Most Sickle Cell Patients Face Stigma During ER Visits

By Pat Anson, PNN Editor

Nearly two-thirds of people with sickle cell disease in the U.S. feel judged and stigmatized when they visit an emergency department due to a pain flare, according to a new survey by Health Union.

About 100,000 Americans live with sickle cell disease (SCD), a genetic disorder that mainly affects people of African or Hispanic descent. SCD causes red blood cells to form in a crescent or sickle shape, which can create blockages in blood vessels that cause intense pain.  It’s not uncommon for someone with SCD to visit an ER a few times each year due to pain or complications such as anemia, stroke, infection and organ failure.

Health Union surveyed 111 people living with SCD to share their experiences dealing with the disease and how they are perceived by healthcare professionals, coworkers, teachers, friends and family members. Most said they did not feel judged or stigmatized by others – except when dealing with ER staff.

Many felt ER staff were rude, ignorant or misinformed about sickle cell disease, didn’t take their pain seriously, and believed they were drug seekers. Nearly half of those surveyed (43%) said they avoided going to the ER because they worried that people would judge them.

“A doctor judged me during a hospitalization. He stated I wasn’t in that much pain to be using Dilaudid. He also stated I was drug seeking because a sickle cell crisis can be managed with Motrin. His statement is not true!” one participant told Health Union.

Sickle cell patients had an entirely different take on their pharmacists, hematologists and primary care providers. Over half (53%) trusted their providers and felt their primary care doctors were friendly, understanding, easy to talk to, and provided excellent care.

"Navigating the healthcare system can already be complex, but undergoing such wildly different experiences can make access to reliable, timely, effective care even more difficult for people with sickle cell disease," said Olivier Chateau, Health Union's co-founder and CEO.

The finding that many people are not happy with their pain treatment in hospitals is not unique to sickle cell patients.  A 2016 PNN survey of over 1,250 hospitalized pain patients found that most felt they were labeled as addicts or drug seekers. Over 80% believed hospital staff were not adequately trained in pain management and over half rated the quality of pain care in hospitals as poor or very poor.  

A report last year by the National Academies of Sciences, Engineering, and Medicine found that sickle cell patients often face discrimination and stigma when navigating the healthcare system. The report found that SCD received little attention from the healthcare community compared to other chronic illnesses. To get proper treatment, many sickle cell patients have to educate themselves about their disease and become their own advocates.

The Health Union survey found that nearly three out of four sickle cell patients (73%) were currently using a prescription analgesic. Many others took prescription strength NSAIDs (35%), muscle relaxants (23%) or anti-anxiety/antidepressant drugs (16%). Only 5% said they experienced an issue with substance abuse.

Cutting My Opioid Dose in Half Left Me in Unbearable Pain

By Virginia Brandford, Guest Columnist

Imagine living with a rare genetic bone disease that has no cure and causes excruciating pain. Then imagine the medication that effectively alleviated that pain for 29 years is abruptly tapered and you are forced to take only half the dose your body has become dependent on.

Not only is the pain unbearable, but the resulting stress placed on the body prevents you from exercising or participating in physical therapy, which is vital to someone with alkaptonuria (AKU) to prevent chronic joint pain and inflammation.

AKU is known as “Black Bone Disease” because it turns bones black and brittle. It is the oldest metabolic disease on earth and has even been found in Egyptian mummies. Watch this video if you want to learn more about my disease.  

After being diagnosed with AKU, I was placed on a very high dose of morphine to stop my body from producing Homogentisic Acid (HGA). People like me born with AKU are missing an enzyme that prevents them from fully breaking down HGA.

When it accumulates at high levels, HGA devours my bones, turning them black and stripping the cartilage and cushions between them.

My longtime physician identified morphine as a pain medication that helped, without causing side effects. I was able to function again and live a decent life, in spite of having such a debilitating disease.

Virginia Brandford

But in 2017, many of the recommendations in the CDC opioid guideline were adopted in Hawaii as state law, and my doctor was driven out of practice. I cannot find a new doctor willing to prescribe the same dose of morphine. They all see my need for opioids, but they do not want to risk their livelihoods by taking me on as a patient. I am being harmed by the state and no one will do anything to help me!

Due to the morphine being reduced to half of my original dosage, the HGA accumulation has eaten two holes into my heart valves, resulting in a life-threatening heart condition. HGA has also accumulated in my spine, liver and kidneys.

I have endured irreparable damage by being forced off my old dosage of medication in such an inhumane manner. Every doctor I have been referred to has refused to accept me as a patient once they look over my medical records and see I have a rare genetic bone disease that requires opioids.

I have never abused drugs or alcohol in any form. I have comprehensive medical records, including MRIs and x-rays documenting my illness and treatment history. It will also show that for 29 years on the original morphine dose, my liver stayed strong and clean, compared to a patient who has been on a toxic medicine like Suboxone that is just as addictive.

Legitimate pain patients like me who never abused drugs are being treated like addicts and demonized for taking prescribed medicines from licensed doctors.

Please help me obtain the help I need before this disease spreads even more. I am totally bedridden and need help. I pray that a revision of the CDC opioid guideline will allow doctors to do their jobs again without being persecuted, and will give me back my life so that I can grow old with dignity.

Virginia Brandford lives in Hawaii. PNN invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org.

Follow Treatment Guidelines for Low Back Pain and Get Back to Work Sooner

By Pat Anson, PNN Editor

Employees with acute low back pain miss fewer days of work if they exercise, take over-the-counter pain relievers and are not prescribed opioid medication, according to a large new study of worker compensation claims in California.

"The closer people's care follows evidence-based guidelines, the faster their back pain resolves, by quite a bit," said Kurt Hegmann, MD, director of the University of Utah Rocky Mountain Center for Occupational and Environmental Health.

Hegmann and his colleagues analyzed insurance data for nearly 60,000 people with low back pain from 2009 to 2018, comparing their treatment to guidelines created by the American College of Occupational and Environmental Medicine. Those guidelines recommend non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and physical therapy for low back pain, while frowning on the use of opioids or invasive procedures such as spinal injections.

The research findings, recently published in PLOS ONE, showed that people who didn’t follow treatment guidelines missed an average of 11 more days of work each year compared to those who only had recommended treatments.

Opioids were once commonly prescribed for low back pain, a practice that has fallen out of favor due to fears of addiction and overdose. In the nine years of the study, researchers found that opioid prescribing for low back pain declined by 86 percent, fueled in part by insurers who were unwilling to pay for the drugs.

