer from chronic pain. We both struggle for acceptance, we both require empathy and understanding from the world around us, and we both require treatment and proper care to lead better and more productive lives.

But, I firmly believe that as long as there are those of us in chronic pain who feel compelled to ridicule and demean those who are addicted, that we will only delay our own quest to receive the empathy we so justly deserve in our journey towards adequate pain care.

Empathy breeds empathy, and if we expect it for ourselves, we must be willing to extend it to others. And that includes the addict. 

Fred Kaeser, Ed.D, is the former Director of Health for the NYC Public Schools. He suffers from osteoarthritis, stenosis, spondylosis and other chronic spinal problems.

Fred taught at New York University and is the author of What Your Child Needs to Know About Sex (and When): A Straight Talking Guide for Parents.

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.

Medical Marijuana Could Help Treat Addiction

By Pat Anson, Editor

Can marijuana be used to treat addiction?

Not according to the U.S. Drug Enforcement Administration, which classifies marijuana as a Schedule I controlled substance with “a high potential for abuse.” Adults who start using marijuana at a young age, according to the DEA,  are five times more likely to become dependent on narcotic painkillers, heroin and other drugs.

But a new study by Canadian researchers found that marijuana is helping some alcoholics and opioid addicts kick their habits.

"Research suggests that people may be using cannabis as an exit drug to reduce the use of substances that are potentially more harmful, such as opioid pain medication," says the study's lead investigator Zach Walsh, an associate professor of psychology at the University of British Columbia’s Okanagan campus.

“In contrast to the proposition that cannabis may serve as a gateway (drug) is an emerging stream of research which suggests that cannabis may serve as an exit drug, with the potential to facilitate reductions in the use of other substances. According to this perspective, cannabis serves a harm-reducing role by substituting for potentially more dangerous substances such as alcohol and opiates.”

In their review of 31 studies involving nearly 24,000 cannabis users, Walsh and his colleagues also found evidence that marijuana was being used to help with mental health problems, such as depression, post-traumatic stress disorder (PTSD) and social anxiety.

The review did not find that cannabis was a good treatment for bipolar disorder and psychosis.

"It appears that patients and others who have advocated for cannabis as a tool for harm reduction and mental health have some valid points," Walsh said.

With medical marijuana legal in over half of the United States and legalization possible as early as next year in Canada, Walsh says it is important for mental health professionals to better understand the risk and benefits of cannabis use.

"There is not currently a lot of clear guidance on how mental health professionals can best work with people who are using cannabis for medical purposes," says Walsh. "With the end of prohibition, telling people to simply stop using may no longer be as feasible an option. Knowing how to consider cannabis in the treatment equation will become a necessity."

The study was recently published in the journal Clinical Psychology Review. Walsh and some of his colleagues disclosed that they work as consultants and investigators for companies that produce medical marijuana.

Previous studies have found that use of opioid medication declines dramatically when pain patients use medical marijuana. Opioid overdoses also declined in states where medical marijuana was legalized..

Fentanyl & Heroin Changing U.S. Opioid Epidemic

By Pat Anson, Editor

A prominent Alabama physician says the U.S. opioid epidemic has changed so profoundly in the last 3 years that a serious reconsideration of government policy is needed.

Stefan Kertesz, MD, an associate professor at the University of Alabama at Birmingham School of Medicine, says heroin and illicit fentanyl are now the driving forces behind the opioid epidemic – not prescription pain medication.

“Reducing opioid prescribing is not going to save many lives at this point, even though it gives many officials a chance to look like they are doing something,” says Kertesz, who is also a primary care physician trained in internal medicine and addiction.

“If we have been reducing prescribing for several years, and the misuse of prescription pain relievers is near all-time lows… and overdoses are either staying very high or skyrocketing, then we need to change our assessment of the problem and refocus our response.”

STEFAN KERTESZ, MD

Kertesz cites recent data from Jefferson County, Alabama showing that most overdoses in the county are now linked to either fentanyl, heroin or a combination of the two. Only 15 percent of the overdoses are associated with prescription opioids.

In Ohio’s Cuyahoga County, about 11 people die each week from fentanyl or heroin overdoses. By the end of the year, the county medical examiner estimates that a total of 770 deaths will be caused by fentanyl or heroin, nearly ten times the number that will die from prescription opioid overdoses.  

source: cuyahoga county medical examiner

“Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, while opioids commonly obtained by prescription play a minor role,” Kertesz wrote in a commentary published in the journal Substance Abuse.

“The observed changes in the opioid epidemic are particularly remarkable because they have emerged despite sustained reductions in opioid prescribing and sustained reductions in prescription opioid misuse. Among U.S. adults, past-year prescription opioid misuse is at its lowest level since 2002. Among 12th graders it is at its lowest level in 20 years.”

Kertesz says the Centers for Disease Control and Prevention relied on faulty data and failed to address the changing nature of opioid abuse when it released its opioid prescribing guidelines in March. Since then, many pain patients have reported their opioid doses have been lowered or discontinued, while some have been discharged by their physicians and forced to seek treatment elsewhere.

He likened the situation to Pontius Pilate washing his hands.

“Discontinuation of prescribed opioids, coupled with encouragement to seek an inaccessible treatment, frees the physician from risk of prosecution or sanction. Inevitably, some patients so discharged will die from drugs they purchase on an increasingly lethal illicit market. At that point, an assertion of ‘clean hands’ by physicians, regulatory authorities or the federal government seems facile,” said Kertesz.

“The changing epidemiology of opioid overdose in 2016 offers no easy resolution to such difficult challenges. But it suggests that a relentless focus on physician prescribing for pain has become less relevant to correcting the forces behind a wave of deaths in 2016. Federal efforts to turn the tide risk becoming a riptide for patients, physicians and communities where access to evidence-based treatment remains a priority neglected for too long.”

