Does Buprenorphine Really ‘Save Lives’?

Legal disclaimer: Nothing in this post is meant to be construed as medical advice. I am not a physician or pharmacist. Discuss any medications, changes, or questions you might have with your medical provider. Do not suddenly stop any medication unless under the direct guidance of a medical provider.

Today was a weird day. What began with some light historic-ecclesiastical reading and plans to write a piece about a specific trend in feminism in antique literature, turned instead into a Twitter brawl in which I repeatedly questioned doctors and pharmacists on a certain status quo, and received 5th-grade-style memes of Homer Simpson in response. What was the cause? Buprenorphine.

More popularly known as Suboxone or Subutex, buprenorphine (“bupe” for short) has been touted in recent years as “the” drug of choice to treat opioid dependence disorders (formerly known plainly as “addiction,” for politically-incorrect and insensitive jerks like me, or so I was told).

Although my concerns about the safety and efficacy of buprenorphine became quickly misinterpreted as a war on drug addicts (or whatever the PC term is now), I ended up spending the day reading through study after study (see below for a list), but was hopelessly ganged up on by dozens of angry and less-than compassionate “professionals” who took the time to point out I must know nothing about the subject because I also “make jewelry.”

They insisted I could not read scientific or medical literature although such things are written in English and I am blessed to have access to ‘foreign’ objects like the internet and dictionaries to look up any unfamiliar terms, and in short, I had it all wrong, and my misinformation would inevitably lead to the untimely end of numerous, unnamed individuals. I just needed “to trust my doctors,” insisted one.

They had already read all the studies and charts I supplied, which is why they needn’t bother to look at the ones I provided and actually answer my questions. I hadn’t been privy to that much gas-lighting since the most recent family holiday.

I guess I touched a nerve.


What is Buprenorphine?

Buprenorphine is most commonly used in the US to treat opioid addiction. The idea is to transition people off heroin (and dirty needles, and other unhealthy practices associated with street drug addiction) and/or illicit painkillers. In much, much smaller doses (micrograms vs. milligrams), it is used to treat severe pain. Bupe is an opioid, and can cause addiction in and of itself.

all opioids are addictive

-Source*


Is Buprenorphine Safe?

This is the question that most concerns me, and I have legitimate reasons to wonder:

Although more people have access to bupe than ever before, OD rates are still rapidly climbing. Dr. Andrew Kolodny insists this is because “more people need more access to bupenorphine,” but haven’t we seen this doubling down of ineffectual policies before? Yes, except 5 years ago, the trend began with the false narrative that irresponsible doctors were getting people hooked on opioids. And who started that claim? Oh, yeah, that Dr. Kolodny guy.

drug overdoes chart for Mont. Co

My interview with a local substance abuse counselor from 5 years ago, indicated bupe was neither as safe nor as effective as touted. She told me then “substance abuse counselors hate it.”


Money, Money by the Pound!

There have been many back-end, sly marketing techniques, going on for at least a decade by the makers of bupe, Reckitt-Benckiser/Indivior, recently accused of attempting to artificially prolong the patent on Suboxone.

There is a ton of money to be made by doctors who prescribe it (average $300 for first appointments, $150 or more for subsequent/monthly appointments, and whatever can be earned in lab and pharmaceutical kickbacks).

Federal guidelines were recently widely expanded to allow those doctors to be able to treat hundreds of patients at one time, instead of the strictly limited 30 patients from 12+ years ago (the strict limit was put in place to prevent doctors from essentially dealing the drugs to patients.

Now that it has been eased, a number of questionable practices have been increasing). A push by none other than PROP board members, via an article in the New England Journal of Medicine, asserts than everyone from nurse practitioners to OB/GYNs can and should be able to dispense buprenorphine, not just addiction specialists.

Bupe, in the form of Suboxone, costs an average of $151-518 for just 30 days of sublingual filmstrips for the uninsured, depending on dosage, and about $180-720 for 30 days of sublingual tablets, depending on dosage, up to 3x/day, although an original study of the drug, paid for in part by Reckitt-Benckiser, show the drug can last up to 3 days before needing a new dose. This was, in fact, a huge selling point of bupe, that people would not need to come daily to Suboxone clinics for the medication.

Patients on bupe can successfully go for 2-3 days on just one dose, reducing the need for daily clinic visits, and/or “reducing the need for take-home medications [which] decreases the possibility of illicit diversion and abuse of opioid dependence pharmacotherapies (Section 6)”


No Such Thing as Chronic Pain?

Contrary to PROP’s claim they do not want to ban opioids (of course they don’t, buprenorphrine is an opioid) or that they want to stop “drug companies” from promoting long-term opioids for chronic, non-cancer pain, Dr. Kolodny, founder and director of PROP, frequently promotes his ideas that essentially, there is no such thing as chronic pain, just opioid addiction.

