NOTICE ON STANDARD OF CARE INQUIRIES
August 20, 2009
The receipt of a number of inquiries from prescription "management" organizations (Medco most prominently) in the last four months would seem to indicate that there is a recent onset of a notable lack of current knowledge about the contemporary standard of care for Intractable Pain. I am writing now to direct Blue Cross, United Health Care, Aetna, Humana and other insurers to the Clinical Guidelines for the Use of Chronic Opioid Therapy in Non-cancer Pain issued by the American Pain Society in February of 2009.
The pain management of all my chronic pain patients conforms to the Clinical Guidelines for the Use of Chronic Opioid Therapy in Non-cancer Pain issued by the American Pain Society in February of 2009. The opioid treatment regimens of all my chronic patients are developed through careful titration and clinical trial. As with any pharmacological treatment, appropriate pain medications are selected, dosage is started low, and titration is upwards until effective pain control is accomplished. During this process the patient is carefully monitored for adverse effects. Opioid medications do not have any absolute maximum dosage, the limit being the induction of respiratory depression.
This treatment is in strict conformity with the guidelines. The treatment consistently results in the effective treatment of chronic pain, without medical complications, adverse effects, aberrant behaviors or evidence of the induction or worsening of any addictive disorder. Effective treatment allows patient to make progress in their quality of life, physical status (frequently with dramatic improvement in their range of motion and social and physical functioning.) They consistently suffer no adverse effects or medical complications. Their progress is consistently documented. Their pain regimen typically becomes stable within 90 days and remains so, without significant variation or change, for periods from 24 to 180 months in my research series.
The treatment is consistently supervised on a timely basis during the entire course of treatment and is unarguably of medical necessity. Patients provide outcome letters which are definitive as to the efficacy and safety of treatment. In most cases, because of the unresolvability of the underlying pathology, their pain management will typically be indefinite.
Sincerely, J.S. Hochman MD
Executive Director
The National Foundation for the Treatment of Pain
www.paincare.org
Thursday, August 20, 2009
Monday, August 17, 2009
MONEY TALKS, PRINCIPLES WALK
MONEY TALKS, PRINCIPLES WALK
The media now informs us that the Government-sponsored alternative to the corporate health insurance companies is dead. If this is true, it represents a crime against the public that makes the Teapot Dome Scandal look like pilferage of Girl Scout Cookies. If the lobbyists for the Insurance Companies pull this one off, they will:
1. Escape meaningful competition in health care insurance
2. Continue their horrendous abuses of the public and physicians (particularly the elderly and chronic pain patients)
3. Gain another 40 million insured by compelling through federal law that they all acquire their insurance from these mega-corporations
4. Gain another half trillion dollars in annual revenues
5. Preserve their criminal overhead rate which varies from 32% (acknowledged) to 50 to 70% (hidden)
6. Demonstrate that swiftboating works with a credible public susceptible to tabloid mentality and incapable of critical and independent analysis
7. Prove that the Congress is owned by lobbyists, political contributions and cronyism
8. Reveal that the Congress (our purported representatives) doesn't give a damn about the people and arrogantly ignores our rights and the government's obligations
9. Seriously raises the question whether it is time for a political revolution in the Congress, such as we have already had in the Presidency. I say that every member of Congress who votes to fold under to the Insurance Companies needs to be voted out of office, and that only candidates who guarantee to serve the needs of the people, not the Trillionaire Insurance Companies, be returned to Washington.
There is still time. EVERY citizen should call, e-mail and FAX their Senators and Representatives and tell them that this an unacceptable crime against the people.
J.S. Hochman MD
Executive Director
The national Foundation for the Treatment of Pain
The media now informs us that the Government-sponsored alternative to the corporate health insurance companies is dead. If this is true, it represents a crime against the public that makes the Teapot Dome Scandal look like pilferage of Girl Scout Cookies. If the lobbyists for the Insurance Companies pull this one off, they will:
1. Escape meaningful competition in health care insurance
2. Continue their horrendous abuses of the public and physicians (particularly the elderly and chronic pain patients)
3. Gain another 40 million insured by compelling through federal law that they all acquire their insurance from these mega-corporations
4. Gain another half trillion dollars in annual revenues
5. Preserve their criminal overhead rate which varies from 32% (acknowledged) to 50 to 70% (hidden)
6. Demonstrate that swiftboating works with a credible public susceptible to tabloid mentality and incapable of critical and independent analysis
7. Prove that the Congress is owned by lobbyists, political contributions and cronyism
8. Reveal that the Congress (our purported representatives) doesn't give a damn about the people and arrogantly ignores our rights and the government's obligations
9. Seriously raises the question whether it is time for a political revolution in the Congress, such as we have already had in the Presidency. I say that every member of Congress who votes to fold under to the Insurance Companies needs to be voted out of office, and that only candidates who guarantee to serve the needs of the people, not the Trillionaire Insurance Companies, be returned to Washington.
