Senator’s Letter Ignores Constituent’s Chronic Pain

By Pat Anson, Editor

Pain News Network received hundreds of comments and emails from readers responding to the open letter we published from Charles Malinowski, a 59-year old California man who suffers from Reflex Sympathetic Dystrophy (RSD) and other chronic pain conditions.

Malinowski is no longer able to obtain opioid medication and blames the CDC opioid guidelines for his “unspeakable and crippling pain.”

CHARLES MALINOWSKI

“Within 60 days I expect that the CDC will have effectively killed me. I honestly don't see myself being able to tolerate the pain any longer than that,” Malinowski wrote in his letter. “Congress, in going along with this blindly, will be explicitly complicit in this negligent homicide - or homicide by depraved indifference, take your pick.”

Malinowski’s letter to Senator Kamala Harris (D-CA) hit home with many readers, who say they’ve been abandoned by doctors who are fearful of prescribing opioid medication.  

“You are correct in saying the CDC is in effect murdering us. I too suffer from chronic pain and am unable to obtain pain meds from a doctor due to CDC guidelines,” wrote one reader.

“I just read your letter and cried all the way through it. My son in law will turn 50 this month and has been living with RSD for over 8 years. His story is a carbon copy of yours. Since the change in his meds about a month ago, (he) is now showing signs of heart trouble,” wrote Jo Ellen.

“Charles you are not alone and this attack on pain patients is affecting every pain patient nationwide,” wrote Pam. “This is terrorism at its finest folks. How many more pain patients will die due to a fictitious opioid epidemic?”

“I’m stuck in bed suffering inhuman pain 24-7 days a week. I’m lucky I have sanity now to write this. For 17 years I was under the watchful eye of a very educated doctor. Now abandoned by all in the medical field,” wrote Christine.

“This exact thing happened to my husband. He unfortunately passed away from a heart attack 6 months later,” wrote Sharon. “I pray your letter falls into the correct place to save your life and many others that are now in the same situation.”

And what about Sen. Harris, who Malinowski wrote his letter to?

She sent him a form letter that completely ignored his severe pain and life-threatening situation. It focused instead on combating opioid abuse and treating addiction.

“Thank you for reaching out to me to express your concern about the opioid crisis,” Sen. Harris wrote. “This administration and Congress must treat opioid abuse as a public health crisis. We need more funding to combat the opioid epidemic that is threatening millions.”

Malinowski replied to Sen. Harris with a second letter.

“I was very disappointed to discover that your response to me was an apparent boilerplate letter about continuing the already out-of-control hysteria over the so-called opioid epidemic,” Malinowski wrote. “My letter had nothing to do with controlling the illicit dispersal of opioids.

SEN. KAMALA HARRIS (D-CA)

"My letter was about the new CDC opioids guidelines being a literal death sentence for people like me. This is a literal death sentence because medication we depend upon is being withheld from us in a grossly and medically irresponsible manner. How you could have completely missed the blatantly obvious topic of my letter and responded so completely off-topic is simply beyond me. I think your response was shamefully ignorant and completely irresponsible.”

Unfortunately, this is not the first time we’ve heard from patients who wrote to their senator or congressman about the poor state of their pain care and gotten a form letter in response about the “opioid epidemic.” Which is no reason to stop trying or holding politicians accountable.  

“I want to hear from you. Contact me,” Sen. Harris says on her homepage. 

PNN tried to contact you, Sen. Harris. We emailed, called and left messages at your offices in Washington and Los Angeles several times in the last two weeks. Not only were we unable to speak to anyone on your staff, we couldn't even get someone to answer your phone. And we have yet to get a reply.

Neither has Charles Malinowski.  

(Update: On January 26, I finally received a reply from Sen. Harris.  But her emailed letter was yet another misdirected form letter. It thanked me for reaching out "to share your views opposing abortion."   

Tom Petty Overdosed on Opioids and Anxiety Medication

By Pat Anson, Editor

Tom Petty died from an accidental overdose caused by a potent cocktail of opioid painkillers, anti-anxiety medication and an anti-depressant that the singer was taking for chronic pain and other illnesses, according to autopsy findings and family members. Two of the drugs detected were illegal fentanyl analogues.

