Prince Treated for Opioid Overdose Days Before Death

By Pat Anson, Editor

Pop icon Prince suffered from chronic pain and was treated for an opioid overdose just days before his death, according to tabloid reports.

Prince’s body was found Thursday in an elevator at his compound in Minneapolis. A cause of death has not yet been determined.

According to TMZ, Prince was treated at a hospital in Moline, Illinois last Friday when his private jet made an unscheduled landing after a concert in Atlanta. Initial reports were that Prince was treated at the hospital for the flu, but TMZ reported he may have needed emergency treatment for an overdose.

“Multiple sources in Moline tell us, Prince was rushed to a hospital and doctors gave him a ‘save shot’ ... typically administered to counteract the effects of an opiate,” TMZ said.

A “save shot” most likely means an injection of naloxone, a life-saving drug that quickly reverses the effects of an opiate overdoses.

TMZ later updated the story to say that Prince was actually given the injection by paramedics at a local airport and then taken to the hospital.

“Our sources further say doctors advised Prince to stay in the hospital for 24 hours. His people demanded a private room, and when they were told that wasn't possible ... Prince and co. decided to bail. The singer was released 3 hours after arriving and flew home,” TMZ said.

An autopsy was performed on the body of 57-year old entertainer this morning, but preliminary findings and a toxicology analysis could take days or weeks.

"As part of a complete exam, relevant information regarding Mr. Nelson's medical and social history will be gathered," the coroner said in a statement, referring to Prince as Rogers Nelson, his birth name. TMZ said authorities were trying to obtain Prince’s hospital records in Moline.

"We have no reason to believe it was suicide," said Carver County Sheriff Jim Olson, who also refused to address reports that Prince had overdosed last week.

"I'm not able to confirm that at this time at all," Olson said. "There have been so many rumors out that I've read about. I don't know if I can dispel all the rumors that are out there."

Prince reportedly suffered from hip problems for over a decade and needed a double-hip replacement. But as a devout Jehovah’s Witness, he would not have a blood transfusion, which made surgery nearly impossible.

“Prince has suffered for years,” a source told The National Enquirer in January. “It’s harder for him to get around.”

The Enquirer said years of strutting and dancing onstage had taken a toll on Prince’s joints and he may have suffered from severe osteoarthritis. 

“If he ignores the doctor’s advice, his walking will become impaired,” said Dr. Stuart Fischer, who did not treat Prince. “He’ll need a cane or a wheelchair for the rest of his life.”

Prince appeared hobbled and used a cane during the 2013 Grammy Awards, but in the past he has also used canes as a fashion accessory.

Prince was seen leaving a Walgreens pharmacy the night before his death. It was his fourth visit to the pharmacy this week. An employee there said he looked frail, according to TMZ.

Don't Flinch From Prescribing Pain Medications

By Forest Tennant, MD, Guest Columnist

By now chronic pain patients and practitioners are well aware of the new Center for Disease Control and Prevention (CDC) “Guidelines for Opioids for Chronic Pain” released on March 15, 2016. Although these guidelines have been, and will continue to be, strongly criticized for the process by which they were created, they are now published.

One of the often stated goals of CDC, despite widespread skepticism from many pain specialists, is that they did not want to limit access to pain care. Let’s take them at their word.

A major “bone of contention” regarding the guidelines is the recommendation that a daily dose of opioid should seldom go over 90 mg equivalents of morphine a day. In the CDC’s words:

“Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day.”

Thankfully, few chronic pain patients require more than 90 MME for pain management. Be alert, however, to the fact that 90 MME in the guidelines is not a maximum ceiling dose but a “trigger” or “call” for a medical-necessity evaluation, including a possible consultation or referral to a pain specialist.

My personal objection about all the new opioid prescribing guidelines, including CDC’s, is that they seem to want all patients on high-dose opioids to be managed by pain specialists rather than primary care physicians (PCPs).

Unfortunately we don’t have enough pain specialists to medically manage these legitimate, suffering patients who can’t function or leave the couch without an opioid dosage above 90 MME.

While the intent of the CDC to have the most serious pain patients managed strictly by pain specialists may be laudable, this won’t solve our nation’s epidemic of untreated and undertreated chronic pain. Incidentally, the new guidelines rightfully mention all the risks of high-dose opioids, such as addiction, diversion, and overdose; but they wrongfully fail to mention all the serious, life-shortening, and physiologic impairments that are the risks of undertreated, severe, chronic pain.

Sadly, without opioids, some of these unfortunate individuals will suffer immense physical dysfunction, endocrine failure (see Hormone Testing and Replacement), cardiovascular collapse, immune dysfunction, dementia, and premature death.

This memo is a plea to not discharge severe pain patients who are currently taking over 90 MME or avoid and deny patients who may need this level of opioid in the future. Be aware that the CDC guidelines do not prohibit dosages over 90 MME—what they rightly recommend is that physicians do an assessment and document medical necessity for dosages above that level.

Here are my personal practice policies and recommendations for dealing with past, current, and future patients who require over 90 MME:

The pain practitioner has to clearly state, in the patient’s chart, that the patient has severe chronic pain due to a specific underlying cause. For a patient to receive high-dosages of opioids, the physician must obtain and document the history, relevant physical exam, laboratory data, informed consent, and past records of treatments that have been tried.

Opioids should not be prescribed in isolation. Rather than just continuing to increase the dose, the physician needs to revisit what other modalities are being used or have been tried. These include: non-opioid medications such as an anticonvulsant if the pain has neuropathic elements, (being certain to titrate up to an effective dose); a topical medication such as Lidoderm patch, Voltaren gel, etc.; a physical therapist-guided home exercise program and other physical activities, including massage; consultation with an interventionist if appropriate; assessment and treatment of co-occurring anxiety or depression.

The new guidelines, in my opinion, could worsen a growing problem of access to medication. Already, in some locales, patients can’t obtain prescriptions and insurance companies don’t want to pay for opioids (or much else!!). If patients need a high, costly opioid dosage, they must personally determine the limits of their insurance coverage and identify pharmacies that will supply opioid medications.

We physicians can help but none of us has the time or influence to help every pain patient with his or her personal supply of medication and insurance issues. Simply stated, a patient must be an active rather than traditional, passive patient: pain patients must now join advocacy groups and begin to lobby for their right to obtain opioids and avoid an agonizing existence and premature death.

