The Opioid Crisis Is Not Just About Pain Medication

By Roger Chriss, Columnist

The opioid crisis is no longer primarily about prescription opioids. Illicit fentanyl, heroin, cocaine and other black market drugs are now involved in more overdoses than pain medication.

However, the current response to the overdose crisis is still focused primarily on opioid prescribing. Arizona just approved  legislation to reduce opioid prescribing for injured workers. And President Trump has stated that he will push for a one-third reduction in opioid prescribing over the next three years. 

The ongoing media narrative reinforces this view. The crisis is blamed on prescription opioids, combined with manipulative marketing by manufacturers, pharma funded advocacy groups, and poor prescribing practices by physicians. Although these factors may have played a role in the onset of the crisis 20 years ago, the “opioid epidemic” has evolved far beyond that.

The National Institute on Drug Abuse summarizes the origins of the crisis this way:

"In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive."

The Centers for Disease Control and Prevention says there have been three “waves” to the crisis:

"The first wave of opioid overdose deaths began in the 1990s and included prescription opioid deaths. A second wave, which began in 2010, was characterized by heroin deaths. A third wave started in 2013, with deaths involving highly potent synthetic opioids, particularly IMF (illicitly manufactured fentanyl) and fentanyl analogs."

CDC researchers recently admitted that they significantly inflated the number of deaths involving prescription opioids for years.  They also acknowledged in an “Annual Surveillance Report of Drug-Related Risks and Outcomes” that high dose opioid prescribing has been in decline for over a decade:

“Between 2006 and 2016, the annual prescribing rate per 100 persons for high-dosage opioid prescriptions (>90 morphine milligram equivalents (MME)/day) decreased from 11.5 to 6.1, an overall 46.8% reduction and an average annual percentage change of 6.6%. The rate leveled off between 2006 and 2009, then decreased 9.3% annually from 2009 to 2016.”

These trends are clearly visible at the state level. Maine’s Attorney General recently said “Fentanyl has invaded our state” and that most of the overdose deaths there were caused by multiple drugs. When pharmaceutical opioids were involved, most of the time they were “not prescribed for the decedent.”

FiveThirtyEight gave a detailed breakdown of drug deaths by state. In an article headlined “There Is More Than One Opioid Crisis,” Kentucky was actually found to have more overdoses involving gabapentin than oxycodone.

And in a recent Cleveland.com interview, FDA Commissioner Scott Gottlieb, MD, refers to the crisis as shifting “from a prescription-pill problem to one centered around deadly street drugs.”

In other words, prescription opioids have become only a small part of a crisis that now includes heroin, illicit fentanyl, and an increasing number of non-opioid drugs. In fact, we are fast approaching what will become the fourth wave of the crisis, one involving poly-drug abuse and overdoses, that will further challenge first responders, emergency rooms and addiction treatment facilities.

But still the response to the crisis has been focused on opioid prescribing. This may have made some sense a decade ago, when surveillance of the crisis was just starting. It made for good optics, but it was bad policy. Curbing prescribing is wreaking havoc with pain management, not only for chronic, progressive and degenerative disorders but also cancer and hospice patients. And it is not helping people who suffer from opioid addiction.

As Drs. Stefan Kertesz and Sally Satel point out: “Too many health care providers have started to see their fierce commitment to dose reductions as a badge of good citizenship, without any effort to measure the human outcomes of their own policies.”

Pain management expert Dr. Lynn Webster wrote this about the recently announced Medicare plan to reduce high dose opioid prescribing: “Such actions will not reduce opioid deaths related to heroin and illicit fentanyl which is the source of most overdose deaths. In fact the opposite effect may occur."

The opioid crisis will not be solved by focusing on prescription opioids. It is too late for that. Failure to recognize the evolving nature of the crisis will simply risk more fatal overdoses.  

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.

FDA Orders Recall of Kratom Linked to Salmonella Scare

By Pat Anson, Editor

The U.S. Food and Drug Administration has issued a mandatory recall for kratom capsules made by a Las Vegas company after several of its products were found to be contaminated with salmonella bacteria.

The FDA said it ordered the recall after Triangle Pharmanaturals failed to cooperate with the agency’s request to conduct a voluntary recall.

The FDA is advising consumers to discard kratom products made by Triangle, which include Raw Form Organics Maeng Da Kratom Emerald Green, Raw Form Organics Maeng Da Kratom Ivory White, and Raw Form Organics Maeng Da Kratom Ruby Red. The products are sold in 300 capsule plastic bottles.

It’s possible other brands may be included in the recall because Triangle manufactures and packages kratom products for other companies.

“This action is based on the imminent health risk posed by the contamination of this product with salmonella, and the refusal of this company to voluntarily act to protect its customers and issue a recall, despite our repeated requests and actions,” said FDA Commissioner Scott Gottlieb, MD, in a statement.

“We continue to have serious concerns about the safety of any kratom-containing product and we are pursuing these concerns separately. But the action today is based on the risks posed by the contamination of this particular product with a potentially dangerous pathogen. Our first approach is to encourage voluntary compliance, but when we have a company like this one, which refuses to cooperate, is violating the law and is endangering consumers, we will pursue all avenues of enforcement under our authority.”

The FDA said Triangle did not cooperate with its investigation or order a voluntary recall after six samples of its kratom products tested positive for salmonella. “FDA investigators were denied access to the company’s records relating to potentially affected products and Triangle employees refused attempts to discuss the agency’s findings,” the FDA said.

The company did not immediately respond to a request for comment.

At least 87 people have been sickened in 35 states by a salmonella outbreak linked to kratom – an herbal supplement used by millions of Americans to treat chronic pain, depression, anxiety and addiction. At least one other kratom distributor – PDX Aromatics of Portland, Oregon – agreed to voluntarily recall its products after several were found contaminated with salmonella.

Salmonella is a bacterial infection usually spread through contaminated food or water. Most people who become infected develop diarrhea, fever and stomach cramps. Severe cases can result in hospitalization or even death.

Kratom is usually sold in powder, capsules or leaves.  The Centers for Disease Control and Prevention has not been able to trace the salmonella outbreak to a single brand or source, so it is recommending that people not consume “any brand of kratom in any form.”

The FDA has also warned against consuming kratom, claiming it has opioid-like qualities and could lead to addiction. In recent months, the FDA has released a public health advisory warning that kratom should not be marketed as a treatment for any medical condition. The agency also released a computer analysis that found kratom contains over two dozen opioid-like substances.

Under the Food Safety Modernization Act, the FDA has broad authority to order the recall of food products when the agency determines that there is a reasonable probability the food is adulterated or could have serious health consequences.

Medicare Finalizes Plan to Reduce High Dose Opioids

By Pat Anson, Editor

The Trump administration has finalized plans that will make it harder for many Medicare patients to obtain high doses of opioid pain medication. Medicare beneficiaries will also be limited to an initial 7-day supply of opioids for acute pain.

Under new rules released today for the 2019 Medicare Part D prescription drug program, a ceiling for opioid doses will be established at 90mg morphine equivalent units (MME).  Any prescription at or above that level would trigger a “hard safety edit” requiring pharmacists to talk with the prescribing doctor about the appropriateness of the dose. If satisfied with the explanation, the pharmacist could then override the edit and fill the prescription.