That being the case, both birds can be killed with one stone groups can be helped via long-term maintenance with the opioid buprenorphine (made by a “drug company”).

only addicts, says kolodny


There is an enormous body of evidence dating back literally millennia that points to the existence of chronic pain as a real and devastating illness if left untreated.

Copies of medical texts from Ancient Egypt and Greece to modern times describe hundreds at least, of debilitatingly painful conditions with no cure from back injuries to rheumatoid arthritis and damaged nerves, that impact the lives of an estimated 50 million chronic pain patients in the United States alone.

It is, at minimum, grossly irresponsible to claim these people and their well-documented diseases and the expertise of thousands of doctors don’t exist!

There is a form of bupe called the “Butrans patch,” made for chronic pain (the chronic pain that “doesn’t exist”). Many insurance companies are forcing patients and/or their doctors to try it or the fentanyl patch, although there are also extended-release (ER) pill formulas for Vicodin/norco at far lesser dosages that suffice most chronic pain patients just fine. Ironically, many of these companies have new “addiction reduction” policies that refuse to take chronic pain patients and their medical histories into account.

So why are these insurance companies pushing so hard for medications that are far stronger than what doctors want patients on? I called one popular insurance company, Anthem/Blue Cross-Blue Shield, who told me the Butrans patch was “not any stronger,” than other ER medications, contrary to what my own doctor and these charts show.

According to Drugs.com, the Butrans patch for chronic pain is known to actually cause pain and severe illness, withdrawal syndrome, and a host of psychological effects associated with drug abuse including anxiety and depression, agitation, hostility, and paranoia. It is not safe around children, pets, pregnant or nursing mothers, and must be dispensed in micrograms not milligrams like most pain medications.

butrans patch dosing


That Old-Time Naloxone is Good Enough for Me

In an odd twist, Dr. Kolodny and his group, PROP, also push for buprenorphine to replace other long-acting, lower-strength opioid medications, insisting the abuse potential is much lower because of the Naloxone (Narcan) element in Suboxone.

However, “The Clinical Pharmacology of Buprenorphine: Extrapolating from the Laboratory to the Clinic,” by Sharon L. Walsh and Thomas Eissenberg, received on Dec. 19, 2002, and published by Elsevier and Drug and Alcohol Dependence on Feb. 4, 2003, and funded in part by Reckitt-Benckiser, the very makers of Suboxone, Subutex, and other very popular forms of buprenorphine, to introduce buprenorphine to clinicians, describing its safety and efficacy findings and how it appears to work, reveals:

“The doses of naloxone that precipitated withdrawal [in patients given 8mg of sublingual and 3 and 10mg doses of BPN/day]…were approx. 10 times greater than those that precipitated withdrawal in patients maintained with 30mg oral methadone” (Section 3.2.3).

Most patients are maintained on far higher doses, and the study’s authors also found other studies reported no withdrawal effects in patients given 8mg/day of bupe and challenged with 4mg of naloxone. The amount of naloxone in 8mg of Suboxone preparations is only 2mg.


The One “Good” Opioid in the Epidemic?

Current stats show the increasing rates of bupe abuse, and the original studies of bupe emphasize it, “does posses abuse potential.” Furthermore, the study describes bupe as producing “paradoxical” effects, “the same dose of buprenorphine can produce no detectable effects or it can produce prototypic opioid agonist effects and intoxication” (Section 3.2, emphasis added by blog author).

“Buprenorphine is not being monitored systematically enough to gauge the full scope of its misuse, some experts say. The Centers for Disease Control and Prevention does not track buprenorphine deaths, most medical examiners do not routinely test for it, and neither do most emergency rooms, prisons, jails and drug courts (emphasis added).

“I’ve been studying the emergence of potential drug problems in this country for over 30 years,” said Eric Wish, the director of the Center for Substance Abuse Research at the University of Maryland. “This is the first drug that nobody seems to want to know about as a potential problem.” –Source


Why Aren’t People Getting Clean with Bupe?

The study’s authors’ appeared to assume that patients on bupe could and would be easily transitioned (weaned) off with minimal withdrawal side effects. A relatively fast period of only 5 days claimed patients went from 8mg to 1mg with no withdrawal signs observed or symptoms reported (Section 3.2.3), but more and more patients are being maintained on moderate doses of 8-20mg of bupe indefinitely.

The study even states that patients on bupe can successfully go for 2-3 days on just one dose, reducing the need for daily clinic visits, and/or “reducing the need for take-home medications decreases the possibility of illicit diversion and abuse of opioid dependence pharmacotherapies” (Section 6, emphasis added by Rambling Soapbox).

suboxone od and abuse-is it safe-Source

Buprenorphine is an unusual drug by all accounts, which has been the cause of much misinformation, however it works just like any other opioid. According to multiple studies, it causes the exact same effects as other opioids, including intoxication, sedation, euphoria, respiratory depression, constipation, behavioral impairment, and urinary retention.

suxone od rises

Source

What sets bupe apart, is how it binds with opiate receptors in the brain. Many people think it blocks the effects of other opioids, but bupe binds faster and longer than more traditional opioids, including heroin and OxyContin.

