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

A Rock and a Hard Place: Pain Patients Suffer from Heroin Laws Fallout

See also: An Open Letter to Dr. Kolodny, The Truth About the Opioid Crisis, and Strangulation on Medicine

Good, law-abiding people are suffering severely in the fallout from recent state and federal laws. Designed to curb heroin addiction, these laws and prevailing societal views all begin with the false assumption that prescription pain pills like Vicodin and oxycodone are entirely to blame for rising heroin and fentanyl abuse rates.

Chronic pain patients, including many elderly and disabled citizens, often feel treated like criminals. What follows is a personal account of what chronic pain patients have to go through to obtain legitimate prescriptions from legitimate, experienced doctors, that enable them to participate more fully in life.

disabled
“Disabled,” Photo credit: User afri.on Flickr.com

A woman, perhaps in her late sixties, wears a tan sweatshirt with the simple, humorously ironic message, “Sarcasm Society: Like we need your membership.” She sits next to her older friend, a frail, bent woman in a wheelchair with a quilted coat draped over it. The “sarcasm” lady unfolds a newsletter, leans close to her friend, and reads. The older woman smiles as she listens.

Nearby, another couple sits; a tall, middle-aged man in military fatigues plays a game on his smartphone while his mother jokes and tells him the family news. He chuckles good-naturedly, but never takes his eyes off his phone.

At the other end of the room sits an older daughter with bushy red-orange hair in a large ponytail, and her thin, elderly father who tries to sit straight and tall with the help of his cane. He wears a black leather jacket and ball cap, and mutters something quietly. “Don’t talk like that!” his daughter admonishes. Then more gently, she says, “You’re over-thinking again…”

This long, narrow waiting room is stuffed with people. People in pain. People like me. At 33, I am perhaps the youngest person in the room. A single TV is mounted above my head, showing President Obama’s last question and answer session with reporters. A lanky black man in a golden velvet pantsuit sits near me. He stares at the floor and listens to the interview. There are many others. Some busy themselves with cell phones; some lay their heads back against the blue wall and close their eyes; one lady reads a colorful, worn-out magazine. Everyone is tired. No one wants to be here.


Once again today, I fight a rising panic that this time my surgery pain will not be treated. This time I will be told about yet another hoop I have to jump through, yet another bill I will have to fight with my insurance over. My husband points out a new sign in the office, “As of June 1, 2016, all self-pay patients will have an increased payment from $85 to $100 per visit.”

My stomach begins to hurt, and I feel like pacing. I watch the enormous clock on the wall beside me, the only decoration in the low-lit room. My appointment was scheduled for 2:45pm, we arrived at 2:35pm, it is now 3:20pm. The cushioned seats smell of stale smoke, and my husband complains of a headache. I shift in my chair but can’t get comfortable.

New laws require these appointments every month, as opposed to the previous 3-6 months, for those prescribed opiates, but every appointment is a real burden on those called chronic pain patients (*pain lasting longer than 3 months). Cost and rising insurance deductibles notwithstanding, most of these patients have to find rides and a helper to get in and out of vehicles, and in and out of the doctor’s office. These patients are physically weak, and have to juggle exhaustion, pain, and a variety of medical devices like canes, walkers, braces, and wheelchairs, not to mention purses, coats, and something to occupy the time.

Helpers and/or drivers have busy lives too, and most of them work full time. These appointments can take hours, and do not include additional appointments for physical therapy, regular doctor appointments, specialized doctor appointments (there may even be 2-3 different doctors), lab work, hospital visits for x-rays, MRIs, and CT scans, dentist appointments, and more. All of these appointments require driving and walking assistance. My husband has taken a half-day vacation today. He has been warned by his boss he has taken too much company time.