"The reduction in opioids prescription is particularly impressive," Hegmann said. "In this case, the insurer is likely to not pay for opioids even if they are prescribed. It suggests what's possible when the 'carrot' of good health care is missed and instead the 'stick' of compliance with a guideline is in place."

Nearly two-thirds of the people included in the study received at least one non-recommended treatment, although adherence to treatment guidelines improved over time. In 2009, 10% were treated according to guidelines, but that rose to 18% by 2018.

Low back pain is the world’s leading cause of disability. It mostly affects adults of working age in lower socioeconomic groups, who often have physically demanding jobs.

Treatment guidelines for low back pain have changed considerably in the last 20 years. At one time, bed rest was commonly recommended, a treatment now seen as counterproductive. Moderate exercise and physical activity help people return to work sooner.

"Being out of work impacts many facets of your life," said first author Fraser Gaspar, PhD. "In addition to the physical disability that's causing the person to miss work, the worker is making less money, while they often incur additional costs and experience mental strain. Getting people back to their normal lives is really important, and our research shows that following guidelines makes that happen faster."

Are NSAIDs Really Better Than Opioids for Post-Operative Pain?

By Pat Anson, PNN Editor

There have been a rash of recent studies promoting the use acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) over opioids for post-operative pain.

One such study at a Houston hospital led surgeons to conclude that patients were better off with Tylenol. "This study provides us with a strategy to successfully manage pain after surgery using over-the-counter pain medication,” said Min Kim, MD, head of thoracic surgery at Houston Methodist Hospital.  

But critics point out that most of the studies never examine how patients feel about the effectiveness of their pain treatment — focusing instead on the number of opioid pills and smaller opioid doses being prescribed. Pain relief was a secondary consideration, if it was considered at all.

A rare exception to that is a study recently published in the Canadian Medical Association Journal (CMAJ), which found that ibuprofen and other NSAIDs gave better post-operative pain relief than the opioid codeine. In a systematic review of 40 clinical trials involving over 5,000 patients who had outpatient procedures, researchers said patients who took NSAIDs had lower pain scores 6 and 12 hours after surgery than patients taking low doses of codeine.

"In all surgery types, subgroups and outcome time points, NSAIDs were equal or superior to codeine for postoperative pain," wrote lead author Matthew Choi, MD, Associate Professor of Surgery at McMaster University in Ontario. "We found that patients randomized to NSAIDs following outpatient surgical procedures reported better pain scores, better global assessment scores, fewer adverse effects and no difference in bleeding events, compared with those receiving codeine.

“These findings are of general importance to any clinician performing painful medical procedures. The various trials in our meta-analysis evaluated a range of procedures, different NSAID types and various degrees of acetaminophen coadministration.”

But critics say the McMaster study also has flaws. The claim that “all surgery types” and “a range of procedures” were included in the analysis is misleading at best. Most of the studies — 28 of the 40 that were analyzed — involved dental surgery, a fact that is not sufficiently disclosed. The rest of the outpatient procedures were for plastic surgery and orthopedic corrections – which can hardly be compared to more serious surgeries that require more pain relief and days or weeks of recovery, not just 6 to 12 hours.      

Another issue is the use of codeine as a research subject. Stefan Franzen, PhD, a chemistry professor at North Carolina State who has an extensive background in biomedical research, questions whether low doses of codeine should even be compared to NSAIDs.

“I question the premise that codeine is the drug that is or should be used by dentists,” said Franzen, author of “Patient Z,” a book the examines the criminalization of pain care. “I read a few papers not cited by this report and they too do not find a great efficacy for codeine. Part of this may be dose. Most commonly they are using 30-60 mg of codeine, which is 5-10 mg of morphine. Not very much if you have severe pain.

“Codeine may be a poor choice, but it may also be a straw man. Why not use tramadol, for example?”

‘Manipulated Data’

Patient advocate Bill Murphy also has doubts about the selection criteria used in studies touting the benefits of non-opioid pain relievers. He believes some researchers cherry-pick evidence to support a conclusion they’ve already reached.

“Opioid sparing post-op surgery programs are nothing more than an attempt to solve a non-problem and in doing so, patients suffer needlessly. The data produced from such programs are very often manipulated by those who designed the program in an obvious attempt to skew the results in favor of a program they endorsed,” said Murphy, who helped get legislation passed in New Hampshire to ensure that pain patients have access to opioid medication.

Murphy has advocated on behalf of patients at Portsmouth Regional Hospital, which has an “Enhanced Surgical Recovery” program that significantly reduced the use of opioids. Instead of Vicodin, patients get Neurontin or nerve blocks for pain relief.

“I was personally called in to advocate on behalf of several patients who were left to suffer in pain following surgery only to have staff assure them their pain was being well managed,” Murphy explained in an email. “Surgeons and nurses reported they were doing very well with Portsmouth Regional’s new protocol for managing post-op pain when in fact, they were not doing ‘very well’ at all.

“These patients were in horrible pain. Of the three I spoke with, none were ever provided any relief. I was with one patient as she was discharged. She was in tears and moved at a glacial pace due to pain as her son and I helped her into his vehicle outside. It was heartbreaking to watch. Her adult son was furious. I stayed in touch with each patient for several weeks afterwards. Each suffered greatly, one was not making any gains in physical therapy due to her lasting pain.”

In 2019, only 11% of patients were prescribed an opioid while at the Portsmouth hospital, and less than 6% were discharged with an opioid prescription. Murphy says the hospital’s policy inevitably leads to some patients with poorly treated pain.  

“What Portsmouth Regional Hospital’s ‘Enhanced Surgical Recovery’ program was doing is akin to making patients bite down on a piece of wood, grind it out, and then convince them the whole experience was for their own good,” says Murphy.    

Did Pacira Lie to Investors or a Federal Judge?

By Pat Anson, PNN Editor

The war of words between Pacira BioSciences and the American Society of Anesthesiologists (ASA) continues to escalate, with new allegations that the drug company either lied to its investors or a federal judge.

New Jersey-based Pacira filed a lawsuit in April over three articles in the ASA journal Anesthesiology that disparaged Pacira’s flagship product Exparel, an injectable non-opioid analgesic used for postoperative pain. An editorial and two peer-reviewed research articles said Exparel worked no better than other bupivacaine products, even though it costs 10 times more.

Pacira filed a libel complaint against the ASA in federal court seeking a retraction and damages for “significant pecuniary harm.” The company said “multiple existing customers” had either stopped using Exparel or were considering it because of the journal articles.

