Opinions

Response to Article by Laurent LePierres in the Herald Opinions May 18, 2012 – Stephen Gelfand , MD

This article was in the Nova Scotia Chronical Herald May 18th , 2012 titled :

LE PIERRÈS: Maybe our assumptions about addictions are wrong

If you’re in a room with a bunch of doctors and they ambush you with some surprising information, this is not normally a good thing. Unless, of course, you are their audience, not their patient.

I tend to fall in the former category. Doctors have made some rather interesting house calls here at the Herald lately.

A few months ago, it was this tidbit from an MD on the front lines that hit me like a bold headline: She said the ever-spreading scourge of cyber-bullying has not, as one might assume, driven up the teen suicide rate.

It remains relatively constant, and while heaps of abuse on social media are the new bane of many a troubled teen’s existence, the impulse to take your own life is also influenced by a host of other factors, not the least of which is your mental health.

Sometimes, we are too quick to connect the dots of causation. Trouble is, the dots form a constellation, not a straight line.

I was reminded of this insight when a small posse of physicians came calling a couple of weeks ago to discuss the ongoing ravages of prescription drug abuse.

They were armed with factoids on opioids — painkillers like OxyContin and Dilaudid.

Among the “counter-intuitive truths” trotted out by Dr. Gus Grant was the following: “The disease of addiction is constant and it’s predictable based on risk factors that have nothing to do with supply.”

In other words, says the registrar of the College of Physicians & Surgeons of Nova Scotia, getting prescription drugs off the street won’t cut the number of addicts. They will simply move to another drug of choice.

Dr. John Fraser, an addictions specialist in Halifax, says much more goes into the making of an addict than the availability of a drug. Most significant are socio-medical factors such as mental health, a family history of addiction, alcoholism or severe past trauma like sexual abuse.

Stories of people who were previously problem-free getting hooked on painkillers after surgery are mostly a myth, he says. “You have a less than one per cent chance of developing an addiction de novo out of getting prescribed opiates. The risk is, in fact, very low in the absence of other risk factors, the primary one being a personal history of addiction. There’s real misinformation around that fact.”

Before you get the wrong idea, these doctors are not washing their hands of the problem of addictive pills falling into the wrong hands. They were, in fact, touting a new measure to impress upon patient and doctor alike that opioid prescriptions must be handled with care.

Patients in Nova Scotia may soon be asked by their doctor to sign a form, detailing a list of mutual obligations, before receiving an opioid prescription. A copy will be sent to the provincial prescription drug monitoring program, which aims to curtail double-doctoring.

Whether you think this goes too far or not far enough, proper management of prescription painkillers is going to be a chronic problem for years to come.

Forget the black market for a moment. The legal market for these drugs is guaranteed to grow, due to medical advances and demographics, says pain specialist Dr. Peter MacDougall. Not only are people living longer with cancer, they are living longer with other conditions that require pain control.

“So we have chronic non-cancer pain, chronic cancer pain and an aging population. All these things add up to the need for ever more pain treatments, and the reality of the matter is that we will be prescribing more of these medications,” he says.

It would be unethical for the medical establishment to turn away from a class of pain-killers that brings relief to the vast majority of patients because they also bring untold misery to a small minority. As Dr. Grant says, “These are incredibly important drugs. These are the flagships for the treatment of pain.”

The solution — if there is one — is to continually refine best practices for prescribing. Putting more resources into methadone clinics, where needed, and being proactive about mental illness, as the province pledged to do in its mental health and addictions strategy released this week, is the right prescription.

(llepierres@herald.ca)

_____________________________________________________________________________________________________________

After reading this I was completely enraged at the flat out lies that were being told in this article . I forwarded a copy of the article to A.R.P.O. ( Advocates For The Reform Of Prescription Opioids) which came back with a response from P.R.O.P. (Physicians For Responsible Opioid Prescribing) :

The article by  Laurent LePierres in the Herald Opinions on 5/18/12, contained gross misinformation and was a mischaracterization of the disease of addiction. It is a blatant insult to the victims of addiction and their families to imply that those who have become addicted from prescription opioids would have become addicts anyway and that this has nothing to do with the supply of opioid drugs.

The professional opinions expressed in this article have rehashed the false statements and myths about addiction and chronic pain initially disseminated by the opioid industry, including the rare 1% chance of developing addiction if you do not have a history of addiction and that more, not less, opioids are needed for the growing population of patients with chronic noncancer pain [CNCP] which is the “flagship” for the treatment of pain. This ‘flies in the face’ of and contradicts evidenced-based research studies, CDC reports and clinical observations, and will only serve to increase the mounting toll of addiction, overdose and death related to prescription opioids.

Physicians for Responsible Opioid Prescribing [PROP] believes that the continued dissemination of such false information will only increase the legacy of harm to the public health from the excessive and inappropriate prescribing of prescription opioids. In discussing the propensity to addiction in a recent interview, Andrew Kolodny, MD, President of PROP, and addiction medicine specialist, made the following comments regarding addiction to prescription painkillers:

“—-the inherently addictive qualities of the drug may be more important than genetics in understanding why users can become addicted. The opioid manufacturers want doctors to think that opioids aren’t inherently addictive and that if they carefully select patients who don’t have a genetic predisposition for addiction then they don’t need to worry. But  simply not true.” 

