Politicians Bamboozle Constituents & Neglect Real Issue of Opioid Risk Mitigation

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…and all this simply to win favor by using the “opioid epidemic” and innocent bystanders.  As the media blitz continues on opioids with the latest focus on Zohydro, politicians thrive on avoiding truthful balance despite clinician voices and legitimate patients in need of opioid therapy.  The real crisis is that innocent patients in pain are not receiving needed care and are unable to fill prescriptions, and that clinicians caring for them are scared to death to write prescriptions or feel compelled to lower dosages because they fear regulatory agency scrutiny mostly at the state level.

An April 23rd Boston Globe article, Mass. limits use of the potent painkiller Zohydro should strike a nerve for anybody that is really in the know as outlined in the blog, Zohydro: Truth or Dare.  Zohydro (hydrocodone extended release) is of course not that potent as suggested in the Boston Globe story title, compared to many marketed opioids, but hey, the title is a grabber to voters and readers, right?  Truth be told, hydrocodone is less potent than oxycodone, oxymorphone, hydromorphone, fentanyl, and others.  I haven’t heard a single politician admit that or even discuss it – don’t you think journalists should ask these important questions?

According to Valencia’s Boston Globe article linked above, “Saying the state faces a continuing public health crisis, Governor Deval Patrick’s administration imposed sweeping restrictions Tuesday on prescribing the powerful painkiller Zohydro, just before a ban on the controversial drug was set to expire.” But at the same time, Patrick is ignoring the other marketed and readily available drugs listed above.

The article goes on to say that when prescribing Zohydro, Massachusetts “…would require prescribers to complete a risk assessment and pain management treatment agreement with patients before prescribing the drug. The agreement would require drug screening and monitoring of the number of pills prescribed, among other conditions the prescriber may find necessary.

“The prescriber would also be required under a state executive order to participate in the Prescription Monitoring Program, which would monitor the number of times the drug is prescribed, a measure designed to detect misuse.”

Interestingly, about three weeks earlier, CBS News ran a story stating “Vermont Gov. Peter Shumlin announced an emergency order that would make it harder for doctors to prescribe Zohydro…”.   It continues, “What puzzles all of us is the recent FDA action to approve a new opiate that’s stronger and likely to be even more addictive because of its strength, Shumlin said.” As pointed out in a recent blog here, hydrocodone cannot be stronger than hydrocodone, certainly hydrocodone is not more addicting than hydrocodone, but thanks for the poor pharmacology lesson Governor! And to further clarify Shumlin’s incorrect statements, hydrocodone is not new, see blog blasting New York’s Senator Schumer on January 13, 2013 when he too incorrectly gave a pharmacology lesson to constituents and journalists ostensibly to gain favor when speaking out about hydrocodone extended release months prior to it’s FDA approval.

Vermont’s restrictions on Zohydro include the following:

  • Conduct and document a thorough medical evaluation;
  • Conduct and document a Risk Assessment;
  • Document in the medical record that the prescription of a hydrocodone without an abuse-deterrent formulation (ADF) is required for the management of pain (i.e. nothing else will effectively manage the severe pain);
    Why isn’t this mandated for all other non-ADF drugs Governor?  [See this blog outlining all the other extended release opioids that are non-ADF.]
  • Receive a signed Informed Consent form including information from the drug insert;
  • Receive a Chronic Controlled Substance Treatment Agreement that shall include conditions such asurine screening, pill counts, safe storage and disposal, andother appropriate conditions as determined by the prescriber;
  • Query the Vermont Prescription Monitoring System;
  • Determine a maximum daily dose, or a “not to exceed value” for the prescription to be transmitted to the pharmacy; and [Governor, this is already covered in federal regulations]
  • Schedule and undertake periodic follow-up visits and evaluations and referrals.

GIVE ME A BREAK!  These are not restrictions,these are good medical practices taken right from any reputable published opioid guideline.  But thank you Governor Shumlin for taking credit for the work of several pain colleagues and yours truly.

The real truth is that these politicians and the journalists who continue to get it wrong are not leaders, they are followers.  The politicians are either truly ignorant to the facts or they are seeking popularity and votes.  The journalists – well, what can I say?  Few have stuck their neck out to tell the unbiased fairly balanced truth.

