The Opposition to Guidelines Discouraging Overuse of Narcotics

By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website

As I have written before as a physician who saw too many dire results of intravenous drug abuse, I was amazed how narcotics were pushed as the treatment of choice for chronic pain in the 1990s, with the result that the US was once again engulfed in an epidemic of narcotic abuse and its effects.  In mid-December, 2015, as reported in the Washington Post,

The nation continues to suffer through a widespread epidemic to prescription opioids and their illegal cousin, heroin. The CDC estimated that 20 percent of patients who complain about acute or chronic pain that is not from cancer are prescribed opioids. Health-care providers wrote 259 million prescriptions for the medications in 2012, ‘enough for every adult in the United States to have a bottle of pills,’ the CDC wrote.

Last week, the National Center for Health Statistics reported that the number of overdose deaths from legal opioid drugs surged by 16.3 percent in 2014, to 18,893, while overdose fatalities from heroin climbed by 28 percent, to 10,574. Authorities have said that previous efforts to restrict prescription drug abuse have forced some people with addictions to the medications onto heroin, which is cheaper and widely available.

This rising tide of death and morbidity seems to have been fueled by reckless, sometimes deceptive, sometimes illegal marketing by the pharmaceutical companies that produced narcotics other than heroin.

Background – Legal Drug Pushing

As I wrote in 2013,

the realization began to dawn that patients, doctors and society were being victimized by a new type of pusher man, this time dressed in a suit and working for an ‘ethical’ drug company.  In the earlier days of Health Care Renewal, we first posted (in 2006) about allegations of deceptive and unethical promotion of fentanyl by Cephalon that lead to its overuse by patients beyond those with cancer who were its ostensible target population. 

Then in 2007 came the spectacular case of guilty pleas by a subsidiary of Purdue Pharma and several of its executives for ‘misbranding’ Oxycontin,  that is, promoting it far beyond any medically legitimate use in severe chronic pain.  Following that various investigations, well chronicled in the Milwaukee Journal Sentinel, showed how pharmaceutical companies employed deceptive marketing techniques, subverting medical education and research, and creating conflicted key opinion leaders and institutionally conflicted disease advocacy groups, to push more ‘legal’ narcotics  For example, see the Journal Sentinel reports the subversion of :  medical schools and their faculty; .medical societies, disease advocacy groups, and foundations; and guideline writing panels.  In 2012, we posted about how a drug company paid key opinion leader admitted to second thoughts about his role promoting narcotics.

As I described in that 2012 post, the new narcotic pushers relied on only the most sketchy evidence about the safety of prescription narcotics.  In the 1990s, they taught that the rate of addiction caused by prescribing legal narcotics was only 1%, but this was based on a tiny flawed case series of a mere 38 patients.  In 1996, a consensus statement from the American Academy of Pain Medicine and the American Pain Society, entitled “The Use of Opioids for the Treatment of Chronic Pain,” included the following statements,

Pain is often managed inadequately, despite the ready availability of safe and effective treatments.

Studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low.

Yet one of the primary proponents of profligate use of narcotics to treat chronic pain later admitted he

erred by overstating the drugs’ benefits and glossing over risks. ‘Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did,’ Dr. Portenoy said in an interview with The Wall Street Journal. ‘We didn’t know then what we know now.’


‘I gave innumerable lectures in the late 1980s and ’90s about addiction that weren’t true,’ Dr. Portenoy said in a 2010 videotaped interview with a fellow doctor. The Journal reviewed the conversation, much of which is previously unpublished.

In it, Dr. Portenoy said it was ‘quite scary’ to think how the growth in opioid prescribing driven by people like him had contributed to soaring rates of addiction and overdose deaths. ‘Clearly, if I had an inkling of what I know now then, I wouldn’t have spoken in the way that I spoke. It was clearly the wrong thing to do,’ Dr. Portenoy said in the recording.

The CDC Attempts to Moderate the Use of Opioids for Chronic Pain

So to me it seems quite reasonable the US Center for Disease Control and Prevention (CDC), being cognizant of the rising toll of narcotic addiction, would attempt to do something about it.  As reported by the Washington Post,

The government on Monday urged primary-care physicians who prescribe opioids for pain relief to rein in their use of the drugs, proposing new guidelines that call for a more conservative approach than the one that has led to a crippling epidemic of addiction to the powerful narcotics.

Just a few days after a new report showed a surge of drug-related overdoses in 2014, the Centers for Disease Control and Prevention suggested in draft recommendations that physicians tackle chronic pain with other methods, such as physical therapy and non-opioid analgesics, before turning to the powerful medications. If opioids, such as OxyContin and Percocet, are necessary, the agency recommended short-acting versions over extended release formulations, the lowest possible dose and short-term prescriptions.

It also suggested that doctors ask patients to take urine tests before prescribing opioids and additional urine tests at least once a year if they continue on the drugs, to ensure that they aren’t secretly taking other opioids or illegal drugs.

‘What we want to just make sure is that doctors understand that starting a patient on an opiate is a momentous decision,’ said CDC director Tom Frieden. ‘The risks are addiction and death, and the benefits are unproven.’

Based on the events since they 1990s, the lack of clear data from well performed randomized controlled trials of the effectiveness of opioids in chronic pain, and their obvious, known risks, that seems like common sense to me.

The Strong but Obscure Opposition to the CDC Guidelines

However,others disagreed.  The guidelines attracted immediate opposition, for reasons that were not immediately obvious.  Four days after the Post article, the Associated Press reported that the guidelines were in big trouble,

A bold federal effort to curb prescribing of painkillers may be faltering amid stiff resistance from drugmakers, industry-funded groups and, now, even other public health officials.


Critics complained the CDC guidelines went too far and had mostly been written behind closed doors. One group threatened to sue. Then earlier this month, officials from the FDA and other health agencies at a meeting of pain experts bashed the guidelines as ‘shortsighted,’ relying on ‘low-quality evidence.’ They said they planned to file a formal complaint.

The CDC a week later abandoned its January target date, instead opening the guidelines to public comment for 30 days and additional changes.

Anti-addiction activists worry the delay could scuttle the guidelines entirely.

This, however, did not make much sense.  I repeat, the evidence that narcotics are effective for chronic pain other than that due to terminal cancer is very weak.  The evidence that opioids have multiple side effects, some fatal, and can cause addiction, which has more side effects, and bad societal consequences, is strong.  So the evidence that narcotics have benefits that are worth their harms, both to individuals and society, in this setting is essentially non-existent.  So why did these guidelines go too far?  Why invoke low quality evidence, when the evidence that is low quality is about the benefits of the drugs?  Who should be sued?  Furthermore, why did the CDC cave in so readily to these critics?

The AP noted,

But industry-funded groups like the U.S. Pain Foundation and the American Academy of Pain Management warn that the CDC guidelines could block patient access to medications if adopted by state health systems, insurers and hospitals.

