'Viewing Pain as a Disease' - a Prescription for Disaster ?

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A real educator September 16, 2012 12:54 am (Pacific time)

April 20 is the counter-culture “holiday” on which lots and lots of people come together to advocate marijuana legalization (or just get high). Should drugs—especially marijuana—be legal? The answer is “yes.” Immediately. Without hesitation. Do not pass Go. Do not collect $200 seized in a civil asset forfeiture. The war on drugs has been a dismal failure. It’s high time to end prohibition. Even if you aren’t willing to go whole-hog and legalize all drugs, at the very least we should legalize marijuana. For the sake of the argument, let’s go ahead and assume that everything you’ve heard about the dangers of drugs is completely true. That probably means that using drugs is a terrible idea. It doesn’t mean, however, that the drug war is a good idea. Prohibition is a textbook example of a policy with negative unintended consequences. Literally: it’s an example in the textbook I use in my introductory economics classes (Cowen and Tabarrok, Modern Principles of Economics if you’re curious) and in the most popular introductory economics textbook in the world (by N. Gregory Mankiw).The demand curve for drugs is extremely inelastic, meaning that people don’t change their drug consumption very much in response to changes in prices. Therefore, vigorous enforcement means higher prices and higher revenues for drug dealers. In fact, I’ll defer to Cowen and Tabarrok—page 60 of the first edition, if you’re still curious—for a discussion of the basic economic logic: Pat Robertson: Pot Isn't The Devil's Harvest? Art Carden Contributor High Roller: How One Billionaire Is Bankrolling Marijuana Legalization Clare O'Connor Forbes Staff The Drug War: What is It Good For? Art Carden Contributor Should We Regulate Sugar Like Alcohol or Tobacco? Art Carden Contributor The more effective prohibition is at raising costs, the greater are drug industry revenues. So, more effective prohibition means that drug sellers have more money to buy guns, pay bribes, fund the dealers, and even research and develop new technologies in drug delivery (like crack cocaine). It’s hard to beat an enemy that gets stronger the more you strike against him or her. People associate the drug trade with crime and violence; indeed, the newspapers occasionally feature stories about drug kingpins doing horrifying things to underlings and competitors. These aren’t caused by the drugs themselves but from the fact that they are illegal (which means the market is underground) and addictive (which means demanders aren’t very price sensitive). Those same newspapers will also occasionally feature articles about how this or that major dealer has been taken down or about how this or that quantity of drugs was taken off the streets. Apparently we’re to take from this the idea that we’re going to “win” the war on drugs. Apparently. It’s alleged that this is only a step toward getting “Mister Big,” but even if the government gets “Mister Big,” it’s not going to matter. Apple didn’t disappear after Steve Jobs died. Getting “Mr. Big” won’t win the drug war. As I pointed out almost a year ago, economist and drug policy expert Jeffrey Miron estimates that we would have a lot less violence without a war on drugs. At the recent Association of Private Enterprise Education conference, David Henderson from the Naval Postgraduate School pointed out the myriad ways in which government promises to make us safer in fact imperil our safety and security. The drug war is an obvious example: in the name of making us safer and protecting us from drugs, we are actually put in greater danger. Without meaning to, the drug warriors have turned American cities into war zones and eroded the very freedoms we hold dear. Freedom of contract has been abridged in the name of keeping us “safe” from drugs. Private property is less secure because it can be seized if it is implicated in a drug crime (this also flushes the doctrine of “innocent until proven guilty” out the window). The drug war has been used as a pretext for clamping down on immigration. Not surprisingly, the drug war has turned some of our neighborhoods into war zones. We are warehousing productive young people in prisons at an alarming rate all in the name of a war that cannot be won. Albert Einstein is reported to have said that the definition of insanity is doing the same thing over and over again and expecting different results. By this definition, the drug war is insane. We are no safer, and we are certainly less free because of concerted efforts to wage war on drugs. It’s time to stop the insanity and end prohibition.

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So you know what's best for the rest September 15, 2012 8:33 pm (Pacific time)

 
Dispelling the Myths about Opioids

Most people facing a very serious illness fear dying in pain as much as they fear death itself. But 95 percent of pain, including the worst cancer pain, can be controlled. When lesser painkillers fail, morphine and its synthetic cousins (opioids) should be considered.

Patients and doctors (who should know better) are unreasonably afraid of opioids. This "opiphobia" is not based on fact, but is a product of outmoded knowledge and the War on Drugs. Medical research demonstrates the utility and safety of opioid use for otherwise untreatable pain. Major medical organizations have created policies and standards to advise doctors on the findings and resultant practice guidelines. A recent joint statement by the American Pain Society and the American Academy of Pain Medicine outlines current goals and standards for the use of opioids in pain management. 

Despite this activity at the top of the profession, pain management in hospitals, nursing homes and doctors' offices in the United States falls far short of the standard for medical care. Doctors only recently had good pain management training available to them. They are often very reluctant to use opioids effectively, even when a patient is dying. Many never even consider opioids for long-term therapy for non-cancer pain. 

Very sick patients are entitled to the best modes of pain control. They, not their doctors, are the best judges of how much pain they feel and whether a particular mode of pain management is working. For chronic pain patients the key is whether the medications make them better able to function in their daily lives than do more frequently dispensed pain medications. 

Opioids are not the answer to every pain problem or even every severe pain problem. They are serious and, if abused, dangerous drugs. However, every patient should receive consideration of pain that is not clouded by ignorance or unreasonable fear of particular medications. 

Pain patients very rarely become addicted

An addict is a person who compulsively takes drugs for non-medicinal purposes. Addicts will continue to seek out the drugs despite bad effects on their ability to function in the community, to hold a job, to care for their families and to maintain social relationships. In contrast, pain patients often take very large amounts of opioids and other medications to improve their function, but do not seek out the drug for its own sake or "crave" the medication. Their ability to work, care for families and live productive lives is improved by their medications. 

A recent study demonstrates that fewer than one percent of pain patients receiving opioids become narcotics abusers. No patient in pain should hear that relief is barred because "you will become an addict." No patient in pain should reject opioids out of fear of becoming addicted. Even former and current substance abusers can be treated for severe pain by doctors with experience in the field.

