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. 

Iowa Lawmaker Calls Cancer Pain ‘Regular Ailment’

By Pat Anson, Editor

An Iowa state legislator is under fire from pain patients and healthcare professionals after suggesting that cancer pain was a “regular ailment” that should not always be treated with opioid pain medication.

Rep. Chuck Isenhart co- hosted a public forum this week on opioid abuse in Dubuque, where he called for new efforts to stop the heroin and opioid epidemic in Iowa.

"We've become dependent really on using strong painkillers for treatment of regular aliments such as cancer and inadvertently many people have become addicted to those painkillers," Isenhart told KCRG-TV in an interview.   

STATE REP. CHUCK ISENHART (D-DUBUQUE)

The comment angered pain sufferers around the country, who left comments on KCRG’s website.

“If cancer is a regular ailment unworthy of relief, what sort of ailment ‘deserves’ relief?” asked Anne Fuqua, a pain sufferer and patient advocate in Alabama. “Patients with chronic pain are suffering horribly due to pressure not to prescribe opioids. Patients have literally committed suicide as a result of uncontrolled pain.”

“I'd like to know how my dead mother’s cancer was a 'regular ailment.' Also, unless you have actually experienced the pain of chemo and all of the side effects from it, I wouldn't lump that in the same category,” wrote Anne Pavao.

“To call cancer a regular ailment just pisses me off. My husband has Stage 4 mets (metastasized) cancer. This is not a freaking headache. This is a chronic PAIN,” said Rene Saylor.

“Suggesting that cancer-related pain is a ‘regular ailment’ that should not be treated with opioids is just beyond the pale,” said Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management. “I worked with people with cancer for 20 years, and I can assure this legislator, and anyone else who cares to ask, that the pain associated with cancer can be very severe and often warrants treatment with opioids—which are usually effective. Statements like this reflect a lack of knowledge that can be very dangerous when making policy.”

Even the CDC's opioid guidelines -- which discourage the prescribing of opioids for chronic pain -- make clear they are not intended for cancer patients or others with terminal illnesses.

"This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care," the CDC guidelines state.

We asked Isenhart if he wanted to clarify his remark.

“Cancers are a common health condition for which painkillers are often properly prescribed per evidence-based medical protocols. In some cases, the use of such opioids – whether proper and improper -- results in dependencies and/or leads to addictions after the initial indication has been addressed,” Isenhart said in an email to PNN.

“This is not my ‘position’ -- this is the testimony we received from medical experts who testified at our forum. If there is testimony to correct or elaborate, we are open to receiving it.”

Isenhart is a member of a special legislative committee charged with evaluating the “prescription pain medication crisis” in Iowa. Among other things, the panel is looking into whether overdoses from opioid medication are under-reported and whether physicians are complying with current prescribing guidelines. The committee is due to submit its recommendations to the full legislature by January 1.

PNN asked Isenhart if further limits on prescription opioids would be recommended.

"This is one of (the) questions that is being asked. I know my own doctor has told me that he would ‘rather prescribe Narcan than narcotics,’” wrote Isenhart. Narcan is an emergency medication used to reverse opioid overdoses.

“The serious lack of knowledge by this legislator is astounding. It suggests to me that his advisors are equally uninformed,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine. “I cannot believe the lack of reason and science that is influencing our policymakers.  It has to be frightening for all people in serious pain from cancer or non-cancer pain.”

Webster says only a small percentage of cancer patients develop an opioid addiction.

“People who develop a substance use disorder to opioids are usually polysubstance abusers and have almost always had a prior substance abuse problem.  It is rarely the exposure to an opioid that is the problem,” said Webster. “The misinformation about opioids and the risk of abuse is astounding.  The real tragedy is that the misinformation will not help solve the opioid crisis but will certainly contribute to more suffering by people in pain who will be ignored or denied compassionate care.”

Like many rural communities and cities across the country, Dubuque is being hit hard by a wave of opioid overdoses. So far this year, 9 deaths and 26 overdoses have been reported In Dubuque County. All were attributed to heroin, not pain medication.

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.

Daughter Says Untreated Pain Led to Mother’s Suicide

By Pat Anson, Editor

Suicides are never easy to accept. Especially if they involve a loved one. Even more so if they could have been prevented.

Lacy Stewart says her mother never would have killed herself if she’d been given proper medical care for her chronic fibromyalgia pain.

“I feel angry about the way she was treated,” says Stewart, a registered nurse who believes the healthcare system not only failed to treat her mother, but drove Marsha Reid to suicide at age 59.

“Her life was taken from her is the way I feel,” says Stewart. “I know it was. A person can only handle so much pain for so long. It takes its toll on every area -- your mind, your body, everything. And she just couldn’t do it anymore. She’d had enough. Because nobody would help her. Nobody.” 

Stewart says her mother was fit and physically active – handling all the chores at her 10-acre farm in north Texas -- until she slipped on ice and landed hard on her face in 2009. Reid broke a few teeth and sustained nerve damage in the fall -- injuries that evolved into the classic symptoms of fibromyalgia: chronic widespread pain, anxiety, fatigue, insomnia and depression.

“Of course she sought out help. Searching for doctors that would take her on, she encountered road block after road block. Many doctor’s offices would just flat out say, ‘We don’t take fibromyalgia patients,’” recalls Stewart.