Under an earlier proposal that was widely criticized, only insurers could decide whether to override a safety edit – a requirement that would have essentially made insurers the final arbiters in deciding who gets high doses of opioid pain medication.

The new rules adopted by the Centers for Medicare and Medicaid Services (CMS) will still allow insurers to implement safety edits, but only at a much higher dose of 200 MME or more.  Insurers will also be given greater authority to identify beneficiaries at high risk of addiction and to require they use “only selected prescribers or pharmacies.”

CMS is also adopting a new policy that requires all new opioid prescriptions for short term acute pain to be limited to no more than 7 days’ supply. Several states have already adopted similar measures.

CMS says this “tailored approach” to opioid prescriptions was needed to address what it called “chronic opioid overuse” at the pharmacy level and to encourage support for the CDC’s 2016 opioid prescribing guideline.

“CMS believes it is important that (insurers) set expectations for prescribers to implement the CDC’s recommendations as a best practice through their provider contracts. PDPs (prescription drug plans) should also reinforce these messages through interactions with prescribers as an integral component of sponsors’ drug utilization management program,” CMS said.

“We also recommend that beneficiaries who are residents of a long-term care facility, in hospice care or receiving palliative or end-of-life care, or being treated for active cancer-related pain are excluded from these interventions.”

About 1.6 million Medicare beneficiaries met or exceeded opioid doses of 90mg MME for at least one day in 2016. The 90mg MME ceiling established by the CDC was only meant as a recommendation for primary care physicians, but has been widely adopted as a rule by other federal agencies, insurers, state regulators and prescribers.

'Cruel' Limits on Opioid Prescribing

"The 90 mg dose they set as a threshold for 'high' or overuse is flawed and not scientifically based.  It is totally arbitrary," says Lynn Webster, MD,  a pain management expert and past president of the American Academy of Pain Medicine.  "It is cruel to impose such a limit on people with involuntary dose reductions who have been functioning well without signs of abuse for years.

"Even the 7 day limit is misguided at best. The average length of time a person requires an opioid post-op involves several factors and include the type of operation, the genetics of the person and the type of medication. The literature states the duration of pain requiring treatment with an opioid post-operatively is 4-9 days for general surgery, 4-13 days for women's health procedures and 6- 15 days for musculoskeletal procedures.  This means half of the Medicare patients will receive less than half of what they will need."  

Over 1,200 people left public comments in the Federal Register about the Medicare proposal, most of them sharply critical of CMS.

“This is archaic medicine and does more harm than one can imagine,” wrote pain patient Henry Yennie. “The DEA, HHS, private insurers, and now CMS are pursuing policies and restrictions that will cause harm and suffering to millions of people.”

“I cannot understand how Medicare can be so uncaring about the pain people have,” wrote Mikal Casalino, a 72-year old pain patient. “Limiting the dosage to an arbitrary amount is not going to be helpful for individuals.”

A joint letter opposing the rule changes was also submitted by 180 doctors and academics, including some who helped draft the CDC guidelines. The letter points out that a steep reduction in high dose prescribing since 2010 has not reduced the number of opioid overdoses. And it faults CMS for being focused on reducing the number of high dose prescriptions – not the quality of patient care.

“The proposal does not consider adverse impacts on pharmacies, physicians or patients…and it will accelerate patient abandonment,” the letter warns. “The plan avows no metric for success other than reducing certain measures of prescribing. Neither patient access to care nor patient health outcomes are mentioned.”

CMS contracts with dozens of insurance companies to provide health coverage to about 54 million Americans through Medicare and nearly 70 million in Medicaid. CMS policy changes often have a sweeping impact throughout the U.S. healthcare system because so many insurers and patients are involved.  The new Medicare regulations will go into effect on January 1, 2019.

Doctors and Pharmacists Targeted in DEA Surge

By Pat Anson, Editor

The U.S. Drug Enforcement Administration has arrested 28 people and revoked the registrations of over a hundred others in a nationwide crackdown that targeted prescribers and pharmacies that dispense “disproportionally large amounts” of opioid medication.

For 45 days in February and March, a special team of DEA investigators searched a database of 80 million prescriptions, looking for suspicious orders and possible drug thefts.

The so-called “surge” resulted in 28 arrests, 54 search warrants, and 283 administrative actions against doctors and pharmacists.  The DEA registrations of 147 people were also revoked – meaning they can no longer prescribe, dispense or distribute controlled substances such as opioids.

The DEA said 4 medical doctors and 4 medical assistants were arrested, along with 20 people described as "non-registrant co-conspirators." The arrests were reported by the agency's offices in San Diego, Denver, Atlanta, Miami and Philadelphia.

“DEA will use every criminal, civil, and regulatory tool possible to target, prosecute and shut down individuals and organizations responsible for the illegal distribution of addictive and potentially deadly pharmaceutical controlled substances,” Acting DEA Administrator Robert Patterson said in a statement.

“This surge effort has demonstrated an effective roadmap to proactively target illicit diversion of dangerous pharmaceuticals. DEA will continue to aggressively use this targeting playbook in continuing operations.”

The DEA surge is the latest in a series of steps taken by Attorney General Jeff Sessions to crackdown on opioid prescribing. Last August, Sessions ordered the formation of a new data analysis team, the Opioid Fraud and Abuse Detection Unit, to focus solely on opioid-related health care fraud. 

Sessions also assigned a dozen prosecutors to “hot spots” around the country where opioid addiction is common.  Last week the DEA said it would add 250 investigators to a task force assisting in those investigations.

Although overdose deaths are primarily caused by illicit drugs such as fentanyl, heroin and cocaine, federal law enforcement efforts appear focused on opioid prescribing. Doctors and pharmacists are easier to target because they are already in DEA databases, as opposed to drug dealers and smugglers operating in the black market.   

As PNN has reported, the data mining of opioid prescriptions -- without examining the full context of who the medications were written for or why – can be problematic and misleading.

For example, last year the DEA raided the offices of Dr. Forest Tennant, a prominent California pain physician, because he had “very suspicious prescribing patterns.” Tennant only treated intractable pain patients, many from out-of-state, and often prescribed high doses of opioids because of their chronically poor health -- important facts that were omitted or ignored by DEA investigators.

Tennant has not been charged with a crime and denied any wrongdoing. Nevertheless, he retired this month due to the stress and uncertainty caused by the DEA investigation. About 150 of his patients now have to find new doctors, not a simple task in an age of hysteria over opioid medication.

In an interview with AARP, Sessions defended the use of data mining to uncover health care fraud.

“Some of the more blatant problems were highlighted in our Medicare fraud takedown recently where we had a sizable number of physicians that were overprescribing opioid pain pills which were not helping people get well, but instead were furthering an addiction being paid for by the federal taxpayers. This is a really bad thing,” Sessions said.

“It’s a little bit like these shysters who use direct mail and other ways to defraud people. They will keep doing it until they’re stopped. In other words, if we don’t stop them, they will keep finding more victims and seducing them.”