According to Emergency Medical News, bupe, methadone, fentanyl, and often even oxycodone CANNOT BE DETECTED IN URINARY ANALYSES, and while chronic pain patients have been legally limited, force-tapered, dropped from practices, abused, forced to endure routine UAs although physically disabled, and stigmatized to taking 90MME (morphine milligram equivalence) or less (or none) for their safety, addicts are recommended to take many times that amount!

how much bupe vs pain pills

 


99 Problems, and the Studies are 1, 2, 3…

Concerning trends arise upon review of certain buprenorphine-related clinical studies, including the Walsh and Eissenberg study. Extremely small numbers of subjects were tested, for example, 7, 5, 10, 8, and 8, throughout the 1990s (Walsh and Eissenberg, Section 3.2.1). Other “larger” studies had only 99 subjects.

More recent studies include odd comparisons of numbers that effectually obscure real conclusions like this one from Spain, which looked at 19 other studies published between 1974-2016 (an odd range with no explanation given) from several high-income countries, more than 70% of whom were males with mean ages of 23-39.6, and featuring around 100K patients in 13 different groups on methadone for 1-13 years, but only around 15K patients in 3 groups on buprenorphine for just 1-4 years, to show how patients remained alive while on MAT treatment.

The doctors I “spoke” with on Twitter claimed that patients were more likely to die once off bupe, citing studies in European countries like this one, but a quick review reveals the key seemed to be patients who were both on a medication-assisted treatment (MAT) like bupe AND in a supervised, residential treatment center. Much like the ones the substance abuse counselor I interviewed 5 years ago lamented the loss of…


This is Not Treatment

Unlike the assumptions in the original study that patients on bupe will either receive treatment in-office, or be prescribed a single dose to last up to 3 days, there has been a strong push to allow addicts to be prescribed bupe for take-home use, such as this message, brought to you by the curious National Alliance of Advocates for Buprenorphine Treatment.

In other words, people with addiction issues to narcotics are being given powerful narcotic prescriptions a month at a time to take home, a scenario the study’s authors never imagined or recommended!

take bupe home with you

Let me restate: people with self-control issues around opioids are sent home with bottles of opioids and expected not to overdose? No wonder the relapse rate is so high. That is devastating.

recidvism rate for OD

Stats prove that drug abusers often mix different classes of drugs (known as a “cocktail) resulting in overdoses, so why should buprenorphine be pushed as the only cure-all when, not only are there two more established addiction treatment drugs, namely Methadone and Naltroxene (Naltroxone, in particular, is a non-opioid that also works to reduce cravings for alcoholism), but Narcan and bupe will not work to reduce cravings for the other types of drugs many users abuse, including antidepressants, anti-anxiety meds, stimulants, and hallucinogenics. This might be why:

-Source

Does Buprenorphine Really Save Lives?

“Buprenorphine is now more popular than cocaine, ecstasy, and heroin in some European countries. It is easy to obtain, currently quite fashionable, popular with opioid aficionados, and apparently associated with a quite pleasurable high when injected or snorted.

I would not be surprised to see more BPN issues in the ED, given the rise in its popularity, its increasing availability, and its perceived wide margin of safety. One might be confused by an opioid toxidrome with a negative drug screen unless the drug has been identified by history.” –Source


Sources Cited


More Sources:

PROPaganda, Part 2 of 2

A 2018 documentary called, “Do No Harm: An Opioid Epidemic,” featuring Dr. Andrew Kolodny (to whom I recently wrote an open letter) and “working closely with Dr. Kolodny and PROP“, is a classic propaganda film that’s been influencing a lot of viewers and, therefore, a lot of lives. I viewed this film a few nights ago, and 90 minutes and 9 pages of handwritten notes later, I began writing this series of posts. View part 1 here.


Bad Science Leads to Bad Policies

One of the goals of the film is to blur the lines between legally prescribed medications, illegally obtained/used prescription medication, and heroin, along with abuse of medication and appropriate (responsible) use of medication. Dr. Kolodny wants all opioids (except his favorite, bupenorphine) eradicated, unless a person is actually dying or for immediate post-surgical pain.

Once again, however, the evidence and science do not line up with the film’s or Dr. Kolodny’s claims. For example, this landmark medical study, one of the largest to date concerning opioids by Porter and Jick from 1980, concerning narcotic addiction specifically, reviewed nearly 40,000 hospitalized medical patients. Although nearly 12,000 of those patients “received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients had no history of addiction.” (my emphasis added)

Classic addiction study 'paragraph'
Although one can clearly see the footnotes in the text, the film’s screenshot makes the full study’s citation unable to be read at the bottom, and then the video pans in, effectively erasing that citation altogether.