There is a critical difference between "addiction" and "tolerance" 

"Tolerance" is a physical event that will always happen when a patient takes opioids. Tolerance begins with even one dose. This physical fact is not linked to harmful effects. It means only that, over time, pain patients can be expected to need higher doses of the medication to obtain the same relief. 

A patient who has been receiving opioids for pain over time can tolerate levels that would kill a person who is "opioid naive" (someone who has not built up any tolerance). For this reason it is often said that there is no theoretical upper limit to the amount of opioids than can appropriately be prescribed to control pain. Careful physicians will monitor dosage closely and increase it when necessary as tolerance builds to maintain a good effect on pain control. Moreover, some medications mix opioids and other pain relievers such as aspirin, acetaminophen and other non- steroidal compounds. A patient taking these medications will reach a ceiling dose at some point because the other drugs in the compound are toxic. Some pain relievers, such as Demerol, should not be used for any extended period because of toxicity. 

Confusion between "addiction" and "tolerance" is common even among physicians. Identification of patients with substance abuse problems is even more difficult. The best distinction between the two is the patient's ability to function. Pain patients can expect to improve function with optimal dosages of opioids. 

"Dependence" is another physical fact. It refers usually to the need to maintain opioid levels in a tolerant individual or experience withdrawal. Both addicts and legitimate pain patients will experience withdrawal if the drug is withdrawn abruptly. 

Until a patient achieves pain relief there is no such thing as "too much" morphine or other opioids. 

Pain experts agree that there is no "theoretical upper limit" for opioid dosages for pain relief. The upper limit is "what works." It is important not to assume that high dosages or a large number of prescribed pills means that the patient is "an addict." Of course, the doctor must monitor to make sure that the dose is appropriate for that patient. 

Morphine and its derivatives do have side effects. The most frequent is constipation. Most side effects can be managed. A doctor may have to try a number of pain medications or combinations of medications to reach the maximum relief with minimum side effects. Patient and doctor need to work together to reach an appropriate dose for the patient. 

Careful pain management does not kill 

Pain researchers and informed clinicians now agree that morphine, properly prescribed, does not depress respiration and kill opioid-tolerant patients. Pain is a powerful antagonist to respiratory depression. (Think, for example of how your heart beats faster and you breathe more quickly when you're in serious pain.) The American Pain Society and the American Academy of Pain Management have concluded in a consensus statement that "respiratory depression induced by opioids tends to be a short-lived phenomenon, generally occurs only in the opioid-naive patient, and is antagonized by pain. Therefore, withholding the appropriate use of opioids from a patient who is experiencing pain on the basis of respiratory concerns is unwarranted."

Despite well-documented evidence to the contrary, the fear of respiratory depression and resulting death permeates medical, legal and ethical discussions of pain management. Advocates will have to be educators and should never fall into the trap of accepting misinformation, however well-intentioned. 

It is very possible to kill an opioid-naive patient with opioids. The critical factor is the physician's intent and his or her adherence to good precepts of pain management.

Pharmacists often err on the side of caution

Pharmacists are not trained to understand pain control. They have legal responsibilities under state and federal licensing regimes to refuse to fill prescriptions they believe are not for appropriate medical purposes. They often err on the side of caution and refuse to fill any opioid prescriptions, or do so with exaggerated scrutiny. A nervous, agitated and upset pain patient may look like an "addict" to them. 

Recent studies signal the possibility of racial profiling in filling and refusing to fill particular prescriptions. Pharmacies in poor inner-city neighborhoods may refuse to carry opioids because they fear robbery. 

Pharmacists' legitimate concerns too often translate into hardship for legitimate pain patients. Patients should not allow pharmacists to intimidate them when they submit valid prescriptions to control their pain. Asking the doctor to intervene should change the pharmacist's approach.

If a pharmacist challenges a prescription, the patient should ask the pharmacist to call the prescribing doctor immediately. Patients should also discuss the problem directly with their doctors. 
Doctors who have legitimate pain practices should make efforts to work closely with pharmacies. They should also, with the patient's consent, be willing to put a note on the prescription showing diagnosis.  
 

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And now to drive home reality September 15, 2012 7:59 pm (Pacific time)

The DEA's intimidation tactics against doctors causes billions of dollars of additional healthcare expenses for patients, billions of dollars in lost productivity because of untreated pain, and is actively destroying or severely limiting the quality of life for tens of millions of people in America every single day.

According to the American Academy of Pain Medicine, seventy-six million Americans suffer from chronic, daily pain, and at least nine million have daily pain that is severe enough to interfere significantly with their jobs and relationships. 

An estimated 20% of American adults (61.5 million people) report that pain or physical discomfort disrupts their sleep a few nights a week or more. 

The annual cost of chronic pain in the United States, including healthcare expenses, lost income, and lost productivity, is estimated to be $100 billion. 

More than half of all hospitalized patients experienced pain in the last days of their lives and although therapies are present to alleviate most pain for those dying of cancer, research shows that 50-75% of patients die in moderate to severe pain. 

In a recent survey, 50% of chronic-pain patients had, at one time or another considered suicide to escape the unrelenting agony of their pain. There are no statistics on the number of suicides attributable to untreated pain, but various studies carried out over the past decade have found that fear of pain is what lies behind the majority of requests for doctor-assisted death. 

Untreated pain also raises blood pressure, and researchers have found that every 10mm increase in systolic blood pressure results, on the average, in a 40 percent increase in risk of stroke and a 30 percent increase in risk of heart attack.

The DEA campaign against prescription drug abuse has stigmatized patients in need of pain medication. DEA intimidation tactics and sting operations against doctors have created a climate of fear, with the predictable result that many doctors now won't prescribe opiates at all or are only willing to prescribe amounts that are totally inadequate. As a result, many more people die from not having the prescription pain medications they need, than die from the drug abuse the government is trying to prevent. The DEA is actually killing chronic pain patients by intimidating their doctors.

One of the major causes of those deaths is the overuse of OTC NSAIDS like acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) by people who are desperate for pain relief. The Food and Drug Administration estimates that 200,000 cases of gastric bleeding occur each year, resulting in nearly 20,000 deaths. 

