As readers are well aware, on July 25, 2012, Physicians for Responsible Opioid Prescribing (PROP) submitted to the U.S. FDA a Citizen Petition requesting a labeling change for opioid analgesics. This certainly stirred up a hornet’s nest of concerned activity and, during the ensuing weeks, a very large number of professionals in the pain management field have devoted countless hours of valuable time in discussing and largely disputing issues raised by the petition. Has all of this commotion been worthwhile or a waste of our time?
Considering just the multiple articles on this subject developed for the Pain-Topics UPDATES site, the articles and commentary here at the PainDr.com blog, the excellent and thoughtful response letter developed by the American Academy of Pain Medicine, as well as ongoing examination by the FDA of the numerous comments submitted to the Petition docket at regulations.gov, the costs in precious time and effort expended by very busy healthcare professionals have been enormous.
I would contend that, judging from the preponderance of commentary to date coming from all directions, the petition represents the opinions of a small minority of professionals in the field who have proposed an untenable and unproven hypothesis. Specifically, that compared with opioid analgesic prescribing practices following indications on current product labeling, patients would be afforded superior effectiveness and safety if opioids were restricted to a dose of ≤100 mg/day of morphine or its equivalent for no more than 90 continuous days and only for severe pain in the case of noncancer conditions.
Evidence in support of that hypothesis presented by PROP in their petition has been thoroughly considered, discussed at length, and disparaged as inadequate and/or of dubious quality by the many articles, letters, and comments in opposition. I have asserted previously in a Pain-Topics UPDATE that the petitioners’ claims may raise reasonable suspicion for justifying further investigation but, in themselves, they do not represent clear and convincing evidence to merit the proposed actions.
In clarifying PROP’s position, Andrew Kolodny, MD, president of PROP, stated in a Pain-Topics UPDATE, “the purpose of [the petition] is to prohibit drug companies from promoting long-term use of opioids for conditions where use has not been proven safe and effective.” There is an inference that opioid manufacturers have encouraged applications of opioid analgesics that exceed the implicitly approved limitations of current labeling and that the FDA has neglected its responsibilities of assuring that the products are safe and effective for purposes that they are being prescribed.
These are disturbing allegations that could merit further consideration and debate within the medical community, and with an examination of much more comprehensive evidence than presented in the petition. Open and fair-balanced dialogue among healthcare professionals regarding such matters plays an essential role in ultimately improving patient care; however, “fair balance” has not been characteristic of the debate thus far in print or otherwise surrounding opioid analgesics.
In a sense, PROP curtailed debate and did an “end run” around traditional channels of scientific discourse, as well as their peers, by expressing their demands in a Citizen Petition directly to the FDA, while also enlisting support from the Congressional Caucus on Prescription Drug Abuse and news media. A rebuttal letter submitted to the FDA by PROMPT (see below), which includes the letter from the American Academy of Pain Medicine, seems to clearly indicate that the petitioners’ perspectives are not consistent with those of their peers in the pain field. Comments at this blog, PainDr.com, by Jeff Fudin and the many other professionals chiming-in generally confirm that as well.
What has come of all of this?
In its broadest sense, the petition raises important questions about the safety and effectiveness of long-term opioid analgesics for chronic pain, whether cancer or noncancer in origin. A great many of us have invested considerable time in pondering these issues, both in print and discussion; however, no truly new insights or guidance have emerged so far from deliberating the petition — in my opinion.
Still, it is probably good that evidence presented in the petition has been re-examined — or perhaps considered for the first time by some professionals — to confirm that it is biased, misleading, and largely of low quality. As a result, it is now more apparent than ever that there is a need for more and better scientific evidence to help guide safe and effective opioid prescribing for chronic pain.
As an evidence-driven organization, I seriously doubt that the FDA would change opioid labeling merely on the basis of this petition; however, the agency is in the unenviable position of, if nothing else, having to invest the manpower, time, and our tax dollars in gathering and assessing public commentary, and responding to the Congressional Caucus and to the petitioners. If, as part of the process, there is a truly objective, fair balanced, and comprehensive evaluation of all relevant current evidence surrounding these issues, it could be a positive step — however, I am skeptical about that happening.
