Heroin, Hydrocodone, Buprenorphine & PROP-aganda

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According to US News Health, PROP’s President, Dr. Andrew Kolodny is quoted to say “There is very little difference between a heroin molecule and a hydrocodone molecule.”  This could be misleading to the layperson, media, politicians, and perhaps many healthcare providers. 

Let’s dissect this a bit further.  While it is true that there is some similarity between heroin and hydrocodone, there are very significant differences.  Heck, there’s cyanide in vitamin B12 (cyanocobalamin), but we require this vitamin even though B12 chemically contains cyanide.

HYDROCODONE CHEMISTRY

There are essentially 5 different chemical classes of opioids.  The prototypical class is known as phenanthrenes, and this is where opium is located on the continuum.  True enough, all of these phenanthrenes share a common chemical nucleus, but manipulating what is attached to a chemical drug nucleus changes the properties. We’ll come back to this.

Let’s look at another example.  Epinephrine (aka adrenalin), serotonin, and dopamine all share a chemical nucleus known as a catecholamine.  As it turns out, all of the following have the same or similar nucleus such that they are catecholamines themselves, are broken down to these and/or inhibit the breakdown of catecholamines; oxymetazoline (Visine Long Acting Eye Drops®, Afrin Nasal Spray®), tetrahydrozoline (Visine® traditional four hour formulation),pseudoephedrine (Sudafed®), propranolol (and all other beta blockers), albuterol (and several other inhalers that are used for acute asthma attacks including Primatene Mist® over-the-counter), phenylpropanolamine (found in many cough syrups as a decongestant and also over-the-counter diet aids), and many more.  Look at the spectrum here folks; Visine Eye Drops® and amphetamine?  Hmm, is there very little difference between using eye drops and amphetamine?…I don’t think so!

BACK TO HEROIN:

Looking at the chemistry again, heroin is diacetyl morphine and it is a hydroxylated phenanthrene (top left side of chemistry link, notice the –OH group circled in red; that’s what makes it “hydroxylated”).    Hydrocodone is a dehydroxylated  phenantherene (it does not have that –OH group).  All of the drugs that appear in the list that contain the –OH group are more similar to heroin, especially opium and morphine.  Opium is simply a concentrated form of morphine.  Heroin is diacetyl morphine.  Essentially then, heroin is two morphine molecules connected by a molecule that many of you know as vinegar (acetic acid). 

Now it gets trickier!  The chemical groups attached to the nucleus have a lot to do with the specificity of activity, but also how your body breaks these drugs down (that’s what we call metabolism).  If that –OH group is present (as we see with morphine that comes from heroin), the breakdown products contain active compounds that stay around for quite some time.  Morphine has two breakdown metabolites; one is called M3G and one is M6G.  The M6G can accumulate and cause toxic effects.

Hydrocodone does not have the –OH group that is circled in red.  In fact, all of the drugs listed beneath the phenantherene class that have an asterisk are missing the –OH group.  It generally makes these drugs a bit better-tolerated compared to heroin or morphine.

chemistry


Is there “very little difference between a heroin molecule and a hydrocodone molecule”?  That is correct but misleading.

Moving on…


BUPRENORPHINE

Buprenorphine has many attributes both for treating pain and for blunting opioid craving in patients with a substance abuse disorder.  While some PROP supporters have heavily advocated for buprenorphine; there is very little difference between a heroin molecule and a buprenorphine molecule.  In fact, buprenorphine and hydrocodone are very similar in that both of them are DEHYDROXYLATED phenanthrenes.  Since they are both dehydroxylated, they are more similar to each other than hydrocodone is to heroin.  I bet it would be difficult to find a statement anywhere in the mainstream media that says there is “very little difference between a heroin molecule and a buprenorphine molecule.

Let’s stop this PROPaganda.  People are smarter than you think!

 

77 thoughts on “Heroin, Hydrocodone, Buprenorphine & PROP-aganda

  1. I have been taking suboxzone for 3 years. I receive them for pain management. I went to the doctor today and was told my urine test came back positive for morphine. I was at one time an opiate addict, but never got into morphine. I’ve heard you can have false positive on urine test for morphine. Please let me know if and how this can be possible.

  2. If man in 50s is presciped vicodin 10, 2tabs 4 x/day, and buprenorphine and used jeroin once; will heroin or the metabolites morphine build up and/ or take longer to leave urine that is sent to lab to confirm concurrent use of prescribed vicodin and bup? Could it increase vic level high enough to show morphine? If so how do u get around this and how long for vic level to b right and no trace of h?

    1. Does vicodin need to be lessened for a short period of time or stopped shortly to bring level back down if affected? He can only be positive for vicodin and bup and md has past levels for comparison. I dont wont him to lose treatment from party at my friend of friends house. First time user of the h and swore it off. He snorted it. Thank u

    2. Please dont think this is an evade test flunk question. He has real need for pain meds for long time and he never messed up except this time and i feel bad bc his depression and pain keeps him home mostly. I talked him into hanging out and now feel bad his care will be compromised over a 1 time expeimenting.

  3. i take hydrocodone acetaminophen 10-325 (5 or 6) a day & 1 or 2 oxycodone acetaminaphen 10-325 some days when pain is more severe & was just tested positive for the 6-acetymorphine metabolite. the pain clinic says this is positive for heroin use & will no longer see me. how is it possible for this result to occur?

      1. thanks for your reply Jeffrey. thats what they told me. i asked if there was any medical reason perhaps a liver problem & asked to talk to the pain clinic dr but he would not call me. i also asked to be tested again & she said no. the nurse said to ask my dr about it that i was discharged & she said the pain dr would not call me. i did call my dr and he said not his area of expertise that the pain clinic doctors would know about that. has to be an error on test or a mix up at the lab as i did not take heroin,. never have ever. are there any medical conditions that could cause this result? if not then it is a lab error or mix up

        1. Some labs use Acetate buffer for preparing enzymatic hydrolysis in order to separate out glucuronide metabolites. That acetate buffer could combine with morphine and make MAM. the only way to know 100% is to have the sample sent for chromatography testing. But a false MAM is pretty rare.

  4. I have been prescribes buprenorphine for almost 3 1/2 months now. I was being tested to ensure my probation officer, rehab counselor, and buprenorphine specialist (doctor) that my medication was the only thing I was taking. For the first 2 1/2 months without insurance I private paid for my urine tests through a comapny called MEDLAB. Every test came back the same: Positive for buprenorphine (Suboxone) and Negative for EVERYTHING ELSE! Now that I have insurance my test was sent to QUEST DIAGNOSTICS, the first one that came back from QUEST was positive for Buprenorphine & MORPHINE?! Why is this I haven’t touched anything but my prescription in over 90 days! And even begfore that it’s been a year since I took an actual opiate! All I’ve taken is Buprenorphine (which I’m prescribed) and they said they did a “confirmatory” and that I have Morphine & Buprenorphine in my system! I swear on everything that’s dear to me I haven’t taken anything but my prescription and I need to know how/why this is happening!!!

    I have read that Buprenorphine is a derivative of the alkaloid thebane (found in morphine). Is it possible that it can metabolize differently in some people?! I need an answer ASAP….PLEASE HELP!!!!

    1. Probably..I’m not a doctor, or a clinical biochemical specialist, but to be on the safe side always tell yer p.o. what’s what..

