Don’t Forget People Living in Pain: War on Opioids and Chronic Pain Patients during COVID-19

good afternoon everyone thank you for joining us my name is jeff singer i'm a practicing surgeon and a senior fellow at the cato institute well before covet 19 began its invasion state and federal policymakers imposed restrictions on the production and use of opioids for medical purposes these restrictions were based on the false narrative that the prescribing of opioids to patients for pain was the cause of the overdose crisis afflicting the united states the drug enforcement administration continues to ratchet down annual production quotas for the various types of opioids used in medical practice that it sets for manufacturers in 2016 the centers for disease control and prevention issued acute and chronic pain prescribing guidelines for healthcare practitioners despite criticism of the guidelines by many academic pain and addiction medicine specialist many states transformed were only guidelines into strict mandates on the dosage and number of opioids that health care practitioners may prescribe to their patients in may of 2019 the cdc released a clarification memo stating that the 2016 guidelines are being misinterpreted and misapplied by many state and local jurisdictions as well as by pharmacists and health care providers federal state and local law enforcement used prescription drug surveillance programs to arrest and prosecute as suspected pill mill operators practitioners who deviate from the guidelines this has cast a chilling effect on providers who care for pain patients causing some to abandon the practice altogether and making others reluctant to take on new patients fear of prosecution also causes many pharmacies and pharmacists to refuse to fill opioid prescriptions all of this leaves many pain patients out in the cold isolated immobilized denied care and stigmatized as addicts or drug seekers the synthetic opioid fentanyl is used in the treatment of covet 19 patients in the icu on ventilators as fentanyl shortages have emerged the dea has relaxed quotas on fentanyl production but it leaves all the other opioid quotas in place maintaining the downward pressure on prescribing opioids although federal and state officials have suspended certain regulations regarding the prescribing of controlled substances for instance permitting the required in-person medical evaluation to take place on tele via telemedicine and in some cases allowing limited initial opioid prescriptions or refills to be given to pharmacists over the phone many of the state prescribing mandates and surveillance processes remain in place as do the dynamics that were already responsible for the under-treatment or neglect of pain patients compounding this problem is the fact that many states have imposed moratorium or bans on elective procedures this has caused cancellations or delays in surgical procedures as well as invasive pain management procedures that would relieve the suffering of chronic pain patients social distancing sheltering place orders and lockdowns of non-essential businesses have caused some medical practices to shut down their doors for the duration of the public health emergency some practices have permanently closed many of these are practices devoted to pain management which had already been be seized by regulations as surveillance by law enforcement access to other quote non-emergency treatments such as physical therapy and other hands-on therapies has likewise been halted many chronic pain sufferers were already isolated by immobilizing pain and have experienced stigmatization loneliness and depression before the arrival of covet 19. the combination of pre-existing regulatory barriers many of which remain in place and the social distancing that is necessary to control the pandemic causes increased suffering isolation and despair among these americans we are fortunate to be joined by three experts on the matter each with unique expertise and perspectives after all three panelists have spoken we will have time for q a please submit your questions via facebook and twitter using the hashtag catocovid which you can see in the lower left hand corner of your screen um and you can also submit questions either directly on the event page or via youtube let's hear first from kate nicholson kate is a civil rights attorney a nationally recognized expert on the americans with disabilities act and a patient advocate she served in the u.s department of justice's civil rights division for nearly 20 years where she litigated and managed cases nationwide and primarily drafted the current ada regulations kate developed intractable pain in tractable pain after a surgical mishap left her unable to sit or stand and severely limited in walking for 15 years she's a 2019-20 may day pain and society fellow kate was recently given a grant to launch the national pain advocacy advocacy center as co-chair of the chronic pain opioid task force for the national council on independent living the country's largest disability rights organization with centers in every state in u.s territory kate's a senior fellow was a senior fellow at dartmouth college and as a graduate of harvard law school kate thank you dr singer and thank you so much to the cato institute for hosting this very important conversation i'm going to begin by talking a little bit about what i see as three intersecting crises right now the first is a crisis of under treated and undermanaged pain in this country one in every six americans experiences pain every day or nearly every day of their lives 40 million have severe pain and almost 20 million have pain so severe that they can't engage in the most basic of life activities this makes chronic pain a larger disease than cancer or diabetes or heart disease or stroke and yet very few research dollars are allocated to understanding the disease processes that cause chronic pain clinicians are radically under undereducated rather in how to treat pain and insurance coverage for a lot of pain treatment is quite spotty on top of that crisis we have the drug overdose crisis sometimes called the opioid crisis and as dr singer mentioned uh simplistic narratives and policy choices that conflate uh legitimate medical use with misuse and physical dependence with addiction have resulted in a very bad situation in which patients who use opioids to manage pain are unable to get access to those