Fewer Opioids Prescribed in Medical Marijuana States

By Pat Anson, Editor

The availability of medical marijuana has significantly reduced opioid prescribing for Medicaid and Medicare patients, according to two large studies published in the Journal of the American Medical Association (JAMA).

In one study, researchers at the University of Georgia looked at Medicare Part D prescription drug data from 2010 to 2015. They found that the number of daily doses prescribed for morphine (-14%), hydrocodone (-10.5%) and fentanyl (-8.5%) declined in states with medical marijuana laws. However, daily doses for oxycodone increased (+4.4%) in those same states.

The drop in opioid prescribing was most pronounced in states that have medical marijuana dispensaries, as opposed to those that only allow home cultivation of cannabis for medical purposes.

“We found that prescriptions for hydrocodone and morphine had statistically significant negative associations with medical cannabis access via dispensaries,” wrote lead author W. David Bradford, PhD, Department of Public Administration and Policy at the University of Georgia.

“Combined with previously published studies suggesting cannabis laws are associated with lower opioid mortality, these findings further strengthen arguments in favor of considering medical applications of cannabis as one tool in the policy arsenal that can be used to diminish the harm of prescription opioids.”

The second study, by researchers at the University of Kentucky, looked at Medicaid prescriptions from 2011 to 2016, and found a 5.88% decline in opioid prescribing in states with medical marijuana laws.  Opioid prescribing for Medicaid patients fell even more -- by 6.38% -- in states where the recreational use of marijuana is legal.

“These findings suggest that medical and adult-use marijuana laws have the potential to reduce opioid prescribing for Medicaid enrollees, a segment of population with disproportionately high risk for chronic pain, opioid use disorder, and opioid overdose,” wrote lead author Hefei Wen, PhD, University of Kentucky College of Public Health.

One weakness of both studies is that they did not determine if Medicaid and Medicare patients reduced their use of opioid medication because they were using cannabis.  They also only included patients that were elderly, poor or disabled. And they were conducted during a period when nationwide opioid prescribing was in decline.

A recent study by the RAND corporation found little evidence that states with medical marijuana laws experience reductions in the volume of legally prescribed opioid medication. RAND researchers believe some pain patients may be experimenting with marijuana, but their numbers are not large enough to have a significant impact on prescribing. 

"If anything, states that adopt medical marijuana laws... experience a relative increase in the legal distribution of prescription opioids," the RAND study found. "Either the patients are continuing to use their opioid pain medications in addition to marijuana, or this patient group represents a small share of the overall medical opioid using population." 

Although 29 states and the District of Columbia have legalized medical marijuana and a handful of states allow its recreational use, marijuana remains illegal under federal law.

An Open Letter to All the Doctors Who Missed My EDS

By Crystal Lindell, Columnist

I hate you. I actually hate you.

Well, maybe not all of you.

But most of you, yes I hate. Actually, hate is too nice word. I detest you. I loathe you. I have venom in my heart for you. I hope your favorite show gets cancelled after a cliff hanger. I hope your air conditioner breaks in your car in July. I hope your crush never likes any of your Instagram photos. I hope every single time you go through the Taco Bell drive thru, they mess up your order. And I hope your phone screen cracks, your laptop crashes and you lose everything you ever saved.

I was recently diagnosed with Hypermobile Ehlers Danlos syndrome (hEDS), a connective tissue disorder that not only explains why my ribs always feel broken, but also why I’m always covered in unexplained bruises, why I sprain my ankles too often, why my vision changed for no reason, why my skin is baby soft, and why I crave salt.

And so many doctors missed it. And I can’t get it out of my head.

Like the doctor at Loyola who told me to stop coming to see him because there was nothing else he could do about my pain.

And the other doctor at Loyola who looked right at me while I was sitting on the exam table in just a paper-thin gown and said, “Well there are two options. You either woke up with a completely unexplainable pain, or you’re a great actress.”

I was so caught off guard that I didn’t even realize he was accusing me of trying to get drugs for like a full 30 seconds.

I also hate literally every single doctor at the Mayo Clinic that missed this crap. You know how easy it is to do an initial test for hEDS?

Doctor: "Can you bend your thumb to your wrist?"

Patient: "Yes."

Doctor: "Yeah, you probably have it. Let’s do a full evaluation."

IT’S THAT EASY!!!

The Mayo Clinic missed it because they were obsessed with me going to their rehab clinic and getting off opioids, despite the fact that it wasn’t covered by my insurance and that they required a $35,000 upfront payment.

So yes, I hate all of you.

I also hate every single chiropractor I ever saw. Seriously, all you guys do is see people in pain, and it never crosses your mind to evaluate for EDS? Why are you not asking every single patient who walks through your doors if they can touch their thumb to their wrist? What is wrong with you?

Not to mention the fact that chiropractors have to be super careful with EDS patients, if they treat them at all, because things can dislocate and all that. It’s irresponsible of you not to be evaluating every single patient for EDS.

I also hate the pain specialist who berated me for not wanting a spinal cord stimulator. If he had evaluated me for EDS, he would have known that a spinal cord stimulator would have probably been a horrible idea for me. Like chiropractors, all pain specialists do is see people in pain. They should be evaluating every single patient they see for EDS too! 

The whole thing is so infuriating and frustrating. I sincerely wish I could go back to every single doctor I have seen over the last five years and personally tell all of them how much I hate them. And then I wish I could tell all of them to freaking check people for EDS. But I can’t do that. All I can do is write this letter and then try to move forward with my new life and my new diagnosis.

But if you’re a pain patient and you can touch your thumb to your wrist, get checked for EDS. Seriously.

And if you’re a doctor, do better.

Crystal Lindell is a journalist who lives in Illinois. She eats too much Taco Bell, drinks too much espresso, and spends too much time looking for the perfect pink lipstick. She has hypermobile EDS. 

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

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

Living in Denial About the Overdose Crisis

By Ann Marie Gaudon, Columnist

Most of us know that denial of reality exists, but why is this so? How can humans with the ability to consider, evaluate, analyze and resolve complex problems ignore the facts? Even when ignoring the truth might lead to disastrous results?

Conceived by Sigmund Freud as a defense mechanism (to “defend” us against that which we do not want to feel), denial has been a concept for many decades. To over-simplify the premise, it’s a belief that something is either true or false when the facts say otherwise. Why would we do this? It’s because people experience a broad range of powerful emotions and intentions, such as greed, pride, revenge, fear, desire and a need for status – just to name a few. The have a strong influence over our ability to interpret facts.

When the Canadian government introduced the 2017 Canadian Guideline for Opioid Therapy, the creators were in denial. They ignored medical facts about chronic pain and turned pain sufferers into sacrificial lambs for people abusing illicit opioids. Patients and doctors tried to tell the truth but were not allowed a seat at the table with the so-called “experts.”

Chronic pain patients have never, ever, had their pain needs met and now they fare much worse. They are in more pain and experience more death and disability due to forced tapering and suicide.

Deniers yell loud and long that opioid pain medications are not effective, dangerous, addictive and will kill you in the end. Except that the evidence does not support that. Those with the worst pain have necessarily taken opioid medications to cope. It was their strongest weapon and were usually taken without danger, addiction or death. Opioids gave them effective pain relief that helped them regain function in everyday life.  Deniers will neither believe nor admit to this.