“So you take that and couple it with the fact that pain medication is often required for these patients and now the CDC has regulations that deter a physician from wanting to prescribe pain medication at all and you end up here. Zero help for a woman suffering day in and day out for all these years. She lost her job, her home, her independence.”

MARSHA REID AND DAUGHTER LACY

In January, Reid checked into a hotel room and tried to kill herself by taking a full bottle of Xanax. The failed suicide attempt left Reid even more depressed and her health deteriorated further. She started having hallucinations, hearing voices and seeing dead people.

In July, Stewart drove her mother for five hours to see a pain management doctor.

“I was appalled at the treatment from the physician. We explained the pain and the issues with her mind, and he said he could only treat one or the other. Not both! Not the whole patient! When I brought up pain medication you would have thought I had asked him for heroin,” says Stewart.

“I'll never forget the conversation I had with him in the hall on the way out. I looked him in the eye and said the pain is so severe she will kill herself! It’s only a matter of time. He basically said his hands were tied because of the regulations and what I was asking was for him to lose his license! I was furious and felt betrayed by the field I loved, medicine.”

One treatment was suggested for her mother.

“They wanted her to go to water aerobics,” said Stewart. “The woman could barely take a bath and they wanted her to go to water aerobics! I read in the CDC (opioid) prescribing guidelines that they wanted doctors to use alternative measures for pain relief such as water aerobics and physical therapy. They never spent a day in pain in their lives, obviously. Because then they would know that is ridiculous. It’s almost a joke to me, the guidelines that I have read.”

Crisis in Pain Care

In recent months, Pain News Network has been contacted by dozens of pain patients who say they are contemplating suicide. It’s not just the difficulty in getting opioid pain medication. The growing crisis in pain care has reached a point where many patients are unable even to get a doctor’s appointment.

“I have been on a wait list for pain treatment for a year now. I am suffering needlessly and am questioning my ability to be able to live like this much longer,” said Isabel Etkind, a Connecticut woman who suffers from severe arthritis pain.

“I don't want to die but I can't live like this either. I know that many other people are experiencing the same thing, but knowing that does not really help! It is inhumane and cruel to treat people this way. If I were a dog, cat or horse, the animal rights people would be all over it, but torturing humans is OK. As is usually the case, the elderly, the military and the poor are suffering the most.”

Another woman, who suffers from chronic back pain, asked that we not use her name. She works in the emergency room of a hospital in southern California that recently adopted a policy of not prescribing opioids unless all other pain treatments have failed.

“Since November 1, we have seen a huge increase in overdoses from street drugs. Nearly all of these patients are chronic pain sufferers who are now getting their medications off the streets. A 33-year old fibromyalgia patient died from fentanyl overdose this week,” she wrote to PNN. “I understand the desperation these patients feel and try to educate the ER doctors about chronic pain from a layman's point of view. This new effort to stigmatize and demonize chronic pain sufferers has got to stop!

“We have full time jobs, pay mortgages, raise families. All this, while in levels of pain that normal people couldn't handle. We hate having to be chained to pill bottles and doctors and pharmacists. What other choice do we have? Curl up and die? I hope the new Trump administration will appoint people to DEA and CDC who will think of us as humans and help us instead of hurting us.”

Suicides Increasing

According to the CDC,  suicides increased by 24 percent from 1999 to 2014, and are now the 10th leading cause of death in the United States.  

In 2014, nearly 43,000 Americans killed themselves, three times the number of deaths that have been linked to prescription opioid overdoses.  

Marsha Reid died of a self-inflicted gunshot wound on November 2, leaving behind a grief stricken daughter who will always wonder if things would have turned out differently if her mother had gotten the pain treatment she needed

“She talked about this a lot, about suicide. That was her plan. She couldn’t deal with this much longer. And that’s what breaks my heart the most is that I was unable to help,” says Lacy Stewart.

“Just mention the heartache she has left behind. Because if another fibromyalgia patient is out there contemplating this and they come across this story, I want it noted that I lost my mom forever and I’m 32 years old. And I’ll never have her back.”

MARSHA REID

Studies Promote Epidurals Without Explaining Risks

By Pat Anson, Editor

Two recent studies presented at a meeting of anesthesiologists are promoting the benefits of epidurals to relieve pain during child birth. But a woman whose spinal cord was permanently damaged by an epidural says new mothers need to be told more about the risks involved.

First, about those studies.

A study of over 200 women presented at the annual meeting American Society of Anesthesiologists found that epidurals – in addition to relieving labor pain – also appear to lower the risk of postpartum depression for new mothers.

"Labor pain matters more than just for the birth experience. It may be psychologically harmful for some women and play a significant role in the development of postpartum depression," said Grace Lim, MD, director of obstetric anesthesiology at Magee Women's Hospital of the University of Pittsburgh Medical Center.

"We found that certain women who experience good pain relief from epidural analgesia are less likely to exhibit depressive symptoms in the postpartum period."

The second study found that women who chose nitrous oxide – laughing gas – to manage labor pain get only limited relief. And a majority wind up getting an epidural anyway once the pain starts.

"Nitrous oxide is gaining interest among expectant mothers as an option to manage labor pain and is becoming more widely available in the United States," said Caitlin Sutton, MD, an obstetric anesthesiology fellow at Stanford University School of Medicine. "However, we found that for the majority of patients, nitrous oxide does not prevent them from requesting an epidural. While nitrous oxide may be somewhat helpful, but epidural anesthesia remains the most effective method for managing labor pain."