The 66-year old rock legend died last October after suffering cardiac arrest and collapsing at his home in Malibu. He had just completed a grueling tour to mark the 40th anniversary of his band, Tom Petty and the Heartbreakers.

In autopsy results released Friday, the Los Angeles County Coroner listed Petty’s cause of death as  "multisystem organ failure due to resuscitated cardiopulmonary arrest due to mixed drug toxicity."

Toxicology tests showed the presence of two prescription opioids (oxycodone and fentanyl), as well as two benzodiazepines (temazepam and alprazolam) for anxiety and the anti-depressant citalopram. Doctors have long warned that such a combination of prescription drugs can be deadly, leading to respiratory depression and overdose.

In addition, the coroner also listed two chemical cousins of fentanyl: acetyl fentanyl and despropionyl fentanyl. They are not prescription drugs, but are illegal synthetic opioids increasingly appearing on the black market in counterfeit medication.  The brief statement by the coroner did not point this out, nor did it list the blood levels at which any of the drugs were detected.

TOM PETTY

Petty’s wife Dana and daughter Adria released a statement saying the singer was prescribed "various pain medications for a multitude of issues including fentanyl patches," and that he suffered from emphysema, knee problems and a fractured hip.

“Despite this painful injury he insisted on keeping his commitment to his fans and he toured for 53 dates with a fractured hip and, as he did, it worsened to a more serious injury. On the day he died he was informed his hip had graduated to a full on break and it is our feeling that the pain was simply unbearable and was the cause for his over use of medication," the statement said.

“On a positive note we now know for certain he went painlessly and beautifully exhausted after doing what he loved the most, for one last time, performing live with his unmatchable rock band for his loyal fans on the biggest tour of his 40 plus year career. He was extremely proud of that achievement in the days before he passed.”

The family said it recognized Petty’s overdose may “spark a further discussion on the opioid crisis” and perhaps save some lives. “Many people who overdose begin with a legitimate injury or simply do not understand the potency and deadly nature of these medications,” they said.

Fentanyl and benzodiazepines were also linked to the deaths of the pop star Prince and the rapper Lil Peep.

In 2016, the Food and Drug Administration expanded the warning labels on all opioids and benzodiazepines because of the risk they pose when used together.

"It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together," said then FDA Commissioner Robert Califf, MD. "We implore health care professionals to heed these new warnings and more carefully and thoroughly evaluate, on a patient-by-patient basis, whether the benefits of using opioids and benzodiazepines – or CNS (central nervous system) depressants more generally – together outweigh these serious risks."

GOP Report Blames Medicaid for Opioid Crisis

By Pat Anson, Editor

A new congressional report claims there is “overwhelming evidence” that Medicaid has  contributed to the nation’s opioid crisis by making it easy for beneficiaries to obtain and abuse opioid prescriptions.

The lengthy report, called “Drugs for Dollars: How Medicaid Helps Fuel the Opioid Epidemic,” was prepared by the Republican controlled Senate Homeland Security and Governmental Affairs Committee. Democrats on the committee complained the report was concocted to discredit and demonize Medicaid expansion under the Affordable Care Act, also known as Obamacare.

The report cites 1,072 people since 2010 that have been convicted or accused of using Medicaid to improperly obtain prescription opioids.  That is only a tiny fraction of the nearly 70 million people enrolled in Medicaid, but the report nevertheless draws some sweeping conclusions.

“Overwhelming evidence shows that Medicaid has inadvertently contributed to the national tragedy that is the opioid epidemic, and has taken a toll that is playing out in courtrooms across the nation,” the committee staff reported.

“Other well-intended government programs, such as Medicare, may provide similar incentives for rational actors to engage in bad behavior with highly addictive opioids. These issues hold major ramifications for public policy, along with the nation’s health. They deserve serious consideration and a sober national debate, one we hope this staff report will help to initiate. The victims of this terrible epidemic deserve no less.”

The report cites dozens of examples of doctors and beneficiaries abusing the system, such as a $1 billion scheme to defraud Medicaid and Medicare that involved numerous health care providers.

Committee staff also claimed that drug overdose deaths were rising nearly twice as fast in Medicaid expansion states as in non-expansion states. About 12 million more Americans receive Medicaid coverage under Obamacare.

