Tennant Patients Live in Fear of DEA

By Pat Anson, Editor

Deborah Vallier is living proof that high doses of opioid medication can safely relieve pain and improve quality of life. The 42-year old Michigan woman says her chronic back pain was so bad before she started getting high dose opioids that she contemplated suicide.  

“I was so bad that I spent most of my time in bed. I didn’t leave my house for almost two years, except for doctor’s appointments,” Vallier says.

After seeing over a dozen doctors in her home state and getting little pain relief, Vallier flew to California last April to see Dr. Forest Tennant, a prominent pain specialist. 

“Now, because of Dr. Tennant, I’m able to go to (my son’s) high school football games. I’m able to go to his wrestling matches. I actually have some of my life back, where I’m not stuck in bed and thinking about suicide.”

It was Tennant who diagnosed Vallier with adhesive arachnoiditis, a disabling, incurable and painful inflammation of nerves in her spine. Tennant put Vallier on a regimen of hormones and opioid  medication – a dose more than double the highest amount recommended by the Centers for Disease Control and Prevention, which is 90mg morphine equivalent dose (MED).

dr. forest tennant

“I would say I’m close to close to 200mg,” Vallier says.

That kind of high dose would be inappropriate – even dangerous – for most pain patients. But for Vallier and about 100 other intractable pain patients that Tennant sees, it’s not unusual at all. Tennant puts many on multiple medications that include opioids, anti-depressants, hormones, muscle relaxants and benzodiazepines, a class of anti-anxiety medication. Patients from 25 different states see Tennant and most consider him a life saver.

“I credit him with saving my life. Absolutely, no doubt,” says Dale Rice.

But to the Drug Enforcement Administration, those high doses of pain medication and multiple prescriptions to out-of-state patients are signs of criminal activity and drug diversion.  

In November, DEA agents raided Tennant’s home and pain clinic in West Covina, CA, using a search warrant that alleged Tennant was part of a drug trafficking organization and insinuated that his patients were selling their drugs on the black market. In early December, the DEA used another search warrant to raid Sunny Hills Pharmacy in Fullerton, CA, where 19 of Tennant’s patients get their prescriptions filled.

“I know based on my training and experience that patients traveling long distances to obtain controlled substance prescriptions is another ‘red flag’ of drug abuse and addiction. The out-of-state patients also received multiple opiate and benzodiazepine drug cocktails,” wrote lead DEA investigator Stephanie Kolb, who according to her LinkedIn profile was self-employed as a dog walker and pet groomer before she started working for the DEA in 2012.

“Either they’re extremely ignorant that patients have to travel out of state to find the top specialists, because no one in their area knows how to treat them, or they’re just trying to go after doctors and eliminate the ones that they see as a problem, the ones that are helping patients who  need high doses,” says Vallier. “We have failed all other treatments and there’s nowhere else to go. Why are they going after him?”

Judging by the search warrants, the medical experts hired by the DEA as consultants in the Tennant case seemed unfamiliar with the nature of his practice. In the Sunny Hills search warrant, Kolb quoted Dr. Timothy Munzing, a family practice physician who reviewed Tennant’s prescribing records.

dr. timothy munzing

Munzing noted that “many patients are traveling long distances to see Dr. Tennant” and thought it unusual that many were prescribed “extremely high numbers of pills/tablets.”

“I find to a high level of certainty that after review of the medical records… that Dr. Tennant failed to meet the requirements in prescribing these dangerous medications. These prescribing patterns are highly suspicious for medication abuse/and or diversion. If the patients are actually using all the medications prescribed, they are at high risk for addiction, overdose, and death,” Munzing wrote.

Munzing is an experienced family practice physician who has worked as a consultant for the DEA and the Medical Board of California for several years.

According to GovTribe, a website that tracks payments to federal contractors, Munzing is paid $300 an hour by the DEA to work as an expert witness and to review patient records. Munzing was paid about $45,000 by the DEA during the period Tennant's prescribing records were under review.   

Vallier says Munzing is not qualified to critique Tennant’s medical practice.

“This is almost like having a proctologist be the advisor for the American Dental Association. Just because he’s an MD does not mean he is trained for intractable pain,” she said.

‘I’m Afraid I’m Going to Die’

Tennant denies any wrongdoing, has not been charged with a crime and – after three years of investigation -- the DEA has not publicly produced evidence that any of his patients have overdosed, been harmed by his treatments, or that they are selling their drugs. Tennant’s clinic also remains open.

But the fallout from the DEA raids has frightened many of Tennant’s patients and left some without adequate medication. 53-year old Dale Rice used to get his prescriptions filled at Sunny Hills, but after the pharmacy was raided he was told to go elsewhere. Rice found another pharmacy in Rancho Cucamonga, but the pharmacist there is only willing to fill some of his high dose opioid prescriptions. Rice estimates he’s now only taking about half of his regular dose of opioids.

“I thought the hardest part was dealing with the insurance company, and now I can’t get a prescription filled,” says Rice, who suffers intractable pain from arachnoiditis, scoliosis, arthritis and failed back surgery. Like many of Tennant’s patients, Rice is also a rapid metabolizer of opioids and gets only a fraction of the pain relief other patients get from them.

“You pull the rug out from under me with all these medications and it’s hard on the body. Dr. Tennant told me I could die from adrenal failure, a stroke, a massive heart attack, anything like that,” Rice told PNN. “I’m afraid I’m going to die. I’m afraid I could drop dead right now.

“I predict by the end of the year I’ll be probably bedridden again, unless something changes.”

Another Tennant patient worried about her future is Trini Yeager, a 59-year old California woman who developed arachnoiditis after a failed back surgery and a misplaced epidural steroid injection into her spine. Once very fit and active, Yeager now has trouble walking and spends most of her day in bed.

“What’s going on is absolutely outlandish and just very corrupt in my opinion,” Yeager says. “I’m just shocked beyond belief that they would do this to Dr. Tennant.

“He is being crucified for cleaning up other doctor’s messes. That’s really what’s happening.”

Yeager takes multiple opioid medications at the highest doses available, and even then gets only limited pain relief. Asked what would happen if her dosage was brought within the CDC opioid guidelines, she spoke bluntly and without hesitation.

“I would commit suicide and I would post it publicly. And I would tell people that the DEA was responsible,” Yeager said. “The pain is so tremendous, I can’t even tell you. If they took my medications away or took them down, they would have a public suicide on their hands.”

Sunny Hills was one of 26 pharmacies recently targeted by the DEA in in “Operation Faux Pharmacy,” an investigation that focused on so-called rogue pharmacies in California, Nevada and Hawaii that the agency alleges “may have operated outside the bounds of legitimate medicine.”

The agency made a public show out of the pharmacy raids, inviting television cameras to record DEA agents hauling medical records out of one Southern California pharmacy.

"I don't prescribe medication, doctors prescribe medication," pharmacy owner David Rubin told KNBC-TV. "I'm not like one of those pharmacies you read about on TV. Everything is documented everything is crosschecked with the doctors."

"We only went after the pharmacies that we thought were prescribing or putting drugs on the street that had no obvious medical reason to do so," said David Downing, the special agent in charge of the investigation.

The DEA may just be getting started. Attorney General Jeff Sessions recently ordered all U.S. Attorneys to appoint “opioid coordinators” in their districts to monitor opioid prescriptions and to convene local law enforcement task forces to identify more doctors and pharmacies for prosecution.

Ironically, a few days after the raid on Sunny Hills, a teenage drug courier was caught in San Ysidro, CA at the Mexican border attempting to smuggle illicit fentanyl into the U.S. Nearly 78 pounds of fentanyl -- a synthetic opioid up to 100 times more potent than morphine -- were found hidden inside a 2010 Ford Focus. Experts say that is enough fentanyl to kill 17 million people --- or half the state of California. 

Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.  

10 Myths About the Opioid Crisis

By Roger Chriss, Columnist

There is no shortage of false statements being made about opioids. As the overdose crisis worsens, old and debunked claims reappear, while new claims rise up alongside them. Pundits, politicians and even physicians are perpetuating them, despite all evidence to the contrary.

So let’s set the record straight in order to promote an informed dialog about opioid medication, chronic pain, and the opioid crisis.

Myth 1: America has 5% of the world’s population but uses 80% of the world’s opioids.

Numerous politicians, such as Missouri Sen. Claire McCaskill and former New Jersey Gov. Chris Christie, as well as many journalists, have made this statement. It is demonstrably false.

In fact, the U.S. only uses about 30% of the world’s opioid supply. That estimate includes the addiction treatment drugs methadone and buprenorphine, both of which are opioids.

Myth 2: 80% of heroin addicts began by abusing prescription opioids.

This myth is pernicious because it is based on a kernel of truth. The number is correct but the implication is wrong. Only 4 to 6% of people who misuse prescription opioids go on to use heroin. And the number of people who start heroin without taking prescription opioids first has been rising in the past year.

Myth 3: Addiction starts with a prescription.

This claim persists despite decades of data to the contrary. A 2010 study found that only one-third of 1% of chronic pain patients without a history of substance abuse became addicted to opioids during treatment. Most abuse begins when people take medication that was not prescribed to them, using pills that were stolen, purchased illegally, or obtained from friends and family members.  

Myth 4: Opioid use leads to pain sensitization or ‘opioid induced hyperalgesia.’

Addiction treatment specialists like to repeat the claim that long-term opioid use makes patients hypersensitive to pain. But hyperalgesia is poorly understood and often confused with opioid tolerance. One study found that chronic pain patients on opioids had no difference in pain sensitivity when compared to patients on non-opioid treatments.    

Myth 5: Opioid overdoses are killing 64,000 people per year.

Nearly 64,000 Americans died from drug overdoses last year, according to the CDC, so that part is true. But opioids were involved in only about two-thirds of those deaths – and most of those overdoses involved heroin and illicit fentanyl.

Myth 6: Reduced opioid prescribing will end the overdose crisis.

Reduced prescribing is clearly not working.The number of opioid prescriptions has been in steady decline since 2010, yet fatal overdoses have risen sharply ever since.

Myth 7: Medical cannabis will cure the opioid crisis.

This is a recurring myth, made popular again in 2017. Unfortunately, not only does the recent data show that medical cannabis is not helping in states where it is legal, the underlying assumption of this myth is that chronic pain care is driving the opioid crisis. This is not the case.

Myth 8: Banning opioid medication will fix the opioid crisis.

This was put forth again early in 2017 by New Hampshire attorney Cecie Hartigan. Setting aside the problem of banning illegal drugs like heroin and fentanyl analogues (they are already banned), opioids are simply too medically useful to give up. Moreover, prior experience with drug bans, from Prohibition to the current overdose crisis, shows that bans do not stop misuse or addiction.

Myth 9: There are lots of ways to treat chronic pain

This myth has become increasingly popular as states, medical facilities, and health insurers pursue policies to reduce opioid prescribing. Although some of these methods, from physical therapy to spinal cord stimulators, may prove helpful, that misses the fundamental point. Chronic pain disorders are so horrible that all effective options, including opioid therapy, need to be on the table.

Myth 10: Opioids are ineffective for chronic pain.

This is the biggest myth of all. There is an abundance of high-quality research showing that opioids can be effective for some forms of chronic pain. Here’s a partial list of recent studies:

• Benefits and Risks of Opioids in Arthritis Management

• Opioids for chronic pain: new evidence, new strategies, safe prescribing

• The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain

• Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects

Adding to these studies is a recent review in Medscape, in which Charles Argoff, MD, a professor of neurology at Albany Medical College, said that “in multiple guidelines and in multiple communications, we have a sense that chronic opioid therapy can be effective."

New myths appear regularly, but these persist despite all efforts to counter them. Like an ear-worm or viral meme, they cannot be eliminated. The only defense is knowledge.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

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.

Tylenol for Postoperative Pain?

By Margaret Aranda, MD, Columnist

I saw them do it to our veterans. Now they were going to do it to me.

I heard the veterans scream decades ago, when I was president of a pre-med club at a VA hospital in Los Angeles. There was a little local anesthetic, no oxygen, no vital signs and no anesthesiologist. The hematologist-oncologist did the bone marrow extraction herself.

Now I was about to have the same procedure myself, to get an early diagnosis of mastocytosis, an orphan disease.  No one was going to tell me that I won’t hurt. The veterans fought in a war, yet they screamed.

After taking my vital signs, the intake nurse interrogated me, eyes peering over her bifocals.

“When was the last time you took OxyContin?” she asked.

(My thoughts: We never asked such a scrutinizing question. They could draw an opioid blood level, to “check” and see if I was telling the truth. Sure, my blood levels would be low, because it’s been a week. I’m not a drug addict. Big breath. Don’t let your thoughts get negative. Just get through this day.)

Postoperative pain was a big concern for me.

“What will I get for post-op pain?” I asked the anesthesiologist.

(My thoughts: I don't want to cry. I don't want to hurt. I've had a lifetime of pain, and I live with it daily. Sores pervade me. They are all over my head, itchy ones that feel like cold sores mixed with chicken pox. If I scratch one, they all itch, including the sores on my arms and back. How much worse is my life about to get?)

"Tylenol. No post-op opioids for pain," was his reply.

You bet my world crashed.

"I can't do Tylenol. I need to save my liver. Everyone knows the smallest dose of Tylenol can hurt the liver. Besides, I don’t want to lose my empathy. Studies show acetaminophen causes a lack of empathy,” I said.

“Ibuprofen,” was his answer.

(My thoughts: How much lower can my world crash? What the heck? Do you really know I’m a doctor, too? Do you know how many patients I’ve personally intubated through a GI bleed so they could breathe?)

“I can’t do ibuprofen,” I told him. “I can’t have a GI bleed. Or a heart attack. Or a stroke.”

“Oh, okay! Morphine and fentanyl, a mixture. Morphine lasts longer," the anesthesiologist said.

(My thoughts: I can breathe again. Now I have to be the perfect patient.)

The pathologist was cheery, polite and smiled a lot. We went over the pathology of mastocytosis, WHO classifications, the systemic vs. cutaneous forms, early diagnosis, and the bone marrow procedure I was about to have. He asked if I had enough opioids for post-op pain. I did. I concluded that he does not write his own pain prescriptions.

Once on the operating table, the surgeon caressed my head, patting it before I fell asleep. I inwardly smiled as I laid straight on my right side. Cold prep solution dripped down my lower back as I sunk into sleep.

The surgeon bore into the ileum, then sucked out the bone marrow with a syringe.

When I woke up, my butt was numb and I did not need any more pain medication. But I was not given a prescription for postoperative pain for when I went home. I was told to use my existing opioid prescription for pain, which is reasonable, as long as my doctor doesn't "count" them against me.

(My thoughts: How do patients defend themselves to get opioids for during and after surgery? I mean, I’m a doctor and I had to stick up for myself. What if the patient does not even know to ask about postoperative pain at all? They must wake up screaming, an insult to any anesthesiologist. What has happened to patient care?

They profession of anesthesiology has changed.

Dr. Margaret Aranda is a Stanford and Keck USC alumni in anesthesiology and critical care. She has dysautonomia and postural orthostatic tachycardia syndrome (POTS) after a car accident left her with traumatic brain injuries that changed her path in life to patient advocacy.