medications in some cases they are being forcibly tapered off of medications they've relied on for years to work and function by their physicians who fear regulatory oversight um and this most beleaguered group of patients is now experiencing basic barriers in just health getting access to health care at all two studies came down the pike in the last um year one at the university of michigan which found that 40 of primary care physicians will not treat a chronic pain patient who uses opioids to manage pain um and a more recent study by the center for addiction and quest diagnostics found that a substantial majority 81 percent are reluctant to treat such patients and now on top of these two crises we have a global pandemic uh covet 19 which has brought to bear new barriers both from the disease itself and from our efforts to contain the spread of the virus chronic pain patients are especially vulnerable to coven 19. a lot of the diseases that cause chronic pain leave patients immune compromised i am one of those patients who uh contracted covenant and is still being treated for the end stages of it so this is more than an abstract concern to me a lot of the treatments uh for pain generating conditions also leave patients immune compromised everything from chemotherapy for cancer to steroids uh to even opioids a lot of people in chronic pain have uh multiple comorbid conditions that may also make them more vulnerable and one of the things that we've seen covered 19 shine a very glaring light on is health disparities what we sometimes call social determinants of health in this country where we've seen people of color individuals with disabilities and older americans at much greater risk to uh covet and and to bad consequences and i want to make the point that these same disparities exist in pain care as well pain is uh the chief cause of long-term disability uh internationally older americans are at greater risk for chronic pain um and people of color uh historically studies have shown have had their pain discounted by clinicians who rate their pain two to three points lower on a pain scale than their caucasian counterparts yet more recent studies using imaging techniques like fmri suggest that actually people of color probably experience greater pain and greater chronic pain because of these same health disparities in addition because of the way in which we have waged the drug war disproportionately against communities of color people of color are more likely to have their pain discounted because they are perceived as drug seekers so i'm going to talk in a little greater detail about some of the barriers to access to medication and services that dr singer mentioned in the introduction we are actually seeing first of all outside of the context of controlled substances new barriers emerge particularly from the hoarding of anti-malarial drugs a study in jama internal medicine suggested a there was a threefold spike in sales of such drugs after well-known public figures lauded their efficacy uh as treatments for covid and the reason that this is a problem is that many patients with chronic pain with certain conditions rely on these drugs in a regular way to treat rheumatoid arthritis or lupus and i hear from a lot of patients who could no longer get access to the medications on which they rely in terms of controlled substances as dr singer mentioned we are seeing a shortage of opioids to treat patients who need ventilators luckily the fda and dea have worked to shore up the drug supply and the dea has raised its quota for the medical supply of opioids by 15 in response to the virus but it points up a problem uh with the approach of just uh making quotas for the medical supply in response to the opioid crisis we saw something like this emerge in 2018 when the dea had limited the quota of medical opioids available and then there were manufacturing problems and this led to a significant shortage in injectable opioids in the hospital system and now we're seeing the same sort of thing a lowered quota uh an unexpected but predictable potential problem arising that made us need more medication and the medications not available to the people who need them with respect to prescribed opioids uh as dr singer mentioned there's good news uh the dea has made a temporary exception to the ryan hatch act which uh allows for telemedicine prescribing of opioids without a prior in-person visit or telemedicine prescribing of opioids from a non-dea registered facility so this is a pretty big exception and an important one it is temporary we can hope that it may be extended and i have heard from patients for whom it works uh swimmingly but i have also heard from a lot of patients who are in states where this has not been adopted or whose insurers will not pay for the telemedicine providing uh who are having barriers to access to getting uh their medications so we've seen this sort of thing happen before where something on a federal level is not well implemented in states and throughout the healthcare system and unfortunately i am still hearing from patients all the time who are experiencing barriers to getting access to their medication i heard from a patient recently who suggested that her doctor was sick they thought it was maybe uh exposure to uh to covet and the doctor who was taking over just refused to prescribe opioids there was a very interesting uh piece in health affairs by a group of palliative care physicians recently that suggested that these changes by the dea may not go far enough for a subset of patients and they're referring to older americans who are sequestered in their homes and who may not have access to or facility with audio visual equipment and they suggest that for these patients particularly since they are likely to continue to be sequestered since they are greater risk the dea should allow uh telephone appointments and insurers should cover telephone appointments in addition to these access to medication issues we're seeing a whole new uh aspect of problems coming from our efforts to contain the virus because so many of the ways in which pain uh is treated have been closed down this can include sort of basic maintenance care adjunctive therapies like physical therapy massage dry needling osteopathic or chiropractic hands-on techniques acupuncture it can include interventional techniques like nerve blocks or surgeries and it can even include something