Conflating Effective Chronic Pain Management and Opioid Abuse Potential Charles E. Argoff, MD

My name is Dr Charles Argoff, and I am professor of neurology at Albany Medical College and director of the Comprehensive Pain Management Center at Albany Medical Center in Albany, New York. The comments that I am about to make reflect my own personal opinion regarding the subject matter.

Appropriate, meaningful, and compassionate treatment options for tens of millions of Americans with persistent chronic pain have come under significant scrutiny in the past few years in the face of our nation’s deepening concerns with rising opioid abuse rates. As a physician who is American Board of Medical Specialties certified in neurology and in pain management, I focus on prescribing safe, responsible, and effective treatments for people who are experiencing severe chronic pain. In that context, I am increasingly concerned that policymakers and prescribers are conflating two different and critically important issues.

Addressing the treatment needs of people experiencing severe chronic pain and addressing real concerns regarding the abuse and misuse of various controlled substances, including opioids, are being conflated to such an extent that, as a result, the concept of undo harm to people in pain is becoming the new standard of care due to the sudden cessation of treatment that had previously been efficacious. This is clinically unacceptable.

The foundation of the accepted standards of medical practice is based upon offering appropriate treatment in as safe and effective a manner as possible. When clinicians are able to choose among multiple treatment options for any medical condition, the safest options are meant to be prioritized over those that are less safe. This principle of medical practice is extremely relevant to pain management. Tens of millions of people experiencing severe chronic pain do not experience sufficient relief from multiple nonopioid therapies. These include complementary approaches, rehabilitation approaches, nonopioid pharmacologic approaches, as well as interventional therapies including injections, spinal stimulation, or even intraspinal analgesic approaches.

For these tens of millions of people experiencing severe chronic pain, who have not benefited from nonopioid therapies, chronic opioid therapy may be a safe and effective treatment approach. Thus, appropriate access to such treatment is necessary, recognizing that all prescribed and over-the-counter medications carry risks and that we need to focus on the availability of all types of medications that are as safe as possible. Patients prescribed opioid analgesics—both immediate release (IR) and extended release (ER)—should only be prescribed the safest available agents.

What is the state of available opioid analgesics? Currently, multiple opioid analgesic preparations, including multiple distinct opioid chemical entities, can be prescribed. This is vital to optimizing patient care. As is true with various nonsteroidal anti-inflammatory agents, statins, and certainly with medications used to treat diabetes, while one compound may be effective for some patients, a different compound may be best for others. This underlies, with respect to opioid therapy, the concept of opioid rotation and highlights the need to have multiple opioid analgesics, including oxymorphone, available to most effectively utilize this class of analgesics to treat chronic pain. Yet, currently available opioid analgesics even of the same chemical ingredient are not equal.

Safety enhancements have been made to certain but not to all preparations. The US Food and Drug Administration (FDA) has designated specific opioid formulations as having abuse deterrent properties. Other formulations have been developed to provide greater safety, but the FDA has not designated them as meeting the standards for receiving an abuse deterrent label. However, what cannot be overlooked is that there are multiple additional IR and ER opioid formulations that have not been manufactured to enhance safety in any specific way.

Again, we cannot overlook that there are multiple IR and ER formulations that have not been manufactured to enhance safety in any specific way. Shockingly, the prescriber too often does not have full control of what preparation his or her patient picks up at the pharmacy. We need to find a path to ensure that all opioids, both IR and ER, are armed with abuse deterrent properties. Equally important, we need to ensure that physicians as well as other prescribers, understand these benefits.

The reality is that for millions of people with chronic pain, opioid therapy is effective and safe in helping them to live more comfortable and productive lives. Let me say that again. The reality is that for millions of people with chronic pain, opioid therapy on a chronic basis is effective and safe in helping them to live more comfortable and productive lives. This is true even in the absence of abuse deterrent formulations for all opioids and for all prescriptions, but we can and must do even better on three fronts.

First, we must maintain the availability of multiple specific opioid analgesics to meet the specific and personalized needs of the people we treat who, without such availability, would suffer unnecessarily. Second, we must take actions that meaningfully incentivize the development of the next generation of abuse deterrent formulations. Third, we must ensure that those experiencing severe chronic pain, for whom chronic opioid therapy is an appropriate treatment option, have access to the safest medication options currently available.

In summary, conflating appropriate and effective opioid use with opioid abuse and harm will neither help those who benefit from chronic opioid therapy to be optimally treated, nor will it sufficiently address the disease of addiction, as well as the harms associated with opioid abuse and appropriate treatment for such. Thank you.

 

Published with permission by http://www.rallyagainstpain.com

5 thoughts on “Conflating Effective Chronic Pain Management and Opioid Abuse Potential Charles E. Argoff, MD

  1. While I believe his heart is in the right place, I must continue to disagree with the desire and intention to make ALL opioid analgesics with ‘abuse deterrent’ technologies. This continues to propagate the notion that ALL who consume these vital medicines 1) are addicts 2) will be addicted 3) cannot control themselves. It is wrong. It is false. It is not supported by science and data. Research continually CANNOT prove that all patients who consume these medicines actually become ‘addicted’ and WILL ‘abuse’ their medicines. To punish and make responsible a population who are not responsible, not to blame, do not abuse or misuse their medicine, on average do not divert since they need their scarce medicines so badly, is dishonest, irresponsible, promotes a false and harmful belief system (and science proves that ‘exposure alone does not create addictions’ and ‘addiction does not live in a pill’) and is morally and ethically highly objectionable and questionable. I understand that addicts may need pain treatment as well, but historically, research continues to prove that addiction is actually in the minority in the greater public. Media sensationalism and exaggeration has led people to believe something is ‘bigger’ than it really is. I will not and will never accept that all opioid therapies MUST be made with abuse deterrent technology. I will concede that SOME medicines should be, out of compassion for addicts, and those patients who are PRE DISPOSED to addiction, to have a safer opioid medicine available to them, to help them with pain management , yet not exacerbate an addiction issue. But not all patients who take them are addicts, not all patients who take them will get addicted, not all patients who take them abuse or misuse them. We either have a compassionate, but rational and intelligent compromise, or we continue to promote lies, hysteria, opiophobia, media scare tactics, and bad medicine.

