Battle Over Opioids: Surprising Push-Back, and Not From Dealers

man in pain
Photo credit: geralt / Pixabay (CC0)

The first known victims of prescription opioids were not hardened addicts who stole the drugs to get high. They were injured workers, whose treatment was driven by a narrative that changed the way doctors thought about pain. Now, says the physician who discovered those first deaths, a “huge counter-narrative” may be putting some unsuspecting patients in danger.

Nearly two decades ago, Dr. Gary Franklin identified 32 “definite or probable” deaths of injured workers in Washington State that had been caused by opioid medication. Franklin is medical director for Washington State’s Department of Labor and Industries, and a vice president of the nonprofit Physicians for Responsible Prescribing (PROP).

He was troubled that the affected workers had sustained only “routine injuries” — sprains and low back pain.

“The teaching at the time was that you should use opioids liberally, in everyone with pain,” Franklin said. “Doses were going through the roof.” The deaths, he said, occurred simply because the workers had taken the medication their doctors had prescribed. “They’re not suicides,” he told WhoWhatWhy. “A doctor gives a patient opioids. They go to sleep and don’t wake up.”

But when he discussed his findings at a meeting of the American Academy of Pain Medicine, “I was practically yelled out of the room. They didn’t want to hear it.”

“The first time he interviewed late-stage cancer patients,” he said, he found their testimony “very similar” to the victims of torture. “They’d do anything” to stop the pain.

A lot has happened since 2003, when Franklin faced a hostile audience. The US has been in the throes of a full-blown crisis that has claimed more than 200,000 lives, 40 percent of them involving prescription opioids.

The number of opioid prescriptions is beginning to decline. But even as late as 2015, enough opioids were prescribed to medicate every American around the clock for three weeks. With new federal guidelines and increased restrictions in at least half the states, the pendulum appears to be swinging toward regulation.

But the debate isn’t over, not by a longshot.

“There’s a huge counter-narrative,” Franklin charged. That narrative is driven in part by chronic pain patients who fear that they will lose access to medications they depend on, and buttressed by supportive nonprofits, as well as by some physicians who continue to question how addictive opioids really are.

Waiting in the wings are opioid makers, who continue to make new versions of their products, now touted as “abuse-deterrent.”

One of the new recruits to the “counter-narrative” camp appears to be the respected nonprofit Human Rights Watch (HRW). The group is still investigating the problem, interviewing scores of pain patients alarmed that they may be cut off from their medications, Diederik Lohman told WhoWhatWhy. Its full report is expected by the end of the year. But Lohman, health director for the group, makes clear that he’s been disturbed by what he’s heard. The new laws and guidelines, he contended, are intimidating many doctors who are worried that they will lose their medical licenses.

What About Chronic Pain Patients?

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“A significant number of patients” who have benefited from opioids, Lohman said, now are being “involuntarily” cut off from these medications and “facing pain again.”

HRW got interested in the issue based on its longstanding work in developing countries with cancer patients and other terminally ill who received no drugs to relieve their terrible pain. “I worked on police abuse” in places where there was armed conflict, Lohman said. “The first time he interviewed late-stage cancer patients,” he said, he found their testimony “very similar” to the victims of torture. “They’d do anything” to stop the pain.

This new culture, which emphasized that pain had been undertreated, and that opioids were safe and effective, caused the company’s sales to explode.

Lohman acknowledged that none of the state laws or regulations or federal guidelines for opioid prescribers applies to cancer pain or those with terminal illnesses. Nevertheless, he said that the testimony HRW has gathered from chronic-pain patients demonstrates there’s a problem. And, he’s heard reports of even cancer patients “being denied morphine” because they were not terminal.

Critics of these new restrictions believe that addiction may happen, but that it’s rare. “People who follow doctor’s orders to the letter, they don’t have a problem,” Lohman insisted.

Addiction psychiatrist Sally Satel makes the same point. Satel, a resident scholar at the American Enterprise Institute, receives a lot of media attention for her views. In a recent op-ed, she claimed that “only a minority of people who are prescribed opioids for pain become addicted to them,” and that opioid deaths largely occur when addicted patients get additional drugs from “sources other than their own physicians.”