Margaret is a board member of the Invisible Disabilities Association. She has authored six books, the most recent is The Rebel Patient: Fight for Your Diagnosis. You can follow Margaret’s expert social media advice on Twitter, Google +, Blogspot, Wordpress. and LinkedIn.

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.

Fentanyl & Heroin Deaths Lead Soaring Overdose Rate

By Pat Anson, Editor

Deaths from drug overdoses soared by 21 percent last year in the United States, with fentanyl and heroin now playing a bigger role in the overdose crisis than prescription pain medication, according to a new report from the Centers for Disease Control and Prevention.

The report estimates that 63,600 Americans died from drug overdoses last year, up from 52,400 in 2015. The soaring overdose rate helped lower U.S. life expectancy for the second consecutive year. A baby born last year is expected to live 78 years and 7 months, about two months less than a child born in 2014.

"If we don't get a handle on this, we could very well see a third year in a row. With no end in sight," CDC researcher Robert Anderson told the Associated Press.

About two-thirds of the drug deaths in 2016 involved opioids, a broad category that includes not only pain medication, but heroin and synthetic opioids such as fentanyl that are increasingly available on the black market. Fentanyl is up to 100 times more potent than morphine.

Fentanyl and its chemical cousins were blamed for over 19,000 deaths last year, followed by heroin (15,500 deaths) and prescription painkillers (14,500 deaths).

In the chart below, fentanyl is included in the category of "synthetic opioids other than methadone," while "natural and semisynthetic opioids" includes pain medications such as oxycodone and hydrocodone.

SOURCE: CDC

The CDC’s new report may actually underestimate the number of people dying from fentanyl and heroin. CDC researchers relied on data from International Classification of Disease (ICD) codes on death certificates, which merely list the drugs that are present at the time of death -- not the actual cause of death.

A more reliable way to list the cause of death is through toxicology blood tests, which often find that multiple drugs are involved in overdoses. Florida, Massachusetts, Pennsylvania and several other states that conduct their own toxicology reports have found that fentanyl, heroin and anti-anxiety medications are responsible for far more overdoses than prescription opioids. A recent study found that fentanyl or fentanyl analogues were involved in over half of the overdoses in 10 states.

Another recent study of emergency room admissions found that heroin overdoses exceeded those from prescription opioids by almost a 2 to 1 margin.

President Trump's opioid commission recognized the need to improve the CDC’s drug overdose data when it released its final report last month.

"The Commission recommends the Federal Government work with the states to develop and implement standardized rigorous drug testing procedures, forensic methods, and use of appropriate toxicology instrumentation in the investigation of drug-related deaths. We do not have sufficiently accurate and systematic data from medical examiners around the country to determine overdose deaths, both in their cause and the actual number of deaths,” the commission found.

Although its own research shows that fentanyl and heroin are causing more overdoses than opioid medication, the CDC continues to focus on painkillers as the root cause of the overdose crisis.  As PNN has reported,  a public awareness campaign recently launched by the CDC only warns about the risks of prescription opioids, while completely ignoring the growing scourge of heroin and fentanyl.

But there is little evidence that awareness campaigns or prescription guidelines are reducing opioid addiction and overdoses, according to a recent op-ed in The New England Journal of Medicine.

"National trends show that we do not yet understand how to stem the tide of opioid overdoses by changing physicians’ prescribing practices. Although the volume of opioid prescriptions has fallen by 12% since its peak in 2012, the rate of overdose deaths continues to increase faster than ever, driven by an influx of potent synthetic opioids such as fentanyl. How and when decreased prescribing will translate into fewer deaths is unclear," wrote lead author Michael Barnett, MD, assistant professor of health policy management at the Harvard T.C. Chan School of Public Health.

"In the meantime, there is a real danger that aggressive opioid-prescribing policies could drive more people to use more dangerous injection opioids or force patients to live with inadequately treated pain. We simply do not know which policies will strike the right balance between promoting safe opioid use and avoiding unintended consequences."

One Million Australians Abuse Rx Drugs

By Pat Anson, Editor

Like the United States, Australia is struggling to find answers to a growing addiction and overdose crisis – and restricting access to opioid pain medication is the favored solution.

A new report by the Australian Institute of Health and Welfare (AIHW) found that a million Australians -- about 4.7% of the population – abused a prescription drug in 2016. That’s up from 3.7% in 2007.   

‘Over the past decade, there has been a substantial rise in the number of deaths involving a prescription drug, with   drug-induced deaths more likely to be due to prescription drugs than illegal drugs,’ said AIHW spokesperson Matthew James.

In 2016, there were 1,808 drug overdose deaths in Australia, but the leading cause was not pain medication. Benzodiazepines, a class of anti-anxiety medication that includes Xanax and Valium,  were involved in 663 overdoses -- compared to 550 deaths linked to opioid medications such as oxycodone and codeine.

Recent reports from Florida and Pennsylvania also show that overdoses linked to "benzos" outnumber those from pain medication, although you rarely hear about that in today’s anti-opioid climate.

Unlike the United States, where prescriptions for opioid medication have been in decline for several years, in Australia they rose by 24% from 2010 to 2015 – driven largely by a 60% increase in the rate of prescriptions for oxycodone.

Like their American counterparts, Australian regulators and health officials are responding to the overdose crisis by reducing access to opioid medication. Starting in February 2018, Australians will need a prescription for codeine, which is now widely available in over-the-counter analgesic and flu medications.  Australia is also introducing a national prescription drug monitoring system.

Economic despair and social isolation appear to be playing major roles in Australia's overdose crisis, just as they are in the United States. Earlier this year, a nationwide survey found that people living in remote, rural areas of Australia were almost twice as likely as those living in major cities to use pharmaceutical drugs for non-medical purposes.

“This finding also held true for Australians living in the most disadvantaged socio-economic areas, with 6 percent having recently misused pharmaceuticals compared with 4.2 percent of those in the most advantaged areas,” James said.

Australians who misused prescription drugs were also more likely to experience mental illness, chronic pain and psychological distress compared with those who did not misuse them. 

What’s the Difference Between Opiates and Opioids?

Rochelle Odell, Columnist

Like many of you, I use the words opioids and opiates interchangeably. I incorrectly thought one was singular and the other plural. It pays to look up definitions before using a word!

Merriam Webster defines opiate as “a drug containing or derived from opium and tending to induce sleep and alleviate pain.”  The first known use of the word “opiate” was in the 15th century. Natural forms of opiates include morphine, codeine, heroin and opium.  

Merriam Webster defines opioid as “possessing some properties characteristic of opiate narcotics but not derived from opium.”  Interestingly, the first known use of the word “opioid” was not until the 1950’s. Two of the most widely prescribed pain medications, oxycodone and hydrocodone, are opioids.

Just Believe Recovery, an addiction treatment center in Florida, has a straightforward explanation of the difference between opiates and opioids on its website:

“Opiates are alkaloids derived from the opium poppy. Opium is a strong pain relieving medication, and a number of drugs are also made from this source.”

“Opioids are synthetic or partly-synthetic drugs that are manufactured to work in a similar way to opiates. Their active ingredients are made via chemical synthesis. Opioids may act like opiates when taken for pain because they have similar molecules.”

But neither opiates or opioids make pain go away – what they do is temporarily block pain signals.  

"Both of these types of drugs alter the way that pain is perceived, as opposed to making the pain go away. They attach onto molecules that protrude from certain nerve cells in the brain called opioid receptors. Once they are attached, the nerve cells send messages to the brain that are not accurate measures of the severity of the pain that the body is experiencing. Thus the person who has taken the drug experiences less pain," is how Just Believe Recovery explains it.