Of course they could reduce access.  The whole point of the guidelines is to reduce access.  But who would want more access to medicines that do more harm than good?

Then there was the issue of just who it was who opposed the guidelines. Much of the opposition seemed to come from rather obscure organizations with authoritative names.  Some of the opposition was chronicled by equally obscure, apparently journalistic organizations. (From now on, I will highlight these mysterious organizations by using bold, italic text in this color.)  For example, according to the Washington Post,

Many of the patient and physician groups opposing the CDC guidelines are part of a larger coalition called the Pain Care Forum, which meets monthly in Washington to strategize on pain issues. Officials from the White House, the FDA, NIH and other agencies have met with the group over the years, according to documents obtained by The Associated Press under the Freedom of Information Act.

The Pain Care Forum presents itself as a leaderless collective that does not take formal positions. But most members receive funding from drugmakers, including OxyContin-maker Purdue, whose chief lobbyist helped found the group and remains at its center.

The mission of the Pain Care Forum, its organizational nature (informal group, membership society, non-profit advocacy group, etc), its leadership, and its sources of funding were not entirely obvious from this article.  But certainly the drift of the article was that the organization maybe represents pharmaceutical manufacturers, particularly the previously discredited Purdue Pharma (see above) more than others.  So why not take what it says with many grains of salt.

But who threatened to sue?  Which FDA officials chimed in, and why, given that the FDA does not have a mission that includes writing guidelines?   That was not clear from the AP story.

My attempts to gain further clarity produced more mystification.  A Medscape article also claimed that the opposition to the CDC guidelines included Dr James Madara, the Executive Vice-President and CEO of the American Medical Association, and “some members of the Interagency Pain Research Coordinating Committee [who] criticized the process, according to the Pain News Network.”  It was not clear whether Dr Madara’s viewpoint had broad support in the AMA, which members of the Interagency Pain Research Coordinating Committee opposed the CDC guidelines, and whether this opposition was personal, or reflected the considered viewpoint of the committee.  Furthermore, that committee’s purview does not obviously include clinical guideline development or public health, so why it was commenting on this issue was also unclear.

The Pain News Network story which apparently was the source used by the Medscape in turn referred to a Politico story, but one which is only available to subscribers.  The Pain News Network also credited a survey by “the Pain News Network and the Power of Pain Foundation.”

The Medscape article said nothing more about the Pain News Network.which is not exactly a household word in health care journalism.  The Pain News Network story did not give more detail about the Power of Pain Foundation, whose mission, nature, leadership, funding etc was not obvious.

The Pain News Network story also quoted the Washington Legal Foundation‘s chief counsel.

The overly secretive manner in which CDC has been developing the Guideline serves the interests of neither the healthcare community nor consumers.

Similarly, the Washington Post article also credited the Washington Legal Foundation‘s opposition to the CDC guidelines,

The Washington Legal Foundation, a public interest law firm dedicated to protecting the free enterprise system, accused the CDC of trying to formulate them secretly by failing to make public the work of its original advisory committee, the Core Expert Group. The CDC disputes that accusation, but issued the recommendations in draft form Monday and will have them reviewed by another advisory panel after receiving more comment over the next 30 days, Frieden said.

Yet, neither the Pain News Network nor the Post explained why a group supporting “free enterprise” was so concerned about this issue, or what expertise it might have in this area.  It is ironic that a group that proclaims opposition to secrecy seems less than transparent about its involvement in this issue.

Finally, the nature of the Pain News Network, which claims to be a “non-profit, independent news source,” is also obscure.  It appears to be one of those non-profits that has no physical address per its web page of contact information, does not disclose its sources of funding, and if it files US Internal Revenue Service 990 forms, I cannot find them.

The most detailed article I could find about the substance of the complaints about the CDC guidelines was in another obscure source, the Legal News Line.  The article mostly described the concerns of

Peter Pitts, a former associate commissioner of external affairs at the U.S. Food and Drug Administration and now president and co-founder of the Center for Medicine in the Public Interest, can be counted among those critical of how the panel was put together.

Pitts’ main issue was that a member of the group that developed the CDC guidelines was biased. He said,

‘So you have to have as open of a mind as possible.’

And that’s exactly where the CDC went wrong, Pitts said, pointing to Jane Ballantyne. Ballantyne served as a member of the CDC’s “Core Expert Group,” which played a key role in developing the agency’s opioid guidelines.

Ballantyne, a retired professor of anesthesiology and pain medicine at the University of Washington, is a member of the International Association for the Study of Pain, or IASP, and last year was named president of the Physicians for Responsible Opioid Prescribing, or PROP.

PROP’s mission, according to its website, is to ‘reduce opioid-related morbidity and mortality by promoting cautious and responsible prescribing practices.’

‘Not only does she have strong opinions, but extra strong opinions — almost on the lunatic fringe — on pain medicine issues,’ Pitts said.

‘For the CDC to say, we’re going to put someone who comes to the discussion with such preconceived notions on such a committee, you have to ask yourself, why? And then why was it hidden from the public?’

The Legal New Line‘s example of supposed journalism did not apparently ask Pitts what was “lunatic” about wanting to promote cautious and responsible prescribing of opioids.  That seems to me like common clinical sense, the opposite of insanity.

Also, Pitts complained that beyond this alleged bias, Dr Ballantyne had a conflict of interest,

Pitts noted Ballantyne’s connection to law firm Cohen Milstein Sellers & Toll PLLC — a plaintiffs law firm that is known for its class action lawsuits and has been hired by a number of state attorneys general in recent years, including some of those to whom it donated.

Ballantyne reportedly disclosed her services as a paid consultant for Cohen Milstein to the CDC. The firm currently is helping to represent the City of Chicago in a lawsuit filed against a group of pharmaceutical companies over the marketing of opioid painkillers.

Note that in the first paragraph above, the writer apparently meant that the law firm donated to the campaigns of the attorney generals.

More importantly, why the apparent conflict of interest affecting a single member of a large group – the core expert group of which Dr Ballantyne sat included 17 people – was so important was not apparent from Mr Pitts’ argument.  Mr Pitts did not explain how any sort of advisory group that included experts in the field could avoid people who already had strong opinions about that field.  The Legal News Line article did not discuss Mr Pitts’ own background, or provide any information about the Center for Medicine in the Public Interest, which he leads.

I could not find reporting in major news outlets or medical/ health care scholarly publications about the opposition to the CDC guidelines beyond the stories in the Washington Post, AP, and Medscape, and a brief report in Modern Healthcare.  I did find numerous articles on yet another little known website called the National Pain Report, (e.g. see this one).

So to summarize so far, the opposition to the new CDC opioid guidelines was apparently strong enough to delay, if not derail them.  Yet who was in the opposition, their funding, and their interests remains obscure.  The arguments of the opposition remain unclear.  Even some of the purported journalists reporting on the opposition remain mysterious.  There seems to be a tremendous amount of fog surrounding the opposition to more conservative prescribing of narcotics for non-cancerous chronic pain.