as simple as as routine blood work for people who are at the early stages of having their pain diagnosed i heard from a patient recently who said um he has rheumatoid arthritis he said i'm supposed to see my rheumatologist we were making progress to figure out why i to figuring out excuse me why i'm in constant pain and now it's just eternal limbo labs need to be done telehealth is of no use here i was so close and it's really important because a lot of patients rely on sort of these maintenance tools to keep their pain at an equilibrium and when those tools are interrupted flare-ups occur and these flare-ups can be very serious and long-lasting or even permanent although we are seeing um some opening now uh just starting to uh of these different procedures there have been numerous studies um or excuse me reports not um of studies uh in the press um in the new york times and um the washington post in box suggesting that the economic consequences of closures may cause permanent closure of a lot of these services many of the adjunctive services are provided by small practices um that may be closed uh there was an article in the post suggesting that primary care physicians were having a trouble getting access to loans and many practices may close and even an article in the new york times about hospital systems which rely on uh elective surgeries to finance a lot of the rest of what they do closing so we may see permanent gaps in care as well i want to highlight one brief patient hypothetical that was raised in one of these articles uh because i think it it touches on a few of the interesting issues um this was in a vox article uh and the pain patient's name is dana uh don yes sorry planker she's a friend of mine she's a professor at georgetown university of health policy and a woman who has serious chronic pain um and the article follows her from washington dc where she lives as she drives to a pain clinic in philadelphia to get a nerve block that she couldn't get in her local area and dunny answers a couple of questions that i think are important the first is she asks the question of whether maintaining your health is urgent and she says well it's not something we usually put in the box of urgent but for many conditions if you don't tend to them they become urgent or emergent and then with respect to chronic pain she says i have pain pretty much everywhere in my body yeah it's not life or death but it's not just quality of life either there's pain that impedes the quality of your life and there's pain that impedes your life and she goes on to explain that she couldn't take care of her daughter without getting access to these nerve blocks finally i want to wrap up by mentioning concerns about isolation dr singer also mentioned this a bit chronic pain patients are isolated often by their conditions or the existential condition of living in pain um chronic pain patients are also at much greater risk for depression and anxiety and suicidal ideation and suicide and so there are real mental health care concerns with the isolation that many are experiencing uh pain news network did a survey of what's happening with chronic pain patients in light of covid um and many wrote back saying they were just barely hanging on by thread there are also serious practical consequences for people uh who need uh the assistance of others in order to do basic things like go to the bathroom or get dinner or shower people rely on family members who may not be as mobile right now particularly if they're elder parents who can't come by because they're concerned about their own risks but there's also a real problem happening in the disability community with paid helpers who do not have sufficient ppes and are not showing up to help people and this is a really serious problem because it puts people at risk of being placed into long-term care facilities and given what we've seen about the deaths uh coming from long-term care facilities uh some studies suggesting that up to a third of cobit-related deaths come from such facilities it's probably the last place any of us would want to be moving right now and not a pretty not a good place to put someone who is at risk or uh immune compromised thank you thank you very much uh kate and we'll take questions of course a bit later our next speaker uh richard lawhearn because of technical problems we can't get his uh video feed but we have a great audio feed so we just have to look at his picture and trust me he looks as good in person as he does in his picture richard lawrence is a technically trained non-physician patient advocate and medical literature analyst with 22 years experience building and moderating online support groups for chronic pain and tens of thousands of person-to-person contacts in patient communities his public published works include over 80 papers articles radio interviews and public addresses in a mix of medical journals and popular media he focuses particularly on patient-centered pain care and evidence-based policy for regulation of prescription opioid therapy he's co-founder and director of research for the alliance for the treatment of intractable pain richard i hope my audio is now clear are we okay good morning actually good afternoon and thank you for the invitation to participate in this panel discussion i interact daily with hundreds sometimes even with thousands of patients and caregivers in social media so i hear a wide variety of patient perspectives on the subject of our discussion many of them dovetailing very closely with the remarks that kate nicholson has just offered my central impression of the impact of the covid19 pandemic on people in pain and on their doctors is that there is no single story that describes the situation instead what we hear is a lot of individual stories with quite a wide range of outcomes and experiences some people find the increased use of telehealth and phone interviews to be a relief from having to appear in person at their doctor's offices but others are being asked to appear in person even more often than before and even if they are immune compromised a central threat in these stories has been continued from the last 10 years patients continue being denied access to opioid therapy involuntarily having their dose levels reduced or sometimes discontinued cold turkey by doctors who have been terrorized by the dea and state drug enforcement authorities or by state medical