Is the War On Addiction Becoming a War On Pain?

Great Debates
82

A consultation with a pain specialist who has access to all the recent imaging/diagnostic tests on the back. Failed back surgery is a complicated mixed diagnosis, and takes a skilled diagnostician to put together the myriad pieces. Beneficial modalities would possibly include physical therapy and regular focused home exercise, stretching, use of standard analgesics like acetaminophen and NSAIDS (if tolerated), topical therapies like voltaren and/or lidocaine gel, possible use of neuropathic pain meds (assuming neuropathic pain is part of the problem) like elavil, cymbalta, and possibly pregabalin or gabapentin, combined with consideration of steroid/lidocaine injections into facet joints and/or epidural spaces along the spine, possible radiofrequency ablation of problematic nerves, plus other stuff, along with consideration of moving to less problematic opioids like tramadol or buprenorphine as a possible pathway to getting off them, or at least being maintained on a safer med.

That’s for starters, after that it would need to be further tailored for individual circumstances.

83

In addition to what @Qadgop_the_Mercotan mentioned, my BIL has gotten substantial relief from his previously crippling back pain with cannabis. Before he started the cannabis i often heard about how he was begging doctors for more opiates, and hoarding them for when the pain was unbearable. Now he rarely uses them.

He has also become a bit of a pothead. But my sister says he used to be extremely stressed, as his base emotional state, and overall she thinks he’s a lot happier this way. And because he has so much less pain he finds it easier to do his job.

84

In my opinion (shared by some others with better credentials than I to hold such opinions), meds like opioids and THC don’t reduce pain as much as they reduce misery. And that misery is a huge component of suffering and dysfunction. And THC is in my estimation a far less problematic misery-reducing substance than opioids are.

In my state, Delta 9 THC is illegal even for medical issues, so I don’t include it in my practice, nor do I advise my typical patient to consider it after they leave prison, as it could likely land them back in prison again. But I don’t consider it an unreasonable drug to try if the legal consequences are not significant.

Delta 8 THC is being sold in my state now. Not sure just what I think about that. It’ll make a drug test positive, so it’s not a good option for my patients either.

And with people with significant addictive disease histories, THC can lower inhibitions enough to lead them back to their drug of choice such as alcohol/heroin/crack etc.

85

@DemonTree In addition to the modalities of treatment in my earlier post on back pain, meditation/relaxation/mindfulness are also among the most effective modalities for reducing chronic pain and improving function.

86

This. CBD/THC concoctions are popular currently because of that. I’ve prescribed it in a few cases, but the hype seems to be over, at least here.
When it comes to reducing misery Acceptance and Commitment Therapy (ACT) seems to do a lot of good as well.

87

That sounds extremely plausible. Cannabis is legal where my BIL lives, and he’s taken to growing his own (also legally, under state law) so he knows what he’s getting. It’s now legal in much of the US, and parts of Europe, and if you don’t have addiction issues, i think it’s worth considering for pain management in jurisdictions where the legal risk is minimal.

I realize that anecdotes aren’t as good as prospective controlled studies, but I’ve really been impressed at how much less impaired he is since he started taking cannabis. Also, I’ve stopped worrying that he’ll develop a dangerous opioid addiction.

88

This. I have a medical condition where once in a great while, I am in great pain for a week or two. I was prescribed opioids for it, but it was very hard to get what I needed. Around 2005, it suddenly got very easy, and they started shoveling oxycontin in my pockets whenever I asked, just way more than was medically necessary. Then around 2015 this ceased and now it’s harder than ever to get what I need.

Courts have ruled that Perdue pharma bears a lot of responsibility for this state of affairs, as is appropriate. But I also can’t help blaming physicians. Every doctor knows the opioid receptor system is highly prone to causing addiction if not properly regulated! How could they believe a pharm rep saying “we’ve invented a non-addictive opioid medication”. It’s like someone selling calorie-free glucose, it simply doesn’t exist. A few minutes of research could have confirmed there’s nothing new under the sun, as far as that goes.