The Common Thread – Stealth Health Policy Advocacy

It was striking that much of the opposition seemed to come from rather mysterious organizations, the Pain Care Forum, Power of Pain Foundation, Washington Legal Foundation, and Center for Medicine in the Public Interest.  However, the reporting on these organizations was minimal.  Furthermore, some of the news sources reporting on the opposition to the CDC guidelines also were rather mysterious, such as the Pain News Network, National Pain Report, and Legal News Line.

One recent media article, and some of our previous blogging, though suggest that the opposition organizations all have ties to the pharmaceutical industry, and in several cases, directly to one of the major producers of legal opioids.  On December 23, 2015, Lee Fang wrote in the Intercept by way of an introduction,

The pharmaceutical companies that manufacture and market OxyContin, Vicodin, and other highly addictive opioid painkillers — drugs that have fueled the epidemic of overdoses and heroin addiction — are funding nonprofit groups fighting furiously against efforts to reform how these drugs are prescribed.

In particular,

An investigation by The Intercept has found that the pharmaceutical companies that dominate the $9 billion a year opioid painkiller market have funded organizations attacking reform of the prescribing guidelines:

  • The Washington Legal Foundation, a nonprofit that litigates to defend ‘free-market principles,’ threatened the CDC with legal action if the agency moved forward with the proposed opioid guidelines. The WLG claimed the CDC’s advisory panel for the guidelines lacked ‘fair ideological balance,’ because it included a doctor who is part of an advocacy effort against opioid addiction. The WLF does not disclose donor information, but has filed friend-of-the-court briefs on behalf of Purdue Pharma, the makers of OxyContin. In a recent article with Pain News Network, a spokesperson for Purdue Pharma conceded: ‘We’re long-standing supporters of WLF, in addition to several other business and legal organizations. We’ve provided them with unrestricted grants.’

  • The Pain Care Forum organized opposition to the CDC prescribing guidelines, mobilizing regular meetings among stakeholders opposed to the idea, according to an investigation by AP reporter Matthew Perrone. A recently re-filed complaint by the City of Chicago found that Burt Rosen, the chief in-house lobbyist for Purdue Pharma, controls the Pain Care Forum. A former drug company employee allegedly told investigators that Rosen tells the Pain Care Forum ‘what to do and how we do it.’ The Pain Care Forum is funded through contributions by
    Purdue Pharma, as well as major opioid manufacturers Cephalon, Endo, and Janssen
    , a subsidiary of Johnson & Johnson.

  •  The Power of Pain Foundation, a group funded by Purdue Pharma, asked supporters to contact the CDC in opposition to the guidelines, claiming that ‘taking away pain medication and making providers afraid to prescribe due to your guidelines is only going to make more abusers, increase suicides, and tear apart the lives of millions.’

Fang also noted that the Legal News Line, the source of the story documenting Peter Pitts’ problems with the CDC guidelines, also is tied to the pharmaceutical industry:

The U.S. Chamber of Commerce, a corporate lobbying group that represents opioid manufacturers, including Johnson & Johnson, issued a press release masquerading as a news story [published by the Legal News Line] criticizing the CDC guidelines. (The U.S. Chamber operates a public relations effort dressed up as a bona fide media outlet called Legal Newsline, which it uses to disseminate stories that support the political priorities of its member companies.)

In addition, on Health Care Renewal we have previously discussed the Center for Medicine in the Public Interest.  Back in 2008, we noted that when writing for the New York Times, Mr Pitts had to disclose that the Center for Medicine in the Public Interest receives pharmaceutical industry funding, including from Pfizer and the PhRMA.  At that time, Mr Pitts’ day job was  Senior Vice President for Global Health Affairs at the big public relations firm Manning, Selvage and Lee. Manning, Selvege and Lee had many big pharmaceutical accounts  Since then, he moved on to become director for global healthcare at Porter Novelli, also a public relations/ communications company with many health care corporate clients, including pharmaceutical companies, and now appears to be a consultant in the life sciences area for YourEncore.  I cannot find any updated information on current Center for Medicine in the Public Interest funding, but there is no reason to think that it is not still funded by the pharmaceutical industry.

Mr Pitts’ published objections to the CDC guidelines had to do with the supposed bias and conflicts of interests of a single member of the guideline expert panel, and the alleged lack of transparency of the guideline project.  Yet Mr Pitts was not very transparent about his own background, and his and his organizations’ financial interests.  For Mr Pitts to condemn the guideline panel member’s conflict while hiding his own conflict amounts to a garish example of the logical fallacy of special pleading.  Similarly, the Washington Legal Foundation‘s objections to the alleged biases of the guideline panel, given that  foundation is apparently funded by Purdue Pharma, is another garish example of the same logical fallacy.

On the other hand, the Pain News Network and the National Pain Report remain obscure.   The former claims to be a non-profit organization, but I cannot find its federal 990 filing, identify its board of trustees, or even determine its physical address. It does claim an affiliation with the Power of Pain Foundation.  The National Pain Report at least has a physical address, which it shares with the equally obscure American News Report. Other details, like its ownership, remain obscure.  The failure of supposedly journalistic organizations to publicly reveal basic information about their nature and operations does raise suspicions that they are not really so journalistic.


In summary, the organizations most widely mentioned as opposing the new CDC guidelines that recommend more conservative use of opioids for chronic pain seem to be heavily involved with the pharmaceutical companies that make such opioids.  Thus, the opposition to the guidelines seems to be arising from a stealth public relations campaign leading to stealth health policy advocacy.  Furthermore, at least so far, the objections to the guidelines do not seem clearly based on logic and good evidence from clinical research, again suggesting they are more about financial interests than improving patient outcomes and reducing risks.

Overuse and misuse of opioids, which may lead to all the individual and social consequences of opioid addiction, are clearly major, worsening medical and public health issues.  We need earnest effort to address these problems, which should be informed by a logical, evidence-based discussion of the clinical and social realities.  Such a discussion is only hindered by the growing fog of objections launched by mysterious organizations funded by the companies who have made the most money selling narcotics.  So we also need some societal response to the growing domination of the public debate by marketing and public relations, often based on emotional manipulation, logical fallacies, and outright deception.

We cannot address our worsening health care dysfunction when public discussion and policy making blunders about in the fog of stealth health policy advocacy, stealth lobbying, and stealth marketing.  If the leaders of big health care corporations really believe they are making good products and providing good services that add value and improve patients’ and the public’s health, they ought to be able to rely on honest and open communications.  If they cannot disavow stealth public relations and stealth marketing, we ought to disavow the companies that practice them.

