Veterans More Likely to Have Chronic Pain

By Pat Anson, Editor

Nearly one out of ten U.S. military veterans suffers from chronic severe pain, according to an extensive new survey that found the prevalence of pain higher in veterans than nonveterans, particularly in veterans who served during recent armed conflicts.

The survey by the National Institutes of Health provides the first national estimate of severe pain in both veterans and nonveterans.

The prevalence of severe pain – defined as pain that occurs "most days" or "every day" and bothers the individual "a lot" – was 9.1% for veterans and 6.4% for nonveterans.

“Our analysis showed that veterans were about 40 percent more likely to experience severe pain than nonveterans,” said Richard Nahin, PhD, lead author of the analysis.

“Younger veterans were substantially more likely to report suffering from severe pain than nonveterans, even after controlling for underlying demographic characteristics. These findings suggest that more attention should be paid to helping veterans manage the impact of severe pain and related disability on daily activities.”

The study is based on data from a survey of over 67,000 adults (6,647 veterans and 61,049 nonveterans) who responded to questions about the persistence and intensity of their pain. The vast majority of veterans were men (92%), while most of the nonveterans were women (56%). The survey did not identify any specific aspects of military service, including branch of the armed forces, years of service, or whether the veteran served in a combat role.

More veterans (65%) than nonveterans (56%) reported having some type of pain in the previous three months.  They were also more likely to have severe pain from back pain, joint pain, migraine, neck pain, sciatica and jaw pain.

Younger veterans (8%) were substantially more likely to suffer from severe pain than nonveterans (3%) of similar ages.

“These findings show that we still have much more to do to help our veterans who are suffering from pain,” said Josephine Briggs, MD, director of the National Center for Complementary and Integrative Health (NCCIH). “This new knowledge can help inform effective health care strategies for veterans of all ages. More research is needed to generate additional evidence-based options for veterans managing pain.”

Veterans Complain About VA Pain Care

The survey adds to the growing body of evidence that military veterans are more likely to suffer from physical and mental health issues, and that their problems are not being adequately addressed by the Veterans Administration, which provides health services to 6 million veterans and their families. According to a recent VA study, an average of 22 veterans commit suicide each day.

One of them was Peter Kaisen. In August, the 76-year old Navy veteran committed suicide outside a VA Medical Center in Northport, New York.  Kaisen’s widow told Newsday that her husband had chronic back pain, but VA doctors had told him there was nothing more they could do to ease his suffering.

According to a 2014 Inspector General’s study, more than half of the veterans being treated at the VA have chronic pain, as well as other conditions that contribute to it, such as depression and post-traumatic stress disorder.

In recent months, dozens of veterans have complained to Pain News Network that their treatment grew worse after the VA adopted the Centers for Disease Control and Prevention’s opioid prescribing guidelines, which discourage doctors from prescribing opioids for chronic pain.

“I am a Vietnam era veteran who has had testicular cancer, prostate cancer, hip joint cancer, and have been living with an inoperable spinal cord tumor,” wrote Tommy Garrett. “I cannot get the VA to prescribe OxyContin that civilian doctors have had me on for 17 years.”

“I received epidurals for 10 years and also I received pain medication for 6 years. The VA quit giving me epidurals and also took me off Vicodin,” said Mitch Kepner. “(Before) I was active and now I just lay around and do nothing wishing I was dead. I have no life, everything I do is a struggle. I don't want pity. I don't want compassion. I don't want (anything) from anybody. I just want Vicodin back so I can function.”

After several years of taking morphine to relieve pain from chronic arthritis, Vietnam veteran Ron Pence had his dosage cut in half by VA doctors – who want him to take Cymbalta, a non-opioid originally developed to treat anxiety. After reading about Cymbalta's side effects, Pence refused to take it.

“Why start something like that when what I was taking had no side effects for me and was working fine? I am sure the pills they are pushing will end in a lot more deaths and terrible disabilities and suffering,” wrote Pence in a PNN guest column.

“We are in one of the most advanced countries in the world medically, yet the doctors and politicians will not use that knowledge to ease pain and suffering. We have to find a solution.”

Misuse of Pain Meds by Teens Continues Decline

By Pat Anson, Editor

Two new studies this week paint a somewhat conflicting picture about the abuse of opioids by teens and pregnant women.