Background

Americans are a generous and compassionate people. But they have been brainwashed their entire lives by the constant drumbeat of anti-drug propaganda coming from drug warriors, law enforcement and the criminal justice system, and endlessly parroted by self-serving politicians and the media. 

Less than 10 years ago, the DEA made prescription drug abuse its primary mission after its survival was threatened because of its failure to have any impact on the availability of street drugs. The DEA ginned-up a lot of bogus statistics about deaths supposedly due to prescription drugs and they cranked-up their propaganda machine in concert with their allies in various public and private agencies who all have one thing in common; they owe their existence to the war on drugs. The media accepts press releases from these agencies and does stories on them without any critical examination of the claims being made. Mothers who lost their children to drug abuse are invited to testify before Congress, giving our representatives an opportunity to exploit their grief in a national spotlight for political gain.  

The DEA has focused on doctors who prescribe a lot of pain medications to chronic pain patients because they are easy targets. Doctors keep good records and they have a lot of assets that can be seized. And the DEA is far more interested in seizing assets than they are in seizing illegal drugs. Doctors who prescribe narcotics are now living under the constant threat that they will be arrested by the DEA and prosecuted as if they were running a drug cartel. 

Once arrested and stripped of all his assets, a doctor will be charged with tens, if not hundreds of individual crimes, so that they will be under tremendous pressure to plead guilty to lesser charges in order to avoid a lengthy prison sentence. Many doctors who are totally innocent cave-in and accept a plea bargain because they know the odds are stacked against them.

In a criminal trial, a jury of ordinary people are asked to decide whether a doctor's care was appropriate, based on the testimony of competing experts on both sides. Prosecutors who want to portray a compassionate doctor as a common drug dealer will hold up bags of pills and argue that the doctor was operating "outside the bounds of legitimate practice." One way they do that is by trying to confuse the jury about what the legal definition of "Standard of Care" really means.

"Standard of Care" aka Reasonable Physician Standard of Care is legally defined as being based on what the science (as reflected in the medical texts and journals) indicates is appropriate care. 

But prosecutors and their hired-gun experts attempt to use "Community Norms" to show that the doctor is operating way out on the fringes -- beyond what "most doctors" would do. Community Norm is defined as what most doctors would do, but most doctors are afraid to do the right thing because of the chilling effects of DEA intimidation tactics.

Doctors who aggressively treat the patients who need the most pain relief are actually doing the right thing, based on any reasonable interpretation of the science. That puts those doctors outside the norm, and in the DEA's crosshairs, because most doctors won't prescribe ANY narcotics for chronic pain. Only a small percentage are willing to prescribe narcotics for the treatment of chronic pain, and the overwhelming majority of those will only prescribe to their comfort level, rather than their patient's. The tiny percentage of doctors who are courageous enough to put their patients welfare first are under constant surveillance by the DEA and routinely subjected to DEA sting operations. 

You can make a difference, and you should try, because you and everyone you care about is at risk for having their life destroyed by untreated pain. Do not accept without question what is being spoon-fed to you daily by those who profit from denying pain medications to people who need it the most. 

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Try again September 15, 2012 7:42 pm (Pacific time)

In areas of moral and political conflict people will always behave badly with evidence, so the war on drugs is a consistent source of entertainment. We have already seen how cannabis being "25 times stronger" was a fantasy, how drugs-­related deaths were quietly dropped from the measures for drugs policy, and how a trivial pile of poppies was presented by the government as a serious dent in the Taliban's heroin revenue.

The Commons home affairs select committee is looking at the best way to deal with cocaine. You may wonder why they're bothering. When the Advisory Council for the Misuse of Drugs looked at the evidence on the reclassification of cannabis it was ignored. When Professor David Nutt, the new head of the advisory council, wrote a scientific paper on the relatively modest risks of MDMA (the active ingredient in the club drug ecstasy) he was attacked by the home secretary, Jacqui Smith .

In the case of cocaine there is an even more striking precedent for evidence being ignored: the World Health Organisation (WHO) conducted what is probably the largest ever study of global use. In March 1995 they released a briefing kit which summarised their conclusions, with some tantalising bullet points.

"Health problems from the use of legal substances, particularly alcohol and tobacco, are greater than health problems from cocaine use," they said. "Cocaine-related problems are widely perceived to be more common and more severe for intensive, high-dosage users and very rare and much less severe for occasional, low-dosage users."

The full report – which has never been published – was extremely critical of most US policies. It suggested that supply reduction and law enforcement strategies have failed, and that options such as decriminalisation might be explored, flagging up such programmes in Australia, Bolivia, Canada and Colombia. "Approaches which over-emphasise punitive drug control measures may actually contribute to the development of heath-related problems," it said, before committing heresy by recommending research into the adverse consequences of prohibition, and discussing "harm reduction" strategies.

"An increase in the adoption of responses such as education, treatment and rehabilitation programmes," it said, "is a desirable counterbalance to the over-reliance on law enforcement."

It singled out anti-drug adverts based on fear. "Most programmes do not prevent myths, but perpetuate stereotypes and misinform the general public.

"Such programmes rely on sensationalised, exaggerated statements about cocaine which misinform about patterns of use, stigmatise users, and destroy the educator's credibility."

It also dared to challenge the prevailing policy view that all drug use is harmful misuse. "An enormous variety was found in the types of people who use cocaine, the amount of drug used, the frequency of use, the duration and intensity of use, the reasons for using and any associated problems."

Experimental and occasional use were by far the most common types of use, it said, and compulsive or dysfunctional use, though worthy of close attention, were much less common.

It then descended into outright heresy. "Occasional cocaine use does not typically lead to severe or even minor physical or social problems … a minority of people … use casually for a short or long period, and suffer little or no negative consequences."

And finally: "Use of coca leaves appears to have no negative health effects and has positive, therapeutic, sacred and social functions for indigenous Andean populations."

At the point where mild cocaine use was described in positive tones the Americans presumably blew some kind of outrage fuse. This report was never published because the US representative to the WHO threatened to withdraw US funding for all its research projects and interventions unless the organisation "dissociated itself from the study" and cancelled publication. According to the WHO this document does not exist, (although you can read a leaked copy at www.tdpf.org.uk/WHOleaked.pdf).

