Region 10 Opioid Summit, August 9, 2019, Vancouver, WA
This conference had over 2 dozen speakers, most of whose talks were very consistent with current opioid epidemic panic narratives, although there were a small number whose presentations were not supportive of regulating dosages based on arbitrary limits, and more focused on their patients being out of pain and able to function. Stand out speakers included Rose Bigam, co-director of Washington Patients in Intractable Pain, who discussed patient abandonment and stigma, Dr. Stefan Kertesz, who discussed prescribing as a risk to the doctor's careeer, and Dr. Steven Stanos, whose talk was called "Patients Who Do Benefit with Chronic Opioid Therapy." Probably the worst was Dr. Jim Shames who described giving Naloxone to the patient's loved one resulting in the loved ones being more open about fears of harm to the patient. To me, this sounded like it being used as a prop to generate or capitalize on fears of opioids as a uniquely dangerous medication, in the service of promoting anti-opioid attitudes and actions. I've been on high dose prescriptions since 1998, and have never had Naloxone in my house. None of the doctors who prescribed for me over the years have ever suggested that I have Naloxone in my house.
Opening speaker, Michelle Marikos, was one of 2 pain patients- out of over 2 dozen speakers. She was colorful and specific discussing herself in a fog under opioids, a growing ziplock bag full of medications, "popping them like candy," her "pain behavior lifestyle," and her wonderful experience of getting off opiates. She made brief mention of a fusion surgery, then ended with a promise to discuss her story in more detail when she was part of a panel in the afternoon. After that panel, I still didn't have a clear understanding of whether she currently uses non-opioid medications or if the surgery she mentioned resolved her pain. If someone needed a poster girl for not treating pain with opiates, Michelle would be a fine candidate.
The second speaker was Dr. Debbie Dowell of the CDC, lead author of the 2016 Guidelines. She said the goal was to prevent harm, and did mention some patients would continue to need even high dose meds, and that patients face challenges if they need to find a new MD. Dr. Dowell describes the Guidelines as being misapplied to existing patients over the past 3 years. She said the goal was to avoid new patients being escalated to high levels, not to control prescribing for existing patients, cancer, palliative care or emergency such as a sickle cell crisis. She specifically said the Guidelines do not support rapid tapering of existing patients. According to Dr. Dowell, the CDC still recommends opioids not be a first line or routine treatment, but for those who get such prescriptions, establishing and measuring goals, starting with immediate release and checking PDMP for other prescriptions. She later mentioned additional recommendations including reviewing risks and benefits every 3 months, sustained improvement and function, use of the PEG scale and meaningful goals, such as walking the dog, returning to work or attending family events. Dr. Dowell emphasized the Guidelines are not - and never were - intended for already-existing patients.
Like most discussions of opioids that have saturated our society in recent years, there was much focus on addiction, and it became clear to me that many of the more onerous requirements of pain patients - the patient contracts, frequent UA, mental health evaluations, peer support, motivated interviewing, pill counts - have been directly imported into the treatment of pain from the world of addiction care, not from the world of medical treatment. It seems to be not uncommon for doctors to be certified in both pain and addiction. This is like promoting the idea that anorexia clinics should be supervised by someone certified in bariatric surgery and cosmetic liposuction.
All the data presented was from remarkably poor studies - tiny numbers of subjects, short duration, and high drop out rates (like 25% in a 4 month study). Especially lacking is data on long-term outcomes. Even speakers presenting the data admitted it came from few and weak studies - but these studies were reported and apparently made use of as if they were reliable, well-replicated studies. Dr. Mark Sullivan, the moderator of the first of the two afternoon panels, even said research is often not applicable to real-world practice (I would emphasize this is especially true for poorly designed, brief, small group studies). But this scant and poor quality data is informing decisions that impact patients all over the US - not just current pain patients, but especially for Americans who will is treated for pain in the future. The overwhelming consensus was that keeping opioids away from people who haven't used them was an unambiguously laudable goal, even if there has to be a bit of grandfathering in existing high-dose patients.
Several speakers made the interesting claim that exposure to opiates can cause the patient to become more sensitive to pain, based on patients receiving prescriptions and still reporting pain. Consider the fact that humans have for many millennia found opium useful for treating pain, that there's a similarly long history of complaints that a very small percent of people develop a habit they can't be persuaded to quit, and that, for the many thousands of years of that history, there were no reports of a paradoxical effect of opium making subsequent pain more severe. Now, mere years since the drug war's moral panic du jour switched from meth to opiates, this paradoxical feature of opiate pain treatment has been fortuitously discovered. I would propose a more Occam-friendly hypothesis - too low a dose causes patients to continue to suffer and report pain to their doctors.