“While there is clearly no single cause to the epidemic, evidence has emerged that Medicaid is playing a perverse and unintended role in helping to fuel and fund the opioid epidemic,” Sen. Ron Johnson (R-WI) wrote in a letter to Eric Hargan, the Acting Secretary of the Department of Health and Human Services.

“The data uncovered in this examination point to a larger systematic problem – because opioids are easily obtained and inexpensive through Medicaid, the structure of the program itself creates a series of incentives for beneficiaries to use opioids and sell them for potentially enormous profits.”

‘Total Hogwash’

The committee’s ranking Democrat, Sen. Claire McKaskill of Missouri, called the report misleading.

"This idea that Medicaid expansion is fueling the rise in opioid deaths is total hogwash," McCaskill said in a statement. "It is not supported by the facts. And I am concerned that this committee is using taxpayer dollars to push out this misinformation to advance a political agenda."

“Separate scientific studies conducted by other authors show that (the) opioid epidemic predates Medicaid expansion and that recent increases in overdoses stem from fentanyl and heroin, not prescriptions obtained through Medicaid.  Unlike the report released by the majority staff today, these studies were both scientific and comprehensive.”

The report’s conclusions were also questioned by a longtime critic of opioid prescribing.

“I believe the access to prescribers that Medicaid, Medicare and commercial insurance offers does increase the likelihood that someone might develop a disease often caused by prescriptions,” said Andrew Kolodny, MD, founder and Executive director of Physicians for Responsible Opioid Prescribing (PROP).

“But I do not believe that Medicaid should be singled out in this regard. Opioid overdoses have been increasing in people with all types of insurance and in people from all economic groups, from rich to poor.”

A report released this week by the Kaiser Family Foundation found that states with above average overdose death rates includes 18 states that expanded their Medicaid coverage and 8 states that did not.  Overall, Medicaid covers nearly 40% of the two million Americans estimated to have opioid addiction.

Opioid Medication Has Been a Godsend to Me

Susan Lay, Guest Columnist

I have been on pain medication for over 30 years, starting with Vicodin. My doctor at the time wasn't concerned about the hydrocodone in Vicodin as much as he was the amount of acetaminophen in it, as it could destroy my liver.

He sent me to an anesthesiologist, who has been my pain doctor for over 20 years. After all the nerve blocks, physical therapy, imagery, TENS unit, spinal cord stimulator, pain pump, etc., I was given Roxicodone. Afterwards, OxyContin was created and then time released OxyContin.

I couldn't tolerate them, so he gave me fentanyl patches (which were new on the market) with fentanyl lozenges for breakthrough pain. My insurance eventually denied the lozenges. The patches were wonderful because I had no feelings of being “high” like other drugs. They made it possible for me to continue working and have a life. I have used the patches since that first day and they've been a Godsend.

Subsys spray was prescribed for breakthrough pain about 6 years ago, but at $22,000 a month, my insurance only paid for a year.

I'm so fortunate to still have the same doctor, although he's getting older and will retire soon. My main issue has been with pharmacies. I live in a very rural area of California and about 2 years ago my regular pharmacy refused to fill any opioids due to DEA and other concerns. My doctor has continued to write scripts for me, but I found them extremely difficult to fill. All the pharmacies I tried, including Walmart, Rite Aid, Walgreens and Safeway, denied me. Some felt uneasy, would only fill a script for 2 months, or just plain would not fill them!

SUSAN LAY

I tried mail order prescriptions, but they eventually stopped. I tried a small pharmacy 2 hours away, but had to talk the pharmacist into it, after he requested 6 months of medical records and advised me they would only fill my prescriptions every 30 days, with no early refills for vacations.

All has been good this past year, although I don't know if my insurance will continue to cover my meds. I'm 70 and on Medicare Part D. I've never increased the amount of patches or strength I use. I have Dilaudid for breakthrough pain, which doesn't help much, but some. I do what many other pain patients do to get their medication: drive for hours to my doctor once a month, undergo drug tests, sign pain contracts, and use no alcohol. I must go to office if they call for a drug count.

I discovered withdrawal from the fentanyl patches isn't as horrible for me as it is for addicts who just want to get high. I've had to go without for 5-6 days a few times, when the pharmacy was closed or I couldn't get to the doctor. My doctor explained that those in real pain are wired differently and withdrawal is usually easier. He did give me a script for methadone if I'm ever in that position again.

