Florida’s ‘Modest’ Reduction in Opioid Prescribing

By Pat Anson, Editor

Florida was one the first states in the country to get serious about fighting the “epidemic” of prescription drug abuse.

In 2010, a year when eight Floridians were dying every day from drug overdoses, the state started cracking down on rogue pain clinics – “pill mills” -- and began to closely monitor the number of opioid prescriptions written and filled by physicians and pharmacies.

By most accounts, the crackdown has been a success – overdose deaths dropped and over 250 pain clinics were closed. But legitimate pain patients also began to complain that they couldn’t get their prescriptions filled. Their search for a pharmacy willing to dispense opioids – a search that could take hours or days – even got a name: Florida’s “Pharmacy Crawl.”

Which makes a new study in JAMA Internal Medicine all the more surprising.

Researchers analyzed an extensive database of prescription claims and found that there was only a “modest” decline of 1.4 percent in the number of opioid prescriptions in Florida from 2010 to 2012.

The reductions were generally limited to prescribers and patients with the highest rates of opioid prescribing and use – meaning the average pain patient shouldn’t have been affected at all.

That 1.4% reduction, researchers say, was a “statistically significant” decline by some measures. But they also acknowledge that Florida’s crackdown on opioids “had no apparent effect on days’ supply per transaction or on total number of opioid prescriptions dispensed.”

That less than overwhelming finding raises questions about the effectiveness of the crackdown and, in particular, prescription drug monitoring programs (PDMPs). Almost every state has implemented a PDMP in the last few years, spending millions of dollars to track patients with electronic databases that have yet to be proven effective. 

“Our findings highlight the need for more evidence demonstrating the effect of PDMP and pill mill laws,” wrote lead author Caleb Alexander, MD, of the Johns Hopkins Bloomberg School of Public Health.

Effect on Pain Patients

So if the number of opioid prescriptions in Florida barely budged, what about all those pain patients who claim they couldn’t get a prescription filled?

"The opioid lobby and media they've influenced portray Florida's efforts as draconian. We keep hearing that pain patients in Florida have lost access to opioids.  The study's findings refute these claims," said Andrew Kolodny, MD, a prominent critic of opioid prescribing practices who is President of Physicians for Responsible Opioid Prescribing.

“Dr. Kolodny can't see the whole picture just by looking at this short term study,” says Donna Ratliff, a chronic pain patient who founded the Fight for Pain Care Action Network, a non-profit group lobbying for adequate pain care in Florida.

“Things did get draconian after the DEA fined the distributors and chain pharmacies. The media headlines stigmatized the pharmacies and doctors early on into not treating legitimate pain patients out of fear.” 

It was in 2012 that Cardinal Health, one of the nation’s largest drug wholesalers, was fined $34 million by the DEA after it failed to report suspicious orders for hydrocodone at a distribution facility in Lakeland, Florida. Shipments of controlled substances from that facility were suspended for two years.

Walgreens and CVS Pharmacy were also fined tens of millions of dollars for violating rules and regulations for dispensing controlled substances. Afterwards, both pharmacy chains began to screen patients with opioid prescriptions more carefully, and told their pharmacists not to fill them if anything appeared suspicious.

Those developments, according to Ratliff, were not fully covered during the opioid prescription study, which ended in September 2012.

“This induced the pharmacy crawl, that got worse as time went by,” she told Pain News Network.

In a recent survey of hundreds of pharmacies, drug wholesalers and physicians by the General Accounting Office (GAO), over half said DEA enforcement actions had limited their ability to supply drugs to patients. Many said they were fearful of being fined or having their licenses revoked by the DEA.

“Some pharmacies may be inappropriately delaying or denying filling prescriptions for patients with legitimate medical needs,” the GAO report states.  

FDA Approves OxyContin for Kids

By Pat Anson, Editor

In a controversial move, the U.S. Food and Drug Administration has approved OxyContin for use by children aged 11 to 16 who suffer from severe, long-term pain.

OxyContin is a potent, extended release opioid painkiller that has been blamed for fueling an “epidemic” of prescription drug abuse and addiction in the U.S.

One critic, whose teenage daughter died after a single dose of OxyContin, called the FDA’s decision “beyond disgusting.”

The agency did not make a formal announcement about its decision, issue a news release, or consult with an outside advisory panel about the risks and benefits of making OxyContin available to pediatric patients.

Instead, the news was revealed in an FDA blog posting, an interview with Sharon Hertz, MD, a Director in the FDA’s Center for Drug Evaluation and Research.

“OxyContin is not intended to be the first opioid drug used in pediatric patients, but the data show that changing from another opioid drug to OxyContin is safe if done properly,” Hertz said.

“In pediatric patients who require opioid treatment to manage pain, extended-release opioids may be a useful alternative because they are taken only once or twice per day rather than every 4 to 6 hours. Fewer daily doses may free patients for physical therapy appointments, allow them to go home from the hospital sooner, and may help them to sleep through the night without waking up from pain. So from that perspective it's very useful.”

Hertz said the FDA decision was a "team effort" involving physicians, pediatricians, clinical pharmacologists, statisticians, ethicists and opioid experts. It came after the safety and efficacy of OxyContin was studied in children who were prescribed the drug after extensive trauma or major surgery. 

“Prior to this action, doctors had to rely on adult clinical data to shape their decision-making in treating pediatric patients. This program was intended to fill a knowledge gap and provide experienced health care practitioners with the specific information they need to use OxyContin safely in pediatric patients,” said Hertz.

She said OxyContin should only be prescribed to pediatric patients when they have shown they can tolerate a 20 mg daily dose of oxycodone, an immediate release opioid.  

The Duragesic patch, which contains fentanyl, is the only other extended release opioid product approved for use by children.

Hertz hinted the FDA would be approving more opioids for pediatric patients in the future.

“Quite a few of the newer opioid drugs have pediatric studies underway to gather the data that will help prescribers use them safely. I expect that our teams will be working together a lot more in future to make sure that new pediatric pain management options continue to be safe for children in the U.S.,” Hertz said.

OxyContin has a controversial history. It was introduced to the U.S. in 1996 and soon became a blockbuster drug for Purdue Pharma, reportedly generating profits in excess of $10 billion.

In 2007, Purdue and three of its top executives pleaded guilty to felony criminal charges for the off-label marketing of OxyContin – falsely telling doctors it had low potential for addiction.

Critics, who blame Purdue for thousands of fatal OxyContin overdoses, are angry about the FDA's decision to approve the drug for children.

“We've known for a long time how immoral this company is.  As far as Purdue's role, this comes as no surprise; they have had this idea for some time now, as it represents a very lucrative market for them,” said Pete Jackson, president of Advocates for the Reform of Prescription Opioids.

Jackson lost his 18-year-old daughter Emily to a single dose of OxyContin in 2006.