There was a great deal of discussion of multi-disciplinary, multi-dimensional, team-based approaches, and clinics where pain patients are treated by pain-management nurses, pharmacists, PAs, mental health professionals, social workers, physical and occupational therapy - even spiritual practices such as tai chi and yoga. Much of this was in relation to tapering existing patients, and giving patients skills to cope with pain. One pain clinic was discussed that provides long-term pain patients (not recent sufferers of traumatic injuries, but people long past that point) a regimen of 5 hours a day, 3 days a week in physical therapy, occupational therapy, psychological or psychiatric counseling and relaxation techniques. This slate of activities was contrasted with the idea of pain treatment as "one and done" - i.e., taking a pill and going about your day. Instead, patients are purported to benefit by spending 15 hours a week in supervised activities - a length of time that would qualify as a part-time job. Consider a patient with any medical complaint other than pain. If such a patient rejected a medication that had long controlled his symptoms and strongly requested increasing the time spent with multiple medical professionals, would that not strongly indicate that the patient be evaluated for hypochondria? But in the pain world, this patient is the model to which all patients are expected to aspire.
There was quite a bit of discussion of opioid use disorder and opioid dependence as outcomes to be strenuously avoided. Newer terms are preferred because apparently pain patients do not react well to being identified as addicts if they don't want to give up pain meds that are working for them, have physical symptoms of withdrawal when their meds are no longer provided, or would lose employment or child custody if diagnosed with addiction, or opioid dependence.
There were many things not mentioned. For example, we have 100 million chronic pain patients - almost 1/3 of the total US population. For the past few years, there have been about 100 million new opioid prescriptions per year for US patients, about 1 prescription for each 3.25 citizens. According to a Washington Post report of Aug.13 2019, between 2006 and 2012, US prescriptions have put 35 billion pills have been put into the hands of patients. According to speakers at this summit, the number of opioid deaths for 2017 was reported to be 47,600, or 1.7% of the 2,813,503 total 2017 US deaths. Illegal opioids account for 2/3, or about 31,700 of those deaths. (The trend in recent years has been that, among those whose deaths are attributed to opioids, 4/5 have 1-4 other drugs listed on the death certificate). Compare these numbers with other causes of death that could be reduced, such as coronary disease - the #1 killer of Americans at over 500,000 per year, and medical errors, reported by Johns Hopkins in 2018 at 250,000 per year, and the 3rd leading cause of death for Americans.
According to Dr. Joe Merrill, who focused on Opioid Use Disorder (OUD) and Opioid Dependence, the number of Americans with OUD was 1.7 million, and OUD from heroin use was reported as 700,000. Americans diagnosed with OUD account for 0.5% of our 2019 population of 329,269,072, and those diagnosed with OUD from heroin, 0.2% of Americans. In 1972, the year the DEA was created, the US population was 209 million, and US heroin users were reported to be about 300,000, 0.14% of Americans, a change in 47 years measurable in fractions of 1% of the population.
Concerns that the U.S. is in the midst of an epidemic of opioid overuse and unintentional opioid deaths don't seem to align with the numbers the conference speakers reported. There may have been increases in opioid prescriptions in the early 21st century, but the percent of Americans using illicit opioids is still measured in fractions of 1%, and deaths attributed to prescription opioids account for 1/3 of opioid death numbers (and there are frequently other drugs on the death certificate). Deaths attributed to opioids seem to be reported in ways that obscure complicating factors. A vast majority, 80% of individuals counted as opioid deaths, have 1-5 drugs on their death certificates, the most frequent additional drugs being benzodiazepines, which alone can cause deadly respiratory failure. The US autopsy rate is a very low 8.5%. Only 1/3 of US coroner/medical examiner offices having in-house toxicology labs, while sending out samples for drug testing costing $2500 for a single decedent. Us spending on death investigations divided by the numbers of US dead per year works out to under $3 per individual. The determination of "opioid death" is very often made by the death investigator making a conclusion based on the decedent's history, loved ones remarks about drug use (prescription or not) or items at the death scene. On top of that, the federal government datamines death certificates for clues to justify adding more deaths to the "opioid" category.
The major idea of the conference was that there's an urgent necessity for people well-documented painful medical conditions to avoid, or transition from, effective, safe oral medications to alternatives, even if some existing pain patients will continue to require high dose opioid prescriptions. There's no hesitation in the face of the weakness of the data used to support alternatives for pain, such as acupuncture (almost half a century of no data to support it as a pain treatment), mystical or religious practices from tai chi or yoga, or psychotherapy. But, from the facts and data that I heard from the many experts report at the Region 10 Opioid Summit, there seems to be no justification for the enormous, expensive and ever-expanding efforts to restrict the use of opioids in pain care.
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