Chronic Pain: NPS and the CDC Guidelines Trending on Social Media

Chronic pain topics trending on social media have increased with the release of the National Pain Strategy (NPS) and the CDC Guidelines for Prescribing Opioids. Having submitted comments on both drafts, I felt it was time to express my personal opinions. There are vast differences between the two, even though the “CDC Guidelines” are specifically mentioned at the conclusion of the NPS report.

CDC Opioid Checklist: The good, the bad, and the ugly 

Overall, the checklist is not difficult to understand and physicians will be more likely to use it. Where I do not comment, assume it to mean I don’t see any reason to mention it.

Good Stuff:

·        “For primary care providers treating adults.” - Primary care physicians need guidelines by government agencies so they do not fear retaliation by the DEA. Not all patients living with persistent pain require supervision by a pain specialist; in fact, there aren’t enough pain physicians to meet the needs of over 100 million Americans living with chronic pain.

·        “Known risk factors” – Important assessment.

·        “Prescription drug monitoring program”  (eleven states do not have a PDMP) – You can read what I think about medication safety on my website. PDMPs are good for identifying signs of drug diversion or abuse, which protects responsible people, but will physicians who treat patients with conditions that cause chronic pain, i.e., pain physicians or rheumatologists be singled out? And, how will this affect patient care in states without a PDMP?

·        “Behavioral treatment” – This piece is often difficult for physicians to discuss with their patient’s, and vice versa. However, there is evidence that shows our behavioral response to pain makes a difference in our ability to cope with the fall of of living with chronic pain, and how we respond to it mentally and emotionally can affect our pain intensity. (This does not mean it treats the pain source directly, however.)

·         “Schedule initial reassessment within 1– 4 weeks.” – This should be done any time a new medication is started, including non-opioids that affect the central nervous system.

·        “Assessing pain and function using PEG scale” – This one gets a mixed review. Relieving pain, decreasing the intensity to improve quality of life is the reason we seek pain care. However, quality of life should be assessed according to what that means for each individual patient. For instance, a diseased spine or joint is not going to function better despite pain relief. Q1 is difficult because it relates to an acute pain scale, which is not helpful for assessing chronic pain, especially in a person with more than one pain condition. Q2 reverts back to my comments on changing behaviors. Enjoyment of life is not affected by opioids, it is affected by developing healthy coping skills as is the truth for any chronic illness. Enjoyment of life fluctuates for everyone.  Q3 Improving endurance, i.e. activity, cannot be achieved without therapies that are often capped by Medicare and is not based on patient outcome. And, easing pain will not necessarily result in increased activity. Overall, asking a patient to make their own assessments is important, but placing an arbitrary number (30% improvement) is punitive. Many factors, life situations, can cause the numbers to fluctuate. One cannot assume status quo for chronic pain anymore than they can assume blood sugars will remain constant in treatment of diabetes.

Bad Stuff

·        “Benefits of long-term opioid therapy for chronic pain not well supported by evidence.” – Describe evidence? Anecdotal reports from physicians who specialize in pain medicine are evidence (but they were not represented in the “Core Group” of experts). If they are referring to research, there is no evidence to suggest opioids don’t work for long-term pain care.

·        “Schedule reassessment at regular intervals (≤ 3 months)” – This guideline is not appropriate for patients who do not need advanced pain care. Patients who have been on the same opioid dose for years do not require such close observation. Many patients, particularly the elderly, do not have the ability to see the doctor this frequently, nor is the physician available. To put an absolute time interval (without cause) puts an unnecessary burden on the physician, patient, and insurance, including Medicare, and drives up healthcare costs. This is a total disregard for common sense.

·        “Urine drug screens.” I am not against them when there are signs of abuse. (Perhaps the checklist should include assessment of those behaviors.) However, using drug screens to assess risk without probable cause is offensive for several reasons: they are accusatory (guiltily until proven innocent), they are humiliating, they are not consistently accurate, and they are not always covered by insurance, which is discriminatory against folks who can’t pay. Innocent people are being tortured by inaccurate results, while drug testing companies are making a killing, sometimes literally.

The Ugly

·        “NON-OPIOID THERAPIES Use alone or combined with opioids, as indicated:” – Suggesting long-term use of NSAIDs is not safe, and there is evidence to suggest this. Antidepressantsare not without consequences; they have many drug-to-drug interactions and can lead to suicidal thoughts, they are not always a safer choice. Anticonvulsantsare also abused because of euphoric effects and can have serious side effects like antidepressants. Non-opioid treatments should be considered, but the effects of alternate drugs should not be undermined.