Stephen G. Gelfand, MD

Physicians for Responsible Opioid Prescribing [PROP]

________________________________________________________________________________________________________

Another response from a member of ARPO :

This is in response to the help asked by Amy Graves.

 

Here are some ideas and research that challenges Dr. Peter MacDougall’s comments about the ongoing use of COT for CNCP and his ties to pharmaceutical companies.

 

Some members of the medical industry and the pharmaceutical industry colluded with each other to begin a practice of chronic opioid therapy (COT) for chronic noncancer pain (CNCP) patients without any quality scientific research to support all the claims then made by these change agents: that COT could be given without addiction; that if addiction developed, it was pseudoaddiction, not real addiction; that OxyContin couldn’t be abused; and that physicians could be trusted to use judicious decision-making of prescribing of opioids if the federal government got out of the way of oversight.

 

Now we know that much of this was propaganda shrouded in a mantra of compassion for pain patients. But compassion fails to be a legitimate motivation when people die from this medical intervention at the staggering rates we are seeing today.

 

A huge motivator for the induction of this practice change was money. Conflict of interest spurred this prescription opioid disaster from the beginning. The early policy makers and physicians were paid off by Big Pharma. It is corrupt to allow the agents of the harm (physicians with association to pharmaceutical companies) to have special ties to the PDMP information.  The principle of Moral Hazard, according to Wikipedia, states that moral hazard occurs when the party with more information about its intentions or actions has an incentive to behave inappropriately from the perspective of the party with less information.

 

Some reasons NOT to prescribe chronic opioids to chronic non cancer pain patients and an aging population:

 

1.      Many Baby Boomers have a history of previous drug abuse, have higher tolerances, and are at an increased risk of respiratory arrest because of a need to satiate their high tolerance and because of greater likelihood of drug-drug interactions from taking drugs for other medical conditions (which happens due to aging). Baby Boomers should have every other alternative pain remedy given them before ever resorting to chronic opioids which will foreshorten their lives.

 

“Although all drugs have adverse effects, we are concerned about the use of opioids for chronic pain because of the lack of efficacy data for pain lasting longer than 16 weeks; the widespread use of opioids; the number of serious adverse effects, including death, attributable to opioid use; and the open question, addressed in a commentary in this issue of the Archives, as to what we are treating when we use opioids for chronic noncancer pain.”

Harm from long-term opioid therapy

http://archinte.jamanetwork.com/article.aspx?volume=172&issue=5&page=430

 

“Consistent estimates of the prevalence of prescription opioid abuse among primary care patients receiving long-term opioid therapy remain elusive. The few surveys in community practice estimate rates of prescription opioid abuse form 4% to 26%, but rennet studies suggest the potentially serious opioid misuse is not rare. For example, Fleming and colleagues conducted 2-hour interviews with 801 patients receiving long-term opioid therapy who were being treated by 235 Wisconsin physicians. They found rates of 26% for purposeful over sedation, 39% for increasing dose without prescription, 8% for obtaining extra opioids from other doctors, 18% for use of purposes other than pain, and 12% for hoarding pain medications.”

Long-Term Opioid Therapy Reconsidered

Von Korff, M., Kolodny, A., Deyo, R. A., & Chou, R. (2011). Long-term opioid therapy reconsidered. Annals of Internal Medicine, 155: 325-328

 

“Illicit drug use generally declines as individuals move through young adulthood into middle adulthood and maturity, but research has shown that the baby-boom generation (persons born between 1946 and 1964) has relatively higher drug use rates than previous generations. It has been predicted that, as the baby boom generation ages, past year marijuana use will almost triple between 1999/2001 and 2020 among persons aged 50 or older. Nonmedical use of prescription-type drugs also has been identified as a concern for this population.”

Illicit drug use among older adults

National Survey on Drug Use and Health, September 1, 201

http://oas.samhsa.gov

 

“The biggest rise in these accidental poisonings is among men and women of working age, 20-64, and is mainly due to abusing prescription pain medicines such as oxycodone, methadone, hydrocodone, fentanyl, and buprenorphine. The most rapid growth in accidental poisoning deaths during the past decade occurred in those 45 to 64 years old, Froetscher says, followed by those 25-44 and then 15-24.”

Drug Overdose Deaths on the Rise

http://www.webmd.com/mental-health/news/20080922/drug-overdose-deaths-rise?src=RSS

 

 “People who start using hard drugs—such as cocaine, opiates and amphetamines—as young adults and continue to use them into their 50s have a fivefold increased risk of early death, researchers report.”