    2. I just checked the structure and YES,buprenorphine would probably “read”basically the same color, the alkyl side-ring chain being of slight configurational shape but with the EXACT same ring-constitution…

    3. Buprenophine ‘specialist’ physician. Hmm…sorry to say, but aside from a handful of specialists, the only people I’ve ever heard from who have had any worthwhile knowledge about buprenophine are long-term patients with a solid biochem or pharm background.

      Ask any doc who should be intimately familiar with bupe a few essential (or what one would believe to be essential) questions about it and the answers you receive will inspire no confidence in their familiarity with this useful molecule; for example:

      -What is the most effective way to decrease bupe dose and how long should pts stay on bupe?
      -Have you ever weaned anyone off of bupe (from >/=8mg to 0mg/day) & had them remain off?
      -I’m in a situation where opiods are (as much as they can be, anyway) necessary. How will my treatment be different from a naïve other?

      And so on. I’ve never met a prescriber who could give me decent answers to these questions- hell, most even believe the naloxone in some bupe drugs has any purpose. Also, one would think the second question there the most important, but just as I’ve never encountered anyone or any consensus from providers about it, the only way anyone gets off bupe is with their own knowledge. It’s awesome that providers want to help people and i applaud them for this, but all of us on bupe know we essentially just need to nod along with the anemic info we get from them and know we are basically holding their hands or using (as closely as possible) our own knowledge to get on a path that is reasonable for decent mgmt of our care if we end up in a scenario where the above questions are relevant.

      In short-term provuders/pharma/policy/regulation (don’t get me started) have made available a unique and life saving drug, but all of you need to have some serious pow-wows regarding bupe bc your current understanding is ‘le crap’ and with the obscenely increasing relevance of this topic it’s just not gonna cut the mustard.

      Still, very much liked your article. Unlike me, concise, well written and informative.

  5. Dr. Fudin,
    I can’t begin to tell you how important it is for me to hear a positive message from a member of the medical profession at this time in my life.
    I have been a patient of the same doctor’s office in Kentucky for 27 years. As I acquired more debilitating medical conditions, I was prescribed opiates to treat the pain and a medication that allows me to get some sleep in spite of the pain. I have NEVER misused, sold or given my medications away. My doctor is in practice with a large group of providers all of whom are employed by a non-profit organization. The organization decided they would not prescribe anymore pain meds since HB 1 went into effect. He said they could not risk the possible legal ramifications of this new law, so they were simply going to change from treating patients’ pain to convincing them they have none. I was told I was going to get one pill less per day until, five months from that day, I would be over the withdrawal of the physical dependence of opiates and I would feel no different than if I had never taken them. Yes, that’s right, I was to believe that not only would I feel no difference in my pain level, but I might actually feel better! He assured me, however, that my Ambien prescription was still going be written because, “We have to make sure you get some sleep” , and, at this point, this was a huge relief. With no pain medication, I already knew sleep was going to be even more of an issue.
    It was May, 2012, and Kentucky’s new “pill mill” law was on its way to complicating life for some and turning some of our lives into hell on Earth. In July, 2012, an “emergency” addition to HB1 now included some lower profile meds which, in short, swooped down and took away my Ambien. I was surprised when I came in for my next appointment only to discover I would not get to sleep to escape my pain now either. I know you understand, Dr. Fudin, but for those of you who think people like me just need to get over it, let me explain how little quality of life you have when Fibromyalgia, degenerative joint disease, restless leg syndrome, polyneuropathy, interstitial cystitis, and migraines are grossly undertreated and there appears to be no hope of any change since it appears the government is in direct control of your medical care.

    1. Listen, what happened with prohibition in the 1920s? Tobacco and alcohol are far and away the most dangerous drugs on earth (health and crime-wise, respectively), but they are legal bc we make the largest amounts of each. Every drug law was passed only through racist propaganda and remain only because we have a for-profit incarceration machine!
      Further, almost all crime and danger from drug use is only due their illegality. All probition does is force creation of insane, untaxed and unregulated profits, violence, dangerous use & impure products, and an overflowing legal system where rapists and murderers go free. The only reason our sad system has survived in this country is bc profit. THIS IS NOT A MORAL ISSUE.

      So..in response to your comment ma’am, it does really stink that pts in pain are only going to have more difficulty as providers try to keep their licenses and freedom and keep up with the ridiculous reactionary drug laws of our amazing country. A MORAL and personal issue cannot be solved with legislation- only with rational thinking, education, and a lack of greed, most importantly.

      1. Spot on. You are brave for speaking the truth and educated on the subject, unlike most who like to talk out the side of their necks. Bravo.

    2. I too have INTENSE pain, and several doctors, including a “Pain Specialist” who tell me my pain is not real. And the same problem of: If you don’t take any pain medication, you won’t have any pain. (I wonder who thought that one up?) Who decided there was an “Opioid Crisis” here, anyway? And, what am I supposed to do to eliminate my pain?!

    3. Omg…i totally feel for ya!!! I’ve been dealing with my chronic pain from nerve damage after I ruptured disk in back and had to have emergency surgery.. cuz if I didn’t have the surgery my left leg would keep shrinking and would constantly be numb and no feeling for ever…so I had to have them go in and take the pieces of disk that ruptured out of my sciatic canal in order for some relief and to feel my leg again..so afterwards I was on my pain meds that helped my quality of life and helped so I can take care of my 3 kids as a single mom without dying on total agony most day..my nerve damage has caused my pain to be a daily occurance..so when the whole opioid epidemic came into affect in ny they started slowly to shrink my dosage of oxycodone daily until they decided I don’t need it..THEY DECIDED!! as u were saying quality of life is very important and I also wish these Dr would really understand people like you and i..we need help daily with pain meds to be able to literally FUNCTION ! AND TO HAVE QUALITY OF LIFE TO CONTINUE ON A GOOD WAY..my kids have even said this past year I’ve changed alot MENTALLY!! Well depression starts to set in when u have pain daily and can’t have the relief that a Dr can easily give for the people who truly need.. I get radial frequency shots in back every 4-6 months to help ,but even after my shots of that not so fun nerve burning shots ( radial frequency) appointments the pain is still there.. helps some but not to point I would like to be to feel better for my kids sake. And my kids are 18,15,13..all teens….as a single mom it’s depressing to not be able to do as much as I can to raise them in a better quality of life stage….so I want to say kim I hear ya!!! And try keep head up …..i try as much as I can for my kids….and I just wish the medical areas in govt would actually study real people with real pain issue….instead they are causing people to become heroine addicts!!! Blame the govt for that!!! I do….

  6. THANK YOU for your time and fighting for us!! I was cardiac RN for ten years. I was proud to be a productive member to society. For the last five years, I dealt with daily disabling pain from thoracic outlet syndrome (TOS) and ehlers danlos syndrome type 3. With TOS, it is a chronic pain condition just like EDS. Any repetitive upper body movements- typing, cooking, or any ADL’s that I have to do daily. I have been taking the SAME dose of pain meds for the last 4 years. It doesn’t cure my EDS or TOS but I am able to do daily activities and the best quality of life that I can at this time. If I did not have this option, I would not be able to be a mother to my preschooler and a wife.
    When someone has cancer, it is the nerves that is causing their pain. The pain is doing the same thing to us. In the medical field, we are taught pain is the 5th vital sign and to treat. It was never to question or judge those that are in pain. I have been judged, discriminated by doctors and pharmacies for having chronic pain. Thank you for listening and allowing us to share our stories.