I feel extremely lucky to have a doctor who actually cares enough to help his patients. His contract says if any patient must go off opioids (for missing an appointment, using alcohol or whatever) he will assist us through withdrawal so we don't suffer.

It's the insurance and pharmacies that are causing us so many problems. Does anyone in other states have these issues? Marijuana is legal in California and we're a progressive state, yet even in my small rural area we're having major issues. Several pharmacies have closed, due to scrutiny by the DEA and other government involvement. It's not worth it to be constantly going through records and double-checking the way they do things.

Insurers and pharmacists have more power than doctors. Even with an honest and necessary prescription, they continue to over-ride doctors’ decisions. Pharmacists refuse to fill for quantities doctors have written, even when insurance agrees with that quantity. When a doctor speaks to the pharmacist, it makes no difference. When did pharmacists become doctors? The same goes for insurance companies that now refuse to pay for prescriptions they've covered for years.

I just don't get it. I'll do anything I can to fight FOR chronic pain patients and AGAINST those who don't give a damn about us and think if you use opioids you're a drug addict!

Susan Lay is a retired nurse and day care operator. She lives with chronic shoulder and knee pain.

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org

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

Surgery Patients Rarely Misuse Opioid Meds

By Pat Anson, Editor

A large new study published in the British Medical Journal is debunking some popular myths about the causes of opioid addiction.

One such myth is that many hospital patients abuse and become addicted to opioid pain medication while recovering from surgery.

But in a data analysis of over 568,000 patients who were prescribed opioids for post-surgical pain, researchers at Harvard Medical School identified only 5,906 patients (0.6%) who were later diagnosed with opioid dependence, abuse or a non-fatal overdose -- collectively known as opioid misuse.

Of those, only 1,857 patients (0.2%) showed signs of misuse in the first year after surgery – suggesting that the dependence or abuse that others later developed may have had little or nothing to do with the surgery itself.

But the remarkably low rate of opioid misuse by surgery patients was not the primary focus of the study. What researchers really wanted to know is whether the dose and duration of an opioid prescription influences future chances of abuse and addiction.

And here another myth was dispelled.

Researchers found that high doses of opioids after surgery appear to have little impact on misuse rates. Their findings show that how long a patient takes opioids is a more reliable predictor of misuse than how much medication they took. Dosage only emerged as a risk indicator for those who took opioids for extended periods.

"Our results indicate that each additional week of medication use, every refill is an important maker of risk for abuse or dependence," said study co-author Denis Agniel, a statistician at the RAND Corporation and a part-time lecturer in the Department of Biomedical Informatics at Harvard Medical School.

Researchers found that each additional week of opioid use increased the risk for dependence, abuse or overdose by 20 percent. And each refill boosted the risk by 44 percent.

But the risk of misuse still remains small. For those who had a single prescription with no refills – the vast majority of patients -- misuse occurred at a rate of only 145 cases per 100,000 patient years. The rate was still minuscule for those who refilled a prescription -- 293 cases per 100,000 patients years.

And for patients who took high doses for short periods -- two weeks or less -- the risk of misuse was no greater than those who took an average dose.

Agniel and his colleagues say their research indicates that opioids -- even at high doses -- can be safely prescribed to patients with post-surgical pain.

“These findings suggest a more nuanced understanding of the relationship between duration and dosage with a focus on early appropriate treatment of pain (including higher doses) for a limited time,” researchers concluded.

“Such findings suggest that optimal post-operative prescribing, which maximizes analgesia and minimizes the risk of misuse, may be achieved with moderate to high opioid dosages at shorter durations, a combination that merits further investigation in population-based and clinical studies.”

Anti-opioid activists and government regulators have long made sensational claims that even just a few painkillers can lead to addiction and death.

“The bottom line here is that prescription opiates are as addictive as heroin. They’re dangerous drugs,” former CDC Director Thomas Frieden told the Washington Post in 2016. “You take a few pills, you can be addicted for life. You take a few too many and you can die.”

The Harvard Medical School study was not the first to find that long term opioid use after surgery is rare. A 2016 Canadian study found that less than one percent of older adults were still taking opioid medication a year after major elective surgery.  