boards the addition of covid19 to the mix has seriously complicated patient efforts to find a doctor who will treat them for pain in any way for instance let's take a few narratives that i've seen from social media and this is a quote my pain doctor reduced a long-standing methadone prescription for my pain leaving me with only 10 milligrams twice a day he refuses to even discuss the reason for doing this this happened on april 17 2020. why is this still happening is what i'm asking during the covid19 pandemic pain patients are still being mistreated another patient wrote me from a rather different perspective my doctor has forced me to go in monthly for urine testing also i have two appointments a month by phone the reason i was given astounded me people are very depressed right now and we can't in all good conscience give more than two weeks of medication this patient made the remark bs this is a money grab because he can't do procedures now from patient reports it seems that doctors and nurses are feeling a financial pinch because hospitals have postponed almost all elective procedures just as kate has remarked one nurse whom i know personally tells me that although the hospital where she works has an entire floor devoted to covid19 patients during her several of her nursing colleagues have been furloughed because the normal caseload of surgical and emergency care patients has dropped by at least half and there have been only two admissions of covid patients in her hospital in the last week contrast that against the reports like the following the worst thing is that i have been making progress with nerve blocks and i had a longer term plan with the same doctor and that's now completely interrupted i've been losing some of the gains i had made and from another patient don't forget the impact of patients who were scheduled for surgeries that have had to have them cancelled due to the virus many of us were living with major pain levels hoping to get some kind of resolution to some of the pain from a surgery but because of cancellations we continue with the pain or it has worsened i personally have had to postpone a total right excuse me a right total knee replacement it's now been scheduled rescheduled but it is still delayed i am still waiting another patient offers this since february i've had to find a new pain management physician along with a new pharmacist i had zero issues with the new physician but i was turned down by over 15 pharmacies for refills i ended up running out of medications twice and had to substitute less effective medications that cost twice as much presently my pain is moderately treated but my out-of-pocket cost has more than tripled for the medications and office visit now remember while we're going through this that just as k as kate has noted many pain patients are in disability that means their incomes are restricted very frequently they lose their homes because they can't work from another patient excuse me it's a common story and there's another one here from another patient since i'm a stable patient i don't have any real need for monthly in-person appointments anyway but now for the problem every single month the pharmacy i've been going to for more than 20 years is out of stock for one or more of my medications so i have to go to other pharmacies or i have to go without until they order more i'm also being slowly tapered for no medical reason but i feel i really have no choice my doctor will desert me if i object from may 4th i live in new york city and all my doctor appointments have been cancelled or moved to video it's been most difficult to get my ms cotton refilled i've been sheltering at our heart farm in connecticut and the local pharmacist said the earliest i could get would be mid-june i had to call my pharmacy in new york city and this refill refill was also postponed a friend had to pick up my partially fulfilled ms cotton sr meds and then mail them to me at our family's farm in connecticut it took 10 months to find a pain management doctor my neurologist called several colleagues on my behalf but on paper my case is so confounding that no one would take me on and these were pain doctors who would not see me as a pain patient i'm highly functioning happy-go-lucky but i couldn't get my foot in the door i've lived read literally hundreds of narratives like these since february another patient writes even more poignantly this weekend past was hell i ran out of painkillers on friday and by monday morning i couldn't stand up straight enough to cook a meal or put the kettle on i had tramadol but not much and i'm very wary of developing a tolerance on using it too often so over the weekend i allowed myself to tram it all a day if i was unable to sleep from the pain on monday i called the pharmacist and they apologized profusely although i'd ordered my repeat prescription the member of staff responsible had thought i was on monthly rather than fortnightly prescriptions and didn't order them i must footnote this quote by observing that for many pain patients tramadol is a very weak pain reliever finally there's a narrative here of a kind that i see with variations all too often this one's just a little extended extended i'll add one more to follow before i wrap up my sister jane died yesterday after an unsuccessful suicide attempt in new york last september following her doctor's reduction of her vicodin dosage without warning and then lying about the fact and refusing to treat her after she spent seven days on a ventilator in an icu and a week in the hospital with no opioid pain meds at all and then limited meds in their behavioral unit after being discharged with a diagnosis of no depression only under treated pain no other pain clinic would accept her so she moved to mississippi in january living with a close pain advocacy partner but she recently lost her meds there as well after a run-in with a nurse practitioner who had been assigned to her rather complex case her chiari malformation brain defect played a big role too she was having trouble swallowing and the headaches and orthopedic pain were unbearable i think jane just finally ran out of steam the pandemic didn't help she and i weren't in contact for about a week we'd had a misunderstanding and i was giving her space but i knew things weren't right and i asked her daughters to go to her at least they got there and had one day with her before she passed