In the film, this screenshot is shown, and the study dismissed out of hand as a “mere paragraph”, a “letter to the editor”, in the New England Journal of Medicine, asserting, “few bothered to check out the source of the study,” implying the NEJM is untrustworthy, even though less than 2 minutes later, the same Journal is cited for a different study the filmmakers do approve of. Going back to Porter and Jick’s study above, although one can clearly see the footnotes in the text, the screenshot makes the full study’s citation unable to be read at the bottom, and then the video pans in, effectively erasing that citation altogether. At the same time, the narrator tells viewers the doctors/research did not draw conclusions about addiction, when a quick scan of this “mere paragraph” shows they obviously did.

Oddly, the only other study or source cited in the entire film was another New England Journal of Medicine study (citation not given in film). The narrator allegedly quotes from this unnamed study saying, “76% of those seeking help for addiction, began by abusing prescription meds, primarily oxycontin.” That raises a lot of questions, most importantly, how many people is the study referring to? Why did they begin abusing prescription medication? How did they obtain that medication in the first place (legally or illegally)? How quickly did they transition from prescription medications to whatever they were now seeking freedom from? What were they now abusing? Does it matter what they started on, or is it more important to learn why they started?

Exploring the reasons for addiction and how it occurs is extremely important; some people begin their addiction journey by abusing paint fumes, alcohol, or other drugs/substances, but neither paint nor alcohol requires a prescription to purchase.

But this figure, claims the film, “draws a direct line between Purdue’s marketing of oxycontin and the heroin epidemic.” Yet even the film goes on to admit that once Purdue Pharma addressed the issue of oxycontin abuse via tampering by inventing a tamper-resistant pill, the rates of prescription drug abuse went down and heroin began to rise.


Curiouser and Curiouser…

Also repeated ad nauseum throughout the film, is the unsubstantiated belief that there is no difference between legally prescribed and responsibly used opioid medications and heroin. Prescription opioids like Vicodin (hydrocodone) are consistently and erroneously referred to as “heroin pills” and “synthesized heroin” throughout the film (and elsewhere by Dr. Kolodny). Hydrocodone IS NOWHERE NEAR as strong as heroin, and notice how much stronger bupenorphine is compared to heroin! These charts show the compared strength between common prescribed opioids, and commonly abused street drugs.

Opioid strength chartrelative strength of opioids from oral morphine to carafentanil


More Bad Science…

“Horrible statistics on teens taking opioids. I think a few years ago it was more than 10% of 12th graders.” – Chris Evans, PhD (emphasis added)

Again, this stat gives no source or context leaving out information that would make it less sensationalized. Like the fact many 12th graders undergo a common, painful, but short recovery surgery called “wisdom tooth extraction”, and if 10% are addicted (which neither the stat nor Evans actually states), that means 90% ARE NOT. *It should be noted that Chris Evans, PhD, claims neither to be a medical doctor, pharmacist, drug expert, educator, or any other related expert.

In the second-half of the film, the plight of heroin babies is addressed, and the tragedy of children in foster care due to the heroin epidemic is highlighted, but becomes mischaracterized during an interview with Julie Gaither PhD, MPH, RN, Yale School of Medicine and child abuse researcher, calls it a “prescription opioid epidemic.”

Further confusing the issue, the filmmakers include the drastic, unscientific claims of Joel Hay, PhD Professor of Pharmaceutical Economics and Policy at USC, who is not a medical doctor, clinician, ER doctor, chronic pain patient, or related expert in the field of pain management, yet declares in an interview:

“The damage that’s been done since then [referring to Purdue’s oxycontin marketing], in terms of the number of people taking not only oxycontin, but many types of opioids for conditions that really have–there’s no value for these drugs.” – Joel Hay, PhD Professor of Pharmaceutical Economics and Policy, USC

At one point, the film admits to the high recidivism rate within 1-2 years, of those they interviewed who struggle/struggled with addiction. Therefore, the key to stopping this “epidemic” is bizarrely revealed by Jeanmarrie Perrone, MD Perelman School of Medicine, University of Pennsylvania:

“We need to stop new cases from feeding into it…that’s what we did with Ebola.” (except this isn’t a biological agent spreading like Ebola)-my emphasis

To the filmmakers and Dr. Kolodny, that means preventing access to pain medication, even for legitimate pain.


Destructive Claims About Chronic Pain

Chronic pain is addressed in the film, though in subtle, confusing, and misleading ways. Near the beginning, a female investigative reporter claims, “People with real chronic pain finally got relief from oxycontin; got their lives back.” That should be something to celebrate, right? As the film progressed, 6 people who were originally featured in a Purdue Pharma ad for oxycontin were highlighted. Purdue even did a 2-year follow-up ad with the same people, showing they were neither addicted nor dead from overdose, neither did they feel differently about how their medication had helped them.