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

Why I Am Closing My Pain Practice

(Editor’s note: Patient abandonment is a serious and growing problem in the pain community. Thousands of patients have been discharged by doctors who have grown fearful of treating chronic pain and losing their medical licenses for prescribing opioid medication. We were recently contacted by a nurse practitioner, who offered her perspective on this disturbing trend. The author asked to remain anonymous.)

I am a nurse practitioner who has been in the field of pain management for the past 4 years. Prior to that, I spent years as an intensive care unit nurse and in primary care as an advanced registered nurse practitioner (ARNP).

Working with chronic pain patients has been the highlight of my professional career. I absolutely love my job and about 99% of my patients. I have had two complaints about me made to the Washington State Department of Health, both of which accused me of prescribing too much opioid medication to my patients. Both complaints were investigated by the state and I was found to be practicing within the standards of care -- and essentially told to continue. Which I did.

Then the Seattle Pain Centers closed in 2016, leaving thousands of untreated pain patients in the Puget Sound area. I inherited some of their patients. I felt like I had been "vetted" by the state, and believed that if I continued to do everything according to the law, I would be safe from any legal action.

In my practice, we fight ALL THE TIME for our patients, against the state, insurance companies, pharmacies and even the patient's families sometimes (when they don't understand). I'm not afraid of a good fight, because I have seen patients’ lives turned around when they are finally given the correct amount of opioids. I believe in opioid therapy.

Of course, all the tools in the box should be used, and I refer routinely to physical therapy, interventional pain specialists, surgeons, acupuncturists, chiropractors and others, in addition to prescribing opioids for pain.

Now I find how naive I have been. I have been to national conferences to learn more about pain management, and have heard the top doctors and researchers talk. One of these giants, Dr. Forest Tennant, was recently raided by the DEA. With Jeff Sessions as Attorney General, there is apparently more money being allotted to these raids and more are promised in the future. I also went to a website called "Doctors of Courage" and learned more about the DEA.

My interpretation of the facts is that it doesn't matter if I practice legally anymore. The DEA will look at my prescribing patterns, and tell me that I MUST have known that the ONLY reason any patient would get that much medication is if they are selling it on the street. And therefore, I am a "drug trafficking organization.” The Justice Department takes over the case and the provider is prosecuted.

If convicted, which seems to be the case recently, the provider becomes a felon and serves a prison term. Medical license is lost, time is served and because it is a "drug crime," asset forfeiture law may be used to confiscate everything I own.

'My Fear Is Very Real'

I am married, with a daughter still at home. I cannot do this to my family. So I am joining the legions of others who are closing their pain practices. I have just begun to tell my patients, and have had many, many tears, thoughts of both suicide and homicide, and one very special patient who told me that she will no longer be able to keep her service dog because she will be unable to care for him.

This whole thing is making me literally sick to my stomach. I've cried a million tears for my patients already, and I'm just beginning. I will be carefully weaning them all down to 90 MED per day over the next 6 months, or arranging transfer of care to anywhere the patient would like. What a joke that is -- there is no one else prescribing effective doses of opioids for chronic pain patients. If I am to be thrown in prison, it should be for that -- not for keeping them on therapy that enriches their lives.

I keep asking my husband to tell me that I am overreacting, but as wonderful and encouraging as he has always been, he is scared too.

Please tell all patients that what may have started merely as a provider being paranoid about his or her license has recently morphed into something truly dangerous for us. I will be absolutely no good to anyone, once locked up. If I can stay clear of the DEA's witch hunt, perhaps I can remain a voice of advocacy for pain patients. God help us all.

Please don't use my name if you post this. I can tell you, my fear is VERY real, and I don't want to call any attention to my practice right now. Thank you for understanding.

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org

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

FDA: Opioid Cold Meds Too Risky for Kids

By Pat Anson, Editor

The Food and Drug Administration has ordered stronger warning labels for cough and cold medications containing opioids and said they should no longer be prescribed to patients younger than 18. The agency also signaled it that it could enact new limits on the dose and duration of other types of opioid prescriptions.

“Given the epidemic of opioid addiction, we’re concerned about unnecessary exposure to opioids, especially in young children. We know that any exposure to opioid drugs can lead to future addiction,” said FDA Commissioner Scott Gottlieb, MD. “It’s become clear that the use of prescription, opioid-containing medicines to treat cough and cold in children comes with serious risks that don’t justify their use in this vulnerable population.”