away thankfully jane understood they were there she'd spent a lifetime in pain endure dozens of surgeries and might still be alive now if she had not lost her life-giving pain medications and finally a narrative it's very nearly real time i spent a half an hour on a phone this morning with a gentleman who has complex regional pain disorder and that was a consequence of being shot in the chest about 10 years ago and this man has been trying to diet and reduce his intake sufficiently that he will die because no pain doctor will take him and several have blacklisted him he is was uh he went to an emergency room because he had a reaction to this this regimen and they put him on a medical hold actually a behavioral hold and accused him of being suicidal they didn't treat him for pain and when they discharged him after his regular doctor away did on the subject it was without prescription of any kind this is a pain patient who is being killed by his doctors he is not a rarity he is common doctors are not being prosecuted out of business they're being persecuted out of business by a dea and state drug enforcement authorities who frankly have gone utterly mad we now know beyond any doubt beyond any reasonable contradiction and this is confirmed by authorities as prominent as nora volkow who heads up the national institute on drug abuse that exposure to medical opioids under medical management is very rarely a factor in either opioid misuse tolerance addiction or mortality in fact we know that from the statistics of the cdc itself that not only has their their 2016 guidelines been misinterpreted as they put it those guidelines were wrong on science and principle in the first place and they are utterly contradicted by data that cdc itself publishes more the the pain patients that we see in general practice are more often than not middle aged or older the rate of opioid related overdose and death in that population is the lowest of any age group but the rate of opioid prescription to that population is the highest youth with that with uh you know excuse me youth be younger than age 19 has an overdose rate from opioids of all kinds that is six times higher than that of of uh seniors and moreover senior overdose rates have been stable for the last 20 years they have skyrocketed among youth there is no way that the dominant narrative can be accepted the narrative that says doctors over prescribing to their patients have been at fault in the generation of the uh opioid crisis that's just not true and so far cdc has refused to acknowledge it let me uh relinquish the mic now and thank you for your time i'll be here for your questions thanks uh richard our final presentation will come from come from dr andrea trescott she's a board board certified in anesthesia and pain management she's been uh the pain fellowship director at the university of florida and later was the director of the pain fellowship program and professor at the university of washington in seattle now she practices in the jacksonville florida area she's past president of the american society of interventional pain physicians has authored more than 150 peer-reviewed articles and textbooks chapters and is the editor and senior author of a 900 page pain textbook peripheral nerve entrapments clinical diagnosis and management as well as co-editor of the three volume pain review textbook pain medicine and interventional pain management a comprehensive review dr tresket thank you very much jeff and thank you to the cato institute for really bringing to light this very very important topic i am a practicing physician i have been both in academics and in private practice and it is a problem that we as the pain physicians are getting caught in the middle we're caught between the patients who are begging for help and the dea and fbi that is threatening not only our livelihood but our license and even our freedom so this covid has been a devastating problem to an already difficult problem we know that the opioid epidemic as it's been described and has read so very eloquently just disputed this has not been a problem with prescribed opioids for pain patients there has been no distinction made between the opioids that have been legitimately prescribed to patients with legitimate pain and those patients who died from perhaps prescription drugs but not medicines that they themselves had been prescribed so we were already fighting the dea issues we were already trying to deal with these imposed restrictions hearing the tears in the eyes of patients every single day i would write a prescription and have a pharmacist refuse to fill it and then all of a sudden in march we were hit with the covet epidemic and because pain management was considered elective offices were shut down as kate described the dea had limited or in the past our ability to do anything that was not a face to face and that opioids had to be done by a written prescription they have temporarily lifted some of those obstructions we can now do telemedicine though many insurances are not covering it or if they're covering it they're not paying for it most of my friends and and my practice included have not been paid for 90 days for some of these visits we have the problems with the written prescription for a while we would talk to the patient on the phone but then we would have to write out a prescription they would have to come and get it now we're trying to fax the prescriptions but the pharmacist's fax machines are not working the patients will get to the pharmacy wait for a long period of time and then be told well the prescription isn't there and then we get the call saying what happened and we're saying well you know it said it went through but anybody who's ever worked with fax machines know that they're terribly unreliable it's also put pain doctors at risk because one of the very few things that we have to monitor patients are the urine drug screens and the pill counts so we're being asked to put our license on the line and yet not able to verify that the patients are taking the medicines appropriate and that they're actually appropriately and they're actually metabolizing the medicines appropriately giving a pain medicine to somebody who can't metabolize it isn't doing anybody any good and we also have a problem with patients losing their insurance because their pro their place of work has shut down and then we've also had the problems with