  7. Thank you Dr. Fudin….I’m beginning to think none of the facts will change the mind of Dr. K. He’s on a mission wearing blinders to the folks his propaganda will hurt. The war on drugs has casualties, …ironically it’s the people who the drugs were intended to help.

    1. I think he knows his proposed ideas will severely hurt chronic non-cancer pain patients. He is a medical doctor, so he should be smart enough to know that much. I think Kolodny doesn’t care about chronic pain patients at all. All of his ideas are designed to help drug addicts and abusers while sacrificing chronic pain patients. That much is clear to everyone. I guess only Kolodny knows why. I would not be surprised if it was financially motivated…..

      1. It is extremely difficult for me to find civil words to describe my feelings about Andrew Kolodny. Considering the horrific stats the CDC reluctantly released about untreated chronic pain and suicide, I’m almost ready to put Kolodny on my list of top ten despots. He hasn’t caused deaths in the millions yet but give him time. Another five years of his policies enforced by his BFFs at the DEA, and I think he’ll be on equal footing with Pol Pot.

        And to think it’s all just about Kolodny and PROP lining their pockets. They don’t really care about Americans and opiates. They just want all pain patients to have to use their rehab clinics (big new lucrative industry) and what better way to get any unending supply of clients than to outlaw palliative care? The fact that Kolodny uses Suboxonein his rehap treatment–which is just another opiate and just as addictive–kinda tells you everything you need to know about his values. I think it’s time for this petty little dictator to disclose his connections to Suboxone manufacturers and he’s funding PROP.

        Andy, thanks for your comment.. When I ask myself, “Who truly benefits from Kolodny’s anti-palliative care policies,” I come up with (1) Kolodny and his friends at PROP, who want to see their rehap clinics stretch from coast to coast (2) Politicians, who thrive on sound-bite crises about national calamaties they claim they can cure but never do (3) the DEA, stout defenders of our Constitution except the Fourth, who are using Kolodny’s claims to bully their way into the pharmaceutical records of every American without probably cause or a warrant cuz anyone who uses prescription opiates is a criminal.

        I guess it’s a lot cushier for DEA agents to stalk law-abiding pain patients than, you know, stop the massive flow of Fentanyl laced heroin onto our nation’s streets. Which, by the way, you all know that the so called “opiate crisis” is actually a heroin crisis and not a pharmaceutical one?
        I’m thinking Kolodny and his DEA buddies are getting Christmas Cards from every Narco lord in the world right now.

  8. Thanks so much for posting this, Dr. Fudin. As an Ehlers-Danlos patient with a keen interest in science, it frustrates me when people can’t get their facts right. If Vicodin is the same thing as heroin, then we might as well say that Maxalt (rizatriptan benzoate) is the same thing as a tricyclic antidepressant because both can contribute to serotonin syndrome. The website for the PBS documentary “The Botany of Desire” outlined the chemical differences between different kinds of opiates quite clearly; interested readers might want to check it out. (I can’t find a link, though.) I have never taken hydrocodone, but I used to use Tylenol w/ codeine in the past for acute pain. Now that I live in New York, I can’t even get a prescription for that. As a result, I’ve had to make a prescription for 20 Tylenol 3 stretch over the course of a year and a half. Some people would be gracious and say that they would never wish their pain on their worst enemy, but if my enemy worked for the FDA, I certainly would. Maybe it would provoke a change of perspective. Thank you for your advocacy.

    1. PROP promotes and encourages people to believe more scientifically/medically false ideas and claims than that all opioid pain medicines are heroin pills. It is quite shameful really. The sad part is many people without an understanding of science and an ax to grind believe it and then subsequently promote and encourage these false ideas among friends and relatives. This is one of the main causes for all the hysteria surrounding opioid pain medicines.

      1. Dear sir,
        as a chronic pain sufferer, I have lost all quality of life. In one years time I went from roller blading 5 miles a day, taking care of a bustling household and family while working full time. My beloved son died in his sleepand since then my life has become a living nightnightmare from which i can not escape. He was to be married and my impending addition to my family warmed my heart. Suddenly struck with fibromyalgia,
        I have lost my life. at first my doc prescribed time released ocycodiene. I did an hour of core exercises per day. Always in pain, but bearable.insurance stopped paying. Very expensive, I was left to lay in bed 24/7. lost my life. My friend has similar scenario and started sniffing heroin. Dangerous ..yes. but take 15 years off my life for 5 quality years. Chronic pain sufferers know this. She is NEVER loopy, never takes more than consistent amount and doesn’t have to be treated like a drug addict, piece of dirt under the medical communities shoe. It’s all politics
        People hear drugs and run screaming. If one would educate themselves and walk a mile with chronic intractable pain, they might, maybe just get it. Walk a mile in my moccasins then judge me.
        thanks for listening to my rant. I’m in bed 24/7 and the thought if living again is overwhelming. I don’t drink, have never taken more than what is prescribed, prefer to remain drug free, but the thought of living again makes me sob uncontrollaby.
        I’m looking further into this.
        thanks Jana .