The nurses and doctors and office staff all work remarkably fast. They are used to this rush of slow-moving people and have a system. I am so deeply thankful for this place of last resort. Recent laws have prevented surgeons from treating surgery pain past three months, even for major surgeries in which recovery can take a full year or more, like my spinal fusion. Although I had referrals from both my doctor and surgeon, after calling over a dozen pain clinics in my area, this is the only one that would take me in. I was told several times the office I’d called did not work with surgery patients. Only a few local clinics are staffed by actual pain doctors. The rest are headed by anesthesiologists, who do not seem to understand the needs of post-surgery patients, or feel prevented by federal and state laws from prescribing opiates.

Due to a major uptick in DEA arrests, license revoking, and heavy fines, regular doctors refuse to prescribe opiates anymore.

The majority of pain clinics likewise either outright refuse to prescribe opiates, or resort to “prescription hopping”, changing a patient’s medication every month to avoid meeting quotas that will likely arouse government suspicion*. This results in potential side effects for patients, some of which can be very serious, as well as expensive medication bills.


I squirm in my chair, realizing I need to go to the bathroom, but I have to wait in order to take the drug test. The drug test that cost my insurance $3500 per test. The drug test which has to be sent to an outside lab for rigorous analysis. The drug test I had to have at every visit at my previous pain clinic to prove I was not abusing my medicine or taking street drugs along with it. Though my medical record and scars should prove my case, at my last visit, my doctor told me the drug screening was also to prove I was the one taking my medicine, and that I was in fact taking it. Although the legal, societal, and medical pressure is immense to be off opiates, I could be kicked out of the pain clinic for not taking my medicine exactly as prescribed, even if I wasn’t taking it, or needed it less often: “Every 4 to 6 hours, no more than 2 max/day.”

I’ve been dropped from a pain clinic before. No test ever came back positive for abuse, and no stated reason was given. My appointment for that week was canceled meaning no prescription for the next 30 days, and no referral, no information, no medication to wean and thereby prevent or reduce withdrawal symptoms was given. The month prior, they had put me on an ER (extended release) hydrocodone that I didn’t want to be on; I was very slowly getting better and wanted to begin lessening my dosage. I needed to get active and strengthen my body, but moving more than a few steps was acutely painful and exhausting. Without pain management, physical therapy was out of the question: I couldn’t even ride in a car more than 5 minutes without tears.

Still, the extended release medications, lasting 12-24 hours, and meant to curb addiction, made addiction more likely as I couldn’t wean off and my body became used to having the medicine around the clock. I called addiction clinics for advise on what to expect, I searched the internet for help in deciding my next steps. No one seemed to know what to do. After several days of highly unpleasant symptoms (including psychological ones such as suicidal thoughts), and being tossed back and forth between my doctors’ offices like a dirty ball that no one wants, I was advised to go to the ER for complications of opiate withdrawal. The doctor there heard my story and sighed deeply. She shook her head, “Everyone is so afraid of these medications now, people like you are getting caught in the cross-fire.”


Back in my current doctor’s office, the testing bathroom is curious. It has no lock on the door, no water to wash with at the sink, and large signs stating that you are not to flush. That job is left to nurses, after they have examined the contents of the toilet. It has always been very difficult for me to give a sample. My back was terribly swollen for months, and bending at all was out of the question for half a year. No other helper could attend you during testing, but a certain amount of urine is still required.


My name is called, I talk with my doctor. I am very proud of the progress I’ve made in healing since my last appointment. I can now handle long car rides, I finally got to visit
family who live 6 hours away for Christmas, I even did a little yard work during a warm spell last week. I haven’t been able to do these things since a year before my surgery last December, and I am so thrilled. I am getting better! To all this, my doctor merely gives a stiff warning not to overdo things, that she cannot increase my medication, and that if I still need medication by my next appointment (regardless of progress in healing), I will have to undergo other procedures or lose my place at the clinic. We have talked about these procedures before. They are very expensive, invasive, painful, and have mixed results, but legally, doctors are not allowed to continue medication alone, even when there is evidence it is helping. If my body does not heal according to a timeline unknown to me, I and my doctors will be forced into this procedure.