the delivery of opioids i thought it was just in alaska i've been practicing in alaska for the last seven years and just moved down recently to florida and very regularly we would get patients told that the pharmacy didn't have their medicines and they weren't expecting the medicines for another week and i thought surely it was just because of the supply lines in alaska but already i'm getting this same information from people that are going to pharmacies in downtown jacksonville and having to go from pharmacy to pharmacy to pharmacy each time being exposed to more potential viral interactions the other thing that's been a real problem is the ability to actually diagnose where people are having their pain the physical exam is one of the most powerful tools we have and yet you can't do that over the phone and i use often the analogy of an infected tooth i can give somebody pain medicines for an infected tooth or appendicitis or a gallbladder attack but that won't fix the underlying problem and so because our procedures which can be absolutely remarkable in providing relief for patients and i hear that every single day as an interventionalist i have the the potential of being able to identify exactly the structure that's causing the problem and to be able to deliver medicine right to that spot to kill the nerves that are in that area to do spinal cord stimulations medicines in the spinal fluid all sorts of options amazing options that we have but because pain management is considered is considered elective that's not being done these this idea of elective is horrifying i have a family member who was diagnosed with cancer her cancer surgery was delayed until just yesterday just this past week because because cancer surgery was considered elective there's nothing elective about treating pain and we've often heard that nobody ever died of pain but that's not true we know that as both kate and red have said that there's the social oscillation there's the desperation of patients who are in pain and now i'm giving them pain medicines that will potentially be lethal so that's one of the reasons why we've been giving the two weeks of medicine hoping that we were giving small enough amounts that the patients wouldn't um be able to commit suicide with that amount we're trying to we recognize that their co-pays it's not a money issue no matter what the patients think it's a way of trying to say well if you're overtaking the medicines at least you're not overtaking them a whole month's worth you can overtake them a little bit and we can monitor that and realize that you're getting out of medicines running out of medicines faster and i'm just going to close with a phone call that i got this weekend from a doctor here in florida he's got seven board certifications seven including one from the world institute of pain which is the highest pain certification in the entire world uh board certified in neurology and sleep medicine and interventional pain from the american and the urine and the um international organizations he had a practice that by everything he described to me was absolutely by the book every single thing that the patients have been told that they need to to do everything that doctors have been told they needed to do he's been doing and the end of february the fbi 50 fbi agents came in swooped down shut down his office seized his um his bank accounts they had to let go all of their employees and thousands of patients were left without a pain doctor right in the middle of the covid crisis so this has been just devastating to that part of the state and a chilling effect again on all the doctors who are in the area so it is happening it's putting a fear of jail and loss of income and license to every pain doctor in the state so it has been a terrible problem and the government has been only making it worse and i hope that we can come together and try and solve this very desperate problem to the benefit of the patients and thank you for your time and let's have some questions thank you very much um we've been just getting loads and loads of questions i'd like to start out first with actually more of a comment that was sent in dr uh stefan kurt kiertes and uh dr allison varley both at the university of alabama birmingham and the pain and addiction programs they write the matter of suicide after opioids are stopped as an urgent one that requires attention and research my team will after ethical reviews complete seek family members who wish to assist in learning about and preventing these deaths please watch us and so in other words they're asking people to follow them on twitter at stefan caretase as s-t-e-f-a-n-k-e-r-t-e-s-e and at allison varley a-l-l-y-s-o v-a-r-l-e-y um so that's a little little shout out to that research project they're working on one person named anonymous asked on the event page does anyone have an idea of how many pain clinics have been shut down as a result of not just the covet crisis but pre-covert prices since about 2015 or so does anybody have an idea what that number might be uh just we've seen sorry yeah we've seen uh um between a quarter and a third of pain clinics in the state of florida shut down over the last two years wow anybody else have anything uh just anybody else have anything to comment on but i have an input if i may we know for instance in the state of tennessee that the entire western half of tennessee has no presently as far as i understand it has no active pain clinic and we also know that as kate remarked the 40 figure is conservative with regard to i believe it was the state of michigan as a matter of fact where that where that occurred the 40 is uh conservative because even when pain clinics are operating great numbers of them are informing their patients unilaterally that they will be tapered involuntarily so this is happening because the regulatory environment is so hostile that doctors have literally been terrorized speaking about that i see a question from candy coming in on the event page uh candy says even though the dea is allowing telehealth a lot of doctors are afraid to use it and are still making all their patients go in for their monthly appointments they offer telehealth but if you use it they will drop you thirty to fifty percent each month you use it until you are off masses i saw dr trescott nodding uh about that are you familiar with that yes i am and the problem is the risk of writing for