The FDA action involves nine different types of cough and cold medicines, four of which contain codeine and five that have hydrocodone. The brand names include Tuxarin ER, Tuzistra XR, Triacin C, FlowTuss and Zutripro. Several of the medications also come in generic form.

The FDA said it conducted an extensive review of the products and convened a panel of pediatric experts, who said the risk of misuse, abuse and addiction outweighed the benefits in patients younger than 18.

“These products will no longer be indicated for use in children, and their use in this age group is not recommended.  Health care professionals should reassure parents that cough due to a cold or upper respiratory infection is self-limited and generally does not need to be treated.  For those children in whom cough treatment is necessary, alternative medicines are available,” the FDA said in a statement.

The agency also ordered stronger “Black Box” warning labels on opioid cough and cold medicines to make them more consistent with safety warnings that come with opioid pain medications.

‘Too Many People Prescribed Opioids’

The FDA this week also released its 2018 Strategic Policy Roadmap, which outlines four priority areas in the year ahead.

The agency's first goal is to reduce the abuse of opioid medication. The FDA said opioid addiction and overdoses were claiming lives at a “staggering rate” of 91 deaths every day – although it failed to point out that most of those deaths involve illegal opioids such as heroin and illicit fentanyl, not prescription pain medication. Also unmentioned in the “roadmap” is that opioid prescriptions have been declining since 2010.

“Too many people are being inappropriately prescribed opioid drugs. When these prescriptions are written, they are often for long durations of use that create too much opportunity for addiction to develop,” the FDA said.

“We need to take steps to reduce exposure to opioid drugs by helping to make sure that patients are prescribed these drugs only when properly indicated, and that when prescriptions are written, they are for dosages and durations of use that comport closely with the purpose of the prescription.” 

Several states have already enacted limits on opioid prescriptions for acute, short term pain. Minnesota, for example, recently adopted strict new guidelines that limit the initial supply of opioids for acute pain to just three days. 

An Open Letter to My Senator: CDC Has Killed Me

(Editor’s Note: Charles Malinowski is a 59-year old Paso Robles, California man who lives with Reflex Sympathetic Dystrophy (RSD), degenerative disc disease, ankylosing spondylitis, spinal stenosis and other chronic pain conditions.  He recently wrote this open letter to U.S. Senator Kamala Harris (D-CA). We thought his letter worth sharing with PNN readers.)

Dear Senator Harris,

The CDC has killed me!

Let me repeat that: The CDC has killed me!

I have a severe neurological condition that causes me unspeakable and crippling pain. Pain medication is literally the only thing keeping me alive. But with the issuance of the CDC’s short sighted, so-called voluntary opioid prescribing guidelines -- which are being rammed down the throats of medical providers -- my pain management doctor has cut me off of opiates.

For the last 10 years, I have been subjected to nearly every type of physical therapy, medical treatment and medication applicable to my affliction. The one and only thing that has ever had any demonstrable benefit in even temporarily suppressing my pain to a tolerable level has, unfortunately, been opiates.

In early October, I was told that I would have to stop taking either the oral opiates or the intrathecal opiates, as it was now illegal for a person to receive two different types of opiates via two different delivery methods concurrently. This was a major problem, as even with both oral and intrathecal opiates, my pain was severely under-managed to the point where I was almost completely bedridden. I left the house only to go to doctor's appointments.

When I was told that my pain management regimen - specifically the opiates - was going to be cut in half, even though my pain was already grossly under-managed, I spoke out about this.

CHARLES MALINOWSKI

As a result, not only was I cut off from the oral opiates, I got kicked out of the pain management practice where I have been a patient for more than seven years. The doctor said he didn't want to risk his license - but was perfectly willing to risk my life - over the CDC opioid guidelines.  These guidelines are supposed to be voluntary and are not supposed to take desperately needed pain medication away from legitimate chronic pain sufferers such as myself.

I expect that within 60 days, I will be dead from either heart failure or a stroke due to my body's inability to cope with the stress of the unrelenting pain. My neuropsychologist, who has been treating me for nearly 10 years, has consistently rated my level of pain as moderate to extreme, even while being medicated with both oral and intrathecal opiates, which I am now denied.