Millions of chronic pain patients now take opioids responsibly and constructively. While opioids aren’t for everybody, many pain patients who are taking high-dose opioids have enhanced their overall health, achieved a decent quality of life, and have likely extended their life span. These patients don’t abuse, divert, or overdose on their opioids, and they don’t develop hyperalgesia or the need to continually escalate their dosage. Isn’t it time we pay as much attention to these worthy folks as those who non-comply, abuse, and overdose?

Dr. Forest Tennant is pain management specialist in West Covina, California who has treated chronic pain patients for over 40 years. He has authored over 300 scientific articles and books, and is Editor Emeritus of Practical Pain Management.

This column is republished with permission by Practical Pain Management, which featured the opinions of several other practitioners on the CDC guidelines this month. You can see them all by clicking here.

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

Pain and Addiction Should Be Treated Separately

By Emily Ullrich, Columnist

Once again, the lack of humanity, honesty, and desire to provide quality pain care to patients on the part of doctors, hospitals, and medical and government organizations has astounded me.

Andrew Kolodny, MD, the founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP), whose name seems to be six degrees of separation from all movements to thwart proper pain care, has submitted a petition asking Medicare to stop requiring hospitals to survey patients about the quality of their pain management.

A group of U.S. senators has gone even further, introducing the PROP Act in Congress, which would prevent Medicare by law from making "any assessments" of pain in hospitalized patients.

As I and others have written, pain is not merely discomfort. It is unhealthy and can even be life-threatening. If a patient is left in severe, unattended pain during a hospital stay, their acute pain can become chronic, triggering a host of other medical problems, such as high blood pressure, impaired immune function, ulcers, rashes, anxiety and depression. So, reporting one’s pain care while hospitalized is essential to the outcome of healing.

But, according to Kolodny and others who signed his petition, asking patients about their pain care leads to “dangerous pain control practices” and “aggressive opioid use.”

My question is, since patient surveys have contained pain evaluating questions for years, where is the evidence that doctors have over-medicated patients so their hospitals will have satisfactory survey ratings?

My guess is there is none. I have been hospitalized and suffered untreated or undertreated pain many times. I not only filled out surveys, but called hospital administrators, wrote the Joint Commission for hospital accreditation, and more, and STILL received sub-par pain care from doctors.

I am not alone. A recent survey of over 1,200 patients by Pain News Network and the International Pain Foundation found that over half rated the quality of their pain care in hospitals as either poor or very poor.

My next question is why doesn’t Kolodny want people to know about our pain? I suspect I know the answer.

As mentioned earlier, Kolodny can be traced back to nearly every movement to intervene in the proper medication of pain patients. In addition to running PROP, he is chief medical officer for the addiction treatment chain Phoenix House, and seemingly has an elaborate plan to have every patient on opioids be treated as an “addict.”  

This brings me to one final question. Why doesn’t any major American media outlet look into the conspicuous ulterior motives of Kolodny, PROP and Phoenix House? I am not much on conspiracy theories, but at this point I am compelled to say there might be something there, but our government and society are already so brainwashed to associate pain with addiction that no media outlet will touch it. Not to mention the political funding and special interest groups that also have a stake in this.

It all boils down to money. Healthcare in this country is treating pain on a financial hierarchy. The Obama administration has bought into the CDC guidelines on opioid prescribing, and the passing of the PROP Act will only further the notion that pain and addiction are one in the same.

Despite what we are being told, pain and addiction are two different issues, which need to be addressed separately. If this havoc wreaking discrimination continues, there will be no such thing as pain care left in this country.

Emily Ullrich suffers from Complex Regional Pain Syndrome (CRPS), Sphincter of Oddi Dysfunction, Carpal Tunnel Syndrome, Endometriosis,  Interstitial Cystitis, migraines, fibromyalgia, osteoarthritis, anxiety, insomnia, bursitis, depression, multiple chemical sensitivity, and chronic pancreatitis

Emily is a writer, artist, filmmaker, and has even been an occasional stand-up comedian. She now focuses on patient advocacy for the International Pain Foundation, as she is able.

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

Pain Clinic Settles Discrimination Case

By Pat Anson, Editor

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

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

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

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

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

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

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

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

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

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

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

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

U.N. Report: War on Drugs a Failure

By Pat Anson, Editor

The international war on drugs has been a costly failure that has created a “public health and human rights crisis,” according to a new report commissioned by the United Nations, which is meeting in special session this week to discuss global drug policy.

The 54-page report by the Johns Hopkins–Lancet Commission on Drug Policy and Health found that many drug policies are based on ideas about drug use and dependence that “are not scientifically grounded” and have been particularly harmful to pain patients.

The commission estimates that about 5.5 billion people worldwide do not have adequate access to controlled drugs for the management of pain. 

“Inequity of access to controlled drugs for pain management and other clinical uses is now a public health and human rights crisis,” the report found. “Yet the obligation to prevent abuse of controlled substances has received far more attention than the obligation to ensure their adequate availability for medical and scientific purposes, and this has resulted in countries adopting laws and regulations that consistently and severely impede accessibility of controlled medicines.”

The commission said there were many “myths and exaggerations” about opioid use that have stigmatized people who use the drugs. And rather than lowering the risk of abuse and addiction, drug prohibition was making the problem worse by forcing some people to turn to the streets for opioids.

“Prohibition creates unregulated illegal markets in which it is impossible to control the presence of adulterants in street drugs, which add to overdose risk,” the commission said. “The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, and alcohol.”

Four mothers who lost their children to drugs have been invited by the Canadian government to attend the U.N. assembly on drug policy. One of them is Jennifer Woodside of Vancouver, whose 21-year son Dylan died of an overdose two years ago after he took a pill he thought was oxycodone, but was actually laced with illicit fentanyl.

 “This is a big epidemic,” Woodside told The Globe and Mail. “I think we’ve got our head in the sand if you think it can’t affect you.”

“The war on drugs has been a war on our families,” said Lorna Thomas, who also lost a son to an overdose of oxycodone and will attend the U.N. conference. “The starting point for it, that we were going to punish people out of using drugs has failed. People will continue to use drugs and we need to acknowledge that reality and keep people safe.”

As Pain News Network has reported, counterfeit pain medications laced with fentanyl began appearing in the U.S. this year and are blamed for a dozen overdose deaths in California and Florida. Coincidentally, the fake pain pills appeared just as the Centers for Disease Control and Prevention (CDC) finalized new guidelines that discourage primary care physicians from prescribing opioids for chronic pain.  Many patients fear losing access to opioids because of the guidelines.