There is still time. EVERY citizen should call, e-mail and FAX their Senators and Representatives and tell them that this an unacceptable crime against the people.
J.S. Hochman MD
Executive Director
The national Foundation for the Treatment of Pain
Wednesday, August 5, 2009
Opiophobia - Racism in Boards of Medicine
I posted this today as my contribution to the on-going dialogue about the persecution of pain management doctors, on the LIST serve "The Project on Pain and Chemical Dependency" (TPPCD)
I'm afraid that what we are dealing with is a form of sick human behavior. There can be no doubt that there is murderous potential in every human being. The BTK murderer is a dramatic example of this. Scout leader; church-goer; a person everyone liked; a long-term employee of an alarm company; married 30 years; father to a charming, healthy daughter; absolutely likable by all who knew him. Yet he secretly harbored a total monster deep inside. When we look around, we see that the history of humans is really a nightmare of horrors. Genocides everywhere we look. 300 million slaughtered in the last 2000 years (if not more). A madman murdering 10 innocent women in a work-out facility - just today. Religious zealots bombing hundreds of innocent people throughout the Middle East. Apparently normal American kids engaging in sexual sadism in Abu Graib. Blue collar folks turning into heartless assassins when they go to work for Blackwater (or the CIA, or state prisons, etc., etc.)
As one of my Psychiatry Professors at UCLA taught us 40+ years ago - "there should never be any doubt about what is inside human beings. The only question is how well they are handling it". (He also used to say that the only crime in psychiatry was being surprised.)
So, the point I want to make is that most people handle their internal monsters by projection. They defend themselves from the emotional trauma of facing their internal monsters by unconsciously projecting the monsters onto others. Take the example of the corrupt prosecutor - who justifies suborning perjury, sequestering exculpatory evidence, fabricating evidence, routinely perjuring ("testilying" the police officers call it) - in order to win a conviction. He (or she) rationalizes this monstrous behavior by perceiving the victim of their behavior as the monster. ("It doesn't matter what it takes me to do to convict this horrible criminal".) This dynamic plays itself out daily in every form of investigation, prosecution and judgment. This Executive Director of the California State Medical Board clearly sees pain management as a meretricious form of behavior hiding behind a white coat. So it is his "duty" to punish it. He (or she) is clueless that what they are doing is denying the most fundamental achievement of physicians since the dawn of the profession - relieving suffering. Their conviction is so intransigent that they don't WANT to interview the patients whose lives have been spared by effective pain treatment (it only gets in the way of their own disturbed emotional needs.) They simply harbor behaviors and attitudes that underlie every mindless prejudice, most notably "racism".
I am convinced that opiophobia is at the deepest level best understood as "pharmacological racism". Just as with any racist belief, it is irrational, springs from vicious and un-understood prejudice, and serves a deep inner illness in the perpetrator. Arthur is a remarkable exception, in his fair-minded rationality. I would hope that there are many like him in his profession. But I have to say that of all the Board (and other) prosecutors I have met, he appears to be a rare exception.
Historically, it took us over 200 years to shake ourselves loose enough from our melanophobia (fear of people with colored skin) and prejudice, to elect an African American to the presidency of the United States. In fact I think it may be a signal of a tidal change in the world. But I hope that it doesn't take that long to change the opiophobia that condemns millions of innocently suffering people, and thousands of compassionate doctors, to a needless hell.
For myself, I have now spent over $40,000 in legal fees dealing with 45 investigations by the Texas Medical Board, over the last two years. All but 14 have been dismissed. The remaining 14, initiated after the first 31, are excellent examples of successful pain treatment (as every patient attests in writing.) But the now Executive Director of the now regressive Texas Medical Board continues to mindlessly and shamelessly seek my destruction (Until eight years ago Texas was a leader in progressive pain managemnt policy. Mr. Bush and his doppelganger, Mr. Perry, changed all that with their appointments to the Texas Board. As Stratton Hill observes, "the opiophobes are winning.").
The pursuit and prosecution of pain management as "injudicious prescription" is simply a smokescreen for the opiophobia that motivates it. And this pursuit is one of the most common activities of State Medical Boards throughout the nation. In many states one simply cannot now find a doctor willing to treat intractable pain. Dr. Robert Kales, a consummate gentleman, an excellent physician, a wise and educated man, has now been persecuted out of Arkansas and now Oklahoma. In New Mexico, where I practiced for 25 years and served two years as the Clinical Director of all the in-patient and community based health programs in the state, a religious cult nut case spent eight years hounding me out of my home and practice, even though I referred the last 142 cases I accepted, to the Pain Clinic at the University of New Mexico School of Medicine for a second opinion and got 100% concurrence and support for my care. Joan Lewis MD, has suffered a similar fate. She now must practice cosmetic medicine because the Board of Medicine stripped her right to prescribe pain medication! How many other cases can we name? Just thinking about it makes me nauseous and disgusted. The State Boards of Medicine give lip service to their Model for the Treatment of Intractable Pain when they are in Washington, at the Federation of State Medical Boards meetings. But when they get back home it's business as usual - lynching pain management doctors. ("Some of my best friends are pain management doctors" I am sure they would say.)
