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

An Open Letter to Dr. Andrew Kolodny

Update 6/27/18: I am overwhelmed by the positive responses I have received for this letter. I would ask that readers also take a look at all the articles and references cited in this piece, and share those as well. Those references go into much, much more detail and research than I have had space or time for here. Thank you all so much for reading and sharing, I believe we will make a difference and win this fight for our lives! #wearehere

See also: A Rock and a Hard Place, The Truth About the Opioid Crisis, and Strangulation on Medicine

Dear Dr. Kolodny,

I am one of millions of chronic pain patients in the United States who has been continually and increasingly oppressed over the past few years by progressively invasive and prohibitive laws at the state and federal levels concerning the delicate relationship between doctors and patients, particularly when it comes to a certain class of drugs, i.e. opiates.

Ever since my very real, physical condition began about 4 years ago, my family and I have been disoriented again and again by a lack of what might be termed, “help,” from doctors. We have discovered a very confused medical community, corruption, and a growing collection of laws being passed so fast and furiously hardly anyone seems to know just what is going on.

This has resulted in doctors leaving my city, doctors outright refusing to accept chronic pain patients (or, if they do accept these patients, refusing to treat them with medications that suit the patient best) or new patients, and unprecedented referrals to pain management clinics and psychiatrists. I have a detailed post planned addressing the pain management clinics, but the psychiatrist referrals were more baffling to me. My local psychiatrists even refused me as a patient about a year ago because, “we don’t see chronic pain patients.” That made sense to me as I don’t suffer from mental illness, still my providers insisted I must be mistaken.


Down the Rabbit Hole

I began researching you and your career last night out of curiosity. I wanted to answer the question, “Who is this Dr. A. Kolodny, that everyone from journalists to policy makers and bloggers keep quoting as an “expert on opiates”?” And I found out. You, sir, are a psychiatrist and board-certified addiction specialist-turned policy maker (1) and buprenorphine (Suboxone) “evangelist” (2).

Your first private clinic was a Suboxone clinic in New York City, established sometime around 2003-2005, and it appears you (and/or other health officials) felt stymied by the federal limit at the time of just 30 patients for such clinics (put in place to stem corruption), because said health officials have been in the background, quietly working away at this very limit which was amended in 2006 (called DATA), to allow 100* patients after 1 year, and is now up in the House for being overturned altogether, along with expanding legal prescribers to nurses and other non-doctor medical staff. And look what has happened as a result:

Health officials, concerned about restricted access, lobbied alongside Reckitt Benckiser for the patient cap to be raised. “Why should we bind a healer’s hands from helping as many as he or she could?” Senator Hatch said, getting an amendment passed in 2006 that allowed doctors, on request, to go from 30 to 100 patients after a year.

The stage was set for more patients, prescriptions and problems. “It’s when the limit was raised from 30 that doctors started to get commercial about it,” said Dr. Art Van Zee, whose buprenorphine program at a federally funded community health center in rural Virginia is surrounded by for-profit clinics where doctors charge $100 for weekly visits, pulling in, he estimated, about $500,000 a year.

“They are not savvy about addiction medicine, don’t follow patients very closely, don’t do urine testing and overprescribe,” he said. “That’s how buprenorphine became a street drug in our area.” https://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html (4)

“In the early days of Suboxone, with Reckitt Benckiser barely marketing its own drug, Dr. Kolodny, then a New York City health official, crisscrossed the city with colleagues to spread the word about the new medication, entice public hospitals to try it with $10,000 rewards and urge doctors to get certified.”

https://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html (4)

Since at least 2005, you have been marketing buprenorphine as if you had a personal stake in the drug, to government institutions and agencies including prisons, public hospitals, and rehabilitation facilities (2). In the fall of 2013, you were appointed Chief Medical Officer (5), of the largest chain of non-profit detox/rehab facilities in the USA (cited for questionable practices and abuse from at least 2012-2015) (6) called Phoenix House, which received $131 million in June 2013 (7), championing the use of MAT, or “Medication Assisted Treatment,” and which now funds your non-profit, policy-influencing group, PROP, or Physicians for Responsible Prescribing. I wonder which drug Phoenix House used?