“We've also known for a long time how unethical the FDA is,” Jackson said in an email to Pain News Network.  “This brings both truths out in the open.  This is the pinnacle of dysfunction in our federal government: that a federal agency would openly sanction the use of a deadly narcotic on kids without even an advisory committee meeting to hear from the experts and the public is beyond disgusting.”

By 2010, nearly half the patients entering drug treatment facilities for opioid abuse said they had used OxyContin to get high at least once in the previous 30 days. That same year Purdue introduced a reformulated version of OxyContin to discourage patients from crushing the tablets for snorting or injection.

As a condition of its approval for use in pediatric patients, Purdue is required to conduct a follow-up study examining rates of injury, overdose, accidents and medication errors involving OxyContin in pediatric patients.

Sedatives or Opioids: Which is the Bigger Problem?

By Pat Anson, Editor

New research shows that the prescribing of opioid pain medications is declining in United States, but the co-prescribing of sedatives with opioids remains a serious problem that raises the risk of an overdose.

In a study of over 35,000 patient visits for acute and chronic pain from 2001 to 2010, researchers found that the prescribing of benzodiazepines was three to four times more likely when opioids were prescribed.

Over a third of the patients prescribed opioids for chronic musculoskeletal pain were given a sedative. And patients with a history of psychiatric and substance abuse disorders were even more likely to be co-prescribed opioids and sedatives.

"Multidrug use is the trailing edge of the opioid epidemic," said Mark Sullivan, MD, a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. "We are making progress on decreasing opioid prescribing, but co-prescribing of opioids and sedatives has not decreased."

The study, published in the journal Pharmacoepidemiology and Drug Safety, estimates that opioid prescribing peaked in 2007. It’s the latest indication there has been a reversal in the growth of opioid prescribing – which has long been blamed for the so-called “epidemic” of prescription drug abuse.

In April, another study was released showing that the painkiller hydrocodone was no longer the most-widely prescribed drug in the U.S.

While opioid prescribing is in decline, researchers found no evidence that the co-prescribing of opioids and sedatives is also dropping. Opioids, benzodiazepines and muscle relaxants are all central nervous system depressants. Mixing the drugs is potentially dangerous because their interaction can slow breathing and raise the risk of an overdose death.

"Patients who are on long-term combined opioid and benzodiazepine therapy are often on a treadmill," said Sullivan. "They feel relief when they take their medications and withdrawal when they stop, so they continue this combined therapy, even though many function poorly and some will die as a result."

A study by the Centers for Disease Control and Prevention found that as much as 80 percent of unintentional overdose deaths associated with opioids may also involve benzodiazepines. Nearly 6,500 people died from overdoses involving benzodiazepines in 2010.

“We are seeing a disturbing increase in the use of benzodiazepines, mostly Xanax and Klonopin and Adderall. I call this the evil trifecta,” said Percy Menzies, president of Assisted Recovery Centers of America, which operates four addiction treatment clinics in the St. Louis, Missouri area. “To make matters worse, the use of heroin continues to grow as Mexican farmers are switching to growing the opium poppy.”

While fewer opioids are being prescribed for pain, Menzies says there has been explosion in the use of buprenorphine – a weaker opioid – to treat addiction. For many years, buprenorphine was only available under the brand name Suboxone, but now there are several other buprenorphine brands competing in the lucrative addiction treatment market. 

“We have reduced the number of prescriptions for opioids but the use of opioids (primarily buprenorphine) are growing. Never in the history of drug treatment, has the sale of a medication exceeded $2 billion,” said Menzies in an email to Pain News Network.

Recent studies by the Substance Abuse and Mental Health Services Administration (SAMHSA)  found a ten-fold increase in the number of emergency room visits involving buprenorphine. Over half of the hospitalizations were for non-medical use of buprenorphine – meaning  many users took the drug to get high.

Over 50,000 visits to ER’s in 2011 involved a combination of benzodiazepines and opioids, according to SAMHSA.

Fear of DEA Causing Drug Shortages

By Pat Anson, Editor

Millions of dollars in fines and thousands of investigations by the U.S. Drug Enforcement Agency have had a chilling effect on the nation’s drug supply chain, leading to quotas, shortages and legitimate prescriptions going unfilled, according to a new government report.

Pain patients have complained for years that it was becoming difficult to get opioid prescriptions filled, but the DEA called the evidence of that “anecdotal” and said it was not responsibility for any shortages.

In a survey of hundreds of pharmacies, drug wholesalers and physicians by the General Accounting Office (GAO), over half said DEA enforcement actions had limited their ability to supply drugs to patients. Many said they were fearful of being fined or having their licenses revoked by the DEA. Others blamed the agency for poor communication and unclear rules.

“In the absence of clear guidance from DEA some pharmacies may be inappropriately delaying or denying filling prescriptions for patients with legitimate medical needs,” the GAO report states.  

In recent years the DEA has fined distributors, pharmacies and practitioners over $94 million for violations of the Controlled Substances Act. Over 4,500 criminal investigations were also launched.

The crackdown helped lead to a reduction in prescription drug abuse and diversion, but it has also disrupted the drug supply chain. The GOA estimates that over half the distributors have placed a strict quota system on the amount of controlled substances that pharmacists and physicians can order.

“A distributor reported it refuses to distribute large volumes of controlled substances to prescribers or pharmacies that specialize in pain management, even if it has no evidence that the prescribers or pharmacies are engaged in diversion,” the GAO said.

One pharmacy chain told the GAO they were “afraid of being the target of DEA enforcement action even if they fill a prescription in good faith.”

Another small pharmacy chain said “we take things to the extreme to the point where we have received complaints from providers for turning away legitimate patients.”

“The DEA has NO communication out to pharmacies at all. The DEA is not preventative, it is all reactive,” one pharmacist complained. “The only experience we get with the DEA is hearing when they investigate and levy fines against a pharmacy for common pharmacy practices.”

The GAO recommended that the DEA improve its communication with distributors, pharmacists and practitioners so they would have a better understanding of what’s expected of them.

In response to the GAO report, a top DEA administrator wrote a letter stating there was only “anecdotal data that patient care is being compromised.”  

“The DEA would like to emphasize that it has no authority to control otherwise legitimate business decisions of registrants,” wrote Joseph Rannazzisi, deputy assistant administrator of the DEA’s Office of Diversion Control. “DEA and state partners have repeatedly and emphatically informed distributors that arbitrary thresholds are inappropriate, negatively impact legitimate patients, and are an inadequate substitute for fulfilling their obligations under the CSA (Controlled Substances ACT).”

The GAO report is the second this year to criticize the DEA for its management and policies. In March, we reported the GAO had faulted the DEA for "weak internal controls" and poor management of the system under which controlled substances are produced and distributed. The GAO said there were 87 “critical” shortages of drugs containing controlled substances, over half of them pain relievers.