Epidurals are effective at relieving pain, but how safe are they?

“By far the gas is safest form of pain relief for women during labor, along with other non-invasive methods,” says Dawn Gonzalez, whose spinal cord was accidentally punctured by an epidural needle during childbirth. “Epidural anesthesia is the most popular form of anesthesia during labor, but women are rarely warned about the long term, devastating effects and consequences that some women will encounter.”

The injury to Gonzalez’s spine during the botched epidural led to the development of adhesive arachnoiditis, a chronic inflammation that caused scar tissue to form and adhere to the nerves in her spine. She now suffers from severe chronic pain and is disabled. Gonzalez says the pain she experiences today is far worse than the temporary labor pain she would have experienced without an epidural.

“The blind insertion of the epidural during birth is basically playing roulette for spinal damage. Normally birthing mothers are told the only side effect possible during epidurals is a spinal headache that lasts a few days. True informed consent is missing from the equation,” says Gonzalez.

“I often wish I could go back and decline the epidural because arachnoiditis has completely turned my life and that of my family upside down. I had so many dreams for the future with my children, and there is so much I miss out on and will never reach due to being injured during my epidural.”

The American Society of Anesthesiologists (ASA) has long defended the use of epidurals, calling the risk of complications a “myth.” The ASA has called the procedure “one of the most effective, safest and widely used forms of pain management for women in labor.”

A study of over a quarter million epidurals by the Society for Obstetric Anesthesia and Perinatology also found the risk of complications to be low. An “unrecognized spinal catheter” – what Dawn Gonzalez experienced – occurred in about one in 15,435 deliveries.

She thinks there are better and safer alternatives.

“Laughing gas, Lamaze, hypnotism, meditation, water birthing and even some medications are the absolute safest and most effective forms of labor pain relief. Every woman deserves to know that when she opts for any kind of invasive spinal anesthesia, the risks are very grave and by far much more common than anybody realizes,” Gonzalez says. “We have a tendency to think it will ‘never happen to me,’ but you do take very serious risks for yourself and your child when opting for an obstetric epidural.”

One hundred years ago, laughing gas was widely used in hospitals to relieve pain during childbirth, but it fell out of favor as more Caesarean sections were performed and women needed more pain relief.  Nitrous oxide helps reduce anxiety and makes patients less aware of pain, but it does not eliminate it. 

In the laughing gas study of nearly 4,700 women who gave birth vaginally at a U.S. obstetric center, only 148 patients chose to use nitrous oxide. Nearly two out of three wound up getting an epidural once labor began.

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.

Pain Patients Say Insurers Interfering with Treatment

By Pat Anson, Editor

It’s no secret that health insurance companies have been raising deductibles and co-pays, and generally making it harder for chronic pain patients to get treatment – whether it’s opioid pain medication or alternative therapy like massage or acupuncture.

But recent actions by some insurers have healthcare providers and patients saying the insurance industry has gone too far in its effort to reduce opioid abuse and is interfering with the doctor-patient relationship.

“My own insurance company just acted as a physician to remove the meds that I need by blackmailing a kind-hearted pain doctor,” says Jennifer Nelson, who has suffered from Reflex Sympathetic Dystrophy (RSD) in her left foot for nearly two decades.

The “blackmail” Nelson refers to is a form letter her pain management doctor received from Blue Cross/Blue Shield of Michigan warning that opioids, benzodiazepines and a muscle relaxant named Soma (carisoprodol) should not be prescribed together. Benzodiazepines such as Valium act as sedatives and are known to increase the risk of overdose when taken with opioids.

But Nelson says she’s used them safely for years to reduce pain, muscle spasms and to help her sleep.   

“Their threat is to pull their coverage from his office if even one patient tests positive for both opioids and benzodiazepines. So now my health insurance has become Big Brother?” said Nelson in an email to Pain News Network. She also included a copy of the form letter sent to her physician.

JENNIFER NELSON

“There is no legitimate medical indication for this combination of controlled substances,” the letter from Blue Cross/Blue Shield (BCBS) says. “If the diagnosis is opioid abuse or dependence, the continued use of sedatives is contradicted and the continued use of opioid analgesics is against DEA regulations. If the diagnosis is legitimately chronic pain, benzodiazepines are still contradicted as they lead to a downward spiral of pain control and function.”   

The only downward spiral Nelson feels is from having her Valium tapered.

“The muscle spasms came back with a vengeance,” she says. “The second night I woke up and I thought someone was pulling my leg off.”

 “I am very concerned that an insurance company states there is ‘no legitimate medical indication’ for the combination of opioids, benzo's and Soma,” says Lynn Webster, MD, past president of the American Academy of Pain Medicine.

“No (insurance) payer nor the DEA should be making this type of dogmatic statement.  Such a statement will be used by the DEA to prosecute any provider who prescribes this combination.  It is inappropriate for either a payer or the DEA to determine what a legitimate medical indication is for any single or combination of drugs prescribed.”  

Webster agrees that combining benzodiazepines with opioids is risky, but says Blue Cross/Blue Shield went too far.

“What is most lacking from the letter is an alternative.  BCBS has a responsibility to offer alternatives to the providers on how to treat anxiety in people who also have pain and or opioid addiction and anxiety,” Webster wrote in an email to PNN.