Hang ‘Em High?

salem witch hanging.PNG
An innocent “witch” (woman) is hanged at the Salem Witch Trials, much like other innocent pain patients are persecuted.

Since you often cite the United States vs. Purdue Pharma (2007) settlement in your interviews and writings, perhaps you saw an opportunity to expand the use of buprenorphine by targeting and demeaning chronic pain patients as mere “addicts”.
It was odd to me in researching that incident, in the official “Purdue Guilty Plea” document (8), the very words they were condemned for, claiming OxyContin to be “less addictive” and “less subject to abuse and diversion” (8), appear to be the exact words you use time and again when describing the benefits of buprenorphine (2).

Kolodny reminds his colleagues of the drug’s advantages. He stresses that bupe in the form of Suboxone is safe and almost impossible to abuse, a huge selling point at many of the clinics they will visit. Suboxone has a second active ingredient in the mix, he explains, an anti-overdose drug called naloxone.

It does nothing if you take bupe as directed. But if you sniff bupe or inject it or otherwise try to pack enough into your bloodstream to get high, the naloxone acts like a chemical booby trap, erasing the effects of any opiate, bupe included, and bringing on sweaty, nauseating withdrawal. “That’s the last time you’ll do it,” Kolodny says dryly. https://www.wired.com/2005/04/bupe/

In 2016, your organization, PROP (Physicians for Responsible Opiate Prescribing), got the ear of the CDC and helped to write the now-infamous, misinformed, and rushed guidelines for prescribing opiates. While these guidelines were fairly general in nature, they have been used as a springboard for countless pieces of state legislation and DEA investigations, which has, in turn, led to the above-mentioned abuse and abandonment of chronic pain patients and doctors, as well as opiate shortages in hospitals and ERs (The DEA, in an attempt to prevent diversion of opiates to the black market, has cut production by an incredible 45% in the past 2 years). I imagine that suits you just fine, since you have publicly stated you believe opiates should be discontinued for all but the dying and post-major surgery “for a few days” (https://www.ket.org/opioids/inside-opioid-addiction-10-questions-with-dr-andrew-kolodny/), and that “more treatment” is needed (https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses), i.e. MAT/Suboxone clinics like Phoenix House.

'The National Gesture' 1926
“The National Gesture” 1926

You have hailed local municipalities and states in their further pursuit of legal action against American Big Pharma, the companies who make such things as Vicodin and Percocet, but not Suboxone/buprenorphine (which is also an opiate), which is made by an overseas company, Reckitt Benckiser, or Naloxone (Narcan), which is produced in a nasal spray exclusively by Amphastar Pharmaceuticals (10), a relatively new company founded in California in 1996 (11),  whose stock (and Narcan prices) have been rising quite a bit, lately (12, 13). Are you truly against the use of opioids, or just the ones that help pain?


The Opioid Epidemic!

mccarthyism
McCarthyism Propaganda

Although your policies, based on inaccurate data (14-15) https://www.acsh.org/news/2017/10/12/opioid-epidemic-6-charts-designed-deceive-you-11935 (15), and http://www.mdmag.com/journals/pain-management/2012/october-november-2012/just-how-responsible-is-prop, have been wildly ineffective at stopping heroin/fentanyl overdoses; although you are not a pharmacologist, opiate researcher, pain doctor, pain patient, surgeon, or even general practitioner; although you ran a private clinic for a short time in 2005 (as far as I’ve been able to learn) that dispensed buprenorphine/Suboxone, you have, for the majority of your career as far as I can tell, been a policy-maker and not directly involved with addiction patients or chronic pain patients whom you recently claimed were simply addicts who needed compassion and “treatment” (and, presumably, Suboxone).

“Many Americans are truly convinced that opioids are helping them. They can’t get out of the bed without them.”

“Policy makers were told by industry-funded pain organizations not to penalize pain patients because of drug abusers. We realized that this wasn’t true. We don’t have these two distinct groups, one for pain patients and the other for drug abusers.” https://www.kolmac.com/2015/12/qa-dr-andrew-kolodny-chief-medical-officer-phoenix-house/ (15a)


If You’re Not For Us, You’re Against Us

sen. joe mccarthy demonstrates the communist threat
Senator Joe McCarthy Demonstrates the Communist Threat in America

You are cited and quoted in an impressive number of articles and interviews as a compassionate person who wants to see people and their families heal from the devastation of addiction, which is why it surprised me to find quotes from you that didn’t seem, well, “nice.”