By “evidence-based treatment,” Kertesz means access to addiction treatment medication such as buprenorphine and methadone, which is lacking in many parts of the country.

As Pain News Network has reported, the DEA says the U.S. is being “inundated” with illicit fentanyl produced in China and Mexico. Illicit fentanyl is often mixed with heroin to increase its potency or used in the manufacture of counterfeit pain medication.

Massachusetts recently reported that three out of four opioid overdoses in the state are now fentanyl-related.  Only about 20 percent of the overdose deaths in Massachusetts involve prescription opioids.

Massachusetts was the first state to begin using blood toxicology tests to look specifically for fentanyl. Toxicology tests are far more accurate than the death certificate codes used by the Centers for Disease Control and Prevention to classify opioid-related deaths. 

Surgeon General Issues ‘Landmark Report’ on Addiction

By Pat Anson, Editor

Calling addiction “America’s most pressing problem,” U.S. Surgeon General Vivek Murthy has released a landmark report on alcohol, drug abuse and substance use disorders. Nearly 21 million Americans are believed to suffer from some form of substance addiction.

“Alcohol and drug addiction take an enormous toll on individuals, families, and communities,” said Murthy. “Most Americans know someone who has been touched by an alcohol or a drug use disorder. Yet 90 percent of people with a substance use disorder are not getting treatment. That has to change.”

The voluminous report, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, takes an in-depth look at the abuse of alcohol, illicit drugs, and prescription drugs.  Murthy called for a cultural shift in the way Americans view addiction.

SURGEON GENERAL VIVEK MURTHY, MD

"For far too long, too many in our country have viewed addiction as a moral failing," Murthy said. "This unfortunate stigma has created an added burden of shame that has made people with substance-use disorders less likely to come forward and seek help.

"We must help everyone see that addiction is not a character flaw. It is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer."

Murthy was blasted by one critic for releasing the report in the final weeks of the Obama administration.

“The timing of Murthy’s report is despicable,” wrote Dr. Manny Alvarez, the senior managing health editor at Fox News. “For two years, he did nothing to develop national protocols to tackle opioid abuse and waited until a Republican was elected president to issue the first-ever report from a U.S. surgeon general dedicated to substance addiction. He could have used this platform to shape his legacy as surgeon general, but instead, it appears he chose to play politics while using our nation’s health as a pawn."

Murthy did send a letter to over 2 million physicians in August, encouraging them to follow CDC guidelines and not prescribe opioids as a first-line treatment for chronic pain.

The report released today, however, makes surprisingly few references to opioid prescribing or to the soaring number overdoses caused by heroin and illicit fentanyl. At times, the report acknowledges that efforts to reduce opioid prescribing may only be making the nation's opioid problem worse.

“Although only about 4 percent of those who misuse prescription opioids transition to using heroin, concern is growing that tightening restrictions on opioid prescribing could potentially have unintended consequences resulting in new populations using heroin,” the report states. “As yet, insufficient evidence exists of the effects of state policies to reduce inappropriate prescribing of opioid pain medications.”

As Pain News Network has reported, fentanyl overdoses have been escalating rapidly. In Massachusetts, nearly three out of four opioid overdoses this year have been linked to fentanyl, far outnumbering the number of deaths associated with prescription pain medication.

One of the findings of the Surgeon General’s report is that addiction treatment in the United States remains largely separate from the rest of health care and serves only a fraction of those in need of treatment. This “treatment gap” is attributed to a number of factors, including lack of access, cost, fear of shame, and discrimination. Many people are also not referred to treatment until there is a crisis, such as an overdose or arrest.

"This report comes at a critical point in time, drawing national attention to a public health epidemic that continues to sweep the country," said Shaun Thaxter, CEO of Indivior, the maker of the addiction treatment drug Suboxone. "We are encouraged by the proactive steps taken by the U.S. federal government to raise awareness about this chronic disease and ensure that patients have access to the treatment they need.”

Kolodny Leaves Phoenix House

In related news, Andrew Kolodny, MD, the founder and executive director of Physicians for Responsible Opioid Prescribing (PROP), has announced that he is no longer the chief medical officer at Phoenix House, which runs of chain of addiction treatment centers.

Kolodny is now co-director of opioid policy research at the Heller School for Social Policy & Management at Brandeis University

PROP, an advocacy group that seeks to reduce opioid prescribing, ended its association with Phoenix House earlier this year. The non-profit Steve Rummler Hope Foundation is now the “fiscal sponsor” of PROP, which allows PROP to collect tax deductible donations.

DEA Bans Opioid Found in Fake Painkillers

By Pat Anson, Editor

The U.S. Drug Enforcement Agency is banning a powerful synthetic opioid linked to dozens of fatal overdoses -- including the death of the late pop star Prince.

Effective Monday, the DEA is classifying U-47700 as a Schedule I controlled substance, making the sale and possession of the drug a felony. Known in law enforcement circles as “pink,” U-47700 is about 8 times stronger than morphine. It was originally developed in the 1970’s as a prescription pain reliever, but was never used for that purpose.  

U-47700 is now being manufactured by illicit drug labs in China and smuggled into the United States, according to the DEA.

“Evidence suggests that the pattern of abuse of U-47700 parallels that of heroin, prescription opioid analgesics, and other novel opioids. Seizures of U-47700 have been encountered in powder form and in counterfeit tablets that mimic pharmaceutical opioids,” the DEA said in a notice published in the Federal Register.

“Abusers of U-47700 may not know the origin, identity, or purity of this substance, thus posing significant adverse health risks when compared to abuse of pharmaceutical preparations of opioid analgesics, such as morphine and oxycodone.”

The DEA said at least 46 overdose deaths have been linked to U-47700 since 2015, including 31 in New York and 10 in North Carolina.

The actual number of deaths is probably higher, according to NMS Labs, a private forensic laboratory in Pennsylvania. The lab said it confirmed U-47700 in toxicology tests involving over 80 deaths nationwide in the first nine months of 2016.