Those patients who do become addicted, she wrote, likely have suffered from depression or anxiety or “prior problems with drugs or alcohol.”

Incurable Addiction to Profits

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But Franklin found that 7.5 percent of Washington State’s workers who received at least one prescription for opioids during the first weeks after an injury went on to “chronic opioid use.” He added: “If they got at least two prescriptions, or more than seven days of opioids, they were twice as likely to become disabled a year later.”

His research, he said, demonstrates that “taking a little bit of painkiller … contributes to initiating and perpetuating disability. … It just looks like they’re in chronic pain. But actually they’ve become opioid dependent. And they may never come off.” 

“You get hooked quickly,” Franklin said. Doctors were told that “addiction was rare,” he said. “Among all the lies, that was the biggest lie.”

It’s been difficult to police the few doctors who are the source of most of the overprescribing.

The “lie” took hold in the 1990s, after Purdue Pharma began aggressively marketing OxyContin. The company courted thousands of physicians, offering them expense-paid trips to learn about this new painkiller. It essentially changed the culture of pain management, experts say. And this new culture, which emphasized that pain had been undertreated, and that opioids were safe and effective, caused the company’s sales to explode. By 2000, OxyContin sales totaled $1.1 billion, and would climb much higher.

Seven years later, Purdue Pharma pled guilty in federal court, admitting it had misled doctors and the public about the risk of addiction, and agreeing to pay $600 million in penalties.

But that did not mean that Purdue and other companies had given up. Between 2006 and 2015 opioid makers reportedly spent nearly $900 million on lobbying and grants to patient groups and other nonprofits, trying to hold on to the the legislative victories the companies had won in the 1990s.  

Is drug company money supporting this current pushback? Lohman said that HRW does not receive direct or indirect support from drug companies for any aspect of its work.

And the testimony he’s heard is borne out by other surveys of thousands of chronic pain patients who report that their doctors no longer want to treat them, or want to cut them off from the opioids they have depended on.

Purdue, now facing scores of lawsuits from states dealing with the consequences of the opioid crisis, have been paying lip service to the need for more responsible prescribing and the risks of addiction.

But as Diana Zuckerman, president of the National Center for Health Research, told WhoWhatWhy: “It’s obviously politically correct to say this is a terrible crisis and we’re going to do everything we can. But for companies that are trying to sell their product, selling less is not helpful to their bottom line.”

While Lohman’s concern for chronic pain patients may be entirely sincere, the arguments he makes about the risks of addiction from these powerful painkillers appear to echo the very same arguments that pain physicians, with extensive links to opioid makers, have put forward for years.

Moreover, in its 2014 annual report, the most recent report for which significant donors are listed, HRW reported a grant of $100,000 or more from the US Cancer Pain Relief Committee. The committee’s five-member board includes two prominent pain doctors, Richard Payne and Russell Portenoy, who have received financial support from Purdue Pharma. (HRW also has received substantial grants from many other funders, including the Open Society Foundations, the Ford Foundation, and the Public Welfare Foundation.)

Last March, 20 public television stations aired a documentary, The Painful Truth, paid for by Dr. Lynn Webster, a pain specialist with longtime financial ties to opioid makers. The documentary raised concerns that the new restrictions on opioids harmed thousands of patients. Viewers were not informed about those financial relationships or the financial ties of other physicians who appeared in the documentary.

This pushback has not yet prevented stricter standards from taking hold.

Drug companies have not ceased making or marketing opioids. Companies now are pitching “abuse-deterrent” products.

For example, new rules for pain clinics in three states — Florida, Ohio, and Kentucky — helped decreased opioid prescribing in many counties. As of March 2018, 25 states had tightened their rules or guidelines on opioid prescriptions.

The Centers for Disease Control and Prevention (CDC) in 2016 issued comprehensive guidelines, advising primary care physicians to limit the use of opioids in treating patients with chronic pain. The CDC recommends using opioids only when all other treatment options have been exhausted, giving the lowest possible doses, and continuing to prescribe them only if it reduces patients’ pain and improves how they function in “clinically significant” ways.