It is the FDA’s role to vigilantly regulate the approval, labeling, and promotion of  pharmaceutical products, not that of counties or municipalities. County and municipal lawyers are inadequately qualified to make or enforce federal drug policy, and these lawsuits serve as a vehicle for local governments to seek revenue  through ill-informed measures under the guise of drug abuse prevention. In a May 30,2014, interview with   FDA Week, a CLAAD spokesman voiced these positions and expressed concern that these lawsuits are part of “a trend that will distract us from the real meaningful approaches to reducing prescription drug abuse.”

After reading the interview, Dr. Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing (PROP)and Chief Medical Officer of Phoenix House,  contacted CLAAD via telephone to condemn its comments. During this conversation, Kolodny threatened that the Internal Revenue Service would revoke CLAAD’s tax-exempt status when alerted to the comments, which he believes conflict with CLAAD’s charitable mission.  CLAAD takes these false allegations and threats very seriously, and  responded in a letter which is publicly available for view on our website.

Critics who categorically dispute the motives of organizations like CLAAD and its diverse coalition members are, at best, narrowly focused. Their zealotry reveals their otherwise undisclosed health insurance industry bias.  At worst, they endanger the lives of people who live with pain and other conditions that can require controlled substances by stifling access to quality care. http://paindr.com/claad-and-phoenix-house-square-off/ (16)

Anyone who questions your authority, expertise, policies, or the efficacy of your pet drug, buprenorphine, is loudly dismissed by you as uneducated (17), addicted (15a), or corrupt (15a, 18), regardless of how closely they actually work with addicts and pain patients (17).

But Dr. Kolodny, I have nothing left to lose — your policies and attitudes have directly impacted my health, my freedom, my ability to be a parent, my work, my hobbies, my family, my finances, my friends, and my personhood. I have no problem announcing to the public, as loudly as I can, “The Emperor is not wearing any clothes!”

emporer has no clothes


Citations

(1) http://www.cecentral.com/search/faculty/136145

(2) https://www.wired.com/2005/04/bupe/

(5) https://www.phoenixhouse.org/news-and-views/news-and-events/phoenix-house-appoints-dr-andrew-kolodny-as-chief-medical-officer/

(4) https://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html

(6) https://www.reuters.com/investigates/special-report/usa-rehab-phoenixhouse/

(7) http://www.phoenixhouse.org/wp-content/uploads/2014/06/2013-Financial-Report.pdf

(8) https://assets.documentcloud.org/documents/4378824/Purdue-Guilty-Plea-Copy.pdf

(9)

(10) https://www.npr.org/sections/health-shots/2015/09/10/439219409/naloxone-price-soars-key-weapon-against-heroin-overdoses

(11) http://www.amphastar.com/about-us.html

(12) https://www.equities.com/news/naloxone-stocks-who-s-really-winning-the-battle-against-the-opioid-epidemic

(13) https://thinkprogress.org/pharmaceutical-company-with-monopoly-on-lifesaving-treatment-jacks-up-prices-3883e95f88c7/

(14) https://medium.com/@stmartin/neat-plausible-and-generally-wrong-a-response-to-the-cdc-recommendations-for-chronic-opioid-use-5c9d9d319f71

https://www.ket.org/opioids/inside-opioid-addiction-10-questions-with-dr-andrew-kolodny/

(15) https://www.acsh.org/news/2017/10/12/opioid-epidemic-6-charts-designed-deceive-you-11935

(15a) https://www.kolmac.com/2015/12/qa-dr-andrew-kolodny-chief-medical-officer-phoenix-house/

https://abcnews.go.com/Health/deaths-drug-overdoses-continue-rise-us-blacks-hispanics/story?id=54094943

(16) http://paindr.com/claad-and-phoenix-house-square-off/

(17) https://www.nytimes.com/2016/05/29/opinion/sunday/addicted-to-a-treatment-for-addiction.html

