Without knowing better, one would think that reporter Radley Balko was writing about some long-forgotten totalitarian country; except, he is describing the United States, today, with its ongoing war against prescription opioid analgesics — and against the professionals who prescribe those medications. Most readers will be upset by what he has to say, they may be fearful or angry, but none will be disinterested.
In a 3-part series, Balko — who is a senior writer and investigative reporter for the widely-respected Huffington Post — offers some much-needed balance in the lopsided dialog about opioid analgesics; countering alarming reports and inflammatory rhetoric coming from government agencies, news media, and fervent cynics emphasizing the dangers of these vital medications. This series is thoughtful and provocative reading of great importance for all healthcare providers and patients with pain.
Part 1: “The War Over Prescription Painkillers,” January 29, 2012 [Available Here]
Balko begins by describing how recent, highly biased reports from the Centers for Disease Control and Prevention (CDC, previously discussed in UPDATE [here]), the Drug Enforcement Administration (DEA), and the journalism non-profit ProPublica, have spurred calls for tighter reins on opioid prescribing and aggressive tactics to prevent drug diversion. He writes…
“There's no question that prescriptions for opioid painkillers like Oxycontin and Percocet have soared in recent years. It's also clear that there are some rogue doctors and "pill mills" who unscrupulously hand out prescriptions, sometimes to patients who shouldn't get them, sometimes to drug addicts and drug dealers pretending to be pain patients. But it's also far from certain that the painkiller abuse and overdoses are as dire as the government is making it out to be. And to the extent that there is a problem, it's due more to a decade of aggressive policing, obstinate federal law enforcement agencies, and the encroachment of law enforcement into the practice of medicine than lax government oversight. The DEA in particular has been scaring reputable doctors away from pain management since the late 1990s. People who suffer from chronic pain simply can't find doctors willing to treat them over the long term. The unscrupulous doctors and pill mills in the headlines have sprung up to fill the void.”
He goes on to discuss problems of chronic pain in America and how the biggest barrier to effective pain treatment may be bad public policy driven largely by the war on drugs. As Balko points out, opioid “abuse” does not necessarily mean using the drug to get high, and “dependence” is not the same thing as addiction — but the government does not seem to understand the differences.
By way of background, Balko provides an overview of government intrusion and aggressive actions spearheaded by the DEA. He recounts the infamous cases brought against doctor William Hurwitz and patient Richard Paey, which will be of interest even to readers already familiar with those examples of alleged persecution by government agencies.
NOTE: Also be sure to read this document referenced by Balko in his article: Libby RT. Treating Doctors as Drug Dealers: The DEA’s War on Prescription Painkillers. Cato Institute, Policy Analysis No. 545. June 16, 2005 [PDF available here].
This 27-page, well-researched report provides excellent background on the treatment of chronic pain in America and how congress and justice agencies have overreacted to reports of opioid-related problems, some of them false, with uncompromising policies and legal actions that actually may threaten the public health.
Part 2: “The New Panic Over Prescription Painkillers,” February 8, 2012 [Available Here]
In this second article, Balko again attacks U.S. government reports that manipulate data to inflate problems associated with opioid analgesics, such as the CDC’s self-proclaimed epidemic of overdose deaths. For example, Balko quotes Dr. Steven Karch, who has written a widely used textbook on drug abuse and pathology, as saying, “…many of the deaths classified as overdoses in recent years may in fact have been caused by something else, but were called overdoses simply because the decedent had what appeared to be an abnormal amount of opioids in his system.”
Dr. Karch goes on to suggest that the government is using questionable overdose diagnoses in formulating public policy. This is especially egregious when considering that some physicians have been charged with manslaughter, even murder, because prosecutors used the same indicators of overdose to argue that the opioid prescriptions caused patients’ deaths.
Balko further writes…
“…prosecutors and DEA officials have over the years compared doctors to drug kingpins, and likened doctors' offices to crack houses. Some doctors were subjected to SWAT raids on their offices, and had all of their assets seized before trial, making it difficult for them to put on an adequate defense. Prosecutors have called press conferences in which they held up big bags of pills the doctor allegedly prescribed, eliminating all context, and effectively convicting those doctors in the press.”
Through the years, a clear message has been sent that there will be no safe harbor in which pain specialists can operate without being concerned about a government investigation. “What was and wasn't criminal would be decided on an ad hoc basis,” Balko writes. “Worse yet, what was criminal versus what was acceptable medical practice would be determined not by other medical professionals, but by drug cops and federal prosecutors.”
Balko observes that legitimate and cautious pain specialists who risk their careers in order to continue to treat patients with pain are likely to be overwhelmed with people needing treatment, which makes them prime targets for investigation. “The successful management of chronic pain requires careful treatment by attentive doctors. The DEA and federal prosecutors [have] gone a long way to prevent that from happening,” he writes. “Instead, patients get rushed care from inattentive doctors, which is not only less effective, not only more likely to cause drugs to end up in the hands of dealers, it's also dangerous for patients.”
As an example of responding to opioid-related problems with bad policy, Balko discusses the situation in Florida...
“Law enforcement agencies have created a system where doctors, pharmacists, manufacturers, and wholesalers have been forcibly deputized to police one another. Given the severity of the penalty — loss of livelihood, even prison time — the overwhelmingly prevailing incentive is to err on the side of control, to halt distribution and report the slightest of suspicions. Some towns and counties in Florida have gone even further, passing yet more restrictions, many of which Ray [Dr. Albert Ray, president of the Florida Academy of Pain Medicine] says, ‘would bring legitimate pain care to a grinding halt on a day to day functional level.’”
