Hyperbole Over Nuance

by Mordecai Potash, M.D.

One of the ways I like to unwind is to watch HBO on my cellphone or tablet. Whether it’s Real Time, Last Week Tonight, Westworld, or Game of Thrones, I am captivated by HBO’s shows!

One show, VICE – and its online companion, VICE News -  has recently featured several stories that have to do with opioids and pain management. The stories do a great job of capturing the multi-faceted aspects of this issue. They also show how strict and unyielding policy solutions to current controversies in opioid-based pain management can make misery out of the lives of countless people.

Several stories have focused on the state of Maine, since it has one of the highest rates of opioid overdose deaths in the country [1]. One story, enticingly titled “The Men Who Catch Your Lobsters Are Self-Medicating with Heroin”, explored the high rate of heroin and other opioid abuse in the lobster fishing industry along rural, costal Maine [2]. It features fishermen who work seasonably and spend almost all their disposable income on heroin, pain pills, and other drugs. The problem has gotten so bad, that these fishermen commonly encounter replacements on their boats because their previous shipmates overdosed and died. As one fisherman put it in a VICE-linked article:

“On Monday morning, I’ll go to work, it will be me and a guy named Jesse, and then the next morning it will be me and a guy named Mike. I’ll say, ‘Oh, where’s Jesse?’ and they’ll say, ‘Oh, he didn’t make it through the night.” [3]

Once a fisherman wants help for substance abuse, there are huge obstacles to obtaining it. Many live and work in a part of costal Maine that is about the size of Delaware but has a population of only 30,000 people - or about 1/25th the population of Delaware. There are no detox beds at all in the area, so a night in an ER or a couple of days in jail is the closest they get to actual medication-assisted detox services. The closest real medication-assisted program at least a 45-minute drive away – way too far away to accommodate the dawn-till-dusk hours of working fishermen.

VICE is hardly the first program to highlight Maine’s opioid addiction problem. There have been many state and national health reports about its steep rise in opioid overdoses as well as an outstanding ten-part report by the Portland Press-Herald [1].

In response, Maine has adopted some of the strictest opioid prescribing restrictions in the country [4]. One provision mandates that Maine prescribers are not allowed to prescribe more than 100 morphine milligram equivalents (MME) to their patients unless they attest that the patients qualifies under a palliative-care exception. Many Maine prescribers are fearful that, unless a patient is actually dying, they will be prosecuted if they prescribe more than 100 MME. They have told their patients that they are not prescribing more than 100 MME under any circumstances – if they haven’t already totally cut of all their patients from pain medications. Dr. Steven Hull, the Director of Pain Rehabilitation at Mercy Hospital in Portland, Maine, is afraid that many chronic pain patients that were well-managed on opioid-based pain medications will become depressed and suicidal by the cutbacks.

Another VICE story titled “Treated like addicts – The crackdown on opioids has left pain patients suffering with chronic pain and stigmatized” reports on patients whose pain was well-controlled on opioid-based pain medication but are now being cut off from this treatment with horrendous results [5].  It documents one patient whose pain from adhesive arachnoiditis was well-controlled with fentanyl transdermal and oxycodone until her doctor began to prescriber her less and less medication at each visit without explanation. When the patient finally brought it up, she was told that new regulations required the progressive decrease. She says now “My pain is out of control… I mean I can stay alive, but my quality of life has dramatically decreased”.

Like any good reporting, this story also features an opposing viewpoint. In this case, VICE interviews a prominent physician who believes that chronic pain patients are mistaking pain relief with opioid dependence. In other words, every patient that believes he or she has responded to opioid-based pain medications is simply psychologically dependent on them.

The reporter documents that many patients see that doctor’s view as “fueling an anti-opioid hysteria that favors hyperbole over nuance and glosses over the complexities of treating many painful conditions” (my emphasis added). Another patient, who is also a retired physician, adds, “They’re confusing legitimate pain management with addiction. Those are completely separate venues.”

After a year and some changes since the CDC Opioid Guideline was released, we have certainly seen a lot of ‘hyperbole over nuance’ in the rush to stem the tide of opioid overdose deaths. In previous columns, I expressed at least a little bit of hope that these changes would still allow for the practice of opioid-prescribing to well-assessed and well-supervised chronic pain patients who simply do not respond to non-opioid medications. Now, I am not so sure.

This past year, I have informally spoken with many pain management colleagues who are seriously contemplating not prescribing opioid-based pain medications any longer. Some are contemplating leaving pain medicine all together forever and go back to practicing neurology, anesthesiology, or another specialty full-time. To be clear, I am not talking about a practitioner whose training consists of attending a pain conference once or twice. These are fellowship-trained, board-certified pain management specialists who have spent thousands of hours building up their pain management practice. And now, they are giving serious thought to closing down their pain practice for good – or at least dramatically changing it.