Drugs show the classic problem for evidence-based social policy. It may well be that prohibition, and distribution of drugs by criminals, gives worse results for the outcomes we think are important, such as harm to the user and to communities through crime. But equally, we may tolerate these outcomes, because we decide it is more important that we declare ourselves to disapprove of drug use. It's okay to do that. You can have policies that go against your stated outcomes, for moral or political reasons: but that doesn't mean you can hide the evidence. 

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Can we be educated September 15, 2012 3:58 pm (Pacific time)

In areas of moral and political conflict people will always behave badly with evidence, so the war on drugs is a consistent source of entertainment. We have already seen how cannabis being "25 times stronger" was a fantasy, how drugs-­related deaths were quietly dropped from the measures for drugs policy, and how a trivial pile of poppies was presented by the government as a serious dent in the Taliban's heroin revenue.

The Commons home affairs select committee is looking at the best way to deal with cocaine. You may wonder why they're bothering. When the Advisory Council for the Misuse of Drugs looked at the evidence on the reclassification of cannabis it was ignored. When Professor David Nutt, the new head of the advisory council, wrote a scientific paper on the relatively modest risks of MDMA (the active ingredient in the club drug ecstasy) he was attacked by the home secretary, Jacqui Smith .

In the case of cocaine there is an even more striking precedent for evidence being ignored: the World Health Organisation (WHO) conducted what is probably the largest ever study of global use. In March 1995 they released a briefing kit which summarised their conclusions, with some tantalising bullet points.

"Health problems from the use of legal substances, particularly alcohol and tobacco, are greater than health problems from cocaine use," they said. "Cocaine-related problems are widely perceived to be more common and more severe for intensive, high-dosage users and very rare and much less severe for occasional, low-dosage users."

The full report – which has never been published – was extremely critical of most US policies. It suggested that supply reduction and law enforcement strategies have failed, and that options such as decriminalisation might be explored, flagging up such programmes in Australia, Bolivia, Canada and Colombia. "Approaches which over-emphasise punitive drug control measures may actually contribute to the development of heath-related problems," it said, before committing heresy by recommending research into the adverse consequences of prohibition, and discussing "harm reduction" strategies.

"An increase in the adoption of responses such as education, treatment and rehabilitation programmes," it said, "is a desirable counterbalance to the over-reliance on law enforcement."

It singled out anti-drug adverts based on fear. "Most programmes do not prevent myths, but perpetuate stereotypes and misinform the general public.

"Such programmes rely on sensationalised, exaggerated statements about cocaine which misinform about patterns of use, stigmatise users, and destroy the educator's credibility."

It also dared to challenge the prevailing policy view that all drug use is harmful misuse. "An enormous variety was found in the types of people who use cocaine, the amount of drug used, the frequency of use, the duration and intensity of use, the reasons for using and any associated problems."

Experimental and occasional use were by far the most common types of use, it said, and compulsive or dysfunctional use, though worthy of close attention, were much less common.

It then descended into outright heresy. "Occasional cocaine use does not typically lead to severe or even minor physical or social problems … a minority of people … use casually for a short or long period, and suffer little or no negative consequences."

And finally: "Use of coca leaves appears to have no negative health effects and has positive, therapeutic, sacred and social functions for indigenous Andean populations."

At the point where mild cocaine use was described in positive tones the Americans presumably blew some kind of outrage fuse. This report was never published because the US representative to the WHO threatened to withdraw US funding for all its research projects and interventions unless the organisation "dissociated itself from the study" and cancelled publication. According to the WHO this document does not exist, (although you can read a leaked copy at www.tdpf.org.uk/WHOleaked.pdf).

Drugs show the classic problem for evidence-based social policy. It may well be that prohibition, and distribution of drugs by criminals, gives worse results for the outcomes we think are important, such as harm to the user and to communities through crime. But equally, we may tolerate these outcomes, because we decide it is more important that we declare ourselves to disapprove of drug use. It's okay to do that. You can have policies that go against your stated outcomes, for moral or political reasons: but that doesn't mean you can hide the evidence. 

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Educate yourself September 15, 2012 3:42 pm (Pacific time)

 
The DEA War on Hydrocodone

The DEA wants to classify hydrocodone the same way it does oxycodone, a more powerful analog that is the active ingredient in the long-lasting painkiller Oxycontin. Oxycontin prescriptions cannot include refills.

Oxycontin or hydrocodone alone are rarely the sole cause of a drug-induced death. More than 95 percent of these deaths are caused by "polypharmacy," the ingestion of multiple illicit compounds, usually laced with a lot of quite legal booze. 

Picking on one drug won't do the trick, but picking on hydrocodone is a particularly bad idea, because the DEA's proposals could well kill more people from pain than they save from abuse. 

How much pain and suffering does hydrocodone mitigate? There were 100 million new prescriptions for the drug last year in the United States, given to 38 million patients. (This doesn't even count in-hospital use.) Hydrocodone is by far the most prescribed drug in the nation. 

Because there will be no more refills, DEA's proposal means at least 300 million office visits per year (figuring that most chronic pain prescriptions are refillable twice). Nowadays, one just doesn't walk in and out of a doc's office. Most pain doctors are so busy that appointments must be made months in advance, and appointment, travel and waiting easily burn half a day. That's 150 million worker days lost. Based upon average annual wages, employers will pay ( and you and I will shoulder ) about $13 billion in wages for doctor-visit induced absenteeism. And the office visits will add another $20 billion in cost, payable through the patient's insurance or someone else's taxes. 

Add this to the fact that, according to Katherine Foley, a pain expert at Sloan-Kettering Cancer Center, pain already costs Americans $100 billion per year in treatment costs and labor-related losses. Making pain relief harder to get will only make it more expensive. 

How risky is hydrocodone? According to the Drug Abuse Warning Network, a systematic effort to procure objective information on drug-related deaths, hydrocodone showed up in 46 bodies last year in Las Vegas, a town surely prone to a bit of drug abuse. The number of hydrocodone pills prescribed there in 2001 was around 27 million, and this doesn't even count the huge number that fly in with tourists, gamblers and others who engage in risk-taking behavior every weekend. I'd say it's a good bet that more people die in legal casinos and brothels in southern Nevada from heart attacks than are killed by hydrocodone. 