If true, that would be a significant blow to Pacira, since Exparel accounted for 96% of the company’s revenues in 2020.

The ASA filed a motion last week asking a federal judge to dismiss the case, calling the lawsuit “an egregious and unjustified public relations campaign that seeks to chill scientific research and debate.”

‘Nothing to Worry About’

The ASA motion quotes a statement from a May 4 earnings call, in which Pacira CFO Charlie Reinhart told analysts that “we don’t have anything to worry about” and “actually things are going very, very well,” despite the negative reviews of Exparel in the medical journal.

In a preliminary report released last week, Pacira even boasted about sales of the drug. “Exparel sales continue to significantly outperform the elective surgery market recovery, with May marking our fourth consecutive month of sequential growth in average daily sales,” the company said in a statement that didn’t mention the lawsuit.

“In other words, Pacira is lying either to a federal judge or its investors,” the ASA said in a press release Monday.  

A Pacira spokesperson declined to respond to the ASA statement, telling PNN that “our corporate policy is not to comment on pending litigation.”

Exparel was first approved by the FDA in 2011 as a local anesthetic for post-operative pain in adults.  Its use has since been expanded to include children and as a nerve blocking agent.  Pacira says over 8 million patients have been treated with Exparel. The drug is primarily sold to hospitals and ambulatory surgical centers. One of the biggest purchasers is the U.S. Department of Defense.

In the past, Pacira has gone to great lengths to promote Exparel and silence critics.  In 2014, the company filed a lawsuit against the FDA after the agency sent a warning letter to Pacira for off-label marketing of Exparel. In 2020, Pacira agreed to pay $3.5 million to resolve allegations that it gave kickbacks to doctors to promote Exparel in research articles.

Did CDC Opioid Guideline Have ‘Unexpected Benefit’ for Surgery Patients?

By Pat Anson, PNN Editor

Since its release in 2016, the CDC’s opioid prescribing guideline has had a sweeping impact on pain management in the United States. Although only intended for primary care physicians treating chronic pain, the guideline’s recommended limits on opioids have been widely adopted by states, insurers, pharmacies, hospitals and doctors treating all types of pain.

A new study published in JAMA Network Open documents how opioid prescribing for post-operative acute pain fell significantly in the first two years after the guideline’s release.      

Researchers looked at prescribing data for over 360,000 patients who had 8 common surgical procedures and found that the amount of opioids initially prescribed after surgery fell by an average of 16 percent. The decline for each patient was the equivalent 11 oxycodone 5mg tablets.  

“This study has important policy and practice implications. Although the primary focus of the 2016 CDC guideline was on opioid prescribing for chronic pain, our findings suggest that the guideline was associated with clinically relevant changes in patterns of opioid prescribing after surgery,” wrote lead author Tori Sutherland, MD, a Professor of Anesthesiology at the Perelman School of Medicine, University of Pennsylvania.

The study didn’t look at what alternatives surgery patients were given for pain management or whether they were satisfied with their pain relief. But because refill rates were unchanged after the guideline’s release, Sutherland and her colleagues concluded that “it is unlikely that guideline misapplication led to significant opioid underprescribing for surgical pain.”

An editorial also published in JAMA Network Open called the decline in opioid prescribing for post-operative pain “a promising trend” and said further cuts were needed to reduce the number of leftover pills.

“The 2016 CDC guideline for chronic pain may have provided an unexpected benefit to surgical patients by accelerating the alignment of opioid prescribing with amounts recommended in surgery-specific prescribing guidelines. Nonetheless, much room for improvement remains,” wrote lead author Mark Bicket, MD, an anesthesiologist at the University of Michigan School of Medicine.

“We have known for a long time that the average patient has been prescribed nearly twice as much opioid as they need, or will use, following surgery,” said Dr. Lynn Webster, a PNN columnist and pain management expert. “This unused medication has been a major source of diverted opioids that have contributed to the national illicit drug use problem. In this regard, their observation does suggest fewer drugs are available for diversion. That is a good thing.

“However, mean data does not take into account an individual’s need. Some patients need more medication than other patients for the same surgical procedure. It is unhelpful to use dose reduction as a measure of improved care. We should focus on using the appropriate amount of opioids for the appropriate length of time to achieve improved prescribing.”

Webster said it was speculative to suggest that the CDC guideline had an “unexpected benefit” for surgery patients. The best measure is whether overdose deaths are decreasing – and by that standard the guideline has been a failure. Five years after its release, opioid prescribing is at 20-year lows while overdose deaths are at record highs, fueled largely by illicit fentanyl and other street drugs.

“Cleary, the decline in opioids prescribed for post-op pain has not improved that outcome which is, arguably, the most important outcome to measure,” said Webster.

Opioid addiction is actually rare after surgery.  A large 2016 study found only 0.4% of older adults were still taking opioids a year after major elective surgery.  Another large study in 2018 found only 0.6% of patients who took opioids for post-operative pain were later diagnosed with opioid dependence, abuse or a non-fatal overdose.

Acetaminophen Use by Pregnant Women Raises Risk of Autism or ADHD in Children

By Pat Anson, PNN Editor 

A large new study in Europe is adding to the growing body of evidence that the use acetaminophen (paracetamol) by pregnant women raises the risk of their children having autism or Attention-Deficit Hyperactivity Disorder (ADHD)

Researchers at the University of Barcelona followed nearly 74,000 mothers and their children in the UK and five other European countries, finding that women who took the pain reliever while pregnant were 19% more likely to have children with Autism Spectrum Conditions (ASC) and 21% more likely to develop ADHD symptoms.

“Associations between prenatal acetaminophen and ASC and ADHD symptoms were consistently positive for both boys and girls albeit slightly stronger among boys,” researchers reported in the European Journal of Epidemiology.

Several previous studies have linked prenatal use of acetaminophen to autism, ADHD and hyperactivity in children, but this was by far the largest. Although the exact cause is unknown, it’s believed acetaminophen affects a baby’s brain development and growth, especially during the third trimester. The study found no evidence that acetaminophen raised the risk of autism and ADHD after the children were born.

Despite the findings, the UK’s National Health Service (NHS) maintains that it is safe for pregnant women to use paracetamol.

“Paracetamol is the first choice of painkiller if you're pregnant or breastfeeding. It's been taken by many pregnant and breastfeeding women with no harmful effects in the mother or baby,” the NHS says on its website.

The U.S. Food and Drug Administration also does not caution pregnant women about using acetaminophen. The agency said in 2015 that the evidence was “too limited” to justify such a warning.  