  9. I read the PROP PROPaganda on their website. The information posted reads more like a law enforcement agenda than a outline for how to help patients deal with chronic pain the “right” way. Dr. Kolodony states that “Opiates are rarely the answer” but never on the site does he or any of the other PROPs say what the answer for the chronic pain patient is.
    It is my misfortune to live in the state of KY. I have Ehlers Danlos with severe spinal issues, bone on bone arthrits in my wrist, multiple painful issues in my right foot and arthritis in my knees, hip and shoulder. I also am unfortunate enough to have a bleeding disorder which makes NSAIDs not a option for me.
    I was diagnosed with EDS and the platelet disorder after a post-op hemorrhage which dropped my h&h by 50% in 3 days my doctors eventually started my on narcotics. By then I had been tried on most of the NSAIDS including Vioxx and Bextra. But I am a bleeder. My back pain secondary to Schuermanns at T10,11 and 12 with anterior bone spurs and posterior disc bulges is so severe that unmedicated I am in bed, fetal position crying.
    KY passed HB1 which mandated urine testing, pill counts etc. My doctor ordered a urine drug screen but the lab tested for morphine at 20,000 ng/ml instead of oxycodone at 100ng/ml. My result was negative. They did not share this with me until it was time for more meds. I insisted that there was no way that my urine could be negative since I had a dose prior to driving to the office. They did another urine, tested it to the morphine standard -was negative. I gave blood.Before the blood test came back I went into acute withdraw. So now the doctor who had accused me of diverting sees me shaking, crying, in pain with hypertension and tachycardia. His solution, send me to a psych hospital for withdraw. I lived with severe pain, chest pain, nausea, diarrhea, sweating, freezing for 4 days in inpatient. When I had to lay down in a fetal position for the back pain they said I was histrionic. After 4 days of being forced to attend drug addiction classes I begged to be discharged. I was a few days later treated in ER for hypertension 220/122. The severe pain, insomnia, visual hallucinations continued as did the hypertension for over 16 days. On the 16th day I had a appointment with a pain doctor. I had been asking for a referral to one for a year with no success. The pain doctor seems very cognizant about the pain of EDS plus he looked at my MRI’s and xrays. When I told him I was not sure I could trust him after what I had been thru he said he understood. I was afraid to go back on my meds for fear of this happening to me again. He assured me that they test for my medication at the pain clinic, which had not been done at my doctor’s office. After I was discharged from the hell of the psych hospital I provided my doctors office with the references indicating that testing for opiate levels set to trigger for natural opiates will not catch oxycodone which needs a trigger of 100ng/ml. I wonder how many other patients were made to go into “detox”. What little faith I had in doctors is now skating on thin ice. The gov. of KY made a statement that they assumed that doctors would know which tests to order and how to interpret them. However, the gov. also said that the drug urine screens cost about $65. Really. I had 5 of them done in 3 weeks. One of them was billed to Medicare in excess of $2000.
    Also KY does not have one lab that is federally certified to meet minimum standards of accuracy for drug testing. So while drug testing is now mandated, and expensive – do not count on it being accurate.
    My hospital expenses related to this medical failure were in excess of $20000. I borrowed from my 401K to pay what Medicare did not. It is a very bitter pill to swallow, how I was not believed, even when I handed my doctor my remaining pills to count, he still wanted to believe I was diverting because of his lab result. And when I inconveniently went into withdraw he sent me to a psych hospital where I was treated terribly. My pain and my Ehlers-Danlos was ignored. They would allow me 6 tylenol per 24/hrs. But when I used the prn tylenol they told me I was using too many prns and thus would “re-abuse” when I left. I told them I never abused my medications and can not foresee that I ever would.
    Their response – eye rolling. It was hell. I will never allow another doctor to do that to me again.
    If PROP prevails I have no hope of having managed pain. They don’t seem to have any suggestions for alternative treatment. My condition is due to physical damage and it is permanent. And I can not use NSAIDS and no safe amount of tylenol touches the pain. It is hard to remain hopeful. I mean I did not think I had anything to fear when KY passed HB1 because I used my medications as ordered. But, apparently the state felt no need to inform doctors regarding how to properly do a urine drug screen and how to interpret it. Oh and one more thing that undermines my trust in doctors for ever more. The day after I was sent to lock down my doctor got my blood test back confirming I was using my pain med. It was a holiday weekend and he apparently tried to call the psych doctor assigned to me multiple times to relay this info. The psych doctor refused to call him back. He told me this when I went to my outpatient appointment. Apparently the psych doctor had already decided to just let me suffer. Can you imagine my anger? I feel as if these PROPagandists are signing my death warrant. I will save my research on their lobby techniques for another post. This one has probably bored you enough.
    I am the EDS patient who had her medication stopped abruptly and was then sent to psych when I went into withdraw. I lost so much weight and strength and remain very weak 7 months later from my lost muscle mass which is hard to rebuild with EDS.
    Thank you for having this forum. We need to make sure that the truth is shown the light of day to cast a shadow across the improprieties been spread far and wide by Kolodony and associates. For example their statement that dependence and addiction are just different names for the same thing.

    1. In response to my own post – a clarification. The cut off for morphine in urine drug screens is supposed to read 2,000ng/ml and not 20000ng/ml. Still this is a huge difference than the 100ng/ml to detect therapeutic use of synthetic and semi-synthetic opiates at 100ng/ml for the oxycodones and 300ng/ml for hydrocodones. Ironically if the test has a cut off of 100ng/ml it would, in theory, catch all of the opiates
      while the higher cutoff of 2000ng/ml is calibrated to catch the “natural” opiates and reduce the risk of false positives. This could have the unintended consequence of failing to catch illegal users of oxycodone and hydrocodone and even giving them a prescription for those drugs in emergency rooms or primary care when they are doctor shopping. If the urine tests negative it would seem they aren’t using. Also since abusers tend to be intermittent users of high doses rather than routine users of therapeutic doses, the likelihood of catching them on a urine drug screen is lower. So, the urine drug screen may well give a negative for a legitimate pain patient who uses the medications with some regularity if not ordered and interpreted correctly. That same negative result may allow a drug abuser to leave a doctor’s office with a legal prescription for their preferred drug of abuse. There are many nuances to using a urine drug screen properly. One of the first hurdlers to overcome is finding a lab with an acceptable quality profile for drug testing. Also doctors and office staff need to be apprised of the proper way to collect and store urine prior to delivery to the lab. My former doctor’s office did not seal the bottles to make them tamper resistant. They did not refrigerate the specimens. Rather they were dropped into a bin hanging on a wall to be picked up twice daily by a lab courier. The lab that the specimens went to had seen a substantial increase in numbers of urine drug screens since HB1 took effect. That lab, which was owned by the hospital that employed the doctor, was not equipped to test for individual drugs accurately, nor were they quality certified to a minimum standard of accuracy. There are many mistakes that can be made in urine drug testing and when a doctor does not question a unexpected result and acts as if a lab test is always definitive we have a set up for disaster. I was once again a medical train wreck. The cars of my health care just kept derailing one after another and my pleas for help were drowned out by attitudes of “the labs are always correct”, “you must have been doing something wrong or your doctor would not have sent you here” My doctor did admit that he knew I was using my medication and not diverting when he saw me in withdraw. But that did not stop him from sending me to “detox” because he had those negative lab tests. When I reminded him that doctors are supposed to treat patients and not their labs his reply was “what was I supposed to think when more than one was negative?” My reply “you might have at least asked yourself why the test was negative when your patient was insistent about using the medication and further went into withdraw” It only took me a few minutes online after I got a copy of my drug screen to find out why it was negative. There is a huge difference between 100ng/ml and 2000ng/ml. My point is that when we criminalize a medical treatment and mandate screening tests we should have an obligation to make sure those tests are as accurate as possible and have procedures in place to verify any unexpected results.

      1. EDSgirl,

        Thanks for sharing this story here. I know how painful & devastating this was (and still is) for you. People need to realize that this story is REAL, and one of the many “unintended consequences” of the failed War on Drugs. This is what happens when we criminalize people with medical disorders, treat people with pain as sub-human, and assume all pain patients are drug addicts and/ or diverters Your doctor’s error could have cost you your life (Cardiac-Adrenal Pain Syndrome), and not just your dignity & your basic human rights. People in pain shouldn’t have to live in constant fear that they will be forced into psych wards, stripped of their legally prescribed, necessary medications, put into excruciating withdrawal, and treated as criminals. Unfortuneatly, this is the new REALITY for people unlucky enough to live with severe pain…..

        1. I am very sorry to read of your horrible ordeal. Is there any way you can sue these doctors and the psych hospital?
          The only way to make a difference is for pain patients to start suing for malpractice and get some of these cases in fron of a jury.

          1. Regarding suing anyone- I spoke with a attorney who basically told me that the expert witnesses would cost as much or more than any award. He said also juries do not often find in favor of the disabled or elderly – assuming that their quality of life was already so poor that even though the doctor may be wrong, the outcome does not matter. He said to accept that it isn’t fair and move on.
            We will make more progress by educating I believer than by suing. Yes, I will always have side effects from what happened and it did impair my quality of life even more. And then their is the psych hospital admission on my medical record. Which may well prejudice further care givers. I also am a RN. I worked in critical care and long-term care for a total of 22 years.
            Keep the comments going to the FDA. Educate your doctors and the public. Our side also deserves to be heard.