The shortages have grown worse in recent years, according to many pain patients, who say controlled substances such as hydrocodone are increasingly difficult to obtain in some parts of the country.

Under federal rules, the manufacture and distribution of controlled substances is regulated by the DEA, while the Food and Drug Administration regulates what conditions the medications can be taken for. The two agencies are supposed to work together when shortages develop, but according to the GAO they do not have a “sufficiently collaborative relationship” and even “disagree about what constitutes a shortage.”

CDC Reports on Opioids Appear Biased

By Lynn Webster, MD, Guest Columnist

Like most people, I respect the opinion of the Centers for Disease Control and Prevention (CDC). It is our first and last line of defense against everything from chronic disease to full-fledged pandemics. That said, I am perplexed why the CDC would sound an alarm, while at the same time acknowledging that the fire doesn’t actually exist.

That’s more or less what the CDC did in a report finding that approximately a quarter of privately insured and a third of Medicaid-enrolled women of reproductive age (15-44 years) filled a prescription for an opioid each year from 2008 to 2012. The report went on to say that the trend of opioid prescriptions among childbearing women places unborn children at risk for birth defects. On this point, the report does not address how many of the women actually became pregnant and otherwise has a glaring absence of empirical data to support its claims.

If you are a clinician or scientist, the CDC report appears incomplete and biased against people in pain. If you are a patient or consumer of the news, the report is alarming. Neither of these outcomes advances medicine, nor do they help people who abuse prescription medication or those who experience chronic pain.

Without question, opioids must be replaced as a primary method of pain treatment in favor of safer and more effective therapies. It is clear that in many instances, the risks of opioid therapy far outweigh the benefits. However, many patients with pain have no other options, so until patients have access to effective alternatives, this type of reporting is counterproductive.

Because the report does not clarify the actual risks, nor compare them with the risks of continued pain in the absence of treatment, the CDC wades into dangerous territory of conjecture. Moreover, an overreliance on retrospective observational studies makes it difficult to evaluate the true impact of opioid use on the incidence of birth defects or whether other factors, such as the mother’s health status and co-occurring tobacco or alcohol use, were greater contributors. Although neonatal abstinence syndrome can definitely be traced to opioid use, the CDC investigators did not examine why the majority of infants born to opioid-consuming mothers do not develop it.

In addition to fuzzy reporting of the science, ethical issues are apparent in considering all women of childbearing age as fundamentally “prepregnant” when it comes to clinical decision making regarding opioid analgesia. These concerns were well delineated by Kristen Gwynne in an online article at RH Reality Check. Clinicians must always weigh potential benefits against potential harm before prescribing opioid therapy. But this has always been true of opioids and all medications, including nonsteroidal anti-inflammatory drugs, antidepressants and anticonvulsants.

The result of incomplete reporting could be the withholding of opioids from people based on gender and age, regardless of pregnancy status, even when strong pain-killing medications are indicated or when safer alternatives are not available. In fact, according to the American Congress of Obstetricians and Gynecologists, “Abrupt discontinuation of opioids in an opioid-dependent pregnant woman can result in preterm labor, fetal distress, or fetal demise.”

To be viable, alternatives to opioids must be effective and be covered by public and private insurance payers. Commentators who suggest opioids should not be prescribed often fail to present this important perspective and also imply that harm from opioids is inevitable, an error that contributes to the stigma and isolation felt by those whose lives would be crippled without their legally prescribed medications.

And yet, slanted reporting continues. In February, another CDC report appeared, endorsing scientifically vague opioid classifications of “stronger vs. weaker” than morphine. In analyzing the February report, June Dahl, PhD, properly pointed out the error in failing to consider the differing pharmacologic factors, mechanisms of action, formulations and the clinical relevance of relative effectiveness when comparing the medications.

Given the concerns with accuracy of scientific reporting, is it reasonable to increase federal funding to the CDC to battle prescription opioid abuse, as requested? Only with an understanding of the real reasons for the current opioid problem can we solve the problem. Perhaps more dollars should instead go to the National Institutes of Health, which is in desperate need of more funding for pain research and to develop safer alternatives to opioids.

Regardless, solutions cannot succeed in the absence of recognition that uncontrolled chronic pain is a major public health problem, worthy of focus similar to efforts to battle cancer, HIV/AIDS and other life-threatening diseases. Education of clinicians is good but cannot create treatment options or adequate insurance coverage where none exist. CDC officials and others must think about the problem differently and with less prejudice against people with chronic pain. Often the focus is on cutting supply alone; but in reality, this is difficult to accomplish without harming people with genuine pain when the payor system does not adequately cover evidence-based alternative therapies, including multidisciplinary integrative programs.

Instead payors, particularly government programs such as the Centers for Medicare & Medicaid Services and workers’ compensation, prefer the less costly opioid methadone, associated with more fatalities per prescription than any other.

Although a majority of opioid-prescribed patients do not abuse or become addicted, it is undoubtedly true that some people have contraindications for long-term prescribed opioids. These are potentially dangerous medications, which can be fatal. But effective solutions require a multifaceted approach and cannot ignore the needs of people in pain. Opioids formulated with abuse deterrents are needed as is greater funding and less stigmatization of people with the disease of addiction. Certainly, payors should cover safer and more effective therapies.

As I’ve said before, I hope opioids will one day not be needed, and commentaries like this one will be unnecessary. If the public health problem from opioids is too great, then it is the purview of the CDC to report on access to safer and more effective therapies in the interest of the other great public health problem: chronic pain. It is not an option to deny people in pain access to opioids if alternatives are nonexistent or unavailable.

Lynn Webster, MD, is Past President of the American Academy of Pain Medicine, and vice president of scientific affairs at PRA Health Sciences. He is a Pain Medicine News editorial board member and author of a forthcoming book, “The Painful Truth.”

This column is republished with permission from Pain Medicine News.

You can follow Dr. Webster on his blog, and on Twitter @LynnRWebsterMD, Facebook and LinkedIn.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study: Opioid Overdoses Occur Even at Low Doses

By Pat Anson, Editor

Overdoses from opioid painkillers occur frequently in people who are taking relatively small doses over a short period of time, according to a new study that has some experts calling for more restrictions on opioid prescribing.

Researchers at the University of Washington School of Public Health analyzed Medicaid data on over 2,200 opioid overdoses in Washington State between 2006 and 2010 – and found that many patients didn’t fit the usual profile of a long term opioid user taking high doses of pain medication.

The study, published in the journal Medical Care, found that less than half of the patients were “chronic users” who had been prescribed opioids for more than 90 days.

Only 17% percent of the overdoses involved patients taking a high morphine-equivalent dose of over 120 mg per day -- what is considered a "yellow flag" in Washington State for possible opioid abuse.