The University of Barcelona researchers are a bit more cautious, saying pregnant women should take acetaminophen “only when necessary.”

“Considering all evidences on acetaminophen use and neurodevelopment, we agree with previous recommendations indicating that while acetaminophen should not be suppressed in pregnant women or children, it should be used only when necessary,” they said.

Acetaminophen is the most popular pain reliever in the world, and is used by over half the pregnant women in Europe and the United States. It is the active ingredient in Tylenol, Excedrin, and hundreds of pain medications. Excessive use of acetaminophen can cause liver, kidney, heart and blood pressure problems. A recent study found little or no evidence to support its use for most pain conditions.  

Overdose Crisis Linked to Poor Mental Health

By Pat Anson, PNN Editor

A comprehensive new study has found that stress and anxiety are key drivers in the U.S. overdose crisis, with poor mental health increasing the risk of dying from a drug overdose by as much as 39 percent.

"We saw a strong association with mental health and substance abuse disorders, particularly opiates," says co-author Diego Cuadros, PhD, an epidemiologist who directs the University of Cincinnati’s Health Geography and Disease Modeling Laboratory. "What's happening now is we're more than a year into a pandemic. Mental health has deteriorated for the entire population, which means we'll see a surge in opiate overdoses."

Cuadros and his colleagues looked at overdose deaths and socioeconomic data in the U.S. from 2005 to 2017, and identified 25 “hot spots” or sub-epidemics where there was a sizeable increase in drug deaths. In the Southwest, sub-epidemics were driven by methamphetamine and heroin, while overdoses in the Northeast and Midwest were first fueled by heroin, then prescription opioids, and now synthetic opioids such as illicit fentanyl.

U.S. Overdose “Hot Spots”

PLOS ONE

While different substances were often involved in sub-epidemics, researchers say the one thing they all had in common was high levels of physical and mental distress.

"This is a complex epidemic. For HIV we have one virus or agent. Same with malaria. Same with COVID-19. It's a virus," Cuadros said. "But with opioids, we have several agents. At the beginning of the epidemic it was heroin. By 2010 it switched to prescription opiates."

Deaths of Despair

The study, published in PLOS ONE, builds on the so-called “deaths of despair” theory that was first described in 2015 by Princeton researchers Anne Case and Angus Deaton, who found that the reduced life expectancy of middle-aged white Americans was linked to substance abuse, unemployment, limited education, divorce, depression and loss of social connections.

The new study found that young white males aged 25 to 29 were most at risk of a fatal opioid overdose, followed by white males aged 30 to 34. In recent years, they were joined by black males aged 30 to 34 who also have an elevated risk of dying from an overdose. Those age groups do not fit the typical profile of a pain patient on prescription opioids, who is usually older and has an age-related disability such as arthritis.

“For the past 20 years, seniors over age 62 have had the highest rates of doctor-prescribed opioid pain relievers, while sustaining the lowest and mostly stable rates of opioid overdose related mortality. During the same period, overdose mortality more than tripled among adults age 25 to 34, who receive far fewer prescriptions than seniors,” says Richard “Red” Lawhern, PhD, a patient advocate who has long argued that the demographics of the overdose crisis prove it is not being driven by opioid medication. 

“Drug abuse and addiction are instead driven by complex socio-economic factors that some investigators have called ‘a crisis of hopelessness.’ Structural unemployment and poverty have rendered some populations more vulnerable to drug abuse than others,” said Lawhern.

“Hot spots of high mortality occur primarily in rural counties of the Rust Belt, deep South and West, with a sprinkling in inner cities also paralyzed by poverty. Communities are being hollowed out and families are failing due to a national failure to invest to replace infrastructure and mining jobs formerly held by high school educated men.”   

A notable holdout in the “deaths of despair” theory is Andrew Kolodny, MD, an addiction treatment specialist and longtime critic of opioid prescribing who is the founder of the newly renamed Health Professionals for Responsible Opioid Prescribing (PROP).

“The vast majority of drug overdose deaths are occurring in people with the disease of opioid addiction, not necessarily people who are drinking or using drugs driven by socioeconomic factors,” said Kolodny in a recent webinar. “The deaths of despair framing, while provocative, is unlikely to explain the main sources of the fatal drug epidemic and that efforts to improve economic conditions in distressed locations, while desirable for other reasons, are not likely to yield significant reductions in drug mortality.”

Kolodny is not an economist, epidemiologist or pain management specialist. He is a well-paid expert witness in opioid litigation cases – lawsuits that depend on a public narrative that excess opioid prescribing, not mental health problems, led to the addiction and overdose crisis. Maintaining that narrative is becoming harder, with opioid prescribing in the U.S. at 20-year lows and overdose deaths at record highs, fueled in part by economic and social issues exacerbated by the pandemic.

In other comments during the webinar, Kolodny said the CDC’s 2016 opioid guideline was “a bit wishy washy” because it only said that opioids were not the preferred treatment for chronic pain. Kolodny said a Department of Veterans Affairs and Department of Defense guideline that came out a year later was “a lot better” because it advised doctors not to begin long-term opioid therapy on any new patients.    

Instead of opioids, the DOD guideline recommends exercise, yoga and cognitive behavioral therapy to treat chronic pain, along with non-opioid drugs such as gabapentin.

How Opioid Hysteria Affects Cancer Patients

By Pat Anson, PNN Editor

Over the years, we’ve received many complaints from cancer patients about their pain being poorly treated or even left untreated. Although the CDC’s opioid guideline specifically says it is “not intended for patients undergoing active cancer treatment,” some doctors take the recommendations so seriously they won’t prescribe opioids to cancer patients, fearing it could lead to abuse and addiction.

“Just last week my 90-year-old mother, who is a cancer patient going through chemo, was accused of having opioid use disorder when she went to the emergency room with a painful bacterial infection. She was left with no pain relief, even though she is a compliant patient with no history of abuse,” one reader told PNN.

“I suffer from severe stage 4 cancer pain that has gotten worse and worse and may be terminal. Despite my increasing pain, no one will increase my dosages directly due to the CDC,” another reader told us.

“I have struggled to find a doctor to treat my pain,” a patient with terminal stage 4 lung cancer said. “I am in total shock that cancer patients have to suffer like this. These guidelines have terrified doctors. If they’re too scared to treat cancer pain, what pain will they treat?”