  10. Dr. Fudin,

    You should write another article on chronic non-cancer pain conditions that are incurable and may require the use of opioids. Another line that the members/supporters of PROP love to parrot is “pain medicines are only masking the symptoms. Pain patients need to cure or treat their condition or cause.” Apparently, A lot of PROP supporters think most diseases can be cured, yet they never offer one. They love to portray pain management doctors who do prescribe opioid pain medicines as being stupid and lazy along with the patients who uses them. It is like they completely ignore the fact that thousands of diseases and conditions have no cure and require palliative care. There is no cure for ankylosing spondylitis ,fibromyalgia ,trigeminal neuralgia, Ehlers–Danlos syndrome and many more agonizing horrific conditions. It is frustrating to see people(especially medical doctors) behave as if every disease or condition can be cured with simple non-opioid treatments, which is obviously false for so many reasons. It is frustrating to see chronic pain patients being portrayed as lazy because they did not try to cure the “root cause,” of a known incurable disease. I don’t why so many medical professionals at PROP seem to believe that humans are invincible and all diseases can be cured if only the “root cause,” is found.

    Some other related lines I see them parroting over and over again are ” Pain patients need to lose weight, do physical therapy, do CBT, and biofeedback. They also need to stop taking opioids because they cause hyperalgesia and increase pain.” As I mentioned previosuly, you cannot use those modalities for a lot of incredibly painful chronic pain conditions. Physical therapy cannot help trigeminal neuralgia or Ehlers-Danlos syndrome. Physical therapy can’t fix lacerated or severely damage nerves. There are a lot of skinny people with chronic pain. Life changing accidents can happen to anyone. Look at cheerleaders and football players. Many of them are fit and suffer irreparable injuries. And hyperalgesia is incredibly rare! If opioid pain medicines cause hyperalgesia, then why do so many patients take them for years and have less pain? Why do so many patients report having long term success and good pain control? The PROPagandists love to act as if opioids will always make CNCP patient’s pain worse and give them an addiction, despite the fact that there is no evidence to support this claim.

    Bottom line, the PROPagandists and their devoted followers love to promote blanket solutions for complex problems and injuries. Many people have tried non-opioid pain medicines before being placed on them. It is disingenuous and cruel to sit there and say they need to do physical therapy or this or that and completely ignore the fact that some conditions can only be treated with opioid pain medicines. And then to threaten to remove the only treatment that works, well that is psychopathic. Only psychopaths enjoy the suffering of innocent people.

    1. Andy,

      Thank you for all your thoughts. There are several links to various articles that do discuss various non-cancer pain issues and the various opioid treatment options. You may want to visit the “RESOURCES” tab on paindr.com, then “SUGGESTED READINGS”. You might also be interested to know that two PROP members (Dr. Roger Chou and Dr. Jane Ballantyne) are authors (with me) and others on the 2009 Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain which is #3 below. Of note, in those guidelines that reviewed over 8000 articles, we identified 200mg of morphine per day as “high dose”, not 100mg per day as suggested by PROP. PROPs proposal is based on 3 observational studies, neither of which were considered as “high quality” by the standards outlined in the 2009 guidelines. And, as per our original response letter from PROMPT, we supported AAPM’s statement, “The [PROP] petitioners cite three large observational studies published in 2010 and 2011 that found a dose-related overdose risk in chronic noncancer pain patients on opioid therapy. Close examination of these studies fails to show evidence that dose alone was the reason for overdose deaths.”

      Here are some for starters:

      Fudin J. Opioid pain management: Balancing risks and benefits. CE program of the University of Connecticut School of Pharmacy and Drug Topics. Drug topics. 2011 September:46-58.

      Zorn KE, Fudin J. Treatment of Neuropathic Pain: the Role of Unique Opioid Agents. Practical Pain Management. 2011 May; 11 (4): 26-33.

      Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P,6 Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O’Connor PG,Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C. FOR THE AMERICAN PAIN SOCIETY–AMERICAN ACADEMY OF PAIN MEDICINE OPIOIDS GUIDELINES PANEL Opioid Treatment Guidelines, Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain, Vol 10, No. 2 (February), 2009: pp 113-130.

      1. Thanks for the links Dr.Fudin. I was aware of some of these articles already. They are great resources. I just wanted to bring up the fact that PROP disseminates and promotes other faulty talking points and dubious claims as well. Referring to all opioid pain medicines as “heroin pills,” is not the only tactic PROP employs to demonize doctors who prescribe opioid pain medicines as well as the pain patients who use them.

  11. Perhaps Kolodny and PROP should disclose their financial backing for such a well coordinated and sustained public relations effort!

    I agree with Mark Barletta that doctors are being frightened into avoiding prescription of any kind of opioids. Using fear to direct medical care is a violation of international human rights treaties.

    When it comes to opioid overdose deaths, there is a better way to limit them and that is to make intranasal naloxone widely available. But PROP doesn’t even talk about that. PROP aims to stop deaths of addicts and recreational users by limiting access to pain patients.

  12. As a physician I swore to an oath to “Do no harm” . The recent statement above stating that there is little difference between the heroine and the hydrocodone molecule conflicts with the moral obligation of a doctor to do no harm. In trying to solve the problem of opioid abuse, as a doctor, it is our moral obligation to tell the whole truth. There is no appropriate place to purposely mislead others who are sincerely trying to find a solution to opioid abuse without huring patients debilitated by pain and are in need of pain control in order to survive each and every day.

    The PROPaganda comment above holds no relevance to the issue at hand. Levo and dextro isomers are molecules that are mirror images of each other, yet can have opposite effects. Most of our human DNA are similar, yet it would be ignorant to say that all humans are the same. A woman who is pregnant has only a few more cells than the week before she was pregnant. To claim that there is little difference between a pregnant and non pregnant woman would be absurd.

    Pain management is so important to the lives of so many patients. It is important as a physician to help and not harm patients who suffer from inadequate pain control. Let us all be completely honest. Not only does lack of pain control hurt patients, but it adversely affects the lives of all the people who love them and who need to be cared for(children of pain patients) by them. Pain from the many complications of EDS has not only forced me to give up my passion to help my patients, but also affects my ability to interact with those who love me. It is truly disheartening to find any physician purposely trying to make my family’s lives even more challenging. It is hard for a child to see their parent suffer in pain.

    In light of recent discussions, another issue for me is that every doctor appointment is a major undertaking for me. It takes much time, causes much pain and causes much fatigue for days after the appointment. It would be horrific to add more appointments to my schedule in order to obtain necessary pain prescriptions. I do not want to have to take extra medicine to be forced to go to extra appointments in order to fill prescriptions my physician already knows I need. There is no cure for my genetic disease. Many injuries cannot be fixed. It will also be a shameful a waste of medical care dollars and my physician’s time.

    1. How true “Physician disabled by Ehlers-Danlos”. Putting this in even more perspective, dextromethorphan (DM) that is an over the counter cough suppressant retains that activity but has almost non-existent analgesic properties at recommended doses. The LEVO isomer, which chemically is identical but the mirror image is a very potent opioid analgesic called levorpahnol.

    1. Thank you for posting that link. She’s got it right, indeed! And another thought…. The article mentions that Dr. Kolodny says PROP’s intent has been misrepresented, and that they don’t intend to interfere with the care of legitimate pain patients….. What PLANET is that man on? These proposed policy changes will ONLY affect the needs of legitimate pain patients. He is just NOT paying attention!