“I agree the combination of opioids and benzos and other CNS depressants should be avoided, but if the payer wants to practice medicine then they should make it clear that they will pay for cognitive therapy and other alternatives as long as it is needed or pay for other medications that are not as risky as benzos. It is unacceptable to just abandon people with pain, anxiety and/or addiction.”

Aetna “Super Prescribers” Warned  

The insurance company Aetna sent a similar letter to nearly 1,000 physicians in August, warning them about their opioid prescribing habits. The doctors were identified as “super prescribers” by Aetna after a review of insurance claims.

"You have been identified as falling within the top 1 percent of opioid prescribers within your specialty," the letter states.

Aetna’s chief medical officer told The Washington Post the letter was not meant as a threat, but merely a note of caution.

"We're asking you to look at your practice...and identify if the way you're prescribing narcotics is best practice," said Harold Paz, MD. "And if it's not, here's an opportunity to improve."

Kaiser Permanente – an HMO -- is also urging doctors in its network to reduce opioid dosages to those recommended by the Centers for Disease Control and Prevention. The CDC’s guidelines say prescribers “should avoid increasing dosage” over 90 mg of morphine equivalent units a day.

“That dose does nothing for me,” says Scott Michaels, who at age 55 is permanently disabled by severe back pain, arthritis and other chronic illnesses.

Michaels has a genetic condition that causes him to metabolize opioids quickly. For seven years, he’s been taking a daily opioid dose of 330 mg of morphine equivalent units – nearly four times what CDC and Kaiser Permanente recommend as a ceiling.

“I have a terrible metabolism so the medication goes right through me, hence the high dose. As of last month, Kaiser is reducing me 10% a month until I’m at 90 mg. I have no choice they said. The pain is already coming back and they don’t care,” said Michaels, who asked that we not use his real name.

“Kaiser is an insurance company and provider. To me that is a conflict of interest. I just don’t know what to do. It can’t be legal to withhold medication that has proven for me to work.”

Jennifer Nelson was also on a high dose of opioids that is now being reduced by her doctor to reach the levels recommended by the CDC. She says her health has deteriorated significantly and she’s worried about become bedridden.

“I lived a very high functioning life. My biggest fear is my seven year old not having a Mom to walk him to the bus stop," Nelson says. “Nineteen years and I've never overdosed or used my meds incorrectly. I submit to random urine tests and pill counts, and educated myself on my meds. So what do we do? Can insurance companies legally threaten doctors like that? And why are they quoting CDC guidelines when doing so? I'm infuriated. Exhausted, unable to sleep, gritting my teeth in pain, but infuriated.”

Insurers say their efforts to wean patients off high doses of opioids are producing results. Blue Cross/Blue Shield of California says its Narcotic Safety Initiative has resulted in an 11% reduction in members using the very highest doses and “prevented” 25% of all new opioid users from using the drugs for more than 90 days.  

Will these new policies also reduce the number of people dying from opioid overdoses?

Blue Cross/Blue Shield of Massachusetts – one of the first insurers to adopt tougher prescribing policies – says it has reduced the dispensing of opioids to its members by 15 percent since 2012.    But the new policies failed to slow the growing number of opioid overdose deaths in Massachusetts, which more than doubled.

What Will Trump Election Mean for Pain Care?

By Pat Anson, Editor

The day after one of the biggest political upsets in American history, millions of chronic pain patients are wondering what a Donald Trump administration will mean for them.

President-elect Trump has repeatedly vowed to “immediately repeal and replace Obamacare,” but has not clearly defined what he would replace the Affordable Care Act with. Trump has also supported reductions in the supply of oxycodone, hydrocodone and other Schedule II opioids.

But perhaps the biggest change will be in leadership positions at federal agencies that set health care policies. That happens whenever a new administration takes office, but the changing of the guard this time will almost certainly mean the departure of several politically appointed administrators who played key roles in setting policies that many pain sufferers consider anti-patient.   

Health and Human Services (HHS) Secretary Sylvia Burwell – who presided over key policy decisions such as the CDC’s opioid prescribing guidelines and Medicare’s decision to drop pain questions from patient surveys – will be replaced.

Also likely to depart are CDC director Dr. Thomas Frieden, FDA commissioner Dr. Robert Califf, acting DEA administrator Chuck Rosenberg, and Surgeon General Dr. Vivek Murthy. All have endorsed policies harmful to pain patients.  

Murthy recently sent letters to over 2 million physicians urging them “not to prescribe opioids as a first-line treatment for chronic pain.”

Rosenberg has called medical marijuana "a joke" and recently tried to criminalize kratom as a Schedule I controlled substance, a move the DEA withdrew after widespread opposition from the public and some members of Congress.

In his short time as FDA commissioner, Califf has overruled some of the FDA’s own experts in endorsing the CDC guidelines and has instituted a series of policies at FDA aimed at reducing opioid prescribing.

Frieden’s departure from the CDC will likely lessen the influence of Physicians for Responsible Opioid Prescribing (PROP) at the agency. PROP founder Dr. Andrew Kolodny has a long association with Frieden, having worked for him when Frieden was commissioner of New York City’s Health Department. PROP President Dr. Jane Ballantyne continues to serve as a consultant to CDC, despite complaints that she has a conflict of interest.

The new heads of the CDC and DEA will be appointed by president-elected Trump, while the HHS Secretary, FDA commissioner, and the Surgeon General are nominated by the president and confirmed by the Senate.