“The recent rise in use of these novel drugs of abuse is contributing to the spiraling of deaths associated with opioid abuse, and is being seen across the country. Their incidence of use is probably underestimated since these drugs are frequently a blind spot for many forensic labs, because they are novel and the labs are not looking for them in their routine procedures,” Dr. Barry Logan, Chief of Forensic Toxicology at NMS Labs said in a statement.

U-47700 and fentanyl, another synthetic opioid, were part of a deadly cocktail of drugs found in toxicology tests on Prince, who died of an accidental drug overdose in April. Investigators believe the musician may have thought he was taking a legitimate painkiller.

Fentanyl and U-47700 have also been linked to an outbreak of deaths and hospitalizations in California involving counterfeit pain medication. A 41-year old woman who suffers from chronic back pain purchased pills on the street designed to look like Norco, the brand name of a prescription drug that contains hydrocodone.  

The woman became unconscious within 30 minutes of taking three of the counterfeit tablets. She next remembers waking up in a hospital emergency room and told hospital staff the pills had the markings of Norco, but were beige in color instead of the usual white. A blood serum analysis revealed the woman had significant amounts of fentanyl and U-47700 in her system.

Fentanyl is legally prescribed in patches and lozenges to treat severe chronic pain, but the DEA believes “hundreds of thousands of counterfeit prescription drugs” laced with illicit fentanyl are on the black market. The agency predicts more fake pills will be manufactured because of heavy demand and the “enormous profit potential” of counterfeit medication.

This temporary scheduling of U-47700 as a controlled substance will last for 24 months, with a possible 12-month extension if the DEA needs more data to determine whether it should be permanently banned.

Fentanyl Deaths Rise Again in Massachusetts

By Pat Anson, Editor

Nearly three out of four opioid overdoses in Massachusetts have been linked to fentanyl, far outnumbering the number of deaths associated with prescription pain medication, according to a new report from the Massachusetts Department of Public Health. 

Massachusetts was the first state to begin using blood toxicology tests to look specifically for fentanyl, a powerful synthetic opioid that is more potent and dangerous than heroin. Toxicology tests are far more accurate than the death certificate codes used by the Centers for Disease Control and Prevention to classify opioid-related deaths. 

Over 1,000 confirmed cases of unintentional opioid overdoses were reported in Massachusetts in the first nine months of 2016. During the third quarter (July-September), 74 percent of the deaths where a toxicology screen was available showed a positive result for fentanyl.

Almost all of those deaths are believed to involve illicit fentanyl, not pharmaceutical fentanyl that is prescribed to treat severe pain.

“The data released today are a sobering reminder of why the opioid crisis is so complex and a top public health priority,” said Secretary of Health and Human Services Marylou Sudders. “This is a crisis that touches every corner of our state, and we will continue our urgent focus expanding treatment access.”

Only about 20 percent of the overdose deaths in Massachusetts were associated with prescription opioids such as hydrocodone and oxycodone, a trend that has held fairly steady since 2014, even as the number of opioid prescriptions in the state has declined.

Massachusetts department of public health

 "I think this points to the fact that cutting scripts for legitimate pain patients and blaming doctors for overdose deaths is pointing fingers in the wrong direction and harming a lot of innocent people living with debilitating pain while doing nothing to reduce overdose deaths – a critical goal,” said Cindy Steinberg of the U.S. Pain Foundation, a patient advocacy group. “People living with the disease of chronic pain and those living with the disease of substance use disorder are two different populations of people with little overlap.

“If we are committed to doing all we can to stop overdose deaths then the only way we can do that is to really understand what exactly is causing them. The fact that illicit fentanyl is the cause points to the need for increased law enforcement efforts to interdict the supply coming into Massachusetts.”

According to the Drug Enforcement Administration, chemicals used to make illicit fentanyl are being smuggled in from China and Mexico. Illicit fentanyl is usually mixed with heroin or cocaine, and it is also appearing in counterfeit pain medication sold on the black market. The drug is so potent that a single pill could be fatal.

Rhode Island is also using blood toxicology tests to help determine the true nature of the opioid epidemic. The most recent data from that state shows that about two out of three opioid overdoses are linked to fentanyl.  Since 2012, overdoses from prescription opioids have fallen by about a third in Rhode Island.

“The shifts in prescription and illicit drug overdose deaths also began roughly when more focused efforts were undertaken nationally to reduce the supply of prescription drugs,” the Rhode Island Department of Health said in a statement.

The CDC uses death certificate codes – not toxicology tests -- in its reports on opioid overdoses. The codes do not indicate the cause of death, only the conditions or drugs that may be present at the time of death. Because of limitations in the data, many overdoses involving illicit fentanyl and heroin are being reported by the CDC as prescription opioid deaths.

Half of New York Overdoses Blamed on Fentanyl

By Pat Anson, Editor

Nearly half of the overdose deaths in New York City since July have been linked to fentanyl, according to a new report that adds to the growing body of evidence that illicit fentanyl is now driving the nation’s opioid epidemic – not prescription pain medication.

In an advisory sent to healthcare providers, New York’s health department said 47 percent of the city's confirmed overdose deaths since July 1 have involved fentanyl. That compares to 16% of overdoses involving fentanyl in all of 2015. So far this year, 725 people have died from drug overdoses in New York.

“Data suggest that the increased presence of fentanyl is driving the increase in overdose fatalities,” the alert said. “While fentanyl is most commonly found in combination with heroin-involved overdose deaths, fentanyl has also been identified in cocaine, benzodiazepine, and opioid analgesic-involved overdose deaths.”

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine. Because of its potency, healthcare providers are being warned that additional doses of naloxone – which reverses the effects of an opioid overdose – may be needed when fentanyl is involved.