The problem with this definition is that it fails to address why an addict uses heroin and other narcotics. It's not to relieve physical pain, it's for the euphoric effect or high. Big difference.

I can attest to that feeling. Years before I developed Complex Regional Pain Syndrome (CRPS), I was hit by a beginner snow skier, who caused a nasty spiral leg fracture. I screamed in pain for what seemed like hours, until a Demerol shot was given. It still hurt, a lot, I just didn't care that it hurt.

A week after the accident, I received a call from my orthopedist (who ultimately saved my left leg) informing me I must get to the hospital for immediate surgery. It turned out that my broken leg had not been reset and cast properly. A rod was inserted to correct the problem, but the post-op pain was excruciating.

I was on strong opioids for the next three weeks, until I had to go back to work and stopped cold turkey. I needed to work with a clear mind, and it was going to hurt whether I was at home or work. I had no cravings for pain medication and no addiction developed. Simply didn't need them.

However, after I developed CRPS and slowly titrated up on Dilaudid, the pain was different than it was from the broken leg. The relief obtained was not the "I don't care" reaction, but one of the pain is less, now I can do what needs to be done at work or at home. That’s the classic difference between acute, short term pain and chronic pain.

"When people use these medications only to treat pain as directed and for a short time, they are less likely to become addicted. Prescription drug addiction occurs when patients develop a tolerance for the level of medication they have been described and no longer get the same level of relief," is how Just Believe Recovery explains it.

"They may not have the same expectations for relief as their physicians and may equate the term ‘painkillers’ with the medication being able to take away all of their pain, while their doctor may be thinking in terms of pain management, which means bringing the pain to a level where they can function at a reasonable manner. When expectations do not match, patients may take more of the pain medication than prescribed to get a higher level of relief and in turn develop a drug addiction issue."

The CDC and several states have now decided to establish what acute pain is and how long it should be treated with opioids, be it three or five or seven days.

But if you suffer from a chronic pain disease or condition, a few days’ supply won’t cut it. You require the medication long term in order to function. Not addicted mind you, you just want the pain at bay. We all know pain medication does not “kill” the pain. It just becomes tolerable. Most pain patients do not increase their pain medication and many, including me, have been on stable doses of opioids for many years.

We also know pain patients are not the driving force in today's misguided opioid crisis or public health emergency or whatever you wish to call it. Illicit drug users are, and they are primarily young adults who snort, smoke or inject heroin and illicit fentanyl. Many are addicts who are in methadone clinics, and they still abuse not only the methadone but other drugs as well.

It's like everyone in power or who is affiliated with rehab has blinders on. Pain patients have become the issue, yet statistics clearly show we are not the problem. The rate for opioid abuse in pain patients is at or less than 5 percent.  Why are patients singled out in this battle?  Even the CDC admits opioid prescriptions are no longer the driving force in the overdose crisis. I believe they never were.

Opiates and opioids are not the same, and should be addressed separately. Instead, they have become interchangeable. We don’t have a heroin or opiate epidemic; we have an “opioid epidemic.”  The government usually lumps them together as one. And, as we all know, what the government decides somehow becomes set in stone.

Rochelle Odell lives in California. She’s lived for nearly 25 years with Complex Regional Pain Syndrome (CRPS/RSD).

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.

Medicare Paid Millions for Bogus Lab Tests

By Fred Schulte, Kaiser Health News

Five years ago, Companion DX Reference Lab hoped to cash in on cutting-edge genetic tests paid for by Medicare.

The Houston lab marketed a test to assess how a person’s genes affect tolerance for drugs such as opiates used to treat chronic pain. It also ran DNA tests to help treat cancer and urine screens to monitor drug abuse.

But the lab went bust last year after Medicare ordered it to repay more than $16 million for genetic tests health officials said were not needed.

Companion Dx is one of at least six clinical labs mired in bankruptcy court after Medicare alleged they improperly billed the government for unnecessary urine, genetic or heart disease tests expected to cause hundreds of millions dollars in losses to taxpayers, an investigation by Kaiser Health News found.

As the nation’s bill for drug and genetic tests has climbed to an estimated $8.5 billion a year, there’s mounting suspicion among health insurers that some testing may do more to boost profit margins than help treat patients.

Medicare has slashed fees for urine tests and tightened coverage of some genetic screens, which can cost Medicare $1,000 or more per person. Private insurers, who mostly have paid these bills without question, also are taking a more penetrating look at spending on the controversial lab work.

Yet, getting these firms to repay Medicare and private insurers remains a formidable challenge. While some doctor-owned labs have dodged collection efforts for years, several testing firms deeply in debt to Medicare appear to have few assets to repay overcharges dating back years, court records show.

COURTESY PAIN EXHIBIT

“Medicare shouldn’t be paying for dubious tests, but the time to catch that is in the very beginning when [labs] are asking for payment,” said Steve Ellis, vice-president of Taxpayers for Common Sense, a budget watchdog group. “They need to increase oversight so the dollars don’t go out the door in the first place.”

A spokesman for the federal Centers for Medicare & Medicaid Services (CMS) had no comment. Neither did the Department of Justice, which represents the government’s interests in court.

Labs can run a range of genetic and drug tests using a saliva sample, blood or urine specimen. The price tag to Medicare can mount quickly, especially when doctors order highly specialized tests for large numbers of patients. Two bankrupt labs that federal officials say routinely overused tests to detect rare heart ailments in the elderly, for instance, could end up owing the government a total of more than $200 million, court records show.

Some labs have kept operating in bankruptcy while others liquidated equipment and sold off assets. Several bankruptcy trustees, whose duty is to ferret out assets, are suing suppliers, insurers and some doctors to recover funds.

Whether they can raise the pile of cash needed to repay Medicare is doubtful.

Companion Dx, according to bankruptcy records, had $117,497 cash on hand at the end of September. Medicare is seeking the return of $16.2 million paid to the company for services “not considered medically necessary,” according to a January court filing.

The Texas lab had no comment, but in court filings has blamed its collapse on disagreements with Medicare over the merits of its tests and government audits that retroactively disallowed claims. Medicare pays only for services it deems “medically necessary,” and audits typically take many years to complete.

Companion Dx opened in January 2012 expecting to “capture favorable profit margins that existed in connection with this cutting edge technology,” the company wrote in its bankruptcy filing.

However, starting in 2013, Medicare began having second thoughts about the validity of some tests and ultimately decided to cover them on just 1 percent of patients, according to the company. The lab declared bankruptcy in July 2016. The case is pending.

Iverson Genetic Diagnostics Inc. is another lab that turned to bankruptcy court as Medicare tried to reclaim $19.7 million, court records show. The case is pending.

Medicare took aim at the Seattle firm in November 2013 after reviewing “numerous” complaints of billings for genetic tests that patients “had not actually received,” federal officials wrote in a court filing.

A later federal audit concluded that Iverson had charged Medicare for tests that were “not reasonable and necessary.” In September 2015, about two months after Medicare called for the refund, the lab filed for bankruptcy.

Iverson denied overbilling Medicare and is appealing the Medicare decision, which it said in a court filing “was not based upon sufficient or proper evidence.” And Iverson denied wrongdoing in court filings.

Neither the lab, now located in Charleston, S.C., nor its lawyers would comment.

‘No Cash Left’

In another case, Pharmacogenetics Diagnostic Laboratory LLC in Louisville exited bankruptcy in late October without repaying Medicare $26.3 million for disallowed genetic tests. The lab, set up in 2004 by two University of Louisville professors, strongly disputed Medicare’s findings but said they were the “primary reason” for the bankruptcy, court records show.

