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As expected, physician organizations are jumping on board with the national anti-pain management fervor set off by the CDC Opioid Guidelines. In the June 15, 2016 American Family Physician, the publication of the American Academy of Family Physicians, is the headline article “Weighing the Risks and Benefits of Chronic Opioid Therapy” by Anna Lembke, MD, Keith Humphreys, PhD, and Jordan Newmark, MD, of Stanford University School of Medicine, Stanford, California (psychiatry and anesthesiology/pain management departments, not family medicine by the way).

Cover of AFP magazine

Cover of AFP magazine

The picture on the front cover of the publication headlining the article says it all. The picture includes:

1. Oxycodone Taper prescription instructions with a 2 ½ milligram per month reduction program in the background.
2. A urine collection cup for urine drug screens in the top right corner.
3. A bottle of Buprenorphine/ Naloxone sublinquals or a transdermal patch bottom left.
4. Patient is in the center looking unsure and uncomfortable.
5. A doctor standing over him trying to cover up what he is doing with an authoritative explanation.

The Big Question

One of the questions that always comes up on any chronic pain patient support group is: Why aren’t doctors coming together to support us? Well, here is the one organization that should be because it is independent family physicians that are being singled out by the Justice Department, charged as criminals, and ruined financially, professionally and personally. So what are they doing?

First, the purpose of AFP is stated “to serve the medical profession and provide continuing medical education (CME)”. CME objectives are (paraphrased): To provide updates on the diagnosis and treatment of clinical conditions managed by family physicians, reference citations, balanced discussions, and evidence-based guidelines.

Pure Propaganda

Let me state that I didn’t even get to the article yet, and I can say the review of this is going to be pure government propaganda. In the editorial by Deborah Dowell, MD, and Tamara Haegerich, PhD, they make the statement in the first paragraph that “it is unclear how effective long-term opioid therapy is for managing pain.” Would anyone in chronic pain like to step and tell them how effective opioid therapy is?

They make the statement that “As many as one in four patients receiving long-term opioid therapy for noncancer pain in primary care settings has opioid use disorder.” And they quote statistics of people dying from opioid-related causes, most of which are caused by the government actions against legitimate pain management today. According to the American Psychiatric Association, the 12-month prevalence of opioid use disorder is approximately 0.37% among adults age 18 years and older in the community population (Compton et al. 2007).  That is a far cry from 25% as stated here.

How can we coordinate this vast difference in percentages? It’s easy. The government, through the new CDC guidelines, is moving anyone that is dependent on opioids for control of their chronic pain as now diagnosed with “substance use disorder”. Substance use disorder in DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe. Each substance is addressed as a separate “use disorder” which would include the “opioid use disorder” term used here. However, the main criteria which supposedly delineates opioid use disorder—a problematic pattern of use leading to impairment—is now only a part of the diagnostic criteria. Simple dependence which happens normally after 3 months of use will give a patient that diagnosis now, as evidenced by Oregon’s new Opiate Prescribing Guidelines that more states will probably adopt.

The actual diagnostic criteria for “opioid use disorder” are:

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  1. Opioids are often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
  3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  4. Craving, or a strong desire or urge to use opioids.
  5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  8. Recurrent opioid use in situations in which it is physically hazardous.
  9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
    2. A markedly diminished effect with continued use of the same amount of an opioid
    3. Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
  11. Withdrawal, as manifested by either of the following:
    1. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).
    2. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

The authors’ response to the CDC guidelines were to say “This guideline is intended to help clinicians decide whether and how to prescribe opioids for chronic pain; offer safer, more effective care for patients with chronic pain; improve clinician-patient communication; and prevent opioid use disorder and opioid-related overdose.” They then go into enumerating the “important points that can help clinicians make treatment decisions” such as:

  1. Nonopioid therapy is preferred for management of chronic pain. Opioids should not be used as routine therapy outside of active cancer treatment, palliative care, or end-of-life care. When used, they should be combined with other therapies.
  2. When opioids are used, the lowest effective dosage should be prescribed.
  3. Clinicians should use caution when prescribing opioids, closely monitor all patients, and continue therapy only after reevaluating the patient to determine benefits vs. risks.