A survey of over 45,000 teens by the University of Michigan and the National Institutes of Health found that teenage drug abuse continues to decline, with a significant drop in the misuse of the painkiller Vicodin. A second study at the university found the number of babies born with opioid withdrawal symptoms has grown substantially, especially in rural areas.

The annual Monitoring the Future survey found that 4.8% of high school seniors had misused an opioid pain reliever in the past year, down from a peak of 9.5% in 2004. In the past five years alone, misuse of opioid pain medication by 12th graders has declined by 45 percent.

Only 2.9% of high school seniors reported the misuse of Vicodin in 2016, compared to nearly 10 percent a decade ago. Vicodin and other hydrocodone products were reclassified as Schedule II controlled substances in 2015, making them harder to obtain.

"Clearly our public health prevention efforts, as well as policy changes to reduce availability, are working to reduce teen drug use,”  said Nora Volkow, MD, director of National Institute of Drug Abuse.

The survey found a continued long-term decline in teenage use of many illicit substances, as well as alcohol and tobacco. The use of any illicit drug was the lowest in the survey’s history for eighth graders. One negative sign was an increase in the misuse of over-the-counter cough medicine by eighth graders.

Marijuana use in the past month by eighth graders fell to 5.4%, down from 6.5% in 2015. However, among high school seniors, nearly one in four reported marijuana use in the past month. There also continues to be a higher rate of marijuana use in the past year (38%) among 12th graders in states with medical marijuana laws.

"It is encouraging to see more young people making healthy choices not to use illicit substances," said National Drug Control Policy Director Michael Botticelli. "We must continue to do all we can to support young people through evidence-based prevention efforts as well as treatment for those who may develop substance use disorders.”

The majority of teens continue to say they get most of their opioid pain relievers from friends or relatives, either stolen, bought or given. The only prescription drugs seen as easier to get in 2016 than last year are tranquilizers, with 11.4 percent of eighth graders reporting they would be “fairly easy” or “very easy” to get.

More Babies Suffering from Opioid Withdrawal

The number of babies born with drug withdrawal symptoms from opioids grew substantially faster in rural communities than in cities, according to the University of Michigan study. The study did not distinguish between opioid pain medication and illegal opioids such as heroin.

Newborns exposed to opioids in the womb and who experience withdrawal symptoms after birth (neonatal abstinence syndrome) are more likely to have seizures, low birthweight, breathing, sleeping and feeding problems.

Researchers found that in rural areas, the rate of newborns diagnosed with neonatal abstinence syndrome increased from nearly one case per 1,000 births from 2003-2004 to 7.5 cases from 2012-2013. That's a surge nearly 80% higher than the growth rate of such cases in urban communities.

"The opioid epidemic has hit rural communities especially hard and we found that these geographical disparities also affect pregnant women and infants," says lead author and pediatrician Nicole Villapiano, MD, whose study was published in JAMA Pediatrics.

Using national data, researchers found that rural infants accounted for over 21 percent of all infants born with neonatal abstinence syndrome. In 2003, rural infants made up only 13 percent of the neonatal abstinence syndrome cases in the U.S.  

Maternal use of opioids in rural counties was nearly 70 percent higher than in urban counties. Rural infants and mothers with opioid-related diagnoses were more likely to be from lower-income families, have public insurance and be transferred to another hospital following delivery.

Villapiano says families in urban areas typically have better access to addiction treatment programs.

"We need to consider what kind of support moms with opioid disorders have in rural communities," she said.

Villapiano suggests that increasing the number of rural doctors authorized to prescribe the addiction treatment drug buprenorphine (Suboxone), as well as expanding rural mental health and substance abuse services, would be good first steps in reversing the trend in neonatal abstinence syndrome.

Cutbacks in Opioid Prescribing Are Not Working

By Pat Anson, Editor

Where is the evidence that reduced opioid prescribing is lowering rates of addiction and preventing overdose deaths?

Opioid prescribing has been in decline for years, but overdose deaths from heroin and fentanyl are soaring around the country, particularly in the East and Midwest. The Centers for Disease Control and Prevention reported this week that 33,091 people died from opioid overdoses last year, a 16% increase from 2014.

Most of the increase was attributed to heroin and illicit fentanyl. For the first time, deaths involving those illegal opioids now outnumber those from prescription opioids.

