Seedy Sea or CDC?

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Perhaps the Seedy Sea storm is past, the weather is clearing, and the CDC will arise once again as a respectable organization to address opioid safety concerns for patients, clinicians, caregivers, and public health at large.


Over the last several months my recent and current student pharmacists and post-graduate doctoral pharmacy residents have been following the Center of Disease Control issues regarding the proposed guidelines.  During their rotations or longitudinal training, they continued to care for challenging patients that were referred to our pain clinic for management of persistent unrelenting chronic pain. 


Most of these young clinicians spent just a few weeks with me, while others have spent a bit more, up to almost 7 months.  Several of them approached me with a desire to share their experiences and insight with the CDC by responding to the guidelines at The Centers for Disease Control and Prevention (CDC) Notice: Federal Register Notice: Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain.
Update: Total number of comments on Federal Register when closed to comments on January 13, 2016 was 4012. 


They did a phenomenal job and kept it fair balanced! Here is their entire response letter as it appears on the Federal Register…

This response to the “Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain” comes from a group comprised of seven Student Pharmacists, three Post Graduate Year 1 (PGY1) Pharmacy Residents, and one Post Graduate Year 2 (PGY2, Pharmacy Resident with specialty training in Pain and Palliative Care).  For clarification, the four residents all have earned PharmD degrees and the student pharmacists are candidates from several different colleges of pharmacy.  All authors have spent four or more weeks under the mentorship of Dr. Jeffrey Fudin, a Clinical Pharmacy Specialist in Pain Management and Director or a PGY2 Pain and Palliative Care Residency program.  All undersigned have participated in direct patient care with focus in ambulatory care chronic noncancer pain. This response has been reviewed in detail by Dr. Jeffrey Fudin in advance of submission.

Pain is often the chief complaint that causes patients to seek medical care and is a prevalent comorbidity of various acute and chronic conditions. Chronic pain affects up to 126 million Americans1,2, which represents more than diabetes3, heart disease4, and cancer5 combined, yet chronic pain remains inadequately managed for a multitude of reasons, not the least of which is poor education in schools of medicine and pharmacy. The proposed CDC draft guidelines for opioid prescribing will likely have a tremendous negative impact on millions of patients. We extend our heartfelt condolences to those who lost a beloved friend or family member to an opioid overdose and we sympathize with the millions of Americans affected by chronic pain. However, we believe that the issues addressed by the CDC guidelines are multifaceted and require zealots on each side of the “opioid-camp” come together to improve outcomes for patients rather than to sensationalize issues that most notably require study and more evidence. Well-trained clinicians in the fields of pharmacy and medicine working collaboratively could help alleviate some of the stressors encountered by patients, improve outcomes, and foster better pain care while mitigating opioid risks.

Upon review of the Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain we find various contradicting statements based on the presented evidence and the recommendation strength. According to the National Guideline Clearinghouse, “level A rating requires at least two consistent Class I studies”.6 However, all of the 12 recommendations provided are based on case series (level 3 evidence) or expert opinion (level 4 evidence) yet assigned a grade A recommendation.7 For instance according to the proposal, providers “should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/ day (recommendation category: A, evidence type: 3)”. The recommendation is based on one randomized unblinded study8 in 135 patients (94% males; 74% have musculoskeletal pain) who received 40 MME/day compared to 52 MME/day, yet the recommendation was generalized to “chronic non cancer pain” and recommended “to avoid increasing dosage to ≥90 MME/ day” which was not evaluated by the referenced study. 

To assign a cut-off of morphine 90mg per day, we believe is over-simplified and may propose challenges in practice. The proposed guidelines recommend a standardized MME, or a “morphine maximum dose” sometimes abbreviated MMD, but did not recommend a standardized method for calculating morphine equivalence. Not surprisingly, there is a wide variability among opioid conversions including, but not limited to online opioid dosing calculators. Rinnick A and others that included nationally renowned pain experts, compared equianalgesic conversion estimates as calculated by practicing clinicians, by surveying 411 healthcare professionals; 129 physicians, 213 pharmacists, and 69 nurse practitioners.9 After adjustment for statistical inclusion, 319 participants were incorporated in the final analysis. Participants were asked to provide the morphine equivalent for hydrocodone 80mg, fentanyl 75mg/hour (1800mcg/day), methadone 40mg, oxycodone 120mg, and hydromorphone 48mg. Participants were also asked to provide the resource used for their calculation.  MME for fentanyl, hydrocodone, hydromorphone, methadone, and oxycodone were: 176 (±117) mg, 88 (±42) mg, 192 (±55) mg, 193 (±201) mg, and 173 (±39) mg, respectively. The authors stated “A total of 124 (46%) respondents identified using personal knowledge as a resource for their conversion problems, followed by use of an online calculator at 83 (31%), a textbook table at 45 (17%), and a conversion table from a journal at 15 (6%). 

