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4 Articles in this Series
Introduction
Forest Tennant, MD, DrPH, Honored for a Lifetime of Achievement in Pain Medicine
PAINWeek 2017 Video Highlights
Time for Pain Practitioners to Take Back Pain Prescribing
Under Scrutiny, What's a Pain Practitioner to Do?

Time for Pain Practitioners to Take Back Pain Prescribing

Presentations by Stephen J. Ziegler, PhD, JD, Kevin L. Zacharoff, MD, and Michael Schatman, PhD 

“I am experiencing a bit of déjà vu,” said Stephen J. Ziegler, PhD, JD, associate professor emeritus of public policy at Purdue University in Fort Wayne, Indiana, who began the keynote address at PAINWeek 2017, “with what may be viewed as opioid McCarthyism—our fears are being exploited in the media and by the government with some individuals being blacklisted, just as occurred 70 years ago.”1

“We have government investigations of prescribers and a marginalization of pain,” Dr. Ziegler said, “to the point that the trend toward undertreating post-surgical pain is now manifesting as chronic pain.” Pain practitioners are essentially operating under a fear of sanction.2

A closer look at the opioid crisis has made two things clear: there is a problem with opioid abuse, but not due to an epidemic of over-prescribing. Rather “we are facing a challenge of elicit opioids like heroin and fentanyl manifesting in treatment inequality and a push to reduce abuse at the expense of pain relief,” said Kevin L. Zacharoff, MD, vice president of medical affairs at Inflexxion in Waltham, Massachusetts.

"Now pain patients can be denied their prescribed medication by pharmacists, who essentially have the ability to withhold medically-advised care," said Dr. Zacharoff.

Pain practitioners need the ability to prescribe medication to chronic pain patients as needed.

When Perception Becomes Reality

While there was and is an opioid crisis, the reasons attributed to the deaths have been misconstrued due to a flawed presentation of the data.3-5

“How can it be that the 16,000 reported opioid deaths annually remains constant,3 while clinicians are too afraid to prescribe in 2017?" said Michael Schatman, PhD, CPE, director of research and network development at Boston Pain Care in Massachusetts.

Let’s take a look at the facts. In 2014-2015, a slight increase in overall deaths attributed to opioids was driven primarily by heroin (20.6%) and synthetic, non-methadone opioids obtained on the street (72.2%).4

In effect, the vast majority of opioid-related deaths occurred from nonprescription medications, specifically fentanyl analogs and precursors, usually mixed with heroin;3,4  yet, Dr. Schatman asked, "how many non-fentanyl, bootleg drug-related deaths are reported, or given proper responsibility as the underlying cause of overdose deaths? " 

Shedding light on the reality of opioid-related deaths,Dr. Schatman presented the data that should be shared with the public:

  • 52% involved alcohol
  • 44% of deaths attributed solely to alcohol
  • 24% included amphetamines
  • The average number of drugs detected in individuals who overdose is 6!

The truth of the matter is—we have a polypharmacy problem, not a prescription opioid problem, Dr. Schatman said

Opiophobia Has Prompted a Failure to Treat

The impact of this “opiophobia” is an intensifying dissatisfaction with care among many chronic pain patients who are being denied treatment that had been working for them without incident for many years, said Dr. Schatman, and now they are faced with having to make changes. 

Whereas pain relief was once a fundamental right, now patients—even those with documented, intractable pain, find themselves struggling to gain relief from their pain just so they can function.1

We [practitioners] know that undertreating chronic pain is the real public health crisis, Dr. Schatman said, the question that we should be asking is “what is the cost of a failure to adequately treat?”

If we were to remove polypharmacy and street-derived fentanyl, then maybe only 1/5 of the deaths would be attributed to prescription opioids.1 In effect, this opiophobia is the medical equivalent of an emperor without clothes, Dr. Schatman said.

The Politics of Pain

Unlike any other aspect of medicine where scientific evidence drives clinical care, “pain is one of the few conditions in which the patient has a say in the goal,” Dr. Ziegler said. and with the heightened debate, stigma, fear, and denials by insurers hampering our ability to deliver the best care possible, the practice of pain management has become politicized.1

Given the federal and state limits on opioid prescribing, patients have had to seek alternatives to prescription opioids to gain any pain respite, but most non-pharmacologic alternatives are not reimbursed. That leaves patients in a position of paying out-of-pocket for therapies that may or may not lessen their pain and restore their quality-of-life.

The consequences of flawed data, fomented by a frenzy of ongoing media coverage, have been to marginalize and stigmatize patients with chronic, often intractable pain conditions who no other viable option than to stay with their prescription opioid therapy,1 said Dr. Schatman.  

Clouded by the media sensationalism, the evidence suggests both indirect and direct discrimination of both patients and practitioners has arisen from the political fallout of the opioid epidemic. In addition, [practitioners and patients] civil rights are being violated, and unnecessary pain persists because those working to relieve patient suffering are unable to carry out the most appropriate, evidence-based medical care.1

The presenters had no financial conflicts of interest to disclose.

In Part II, the speakers discussed the societal impact of current legislation and the actions needed in order to move pain management forward with patients' needs in mind.

References:

  1. Schatman ME, Zeigler SJ, Zacharoff KL. Are you now or have you ever been? Saving pain medicine from zealotry. Presented at: PAINWeek 2017. September 4-9, Las Vegas, Nevada.
  2. Dineen KK, DuBois JM. Between a rock and a hard place: Can physicians prescribe opioids to treat pain adequately while avoiding legal sanction? Am J Law Med. 2016;42(1):7-52.
  3. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Wkly Rep. 2016;65(5051):1445-1452.
  4. Schuchat A, Houry D, Guy PG. New Data on Opioid Use and Prescribing in the United States, 2017. JAMA. 2017;318(5):425-426. NOPE Task Force. Available at http://www.nopetaskforce.org/about.php. Accessed September 12, 2017.
  5. Hannah HA, Arambula K, Ereman R, Harris D, Torres A, Willis M. Using local toxicology data for drug overdose mortality surveillance. Online J Public Health Informatics. 2017;9(1)e143. Available at: http://journals.uic.edu/ojs/index.php/ojphi/article/view/7733. Accessed September 13, 2017.
Next summary: Under Scrutiny, What's a Pain Practitioner to Do?
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