I walk down the winding hallway of exam rooms towards the exit, make another appointment, and sit down once more in the waiting room for my prescriptions. 3:45pm. My last month’s prescription cost over $40 with insurance. My oldest daughter needs new clothing. My husband needs new glasses. My son’s class is taking a field trip next week and the fee is due tomorrow. 3:55pm. I’m so thankful my dad lives nearby and is a willing and able babysitter for my three children. 4:05pm. “Mrs. Lawrence,” I walk over and check my scripts, thank the nurse, and turn around to gather my things. I glance around once more at the still-full room. Unlike me, most of these people will not get better. Unlike me, most of these people have serious and/or multiple medical conditions.

This is compassion? This is freedom? This is the state of modern medicine.


Additional Resources:

A ‘civil war’ over painkillers rips apart the medical community — and leaves patients in fear

http://america.aljazeera.com/opinions/2015/12/dea-crackdown-on-pain-meds.html

*Photo by, https://www.flickr.com/photos/cacis/

https://llawrenceauthor.wordpress.com/2016/03/13/on-opioids-one-year-after-dea-reforms-part-1-of-2/

https://llawrenceauthor.wordpress.com/2015/04/06/wackydruglaws/

Strangulation on Medicine: My Life as a Pain Patient

See also: An Open Letter to Dr. Kolodny, The Truth About the Opioid Crisis, and A Rock and a Hard Place: Pain Patients Suffer from Heroin Laws Fallout

Imagine, if you will: Waking up morning after morning, with sudden, inexplicable, extreme pain in one side that leaves you bedridden for a few hours, then a few days, a few weeks, a whole year.

Imagine not being able to find the source of the pain. Spending every week with a different doctor. Spending at least $200 on each doctor. Trying at least one new prescription every month. Spending at least $30 on each prescription. Watching the medical bills pile up, knowing you are the sole cause of each one.

IMG_9121_1a_watermarkImagine watching your young children struggle to learn to live without you. Being unable to volunteer at your child’s school because, although you have the time, you don’t have the physical stamina. Being unable to attend most school events, and seeing the disappoint on your children’s faces when you have to tell them, “I’m so sorry, baby, Mommy just can’t do it.” Spelling bees, science fairs, choir concerts, end-of-school picnics, and most painful, 5th grade graduation.

Imagine seeing your spouse become literally bent over and graying early under the stress of being essentially a single parent, plus the stress of being a full-time adult care-giver, while holding down a full-time job, and doing all the cooking, cleaning, and fixing, while also going to school part time.

Imagine being unable to visit your beloved, aging grandparents who live 5 hours away. Or being unable to visit best friends who live 1 hour away. Being unable to attend weddings of dear family and friends because they are “too far away” at 30 minutes to 1 hour. Being unable to travel more than 15 minutes by car. Being unable to walk more than 10 minutes-on a good day.

Imagine being a house-bound invalid at age 31, feeling your muscles becoming a little weaker every day. Swallowing your pride to buy a cane, and using that cane (in public) to support your bad leg on those lucky days you do get out. Imagine shopping for electric wheelchairs since not walking seems to be the new normal, and you are being driven crazy from being stuck inside for so long. Imagine shopping for walkers at age 31. Imagine the embarrassment of personally knowing many people, twice your age, more active than you.

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Me, my dog, and Poe. This is where and how I spent much of my life for 2 years.

With “Care” Like This…

Imagine having your insurance company refuse to pay for things that might shed important light on your problem, or help make it better. Things like MRIs, prescribed back braces, insurance-required physical therapy, any number of expensive drugs or treatments.

Imagine having your primary care doctor whom you’ve known for 7 years, refuse to treat your pain, because new laws prevent him. Imagine him suggesting you are overreacting,and your pain can’t be as bad as you say, even though he just looked at your x-rays and declared your problem will never get better, and cannot be fixed.