Surprisingly, nearly three out of ten (28%) patients who overdosed were taking a relatively low opioid dose of just 50 mg per day.

Sedatives were involved in nearly half of the overdoses and methadone in about a third of them.

In 2007, Washington State adopted some of the toughest regulations in the country on opioid prescribing -- guidelines that the researchers believe should be even more restrictive.

"It may be prudent to revise guidelines to also address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use, in addition to chronic, high-dose use," said lead author Deborah Fulton-Kehoe, PhD, a research scientist in the Department of Environmental and Occupational Health Sciences at the University of Washington School of Public Health in Seattle.

Based on the recommendations of this and other studies, Washington State’s Interagency Guideline on Prescribing Opioids for Pain was recently revised to caution doctors about prescribing opioids at any dose. The new guidelines extend to the treatment of acute pain, not just chronic pain. Physicians are also advised not to continue prescribing opioids to a patient if they don't show “clinically meaningful improvement” in physical function, in addition to pain relief.

While the overdose study focused on only one state, one expert says it has national and even global implications.

“The article notes that many overdoses occur when patients are prescribed medications at low doses. This has important implications for national policy and debate,” said  Dr. Jeroan Allison of University of Massachusetts Medical School, who is co-editor-in-chief of Medical Care. "The statistics are quite overwhelming and dramatic, and this problem affects every state in our nation."

According to the Centers for Disease Control, over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010.

More recent data suggest that the “epidemic” of painkiller abuse is abating.

Hydrocodone prescriptions fell by 8% last year and it is no longer the most widely prescribed medication in the U.S.

A recent report by a large national health insurer found that total opioid dispensing declined by 19% from 2010 to 2012 and the overdose rate dropped by 20 percent.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.

Study: Drug Abusers Responsible for Painkiller Misuse

By Pat Anson, Editor

A new analysis of a federal health survey has confirmed what many pain patients have been saying all along – that drug abusers, not patients, are largely responsible for the so-called epidemic of prescription painkiller abuse.

Researchers at the University of Georgia analyzed data from the 2011-2012 National Survey on Drug Use and Health. Over 13,000 Americans aged 12 and older were asked about their use of prescription drugs, illegal drugs, tobacco, and alcohol.

Less than 5% of those surveyed reported they had used a pain medication not prescribed for them or that they took it only for the "high" feeling it caused.

A further analysis of those abusers found that marijuana, cocaine or heroin use within the past year was the “only consistent predictor” of pain reliever misuse among all age groups.

"Male or female, black or white, rich or poor, the singular thing we found was that if they were an illicit drug user, they also had many, many times higher odds of misusing prescription pain relievers," said lead author Orion Mowbray, an assistant professor in the School of Social Work and the University of Georgia.

The findings are published in the journal Addictive Behaviors.

Asked where they obtained painkillers, the vast majority of the abusers said they did not get the drugs through a legitimate prescription, but had stolen them, acquired them from friends or relatives, bought them from a drug dealer, or used a fake prescription.

"If we know how people come to possess the pain relievers they misuse, we can design better ways to lower that likelihood," said Mowbray. "This study gives us the knowledge we need to substantially reduce the opportunities for misuse."

Adults aged 50 and older were more likely to acquire pain relievers through more than one doctor, although the rate of misuse in that age group was the lowest (1.7%).

People between the ages of 18 and 25 were most likely to misuse painkillers (10.2%) and more likely to get them from a friend, relative or drug dealer.

The study calls for greater coordination between medical care providers to reduce the possibility of over-prescription of painkillers, and for improving the communication between doctors, patients and the public.

"Doctors may conduct higher quality conversations with older patients about the consequences of drug use before they make any prescription decisions, while families and friends should know about the substantial health risks before they supply a young person with a prescription pain reliever," said Mowbray.

According to the Centers for Disease Control, over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010.

More recent data suggest that the “epidemic” of painkiller abuse is abating.

Hydrocodone prescriptions fell by 8% last year and it is no longer the most widely prescribed medication in the U.S.

A recent report by a large national health insurer found that total opioid dispensing declined by 19% from 2010 to 2012 and the overdose rate dropped by 20 percent.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.

A Pained Life: Speak Up, Speak Out

By Carol Levy, Columnist

I saw an advertisement on TV a few days ago. It was for some sort of a patch they were hawking for those with pain.

The testimonials were typical: "I use it and it's wonderful," said one man. "I recommend it highly," says a woman.

One testimonial really caught my attention: "I use it because I don't want to become addicted to pain medication."

So now the lie is even in TV commercials: Pain medication leads to addiction. And that should be your first thought and worry.

Never mind the reality that few people who use opioids for pain management become addicted. The lie has taken hold and is now part of the myth and stereotype; there is an epidemic of painkiller abuse and overdoses, and pain patients are on their way to addiction when they use these medications.

What bothers me about this, other than the spread of and belief in the lie, is the too many posts from members of chronic pain groups who have bought into the mythology and do not understand the difference between addiction and dependence.

They write they were on such and such a medication, often non-narcotic drugs like Lyrica, Cymbalta or anti-convulsants; drugs that do not have addictive properties.

"I have tried to get off it but I get sick when I do. Could I be addicted?"

No. Not from the poster's words. It may be physical dependence, which is nothing to be sneezed at. It is a bad problem and requires hard work to get off the medication. But that does not make it addiction.

The American Society of Addiction Medicine defines addiction behavior as an “inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.”

PainEDU.org defines dependence as a “state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.”

I cannot recall every reading or talking with people in chronic pain who said liked the narcotics they were prescribed. No one has ever said to me, "Wow. I love the way this drug makes me feel."

They may write or say the opioid has helped reduce their pain and that makes them happy, but invariably this lament usually follows: "But I hate the way it make me feel. Foggy, dry mouthed, and slow."

I hate writing and saying this because we have so much on our plates already, just getting through a day with pain, but we have to be the advocates. We have to get out the word that we do not take these drugs for fun. For some of us they are truly life savers. And yet it is our voice that seems to be absent in the midst of all the media hoopla and sensationalism.  

It is past time for us to take up our pens and raise our voices. We are the ones who get hurt by the misinformation. It is up to us to change the conversation.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” 

Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Changing Our Country One Addict at a Time

By Mary Maston, Guest Columnist

It’s obvious that our current ways of dealing with addiction aren’t working. They have never worked. The entire process of making drugs illegal and incarcerating those who use, possess, and sell them has been an epic fail in every way imaginable.

The “War on Drugs” – a phrase coined by President Nixon -- has been raging for almost 45 years, longer than I have been alive. How many trillions of our tax dollars have been spent in that time and where has it gotten us?

According to the officials, the problem of addiction is worse now than it’s ever been, despite throwing people in jail left and right. Making things even worse, legitimate chronic pain patients are being lumped together with addicts and drug abusers -- making opioid pain medication harder and harder to get.