I know that President Obama is aware of this calamity (one of my patients, a victim of intractable pain, the son of a prominent newsman, spent half an hour with him during the campaign, smoking cigarettes, and told him his whole story - for which the then Mr. Obama thanked him - "I had no idea that this was happening, Mr. Obama told him. "But I know about it now".). It is on his list of priorities for change in America. But, unfortunately, it is a ways down the list, under the economy, Iran's nuclear development, reform of Health Care, reforming Drug Policy, congressional corruption by lobbying and special interests, etc., etc.
So, I don't know what more we can do except what we have been doing. Talk about it, write about it. Give interviews, write articles, do research (Craig - where is that damned, history-changing manuscript?), share our knowledge and experience at every opportunity, defend the truth, uphold reality and factuality, defend rationality and science to the death. For myself, if the epithet on my tombstone reads, "they may have destroyed his career, but they didn't touch his convictions, his integrity, or the scientific truth" I will smile proudly for eternity.
JSH
I'm afraid that what we are dealing with is a form of sick human behavior. There can be no doubt that there is murderous potential in every human being. The BTK murderer is a dramatic example of this. Scout leader; church-goer; a person everyone liked; a long-term employee of an alarm company; married 30 years; father to a charming, healthy daughter; absolutely likable by all who knew him. Yet he secretly harbored a total monster deep inside. When we look around, we see that the history of humans is really a nightmare of horrors. Genocides everywhere we look. 300 million slaughtered in the last 2000 years (if not more). A madman murdering 10 innocent women in a work-out facility - just today. Religious zealots bombing hundreds of innocent people throughout the Middle East. Apparently normal American kids engaging in sexual sadism in Abu Graib. Blue collar folks turning into heartless assassins when they go to work for Blackwater (or the CIA, or state prisons, etc., etc.)
As one of my Psychiatry Professors at UCLA taught us 40+ years ago - "there should never be any doubt about what is inside human beings. The only question is how well they are handling it". (He also used to say that the only crime in psychiatry was being surprised.)
So, the point I want to make is that most people handle their internal monsters by projection. They defend themselves from the emotional trauma of facing their internal monsters by unconsciously projecting the monsters onto others. Take the example of the corrupt prosecutor - who justifies suborning perjury, sequestering exculpatory evidence, fabricating evidence, routinely perjuring ("testilying" the police officers call it) - in order to win a conviction. He (or she) rationalizes this monstrous behavior by perceiving the victim of their behavior as the monster. ("It doesn't matter what it takes me to do to convict this horrible criminal".) This dynamic plays itself out daily in every form of investigation, prosecution and judgment. This Executive Director of the California State Medical Board clearly sees pain management as a meretricious form of behavior hiding behind a white coat. So it is his "duty" to punish it. He (or she) is clueless that what they are doing is denying the most fundamental achievement of physicians since the dawn of the profession - relieving suffering. Their conviction is so intransigent that they don't WANT to interview the patients whose lives have been spared by effective pain treatment (it only gets in the way of their own disturbed emotional needs.) They simply harbor behaviors and attitudes that underlie every mindless prejudice, most notably "racism".
I am convinced that opiophobia is at the deepest level best understood as "pharmacological racism". Just as with any racist belief, it is irrational, springs from vicious and un-understood prejudice, and serves a deep inner illness in the perpetrator. Arthur is a remarkable exception, in his fair-minded rationality. I would hope that there are many like him in his profession. But I have to say that of all the Board (and other) prosecutors I have met, he appears to be a rare exception.
Historically, it took us over 200 years to shake ourselves loose enough from our melanophobia (fear of people with colored skin) and prejudice, to elect an African American to the presidency of the United States. In fact I think it may be a signal of a tidal change in the world. But I hope that it doesn't take that long to change the opiophobia that condemns millions of innocently suffering people, and thousands of compassionate doctors, to a needless hell.
For myself, I have now spent over $40,000 in legal fees dealing with 45 investigations by the Texas Medical Board, over the last two years. All but 14 have been dismissed. The remaining 14, initiated after the first 31, are excellent examples of successful pain treatment (as every patient attests in writing.) But the now Executive Director of the now regressive Texas Medical Board continues to mindlessly and shamelessly seek my destruction (Until eight years ago Texas was a leader in progressive pain managemnt policy. Mr. Bush and his doppelganger, Mr. Perry, changed all that with their appointments to the Texas Board. As Stratton Hill observes, "the opiophobes are winning.").
