A GROUP OF DOCTORS WANT TO DECIDE FOR ALL PAIN PATIENTS

"I could imagine the cocaine high.  I hadn't touched the stuff for 6 months but I had never stopped craving it."
He took the cocaine,  liquid on his tongue.  "(His) anxiety melted away.  (His) level of alertness rose." (from PROJECTION by Keith Ablow)

"I had to take codeine for the pain.  My mouth is dry, my head feels fuzzy, and I just hate this feeling the drug gives me but I have to take it."
"I was on up to 14 grains a day for 12 years and the day after the pain stopped, I stopped taking the codeine and I was fine."

The first is addiction, from a novel. 

The second is my experience.  It is also what I read and hear all the time from other people with chronic pain.  We hate the drug, we hate having to take them, and we hate the feeling.  (My experience of getting off without problem may be an exceptional one, the chances of some form of physical dependence was certainly possible.)

Yet some doctors are trying to take away our physician's ability to write prescriptions for these drugs in the way they feel their patients need to have them.  Some doctors want to take away prescriptive autonomy from physicians trying to care for their patients in the best way, and sometimes the only way, they know, the only way they have.

The Physicians For Responsible Opioid Prescribing has asked for the following changes to the way opiates are prescribed and for what type of pain:

"SPECIFIC ACTIONS REQUESTED FOR CHANGES TO OPIOID ANALGESIC LABELS:

1. Strike the term "moderate" from the indication for non-cancer pain.

2. Add a maximum daily dose, equivalent to 100 milligrams of morphine for non-cancer pain.

3. Add a maximum duration of 90-days for continuous (daily) use for non-cancer pain.

It continues with "STATEMENTS OF SCIENTIFIC BASIS FOR PETITION":

1. Over the past decade, a four-fold increase in prescribing of opioid analgesics has been associated with a four-fold increase in opioid related overdose deaths and a six-fold increase in individuals seeking treatment for addiction to opioid analgesics.5
2. Prescribing of opioids increased over the past 15 years in response to a campaign that minimized risks of long-term use for CNCP and exaggerated benefits.

3 Long-term safety and effectiveness of managing CNCP with opioids has not been established.

9 4. Recent surveys of CNCP patients receiving COT have shown that many continue to experience significant chronic pain and dysfunction.

5  surveys using DSM criteria found high rates of addiction in CNCP patients receiving COT.

6. A large sample of medical and pharmacy claims records found that two-thirds of patients who took opioids on a daily basis for 90 days were still taking opioids five years later.

7. Patients with mental health and substance abuse co-morbidities are more likely to receive COT than patients who lack these risk factors, a phenomenon referred to as
adverse selection.15

8. Three large observational studies published in 2010 and 2011 found dose-related overdose risk in CNCP patients on COT.

9.COT at high doses is associated with increased risk of overdose death18, emergency room visits19 and fractures in the elderly20. "
((http://www.citizen.org/documents/2048.pdf )

I cannot respond to all of it.  I can to the issue of abuse and misuse, which is what they have been throwing at us (or against us) for some time now.

It is disturbing to me that the information they use is wrong.

Chronic pain patients rarely become addicted.  they may become physically dependent which is a completely different animal.  For instance one study found:
"The results of this evidence-based structured review indicate that COAT  chronic opioid analgesic therapy) exposure will lead to abuse/addiction in a small percentage of CPPs (chronic pain patients), but a larger percentage will demonstrate ADRBs (abuse/addiction and aberrant drug-related behaviors) and illicit drug use. These percentages appear to be much less if CPPs are preselected for the absence of a current or past history of alcohol/illicit drug use or abuse/addiction." 
(http://www.ncbi.nlm.nih.gov/pubmed/18489635 )

This is what most of us already know, a small number of people with chronic pain develop addiction and the larger number that they say abuse/use illicitly tend to have a history of abuse.

That leads (me) to the conclusion that it is not the majority of pain patients but a subset that most doctors should be already careful with because of their history of substance abuse.

They also rely on the statistics: "four-fold increase in opioid related overdose deaths and a six-fold increase in individuals seeking treatment for addiction to opioid analgesics."

Sounds scary but there is no proof or data included that makes it a 1 -1 relationship, that the increased number of people given the drug(s) are the same as the ones who are overdosing or seeking treatment for addiction.  (And seeking treatment is not synonomous with being diagnosed as addicted or being treated for addiction/abuse.)

They also talk about overdose risk, that is the case with many medications, not just opiods.  I am not aware (which does not mean it is not out there) of a similar petition from physicians that, say, psychiatric medications, or even aspirin or ibuprofen, be limited to 90 days and specific dosage because of the risk of overdose.  All medications have an overdose risk, specifically if you give them to people that should not be receiving them in the first place.

That is part of a physician's job; to weed out those patients he sees as someone who would be at risk if given a certain drug, a specific dosage.

I find this petition appalling.  Once again it is chronic pain patients who are under attack.

It seems more relegated to the fallacious War On Drugs, then a medical issue, even for these physicians behind the petition.

If you are concerned about this rrequest to the FDA you can make comments at this site: http://www.regulations.gov/#!submitComment;D=FDA-2012-P-0818-0001