“These CDC guidelines are brand spanking new. I think it’s hard to draw any sort of conclusions from that,” said Rusty Payne, a spokesman for the Drug Enforcement Administration. “I don’t think the Mexican cartels are paying one lick of attention to what the CDC guidelines are. What they see are thousands and thousands of addicts that they can push a product on, whether it be heroin or now fentanyl. And introducing it in pill form is just another way to make a lot of money."

The U.N. report on drug policy recommends decriminalizing nonviolent drug offenses and phasing out the use of military forces to enforce drug laws.

“Policies meant to prohibit or greatly suppress drugs present a paradox. They are portrayed and defended vigorously by many policy makers as necessary to preserve public health and safety, and yet the evidence suggests that they have contributed directly and indirectly to lethal violence, communicable disease transmission, discrimination, forced displacement, unnecessary physical pain, and the undermining of people’s right to health,” the report concludes.

The president of Columbia, which has long been on the front lines of the war on drugs, will urge the U.N. to radically change drug policies.

"Vested with the moral authority of leading the nation that has carried the heaviest burden in the global war on drugs, I can tell you without hesitation that the time has come for the world to transit into a different approach in its drug policy," President Juan Manuel Santos wrote in a column published in The Guardian.       

"No other nation has had to endure the terrible effects of the world drug problem in such magnitude and over such extended period of time as Colombia. The international community can rest assured that, when we call for a new approach, we are not giving up on confronting the problem; we are moved by the aim of finding a more effective, lasting and human solution."

Fake Oxycodone Seized at US-Mexican Border

By Pat Anson, Editor

Federal prosecutors this week filed charges against an alleged smuggler caught at the California-Mexico border with nearly 1,200 fake oxycodone pills, the latest sign that Mexican drug cartels are targeting pain patients in the U.S.

The pills were made with illicit fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine and can be lethal in very small doses. Counterfeit fentanyl pills are blamed for 11 deaths and dozens of overdoses in recent weeks in the Sacramento area, where they were disguised to look like Norco pain medication. Some of the victims were patients who sought painkillers on the street because they couldn’t obtain them legally.

Fake oxycodone, Percocet and Xanax pills have also been appearing in Florida, where they are blamed for at least one death.

19-year old Sergio Linyuntang Mendoza Bohon of Tijuana, Mexico was arrested at the Otay Mesa port of entry on February 10. Border patrol agents became suspicious when they saw “an unnatural looking bulge” in his underwear.

A search turned up 1,183 tablets labeled as oxycodone and 5.4 grams of powdered fentanyl. Laboratory tests later determined the pills were made with fentanyl, not oxycodone.

“This investigation involves the first interdiction of counterfeit oxycodone pills containing fentanyl that were smuggled from Mexico into the U.S. at the local ports of entry,” said Dave Shaw, special agent in charge for Homeland Security in San Diego.

FILE PHOTO of otay mesa border crossing

“While this time we’ve successfully prevented a potentially deadly drug from reaching the streets, we face an uphill battle stemming from the rapidly growing demand for pharmaceutical painkillers on the black market.”

Last year, the DEA issued a nationwide public health alert for acetyl fentanyl, a synthetic opioid produced by illegal drug labs in China and Mexico. Acetyl fentanyl is virtually identical to fentanyl, a Schedule II controlled substance that is often used in patches to treat more severe forms of chronic pain.

Acetyl fentanyl has been blamed for thousands of overdose deaths in the U.S. and Canada. It typically is mixed with heroin and cocaine to make the drugs more potent, but is now showing up in pill form – sometimes disguised as pain medication.

“These criminals are putting fentanyl into fake pills and passing them off as legitimate prescription medications.  Fentanyl is extremely powerful and can very easily lead to overdose deaths,” said William Sherman, DEA Special Agent in Charge.

“Unsuspecting individuals who illegally purchase oxycodone could potentially die from the ingestion of what turns out to be fentanyl tablets,” said U.S. Attorney Laura Duffy. “We are very concerned that these counterfeit pills could cause serious harm to users. Even miniscule amounts of fentanyl can have devastating consequences for those who abuse it or literally even touch it.”

Bohon faces up to 20 years in prison if convicted of unlawfully importing a controlled substance. His next court appearance is scheduled for May 2.

Public Health Emergency in Canada

British Columbia this week became the first province in Canada to declare a public health emergency due to a spike in fentanyl overdoses. Health officials say 201 overdose deaths were recorded in the first three months of 2016. 

Counterfeit fentanyl pills disguised as oxycodone started appearing in Canada about two years ago, where they are often called “greenies” when sold on the street.

ROYAL CANADIAN MOUNTED POLICE photo

“When it's mixed into these tablets it's highly variable from one to the next. So an individual who uses a pill they bought off the street that contains fentanyl may crush up a tablet, inject it and be fine but with the next one they do they may overdose.” Dr. Matthew Young, a substance abuse epidemiologist in Ottowa, told Vancouver Metro.

Like the United States, Canada has a serious problem with opioid abuse and addiction. Young says efforts to reduce opioid prescribing may have contributed to the current wave of fentanyl overdoses.

“That also created a market where organized crime stepped in and started selling these counterfeit tablets containing fentanyl,” he said.

Joint Commission Defends Hospital Pain Standards

(Editor’s Note: As Pain News Network has been reporting, an intense lobbying effort is underway to stop requiring U.S. hospitals to ask patients about the quality of their pain care. Critics contend the practice creates a financial incentive for hospitals to treat pain and leads to “aggressive opioid use.”  The Joint Commission, which accredits hospitals and sets pain management standards, released this statement about the controversy, which we thought you should see in its entirety.)

By David Baker, MD

In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame.  We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.

The Joint Commission’s standards require that patients be assessed for pain, and if they are experiencing pain, then it should be managed. The standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.

Our foundational standards are quite simple. They are: 

DAVID BAKER, MD

• The hospital educates all licensed independent practitioners on assessing and managing pain.
• The hospital respects the patient's right to pain management.
• The hospital assesses and manages the patient's pain. (Requirements for this standard follow)
  1. The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient's condition.
  2. The hospital uses methods to assess pain that are consistent with the patient's age, condition, and ability to understand.
  3. The hospital reassesses and responds to the patient's pain, based on its reassessment criteria.
  4. The hospital either treats the patient's pain or refers the patient for treatment. Note: Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient's current presentation, the health care providers' clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.