      1. Nancy,
        I was wondering the same thing, I would like to know what exactly Dr. Kolodny means by saying PROP’s intent has been “misinterpreted” and they do not want to see legitimate access reduced.*
        I think it’s a bit late now, or is it Dr. Kolodny is having second thoughts with the mess he has created. First he said “It will lead to less people becoming addicted, which is the most important thing that needs to happen to bring this crisis under control.” PROP has petitioned the FDA to tighten the official labeling on opioids, which critics say would result in even more severe restrictions. Well that’s what happens to people who abuse pain medications they become addicts and need professional help after all this is Dr. Kolodny’s job to treat people abusing the very same medications that keep chronic pain sufferers from being paralyzed by chronic pain. Seems Dr. Kolodny wants to make all these new recommendations and restrictions to opioids for the public but doesn’t want to be responsible for the ultimate outcome of the suffering it will cause real people that suffer from chronic intractable pain. Seems he is talking out of both sides of his mouth.

      2. Clearly, Kolodny is trying to publicly diminish the consequences of his petition if it should succeed. It seems like he is an expert at finding loopholes. According to Kolodny, pain patients will be “safe,” because only the label/indications will be changed. So, pain patients will have to take their medicines “off label.” That is all fine and dandy, until you realize a lot of health insurance plans and programs will not cover “off label” medicines, especially if they are expensive (which most extended release pain medicines are). Kolodny seems to be getting a lot of help and support from companies that provide workers’ compensation. Gee, I wonder why? And I wonder, is that where some of the financing for PROP is originating from? The PROP petition is essentially an indirect way for PROP to effectively ban opioids for chronic non-cancer pain while maintaining that they are not responsible for the horrific consequences and ruined lives that the ban will cause. It seems like PROP has very high hopes that they can have their cake and eat it too.

        I liken Dr. Kolodny’s stance on much of this to the very patients he most likely treats. Most noticeably, he is blaming everyone and everything for social problems related to opioids just like an people who have substnance abuse issues with alcohol or drugs and can’t see the whole picture.

        First, it is the fault of the pharmaceutical companies for “improperly marketing opioid pain medicines.” Second, it is the pharmaceutical companies fault for having the audacity to even make pain medicines. Third, it is the prescribing physicians fault because they cared enough to prescribe a medicines that works for their patient. Fourth, it is the physicians fault for not “understating how dangerous and addictive opioid pain medicines are.” Fifth, it is the prescribing physicians fault for not finding and curing the “root cause,” of the pain (despite the fact many diseases/conditions have no cure and sometimes no known treatment). Sixth, then it’s the patients fault for filling a medicine that could be accidentally diverted, lost, or stolen. Seventh, it is the patients fault because they “want to mask the symptoms.”

        It is becoming ridiculous. Why are the drug addicts never blamed? Why does PROP blame the medicines and not the addicts? Does PROP not believe in personal responsibility at all? Does PROP have some weird philosophy about choices, consequences, and causality? NewFlash PROP! Pain medicines are inanimate objects. Pain medicines don’t force themselves down an unwilling persons throat. They don’t crush themselves and fly up people’s noses. You would think some of the PROP doctors would be intelligent enough to realize this since they went to medical school.

  13. It seems to me that there is a fundamental conflict between this type of advocacy and the arguments that go with it, and the core of America’s “pull yourself up by the boot straps, and be all you can be” philosophy.

    For many patients with chronic, incurable conditions (including myself; I suffer from Ehlers-Danlos Syndrome), properly medicated pain is the difference between living a productive life and being completely disabled. Having spent >10 years obtaining an elite education, only to be diagnosed with this disease, I hardly think it makes sense for me to sit at home, in agonizing pain, contributing nothing to society, when, by being properly medicated, I hold a job, pay taxes, and am a productive citizen. Is it really worthwhile to throw up barriers to my getting the medications I need, and make it even harder for me, as a professional with a disability, to manage a demanding and productive life? I can’t see how that would be the case.

    The chemical fallacy Dr. Kolodny cites hardly dignifies response; suffice it to say that with a PhD in Immunology I have the basics of chemistry more or less under my belt, and the statement made me laugh out loud. As previous posters have pointed out, very minor changes in biochemistry can result in enormous changes in the action of the compound or organism in question.

    Aside from all of this, I couldn’t agree more that this represents a complete lack of humanity and empathy towards the patients and doctors affected by the proposed changes. Being in pain severe enough to warrant medication with prescription drugs, and often having spent years seeking a diagnosis and medical support, not to mention being afflicted with whatever underlying condition is causing the pain, would seem to be punishment enough. Being treated like a criminal adds insult to injury, and seems unlikely to have any real effect (hence the complete and utter lack of scientific evidence to support the proposed changes).

    1. I agree with you completely. I cannot believe how short-sighted and dangerously ignorant the supporters/members of PROP are. There are at least 100 million people in the United States who suffer from chronic pain. A significant number of them control it with some type of opioid pain medicine. We already know that PROP is callous and vicious enough to destroy and decimate the lives of pain patients, but I wonder if PROP has truly considered the very dangerous unintended consequences they could cause for everybody else as well or if they are blinded by their foolish ambition. Has PROP considered that the United States loses over $600 billion dollars a year due to chronic pain? We lose $600 billion dollars a year and that is with having access to the proper medicines. That figure could easily double or triple if PROP had their way. I think it may be enough to cause an economic depression. Has PROP considered how many families they will ruin? Chronic pain is a family affair. How will family units remain intact when the person with chronic pain will be in bed all day crying? How will families feel when loved ones commit suicide because of the pain?

      1. And they are doing all this to save a bunch of junkies! I don’t get the: screw the law abiding pain patient in order to save the criminal drug addict philosophy they have? I understand that drug addiction ruins lives and destroys families but am I the only one who noticed that the drop in heroin use happened at the exact same time that the rise in opioid pain medicine abuse occurred? These addicts are just going to go right back to heroin! Obviously more Methadone clinics need to be opened in rural areas to help combat this epidemic. No one wants a methadone clinic in their neighborhood but they want their children to stop getting high! I think that more methadone clinics in the suburbs (where all of these middle class addicts live) along with psychiatric treatment of addiction would do a far better job of cleaning this mess up then making it harder for pain patients to get their medicines. A drug addict will get high on whatever they can so if you take away the pills they will find something far more dangerous to get into.

        1. Tom,

          To be fair, and I think that Dr. Kolodny would agree with this, perhaps we should be looking more to get some of these folks on buprenorphine instead of methadone. If Dr. Kolodny is inclined to comment here in that regard, I would welcome it.

  14. Thank you for your advocacy. This is just crazy. We legitimate pain patients are have got to make a point to make our voices heard. It is far too easy for people who have never dealt with chronic pain to just assume that we just want the drugs to be relaxed or whatever – nothing could be farther from the truth – we need the medication simply to have some level of a quality of life – period, full stop.

    I would have been in favor of drug testing too for we pain patients- until I heard the story of a fellow EDS patient who was stripped of all her pain medications and thrown into the psych ward- because of a LAB ERROR. So that too is not the blanket policy answer. Labs are going to be right most of the time. But not always. They are run by humans.

    At any rate- if you’re reading this, and someone you care about or you yourself are a pain patient, you better sit up take notice and make your voice heard. As they said back in the day – YOUR SILENCE WILL NOT PROTECT YOU.

    You might think it’s too inhumane to take pain meds away from people who need them – think again.