Some other state data can be used to make fuzzy estimates of abuse-related deaths. In 2002, there were 150 findings of fatal concentrations of hydrocodone in postmortem examinations in Florida. Assuming conservatively that this may catch half the deaths, and way too conservatively that "Miami Vice" Florida is typical, this would maximize the number of deaths per year associated with fatal concentrations of this drug at around 6,000 nationwide. 

Given the problem of polypharmacy, it's charitable to assume that the DEA's proposal may prevent half those deaths. Are 3,000 deaths pretty high overhead for pain relief? Well, consider NSAIDs. About 16,000 people who use these medications for arthritis alone die each year, due to the drugs' propensity to enhance internal bleeding. It would seem from this that DEA would save a lot more lives if it made ibuprofen harder to get, so that those with pain would have to switch to hydrocodone or oxycodone. 

But that may be just one tip of the iceberg. Pain raises blood pressure and researchers have found that every 10mm increase in systolic blood pressure results, on the average, in a 40 percent increase in risk of stroke and a 30 percent increase in risk of heart attack for your age class. 

So if hydrocodone became less available, we could expect potentially 8,000 more deaths from stroke and heart attack every year. And, although there's no way to reasonably estimate the number of people who will suffer bouts of depression, thoughts of suicide and actually commit suicide after being denied adequate pain medication because of the DEA's increasingly draconian measures, it's safe to assume that number will be in the millions.

Compare that with about 3,000 deaths that can prevented by the DEA's proposal. Those deaths are very unfortunate, but any "solution" that punishes the 38 million pain patients who use hydrocodone safely is not a reasonable solution.

Adapted from an article by Patrick Michaels, a senior fellow in environmental studies at the Cato Institute.
 

 

Go to the DEA Sucks home page

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Educate all September 15, 2012 2:43 pm (Pacific time)

More than 20 years ago when I was removing destroyed heart valves from infected intravenous drug abusers I assumed that these seriously ill patients represented just the tip of the iceberg of narcotic abuse. In an effort to ascertain what proportion of serious or fatal drug-related disease this group represented, I sought information from the San Francisco Coroner. To my surprise he reported that infections from contaminated intravenous injections were the only cause of drug-related deaths he saw except for occasional deaths from overdoses. He confirmed the inference that clean, reasonable dosages of heroin, cocaine and marijuana are pathologically harmless. He asserted he had never seen a heroin user over the age of 50. My obvious conclusion was that they had died from their. habit but he was confident that they had simply tired of the drug and just quit. When asked if the same were basically true of marijuana and cocaine, he responded affirmatively. That caused me to wonder why these substances had been made illegal.

It is frequently stated that illicit drugs are "bad, dangerous, destructive" or "addictive," and that society has an obligation to keep them from the public. But nowhere can be found reliable, objective scientific evidence that they are any more harmful than other substances and activities that are legal. In view of the enormous expense, the carnage and the obvious futility of the "drug war," resulting in massive criminalization of society, it is high time to examine the supposed justification for keeping certain substances illegal. Those who initiated those prohibitions and those who now so vigorously seek to enforce them have not made their objectives clear. Are they to protect us from evil, from addiction, or from poison?

The concept of evil is derived from subjective values and is difficult to define. just why certain (illegal) substances are singularly more evil than legal substances like alcohol has not been explained. This complex subject of "right" and "wrong" has never been successfully addressed by legislation and is best left to the pulpit.

Addiction is also a relative and ubiquitous phenomenon. It certainly cannot be applied only to a short arbitrary list of addictive substances while ignoring. a plethora of human cravings - from chocolate to coffee, from gum to gambling, from tea, to tobacco, from snuggling to sex. Compulsive urges to fulfill a perceived need are ubiquitous. Some people are more susceptible to addiction than others and some "needs" are more addictive than others. Probably the most addictive substance in our civilization is tobacco - yet no one has suggested making it illegal.

As for prohibition, it has been clearly demonstrated that when an addictive desire becomes inaccessible it provokes irresponsible behavior to fulfill that desire. Education and support at least have a chance of controlling addiction. Deprivation only sharpens the craving and never works. Even in prison addicts are able to get their `fix.'

And "poison" is also a misleading shibboleth. The widespread propaganda that illegal drugs are "deadly poisons" is a hoax. There is little or no medical evidence of long term ill effects from sustained, moderate consumption of uncontaminated marijuana, cocaine or heroin. If these substances - most of them have been consumed in large quantities for centuries - were responsible for any chronic, progressive or disabling diseases, they certainly would have shown up in clinical practice and/or on the autopsy table. But they simply have not!

Media focus on the "junkie" has generated a mistaken impression that all uses of illegal drugs are devastated by their habit. Simple arithmetic demonstrates that the small population of visible addicts must constitute only a fraction of the $150 billion per year illegal drug market. This industry is so huge that it necessarily encompasses a very large portion of the ordinary population who are typically employed, productive, responsible and not significantly impaired from leading conventional lives. These drug users are not "addicts" just as the vast majority of alcohol users are not "alcoholics."

Is it not a ridiculous paradox to have laws to protect us from relatively harmless substances and not from the devastating effects of other substances that happen to be legal? It is well known that tobacco causes nearly a million deaths annually (in the US alone) from cancer, cardiovascular disease and emphysema; more than 350,000 die from alcohol-related cirrhosis and its complications and caffeine is the cause of cardiac and nervous system disturbances. These facts suggest that the public is being fraudulently misled into fearing the wrong substances and into complacency about hazardous substances by allowing their sale and even subsidization.

Our environment contains a plethora of hazards, of which recreational substances are much less important than many others. Recognizing the reality of consumer demand and the perspective of relative harm should make a strong case for alternatives to prohibition. Should we not have teamed from the failure of the Volstead Act of the 1920s and the current ubiquitous availability of illegal drugs that prohibition is the height of futility?