After hearing stories like those, it was startling to read the results of a small study in the journal Cancer that found some cancer patients were so traumatized by opioid hysteria they were reluctant to take opioids because of the stigma associated with their use. Researchers at the Dana-Faber Cancer Institute in Boston interviewed 26 patients with advanced cancer and found that many were fearful of using opioids — even though the risk of opioid addiction and overdose is low for cancer patients.

“Patients consistently described the negative impact of the opioid epidemic on their ability to self-manage pain. Negative media coverage and personal experiences with the epidemic promoted stigma, fear, and guilt surrounding opioid use. As a result, many patients delayed initiating opioids and often viewed their decision to take opioids as a moral failure,” wrote lead author Desiree Azizoddin, PsyD.

“Patients frequently managed this internal conflict through opioid-restricting behaviors (eg, skipping or taking lower doses). Stigma also impeded patient-clinician communication; patients often avoided discussing opioids or purposely conveyed underusing them to avoid being labeled a ‘pill seeker.’”

Adding to the stigma, researchers said several patients ran into “logistical complications” with pharmacies and insurers when they tried to get an opioid prescription filled.

“Patients experienced structural barriers to obtaining opioids such as prior authorizations, delays in refills, or being questioned by pharmacists about their opioid use. Barriers were stressful, amplified stigma, interfered with pain control, and reinforced ambivalence about opioids,” they said.

Reports of opioid hysteria affecting cancer care are not new. In 2019, the Cancer Action Network said there was “a significant increase in cancer patients and survivors being unable to access their opioid prescriptions.”

That same year, the CDC issued a long-awaited acknowledgement that the “misapplication” of the 2016 guideline had been harmful to pain patients, including those being treated for cancer. The agency said it would evaluate the impact of the guideline and make changes “when new evidence is available.”   

Five years after the guideline’s release, cancer patients are still waiting for those changes to be made.

“I had breast cancer twice and suffer severe chest wall and referred pain from surgery and radiation treatments, plus severe spine damage, but have been denied pain treatment. This has become a crime against humanity which would never be allowed in any other country,” a cancer survivor told us.

The Trouble With Pain Treatment Guidelines

By Donna Gregory Burch

I'm trying to figure out why certain medical organizations think they know more about treating my chronic pain than my actual doctors. It seems every single one of these groups shares the same opinion: Opioids are bad. Antidepressants, exercise and meditation are good.

That's the takeaway from new treatment guidelines for fibromyalgia and other forms of “chronic primary pain” released by the European Pain Federation and the UK’s National Institute for Health and Care Excellence (NICE). Both sets of recommendations are on trend with the opioid prescribing guideline adopted by the U.S. Centers for Disease Control and Prevention (CDC) in 2016.

The European Pain Federation recommends against using opioids to treat fibromyalgia, low back pain, irritable bowel syndrome and other forms of chronic primary pain for which there is no known cause. Opioids can be used for certain types of “secondary” pain caused by surgery, trauma, disease or nerve damage, according to the federation, but only when other treatments such as exercise, meditation and non-opioid medications have failed.

The NICE guidelines are even stricter, advising physicians not to prescribe any kind of painkiller to those with fibromyalgia, chronic headache, chronic musculoskeletal pain and other chronic primary conditions. That includes non-opioid painkillers like paracetamol (acetaminophen), non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids (gabapentin, pregabalin), corticosteroids (prednisone, prednisolone) and benzodiazepines (Valium, Xanax).

As someone who lives with fibromyalgia, chronic lower back pain and chronic daily headaches, I thank God that I don't live across the pond, as they say. Frankly, I'd probably throw myself off a bridge if my doctors adhered to either of these guidelines.

And no, I'm not being overdramatic. I'm sure I speak for many of the readers here at Pain News Network and my own website, Fed Up With Fatigue, when I express alarm over how authoritarian and inhumane these guidelines aimed at chronic pain patients are becoming.

Of course, things aren't much better on U.S. soil. Physicians here are still running scared due to the CDC's opioid guideline. It's becoming increasingly difficult to find doctors who will prescribe opioids or even accept a patient who is already on opioids. It matters little if the patient has been using them responsibly for years or even decades.

A ‘Little Bit of Life’ Gone

A couple of weeks ago, one of my readers shared that she used to be able to work and manage her home when her opioid dosage was at a certain level. But then the CDC decided to stick its nose into her personal health journey by recommending that general practitioners should not prescribe opioids to patients with fibromyalgia.

Her doctor saw those recommendations and cut her dosage. Now, she's basically homebound. The little bit of life that she had as a chronic pain patient is no longer.

How is this fair? Or humane?

It isn't.

And why is she being punished because a small number of opioid users were irresponsible and became addicted? That is not the fault of the millions of opioid users who do use them responsibly!

It's easy for “experts” and regulators to condemn opioids when they're not the ones in pain. And it's a slap in the face to have them tell me I should take ibuprofen for a migraine, or worse yet, to go take a walk.

Obviously, they haven't experienced the headaches that I have - one of which was so bad that I curled up in a ball on the sofa and whispered to my husband through tears, "I just want to die."

And yes, it really was that bad! To suggest that doing some deep breathing or talking with a counselor is going to help that level of pain is completely asinine.

Opioids and Fibromyalgia

But I think what pisses me off the most is that these government agencies and medical organizations constantly say over and over and over again that opioids don't work for fibromyalgia. There's no way they actually took the time to review the existing research, because if they had they would know that statement is based on opinion, not fact.

The truth is very few research trials have actually studied if opioids are an effective treatment for fibromyalgia. In 2016, I took a deep dive into the research on using opioids for fibromyalgia and was stunned by just how little data there really is.

In 2011 and 2013, there were a couple of large studies at McGill University in Montreal, Canada, involving around 300 fibromyalgia patients who were being treated with opioids. The researchers concluded "opioid-treated patients were more symptomatic and were more likely to be unemployed and to be receiving disability benefits."

The inference from that statement is that somehow the opioids increased the patients' symptoms when there's no way to know for sure if that's what really happened. It's entirely possible those patients were on opioids because their symptoms were more severe, which would also explain why those particular patients were more likely to be unemployed and on disability.

You'd think these researchers would remember a simple principle that many of us learned in college: Correlation doesn't equal causation.

Then, there have been at least three studies (2000, 2003 and 2011) that looked at the effectiveness of tramadol, a weaker synthetic opioid, at reducing fibromyalgia pain. All of these studies confirmed tramadol improved fibro-related pain.

A small Swedish study from 1995 found intravenous morphine did not improve fibromyalgia pain, and a 2003 study from the University of Cincinnati College of Medicine concluded opioids were not effective.