Despite the stability and simplicity of our standards, misconceptions persist, and I would like to take this opportunity to address the most common ones:

Misconception #1: The Joint Commission endorses pain as a vital sign

The Joint Commission does not endorse pain as a vital sign, and this is not part of our standards. Starting in 1990, pain experts started calling for pain to be “made visible.” Some organizations implemented programs to try to achieve this by making pain a vital sign. The original 2001 Joint Commission standards did not state that pain needed to be treated like a vital sign. The only time that The Joint Commission referenced the fifth vital sign was when The Joint Commission provided examples of what some organizations were doing to assess patient pain. In 2002, The Joint Commission addressed the problems in the use of the 5th vital sign concept by describing the unintended consequences of this approach to pain management and described how organizations had subsequently modified their processes. 

Misconception #2: The Joint Commission requires pain assessment for all patients

This requirement was eliminated in 2009.

Misconception #3: The Joint Commission requires that pain be treated until the pain score reaches zero.

There are several variations of this misconception, including that The Joint Commission requires that patients are treated by an algorithm according to their pain score. In fact, throughout our history we have advocated for an individualized patient-centric approach that does not require zero pain. The introduction to the “Care of Patients Functional Chapter” in 2001 started by saying that the goal of care is “to provide individualized care in settings responsive to specific patient needs.”

Misconception #4: The Joint Commission standards push doctors to prescribe opioids

As stated above, the current standards do not push clinicians to prescribe opioids. We do not mention opioids at all:
The note to the standard says: Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient's current presentation, the health care providers' clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.

Misconception #5: The Joint Commission pain standards caused a sharp rise in opioid prescriptions.

This claim is completely contradicted by data from the National Institute on Drug Abuse (Figure 1).

The number of opioid prescriptions filled at commercial pharmacies in the United States from 1991 to 2013 shows the rate had been steadily increasing for ten years prior to the standards’ release in 2001. It is likely that the increase in opioid prescriptions began in response to the growing concerns in the U.S. about under treatment of pain and efforts by pain management experts to allay physicians’ concerns about using opioids for non-malignant pain. Moreover, the standards do not appear to have accelerated the trend in opioid prescribing. If there was an uptick in the rate of increase in opioid use, it appears to have occurred around 1997-1998, two years prior to release of the standards.

The Joint Commission pain standards were designed to address a serious, intractable problem in patient care that affected millions of people, including inadequate pain control for both acute and chronic conditions. The standards were designed to be part of the solution. We believe that our standards, when read thoroughly and correctly interpreted, continue to encourage organizations to establish education programs, training, policies, and procedures that improve the assessment and treatment of pain without promoting the unnecessary or inappropriate use of opioids. 

The Joint Commission is committed to working to dispel these misunderstandings and welcomes dialogue with the dedicated individuals who are caring for patients in our accredited organizations.

David Baker, MD, is Executive Vice President of Healthcare Quality Evaluation at The Joint Commission

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.

Significant Decline in U.S. Opioid Prescribing

By Pat Anson, Editor

Nearly 17 million fewer prescriptions were filled for opioid pain medications in the U.S. in 2015, driven largely by a significant decline in prescriptions for hydrocodone, according to a new report by IMS Health.

The report adds further evidence that the so-called “epidemic” of opioid abuse and addiction is increasingly being fueled by illegal opioids such as heroin and illicit fentanyl, not by prescription pain medication intended for patients.

Hydrocodone was reclassified by the Drug Enforcement Administration as a Schedule II controlled substance in October, 2014 – making 2015 the first full year that more restrictive prescribing rules for the pain medication were in effect. But hydrocodone prescriptions were falling even before the rescheduling. They peaked in 2011 at 137 million and fell to 97 million in 2015, a 30% decline.

Hydrocodone is typically combined with acetaminophen to make Vicodin, Lortab, Lorcet, Norco, and other brand name hydrocodone products. The rescheduling of hydrocodone limits pain patients to an initial 90-day supply and then requires them to see a doctor for a new 30-day prescription each time they need a refill.

“It is not surprising that we have seen a dramatic drop in hydrocodone prescribing,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine and vice president of scientific affairs at PRA Health Sciences. “Patients are being told they are not going to be prescribed opioids in general by many physicians. Since hydrocodone has been the most prescribed, it is the most affected. Schedule II opioids are more of a hassle so prescribers shun away from them.

“What is most striking is that the number of unintentional overdoses are still climbing despite fewer pills being prescribed.  Obviously this is a reflection that the goal to reduce harm from reduced prescribing is not working.  We have to wait to see if that trend continues.”

The Centers for Disease Control and Prevention recently adopted new guidelines that discourage primary care physicians from prescribing opioids for chronic pain. The agency also reported that 28,647 Americans died from opioid overdoses in 2014 and attributed about 19,000 of those deaths to prescription opioids. However, the CDC admits the data is flawed. Some overdoses may have been counted twice and some deaths blamed on prescription medications may have been caused by illegal opioids.

Hydrocodone Falls to #3

For several years hydrocodone was the #1 most widely filled prescription in the U.S. It now ranks third behind levothyroxine (Synthroid), which is used to treat thyroid deficiency, and lisinopril (Zestril), which is used to treat high blood pressure.

“Over 16.6 million fewer prescriptions were filled for narcotic analgesics, driven mainly by a sharp decrease in prescriptions for acetaminophen-hydrocodone, whereas prescriptions for oxymorphone, another controlled substance, increased 5.3%,” the IMS report said.

Oxymorphone is the generic name for Opana, a semisynthetic opioid that is also abused by drug addicts.  

The IMS report also found an increasing number of prescriptions being written for gabapentin (Neurontin), a medication originally developed to treat seizures that is now widely prescribed for neuropathy and other chronic pain conditions.  About 57 million prescriptions were written for gabapentin in 2015, a 42% increase since 2011.

After steadily increasing for several years, the number of prescriptions for tramadol appears to have leveled off, according to IMS. Last year about 43 million prescriptions were written for tramadol, a weaker acting opioid also used to treat chronic pain.

Overall spending in prescription drugs reached $310 billion in 2015, according to IMS, a 8.5% increase largely fueled by expensive new brand name and specialty drugs.

PROP Leads New Effort to Silence Pain Patients

By Pat Anson, Editor

Physicians for Responsible Opioid Prescribing (PROP) has joined in the lobbying effort to stop asking hospital patients about the quality of their pain care.

In a petition to the Centers for Medicare and Medicaid Services (CMS), PROP founder and Executive Director Andrew Kolodny calls on the agency to stop requiring hospitals to survey patients about their pain care because it encourages “aggressive opioid use.” PROP is funded and operated by Phoenix House, which runs a chain of addiction treatment centers, and Kolodny is its chief medical officer.