(18) https://www.kolmac.com/2015/12/qa-dr-andrew-kolodny-chief-medical-officer-phoenix-house/

https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses

https://www.cdc.gov/drugoverdose/prescribing/guideline.html


Further Resources

https://www.cdc.gov/drugoverdose/prescribing/guideline.html

https://www.bendbulletin.com/topics/5342867-151/opioid-crisis-pain-patients-pushed-to-the-brink

http://www.mdmag.com/journals/pain-management/2012/october-november-2012/just-how-responsible-is-prop

http://nationalpainreport.com/cdc-does-not-comply-with-federal-law-8828305.html

https://www.chronicle.com/article/To-Counter-Opioid-Crisis-NIH/240219

https://www.painnewsnetwork.org/stories/2016/8/11/prop-ends-affiliation-with-phoenix-house

https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-abuse-heroin-use/introduction

On Opioids, One Year After DEA Reforms

It’s been nearly one year since my researched article on the heroin epidemic (link) in my city, and I’ve been keeping tabs on the results of the DEA’s new prescription opioid reforms. How have things have panned out for pain patients, and opioid and heroin addicts in the past year?

poppies2
“My Little Chinese Book”, by Mary Audubon, 1912. Image courtesy of The British Library Catalogue

Two years ago, National Pain Report, a patient advocacy group, published an article predicting what might happen after the DEA’s reforms were passed.

“Pain management experts say the rescheduling of hydrocodone by the U.S. Drug Enforcement Administration could have many unintended consequences, including higher healthcare costs, as well as more suicides, addiction and abuse of opioids. Many physicians may also refuse to write prescriptions for hydrocodone products, fearing fines or prosecution.”

All they predicted has happened, and more. Drug rationing (see here and here) for pain patients, some of whom are cancer patients, has been a major problem especially in Florida, which in addition to having a higher (nationally) number of opioid abusers, also has a higher number of elderly and sick. *Update: I recently heard a rumor that a documentary is being made about the Florida issue.

“[Pharmacist] Bill Napier, who owns the small, independent Panama Pharmacy in Jacksonville…says he can’t serve customers who legitimately need painkillers because the wholesalers who supply his store will no longer distribute the amount of medications he needs. “I turn away sometimes 20 people a day,” says Napier.

Last year Napier says federal Drug Enforcement Administration agents visited him to discuss the narcotics he dispensed.“They showed me a number, and they said that if I wasn’t closer to the state average, they would come back. So I got pretty close to the state average,” Napier says. He says he made the adjustment “based on no science, but knowing where the number needed to be. We had to dismiss some patients in order to get to that number.”

According to Napier, DEA agents took all of his opioid prescriptions and held on to them for seven months. Napier hired a lawyer and paid for criminal background checks on his patients taking narcotics to help him decide which ones to drop.” (source)

In this one-year post report from Northern Ohio, another state that has been hard-hit with opiate addictions, a lot of facsimile changes were made in local laws, which resulted in anywhere from no changes, to an increase in heroin use. Thankfully, this report specifically mentions heroin as the drug to be battling against, rather than other articles and news reports, including recent comments from President Obama, that have made pain patients out to be drug abusers, by default. They group heroin use/abuse with anyone taking an opioid for any reason (see here and video here).

While the DEA has succeeded in reducing the number of opioid prescriptions by strong-arming doctors and pharmacies, they have condemned chronic pain and surgery patients to depression, exhaustion, high levels of mental and physical stress, brain shrinkage, trouble concentrating and making decisions, insomnia, and anxiety, all side effects of uncontrolled chronic pain. As a result of these stressors, it remains to be seen (for lack of hard numbers) if the suicide rate among chronic pain patients, already known to be twice the rate of non-chronically-pained patients, has indeed gone up (source). But what has the DEA done about opioid abuse on the street? What have they done to stem the ever-rising tide of heroin trafficking and use? What have they done to reduce the rate of prescription abuse, not just use? Not one thing. What viable alternatives for pain patients have been produced in the past year?