Yet doctors remain under enormous pressure from lawmakers, regulators, hospitals, insurers, medical societies and the media to reduce their opioid prescribing. Two recent examples come from healthcare providers in Pennsylvania.

Geisinger Health System, a large healthcare provider with nearly 1,600 physicians serving over three million people in Pennsylvania, is preaching the benefits of reduced prescribing.

"Opioids are not the answer," Mellar Davis, MD, a palliative care physician at Geisinger, said in a news release. "Chronic pain rehabilitation, exercise, cognitive behavioral therapies, acupuncture, yoga or tai chi are all better options than opioids.”

PinnacleHealth Medical Group, a smaller network of more than 200 primary care providers in central Pennsylvania, released an update on the opioid reduction program it began in 2014. Opioid prescribing by PinnacleHealth physicians has fallen by 20 percent, and a spokesperson says there is some evidence the program is helping to reduce overdoses in its coverage area.

“According to our internal data, our admissions for overdoses have declined in our primary zip codes.  This data was not tracked by what type of drug (prescribed or street) that led to the overdose,” Kelly McCall, public relations manager for PinnacleHealth said in an email.

“While the medical group initiative would not be the sole reason for this decline, as PinnacleHealth is part of several community wide initiatives to curb drug abuse, it does demonstrate that the reduction initiatives haven’t caused an increase in misuse of other drugs and has been part of multiple system-wide efforts to address drug misuse.” 

With so many doctors cutting back on opioid prescribing, overdose deaths in Pennsylvania should be falling, right?

Wrong.

According to a lengthy and detailed report by the U.S. Drug Enforcement Administration, drug-related overdose deaths increased by over 23 percent in Pennsylvania last year.

Heroin was involved in over half of those deaths (55%), followed by fentanyl (27%), cocaine (24%) and the sedative Xanax (21%).

Prescription pain medications such as oxycodone (19%) and hydrocodone (6%) play a relatively minor role in Pennsylvania’s overdose epidemic.

Sadly, Pennsylvania’s heroin and fentanyl crisis has only worsened in 2016. On a single day in Philadelphia last month, nearly 50 people overdosed on a “bad batch” of heroin that was most likely mixed with illicit fentanyl.

Pennsylvania lawmakers have responded to this crisis by going after pain medication. Governor Tom Wolf signed legislation last month that reduces the number of painkillers than can be prescribed in emergency rooms and to minors, establishes mandatory education in safe prescribing for doctors, and creates more drop-off locations for unused prescription drugs.

All of that is well and good – and may prevent some deaths – but there is no evidence that it will have much of impact on the overall problem. It also serves as a diversion from the real issue, which is fentanyl and heroin.

While it is often argued that many heroin users start out with prescription opioids, the vast majority are not legitimate pain patients. They obtained the pain meds illegally, used them non-medically, and got hooked. Taking opioids away from pain patients has not stopped people from using heroin or fentanyl – and it may actually be making the problem worse by forcing some patients to turn to streets drugs for pain relief.

But the head of the Centers for Disease Control and Prevention still sees the two problems as being "intertwined."

"The epidemic of deaths involving opioids continues to worsen," said CDC Director Tom Frieden, MD. "Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems. We need to drastically improve both the treatment of pain and the treatment of opioid use disorders."

“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,” Stefan Kertesz, MD, a primary care physician and an associate professor at the University of Alabama School of Medicine, recently told PNN. “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.”

It’s not just Pennsylvania that has gone down the wrong rabbit hole. In October, the CDC released a report complimenting Blue Cross Blue Shield for its efforts to reduce opioid prescribing in Massachusetts. The CDC said over 21 million fewer opioid doses were dispensed to Blue Cross Blue Shield members in the state from 2012 to 2015.

What happened to overdose deaths during that period? Fueled by fentanyl and heroin, opioid overdoses in Massachusetts more than doubled – which neither the CDC nor Blue Cross Blue Shield were all that eager to discuss.  The CDC told Pain News Network it will "take time" before overdoses start to decline and that “assessing what happened before and after the policy at the mortality level is inappropriate."

CDC Guidelines Causing "Passive Genocide"

The message is clearly going out to doctors around the country that they better cutback their opioid prescribing, even though reducing the supply of pain medication has had little or no impact on addiction and overdose rates. Some critics believe the CDC’s own prescribing guidelines, which discourage opioid prescribing for chronic pain, have actually caused more harm than good.