·        “Calculate opioid dosage morphine milligram equivalent (MME).” Every patient is different. It is common sense to taper any drug or treatment to effect, but this particular issue could put a prescribing physician at risk of litigation.  (See Dr. Fudin's opinions.)

The National Pain Strategy (NPS)

“National Pain Strategy outlines actions for improving pain care in America

Plan seeks to reduce the burden and prevalence of pain and 

to improve the treatment of pain”

There are many things I agree with, some that I can tolerate, and others that I felt needed attention. The NPS did have representation by advocates during its draft, and we have all been waiting for it to be released. And, so it has been. You can see and overview and download the National Pain Strategy here.   

“The Strategy provides opportunities for reducing the need for and over-reliance on prescription opioid medications;” this statement disturbs me. I believe the only way we can reduce the need for pain relief is to find a cure for scleroderma, complex regional pain syndrome, the effects of aging on the body, arthritis, fibromyalgia, EDS, myofascial pain syndrome, the centralization of pain, etc. Relieving pain is instinctive to all animals, including humans.

Not including all the stakeholders in the drafting of the CDC guidelines has many advocates and advocacy groups incensed, and rightly so. Public notice of the guidelines was made public for only 3 days. Only after being caught, did they allow our voice. But, despite pleas made by people far better equipped and knowledgeable (and unlike me, able to retain what they read), the CDC published them anyway. The total disregard for our government process - by, with, and for the people - is deplorable.

The CDC guidelines could have been done much better and would have been better received if our voices had been heard. And, it bothers me that the NPS overview ends with this statement, The goals of the National Pain Strategy can be achieved through a broad effort in which better pain care is provided, along with safer prescribing practices, such as those recommended in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain. I doubt many of those who helped draft the NPS were aware of these guidelines being drafted when they participated in the drafting of the NPS. Some of those same people are among those who tried to hold the CDC accountable for their lack of transparency. (Read about it in The Guardian.) The CDC Opioid Prescribing Guidelines are not all bad, but they are written with a discriminatory tone, which is counter-productive to the Institute of Medicine’s report, Relieving Pain in America, available from my website here.

To me, it is more of the same and that’s really is a shame. Persistent untreated pain has biological consequences that are seldom considered, and certainly not here. A great opportunity has been squandered by lack of corroboration, something I value.

You can read my comments to the NPS and the CDC guidelines:

• Make a Public Comment on theNational Pain Strategy
• The CDC Opioid Guidelines:Exercise Your Right to Be Heard

Other blogs of interest:

• Healing What Hurts: The Politics of Pain: A Symposium Overview by Celeste Cooper
• The symposium "Patients as Teachers," "Clinicians as Learners," a synopsis by Celeste Cooper 
• A Patient Powered Network: Change Agents for Relieving Pain in America (About our group coming together to change the way pain is perceived, judged and treated.)

~ • ~ • ~ • ~ • ~ • ~

"Adversity is only an obstacle if we fail to see opportunity."  

Celeste Cooper, RN

Author—Patient—Health Central Chronic Pain Pro —Advocate

Celeste’s Website: http://CelesteCooper.com

Learn more about what you can do to help your body function to its potential in the books you can find here on Celeste's  blog. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others.

All answers and blogs are based on the author's opinions and writing and are not meant to replace medical advice.  

Bias and the Band. Concerns and comments, “Are Doctors Paying Attention to Women in Pain?” from the National Pain Report

RE:

Are Doctors Paying Attention to Women in Pain?

July 8th, 2013 by Ed Coghlan

At the National Pain Report, here.

CDC Vital Signs. “Prescription Painkiller Overdoses: A growing epidemic, especially among women,” saying opioid deaths are as “under-recognized problem, here.

My comments:

This is what I have to say about the CDC report. [Vital Signs]. The IOM report "Relieving Pain in America..." states there are three groups of people who are discriminated against when it comes to adequate pain management, WOMEN, the poor, and African-Americans. [Complete report, pg 69-70, here. IOM Brief, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, here.] 

It perplexes me that opioids are the big concern when the first drug used to treat women is antidepressants and psychoactive drugs, because after all, we are a stressed out lot in an emotional state, right? 