Let’s take a look at some of the strong influences which spur deniers to ignore the facts. We can see through many interviews and articles that McMaster University’s chosen group for creating the Canadian guideline enjoyed inflated reputations as “progressive thought leaders” who were “experts in pain management.” Add in the prestige and desire for status that comes from speaking engagements, media interviews, and more committees to participate in. Imagine the pride and prestige from conducting more studies (despite knowing little about the study area), and let’s not forget the enormous sums of monies paid to them by our government.

Greed, desire and a need for status can easily veto reality. So can feelings of morality and “doing the right thing” for people, while living under the fictitious perception that they are making positive inroads into addiction and overdose deaths while saving chronic pain patients from themselves.

In the real world, what has been the impact of the guideline on addiction? Nothing.

What has been the impact on pain patients? Devastation.

Most people can’t seem to figure out why the very same dreadful outcomes keep happening until they are knee-deep in it. Health Canada said this week that over 4,000 Canadians died from drug overdoses in 2017, the most ever. Most of those deaths – 72 percent – were caused by illicit fentanyl, not prescription pain medication.

Jordan Westfall, President of the Canadian Association of People Who Use Drugs, was bang on when he wrote in the Huffington Post that “it should shame this country to no end that our federal government is still afraid to see this epidemic for what it is in reality… What’s killing people is drug overdose and an apathetic government.”

May I add that what has never been killing people are chronic pain patients and their medications. Remorse and shame are powerful motivators for living in denial. Deniers continue to believe that punishing patients will somehow decrease the alarming rate of overdose deaths.

Chronic pain patients have always known the emperor has no clothes. It is a fact that all over North America prescriptions for opioids continue to go down, while overdose deaths continue to go up.  Does this suggest a statistically significant relationship between prescription analgesics and overdose deaths?  Yet the deniers continue with the same old agenda, despite the disastrous situation they have created.

There is an annoying little fact about denial. It doesn’t work in the long-term. Reality always wins out and when that happens, the next step for the deniers will be to place misdirected blame onto someone else. Count on it. It’s already happening. Doctors put the blame on the guideline’s creators and the creators reply, “No, no, no…it’s the doctors who have misunderstood the guideline.”

Here’s a message to the Canadian government and to the plethora of advisory groups, committees, response teams, et cetera and ad nauseam that are funded with taxpayers’ money to deny the facts:

When you are consistently creating the same disastrous outcome over and over again, you are in denial. And if this shameful situation continues, it will only lead to more suffering and deaths.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for 33 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

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

CDC Blames Fentanyl for Spike in Overdose Deaths

By Pat Anson, Editor

The Centers for Disease Control and Prevention released a new report today estimating that 63,632 Americans died of a drug overdose in 2016 – a 21.5% increase over the 2015 total.  

The sharp rise in drug deaths is blamed largely on illicit fentanyl, a powerful synthetic opioid that has become a scourge on the black market. Deaths involving synthetic opioids doubled in 2016, accounting for about a third of all drug overdoses and nearly half of all opioid-related deaths.

For their latest report, CDC researchers used a new “conservative definition” to count opioid deaths – one that more accurately reflects the number of deaths involving prescription opioids by excluding those attributed to fentanyl and other synthetic opioids. Over 17,000 deaths were attributed to prescription opioids in 2016, about half the number that would have been counted under the “traditional definition” used in previous reports.

CDC researchers recently acknowledged that the old method "significantly inflate estimates" of prescription opioid deaths.

The new report, based on surveillance data from 31 states and the District of Columbia, shows overdose deaths increasing for both men and women and across all races and demographics.  A wider variety of drugs are also implicated:

• Fentanyl and synthetic opioid deaths rose 100%
• Cocaine deaths rose 52.4%
• Psychostimulant deaths rose 33.3%
• Heroin deaths rose 19.5%
• Prescription opioid deaths rose 10.6%

The CDC also acknowledged that illicit fentanyl is often mixed into counterfeit opioid and benzodiazepine pills, heroin and cocaine, likely contributing to overdoses attributed to those substances.

2016 DRUG RELATED DEATHS

West Virginia led the nation with the highest opioid overdose rate (43.4 deaths for every 100,000 residents), followed by New Hampshire, Ohio, Washington DC, Maryland and Massachusetts.  Texas has the lowest opioid overdose rate.

‘Inaccurate and Misleading” Overdose Data

The CDC's new method of classifying opioid deaths still needs improvement, according to John Lilly, DO, a family physician in Missouri who took a hard look at the government’s overdose numbers. Lilly estimates that 16,809 Americans died from an overdose of prescription opioids in 2016.

“Not all opioids are identical in abuse potential and likely lethality, yet government statistics group causes of death in a way that obscures the importance of identifying specific agents involved in deadly overdoses,” Lilly wrote in a peer reviewed article recently published in the Journal of American Physicians and Surgeons..

Lilly faults the National Institute on Drug Abuse (NIDA) -- which relies on a CDC database -- for using “inaccurate and misleading” death certificate codes to classify drug deaths. In its report for 2016, NIDA counted illicit fentanyl overdoses as deaths involving prescription opioids. As a result, deaths attributed to pain medication rose by 43 percent, at a time when the number of opioid prescriptions actually declined.

“That large an increase in one year from legal prescriptions does not make sense, particularly as these were being strongly discouraged,” Lilly wrote. “Rather than legal prescription drugs, illicit fentanyl is rapidly increasing and becoming the opioid of choice for those who misuse opioids... Targeting legal prescriptions is thus unlikely to reduce overdose deaths, but it may increase them by driving more users to illegal sources.”

Some researchers believe the government undercounts the number of opioid related deaths by as much as 35 percent because the actual cause of death isn’t listed on many death certificates.

“We have a real crisis, and one of the things we need to invest in, if we’re going to make progress, is getting better information,” said Christopher Ruhm, PhD, a professor at the University of Virginia and the author of a overdose study recently published in the journal Addiction.

Ruhm told Kaiser Health News the real number of opioid related deaths is probably closer to 50,000.

4 Alternative Therapies That Help Lower Pain Levels

By Barby Ingle, Columnist

This is the 11th month of my series on alternative therapies for chronic pain management. As I have stressed month after month, each of us is different, even if we are living with the same diseases. No one treatment works for everyone. We must find creative and effective ways to get our pain levels lower.

This month I am shining a spotlight on four treatments that may help you or your loved one in chronic pain: Quell, radiofrequency ablations, reflexology and sonopuncture, also known as sound therapy. I have tried all four of these treatments with varying degrees of success.

Quell

Quell is a wearable medical device that uses electric nerve stimulation to deliver relief from chronic pain. I have tried this device and passed it on to some of my friends with back, arthritis, nerve, leg and foot pain. For me, the relief was not as significant as I had hoped, but I have a friend who has used it daily for a year and swears that it helps her leg pain.

NeuroMetrix, the maker of Quell, designed the device to be worn on the upper calf muscle. It was small enough to wear under my sweatpants and not too big or bulky to get in the way. The device sends neural pulses through the central nervous system to the brain to trigger the body’s own pain blockers. It has a variety of stimulation patterns and sleep modes, and the intensity of therapy can be adjusted through an app.