Is it not time to recognize that the " problem" is not the drugs but the enormous amounts of untaxed money diverted from the economy to criminals? The economic incentive for drug dealers to merchandise their product aggressively is a multi-billion dollar return which has a far more powerful effect to increase substance abuse than any enforcement program can possibly do to, constrain that usage. The hopeless challenge of drug crime is compounded by the parallel expansion of theft, crime, which is the principal economic resource to finance the drug industry. How can this be anything but a lose-lose situation for society?

We should look at the fact that a relatively low budget public education campaign has resulted in a significant decline in US consumption of both alcohol and tobacco during a period when a costly and intensive campaign to curtail illegal drugs only resulted in their increased usage. Is there a lesson to be heeded?

Of course there is. Scrap the nonsense of trying to obliterate drugs and acknowledge their presence in our society as we have with alcohol and tobacco. Legalization would result in:

purity assurance under Food and Drug Administration regulation;
labeled concentration of the product (to avoid overdose);
obliteration of vigorous marketing ("pushers");
obliteration of drug crime and reduction of theft crime
savings in expensive enforcement and
significant tax revenues.
Effort and funds can then be directed to educating the public about the hazards of all drugs.

Can such a change of attitude happen? Probably not, because the huge illegal drug industry has mountains of money for a media blitz and for buying politicians to sing the songs of "evil" and "danger" which is certain to kill any legislative attempt at legalization. Perhaps it will take some time before reality can prevail, but meanwhile we should at least do more to expose deception and to disseminate the truth.

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M. Dennis Paul, Ph.D. September 12, 2012 8:03 pm (Pacific time)

Nice try, Larry G. You do know I am laughing at your childish attempt to goad me into entering your arena. If I actually had the time to do a show at this point, it would be with a neutral host who was willing to listen as well as talk. Willing to explore rational solutions rather than engaging in pissing contests. I can assure you I make no money directly or indirectly from any source vested in pharmaceuticals. If you have bothered to check, you know that I develop treatment programs and have a strong background in teaching as well as treatment. As I stated prior, my position has been made clear through my article and comments. I have absolutely no desire to argue statistics or facts. I have no desire to go off into fruitless tangents. I am interested in developing and supporting rational solutions. If you, Larry G. are serious about finding solutions, perhaps you will open mindedly consider the large lists I have offered and use your show to solicit others. Larry, you may be able to argue...most people can. The question is, at least in my mind, can you actually understand studies and how they are conducted, interpret the data absent preconceived bias, and reach rational conclusion on the further direction research should suggest? Further, can you recognize when a person has purposely misquoted another in an effort to cast a dark shadow on that person's character and do you truly respect that sort of "journalism"? If so, this only further supports my decision to not engage with you on a radio show. I am interested in solutions, Larry G, not arguments and comparing penis size. Sadly, you appear unable to realize the area in which I support awareness of over and improper prescription, lack of education and lack of proper monitoring and prefer to challenge the distortions you have constructed within your own mind. As for Salem-News, they graciously provide the forum you are using for your petty inferences as a place for you or anyone else to ask questions. You are certainly free to engage in such an endeavor. I am willing, as time allows, to respond... so long as the questions are rational and unlike the one you previously postured as the opening to an "interview". I am still chuckling about that one, Larry G. In the vernacular, Larry G. , your chastising of Salem-News over my stated inability to join you on your show, and the concerns I have about you in general, while consciously choosing to ignore the open forum you are actually commenting in is what we, in thought addiction, call a cognitive distortion....a demand that life conform precisely to your desires. It doesn't.

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M. Dennis Paul, Ph.D. September 12, 2012 8:01 pm (Pacific time)

Mr Cairn's portrait of absolute innocence is, I suggest, a strong desire on his part to believe deception and denial are non-existant in the population he describes. Years of actually detoxing and treating those with both dependence and addiction provides a more realistic picture. One of my dearest friends, now deceased, was a founder of "Free Clinics" in the 60's. One of the first things he learned about the young "junkies" who lined up each week for free medical services was that they had a story for everything and at the moment they imparted a story to you, they believed it. Most all surveys by both governments and organizations strongly suggests that the majority of these kids began by using other individuals prescriptions which were either shared by friends or stolen from parents medicine cabinets. This is not to deny that a percentage actually were prescribed opioids. It is a fact that undereducated doctors have historically failed to control their prescriptions and properly assess and monitor the behaviours of their clients. This fact, however, does not require a response that sets artificial, irrational, unreasoned, inhumane and oft political restraints. It requires education both for doctors and clients, practical, enforceable tracking of prescriptions, ability by doctors to prescribe marijuana which may be sufficient relief in itself or greatly reduces the required dose of other pain relief medications, It also requires a real world understanding that a percentage of individuals will become dependant based upon the presence of a chronic disease, or addicted due to their failure to exercise personal control and /or underlying psychosocial issues for which they consciously seek an escape either through conning doctors or shopping the streets, The vast majority of what passes for treatment today is little more than attempted maintenance of sobriety for 28 days. Underlying issues are passed off to a "higher power" and relapse is inevitable. True addiction requires much more attention to the psychosocial issues and the cognitive distortions present in the addicts' mind. Insurance companies and governments are unwilling to pay for this despite the costs of unchecked addictions on society (both in dollars and societal collapse). Until there is a willingness to provide known medications and methods to effectively curtail addiction (Ibogaine and CBT being the most effective) and a recognition of fact that some will never surrender an addiction but can be controlled and made productive through proper maintenance, the high cost to society and individuals will persist. It was understood that an exponential number of dependencies and addictions would occur when more compassionate use of opioids became available. The answer is not to return to inhumane ignoring and under-treating of pain. The answer is education and rational control, treatment, and maintenance.

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Larry G September 12, 2012 2:38 pm (Pacific time)

I want to again thank Marianne and Dr. Gelfand for revealing further the opioid epidemic. Mariane has been masterful at revealing those who continue to defend the mass distribution of legal narcotics without attempting to educate the public about the masterful and diabolical marketing of the repackaging of opium. As for Dr. Paul, the radio show does not screen calls or have a "kill switch". In an open forum, the cowards and phonies who make their money directly or indirectly from the over distribution of the narcotics refuse my invitation. My next response to Dr. Paul will be on a live radio show if he has the courage to call in to a host who has the ability to challenge him on his facts. I also question why Salem News would publish an author who can't take questions about what they write publicly. Cased closed with Dr. Paul and again my thanks to Marianne for exposing another "expert's" insincerity to a serious epidemic.