According to Politico, one of the front runners to be nominated by Trump as HHS Secretary is Dr. Ben Carson, a former Republican presidential candidate and retired brain surgeon, who Trump has called a “brilliant” physician.

"I hope that he will be very much involved in my administration in the coming years," Trump said at a campaign rally.

Other names being mentioned for HHS Secretary are Florida Gov. Rick Scott, former House Speaker Newt Gingrich, and Rich Bagger, a pharmaceutical executive on leave from Calgene who is the executive director of Trump's transition team.

None of this means that a Trump administration will reverse any of the pain care policies at CDC, FDA and other federal agencies. Like most Republicans, Trump wants to reduce government regulations, not increase them. But as PNN reported last month, the president-elect has already indicated he supports measures to limit the supply of opioids.

“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 at a campaign rally in New Hampshire. “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 wants the FDA to speed up the approval of opioid pain medication with abuse deterrent formulas. And he wants to increase the number of patients that a doctor can treat with 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.

The president-elect has also pledged to stop the flow of fentanyl and other 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.” Trump said.

“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.”

Trump has personal dealings with addiction, having lost a brother to alcoholism at age 43. Watching the long downward spiral of his older brother Fred led Trump to a life-long aversion to alcohol, drugs and tobacco.

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.

Does Canada Need ‘Enforceable’ Opioid Guidelines?

By Pat Anson, Editor

Canada should adopt nationwide “enforceable guidelines” to limit the prescribing of opioid pain medication and doctors should be sanctioned if they fail to follow them, according to a new commentary in the Canadian Medical Association Journal.

The head of the Chronic Pain Association of Canada called the proposed guidelines “another sad effort to punish people with pain.”

Like the United States, Canada has been hit by a wave of opioid overdoses – deaths increasingly attributed to heroin and illicit fentanyl, not pain medication. According to one estimate, over 1,000 Canadians have died so far this year from fentanyl overdoses.

But, like its neighbor to the south, Canada has been trying to fix the opioid problem by restricting access to pain medication.

“This crisis is only getting worse, and Canada urgently needs to implement effective measures aiming at and addressing the underlying drivers of the opioid epidemic,” writes lead author Benedikt Fischer, PhD, of the Centre for Addiction and Mental Health at the University of Toronto.

Fischer and his two co-authors specialize in addiction, mental health and epidemiology, not in pain management.

“Evidence of the therapeutic effectiveness of prescription opioids for pain is rather limited. Data show some benefits for treatment of acute pain, but evidence to support using opioids to treat long-term chronic pain is weak and insufficient,” they wrote.

Only in passing do Fischer and his colleagues even mention the rising number of deaths in Canada being blamed on illicit fentanyl – a synthetic opioid 50 to 100 times more potent than morphine.   

They propose several measures similar to the opioid prescribing guidelines released by the U.S. Centers for Disease Control and Prevention:

• Prescribe opioids in “the lowest possible dose and for the shortest possible duration”
• Establish prescription drug monitoring systems across Canada
• Develop a “national surveillance system” for opioid-related overdoses and emergency room visits
• Expand access to opioid addiction treatment

One key difference from the so-called “voluntary” guidelines of the CDC is a recommendation that Canada adopt “enforceable guidelines” that would allow for opioids to be prescribed only as “an exceptional treatment” and only when there is “good scientific evidence” for their use.

The guidelines would be similar to professional medical standards recently adopted in British Columbia and Nova Scotia, which make physicians in those provinces liable for professional, civil or even criminal sanctions if they don’t follow them.

Critics say the guidelines are having a chilling effect on both patients and prescribers.

“Limiting prescriptions of opioids will do absolutely nothing to stop this problem and just the notice of intent has already made the problem for pain sufferers worse,” said Barry Ulmer, executive director of the Chronic Pain Association of Canada.

“They are forcing patients on high doses to come off their medications, stopping family doctors from actually working with patients who have been in their care for years, and even giving names of patients on high doses to the police as potential dealers. One doctor had his practice visited by police with 3 names of patients and took their files for investigation.”

Like the United States, Ulmer says the debate over opioids in Canada is being led by addiction treatment specialists, not by pain management physicians.

As an example, he cites this month’s National Opioid Conference in Ottawa, which is being hosted by Canada’s Minister of Health. The invited keynote speaker is David Juurlink, MD, an academic toxicologist at Sunnybrook Health Sciences Centre in Toronto, who is also a board member of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that played an influential role in drafting the CDC guidelines.

“It is not a conference on opioids, but an addiction conference or more probably an effort to restrict opioids or just prohibit them,” said Ulmer. “It is clear what direction they are going in when they invite Juurlink to be the keynote speaker and have not invited some of the preeminent doctors who are experts in the use of opioids. Tantamount to medical malpractice. They don’t want to talk about the illicit problem because that destroys their whole argument.”

Health Canada is currently conducting a review of Canada’s opioid prescribing guidelines, which have not been updated since 2010. The Centre for Addiction and Mental Health in Toronto – Canada’s largest addiction treatment hospital -- released a report today urging Health Canada to pull all high-dose opioid medications off the market, according to The Globe and Mail.

Medicare Pain Questions Being Dropped in 2017

By Pat Anson, Editor

Hospital patients will no longer be asked about the quality of their pain care under new rules released this week by the Centers for Medicare and Medicaid Services (CMS) for 2017.