In 2017, the CDC issued a factsheet that encouraged doctors to also curb their prescribing of opioids for acute pain as well limiting duration of treatment to under a week, and restricting the size of doses. The CDC informed physicians that prescribing opioids for more than three months increases the risk of addiction by 15 times. Giving an opioid equivalent to 90 milligrams or more of morphine a day increases the risk of a fatal overdose by ten times.

However, Franklin believes there continue to be big problems. Opioids still are routinely given for acute pain after surgery or even tooth extractions, he said. “Eight-five percent of dentists are still using opioids as first-line therapy. The median number of pills they’re giving is 20 pills.”

And while some doctors might fear losing their medical licenses if they prescribe opioids too liberally, those fears may be overblown.

Granted, there has been more scrutiny of physicians by the Drug Enforcement Agency (DEA), experts say. But even then, few physicians were implicated. In 2016, for example, the DEA took action against 479 physicians, a tiny fraction of the more than 800,000 doctors in the US.

DEA, agent

Photo credit: DEA

While state medical boards have increased their discipline of doctors, the boards actually sanction very few physicians. In 2012, for example, fewer than one percent of actively licensed physicians were disciplined by state boards. Between 2010 and 2014, Ohio’s state medical board reviewed only about 35 doctors a year because of concerns about their overprescribing.

State medical boards, Franklin said, lack the resources to scrutinize doctors and rarely act unless there is a complaint. When facing board scrutiny, “the doctors lawyer up,” and usually escape strong punishments, he said. That’s particularly true in states with laws that give doctors wide discretion in prescribing FDA-approved drugs. “It’s very hard for these boards to be effective,” he said.

Indeed, it’s been difficult to police the few doctors who are the source of most of the overprescribing.

“There is still a small number of doctors treating a large number of patients on high-dose opioids,” Franklin said. As a consequence, he charged, “a small number of believers” in the efficacy of opioid treatment are treating “millions of patients in those practices in the country.”

Label Abuse

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And drug companies have not ceased making or marketing opioids. Companies now are pitching “abuse-deterrent” products. That term is widely misunderstood, Zuckerman said. “There is this assumption by patients, family members, and doctors that it means less addictive.”

But all the term really means is that you can’t crush the pills, so you can’t inject or snort them. Zuckerman and experts at her center have urged the FDA to do more to inform doctors about the label’s true meaning, and to apply more scrutiny when being asked to approve “abuse-deterrent” painkillers. As of mid-July 2017, the FDA had approved the “abuse-deterrent” label for eight opioid drugs.

“Obviously abuse-deterrent has great marketing appeal, more appeal than crush-resistant,” she added. “The companies have no incentive — and no interest — in clarifying that point.”


Related front page panorama photo credit: Adapted by WhoWhatWhy from pain scale (Tom Woodward / Flickr – CC BY-SA 2.0).

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16 responses to “Battle Over Opioids: Surprising Push-Back, and Not From Dealers”

  1. Scott Fulmer says:

    Last week the MA DPH released a study quantifying the association between certain categories of work and fatal opioid overdose in Massachusetts.

    People need to realize that reducing exposure to risk for pain and injury at work is frontline in the battle to prevent opioid addiction and overdose. It’s not the only frontline, but an important one.

  2. russ crawford says:

    Have there been any articles published which answers the question of why doctors refuse to prescribe the safe and effective drugs all the rehab centers use? These doctors are instead requiring their patients to submit to a totally unnecessary treatment at a rehab center often suggesting a preferred one. Could the reason be that they get a financial reward for every referral? Millions are looking for the release from their addiction but cannot afford the price tag. They know what dope sickness feels like and are willing to do anything to get the money to get the drugs in order to avoid the painful withdrawal. A simple prescription for a 2 day supply of these inexpensive detox drugs can be shown to be just as safe and effective administered in the home as they are in any $1,000 a day stay at a rehab center. I should know, I went through detox and was given a list of the drugs given. The access to the 6 detox drug .2Catapres capsules was my only reason for having to pay over $2,000 for the two day stay. Why are doctors refusing to prescribe the cure? Could the reason be that there is more money to be made in referring you to a center where they will receive an undisclosed kickback for the referral? I don’t know this for a fact but I suspect a legal system that allows drug reps to reward doctors financially can’t be very far from allowing what I suggest as being legal and therefore assuredly operational. Will no one step forward to confirm what I’ve supposed? If what I say is true then let’s try and stop it by exposing it and making the physicians feel ashamed for continually choosing what is best for themselves over what is best for their patients.

