I’ve written about the Pain Relief Network in prior posts — one side of the battle between those trying to limit access to schedule II opioids (led by PROP, or Physicians for Responsible Opioid Prescribing), and until recently, the Pain Relief Network, or PRN.

If you haven’t read my earlier posts on the subject, I encourage you to do so;  the final chapter, including the death of PRN’s founder in a plane crash, had all of the drama of a made-for-TV movie.  PRN suffered a number of consecutive blows, including the founder’s death, the loss of a major case against a ‘pill-pushing’ doctor, and investigations into PRN’s finances by the prosecutors of the doctor’s case.

PRN did things that angered too many people, including placing a billboard for jurors to see on the way to the doctor’s case; a deliberate ‘spit in the eye’ of the judge and prosecutors in the case.  At some point, I think PRN went too far, and discovered that they didn’t have quite as much power as they thought. PRN no longer exists.

My dad used to tell a joke about a bunch of soldiers sitting around the barracks.

One old guy yelled 31! – and the place broke out in laughter.  After a moment or two, another guy yelled 52! – and more laughter erupted.  Then a depressed-looking guy in the corner yelled 29! — followed by silence.  He yelled again, 68!—and again, the room was silent.

The new recruit asked the guy in the next bunk what was going on.  The guy answered, “we’ve been together so long that we know each others’ jokes too well—we decided to just number ‘em and save us the time.”

The new guy asked again, “but what about that guy in the corner?”

“Oh—that’s just Slim—he never could tell a joke.”

I recently exchanged emails with a patient about his complaints of back pain.  After reading about his symptoms and history by email, I told him– prior to his first visit– that I would consider treating his back pain and his use of opioids using buprenorphine, but I would not prescribe opioid agonists.

We met and started buprenorphine, but after the second or third visit, he began asking for opioid agonists.

Next month I will be presenting a paper at the annual meeting of ASAM, the American Society of Addiction Medicine.  The paper discusses a new method for treating chronic pain, using a combination of buprenorphine and opioid agonists.  In my experience, the combination works very well, providing excellent analgesia and at the same time reducing—even eliminating– the euphoria from opioids.

Ten years ago, I would have really been onto something. Back then there were calls from all corners to improve the pain control for patients.  The popular belief regarding pain control was that some unfortunate patients were being denied adequate doses of opioid medications. I remember our hospital administrators, in advance of the next JCAHO visit, worried about pain relief in patients who for one or another reason couldn’t describe or report their pain. Posters were put up in each patient room, showing simple drawings of facial expressions ranging from smiles to frowns, so that patients in pain could simply point at the face that exhibited their own level of misery.

What a difference a decade makes!  Purdue Pharma, the manufacturer of Oxycontin, was fined over $600 million for claims that their medication was less addictive than other, immediate-release pain-killers. Thousands of young Americans have died from overdoses of pain medications, many that came from their parents’ medicine cabinets.  Physician members of PROP, Physicians for Responsible Opioid Prescribing, have called out physicians at the University of Wisconsin School of Medicine and Public Health for having ties to Purdue while arguing against added regulations for potent narcotics.

A reader sent a link to a recent NYT editorial about the lack of pain medications in some countries.  The writer of the editorial injured his leg while traveling in Africa, and was dismayed to find that opioid pain medications were in limited supply, with only enough for patients admitted to the hospital.

The writer went on to describe a number of developing countries where pain medications are in short supply, and in some cases totally unavailable.  He described hospitals and clinics where he was visited, where patients await treatment for horrible injuries without so much as a tablet of Tylenol.

I don’t want to rewrite the editorial, and I cannot copy it, for obvious copyright reasons– so you’ll have to follow the link.  The story mentions the efforts of a group called ‘GAPRI’, for Global Access to Pain Relief, that tries to reduce barriers to effect pain relief measures in developing countries.

Wow. I just read an email about a story that I was vaguely aware of– about a doctor in Kansas and his wife, who were together linked to scores of overdose deaths. But that is just the beginning. The doctor was supported, during his trial, by Siobhan Reynolds, founder of a nonprofit advocacy group called ‘Pain Relief Network.’ She started the group back in 2003, when her ex-husband was suffering from severe pain from a congenital connective tissue disorder.