Medicare uses a funding formula that rewards hospitals that provide good care and are rated highly in patient satisfaction surveys. Critics claimed that three questions in the survey asking patients about the quality of the pain care created a financial incentive for doctors to prescribe opioid pain medication to boost their hospital’s scores.

The three questions being dropped, which don’t even mention opioids, are as follows:

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?

CMS said it was still developing and field testing alternative pain questions to replace the ones being eliminated.

“Today’s final rule would address physicians’ and other health care providers’ concerns that patient survey questions about pain management in the Hospital Value-Based Purchasing program unduly influence prescribing practices," CMS said in a statement.

"While there is no empirical evidence of such an effect, we are finalizing the removal of the pain management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey… to eliminate any financial pressure clinicians may feel to overprescribe medications.”

The American Medical Association (AMA), one of the groups that lobbied CMS to drop the pain questions, applauded the move.

"CMS understands that these policies effect how physicians practice medicine and how patients receive treatment," said AMA President Andrew Gurman, MD, in a statement. "By listening to our concerns, CMS made clear that patient care was the top priority. We look forward to continuing to work with CMS to improve patient health and enhance access to affordable quality care."

CMS was under intense political pressure to drop the pain questions. Twenty-six U.S. senators sent a letter to Health and Human Services Secretary Sylvia Mathews Burwell claiming “physicians may feel compelled to prescribe opioid pain relievers in order to improve hospital performance."

Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group,also said the patient survey "fosters dangerous pain control practices."

But a top Medicare official disputed those claims in an article published in JAMA, saying “nothing in the survey suggests that opioids are a preferred way to control pain.”

Pain patients have long complained about the poor quality of their treatment in hospitals. In a survey of over 1,250 patients by Pain News Network and the International Pain Foundation, nine out of ten said patients should be asked about their pain care in hospital satisfaction surveys. Over half rated the quality of their pain treatment in hospitals as poor or very poor, and over 80 percent said hospital staffs are not adequately trained in pain management. 

What Grade Should Your State Get for Pain Care?

By Pat Anson, Editor

Millions of Americans who suffer from chronic pain are having trouble finding doctors, obtaining pain medication, and getting health insurance to cover their treatment. So imagine their surprise when a recent study gave passing grades to all 50 states for their pain care policies and said there was “an overall positive policy environment across the nation.”  

“We saw that report and were disgusted. At a time when chronic pain patients across the country are losing their medications and treatments to manage their pain, giving no state a grade below a 'C' is insulting,” said Amanda Korbe, who suffers from Reflex Sympathetic Dystrophy (RSD) and is a founder of Patients Not Addicts, a patient advocacy group.

“Achieving Balance in State Pain Policy” was released over the summer by the Pain and Policy Studies Group at the University of Wisconsin School of Medicine. The report looked at state laws and regulations in 2015 that governed drugs, prescribing and pain care practices.

“This evaluation is meant to identify relevant language in each state’s legislation or regulatory policies that have the potential to influence appropriate treatment of patients with pain, including controlled medication availability,” the study says.

The study gave 13 states an “A” for the quality of their pain care policies:  Alabama, Georgia, Idaho, Iowa, Kansas, Maine, Michigan, Oregon, Rhode Island, Vermont, Virginia, Washington and Wisconsin.

Thirty-one states were given B’s and the rest got C’s. No state was given a failing grade. A complete list of grades for all 50 states and Washington DC can be seen at the end of this story.

“I know that as an Oregon chronic pain patient, I can say my state does not deserve an 'A' right now. We have too many under treated patients, and too many that can't get care at all. For those of us that can't get proper pain management, these high grades are a slap in the face. It invalidates our experiences and struggles to get proper pain management,” said Korbe.

“Would pain management be in such a sorry state if these ‘grades’ actually meant anything? I personally think they are worthless,” said Janice Reynolds, a retired nurse, pain sufferer and patient advocate in Maine, which received an “A” grade.  

Rather than look at state policies and regulations, Reynolds said the study would be more meaningful if it examined whether opioids were being prescribed appropriately, if patients were having a difficult time finding providers, and if untreated pain was leading to more suicides.

“Every state would get a D or F if this was done,” she said.

Study Looked at Pain Policy, Not Practice

“To really look at this comprehensively, it requires a broader analysis to really get an understanding of things,” admits Aaron Gilson, PhD, the lead researcher for the study, which was funded by the American Cancer Society.

Gilson told Pain News Network the study only looked at state policies and regulations as they exist on paper – not how they were being implemented or even if they were effective.

“There’s not necessarily a 100% correlation between policies and practice. The policies in and of themselves don’t create barriers to pain management that we’ve identified. The grade that each state earned is really based on policies that can improve pain management for patients when put into practice,” he said.  

“Sound policy that's not implemented is only words wasted,” says Anne Fuqua, a pain sufferer and patient advocate, whose home state of Alabama was given an “A” grade.

“I'd give Alabama a 'C' for being better than the worst states like Ohio, Kentucky, Tennessee, Florida, West Virginia, Washington, and Oregon.  On paper the policy is excellent and it deserves the 'A' it gets. It just needs to be implemented.”

The study also didn’t look at insurance reimbursement issues or how doctors are responding to federal policies such as the CDC’s opioid prescribing guidelines, which were not released until this year and are having a chilling effect on both patients and doctors.    