If you have tried a TENS unit or Calmare and gotten some relief, this might be a successful tool to help you manage your pain. A Quell starter kit costs $249. Each unit comes with the device, leg band, two electrodes and charging cords. You have to replace the electrodes about every two weeks with normal use, but the battery is rechargeable.

I believe Quell is an option that is worth looking into and they have a 60-day moneyback guarantee if it doesn’t help you.

image courtesy neurometrix

Radiofrequency Ablation

Radiofrequency ablation (RFA) uses heat to stop the transmission of pain. Radiofrequency waves “ablate” or burn the nerve that is causing the pain. The nerve stops sending pain signals until it regrows and heals from the ablation. RFA is most commonly used to treat chronic pain caused by arthritis and peripheral nerve pain.

I had RFA procedures 36 times from 2005 to 2008. It never took my pain away but did lower my pain levels and helped take the edge off. The doctor performed them on the ganglion nerve bundle in my neck. My insurance covered the procedures and it was helpful in keeping the need for high dose pain medications down.

RFA procedures are typically done in an outpatient setting under local anesthetics or conscious sedation anesthesia. The procedure is done under guidance imaging, like a CT scan or by ultrasound machine, by an interventional pain specialist.

RFA is said to help in treating the desired nerve without causing significant collateral damage to the tissue around where the ablation is performed. Still, a patient should take precautions and understand that the ablation can cause trauma or injury to the body, and conditions such as CRPS or arachnoiditis can be exacerbated long-term with this treatment.

When I was having RFA, it was one of the only options I had access to. Once less invasive options became available to me, I opted to stop these and nerve blocks all together.

Reflexology

Reflexology involves the application of pressure to the feet and hands with thumb, finger, and hand techniques. Reflexology is very relaxing and calming for me but there is no consensus among reflexologists about how it works, and some technicians are better at it than others.

Practitioners believe that there are specific areas in the hands and feet that correspond with organs in the “zones” of the body. There are five zones on each half of the body that reflexologists work on. In theory, they help stimulate blood flow and better blood flow leads to better working organs and muscles

The research on reflexology is skimpy and it has not been proven as an effective treatment for any medical condition.  It’s more of an approach to health lifestyle living, which can be of benefit to pain patients. This can help lower blood pressure and relax a pained body by taking the edge off.

I can say reflexology did seem to help with my constipation issues, but I was doing it while taking OTC and prescription strength medications, as well as stretching and stomach massages.

Sonopuncture

Sonopuncture is also known as vibrational or sound therapy. The idea behind it is similar to that of acupuncture, although instead of needles they use sound waves. Sonopuncture practitioners believe that sound waves stimulate the body into healing.

Sonopuncture was recently highlighted on an episode of “Keeping Up with the Kardashians” when Kendall Jenner was going through some anxiety challenges. I have used sound therapy myself to help with the stress of living with chronic pain and find it relaxing and mentally therapeutic.

Typically, the patient lays down in a comfortable position on the floor or a massage table. The practitioner will used tools like a tuning fork, glass bowls, chimes, metal or electronic devices that emit harmonic sounds or vibrations on acupressure points for about a minute each.

This is a noninvasive therapy and is suitable for all ages. Since no needles are involved, it could be seen as an alternative to acupuncture. With one in four patients afraid of needles, this could be a great way to calm your nerves and mind to help manage the challenges of living with chronic pain.

If you are considering any of these alternative treatments, I encourage you to first talk with a medical professional who is familiar with your past and present care and can help you discover what would be appropriate for you.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website. 

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

Opioid Hysteria Leading to Patient Abandonment

By Pat Anson, Editor

As the overdose crisis has worsened, doctors are under increasing pressure from law enforcement, regulators and insurers to reduce or stop prescribing opioids.

A nurse practitioner in the Seattle area – who asked to remain anonymous -- recently told us that she was closing her pain clinic because she was afraid of losing her license and going to prison. 

“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,” she wrote.

“I will be carefully weaning them all down… 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."

Patient abandonment is a growing problem in the pain community. Patients safely prescribed opioids for years are being dropped by doctors – often without weaning or tapering -- after they fail a drug test, miss a pill count, or become disruptive during an appointment. Sometimes they’re dropped for no reason at all.

Such is the case of Chris Armstrong, a 50-year old Orlando, Florida man severely disabled by multiple sclerosis and trigeminal neuralgia, a chronic pain facial disorder sometimes called the “suicide disease.” For over six years, Armstrong’s pain was treated with relatively high doses of morphine and hydrocodone at Prospira’s National Pain Institute in Winter Park.

That came to abrupt ending in late December, when Armstrong’s 74-year old mother and caretaker was handed a brief letter during their last visit to the clinic.

"This letter is to inform you that I will no longer be your physician and will stop providing medical care to you,” wrote Cherian Sajan, MD. “I will continue to provide routine emergency and medical care to you over the next 30 days while you seek another physician.”  

No explanation was given for Armstrong’s dismissal. Dr. Sajan did not respond to a request for comment.

“To have the plug pulled just like that,“ says Chris. “There’s nothing in my record that I’ve ever done anything wrong. I was a model patient.”

“They discharged him and gave no reason,” Valerie Armstrong said.  “They gave us a name of another pain doctor which they scribbled on a piece of torn paper. We went to see him, but after a few visits, (that doctor) told my son he was discharging him as well, as he needs ‘long term care’ which they refuse to provide.”

At the National Pain Institute, Armstrong says he was prescribed 150 morphine equivalent units (MME) of opioid medication daily. The second doctor reduced that dose to 100 MME – still above the maximum dose of 90 MME recommended by the CDC.  

Chris has been unable to find a new doctor and believes he’s been red flagged as a patient who needs high doses of opioids. 

“I went to another one and he said he can’t do anything because his hands are tied because I’ve been ousted by another pain doctor,” he told PNN. “What am I going to do, if no one will see me because of that?”

CHRIS ARMSTRONG

“I have called every pain clinic in my area and no one will see my son because he has been discharged by the previous pain clinics,” says Valerie. “My son is bed-bound quadriplegic, only travels in a wheelchair and can barely talk or eat from trigeminal neuralgia pain. His health is extremely fragile, and he will surely die if he has to stop his pain medication abruptly. That happened once before and he went to the ER in an ambulance having seizures.”

Armstrong has only a few days left of his last prescriptions.

“We need help and we need it now. He only has a few days supply of his pills left and then I'm sure his body will give out from withdrawals,” says Valerie. “My son had never taken any kind of pain medication before going to the National Pain Institute six and a half years ago and now he is physically dependent on them. I have begged and pleaded with them to take him back and even called their corporate headquarters to no avail.”

There is often little recourse for patients like Chris Armstrong.  Malpractice and patient abandonment laws vary from state to state, but discharging a patient is generally considered legal, as long as it isn’t discriminatory.

Florida’s Board of Medicine says a “health care practitioner can terminate a patient relationship at any time, but the practitioner may not abandon a patient” and should provide “continuity of care” until a patient can find a new doctor. To fulfill that requirement, the Florida Medical Association recommends that patients be given adequate notice in writing, be provided with medical care for at least 30 days, and be offered assistance in locating another practitioner – which Armstrong’s previous doctors did.