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ken cairns September 11, 2012 7:54 pm (Pacific time)

i have faith that what i say is true but i have not yet concluded that all i say is true and that everything else is false. in 78 yrs of life and 52 years doing medical care i had zero idea what was going on all over the world in a hidden underclass. i knew there were methdone maintenance clinics for heroin addiction in places like the south bronx of he 70's...but recently i have had ocasion to spend time in such in a small college city in a rural western state, seeing hundreds of wonderful people of all ages come to try to get help for their opioid addiction, level of tragedy totally impossible to know w/o being there and listening, and it didnt begin w heroin but w pills, prescribed pills w/0 warning, the video doesnt even come close, kids w all veins used up and working on neck veins, with hiv and hep c, long histories of prison and failed treatments, depressed desperate, suicidal, pregnant, they did not ask to be like this, they did not choose to abuse a drug, but took it trustingly and it abused them, to blame these victims is the height of nonrighteous behavior...it is mad max territory where so many people do so much professing while totally clueless...now these clinics are everywhere in america and he world, a whole industry has been created. imho, please all of you who want to take your pills no one wants to interfere, you re not considered enemies by those of us who just dont want to see trusting yet unharmed people be harmed and it is not clear to me what it is that makes you call us draconian. i cry for and with people who suffer wearing their scarlet a for addict tothe grave like hester prynne thought she would wear hers but i stand with these good people thatg they may rediscover the fundamental goodness in themselve and to emerge as strong as hester even afger all she was made to suffer...chronic pain suffers i want you to be well as you define welllness for yourselves and hope you will pray for the same for opioid addicts very thing

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M. Dennis Paul, Ph.D. September 11, 2012 1:52 pm (Pacific time)

To Larry G. (Radio Show Host?) 1st, thanks for the invitation. Having done numerous radio interviews throughout my life, I have learned that it is usually non-productive to do an interview where the host has control of the air with a clearly applied bias holding its finger on the kill switch. By the composition of your first question, it is already clear to me that real issues will be left to the wayside and ludicrous lead ins will comprise the interview. This is not, actually, how an "interview" is conducted. Alas, I am presently preparing a major move and with all the inherent activity simply do not have time for such things. I believe, if you, Larry, wish to know anything about my position on the real issues you can read my article in Salem-News and add my comments in so reading. My position on this is rather clear. I believe I listed a large number of humane,rational and reasonable recommendations for dealing with use, abuse, tolerance, dependence, addiction and withdrawal as well some recommendations for treating pain with a mix of natural substances that will, in large measure, alleviate many or most concerns. I'm not as impressed by Dr. Gelfand as you appear to be and I believe his support for the disingenuous and obviously false assertions of Marianne are sufficient to support my lack of regard for him, however, I will add that I further have no regard for the poor quality of "science" he almost offers and his backwards view of pain and treating pain.

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M. Dennis Paul, Ph.D. September 11, 2012 1:27 pm (Pacific time)

'A man is never more truthful than when he acknowledges himself a liar.' - Mark Twain This applies to women, also, Marianne. Your inference about an opioid clear mind was rather pathetic and shows an incredible lack of knowledge regarding opioids and the mind. It might interest you that Mark Twain was a frequent participant at opium dens during his time.. as were literally hundreds plus of writers, artists, and intellectuals. Rather than making slurs, perhaps you will make corrections and properly attribute to Fishman his own words as opposed to the words you want readers to believe he said. That Dr. Gelfand supports such slanted journalism and empirically imposes his hypotheses (which is all they are) as anything but hypotheses without advocating for genuine research and without advocating for medication which has over 5000 years of demonstrated efficacy and safety (far more safe than ANY pharmaceutical)says much about his lack of credibility. I am , of course, talking about marijuana. His lack of genuine regard for individuals suffering very real and very intense chronic pain simply because he can find no diseased or corrupted tissue is appalling. Your deceptive writing has now, also become appalling and has caused me to regret having supported your integrity. I, unfortunately, must now withdraw that support.

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James Twilley September 11, 2012 1:02 pm (Pacific time)

I'm a chronic pain sufferer that uses extended release opiates. I’ve also done everything in my power to find another way. I’ve personally spent over $30k this year alone. Why should I have to suffer because the only thing most people have seen is the addiction side of these medicines? I’m very sorry that people have abused these medicines, and many have overdosed and died. To blame the medicines rather than accept any ownership on the abusers part is just as bad as saying the doctors don’t care about the patients they’re treating. You’ve gone out of your way to villainess the doctors who are prescribing these meds, yet seem to care about the ones they’re helping. How is that any different than the doctors you’re raging against? Just because my pain was caused by an accident rather than cancer doesn’t make it hurt any less. With these new guidelines I would be denied the medicines that give me what little quality of life I currently have.

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Larry G September 11, 2012 12:11 pm (Pacific time)

Dr. Steve Gelfand has been a guest of The Prescription Addiction Radio Show - Breaking the Silence a number of times. My experience with Dr. Gelfand is that he is knowledgeable, articulate and has studied the opioid issue for a number of years. This is an open invitation to Dr. Paul to join me on a live interview concerning the opioids. My first question of Dr. Paul will be for him to explain how OTC medications and their outcomes should be compared to the negative outcomes after the prescribing of the opioids?

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Marianne Skolek September 11, 2012 9:09 am (Pacific time)

Dr. Gelfand has been written about in many of my articles as a member of PROP. It has never been withheld. My research and his medical expertise as well as credibility comes from an opioid clear mind. Enough said.

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M. Dennis Paul, Ph.D. September 11, 2012 7:38 am (Pacific time)

Dr. Gelfand loses all credibility in ignoring the misquotes and out of context statements in this article and continuing to hold the article up as itself credible. Further, he states abundant evidence that the pain he references is caused by depression, anxiety etc and yet no evidence is offered. What "evidence" exists is highly questionable, unsubstantiated, and from dubious study methodologies. Apparently the Doctor has found the cause for the disease I and millions suffer but which research specialists having spent their entire lives in search have failed to identify. This applies to all the other chronic pain conditions so all those researchers can fold up their tents and go home...problems solved, according to the Doctor. This "it is all in their heads" mentality has been the largest roadblock, for many decades, to not only treating pain effectively but of improving and promoting research into genuine causes. DR. Gelfand should identify himself as a member of PROP, a group that represents draconian thinking about treating patients and addressing genuine issues of abuse, dependence and addiction. Please see my article in Salem-News http://salem-news.com/articles/september082012/controlling-opium-mdp.php for more.