Gilson said the methodology used to prepare the next pain care policy report – which was first released in 2000 – probably needs to be updated.

“That’s the first order of business in terms of continuing to do this, to really understand how policies have changed,” Gilson said. “I think it’s really time to examine the criteria that we use to see to what extent we might be missing policy because we’re not looking at the right thing, because barriers are erected in other ways than when we constructed this type of evaluation 16 years ago.”

Patient Survey Underway

One way to better understand those barriers is to simply ask patients what they are experiencing.

“Legitimate patients report the entire move to reduce (opioid) production and restrict prescribing is having a profoundly negative impact on their treatment protocols. Understanding how they are being impacted is important,” says Terri Lewis, PhD, a patient advocate and researcher.

Lewis is conducting a lengthy and detailed 29-question survey of pain patients to see how they are being impacted by efforts to reduce opioid prescribing. To take her online survey, click here.

Lewis will be able to breakdown the data state-by-state to get a real indication of how pain care policies and practices are being implemented.

“We will get that patient voice into this conversation,” she says. “Reports from patients are important and add value to the public conversation.  Reports will be analyzed and compared to months long data collection to look at trends, the impact of increasing restrictions, the fear of physicians to treat patients in this climate, and the influence of other factors like insurance restrictions and red flagging. This is a complex problem.”

SOURCE: PAIN & POLICY STUDIES GROUP, UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE

Unwilling to Suffer in Silence over Opioid Guidelines

By David Hendry, Guest Columnist

As an Army combat veteran, certified public accountant, law-abiding citizen and also a 70-year old arthritic, I am outraged by the restrictions imposed on primary care physicians for prescribing opioid pain medication.

The Centers for Disease Control and Prevention’s opioid guidelines are officially "voluntary" but have primary care physicians plainly scared about losing their licenses. My own physician, who has provided me with a low dose of Norco (and I have never asked for an increased dose), has suddenly found a host of reasons to discontinue it.

I listened carefully to this man I have known for years. He is not a very good liar. He is scared.

The "voluntary" guidelines seem to be saying to doctors: "Cooperate. We would not want anything to happen to your medical license, would we?"

That is the phrasing and logic of an extortionist.

How did Norco and heroin get lumped into the same set of statistics? I have even heard someone say, "Norco is a gateway drug to heroin.”

In fact, heroin has been a problem for decades. Actions to reduce its use have been ineffective and heroin has nothing to do with mild doses of relief for painful medical conditions that will never go away.

DAVID HENDRY

And how did I get statistically lumped in with addicts and criminals? The New England Journal of Medicine article "Reducing the Risks of Relief" acknowledges the opioid problem, but it is clear that there is not enough scientific evidence for such a "one size fits all" rule.

It is inhumane to remove pain relief and offer nothing as a replacement. Over-the-counter medications have their own problems and now we are told to go back to them? If they were effective, we would not need stronger medications.

The callous decision-makers (we're from the government and we are here to help!) exemplify the words of Francois de La Rochefoucauld: "We all have enough strength to endure the misfortunes of others."

We need a class action lawsuit to restore a reasonable balance between "pill mills" and the responsible use of narcotic pain relief. The class of people injured by the CDC guidelines and subsequent state-by-state actions include people like me, my wife (who suffers from post-polio syndrome), wounded veterans, and many others.

We are law-abiding Americans who recognize government over-reach and are unwilling to suffer in silence just because of a bureaucrat's decision.

David Hendry lives in Arizona. He has been a Chief Financial Officer and CEO for several mid-sized businesses. He also has a Master’s Degree in Health Care Management and a Master's in Education. David enjoys tennis, the outdoors and teaching, and is a proud Army combat veteran.

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 represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Indians Manager Battles Back from Chronic Pain

By Pat Anson, Editor

Cleveland Indians manager Terry Francona – who has led the Indians to their first World Series since 1997 -- has struggled for decades with chronic pain from knee, wrist and shoulder injuries.

His story is an inspirational one to pain sufferers who have also dealt with the stigma associated with chronic pain and the use of opioid pain medication.

Francona may be the front runner for American League manager of the year, but it wasn’t too long ago that he was barely able to walk after complications from knee replacement surgeries left him in severe pain with blood clots and staph infections.

His managerial career also seemed finished after rumors surfaced that he abused pain medication while managing the Boston Red Sox.

Francona was upfront about his health problems and use of painkillers like oxycodone and Percocet in his book with Dan Shaughnessy; “Francona: The Red Sox Years.”

“I think I probably should have died with all that happened,” Francona said of one extended hospitalization in 2002, when his right leg almost had to be amputated.

“There were a couple of nights in the hospital where I was thinking, I can’t take this anymore.  The nurses would come running in because I’d stop breathing. I was in bad shape. There were people around who did not think I was going to make it. I know I came real close to losing the leg.”

Pain medication helped him survive the ordeal.

TERRY FRANCONA

“I lived on it at that time,” Francona recalled in the book. “When I left the hospital, I was on heavy-duty drugs, and it was tough.”

Francona recovered and resumed his career as a baseball coach. In 2004, he was hired as manager of the Red Sox and led the team to its first World Series title in 86 years. They added a second title in 2007. Through it all, Francona was still in pain and taking so much medication he would sometimes joke about it. He also started hoarding pain pills.