“Medication is not the only way to manage pain and should not be over-emphasized. Setting unrealistic expectations for pain relief can lead to dissatisfaction with care even when best efforts have been made to resolve pain. Aggressive management of pain should not be equated with quality healthcare,” Kolodny wrote in the petition on PROP stationary, which is co-signed by dozens of addiction treatment specialists, healthcare officials, consumer advocates and PROP board members.

The same group signed a letter, also on PROP stationary, to The Joint Commission (TJC) that accredits hospitals and healthcare organizations, asking it to change its pain management standards.

“The Pain Management Standards foster dangerous pain control practices, the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families and communities. To help stem the opioid addiction epidemic, we request that TJC reexamine these Standards immediately,” the letter states.

Medicare has a funding formula that requires hospitals to prove they provide good care through a patient satisfaction survey known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).  The formula rewards hospitals that are rated highly by patients, while penalizing those that are not. 

The petition asks that these three questions be removed from the survey:

During this hospital stay, did you need medicine for pain?

During this hospital stay, how often was your pain well controlled?

During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

As Pain News Network has reported, 26 U.S. senators and the Americans College of Emergency Physicians have sent similar letters to Medicare asking that the pain questions by dropped from the survey. A recently introduced bill in the U.S. Senate called the PROP Act of 2016 would also amend the Social Security Act to remove "any assessments" of pain in hospitalized patients.

The PROP-led petition cites a 2013 study that found opioid pain medication was prescribed to over half of the non-surgical patients admitted to nearly 300 U.S. hospitals.

“Pain management is obviously an important part of patient care and we’ve always acknowledged that. But the problem here is that one should not have financial incentives and that’s essentially what happens through the CMS survey,” said Dr. Michael Carome of the consumer advocacy group Public Citizen, who co-signed the petition.

“The way the CMS survey and Joint Commission standards have driven the focus on pain has overemphasized its importance. We’re not saying don’t assess it at all, we’re saying the survey and standards have done more harm than good,” Carome told Pain News Network.

A top Medicare official recently wrote an article in JAMA defending the CMS survey.

"It has been alleged that, in pursuit of better patient responses and higher reimbursement, HCAHPS compels clinicians to prescribe prescription opioids. However, there is no empirical evidence that failing to prescribe opioids lowers a hospital’s HCAHPS scores," wrote Lemeneh Tefera, MD, Centers for Medicare & Medicaid Services. “Nothing in the survey suggests that opioids are a preferred way to control pain.”

Before joining Phoenix House in 2013, Kolodny was Chairman of Psychiatry at Maimonides Medical Center in New York City, a hospital that was given a one-star rating by patients in the CMS survey.   Only 61 percent of the patients said their pain was "always" well controlled at Maimonides and 11 percent said their pain was "sometimes" or "never" controlled. Only 59% of the patients said they would recommend Maimonides, compared to a national average for hospitals of 71 percent.

PROP has long been active in lobbying federal agencies to rein in the prescribing of opioids. It recently had some major successes in achieving its goals.

Five PROP board members helped draft the opioid prescribing guidelines released by the Centers for Disease Control and Prevention, which discourage primary care physicians from prescribing opioids for chronic pain. 

The Obama administration also recently asked Congress for over a billion dollars in additional funding to fight opioid abuse, with most of the money earmarked for addiction treatment programs such as those offered by Phoenix House, which operates a chain of addiction treatment clinics. A proposed rule would also double the number of patients that physicians can treat with buprenorphine, an addiction treatment drug. 

According to OpenSecrets, Phoenix House spent over a million dollars on lobbying from 2006-2012.  PROP calls itself “a program of the Phoenix House Foundation” on its website.     

PNN and the International Pain Foundation recently conducted a survey of over 1,250 pain patients and found that over half rated the quality of their pain treatment in hospitals as poor or very poor. Over 80 percent said hospital staffs are not adequately trained in pain management. Nine out of ten patients also said they should be asked about their pain care in hospital satisfaction surveys.

Canada: Abuse Deterrent Opioids Too Expensive

By Pat Anson, Editor

At a time when the U.S. Food and Drug Administration is actively promoting the development of more opioid pain medication with abuse deterrent formulas (ADFs), Canada is saying the drugs are too expensive and will have “little to no effect” in the fight against opioid abuse and addiction.

Health Canada last week rejected a proposed regulation that would require all medications containing the painkiller oxycodone to have tamper resistant properties.  ADFs generally make it harder for drug abusers to crush or liquefy opioids so they can be snorted or injected.

“(After) a review of the latest scientific evidence, the department has concluded that this specific regulatory approach, requiring tamper-resistance, would not have had the intended health and safety impact,” Health Canada said in a statement.

“Specifically, requiring tamper-resistant properties on all legitimate preparations of controlled-release oxycodone would have served to eliminate certain lower cost drugs from the market, increasing costs for patients and the health system, while having little to no effect in the fight against problematic opioid use.”

Like the United States, Canada has a severe and growing drug problem. According to the World Health Organization, Canada consumes more opioid painkillers per capita than any other country.

But Health Canada recently told drug makers to conduct more research demonstrating that ADFs do not change the safety and effectiveness of drugs. Until those studies are completed, the agency said it would rely on programs educating patients and prescribers about the safe use of opioids.

Purdue Pharma Canada released a statement saying it was disappointed in Health Canada’s decision and asked Health Minister Jane Philpott to reconsider.

“We continue to believe products with features designed to deter misuse, abuse and diversion, can and do have a positive impact on public health, based on the abundance of published evidence,” Purdue said in a statement. The company also urged Canada to “align with the FDA” by moving to require ADFs “across the entire class of opioids.”

In 2010, Purdue's OxyContin became the first opioid to be reformulated to make it harder for addicts to crush or liquefy. Since then, four other ADF opioids have been approved by the FDA and drug makers have spent hundreds of millions of dollars developing new formulas to make opioids even harder to abuse. Last month the FDA issued draft guidance encouraging drug makers to develop generic versions of opioids with ADF.

A major issue that has slowed the use of opioids with ADF is their cost. 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 in southern California is $352. A 60-day generic version of oxycodone -- without abuse deterrence -- retails for as little as $138.

Many health insurers have been reluctant to pay the extra cost of ADF.  A recent study found that only a third of Medicare Part D plans cover OxyContin and in many cases prior authorization is needed. Oxycodone, however, is covered by all Medicare Part D plans and prior authorization is rarely required.

Another recent study found that over a quarter of patients admitted to drug treatment facilities in the U.S. were still abusing OxyContin, five years after it was reformulated.