Considering the Rennick study, it is of particular importance that the standard deviations for fentanyl and methadone “morphine equivalents” will exceed the CDC cut-off by CDC’s own definition of morphine equivalent. In other words, the current CDC guidelines suggest that patients should not receive more than a 50 MME and not to exceed 90 MME.  But by Rennick’s findings, a calculation for fentanyl 7.5mg patch would be up to 117 MME less than and 117 MME more than the 7.5mg (75mcg/hour) fentanyl dose.  What does this mean?  Looking at this another way, one clinician’s MME in this case could be 59 MME and another clinician might assign the equivalence of 293 MME, a range spanning 234mg of morphine equivalent. Just the standard deviation alone is a recipe for death in the untrained professional.

Given lack of standardization, potential drug interactions, patient’s physical features such as height and weight, gender, end organ (dys)function, coupled with patient individualized pharmacokinetics due to polymorphism, we respectfully disagree with utilizing a standard cut-off for morphine dose. We suggest that the CDC give credence to these mathematical and physiological variabilities and employ efforts to mandate education for providers and to approach every conversion for each individual patient slowly and carefully.

We believe that increasing awareness of the opioid overdose risk is appropriate, but claiming certain unsubstantiated risks outweigh the benefits of using opioids to treat pain lacks scientific foundation. According to a recent study by Dasgupta et al., of 2,182,374 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year).10 Over the past 2 years, there have been recent studies by Dr. Barbara Zedler et al. that identified risk factors associated with overdose or serious opioid-induced respiratory depression.11,12 The authors used a multivariable linear regression model to assign a score to each identified risk factor and to calculate a risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) score. The calculated total RIOSORD score corresponds to an average predicted probability of opioid-induced respiratory depression of 2% to 84%.  The risks taught by this regression analysis should be considered by all prescribing clinicians – the sad truth is that most prescribers don’t even know the RIOSORD model exists. 

We firmly believe the problem is a lack of training and education on opioid prescribing; instead of improving the knowledge of healthcare professionals, the guideline is placing the burden on patients by reducing opioid access for patients that may legitimately require them. There is a deficit in the education provided on pain management in medical and pharmacy schools. A study by Mezei L et al. concluded that education for North American medical students is limited, variable, and often fragmentary.”13 Over 80% of attending physicians rate their education on chronic pain during medical school as “inadequate”.13 Another study by Yanni et al. identified lack of confidence in treating chronic pain among physicians, where 59% of the participants rated the education on pain management as “fair” or “poor”.14  As for opioid abuse, the National Center on Addiction and Substance Abuse at Columbia identified that 67% of  primary care providers do not screen for substance abuse, 83.1 feel unprepared to detect aberrant drug-related behaviors, and about 70% are unprepared to detect prescription drug abuse.15,16

 This lack of emphasis on pain management is also prevalent in the pharmacy school curricula. A qualitative assessment of pharmacy school faculty members found that out of 28 pharmacy schools, 21 (75%) believed that “too little” emphasis was being given to pain management.17 There are only 8 accredited PGY-2 training programs for pharmacists on pain management and palliative care in the U.S, which pales compared to the prevalence of chronic pain.18 To put this in further perspective, as of November 2015, there were 1158 PGY1 general practice residency programs and 853 PGY2 specialty practice programs throughout the US. Pain residencies for pharmacists are represented by less than 0.4% of all residency training programs and 1.4% of all specialty training programs. This is grossly out of proportion when matched against disease prevalence and other common medical conditions. We believe there is a knowledge and training deficit across the pain management continuum among all healthcare professionals, and increasing the emphasis on pain education beginning early on in their training and continued throughout their practice years could be a major step towards safe and effective pain management.