Perhaps, a most favorable outcome of the petition has been inspiration for the formation at this PainDr.com blog of PROMPT — Professionals for Rational Opioid Monitoring & PharmacoTherapeutics. This nascent organization recognizes that all healthcare professionals, not just physicians who prescribe opioids, have a stake in better pain care resulting from the safe, individualized, and effective prescribing of all pharmacotherapy.
As it develops and grows, PROMPT could be a major force in fostering a more objective and balanced dialogue surrounding issues raised by the petition — and beyond. Or, will it fizzle once the brouhaha of the PROP petition fades away? Time will tell.
Stewart B. Leavitt, MA, PhD, has more than 30 years of experience in healthcare education and medical research/communications serving numerous agencies and organizations nationwide. He was educated in biomedical communications at the University of Illinois Medical School, Chicago, and then served as a Commissioned Officer in the U.S. Public Health Service at NIH. His other graduate degrees (MA, PhD) are from Northwestern University, Evanston, IL, specializing in health/medical research and education, where he also was an instructor and a Ford Fellow researching urban healthcare delivery systems. In 2005, Dr. Leavitt founded Pain Treatment Topics (Pain-Topics.org), where he currently serves as executive director and editor in chief and, prior to that, he was the founding editor of Addiction Treatment Forum (ATForum.com) in 1992, which he worked on for 15 years.
I am 7 years off opiates. I have major depressive disorder, 3 suicide attempts, and I am agoraphobic. Everyday is a struggle my uncle who I lost this year took his own life . Now I see my son having the same traits. Been on every medicine available the only reason I used opiates was because I felt normal and it gave me energy. My uncle had extreme back pain this year they took him off his percs because of new laws. For 2 months he laid on that sofa before taking a gun to his face. Why doesn’t the government just let us have the meds we need. I have no doubt that my ending will be just as bleak. It was sad seeing an active person lose all hope and drive even after months.opiates were the only thing that has ever helped my depressive disorder. I have not left my house for a month.
Rebecca, You probably will not be able to find a doctor to do that. But, if you’ve never had a genetics test by your PCP (if they are savvy with that) or a psychiatrist, I would definitely look into that.I have seen patients fail all therapies, when a simple fix was to give a supplement due to an inadequate MTHFR gene.
This is also about the hell you have to go thru to get pain medications, the proposal of PROP’s petition in my opinion has been a bunch of Malarqe Crap, in the summer of 1972 while driving my motorcycle I crashed head on with a car, I had 18 fractures on my left leg, one hip
Fracture, one wrist fractured. And I lost my best friend in this accident I was one year in the hospital. In 1974 I had a pituitary Brain Tumor Craniopharyngioma full craniotomy full frontal exposure, I did fine for 20 years then hello pain, I got Lupus, I was going to a cancer center but a
So called new law started that if you don’t have cancer you cannot be seen for pain medications.
Now I understand for people who have absolutely nothing wrong no they should not get pain medications, just get a job, but for the people suffering like myself the government should be ashamed at what they are doing to the poor people who are seriously ill and suffering like animals, please our country can do better than this, if you are seriously ill and have proper medical records there should be no reason to let people die in pain, you complain about suicides, don’t mix things up with street drugs, people on street drugs, or pain pills if they do not follow the doctor’s orders, don’t abuse them if you do then the dr should take them away..
Well this is my 2cents worth, of my opinion for the people suffering like myself. There are a lot of people die’ing in vain and rather do suicide then to continue to suffer. I understand your pain!!