New Yorker Quote
“The Neuroscience of Pain,” by Nicola Twilley, New Yorker

When, “Do No Harm” was made, the filmmakers revealed that many years later, 3 of the original female patients still felt the same way about their medication, while 2 males had died of unrevealed causes. Though all of the patients were older, the film ominously (and potentially slanderously) stated they had died, “of reasons thought to be related to their opioid addiction.” Considering the film’s strict and unscientific stance that anyone who takes opioids for any reason is “addicted”, there is really no way to interpret the narrator’s vague statement. The last patient had been interviewed for a PROP (headed by Dr. Kolodny) commercial sometime prior to the film, and that clip was shown. Since her Purdue commercial debuts, she had lost her insurance and therefore her medication. She never denied having relief from the medication, and never admitted to addiction or feelings of euphoria, but still claimed she, “would probably be dead,” from oxycontin overdose by now, and described the medication as “synthetic heroin”, though it is not clear why she thought that. The narrator went on to describe her as, “one of the lucky survivors.” Her current pain, disability, and lifestyle were never addressed.


Helping Keep Grandma “Clean”?

Without providing evidence from even one pain specialist or any study, the film went on to claim that elderly patients will (not “can”) get addicted to their medication, describing one unnamed grandma who doctor-shopped for reasons unknown (though the film, of course, assumes this grandma was trying to get high), and another grandma named Linda, who had been struggling with apparent over-medication, although the film’s narrator describes Linda as having been “addicted” (neither Linda nor her doctors described her this way). Once a correction in dosing was made (never revealed in the film), Linda was able to have improved quality of life and seemed quite happy, yet the film characterized her story this way, “Linda lost years of quality of life by innocently trusting her doctors…”

Statistically, the elderly make up the majority of the roughly 100 million American chronic pain patients, suffering daily, hourly, from severely painful and debilitating conditions like arthritis, joint pain, hip pain, knee pain, back pain, and more. Many undergo major surgeries with very long recovery times, yet the filmmakers and Dr. Kolodny seem to feel it is imperative to allow elderly people to suffer in unbearable, crippling pain that is easily preventable, in order to “prevent addiction.”


Conflating Pain and Abuse

Yet, while there was no evidence of abuse in either of the elderly women featured, the film quickly switched to the stories of pain patients (all but one suffering from acute, short-term pain) who had started abusing their medications and had quickly progressed to heroin.

Although numerous medical studies (also here, here, here, here, and here) over the decades have shown that pain patients without a prior history of abuse are statistically unlikely to become addicted, the film did not make it clear whether any of these patients had a history of prior abuse or mental illness, and 2 of the 4 obtained their medications illegally from the start. In follow-up interviews it was revealed the one chronic pain patient (middle-aged) had remained clean from all narcotics for at least a year, but had been forced to leave his job due to disability and move in with his parents. He had lost his career, his independence, his finances, and his personal identity (as he describes it in the film), but hey, at least he wasn’t “addicted”.

The next interview (still in the section about chronic pain patients) featured an addiction specialist who stated:

“The most challenging are the opiate addiction patients, because when people are dependent on opiates and it’s controlling their life, you’re dealing with a monster the size of that wall…It changes their thinking.” He goes on to describe the dishonesty associated with addiction.

Another addiction specialist with no clinical experience regarding pain patients, claimed people in chronic pain and their doctors can’t tell the difference between withdrawal and the associated pain, and their chronic pain. It did not seem to occur to that specialist that withdrawal pain will subside in a matter of days, and chronic pain, is, well CHRONIC.

Finally, giant text on the screen reads around the 38 minute mark, “Women over 45 have highest incidence prescription drug overdose,” while the narrator craftily says, “Women over 45 have the highest rate of accidental death–we think it’s accidental–of use and overuse of prescription drugs.” Did you catch that? “Use and overuse of prescription drugs,” which may and may not include prescription opioids. It’s a dirty trick.

Women over 45 have the highest rate of prescription opioid use due to chronic pain, and they also, because of their age, have the highest rate of “prescription drug use”. It’s also true that women outlive men, making the “women over 45” population higher than other groups. It does not mean these women (or men) are addicted, and there is no evidence for that egregious claim!

Most chronic pain patients are trying to live, work, and play, not “get high” or escape their responsibilities. They have a proven track record for both their medical conditions and responsible use of their medication, and it is both discriminatory and defamatory to call them addicts because other people do not use the same medications responsibly or legally.

While the film promotes a zero-tolerance medication approach for chronic pain patients with legitimate, physical disabilities, most of whom are elderly, it also never promotes alternative therapies and legislating insurance coverage for those. It never champions pain research, or offers any real hope for pain patients at all. Chronic pain patients are used, instead, to conflate the false idea that all opioids lead to addiction, and are then left out in the cold, even though there is a large body of consistent evidence proving “less than 4% of those who abuse prescription opioids go on to develop heroin addiction.” Meanwhile, the film hypocritically calls for ongoing treatment of addiction using medication, and the number one and two MAT drugs are opioids!