The pursuit and prosecution of pain management as "injudicious prescription" is simply a smokescreen for the opiophobia that motivates it. And this pursuit is one of the most common activities of State Medical Boards throughout the nation. In many states one simply cannot now find a doctor willing to treat intractable pain. Dr. Robert Kales, a consummate gentleman, an excellent physician, a wise and educated man, has now been persecuted out of Arkansas and now Oklahoma. In New Mexico, where I practiced for 25 years and served two years as the Clinical Director of all the in-patient and community based health programs in the state, a religious cult nut case spent eight years hounding me out of my home and practice, even though I referred the last 142 cases I accepted, to the Pain Clinic at the University of New Mexico School of Medicine for a second opinion and got 100% concurrence and support for my care. Joan Lewis MD, has suffered a similar fate. She now must practice cosmetic medicine because the Board of Medicine stripped her right to prescribe pain medication! How many other cases can we name? Just thinking about it makes me nauseous and disgusted. The State Boards of Medicine give lip service to their Model for the Treatment of Intractable Pain when they are in Washington, at the Federation of State Medical Boards meetings. But when they get back home it's business as usual - lynching pain management doctors. ("Some of my best friends are pain management doctors" I am sure they would say.)
I know that President Obama is aware of this calamity (one of my patients, a victim of intractable pain, the son of a prominent newsman, spent half an hour with him during the campaign, smoking cigarettes, and told him his whole story - for which the then Mr. Obama thanked him - "I had no idea that this was happening, Mr. Obama told him. "But I know about it now".). It is on his list of priorities for change in America. But, unfortunately, it is a ways down the list, under the economy, Iran's nuclear development, reform of Health Care, reforming Drug Policy, congressional corruption by lobbying and special interests, etc., etc.
So, I don't know what more we can do except what we have been doing. Talk about it, write about it. Give interviews, write articles, do research (Craig - where is that damned, history-changing manuscript?), share our knowledge and experience at every opportunity, defend the truth, uphold reality and factuality, defend rationality and science to the death. For myself, if the epithet on my tombstone reads, "they may have destroyed his career, but they didn't touch his convictions, his integrity, or the scientific truth" I will smile proudly for eternity.
JSH
Monday, August 3, 2009
Opioids and Depression
The following is from the LIST serve TPPCD (The Project on Pain and Chemical Dependency)
On Mon, Aug 3, 2009 at 1:28 PM, wrote:
a separate musing thread
recently-I have been seeing sales reps trying to get me to use various psych meds for resistant depression. I hear the same thing- 1/3 get total relief of depression and up to 50% get total relief with a combo of drugs. That leaves 50% of patient with little or partial relief of depression with traditional therapies. Why is that??
The simple answer is that traditional therapies do not treat the neuro-physiologic abnormalities in these patients.
Now , I know we dont have a good grasp on the etiologies of most affective disorders but the effectiveness and mechanisms of traditional therapies have led to a belief that imbalances in seratonin, norepinephrine and/or dopamine are some how contributory. All the patients have a "chemical imbalance"
So can we conclude that in the 50% poorly treated that the "chemical imbalance" occurs in an area separate from these neurotransmitters??
15 years ago a study was published looking at a small number of resistant depressives with no history of opiate abuse. They were given buprenorphine with a significant reduction in symptoms. Could an endogenous endorphin deficiency have been at play here??? If so, how frequent does it occur in clinical practice??
I think that attempting to treat patients for depression with opiates is scary because of the stigma and risk for physical dependency. . And it should be a lesser used treatment. I wonder if that is why no one ever thought of doing the experiment. However, with buprenorphine we have a safer alternative- should it be looked at.???
Stu
--------------------------------------------------------------------
The history of psychiatry reveals that prior to the age of anti-depressant medications, the treatment of choice for depression was opiates!!
Intractable pain patients suffer depression far more frequently than the general population. Clearly this has to be related to the consequences of being disabled, but depletion of endogenous opioid substances must be a major factor.
Opiate addiction is another major clue to the connection of endogenous opioids to addiction. Of the hundreds of heroin addicts with whom I have worked over the decades, parenteral opiates were obviously self-treatment for major depression. All required an anti-depressant as a component of their treatment. Also, the efficacy of methadone suggested the role of opioids and pleasure (the opposite of depression.)
The demonization of opioids is a fascinating historical oddity. I see it as exactly analogous to the history of racism. Recall the Roman Empire. Recall Shakespeare and Othello. Black skin was not always associated with negative prejudices.
It has taken a century to make a dent in melanophobia. Probably it will require the same for opioids. Buprenorphine? Seems like a rational inquiry to me.
JSH
On Mon, Aug 3, 2009 at 1:28 PM,
a separate musing thread
recently-I have been seeing sales reps trying to get me to use various psych meds for resistant depression. I hear the same thing- 1/3 get total relief of depression and up to 50% get total relief with a combo of drugs. That leaves 50% of patient with little or partial relief of depression with traditional therapies. Why is that??
The simple answer is that traditional therapies do not treat the neuro-physiologic abnormalities in these patients.