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Stephen G. Gelfand, MD September 10, 2012 7:43 pm (Pacific time)

Marianne has courageously tackled another vital medical issue of the prescription opioid epidemic; one which has been distorted by the opioid industry to encourage primary care providers to write more scripts for opioids by viewing pain in isolation as a "disease", rather than as a symptom of a number of diverse processes of the body and brain. What has been frequently ignored by the opioid industry is that a large segment of the chronic pain population has chronic noncancer pain which originates, not from peripheral tissue or structural pathology, but from brain-derived or central mechanisms, termed central pain sensitivity states. Abundant research has identified this common type of chronc pain which is often generated by persistent psychological distress and associated with a spectrum of depression and anxiety disorders, such as seen in fibromylagia, nonstructural back pain and tension headache. These are patients in whom the risks of opioids can be very high, especially when combined with other centrally-depressing drugs such as tranquilizers and/or sedatives which many of them are also on. But as a result of the opioid industry and segments of the pain management community selling the concept to primary care providers to consider pain in isolation "as a disease," this all too often has become a "justification" for opioid therapy, instead of seeking the true source of pain, especially that of central pain sensitivity states. Failure to recognize this source has led to many erroneous diagnoses and misattributing chronic pain to asymptomatic structures. As a result, far too many of these patients have been placed on opioids inappropriately, while adding to the mounting toll of addiction, overdose and death as noted in this article.

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Tonya Roberts September 10, 2012 6:36 pm (Pacific time)

Please visit www.stopmethadonedeaths.com and sgn the petition!

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Tonya Roberts September 10, 2012 6:34 pm (Pacific time)

Great article!You have my support! Keep writing! There is strength in numbers.

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Amy Graves September 10, 2012 6:18 pm (Pacific time)

Thank you Marianne for exposing these pain mongers for what they are . No pain , no gain for these folks. Its disgusting and shameful . I hope the senate investigation shines a light on these doctors for what they really are. They are not educating , they are marketing and until people understand that we will never get ahead of the rx drug abuse epidemic.

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Anonymous September 10, 2012 5:43 am (Pacific time)

I feel it is important to note that Marianne has misquoted Dr. Fishman from his response in Propublica. He did not state that the risks of opioids outweighs the benefits as she claims, His actual statement was:  "I believe this is a serious problem we can resolve the same way we have approached many other treatments that have significant risks but also benefits when the treatment is used wisely by trained providers." and "Opioids are addictive but I doubt that most medical leaders would agree that they are only to be used as a last resort. I believe opioids should only be used when the benefits outweigh the risks - when less risky and reasonably effective options have been tried. For instance, it would not make sense to use a treatment that is more risky than opioids simply because opioids are only to be used as a last resort."  I suggest that readers do not take statements made in these PROP aligned articles at face value. Read the citations and articles cited for yourself and do fact checking. Marianne takes a rather disingenuous leap with such misquotes and, as such, calls her work into question.

 I should also note that Marianne takes further license in quoting DR. Fishman out of context from his Medscape interview and applying another leap from the reality of what he actually stated. Compare the following to her interpretation (which only stands out of context): "There are great responsibilities when treating pain. Doctors must look at pain not just as a symptom, but also as a disease in its own right. Pain itself becomes a disease when the organ involved with perpetuating the alarm of pain becomes damaged and doesn't shut off, leaving the patient with chronic pain. The number of people suffering from chronic pain is huge, exceeding that of many other chronic diseases into which we've put many more resources." Again, reader, fact check and discover where reason and rationality have been trampled. These articles (in Salem-News) are vendetta articles born of emotionality.. not reason and sound journalistic advocacy. 

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M. Dennis Paul, Ph.D. September 10, 2012 1:01 am (Pacific time)

The cited video in this article actually examples poorly controlled pain management and personal abuse of medication by the patients..Listen very carefully to what is stated in this video. To further bolster the video's case, it actually projects, through unsubstantiated inference, the death of a 3rd patient. These features make this video highly disingenuous. At the same time that I point to the spurious nature of this video, I add that Oxycontin is a medication that has been highly improperly prescribed and due to the nature of the drug is not a "best" choice. Where appropriate, there are other long acting opioids that are safer and more practical. It is sad that the writer and the organizations she touts base all opioid use on the poor management and features of this one drug. Purdue Pharma does bear responsibility for their push to prescribe this drug inappropriately. Doctors do bear responsibility for inappropriately prescribing, over prescribing and failure to control/manage their therapy with patients. Overreacting by leaping at all opioids and seeking to either ban them or curtail their use beyond what is rational and reasonable is an hysterical approach to dealing with this issue. Generating unsubstantiated numbers regarding overdose deaths is further disingenuous. Over the counter pain medications have been stated to cause roughly 5000 deaths per year and contribute to upwards of 100,000 deaths per year. Iatrogenic (deaths caused by medical treatment) are attributed to over 700,000 deaths per year. 1/3 of all opioid attributed deaths per year are blamed on Methadone. I can cite statistics until the cows come home but it will not address the problem nor will irrational proposals that disallow opioid therapy where genuinely applicable. Properly defining addiction and abuse and accepting that with some patients, while addiction is unfortunate it is better than the alternative ... as is the case with chronic cancer patients. Finally, it is poor journalistic endeavor to harp upon the fact that individuals are under Senate investigation and use this to support a case. Being under investigation is meaningless. Proof and conviction are all that matter. One could easily caveat mention of the article's author suggesting the belief, by some, that she is possibly mentally ill. Without stating fact, it is likely some readers might come to believe it is true based simply upon the unsubstantiated inference. Seriously, what does it really mean to be Under Investigation by a Senate committee likely comprised of Senators who, themselves, should be under investigation for their own ties to corporations, lobbyists and special interests?

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