Despite blistering cold winds, the
#RALLYAGAINSTPAIN in Washington DC held at the Ellipse on the National Mall area across from the White House was a success. The real heroes were the patients and their significant others that showed up from all corners of the US Map, from as far west as California all the way to Buffalo NY, Cincinatti OH, Richmond VI, and more. To think that these folks with daily severe chronic pain could even make this trek was an amazing feat. And guess what?!?! I didn’t see a single governor, senator, congressman, or lawmaker. But, I am not surprised, because reality doesn’t bring media attention, votes, or revenue. And while I understand Congress isn’t in session, there were plenty of folks around, including CDC affiliates that were contacted and could have come. #OutofSiteOutOfMind.
I was honored for the opportunity to deliver an invited speech as one of several advocates, some of whom called in and had their voices amplified. By popular request, below is a copy of the speech I gave at the Ellipse today, October 22, 2016.
Two hundred and forty-one (241) years ago and 100 miles southwest of here, Patrick Henry said “give Me Liberty or Give Me Death”. Many victims gathered here today are contemplating death, others that have not made it here have chosen death, and all because they have been stripped of their liberty.
My name is Dr. Jeffrey Fudin. I am a Clinical Pharmacist from Upstate NY. I’m delighted to be here today and I thank all of you for the opportunity to speak and advocate for patients that live daily with unrelenting physical and emotional pain, at least in part due to inadequate treatment resources and political rhetoric nationwide. I am disappointed that in our United States of America, it has actually come to this – that aching patients have to rally in this great nation’s Capitol to provide a much needed voice that heretofore has essentially fallen on deaf ears.
What makes this even more disheartening and personal for me is that I’ve cared for US Veterans for over 3 decades, the very people who made personal sacrifices to ensure our citizens are treated fairly and respectfully. And I want to remind all of us; citizens, lawmakers, politicians, and the media of our much cherished document which freed us as a nation of people, the Declaration of Independence that states; “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”
Victims here today, suffering from pain day in and day out, and those caregivers that love them have been stripped of these coveted unalienable rights and in fact been ALIENATED if their pain treatment requires chronic opioid therapy.
Many here today have lost their independence…
They have NO LIFE to speak of
They have NO LIBERTY because they are captivated by pain
and any hope for pursuit of HAPPINESS has vanished.
In 1993, Dr. Ted Knox and colleagues demonstrated that Hispanics were about half as likely as Caucasians to receive pain medications for bone fractures of equal severity and that prescriptions for opioids to treat related pain was markedly disparate based upon race/ethnicity. Yet here we are today with some ironic equality – that is, regardless of skin color, when it comes to pain management, patients are treated equally poorly throughout this great nation.
Although access to opioid therapy is thought by many to be a civil right, there is a double-edged sword, because as a clinician involved in prescribing such medications, it also needs to be a privilege to ensure safety of patients and the community in which they live. Here within lies perhaps the most disregarded piece of the puzzle. That is, the majority of clinicians prescribing opioids do not have the education, time, or wherewithal to safely assess, document, and monitor these therapies. And those that do, have been largely intimidated by the recent CDC Guidelines, insurance companies, the media, and state regulatory agencies.
Some may argue that state bureaus of narcotic agencies do not or have not harassed their constituent physicians. I know differently. How do I know? Because each week I receive countless emails and telephone inquiries from attorneys, physicians and other healthcare providers with prescriptive privileges where their state has accused them of wrongdoing simply because names surfaced on a data report that indicated certain patients exceeded a predetermined daily morphine equivalent dose.
For any lawmakers or media persons out there today, I challenge you to provide any universally accepted morphine daily equivalent, a number that presumably could equate one opioid dose to another, such as oxycodone or hydrocodone or methadone, that is essentially equivalent to morphine. THERE IS NONE – and if you don’t believe me, get the presidential debate fact-checkers to help you out. I’m not saying that we can’t make an estimate, but what I am saying is that such an equivalent in not perfect and ignores patient individuality. In fact, almost two years ago, President Obama had the acumen to support precision medicine launching “an innovative approach to disease prevention and treatment that takes into account individual differences in people’s genes, environments, and lifestyles”.