Imagine your doctor prescribing a medication that does nothing for your pain, but causes brain dysfunction in the form of a manic episode. Imagine that when you tell your doctor this, he suggests you see a chronic pain specialist who cannot see you for at least 1 month, will insist on giving you invasive, risky, epidural (link) injections that may or may not help your pain, but are terribly expensive and painful.

Imagine your doctor, after telling you you will not get better, brushing off your request for disability papers because you are “too young”. Imagine your doctor brushing off your request for an expert opinion in the form of a neurosurgeon referral, or brushing off your request for further testing.

Imagine, if you will: Being unable to think or work. Imagine feeling so very tired all the time, or anxious too often, or deeply depressed. Imagine feeling worthless, no, more than worthless, a real burden on the ones you love most financially, emotionally, mentally, and physically. Imagine wanting to end your life, and planning it, at least once a week. Imagine crying for hours at a time, because there seems to be no end to the pain, the frustration, the uncertainty, the bills.

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The Solution to Your Problem is Simple…

Now imagine, if you will: At the end of the year, finally having your chiropractor (whom you have been seeing for insurance-required, but not insurance-paid physical therapy) order an MRI. Imagine, after a fight with your doctor who was annoyed you went over his head and had an MRI, while also insisting on a neurosurgeon referral, finally landing a doctor who reads the x-rays and MRI, understands your problem and (could it be possible after all this time!?) fix it.

Imagine hearing the news you were dreading, that you will need a spinal fusion (a major, delicate surgery, with a long recovery) and discectomy; that your lowest vertebrae are separated, and have been for years and years; that this has allowed a spinal disc to slide out of place, forcefully compressing a nerve; that this is the cause of your inability to walk, to ride in a car, to sit comfortably, to sleep through the night, to live well. Imagine scheduling your surgery and feeling like all the pieces are finally falling into place; there is a light at the end of the tunnel!

Imagine, if you will: A slow recovery that begins with immense pain and not being able to walk, to dress yourself, to bathe yourself, to lie down, to sit outside. Imagine feeling very old and very frail. Imagine every month expecting to turn an invisible corner in pain relief, energy, and movement ability, but only seeing little, gradual bits of progress here and there. Imagine that month 3’s post-op big accomplishment is going to the store (accompanied by a driver, because you have hardly driven in well over a year), by using the store’s electric cart and your back brace. Image month 4’s big accomplishment is making it through a brief session of physical therapy without needing a 3-hour nap afterwards.

The Right to Suffer:

Imagine everything you do/can do depends on how well your pain is managed: Getting necessary and wanted exercise; getting (finally) out of the house; getting around the house; sleeping through the night; doing a few light chores; having the energy and ability to focus on things you love like reading, playing board games with the kids, having visitors over, sitting in your garden swing, or just laughing.

Now imagine, if you will: Your surgeon, the only one familiar with your case, your surgery, your history, not legally being able to manage your pain after just 3 months. Imagine being referred by your surgeon to your primary care doctor, who refuses to treat your pain (but only tells you that after an office visit), and refers you to a chronic pain specialist who cannot see you for at least 2 weeks, who has little knowledge of how to treat acute (short term and surgery) pain, who has little knowledge of spinal fusions or surgeries in general, who changes your medication 7 different times in 3 months, who prescribes super-expensive medicines that you cannot pay for, who prescribes medicines that make you so sick, you are either in bed or in the bathroom all day, meaning your spouse must work from home to watch the kids, making you worry about his job security, which makes you anxious for how to feed your kids.

pain scale

Imagine this chronic pain specialist under-medicates you for 3 months, insists on treating periodic, break-through pain with 12 and 24 hour narcotics which make you sick, which are MORE likely to produce addiction. Imagine, that despite doctors’ promises about proper pain management, when you finally refuse to be a guinea pig anymore, and ask for the simple, effective, economical medicine option, you are treated like an addict despite all the urine tests you’ve taken to prove you are not, despite the good faith contract you signed at the office just to be seen, and despite all the paperwork that double-checked your claims, medical history, and medicines across your entire provider network–hey, whatever happened to HIPPA laws?