“There not a lot of strength in the law here,” says Diane Hoffman, a professor of health law at the University of Maryland Carey School of Law. “That makes it very challenging for chronic pain patients. And for physicians, they are trying to find the right place to be. Physicians are very risk averse in terms of the law.”

If patients have a complaint about a doctor, Hoffman says they should contact their state medical board or their state’s consumer protection office.

If you have an experience with patient abandonment that you’d be willing to share, Hoffmann is collecting patient experiences on the issue. You can send your story to her at:  patientstories@law.umaryland.edu

Wear, Tear & Care: Rating Omron's Avail TENS Unit

By Jennifer Kilgore, Columnist

I don’t use TENS units very often. Since I wear the Quell on a daily basis, it usually seems superfluous -- unless I’m having a very bad day.

Then my TENS unit makes an appearance, wires snaking under my shirt and sticky pads placed wherever I can get them. The power pack is latched to my pants, and the result is that I feel like a moron. Even if there is nobody at home to witness my treatment, I become self-conscious. My cat has an opinion, I’m sure.

That’s why I was excited to try the Omron Avail TENS device. It’s wireless, has two large pads, and can be controlled from my phone. There’s no bulky battery pack to wear on my belt, no wires tangling me, and the pads themselves are larger than the unit I currently have. The coverage of more bodily real estate is always a winner for me.

The Avail TENS is a wearable electrotherapy device that is designed to alleviate chronic muscle and joint pain. It has various pre-programmed settings designed for the shoulder, arm, back or leg; as well as modes that include both TENS and microcurrent, the latter of which applies electrical stimulation that one can hardly feel. The TENS modes are much stronger in sensation.

IMAGE COURTESY OF OMRON

I actually didn’t know that microcurrents were used in pain relief -- I thought they only applied to anti-aging treatments at spas. However, this therapy mimics the body’s natural currents, which are believed to restore normal frequencies within cells.

I don’t know how well the microcurrent mode works yet, because I still experienced pain when I tried it.  I imagine it takes some getting used to and that benefits accrue over time. However, the TENS mode works wonderfully, and having such large pads means that I can get more coverage.

Treatment sessions run between 30 and 60 minutes, depending on the mode chosen. You can also set sessions to run indefinitely. To charge the sensors, they must be placed on a special charging box that comes with the device. I’ve managed to use it multiple times now after the initial charge.

IMAGE COURTESY OF OMRON

It is very easy to set up and use, as most of it is intuitive for a chronic pain patient. The device must be paired with your smartphone, and the app is fairly straightforward. The only thing that kept happening to me was that the pads would unlink with the app because I kept pressing the power button on the pads by mistake -- for instance, when I leaned back on a couch.

The pads stay on well. The "help” section of the app states I can use them up to 30 times, and replacement pads range from $12.75 to $19.99. I might resort to using athletic tape to keep them on longer, as I do with normal TENS pads. I know that isn’t advised, but I want these pads to last as long as possible.

So far, my only complaint is the slight bulkiness of the pad itself. Having a wireless device means that a sensor must be placed on the pad, which ties it to the app. These blink in orange or green lights, which are even visible from underneath two shirts. Granted, clothing manufacturers have been making clothing thinner and thinner so you are required to buy more clothes, so maybe that’s not Omron’s fault. There’s even a name for this clothing phenomenon: “planned obsolescence.”

Additionally, since my problem areas are on my back, sitting in a chair can be awkward. The pads stick out and rub against the seat, which turned them off once or twice. I don’t think the unit is meant to be worn all day, though, unless one plans to use microcurrents alone. The company only recommends that three TENS treatment sessions be completed on a daily basis.

My overall impression is a good one. I like the device, and I think it works well. It controls my pain when I use the TENS settings. I just wish the sensors on the pads were thinner -- that would help my back-pained compatriots (and me) when leaning back into a chair. That seems like a small complaint for such a device, though.

The Omron Avail is currently on sale for $159.99 (normally retails at $199.99). 

Jennifer Kain Kilgore is an attorney editor for both Enjuris.com and the Association of International Law Firm Networks. She has chronic back and neck pain after two car accidents.

Jennifer receives products or services mentioned in her reviews for free from the manufacturer. She only mentions those that she uses personally and believes will be good for readers. You can read more about Jennifer on her blog, Wear, Tear, & Care.  

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

Dr. Forest Tennant Retiring Due to DEA Scrutiny

By Pat Anson, Editor

A prominent California pain physician and a longtime champion of the pain community has announced his retirement. Dr. Forest Tennant, and his wife and office manager, Miriam, have informed patients that they are closing their pain clinic in the Los Angeles suburb of West Covina, effective April 1.

“On strong legal and medical advice, as I am 77 and Miriam 76, we are closing the Veract Intractable Pain Medical Clinic and taking retirement. I will write no additional opioid prescriptions after this date,” Tennant wrote in a letter to patients. “We very much regret this situation as the clinic is filled with patients we consider beloved family and friends.”

Tennant’s retirement is largely due to an ongoing DEA investigation of his opioid prescribing practices.   DEA agents raided the Tennants’ home and clinic last November, while Tennant was testifying in Montana as a defense witness in the trial of doctor accused of negligent homicide in the overdose of two patients. The Tennants arrived home to find the front door of their home had been kicked in by DEA agents.

A DEA search warrant alleged that Tennant was part of a “drug trafficking organization” and had personally profited from the sale of high dose opioid prescriptions. Tennant has denied any wrongdoing and no charges have been filed against him, but the investigation remains open and the resulting stress and uncertainty have taken their toll.

“It’s hard to continue operating when they never closed my case, and so I’m going to retire and move on,” Tennant told PNN. “That’s on the advice of both my lawyers and my doctors."

DR. FOREST TENNANT  (courtesy montana public radio)

Tennant is a revered figure in the pain community because of his willingness to treat patients with intractable pain who were unable to find effective treatment elsewhere or were abandoned by their doctors. Many travel to California from out-of-state, and some are in palliative care and near death.

Tennant and his colleague, Dr. Scott Guess, treat about 150 intractable pain patients with a complex formula of high dose opioid prescriptions, hormones, anti-inflammatory drugs and other medications. 

Tennant says the DEA effectively forced him into retirement by refusing to drop the case.   

“You can’t do the kind of work I do and operate in legal uncertainty,” Tennant said. "You’ve got to have legal backing to treat these individuals. And I don’t know what the law is anymore.”

‘Many Patients Will Die’

This was a difficult day for Tennant's patients -- as many see their lives dependent on his continued care and treatment.

“I believe many of Dr. Tennant’s patients will die because they will never find another doctor to treat their painful condition,” says Gary Snook, a Tennant patient who lives with adhesive arachnoiditis, a painful and incurable inflammation in his spinal nerves. “I haven't decided if I will even look for another doctor, nobody will take a patient like me. And to be honest with you, I am tired of looking, tired of being treated like an addict, tired of being treated like a curiosity and nothing more, not a human being with a serious health issue that deserves to be treated.