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  1. timotheus

    Amazing how simple it is to dupe journalists who don’t do their homework with a sober-sounding but bogus official title. Those eager to get “both sides” of a story frequently concoct a “blazing straddle” of he said/he said that ends up sounding like Talmudic exegesis with plenty of room to escape the facts. If a reporter isn’t alert enough to ask–and find out–who is behind the “educational” or “patient-advocate” entity mouthing industry propaganda, they become its mouthpiece. The tobacco industry pioneered this strategy, followed by fossil fuels, to the point where facts are obscured right up to the point when you can boil eggs in your swimming pool.

    1. Carolinian

      It’s hardly original to point out that the target audience for most news organizations is not their readership or viewership but rather their advertisers. On any given tv news show a huge proportion of the ads are from drug companies. A ban on drug advertising–as seen in other countries–would not only be good medicine but would also remove this incentive for the media to play nice with big pharma.

      Hard to see a solution on the horizon but at least we have the web and articles like this one.

      1. subgenius

        “I don’t practice what I preach, because I am not the kind of person I am preaching too”

    2. Elizabeth Burton

      It’s important to keep in mind that in many, if not most newsrooms, a knowledge of science is not a prerequisite for reporting on same. Indeed, at one daily for which I worked it was considered a disadvantage since clearly anyone who might know how to ask pointed questions and understand when they were maybe being handed a basket of goods couldn’t be unbiased.

      That kind of attitude makes it easy for this to happen, and it’s gotten even easier as experienced journalists are replaced by newbies who can be paid less and be less likely to object to slanted stories.

      1. Carolinian

        Indeed, at one daily for which I worked it was considered a disadvantage since clearly anyone who might know how to ask pointed questions and understand when they were maybe being handed a basket of goods couldn’t be unbiased.

        Amazing. I’ve always believed that reporters are primarily hired for their ability to turn out good copy on deadline. In the same way tv reporters tend to be “news performers” whose stories are often researched and reported by behind the scenes producers. The romantic truth seeker role depicted in movies like Spotlight is very rare these days.

    3. jkl

      This is seen in pharmacy all the time. Depending on the community, patients sell them on the street. However, there are tight-knit networks of hydrocodone and oxycodone addicts that push for early fill, are dysfunctional, complain of lack of a full script, etc. Some Southern states have such a severe problem, that chains and indepedents are under unofficial orders to not accept new C2 narcotic patients.

      I heard Japan allowed direct-to-consumer advertising, the U.S. as the model. The U.S. is still a trend setter.

  2. Juneau

    I believe this is the reason buprenorphine was not approved as an oral pain medication even though the overdose risk is lower than with the full mu agonist opioids. Wonderful expose.

    What a shame that medicare has put hard limits on PT (I think it is 30 visits a year which sounds like a lot unless you really need more for chronic pain or have multiple issues)….and alternatives are not promoted more. Many pain specialists do urine testing. Still physicians are essentially mandated to do FDA approved treatments in standard of care to treat pain. Without adequate insurance coverage for alternatives even if physicians change their practices patients won’t be able to pursue.

    Seen so many 20 somethings on oxycodone for first episode back pain…

  3. alex morfesis

    Pirate gangs and krewz…doctor pleez…4 more of these…things are different today…

    Paging the delaware atty generals office…your allowance of pirate corporations to operate in your state as a chartered entity helped leave one or two orphans last year…and the year before…and the year before that…hope improving your golf game is a fair trade off…maybe you could join some state troopers as they watch people scrape body parts off the asphalt…

    Through the busy dying days…

    Inalienable rights have had to be suspended since 2001 because a thousand extra people died due to the terminal incompetence of mayor rudy and his incapacity to properly fund a fire department to handle a problem above the 7th floor in a city of iron and steel mountains…

    Yet over 250 thousand americans have died since then from the refusal of the Delaware AG to use its charter suspension and revoking powers to stop a bunch of biker gangs in brooks brother suits

    But that handicap has adjusted…and that is really all that matters…maybe a photo op with tiger before his nike contract expires…

  4. abynormal

    i’m impressed with al Jazeera in depth & undercover expose on opiates over prescribed to elderly.
    sadly, the obviously most vulnerable patients response are “Because My Doctor Told Me To”

    It’s no secret that there’s an opioid drug addiction epidemic in the U.S., which consumes 80 percent of the world’s pain pills. But what may be surprising is that a growing number of American senior citizens are also becoming addicted to these powerful painkillers.

    According to a lawsuit brought by two counties in California, top opioid drug makers targeted certain well-insured groups, like the elderly, in their marketing to doctors. And it claims that prominent pain management physicians were complicit in promoting misleading facts about the effects of these painkillers on seniors.

    Fault Lines speaks to former and current elderly opioid addicts—as well as a man who lost his wife to an overdose—and looks at how some are fighting back to stop the epidemic in its tracks.

    1. ambrit

      I obviously hang out with the wrong crowd. Most of the doctors I encounter under ‘professional’ circumstances are afraid to write prescriptions for any opioids. Even when I legitimately needed some. (Actual exchange: “This infected tooth is so painful, my eyes sometimes begin to water. Please help.” Doctors nurse: “Try alternating two Acetaminophen with two Ibuprofen every two hours until it stops hurting.” This from a doctor I’ve visited before and never raised the issue of pain pills with.)
      As I said; I obviously hang out with the wrong crowd.

      1. Yata

        “This infected tooth is so painful, my eyes sometimes begin to water. Please help.”

        At the risk of catching you at a disadvantage, the simple cure for that is chewing the bark, or slender twigs, of a prickly ash tree. Remove the thorns first of course. I’ve never heard of anyone suffering a dependency problem form this, must be the awful taste.

  5. sd

    Not mentioned, if a physician prescribes a pill, insurance is more likely to cover the visit with no questions asked.

  6. Eleanor

    Another possible factor in the rise in drug use is the state of the economy and the country. If people’s lives turn to crap and they have no hope for the future, they are likely to turn to some kind of pain killer. I just got back from a visit to a very prosperous part of the country, full of the weekend homes of well-to-do city folks. The original local economy has been destroyed, and there are no decent jobs for the children of the locals. There is apparently a drug problem among kids who have no future they can see.

    1. bob

      “I just got back from a visit to a very prosperous part of the country, full of the weekend homes of well-to-do city folks”

      Best summation of those “communities” Ive heard- You either have 8 houses, or you have 8 jobs.

  7. John Day

    As a MD since 1986, I have seen this turn to long term use of addictive opioids play out over time, and it has been puzzling. We all knew that the doses have to keep rising to get the same effect, and that the risks of toxicity and fatality follow them. “Pain Management” has become a medical specialty, and it largely comes into play for funded patients who have already tried non-narcotic pain control, and are ready for things like oxycodone and frequent visits for prescription refills.
    The urine testing does another thing It tells if the patient is actually taking the opioid. Some are not. These things are very big money at street-level, a real monthly income for some people. Those people really fight tooth and nail for their prescriptions, their livelihood, their rent, their car payment and groceries. They may be accompanied on their visits by a concerned family member., advocating for their needs.
    Many of us in public health have never fallen into the trap of prescribing short term medicines for chronic problems. We were taught the problems of this in medical school. Nothing has changed except the cash flows.