  15. On January 18, 2013 I went to battle along with another family member. We were trying desperately to obtain the strongest pain medications we could get from doctors. Those would be the same so called doctors who have treated my brother for stage 4 Colin cancer, liver cancer and skin cancer. After colon surgery, liver resection surgery, painful skin procedures digging out the cancer and leaving spoon size opening in his skull and rounds of chemo he was given Tramodal and valium. The Tramodal isn’t working. why would you give someone with 50% of his liver gone 360 Tramodal pills monthly? We finally were referred to a local doctor, a compassionate beautiful doctor who has prescribed medication so my brother has some relief. What is happening in this country?

  16. I’ve been holding this in for some time now and well I wasn’t going to say it, but here it goes.

    Pain patients including myself have had to read about Dr. Kolodny’s mission constantly for months. His incessant behavior on Twitter, blog posts, Internet, and printed media have been most aggravating to me and others throughout the country on a sometimes daily basis. We are scared, panicked, aggravated, and feel cheated by the medical establishment.

    This has not just affected patients. It has disrupted the lives of busy clinicians that are fearful of writing opioids when previously they were either comfortable doing it or teetering on the edge but still treated appropriate chronic pain patients. I believe that what many of us have spent in time and travel (from doctor to doctor and pharmacy to pharmacy, plus all the sleepless nights), many kind-hearted physicians and administrators have spent an equal amount of time writing, blogging, interviewing, and traveling to Washington or Bethesda to visit with the FDA.

    It is uncanny that one person (or a few people that are PROP members) could have such a disruption on so many lives. It sickens me to think of all the people that have been affected up until now, regardless of the eventual outcome of the regulations.

    Anyone can start a Citizens Petition and ask for change in the way opioids are prescribed but must we even take into consideration such utter abusive disregard for the sick and suffering people of the United States of America. Why should we, the suffering people of the U.S. even consider striking moderate chronic pain from being treated in a proper way?

    Why should we that suffer from chronic pain even take in to consideration that a psychiatrist practicing behavior health such as Dr. Kolodny thinks 100 mgs of morphine is enough for all suffering persons (with few exceptions) such that a law should be written to match his personal agenda. It has been stated by many medical providers across several medical specialties on blogs, in the media, and by submissions to the FDA that he and PROP are mistaken. Many have said that there is not a hard and fast equivalent to morphine and that even medical doctors haven’t completely determined the exact equivalent, and may never determine that equivalent because of biological differences between patients. I am not a medical doctor or pharmacist, but it is very clear to me and others that are not encapsulated in PROPs microcosm.

    What is this thing about 90 days being the set number of days for the treatment of chronic pain when chronic intractable pain comes with a lifetime guarantee? I read a post somewhere from Dr. Fudin that asked the question about if 90 days really means 90 days, or the doctor will need to begin a taper weeks before the 90 days to prevent withdrawal. This just is not very well thought out!

    Suboxone, a medication increasingly being used to treat addiction to opioid drugs – both legal and illegal – is sending ten times as many people to hospital emergency rooms.

    Dr. Kolodny said. “We need to do a much better job of expanding access to Suboxone. If there was better access to doctors who know how to prescribe Suboxone responsibly, I think we’d see less people buying it on the street.” Dr. Kolodny has been a leading advocate of Suboxone to treat people who abuse pain medications meant to treat those that suffer from chronic pain.

    I read up on Suboxone and asked some medical doctors and pharmacists about it. I learned that it does have an opiate blocking effect as well as a positive effect to curtail opiate craving and treat pain…good drug right? Yes, probably is, but with that blocking effect also comes a plateau of how much pain you can treat with it if one were to prescribe it for pain. So, unlike regular opiates that may have an increased benefit to combat pain as doses approach or exceed 100mg of morphine or equivalent, buprenorphine will stop working at some point in time when it’s blocking effect kicks in. Again, I’m not a medical doctor or pharmacist, but I can read and I do understand, oh, and yes, I can do all this while taking opiates and functioning. Apparently some of the people pushing for these changes without scientific evidence are less capable of thinking this through while not taking opiates and with a science background to boot. In any case, it will be a sad day if the PROP petition gets through the FDA. I’m hoping that they can see through all this and help protect the patients with more reasonable alternatives.

    1. I completely agree with you. I have to say “Bravo!” for standing up and saying what you said. Those of us with chronic pain need help managing it and we can’t have our ability to get the medicines that help us restricted even more than they are. I applaud your comment.

  17. Someone posted your blog on the inspire EDS page. I am terrified that I will not have access to the medicines I need to control pain. There needs to be a better solution regulating those of us that actually need the Rx and what type and abusers. Maybe like gun control…I don’t know. But just like eliminating guns completely…it doesn’t make sense. Hold patients accountable.
    Give us drug tests. Whatever…clearly those of us that need it won’t mind regulation. Right now I have a GP, a Pain Doc and a Rhuemy that are all hesitant to prescribe any narcotics because of what ever broken legislation, rules and regulation are in place now. They all would rather someone else manage the pain. It would make sense for the ‘ pain doc’ to do that…but they like to do procedures injections….etc it pays so much more than writing a Rx that you may get heckled for. Don’t force those of us in chronic pain that have never so much as smoked a cigarette let alone abused Rx go to Methadone clinics for relief. We are zebras–we can’t be treated like horses. Believe me, I would give up my pain meds for a week to be pain free for a day. They only take the edge off and enable me to function as a full time employee, wife and mom. Would they rather us be on SSDI? Or simply help is control our true pain.
    Thank you for your time,

    Sheila
    Ehlers-Danlos Syndrome Patient

    1. I think I do mind mandatory drug testing for chronic pain patients – I’ve heard too many horror stories about chronic pain patients having false negatives or false positives and being cut off and sent into withdrawal, or patients without insurance (who had been paying out of pocket) being told that they need to pay hundreds of dollars more every month to cover new drug tests.

      Drug testing also makes me nervous because of the current incomplete understanding of opioid metabolism. For example, we’re just starting to learn about the genetic variations in how these drugs are processed. How will drug testing account for those differences? How many doctors even know how to interpret the results?

      I think that actually implementing electronic prescription monitoring would be a great idea (as long as there are safeguards in place to protect patient privacy). Pill counts also seem less invasive, risky, and expensive than widespread drug testing.

      1. Rebecca; You bring up all very excellent points! I am in favor of drugs tests, but there is much validity to your counter arguments, perhaps the most important of which are biological differences and the knowledge of how to interpret the tests. The only thing I don’t agree with totally are “pill counts”. In this day of cell phones, texting, and Tweeting, it’s too easy for someone shady to get the tablets they need. I don’t mean to disrespect honest chronic pain patients needing opioids, but I do intend to help them by sorting out those that divert drugs. It seems that pretty much all the folks I’ve communicated with on here want to see that too. The problem of course is that it costs all of us money personally, and in insurance premiums and taxes. There just are no simple answers, but your comments were very insightful. Thank you!

        1. Thank you! I do think that there are ways to implement mandatory drug screening that would protect honest patients and account for my concerns. However, the ways I see it being implemented so far do not inspire much confidence. Call me cynical…

          Just to clarify, are you saying that pill counts are helpful because they prevent people from being careless with their meds, or that they are not helpful because it’s too easy to “beat” a pill count?