To assume that opioid dosing is a one-size fits all (See One Size Opioid Dose Does Not Fit All to learn more), and to harass clinicians into squeezing their patients into such a mold, and to allow insurance providers to dictate doses is flat wrong and based on pseudoscience. This is clearly outlined in a recent publication in the Journal of Pain Research entitled, The MEDD (morphine equivalent daily dose) myth: the impact of pseudoscience on pain research and prescribing-guideline development.
I’m a doctor of pharmacy, and I well understand that this gathering cannot and should not be about opioids alone. It’s about what’s right and wrong medically, and about the needs of our citizens. It’s about access to good medical care, mandatory education by QUALIFIED teachers in colleges of medicine, pharmacy, nursing, and the like. It’s not about 1-3 hours of mandatory continuing education for prescribers – that clearly is inadequate. It’s also about including the biopsychosocial aspects of treatment into a comprehensive treatment model that encompasses physical rehabilitation, behavior modification, and yes, APPROPRIATE ACCESS to medication when clinically indicated. And, our government should require insurance providers to cover opioids and other medications when deemed appropriate by a qualified prescriber, but also insurance companies should pay for non-medication therapies such as physical rehabilitation, diet and exercise programs, and alternative medicine to be used alone or combined with appropriate medication management. People should also have ready access to rehabilitation counseling for substance abuse disorder should things get out of hand with opioids or other abusable drugs – this needs to be treated as a disease, such that people in danger of opioid abuse don’t feel ashamed to seek help through counseling. Allowing insurance companies, a free pass to pay for the least expensive options, the most abusable of all opioid therapies and selectively excluding payment for any non-medication options, or to limit supportive therapy such as biofeedback or psychotherapy is plain wrong. If we believe that there is an opioid epidemic, it is at least in part because insurance companies have been allowed to dictate therapy without incurring any of the responsibility for outcomes. This paradigm is not limited to pain management – it has been accepted as a way of life across many medical conditions where treatment selection is dictated by medical coverage instead of the most appropriate options. Doctors are worn out and in many cases have given up and bow to the insurance company when better medical options are available, because if they don’t move on to the next patient, the next patient is affected.
To the suffering patients here today, your lives have been politicized by lawmakers and media muckrakers who know very little about chronic pain management. And for that you should be angry. Various medical clinicians and organized affiliates with little to no formal training in pain therapeutics have successfully manipulated political strategists into believing that opioids are synonymous with the devil. They have manipulated statistics, cited poor evidence, and avoided very real evidence in support of certain medication stratagems, including chronic opioid therapy for certain chronic pain conditions.
What are the issues?
First, it’s important to understand that we have two very real public health crises on our hands.
1. Opioid Abuse and diversion
2. Lack of opioid access to patients with excruciating chronic pain
It is high time to stop making pain patients suffer in ways that are aimed at but WILL NOT solve the opioid addiction problem in this nation!
What are the facts?
There are more yearly deaths from tobacco than by all combined deaths from HIV Disease, illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. Yet, our government complacently turns a blind eye because of tax revenue from cigarette sales tax, and the lobby against gun control is strong. My purpose for sharing these facts is not to take sides or create another debate here today, but simply to point out the irony of political decisions surrounding opioid access at the expense of suffering among those in pain, all because of selfish personal or political agendas.
Annual NSAID-related deaths from gastrointestinal bleeds are about equal to that of illegally obtained prescription opioids – but alas, there is no black market, profitability from NSAID-rehab clinics, or sexy media initiatives to highlight these realities.
Many sources quote the misleading statement “Americans use 99% of the world’s hydrocodone”. But in Europe, dihydrocodeine is used instead and in Canada, hydrocodone is only available in cough and cold products. Most other countries use morphine for pain instead of hydrocodone. But these facts are purposefully avoided.