"I am completely devastated for myself and my family, for Dr. Tennant and Miriam, for his patients and their families, and for all those who could have benefited from his continued breakthrough treatments and research," said Denise Molohon, another Tennant patient who lives with arachnoiditis, in an email.

"But I am most deeply saddened today for the entire chronic pain community - both patients and providers - for the tsunami of injustices perpetrated by DOJ/DEA and CDC in their cruelty, ignorance and haste to appear as though they are fighting the opioid overdose epidemic by ruining the lives of many innocent physicians. Their combined actions have had the tragic result of harming untold millions and leading to the senseless, needless deaths of patients all across our country whose only fault was suffering from horrific, intractable pain."

"The government has stepped in and stopped doctors from treating patients. They have created a hostile work environment for physicians who refuse to conform. Physicians who refuse to let their patients suffer. Addiction is a huge problem but so is intractable pain, yet those of us who play by the rules are the ones who suffer," said Kate Lamport, a Tennant patient who has arachnoiditis.

"Dr. Tennant and Mrs. Tennant have been a Godsend to all whom have crossed their paths and will never be forgotten by the thousands of lives they have touched and saved. Our blood is not on their hands, it is on the hands of those who have taken Dr. Tennant and every other doctor from us by way of fear." 

“Forest and Miriam treated me like a son as they did all their family, their patients. They did their best to take care of us," added Snook. "How could any doctor do so and pay $1,000 an hour in legal fees just to defend himself from false charges from the DEA?”

Tennant is referring all of his patients to new doctors, but in an age when many physicians are afraid of prescribing opioids, its unlikely they'll find similar care elsewhere.  Tennant has operated his pain clinic basically as a charity for years and charged patients little, if anything. He and his wife live modestly, and drive cars that are nearly 30 years old.

“They (the DEA) think my clinic has been operated to make a great deal of money. Some years it loses money. The last two years, it actually lost money. We subsidize it,” Tennant explained.

‘Highly Suspicious’ Prescribing

One medical professional who has been critical of Tennant's prescribing practices is Dr. Timothy Munzing, a Kaiser Permanente family practice physician who was hired by the DEA to review Tennant’s prescriptions.

Munzing was quoted in a DEA search warrant saying it was suspicious that “many patients are traveling long distances to see Dr. Tennant” and that they 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,” Munzing wrote.

Munzing has worked for several years as a consultant for the DEA and the Medical Board of California, creating a lucrative second career for himself.

dr. timothy munzing

According to GovTribe, a website that tracks payments to federal contractors, Munzing is paid $300 an hour by the DEA. In the past few months, Munzing has been paid over $250,000 by the DEA to review patient records and testify as an expert witness in DEA cases.

The agency recently created a task force to focus on doctors like Tennant who prescribe high doses of opioids. The task force appears focused solely on the dose and number of prescriptions, not on the quality of life of patients or whether they’ve been harmed.   

After three years of investigation, the DEA has not publicly produced evidence that any of Tennant’s patients have overdosed, been harmed by his treatments, or that they are selling their drugs.

Tennant says he and his wife plan to retire to their home state of Kansas, where they have real estate investments. Once out of the picture, he hopes the medical profession and law enforcement will someday come to a sensible approach about how to deal with patients who need high doses of opioids.

“I have learned that my personality and my image is such that I think its prohibiting a good debate and discussion as to how the country is going to deal with people with really severe pain,” he said.

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

Doctor Shopping Has Always Been Rare

By Roger Chriss, Columnist

A commonly cited factor in the opioid crisis is "doctor shopping" -- the act of seeing multiple physicians in order to get an opioid prescription without medical justification. States like Indiana are passing prescribing laws with the specific goal of preventing doctor shopping in an effort to address the opioid crisis.

However, doctor shopping has not at any time in the past decade been a statistically significant factor in the opioid crisis.  The National Institute of Drug Abuse tells us that only one out of every 143 patients who received a prescription for an opioid painkiller in 2008 obtained prescriptions from multiple physicians "in a pattern that suggests misuse or abuse of the drugs." That’s a rate of about 0.7 percent.

The importance of doctor shopping over the last decade was not because of frequency -- it has more to do with quantity. Research shows that the 0.7% of people who doctor-shopped were buying about 2 percent of the prescriptions for opioid medications, constituting about 4% of the amount dispensed.

Moreover, these doctor-shoppers tended to be young, to pay in cash, and to see five or six prescribers in a short period of time, so they are easily identifiable and can be thwarted with prescription drug monitoring programs (PDMP’s).

Diversion prevention had long been seen as important. Back in 1999, the Drug Enforcement Administration published “Don’t Be Scammed by a Drug Abuser,” which included advice to doctors and pharmacists on how to recognize drug abusers and prevent doctor-shopping. And states like Washington specifically list doctor shopping among the indicators of opioid addiction in prescribing guidelines, making recognition and intervention key goals for prescribers. 

These efforts have paid off. A study in the journal Substance Abuse found that the number of prescriptions diverted fell from approximately 4.30 million (1.75% of all prescriptions) in 2008 to approximately 3.37 million (1.27% of all prescriptions) in 2012. The study concluded that “diversion control efforts have likely been effective.”

Similarly, Pharmacy Times reported a 40% decrease in doctor shopping in West Virginia between 2014 and 2015, thanks in part to efforts by that state’s Board of Pharmacy Controlled Substance Monitoring Program.

The Inspector General of the Department of Health and Human Services found in 2017 that among 43.6 million Medicare beneficiaries, only 22,308 “appeared to be doctor shopping.” That’s a minuscule rate of 0.05 percent.

“You have this narrative that there are these opioid shoppers and rogue prescribers and they’re driving the epidemic, and in fact the data suggests otherwise,” says Dr. Caleb Alexander, who co-authored a 2017 study in the journal Addiction.

"The study found that of those prescribed opioids in 2015, doctor shoppers were exceedingly rare, making up less than one percent of prescription opioid users,” Alexander told Mother Jones.

Doctor shopping is still a problem in other contexts. Opioids are not the only class of medication that people seek to obtain illicitly for a variety of reasons, from hypochondriasis to malingering. PDMPs and other law enforcement efforts have a useful role to play in addressing these issues, and the opioid crisis requires ongoing efforts to prevent drug theft and diversion at all levels of the supply chain.

But claims that doctor shopping is a significant factor in the opioid crisis are mistaken. Doctor shopping was not significant in 2008, and measures to reduce diversion have succeeded, making doctor shopping in 2018 that much rarer.

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.

How I Started Telling People I Have EDS

By Crystal Lindell, Columnist

One of the first people I told about my new Hypermobile Ehlers-Danlos syndrome (hEDS) diagnosis was a local politician.

I was still trying to get a feel for how the letters EDS tasted on my lips. How they felt in my breath. How people would react when I said them. And truth be told, this was when doctors were telling me I probably had it, but before I was officially diagnosed — that came later.

He didn’t know he was among the first people I told — that he was a test case. But there we were, at a local Democrats meeting and he asked me about medical marijuana, and I decided to go for it. 