Now , I know we dont have a good grasp on the etiologies of most affective disorders but the effectiveness and mechanisms of traditional therapies have led to a belief that imbalances in seratonin, norepinephrine and/or dopamine are some how contributory. All the patients have a "chemical imbalance"
So can we conclude that in the 50% poorly treated that the "chemical imbalance" occurs in an area separate from these neurotransmitters??
15 years ago a study was published looking at a small number of resistant depressives with no history of opiate abuse. They were given buprenorphine with a significant reduction in symptoms. Could an endogenous endorphin deficiency have been at play here??? If so, how frequent does it occur in clinical practice??
I think that attempting to treat patients for depression with opiates is scary because of the stigma and risk for physical dependency. . And it should be a lesser used treatment. I wonder if that is why no one ever thought of doing the experiment. However, with buprenorphine we have a safer alternative- should it be looked at.???
Stu
--------------------------------------------------------------------
The history of psychiatry reveals that prior to the age of anti-depressant medications, the treatment of choice for depression was opiates!!
Intractable pain patients suffer depression far more frequently than the general population. Clearly this has to be related to the consequences of being disabled, but depletion of endogenous opioid substances must be a major factor.
Opiate addiction is another major clue to the connection of endogenous opioids to addiction. Of the hundreds of heroin addicts with whom I have worked over the decades, parenteral opiates were obviously self-treatment for major depression. All required an anti-depressant as a component of their treatment. Also, the efficacy of methadone suggested the role of opioids and pleasure (the opposite of depression.)
The demonization of opioids is a fascinating historical oddity. I see it as exactly analogous to the history of racism. Recall the Roman Empire. Recall Shakespeare and Othello. Black skin was not always associated with negative prejudices.
It has taken a century to make a dent in melanophobia. Probably it will require the same for opioids. Buprenorphine? Seems like a rational inquiry to me.
JSH
Saturday, August 1, 2009
The Essential Requirements of Reformed Health Care
Although I am a member of AAPS, I have not been happy with their input into the reform of Health Care. For the first time today AAPS issued a POSITIVE statement for the dialogue. I can support this 100% as an addition to my letter to President Obama.
* improve the quality of care by encouraging innovation;
* decrease systems-gaming and nonproductive work related to justifying price-
controlled fees;
* allow physicians to concentrate on healing rather than constantly changing
administrative rules;
* restore the patient/physician relationship and the joy of practicing medicine;
* increase supply, availability, and competition, and thus decrease costs and make
it easier to serve those who are most in need of help; and
* discourage frivolous or predatory litigation.
http://www.aapsonline.org/newsoftheday/00406
* improve the quality of care by encouraging innovation;
* decrease systems-gaming and nonproductive work related to justifying price-
controlled fees;
* allow physicians to concentrate on healing rather than constantly changing
administrative rules;
* restore the patient/physician relationship and the joy of practicing medicine;
* increase supply, availability, and competition, and thus decrease costs and make
it easier to serve those who are most in need of help; and
* discourage frivolous or predatory litigation.
http://www.aapsonline.org/newsoftheday/00406
The Data from the Drug Czar don't support his Claims
June 9, 2009
The statisticians at the Adverse Events Reporting System clearly state that the system does not report incidence but occurrence, and is unreliable. Is there any data other than from AERS that substantiates an imminent risk from prescribed opioids?
“Reports contain only those reactions voluntarily submitted either directly to the FDA or to the drug manufacturer by consumers and /or members of the health profession and which have been entered into the AERS computerized filing system since November 1, 2007.
The information contained in the reports has not been scientifically or otherwise verified. For any given report there is no certainty that the suspected drug caused the reaction. This is because physicians are encouraged to report suspected reactions. The event may have been related to the underlying disease for which the drug was given to concurrent drugs being taken or may have occurred by chance at the same time the suspected drug was taken.
Accumulated case reports cannot be used to calculate incidence or estimates of drug risk Numbers from these data must be carefully interpreted as reporting rates and not occurrence rates. True incidence rates cannot be determined from this database. Comparisons of drugs cannot be made from these data.”
The “National Prescriptive Drug Threatö is based upon “synthesized dataö. The data quoted by the DEA (National Drug Threat Assessment 2009), available at:
* HYPERLINK "http://www.usdoj.gov/ndic/pubs31/31379/index.htm" *http://www.usdoj.gov/ndic/pubs31/31379/index.htm#Contents*
* HYPERLINK "http://www.usdoj.gov/ndic/pubs31/31379/appendb.htm" *http://www.usdoj.gov/ndic/pubs31/31379/appendb.htm#Top*
simply does not support the claim of an “epidemic of diversion and abuse”. What data substantiates an “epidemic”?
In the data cited above, from 2001 to 2005, opioid deaths are said to have increased 113.8% (from 3994 to 8451). However, the survey “drug use in the past month” reports that the use of opioids has increased only 5% from 2003 to 2007 û from 2% of the population to 2.1%. During the same period the population grew 6%. How can this be called an “epidemic”?
