Saturday, August 12, 2017

Dear Trump Administration, Signed, Chronic Pain Patients

** Credit for this letter and all information due to Joe Aquilino, a very helpful chronic pain activist. Ever since I have been diagnosed with RSD/CRPS and had a Facebook account, Joe Aquilino was one of my first chronic pain friends. If you are not familiar with him, check out his podcast! 

Here is a letter that you can copy and paste to the Presidents Commission for Opioids. We need everyone involved to fight to get the opioids back. You just need to put their name after the dear and after the sincerely your name and city and state 

Dear [Name],
The published schedule for the Commission calls for review of a draft report to the President just ten days after your first working meeting. This is not a substantial amount of time to review all of the public comments and emails in regards to this issue, nor is it enough time to fully consider the many intricacies of this issue and come up with a solution that does not adversely harm particular populations such as the 116 million Americans suffering from chronic pain (Institute of Medicine, 2011), or the 5-8 million receiving long-term opioid therapy (Kroenke and Cheville, 2017), the majority of whom reap greatly improved function, quality of life, and are even able to work a job and/or go to school. 

With no intention of discourtesy, I must seriously ask whether you wish to have your name associated with such a transparently political agenda that has the potential to harm and even kill 2millions of people if not executed in an extremely precise manner. If the "fix" involves the further restriction of when, where, or how doctors may prescribe pain medication, it will cause a multitude of unintended harm unless doctors who treat pain from a variety of chronic and painful conditions on a daily basis (such as Dr. Forrest Tennant who is also an expert in the treatment of addiction) are not actively involved in the effort to reduce overdose deaths. If people suffering from persistent pain are about to be disregarded and abused by their own government once again, in the name of trying to solve an opioid crisis that isn't their fault, it will result in more overdose deaths from people in pain left with no other options who turn to the black market, and the suicide rates of veterans (and people suffering from persistent pain more generally) will also sharply increase,–the reduction of which the commission discussed as a goal– and the problem of overdoses won't be helped in the least by denying people suffering from persistent pain effective pain management. 

Consider for a moment that many authors, including (Inturissi, 2002) (Fishbain et al., 2008) noted that the rates of addiction in chronic pain patients receiving long term opioid therapy were particularly low (below even the population average) because persistent pain seems to interfere with the intrinsically rewarding nature of opioids.

Much of the stigma against opioids that is driving restrictive prescribing policies is based in doctors’ lack of knowledge about pain (and subsequently the public’s misconceptions), about how to treat it, and about the difference between dependence and addiction (Rich, 2000). These issues can be resolved by simply educating doctors more effectively. 

Dependence is simply the presence of withdrawal symptoms upon the cessation of a drug, (Inturrisi, 2002) which happens every morning to much of America as they make coffee. The grogginess, headache, and nausea are withdrawal symptoms of caffeine, and these are ordinary citizens, not addicts–addiction, which is something that a person must be genetically predisposed to in order to develop–is an entirely different condition that is a neurological disease (Morgan and Christie, 2011) and requires considerations separate from the domain of doctors’ prescribing patterns. In order to have the capability of developing an addiction, a person must have disturbed caregiver attachment bonds, caused by trauma at an early age, and it involves widespread alterations to the reward system in the brain that you simply do not see in chronic pain patients, as well as continuing to obtain the drug despite harm to others, a hallmark of addiction (Flores, 2004).

On the other hand, in chronic pain, although the patients require their medication to avoid withdrawal (dependence) and to avoid severe pain, chronic pain interferes with the intrinsically rewarding tendencies of opioids (Inurrisi, 2002), meaning that because the medicine is being used properly under proper supervision, that in appx. 98% of chronic pain patients receiving opioids long-term, addiction doesn’t occur (Fishbain, et al., 2008) (Burgess et al., 2014). The last conflated term, tolerance simply means that the body is habituating to its environment, the way the human body is designed to (Inurrisi, 2002). There is nothing inherently wrong with this, as it is an important survival mechanism built into the human body.
Another author noted the usefulness of long term opioid therapy in chronic noncancer pain, and the outlandishness of using addiction as the rationale to not to treat pain: 

“A Cochrane Review on long-term opioid management for chronic noncancer pain published in 2010 reported similar findings, with an estimate of opioid addiction of 0.27%, leading the authors to conclude that the risk of iatrogenic opioid addiction is low. [Hojsted, 2007]” Burgess et al., 2014 went on to summarize Boscarino’s 2010 study stating: “One of the most consistent risk factors predicting opioid abuse/addiction, is a history of opioid abuse (odds ratio of 3.81).[Boscarino, 2010] Patients with a history of severe…abuse had an odds ratio of 56 for developing abuse/addiction. [Boscarino, 2010] Weisner et al surveyed patients receiving long-term opioids in two large group health plans and found that patients with a history of opioid abuse had a prevalence rate of opioid use approaching 50%, compared to patients without a prior opioid abuse history of 2–3%.” (Burgess et al., 2014)

The nature of the so called “opioid epidemic” has been misunderstood, and as a result the responses have been directed at the wrong targets. “Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, whereas opioids commonly obtained by prescription play a minor role, accounting for no more than 15% of reported deaths in 2015.” (Kertesz, 2016)