Fentanyl is available legally by prescription in patches and lozenges to treat more severe types of acute and chronic pain, but illicitly manufactured fentanyl has become a scourge across the U.S. and Canada, where it is often mixed with heroin and cocaine or used to make counterfeit pain medication.

Unsuspecting buyers, including some pain patients who were unable to get opioid medication legally, often have no idea the drug they’re getting from a dealer or friend could contain a lethal dose of fentanyl.

dea image of fentanyl

In addition to New York City, several states in the Northeast and Midwest have reported that fentanyl is now involved in about half of their overdose deaths.

The sharp increase in fentanyl-related deaths has coincided with new restrictions on the prescribing of opioid pain medication. In the past year, the Drug Enforcement Administration has issued two public safety alerts about fentanyl, but the Centers for Disease Control and Prevention has remained relatively quiet about the problem – focusing instead on opioid prescribing guidelines that were released in March of this year.  

Those guidelines have led many doctors to reduce doses or stop prescribing opioids altogether, but they have failed to make a dent in the number of Americans dying from overdoses. There have also been anecdotal reports of a rising number of suicides by patients unable to get opioid medication.

“I know five people who have committed suicide from being denied pain medication by doctors after the CDC came out with their ridiculous statements of the ‘epidemic’ of prescription opioid use,” says Nina Stephens, a Colorado woman who suffers from chronic pelvic pain. 

“Doctors are so afraid of getting in the middle of this epidemic mess with the FDA that they have decided to stop prescribing opioids to their patients, even those patients who are in desperate chronic pain. We are now treating our patients worse than dogs when it comes to pain.”

Stephens says she has to drive 4 hours each month to see a doctor who is still willing to prescribe opioids. A local pain management doctor just 20 minutes away said he would take Stephens off opioids and give her epidural injections instead, which she refused.

“I am truly afraid that soon I will have to drive even farther to find a doctor who will still be willing to prescribe pain pills to me each month or I will have to start looking at the black market.  Maybe a veterinarian would be willing to start treating me?  No wonder the suicide rate is going up so dramatically!” Stephens wrote in an email to PNN.

Canada’s Fentanyl Crisis

Counterfeit fentanyl pills started appearing in British Columbia about two years ago and have since spread throughout Canada. The fentanyl crisis is so severe a two-day conference was held in Calgary this week for healthcare providers and law enforcement.  There were 153 deaths associated with fentanyl in Alberta province during the first six months of 2016.

Some attendees want Alberta to declare a public health emergency – as British Columbia did in April. But Alberta’s Minister of Justice says the current fentanyl situation doesn’t warrant such a declaration.

“None of those powers will assist us in this case but they do give the government a significant ability to violate civil liberties,” said Kathleen Ganley. “We think it’s important we use those powers that have significant impact on Albertans only where they would be helpful to us.”

On display at the conference was an illegal pill press seized by law enforcement that is capable of producing 6,000 fentanyl laced pills per hour.

“Some of the tablets we’ve been seizing in Calgary have ranged from 4.6 milligrams to 5.6 milligrams per tablet—which is very high obviously, considering a lethal dose is two milligrams,” said Calgary police Staff Sgt. Martin Schiavetta in Calgary Metro.

Trump and Clinton Pursue Same Policies in Pain Care

By Pat Anson, Editor

Chronic pain patients hoping for a dramatic change in federal pain care policies as a result of the presidential election are likely to be disappointed.

Both Donald Trump and Hillary Clinton favor more restrictions on opioid prescribing, as well as expanded access to addiction treatment programs, which are essentially the same policies being pursued by the Obama administration.

At a rally in New Hampshire this weekend, Trump outlined for the first time his strategy to combat the nation’s so-called opioid epidemic.

“DEA should reduce the amount of Schedule II opioids -- drugs like oxycodone, methadone and fentanyl -- that can be made and sold in the U.S. We have 5 percent of the world’s population, but use 80 percent of the prescription opioids,” Trump said in prepared remarks.

“I would also restore accountability to our Veterans Administration. Too many of our brave veterans have been prescribed these dangerous and addictive drugs by a VA that should have been paying them better attention.”

Trump said the Food and Drug Administration has been “too slow” in approving opioid pain medication with abuse deterrent formulas. And he said he would “lift the cap” on the number of patients that a doctor can treat with addiction treatment drugs.

donald trump

But the Republican nominee seemed confused about the difference between abuse deterrent formulas and addiction treatment drugs like buprenorphine (Suboxone).

"The FDA has been far too slow to approve abuse-deterring drugs. And when the FDA has approved these medications, the rules have been far too restrictive, severely limiting the number of authorized prescribers as well as the number of patients each doctor can treat," he said.

There are no limits on doctors for prescribing abuse deterrent drugs, but there are for the buprenorphine. In August, the Obama administration nearly tripled the number of patients that a doctor can treat with buprenorphine.

Trump also seemed unaware that the DEA recently said it would reduce the production quota for many opioids by 25 percent or more.

Trump claimed the Obama administration has worsened the nation’s drug problem by commuting the sentences of drug traffickers and by releasing “tens of thousands” of drug dealers early from prison. He also pledged to stop the flow of illegal drugs into the country.

“We will close the shipping loopholes that China and others are exploiting to send dangerous drugs across our borders in the hands of our own postal service. These traffickers use loopholes in the Postal Service to mail fentanyl and other drugs to users and dealers in the U.S.” said Trump.

“When I won the New Hampshire primary, I promised the people of New Hampshire that I would stop drugs from pouring into your communities. I am now doubling-down on that promise, and can guarantee you – we will not only stop the drugs from pouring in, but we will help all of those people so seriously addicted get the assistance they need to unchain themselves.”

Like Trump, Hillary Clinton has also promised to expand access to addiction treatment, but in more detail. Her Initiative to Combat America's Deadly Epidemic of Drug and Alcohol Addiction would allocate $10 billion in block grants to states to help fund substance abuse programs.  