        2. I agree 100% with you. Anyone who so much as gives one pill away does not deserve to have their prescriptions at all. These are the people who are contributing to the problem. I am on 1 opioid medicine in which I take 2 tablets 3 times a day. I have been doing exactly that for 4 years now on the same dose. People get the “high” which is a side effect confused with the pain relief which is the effect and that is a huge problem in our country. People need to be educated before going into pain management that the “high” is a side effect that will go away in a week or two and to look for the effect which is the pain control. My pain level is a 2 or 3 and I think that is wonderful since without the medicine I am a 7 to 9.5 (I never use 10. I think that number should be reserved for deadly pain only) For instance my last 10 was when my hip replacement popped out of placed while being infected and my upper thigh was swollen to 3 times is normal size. When I was getting into the back seat of my moms car to go to the hospital I had to grab the headrest and slide myself into the back seat. It hurt so bad that I vomited. That was a 10! That is why I save the “10” for those type of situations. I dislike when people call a “5” a “12” because they think the doctor will help them quicker. I think honesty in pain rating is more respected by doctors during a hospital stay then always screaming “10”!

  18. Dr. Fudin,
    I am surprised you are writing an article about this now. Every group that is opposed to opioid pain medicines for chronic non-cancer pain and even some that oppose them altogether constantly state the generic banal and patently false lines “Opioids are heroin pills,” or “Opioids work just like heroin and everybody becomes addicted to them.” It is maddening and frustrating beyond belief. I find it especially appalling and egregious that men like Andrew Kolodny and Pete Jackson who have science degrees actively promote this idea, even though it is scientifically false.

    Referring to opioid pain medicines as “heroin pills,” is just another tactic that anti- pain medicine extremists use to demonize opioid pain medicines and the patients who use them. The term “heroin pill,” was clearly created to demonize pain management doctors and pharmaceutical companies while deflecting attention away from drug abusers/addicts. The term “heroin pill,” was also intentionally created to reverse who is responsible for when a person overdoses. It removes blame from the addict/abuser and places it on the doctor and pharmaceutical company. I often see people writing things like ” Oh he/she was prescribed an opioid and didn’t know it was a heroin pill. The doctor and pharmaceutical company did tell he/she so he/she overdosed.”

    Here is an article and prime example of all opioids being called heroin:
    http://www.rxreform.org/prescription-opioids/similarities-to-heroin/

  19. “PROPaganda” is right. It’s impressive how much media attention they’ve garnered, and how they’ve managed to control the conversation. Patients like me who use opioids to help manage chronic pain already face enough stigma, and these statements comparing hydrocodone to heroin are only going to make it worse.

    I do have to wonder if it was an intentionally misleading oversimplification, or if Dr. Kolodny actually believes that hydrocodone and heroin are comparable. It feels like a political spin on what should be a medical conversation, if that makes sense?

    Anyway, thank you for all your work in support of (rational) pain management!

    1. I would compare 60 – 5mg Hydrocodone tablets to $10 worth of heroin. That is the truth in the matter. Oh, and the 30,000mgs of acetaminophen that go along with those 60 Hydrocodones would probably kill a heroin addict. So this comparison is useless and just utter nonsense. I grew up in Baltimore and heroin took a lot of my close friends from me. Not all from death but a lot are in prison on the 3rd strike felony law (automatic 10 to 15 years in prison), no longer able to be around or trust, heroin addicts stick together so if your not one you are not in their circle, try to borrow money, etc… I have a best friend from childhood that got 11 years and my cousin just got 10 years in prison. All from criminal acts such as theft and burglary to get money for dope. It is sad. But people in pain should not have to pay for their crimes.

  20. I agree, he thinks we are all stupid! Great write up Dr. Fudin!!! AK thinks all chronic pain patients should suffer. This was another opinion of him that I read in an article..Hope you are ready to blast him down at the FDA meeting..

  21. PROP and their advocates need to leave legitimate patients who are in chronic pain, being treated with opiates alone. Their agenda will result in suffering and inability for many legitimate people to obtain medications that otherwise allow us to get out of bed in the mornings and try to live some semblance of a life. If my medications were to be taken away, I would be bed ridden in agonizing pain. Injections have done nothing to help me, they have cost money and injured me, causing more harm and no good what-so-ever. PROP would probably tell me to take Advil or go have more physical therapy, neither of which have been helpful for me. People need to know that PROP will do more harm than good and need to be stopped!

  22. Dr. Kolodny really does think people are dumb….

    Well, he should know THIS. As long as opioids like Hydocodone are still available and accessible to patients who suffer from serious pain conditions, they won’t need to use those oh-so-similar Heroin molecules for pain relief.

    PROP-aganda at its finest!

    Nancy

    1. Thank you, we need to stop PROP!

      There are alternative solutions.

      It’s all based on “media hype”, grieving parents, and many many misguided “facts” right now.

      Prop supporters don’t even realize that this will cause human beings to be treated less humanely, than we choose to treat animals in this country.

      PROP supporters are attacking the weakest of society, those that are already suffering. Many are disabled or retired. They want these people in society to suffer more than they already do, to protect individuals that knowingly do wrong by choice & don’t want their “help”.

      Since when have we become a society that protects the criminal, and punishes the innocent.

      The people taking medication that doesn’t belong to them, don’t want PROP protection, they want the drugs. One way or another they will find them, if they want them. They will not be protected by PROP. Odds are the drugs they will be taking will be much more dangerous, because they will come from the streets. Then who will PROP supporters blame.

      Again, thank you

  23. And, as long as we are making silly arguments, the DNA of a chimpanzee is far almost identical to the DNA of a human being. Just a few thousand base pairs out of tens of millions.

  24. There is very, very little difference between a water molecule and a hydrogen peroxide molecule, just one tiny little hydrogen atom. There is even less of a difference between a hydrogen atom and a deuterium atom, just one tiny little neutron.

    And yet, there is a world of difference between H2O and HO, and deuterium is radioactive and hydrogen is not.

    What a ridiculous argument PROP makes.

  25. Kolodny obviously does not have the same chemistry background or at least wasn’t clear, and was misleading; why is he allowed to give his opinion in such matters??!!

    1. Some would argue that is problem with America. Too many ill informed people are giving bad advice (i.e all opioids are heroin and work in exactly the same way) and people mistake the opinions of idiots’ for facts.

    2. Yes Ms. Andreasen…You are correct!

      From his site at his teaching institution:

      “Dr. Kolodny is the Chair of Psychiatry at Maimonides Medical Center in Brooklyn, NY. Board certified in Psychiatry and Addiction Medicine, Dr. Kolodny is a national expert on the opioid addiction epidemic. In his clinical practice, he specializes in the treatment of opioid addiction.

      Dr. Kolodny has a long-standing interest in public health and community psychiatry. He is currently President of Physicians for Responsible Opioid Prescribing (PROP) and was previously the Medical Director for Special Projects in the Office of the Executive Deputy Commissioner for the New York City Department of Health and Mental Hygiene. For New York City, he helped develop and implement multiple programs to improve the health of New Yorkers and save lives, including city-wide buprenorphine programs, naloxone overdose prevention programs and emergency room-based screening, brief intervention and referral to treatment (SBIRT) programs for drug and alcohol misuse.”

      SO HE SHOULD KNOW BETTER! HE SHOULD KNOW AT LEAST AS MUCH AS DR. FUDIN ABOUT BUPRENORPHINE!

      HOW? WHY? …THERE SEEM TO BE DEEPER AND LESS ALTRUISTIC MOTIVES WHICH LURK WITHIN THOSE WHO OPPOSE OPIOIDS….

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