Doctors said that the vast majority of the patients who need pain medications don’t abuse them. Source

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The way is shut.

Imagine having a pain specialist who you cannot get in touch with for 3 days when your latest prescription, filled only 3 days prior, gave you diarrhea, chills, major migraines, insomnia, and finally a psychotic episode in which you cried for 3 hours and stormed out of the house at 5am, pacing the front yard like an animal as your spouse watched horrified from the front door.

Imagine having a pain specialist who accuses you of breaking your signed pain contract with them, because you told them in order to make it through the weekend, you had to cut old medicines from right after the surgery in half, since you couldn’t get in contact with them. Imagine having to tell them this, because at first they thought you hadn’t taken anything over the weekend, therefore you didn’t “need anything now”. Then imagine them dropping you as a patient like a hot rock.

Imagine:

Without pain management, not only can you not do what you need to or want, you begin to get cranky. You lash out at your kids and spouse without reason, like an animal in pain, because that’s what you are. Imagine finally collapsing into a tired, depressed heap, contemplating the cleanest ways to end your life, to end this pain for good.

Imagine:

  • Knowing that government officials who don’t know you, who are not doctors, who don’t see your pain, assume you will abuse the legitimate medicines that make life livable for you. 
  • Knowing that these officials have made it effectively, though not “technically”, impossible to get what to you, is truly a life-saving medicine. 
  • Knowing that the “stats”, “facts”, and “research” that are behind the new laws that have made it impossible for you to get help, are very, very skewed and without actual merit. 
  • Hearing glib, pain-free people cheerfully announce that exercise, meditation, and a funny movie will remove their pain as well as any pill. 
  • Knowing that real drug abusers who have been breaking laws, can get their addiction meds, often free, while your legitimate, provable, documented, legal medical condition is treated with contempt by law makers. *Sign a petition here! 
  • Knowing that pain patients all over America, “the land of the free”, are needlessly suffering so that some politicians can look good in photo ops and in newspapers. 
  • Knowing that we don’t allow animals to suffer like the laws have made actual people suffer. 
  • Knowing that pain patients have a small voice, because they are too broke from trying to follow the burdensome laws suddenly imposed on them for things outside of their control; because they are too tired from fighting pain and doctors all day, all week, all month, all year long, to use the last of their energy to make their voices heard in politics, rather than spending time with family.

Imagine:

Spending all day trying to find another pain specialist, but being told by the first promising 4 they would not take acute pain cases, and could not recommend any one who would. Imagine calling your surgeon, desperate for help but being told their hands were legally tied. Imagine calling your primary care doctor, but being told they would not do anything, and to go to the ER if the pain “was that bad” (it’s not; you don’t need morphine injections, you just need something a bit stronger than acetaminophen, and you certainly don’t need an extra $6,000 medical bill).

Imagine not being able to take even ibuprofen, per your surgeon’s instructions, or being afraid of liver damage from too heavy acetaminophen use, or being on the phone for 5 hours, trying to find someone, anyone who can or will help.Imagine hanging up exhausted at the end of the day, and having nowhere to turn.

While nerve pain seeps into your side, your muscles begin to stiffen, and you desperately try to ward off an aching back and tailbone (you know, those parts that were recently severed and have bones, new hardware, and deep tissue working to heal) by sitting on an ice pack. The ice pack your now-defunct pain specialist told you not to use (although your surgeon recommended it), along with discontinuing those muscle relaxers your surgeon prescribed.

Imagine all this, if you can…

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Take a walk in my shoes

See also: On Opioids: OneYear After DEA Reforms and On Opioids: America’s Drug Addiction and the Wacky Laws that Perpetuate Them


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Take Action Now!

Garnering Support for Pain Patients, Media Sample Letter

Garnering Support for Pain Patients, Political Sample Letter and Petition


Learn More:

Opioid Epidemic, Drug-Mix Overdose Death

Pain Care Shouldn’t Be Political Theater