Clinton also wants doctors to undergo training in opioid prescribing before they are licensed to practice and to require that they consult prescription drug databases before writing prescriptions for controlled substances.

One area where Clinton differs with Trump is that she puts less emphasis on law enforcement. Saying she wants to “end the era of mass incarceration,” Clinton has called for low-level drug offenders to get treatment and not just be locked up.

“For those who commit low-level, nonviolent drug offenses, I will reorient our federal criminal justice resources away from more incarceration and toward treatment and rehabilitation. Many states are already charting this course — I will challenge the rest to do the same,” Clinton wrote in an op/ed published in the New Hampshire Union Leader.

hillary clinton

In their public statements, neither Trump or Clinton have given any indication that they believe that  federal policies affecting pain care, such as the CDC’s opioid prescribing guidelines, have gone too far. If anything, they want to go further.

Clinton has endorsed a proposed tax on opioid pain medication sponsored by West Virginia Sen. Joe Manchin (D). If approved, the so-called Lifeboat Act would raise $2 billion annually to fund addiction treatment programs. The tax would be the first federal tax on a prescription drug ever levied on consumers.  

During a roundtable discussion about opioid overdoses in West Virginia, Clinton called the tax “a great idea” and said it was “one of the reasons why I am such an admirer of Sen. Manchin.”

Pain News Network has asked the Trump campaign where the Republican nominee stood on the opioid tax. We have yet to get a response.

An Open Letter to DEA About Banning Kratom

By Rebecca Shanks, Guest columnist

Dear DEA,

Several years ago, I was diagnosed with Ehlers Danlos syndrome and spondylolysis, which in turn caused degenerative disc disease. Like most people, I was prescribed narcotic painkillers.

At first, they prescribed MS Contin. That's a pretty powerful drug for a first time narcotic user, and it made me sick. I took back the pills and handed them to the doctor, who replaced it with methadone.

There still, I couldn't do much except zone out on the couch and sleep. I was lucky if they didn't send me to the restroom vomiting. I got tired of that, and they prescribed Percocet and Vicodin. I was to take the Percocet three times a day, and if I had breakthrough pain, I was to take a Vicodin. 

REBECCA SHANKS

After a while, like so many chronic pain sufferers, I became more than dependent on painkillers, got addicted, and found my life spiraling out of control.

In 2008, I lost everything and everyone. I lost my husband. I lost my children. I lost my home and wound up moving into a hotel room.

Finally, I was approached by my grandfather, God bless his soul, and he had a heart-to-heart talk with me that something had to change. I took his advice with tears in my eyes, and I went to rehab.

After rehab, while I was clean, the pain was becoming unbearable. Tylenol, ibuprofen and other NSAIDs that were given to me in place of narcotics did absolutely nothing.

I was scared. I knew that it would only be a matter of time before I had to go back on the pills and run the risk of addiction yet again.

That's when I met a woman who ran an herb shop and she told me about kratom. I had nothing to lose by trying it, and when I did, I was more than surprised. It worked. My pain was gone and I didn't have any of the horrible side effects of the pills that were pushed down my throat. It truly was a miracle. 

When I was in pain, I would take kratom and a few minutes later would be able to easily go back to whatever it was I was doing. There was no sleeping all day. There was no drunken fog. I have been using kratom for a few years now.  When I don’t take it, on days that my pain is not that bad, I feel nothing more than a headache.

I got my life back. I got my children back. My ex-husband and I are on very good terms, residing in the same vicinity with nary an argument between us. I have even chased the dream of being an author and have already published one book under a pen name, with two more in the works that will be released soon. I am now a productive member of society, and the mother I should have always been.

DEA, if you ban kratom, what will happen to me? Will I have to go back to the pills, run the risk of addiction once again, and be unable to do anything aside from sleep all day, or zone out on the couch? 

Will I have to just suck up the pain? In that scenario, I will still be in bed all day, screaming and crying out of sheer misery, wanting it to end. My children do not need to bear witness to that.

In any of those scenarios, I will no longer be productive, and I see myself winding up on disability, unable to work. I don't want that. The taxpayers don't want that either, not when I am doing so well on my own.

But if I choose the other route, and continue to use kratom, I become a felon. I run the risk of being shipped off to prison, for doing nothing more than trying to manage my pain while still being a productive member of society. 

So what would you have us do, DEA? Which path should I choose? Right now, I'm not sure. All I know is that I am afraid of what will happen to my life and my family should you choose to continue with this ban. 

By banning kratom, you are not hurting the drug addicts that you have a war with. You are hurting every day, productive citizens. You are hurting mothers, fathers, grandparents and other people, who you would never even know took kratom unless they told you. The plant is that mild.

DEA, I beg you to please stop this. You can stop this. Please listen to the people. 

Rebecca Shanks is the mother of two children and lives in Illinois. Under the pen name J. Theberge, she published her first book, Subject Alpha, and is currently working on two other books. When she isn't working, Rebecca is active in her children's education and promoting autism awareness.

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.

Living with Chronic Pain After Being Labeled an Addict

By Patricia Young, Guest columnist

I am writing this article from the perspective of a patient who has chronic back pain and also an unwarranted, doctor-imposed label of “addiction.”

As most people can imagine, having both of these problems -- chronic pain and a substance use disorder -- can be very difficult for a healthcare provider to manage. Imagine though how harmful it is when someone is diagnosed or labeled as an addict and it is not an appropriate diagnosis.

The new polite wording for addiction is "chemical dependence," "substance use disorder" or "opiate dependence."

But these terms are not helpful either, since they have the same meaning to most healthcare professionals, as well as the general public.

To make matters worse, I was totally unaware that this diagnosis was ever made and it was never explained to me that it would be in my medical record. I want to share some of the problems this has caused me.