“The CDC guidelines have become an epidemic. More and more organizations and offices have signed on with them and people are being treated shamefully and unethically,” says Janice Reynolds, a retired nurse, pain sufferer and patient advocate. “These so called guidelines are a major part of the passive genocide of people living with pain. The stress related to them is also increasing the number of diseases and deaths we are seeing. I am sure if someone really looked at it, we would see more deaths from them than the so-called addiction epidemic.”

You would think medical organizations would be rising to defend pain patients from the anti-opioid hysteria, but just the opposite is happening. At a pain care summit this week in Washington DC, hosted by the physician’s group Alliance for Balanced for Pain Management, the focus was clearly on prescribing fewer opioids.

The keynote speaker at the summit was not a pain patient or even a pain doctor, but Ryan Leaf, a failed NFL quarterback who struggled for decades with painkiller addiction, and is now in recovery after serving a prison term for burglarizing homes for oxycodone and Vicodin. Hardly the poster child for responsible opioid use.

The Alliance also released a promotional video promoting the need for “multimodal analgesia,” which is described as a “personalized, multi-prong approach” to pain management that includes nerve blocks, epidurals, injections, physical therapy, acupuncture, massage and biofeedback, among other treatments.

Opioids are only mentioned in passing, with the caveat that “they are hardly the only pain treatment or the best treatment.”

Former Insys Executives Arrested for Bribing Doctors

By Pat Anson, Editor

The former CEO of Insys Therapeutics and five other former company executives have been arrested on federal charges of racketeering and bribing doctors to prescribe a potent painkiller off-label.

The arrests culminate a lengthy investigation into the Arizona drug maker, which has been accused of sordid sales practices that led to the overdose deaths of hundreds of pain patients.  

The fentanyl-based painkiller, called Subsys, has FDA approval for breakthrough cancer pain. The Insys executives allegedly bribed and gave kickbacks to doctors to prescribe the oral spray off-label for patients suffering from conditions such as joint pain and post-traumatic stress disorder.

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine.

“Patient safety is paramount and prescriptions for these highly addictive drugs, especially fentanyl, which is among the most potent and addictive opioids, should be prescribed without the influence of corporate money,” U.S. Attorney Carmen Ortiz said in a statement. 

Former CEO Michael Babich and the other Insys executives are also charged with misleading and defrauding insurance companies that were reluctant to approve payments for Subsys when it was prescribed for non-cancer patients. The company created a special “reimbursement unit” that was dedicated to obtaining prior authorization from insurers, often by falsely claiming they were for patients with medically urgent cancer diagnoses.

“As alleged, top executives of Insys Therapeutics, Inc. paid kickbacks and committed fraud to sell a highly potent and addictive opioid that can lead to abuse and life threatening respiratory depression,” said Harold Shaw, Special Agent in Charge of the FBI’s Boston Field Division.  “In doing so, they contributed to the growing opioid epidemic and placed profit before patient safety."

The Southern Investigative Reporting Foundation released a report last year, headlined “Murder Incorporated,”  that blamed aggressive sales practices at Insys for the overdose deaths of hundreds of pain patients.  CNBC also accused the company of “putting profits before patients as it makes millions off your pain.”

In June, federal agents arrested two Insys sales representatives for bribing doctors to prescribe Subsys. Some physicians were wined and dined at upscale restaurants in New York City, while others were taken to private tables at a strip club and given free drinks. According to the indictment, the salesmen were instructed to "expect and demand" that doctors hired by Insys to speak at promotional events prescribe "large quantities" of Subsys. The doctors obliged, prescribing over $5 million worth of Subsys in 2014, much of it billed to private insurers or Medicare.

Doctors are allowed to prescribe drugs for conditions not approved by the FDA, a practice known as off-label prescribing, but drug makers are not permitted to market or promote medications for off-label use.

According to Open Payments, a government website that tracks industry payments to doctors, Insys paid over $6 million to nearly 7,800 doctors last year for food, beverages, travel, lodging and speaker fees. The payments were 30 times more than what the company reported spending on research.

Subsys is a lucrative product for Insys and its biggest moneymaker. According to the Healthcare Bluebook, 30 spray bottles of Subsys currently cost about $5,600.