My GP is absolutely paranoid about prescribing opioids so I see a pain specialist who comes to our city once a month from Omaha. I have had chronic PHN for twenty years now and have tried every known thing that might help from acupuncture to TINS to homeopathy. Only thing that has ever helped is hydrocodone. Lyrica is good for maybe one point on a ten point scale. About five years ago I started to have incapacitating PHN attacks which has every nerve fiber injured in the initial shingles outbreak lighting up with pain severe enough to cause loss of conscience. Like a bright light illuminates my mind and then nothing. Trouble is I don’t stay out long enough for the pain to subside so I live in almost suspended animation between the past, present and future. There isn’t anything but the pain. After one to four hours the pain begins to abate but it takes an hour or more for me to get to normal which is painful enough. My spine is so curved from the pain around my right waist that my right arms hangs three inches out from my body. I can’t walk a straight line and my balance is shot. I haven’t been any place in twenty years except to my mother’s funeral which I missed because I got caught in DIA in a freak Mayday snow storm and was stranded there for ten hours. The scramble to find a connecting flight across two or three concourses plus the tension precipitated an attack that was so bad that I seriously considered going to the emergency room when I reached my destination at two thirty in the morning. I didn’t go because I knew I would be waiting for hours ,and when I did see a doctor they probably would have pegged me for an addict and sent me away with two Tylenol. I change out of street clothes at five in the afternoon for loosely fitting nighware. I haven’t been anyplace after four PM for twenty years. Being dead is beginning to look like the best thing that could happen to me since I don’t really have a life. My pain doctor is understanding, but like my GP, won’t prescribe anymore than forty 325/10mg of hydrocodone which must last thirty days. Several requests to prescribe a better painkiller have been rejected. Every night when I turn the light out, I hope I won’t wake up. I can’t think of a reason to get out of bed in the morning anymore. A tiny bit of DNA that can only be see with an electron microscope ruined by retirement after saving for a lifetime and living a conservative life. If it ain’t one thing it’s another. With all that said, many more individuals in our city and across the world are dealt much worse hands. I would personally like to strangle the SOB that coined the term “golden years. They ain’t for many of us. Rambling of an old fool occupying time and space.
I believe chronic pain suffers should have the right to die. MD are afraid to help us because the night get in a bit of trouble with the Gov.However the really don’t care ab o it our right to be independent and free of deliberating pain.So the let us die slowly in pain.Shame on these MD for not fighting for our right to live as pain free as possible.My pain is a slow drawn out death sentenced. If we left an animal in this chronic pain we would be locked in prison.It’s ok to let ave a human suffering and then call yourself a MD. Well it will. Hurt your practice when we decided we have had enough and choose death over living in severe pain everyday with no hope of help from our MD.
This is in response to tightening controls over physicians in treating for pain. Explicitly concerning the very recent announcement that patients still have to get a written RX every month from their pain management physician.
I have extreme chronic nerve pain in my pelvis, buttocks and back of thighs to where I cannot think or make decisions. This will only penalize people like me. My nerve pain will never be cured. I also have Crohns Disease. I would gladly give up pain meds, if I could lead a somewhat normal life and function like a human being. I walk every chance I can get, but it doesn’t help chronic pain.
Has all of this commotion been worthwhile or a waste of our time?
I have to say the proposal of PROP’s petition — in my opinion has been a waste of time.
I’ve been stable on very little of a long lasting pain medication and its kept my never ending severe chronic cervical pain under control with no side effects. After 20 plus years I’ve had blood test done to check my liver and kidneys functions and their fine, as is other blood test. Testosterone was low, I’m 56 years old and AndroGel 1.62% is helping that problem. My health is good ,I’m still walking 4 miles a day and this long term treatment for the chronic pain I suffer from is very well controlled. So for those worried about long term use of opiates for chronic pain I’m doing good. This is proof enough for me to feel relaxed and not worry about long term side effects. I think to myself why all the commotion in the first place, it seems it rattled many people already suffering with chronic pain just stressing them out causing yet more unnecessary pain.
In my lifetime this thing with chronic pain I’ve learned to stay relaxed ,let the small things go and be your own advocate. You and only you can either let things like this get the best of you or just put it a side and move on with your life ,this chronic pain thing is enough,adding stress worsens a already bad situation.
Stewart B. Leavitt, MA, PhD along with Dr. Jeffrey Fudin have done their homework and thanks to them I can rest to sure everything will be fine.
To all of the people out there that deal with chronic pain on a daily basis keep yourself free of this stress, it can kill a person, just stress alone.
And thank you Dr. Fudin for your tireless work with PROMPT.
Also thank you Dr. Leavitt for founding Pain Treatment Topics (Pain-Topics.org). most excellent information on anything to do with chronic pain and keeping people safe.
Now I bow my head as the PROP petition fades away in the deep blue skies of America.
Sincerely,
Mark S. Barletta
Important Follow-up! It’s About Florida: Pill Mills, WFSU audio interview, 9/2/2012.