When one of Francona’s adult daughters found a bottle in his home with 100 Percocet pills, she convinced her father to see a pain management specialist and enter a confidential drug treatment program managed by Major League Baseball.  

That was in 2011, the year Francona’s marriage and his career as Red Sox manager unraveled at the same time. A team that many predicted would win yet another World Series suffered an historic collapse. Stories surfaced about players drinking beer, eating fried chicken and playing video games in the clubhouse during games. Anonymous sources pinned much of the blame on Francona, who was unceremoniously dumped by the Red Sox at the end of the season.

“Team sources said Francona… appeared distracted during the season by issues related to his troubled marriage and to his health,” reported the Boston Globe. “Team sources also expressed concern that Francona’s performance may have been affected by his use of pain medication.”

Francona felt betrayed by the team and by the insinuation that he was an addict.

“I don’t have a drug problem, that’s pretty obvious. I don’t drink that much, but I joke about it a lot. Anybody that knew me knew that I had taken more painkillers in ’04, because my knees were shot,” he said.

Francona was hired as manager by the Indians in 2012 and has guided them to four consecutive winning seasons. The Indians swept Francona’s old club – the Red Sox – to win the American League’s divisional series this month. They went on to beat the Toronto Blue Jays to win the American League pennant and now face the Chicago Cubs in the World Series.

This is Francona’s 16th year managing in the big leagues. At 57, he doesn’t talk much about his health problems – preferring instead that the attention be focused on his players. In addition to pain medication, Francona reportedly takes blood thinning medication and wears compression sleeves on his legs to improve blood circulation.  

Fewer Pain Meds but More Overdoses in Massachusetts

By Pat Anson, Editor

Opioid prescribing fell by 15 percent for members of Blue Cross Blue Shield of Massachusetts after the insurer adopted policies that discourage the dispensing of opioid pain medication, according to a new analysis by the Centers for Disease Control and Prevention.

The CDC’s Morbidity and Mortality Weekly Report found that 21 million fewer opioid doses were dispensed to Blue Cross Blue Shield members from 2012 to 2015. But the new policies failed to slow the growing number of opioid overdose deaths in Massachusetts, which more than doubled during the same period.

The CDC said it will "take time" before overdoses start to decline.

“Reducing the level of opioid prescribing is a long term strategy to limit exposure to these drugs. Mortality outcomes would not be expected to change for several years after implementation, and impact would be complicated by the increasing supply of illicit opioids,” Courtney Lenard, a CDC spokesperson, said in an email to Pain News Network.  

"Long-term strategies like the one outlined in the report take time to make an impact and therefore no immediate impact can be expected during the first several years of program implementation. Assessing what happened before and after the policy at the mortality level is inappropriate."

Blue Cross Blue Shield (BCBS) of Massachusetts is the state’s largest insurer, with about 2.8 million members.

In 2012, the insurer adopted policies that discourage opioid prescribing by requiring doctors to develop treatment plans that consider non-opioid therapies; requiring pre-authorization for all opioid prescriptions after an initial 30 day supply; and limiting some pain patients to use of a single pharmacy.

The effect was immediate, with an average monthly decline of 14,000 prescriptions for both short and long-acting opioids.

Although cancer patients were exempt from the policies, there was a 9% decline in opioid prescriptions to BCBS members with a cancer diagnosis. The CDC attributed that to a “sentinel effect” in which doctors implement the same policies for all of their patients regardless of diagnosis.

“I think oncologists were becoming more thoughtful and maybe more vigilant about how much narcotics they were prescribing and I think that’s why we saw that decrease in cancer patients,” said Tony Dodek, MD, associate chief medical director for BCBS of Massachusetts. “We’ve only received one complaint about the program in terms of people having access to necessary pain medications.”

Like the CDC, Dodek said it may take years before the stricter prescribing policies start to have an impact on overdoses. So far the signs are not encouraging.

Opioid overdoses in Massachusetts rose from 698 deaths in 2012 to 1,659 deaths in 2015. The trend has continued in the first six months in 2016, with nearly a thousand opioid overdoses reported. Two-thirds of this year’s deaths were related to fentanyl, a synthetic opioid that is increasingly appearing on the black market. Illicit fentanyl is often combined with heroin and cocaine, or used in the manufacture of counterfeit pain medication.

MASSACHUSETTS DEPARTMENT OF HEALTH

“It’s not surprising to me that overdoses have not gone down because there is still a lot of drugs in circulation,” said Dodek. “What we did was slow the supply of new medication that’s in circulation. The fact is there is already way too much medication sitting in people’s medicine cabinets at home and that is what was available to start this epidemic.”

The Drug Enforcement Administration has said the U.S. is being “inundated” with counterfeit painkillers and there are anecdotal reports of some patients turning to street drugs for pain relief as opioid medication has become harder to get. But Dodek says it is recreational users – not pain patients – who are resorting to the black market.

“Any pain patient isn’t having access problems to getting opioids,” he said. “Those who may be using it for recreational purposes or for diversion probably are having a more difficult time (getting prescriptions). We still need to figure out what to do about illicit drugs, but I think decreasing the amount of prescriptions drugs will only be a good thing in the end.”

And what about the effect on pain patients as these policies are adopted? The CDC report ends with this telling statement:

“Finally, it is not known from these data how patient pain and function were affected by limiting access to opioid prescriptions.”