I'm not dead yet, but within 60 days I expect that the CDC will have effectively killed me. I honestly don't see myself being able to tolerate the pain any longer than that.

Congress, in going along with this blindly, will be explicitly complicit in this negligent homicide - or homicide by depraved indifference, take your pick - of one Charles James Malinowski, that being myself.

I would like to thank you, Senator, and all the rest of your colleagues for murdering me.

To help ease your conscience, it is not just me that Congress is complicit in murdering, but thousands, possibly tens of thousands of people in like positions.

Sincerely,

Charles Malinowski

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org

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

Ibuprofen Linked to Reduced Male Fertility

By Pat Anson, Editor

If you’re a man who uses ibuprofen regularly for muscle pain or  headache, you could be compromising your ability to have children, according to a small new study.

French and Danish researchers enrolled 31 young male volunteers between the ages of 18 and 35 in the study, and gave about half of them 600 milligrams of ibuprofen twice a day -- the highest recommended dose. The other participants were given a placebo.

After just 14 days, the researchers noted signs of hormonal dysfunction in the men who took ibuprofen, who had high levels of luteinizing hormone, which the pituitary gland produces to stimulate testosterone production in the testicles. 

That condition -- known as hypogonadism -- is usually seen in older men who have low testosterone levels. Hypogonadism is associated with reduced fertility, lower sex drive, depression, fatigue and an increased risk of cardiovascular problems.

“We normally see this condition in elderly men, so it raises an alarm,” study co-author Bernard Jégou, PhD, of the French National Institute of Health and Medical Research, told The Guardian. “We are concerned about it, particularly for healthy people who don’t need to take these drugs. The risk is greater than the benefit.” 

Researchers say the disorder was mild in the ibuprofen group and went away when the men stopped taking ibuprofen. But they worry what would happen to men who take the pain reliever for longer periods. Many professional athletes regularly take high doses of ibuprofen.

“Our immediate concern is for the fertility of men who use these drugs for a long time,” said co-author David Møbjerg Kristensen, PhD, a professor of biology at the University of Copenhagen. “These compounds are good painkillers, but a certain amount of people in society use them without thinking of them as proper medicines.”

The study was published online in the Proceedings of the National Academy of Sciences .

“Ibuprofen appears to be the preferred pharmaceutical analgesic for long-term chronic pain and arthritis. Therefore it is also of concern that men with compensated hypogonadism may eventually progress to overt primary hypogonadism, which is characterized by low circulating testosterone and prevalent symptoms including reduced libido, reduced muscle mass and strength, and depressed mood and fatigue,“ the researchers warned.

The same team of researchers reported in earlier studies that aspirin, acetaminophen and ibuprofen affected the testicles of male babies born to mothers who took the drugs during pregnancy.

Ibuprofen is a widely used over-the-counter pain reliever found in brand name products such as Motrin and Advil.   

Acetaminophen May Slow Language Development

By Pat Anson, Editor

Another study has linked acetaminophen to learning difficulties in young children born to mothers who used the over-the-counter pain reliever during pregnancy.

Researchers at the Icahn School of Medicine in New York City say toddlers exposed to acetaminophen in the womb had a slower rate of language development at 30 months. The findings are consistent with other studies reporting higher rates of autism, attention deficit disorder (ADHD) and behavioral problems in children born to mothers who used acetaminophen while pregnant.  

Acetaminophen (paracetamol) is one of the most widely used pain relievers in the world. It is the active ingredient in Tylenol, Excedrin, and hundreds of other pain medications. Researchers say over half the pregnant women in the United States and European Union use the drug.

“Given the prevalence of prenatal acetaminophen use and the importance of language development, our findings, if replicated, suggest that pregnant women should limit their use of this analgesic during pregnancy,” said senior author Shanna Swan, PhD, Professor of Environmental and Public Health at the Icahn School of Medicine at Mount Sinai.

“It’s important for us to look at language development because it has shown to be predictive of other neurodevelopmental problems in children.”

The study involved 754 women who enrolled in the Swedish Environmental Longitudinal, Mother and Child, Asthma and Allergy study (SELMA) during weeks 8-13 of their pregnancy. Researchers asked the women to report the number of acetaminophen tablets they took between conception and enrollment, and tested the acetaminophen concentration in their urine.

