An Open Letter to the President’s Commission on Combating Addiction and the Opioid Crisis

Richard Lawhern, PhD
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This article is edited from correspondence sent to the Office of National Drug Control Policy on June 17th, 2017. Others who wish to make their voices heard may also do so by email to [email protected].

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With many others, I listened and watched for two hours of the first working meeting of the Commission on Friday June 16, 2017. The Commission was addressed by leaders of nine Non Profit Organizations engaged with various aspects of addiction treatment. Much of the input seemed quite apropos. But one voice was missing from the session that is vital if the Commission is to arrive at safe and supportable recommendations on this important public health issue.

Speakers failed to include even one practicing physician or advocate for pain patients who have largely and unfairly been blamed for the so-called “opioid epidemic.” I urge the Commission to remedy this exclusion by inviting participation in an additional session by organizations such as the American Academy of Pain Medicine, the American Academy of Integrative Pain Management,  the National College of Physicians,  PAINWeek, Pain News Network, National Pain Report, and/or the US Pain Foundation. Commission staff should be able to identify other physicians who are deeply trained in this field.

I am myself neither a physician nor an expert in addiction. My training is in systems engineering, experimental design and technology analysis. My wife and daughter are the pain patients in my family. But I talk with and read the work of many medical and pharmacy professionals, including several who were originally copied on this letter — all of whom have published in this field. In the absence of such input, I offer my own insights as a 20-year volunteer advocate who daily interacts with more than 20,000 chronic pain patients, among the estimated 100 million Americans affected by persistent, long-lasting pain (by the American Academies of Medicine). Within this group, an estimated 16 Million are treated in any given year for recurrent persistent pain, and on the order of 3 Million are treated for more than 90 days with opioid analgesics.1

I believe I can lend support or amplification to several points made by speakers in the first session of the Commission. Certain aspects of the discussion stand out.

1.  A large number of addiction treatment and recovery programs now operating in the US are funded by Medicare. To address the “opioid crisis,” the Commission must be prepared to advise President Trump to expand the scope of conditions treated under Medicare, not reduce it.

2.  As several speakers suggested, effective programs to reduce the death and destruction wrought by illicit drugs must be multi-dimensional. Five aspects must be addressed. None is adequate to stand alone, or will be effective standing alone. There are no simple solutions here.

a. Prevention in kids, beginning in Middle School, continuing through High School and beyond.

b. Prevention in adults, focusing on employment development and the creation of hope. Addiction in adults is not primarily a disorder created by drug exposure. It is created by social disintegration and hopelessness that leave people vulnerable.

c. Initial recognition of addiction by properly trained community medical professionals.

d. Ongoing community engagement and support for recovering addicts over periods of at least 3-5 years and possibly longer. Relapse is an ongoing issue for which there are no simple, one-size-fits-all solutions.

e. Diversion of addicted kids and adults out of the prison system and into community treatment and re-integration programs.

As noted by Governor Christie, overshadowing all of these dimensions is the reality that we must reduce the moral condemnation and stigma now assigned to addicts in order to be able to engage them, their families, and their communities in corrective initiatives. Not mentioned in the proceedings, the same is true of the stigma and abuse which are regularly experienced by long term pain patients and by doctors who attempt to treat their pain.

3. As several speakers suggested, any program recommendations must be evidence-based and reinforced by sustained observation of outcomes. We should not be wasting limited resources on measures that don’t work. Some of the statements of participants stand out in flashing lights. These can be readily confirmed by even minimal research on the part of Commission staff.

a.  90% of drug addicts first encounter opioids or other intoxicants as adolescents, either on the street or by diversion or theft from family members. Not explicit in the proceedings is the reality that it is unusual for adolescents to have medical encounters which require treatment with opioid analgesics. Thus this statistic makes clear that prescription drugs under active physician management are NOT the primary cause of the opioid epidemic and likely never were. Further restriction of prescriptions to people in agony will not be a solution for this essentially “social” problem.

b. The most effective interventions for confirmed addiction are medication-assisted. This means programs like Methadone maintenance. We have multiple international examples of maintenance programs which work. For the politically bravest of the brave, we should also examine the experience of Portugal, where possession of drugs has been decriminalized for 14 years—and where overdose deaths have dropped to near zero as rates of addiction are dropping.

c. Although community-based therapy in the 12-Step model might be a supporting element in recovery, this model is clearly inadequate by itself. Relapse rates into addiction by 12-step attendees are abysmally high.

d. As one speaker noted, “more beds are not the answer.” 28-day detox programs—including those used in the Phoenix House chain of addiction treatment centers, on the Board of which one of the speakers participates—are ineffective when not backed by ongoing community interventions. Media are littered with stories of addicts whose first act after leaving a treatment center is to find a dealer and shoot up. Some published figures on relapse rates for discharged addicts approach 95% within one year. This too can be confirmed by Commission staff.

4. I note in passing, that the Commission must also wrestle with a contentious reality:  not all sources of advice are equally credible. My sense of the working session was that some of those who addressed the Commission were financially or professionally self-interested. I personally have particular reservations concerning the helpfulness of psychiatric care, given that the entire field of psychiatry is now experiencing a crisis in public confidence due to scientific corruption and over-medication promoted by pharmaceutical companies.

