MANCHESTER — I’m writing to express concerns about the 350,000 Mainers with chronic nonmalignant pain and L.D. 1646, meant to better control dispensing pain medicine in Maine.

As a federal expert witness and litigation consultant for the U.S. Drug Enforcement Administration, the FBI and the Office of the Inspector General, I’ve helped imprison and remove from practice physicians around the country who have killed patients by overprescribing controlled substances.

Heroin and illicit opiate use is at a record high. But legitimate pain patients using opiates for therapeutic purposes should not suffer because of the impact of addiction and political pressure to fix what has become an epidemic in our country.

There are more patients in chronic nonmalignant pain than cancer, cardiac and diabetic patients combined. Yet pain patients – legitimate, well-vetted patients – are treated like pariahs. From family and co-workers to pharmacists and ERs, pain patients have overt biases thrust on them.

Needing pain medicine does not make one a drug addict or a criminal. Arguably, neither does being an addict make someone a criminal. However, in our current societal climate, those physically dependent and using medication appropriately are treated like drug addicts. “Drug addicts” – people with a substance use disorder – are treated worst of all, though they have an illness that needs treatment, not disdain and criminalization.

The issue becomes confusing, as policy focus is to limit drug access to substance use disorder patients actively using opiates, yet getting high may not be why they take pain medication.

Nonmedical use of prescription opioids is the real issue. Nonmedical users take pain medicine either not as prescribed or from a nonmedical source; that is, other than how it was prescribed or intended. While nonmedical opioid use has dropped, it correlates with escalation of heroin use.

A significant portion of nonmedical users in the general population (48 percent) use opiates for untreated or poorly treated pain; another 32 percent have mental health disorders.

Moreover, the notion that taking prescription pain medicine inevitably leads to addiction is absurd. Addiction is a biogenetic, behavioral disorder with predictable risk factors. Using pain medicine nonmedically may potentially increase the risk of abuse, but it does not mean that pain medicine causes abuse. Limiting access to opiates in appropriate, therapeutic medical settings will only lead to more nonmedical use, diversion and heroin use.

In the pain world, there are two camps on pain medications: those who believe in using opiates and those who don’t. There’s not much gray area.

The U.S. Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain were designed for primary care, not pain medicine. L.D. 1646 does not distinguish between the two. Moreover, the consulting CDC authors were not the national opiate authorities. In short, the study was biased to address addiction issues, not pain management.

We have over 4,000 patients in our pain practice; only 209 are on chronic pain medication. Functionality, not pain relief, is the goal for pain treatment.

With proper risk-mitigation strategies (i.e., controlled substance agreements, urine drug screens with confirmation testing, random pill counts, Prescription Monitoring Program participation, scheduled risk stratification of each patient) in place, diversion and subsequent illicit use can be rapidly identified. It is imperfect, but it is the best means to identify and stop diversion while still providing care to those who need it.

Such monitoring should not stop at the doors of pain practices. Pediatricians treating attention-deficit hyperactivity disorder and attention-deficit disorder with Ritalin, Adderall, etc., and psychiatrists treating anxiety with Ativan, Valium, Xanax, etc., should be accountable as well. Drug diversion in these populations is rampant; worse, polypharmacy (multiple medications) is what leads to overdose death, as it’s unusual to see overdoses involving just heroin or just opiate pain medicine.

Rhetoric and fear mongering are inappropriate methodologies to manage a medical condition. Legitimate patients must not suffer because addiction has become the enormous problem it is. Putting in risk-mitigation strategies and identifying patients for whom opiate therapy is appropriate, as part of a multidisciplinary and multimodal approach, is what good pain management is and should be.

Legislating medical management is a dangerous trend. However, mandating risk-mitigation strategies and appropriate regulatory utilization does not dictate medical practice and makes sense for those prescribing controlled substances. If these providers and practices won’t implement such strategies, perhaps they should reconsider what and how they are prescribing.

 

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