89

This was all occurring around the time that there was a HUGE push against undertreated pain! Pain was declared to be the “5th vital sign” and something that had to be assessed at every patient encounter. Doctors were taken to task (and sued) for being callous about our patients’ suffering: some legit and horrific, lots of it trivial. Regulatory agencies such as the JCAH required hospitals to have an individual pain control plan for every patient, and record of the patient’s pain was adequately controlled, not just while hospitalized, but also after discharge. Drug companies pushed lousy studies on opioids that seemed to indicate that opioids, especially the long-acting ones like oxycontin, MS contin, etc were NOT likely to be addictive in properly selected patients, and they told us that 98+% of the patients out there wouldn’t have addiction problems on these delayed release meds, since they had ‘legitimate pain’ that needed treating. Doctors had parts of their salaries based on ‘satisfaction surveys’ by their patients, and found quickly that prescribing narcotics for any pain complaint resulted in happier patients. Medical students and residents were taught that pain needed to be treated with opioids. It was an INSANE time.

I, as a recovering addict during that era (I got clean in 1990) never bought into all that and didn’t change my practice much. Opioids for significant acute pain, and malignant pain, etc. That pissed off some of my patients but by that time my pay wasn’t based on inmate-satisfaction surveys. I only occasionally was threatened with a shanking over the issue. Lawsuit threats were pretty common over the issue, including some that actually did go to court (I didn’t lose any of them).

Summary: Some docs should have known better, some docs did know better, many spoke out, but we were ignored largely, and our young professionals were schooled to believe they were doing the right thing by providing opioids.

Stupid stupid stupid on so many, many levels.

90

I have a pseudo- in- law in the same circumstances - down to growing his own in a state where its legal. He’s legally disabled from falling off a roof and breaking his back (but not severing his spinal cord - he’s mobile, but in pain). From opiate dependent to cannabis dependent. He’s still dependent, but on a less dangerous substance and one where - for good or bad - he isn’t dependant on a doctor worried about his license to prescribe and deciding to pull the prescription that could lead to illegal drug seeking. And I agree that its probably relieving less pain than making him care less about the pain - but his quality of life is better.

91

Att @moderators

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"Lawsuits are filed in civil courts, and the documents filed in these civil cases are presumed to be open to the public. … In some cases the courts are even posting electronic copies of court documents filed in the cases that you can view on the website for the court.

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@aruvqan

Here’s some research I’ve been doing, I’m not finished and it late. I’ll get more info later.

WALMART INC., Plaintiff, v. U.S. DEPARTMENT OF JUSTICE; ATTORNEY GENERAL WILLIAM P. BARR; U.S. DRUG ENFORCEMENT ADMINISTRATION; ACTING ADMINISTRATOR TIMOTHY J. SHEA

Page 5 of 54 PageID #: 5

By law, pharmacists presented with an opioid prescription cannot interfere with the
doctor-patient relationship by usurping the doctor’s professional judgment—and understandably
so, because they are not doctors, do not examine or diagnose patients for purposes of dispensing
opioid medications, and do not have access to patients’ medical records. Pharmacists accordingly
lack the tools needed to second-guess doctors’ judgments about questions that remain vigorously