We haven’t solved anything, and we never will if this is the path we continue to take.

"Insanity: doing the same thing over and over again and expecting different results.” -- Albert Einstein

It’s time that we start thinking outside the box. We need a different approach and the police chief of Gloucester, Massachusetts may have found one.

Chief Leonard Campanello has worked in law enforcement for 25 years. In that time, I’m sure he’s seen just about every scenario imaginable and then some. Perhaps he’s grown tired of seeing the same people in and out of his jail repeatedly. Or perhaps he just has a bigger heart than most, and the desire to contribute to a real solution. That’s what I choose to believe.

After dealing with addicts repeatedly over the years, Campanello has decided to change the way he does things and tackle the issue from a totally different angle.

Campanello recently announced that anyone who walks into his police station and asks for help with addiction, and surrenders any drugs and paraphernalia they have, will not be arrested. Instead he/she will be put into a detox and rehab program, funded by the money the police department has collected from drug raids.

You read that correctly: Anyone who asks for help will receive it without judgement, persecution, fines, or jail time. It’s called the Gloucester Initiative.

It’s a bold move. It’s never been attempted before. Many may say it’s crazy, that it will never work. It goes against everything we’ve heard about addiction.

Get this though: it is working.

It’s an absolutely brilliant concept and it’s already changing lives in the short time since it’s been started. It’s also gaining national attention. There are many organizations that are starting to come on board, and because of that, the Police Assisted Addiction and Recovery Initiative  was born.

police chief leonard campanello

So far over two dozen people have entered the program. While that doesn’t seem like many in the grand scheme of things, it’s a start. The drugs those people had are off the streets, and they are getting help when they would otherwise be using and selling. What if 28 drug addicts were no longer on YOUR streets and in YOUR community? Would you feel a little bit safer, maybe a little less cynical? Everyone has to start somewhere.

This proves that there are people who are addicted and who truly want help, but haven’t been able to get it for any number of reasons. Maybe they can’t afford it – rehab facilities aren’t cheap. Maybe they don’t have insurance or if they do, it doesn’t cover extended treatment.

If they are using illegal drugs but haven’t been caught yet, maybe they are afraid of going to jail for the first time. Maybe they enjoyed being an addict for a long time, but don’t want to be one anymore and don’t know how to stop.

Think about it for a moment. This could be a huge game changer for chronic pain patients, especially if this initiative takes off nationally like I’m hoping it will.

Right now, everyone is so quick to label anyone that uses pain medication for any reason as an addict. What if addicts weren’t abusing anymore? Perhaps that would equate to better treatment for us, without the stigma of being judged so harshly because we actually need medications to function; not because we want to get high, but because we want to live somewhat productive lives and medication is the only thing that helps us.

Think about how much better your life would be if medical professionals got back to actually treating patients with debilitating diseases and conditions – respectfully – instead of focusing on policing everyone that walks through their doors and denying medical care.

I’m not naïve enough to think that this is going to completely solve everything. Not everyone wants help and there are some genuinely bad people in this world, but I’m holding onto hope that this can potentially make a positive difference in the lives of millions – the ones that do want help.

Putting people in jail doesn’t accomplish that, and there are people out there that would stop using drugs if given the opportunity to do it in the right environment.

Just ask those that have come forward. Out of all of the things I’ve read over the years on the subject of the war on drugs, this is the only thing I’ve come across that has the potential to actually change things for the better and make an impact.

That’s why I fully support this cause. I would be insane not to.
 

Mary Maston suffers from a rare congenital kidney disease called Medullary Sponge Kidney (MSK), along with Renal Tubular Acidosis (RTA) and chronic cystitis. She is an advocate for MSK and other chronic pain patients, and helps administer a Facebook support group for MSK patients.

Mary has contributed articles to various online media, including Kidney Stoners, and is an affiliate member of PROMPT (Professionals for Rational Opioid Monitoring & Pharmaco-Therapy).

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Opioid Implant Raises Safety Questions

(Editor’s Note: Our story about an opioid implant that could someday be used to treat chronic pain struck a nerve with a lot of readers. One of them was Mary Maston, a pain sufferer and  patient advocate, who wrote in expressing concern about the safety and risks associated with implants and other medical devices.)

By Mary Maston, Guest Columnist

Why is everything going to implants? Implants seem to have an initial success rate and I can't argue with the fact that they do work for some, but it seems that class action lawsuits for side effects and internal injuries invariably come about down the line.

Transvaginal mesh was touted as the "next big thing." I had a doctor try to convince me that it would solve all of my female problems. Luckily, I didn't bite. We all know how that ended up.

Bladder slings come to mind too. Some IUD’s have caused issues. People have had major problems with hip and knee replacements. Spinal cord stimulators are being pushed on patients in record numbers, and the bomb is eventually going to drop on those too.

While there are success stories, there are some pretty horrific stories floating around online about implanted devices in general. Some will argue collateral damage: "Just think of the ones they've helped. The many outweigh the few.”

But I can promise you that the ones that have been harmed by these implants see things much differently.

Here's the thing: anything implanted in the body is going to be seen as a foreign object. What does the body tend to do when there's a foreign object inside it? It attacks it, trying to force it out. That's why your eyes water when you get something in them, that's why you vomit when you ingest something that's harmful, and that's why you go to the bathroom -- so the body can rid itself of waste.

When it can’t force the implants out, the body rebels with side effects, infections and pain. The surgeries required to implant these things damage nerves and create scar tissue, which also contribute to pain.

courtesy titan pharmaceuticals

If they're planning on this new implant being simply injected into the arm instead of being surgically implanted, that's going to have to be one heck of a big needle! The size of a match stick? Ouch!!

Then there is the issue of tolerance. Pain medication is not a "one size fits all" fix like the makers of this implant are implying. It comes with a preloaded dose of buprenorphine. How can they guarantee that the dosage they put in it is going to work for the majority of the people it's implanted in? 

What if it stops working in a month or two, or doesn't work at all? Do they have that one taken out and another one put in, or is the old one left in and a new one with a stronger dose implanted?

Will the patient be able to go back to taking oral pain medication? What if it causes side effects in the patient after a few days or weeks that they can't handle, or they end up being allergic to the medicine? How long would they have to live with those issues before it is removed?

Some people metabolize medications faster than others, so saying that it's going to work for a full six months for the implant or an entire month for the injection in everyone isn't practical. What about breakthrough pain? If someone had the implant, but showed up in the ER in pain because of their condition, would they be treated respectfully and in a timely manner, or dismissed because they had the implant and "that should take care of all of your pain."

There needs to be a very specific and compassionate treatment protocol set up for patients before this scenario happens, and all doctors need to be required to follow it.