Lawmakers and educators need to combat flippant prescribing practices and perhaps consider legislation to mitigate such carelessness.  Within the last several months, a close relative was prescribed #30 Lortabs 5/325 by a dental surgeon following a dental procedure of 3 molar extractions.  Instead (s)he took COX-2 specific NSAIDs prior to the procedure and religiously following the procedure – (s)he was eating dinner the same day and never took a single Lortab.  The same relative was evaluated for an unrelated “potential” maxillofacial surgery by an otolaryngologist just days ago.  Upon evaluation, (s)he was handed a prescription for #40 Percocet 5/325 “in case she had the surgery” – needless to say, this was not filled.  Had these prescriptions been filled, and had they found their way into the wrong hands, they could have been the last item ingested by an unsuspecting teen prior to death – this is what grieving parents that have fallen victim to losing a child from opioid addiction should be focusing on, not whether or not Zohydro makes it to market or stays on the market.  As pointed out in a previous blog, drug seekers will simply seek another drug in a “whack-a-mole” fashion as certain ones become less easily obtainable.  But teens or others that were inadvertently hooked on opioids because of poor prescribing practices and equally poor monitoring could be saved if clinicians were smarter about prescribing.

In closing, I call attention to the bold-typed, underlined print above, because the real issue is “Universal Precautions” when prescribing all opioids in an effort to mitigate risk – it’s not just about Zohydro.  These highlighted items are precautions that ALL clinicians should do ANY time a patient is placed on ANY chronic opioid therapy, not just Zohydro.  If lawmakers want to do the right thing and have a real impact, they would work with medical/pharmacy boards and state regulatory agencies to require ALL of these things ALL of the time for ALL chronic opioid prescribing.  But, instead the politicians listed herein are focused on the political Zohydro media blitz, and others, for example Senator Manchin of West Virginia, profess to be expert in an area they know nothing about – stop playing doctor.  For the sake of common decency, stop bamboozling your constituents!  Take a lead role with appropriate persons to endorse education for clinicians, encourage risk stratification when prescribing opioids, and engage in proper evaluation and monitoring for all patients that require chronic opioid therapy.

As always, comments are encouraged and met with enthusiasm!

18 thoughts on “Politicians Bamboozle Constituents & Neglect Real Issue of Opioid Risk Mitigation

  1. Thank God all of these politicians went through years of med school, residency, and pain medicine certification, otherwise pain patients might actually get proper care from ACTUAL DOCTORS!! Step out of this arena, lawmakers, and let TRAINED PROFESSIONALS do their jobs!! Chronic pain is a disease, just like diabetes or high blood pressure, but policy-makers wouldn’t dream of trying to demonstrate their knowledge (or lack thereof) regarding medicines that control those illnesses, because the public would be outraged at their pomposity, why are they not being challenged regarding their obvious overstepping into the pain management arena!?

  2. A common theme here is that heroes like Dr Fudin are so rare that his message seldom breaks through to the reporters whose job it is to produce sensationalist stories that sell papers and ad time. Into this void steps PROP, whose jihadists have demonstrated that they have absolutely no scruples about inventing facts and studies that promote their goal of eliminating opioid pain relievers from legal use in the US.

    However, we pain sufferers are not completely powerless. Whenever you spot an objective and humane reporter, offer yourself as the subject of a feature story. I did this back in 2011, resulting in a newspaper report that really resonated among readers and even some elected officials. The link is below. Baby steps like this can accomplish a lot, but YOU must initiate them, particularly since . PROP “experts” say you don’t exist.


  3. The way pain medications and the media is handling uneducated stories should honestly be illegal. I can’t believe that they are allowed to report just anything they dream up and are NOT made to report the FACTS. I agree with everyone here.
    It does seem that, all we say and try to do is falling on deaf ears. For Florida and maybe some other patients from other states?

    Our legal medications are controlling the lives of legitimate pain patients and this shouldn’t happening. For legal patients, they should be getting filled all their medicines at the same time so they can travel when needed, as many used to do. Just head to pharmacy on the 28th day and be refilled and take your trip, but not anymore.. or fill when you need the medicine while on your trip, not anymore. Patients can’t take a vacation or travel anywhere because their Rx’s are refused and won’t be filled out state now because of fear. If it’s not filled in their home state within 5 miles of their homes, how can they go anywhere? This is a civil rights issue as well a human rights issue. Just to have some pain relief? These people have can’t do anything and they wonder why some are depressed?.