In the DEA cited data from the survey “the use of psychotherapeutic drugs in the previous month”, the use of pain medications decreased 12.5% from 2003 to 2007. How was this data considered in arriving at a conclusion that an epidemic is occurring?
From 2003 to 2007, the DEA reports that the annual opioid production rose 51% - from 25,607 kg to 38,680 kg. Despite this increase, the “use of pain medication in the previous month” decreased 12.5% . Based on this data, how can DEA or FDA claim an “epidemic”?
Again, using the DEAÆs own data, the incidence of deaths per grams produced, per 100,000 population, decreased 11.6% from 2003 to 2007, while the amount manufactured increased 51.5%. DoesnÆt this data disprove any form of “epidemic” of drug use?
Based upon the federal government’s survey data, drug use of every drug, by all age groups, declined slightly from 2003 to 2008, and occurred amongst no more than 6.9% of adults for the use of cocaine, 1% for the use of crack, 0.5% for the use of Heroin, 1.9% for the use of metamphetamine, 12.4% of adults between the ages of 18 and 25, and 3.6% of adults 26 and over, for the use of prescription drugs. The use of “Prescription Narcotics” (presumably referring to opioids, benzodiazepines, barbiturates and other central nervous system affecting pharmaceuticals) has occurred in no more than 5.1% of all people over the age of 12, and has actually increased no more than 0.1% over the last five years. Doesn’t this data argue against an “epidemic” of prescription drug abuse?
Based upon the DEA’s data from “Monitoring the Future”, the use of “prescription narcotics” reached a maximum of 9.5% of 12th graders in 2004 and decreased to 9.2% in 2007. The use of sedative/barbiturates reached a high of 7.2% of 12th graders in 2005 and decreased to 6.2% in 2007. The use of tranquilizers dropped from 6.7% in 2003 to 6.2 % in 2007. Where is the “epidemic” in this data?
The incidence of hospitalizations primarily for substance abuse from 2002 to 2006 declined dramatically for heroin, barbiturates and tranquilizers. Hospitalizations for barbiturates declined 36.1% from 2002. However, hospitalizations for opiates and synthetics increased 62.0% for the period, from 46,138 to 74,750.
Given that there were 150,000,000 opioid doses legitimately prescribed in that year, will FDA and the DEA acknowledge that the incidence of hospitalization could have been no more than 74,750/150,000,000 (0.41%)?
Will FDA and the DEA acknowledge that the incidence of fatal overdoses from opioids diverted or illegally obtained could have been no more than 8,450/150,000,000? (0.0053%)?
Given that use of opioids has not increased dramatically in the last five years, will the FDA and the DEA acknowledge that the most logical conclusion is not that there is an “epidemic” of opioid usage, but that usage has become more frequent and reckless among a numerically tiny group of abusers and diverters?
Lastly, can the FDA and the DEA acknowledge that reducing the availability of life-saving pain medication for 50,000,000 legitimate and innocent chronic pain patients is an indefensible and inappropriate approach to reducing the abuse and diversion of opioids by, comparatively speaking, an extremely small number of reckless non-pain patients?
How will the FDA guarantee that any opioid-related REMS will not increase the current unavailability and unwillingness of physicians to prescribe effective pain control for legitimate, innocent and deserving chronic pain patients?
The National Foundation for the Treatment of Pain
J.S. Hochman, M.D.
Executive Director
----------------------------------------------
Anyone wishing to obtain a copy of the PowerPoint presentation specifically reviewing the data, please email jfshmd@gmail.com
The Drug War Inquisition
The following is part of a current dialogue on the LISTserve "The Project on Pain and Chemical Dependency" (TPPCD) which, founded by Russell Portenoy MD, is now over 30 years old and until four years ago was supported by Beth Israel Hospital (until it got too politically hot for them.
-----------------------------------------------------------------------------------
On Fri, Jul 31, 2009 at 11:01 PM, Sara wrote:
To all,
While sitting and watching "Cops" and other such shows on TV, I am struck by how much more frequently drug busts these days seem to feature psychostimulants (cocaine and methamphetamine, mainly) and potential anti-anxiety drugs (benzos and pot), with a corresponding decrease in frequency of opioids. You still see plenty of IV heroin and other opioid users, but not many that pop opioid pills. This leads me to wonder about something. We have always speculated about how many opioid users wouldn't use if they just had an adequate amount of opioid for their somatic pain. (Pseudo-addiction) Along that same line, I am wondering how often the illegal use of these two classes of drugs reflects a legitimate medical need for them.
The huge frequency of the anxiety disorders has been well documented for the past 30 years. And still is grossly undertreated, with useless drugs like BuSpar, or inferior ones like the antidepressants, being foisted on the patients for much the same reason that gabapentin, tricyclics, antiseizure drugs and tramadol are dumped onto the pain patients. The safest, surest, most effective drugs --- the benzodiazepines --- are denied due to addiction myths and hysteria.