opioids when you have no way of monitoring it so one option that some doctors have taken has been to involuntarily wean the patients off the medicine for which the doctor is at greatest risk and so it is a problem because with telemedicine none of the very few safeguards that we have available are utilizable and so it just hangs the doctor out to dry doctor you know dr tresket you wrote medicines for this patient that are potentially lethal and potentially addictive and you have not laid hands or laid eyes on this patient for two months what do you say yeah sure also uh dr sharon berenfeldmd writes in on the event page uh also remember refills can only be refilled 24 hours before the meds run out in the state of tennessee resulting in monthly anxiety and hope and and hope the pharmacy has the med in stock dealing with this for two decades uh kate you got anything to say about that i mean there are all kinds of limitations in the various states about about things like that um and i think the exact i think the anxiety that patients feel is very real um even calling and checking on prescriptions by a pharmacist can make someone tagged as a drug seeker um and you know trying to be responsible and proactive with your physician can make you seem overly eager and like someone who's potentially misusing um so i mean the problem is that you know pharmacies states health care systems all have a patchwork of different kinds of requirements that vary considerably um all of which put limitations but uh it puts patients in a really difficult bind so so even though at least on a national level the dea has done has relaxed a lot of things to try to make it easier for pain patients to get their medicine many of the states have really not been nearly as flexible as basically what you're saying yeah that's right and the dea policy says very clearly that it's it goes up to what the states require so if states haven't adopted the same policy they can do you know whatever whatever they wish to um so there are really a lot of gaps uh in this for patients in pain uh jessica m writes in on youtube my doctor recently told me that long-term use of opioids causes heart problems and wants me to see a cardiologist is there any proof to back this up uh you're the besides me you're the other md on this that sound i never heard of that before have you dr trusted and you're a pain specialist do you know more author on the uh asap opioid guidelines i've written extensively on the metabolism and the contraindications and complications of opioids there is nothing about cardiac disease at all i was going to make the comment as well that uh when we talked about state by state the state of florida had their emergency suspension of the dea requirements was set to expire yesterday which would have forced us to go back to in-person visits and the it has been we only found out about it yesterday as the as the order was was expiring that we were actually going to be extended for another two to three weeks so it's being that we're being held again nobody will make a decision and everything is in flux and pandemonium and i think red you had a question as well i had an observation to share if i might one of the things that makes all of this terribly complicated was something that both you andrea and kate uh referred to we now know that the ama the american medical association has repudiated morphine milligram equivalent daily dose as a measure of merit in anything because as ama put it in their resolution 235 about a year and a half ago there are patients who benefit from opioids at those levels substantially exceeding those of the 2016 opioid guidelines we also know that there is presently no useful predictive measure that allows the identification of excessive risk in any individual patient there just isn't anything out there you can't profile a patient and determine whether their their past history even if they give you all of it and even if it might happen to have opioid misuse in it you can't look at that patient and say you have an elevated risk of opioid addiction so we can't use them with you and that's something that's been acknowledged by the agency for healthcare research and quality we are facing a situation where ama is exceeding ama but but dea is imposing a one-size-fits-all standard pinned to the cdc guidelines and that standard is wrong and it is provably wrong and yet policy and lawmakers don't want to hear it because it makes their lives complicated and it means they might have to challenge the political contributions of big of big insurance companies and others who want to control the conversation um i see a question from yes yes yeah no i i just wanted to say you know it is sort of interesting and curious however that the dea has now tacitly acknowledged that there is an appropriate role for opioid prescribing and pain by making this exception so uh it's it's there is something positive in that i think as well one can only hope bob bob sheeran uh asks on our event page um this brings in for a greater risk of pain pump abuse by doctors has been going on for some years targeted pain is now suddenly a full-body cure uh you know anything about the pain pump abuse dr tresket okay um i put my per first intrathecal pump in in 1991. so i was the first female credential in the united states to do it it's a remarkable way of delivering medicine directly to the spinal fluid but it has been looked at recently as a way to provide pain relief to patients without having to write opioids unfortunately it is a procedure for which doctors make a lot of money and i have seen a surprising and perhaps distressing increase in the number of patients being put on being pushed to intrathecal or inside the spinal fluid medications the thought being that the abuse is at the doctor level and not at the patient level the patients have relatively little control over these medicines they get a device where they can give themselves ebola sort of like anybody who's had a pca pump in the hospital which will allow you to be able to um the the allows you to be able to give yourself a dose of medicine by vein but it is has been concerning that all of a sudden this big group of pain patients are being offered nothing but it's a pump or nothing else and so it is concerning um f1 rocket engine asks on youtube what about the the i hear this a lot so i'd like to hear from all of you if you can if you're interested