7 of 54 PageID #: 7
11. Defendants’ position is an attempt to effectively shift to pharmacists duties that
Congress has assigned to DEA and that state law assigns to state medical boards. DEA is charged
with revoking or refusing to renew doctors’ registrations to prescribe controlled substances if they
write medically unnecessary prescriptions. DEA has the legal authority to conduct investigations
and even revoke credentials on an emergency basis. And state medical boards police standards of
medicine and may suspend or revoke doctors’ licenses if they violate their professional obligations.
Under Defendants’ view, however, pharmacists must reexamine every doctor’s diagnosis to
confirm that the prescription written by the doctor was medically proper for the patient in question,
and then categorically block those doctors that pharmacists deem suspect.
12. These supposed duties find no basis in the text of DEA’s own regulations, much
less the statutes that Congress enacted. On the contrary, Defendants can piece them together only
from scattered letters, PowerPoint presentations, and other materials that are—at best—informal
“guidance.” Under its own rules, however, DOJ is not permitted to use guidance like this as the
basis for enforcement actions. And DOJ has likewise forsworn lawsuits that seek to impose
penalties for violating “rules” announced only after the conduct at issue. DEA could have
promulgated regulations dictating how pharmacists and pharmacies should evaluate opioid
prescriptions, and pharmacists and pharmacies would have complied. But DEA never did.
Defendants’ threatened suit based on sub-regulatory guidance and post hoc asserted obligations
cannot be squared with DOJ’s formal renunciations of just such unlawful tactics.
13. DOJ’s and DEA’s current position is also impossible to square with DEA’s own
prior positions and those of other expert federal agencies. DEA has emphasized that the decision
to fill a prescription depends on the prescription-by-prescription judgment of licensed medical
professionals. DEA, The Pharmacist’s Manual 42 (2020); DEA, Dispensing Controlled
Case 4:20-cv-00817 Document 1 Filed 10/22/20 Page 7 of 54 PageID #: 7

  1. For example, the AMA wrote to Walmart to criticize its restrictions on initial acute opioid prescriptions, claiming that these restrictions have blocked access for patients “with acute, palliative, cancer-related, chronic pain and other medical conditions requiring amounts or doses greater than [Walmart’s] corporate policy.” Letter from James L. Madara, M.D., to Thomas Van Gilder (Sept. 24, 2019). The AMA similarly criticized Walmart’s new blanket refusal-to-fill and corporate refusal-to-fill policies. In the same letter, it complained that Walmart’s policy had “disrupted legitimate medical practices that receive form letters telling them their prescribing rights under state law will be superseded by a Walmart-created algorithm that deems a physician unfit to prescribe.” In its view, Walmart was “interfering in the practice of medicine and pharmacy” by assuming the “licensing oversight” that is supposed to be maintained by “medical [and] pharmacy board[s].” Id.; see also Report 22-A-19 of the AMA Board of Trustees, https://www.ama-assn.org/system/files/2019-05/a19-refcomm-b-addendum.pdf (criticizing Walmart’s “blacklist” letters). Case 4:20-cv-00817 Document 1 Filed 10/22/20 Page 27 of 54 PageID #: 27>

Page 32 of 54 PageID #: 32
DEA authorized manufacturers to produce ever-increasing quantities of the drugs, and largely abandoned its most potent enforcement tools against bad actors. Most egregiously, despite years of complaints about the conduct of certain doctors, DEA not only allowed those doctors to continue prescribing opioids, but in many instances renewed their registrations. DEA also refused to provide any clear rules to distributors on how they should detect and report “suspicious orders” from their customers. And DOJ’s own Inspector General concluded that when suspicious orders were reported, DEA had ignored and discarded the reports with no investigation or follow-up.

https://corporate.walmart.com/media-library/document/walmart-v-doj-dea-complaint/_proxyDocument?00000175-522e-dbe2-a9fd-7f6e94120000

"Unless court documents are filed under seal, which is rare, they are in the public domain and can be seen by anyone. In 31 years of law practice, I've never seen a publicly filed court pleading that had copyright protection."
https://www.avvo.com/legal-answers/are-lawsuits-public-domain-and-uncopyrighted--2639830.html


 "Lawsuits are filed in civil courts, and the documents filed in these civil cases are presumed to be open to the public. ... In some cases the courts are even posting electronic copies of court documents filed in the cases that you can view on the website for the court.

https://multimedia.journalism.berkeley.edu › 
Civil Court Lawsuits | Tutorial | Berkeley Advanced Media Institute"
92

Really. I spent some time in the lower echelons of health care during the mid 80s (Pharmacy Tech at a hospital) and I thank you for letting me know I do not misremember that much.

93

I liked the compromise solution proposed upthread. If there was going to be a sea change in medicine about the proper prescribing practices regarding opioids, it should have changed on X date. Prior patients treated the old way and new patients treated the new way. That could have solved both issues: no withdrawal and no opioid crisis, and for new patients, the new and improved treatment.