And even more, I wonder how many people on illegal pschostimulants or cocaine have some form of ADD, narcolepsy, or resistant depression that these drugs actually help. The numbers of such people are far less documented than are the anxiety patients, but their numbers may be just as large.
My wife has a severe anxiety disorder that would leave her in a constant and absolute hell were it not for a combination of SSRI, atypical antipsychotic, and Xanax. (Thank God her metabolism is such that only a tiny dab of Xanax will do the job, enough for her panic-stricken doc to prescribe!) Numerous attempts to wean down any of the three are met with prompt dysfunction, but she functions OK with them. But it has often occurred to me: For all I know, a couple of joints a day might eliminate the need for two of the three. Not that we would dare, but I have to wonder how many other people functioin well for just that reason, as long as their employer doesn't do drug screens.
I would welcome anyone's opinion on this. Joel's perspective as a psychiatrist and Stu's as an addiction specialist would be especially valued, but I'd like to hear from anyone. What percentage of people currently labeled as abusing psychostimulants or pot are actually "pseudo-addicts" just like with pain treatment?
Joe Talley, M. D.
OK. Let me reflect a bit. I have been a psychiatrist for 39 years. I have over 100,000 hours of clinical experience. I have treated approximately 10,000 patients (in and out-patient) and 4,000 intractable pain patients. So, how many patients have I seen with:
1. opioid (for pain treatment) induced addictions
2. benzodiazepine addiction
3. cannabis addiction
The answers are:
1. 0 I have seen hundreds of patients who came to me for opioid addiction (mainly heroin) who were not pain patients (methadone candidates in the 70's, 80's and 90's, now Suboxone candidates). But I have NEVER seen a patient who developed an addictive disorder from taking opioids for pain. I understand this because the pain perception mechanism lies in the periaqueductal grey area of the brain and pleasure is mediated in the nucleus accumens. Apparently the neurophysiology is very different. Stimulating pleasure by exogenous opioids requires dose escalation at the nucleus accumens. Controlling pain at the P.A.G. does not. Once you reach containment the patients remain stable in dose and schedule for decades (unless the underlying pathology becomes significantly worse or the patient does things that aggravate the pain).I have followed 204 cases now for over a decade whose data absolutely demonstrates this.
Footnote: If Mr. Craig Dietrich will ever finish his commitment to
analyze the data and complete our manuscript I will have a ground-
breaking,peer-reviewable article to establish this once and forever.Craig
works at a major hospital here in Houston. His employment contract
states that he cannot do research or analytical work for anyone else.
They insisted on reading the manuscript and then told him if he published
it he would be fired. He has repeatedly promised to bring me the finished
m.s.and all the data and reference material I have sent him. To date
he has not done this. I am having a fit.
2. 1 When I was doing in-patient psychiatric medicine I once got a patient
through an emergency commitment who was strung out on benzos (Xanax 6 to 8 mg/day). It took about a week to resolve the case by officially diagnosing his Anxiety and Panic disorder, migrating him to a longer-acting drug, Klonopin, and initiating an effective anti-depressant treatment. I followed him for four years afterward and he never had another problem.
3. 0 I have seen hundreds (if not thousands now) of patients who experimented
with cannabis, smoked it regularly when they were younger, or continued to use it for decades. The results of a five year study I ran at UCLA were published in my book, "Marijuana and Social Evolution" (Prentice-Hall, which is still available on Amazon.com) reviews the extensive data developed in this multi-million dollar NIMH sponsored study at UCLA.) It destroyed my academic career, for which I have been eternally grateful.
As my data analysis of the Drug Czar's (and the FDAS's) own data on the "epidemic of drug diversion and abuse" demonstrates beyond any rational doubt, all this current brouhaha about "drugs" is a pile of you know what. It serves the vested interests of politicians, law enforcement, right-wing ideologues, troglydyte Board of Medicine members, judicial-correctional-legislature entrepeneurs. Michael Jackson was, statistically speaking, about four standard deviations outside the norm in the bell-shaped curve of human behavior. But, of course, all the above will attempt to use his sad life as evidence to support their cynical and/or self-deluded hysteria. All we can do is sit patiently in the middle of the riot and keep repeating our mantra - "two plus two is four. It is not six or 104. It is four." Of course we run the risk of being burned at the stake, because truth, rationality and reason are not popular in Inquisitions (ask Gallileo).
JSH
-----------------------------------------------------------------------------------
On Fri, Jul 31, 2009 at 11:01 PM, Sara
To all,
While sitting and watching "Cops" and other such shows on TV, I am struck by how much more frequently drug busts these days seem to feature psychostimulants (cocaine and methamphetamine, mainly) and potential anti-anxiety drugs (benzos and pot), with a corresponding decrease in frequency of opioids. You still see plenty of IV heroin and other opioid users, but not many that pop opioid pills. This leads me to wonder about something. We have always speculated about how many opioid users wouldn't use if they just had an adequate amount of opioid for their somatic pain. (Pseudo-addiction) Along that same line, I am wondering how often the illegal use of these two classes of drugs reflects a legitimate medical need for them.