Charity Neukomm, a lawyer for the lab, said another medical group agreed to purchase all its assets “free and clear of liens.” That left nothing for the government.

There’s also little chance that Natural Molecular Testing Corp., a defunct genetic testing lab, will repay the $71 million it owes Medicare, according to John Kaplan, an attorney for the bankruptcy trustee.

Kaplan said the lab near Seattle, which opened in 2010, was “printing money from billing Medicare” until the government suspended payments in April 2013. The company filed for bankruptcy in 2013 in the face of a Medicare audit of its billing and concern over its business practices, such as paying some doctors who ordered its tests as much as $10,000 a month in consulting fees, according to court records.

Five years in, the bankruptcy case is expected to settle next year, but there’s likely to be “no cash left” to repay Medicare, Kaplan said.

Critics argue that Medicare has been slow to assess the benefits of new and controversial tests and technologies — even when soaring costs signaled a warning of possible overuse.

Spending on genetic testing, for example, shot up from about $167 million in 2013 to more than $466 million a year later, according to Medicare billing data. In 2015, the program spent about $317 million on the tests and some $165 million last year. Government auditors credit tighter oversight for the sharp decline in billing.

Ellis, the budget watchdog, said the “huge jump” in these bills should have “sent out a red flag.”

Medicare officials don’t routinely verify that the sales claims labs make to doctors are rooted in scientific evidence. Some labs have hawked genetic tests as a tool for making pain management safer. The labs contend the tests can pinpoint the proper drugs and dosage for each patient based on their genetic makeup, thus reducing the threat of overdose or other injury.

However, many experts argue that the science hasn’t caught up to the sales pitch — and that some high-priced tests may do little to diagnose or treat illness.

Genetic tests “are not ready for prime time,” said Charles Argoff, professor of neurology at Albany Medical College in New York. He said their impact on medical care “hasn’t been measured.”

Court records show that the legal battles to recover assets from failed labs often plod on for years, especially when trustees believe labs paid illegal fees or other kickbacks to persuade doctors to order dubious tests.

“Some of these cases never go away,” said David Schumacher, a Boston health care lawyer who has defended doctors against these claims. Still, he said that even after years of legal wrangling Medicare often is unlikely to “be made whole and fully repaid.”

The trustee for Heart Diagnostic Laboratory, which marketed a panel of blood tests to detect heart disease and other illnesses before its June 2015 bankruptcy, has filed more than three dozen lawsuits to recover money paid to doctors and medical offices, including suspect consulting fees.

“Our analysis is that all of these payments were tainted and therefore we’re entitled to go after them,” said Richard Kanowitz. He added: “It’s an uphill battle.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Teen Misuse of Rx Opioids at Historic Lows

By Pat Anson, Editor

Misuse of opioid pain medication by American teenagers is at an historic low, according to a nationwide survey that also found prescription painkillers have become increasingly harder for teens to obtain.

Nearly 44,000 students in 8th, 10th or 12th grade were questioned about their drug use in the University of Michigan’s annual Monitoring the Future (MTF) survey. Overall, the number of teens drinking, smoking and abusing drugs is at the lowest level since the 1990’s, although marijuana use spiked upward in 2017.

While the so-called opioid epidemic continues to make national headlines, misuse of prescription painkillers by teenagers has been steadily falling for over a decade.

The survey found that 4.2% of 12th graders used “narcotics other than heroin” in the past year, down from 9.4% in 2002.

Only 35.8% of high school seniors said the drugs were easily available in the 2017 survey, compared to more than 54 percent in 2010.

“We’re observing some of the lowest rates of opioid use that we have been monitoring through the survey. So that’s very good news,” said Norah Volkow, MD, director of the National Institute on Drug Abuse. "The decline in both the misuse and perceived availability of opioid medications may reflect recent public health initiatives to discourage opioid misuse to address this crisis."

The misuse of the painkiller Vicodin continues a decade long decline, falling to 2.9% of high school seniors in 2017. That’s down from 10.5% of seniors in 2003. Similar declines were reported in the misuse of OxyContin.

Marijuana use by teenagers rose by 1.3% to 24 percent in 2017, the first significant increase in seven years.

“This increase has been expected by many,” said Richard Miech, lead investigator of the study. “Historically marijuana use has gone up as adolescents see less risk of harm in using it. We’ve found that the risk adolescents see in marijuana use has been steadily going down for years to the point that it is now at the lowest level we’ve seen in four decades.”

For the first time, the survey asked students about vaping.  Nearly 28 percent of high school seniors said they had used a vaping device in 2017. A little over half said the mist they inhaled was "just flavoring," about a third said they inhaled nicotine, and 11% said they vaped marijuana or hash oil.

After years of steady decline, binge drinking appears to have hit bottom. Nearly 17 percent of 12th graders said they had five or more alcoholic drinks in a row sometime in the last two weeks. That’s a lot, but it's down from 31.5% in 1998.

Painkillers Raise Risk of Obesity and Hypertension

By Pat Anson, Editor

Commonly prescribed painkillers such as opioids and gabapentinoids  -- a class of pain medication that includes Lyrica and Neurontin – significantly raise the risk of obesity and high blood pressure, according to a large new study published in PLOS ONE.

British researchers analyzed health data on over 133,000 people, comparing the Body Mass Index (BMI), waist circumference, blood pressure and sleeping habits of patients taking pain relievers to those who did not. The study is believed to be the largest to look at the effects of painkillers on overall health.

“In the last two decades there has been a significant increase in the number of people being prescribed both opioid and non-opioid medications to treat chronic pain,” said lead author Sophie Cassidy, PhD,  a research associate at the Institute of Cellular Medicine, Newcastle University. “We already know that opiates are dependency-forming but this study also found patients taking opiates have the worst health. Obesity rates are much higher and the patients reported sleeping poorly.”

Those taking opioids were 95% more likely to be obese, 82% more like to have a “very high” waist circumference and 63% more likely to have hypertension compared to the control group.  

“There could be a number of possible mechanisms by which opioids might be associated with weight gain. Sedation might decrease physical activity and therefore reduce energy expenditure, those in our cohort taking opiates were less active, and those taking both opiates and other sedative drugs were the least active. Opioids have also been shown to alter taste perception with a craving for sugar and sweet foods described,” Cassidy wrote.

“These results add further weight to calls for these chronic pain medications to be prescribed for shorter periods.”

Patients who took gabapentinoids were also more likely to be obese, have a bigger waist and higher blood pressure compared to those not taking the drugs.

Gabapentinoids are commonly prescribed as alternatives to opioids to treat neuropathy, shingles and fibromyalgia, although many patients complain about side effects such as weight gain, depression and anxiety.

As PNN has reported, gabapentinoids are also coming under scrutiny because they are increasingly being abused. Lyrica (pregabalin) and Neurontin (gabapentin) are being reclassified as controlled “Class C” substances in the UK, following a spike in the number of deaths involving the medications.

Last week, the West Virginia Board of Pharmacy designated gabapentin as a “drug of concern,” after overdoses in the state involving gabapentin rose from 36 deaths in 2012 to 106 in 2016.  Ohio, Pennsylvania and Kentucky have also reported increases in fatal overdoses involving gabapentin.

12 Myths About Opioid Pain Medication

By Ryle Holder, PharmD, Scott Guess, PharmD, and Forest Tennant, MD, Dr. P.H.

Myth #1: Above 100mg of morphine equivalence, opioid pain medications are ineffective. NONSENSE! They have no ceiling in most patients and may remain effective at dosages in the thousands.