Abuse Deterrent Pain Medications Deserve Support

Barby Ingle, Columnist

It's no secret that the abuse of pain medication and illegal opioids has led to a growing public health problem across the country. The numbers are alarming and they are growing.

Also alarming is the number of people who suffer with chronic pain. According to the Institute of Medicine, one in three Americans – about 100 million people – have been affected with a condition that causes pain.

Since 2002, I have been battling Reflex Sympathetic Dystrophy (RSD), a progressive neuro-autoimmune condition that affects multiple systems in the body. The worst symptom for me is the constant burning fire pain. It feels like someone put lighter fluid in me, lit it, and I can’t put the fire out. I know firsthand how difficult the journey for pain relief can be, particularly the sidelong glances and disbelief from medical professionals.

The challenges are complex and multi-layered, and I always applaud solutions that help to balance pain management with the cost that prescription drug abuse has on society. Promising technological advancements in recent years are proving to be an important part of the battle.

Among these are so-called "abuse deterrent formulas" (ADFs) of commonly prescribed opioid pain medications that are being developed to prevent some of the deadliest forms of opioid abuse. The formulas generally make it harder to crush or liquefy pills for snorting or injecting.

These tamper deterring formulas of pain medications provide patients with the same pain relief as conventional opioids, but incorporate breakthrough technology designed to protect against tampering and abuse.

Since Purdue Pharma introduced a reformulated abuse deterrent version of OxyContin (oxycodone ER) in 2010, the “nonmedical” or recreational use of OxyContin has fallen dramatically.  

source: radars system

Several states are considering legislation in 2017 to improve patient access to these new abuse deterrent formulas of painkillers. As bills are introduced and updated, the International Pain Foundation and other pain organizations track them on our websites, put out action alerts and ask for the pain patient community to get involved by sharing their stories.

ADFs have received widespread support as part of a comprehensive effort to combat prescription drug abuse and promote appropriate pain management, including from the Office of National Drug Control Policy, the Community Anti-Drug Coalitions of America, members of Congress, and the National Association of Attorneys General — including California Attorney General Kamala Harris, who was recently elected to the U.S. Senate.

Abuse of pain medications has led to a growing public health problem nationwide. Each year approximately 4.5 million Americans use prescription pain medications for non-medical purposes, contributing to more than 14,000 overdose deaths annually.

To date, the Food and Drug Administration has approved abuse-deterrent labeling for seven drugs (OxyContin, Targiniq, Embeda, Hysingla, Morphabond, Xtampaza, and Troxyca), with two other abuse-deterrent opioids under review.

This technology is only part of the solution, but it is a solution nonetheless. Patients that have struggled with addiction or substance abuse in the past, those who live with others who are current or recovering addicts, and those who live with teens or young adults who may seek opioids for recreational use can all benefit from ADFs.

For the sake of those with legitimate, life-altering pain and for the safety of those prone to abuse these medications, I urge our lawmakers to stand up for policies that preserve and improve patient access to ADF technology.

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website.

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.

Surge in Fake Painkillers as Opioid Prescribing Drops

By Pat Anson, Editor

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

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

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

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

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

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

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

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

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

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

The DEA predicts the problem will only grow worse.

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

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

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

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

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

SOURCE OF PAINKILLERS USED NONMEDICALLY

SOURCE: DEA

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

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

Antibiotics Overprescribed More Than Opioids

By Pat Anson, Editor

Many pain patients report having trouble getting opioid pain medication prescribed by their physicians. So they may be surprised to hear about a new survey that found many doctors believe the overprescribing of antibiotics is a far bigger problem than opioids.

The random survey of over 1,100 members by the American College of Physicians (ACP) – most of them doctors who specialize in internal medicine -- asked them to identify two treatments frequently used by internists that are unlikely to provide “high value care” to patients.

The number one problem – identified by over 27% of the doctors -- was antibiotic prescribing, mostly for treating upper respiratory infections.

The second biggest problem was aggressive life support treatment for terminally ill patients (8.6%), followed by opioid medication for chronic pain management.

Only 7.3% of the doctors felt opioids do not provide high value care.

Dietary supplements (4.9%); statins (4.8%); proton-pump inhibitors (4.5%); cardiac procedures such as angioplasty, stents and catheters (3.5%); and antidepressants and sleep aids (3.4%) were also identified as treatments that often do not provide value.