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    1. Concerned patient, I hope you will forgive me if I have missed something in your comment about this, but I wonder what harm would come from the universal application of abuse deterrent technologies (I’ll call them AD for the sake or brevity). I don’t fully understand why anyone would be opposed to AD opioids. Again, maybe you answered this, and I missed it, but what’s the downside? I have taken multiple different opioid medications for chronic pain, including both IM and ER formulations (both with and without AD) and have safely done so for many years, yet I can’t think of any reason why the non-AD version would be better/more appropriate for anyone.

      I should also say that I was once fearful and reluctant to take opioids for my pain. I bought into the social stigma and sensationalized addiction mania- so much so that the pain nearly killed me before I seriously considered taking them. I understand the dangers of addiction, I have seen its devastation in my extended family, close friends and community at large, yet I also understand the legitimate need that exists for myself, and millions of people like me. Many of us face the risk/reward dilemma and choose to take these medications rather than to endlessly endure the mental and physical trauma inherent in chronic pain disorders. I admit that I am frustrated, and at times upset, the feeling that I am a criminal (or at the very least treated with a great deal of suspicion) when I interact with new people at my prescriber’s office or pharmacy (admittedly, much of this may only be in my head). I admit that I think it’s wrong that I have to alter my work/school schedule to physically obtain a hard copy triplicate rx, when all other medications can be submitted electronically (as an aside, isn’t the hard copy easier to fake/alter than an escript?). I think it is ludicrous that I cannot get a refill until the day I run out of the previous rx, which makes me worry that I won’t have these medications in an emergency, when I might need them most. What happens if we have an earthquake, power-outage, flooding, etc. and I’m unable to get to my doctor and the pharmacy for a refill? It is acceptable for me to endure withdrawal symptoms during one of these disasters- a time when I most need to function and care for my family? I should point out that I have never done anything to earn these suspicions. I have, and continue to, done everything that I’ve been asked to do, including random drug screenings, which I do without complaint, despite the aforementioned uneasiness over feeling as thought I am being treated with constant suspicion.

      Why do I mention all of this? Simply to assure you that I am well antiquated with the difficulties inherent with being prescribed opioids for chronic pain. Yet, again I must ask, what harm could come from the AD formulations? What am I missing? I may be physically dependent, as many people are to insulin, SSRI medications, air, water, etc., but I am not addicted. Yet I am against addiction. If we can reduce addiction, and diversion, through AD, why wouldn’t we? This doesn’t hurt me one bit, but rather it could help me. Among other benefits, reducing addiction/diversion can help by: calming the media-driven opioid madness; saving lives; reducing homelessness; reducing unemployment; reducing medical and incarceration costs and reducing crime- all without costing me a thing. I am unable to think of any reason why mandating that all opioids be made AD would be harmful for a legitimate user. It seems like a win-win situation.

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      1. Just my two cents, and experience with AD opioid formulations, the AD prescription didn’t work because it wasn’t able to release all the actual medicine, thus passing through and out of my system.

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      2. If the AD formularies were FDA approved and effective in treating pain, I would certainly be all in. However, until and if that becomes available, people continue to die from complications from the complications arising from under-treated or untreated pain, deaths due to physician abandonment or sudden discontinuance, without tapering, of pain meds which have kept the patient stable sometimes for decades, and the suicides that occur when the patient is in so much pain, see no light at the end of the tunnel, and decide they have had enough. I just don’t think it’s fair to chronic pain patients, who are the most closely monitored people in America, to take away THEIR pain meds. Monthly urine tests confirm the presence of the opioids (thus negating the possibility of diversion) and searching for anything that might be in a person’s system that wasn’t prescribed. In addition, people are subject to pill counts on a 2-hour basis. This would mean that working people would have to carry their meds on them at all times and then come up with some explanation to their employer when they’re called in for a pill count in the middle of the day. Just once, I would love to see everyone in America drug tested and see who has what in their system. The people in pain management walk a straight line or they’re thrown out and not likely picked up elsewhere. And by the way, I don’t care what the FDA says, they swore Tramadol wasn’t addicting for years and then said oops, it is. And please understand one thing. We’re not talking about people with back strains here. There is a long list of diseases, hundreds of horrific injuries, and birth defects which are beyond any pain you’ve probably ever seen in your life. So, while it’s easy for you to say … hang in there and wait for the AD, truth is some can’t wait. This man died from complications related to his disease, not from drug abuse or suicide. A Win-Win situation would be for the legislation to stay out of the doctor’s office and let them do their jobs. Bad doctors, good doctors … good people, bad people … it’s part of life. One thing I know for sure. The harm that has been inflicted on people that I know personally certainly hasn’t been inflicted on heroin addicts. But then again, we must be nice and acknowlege their “disease” and give them all the support we can muster up. These are two separate segments of society. And please do a little research on addiction versus dependency based on medical need. If we found out that addicts were shooting insulin and dying, would we deny insulin to diabetes patients?

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