Myth #2: All pain patients who take over 100mg of morphine equivalence are diverting or selling part of their prescription allotment. NONSENSE! Most patients who have a bad enough pain problem to need this much opioid don't usually want to part with it.

Myth #3: All patients who use the "Holy Trinity" of an opioid, benzodiazepine, and muscle relaxant are either selling their drugs or will shortly overdose. NONSENSE! The original "Holy Trinity" was a simultaneous ingestion of a combination of the short-acting drugs hydrocodone (Norco), alprazolam (Xanax), and carisoprodol (Soma). A different, long-acting drug from either of these 3 classes (opioid, benzodiazepine, muscle-relaxant) markedly lowers the risk. So does taking the drugs separately.

Many severe, centralized pain patients have to take a drug from the 3 classes and do it safely and effectively. In other words, they take the drugs "as prescribed."

Additionally the “Holy Trinity,” originally called the “Houston Cocktail,” is a term coined by law enforcement. Addicts tend to use monosyllabic terms to refer to their poison of choice; “Holy Trinity” has too many syllables.

Myth #4: Centralized, intractable pain doesn't exist. NONSENSE! Much research documents that pain from an injury or disease may cause glial cell activation and neuroinflammation, which may destroy brain and spinal cord tissue. Multiple, high dose drugs may be needed to prevent tissue damage and control the immense pain that this condition may produce. As inflammation develops, the overall stress on all organ systems increases dramatically, occasionally to a life-threatening level.

Myth #5: The risks of an opioid dosage over 100mg of morphine equivalence are too great to prescribe opioids above this level. NONSENSE! If a severe, chronic pain patient can't find control with opioid dosages below 100mg or with other measures, the benefit of the high dose far outweighs the risks.

Myth #6: Overdoses occur even if opioids and other drugs are taken as prescribed. NONSENSE! If this even happens, it is extremely rare. Overdose victims often take alcohol, marijuana and other drugs in combination, but opioids and the prescribing doctors are always blamed.

Myth #7: There are no "proven" benefits to long-term opioid therapy. NONSENSE! Simply talk to someone who has taken them for 10-20 years. Never has there been, nor will there ever be, a double-blind, placebo-controlled study to provide "evidence." Opioids are a last resort when all else fails. Opioids in doses >100mg have improved quality of life and prevented death in some instances.

Myth #8: Chronic, severe or intractable pain is just a nuisance that doesn't warrant the risk of opioids. NONSENSE! Severe pain has profound detrimental effects on the cardiovascular, immune, endocrine (hormone) and neurologic systems. Pain must be controlled or pain patients may die of stroke, heart attack, adrenal failure or infections due to a suppressed immune system.

Myth #9: Genetics has no effect on the need for a high opioid dosage. NONSENSE! Bigger and heavier people need a higher dose of medications (just add 1 drop of food coloring to a 1 gallon bucket and then a 5 gallon bucket and observe). It is well documented that some genetic variations impede opioid metabolism to the active form of the drug, or increase the speed the body excretes the opioid. Both metabolic variations will require a higher dosage.

Myth #10: All pain patients can get by on standard opioid dosages under 100mg. NONSENSE! There are persons who are outliers with all disease conditions such as heart failure, diabetes and asthma. Same with pain. A few unfortunate individuals will always require high dosages. Remember our friend the bell curve? What if YOU were on the extreme end?

Myth #11: All patients started on opioids some time ago can just suddenly stop opioids. NONSENSE! Once a person is on high dose opioids they don't dare suddenly stop, because sudden withdrawal may cause hypertension, tachycardia, adrenal failure, and sudden heart stoppage. Some patients who have stopped too suddenly have committed suicide because they had no way to control pain. Montana reports that 38% of all suicides in the state are pain patients, many of them undertreated.

Myth #12: There are plenty of alternatives to opioids. NONSENSE! Common pain problems are generally mild to moderate and respond to a variety of non-opioid treatments. Unfortunately, there are some severe, intractable pain patients who can only control their pain with opioids.

Forest Tennant is a pioneer in pain management who operates a pain clinic for intractable pain patients in West Covina, CA. His clinic was recently raided by DEA agents.

Ryle Holder is a Georgia pharmacist and patient of Dr. Tennant. Scott Guess operates an independent pharmacy  and clinic in Atascadero, CA that specializes in pain management.

This column was distributed by Families for Intractable Pain Relief, a project of the Tennant Foundation.

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.

Study Advocates Guidelines for Postoperative Pain

By Pat Anson, Editor

Patients recovering from gallbladder surgery need only about a third of the opioid painkillers that are prescribed to them, according to a small new study that could lay the groundwork for new national guidelines on treating postoperative pain.

Researchers at the University of Michigan looked at prescribing data on 170 people who had their gallbladders surgically removed in a laparoscopic cholecystectomy and found that the average patient received an opioid prescription for 250mg morphine equivalent units. That's about 50 pills.

But when the researchers interviewed 100 of those patients, the amount of opioid medication they actually took after their surgeries averaged only 30mg, or about 6 pills. The remaining pills were often left sitting in their medicine cabinets for years.

"For a long time, there has been no rhyme or reason to surgical opioid prescribing, compared with all the other efforts that have been made to improve surgical care," says lead author Ryan Howard, MD, a resident in the U-M Department of Surgery who began the study while attending the medical school.

"We've been overprescribing because no one had ever really asked what's the right amount. We knew we could do better."

When U-M surgical leaders heard about the findings, they gave Howard and his colleagues permission to develop a new prescribing guideline that recommended just 15 opioid pills for gallbladder patients.

Five months later, the average prescription for the first 200 patients treated under the guideline dropped by 66 percent -- to 75mg morphine equivalent units. Requests for opioid refills didn't increase, as some had feared, but the percentage of patients getting a prescription for “safer” non-opioid painkillers such as acetaminophen or ibuprofen more than doubled.

Interviews with 86 of the patients who received the smaller prescriptions showed they had the same level of pain control as those treated before -- even though they took fewer opioid painkillers. A new education guide for patients counseled them to take pain medication only as long as they have pain, and to reserve the opioid pills for pain that's not controlled by ibuprofen or acetaminophen.

"Even though the guidelines were a radical departure from their current practice, attending surgeons and residents really embraced them," said U-M researcher Jay Lee, MD. "It was very rewarding to see how effective these guidelines were in reducing excess opioid prescribing."

Researchers estimate that implementing the new guideline has kept more than 13,000 excess opioid pills out of circulation in the year since the rollout began. Their findings were published in JAMA Surgery.

U-M researchers have expanded on their efforts by developing prescribing guidelines for 11 other common surgeries, including hysterectomies and hernia repair. They believe the guidelines could serve “as a template for statewide practice transformation” and could be adopted nationally as well.   

It’s a common misconception that many patients become addicted to opioid medication after surgery. According to a recent national survey, one in ten patients believe they became addicted or dependent on opioids after they started taking them for post-operative pain. But a recent study in Canada found that long term opioid use after surgery is rare, with less than one percent of older adults still taking opioid pain medication a year after major elective surgery.

Another fallacy is that leftover pain medication is often stolen, sold or given away. The DEA says less than one percent of legally prescribed opioids are diverted.

Many patients are dissatisfied with the quality of pain care in hospitals. In a survey of over 1,200 patients by Pain News Network and the International Pain Foundation, 60 percent said their pain was not adequately controlled in a hospital after a surgery or treatment. And over half rated the quality of their hospital pain care as either poor or very poor.

Former California Lawmaker Charged in Wife’s Suicide

By Pat Anson, Editor

A former California lawmaker has been charged with helping his wife -- who suffered from chronic back pain -- commit suicide last year.