New York Opium Den
New York Opium Den, 18__

In the middle of all this madness, is a push for new (supposedly non-addictive) drugs and treatments. Unfortunately, these new treatments tend to be very expensive, are more invasive, have mixed rates of effectiveness, and are rarely covered by insurance. One news article blithely claimed (using new CDC guidelines) that boosting endorphins via exercise was on par with taking narcotic pain medicine. What they failed to keep in mind is that those who are elderly, sick, or disabled, or those recovering from surgery, may not be able to exercise, especially if they’re in pain! While this same video also recommended OTC pain meds like Tylenol or Motrin, one main reason chronic pain patients are prescribed opioids in the first place, is to avoid the associated and well-documented kidney, liver, heart, or stomach damage from high and/or prolonged use of OTC medicines.

“The misguided, insensitive and inhumane policies of our government and the DEA in particular, have led us to create a Facebook page called Patients United for DEA Reform.

…All of us are only one injury or diagnosis away from being crippled with pain.  Think of living every day with a toothache that won’t stop, an untreated broken bone, or surgery with no post-operative pain relief.

People are living with untreated pain every moment of every day because of government over reach and inhumane DEA policies. It must be stopped and it must be stopped now.” (Source)

As if this weren’t enough, there have been several politicians in the past few weeks advocating for even further restrictions on prescription narcotics. Vermont Governor Peter Shumlin (D) and Kentucky Gov. Matt Bevin (R), are now pushing for even more legislation that will keep pain patients (who have a difficult time as it is getting around) from receiving more than ten pills at one time. Shumlin wrote, “opioid medications, as we know them, must be made obsolete”.

If this war on opioids has resulted in the predicted effects of more illicit drug abuse, of more patients in desperate pain, of an increase in deaths related to drug overdose and suicide, in more frustrated doctors and pharmacies, and an increase in healthcare costs,  it seems clear these new laws have helped no one, and hurt millions. Or have they?

See also: Strangulation on Medicine: My Life as a Pain Patient

*If you liked this post, please consider subscribing to my blog for just $1.50/month.


Sources in order of appearance

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

http://nationalpainreport.com/a-worried-dad-pain-patients-need-to-unite-for-dea-reform-8819510.html

http://www.pbs.org/newshour/updates/americans-spend-much-pharmaceuticals/

http://wellescent.com/health_blog/the-damaging-effects-of-chronic-pain-on-the-brain

http://commonhealth.wbur.org/2015/11/chronic-pain-suicide

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

Pain Patients Say They Can’t Get Medicine After Crackdown On Illegal Rx Drug Trade

http://abcnews.go.com/US/prescription-painkillers-record-number-americans-pain-medication/story?id=13421828

http://www.painnewsnetwork.org/stories/2015/9/16/cdc-opioids-not-preferred-treatment-for-chronic-pain?rq=preferred

The Truth About the Opioid Crisis

*This article was originally written in 2015. It has since been updated with new, groundbreaking information and facts.

Previously titled, “On Opioids: America’s Drug Addictions and the Wacky Laws that Perpetuate Them.” See also: PROPaganda: Part 1 and Part 2; An Open Letter to Dr. Kolodny; A Rock and a Hard Place; and Strangulation on Medicine vintage heroinTwo years ago, a little silver car sat parked outside our home. As the sun was going down an ambulance, police cruiser, and firetruck suddenly arrived to pull an unconscious young woman with a bobbing blonde ponytail out from the driver side of the car, a bottle of heroin found next to her. We didn’t even know anyone was inside the vehicle. I never saw that young woman again, and the police came to impound her car a few days later.

Last July, I sat in the small chapel at a local funeral home staring at the body of my husband’s cousin. Only 29 years old, living less than a mile from our house, married and a daddy-to-be, and there he lay in an open coffin looking sound asleep. After months of staying clean he had found a dealer in the apartment complex he and his wife had just moved in to. That night he took heroin, unknowingly laced with fentanyl, for the last time.


drug dog
McGruff the Crime Dog teaches kids to “Just Say No” to drugs. I remember this guy!

In 2013, Ohio Senator Mike DeWine decried heroin use as “a statewide epidemic.” (1) A rising tide of heroin-related deaths totaled over 900 for Ohio in 2013, a sharp increase from previous years that showed no signs of leveling off or decreasing (1). Heroin is cheap, easy to get, and often deadly (1). Heroin use is also linked to prescription narcotics, which studies (2) show has decreased in rates of abuse in my area (heroin and fentanyl have continued to rise), ostensibly due to tougher federal and state laws (3) implemented last year that limit their prescription by practitioners.