"It is commonly thought that opioid dependence often begins through an initial, possibly chance, exposure to a physician-prescribed opioid, although data from studies to empirically evaluate this claim are lacking." (Barnett et al., 2017) In other words, people do not simply become addicted by being exposed to opioids, and there is no evidence to support this claim. There is however limited evidence to suggest that chronic pain patients receiving long term opioid therapy have extremely low rates of addiction (Fishbain et al. 2008) (Burgess et al., 2014) (Hojsted, 2007) and many derive greatly enhanced health, wellness, quality of life, and function from long term opioid therapy (Furlan et al., 2006).
When addiction is looked at as an attachment disorder (that also happens to be neurological disease), it becomes much clearer why some people suffer from addiction upon exposure to drugs and others do not. Those that do are using a drug (it could be nearly any drug) to replace the comfort that social interaction and healthy peer bonding provides to non-addicted individuals (Flores, 2004), this is when addiction develops. This is markedly different from chronic pain patients who are able to socialize, function, and live a fulfilling life because of opioid medications. 

The Furlan et al. literature review on the efficacy and safety of long term opioid therapy for chronic noncancer pain concludes that while the studies are limited, there is sufficient evidence that opioids are beneficial for some individuals with chronic noncancer pain, and considering the complete lack of alternatives with similarly efficacy, there is no rational reason to deny treatment to these individuals, especially considering the deadly consequences of doing so. Leaving pain untreated, as restricting pain medication further tends to do, is condemning the well over 25 million people with severe and intractable chronic pain to a slow, agonizingly painful death, feeling betrayed by their government, their physicians, and life itself. (Grol-Prokopcyzk, 2016) (Epel, 2004) (Mcewen, 2004) (Lohman, 2010) (WHO, 2000)

Restricting opioid prescribing as the CDC recommended for primary care physicians only would have dire consequences if it were implemented as a policy of any kind. It would disable the 5-8 million people currently on long term opioid therapy who are able to live a normal life because of these medications. Those who are not currently on medication have either already been stripped of their dignity and quality of life by needless suffering, due to the immense difficulty involved in finding a physician who is willing to treat their pain, to the point where most are totally disabled (many of whom re receiving social security benefits, who could be made able to work again if they were given adequate treatment that such a policy would completely prevent) because of their pain, and are causing a totally unnecessary financial drain on the U.S. government in the order of $560-635 Billion per year (Institute of Medicine, 2011). The cost of this could be almost entirely eliminated (or at the least greatly reduced) if the availability of opioids were to increase substantially. (Seya et al., 2011) (Sessle, 2012)

Richard Lawhern writes as a non-physician writer, research analyst, patient advocate and website moderator for chronic pain patients, families, and physicians. My wife and daughter are chronic pain patients. His 20 years of volunteer experience has produced articles and critical commentaries at the US Trigeminal Neuralgia Association, Ben’s Friends online communities for patients with rare disorders, US National Institutes for Neurologic Disorder and Stroke, Wikipedia, WebMD, Mad in America, Psychiatric News, Pain News Network, National Pain Report, the American Council on Science and Health, the Global Summit for Diagnostic Alternatives of the Society for Humanistic Psychology, Psychiatric News and Psychology Today. He wrote a piece that is extremely relevant to this issue.

I urge you–indeed, I IMPLORE –to read the article in which this summary appeared. It is titled "Warning to the FDA - Beware of 'Simple' Solutions in Pain and Addiction." It may deserve to become a part of your report to President Trump. It demonstrates that the balance between concerns of people in agony and those of families who have lost children to opioid addiction have become seriously skewed in utterly unproductive and dangerous directions. It also demonstrates that the March 2016 CDC guidelines on the prescription of opioids to adult noncancer pain patients are seriously dangerous due to weak evidence, scientific errors and outright omissions of vital medical science. The guidelines are already killing patients across the U.S. (Webster, 2014). If enshrined as mandatory limits on opioid prescription, they will kill many thousands more.

Visit this link! 

Sincerely, [Your Name, City, and State]
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Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C: National Academies, 2011. Print.
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Mcewen, Bruce S. "Protection and Damage from Acute and Chronic Stress: Allostasis and Allostatic Overload and Relevance to the Pathophysiology of Psychiatric Disorders." Annals of the New York Academy of Sciences 1032.1 (2004): 1-7. Web
Morgan, Michael M., and Macdonald J. Christie. "Analysis of Opioid Efficacy, Tolerance, Addiction and Dependence from Cell Culture to Human." British Journal of Pharmacology 164.4 (2011): 1322-334. Web.
Rich, Ben A. "An Ethical Analysis of the Barriers to Effective Pain Management." Cambridge Quarterly of Healthcare Ethics 9.01 (2000): n. pag. Web.
Sessle, Barry J. "The Pain Crisis: What It Is and What Can Be Done." Pain Research and Treatment 2012 (2012): 1-6. Web.
Seya, Marie-Josephine, Susanne F. A. M. Gelders, Obianuju Uzoma Achara, Barbara Milani, and Willem Karel Scholten. "A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country, Regional, and Global Levels." Journal of Pain & Palliative Care Pharmacotherapy 25.1 (2011): 6-18. Web.

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