Ron Paul Classic: War on opiods and doctors or war on patients?

Shortly after the U.S. Senate passed legislation authorizing the creation of “best-practices” for pain management, the Center for Disease Control unveiled new “guidelines” for the use of pain medicines.

While the guidelines are non-binding, the fact that they come from a federal agency means they will influence the way regulators, insurance companies, and even malpractice lawyers, judge, and juries adopt issues related to pan management. Thus, every American who suffers from, or could suffer from, or has a loved one who suffers from, extreme pain–meaning every American– should be concerned about these “guidelines.”

Jacob Sullivan writing at Reason magazine provides more details:

But doctors who internalize the CDC’s overwrought concerns about addiction and overdose (more on those in a minute) will be inclined to avoid opioids even when the alternatives are only half as effective, leaving patients to suffer unnecessary pain. The CDC wants doctors who are already inclined to treat patients complaining of pain with suspicion to be even more leery. It recommends interrogation and urine testing aimed at discovering illicit drug use, ostensibly to inform clinical decisions. It does not explicitly say that someone who, say, admits consuming cannabis or tests positive for it should be denied the drugs he needs to control his pain, but you can be sure that will be the result in some cases.

“Clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids,” the CDC says. “Three days or less will often be sufficient; more than seven days will rarely be needed.” Since pain cannot be objectively verified, what counts as an “effective dose” or a “needed” quantity depends not only on the patient’s report but on the doctor’s willingness to believe it. The CDC is encouraging doctors to be more skeptical of patients’ reports and to substitute their judgments for those of the people who are actually experiencing the pain. That tendency, combined with the arbitrary limits on pill counts, will mean more needless suffering.

The official justification for exercising that clout is the need to curtail the “epidemic of prescription opioid misuse and overdose,” which according to the CDC killed more than 165,000 Americans between 1999 and 2014—around 10,000 a year on average. That sounds like a lot, but it’s a tiny percentage of the people who received opioid prescriptions during that period. The CDC says “health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills.” On the face of it, 10,000 or so deaths out of 259 million prescriptions—one for every 26,000—do not amount to a very big risk.

The same goes for addiction. According to the National Survey on Drug Use and Health (NSDUH), a bottle of opioids for every American adult resulted in about 2 million cases of “abuse or dependence” in 2014, or one for every 130 prescriptions. The rarity of abuse or addiction should come as no surprise to the vast majority of Americans how have taken Vicodin or Percocet for pain. Maybe you enjoyed the buzz, but odds are you did not continue taking painkillers every day once your pain was gone.

The truth is that using such drugs regularly for their psychoactive effects appeals to only a small minority of people, which is one reason heroin has never been very popular even among illegal drug users. “We lose sight of the fact that the prescription opioids are just as addictive as heroin,” says CDC Director Thomas Frieden.

In other words, not very. The risk of addiction for pain patients is even smaller than these numbers suggest, because most nonmedical opioid users do not start as pain patients. According to NSDUH, only a quarter of people who take opioids for nonmedical purposes get them by obtaining a doctor’s prescription. Most (66 percent) get them from a friend or relative, usually for free by asking, sometimes surreptitiously and sometimes in exchange for money. Another 5 percent buy opioids from a dealer or other stranger.

Theft, fake prescriptions, the Internet, and “other” account for the rest. Hence the sequence that many people imagine—a patient takes opioids for pain, gets hooked, and eventually dies of an overdose—is far from typical of opiod-related deaths. Opioid-related deaths are rare even for patients who take narcotics every day for years. The CDC cites “a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain” who were followed for up to 13 years.

The researchers found that “one in 550 patients died from opioid-related overdose,” which is a risk of less that 0.2 percent. Furthermore, that risk is not random, since deaths attributed to opioids generally involve combinations of two or more drugs.

Discouraging such dangerous mixtures, combined with wider availability of naloxone, would help reduce the number of deaths involving prescription opioids and heroin, which hit a record high of 29,467 in 2014. Cracking down on painkillers, by contrast, will only drive more prescription opioid users to heroin, which exposes them to more danger. “In the case of heroin,” observes Norah Volkow, director of the National Institute on Drug Abuse, “this danger is compounded by the lack of control over the purity of the drug injected and its possible contamination with other drugs (such as fentanyl, a very potent prescription opioid that is also abused by itself).

All of these factors increase the risk for overdosing, since the user can never be sure of the amount of the active drug (or drugs) being taken.”

Read the whole piece here.

Kentucky Senator Rand Paul has proposed making it easier for physicians to treat heroin addiction by repealing federal regulations that make it more difficult to treat addicts:

U.S. Senator Rand Paul of Kentucky says Congress is close to approving a bill that will help combat heroin addiction in his home state. Speaking at a medical town hall in Bowling Green today, the Republican lawmaker said federal restrictions have too often stood in the way of giving heroin users effective treatment for their addictions.

Under current law, doctors can prescribe suboxone to 30 patients at a time in the first year, and 100 the following year. Suboxone can help lessen dependence on the drug. Paul is co-sponsoring a bill to increase the cap to 500 patients. “There is said to be a million patients who need to be treated but don’t have a doctor to go to because of this federal law limiting access,” Paul says. Paul said those limits have maxed out doctors.