uh what about the theory that many doctors push that opiates cause pain and that if you're still feeling pain you need to go to detox who wants to take that one first uh how about kate why don't you go first in that way oh you'd love that one um okay so uh andrea's probably the best to to really talk about um uh this phenomenon which certainly has been acknowledged in studies and rats um uh and it is that if people take pain it can cause a hypersensitivity to happen um but it is certainly not true uh for everyone or even nearly everyone i uh took uh prescribed opioids for 20 years um when i couldn't sit stand or walk and continue to work at the justice department and certainly never uh never had to have escalating doses never had to have never had greater pain because of the medication i think people are different um and uh though it may be a valid concern in some patients there are certainly doctors who report having seen it um it is you know i think it's overrated uh in terms of being applied to all patients uh andrea you want to go next oh absolutely so this term opioid hyper algae is a real but rare phenomenon um the best example i have of it was a kid who was on the cancer ward on a thousand milligrams of morphine a day just screaming we weaned him down to 30 milligrams and he got good relief morphine and and it's been shown in other medicines as well gets metabolized to medicines that give pain relief but also cause pain and we see these patients who are on escalating and escalating doses of medicine you increase the medicine and they get no improvement in their pain those patients can be candidates for a weaning of medicine to see if that helps and just like the the kid i described it can be effective normally my approach is to increase the medicine if there's no improvement in that increase in medicine or if they've been no at their they're on high doses and they're getting no improvement the urine shows that they're metabolizing they're getting huge doses in their urine and it's um being metabolized primarily to that inactive or the hyper pain metabolite those patients often will benefit from a switch in medicines or a wean in medicines so it is something to think about when somebody comes in on high doses it is i have seen it a patient who was on 80 milligrams four times a day of oxycontin with pain scores of eight and nine switched her to another medicine which would be considered a milder medicine pain scores of zero to one so it's a real phenomenon it is however not a common one and is being over diagnosed in my mind yeah go ahead richard yeah um i would go so far as to suggest that the only place where we do see confirmation of what is called hyperalgesia is in rat studies now that may sound a little ironic but it's out there and i would add to andrea's remark there are about six different enzymes in the liver that are involved in metabolism and they act differently with different opioids the explanation for hyperalgesia and for the kind of of improvements that andrea is observing is simply that you have to do trials and when a patient does not respond to one opioid it's perfectly reasonable and in fact may be indicated to try another or a combination and quite difficult yeah a different class exactly that reinforces the understanding that there is no one-size-fits-all patient or treatment protocol treatment must be developed individually and that's a perfect segue into this next question that i'd like to ask comes from michelle banash on youtube in your opinion will there ever be freedom for physicians to treat appropriately again i like to chime in on that myself as a physician you know we're seeing this intrusion into the patient-doctor relationship by uh politicians on all fronts and opioids of course they're they're you have people presuming to know to how many how much pain medicine people in the country need uh in the entire for the entire year and what is the appropriate dose to give every patient that a doctor sees we're seeing it in other even now with the covert pandemic we're seeing this controversy arise with respect to off-label prescribing of different medications uh so i i'm not optimistic that the trend of intruding into the patient doctor relationship is going to be slowing what do you think dr trescott it is devastating to see how much the insurance company has controlled the narrative the controlling what what i can give what i can do what the patient is allowed to have what the patient is allowed to do there has been a huge intrusion of that the decisions are being made by people who have no medical background and no interaction with the patient at all and it has become now uh we've got state that we've got uh municipalities that are making decisions on the opioids and there are um a it's a terrible problem so and i'd see it getting worse and worse okay kate wants to say kate wants to say something about this as well just uh just about the whole one size fits all just for our viewing audience i mean i think it's really important to remember that chronic pain is a huge category um that includes pain from inflammatory conditions it hurt includes pain from cancer it includes pain from neuropathic or nerve damage related conditions it includes autoimmune disorders so a huge uh variety of things that are driving pain and so this idea of sort of allowing pharmacy benefit managers or uh politicians to decide that one dose is going to work for every condition that generates chronic pain um is is relatively absurd um and uh as we also know that there's variability in in human beings and how we respond to different medications that's true of opioids it's true of everything else as well well uh this hour went too quickly i'm sorry to say where our time is up i have so many more questions that i was unable to get to because there's such an interest in this topic um i want to let everybody know that later on today this video will be uploaded so you can anybody who missed it or would like to see it again could watch it on the cato webpage and i'm really grateful for the uh for the attendees we had today thank you again kate nicholson andrew trescott richard lawhearn um and thank you for all you're doing in this field and thank you everyone for watching

Channel: The Cato Institute

Views: 15,888

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Id: UB6QLA8TgjA

Length: 60min 46sec (3646 seconds)

Published: Wed May 20 2020