  3. barbara henninger says:

    The deaths and addictions I’ve heard about are from prescription drugs bought second hand. This means that there are too many pills being prescribed. If the drugs were only used by those who need them, there wouldn’t be so many sold on the street. Capitalism dictates that drug companies will push as much of their product out without regard to whom it hurts. They will always be the pushers and the push-backers when it comes to safety regulations.

    • Leon says:

      Well you have heard wrong. Most of the deaths are from street drugs. Most of those deaths are preventable but no one in this country is going to legalize heroin. The amount that comes from pain patients is small. The people pushing back on all this bs are pain patients who just want a life. Don’t believe the propaganda.

  4. Lawrence F says:

    With all due respect to Claire above, I’ve got 30 yrs worth of RSD/CRPS nerve pain in all four limbs. Chiropractic was wonderful for two hours of short term spasm relief until the physical manipulation itself became 8 hours of subsequent hell. Meditation, visualization are decent tools in conjunction with the pain pills & muscle relaxants that I use, the dosage of which has remained steady for the past eight years without me cajoling doctors for extra, seeking more on the street, all the while selling my family down the toilet for a high that oddly, as a legit chronic pain patient, responsibly following doctor’s orders, I have never had. Physical dependence, maybe, but no more than a diabetic is physically dependent on insulin to live their life as best they can. Most people who abuse prescription opiates intended to from the beginning, or never should have been prescribed opiates as they had a prior addiction problem or showed signs of addictive personality or an inability to follow the doctor’s instructions. No drug relieves all the pain all the time. RSD/CRPS at its worst is rated as more painful than childbirth. When the pills and the particular day are at their best my pain is still a 4 on a ten scale. I don’t take extra tablets in some fool belief that it will lower to ‘0’. And too many deaths that lead to all the political posturing and sexy media stories ignore that the opiate involved is often a supporting player to benzodiazepines and alcohol. Lastly, I don’t know about Dr. Franklin per se, but his colleagues on PROP, like Andrew Kolodny, have deep ties to addiction conglomerates like Phoenix House which don’t make money when physicians write prescriptions, but God, they do make out from repeat clients at the doors of failed addiction programs. Money in the pocket IS a conflict of interest.

  5. CA Saether says:

    Thank Goodness! there are people advocating for chronic pain sufferers! Pretty much on par with those who fight against torture practices, truth be known. Sure would be nice if those of us who rely on opiates to function weren’t so haplessly roped into the grueling tug-of-war between all of the problems and all of the ‘solutions’ surrounding their abuse, though. ..

  6. Claire says:

    I believe there are far better options than opioids for patients with chronic pain. Treatments like physical therapy, chiropractor care, yoga and other somatic exercises and even mental health therapy can have profound improvements on patient outcomes; especially long term. However, these services are rarely covered by insurance companies and if they are it is very short term and the co-pays and co-insurance costs limit many patients’ ability to continue treatment. If we are serious about this issue, then de-regulating the services that insurance companies must cover is NOT the answer! We must regulate insurance companies to ensure patients are fully covered for services and have th ability to intimidate a course of treatment for long-term, improved pain outcomes.

    • Reese Tyrell says:

      This is mostly right. Many patients would benefit from regulation requiring insurance companies to cover every alternative therapy. However, these alternatives are not “far better options” for every patient. There are, for instance, rare autoimmune diseases for which none of those therapies make any difference.

    • SophieBlue says:

      It’s an “all of the above” issue. For my part, a spinal cord issue first caught by a chiropractor in the 1980s finally came home to roost a few years ago. I have always been active, and I believe that is what kept the condition under wraps for so long. But when it got worse–and was unrelieved by radical surgery–I became the “chronic pain patient.” I use yoga, physical therapy, massage, and chiropractic medicine to reduce the amount of pain meds I need. Before the pain meds, I was damaging my liver with Tylenol and my stomach with ibuprofen. I tried gabapentin, but the effects on my brain were horrendous. The drug with the lowest systemic effect on my body is the hydrocodone. I was lucky in that I didn’t also have conditions that limited my ability to use yoga, etc. Like so many other chronic pain patients, I need the pain meds just to function normally.