    Take me for example.. My medicines are split up by 2 weeks apart for filling because a pharmacy (months ago) claimed they didn’t have both meds in stock and I had to wait 2 WEEKS for second med (bt ) med to be filled. This not including that the next monthly appointment for pain doctor that is somewhere in the middle of all this.. this is taking up the entire month! This is just down right WRONG!! Angry is understatement!

    I really wish that some how hundreds or possibly thousands of patients, perhaps (gathering all pain foundations) and our best doctor supporters that we could get a major news channel to listen to us. Even if we have to bombard them with our stories and the doctors papers on the facts about the medicines. CNN, or one of the major networks.

    FFPCAN is doing ALL we can to get the message about out about awareness to the huge medicine access problems we are experiencing, but we honestly NEED more help!

    I am getting sick of all this and I know all of you are too!
    Does anyone know how we can bring all this together before there is NO more ACCESS?

    A ridiculous mess this is! No doubt…

  4. It’s disheartening to say the least when we see celebrity doctors speaking out against Zohydro before it’s even brought to market. Add to that the politicians running on the platform of drug reform and it’s an uphill battle. Also, to James Patrick Murphy, the group Fight for Florida Pain Care Action Network works tirelessly to bring awareness, through letter writing and telephone campaigns, petitions, and march on Tallahassee. There simply doesn’t seem to be as many chronic pain patients as there are drug reform zealots. Thank you Dr. Fudin for your continued work.

  5. All the extra hoops dictated by government end up costing those who suffer, the most. They bare the brunt of the expense of added drug testing and precious time in red tape scrutiny, both financially and emotionally. Many suffer in silence, not wanting to burden those around them but non-the-less, are searching for some hope for quality of life. We now find ourselves depicted as criminals FIRST and delayed or even flat out refused access to pain medication. It is a sad day when politicians play doctor.

  6. Good post, Jeff, but 2 concerns….

    (1) Urine drug testing is an expensive clinical tool that, used selectively and appropriately, can be helpful; however, many clinicians are still unskilled in interpreting UDT results and use them punitively.

    (2) Informed consent is important and should include conditions for safe use — of ANY medication. However, there is still no solid evidence to confirm that separate opioid-treatment agreements improve patient care.

    1. Thank you Stew! I wholeheartedly agree with both of these points. For your first comment, that is exactly the reason I suggest we need education – these tests must not be used punitively as routine practice, and if interpreted correctly in the case of aberrancy should be used as an opportunity to help the patient receive the needed behavior health interventions or as avenue to mitigate community risk. Regarding costs, the IA tests are not too expensive. The definitive tests without a doubt are more expensive, but compared to a multitude of other routine tests that providers are expected to follow in order to comply with standards of care in other areas, I don’t think this urine monitoring is an unreasonable outlier.

      Regarding point #2, certainly we should provide informed consent for all medications or at least document that the discussion was had. But to the second half of that comment, I believe that although we don’t have solid evidence to support that “agreements” are helpful, it still makes sense to have them for a number of reasons. And in fact, these “agreements” can serve a dual purpose to inform of potential risks and side effects of the prescribed drugs and to lay out the ground rules in this opioid marriage between patient and provider.

      1. By IA tests, I assume you mean the in-office urine tests using immunoassay. Sure, these are convenient, quick, and relatively inexpensive tests, but they also are most prone to inaccurate and/or misleading results that, in the hands of an unskilled clinician, can do more harm than good. As you say… education is of paramount importance.

  7. Its amazing what the media reports that will freak out the public in to doing the strangest of things ,things that would cause more harm and deaths than if the media didn’t say anything at all . This doesn’t have anything to do with opioids but shows you how bad news reporting made the public do things that didn’t have to happen and it led to more deaths and gridlock than I’ve ever seen in my life.
    After the devastation of Hurricane Katrina everyone was in awe of the power of a bad hurricane. New Orleans was worst hit mainly because this city is below sea level.
    Many people died, it was tragic and till this day was the worst hurricane and caused more deaths and damage than any hurricane I’ve ever seen.