“I actually have EDS,” I said. “My thumb touches my wrist, want to see? Yes, marijuana should be legalized. No, it won’t help everyone.”

He had the response most people seem to have.

“Maybe it will get better?”

“It won’t get better,” I told him.

“Yeah, but maybe it will! Once, I was sick and then I got better. So maybe you will get better.”

“It won’t.”

I get it. Nobody wants to really understand that being born in the wrong family is enough to sentence you to a lifetime of weak ankles and debilitating pain. It’s hard to understand that. It’s hard to accept that. It’s a lot easier to believe someone might get better.

It’s been hard for me to accept that. And harder still to say it out loud.

I have found though that it feels easier to lay the news on random acquaintances. The Tinder guy I met once. The woman who expertly bleaches my hair at the over-priced salon. The clerk at Walgreen's ringing up my pain medications.

There’s something to be said for telling random strangers something so overwhelming. It greatly reduces the consequences of your words — and of their reaction.

My initial instinct was to tell the people closest to me, my inner circle, first. But that quickly become completely overwhelming. Those people care way too much about me. They take it way too hard. It cuts too deep.

No, strangers are much better. They are morbidly impressed with my thumb to wrist trick. They are able to distance themselves from the depressing, long-term aspects of the diagnosis and ask horrifically, wonderful mundane questions like, “What does EDS stand for?”

And they never stop to think about what it might mean for my future. That’s my favorite part. Because the future looks very scary right now. And I need to do my best to stay in the present.

I have forced myself to pepper in the tougher conversations with the people who care about me. The late-nights over tears with my best friend wondering what this might mean for my future. Asking things like, what if I can never kids? And even if I can, do I want to risk passing it on to them?

Will I need assisted care sooner than most? How will I ever explain my health to future lovers? Why did it take so excessively long to get the diagnosis? How much of my life was wasted waiting for it? What could have been different if only I had known sooner? Will my siblings need to be evaluated? And what happens if they have it too?

All the things that fill me with grief and despair if I let them.

But strangers never ask questions like that. And even if they do, they don’t actually care about the answers that much. And I love that about them.

Eventually, hopefully, it will just become one more things about me. I’m blonde, I don’t like Trump, I love Burn Notice, I eat too much Taco Bell, and I have hEDS. It’s part of who I am, but not the whole part, or even the most important part. Just another casual fact in my Instagram bio next to things like, “I like lipstick.”

And no, I won’t actually ever getter better, but eventually, hopefully, I’ll get better at having hEDS and telling people about it.

Crystal Lindell is a journalist who lives in Illinois. She eats too much Taco Bell, drinks too much espresso, and spends too much time looking for the perfect pink lipstick. She has hypermobile EDS. 

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

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

Do Hungry Mice Have the Answer to the Opioid Crisis?

By Pat Anson, Editor

Yes, that a silly headline. There have been a lot of them lately on how to end the opioid crisis, most of them involving new ways of treating chronic pain without the use of addictive drugs.

Some of these ideas are sincere, some are strange and others are just plain silly. There were a quite a few this week that produced some interesting headlines.

“Staying hungry may suppress chronic pain” was the headline in a Chinese website that reported on a study conducted at the University of Pennsylvania. Researchers there found that laboratory mice that weren’t fed for 24 hours still felt acute short-term pain, but their chronic pain was suppressed by hunger.

“We didn't set out having this expectation that hunger would influence pain sensation so significantly," says J. Nicholas Betley, an assistant professor of biology in Penn's School of Arts and Sciences. "But when we saw these behaviors unfold before us, it made sense. If you're an animal, it doesn't matter if you have an injury, you need to be able to overcome that in order to go find the nutrients you need to survive."

Betley isn’t suggesting that chronic pain patients stop eating or starve themselves, but he believes the finding could pave the way to new pain medications that target brain receptors that control survival behavior.  

“Chronic pain relief: How marine snails may be able to help” was the headline used by WNDU-TV to report on a recent study at the University of Utah. 

Researchers there say a compound in the venom of cone snails could someday be used in pain medication. The venom paralyzes small fish so that hungry cone snails can slowly eat their prey alive.  

"We really hope that we will find a drug that could be as effective for severe pain as opioids but has far less side effects and is not addictive," says Russell Teichert, PhD, a research associate professor in the Department of Biology.

Interestingly, the cone snail study is funded with a $10 million grant from the U.S. Department of Defense. Human trials are expected to begin in a couple years.

“Why Tai Chi Works So Well for Pain Relief” was the headline in Time about a study by researchers at Tufts Medical Center. The headline is a bit misleading, because the study only included fibromyalgia patients and compared the effectiveness of tai chi to aerobic exercise in relieving pain.

The last thing many fibromylagia sufferers want to do is practice tai chi, but the Chinese martial arts exercise was found to be just as good or better than aerobics, which is sometimes recommended as a non-drug treatment for fibromyalgia.

“It is low risk and minimally invasive, unlike surgery, and it will not harm your organs, like long term drug use,” said Amy Price, a trauma survivor who lives with chronic pain.

“Kellyanne Conway Tells Students to Eat Ice Cream and Fries Rather than Take Deadly Drug Fentanyl”  is how Newsweek summed up a speech by a top presidential advisor to a group of college students.

“On our college campuses, you folks are reading the labels, they won’t put any sugar in their body, they won’t eat carbs anymore, and they’re very, very fastidious about what goes into their body. And then you buy a street drug for $5 or $10, it’s laced with fentanyl and that’s it,” said Conway, who oversees the Trump administration’s response to the opioid crisis.

“So my short advice is, eat the ice cream, have the French fry, don’t buy the street drug—believe me, it all works out.”

Conway probably said this tongue-in-cheek, but critics were quick to pounce.

“Was feeling bad about my McDonalds ice cream cone today until I realized it helped me avert opioid addiction. Thanks Kellyanne Conway!” Lola Lovecraft tweeted.

 “I was considering doing fentanyl but now thanks to Kellyanne I’m just gonna 'have the French fry” instead. Saved me from a life on the streets!” tweeted Mike Stephens.

Conway’s boss had zinger of his own after signing a $1.3 trillion spending bill on Friday.

“We’re also spending $6 billion on, as you know, various forms of drug control, helping people that are addicted,” said President Trump.  “The level of drugs that are being put out there and the power of this addiction is hard to believe. People go to the hospital for a period of a week and they come out and they’re drug addicts.”

No, Mr. President, that’s a myth. Studies have repeatedly shown that it is rare for hospital patients to become addicted to opioids.

One study found that only 0.6% of patients recovering from surgery were later diagnosed with opioid misuse. Another study found that only 1.1% of patients treated with opioids in a hospital emergency room progressed to long term use.

What is true is that there’s a growing shortage of opioid medication in hospitals and hospices, and that’s leading to medical errors and the unnecessary suffering of patients. The shortage is due in part to manufacturing problems and severe cuts in opioid production quotas ordered by the DEA.

President Trump is aware that opioid prescribing has declined significantly, but he’d like to see more.  This week he called for opioid prescriptions to be cut by a third over the next three years. “Doctors are way down now in their orders of the opioids, way down. It’s a great thing,” he said.

Let's hope the hungry mice and cone snails share their secrets soon.