    1. bob

      I had a friend who was selling legal drugs to docs in the oughts. He had insanely detailed, in some cases down to the city block, reports on usage. Areas that were shown to not be using enough had their Dr’s pitched.

      The data was so granular that it’s a complete lie that the drug companies don’t know A) who is writing the scripts and B) who is receiving the scripts.

      The way they presented the data was also very odd- “zoomed out” just enough so that they could claim “privacy” was being protected. I had a feeling that they had much more detailed records and then had to dumb them down a notch to make it look like they were respecting privacy.

      It completely belies the notion that the people making and selling this stuff don’t know it’s being abused, and EXACTLY where it is being abused. They have to send the drugs there, after all.

      1. John Zelnicker

        The feds just busted a couple of pain docs here in Mobile. They were writing about 185 prescriptions per day (!) for opioids. (All the nursing staff were filling out scrips, as well as the docs.) They were also busted for Medicaid/Medicare fraud for billing for procedures that were never performed. They got away with it for 6-7 years before being taken down.

        It was so lucrative, one of the docs had 7 or 8 very high-priced luxury cars such as a Bentley Continental, a Ferrari, a Maserati, a Lamborghini, etc.

        1. ambrit

          I was on a Federal Jury for a “pill mill” case arising out of Biloxi. The “perps” had leased an older strip mall and were running the “Doctors Office” on one end of the “mall” and a Pharmacy on the other. It was ‘advised’ that patients use the adjacent Pharmacy so as to avoid “Imperial Entanglements.” Much money was made by all and sundry. The local law were nowhere to be found. It took the Feds to bust the operation. Then, to top it all off, the trial ended in a ‘hung’ jury. This was such an ‘affront’ to the Law that the Judge came back to the Jury after the verdict was read and questioned us as a group as to why no conviction was forthcoming. Plainly put, the street level ‘narcs’ had acted up a bit in the court gallery, like kids playing a game, and alienated the Jury. The ‘perps’ were tried again and finally convicted.

  8. tegnost

    I recall some news last fall re oxycontin quotas, where production quotas were increased beond demand. A less than simple google search turned up these stories…
    from the article
    “Purdue was ordered to pay a fine of $600 million for deliberately misleading doctors between 1996 and 2001. Not a single day of incarceration for any of the convicted executives was ordered.”
    Too big to jail I guess…


    from the article

    “in 1997, a year after prescription drugmaker Purdue Pharma first brought Oxycontin (the first branded version of Oxycodone) to market, the total production quota approved by the Office of Diversion Control was 8.3 tons. By 2011, it had risen to 105 tons, an officially sanctioned 1,200 percent increase over the same period that saw Oxycodone emerge as what Haislip calls “the Cadillac of America’s prescription drug abuse crisis.”

  9. Left in Wisconsin

    What boggles the mind in this story is not the sleaziness of the drug companies and the front groups they sponsor, which is disgusting but not at all surprising, but how easily the CDC rolled over to accommodate them. Your government at work (against your interests).

  10. Synoia

    All I read comes down to greed.
    What happened to common good?
    It died, for lack of profit.
    Profit and greed are sovereign.

    This is not the world which we believed,
    it is the world we have made,
    we worship greed.
    What’s in it for me? How sad.

  11. DWD

    On December 12, 2006 at 8:20 in the morning I started my teaching day by reaching into my bottom desk drawer for some paper as I needed to duplicate a lesson. In my rush to get this done before the students arrived at 8:25 I neglected to close the bottom drawer. Carrying the sheaf of papers against my chest I managed to block my view of the drawer and tripped.

    I fell harder than I can ever imagine. When I got up I was woozy and blood was dripping all over. I managed to get the principal’s office and asked him to welcome the children to get me a few minutes to get my shit together. He agreed.

    Fifteen minutes later I resumed my duties. (Blood on my shirt and the floor and a tremendous headache)

    The upshot of this is that I displaced C4 and C5 vertebra. I have tried everything I know of to stop the constant pain: therapy (at least five different times) injections in the spine (4) consultation with a surgeon (who gave me a 50/50 chance of things getting better – and could get worse)

    I went through the usual assortment of pain pills: acetominophen, ibuprofin, finally moving to Tramdol which worked for a while but I developed an allergy. Tried Vicodin to the same effect. Had a great drug to us in Darvon but it was determined this should be removed from the market. Tried codeine and even daily dose weak morphine – none of these worked and the pain made living a normal life nearly impossible.

    Finally the doctor prescribed Endocet (Oxycodone and Tylenol) They have worked ever since and really are necessary to my enjoyment of life.

    I try to take less than I am prescribed and only take a half dose at a time as taking a whole dose distorts my reality.

    I read about these people who do not suffer this debilitatation and thinking, “What can they know of the misery?”

    I dunno: used judiciously they are a godsend. And yes, they can be abused but don’t lump everyone together here.

    1. Michael

      This is almost precisely my experience. Was up to 30mg of Percocet (oxycodone and acetominophen) a day for 3 years. Eventually, the underlying condition got properly treated, an event which required me to be functional enough to do my own detective work.

      I titrated myself off over a month. The last week was truly terrible, and I was in a lousy mood for a couple of months. Then I got over it.

      Withdrawal isn’t that bad. You just have to want to live afterwards. If you’re in chronic pain, physical or emotional, you won’t. Most people live lives of quiet desperation.

    2. Ben G

      Thanks, I too suffer from lower back pain. Therapy helps, but is expensive. One must be very careful, but the meds are the difference between functioning and excruciating pain some days. How dare some bureaucrat decide for me whether I can get relief or not. Imagine not being able to sit, stand, or lie down without throbbing nerve pain. Have some compassion people.

  12. Patricia

    A few peculiar quotes:

    “The CDC estimated that 20 percent of patients who complain about acute or chronic pain that is not from cancer are prescribed opioids.”

    “….evidence that narcotics are effective for chronic pain other than that due to terminal cancer is very weak.”

    “…fog surrounding the opposition to more conservative prescribing of narcotics for non-cancerous chronic pain.”

    Yes, big pharma sucks. Yes, there are addicts and abusers. Yes, our government is captured. Yes, there are stupid doctors out there.

    But in exposing these things, one needs also remember that there are many who require help to endure pain. You know, besides the above-mentioned cancer patients. :eyeroll:

    Please avoid a bandwagon that will drive to insanity/suicide those who suffer daily loud pain, who have tried all the options and who well know the problems of the few available medications for reducing pain to manageable size. (This includes many old people.)

