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12 Articles in Volume 18, Issue #4
A New Frontier in Migraine Management: Inside CGRP Inhibitors & Migraine Prevention
Assessment of Patients with Rheumatoid Arthritis or Osteoarthritis
Biosimilars in Rheumatology: How Popular Will They Be?
Case Studies in Regenerative Cellular Therapy: Tendinopathy and Osteoarthritis
Commentary: Make the Easy Choice for Care
Editorial: The Emergence of Trackable Pill Technology: Hype or Hope?
Editorial: The Practicality of Pain Acceptance
How to Avert Government Scrutiny When Prescribing Opioids
Letters to the Editor: DEA and Prescribing, the War on Statistics, Failing Treatments, Patients' Options
Meet the Migraine Game-Changers
Platelet-Rich Plasma and Stem Cell-Rich Prolotherapy for Musculoskeletal Pain
With concerns over opioids, could novel receptors be useful?

Letters to the Editor: DEA and Prescribing, the War on Statistics, Failing Treatments, Patients' Options

June 2018 PPM Letters to the Editor from practitioner peers and patients

A Word of Warning about the DEA and Prescribing

Dear PPM Peers,

I have another perspective to complement those shared in the March 2018 edition of PPM: “Sharing the Risk-An Update to DEA and Doctors Working Together.” Physician efforts to better serve our patients and our communities are to be expected. In this regard, to better assure comprehensive and collaborative care in addressing complex pain patients, and to work in conjunction with law enforcement agents makes total sense. As sensible as all this may be, sensible actions are not the reality that I and others have experienced.

I am an ambassador of the Doctors of Courage, established by a group of physicians, many who have been unfairly targeted by the DEA, often in association with state regulatory bodies. This pattern was documented in 2008 by professor RL Libby in his book, “The Criminalization of Medicine–The War on America’s Doctors.”

At the time I was investigated by the DEA and Medicaid, I was serving as president of the Washington State Society of Addiction Medicine. I had been working quite closely with the DEA and Medicaid to assure necessary and indicated services were available to help patients recover from pain and comorbid addictions, in addition to other common comorbid mental and general health concerns. As a former health officer, I was also doing all I knew to better ensure that our communities were safe from substance abuse and misuse. I naively assumed that the DEA, our state agencies, and physicians in the trenches were all on the same team.

If one is part of a large institution, I expect one is less likely to experience what I and many other colleagues have. I think, in part, because in that context one has implied political and legal support. Charges were never made in my case. I am most thankful. I believe it was because of political and substantive support from my community, as well as the legal support I received. I was also able to demonstrate my income significantly suffered based on providing care to Medicaid clients, so any intent to profit from the care was refuted.

I was fortunate to not have any overdoses or serious complications associated with my care. When one treats a lot of high-risk patients, even with the best of professional care, whether in or out of the hospital, one eventually encounters complications, even dire ones. So I remain grateful. I have seen colleagues crucified for complications associated with opioid prescribing, even when their complication rates were arguably much lower than what would be the generally expected morbidity and mortality in the population served. We do not close hospitals simply because people die in them, even when such deaths are not infrequently from medically induced complications or errors. We strive to do better.

Throughout the United States, access to ongoing comprehensive and collaborative care for complex pain patients is rarely adequate. I practice in a rural area where even getting notes from colleagues is a major obstacle, let alone finding practitioners who are willing to work with complex patient conditions. Options for adjunctive and comprehensive care are quite limited based on third-party reimbursements and the lack of disposable income. While the CDC argues that opioids have little proven long-term efficacy, the truth is that very few medications, particularly medications with indications for pain, have demonstrated long-term efficacy. Yet, we commonly and effectively prescribe them. For the 20 to 25% of Chronic Opioid Agonist Therapy patients who develop an opioid use disorder (OUD), the barriers to proven effective care is even worse. For those with comorbid OUDs, higher morphine equivalents and long-term agonist therapy is an established standard of care.

In summary, while we may work with the DEA, I advise my colleagues not to assume the DEA is a friend. Do not necessarily trust what they tell you. Be most careful what you ask or share. When possible, get clarifications in writing. Do not assume that providing professional care will be an adequate defense. The DEA’s job is to enforce the regulations, and they have a large latitude to interpret.