Many times a person will experience legitimate pain, be prescribed a narcotic, get hooked on the high, and then turn to heroin when their prescription is over and they can’t get a refill (2). (*New information and stats show this commonly held narrative is overwhelmingly false. The vast majority of those abusing prescription drugs ALREADY had a history of drug or alcohol abuse.) Heroin is essentially morphine, a drug (morphine, not heroin) commonly used in emergency rooms for severe pain (5). It is one of the strongest opioids available (5) and it is a major problem that people are taking the leap from prescriptions like Vicodin and Percocet (hydrocodone and oxycodone) to street heroin. (*It is actually not one of the strongest opioids available) While lawmakers are right to be concerned about prescription opioid abuse (*which has been decreasing since it peaked in 2012), they are not focusing efforts on the much larger problem of heroin abuse, and the sad results are astounding.

Last May 2014, The National Institute on Drug Abuse, a component of The National Institutes of Health, presented the following information at the Senate Caucus on International Narcotics Control (4).

“To illustrate this point, the total number of opioid pain relievers prescribed in the United States has skyrocketed in the past 25 years  (Fig. 1).[4]  The number of prescriptions for opioids (like hydrocodone and oxycodone products) have escalated from around 76 million in 1991 to nearly 207 million in 2013, with the United States their biggest consumer globally, accounting for almost 100 percent of the world total for hydrocodone (e.g., Vicodin) and 81 percent for oxycodone (e.g., Percocet).[5]

This greater availability of opioid (and other) prescribed drugs has been accompanied by alarming increases in the negative consequences related to their abuse.[6] For example, the estimated number of emergency department visits involving nonmedical use of opioid analgesics increased from 144,600 in 2004 to 305,900 in 2008;[7] treatment admissions for primary abuse of opiates other than heroin increased from one percent of all admissions in 1997 to five percent in 2007[8]; and overdose deaths due to prescription opioid pain relievers have more than tripled in the past 20 years, escalating to 16,651 deaths in the United States in 2010.[9]

Pretty scary-sounding stuff, but notice in the argument above words like “opiates other than heroin” which may or may not include prescription narcotics, and may in fact include Suboxone *also here (more on that in minute). Although the number of prescription opioids has increased over 10 years, the percentage of abuse represents only a fraction of the number of people taking these medicines, 305,900 to 207 million. Compare that to the numbers of heroin users which is double the amount of prescription narcotics abusers, “The number of past-year heroin users in the United States nearly doubled between 2005 and 2012, from 380,000 to 670,000” (4). Policymakers have put the emphasis on the wrong syllable and no one is being helped.

Indeed, the recent laws our country and states have implemented to purportedly alleviate the “problem” of prescription opioid abuse, have only exacerbated the very real problem of heroin abuse, which is reaching epic proportions around the nation (4). I recently spoke with a local 25-year veteran chemical dependency counselor that I’ll call “Glinda” (not her real name). Poor Glinda was very frustrated with the current system of treatment for drug abusers, telling me quite frankly, “People are dying because of this new policy!” What policy was she referring to?

drug overdoes chart for Mont. Co

Glinda informed me that up until 5-6 years ago, the standard form of treatment for heroin users who wanted to be free was a very selective residential treatment program. After being selected for treatment, the heroin addict was admitted to a local hospital that partnered with the chemical dependency clinic. The patient stayed in the hospital for 3-4 days, being observed and weaned off all drugs. By the end of those 3-4 days, the patient was completely drug-free and then sent to a residential treatment facility for another 28 days, at least. Although it was not 100% fool-proof, Glinda admitted, “We had a pretty high success rate.” This program had been in place since 1960 in Dayton, Ohio, until about 5 years ago when drug companies came out with Suboxone (also known as buprenorphine), a drug created to help users stop their opiate addictions. A slightly less intense form of synthesized heroin, *Suboxone/bupenorphine is actually stronger, and therefore more addictive than heroin. 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!). Although touted as “life-saving” for the Naloxone additive it contains, Suboxone is still a powerful narcotic/opioid with the same potential for addiction.

Chemical dependency counselors hate it.”

Poppies
Dorothy Gale sleeps among the poppies in “The Wizard of Oz”.