Fentanyl ‘Death Pills’ Spreading Coast-to-Coast

By Pat Anson, Editor

Law enforcement officials are warning that counterfeit pain and anxiety medications laced with illicit fentanyl have started appearing in Florida, where they are blamed for at least one overdose death.

The pills in Florida are disguised to look like oxycodone, Percocet or Xanax, but are actually made with fentanyl, a powerful and dangerous drug 50 times more potent than morphine. Similar counterfeit pills, made to look like Norco hydrocodone medication, are blamed for at least ten deaths and dozens of overdoses in the Sacramento, California area in recent weeks.

“I've had one of these so called super Norco’s,” said David, a 25-year old father of two, who started using street drugs for back pain.  “I only took a half just in case because of the news from the day and luckily I did. It was unlike any high I've had. It made me dizzy.  I couldn't see straight or sleep.”

As Pain News Network has reported, some of the victims in California are pain patients like David who sought opioid medication on the street because they can no longer get it prescribed legally.

"The people who have overdosed are not typically drug addicts," Olivia Kasirye of the Sacramento County health department told Agency France-Presse. “Many of the individuals said at one time or another they had a prescription and either they didn't get it refilled or the doctor said they didn't need it anymore."

Florida "Death Pills"

fake fentanyl pills disguised as norco

"It is here, it is deadly and it will continue to grow in our community,” said Danny Banks of the Florida Department of Law Enforcement in the Orlando Sentinel.

“If you are dependent upon or if you are experimenting with prescription painkillers, please make sure you are getting those painkillers from a licensed pharmacy. I cannot assure you right now, if you are buying prescription painkillers from either the black market or on the street, I cannot assure that they will not be laced with a deadly concoction that contains fentanyl. And it will kill you.”

In many cases, Banks said, neither buyers or sellers know the so-called “death pills” contain fentanyl.  He said fentanyl-laced pain pills have been seized in Osceola and Brevard counties, and have been linked to at least one fatality.

Florida’s Pinellas County Sheriff's Office has attributed nine recent fentanyl deaths to a batch of fake Xanax, an anxiety medication.

DEA Sees No Link to CDC Guidelines

In recent years, Illicit fentanyl has been blamed for thousands of overdose deaths. It is usually produced in China and then imported by Mexican drug cartels, which often mix fentanyl with heroin or cocaine before smuggling it into the U.S. The recent appearance of fentanyl in counterfeit pills is an ominous sign that drug dealers could now be targeting patients as customers, not just addicts.

But a DEA spokesman in Washington, DC disputes that notion.

“I don’t think you’re seeing that at all,” says the DEA’s Rusty Payne. “They’re going after anybody who will buy the product. By and large they are reaching hard-core addicts.”

Payne also sees no connection between the fake fentanyl pills and the recent adoption of the CDC’s opioid guidelines, which discourage primary care physicians from prescribing opioids for chronic pain. Many patients fear losing access to opioids because of the guidelines.

“These CDC guidelines are brand spanking new. I think it’s hard to draw any sort of conclusions from that,” Payne told PNN. “I don’t think the Mexican cartels are paying one lick of attention to what the CDC guidelines are. What they see are thousands and thousands of addicts that they can push a product on, whether it be heroin or now fentanyl. And introducing it in pill form is just another way to make a lot of money."

In a survey of over 2,000 pain patients last fall by Pain News Network and the International Pain Foundation, 60 percent predicted patients would get opioids off the street or through other sources if the CDC guidelines were adopted. Another 70% said use of heroin and illegal drugs would increase.

According to a story in STAT, drug cartels are now shipping machinery into the U.S. that can manufacture pills, allowing dealers to mass produce fentanyl in pill form. In March, the DEA arrested four men in southern California who were operating four large presses to make counterfeit hydrocodone and Xanax pills.

Recently the Royal Canadian Mounted Police arrested 14 people in British Columbia, seizing firearms, diamonds, cash and about a thousand fentanyl pills.

A Brush with Death and Fake Pain Pills

By Pat Anson, Editor

At least ten deaths and 42 overdoses have now been blamed on counterfeit pain pills in the Sacramento, California area.

The pills are disguised as Norco – the brand name of a common hydrocodone medication – but they are actually made with illicit fentanyl, a dangerous and sometimes deadly drug that is 50 times more potent than morphine.      

One of those fatal overdoses could have easily been a 25-year year old father of two, who we’ll call “David” to protect his identity.

“I've had one of these so called super Norcos,” says David.  “It had the markings of a regular prescription, M367. I only took a half just in case because of the news from the day and luckily I did. It was unlike any high I've had. It made me dizzy.  I couldn't see straight or sleep.”

It’s not just street addicts who are being victimized by the fentanyl scam. Many are pain patients like David who turned to the black market for relief when they could no longer get opioid prescriptions legally.

David suffered a herniated disc several years ago. He was prescribed morphine for his pain and took it three times a day for six months before being abruptly cut off by his doctor. 

counterfeit norco pills

“I tried everything to get more and more prescription drugs prescribed. After that I had no choice but to turn to the street. It's a huge problem here in Sacramento,” David told Pain News Network.

“Ever since middle school and high school I recall the widespread use of opiates and heroin. But now there is such a high demand for the pills because of the increased regulations on them and not being able to scam an early refill. It has caused the price to spike on the streets and as soon as the word gets out someone has them they are immediately sold for ridiculous prices. It’s not all addicts and not all pain patients. The doctors around here are cutting people down on the amount they are prescribed, causing them to have nowhere else to turn but the neighborhood dealer.”

After three years of buying street drugs, David knew he had a problem and entered a treatment program, where he was prescribed Suboxone, an opioid medication that’s widely used to treat addiction. The treatment worked well for several months, but then his health insurance with Covered California lapsed and he missed a re-enrollment period. David could no longer get treatment.

“The withdrawal from that (Suboxone) was about 3 weeks and felt like it was getting worse, so I really felt as if I had no choice but to ease the pain by once again turning to the streets to feel better. I told myself I'd only do it for a month then that turned into two months, now it's going on seven and I can't stop,” said David. “I got the Norco from a friend who is usually prescribed oxycodone but had run out and he too was forced to go out and find something to get him through till his refill was due.”

David bought 16 Norco pills for $5 each, not knowing he was actually getting fentanyl.

“Adding fentanyl of course to the Norco makes it much more powerful and deadly at the same time,” says John Burke, a former drug investigator for the Cincinnati Police Department who is now president of the International Health Facility Diversion Association. “Dealers brag about the potency of their products, and even brag when someone overdoses or even dies as proof of superior product. Screwed up thought process, but nevertheless that’s the world of illicit drug dealing.”