“One of the problems we have with this epidemic is that people are not getting an acute illness that can be treated with surgery, or an antibiotic, or some short course of treatment. People have developed a chronic brain disease that needs management.” –Kelly Clark, MD, MBA, DFSAM, Addiction Medicine and Psychiatry Louisville, KY

I want to know why Dr. Kolodny and the filmmakers of “Do No Harm” feel that those with addiction deserve compassionate, ongoing treatment, including with medications that happen to be opoids (bupenorphine), but law-abiding, responsible chronic pain patients do not deserve the same.


Recap

What the film did not have:

  • It did not feature one pain specialist.
  • It did not feature more than 2 chronic pain patients;
    • 1 who had been over-medicated in the past and was doing well on a reduced dose (not revealed in the film).
    • 1 who was on no medication and had been forced to leave his job and move in with his parents in his 40s-50s due to his now-unmanaged pain.
  • It did not feature a pharmacist.
  • It did not feature a pharmacologist.
  • It did not feature representatives from the FDA, CDC, NIH, or any other government health agency.
  • It did not feature more than 1 study to back claims made throughout the film.
  • It did not feature accurate, verifiable statistics, but it did include a lot of “we think…” and “probably”.
  • It did not feature what might be termed “facts”.
  • It did not feature an unbiased approach.
  • It did not feature personal responsibility.
  • It did not explain why it is ok for addicts to have ongoing medication assisted therapy for their “chronic disease” of addiction, but not ok for law-abiding chronic pain patients to have ongoing medication assisted therapy for their chronic diseases.
  • It did not feature alternatives for chronic pain patients, no acknowledgement of their very real pain and disability from lack of treatment, no help at all. Meanwhile, the film strongly criticized hospitals, doctors, and other medical personnel for not finding alternative therapies for addiction patients, for not acknowledging their pain and disability from lack of treatment, from turning them out on the street with no help at all.
  • It did not show how the suicide rate has gone up an alarming 30% between 1999-2016, the exact years opioid prescribing was strictly reduced and began a downturn. Not only that, the rates have gone up among those age groups most likely to be chronic pain patients.*

What the film did have:

  • Giant text that read, “From 1999-2017, over 500,000 opioid related deaths.”
    • Except this stat is untrue. According to the CDC’s own data, the estimated number of deaths during that time frame was 123,560.
  • Claiming the opioid epidemic can be “traced back to Purdue’s oxycontin,” in 1996, as if the heroin epidemic of 1976 never happened, as if people never used opioids before 1996, and as if doctors haven’t known for literally all of recorded medicine (5000 years) the pros and cons of opioids.
  • It did feature highly emotive language and muckracking techniques.
  • Screaming babies.
  • Bias.
  • A dizzying back-and-forth and mash-up of arguments that made the film hard to keep up with.
  • It did feature inflammatory statements about doctors, the FDA, pharmacists, pharmaceutical companies (Purdue Pharma, especially), and the medical community in general. An interesting approach, since Kolodny was quite unhappy with my own “Open Letter…”
  • It did reiterate everything Kolodny himself has ever said on the subject.
  • It did manipulate grieving parents, lying to them, and harnessing their natural, good desire to make a positive change; to make their child’s death meaningful. As a parent who has lost a child (though not to heroin or drug overdose), that has made me more upset than anything else in the film, and shows just how low the anti-opioid crusade will go to make itself heard.

Sources Cited:

http://www.donoharmdocumentary.com/

https://ramblingsoapbox.com/2018/06/26/an-open-letter-to-dr-andrew-kolodny/

https://lptv.org/do-no-harm-the-opioid-epidemic-3/

https://www.addictioncenter.com/treatment/12-step-programs/

https://beittshuvah.org/treatment/residential-program/

https://www.newyorker.com/magazine/2018/07/02/the-neuroscience-of-pain?mbid=contentmarketing_facebook_citizennet_paid_magazine_the-neuroscience-of-pain_2-4-visit

https://www.ncbi.nlm.nih.gov/pubmed/18489635

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711509/

https://www.ncbi.nlm.nih.gov/pubmed/15102251

https://www.ncbi.nlm.nih.gov/pubmed/2873550

https://www.ncbi.nlm.nih.gov/pubmed/18164924

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073133/#!po=13.0952

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940677/


Further Reading:

https://www.politico.com/magazine/story/2018/02/21/the-myth-of-the-roots-of-the-opioid-crisis-217034

http://ehealthmagz.com/2018/07/20/chronic-pain-patients-did-not-cause-opioid-epidemic/#comment-77

PROPaganda, Part 1 of 2

Updated 8/9/18 and cut for length. Please see part 2 to view previous info, now in that segment.

“…A Terrible Disease.”