I might have missed a small trial here and there, but that's basically the gist of the research that has studied the use of opioids for fibromyalgia. Little has changed since I reviewed the research five years ago. There still haven't been any large trials testing the efficacy of opioids in fibro patients.

So looking at the scant research that's available, how can the people who develop these treatment guidelines honestly say opioids don't work for fibromyalgia patients? They can't.

As the saying goes, "absence of evidence is not evidence of absence." In other words, you can't say opioids don't work when you've never even taken the time to study whether opioids help fibromyalgia pain or not.

And it is disingenuous to suggest otherwise.

Donna Gregory Burch was diagnosed with fibromyalgia in 2014 after several years of unexplained pain, fatigue and other symptoms. She was later diagnosed with chronic Lyme disease. Donna covers news, treatments, research and practical tips for living better with fibromyalgia and Lyme on her blog, FedUpWithFatigue.com. You can also find her on Facebook, Twitter and Pinterest. Donna is an award-winning journalist whose work has appeared online and in newspapers and magazines throughout Virginia, Delaware and Pennsylvania.

Why Do Opioids Stop Working?

By Forest Tennant, PNN Columnist

One of the most common complaints that we receive from people with intractable pain syndrome (IPS) is that opioids quit working when they previously provided good pain relief. They usually report that increasing the dosage was ineffective as well. The cause is known as “opioid receptor failure.”

Every person with IPS who takes daily opioids needs to carefully review the information given here. Once your opioid quits working, it will likely not work again. You can be left without good pain control options.

Patients are at risk for opioid receptor failure if they use a long-acting opioid such as a fentanyl patch, or oxycodone, morphine, hydromorphone or methadone. Intrathecal pump administration of any opioid also raises the risk for opioid receptor failure.

The reason for this is that long acting and intrathecal opioids never leave the blood and spinal fluid. Consequently, they continually coat opioid receptors, and with prolonged use they literally render the receptor incapable of pain relief.

A good analogy is stretching a rubber band too long and seeing it lose its elasticity. The receptors may become permanently altered. Short acting opioids leave the blood and spinal fluid for a time and that lets the receptors recuperate and re-energize, so opioids usually stay effective over a long-time period.

How to Keep Opioids Working

1. Opioid receptors hold up better in patients who take vitamin and mineral supplements, and have diets low in sugar and starch, and high in proteins and green vegetables.

2. Hormone levels must be normal to keep opioids effective. Opioid receptors require adequate blood levels of testosterone, cortisol and pregnenolone.

What To Do If Opioids Quit Working

Here are six recommendations to try, but remember when opioids quit working, they may not work again.

1. Get a hormone test for testosterone, cortisol and pregnenolone. If you have a deficiency, start hormone therapy and continuously raise the dosage over a 6-week period until your hormone level is normal.

2. Start a nutrition program with vitamins, minerals, and a low sugar/starch, high protein/green vegetable diet.

3. Switch to a short acting opioid, if possible.

4. The addition of an adrenaline or dopamine stimulant such as Adderall or Ritalin may help.

5. Get an injection of ketorolac to determine if this potent anti-inflammatory analgesic may provide some pain relief.

6. Take taurine 4,000-8,000 mg per day for 5 days. If there is improvement, continue at 2,000 to 4,000 mg per day.

If you are doing well on a long-acting or intrathecal opioid, don’t stop. Some persons on long acting and intrathecal opioids do well for years. But don’t get overconfident. Opioid receptor failure can be sudden and unexpected. 

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.   

Legal Fight Brews Over Non-Opioid Pain Reliever

By Pat Anson, PNN Editor

Competition between drug companies can get so intense that some resort to bare knuckle tactics to preserve market share. Such is the case for Pacira BioSciences, which filed a lawsuit against the American Society of Anesthesiologists (ASA) last month for “false and misleading conclusions” about the effectiveness of Pacira’s flagship product Exparel, an injectable non-opioid analgesic used for postoperative pain.

In February, the ASA published two research articles and an editorial in its journal Anesthesiology saying Exparel works no better than other bupivacaine products on the market. New Jersey-based Pacira considered that libelous, and filed a complaint in federal court seeking a retraction and damages for lost business.

Now comes word that Pacira’s attorneys withdrew their motion for a retraction after the ASA asked the court for a prompt hearing “to expose flaws in Pacira’s claims.”

“It is vitally important that we defend and stand behind these three works and the integrity and scholarship of those who contributed to them,” said Evan Kharasch, MD, editor-in-chief of Anesthesiology. “These authors are leading physicians and researchers in the fields of anesthesiology and clinical studies. Physicians and patients must have trusted information on which to base clinical decisions and care, and that information needs to be unaffected by commercial interests.”

It is not yet clear if Pacira will withdraw the rest of its libel case. “Our corporate policy is not to comment on pending litigation,” a spokesperson told PNN.

This is not the first time Pacira has used aggressive tactics to promote Exparel or fend off criticism. In 2014, the company filed a lawsuit against the FDA after the agency sent a warning letter to Pacira for off-label marketing of Exparel. The FDA said Pacira promoted Exparel for “surgical procedures other than those for which the drug has been shown safe and effective.”

Pacira won that case in an out-of-court settlement after the FDA backed down, withdrew its warning letter and changed Exparel’s label to say that it can be used for more types of post-operative pain.

In addition to doubts about Exparel’s effectiveness, some have questioned its cost. A 2015 STAT story pointed out that a vial of Exparel cost $285 and provided no better pain relief than a $3 vial of generic bupivacaine. 

In 2016, Pacira funded a report by an expert panel at the Jefferson College of Population Health that called for greater use of non-opioid medication for post-operative pain. One of the non-opioids recommended by the panel was Exparel. Pacira’s funding of the project was only noted at the end of the report.

In 2020, Pacira agreed to pay $3.5 million to resolve federal allegations that it gave kickbacks to doctors in the form of fake research grants that promoted Exparel.

Pacira has also been active politically, spending over $1.7 million on lobbying and campaign donations since 2018, according to OpenSecrets.org.

In 2019, Pacira hired former New Jersey Gov. Chris Christie as a consultant for $800,000 and lucrative stock options. The move was controversial, because Christie had just chaired President Trump’s opioid commission, which recommended that Medicare and Medicaid reimbursement policies be changed to encourage hospitals to use more non-opioid painkillers.

All this suggests that Pacira won’t back down easily from a fight. But it doesn’t sound like the ASA will either.