Steven Clute allegedly provided his wife Pamela with a handgun so she could kill herself. He is charged with felony aiding a suicide and will be arraigned tomorrow. Medically assisted suicide is legal in California for terminally ill patients, but suicide by firearm is not permitted.

Pamela Clute was 66 when she killed herself on the morning of August 21, 2016 at the couple’s home in Palm Desert. According to the Desert Sun, her husband found his wife with a gunshot wound and called 911, telling the dispatcher she suffered from severe pain and wanted to end her life.

"Steven said he had given Pamela the revolver as an option to end the pain she was going through based on a previous discussion they had about using the revolver as an option," an arrest declaration released Monday said.

It is not clear what new evidence emerged since the suicide or why the Riverside County District Attorney waited over a year to file charges.

PAMELA CLUTE

Friends and acquaintances of the Clutes said there were rumors of a suicide but didn’t know the cause of Pamela’s death until recently, according to The Press Enterprise. The autopsy report now says she died from a gunshot wound.

steven clute

Pamela Clute was a well-known math professor at the University of California, Riverside. Her husband is a former Navy pilot who served in the California state assembly from 1982 to 1992. The couple had been married for 40 years.

Defense lawyer Virginia Blumenthal told the Associated Press that Clute, who is 69, would plead not guilty at his arraignment.

"You have to understand that everyone around here knows how much in love he was with her," said Blumenthal, who was friends with the Clutes. "They were always together. They were very much in love with each other."

The case is similar to the sad story of Jay Lawrence, a chronic pain sufferer who committed suicide earlier this year with the help of his wife Meredith after his opioid pain medication was cutback.

“I bought the gun that Jay used -- and yes, we talked about the ramifications of that action,” Meredith Lawrence wrote in a PNN guest column. “We went to the park where we had renewed our vows in 2015.  We talked in the car for a while, and then we sat in the same place we had cut our wedding cake.  I was holding his hand when he pulled the trigger.”

Meredith was arrested and charged under Tennessee’s assisted suicide law. She pleaded guilty to a reduced charge of reckless endangerment and is currently on probation.

“I know Jay wanted me to put his story out there.  I know he wanted people to know what it was like to live with the pain he lived with daily. When the doctor took away Jay’s medications, they took away his quality of life. That was what led to his decision,” Meredith wrote.

“Something has to be done to wake up the doctors, insurers and regulators to make them see pain patients as real people. People with husbands, wives and children that love them.”

Canada’s ‘Deeply Flawed’ Opioid Guideline

By Pat Anson, Editor

Just six months after adopting an opioid prescribing guideline modeled after the CDC's guideline in the United States, they’re already having second thoughts in Canada.

An editorial published in the Canadian Medical Association Journal says the guideline is “deeply flawed,” may have contributed to several deaths, and has created “a climate of fear” among doctors and patients.

Like the opioid guideline released by the Centers for Disease Control and Prevention in 2016, the Canadian version strongly recommends that patients not receive opioid doses in excess of 90mg morphine equivalents daily (MED), and that patients receiving a higher dose by tapered to the “lowest effective dose” or stop getting opioids altogether.

“The Guideline neglects to warn physicians that tapering can put patients at high risk for overdose, because patients will lose tolerance, experience distressing withdrawal symptoms, and turn to other sources for their opioid,” warns lead author Meldon Kahan, MD,  director of addiction treatment at Women’s College Hospital in Toronto.

Kahan helped write Canada’s 2010 opioid guideline, which recommended a much higher ceiling of 200mg MED.  He says the current guideline fails to address addiction or how to treat opioid use disorder with medications such as buprenorphine and methadone.

“By not discussing these treatments, the Guideline encourages physicians to manage opioid addiction through tapering, which is usually ineffective and sometimes dangerous,” wrote Kahan.

“The Guideline is contributing to a climate of fear around opioid prescribing. We are aware of several instances of death following rapid tapering or abrupt discontinuation. The Guideline needs extensive revision to ensure patient safety; until this is done, the medical community and medical regulators must not use the Guideline as the standard for opioid prescribing.”

Over 50 clinicians, academics, patients and “safety advocates” helped draft the Canadian guideline. Among them were three board members of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that played a key role in drafting the CDC guidelines: PROP Vice-President Gary Franklin, MD, Mark Sullivan, MD, and David Juurlink, MD.

One major difference between the Canadian guideline and the CDC’s is that the latter is only intended for primary care physicians, while Canada’s guideline applies to all prescribers, including family physicians, pain specialists and nurse practitioners.

Nearly 1 in 5 Canadians suffer from chronic pain and Canada has the highest rate of opioid prescribing outside the United States. Opioid prescribing peaked in the U.S. in 2010, but prescriptions are still trending upward in Canada. A report released last week by the Canadian Institute for Health Information shows that the total number of opioid prescriptions rose by nearly seven percent between 2012 and 2016, although fewer pills are being prescribed.

Opioid overdoses are soaring in Canada, as they are in the United States, but increasingly the deaths involve illegal opioids such as heroin and illicit fentanyl, not prescription painkillers.

Minnesota’s Tough New Guideline

Canada may be having second thoughts about its guideline, but Minnesota appears close to adopting even tougher rules for prescribers – which would arguably be the most draconian anywhere in the United States.

The draft guidelines released last week by the Minnesota Opioid Prescribing Work Group (MOPWG) would limit new opioid prescriptions for acute, short-term pain to just three days’ supply and a total of no more than 100mg MED – meaning the average daily dose would be less than 34mg MED.

Treatment for acute pain that lasts longer – for up to 45 days – would be limited to a total of 200mg MED every 7 days. Prescriptions would also have to be obtained weekly.

Daily doses for chronic pain lasting longer than 45 days would be limited to 90mg MED – if a patient is able to get them at all. The guideline specifically discourages doctors from prescribing opioids for fibromyalgia, migraine, “uncomplicated” back pain, and just about every other chronic pain condition. It also strongly recommends that  doctors discuss tapering with patients on long term opioid therapy, "regardless of their risk of harm."

“Opioid analgesics should not be used to manage chronic pain. There is very limited shorter-term evidence on the efficacy of opioids for chronic pain management and a growing body of evidence of significant harm associated with use,” the MOPWG said in a statement.

The MOPWG was chaired by Chris Johnson, MD, an outspoken critic of opioid prescribing who is a board member of PROP, as well as the Steve Rummler Hope Foundation.

“If pain doctors still think these medicines are effective, then they have a lot of explaining to do and their competence and professionalism deserve to be challenged,” Johnson said a few months ago.

If opioids are prescribed long term, Minnesota's guidelines recommend that doctors evaluate a patient’s mental health, as well as any history of physical or emotional trauma. The guidelines claim that patients with a history of trauma are more likely to develop chronic pain.

“Patients with chronic pain tend to report higher rates of having experienced traumatic events in their past, compared to people without chronic pain. A traumatic event is an event (or series of events) in which an individual has been personally or indirectly exposed to actual or threatened death, serious injury or sexual violence,” the guideline states.  

“Traumatic events illicit a number of predictable responses, including anxiety, physiological arousal and avoidance behaviors. A growing body of evidence finds that individuals who have experienced trauma may develop a persistently aroused or reactive nervous system. When confronted with an acute injury or pain following a surgical procedure, people whose nervous systems are already in a state of persistent reactivity due to a past trauma may be more likely to transition for acute to chronic pain.”

If adopted, Minnesota’s draft guideline would only apply to patients covered by the state’s Medicaid programs. However, they are expected to influence all prescribers, as well as insurance company policies and state regulatory boards. The guideline is available for public review and comment for the next 30 days.

Are My Good Years Over?