Politicians have advocated for dual prescribing of naloxone, and opioid reversal agent for patients receiving chronic opioids or for non-pain patients that have an opioid addiction disorder. They dwell on and even advertise support for such programs as do various large chain pharmacies that flaunt their pharmacists can provide this life-saving drug. But in a recent survey of over 100 pharmacies in upstate NY, over 70% did not carry this product because it simply isn’t prescribed or the pharmacists were not encouraged to advocate for such prescriptions. Again this is a façade that should be blasted wide open and exposed by professional organizations, and academic institutions should be in the forefront of such patient advocacy.
Last year on Super Bowl Sunday, which has become somewhat of a National Holiday, politicians had a field day criticizing 2 large pharmaceutical companies for advertising their drug which is FDA approved for opioid-induced constipation. The LA Times criticized the ad blaming Big Pharma for “hoping to profit from a controversial market that has arisen alongside the nation’s opioid addiction crisis”. The article went on to say that the ad has “drawn criticism from federal and local officials for not mentioning the issue of opioid addiction”.
Vermont Governor Peter Shumlin criticizing AstraZeneca and Daiichi-Sankyo said: “In the midst of America’s opiate and heroin addiction crisis the advertisement was not only poorly timed, it was a shameful attempt to exploit that crisis to boost your companies’ profits.” He went on to make the following request: “I ask that you immediately pull this advertisement – and others promoting this drug – from the air and instead use the money to fund opiate and heroin prevention efforts.”
THIS POLITICING SICKENS ME!
In reality, the advertisement did not advocate for opioid use; it simply advertised a legitimate product to combat a common side effect of chronic opioid therapy for patients that require these drugs to have some normalcy in their lives, but once again these patients were treated as some sort of scavengers.
Now, I ask all of you…
Where was the outrage from multiple beer commercials? Did Shumlin ask them to spend advert money on the dangers of drunk driving, alcohol poisoning, liver toxicity, or alcohol neuritis?
Similarly, PepsiCo had multiple ads during the Super Bowl. They make products such as Lays potato chips, Gatorade, Quaker, Tostitos, and Pepsi. Should PepsiCo be required to sponsor ads about obesity prevalence in America, diabetes, and associated morbidity and mortality.
Promoting simplistic policy responses to complex social issues rarely produces meaningful solutions. As the opioid clock ticks on and the figurative pendulum continues to swing from over prescribing to under prescribing opioids, legitimate patients are suffering, heroin abuse is rising, and suicides among chronic pain sufferers is at an all time high.
What is the solution?
There is no simple solution, but for certain it’s not to throw the baby out with the bathwater.
There is a shortage of well-trained pain clinicians and many that have formal training in the specialty field are not medication therapeutics experts. Congress should support and encourage pharmacist clinicians to work side-by side with physicians and other medical providers. After years of lobbying and requests from professional pharmacy organizations, Congress should jump down from their high horse and do the right thing; grant pharmacists provider status so that physicians can afford to work side-by-side with the real therapeutics experts and bill for their services to manage medications in a clinic setting. (See Nobody Knows to learn more about pharmacists as providers.)
The American Academy of Pain Medicine Foundation created a Unity Circle emblem with the assistance of numerous pain advocacy organizations to amplify the voices of pain patients, survivors, and caregivers as they work to increase patient access to research, treatment, and care through public awareness. The Unity Circle provides a visual tool to assist advocates in reaching the shared desired goal: a sustainable model for funding and provider resources. See more HERE.
Medical providers must work in concert with behavior health clinicians, pharmacists, nurses, and other specialists, lawmakers, and patient advocacy groups to ensure our country provides compassionate access and care to the citizens of this great nation. There is no benefit to squabbling over pain versus addiction without looking for solutions, as limiting prescription opioid access for legitimate patients has proven to be a miserable failure for everyone involved.
In closing, I challenge lawmakers, medical providers, and scholars to work in concert to improve legitimate access to opioids for those that really need them and to keep them out of the hands of those that do not. Help us to restore the rights of pain patients such that they may once again embrace their unalienable Rights of Life, Liberty and the pursuit of Happiness.
As always, comments are encouraged and welcome!