Hard drug use in middle age could prove fatal, study finds

http://www.nlm.nih.gov/medlineplus/news/fullstory_121560.html

 

“One of every 33 Baby Boomers is living with hepatitis C.” (unhealthy livers increase risk of poor metabolism of opioids and other drugs)

Hepatitis C deaths up, Boomers most at risk

http://yourlife.usatoday.com/health/story/2012-02-20/Hepatitis-C-deaths-up-Boomers-most

 

 

 

2.      Wherever rates and doses of opioid prescribing go up, death rates from opioid-related causes go up, too. To declare that opioids will be more prescribed in the future is to announce that more people will die from opioid-related causes in the future than the huge numbers of people that currently die from this iatrogenic cause.

 

“The findings of our exploratory study suggested a strong association between opioid-related mortality and the dose of opioid dispensed.”

Trends in opioid use and dosing among socio-economically disadvantaged patients

http://www.ncbi.nlm.nih.gov/pubmed/22046214
“States with higher sales per person and more nonmedical use of prescription painkillers tend to have more deaths from drug overdoses.”

Prescription Painkiller Overdoses in the US

http://www.cdc.gov/vitasigns

November, 2011
“Back in 1997, which is the earliest year that we had data, there was about 100mg of the major opioids dispensed per person in the United States. By the time we get up to 2006, we are about up to 600mg per person, indicating at least a 6-fold increase between 1997 and 2006 in the volume of opioids being distributed. That trend fairly closely tracks the rise in unintentional drug overdose deaths” (Dr. Paulozzi, 2010).

 

 

3.      Opioids are linked to greater risk of morbidity and mortality in senior citizens

 

 “Our findings plus the recent FDA withdrawal of Propoxyphene-containing products point out that not enough is known about the cardiovascular side effects of commonly used opioids,” Dr. Solomon concluded. “Because so many older adults with chronically painful conditions like arthritis and back pain who are using opioids also have cardiovascular disease, understanding the potential link is critical. Additional research should focus on specific cardiovascular endpoints, like arrhythmias, and specific patient subgroups, like those with known cardiovascular disease or cardiovascular risk factors.”

Opioids linked to more adverse events in older adults with arthritis

http://www.medscape.com/viewarticle/734569_print

 

 “The number of hospital admissions among Americans ages 45 and older for medication and drug-related conditions doubled between 1997 and 2008, according to new report released today the Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ)…Poisoning by pain medicines or other drugs containing codeine, meperidine or other opiates can be caused by accidental overdosing or the failure to recognize the drug’s active ingredient. Drug withdrawal occurs when there is an abrupt withdrawal or significant reduction in the dosage of pain or other prescription medicines to which a person can become addicted, as well as of illicit drugs…’Substance abuse is rising, and drug abuse of all kinds is exploding as a major public health concern for our country,’ said SAMSHA Administrator Pamela S. Hyde, J. D.’”

Hospitalizations for medication and illicit drug-related conditions on the rise among Americans ages 45 and older

http://www.ahrq.gov/news/press/pr2010/hospmedpr.htm

 

 “Among 391,139 opioid-naïve patients undergoing short-stay surgery, opioids were newly prescribed to 27,636 patients (7.1%) within 7 days of being discharged from the hospital, and opioids were prescribed to 30,145 patients (7.7%) at 1 year from surgery. An increase in the use of oxycodone was found during this time (from 5.4% within 7 days to 15.9% at 1 year). In our primary analysis, patients receiving an opioid prescription within 7 days of surgery were 44% more likely to become long term opioid users with in 1 year compared with those who received no such prescription (adjusted odds ratio, 1.44; 95% CI, 1.39-1.50).”

Long-term analgesic use after low-risk surgery

http://archinte.ama-assn.org/cgi/content/short/172/5/425

 

 

These are just some of the reasons that COT for CNCP has been a failure. We must insist that the initiators of this problem of prescription opioid abuse and diversion have no special ties to the information being gathered to try to remedy this problem. It seems obvious on its face to have the PDMP system free from any ties with those who stand to benefit from the “oversight” of the problem.

 

 

Suzanne Lee DNP, APRN-BC

 

Certified Addictions Registered Nurse-Advanced Practice

 

__________________________________________________________________________________________________________

One of the doctors who was quoted in Dr. Gelfands response and Suzanne Lee’s is the Medical Consultant for the Nova Scotia Prescription MonitoringProgram as well as Network Director for The Nova Scotia Chronic Pain Collaborative Care Network which is funded by Purdue Pharma , the maker of OxyContin , Dilaudid , and other opiate narcotics. Just a few weeks ago the United States Senate launched a investigation involving Purdue Pharma’s finanacial connections to Pain Networks in the U.S. See Investigation Letter Here <——– . I think Nova Scotia and the rest of Canada need to take a hard look at who has Big Pharma’s hand in their pocket !

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2 thoughts on “Response to Article by Laurent LePierres in the Herald Opinions May 18, 2012 – Stephen Gelfand , MD

  1. A well written response Amy. Your words have weight amd I’m very impressed that you have pointed out the background of one of the doctors who clearly has a financially biased opinion which dismisses his word, immediately, as moot. Keep up the great work. Your efforts are noble and if they save just one life, which I’m sure has happened, then they are not in vain.

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