–JK Rotchford, MD, MPH
Author of the forthcoming book, “Opidemic–A Public Health Epidemic”

See also: Averting Government Scrutiny in the Wake of an Opioid Prescribing Crackdown

The War on Statistics

Dear PPM,

I have been a loyal reader and teacher of your content for over seven years. I would very much like to know the current statistics regarding patients that commit suicide because they cannot get adequate chronic pain treatment, as well as how many attempts have been made. There is a lot of misinformation out there. Why doesn’t the government report that we have an opioid crisis, but not a prescription opioid crisis?

Most opioid-related deaths occur from powder and pressed fentanyl and carfentanyl. No physician can prescribe in “powder” form... The compounding factor is that many individuals may have a prescription opioid in their system at the time of an overdose death, but that prescribed medication was not necessarily the cause of death.

Most pain patients do not divert or sell their medication because they need them. Those individuals that manipulate the system are the exception, not the rule.

I taught chronic pain management at the University of Tennessee School of Medicine as an Addiction Medicine Fellow, while the state changed its rules on who could direct a pain clinic, regardless of experience or training. In one night, many successful clinics had to shut their doors, leaving thousands without refills or access to care. In the pain clinic where I was working, the average wait to be seen was nine months. So I continue to question, are the statistics higher for those patients who take their lives because of poor access to treatment or for those who die of accidental opioid overdoses?

–JS Sappington, MD

When Treatments Fail

Dear PPM,

I live in the Tucson area and cannot find anyone willing to help me with my severe chronic pain. A 69-year-old male, I had a complete lumbar discectomy in 2009; the surgery was a failure and ever since, I have been left to deal with my pain, which is alleviated by narcotic pain medication. I also have psoriatic arthritis and see a rheumatologist who has prescribed Celebrex and Cosentyx; I believe this disease is being managed properly.

However, I continue to have severe bilateral lumbar pain and sciatic pain in my left leg from thigh to foot. I have tried epidurals, acupuncture, chiropractic, physical therapy, etc. Two neurosurgeons told me there is nothing further that can be done. My PCP has refused to prescribe oxycodone, because of pressure by the DEA (I was taking one to six 30-mg tablets/day for the past two years). Recently, I tried to get suboxone prescribed, but no one is willing to accept Medicare. I know I am physically dependent on narcotic pain medication, and I hope to live at least another 10 years, but I do not see how if my current situation cannot be managed.

–RL Baron

Dear Mr. Baron,

Your history and symptoms suggest you may have arachnoiditis. It is crucial to obtain a proper diagnosis, which will guide specific treatment to help relieve your pain. The second issue is that you are unable to obtain enough opioids to symptomatically control your pain. Be clearly advised: multiple federal agencies have made it clear that any physician who prescribes over 90 mme/day will be taking on serious legal liability.

I recommend you find a physician or nurse practitioner who will prescribe up to the federal level of 90 mg. An ongoing treatment plan should include acceptable opioids, non-opioid pain relievers, and specific arachnoiditis treatment.

–Forest Tennant, MD, Editor Emeritus

Relaying Treatment Options to Patients

In the Jan/Feb 2018 issue, PPM shared a letter from K Zinda regarding her struggles with chronic pain, including breakthrough pain and a reduction in pain medication after the CDC guidelines. She has fibromyalgia, herniated discs, hip pain, and sacroiliac joint dysfunction (SIJ).

Dear Ms. Zinda,

While a single treatment modality is rarely optimal for complex chronic pain, there are a variety of effective options you can consider. Since you listed opioids as a single modality, I encourage you to explore other evidence-based therapies such as acupuncture, aqua-therapy, epidural steroid injections (for disc herniation), hip injections, SIJ injections, and ablation. In conjunction, targeted CBT, mindful-based stress reduction, and meditation may be helpful. Other crucial elements include a healthy diet and sleep habit, and structured daily exercise you can adhere to. Lastly, I advise your Vitamin B12, D, and hormone levels be checked and supplemented if indicated.

Medications, especially opioids, are generally effective in the short term, but their benefits need to be weighed against long-term risks. The ultimate goal of chronic pain care is not a cure but rather improvement of physical and mental functions, and delay of disease progression. May these suggestions give you some hope in your pain management journey.

–H Hoang, MD, DABAPM

Last updated on: April 12, 2019
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