The first time I thought something was wrong was when I found myself having severe eye pain. I called ahead to the emergency room to make sure they had an eye doctor available to see me and decided to go in when they said they did. Instead, I was examined by a physician’s assistant (PA) after he reviewed my medical records. He looked at my eye from a distance without using any diagnostic equipment, told me I had an infection, and gave me antibiotic drops for it. The eye drops only made the pain worse.

I thought it was odd since I had no eye drainage of any kind and never had such pain before with an eye infection. A few days later I learned I had a herpes sore in my eye. No wonder those eye drops didn’t work!

Not one medical doctor or PA had taken my pain seriously in the ER because I had been labeled as having “drug seeking” behavior. But I did not know that until much later.

At the time I was taking opioid pain medication prescribed by my doctor to treat chronic pain from a lower back injury and two back surgeries. Sometimes I have flare ups of severe pain in my left hip, groin and leg despite the prescribed opiate drugs.

I went another time to the ER in severe pain and was seen by another physician’s assistant. After looking at my medical record, the PA proceeded to tell me to get out of the ER as I lay there on a gurney. My husband and I had no understanding at the time why 3 security guards came and told me to get back in my wheelchair myself or they would pick me up and put me there.

My husband picked me up and we were escorted out the door. I was 59 years old, disabled and was no threat to anyone. It was at that point that I started to wonder what “red flag” was in my medical records to make them treat me like that.

Later I found out what that red flag was. A doctor had written down after one visit that I had a “history of addiction.” This was the first time I became aware of this. I really could not understand why since no medical person had ever said I may have this diagnosis or even mentioned the word “dependency” to me.

I later had to move to Florida from upstate New York because my disability made it hard to cope with harsh winter weather. After the move I had great difficulty finding a new primary care physician. I believe no doctor wanted me as a patient after they saw the diagnosis of “history of addiction.”

We all know how difficult it can be to deal with an individual with a drug addiction. It’s a diagnosis that follows people for a lifetime. Unfortunately, when it is made in error, it is very detrimental and can even be a factor in someone’s death. Not only can there be a huge physical ramification from a diagnosis of addiction, but it can do harm to a person’s mental and emotional health, as well as cause family problems. I know it has affected me that way. The diagnosis evokes many people to make judgements.

I had many angry responses from healthcare professionals in my times of real need. The ones that threw me out of the ER demonstrated their anger by tone of voice, gestures, and curtness. I felt hopeless leaving there and my husband was so stunned he had no words to say. It was a very dark time in my life that is difficult to forget.

It has been suggested to me that I now suffer with post-traumatic stress syndrome and anxiety. Doctors want me to take anti-hypertensive medications daily as a result. This very frustrating and damaging diagnosis has led me to distrust the very physicians I go to for help. My blood pressure is high in their offices but not at home.

I also wrestle now with the problem of feeling as if my reputation has been harmed. I am seen by doctors as untrustworthy and in denial since I disagree with the addiction diagnosis. The very medical system that I worked in for almost 35 years has now mislabeled me and treats me harshly at a time when I need care myself.

I strongly believe there needs to be more understanding within the medical community as well as the public arena about this problem. There is a definite difference between a physical dependence on a substance versus an addiction to it. An addiction diagnosis suggests that one has misused drugs and has a mental disorder.

I have been judged as one of those types of people and it’s wrong. I had many medical professionals come up to me and congratulate me for stopping my pain medication. I thought they were crazy. It was no mental feat to stop taking the drugs, but I must admit my body’s physical reaction was not good. That is normal for someone that has taken opioid pain medicine for a period of time.

It is time we stop hurting and stigmatizing pain patients in this manner. It just makes our pain worse and can even lead to serious mental health problems and in some cases suicide.

Please healthcare providers, make sure your diagnosis is made correctly. I believe that an addiction or dependency diagnosis should only be made by someone who is trained in addiction medicine and who specializes in treating addictive disorders.

Patricia Young 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.

CDC: Prescription Opioid Abuse Costs $78.5 Billion

By Pat Anson, Editor

A new analysis by the Centers for Disease Control and Prevention estimates the total “economic burden” of prescription opioid abuse in the United States at $78.5 billion a year.

Researchers at the National Center for Injury Prevention and Control – the same agency that oversaw development of the CDC’s controversial opioid prescribing guidelines – analyzed economic data from 2013 associated with opioid abuse, including the cost of health care, lost productivity, substance abuse treatment and the criminal justice system.

“A large share of the cost is borne by the public sector, both through direct services from government agencies, but also through tax revenue that will be lost from reduced earnings. Also, the health care sector bears approximately one third of the costs we have estimated here,” wrote lead author Curtis Florence, a senior health economist at CDC.

Florence and his colleagues estimated that nearly two million Americans abuse or are dependent on opioids. Their study is published online in Medical Care, the official journal of the American Public Health Association.

 "More than 40 Americans die each day from overdoses involving prescription opioids. Families and communities continue to be devastated by the epidemic of prescription opioid overdoses.” said CDC Director Tom Frieden, MD, in a news release.

"The rising cost of the epidemic is also a tremendous burden for the health care system."

Exactly what that burden is is open to conjecture. The researchers admit that some of their data is flawed because they relied on death certificates codes – which often fail to distinguish between deaths associated with prescription opioids and those caused by heroin. Heroin users and prescription opioid users are essentially lumped together – even though heroin users are far more likely to enter the criminal justice system.

In addition, opioids associated with death were considered a sign of abuse even if multiple drugs were involved. No distinction was made if the deaths were accidental, intentional or undetermined.

“Our health care cost estimates used the definition of opioid abuse and dependence identified by ICD-9 diagnosis codes. This definition does not differentiate between prescription opioids and heroin,” said Florence. "We did not attempt to attribute costs to specific drugs if multiple types of drug abuse were reported. This could bias our results if the health care cost impact of abuse and dependence is different between prescription opioids and heroin, or if abuse of prescription opioids alone has a different effect from abuse of multiple drugs,”

The researchers also were unable to distinguish between the “nonmedical” use of opioids by someone who obtained the drugs illegally and those who obtained them legally through a prescription.  