“Although Pacira started this lawsuit, ASA will not shy away from refuting Pacira’s claims and from exposing the important issues with Pacira’s controversial drug,” the ASA said in a news release.

Zynrelef Approved

Pacira is about to get more competition in the post-operative pain market. San Diego-based Heron Therapeutics says it has received FDA approval for Zynrelef, an extended-release analgesic for use by adults up to 72 hours after a bunionectomy, hernia repair and total knee replacement surgery.

Zynrelef combines bupivacaine with a low dose of the nonsteroidal anti-inflammatory drug (NSAID) meloxicam. In clinical studies, the company says the synergy between the two drugs resulted in patients experiencing significantly less pain with less use of opioids compared to bupivacaine alone.

"The first three days after surgery are when patients experience the most severe postsurgical pain and are most likely to receive opioids to manage that pain. With the impressive reduction in pain and opioid use demonstrated by Zynrelef, we now have an important new option to help many patients achieve an opioid-free recovery," said Roy Soto, MD, an anesthesiologist at Beaumont Health System who consults with Heron. 

The company expects Zynrelef to be available by July. Patients are advised not to take the drug if they are allergic or have side effects from NSAIDs. The most common side effects of Zynrelef are constipation, vomiting and headache.

Hospira Recall

Pfizer’s Hospira division is voluntarily recalling a single lot of bupivacaine and a lot of lidocaine due to mislabeling that caused some of the vials to be incorrectly labeled as the other product. Both drugs are used to treat surgical pain. The mislabeling was identified after a customer complaint.

Hospira assessed the potential risk to patients if the mislabeled products were used to be “moderate to high severity.” If the mislabeled lidocaine was administered to a patient instead of bupivacaine, the patient may not get enough pain relief. If the bupivacaine was administered instead of lidocaine, the outcome could be even worse: an overdose of bupivacaine may occur, which could lead to seizures, respiratory problems, irregular heartbeat and cardiac arrest.

The recalled lots were distributed nationwide to wholesalers and hospitals in the United States, Puerto Rico and Guam from December 29, 2020 to April 15, 2021.

Hospira has not received reports of any adverse events associated with the mislabeling. The company did not respond to a request to explain how the mislabeling occurred or how it went undetected for nearly five months.

Patient Z and the Criminalization of Pain Care

By Pat Anson, PNN Editor

Dr. Stefan Franzen is not a physician or pain patient, but his new book is likely to open some eyes about the poor quality of pain care in the United States and the consequences of criminalizing opioid medication.

“Patient Z” is Franzen’s pseudonym for a family member who lives with ankylosing spondylitis, a severe form of arthritis, who was cut off from opioids when his longtime doctor came under investigation and was forced to stop prescribing. Patient Z struggled for years to find a new doctor and effective treatment, at times contemplating suicide during bouts of intense pain.  

When Franzen, a chemistry professor at North Carolina State with an extensive background in biomedical research, tried to help by speaking with doctors – he came to the realization that Patient Z and millions of others like him had been stigmatized, terrorized and abandoned in the name of fighting opioid addiction.   

“There are doctors who would like to help patients like Patient Z, but they feel that matters are out of their hands. There is not likely to be major change until the citizens of the United States realize that the denial of pain management care is an attack on patients’ rights and that what happened to Patient Z can happen to anyone,” Franzen writes.

Franzen’s book is comprehensive and well-researched, with several chapters dedicated to debunking some of the myths about opioids, such as addiction and overdoses being inevitable after high doses and long-term use. Those myths have been codified into medical guidelines, laws and regulations to a point where many doctors are now afraid to prescribe opioids or even see pain patients.

“It feels like the tribe is moving on and leaving the patients behind. Our attitude is ‘everybody for themselves’ and the doctors are saying, ‘Hey, I could go to jail.’ And the patients are screwed, which is absurd. The criminalization of medicine is a big part of this problem,” Franzen told PNN.

“My book looks at this from the point of view of the pain patient. What does this look like? And to realize what it’s like when you’re rejected. You’re afraid you’ll be called an addict. You’re afraid someone is going to cut you off at any time.”

Franzen says the war on drugs has been a misguided failure that has only made drug trafficking worse, with pain patients caught in the crossfire. As an example, he points to Florida’s crackdown on pill mills a decade ago.

“When they finally cracked down, there was this massive switch to heroin. It was in 2011 and the heroin numbers shot up. And of course, everyone went to draw the conclusion that the prescription drug crisis caused the heroin crisis. It’s the wrong conclusion,” says Franzen.

“I think the reason the heroin numbers went up is the way they clamped down. They were shutting down methadone clinics. They were making it as hard as possible for anyone with an addiction problem to get help. Here are all these people who got hooked and they’re shutting every single door. What choice do those people have? They can either go cold turkey and go into withdrawal or, suddenly, there’s a lot of heroin available.”

PROP’s ‘Lack of Ethics’

Franzen acknowledges that at one time opioid prescribing was excessive and it was too easy to get opioid medication. But he says the reaction to that by government regulators and law enforcement was “draconian and just absurd.”

Much of the blame for that, according to Franzen, lies with Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that questioned whether opioids were even effective in treating pain. That led to what Franzen calls a “medical coup d’état” in which PROP bypassed the FDA and persuaded the CDC to release its controversial opioid guideline in 2016.

Franzen says if PROP founder Dr. Andrew Kolodny, PROP president Dr. Jane Ballantyne and PROP board member Dr. Anna Lembke were in his chemistry class, he’d give them all F’s.  

“They’d get an F because they misrepresented the facts. And they did things that were intellectually dishonest. I’d actually not give them a grade. I’d kick them out of the class. They cheated,” says Franzen. “Their academic papers are bunk. Part of what I do in this book is debunk them. I do exactly what I would do if I was writing about somebody in chemistry, which is my area of research, who I thought had written something that did not make sense and was not supported by the data.

“They’re ignoring all of these facts or even contradicting themselves. They’re suggesting that a patient has to admit they’re an addict before you can treat them. Huh?”

As PNN has reported, Kolodny and Ballantyne have been well-paid expert witnesses for law firms that stand to make billions of dollars in contingency fees from opioid litigation. But they neglected to mention that conflict-of-interest in several papers and had to make new disclosure statements.

“That too is just stunning to me. The lack of ethics by Kolodny and Ballantyne, specifically, is just jaw dropping,” says Franzen. “I hope they read my book and come after me. I want them to know what I said about them and try to defend themselves, because I don’t think that they can.”   