I can’t blame my colleagues. Those of us that continue to offer opioid-based pain management services find ourselves being attacked on all fronts.

On the insurance side, several health insurers are requiring oodles of prescriber documentation in order to approve the coverage of any extended release opioid pain medication – even ones on the insurance formulary. I have filled out a couple of these documents recently for my own patients. On each patient, I had to compile a dossier of urine drug screens, opioid agreements, treatment plans, substance use assessments, and other clinical documentation  – requiring about an hour per patient.

On the legal side, pain management specialists are terrified of being investigated or arrested if they continue to prescribe any amount of opioid-based pain medication. And that fear is not without foundation! There have been many investigations and arrests of opioid prescribing physicians, including several in the South [6]. Federal agencies also don’t shy away from declaring that this is just the start of their crackdown. In fact, the FBI very recently sent out a press release titled “Health Care Fraud Takedown - Nationwide Sweep Targets Enablers of Opioid Epidemic” [7].

Given all the heat that’s on us right now, it is no wonder my colleagues are thinking of giving it all up. The professional satisfaction a pain specialist gets when serious pain is made more manageable by opiates does not compare with the panicked dread of worrying about being arrested for providing that humane care.

I certainly hope that this column has not convinced even more of my colleagues to throw in the towel and to just offer trigger points and ESI’s as their sole contributions to pain management. Rather, I hope that it has reaffirmed to those that have been having these contemplations that they are not alone in these thoughts or fears!

Indeed, I think we have done a really good job of organizing our upcoming Southern Pain Society Conference to discuss these topics robustly.

On Friday, we will hear a talk on opioids and abuse deterrent formulations from Dr. Feng Zhang. Dr. Zhang and his team at the University of Texas have been responsible for developing the abuse deterrent formulations used in Oxycontin and Opana and have several new abuse-deterrent formulations in the pipeline as well. Dr. Zhang will undoubtedly explore what role will these abuse deterrent formulations have in stemming the tide of pain medicine overdose incidents.

On Saturday, we will be hearing from Duke University’s Dr. William Maixner. Dr. Maixner is the Director of Duke’s highly prestigious Center for Translational Pain Medicine. He will talk about translational medicine for chronic pain and how that multi-disciplinary, highly collaborative approach is speeding up the development of new treatments for complicated chronic pain patients.

Later on Saturday, we will be hearing from Dr. Hans Hansen – a “fan favorite” from last year’s conference! Dr. Hansen will reflect on the tectonic shifts that have changed the landscape of pain medicine since the CDC Guidelines were released year.

Then on Sunday, we will hear from my friend and colleague, Dr. Arwen Podesta. Dr. Podesta is an expert in holistic medicine, addictionology, and forensic psychiatry and will use these expertise areas to present the latest in the assessment and management of addiction issues in chronic pain.

So, you can see that we – along with our Southern Headache Society colleagues – have put together a program worthy of the multi-faceted challenges we face.

See you in New Orleans!

--Mordi

REFERENCES:

[1] Eric Russell. A deadly epidemic: Addiction to opioids has put an entire generation at risk. Portland Press Herald. http://www.pressherald.com/2017/03/26/lost-heroins-killer-grip-on-maines-people/  Published 03/26/2017

[2] See URL   https://tonic.vice.com/en_us/article/ev43gk/the-men-who-catch-your-lobsters-are-self-medicating-with-heroin

[3] See URL   http://www.pressherald.com/2017/04/02/lobstermen-under-siege-heroin-epidemic-feeds-on-an-iconic-way-of-life/

[4] Marina Villeneuve. Chronic Pain Patients Say Opioid Law Creates New Crisis. The Associated Press. Published on 04/22/2017 and accessed at URL   https://www.usnews.com/news/best-states/maine/articles/2017-04-22/chronic-pain-patients-say-opioid-law-creates-new-crisis

[5] See URL   https://news.vice.com/story/opioids-chronic-pain

[6] See the following URLs for recent local opioid prescriber arrests:
http://www.heralddemocrat.com/news/20170711/fbi-arrests-sherman-doctor
http://www.theadvocate.com/baton_rouge/news/article_d6c70fe8-67f5-11e7-b922-db0d97ccab9c.html
http://www.fox9.com/news/267649616-story

[7] See URL https://www.fbi.gov/news/stories/nationwide-sweep-targets-enablers-of-opioid-epidemic