A delay in a child's language development, defined as the use of fewer than 50 words at 30 months of age, was measured by a nurse and a follow-up questionnaire filled out by the mothers.

Girls born to mothers with high exposure -- those who took acetaminophen more than six times in early pregnancy -- were nearly six times more likely to have language delay than girls born to mothers who did not take acetaminophen.

While the number of acetaminophen tablets and concentration in urine were associated with a significant increase in language delay in girls, there was only a slight increase in boys.  The findings suggest that acetaminophen use in pregnancy results in the loss of the well-recognized female advantage in language development in early childhood.

The study is published online in the journal European Psychiatry. Researchers will follow-up with the children and re-examine their language development at age seven.

A 2016 study of over 2,600 Spanish women linked acetaminophen to autism and attention deficit problems in their children. Studies in Denmark and New Zealand have also linked acetaminophen to a higher risk of ADHD.

Over 50 million people in the U.S. use acetaminophen each week to treat pain and fever. The pain reliever has long been associated with liver injury and allergic reactions such as skin rash. In the U.S. over 50,000 emergency room visits each year are caused by acetaminophen, including 25,000 hospitalizations and 450 deaths.

Lyrica and Neurontin Use Triples

By Pat Anson, Editor

The use of gabapentin (Neurontin) and pregabalin (Lyrica) has soared in the United States, with little attention paid to their safety and effectiveness, according to a research letter published in JAMA Internal Medicine.

Gabapentin and pregabalin belong to a class of nerve medication known as gabapentinoids, which are increasingly prescribed as alternatives to opioids in treating neuropathy, fibromyalgia and other types of chronic pain.

In an analysis of health data for nearly 350,000 patients, researchers found that the use of gabapentinoids more than tripled in the past decade, from 1.2% of patients in 2002 to 3.9% in 2015.

Use of the drugs was concentrated in older patients with numerous other health problems, who were often co-prescribed opioids or benzodiazepines, a class of anti-anxiety medication.

“The combination of a dearth of long-term safety data, small effect sizes, concern for increased risk of overdose in combination with opioid use, and high rates of off-label prescribing, which are associated with high rates of adverse effects, raises concern about the levels of gabapentinoid use,” wrote lead researcher Michael Johansen, MD, of OhioHealth, a large non-profit health system based in Ohio.

“While individual clinical scenarios can be challenging, caution should be advised in the use of gabapentinoids, particularly for those individuals who are long-term opioid users, given the lack of proven long-term efficacy and the known and unknown risks of gabapentinoid use.”

JAMA INTERNAL MEDICINE

Johansen’s research adds to a growing body of evidence that pregabalin and gabapentin are overprescribed and being abused. A recent study by Canadian researchers found that there was “no clear rationale” for the off-label use of the drugs and warned that they have a “significant risk of adverse effects” such as dizziness, fatigue and diminished mental activity.

Lyrica (pregabalin) and Neurontin (gabapentin) are both made by Pfizer and are two of the company’s top selling drugs, generating billions of dollars in annual sales. Lyrica is approved by the FDA to treat diabetic nerve pain, fibromyalgia, post-herpetic neuralgia caused by shingles and spinal cord injuries; while Neurontin is approved to treat epilepsy and post-herpetic neuralgia. Both drugs are also widely prescribed off label to treat back pain, depression, migraine and other conditions.

Sales of pregabalin and gabapentin have risen steadily in recent years, in part because of CDC prescribing guidelines that recommend the two drugs as alternatives to opioid pain medication. About 64 million prescriptions were written for gabapentin in the U.S. in 20l6, a 49% increase in just five years.

“We believe… that gabapentinoids are being prescribed excessively — partly in response to the opioid epidemic,” Christopher Goodman, MD, and Allan Brett, MD, recently wrote in a commentary published in The New England Journal of Medicine. “We suspect that clinicians who are desperate for alternatives to opioids have lowered their threshold for prescribing gabapentinoids to patients with various types of acute, subacute, and chronic noncancer pain.

Gabapentinoids are increasingly being used recreationally by addicts who have found the medications enhance the effects of heroin and other opioids. Lyrica and Neurontin have been linked to heroin overdoses in the United Kingdom, where prescriptions for both drugs have soared in recent years. 

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."