Burke says the counterfeit Norco most likely came from Mexico, where drug cartels manufacture fentanyl before smuggling it into the United States. Usually the fentanyl is mixed with heroin or cocaine to boost their potency. By disguising fentanyl as a legitimate pain medication, the dealers are tapping into a large and growing black market for opioids sought by addicts and pain patients.

“Putting fentanyl in pill form makes it less of a problem in hiding and transporting the drugs,” says Burke. “These pills probably bring more money, especially when the testimonials roll in as to how potent they are. Their drive is their bottom line.”

The bottom line for David is that he nearly overdosed and could have died. For the sake of his children, he’s gotten rid of the remaining Norco pills and is hoping to wean himself off opioids.

“I'm starting to taper myself down. I have to, this pill scare is enough to scare someone that has a lot to lose like myself,” he said.

ER Doctors Lobby to Silence Pain Patients

By Pat Anson, Editor

A professional organization for emergency room physicians has joined in a lobbying effort to stop asking hospital patients about the quality of their pain care.

At issue is a Medicare funding formula that requires hospitals to prove they provide good care through patient satisfaction surveys. The formula rewards hospitals that are rated highly by patients, while penalizing those that are not. 

In a letter to Health and Human Services Secretary Sylvia Mathews Burwell, the head of the American College of Emergency Physicians (ACEP) claims that asking patients about their pain care could lead to overprescribing of opioid pain medication. To see the letter, click here.

“Patient experience/satisfaction surveys are important, particularly regarding issues of treating patients with dignity and respect, but questions about pain have resulted in unintended consequences and the pursuit of high patient-satisfaction scores may actually lead health professionals and institutions to practice bad medicine by honoring patient requests for unnecessary and even harmful treatments,” wrote Jay Kaplan, MD, President of ACEP, which represents over 30,000 emergency room physicians in the U.S.

“Any questions which provide an opportunity for patients to express dissatisfaction because they didn’t get the drugs they sought, provide disincentives for physicians to prescribe non-opioid analgesics which will negatively affect their scores.”

Only two questions are asked about pain in the 32-question survey known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS):

During this hospital stay, how often was your pain well-controlled?

During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

In his letter, Kaplan states “there is no objective diagnostic method that can validate or quantify pain” and until one is developed, both pain questions should be dropped from the survey.

“We are concerned that the current evaluation system may inappropriately penalize hospitals and physicians who, in the exercise of medical judgment, opt to limit opioid pain relievers to certain patients and instead reward those who prescribe opioids more frequently,” Kaplan wrote. “We urge the Department to undertake a robust examination of whether there is a connection between these measurements and potentially inappropriate prescribing patterns, and, until that is completed, we urge you to remove pain questions from the various CAHPS surveys.”

Kaplan’s letter is similar to one sent to Secretary Burwell in February by Sen. Susan Collins (R-Maine) and 25 of her colleagues in the U.S. Senate. To see that letter and the senators who signed it, click here.

“The evidence suggests that physicians may feel compelled to prescribe opioid pain relievers in order to improve hospital performance on quality measures,” wrote Sen. Collins.

Both Collins and Kaplan cite only one piece of “evidence” – a 2013 magazine article in The Atlantic  -- that mentions a small study of “drug seeking behavior” by emergency room patients. The article's author, who is a physician, also mentions anecdotal comments from colleagues and concludes “this problem is widespread.”  

Pain News Network and the International Pain Foundation recently conducted a survey of over 1,250 pain patients and found that what is actually widespread in hospitals is poor pain care. Over half the patients surveyed said the quality of their pain treatment was poor or very poor and over 80 percent said hospital staffs are not adequately trained in pain management. Nine out of ten patients said they should be asked about their pain care in hospital satisfaction surveys.

“Before eliminating patients' right to critique their pain care, a better idea would be to ask doctors what they know about pain!” wrote one patient. 

When Pain News Network provided ACEP with the survey results, a spokesperson declined to comment on the findings.

A top Medicare official recently wrote an article in JAMA defending the HCAHPS survey.

"It has been alleged that, in pursuit of better patient responses and higher reimbursement, HCAHPS compels clinicians to prescribe prescription opioids. However, there is no empirical evidence that failing to prescribe opioids lowers a hospital’s HCAHPS scores," wrote Lemeneh Tefera, MD, Quality Measurement and Value-Based Incentives Group, Centers for Medicare & Medicaid Services.

"Although opioids are sometimes appropriate, depending on the underlying cause, other nonpharmaceutical approaches and multiple nonopioid pain medications are available to treat pain. Nothing in the survey suggests that opioids are a preferred way to control pain. On the other hand, good nurse and physician communication are strongly associated with better HCAHPS scores."

“I find this notion that we would stop asking patients how well their pain was controlled in the hospital appalling,” said Cindy Steinberg, National Director of Policy and Advocacy for the U.S. Pain Foundation. “I find it perverse that we would be more concerned with whether doctors in a hospital setting felt ‘pressure’ to provide pain relief than whether patients felt the hospital staff did all they could to help them with their pain. What ever happened to the focus on ‘patient-centered’ care?"

DEA Warns of Fake Fentanyl Pain Pills

By Pat Anson, Editor

In the wake of nine deaths and dozens of overdoses in the Sacramento, California area in recent weeks, the U.S. Drug Enforcement Administration has issued a public safety alert about illicit fentanyl being disguised as opioid pain medication and sold on the black market.

Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine and can be lethal in very small doses. Fentanyl is available by prescription to treat more severe types of chronic pain, but illicitly manufactured fentanyl is fast becoming a scourge across the U.S. and is blamed for thousands of fatal overdoses.

White fentanyl powder is usually mixed with heroin or cocaine to give those drugs an extra kick, but in Sacramento the drug was disguised as counterfeit Norco pills, a legal opioid pain medication that combines hydrocodone with acetaminophen.

“Public Health and Law Enforcement officials believe that the pills containing Fentanyl were likely sold on the street under the guise of being legitimate hydrocodone.  Additionally, the pills are marked to mimic the authentic hydrocodone product. However, the Sacramento County Department of Health and Human Services reports that test results show that some of the tested pills did not contain hydrocodone, but rather fentanyl,” the DEA said in a statement. 

IMAGE OF COUNTERFEIT NORCO

“The DEA urges the public not to take a prescription drug unless prescribed by your own physician and obtained from a reputable pharmacy."