By Louis Ogden, Guest Columnist

My story is a follow-up to the guest column by Kimberley Comfort that was recently published here in Pain News Network.

I am also a patient of Dr. Forest Tennant and, after reading Kimberley’s heart-felt story, I immediately felt compelled to write mine.  I am currently 67 years old and, much like Kimberley, my problems with pain started during childhood.

kristen and louis ogden

The pain waxed and waned until I was in my mid-20’s, when it became a daily part of my life.  I tried very hard to ignore the pain and remained in denial until many years later. I did not even tell my wife at the time. I did realize that I was consuming way too much Excedrin and was aware of the dangers posed by taking too many NSAIDs. 

I went to several doctors seeking help in the 1980s, but none of them could find anything wrong with me.  I worked through the pain until it became impossible for me to continue doing the physical work required of an electrician. The pain was body-wide, but the worst pain of all was constant, crushing headaches that were absolutely paralyzing. 

Deciding that I must change careers, I returned to college.  I was accepted at James Madison University and enjoyed college life so much that after graduation I decided to stay in academia and teach.  I received an academic scholarship to Syracuse University, but was not able to finish my Master’s thesis due to the excruciating pain, an inability to concentrate, and the severe chronic fatigue that often accompanies extreme pain.

Then I started searching again for a doctor that could help me.  My initial diagnosis was fibromyalgia.  I asked that doctor if there were anything he could give me for the pain and his exact words were, “Yes, I could, but you would be a junkie within two weeks.”  He offered no medication or treatment of any kind. 

I kept trying doctor after doctor, and almost every therapy and medication known to science. Nothing helped.

My search finally took me to Dr. Tennant in 2010.  He is considered one of our country’s foremost experts on pain and the prescribing of opioids, having operated a pain clinic in West Covina, CA since 1975.  He is also the Editor Emeritus of Practical Pain Management, a monthly medical journal about pain.  His current research interests are inflammatory markers and the role of hormones in pain care.   He is a frequent speaker at major pain conferences. 

How could I possibly go wrong by having this expert in pain as my doctor? 

When I first saw Dr. Tennant in 2010, he was very blunt with me and told me that I might not live much longer.  By then my severe chronic pain had given me high blood pressure, which can cause heart failure or stroke.  In addition, my lab results were not good.  Dr. Tennant told me that my pain had “centralized” -- meaning that I had suffered the pain so long that it had become my normal state.  Pain that has not centralized will be sporadic, while centralized pain is constant.

DR. FOREST TENNANT

I suffer from a post-viral autoimmune illness that first presented years ago with symptoms similar to fibromyalgia, arthritis, and myalgic encephalomyelitis.  Dr. Tennant began treating me with opioid medication and titrated me to a higher dose to effectively manage my pain.  I had been on a standard dose, but Dr. Tennant found through genetic testing that I have a genetic anomaly that makes me a poor metabolizer of many medications.  This is why I required a high-dose therapy. 

Here is where I differ from Kimberley Comfort.  She metabolizes her medications so rapidly, that she could not reach a level of comfort on a standard dose.  My problem is the opposite – I am a very poor metabolizer -- but the outcome is the same.  We both require high doses to properly treat our pain. 

After years of debilitating constant pain, I began feeling much better.  Opioid medication not only did a good job of relieving the pain, but along with hormone supplements and anti-inflammatory drugs, they also improved my quality of life, allowing me to do things now that I could not do before.  It may sound trite, but this man “gave me my life back.”

In late 2015, I was diagnosed with cancer, the onset of which may have been facilitated by my overall disease state.  More recently, imaging has shown that I have abnormalities of the cervical spine that likely contribute to my continuing complex array of symptoms.  Like most of Dr. Tennant’s patients, I am an outlier – a patient whose complex disease state places me far outside the usual patient, in terms of severity and resulting disability and pain.  I believe that I would probably not be alive today without the thorough assessment, evaluation, diagnosis and treatments provided by Dr. Tennant. 

Now, the DEA has raided his office and seized all of his patients’ records.  I have read the search warrant and was very surprised to find that a family practice physician (not a pain specialist) had advised the DEA. Dr. Timothy Munzing suggests in the warrant that any patient from out of state receiving high-dose prescriptions for opioids must be selling their medications because they could not take those doses and survive.  That is absolutely not true. I’ve been taking these high doses for seven years and have had the best seven years of my adult life. 

Dr. Tennant’s practice is in California and I live in Virginia, so imagine how I feel now. I am quite frankly scared to death of having my door kicked in, my medications seized, and then going into serious withdrawal.  At my age and my level of pain, I could die along with many other patients of Dr. Tennant.  How can the DEA practice medicine?  They have no medical license.  These decisions should be made by the doctor and the patient. 

Dr. Tennant recently received a Lifetime Achievement Award for Pain Medicine from his colleagues at PainWeek.  In making the presentation, Dr. Kevin Zacharoff described Dr. Tennant as “the kind of doctor that listens, digests, and most importantly, invests in every patient, the patient's problems, and those of society."  Zacharoff describes him as “the true doctor's doctor," a term used in years past to mean the kind of physician other physicians would want to seek out for their own medical care.  

Why doesn’t the DEA understand what pain physicians and patients understand about Dr. Forest Tennant?

Louis Ogden and his wife Kristen live in Virginia. Kristen volunteers in Dr. Tennant’s pain clinic and recently wrote a column about why it is such a “special place” for patients and their families.

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.

Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.  

Chronic Pain and Depression Common in Overdoses

By Pat Anson, Editor

People who die from opioid overdoses are significantly more likely to suffer from chronic pain and depression, according to a new study that highlights the risk of combining opioid pain relievers with benzodiazepines, a class of anti-anxiety medication.

Researchers at Columbia University Medical Center analyzed over 13,000 overdose deaths among Medicaid patients and found that over 61 percent had been diagnosed with back pain, headaches or some other chronic pain condition. Many also suffered from depression, anxiety, bipolar disorder, schizophrenia and other mental health problems.

Significantly, nearly half of those with chronic pain (49%) filled a prescription for opioid pain medication during the last 30 days of their lives, and just over half (52%) filled a prescription for benzodiazepines. Prescriptions for anti-depressants, anti-psychotics and mood stabilizers were also common.

“This medication combination is known to increase the risk of respiratory depression, which is the unusually slow and shallow breathing that is the primary cause of death in most fatal opioid overdoses," said Mark Olfson, MD, a professor of psychiatry at Columbia and lead investigator of the study.

“Most persons with opioid-related fatalities were diagnosed with one or more chronic pain condition in the last year of life. As compared to people with opioid-related deaths without diagnosed chronic pain conditions, the decedents with chronic pain diagnoses were more likely to have also received substance use and other mental health disorder diagnoses. They were also more likely to have filled prescriptions for opioids, benzodiazepines, and other psychotropic medications and to have had a nonfatal drug overdose.”

The Columbia study included opioid overdoses linked to both pain medication and illegal opioids such as heroin, but was limited to Medicaid patients who died between 2001 and 2007. Since that time, opioid prescribing has declined, while illegal opioids and counterfeit medication have become increasingly available on the black market.

Public health officials have only recently started warning about the risks of combining opioids with benzodiazepines, and some insurers now refuse to pay for the medications when they are prescribed jointly.

A recent study of overdose deaths in Florida found that benzodiazepines such as Xanax and Valium killed nearly twice as many Floridians in 2016 as oxycodone. Another study in Pennsylvania also found that overdose deaths involving benzodiazepines exceeded those from opioid painkillers.

The Columbia study was published online in the American Journal of Psychiatry. The study was funded by the Agency for Healthcare Research and Quality, the National Institute on Drug Abuse, and the New York Psychiatric Institute.