    It is good to keep several thoughts in mind while also refusing the weird deep-Calvinist re-up that we USians seems to keep discovering, like a virus in the interstices of our psyches.

    1. Lee

      I suffer from severe chronic pain from spinal stenosis and spondylolisthesis. I cannot tolerate anti-inflammatory drugs and physical therapy has little effect. The surgical options are highly invasive and risky. Even if successful the recovery period from the surgery is a year.

      I have been using low-dose, time released Oxycontin for years to good effect. I don’t get high and am capable of mental and physical activity that would otherwise be impossible not to mention that the pain might well have caused me to end my life years ago.

      I am required to visit the doctor every 60 days, take a urine test, and am issued two specially printed scripts for 30 days supply each. I can only acquire 30 days worth at a time and only after at least 75% to 90%, depending on the pharmacy, of my existing supply has been used.

      1. Inverness

        I’m very glad you get relief. Not everyone does — I found morphine added depression to the mix, it stopped helping the pain, in a very short time, although that could have been because the pain was increasing.
        I wish I were encouraged to try marijuana, at least for the nausea. I don’t think people here are suggesting there are not appropriate uses for these kinds of heavy drugs, but it is also interesting that with the lovely state of American health care, there is no discussion of pain clinics and how they could help people manage severe pain.

  13. Jim Haygood

    One has to wonder whether old-fashioned opium is safer than concentrated products such as oxycontin and heroin.

    Since neither the pharma cartel, nor the physicians guild, nor the drug prohibitionists (whose objective is to feed the Gulag) necessarily have our best interests at heart, maybe it’s time to take control of our health by planting poppies fencerow to fencerow.

    Laudanum, comrades: your great grannie swore by it.

    1. Swendr

      Hah! Confused you with Jim Hogshire for a minute there. He wrote Opium For The Masses on that very subject. Worth a read if you can find it. I think he wrote a decent Harper’s article on the subject in the ’90’s too.

    2. Lord Koos

      As far as I can tell, the main difference between synthetic Vicodin, Oxycontin, and real opiates, is that the first two can be patented…

    3. ambrit

      *Looks around furtively* Psst! Hey, bud! Yeah, you. Cmere! Opium? You mean the stuff the Chinese government went to war to try and stop? (Where do you think Hong Kong came from?)
      The Manchus fought to stop it for a reason. Plain old Opium is indeed an addictive substance. Its’ use was measured in “pills” per day. Regular use makes one pretty much useless for high level functioning. (Take it from me.) The only other substance that produced such an effect was Prozac. There’s an interesting intersection for you. Opium and Prozac have similar effects, and for similar reasons; to help escape from something.

  14. newyorker

    Consider the incidences of working class people claiming back pain turned down repeatedly by disability, and so must work their miserable say Walmart jobs for support or rely on family. What are their options? Sometimes a suboptimal risky solution is better than none at all. Sometimes there really are no good solutions and not all people are paragons of self denial who won’t even take aspirin.

    Consider as well what drives otherwise respectable people to buy brown street heroin when their supply of opioids is cut off. At least the pharmaceuticals come in measurable doses; now the amount of heroin to administer is anyone’s guess and can easily result in an overdose.

    Reformers should take care not to further injure the vulnerable, given the stingy realities of social services. Do not make the perfect the enemy of the good.

  15. nat scientist

    It’s a good drug when it’s produced by and delivered by monopolies,
    and renders the individuals numb and dumb.
    What’s not to expect? There is no surprise for business as usual.
    Free-range for chickens, but the war on natural substance economy is the cage.

  16. Swendr

    I hate to accuse our anecdotal pain-sufferers of being paid commenters, but the thought occurred to me. You will note their arguments completely ignore the substance of the post. I’m no Calvinist, but the current situation is bad. I’d suggest new guidelines and massive funding for treatment of the addicted paid for by fines on Pharma.

    1. Patricia

      This is the problem I was trying to address in earlier comment. You are not alone in your suspicions but where do they come from? Do you believe that whoever complains of chronic pain must be a wimp and whiner? Or is it ignorance?

      I have rheumatoid disease. Most of my joints and their fascia, surrounding ligaments and bursa are inflamed to varying degrees. It is an auto-immune reaction for which science has yet found no source. Unscrewing a lid means using ~15 inflamed finger/wrist joints. Activity makes inflammation worse and yet I need exercise to stay healthy. The couple of outrageously expensive biologics I’ve tried (yes, big pharma) don’t do much for me. I am on injections of methotrexate (cancer drug) and plaquenil (anti-malarial) and they help somewhat. Anti-inflammatories have stripped my intestines.

      The reason I am cranky today is that I moved 2 months ago but my appt with a new rheumatologist is still three months away (yay, US health care). I am in pain and cannot do much at all until that appt because a doctor may give only a one-month script for pain meds without revisiting his office.

      Because there are addicts/abusers, because there is corruption in big pharma and government, because of foolish doctors (see, I read the post), many people in chronic pain are fighting to get what they need to live reasonable lives.

      Of all the crises, of all that which is f**ked up, why is this one being acted upon?

      Prohibition, war on drugs, austerity, fighting decent minimum wages, narrowing health care, limiting pain medicines—these are similar responses. They smack of stoicism, guilt-assumption, bootstraps, workaholism, bucking up, and buckling down. We put up with it. So I wonder whether these are stains remaining on the social psyche long after certain strains of Protestantism have left the room. I don’t know what else it might be. I’d be glad to be enlightened.

      1. McKillop

        Hello Patricia (forgive me for failing to respond to your initial post addressing me sometime back when F. Beard counselled patience to divine testing!) – curiously, I was going to respond to Swendr by referring to your initial post but was called away and so avoided any comment. Brava to you for responding.

        People do seem to enjoy minimizing the pain of anyone other than themselves and spend time rehearsing the poorly scripted lines of ‘journos’ who either refuse to seriously consider the nature of suffering or conflate heroin use and deaths with therapeutic use of medicine made unavailable. My own doctor has distinguished between dependency and addiction and points out that diabetics are not considered addicted. And you and I and other people who suffer rheumatoid arthritis know that their is little appeal, or possibility of, a “high” when even pain management is difficult. Judicious use of pain medication is the key and, I think, after listening to many people who suffer, the norm.
        Further, so long as people are able to access medicine, and not have to depend upon street drugs or exorbitantly priced ‘second-hand’ prescriptions, I’d argue that there is less of a chance of fatal abuse. If a person cannot get a doctor to oversee medical treatment then any relief becomes desirable. Psychological pain may require different treatment but people do what they can, including abusing alcohol.
        I’m concerned that bureaucrats, self-serving pharmaceutic corporations and rabble rousing by media will harm rather than help patients who should be listened to and given heed.
        Stay well.
        By the way, I’m currently using a biologic in ‘pill’ format that is doing wonders for me. And while the damage done in the past still causes pain the disease itself has abated somewhat miraculously.(pace M. Frank).