While we know that many addicts also deal with life crisis problems called “mental disorder,” there is legitimate doubt that psychiatry presently has reliable remedies to offer. More basically, use of anti-psychotic drugs has been associated with a marked drop in life expectancy and function among patients who are medicated involuntarily. For further on this subject, a useful resource is Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform by Whitaker and Cosgrove. I would advise the Commission to apply the same standards of evidence to psychiatric programs as to all others considered.

5. If the Commission is to seek solutions to the addiction crisis, then it seems to me that they must first be able to separate out hype from facts in understanding what is going on. I offer the following in my role as an advocate for people in agony who stand to be grievously harmed if the Commission gets this narrative wrong.

a. Origins of the rising tide of opioid-related deaths are frequently attributed to careless prescribing practices of the 1990s, encouraged by pharmaceutical companies who touted “Pain as the 5th Vital Sign.” It is certainly evident that prescribing practices were greatly liberalized during that period. What is not so obvious is that ill-trained physicians not only over-prescribed to patients whose pain might have been managed by other means, but also to undetected addicts who shammed pain to get safe and regulated drugs of choice.

b. The impact of over-prescribing was arguably and primarily NOT on legitimate pain patients themselves. A Cochrane Review of 2010 of long term effectiveness and risks of opioids, found that among patients who were previously opioid-naive, the number who later presented with opioid abuse disorder was fewer than 1%. Other and later studies have placed abuse rates at 5-10%.2

c.  Much of the present “crisis” in opioid related deaths can be laid at the feet of the FDA, when they forced the reformulation of OxyContin into “abuse resistant” form in 2010. In the next three years, deaths attributed to heroin increased by more than 200% while prescriptions of Oxycontin dropped by 66%.3

Heroin deaths continued to skyrocket in 2014-2015. A plausible explanation for these statistics is that addicts who previously used Oxycontin found that they no longer got high on it, and were forced into unsafe street drugs.

d. Whatever we may believe concerning how the “opioid epidemic” got started, there is ample evidence that it is no longer sustained by prescribed analgesics if it ever was. Mortality statistics of the CDC itself reveal that in 2015, deaths attributed to overdose were dominated by heroin, imported fentanyl, diverted or stolen morphine and methadone. Co-prescription of anti-anxiety medications (Benzodiazepine) was observed in about half of the 33,000 estimated accidental overdose deaths in 2015, and alcohol played a role in more than half.4

In States like Massachusetts where mortality statistics have been compared with prescription databases, it is found that fewer than a quarter of the deaths attributed to opioids occurred among people who had a current prescription for them. It also seems likely that many deaths reported as accidental were in fact suicides or sudden cardiac arrests caused by unsupervised sudden withdrawal of opioids by physicians leaving pain management. Veteran suicide due to denial of pain relief is an even more evident trend.

e. One of the speakers to the Commission asserted that simple “enforcement” of the March 2016 CDC Guidelines might reduce overdose deaths by half. The implication was that a 90 MMED dose limit should become a standard of practice for all pain management physicians. Unfortunately, I believe that speaker was grievously wrong.

I would assert from wide reading and direct observation of social media, that CDC guidelines have already been directly responsible for at least hundreds of patient deaths in the past year. In their present form, they are deeply and unfairly biased against opioid pain relief, scientifically unsupported, and vastly incomplete. Of particular concern is that natural genetic variability of patient responses to opioids was utterly ignored by those who wrote the Guidelines. Any physician training that is based on these Guidelines may be responsible for deaths among patients who hyper-metabolize opioid analgesics, and therapy failure among many more who are poor metabolizers due to polymorphisms in the expression of key liver enzymes.5

These errors and omissions are well known among pain management physicians. The Commission should consider recommending that the CDC Guidelines be totally rewritten by a qualified consultants group led by pain management physicians and supported by patient advocates and medical ethicists. In their present form, the Guidelines are “unsafe at any speed.”

Thank you for accepting this input.

8 COMMENTS

  1. Richard

    I agree that many chronic pain patients have been scapegoated and abandoned by the very system that created the current poly-drug overdose crisis. I use the term “poly-drug crisis” because very few people ever die from opiate drugs by themselves.

    However, I must disagree with much of the rest of your analysis of this problem.

    You said: “… among the estimated 100 million Americans affected by persistent, long-lasting pain (by the American Academies of Medicine). Within this group, an estimated 16 Million are treated in any given year for recurrent persistent pain, and on the order of 3 Million are treated for more than 90 days with opioid analgesics.”

    The so-called “…100 million Americans affected by persistent, long lasting pain…” sound like a highly inflated figure that only serves the needs and interests of the pharmaceutical and pain medicine industry. This sounds very similar to the extremely high figures of so-called “mental illness” estimated and promoted by Biological Psychiatry to sell all their oppressive forms of “treatment.” These are exactly the kinds of statistics that lead to over “treatment,” including more drug prescriptions.