We believe the implementation of the CDC guidelines may have a drastic negative impact on patients living with pain and their loved ones. The Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain recommendations may place restrictions on personalized patient care and prevent clinicians from providing high quality of care. We believe that management of persistent pain requires a multidisciplinary team including but not limited to physicians, physician extenders, pharmacists, and behavioral health clinicians, all of whom who provide overlapping and synergistic services. The variability in opioid conversion tools, altered pharmacokinetics; polypharmacy, and drug-drug or drug-food interaction potential, could all complicate medication management within the chronic pain population. Therefore, we believe that improving education and fostering a multimodal approach in pain management is a reasonable and responsible approach.


  1. Mena Raouf, Doctor of Pharmacy Candidate 2016, Albany College of Pharmacy and Health Sciences
  2. Lisa Dragic, Doctor of Pharmacy Candidate 2016, Temple University School of Pharmacy
  3. Jacqueline Pratt Cleary, PharmD, PGY-2 Pain and Palliative Care Resident, Albany NY
  4. Alireza Shamsali, Doctor of Pharmacy Candidate 2016, Albany College of Pharmacy and Health Sciences
  5. Mazen Saeed, 2016 PharmD/MBA Candidate, Albany College of Pharmacy and Health Science
  6. Uyen Nguyen, Doctor of Pharmacy Candidate 2016, Western New England University College of Pharmacy
  7. Jeffrey Bettinger, Doctor of Pharmacy Candidate 2017, Albany College of Pharmacy and Health Sciences
  8. Phillip Boglisch, PharmD/MBA Candidate 2016, Western New England University College of Pharmacy
  9. Steven Sparkes, PharmD, PGY-1 Pharmacy Resident, Albany NY
  10. Daralyn Morgenson, PharmD, PGY-1 Pharmacy Resident, Albany NY
  11. Joni Carroll, PharmD, PGY-1 Pharmacy Resident, Albany NY

Statements made are the opinions of all signatories and do not reflect the opinion of any listed affiliations. The information contained herein was not prepared as any part of participant government duties.


  1. National Institutes of Health. Estimates of Pain Prevalence and Severity in Adults. August 2015.
  2. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.
  3. American Diabetes Association.
  4. Heart Disease and Stroke Statistics—2011 Update: A Report From the American
  5. American Cancer Society, Prevalence of Cancer:
  8. Dowell D. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Available at:!documentdetail;d=cdc-2015-0112-0002. Accessed April 2016. =!documentDetail;D=CDC-2015-0112-0002
  9. Naliboff BD, Wu SM, Schieffer B, et al. A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain. J Pain 2011;12:288–96.
  10. Rennick A, Atkinson T, Cimino NM et al. Variability in Opioid Equivalence Calculations. Pain Med. 2015 Sep 9. doi: 10.1111/pme.12920. [Epub ahead of print]
  11. Dasgupta N, Funk MJ, Proescholdbell S. et al. Cohort Study of the Impact of High-dose Opioid Analgesics on Overdose Mortality. Pain Medicine 2015
  12. Zedler B, Xie L, Wang L, et al. Development of a risk index for serious prescription opioid-induced respiratory depression or overdose in Veterans’ Health Administration patients. Pain Medicine. 2015 Jun;16:1566-79.
  13. Zedler B, Saunders W, Joyce A, et al. Validation of a screening risk index for overdose or serious prescription opioid-induced respiratory depression prescription opioid use and deaths from overdose or opioid-induced respiratory depression. Presented at the 2015 AAPM Annual Meeting. March 2015.
  14. Mezei et al. Pain Education in North American Medical Schools. The Journal of Pain, 12:12 (December), 2011: 1199-1208
  15. Yanni LM, et al. Preparation, confidence, and attitudes about chronic noncancer pain in graduate medical education. J Grad Med Educ 2010 (2):260–268
  16. National Center on Addiction and Substance Abuse at Columbia. Missed opportunity: national survey of primary care physicians and patients on substance abuse. Columbia University, Center on Addiction and Substance Abuse 2000. Available at: Accessed September 21, 2012.
  17. Zacharoff KL. The Role of Education in Safe and Effective Pain Management.
  18. Singh RM, Wyant SL. Pain management content in curricula of U.S. schools of pharmacy. J Am Pharm Assoc (Wash). 2003 Jan-Feb;43(1):34-40.






19 thoughts on “Seedy Sea or CDC?