“They didn’t want people to prescribe too many of the drug replacements, like the pill-mill, so they limit the number of patients. But as a consequence, they made the number small enough. And there aren’t many doctors treating heroin addicts that now there’s more heroin addicts than doctors that they can see,” he says.

In 2004, following radio talk show host Rush Limbaugh’s legal troubles for his use of painkillers, Campaign for Liberty Chairman Ron Paul addressed how federal drug laws interfered with effective pain treatment:

Mr. PAUL. Mr. Speaker, the publicity surrounding popular radio talk 
show host Rush Limbaugh's legal troubles relating to his use of the 
pain killer OxyContin will hopefully focus public attention on how the 
federal War on Drugs threatens the effective treatment of chronic pain. 
Prosecutors have seized Mr. Limbaugh's medical records in connection 
with an investigation into charges that Mr. Limbaugh violated federal 
drug laws. The fact that Mr. Limbaugh is a high profile, and often 
controversial, conservative media personality has given rise to 
speculation that the prosecution is politically motivated. Adding to 
this suspicion is the fact that individual pain patients are rarely 
prosecuted in this type of case.
  In cases where patients are not high profile celebrities like Mr. 
Limbaugh, it is a pain management physician who bears the brunt of 
overzealous prosecutors. Faced with the failure of the War on Drugs to 
eliminate drug cartels and kingpins, prosecutors and police have turned 
their attention to pain management doctors, using federal statutes 
designed for the prosecution of drug kingpins to prosecute physicians 
for prescribing pain medicine.
  Many of the cases brought against physicians are rooted in the 
federal Drug Enforcement Administration (DEA)'s failure to consider 
current medical standards regarding the use of opioids, including 
OxyContin, in formulating policy. Opioids are the pharmaceuticals 
considered most effective in relieving chronic pain. Federal law 
classifies most opioids as Schedule II drugs, the same classification 
given to cocaine and heroin, despite a growing body of opinion among 
the medical community that opioids should not be classified with these 
substances.
  Furthering the problem is that patients often must consume very large 
amounts of opioids to obtain long-term relief. Some prescriptions may 
be for hundreds of pills and last only a month. A prescription this 
large may appear suspicious. But, according to many pain management 
specialists, it is medically necessary, in many cases, to prescribe 
such a large number of pills to effectively treat chronic pain. 
However, zealous prosecutors show no interest in learning the basic 
facts of pain management.
  This harassment by law enforcement has forced some doctors to close 
their practices, while others have stopped prescribing opioids--even 
though opioids are the only way some of their patients can obtain pain 
relief. The current attitude toward pain physicians is exemplified by 
Assistant U.S. Attorney Gene Rossi's statement that ``our office will 
try our best to root out  like the Taliban.''
  Prosecutors show no concern for how their actions will affect 
patients who need large amounts of opioids to control their chronic 
pain. For example, the prosecutor in the case of Dr. Cecil Knox of 
Roanoke, Virginia told all of Dr. Knox's patients to seek help in 
federal clinics even though none of the federal clinics would prescribe 
effective pain medicine.
  Doctors are even being punished for the misdeeds of their patients. 
For example, Dr. James Graves was sentenced to more than 60 years for 
manslaughter because several of his patients overdosed on various 
combinations of pain medications and other drugs, including illegal 
street drugs. As a physician with over thirty years experience in 
private practice, I find it outrageous that a physician would be held 
criminally liable for a patient's misuse of medicine.
  The American Association of Physicians and Surgeons (AAPS), one of 
the nation's leading defenders of private medical practice and medical 
liberty, has recently advised doctors to avoid prescribing opioids 
because, according to AAPS, ``drug agents set medical standards.'' I 
would hope that my colleagues would agree that doctors, not federal 
agents, should determine medical standards.
  By waging this war on pain physicians, the government is condemning 
patients to either live with excruciating chronic pain or seek opioids 
from other, less reliable, sources--such as street drug dealers. Of 
course, opioids bought on the street will likely pose a greater risk of 
damaging a patient's health than will opioids obtained from a 
physician.
  Finally, as the Limbaugh case reveals, the prosecution of pain 
management physicians destroys the medical privacy of all chronic pain 
patients. Under the guise of prosecuting the drug war, law enforcement 
officials can rummage through patients' personal medical records and, 
as may be the case with Mr. Limbaugh, use information uncovered to 
settle personal or political scores. I am pleased that AAPS, along with 
the American Civil Liberties Union (ACLU), has joined the effort to 
protect Mr. Limbaugh's medical records.
  Mr. Speaker, Congress should take action to rein in overzealous 
prosecutors and law enforcement officials and stop the harassment of 
legitimate pain management physicians, who are acting in good faith in 
prescribing opioids for relief from chronic pain. Doctors should not be 
prosecuted for doing what, in their best medical judgment, is in their 
patients' best interest. Doctors should also not be prosecuted for the 
misdeeds of their patients.
  Finally, I wish to express my hope that Mr. Limbaugh's case will 
encourage his many fans and supporters to consider how their support 
for the federal War on Drugs is inconsistent with their support of 
individual liberty and Constitutional government.

Ron Paul Classic: War on opiods and doctors or war on patients?

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