What went on behind the scenes one can only guess at, but, Glinda told me, lawyers, policymakers, lobbyists, and state and city medical boards all  jumped on the Suboxone bandwagon (6) as a cheaper alternative to hospital detox programs. Laws were passed to ensure Medicaid would pay for new Suboxone and methadone clinics, which popped up over the city of Dayton and state of Ohio like daffodils in spring. According to Glinda, these clinics simply hand out free Suboxone or methadone (an opiate drug even stronger than heroin) to any user who comes in asking. They are limited to one round a day or week depending on the clinic. Users are supposed to go through counseling before they can have the drugs, but Glinda said, “Many times this ‘counseling’ is nothing more than an hour-long video.”

Glinda told me that Suboxone users sometimes take an additional anti-anxiety medicine with benzodiazepines like Xanax, Valium, or Ativan, to get back the extra high Suboxone purposely leaves out, often resulting in the user’s death. However, many other times users will take their free drugs and just sell them on the street for heroin. “It may be a cheaper ‘solution'”, Glinda said, “but no one is getting clean. Chemical dependency councilors hate it.” The article, The Misguided Obsession with Heroin / Opiate Maintenance Drugs (Suboxone, Subutex, Buprenorphine, Methadone) (7), from The Clean Slate Addiction Site, echoes Glinda’s concerns,

“Most of the research on drugs like Suboxone (a popular formulation of Buprenorphine and Naloxone) checks the effectiveness of the drug over a 12 week period. That’s it. And as stated above, long term results are essentially unknown. Also, most of the “success” that’s found with drugs like Bupe and Methadone is that people who take it stay engaged in treatment programs longer than those who just receive counseling (without drugs).  

If the NESARC results from heroin and prescription opiate users are to be factored into the equation, we might decide less treatment is better. After all, those opiate and heroin addicts who received treatment had MUCH longer periods of abuse and dependence before actually remitting. Which in itself means more occasions of use, which means more opportunity to overdose.”

At the same time safer (compared with street heroin) and documented prescription narcotics are being locked down, marijuana (8) is becoming legalized in various forms around the nation and addicts get their stronger-than-prescription-narcotics Suboxone or methadone free, allegedly to help them get off narcotics. By severely limiting the prescription of legitimate narcotics, not only have policymakers been contradictory, they have effectively tied the hands of America’s doctors and punished law-abiding citizens in real pain, in order to prevent them from potentially becoming law-breakers. But we also have laws in place that essentially reward law-breakers by giving them free drugs, as a way of trying to make them law-abiding citizens. We are making more heroin addicts with these policies, not fewer, and the numbers sadly corroborate.

After speaking with Glinda for over an hour, my final question was simply, “What can we do to change this?” Her response, “Activism is the key. Contacting policymakers including county commissioners and boards of health (these links are for Montgomery County and Ohio), and pointing out the facts that these [Suboxone and methadone] clinics just are not working. Then maybe we can help save some lives.” Or, in the words of one of my favorite films…”People are dying! Would you please shut down the system?”


Sources (in order of appearance)

https://www.mikedewine.com/dewine-heroin-epidemic/

http://mha.ohio.gov/Portals/0/assets/Research/OSAM-TRI/Dayton.pdf  (Pages 114-118)

http://www.usatoday.com/story/news/nation/2014/08/21/us-restricts-hydrocodone-painkillers/14387867/

http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse

http://mcintranet.musc.edu/agingq3/calculationswesbite/convchart.pdf (Pages 2-3)

http://www.thefix.com/content/best-kept-secret-addiction-treatment?

http://www.thecleanslate.org/the-misguided-obsession-with-heroin-opiate-maintenance-drugs-suboxone-subutex-buprenorphine-methadone/

http://www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html

http://www.mcohio.org/government/bcc/index.html

https://odhgateway.odh.ohio.gov/lhdinformationsystem/Directory/GetMyLHD


Read More:

http://www.daytoncitypaper.com/a-light-at-the-end-of-the-tunnel/

http://novusdetox.com/heroin-effects-history.php

http://www.historytoday.com/ian-scott/heroin-hundred-year-habit

http://www.drugabuse.gov/publications/drugfacts/heroin

http://www.drugpolicy.org/new-solutions-drug-policy/brief-history-drug-war