The huge frequency of the anxiety disorders has been well documented for the past 30 years. And still is grossly undertreated, with useless drugs like BuSpar, or inferior ones like the antidepressants, being foisted on the patients for much the same reason that gabapentin, tricyclics, antiseizure drugs and tramadol are dumped onto the pain patients. The safest, surest, most effective drugs --- the benzodiazepines --- are denied due to addiction myths and hysteria.
And even more, I wonder how many people on illegal pschostimulants or cocaine have some form of ADD, narcolepsy, or resistant depression that these drugs actually help. The numbers of such people are far less documented than are the anxiety patients, but their numbers may be just as large.
My wife has a severe anxiety disorder that would leave her in a constant and absolute hell were it not for a combination of SSRI, atypical antipsychotic, and Xanax. (Thank God her metabolism is such that only a tiny dab of Xanax will do the job, enough for her panic-stricken doc to prescribe!) Numerous attempts to wean down any of the three are met with prompt dysfunction, but she functions OK with them. But it has often occurred to me: For all I know, a couple of joints a day might eliminate the need for two of the three. Not that we would dare, but I have to wonder how many other people functioin well for just that reason, as long as their employer doesn't do drug screens.
I would welcome anyone's opinion on this. Joel's perspective as a psychiatrist and Stu's as an addiction specialist would be especially valued, but I'd like to hear from anyone. What percentage of people currently labeled as abusing psychostimulants or pot are actually "pseudo-addicts" just like with pain treatment?
Joe Talley, M. D.
OK. Let me reflect a bit. I have been a psychiatrist for 39 years. I have over 100,000 hours of clinical experience. I have treated approximately 10,000 patients (in and out-patient) and 4,000 intractable pain patients. So, how many patients have I seen with:
1. opioid (for pain treatment) induced addictions
2. benzodiazepine addiction
3. cannabis addiction
The answers are:
1. 0 I have seen hundreds of patients who came to me for opioid addiction (mainly heroin) who were not pain patients (methadone candidates in the 70's, 80's and 90's, now Suboxone candidates). But I have NEVER seen a patient who developed an addictive disorder from taking opioids for pain. I understand this because the pain perception mechanism lies in the periaqueductal grey area of the brain and pleasure is mediated in the nucleus accumens. Apparently the neurophysiology is very different. Stimulating pleasure by exogenous opioids requires dose escalation at the nucleus accumens. Controlling pain at the P.A.G. does not. Once you reach containment the patients remain stable in dose and schedule for decades (unless the underlying pathology becomes significantly worse or the patient does things that aggravate the pain).I have followed 204 cases now for over a decade whose data absolutely demonstrates this.
Footnote: If Mr. Craig Dietrich will ever finish his commitment to
analyze the data and complete our manuscript I will have a ground-
breaking,peer-reviewable article to establish this once and forever.Craig
works at a major hospital here in Houston. His employment contract
states that he cannot do research or analytical work for anyone else.
They insisted on reading the manuscript and then told him if he published
it he would be fired. He has repeatedly promised to bring me the finished
m.s.and all the data and reference material I have sent him. To date
he has not done this. I am having a fit.
2. 1 When I was doing in-patient psychiatric medicine I once got a patient
through an emergency commitment who was strung out on benzos (Xanax 6 to 8 mg/day). It took about a week to resolve the case by officially diagnosing his Anxiety and Panic disorder, migrating him to a longer-acting drug, Klonopin, and initiating an effective anti-depressant treatment. I followed him for four years afterward and he never had another problem.
3. 0 I have seen hundreds (if not thousands now) of patients who experimented
with cannabis, smoked it regularly when they were younger, or continued to use it for decades. The results of a five year study I ran at UCLA were published in my book, "Marijuana and Social Evolution" (Prentice-Hall, which is still available on Amazon.com) reviews the extensive data developed in this multi-million dollar NIMH sponsored study at UCLA.) It destroyed my academic career, for which I have been eternally grateful.
As my data analysis of the Drug Czar's (and the FDAS's) own data on the "epidemic of drug diversion and abuse" demonstrates beyond any rational doubt, all this current brouhaha about "drugs" is a pile of you know what. It serves the vested interests of politicians, law enforcement, right-wing ideologues, troglydyte Board of Medicine members, judicial-correctional-legislature entrepeneurs. Michael Jackson was, statistically speaking, about four standard deviations outside the norm in the bell-shaped curve of human behavior. But, of course, all the above will attempt to use his sad life as evidence to support their cynical and/or self-deluded hysteria. All we can do is sit patiently in the middle of the riot and keep repeating our mantra - "two plus two is four. It is not six or 104. It is four." Of course we run the risk of being burned at the stake, because truth, rationality and reason are not popular in Inquisitions (ask Gallileo).
JSH
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