  7. Kathleen Carroll says:

    Long-term pain patients are a very mixed bag of folks. Many are our heroic veterans, injured during their service protecting us all. Some have been in horrific accidents. Others moved the wrong way or lifted something heavy that set off a series of physical issues. Some have genetic degenerative conditions. Some have life-threatening or terminal illnesses. Others, like me, have incurable, but non-life threatening diseases. Almost all causes were out of our control. The reasons are numerous, but immaterial, really.

    The important point is, patients with legitimate chronic pain, for whatever reason, are finding it more and more difficult to access pain medications. These types of drugs have been used for pain for literally centuries. Yes, a certain percentage of the population will become addicted to SOMETHING, be it heroin, fentanyl, opioids, alcohol or tobacco. Amazingly enough, that percentage has not changed that much. There are more addicts because there are more people. There are more overdoses because the drugs people who abuse are taking have become very dangerous. They are more potent, mixed with other unknown drugs, or mixed with alchohol.

    The truth is, very few pain patients take these meds from choice. They merely make our lives bearable. They do NOT make us “high” or euphoric. Our pain is rarely completely alleviated. And very few patients share, steal, or sell their meds. We need them too much to risk messing up our access; access which is becoming more and more difficult because we are an easy target.

    Even hospitalized, painful post-op patients are being denied proper pain care. People are postponing surgeries due to the real fear of hospitals not having the pain meds or refusing to administer them.

    Congress is busy legislating the quantity of opioids being manufactured, while vast amounts of illegal heroin, fentanyl and variations thereof, as well as new synthetic marijuana varieties that are complete unknowns are pouring into our country from Mexico and China. They come in the U.S. MAIL(!), and over the borders. Why are these “easy” targets not being taken out? Why is everyone focusing on people who have legitimate pain needs, are stable, don’t run out of meds early, or take more than prescribed? Why are millions of Americans, who do all the right things, being abandoned by our doctors and our government? Both are sworn to protect us and neither are.

    I have been in continual pain since sometime in 1994. Due to my particular illness, my meds allow some relief, but not enough to be able to work, enjoy hobbies I loved, maintain relationships, personal or social, or to even be able to make plans. I never know until I wake up what kind of day I’ll have. Some days aren’t bad, others are so bad I can’t get out of my bed. Imagine the kind of anxiety and depression that years and years of this cause, in addition to the pain. I am not unique.

    I am extremely fortunate, so far, to have a very sensible pain management doctor and to live in a state that hasn’t made the ridiculous CDC “guidelines” law. Even he attempted to taper me, with disastrous results. I worry about what I’d do if I lost him.

    Many people are not so fortunate. They are being forcibly tapered or entirely cut off, even if they are stable, able to have a reasonable semblance of a normal life, never ask for a dosage increase and follow all the rules. These people’s lives have been completely turned upside down, AGAIN! Apparently once was not enough. Why?

    We, as a country, need to get our focus right. It’s not left or right, blue or red. It’s American. And millions of Americans have severe chronic pain. Think about how you would feel if it was YOU or your loved one. What would YOU do? Where would YOU turn for help? How would YOU feel?

  8. Pam Aylor says:

    Chronic pain patients are not addicts! Nor should we be under treated or receive no treatment for our pain due to the actions of addicts. Addiction begins in the brain and is a tragedy, but that should be a separate issue. Keep the government out of the doctor-patient relationship!

  9. Jason says:

    Great article. Although, you’ve missed out on the numerous patients who have been cut off and committed suicide. Many thousands of vets especially who the VA has cruelly cut cold turkey since 2014.