“It is extremely difficult to measure all costs to society from an epidemic. In this case, there are many costs we were unable to measure, such as the reduction in quality of life of those who are dependent,” wrote Florence.

Despite these limitations, the CDC research team said their estimates should be considered by healthcare providers and regulators in deciding whether prescription opioids should be used to treat pain.

“In the ideal case, decision makers could use these estimates when weighing the benefits and risks of using opioids to treat pain, and evaluating prevention measures to reduce harmful use. However, at the present time a full accounting of both the benefits and costs of prescription opioid use is not available,” they wrote.

The CDC estimate of $78.5 billion as the annual cost of prescription opioid abuse is only a fraction of the total cost of chronic pain on society. Using data from 2008, researchers from Johns Hopkins University estimated that the economic cost of pain in the United States ranged from $560 to $635 billion annually.

The CDC’s opioid guidelines discourage primary care physicians from prescribing opioid for chronic pain. Although voluntary, anecdotal reports from patients and doctors suggest the guidelines are being widely adopted by many prescribers. Some states have even adopted the CDC guidelines as official policy or in legislation.

The CDC has released no estimate on the economic impact of its guidelines or on the reduction in quality of life for pain patients who are no longer able to obtain opioids.

Kratom Supporters Rally at White House

By Pat Anson, Editor

Hundreds of protestors chanting “kratom saves lives” and “I am kratom” rallied in front of the White House today, hoping to turn their passion for an herb into a movement that stops the Drug Enforcement Administration from making kratom illegal.

“This stuff saved my life. It gave me my life back,” said one protestor.

Kratom comes from the leaves of a tree that grows in southeast Asia, where it has been used for centuries as a natural medicine. In recent years, kratom has grown in popularity in the United States, where it is made into teas and supplements as a treatment for pain, depression, anxiety and addiction.

All of that may change on September 30th, when the DEA plans to schedule the two main active ingredients in kratom as Schedule I controlled substances -- alongside heroin and LSD. That would effectively make the sale and possession of kratom a felony.

Under its emergency scheduling order, the DEA invited no public comment and held no public hearings.

“Stop this ban immediately. You’re trying to protect your jobs. You’re not trying to save Americans,” said Ryan Connor, a military veteran who lost a sister to a heroin overdose. “If you take away this herb, more and more people are going to die."

Connor said he uses kratom to treat his own opioid addiction.

image courtesy american kratom assn.

“I’ve been on every opioid under the sun. I was on Suboxone. I was told it was a cure for addiction, but it did not cure my addiction. In fact, it made it worse. I used kratom to get off Suboxone. It was painless. I had zero side effects from it. And I think as Americans we have the right to choose our health over getting poisoned by pharmaceuticals,” Connor said.

In a notice published in the Federal Register, the DEA said an emergency scheduling of kratom was necessary because it has no approved medical use. The DEA claimed the herb was being used recreationally for its "psychoactive effects" and as a substitute for heroin.

The Centers for Disease Control and Prevention also issued a report last month calling kratom "an emerging public health threat." The agency said there were 660 calls to U.S. poison control centers about kratom in the last six years. About 8 percent of the calls involved a life threatening condition. One death was reported.

courtesy patti belmont

Kratom supporters say the death was more likely caused by prescription drugs and that kratom actually saves lives.

“It changed my life. It rescued me from a very severe addiction to narcotics. It took me out of a home and bed-bound existence. It gave me the energy and pain control that I needed,” said Susan Ash, who founded the American Kratom Association, which organized the rally outside the White House.

“We want a regular scheduling process that involves public comment and the best available science, and not just a note from the CDC that said they got all of 660 calls to poison control when they’re getting three to four million calls a year. How do 660 calls make an emerging public health threat?”

Kratom supporters have gotten over 120,000 signatures on an online petition asking the Obama administration to stop the DEA from scheduling kratom as a Schedule I substance. Under its "We the People" petition rules, the administration promises to "take action" on a petition within 60 days if supporters are able to gather at least 100,000 signatures.   

According to the website whpetitions.info, the average response time for a successful White House petition is well over 100 days – not 60 days. Six petitions -- including the kratom petition -- are currently waiting for a response.

Meanwhile, the Center for Regulatory Effectiveness (CRE), a government watchdog group, has asked the DEA to postpone the scheduling of kratom.

In a September 12 letter to acting DEA Administrator Charles Rosenberg, a CRE official pointed out that the National Institutes of Health has conducted research to explore the therapeutic value of kratom as a treatment for chronic pain and substance abuse.

“The research was so well conducted and received by the scientific community that the aforementioned institutions applied for a patent. How much more additional evidence is needed to demonstrate that the DEA has acted arbitrarily in issuing a ban on kratom?” asked Jim Tozzi, a member of the CRE Board of Advisors.

“In short, without going through a notice and comment process, DEA is obviating another agency’s research that was conducted with appropriated funds. With its action, DEA is also obviating the progress and promise of kratom research to boosting the American bio-sciences industry.”

Tozzi’s letter said the DEA’s “rush to judgement” may have violated the federal Data Information Quality Act and was a “clear and flagrant abuse of discretion.”

He asked the DEA to extend the effective date for scheduling kratom to July 1, 2017, to allow for public comment and a peer review of the science behind the agency’s decision.

Why Opioid Addiction Treatment Often Fails

By Percy Menzies, Guest Columnist

The two most contagious factors linked to addiction are accessibility of the drug and price. If there is easy access to the drug (and this includes alcohol), the number of people exposed is going to increase and a higher number will become addicted.

Every single epidemic has followed this principle. Let’s look at the present problem in the U.S. with the abuse and addiction to prescription opioids.