Dr. Ray further observes that Florida’s “new laws” are no different than others coming before it, which have targeted controlling abuse of drugs with a legitimate medical purpose, even if it means restricting access to the drugs for patients who need them. “We need to view this through the lens that the patient comes first — what they need, and what the best ways are to get it to them,” Ray says. “How to get the system to respond in that way remains a frustrating problem.”
Part 3: “Painkiller Access Debated as Patients Suffer,” March 9, 2012 [Available Here]
In this third and final article in the series, Balko looks further into the lack of balance in the public debate over opioid analgesics. He writes…
“The issue of pain, particularly chronic pain, is endlessly complex, and fraught with years of contradictory policies, a lack of research, contradictions in the existing research, push and pull from government agencies, and — particularly over the last few years — contentious disagreement within the medical community over what's safe and what's effective. For people who suffer from chronic pain that can be debilitating, the resulting mixed messages can be terribly frustrating. They face difficulty finding doctors who are willing to treat them, doctors who are incentivized to be suspicious of them, and in some parts of the country, a paradoxical influx of "pill mills" run by unscrupulous doctors, where prescriptions for opioids flow freely, but without the sort of individualized care and monitoring chronic pain patients need.”
Part of the problem, according to Balko, is that the U.S. government agency that controls the supply of opioid analgesics, the DEA, also is charged with eradicating drug abuse. There is no countervailing mission in the DEA to ensure that legitimate patients with pain have ready access to analgesic medications. “The incentive is to err on the side of control and restricted access,” he observes.
Balko quotes Dr. Russell Portenoy — who chairs the Department of Pain Medicine and Palliative Care at the Beth Israel Medical Center in New York and is a leading supporter of opioid treatment— as saying that there is a concerning lack of balance in the dire warnings about opioid analgesics. “There are just as many deaths associated with the use of anti-depressants, or from liver failure associated with the use of acetaminophen, but you don't see the same sort of language about risks associated with those drugs,” Portenoy says. “Opioids are just a medical therapy. They need to be carefully managed, but there's this age-old fear of them that seems to make them more urgent than other public health concerns.”
In fair balance, Balko acknowledges the skeptics who say there is no evidence supporting the benefits of long-term opioid therapy for chronic pain. One of them is Andrew Kolodny, an addiction specialist who founded Physicians for Responsible Opioid Prescribing. “The people advocating for [long-term opioid therapy] are advocating a treatment with substantial risk. And there's just no data showing that it's effective,” according to Kolodny.
Portenoy agrees that more data are needed; but, until then, “you have to go with physician experience, with anecdotes, with testimonials. And I'm certain that there is a percentage of chronic pain patients for whom this therapy not only works, but it's the only therapy that works.” Yet, Kolodny insists that that there is an epidemic of opioid overdose and addiction in these patients that is not worth the risk — referring to research claiming that a third of chronic pain patients on opioids “meet the criteria for addiction.” However, Balko notes that other research finds no more than 1% to 3% of bona fide patients become addicted to their opioid medications.
Balko mentions a video about high risks of opioid addiction among pain patients on the Physicians for Responsible Opioid Prescribing website that includes clips of Portenoy admitting such addiction is a serious problem. However, Balko also found this was a deception…
“…Portenoy, who says he finds the message of Kolodny's group ‘troubling and concerning,’ says the clips of him were taken out of context, and posted without his consent. He doesn't agree with the video's message. [Instead, Portenoy says] ‘Patients treated by well-trained doctors, [and] who are carefully screened, monitored, and treated aren't going to get addicted.’”
Portenoy stresses the need for better training in pain management for all physicians. Physicians also “need a safe harbor within which they can prescribe without fear of investigation, and that safe harbor should allow for innovation and outside the box treatment.” He further eschews limits on maximum dosages or total prescriptions written, beyond which a doctor's treatment becomes criminal.
Kolodny disagrees, “There's no question that the move toward treating chronic pain patients with opioids is leading to overdose and death. The opioid advocates will talk about balance, but this isn't about balance. This treatment is harming far more people than it's helping.” However, Kolodny provides no evidence to support his claims.
Meanwhile, Balko says that, on the government side, nearly all agencies advocate restricting access to opioid analgesics, databases for monitoring patients and doctors, and a greater role for law enforcement and regulatory agencies to investigate prescribers, pharmacies, wholesalers, and pharmaceutical companies.
Fair-balance notice: The brief snippets above hardly do justice to Balko’s series, which is well researched and quite comprehensive in its approach. At the same time, however, the series reflects some viewpoints that may be contrary to what other authors, groups, and government agencies have asserted regarding opioid-related problems. As with any journalistic endeavor, there may be some biases in what Balko writes; but this would be true of authors on both sides of the dialog.
Furthermore, the document from the Cato Institute, recommended above, is now nearly 7 years old and may not fully reflect the current situation; however, the essential principles described are probably still valid. The Cato Institute — founded in 1977 and headquartered in Washington, DC [website here] — is a public policy research organization, or think tank, “dedicated to the principles of individual liberty, limited government, free markets, and peace.”
As always, we advise readers to consider all facts, opinions, and commentary circumspectly, with the understanding that there are many ways in which authors — whether news journalists, researchers, government representatives, and others — may construct their presentations to support their particular viewpoints.
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