I can understand and appreciate some of the pros listed in the article. Not having to make trips to the pharmacy, not having to remember to take pills and waiting for them to kick in to feel better. Possibly and hopefully not having to go to the doctor every month and being subjected to random drug screens and pill counts.

Doctors would certainly benefit because they wouldn't be prescribing pain medications nearly as much or maybe not at all. That would definitely get them off the hook with the DEA and I can see how that would make them want to push it onto all of their patients.

I understand that addiction and chronic pain go hand in hand for some people. Not all, but some. But as a chronic pain patient, I don't want to be lumped into the same category as addicts, because I am not an addict, never have been and never will be.

This raises serious questions that I think should be considered before we shout to the heavens how wonderful this new implant is going to be for addicts and legitimate chronic pain patients alike.

I understand there is still a lot of work to be done, and that it's going to take time and testing to answer a lot of these questions. Oral medications certainly have their own set of problems and aren't without risks either. However, history tells us that jumping on a bandwagon isn't necessarily a good thing down the road in a lot of cases.

I'm not saying that the thought of being pain free for an extended amount of time isn't appealing. Honestly, I would probably be more apt to try this than a spinal cord stimulator. But I hope that the manufacturers and the FDA will address the questions I've posed. I guarantee you I'm not the only one that will ask them.

Mary Maston suffers from a rare congenital kidney disease called Medullary Sponge Kidney (MSK), along with Renal Tubular Acidosis (RTA) and chronic cystitis. She is an advocate for MSK and other chronic pain patients, and helps administer a Facebook support group for MSK patients.

Mary has contributed articles to various online media, including Kidney Stoners, and is an affiliate member of PROMPT (Professionals for Rational Opioid Monitoring & Pharmaco-Therapy).

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Implant Could Be ‘Game Changer’ in Pain Treatment

By Pat Anson, Editor

Imagine going to your doctor’s office and getting an implant put in your arm that delivers a steady flow of pain medication for six months.

No more pills. No more trips to the pharmacy. No more worries about your pain medication getting lost or stolen.

That’s the scenario a New Jersey drug maker envisions for its Probuphine implant – tiny rods about the size of a matchstick designed to be inserted subcutaneously under the skin of the upper arm.

Probuphine was developed by Braeburn Pharmaceuticals under a license agreement with Titan Pharmaceuticals (OTC: TTNP), which holds the rights to the implant technology. Both companies have applied to the Food and Drug Administration to have Probuphine approved to treat opioid addiction, but Braeburn’s long term goal is to also have the implant approved for chronic pain.

COURTESY TITAN PHARMACEUTICALS

“We are definitely interested in talking to the FDA about the use of Probuphine in pain,” said Behshad Sheldon, President and CEO of Braeburn.

The active ingredient in Probuphine is buprenorphine, a weaker opioid that’s long been used as an addiction treatment drug sold under the brand name Suboxone. Buprenorphine is also used to treat chronic pain and comes in various forms – pills, patches and film strips – but none as long-acting as an implant.

The advantages of an implant are many. The dosage is controlled and there’s hardly any risk of abuse, diversion, or accidental overdose. You also never have to remember to take a pill.

“We believe a buprenorphine implant could be a really great clinical tool to treat pain,” Sheldon told Pain News Network. “There’s just a peace of mind aspect for the patients. The medicine’s on board and they don’t have to worry about it.”

“I personally would want a Lipitor implant, because I can’t manage to take it three days in a row,” she joked.

Probuphine’s path to the marketplace hasn’t been a smooth one. Braeburn and Titan were stunned in 2013 when the FDA denied approval of the implant and asked for a new clinical study of Probuphine’s effectiveness in treating opioid addiction.

Braeburn recently reported the results of a six month, double-blind clinical trial of Probuphine on 177 patients, which found that the implant was more effective than buprenorphine tablets in treating addiction. The company said the implant insertion and removal were "generally well tolerated," although nearly one in four patients had a "mild" adverse event at the implant site.

“The data from this trial are encouraging and underscore the benefit of longer term medical treatments for patients with opioid addiction. I am confident that the implant, if approved by FDA, will be at least as effective as a sublingual formulation and have the added benefits of reducing problems related to compliance, misuse and abuse,"  said Richard Rosenthal, MD, Professor of Psychiatry and Medical Director of Addiction Psychiatry at the Icahn School of Medicine at Mount Sinai.

Braeburn and Titan plan to resubmit a New Drug Application (NDA) for Probuphine to the FDA in the second half of this year.

Long Term Injection for Pain

Braeburn has formed another partnership with Camurus, a Swedish drug company, to develop an injectable buprenorphine drug to treat addiction and chronic pain -- a single injection that lasts as long as a month. Camurus has already completed successful Phase I and II studies on the drug and both companies hope to start a Phase III trial later this year -- with the goal of seeking regulatory approval in 2016.

“There have been many conversations with expert clinicians and they’ve told us that they think buprenorphine in general, in a non or less abuse-able form of buprenorphine, in either an implant or an injection could really be game changing,” said Sheldon. “It is part of our plan to move into pain because pain and opioid addiction are so interconnected and we think there are ways, by treating patients with a less abuse-able formulation, you could actually help alleviate the addiction problem.”

Sheldon admits a lot more work needs to be done before a buprenorphine implant or injection is available to treat chronic pain.

“We haven’t studied it yet in pain and we haven’t had any conversations yet with the FDA. So there’s a lot more to do to get to that point,” she said.

Another formulation of buprenorphine to treat pain may be coming to the market relatively soon. Endo International (NASDAQ: ENDP) and BioDelivery Sciences (NASDAQ: BDSI) have submitted a new drug application for a buprenorphine film patch to the FDA. The companies are hoping for FDA approval by October of this year.

Although the patch contains much smaller doses than buprenorphine tablets or patches already on the market, the companies say the film is very effective in treating pain because the drug is absorbed through the inside lining of the cheek and enters the blood stream faster.

Survey Finds Doctors Need More Addiction Education

By Pat Anson, Editor

Many primary care physicians -- the top prescribers of opioid pain medication in the United States – lack a basic understanding of how the drugs can lead to abuse and addiction, according to a new survey by the Johns Hopkins Bloomberg School of Public Health. The survey was conducted by several longtime critics of opioid prescribing practices who advocate tighter restrictions on painkillers.

The survey of over 500 practicing internists, family physicians, and general practitioners was conducted by mail in early 2014. Primary care physicians treat over half of the chronic pain patients in the U.S. and prescribe most of the pain medication.

The survey results, reported in the Clinical Journal of Pain, found that nearly half the physicians incorrectly believe that abuse-deterrent pills – which are harder to crush or liquefy for snorting or injecting – are less addictive than their standard counterparts. .

"Physicians and patients may mistakenly view these medicines as safe in one form and dangerous in another, but these products are addictive no matter how you take them," says study leader G. Caleb Alexander, MD, an associate professor in the Bloomberg School's Department of Epidemiology and co-director of the school's Center for Drug Safety and Effectiveness.