Addiction is, indeed, a terrible thing, and I am glad to see it being recognized, less stigmatized, and more genuine help offered to those struggling. But agenda-driven propaganda will not help those with addiction, in fact it has already been shown to cause harm to both addicts and chronic pain patients, who have found themselves blind-sided in recent years with a new stigma attached to their medical needs, particularly, the medications they need to stave off disability, poverty, loneliness, depression, anxiety, high blood pressure, loss of quality of life, and even early death (by natural-the body can only take so much untreated pain-and suicidal means). Those medications are overwhelmingly opioids.

A 2018 documentary called, “Do No Harm: An Opioid Epidemic,” featuring Dr. Andrew Kolodny (to whom I recently wrote an open letter) and “working closely with Dr. Kolodny and PROP“, is a classic propaganda film that’s been influencing a lot of viewers and, therefore, a lot of lives. I viewed this film a few nights ago, and 90 minutes and 9 pages of handwritten notes later, I began writing this *series of posts.

The film begins by insulting doctors, painting a portrayal of Purdue Pharma as an “evil” corporation (and, by extension, their products, aka opioids), castigating chronic pain patients (presumably for having the audacity to be in pain that only responds to opioids), and throwing out odd claims without sources of any kind. For example, one of the closing statements says:

“While watching this documentary, 6 Americans have probably died from an overdose.” -Narrator (my emphasis added)

We’re off to a great start already!

Throughout the film, people struggling with addiction are consistently portrayed as “brave survivors” and innocent victims who just didn’t know what they were getting into. A few blame Purdue Pharma (in particular) in the interviews, while others have a hard time admitting they did wrong or chose poorly. According to Alcoholics Anonymous, one of the classic first steps to addiction recovery is, “Admit you have a problem,” not “blame someone else.” Other steps include:

  • Make a searching and fearless moral inventory of ourselves.
  • Admit to God, to ourselves and to another human being the exact nature of our wrongs.
  • Make a list of persons we had harmed, and become willing to make amends to them all.
  • Make direct amends to such people wherever possible, except when to do so would injure them or others.
  • Continue to take personal inventory and when we were wrong promptly admitted it.

Even Do No Harm admits the high recidivism rate of all those interviewed as poster-recovered-addicts (all clients from the Beit T’Shuvah Recovery Center). Out of approximately 11 people (the film jumps back and forth quite a bit), 2 went back to heroin within 2 years or less, and 5 are never even followed up with. One interviewee who was also an employee at the Recovery Center, said, “You see people coming and going all the time. It’s sad.” The film never reveals the type of treatment or therapy given at the center, but an internet search for the site and phone call to the center, proved that medication-assisted treatment (typically Suboxone/Subutex, a popular form of bupenorphine) “may be used, if deemed appropriate by the resident psychiatrist there.” Furthermore, the site claims they do use a 12-step recovery model, based on AA, though the statements of the interviewees and the purpose of the documentary itself, don’t seem to line up with those recovery values.

Medication-Assisted Therapy

“We have to keep people alive so that they can recover,” states Casey’s mom, tearfully. Dr. Kolodny and the filmmakers of “Do No Harm” seem to think “recovery” means ongoing bupenorphine treatment for everyone, and sickeningly hints at the end of the film that all those dead children featured would probably be alive today, if bupenorphine had been a part of their treatment. For many people, medication-assisted therapy (MAT) is a part of their treatment, with highly mixed results. Furthermore, while heroin has a relative strength of 5x potency of oral morphine, bupenorphine has a relative strength of 40x, while hydrocodone (Vicodin) has a potency strength of -100x and oxycodone (the generic, short-acting version of Purdue Pharma’s oxycontin) has about 1x! see chart below.

In a separate phone conversation I had with Dr. Kolodny, as well as nearly every news article featuring him, Kolodny reiterates his strong support for MAT, or ongoing management of addiction symptoms and behavior using drugs. Dr. Kolodny’s drug of choice for such treatment has long been bupenorphine, an opioid sometimes combined with Nalaxone (popularly known as Narcan). Why would he promote this opioid, while staunchly condemning all the rest, I asked? “Because of the Naloxone element,” he told me, people are less likely to die or even overdose to begin with.

He’s been singing bupenorphine’s praises for decades, even formerly heading up a large chain of addiction centers called Phoenix House that touted heavy use of MAT. But investigative articles have been coming forth more and more, showing how Suboxone has been increasingly “diverted” for abuse, and may be complicit in a rise of overdose deaths. When I asked Dr. Kolodny about this on the phone, he dismissed these articles as “bad journalism.”

Dr. Kolodny’s apparent obsession with opioids is hard to understand. While certainly a major issue that needs addressed (and has been), heroin is not the only drug people overdose on (and drugs are not the only things people can be destructively addicted to), and in fact, cocaine has been consistently number 2 and 3 for overdose deaths in 2010-2014 (Table B), according to the CDC. Other drugs include fentanyl (the illicit kind, not the prescription kind), methamphetamine (which is on the rise), hydrocodone (Vicodin/norco), and benzodiazepines (anti-anxiety medications).