        1. Patricia

          Hey, McKillop, marvelous that orals are working! Having one’s life back, yumm.

          I don’t remember your lack of response back when F Beard was around, so no problem. (I miss him, a tiny bit.)

          Very good to remind about the difference between dependency and addiction. It shows up even when one has to stop a drug—the former is frustrating/wearing, the latter is terrible.

          May the orals continue to work for you…for decades.

      2. swendr

        Do you believe that whoever complains of chronic pain must be a wimp and whiner? Or is it ignorance?

        In the context of this debate, I consider that person selfish and short-sighted – justifiably so in the case of someone who is sincerely suffering. Nonetheless, this article is about the wider suffering in society by those unwitting patients that research shows do not benefit from the use of legal narcotics, yet end up hopelessly addicted. I guess I’m agreeing with the author in as much as new stricter guidelines would help by reducing the flow of new addicts into what looks to be a broken system of blatant exploitation by drug companies and their hired concern trolls. It’s odd that someone with a presumably legitimate case of need would argue against the guidelines that would not affect them, guidelines that are designed instead to prevent some of the worst abuses of the pharmaceutical companies and careless doctors. Calling that prohibition is disingenuous, and frankly, it smacks of something a paid commenter would say. Please do note that the article was also about how these same pharmaceutical companies have stooped to hiding their influence on the debate behind a bunch of fake non-profits and news sources. Is it really much of a stretch to assume they would pay a bunch of commenters to come on a popular blog like this and muddy the water?

        1. Yves Smith Post author

          There has been a great deal of straw manning of this article and the CDC’s position. No one is talking about getting rid of the use of opiates for chronic pain. What they are talking about cracking down on is overprescription. The way the authorities will do that is to go after doctors who write too many scrips, not after patients.

          Having said that, when I had severe pain (lost clot after having a wisdom tooth pulled, you have no idea how awful that pain is), I took opiates. I had a scrip for Vicodin and took it. Not only did it do squat for the pain, I felt crappier. The only thing that gave me relief, and then not much, was once an hour doses of OTC painkillers. I’d do one day on aspirin and the next on naxprofen (sp?) sulfate (brand name Aleve).

          1. Inverness

            Straw men arguments, indeed. As if anyone is begrudging anyone relief. Years ago, I su broke my elbow, and both specialists I consulted pushed Percecets. Yet OTC drugs were more than enough. What’s going on in that scenario? Why would doctors push for the heavy stuff, when Advil did the job?

            As I already mentioned, Morphine wasn’t helpful for my severe, chronic pain. And boy, those accompanying dark thoughts weren’t pretty. So, some considered arguments as to why, for me, opiates were highly problematic, at best.

            I wish people would avoid “you have no compassion!” arguments, and simply add nuance to the discussion. Instead of shutting down different experiences, which is what makes the NC boards so meaningful.

            1. Yves Smith Post author

              Did you miss the post??? Big Pharma pushes the stuff!!!

              Every time I see a dentist for anything non-trivial, they are all over me to give me a scrip for painkillers. I get handed them even when I say I don’t want them.

              And as a doctor who has experience with presecribing opiates said, way higher, is that opiates stop working at the same dose over time. You have to keep INCREASING the dose to get the same relief when you do get relief, and ultimately, the patient starts having problems with toxicity.

              In other words, opiates are a bad solution for long-term pain management. But the need to increase dosage is no doubt a very attractive feature for Big Pharma, and has likely led them not to bother to find (or promote) alternatives.

          2. wendy davis

            From the little I know, NSAIDs are frequently helpful because of their ‘anti-inflammatory’ properties. (The ‘A’ in NSAIDs.) With dentistry and oral surgery, the swelling can equal heat and pain. And I’ve heard that dry sockets are indeed agonizing.

  17. kcalkin

    When I have a back spasm, I cannot get up to go to the bathroom or fix myself something to eat. However, these spasms happen only a couple of times in six months. I use Vicodin, and the pain goes away in a few days. Then, I stop taking the Vicodin until my next spasm. I would never take an opiate for continuous pain, because it might lead to addiction. I feel very bad for people with unremitting pain and hope that the vaunted use of venom for pain relief might become a reality soon.

    1. McKillop

      Venom seems to be used now to hinder patients from pain relief. Patricia asked for a motive for now increasing restrictions beyond the social virus of protestant belief that suffering is good for the soul. It seems to be merely -ha! “merely!- just another effort to impose control upon people who are demonized so that austerity is justified.
      Only lazy people demand welfare; only union members are greedy; only those of weak character need opiates and heroin. Alas. No wonder the western world is troubled and -must be made great again -having been taken back by the worthy.

      1. Patricia

        Re the ‘suffering is virtue’ meme, I was thinking primarily of the OP author, who is an MD ensconced in academia. There are numbers of practicing doctors who think similarly to him re pain. It’s an occasionally heated debate within medicine. Why would a doctor believe that cancer is the one legitimate reason for heavy pain medicines? Because it comes to an end, one way or another? But so also does death create an end for old people with failing bodies. So also does healing for the damage caused by many accidents.

        What is it about the research that brings this author to his conclusions?

        This one issue is ignored among the many important problems that the doctor so ably delineates. It’s fascinating and frustrating.

        Perhaps many of our doctors-in-training are taught science at the expense of art. Perhaps it gives rise to an arrogance of certainty which merely looks like the old Protestant meme. I am unsure.

        For those like Swendr, I suspect lack of empathy or ignorance or both.


  18. lyle

    Of course there is the libertarian alternative, legalize drugs, provided that operating machinery under the influence is still an offense, ala Co and weed. Interestingly history reveals that before the Opium wars China did not have a large percentage of addicts. Then of course big pharma might become big recreational drug sellers. You might slap a tax on the drugs to pay for rehab and the like, (taking its cost out of medical insurance)

    1. ambrit

      I don’t know about the percentage of the population of 18th and 19th century China using Opium, but imports of Opium into China showed a great increase prior to the First Opium War.
      This on top of domestic production! We are talking about Tonnes of Opium. The Quing Dynasty outlawed it for a reason.
      Malraux has some interesting things to say about the Opium habit in his book “Mans’ Fate.”

  19. HarrySnapperOrgans

    In a ‘single payer’ system, (e.g. UK – though increasingly less so of late) there are well-founded (collective) financial grounds for the state to play a significant role in control of access to medication. In the US: less so.

  20. Jim in SC

    I would encourage anyone experiencing chronic pain to give acupuncture a try. It either works for you or it doesn’t, but I have a family member who essentially became pain free through acupuncture after being told by a surgeon that her only hope was a shoulder replacement. Acupuncture sometimes takes a few months to work, but if you can avoid surgery, it is worth it.