    The “epidemic” since 2015 has largely been users of heroin who’ve had their doses spiked with fentanyl, and more recently, the far more potent drug “carfentanil” which is terrible. They need to expand access to maintenance drugs like suboxone, or consider an approach like Portugal and some cities in Canada where they provide a safe supply of heroin to decrease death rates. They inject folks in the clinic; treatment is by a doctor so no deaths have happened. It’s worked out better than some of the maintenance drugs like Suboxone or Subutex.

    I believe if you have pain, you shouldn’t be told that you’ll have to suffer simply because other folks couldn’t keep to the rules. I’m terminally ill with a neurodegenerative disease, I should be told I have to come in and urinate in a cup to get my medication when even that alone is so tiring. This is nonsense and when you have folks at the DEA and CDC trying to be shadow-legislators who aren’t accountable to anybody, it is unacceptable. They aren’t the FDA. Get out of my doctor-patient relationship and stick to diseases because if you can’t see that 90% of these deaths are heroin related, then these folks at the CDC have failed their jobs. So frustrating that folks with legit chronic or terminal illnesses are left with the choice of enduring the pain, buying drugs on the street, or committing suicide (which happens a lot, check google for intractable pain suicides).

    • CHERYL says:

      We live in a society that has used drugs, inc the legal one, alcohol since this country began. While those in chronic pain suffer mostly in silence, I believe we should start bringing class action lawsuits to doctors who refuse to treat our pain if we are long standing patients and are being cut off of meds.

      They are more afraid of losing their Mercedes than alleviating my suffering and standing by the oath they took.

      No remembers the cocaine epidemic of the 80’s. People dying, chronic overdoses, everyone scared. Now you rarely hear of it, but it still exists. Oxycontin is the new cocaine of the new millennia.

      There are far more deaths, addicts, health problems and abuse by LEGAL alcohol than by prescription drugs. Believe me, a lot of pain sufferers are going to turn to alcohol as a means of legal relief.

      If you are under a physician care and you are compliant, there is no reason not to be prescribed your working dosage of meds. What these politicians and doctors fail to see is the every day life of a chronic patient.

      The day for us revolves around trying to get out of bed, getting dressed, trying to sit to eat, using the facilities, bathing, taking care of family, working jobs and maintaining some kind of social life all with excruciating pain that feels like you were in a car pileup. All while doing it without complaining for fear of job, family, social and dignity loss.

      This is where the meds kick in so we may endure our path in life. None has asked for the cross we bear. But now we are given the life sentence of pain once again because a small segment of society has an addiction problem.

      They tried prohibition, they tried to stop marijuana, which is now legal in some states, they tried to stop the flow of illegal drugs, all to no avail.

      We don’t let animals suffer, but politicians and now the very doctors who took an oath allow us to suffer needlessly. When euthanasia becomes law, you will have lines out the door and down the street. All because of medical science.. or lack there of.

  10. The opiate is highly addictive. Less pills = Less deaths. End the opiate Epidemic.

    • Reese Tyrell says:

      Less pills for short-term pain? Very much needed. Less pills for someone like me, with a rare genetic disease (IC/BPS = open wounds in the bladder that never heal), would have meant 20 years unable to leave the bathroom, let alone earn a Ph.D., teach college, or parent my son.

      I’ve been through every alternative therapy there is, including multi-modal pain clinics. My marriage and my happy healthy son would never have existed if I hadn’t found a pain specialist who was a “believer.” I know it’s no karmic balance for countless lives lost to bad prescribing, but I can say there was one life gained from good prescribing, and that’s not nothing.

      Dr. Franklin, if you are reading this, I am open to talking and would very much like to have a conversation about these “patients on high-dose opioids,” who we really are, and the horrifying incurable diseases that would have left us disabled for the last 20 years.

    • Annie says:

      That’s not true, addiction is a set of heritable traits found in only 2% of medical opioid users. Some illegal drug users do start on pills but they start on diverted pills, prescription opioids that were given to them, stolen, or bought from a dealer. They are not initiating on as-directed pain medication prescribed for them by their doctor, it was found 78% of people in heroin rehab had never legally taken an opioid in their lives. CDC data supports that prescription are not driving the OD Crisis as prescriptions are at a 10 year low while overdose deaths are at a 10 year high. All this “cracking down” did was send people with OUD from pills to more potent street drugs with a deadly lack of quality control.