The film throws shocking stats around — stats that have also appeared in other media — such as:

“The Centers for Disease Control and Prevention estimates that more than 500,000 people in the United States have died from overdoes of opioids since the year 2000.”

Thankfully, this is not accurate, neither is the study sourced in the film. Rather, this CDC media release from 2015 which states, “nearly a half-million Americans” have died from prescription opioid overdoses and heroin OD, is not shown via stats, just statements, by Tom Frieden, the then-CDC head until 2016. https://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html. However, the CDC has NOT estimated anywhere near this number. The recorded number of deaths in 2016 was roughly 42,200, 5 times higher than in 1999, or roughly 8400. Even assuming that the death toll was 40,000 (it wasn’t) each year from 2000-2015, you still only get 200,000, not 500K. https://www.cdc.gov/drugoverdose/data/statedeaths.html

Even when presented with current studies and facts, Dr. Kolodny refuses to update his methods, teachings, or beliefs according to data and science. Although he invited me to share updated studies with him via email, he never responded to my email or a Tweeted reminder from myself. He goes so far as to directly blast anyone or any study that disagrees with his teachings, throwing them under the proverbial bus for not being as unbalanced in approach as he is.


Attacking Doctors and Other Medical Professionals (Along with the FDA, Purdue Pharma, and Whomever Else is Convenient)

The opening statement of the film reveals all:

“The drug companies are the cartel, the doctors are the pushers, and the pharmacists are the suppliers: that’s how the DEA is seeing it.” –Mark Borovitz, Rabbi/CEO, Beit T’Shuvah Recovery [Addiction] Center

That hard-line idea is pushed repeatedly throughout the film. In just the first 2 minutes, the notion of corrupt doctors, evil pharmaceutical companies, and irresponsible pharmacies, is reiterated 3 different times!

The narrator says early in the film that Purdue Pharma’s goal in marketing oxycontin was, “corrupting doctors and nurses to sell the Kool-Aid,” and later on at the 21 min. mark, giant text reads, “The Epidemic Spreads: From the Doctor’s Office to the Street.”

Much later in the film, Anna Lembke, MD Chief of Addiction Medicine at Standford claims, “Opioids are a proxy for doctor-patient relationships.” She then goes on to describe the euphoric high that addicts experience (it should be emphasized that the majority of pain patients do not experience this euphoric high), ending with, “…you feel cradled [by the doctor]…You thank them, the doctor feels gratified, the doctor writes another script.”

A chronic pain patient featured in the film, who had probably been over-medicated for a number of years and had since been tapered down from her previous fentanyl patches and oxycondone to a new, unrevealed dose, is described at the end of film by the narrator, “Linda lost years of quality of life by innocently trusting her doctors to do no harm.”

The film then switches tactics to blast the FDA for it’s “ludicrous” (and alleged conspiracy-theory) decision to add pain as the 5th vital sign in the 90s (actually a 2001 Joint Commission decision), because it was allegedly paid big money by Purdue Pharma. While no evidence has yet been found for this claim, the film blames “dark money”. Kolodny’s still pretty sore, I guess, that the FDA didn’t acquiesce to his demands in 2013 to strictly limit the use of opioids in chronic pain (see image below). Allegations are lobbed about an “unholy alliance” between the FDA and Purdue to get oxycontin approved, although this is exactly what the FDA does: approve pharmaceuticals if they meet government standards.

FDA rejects PROPs opioid limits on chronic pain proposal, 2003


Bad Science Leads to Bad Policies

Giant text on the screen reads, “Over 259 million opioids prescribed per year,” while narration adds, “at the height of the epidemic”. But which year is being referred to? Which study is being referenced? There are an estimated 326 million people currently in America, and we document EVERY prescription written, which means 1 prescription every month for chronic pain patients, or roughly 21.5 million per month. That’s only about 6.6% of the total population. Don’t the filmmakers know that the rate of opioid prescribing WAS ALREADY GOING DOWN by 2012, presumably because of far stricter state laws? Yet another bit of giant text reads, “From 1999-2017, over 500,000 opioid-related deaths.” Except that turns out not to be true at all. More like roughly 123,560, less than a quarter of the “estimated” number of deaths, according to the CDC (Table B).

Please read part 2 here.


Sources Cited:

 

 

http://www.donoharmdocumentary.com/

https://ramblingsoapbox.com/2018/06/26/an-open-letter-to-dr-andrew-kolodny/

https://lptv.org/do-no-harm-the-opioid-epidemic-3/

https://www.addictioncenter.com/treatment/12-step-programs/

https://beittshuvah.org/treatment/residential-program/

https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_10.pdf

https://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html

https://www.cdc.gov/drugoverdose/data/statedeaths.html

https://www.medpagetoday.com/publichealthpolicy/publichealth/57336

https://www.nbcnews.com/health/health-news/number-prescriptions-opioid-painkillers-drops-dramatically-u-s-n867791

http://www.supportprop.org/faqs/