One of the overdose victims in California was David Alfaro, a 53-year old man who suffered chronic pain from a leg injury, according to a report by KCRA-TV.

"He bought what he thought was Norco, and it ended up being fentanyl -- and it killed him," said Marinda Conway, Alfaro’s common law wife. "He wasn't a heroin addict that was looking to substitute his addiction by buying street pills. He wasn't an opioid addict by any means.”

Conway said a single fake Norco pill was enough to kill Alfaro, although autopsy results are pending.

"This has been my fear with the new CDC guidelines that more people with pain will have less access to prescription medications; therefore taking matters into their own hands, self-medicating with medications bought on the street," said Paul Gileno, president of U.S. Pain Foundation, referring to recently adopted government guidelines that discourage primary care physicians from prescribing opioids for chronic pain.

"The CDC never thought about the unintended consequences from limiting access to legitimate patients needing care whose clinicians now feel unable to prescribe or treat appropriately. My worst nightmare is the possible repercussions looming in the future due to these hindering guidelines," Gileno said.

In a survey last fall of over 2,000 pain patients by Pain News Network,  70 percent predicted that use of heroin and other illegal drugs would increase if the CDC guidelines were adopted.

The DEA says illicit fentanyl is primarily manufactured in Mexico and China before being smuggled into the U.S. Because of the nature of the drug, it’s impossible to tell if fentanyl was prescribed legally and used for medical reasons or manufactured illegally and used recreationally. The CDC admits many fentanyl overdoses may have been misclassified as deaths caused by prescription painkillers.

White House Steps Up Anti-Opioid Campaign

By Pat Anson, Editor

The Obama administration has unveiled a series of new initiatives aimed at treating addiction and educating doctors about prescription opioid abuse – amid growing signs the nation’s drug abuse epidemic is being fueled more and more by illegal opioids such as heroin and illicit fentanyl.

The new campaign, unveiled at the National Rx Drug Abuse and Heroin Summit in Atlanta, expands on a $1.1 billion funding proposal the President sent to Congress last month to address the nation’s growing drug problem.

One change that could greatly expand access to addiction treatment is a proposed rule by the Department of Health and Human Services (HHS) to double the number of prescriptions that a doctor can write for buprenorphine, an opioid used to treat addiction. Doctors currently are limited to 100 buprenorphine patients, but the new rule would expand that to 200 patients. The number of doctors trained and licensed to prescribe buprenorphine will also be increased.

HHS and the Substance Abuse and Mental Health Services Administration (SAMHSA) will also release over $100 million to expand access to addiction treatment.

"Expanding access to medication-assisted treatment for opioid-use disorders has been a top priority for this administration. Research clearly shows that this approach, when combined with behavioral therapies, is more effective at sustaining recovery and preventing overdose," said Michael Botticelli, director of the White House Office of National Drug Control Policy.

The policy changes and funding support stand to greatly benefit addiction treatment centers such as Phoenix House, whose medical director has lobbied for expanded access to buprenorphine treatment. Andrew Kolodny, MD, is also the founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP) which had five board members, including Kolodny, advising the CDC about its new opioid prescribing guidelines.

While buprenorphine is considered a “safer” opioid and has long been used to treat addiction (under the brand name Suboxone), it is prized by some addicts and can be abused. A 2013 study by SAMHSA found a ten-fold increase in the number of emergency room visits involving buprenorphine. Over half of the hospitalizations were for non-medical use of buprenorphine – meaning many users took the drug to get high.

“One of the most effective medications for opioid addiction is a drug called buprenorphine or Suboxone,” said Kolodny in an interview on C-SPAN last October.

A request to Phoenix House and Kolodny for comment on the HHS buprenorphine proposal went unanswered.

The White House also announced this week that 60 medical schools will require students to take some form of prescriber education, modeled after the CDC’s opioid guidelines, in order to graduate.

The lack of pain education in medical schools has long been recognized as a problem. A 2012 study published in the Journal of Pain called pain education "lackluster" in the U.S. and Canada. Few schools required a course in pain education and many did not have any pain courses.

A recent survey by Pain News Network and the International Pain Foundation (IPain) found that 8 out of 10 patients feel that hospital staffs are not adequately trained in pain management. Over half rated the quality of their pain care in hospitals as either poor or very poor.

Some fear the new White House plan is focused more on addiction treatment and limiting access to opioids than it is on educating doctors about pain management.  

“What remains astonishing is the total deafness to the needs of people in pain. It is as if people in pain don't exist and that they are not important,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine and vice president of scientific affairs at PRA Health Sciences.

“Focusing on opioid prescribing education in medical schools without also educating medical students about pain medicine is only going to further stigmatize people in pain and those who develop addictions. This is a true Back to the Future nightmare.  We will be practicing 1950's medicine for the most prevalent public health problems in America.  Absolutely astounding to me.”  

Six Fatal Fentanyl Overdoses in California

While the Obama Administration was announcing its new plan, health officials in Sacramento, California confirmed that six people died and over two dozen were hospitalized this month after ingesting a black market version of Norco, a widely prescribed opioid painkiller.

Legitimate Norco pills are a combination of hydrocodone and acetaminophen, but the “street” Norco was laced with fentanyl, a much more potent and potentially deadly opioid. Fentanyl is odorless and cannot be easily distinguished from other drugs.

“Some who have taken it stated that they were told that it was Norco.  However, results just released indicate that some of the pills that were retrieved have been tested and show that they did not contain Hydrocodone or Acetaminophen. The lab was able to identify the pills as containing Fentanyl instead.  This indicates that they are really Fentanyl pills that have been made to look like Norco,” the Sacramento County Division of Public Health said in a statement.

Fentanyl deaths have been rising around the country – at least 22 died from fentanyl overdoses in the Cleveland, Ohio area this month alone and dozens of deaths have been reported in West Virginia.

Last year the Drug Enforcement Administration issued a nationwide alert about the abuse, diversion and illegal manufacture of fentanyl. Thousands of people are believed to have died from fentanyl overdoses, but because of the nature of the drug it is impossible to tell whether it was prescribed legally and used for medical reasons or manufactured illegally and used recreationally. The CDC admits many fentanyl overdoses may have been misclassified as deaths caused by prescription painkillers.

Meanwhile, a report this week in Maine’s Portland Press Herald suggests that there is a correlation between rising heroin use and reduced access to prescription opioids. In recent years the number of people being treated for heroin addiction has nearly tripled in Maine, at a time when the number of prescriptions written for opioids dropped by 45 percent.