He (the ex-husband) found relief in combinations of high-dose opioids and benzodiazepines, at least until his doctor, Virginia pain specialist William Hurwitz, was convicted on 16 counts of drug trafficking. The ex died, by the way, in 2006. Are you still with me?

The trial of the Kansas doctor, Stephen Schneider, went on for years. During the trial, Ms. Reynolds apparently helped support what she considered to be a ‘dream team’ of attorneys. She used the case as an opportunity to increase her visibility, encouraging the Schneiders to aggressively fight the charges against them on the basis of ‘patient rights.’ Ms. Reynolds, through the Schneiders, argued that suffering patients are being denied appropriate care because of a war, waged by overly-aggressive prosecutors, against doctors who prescribe pain medication.

I’ve described the ongoing debate over use of opioids for chronic pain, and shared information about a group of physicians who are attempting to reduce the damage caused by careless over-prescribing.  Their attempts have created some backlash, as described here.

Feel free to comment in response — here or there, or both!

http://seattletimes.nwsource.com/html/localnews/2012873602_drugs12m.html

Pills photo available from Shutterstock.

Thank you for your comments about my post about treating chronic pain with opioids.  I was in the middle of adding a response to one of the comments this morning, when I decided to elevate my response to a post of its own. Starting a new post might, I hope, keep the discussion going… and besides, I was struggling to find a stopping point!

Here are highlights from the comment I was responding to this morning:

My aunt can attend family functions and be active in her children’s lives WITH the medication. Before she was put on methadone she couldn’t function at all and just lied in bed wanting to commit suicide… I definitely don’t think function is improved by withholding pain medication… I have experienced pain and… I know that when I’m in pain I don’t function well but if I take something for that pain I do. I had a bad headache earlier today and all I wanted to do was to lie on the couch… I think it would be extremely cruel for a doctor to not give me medication that would relieve that pain… Isn’t it as much worth to give opiates to pain patients to save their lives as it is to give them to addicts to save theirs?

One thing I’ve noticed, as a 50-something doc, is that it is one thing to talk about pain, and something else to experience pain.  I’ve had thoughts on occasion that the injury I’m suffering at a given time is there, in part, to remind me of what it is like for my patients–who generally are much worse off.

I have asked for permission to repost an article from the web site of CBC Radio, and I’m waiting for their answer.  In the meantime, I’ll provide a link to the article, along with a teaser.  The article also refers to a podcast of a Town Hall event featuring Dr. Andrea Furlan, a pain specialist from Toronto, Christine Bois from the Centre for Addiction and Mental Health (Canada), and Detective Shawn White, an expert in opioid diversion in Eastern Ontario.

Just a quick note– A group of researchers from Boston University School of Medicine weigh in on the issue of opioid prescribing in an online editorial available through this link.  The editorial appears in the Journal of General Internal Medicine, and I do not know how long the link will be active.  All such articles are copyright-protected, keeping me from posting them here– but the link operational for non-subscribers, at least for now.

In short, the editorial calls for several measures for patients prescribed chronic opioids, including monitoring for abuse, greater education, and creation of databases to prevent over-prescribing, doctor shopping, etc.

Thank you to everyone who chimed in with opinions about the PROP letter.  I shared the comments with the people at PROP, and those who read the comments saw an interesting exchange between the a couple of physicians from that group and a physician from pain-topics.org.  Hopefully the letter and comments– along with the other articles I’ve highlighted– will help provide an understanding of the current debate over using opioids for chronic pain.

Backache photo available from Shutterstock.

I’ve written about the spectrum of medical and scientific opinion (not, unfortunately, always the same thing) over the use of opioids for treatment of chronic pain.  For those who missed the earlier discussion– one that produced a heated response from readers– I invite you to review those posts.

The essence of the issue is that over many years, there has been significant effort to increase patient access to potent opioids.  This effort has come in part from the pharmaceutical industry, but also from organizations that advocate for patients with a wide range of painful conditions, some with connections to pharma, and some without connections to pharma.

There has even been a push to increase opioid prescribing from Federal agencies.  Back in the 1990′s, when I chaired my local hospital’s Department of Anesthesia, we were warned by agencies hired by the hospital that the Joint Commision on Accreditation was focusing on pain control one particular year, and that some hospitals had been cited for insufficient prescribing of pain medications.