    Just three weeks after Hurricane Katrina devastated the northern Gulf Coast, the threat of yet another major hurricane named Rita prompted mass evacuations in coastal Texas. On Wednesday, September 22 ,2005 Houston mayor Bill White urged residents to evacuate the city, telling residents, “Don’t wait; the time for waiting is over,” reminding residents of the disaster in New Orleans. An estimated 2.5 – 3.7 million people fled prior to Rita’s landfall September 25 of 2005, making it the largest evacuation in United States’ history. Rita attained Category 5 hurricane intensity the highest intensity classified on the Saffir–Simpson hurricane wind scale with winds up to 180 mph . Looking at hurricane Rita on the news it filled the entire Gulf of Mexico and was headed straight towards the Houston – Galveston area on September 22 , 2005. I got caught up in this evacuation with my brother and his family and it took us 24 hours to drive from Houston to Dallas that’s usually a 4 hour drive. The things I saw where amazing ,cars over heating, people running out of gas and panicking. The chronic pain I had in my cervical spine got so far out of control from sitting for so long I thought I was going to lose my mind. I had to step out of my brothers SUV and walk beside his vehicle on the Hwy 45 just to stay sane. Cars where lined up for miles on Interstate 45 going north. We moved 10 feet every couple of seconds so I walked behind his SUV and made sandwiches for my brothers two kids and 3 other adults. The combination of severe gridlock and excessive heat led to between 90 and 118 deaths even before the storm arrived. Reports from the Houston Chronicle indicated 107 evacuation-related fatalities. Deaths attributed to heat stress were a combination of hyperthermia and chronic health conditions. Then if that wasn’t bad enough we watched in horror as a bas of senior citizens caught fire, 23 nursing home evacuees were killed on this bus on Interstate 45 near Wilmer, TX. The bus erupted into flames after the vehicle’s rear axle overheated, due to insufficient lubrication, and ignited oxygen tanks on board. I heard three explosions , I couldn’t get anywhere near that buss the heat was so intense. After all of that evacuation on September 25 hurricane Rita made landfall in extreme southwestern Louisiana between Johnson Bayou and Sabine Pass. So we evacuated for no good reason because of media hype.

    Now the news media and senators and whoever is making everyone panic over this Zohydro and its so ridiculous. Please get your facts straight before reporting news that’s not true.
    Blocking Zohydro from being sold in any state is not going to fix anything but make things worse just like that darn evacuation we went through for no good reason.
    Innocent people died for no reason other than trying to escape a hurricane that missed Houston – Galveston area by a long shot. My God that was a nightmare I will never forget.

  8. You might need to give a pharmacology lesson to the DEA, too. Apparently, at the recent Rx Drug Abuse Summit, Joe Rannazzisi, head of the DEA Diversion Division (and trained as a pharmacist) stated that hydrocodone is 1.5 times as potent as morphine, and equivalent to oxycodone.

  9. Jeffrey, as usual you are a champion for the millions of chronic pain sufferers in America. But I’m afraid voices like yours and mine will be no more than static unless the collective voices of the deserving people we serve come together in harmony and send a loud message.

    1. Well my friend Pat, let’s hope that happens some time soon! At least opioids are on the radar – now if we can shift that radar to focus on the right issues, perhaps there will be a light at the end of the tunnel. If either of us thought there was no hope, I’m certain we’d be spending more time with our families and vacationing in a warmer climate.

    2. Dr. Murphy,

      We are trying to get things going on this issue. Last Thursday, the page’s cofounder, Sheila Kim Purcell, received a call from NBC Nightly News about the Opposition Page. They knew my name and said they we’re informed of our page when looking for people to speak to as a follow up to their week long series on heroin. Waiting on a follow up call, let’s hope it happens. I am anxious to speak for chronic pain patients and welcome the opportunity.

      Kim Miller, US Pain Ambassador

    3. People have sent loud messages repeatedly. What has been done? Shioban Reynolds. Has anyone heard of her? If not, check it out. Oh, and her website she founded, painreliefnetwork was shutdown by the government. And as for Shioban Reynolds (RIP).

        1. For your readers… Siobhan Reynolds was a champion for patients right to adequate treatment for chronic pain. She also defended Physician’s right to prescribe medications for that treatment. When she got in the way of the prosecution of one of these physicians, by Assistant US Persecutor Tanya Treadway, she was made to defend herself for her right to free speech. This exhausted her personal funds as well as that of the Pain Relief Network. Now, no one dares to stand up for our rights. Unless they face prosecution, jail or death. She has been silenced. How dare Murphy ask us to rise in a collective voice. Nothin’ doing.

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