“Opioids serve an important role in the treatment of some patients. However, our findings highlight the importance of patient and provider education regarding what abuse-deterrent products can and cannot do. When it comes to the opioid epidemic, we must be cautious about overreliance on technological fixes for what is first and foremost a problem of overprescribing."

Every primary care physician who was surveyed thought that prescription drug abuse was a problem in their communities. Large majorities also supported efforts to reduce abuse, including patient contracts, urine drug testing, databases that monitor opioid prescribing, and greater restrictions on the marketing and promotion of opioids.

About a third of the doctors incorrectly reported that the most common route of prescription drug abuse is by means other than swallowing pills. Numerous studies have shown that most drug abuse is through oral ingestion, followed by snorting and injection.

Interestingly, one third of the physicians (33%) believed that efforts to reduce opioid abuse have had a chilling effect on pain management practices, and were preventing legitimate pain patients from gaining access to appropriate treatment.

Despite that finding, Alexander said further efforts are needed to combat opioid abuse, saying “doctors continue to overestimate the effectiveness of prescription pain medications and underestimate their risks.”

"For the sake of making a dent in an epidemic of injuries and deaths, we have to find ways to make changes. Too many lives are at stake to stick with the status quo," he said.

Two of the co-authors of the study are Andrew Kolodny, MD, and Stefan Kruszewski, MD. Kolodny is president of Physicians for Responsible Opioid Prescribing, a group that has lobbied Congress and petitioned the Food and Drug Administration to limit access to opioids. Kruszewski has served as an expert witness in multiple lawsuits against pharmaceutical companies.

Their research was supported by the Robert Wood Johnson Public Health Law Research Program and the Lipitz Public Health Policy Award at Johns Hopkins Bloomberg School of Public Health.

The Centers for Disease Control says over 16,000 Americans die annually from painkiller overdoses, an estimate that dates back to 2010. Most of those deaths also involved alcohol or other drugs.

Several recent studies suggest the tide of opioid abuse has turned in the U.S.

Dispensing of opioid pain medication and painkiller overdoses have declined substantially since 2010, according to a recent study published in JAMA Internal Medicine.

The number of prescriptions filled in the U.S. for hydrocodone has also declined, the first concrete evidence that restrictions on hydrocodone prescribing that were adopted in 2014 are starting to have an impact. Hydrocodone is no longer the most widely filled prescription in the U.S.

The National Institutes of Health estimates that only about 5 percent of pain patients become addicted to opioids after using them as directed for a year.

Opioid Abuse Takes Back Seat to Cost at Medicare

By Pat Anson, Editor

The U.S. Food and Drug Administration calls the development of abuse deterrent opioids a “priority” in combatting the so-called epidemic of prescription painkiller overdoses.

But when it comes to Medicare coverage of opioids, new research shows that lowering the cost of painkillers is a bigger priority for the federal government than discouraging abuse.

The study by Avalere, a health analytics research firm, found that Medicare Part D coverage of abuse deterrent OxyContin is falling rapidly. From 2012 to 2015, OxyContin coverage fell from 61% to 33% of Medicare Part D plans. In addition, one quarter of Part D plans now require prior authorization for OxyContin. 

In contrast, a generic version of OxyContin (oxycodone hydrochloride) that has no abuse-deterrent properties is covered by all Medicare Part D plans – and prior approval for it is only needed in 0.3% of Part D plans.

“While prescription opioid abuse continues to be a priority for public health experts and lawmakers, coverage for these products by Part D plans is limited and plans are increasingly favoring lower-cost generic products on their formularies,” said Caroline Pearson, senior vice president at Avalere.

“Policymakers seeking to limit opioid abuse will have to balance the desire for greater access to abuse-deterrent opioids with the increased costs of such medications to public programs and private payers.”

OxyConin was reformulated by Purdue Pharma in 2010 to make it harder for addicts to crush or liquefy for snorting and injecting. In 2014, the FDA approved three other opioids with abuse deterrent properties and in April of this year issued guidance to drug makers strongly encouraging them to develop more.  

“The science of abuse-deterrent medication is rapidly evolving, and the FDA is eager to engage with manufacturers to help make these medications available to patients who need them,” said FDA Commissioner Margaret Hamburg, MD. “We feel this is a key part of combating opioid abuse.”

But combating opioid abuse apparently takes a back seat to price, not only for Medicare but private insurers and the drug makers that developed abuse deterrent formulations.

According to the Healthcare Bluebook, a website that estimates the market price of medications, the “fair price” for a 60-day supply of OxyContin 20mg is $316.

A 60-day generic version of oxycodone -- without abuse deterrence -- retails for just $78.

“It will be important for policymakers to monitor and consider the implications of these trends,” the Avalere study says, warning that abuse-deterrence formulations may be pricing themselves out of the market.

“The potential increase in costs due to new innovations may be a barrier to policies that increase the coverage of abuse-deterrent opioids, especially in public programs, despite potential long-term public health savings associated with lower levels of opioid abuse. While the greater number and quality of abuse-deterrent options—both brand and generic—can support competition, reduce cost, and increase plan coverage, the potential of abuse-deterrent technologies may not be fully realized as long as non–abuse deterrent alternatives have less restrictive insurance coverage.”

Funding for the Avalere study came from Pfizer. Avalere says it maintained “full editorial control” over its content.

Over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010, according to the CDC. The government estimates that over 400,000 seniors are  “misusing” pain medication.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.

Five Ways TIME Gets Pain Pills So Wrong

By Crystal Lindell, Columnist

Access to pain pills is not a cause I chose. I didn’t wake up one day and think, “Gee, more people need opioids.”

No, access to pain pills is a cause that chose me. Because I really did wake up one day two and half years ago, and say, “What is wrong with me? Why do I suddenly have insane pain in my ribs?”

It’s a pain that never went away. And for months, the doctors didn’t take me seriously. They gave me prescription-strength Advil, Lidoderm patches, and told me to wear looser bras.

None of that worked.

So, for weeks on end, the pain got worse and worse, while I tried multiple doctors, trying to find someone who could help.

I was in so much pain that I would often lay down on the ground mid-sentence because I didn’t have it in me to keep standing. The pain was just that overwhelming.

And at night, after trying to survive the day, I would lay in bed and plan ways to commit suicide. I wish I was exaggerating.

Finally, I found a pain specialist who put me on hydrocodone. At the time I had no idea that opioids were controversial. I was just happy to finally have found something that gave me relief.

The problem with hydrocodone though is that it comes with these crazy spikes. So you take a pill, it relieves the pain and then it completely wears off within a couple hours — and you to wait six hours for your next dose. It’s a horrible way to live.