  21. Wade Riddick

    What’s really interesting is how they’ve tanked the use of good science for pain management over the last decade. This goes way beyond physical therapy and B vitamin shots. If you absolutely have to use opiates, it’s very easy to prevent the side effects in most patients. For at least a decade, we’ve know that low-dose naltrexone can reduce tolerance, addiction and dependence on opiates. Even by itself, LDN can relieve pain – and, yet, for some magical reason nobody prescribes this cheap drug and nobody reimburses for it.

    LDN also prevents/treats some cancers via the OGFr pathway and also treats autoimmunity via B cell deletion, making it at least $50,000 cheaper than the other alternative on the market for this, rituximab. LDN is one of very few compound that can do all three things at once.

    In terms of over-the-counter items, low-dose lithium and agmatine probably also have this affect on opiate addiction (and sugary diets definitely worsen addiction). Yet rather than do cheap things to solve the problem, corporate America will brook no inconvenience for its margins on addictive foods and overpriced sick care.

    The FDA’s response?

    They want to shut down the compounding pharmacy industry that also supplies remedies like methyl-cobalamin shots for chronic pain – you know, because addicts are so busy buying vitamins on street corners and fighting over supply routes in Afghanistan.

  22. Wade Riddick

    I forgot to mention that, aside from the loss of fiber in the diet – which feeds healthy bacteria – antibiotics are also a direct driver of opiate addiction in society (and, to a lesser extent, cannabis use). These healthy bacteria regulate our opioid and cannabinoid networks. Without them, it’s possible to develop pain sensitivity all on your own with no external driver. Gut worms also regulate opioid signaling and, of course, all Americans are dewormed. The CB1/CB2/mu opioid receptor complex is a deep regulator of inflammation, immunity and adipose tissue, not to mention the CNS. Interrupting this complex involves every end of the food industry.

    fiber -> feeds bacteria -> butyrate -> CB1/CB2/mu opioid receptors
    -> GLP-1 -> insulin sensitivity

    !-> dead healthy bacteria -> insulin resistance -> diabetes, Alzheimer’s risk (+ acne, PCOS)
    !-> loss of mu opioid/CB1/CB2 receptor levels -> chronic pain, cancer, autoimmunity risk

    no fiber in diet
    !-> dead healthy bacteria -> no GLP-1 -> insulin resistance -> diabetes, Alzheimer’s risk (+ acne, PCOS)
    !-> loss of mu opioid/CB1/CB2 receptor levels -> chronic pain, cancer, autoimmunity risk
    !-> bad bacterial overgrowth
    !-> excessive sugar/insulin in the blood -> excess dopamine release in brain -> dopamine resistance
    -> insulin resistance

    It sounds crazy until you experience it.

    Omega-3’s act similar to dietary fiber in that they also promote insulin sensitivity via GLP-1.

    There’s nothing Calvanistic about having your free will sabotaged through drug delivery devices we call junk food.

  23. Roy M Poses MD

    Just a reminder – the original blog post was mainly about stealth public relations/ stealth health policy advocacy. I tried to focus on the organizations which made rather vague complaints about the CDC guidelines, centering on allegations of lack of transparency in and conflicts affecting the guideline development process. Yet these organizations were not exactly transparent about their own glaring conflicts of interest. Furthermore, their opposition was publicized by somewhat mysterious news sites, at least one of which actually appears to be a full-time PR operation by the US Chamber of Commerce.

    I did not mean to discuss the content of the guidelines in detail. Yet nearly all the comments here seem to be about the management of chronic pain, not the issues I brought up. And many comments make all sorts of complex biological or clinical assertions without supplying any evidence, especially from good clinical research, to support them. And this is on a blog focused on economics, politics, business, finance, etc not medicine or health care.

    I realize comments sections often get tangential, but this one has gotten so tangential I wonder if some of the comments are meant as deliberate distraction?

    1. Drew F.

      No doctor. Nobody is intentionally trying to throw this off topic.

      The reason so many of us are writing about pain is because it’s been completely ignored in this whole effort to reduce overdoses of pain medication. In fact, although I doubt you intended to in this piece, in demonizing the bad parties without discussing the real issue pain sufferers are experiencing (severely increasing cost and effort required to get even minimal treatment because of the attempt to shut down these bad actors) you allow the reader to go on with whatever misconceptions they may have about pain sufferers. I think it is safe to say that most believe that those who use opioids use them because they are spineless, weak people.

      I would guess the reason so many of us have written about our pain problems is we’re trying to get people to understand exactly what we are experiencing so they don’t continue on with these misconceptions. We’re not all malingerers.

      We should not be forced to bear the cost of these overdoses which is what is happening. The increased visits to the doctor, the need to always have a paper prescription, urine testing, smaller prescription quantities leading to increased total cost for less treatment.

      I want to hold the pharmaceutical companies responsible, just like you. But I don’t want to be the scapegoat. I don’t want to bear the majority of the cost. The only way I can make this happen is by getting more people to be empathetic of our situation. Therefore, we submit to forms like this.

      1. Yves Smith Post author

        Yes, you ARE throwing off this topic.

        The issue is cracking down on what is a clear, massive public health problem. Did you miss that lifespans are falling among lowering income white, and opiate abuse is the number one cause of deaths? And those opiates are prescribed by doctors?

        The restrictions are not going to take place on a patient level. Way too costly to enforce. The enforcement mechanisms will target doctors who overprescribe. It won’t be hard to see at a practice level.

        And I also have to tell you that the data says that only a minority of people who have non-cancer-related pain get relief from opiates. I can confirm that from my own experience with Vicodin. Never never gonna ever take that again.

        Someone with long-standing use, particularly if they use it only in acute phases, is very unlikely to have a problem.

  24. Wade Riddick

    Your case for fraud in drug marketing is bolstered by the twenty years of fabricated papers on painkillers that came from a single researcher, Scott Reuben. He falsified literature on Pfizer’s Bextra, Celebrex and Lyrica (not to mention Merck’s Vioxx).

    If you want to step back and discuss pain relief and corporate fraud more broadly, you could discuss the $100m+ criminal fines with gabapentin and lyrica marketing. If patients want relief from chronic pain, is there any place to turn that hasn’t been involved in organized criminal activity?

    Opiate overprescription is also a cheap way to coverup the evisceration of workman’s comp insurance.

    With regards to the drug legalization issue, how do you have a rational free market in a good whose proper use denies you of that very rationality needed to partake in said market? Opiate addicts do not have rational desires. They have been reprogrammed to having irrational cravings. There is never a free market in any addictive substance.

    What in this pattern of elite behavior is any fundamentally different than what we saw with the politics of sugar cane or the opium wars?

    Imagine what the TPP agreement might do to attempts at opioid regulation in other health care systems. Corporate welfare checks for Perdue?

    It stands to reason if someone is will to cheat and bend/break the science to push a particular pain solution, opiates, they might also cheat to knock other solutions off the market.

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