The full CDC guideline is available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Another editorial by Patrice A. Harris, MD, MA entitled “The Opioid Epidemic: AMA’s Response” is pushing the currently politically-motivated acceptable government solution to the opioid epidemic, i.e. put everyone on the latest, more addictive opioid—buprenorphine/ naloxone. The politics is obvious, with her stating that the AMA is working with the National Governors Association and other leading stakeholders as well as the Obama administration. Recommended solutions are more physician training and increasing the number of physicians certified to prescribe buprenorphine or naloxone. She also states that “the AMA largely supports the CDC guidance” but then goes into concerns about the recommendations. However, there are no stated solutions to those concerns, just “wait and see”.

On their CME Quiz questions, the question about the article on Chronic Opioid Therapy is: Which one of the following formulations should be considered when initiating chronic opioid therapy in a patient at risk of opioid use disorder?

  1. Transdermal buprenorphine
  2. Transdermal fentanyl
  3. Methadone
  4. Morphine.

And the answer is…drum roll… A. Transdermal buprenorphine. I.e. The latest and greatest opioid giving a high 4x that of OxyContin to addicts.

So now let’s look at the article “Weighing the Risks and Benefits of Chronic Opioid Therapy”, dissect it, and read between the lines. The article can be found at: http://www.aafp.org/afp/2016/0615/p982.html. The cost for access to the article is $14.95.

The article starts out with the premise currently pushed by the government today: that the use of chronic opioid therapy for chronic pain is not supported by evidence, and the risks might outweigh the benefits. So right from the start, family physicians are warned that they are treading on quicksand if they choose to treat their patients with long-term opioid therapy, and they will get no support from their association. They also push the use of buprenorphine for patients at risk for opioid use disorder, which is pretty much everyone on an opiate longer than 3 months. They do open the door for treatment, however, by stating:

“Chronic opioid therapy benefits some patients with chronic pain.” And they urge physicians “to individualize therapy based on a review of the patient’s potential risks, benefits, side effects, and functional assessments, and to monitor ongoing therapy accordingly.”

 

But I’m afraid the effect of family physicians using this article as a basis for treatment is just putting more of them in the judicial noose.

“Recent reports indicate higher rates of opioid use disorder in this population [patients receiving opioids from a licensed physician for treatment of a medical condition] than previously assumed, with some studies finding prevalence rates as high as 50% in patients receiving chronic opioid therapy.” “Patients receiving opioid therapy for more than 90 days at doses of more than 120 MME (morphine milligram equivalent) are more than 100 times as likely to develop opioid use disorder as patients who do not receive opioids for similar conditions.”

danger-fi325xBut then they recommend to physicians for them to not suddenly remove patients from opioid therapy if they are found to have opioid use disorder. Either these authors are so protected from reality by academia, or there is a government agenda here. (Pardon my paranoia). In real life, if a doctor diagnoses a case of opioid use disorder, or even if one of his patients has a “red flag” the doctor doesn’t even know about, and he prescribes even one day more of an opioid, he is open to charges by the government of practicing “outside legitimate medical practice”.

And finally, on page 1042 we find the AFP Practice Guidelines based on the CDC Guidelines.

Key Points for Practice (identified as coming from the AFP Editors):

  1. Chronic pain should be managed primarily with nonpharmacologic therapy or with medications other than opioids

  2. Physicians should routinely discuss the risks and benefits of therapy and the mutual responsibility to mitigate risk with patients who are receiving opioids

  3. When opioids are prescribed, they should be titrated to the lowest effective dosage.

Treatment should be offered or arranged for patients with opioid use disorder

 

Even though the statistics quoted are that the prevalence of chronic pain among adults in the US is approximately 11% and that as many as 43% experience daily pain, the AAFP reviewed the CDC guideline and gave it an affirmation of value.

I predict that the effect of the medical profession being forced to use this guideline is more addiction and more death due to opiates. The reason for this prediction is that, as a result of the current addiction situation, the government has put the blame on long-acting opiates. But the long-acting opiates are not to blame. Instead, as shown by studies done during the development of the long-acting opiates, keeping the levels constant in the bloodstream instead of the too much-not enough treatment of the short-acting opiates actually lowers the milligrams required to achieve pain relief. The problem with the long-acting opiates is when they are ground up and turned into short-acting by the addict. Chronic pain patients don’t do that. Now the problem with prescribing short-acting is that more are given out and patients then have access to using some and selling some. I anticipate more doctors will be charged with criminal activity because of this. But maybe that’s the plan all along.

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