"While many current clinical guidelines recommend appropriate care, the results of this survey may reflect intrinsic motivations to err on the side of treatment rather than 'doing nothing,'" said lead author Amir Qaseem, MD, Vice President of Clinical Policy at ACP. "However, as health care shifts to a value driven system, this study shows that doctors are willing to critically assess their own clinical practice."

Interestingly, non-pharmacological pain management -- mostly related to back pain -- was mentioned by 1.8% of the doctors as a treatment that provides little value. The Centers for Disease Control and Prevention recommends non-pharmacological treatment, such as physical therapy and cognitive behavioral therapy, as an alternative to opioids.

The study findings are being published in the Annals of Internal Medicine.

The ACP maintains a list of "high value care" recommendations to help doctors and patients better understand the benefits, harms, and costs of healthcare. Some expensive tests and treatments have high value, according to the ACP, because they provide high benefit and low harm. Conversely, some inexpensive tests or treatments have low value because they do not provide enough benefit and might even be harmful.

The ACP is the largest medical specialty organization in the United States. ACP members include 148,000 internal medicine physicians (internists), related subspecialists and medical students.

Opioid Pain Meds Rarely Involved in Suicide Attempts

By Pat Anson, Editor

Opioid pain medication is involved in less than 5 percent of the attempted suicides in the United States, according to a large new study of emergency room visits.

Researchers at Johns Hopkins University School of Medicine studied a national database of more than one billion emergency department visits from 2006 to 2013, and found that antidepressants and anti-anxiety drugs were far more likely to be used in an attempted suicide than opioid medication.

The findings appear to contradict numerous government and media reports suggesting that opioids play a significant role in the nation’s rising suicide rate.  A recent VA study, for example, found that veterans receiving the highest doses of opioid painkillers were more than twice as likely to die by suicide.

According to the Centers for Disease Control and Prevention, suicides in the U.S. increased by 31 percent over the past decade and are now the 10th leading cause of death. In 2014, nearly 43,000 Americans committed suicide, three times the number of overdose deaths that were linked to prescription opioids.

The Johns Hopkins researchers were puzzled to find that while suicides had risen, there was no corresponding increase in attempted suicides. Their findings are published in the journal Epidemiology and Psychiatric Sciences.

"What stood out to us the most is that while the rate of fatal suicide has increased, the overall rate of nonfatal suicide attempts has not changed much over the years, nor have the patterns -- age, sex, seasonality, mechanism, etc. -- changed much," said lead author Joseph Canner, interim co-director of the Johns Hopkins Surgery Center for Outcomes Research.

Canner and his colleagues analyzed over 3.5 million emergency department visits involving patients who were admitted for attempted suicide or self-inflicted injury. Poisoning was the most common means of injury, accounting for two-thirds of all suicide attempts. Benzodiazepines, anti-anxiety medication, tranquilizers and antidepressants were the most commonly used drugs.

Codeine, morphine, methadone and other opioid medications were involved in only 4.9% of the suicide attempts.

The study confirmed that suicide attempts peak during the spring, dispelling the popular myth that suicides increase during the holiday season. Attempted suicides actually decreased in November and December.

Over 80 percent of those who were admitted for a suicide attempt suffered from a mental health disorder, a broad category that includes depression, anxiety, substance abuse and alcohol disorders.

There have been anecdotal reports of suicides increasing in the pain community since the release of the CDC’s opioid prescribing guidelines in March, 2016. But the guidelines – and their impact on suicides – did not fall within the study period. Johns Hopkins researchers also did not study the relationship between chronic pain and attempted suicide.

“The study fails to reflect, evaluate or acknowledge suicides after the crackdown on opioid analgesics to relieve chronic and intractable pain,” said Twinkle VanFleet, a chronic pain sufferer, patient advocate and suicide survivor.

“Chronic pain sufferers are at a higher risk in contemplation, ideations, and actual attempts on their lives due to the CDC guidelines being developed without consideration to the suffering… inflicting fear in providers to prescribe and fear in patients to live.”

Earlier this year, VanFleet said she became suicidal due to her own undertreated pain. She sought help from two doctors and also went to an emergency room – and was sent away all three times without treatment.

“I still don't know why I'm still here,” she said.

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.