  1. I wish as a chronic severe increasing pain human being the CDC would listen to some of us and our families.Thanks to the relief that my medication provides I can visit with my one year old grandson and actually enjoy it.I don’t have to pretend knowing I am not fooling any of my family.I can also be a more positive influence on two of my grandsons who live with us.I can help with their homework and so on without getting irritable and impatient.There are still days when my pain is so bad despite the meds that I keep away from family because of my mood.That use to be every day though.I am as my doctor described a model pain patient.My urines always come back right,my pill counts are always correct and I am always willing to try different things.That is not true of addicts.Do they think an addict with a months worth of opioids would have it last all month?I was very impressed by the letter the students wrote.I wish more were like that.It is hard to live with increasing disability and pain but what is almost worst is living in fear of the day I may no longer receive my pain meds.To those who think that means I am an addict I would like them to contemplate a life of continuous severe pain with no hope.Hopefully you will stop being so judgemental.

  2. I wrote an email to Dr. Fudin and he graciously invited me to share my opinions in this forum. I am honored to do so:

    The attempt by CDC officials to control the discussion and events regarding prescription opioid treatment of chronic pain is deeply concerning. To the extent that a large number of individuals are dying from opioids and other drug overdoses, their honest reporting could have provided a valuable service. However, it seems increasingly clear that individuals in charge of this project were guided primarily by a preexisting and largely unfounded bias against prescription opioids for nonmalignant pain. The CDC seemed to acknowledge the weakness of the investigation linking deaths to prescription medications, and yet they promote the findings as if they have first rate study methodology.

    Regardless of the tentative nature of the information, CDC officials wasted no time proclaiming a well established association and developing policy solutions. The damage to people, including end-stage cancer patients is profound. Our nation is more afraid of opioid analgesics than ever and the inevitable result is that many people will suffer for a long time to come. Opioids are more stigmatized that at any point I can remember and regaining minimal ground will be a great challenge.

    The worst consequence is of course the untold and unmitigated suffering we see now. The damage is greater though. The CDC has a, perhaps not entirely deserved, admirable reputation as a institution that evaluates scientific information and advises the country on optimal responses. One would hope and I think many believe that these professionals proceeded with the objectivity required for such a responsible position. Clearly we understand that many medical studies are marred by poor study design and bias. We grudgingly accept the inevitable limitations that prevent robust research. Yet we ought to have some faith that an agency like the CDC will work hard to provide the most accurate information possible. Objectivity ought to be a minimal job requirement. We all become poorer when agencies like the CDC become bully pulpits for selective political opinions.

    I could of course go on….. and on, about the lapdog role the media has played and other obvious problems, but I know that I am already preaching to the choir. Perhaps I am too naive but I trained in both medicine and epidemiology and learned from some of the smartest and most dedicated people in the world. I am outraged at the lack of objectivity and professionalism shown by the CDC.

    Thank you so much for the fine work you continue to do. Keep up the good fight!


    Carol Kennon, MD, MPH

    1. Dr. Kennon,
      Thank you for your observations. And thank you, Dr. Fudin, for constantly informing us on this issue.

      I am a chronic pain patient with complex issues: vascular, hypermobile and classic forms of Ehlers-Danlos Syndrome, Ankylosing Spondylitis, Autonomic Nervous System Dysautonomia, Mast Cell Disorder, and if you can believe it, mitral valve prolapse, seizures and Scleroderma–some determined by genetic testing, others by blood tests and bone marrow biopsies…

      … and 5 decades of chronic pain. I had a small stroke at 36, saphenous vein ablations, multiple blown vessels, a thin-walled abdominal aorta.

      Despite all this, we finally managed to get disability at age 50. I use a walker or an electric wheelchair to go from point A to point B depending on which vertebrae are subluxated or which hip sockets are dislocated. Not to mention the fatigue. I’m young looking and have a positive outlook, since EDS provides me with a higher than normal level of seratonin.

      My 74 year old geneticist (the only MD/PhD in Florida who sees adults with EDS) is appalled by the lack of care by my PCP, who informed me last year he only wanted to treat my lung issues. I’ve been on my own except for an excellent pain Doctor affiliated with a local hospital. I sleep with oxygen.

      Yesterday, my husband checked with ExpressScripts to see if my OxyContin (80mg, 3x/day) was shipped. Instead of finding that, he saw a letter saying I had exceeded my yearly amount of 180 pills in February! Say what???

      What is so shocking to my husband and me (as a patient who would like to enjoy a quality of life that includes simple things like getting out of bed) is that the CDC’s actions forget to take into account the hundreds of thousands of people like me with rare and incurable diseases who rely on palliative care to get through each hour of each day. I have never abused my medicines, nor do I complicate them by drinking alcohol or taking sleeping pills, etc. I have gladly submitted to urinalysis as required, and am a “model patient.”