    And some of the organizations you listed as positive sources of information and support, such as The American Academy of Pain Medicine, The American Academy of Integrative Pain Management, and U.S. Pain Foundation, where were they back in the 1990’s when the 5th Vital Sign Campaign was initiated and then promoted the proliferation of pain clinics and pill mills that spread all the country fueling the rapid rise in opiate prescriptions? And what are THEIR current connections to the pharmaceutical industry – how many of their members are on Big Pharma’s payroll? You cannot deny the fact that they have a direct stake in having a high number of pain patients to treat in this country.

    You said: ” The most effective interventions for confirmed addiction are medication-assisted.”

    This statement could have come out of the mouths of the most ardent supporters of Biological Psychiatry and CANNOT be substantiated by LEGITIMATE statistics or studies. And “medication assisted treatment” is the new euphemistic term that describes “opiate replacement therapy” because the latter term is not so much socially accepted by the public. And of course today many addiction patients are also guinea pigs for a host of other mind altering psych drugs. ADDICTION IS NOT A DISEASE AND DRUGS ARE NOT THE CURE.

    I am not saying that some of these drugs such as suboxone should never be used or don’t have a SHORT TERM ROLE in helping some people break their addiction problems. But these drugs, including methadone, are grossly overused in long term “maintenance” programs which are both highly profitable and also become an oppressive means of social control in our society. And these drug replacement programs ARE NOT solving the drug problems, including overdose epidemic, in this country.

    And given the 100 million yearly benzo prescriptions (mostly long term) in this country, giving out MORE synthetic opiates to people with addiction problems is a recipe for even MORE overdose deaths. This is especially true given that I agree with the statistic you include that probably 50% of all overdose deaths involve benzos, where I believe benzos may actually be the decisive component in the deadly drug cocktail.

    And finally, while I believe chronic pain is an issue for a certain segment of the population, I also believe that organized medicine (as a whole) doesn’t have a clue how to treat the problem and most of their treatments have made the problems worse for patients. While I believe that pain drugs have a role in some treatment regimens, overall it SHOULD NOT BE THE MAIN FORM OF TREATMENT. Unfortunately, once drugs have been administered for an extended time it makes it very difficult to switch course in treatment. This is why I stated in my first sentence that the Medical Establishment is now prepared to scapegoat and abandon these patients because they created a problem they have no idea how to solve.

    There is evidence in many of these chronic pain cases of “opioid induced hyperalgesia,” where long term use of these drugs INCREASES pain sensitivity by lowering a person’s pain/frustration threshold for tolerance. These drugs (over time) often lead to less activity and physical motion by those taking them which will also exacerbate pain issues by increasing body stiffness and ultimately affecting mood related problems.

    These are clearly complicated problems but just freeing up easier access and/or opposing more restriction of opiate drugs is also NOT the answer. Certainly the lessons of the Portuguese experiment is definitely worth further examination. And as far as rewriting new guideline for pain treatment in this country, I would place very little trust in including a group of “pain management physicians” to come up with safe and effective protocols. Their track record is not very good.

    Richard Lewis

  2. On March 5, 1982, John Belushi was found dead in his hotel room at the Chateau Marmont in Los Angeles, having been injected with a “speedball”, a mixture of heroin and cocaine. If that happened today the fake news media would most likely report it as an opiate overdose and completely omit the cocaine part.

    http://www.google.com/search?q=drug+war+fail

    No need for a long comment when I can just post the link above to search results to “drug war fail” and the 100s of web pages that explain why.

    The pain patient is the fat man. I guess the two people would be the “addicts” [people who use opiates for mental pain]

    A trolley is hurtling down a track towards two people. You are on a bridge under which it will pass, and you can stop it by putting something very heavy in front of it. As it happens, there is a very fat man next to you – your only way to stop the trolley is to push him over the bridge and onto the track, killing him to save those two. Should you proceed?

  3. I personally know two people who have had non fatal overdoses in the last month, do the 12 step meeting thing for a wile and that happens.

    Its horrible but I know the addict world but throwing the pain patients under the bus is not going to help. The gangs running the distribution are entrenched. This is going to continue no matter what the rules are for pain treatment. They have a whole system where the last part of the distribution is the addicts who have a contact get it for the end users in order to pay for their own supply.

    Opiates are not my thing, alcohol always hit the spot for me but it only took that one experience of that spot being hit and feeling astonishingly better then before to get that drive to keep seeking it out. This business of being cheap with pain treatment is not going to prevent hardly any future addict from learning opiates are a fix for them and is going to have little effect on the supply available to them.

    Maybe pharma and the medical mafia made opiates popular again but the cats out of the bag, you can’t stuff it back in.

  4. Our beloved political leaders aren’t going to do anything sane. Their plan will doubtlessly devolve into something involving the old rubbish about cannabis consumption being the cause of the opioid epidemic, which they will solve by eliminating the potheads with savage punishments, like trying to get the dead horse to pull the buggy by whipping it into life and breaking out the chainsaws when it fails to rise. After all, our present drug “czar” was once a spokesman and apologist for opioid manufacturers, who would ruin his post-political career by cramping his clients’ style and actually doing something realistic about their antics.