I’m also on a time-released morphine that lasts about 8 hours. I take it three times a day — so I am always on an opioid, 24 hours a day. And then, on top of that, I also take hydrocodone as needed.

I pretty much always need it.

The pain still gets bad. But now, because of the pain pills, I have times when I am nearly pain free. Times when I can catch my breath and remember that life is worth living.

Opioids have literally saved my life.

Which is why I’m so upset about TIME magazine’s cover story about the “worst addiction crisis America has ever seen.” 

I realized when I read the article that I am spoiled by my Facebook news feed. I tend to follow chronic pain groups, so most of the information I see is about how chronic pain patients need access to these drugs. As a result, I’ve been lulled into thinking that the chronic pain community is actually making progress on this issue.

Apparently, we aren’t.

And it is articles like this that make it that much harder for pain patients like me to get the relief they need.

Let’s break down what it gets so wrong, with some quotes from the report:

1.    It implies time-released morphine is basically heroin.

“The longer patients stay on the drugs, which are chemically related to heroin and trigger a similar biological response, including euphoria, the higher the chances users will become addicted.”

Aside from the excessive number of commas, there are so many infuriating things about this sentence. 

While the drugs can give you a “high” feeling when you first start taking them, I can promise you — after being on morphine all day, every day for over a year — that the “high” is only a short-term side effect.

Also, comparing the drugs I take to heroin is like saying that both TIME and US Weekly are similar because they both require reading. Yes, that’s true. But that’s about all they have in common.

2. The article focuses on how much the drug companies are supposedly making on these meds.

“The total annual sales for opioids in the U.S. has grown over 20 years to more than $8 billion.”

While there have been some new meds on the market, like Zohydro, the pills that I take and the pills most of the people I know take, are generic. Morphine isn’t exactly a brand name.

Giving people relief from horrific, daily pain is not part of some drug company conspiracy. It’s called compassion.

3. It devalues how horrible pain can be.

“The standard-setting Joint Commission on Accreditation of Health Care Organizations in 1999 required doctors to measure pain as part of their basic assessment of a patient’s health, which had the effect of elevating pain the same level of importance as objective measurements like temperature and heart rate.”

The author writes that like it’s a bad thing. I’m here to tell you, it’s not. Pain is such a huge part of your health. And managing it is just as important as managing your blood pressure or your insulin level.

Having too much pain will ruin your life and your body just like any other health issue.

Living with chronic pain is like living every day of your life with the same amount of pain you would wake up with after an extensive surgery, or a horrific car accident, or a stabbing.

Anyone in those situations would be given adequate pain relief. And, just because people with chronic pain have that same pain every day, all day, doesn’t mean they don’t deserve the same relief.

4. It implies that anyone on long-term pain medications is an “addict.”

“With America awash in opioids for the foreseeable future, health care providers and public officials are searching for ways to help addicts get clean.”

I don’t need to “get clean.” I need a cure, but there isn’t one for what I have. The next best thing is daily pain relief. Going off all my meds would be catastrophic for me, not because I’m addicted, but because I would end up stuck on the couch for the rest of my life in too much pain to shower.

Also, we need to take a second to talk about the word “addicted.” It is very different from what’s actually happening for most people, which is “dependence.”

Dependence is what happens when you take lots of different types of drugs long-term. Your body becomes dependent, so going off them cold turkey would be hell. However, if you taper off it, you’re good. Just like anti-depressants. And nobody ever says people are “addicted to anti-depressants.”

Addiction is when you start to crave that high feeling you get the first few times you take the drug, so you start taking higher and higher doses seeking it out. Sort of like how all of us are dependent on food, while a select few are addicted.

5. The authors don’t mention any alternatives.

For those enduring chronic pain, the real-life alternative to not having adequate pain pills is suicide.

Articles like this just make it that much harder for people with chronic pain to get the medications they need. If you want to see the suicide rate jump, just take away the medications that so many people rely on to do even simple things, like make dinner or do a load of laundry.

Look, I’m not saying everyone with a cold should get a prescription for morphine. I’m just saying that there are millions of people out there who need these drugs. And more regulation just gets in the way of decisions that doctors and patients should make together to help those who are suffering cope with their pain. The government should never be in anyone’s doctor’s appointment.

At the end of the day, I guess I just wish that TIME had talked to even one chronic pain patient for the article. There are millions of us out here, responsibly using opioids long-term, and we would have loved to chat with TIME.

If only they had asked.

Crystal Lindell is a journalist who lives in Illinois. She loves Taco Bell, watching "Burn Notice" episodes on Netflix and Snicker's Bites. She has had intercostal neuralgia since February 2013.

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Many Doctors Not Confident Prescribing Opioids

By Pat Anson, Editor

Nearly two-thirds of physicians who prescribe opioids say they are not confident or only somewhat confident about managing patients on opioid painkillers, according to the results of a new survey that found widespread gaps in education about opioid safety.

"This indicates a critical need for provider education addressing this issue. It is important our medical community is given the training it needs to confidently manage chronic pain while significantly reducing prescription opioid misuse, overdose and diversion," said Daniel Alford, MD, of Boston University School of Medicine.

Boston University and Haymarket Medical Education conducted an online survey of nearly 800 physicians who are registered with the Drug Enforcement Administration to prescribe Schedule II and III controlled substances.

Over a quarter (28%) said they had not completed certified medical education (CME) in safe opioid prescribing. Many also said they lacked the time or staff to implement an opioid monitoring system for patients, such as drug testing and pill counts.

"It's troubling that so many physicians say implementing safe opioid prescribing systems is not a priority, even though this is an acute issue. We've created a situation where some physicians are comfortable not doing anything about it,” said Alford.

Only a quarter of the doctors surveyed said they were very confident about their ability to safely manage chronic pain with opioid pain medication. Four out of ten said they don’t even prescribe opioids.

 “Lack of knowledge regarding some narcotics. Concerns of dealing with patients who appear to be drug seeking. Lack of time to follow some of these patients closely,” said one doctor who was not confident about prescribing opioids.

“Lack of training. Fear of providing access to patients who might abuse opioids,” said another.

Pain education for doctors – or the lack of it – is such a concern that the recently released National Pain Strategy considers it a top priority.

“Many health professionals, especially physicians, are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain,” a draft version of the report states. “Core competencies in pain care are not fully developed and generally do not inform undergraduate curricula in health professions schools or graduate training programs, even those in pain medicine.”

A 2012 study published in the Journal of Pain  called pain education in the U.S. and Canada “lackluster” and warned that unless steps were taken to improve the training of pain physicians, “the crisis in pain care and resultant deaths from opioid abuse will only spiral upwards.”

The study of 117 U.S. and Canadian medical schools found that less than 4% required a course in pain education and only one in six schools offered a pain elective. A large number of U.S. medical schools do not have any pain courses and many of those that do have less than five hours of classes.