      The CDC forgets that people like me can’t control blood pressure, have seizures, and can quickly die from strokes and aneurysms—and the lack of pain control can kill someone like me very easily.

      Of all the people who die from narcotic abuse, their deaths are on them. But for people like me, deaths will be on every single CDC members’ heads! I’ll get off my soapbox in a second, but may I also say it appears Obamacare appears will possibly be remembered as, “The American Holocaust.” This may sound dramatic, but you wait and see…

      …once the silent sick people stop draining the coffers of Insurance Companies and make Mortuaries richer than ever, perhaps THEN the CDC and our government will be satisfied.

      I can see it now: Families grieving their loved ones over scads of holes in the ground, while smug smiles cover the faces of those who “solved” the narcotic death “problem” in America. Good job, CDC! If this is their aim, they are probably going to be VERY successful.

      How many of us have to die at their hands before they realize they are responsible for this travesty?
      And now, as I type this lying on my side in bed, guess who runs out of pain medicine in 10 days?

      Let’s hope my insurance company’s Pharmacy changes their mind and agrees with me that 180 pills a year maximum is going to provide nothing more than torture and great suffering. I’d hate to think this may be my last comment on, but it’s entirely possible.

      If so, Dr. Fudin, please–carry on fighting for chronic pain patients and their families who think we are not burdens, but a vital force in the family unit!

  3. Dear Dr. Fudin & Colleagues,

    Thank you for all of your excellent work, research and continued contribution in this constant uphill battle we face. For those of us living with the real fear of what the future may hold for the millions of chronic pain patients all across our country, I cannot thank you enough. As a patient of Dr. Tennant’s, patient advocate, and columnist, every day brings new challenges and honest concerns that no matter how loudly we cry out or how many voices join in our fight, they either do not inherently understand or do not care to know how to treat truly severe, intractable pain disease and disorder. But continue the fight we must. We certainly empathize with addiction and overdose and agree that education, treatment and prevention are desperately needed. However, the other side does not seem to share our compassion for the millions suffering with chronic non-cancer pain even with multimodal therapies and a tolerance of low to mid-level daily pain, require opioid medications to live some semblance of a quality of life. Nor do they seem to want to allow fair & balanced representation of the patient side in the development of these guidelines.

  4. Bravo; very well done and appreciated. I would ask that these students learn the importance of nurses in pain management (and patient safety). We are not physician extenders. As a pain management nurse I know pain and pain management is not taught a sufficient amount in nursing schools yet we are responsible for implementing orders and catching those that are not safe or inappropriate. Nursing does most of the patient education as well. Nurse practitioners are prescribers. Just learn to include them when taking about education and lack there of as well as that multidisciplinary team of which they are an important part.

    1. Janice, Thank you for your kind comments and insight. There certainly was no intent to exclude nurses and in the context of this post, nurses were considered CLINICIANS, as were all licensed professionals who care for patients. I can tell you that from our perspective, we couldn’t survive without nurses and the patients also would suffer emotionally and physically if the nurses weren’t there as part of the team. Also, please note that we did include nurse practitioner and others by name. In the context of the post, behavior health clinicians included psychiatrists, psychologists, and social workers. The post purposefully did not call any prescribers other than physicians, “mid-level providers” because it is an inappropriate term. In fact, I suppose it would be equal to calling a physician a mid-level nurse, as nursing is not their expertise. The term “physician extender” was used to denote clinician that extends beyond the physician. I suppose I can see your point that the focus per se could be the physician if we are all an “extension” of them. But you are correct, because in our clinic we are all connected and nobody is an extension of anyone. Thank you for bringing this to our attention and thanks for caring for patients!

  5. Well done!!! Thank you from the bottom of my heart for taking the time to put together such a well written, intelligent and scientific comment for the CDC. It is my hope they will listen to the professionals in the field. Thank you for doing such important work , it gives me hope that a new generation of Pharmacist’s are being trained under such a fine doctor. We need more of the “good ones” out there! We can’t give up hope, as pain knows no race, gender or class, it can arrive as an unbidden guest on anyone’s door. Thank you again!!

  6. I’m living with chronic pain. I have arachnoiditis. Opioid drugs are my only option for relief. Please don’t take them away. If you do I believe patients like me will simply commit suicide. Sad but true.