For decades access to prescription opioids was restricted to patients in acute pain and the only exception was terminal cancer pain. We did not have a major health crisis with opioids in the 1980’s and early 1990’s. 

Then in the mid 1990’s, articles and papers started appearing in the media and medical journals about the under-treatment of chronic pain. Respected clinicians and researchers made a strong case for using opioids to treat chronic pain. They insisted that opioid medication had little or no potential for abuse.  Clinicians were expected to treat chronic pain as the “fifth vital sign” and use opioids as a first-line treatment. The access door was thrown wide open and, for most patients, insurance covered the prescription cost.

When the alarm bells sounded years later and physicians cut back on prescribing, some patients who use opioids medically and many others who use them to get "high" found an alternative: heroin.  This illegal drug was relatively easy to obtain and the price was substantially lower than prescription opioids. 

Now heroin is becoming the gateway drug.  The potency of street heroin is increasing and there are many reports of heroin being laced with the very potent opioid fentanyl to increase the high. The DEA also tells us that hundreds of thousands of counterfeit pain medications made with illicit fentanyl are on the black market.

How do we fight this? Look at how we've reduced access to alcohol and cigarettes.

Access to alcohol is restricted by age, taxes on alcoholic beverages, licensing restrictions, campaigns against drunk driving and other measures. Policies to reduce smoking have also had dramatic results. The smoking rate in the U.S. has dropped from 50% to about 19% in the last twenty years. How was this achieved? By tightening access: no cigarette vending machines, no sale of single cigarettes, limits on places where people can smoke, and substantially higher taxes on tobacco products.

Look at addiction to cocaine. Cocaine was once glamorized as a drug that was only psychologically addicting. The abuse of cocaine and later crack cocaine skyrocketed in the 1980’s. In response, very harsh and discriminatory criminal measures were instituted, but with little effect. Some groups even advocated legalization.

The government promised effective treatments for cocaine addiction, including vaccines, but to date we have neither the treatments or vaccines. Yet addiction to cocaine is way down. Why? Because of reduced access. The countries growing coca came under increased international pressure and destroyed coca crops by spraying them with herbicides.  What would have happened if cocaine was legalized?

Legalization of a drug greatly increases accessibility and increases the number of people exposed to it.  The increased legalization of marijuana has made cannabis accessible to millions of people who never would have considered using it before. There are projections of marijuana becoming a $70 billion plus product in the next 5 to 10 years!

Accessibility undermines recovery.  The conventional treatment approach is to send patients away to residential programs for weeks and months.  The thinking is that behavioral and life skills learned during “rehab” will protect patients from relapsing when they return home. Does this really happen? Can patients successfully navigate the plethora of cues and triggers greeting them when they return home?  Will they be able to resist or ignore the ringing of the bell of Pavlovian conditioning?

It is not likely to work because of a well-researched phenomenon called Conditioned Abstinence or the Deprivation Effect. When a patient is sent away and deprived of access to a drug or alcohol, the addiction goes into an internal “incubator” where it is nourished by anxiety, exchange of war stories with other patients, and ruminating about drug use.

When the patient returns home to the familiar environment of past drug use, the fortified addiction powerfully reemerges from the incubator, leading the patient into relapse.

Repeated attempts at incarceration and long-term residential treatment have failed to curb high relapse rates, especially for opioid addiction.  This led to a wrong and highly controversial conclusion that addiction is a brain disease and the only approach is palliative treatment with other opioids, often for life.

The common and inappropriate analogy is to diabetes. Rather than looking at access as the contributing factor to relapse, patients are told they need opioids like methadone and buprenorphine to ease their withdrawal pains, much like diabetic patient needs insulin.  A clever but unproven theory called the “metabolic syndrome” was put forward to explain this. Patients are left feeling hopeless, helpless and resigned to their fate.

We need look no further than the U.S. soldiers that got addicted to heroin in Vietnam to debunk this theory. The addiction of some soldiers was spawned by cheap and easy access to heroin in villages and hamlets. Our country was in a state of panic about these soldiers continuing their heroin use when they returned home. There was even fear that their weapons training would be used to obtain the drug.

To everyone’s surprise, less than five percent of the soldiers continued using heroin when they returned home. Did these soldiers not suffer from the metabolic syndrome?  They did not continue their heroin habit because they had no easy access to heroin when they came back. If they had been sent back to Vietnam, many would have relapsed because they would have easy access again to heroin.

Compare this to the soldiers returning from Iraq and Afghanistan. Many have been able to continue the addiction because they have easy access to opioids and heroin in the U.S.

Palliation or substitution with methadone or buprenorphine has done little to blunt the heroin epidemic. We have not found a way to reduce access and indeed it is growing. A record quantity of potent heroin is flowing into this country from Mexico. The other two major producer countries, Afghanistan and Burma, are politically unstable and their poppy acreage has grown at alarming rates. It is only a matter of time before the heroin from these countries will start trickling in.

There are no easy answers. Unlike cocaine, products made from the opium poppy are essential for the treatment of pain. There is little we can do to reduce access to heroin. We need to seriously relook at the present treatment infrastructure. Addiction treatment often is episodic, non-medical, punitive, expensive and ineffective. Few patients are sent home on medications like naltrexone to protect them from relapsing in the first days and weeks after rehab. Medications like naltrexone and Vivitrol that give patient a fighting chance of long-term recovery are rarely used.  

We are woefully unprepared to deal with the present situation and the bigger problems to come. One thing is certain: legalization of heroin is not the answer. Decriminalization and standardized treatment with non-opioid drugs can be.

Percy Menzies is the president of the Assisted Recovery Centers of America, a treatment center based in St Louis, Missouri. He is a passionate advocate of evidence-based medical treatment for addictive disorders.

He can be reached at: percymenzies@arcamidwest.com

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.