As for Patient Z, Franzen says he is in palliative care and getting opioids again. He needs to use a walker and wheelchair to get around, but the pain is at least tolerable. Patient Z has also become a fierce advocate for patient rights.      

Opioid Prescribing Reduced by 50% After Some Surgeries

By Pat Anson, PNN Editor

In recent years, hospitals around the country have adopted policies to reduce the use of opioids for post-operative pain, fueled in part by studies showing that many surgery patients were sent home with more pills than they need. New research shows just how far efforts to reduce “overprescribing” have gone.

In an analysis of nearly half a million common surgeries performed at 87 U.S. hospitals, the Epic Health Research Network found that the number of opioid pills prescribed to patients decreased by 50% since 2017. The surgeries included in the study were low-risk arthroscopic or laparoscopic surgeries in which small incisions are made and patients are sent home from the hospital the same day.

Researchers say outpatients are just as likely to get opioids today after surgery as they were in 2017, but they will get significantly fewer pills. For example, a typical patient recovering from arthroscopic rotator cuff surgery in 2017 was prescribed the equivalent of 60 oxycodone 5mg tablets. By the end of 2020, the average patient received about 30 tablets after that procedure.      

“By reducing the number of pills that go out the door, we reduce the amount of time the patient is on opioids and we reduce their risk of long-term opioid use,” explained David Little, MD, a Physician Liaison with Epic Health.  

“The other thing that happens when someone goes home with 60 tablets of opioids is that they probably end up with 50 of them left sitting in the medicine cabinet. Those 50 pills in the medicine cabinet then become a problem in and of themselves, because patients start taking them later for unrelated stuff and they get addicted. Or the teenage child finds the pills and they start on them or take them out to be sold or give out to their friends.”

While the number of pills prescribed has declined significantly, Little told PNN they need to be reduced even more to meet treatment guidelines established by Johns Hopkins University.  A patient recovering from rotator cuff surgery should only get about 20 oxycodone pills according to that guideline, which recommends that ibuprofen also be used for pain relief.   

The Epic Health study did not look at what other medications were given to patients or if they were satisfied with their pain relief.

A recent Mayo Clinic study found that surgery guidelines are useful in reducing the number of pills prescribed, but sometimes go too far. While most patients were satisfied with their pain control, about 10 percent were not.  

Opioid addiction is actually rare after surgery.  A large 2016 study found only 0.4% of older adults were still taking opioids a year after major surgery.  Another large study in 2018 found only 0.2% of patients who were prescribed opioids for post-operative pain were later diagnosed with opioid dependence, abuse or had a non-fatal overdose.

Are Prescription Opioids Really the Same As Heroin?

By Roger Chriss, PNN Columnist

The new HBO documentary “The Crime of the Century” is garnering a lot of attention for its take on the opioid crisis. In the documentary, Dr. Andrew Kolodny, the founder of Physicians for Responsible Opioid Prescribing (PROP), claims that prescription opioids are “essentially heroin pills.”

This is a common claim. Dr. Corey Waller, an addiction and emergency medicine expert, recently testified in a West Virginia lawsuit that opioid drugs and heroin are "identical."

"The brain doesn't know the drug you just gave it," Waller said. "It just knows the action that it has."

But it’s not quite that simple. There are two standard ways to look at drugs: pharmacology and epidemiology. The former takes into account a drug’s chemical structure and mechanism of action in the human body. The latter looks at the public health effects of a drug.

Opioid Pharmacology

The National Institute on Drug Abuse (NIDA) explains that heroin is a type of opioid made from poppy plants that is “chemically similar and can produce similar effects” as prescription pain relievers.

But chemically similar does not mean functionally identical. Small chemical differences affect how quickly a drug is absorbed, how strongly it acts and how long it remains in the body. The specific action of each opioid drug at the various mu, kappa, and delta opioid receptors also varies, creating differing levels of analgesia and other effects.

For example, oxycodone’s chemical composition makes it a particularly powerful opioid.

“What's unique about oxycodone relative to other opioids is the speed at which it's presented to the brain,” anesthesiologist Dr. Heath McAnally explained in a recent MedPage Today op-ed. “And in that regard, oxycodone reigns supreme (rivaling heroin), likely having to do with the fact that oxycodone's transport across the blood-brain barrier is considerably faster and more efficient than that of other opioids.”

Further, oxycodone is more active at kappa opioid receptors, possibly explaining the harder withdrawal that some people experience. It also acts more strongly on mu receptors, which may explain its greater euphoria. Morphine, by contrast, is more prone to histamine effects like itching and is associated with less positive feelings.

The opioid tramadol is also a serotonin-norepinephrine reuptake inhibitor, while tapentadol is a norepinephrine reuptake inhibitor. Some people do not tolerate tramadol well, and there is less abuse of tapentadol than other prescription opioids. They are very different than heroin.

Opioid Epidemiology

A 2013 study found that about 80% of heroin users first misused prescription opioids, but in more recent years heroin has become the first opioid people abuse in many cases. Heroin’s so-called “capture rate” -- a proxy for the addictiveness of a substance -- is thought to be about 25 percent.

By contrast, NIDA says about 8-12% of people on long-term prescription opioids develop some form of opioid use disorder, and less than 4% of people who misuse prescription pain medication start using heroin within five years.

Among prescription opioids, oxycodone is the most abused. According to a 2020 DEA report, the diversion and abuse of oxycodone “has become a major public health problem in recent years.”

Street prices and illicit sales are similarly revealing. Prescription opioids sold illegally are not all priced the same, nor treated with the same level of interest. There is a clear hierarchy, with oxycodone on top.

But the key driver in the overdose crisis today is illicit fentanyl made in clandestine labs and sold illegally on the street or online, often adulterating heroin or used in counterfeit oxycodone or Xanax pills.

Illicit fentanyl’s impact on the U.S. overdose crisis cannot be overstated. Other opioids, including heroin, do not come close to its level of abuse, addiction and death. Meanwhile, countries like Germany have not seen an opioid crisis, even though Germans are the second largest consumers of opioids worldwide.

It is also important to note that prescription opioids are medically essential, not only for pain management but also when sedating Covid-19 patients for ventilator use, for controlling air hunger in congestive heart failure, and for hospice and palliative care. Prescription opioids are medically useful in ways that heroin is not.

The claim that prescription opioids are identical to heroin does not hold up well. It obscures important information about opioid pharmacology and epidemiology. It may make a good soundbite, but it doesn’t shed light on the risks of opioids or how to address the overdose crisis.

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.