  7. I am at a loss to understand who decides your in pain or not. Yes, some can fake it! But today I am in terrible pain, in bed, Dr. Insists I would feel better taking a long walk with 3 grand children 1, 5, and 7, who don’t obey me. Also have COPD, am in a snowy 20 degree day. Have diabetes 53 years, 6 major surgeries, Fibro., known back and hip problems and intestinal problems and ankylosing spondilytis, 8 surgeries on hands, frozen elbows and shoulders and much more.

    There are so many like us! I’ve waited 3 months for a pain clinic and have been told they won’t do anything the first visit. I’m almost off all pain meds yet they are blaming those meds for me falling asleep because I’m in too much pain. Can’t get full disability even though I’ve had it before. My pain is not one level. It stays medium but shoots up to a 10 for hours and even the meds give no relief. Had consistent pain since 1990 and didn’t start pain meds until 2000. New Dr.s do not look at my past history.

    Some of these rules need implemented soon and more! The survey was useless. When you said you had only 2,000 Dr.s and only 1,600 patients that’s a drop in the bucket! And I’m sure the appropriate question were not asked of I he act.s I.e. Are you worried you’d get in trouble for prescribing the meds, etc.

    This reminds me of the Hitler era, trying to get rid of people who would not make it in the “New Society”. Until the end of the world you will have people like us, so treat us with understanding and respect. We are hopeful! If this is not controlled, there will be worse consequences.

    If there are patients abusing these drugs, they will get them somewhere else!

  8. A tremendous Thank You to all who took the time to Advocate for those of us who live with Daily Chronic Pain!! I truly believe that if those who are making these decisions had to live in the body of a Daily Chronic Pain Patient, this wouldn’t even be a topic of discussion. I pray that your information is seriously considered by those who are making such decisions, and changes are made to further the study and understanding of Chronic Pain Diseases. MY hope is that with that will come the knowledge and understanding that treatment is different for each Chronic.Pain Patient. THAT is what we NEED!!

  9. I am a chronic pain patient, if it weren’t for my pain meds I couldn’t get out of bed. Thank you to all of you who give us a voice!

  10. May God bless each and everyone of you. I hope for all who suffer debilitating pain 24/7 that they truly take to heart what was written above. Thank you Peggy

  11. Very well written Thank you for weighing in and giving a voice to those who cannot speak out. I’m very proud of the work that you have done! Hopefully, if the CDC won’t listen to the pain sufferers (because they believe them to be just addicts) maybe they will consider well thought out statements, with data supporting those statements, and reconsider involving themselves in an area of which they have very little knowledge. Thank you for your support

  12. Jeff and team – very commendable! Thank you for all the effort that was put into this piece. Let’s hope that good and appropriate measures will ultimately be made available.

  13. Bravo!
    Well done, well written and well, just great, As a practitioner, oft seeing the failures of our system, it heartens me to see young professional still willing to ‘write’ what is wrong.

    A more scary situation however will soon exist: The specter of increased oversight now being placed, will have some immediate effects.(don’t be surprised to see an increase in heroin related deaths) However, the long term pernicious nature will be seen as in–coming med and pharmacy students enter a transformed milieu, where artificial limits, poor science, and alas, more enraged anti-opiate zealots populate faculties, using CDC -a voice of governmental authority- to support arguments against individualized care.

    Thanks for wonderful work and best of luck

  14. Thank you, authors. As one who attempts to understand the science behind my 30+ years of chronic spine disease and pain, I’m often at a loss to find objective data on people like myself, who for various facts of genetics, land inked comorbidities, find that opioid treatment has given me a functional life, but for years doctors have been trying to ignore simple facts of tolerance, degenerative disease, and who knows how many other confounding treatment factors have ‘discovered’ reason to reduce or change my medications.

    When outcomes don’t match expectations, I’m assigned other possible dx like hyperalgesia, which from what I understand from the literature is either a disease acquired by my tortured lab rats, a syndrome associated with opiate naive post surgical patients causing temporary temperature sensitivities, or a condition developed by certain level 1 paid participants in medical studies who are methadone tolerant heroin addicts – a group classified as ‘guinea pigs in Carter Elliot’s 2010 book White Coat, Black Hat that explores the mind-bending, rule- bending world of high payoff drug development in the world of BigPharma.

    Yet there is very little data on the millions of Americans like me – living with severe pain, interventional procedures, and high tolerance to opioid agonists, getting by on lower opioid doses that 5 years ago, and enduring more pain and scrutiny while doing so.

    Thanks for offering a glimpse into our reality.

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