Antidepressants are handed out like candy. I would argue that opioids are not, at least in my experience. The culture on managing pain has changed drastically over the past 5 years. Antidepressants interact with more medications, and when prescribed inappropriately, can increase the likelihood of suicidal ideation even when the patient wasn't clinically depressed. 

[See Dr Oz, Antidepressant Serotonin Imbalance, Suicide Warning, Depression, here]

One must bid the question, "Why are the effects of this classification of drugs not sensationalized, or considered?"  “How many women were also on these meds?” “Where is the data collection tool for this classification of medications? They are not only expensive; they come with far greater consequences.  They are not as effective as the pharmaceutical sales agent attempts to convince physicians, i.e. relieving pain and IMPROVING symptoms. There is an “under-recognized problem” on the effect of antidepressants, which completely restructure the brain. 

[See. CDC Vital Signs. “Prescription Painkiller Overdoses: A growing epidemic, especially among women,” saying opioid deaths are as “under-recognized problem, here.]

In their own report, they say men are more likely to die from overdose, so we focus on educating women? Hey! Aren't men important too?  This reeks of bias, just as stated in the IOM report. [And, the band rolls on, but the sound is deafening]

Statistics are just that, statistics. They can be skewed in data collection and study constructs.  Pain is pain. The CDC only focused on "illicit" pain killers. I would argue that NSAIDS are abused because they are about all we have left to take, and they are equally life threatening. [See, Study Finds NSAIDs Overused for Chronic Pain, here.]  Where are the stats on those? We were given opioid receptors for a reason, and I would like to see the research move in that direction. We should be focusing on the patient.

Summing up post comment:

I am not a proponent of any one thing except the right to choose and have our pain treated adequately. Instilling fear in our physicians and pharmacists creates malfeasance.  The biased culture on pain is not improving things. Look at the correlation with the CDC report.

I have the same concerns as Dr. Mehmet Oz regarding overprescribing of antidepressants. Read “Antidepressants: Are They Right For You?” here. or Dr Amen, expert psychiatrist, on “Do Antidepressants Do More Harm Than Good?” here.

In my search I found studies suggesting that antidepressants aren't treating clinical depression effectively, if at all. Other information suggests that antidepressants are treating the depression angle of chronic pain, but even in these studies, they were considering people with MAJOR depression, a clinical psychiatric condition.  We need research on psychoactive drugs that are NOT conducted by pharmaceutical companies.

Opioid medications have been around for centuries, physicians have a firm understanding of what they are, but there is a educational deficit between defining addiction vs. dependence, and patient teaching needs, but I would argue that patients do not receive enough information on psychoactive drugs of ANY sort. Also to be considered are any medications that increase tolerance, antidepressants happen to be among that group. Any medication that requires you to reduce the dose slowly has the propensity to be life threatening.

Wouldn't it be better to educate physicians and patients on how to watch for untoward symptoms and restore the doctor and patient relationship?    Relieving pain responsibly is only manifested by an improvement in function. We don’t need new tools, we have them. They are called patient assessment. Have we become so technological that we have forgotten how to interact with a human being?

You might be interested in reading the PAINS/Project Environmental Scan, Chronic Pain Management and the Practical Implications of Addressing Recommendations Put Forth in the Institute of Medicine (IOM) Report, Relieving Pain in America, here.

Treatment without bias is our right, and we as patients  must speak up. You can find ways of doing that on my website, here. I encourage you to leave comments when you read an article.  Feedback from the people like us is not only needed, it is desired. We must begin the dialogue.

We are law abiding citizens. Most of us do play by the rules, so why do we allow ourselves to be treated as criminals, or to be discriminated against because of our gender, our socio-economic status, our age, or the color of our skin? How can criminalizing a human condition be legal? What is happening to our society?

All answers and blogs are based on the author's opinions and writing and are not meant to replace medical advice.  For more information about the author see http://TheseThree.com

Celeste Cooper is a retired RN, educator, fibromyalgia patient, and lead author of the Broken Body Wounded Spirit: Balancing the See Saw of Chronic Pain devotional series (coauthor, Jeff Miller PhD), and Integrative Therapies for Fibromyalgia, Chronic Fatigue Syndrome and Myofascial Pain: The Mind-Body Connection (coauthor, Jeff Miller PhD)

She is a fibromyalgia expert for Dr. Oz, et al., at Sharecare.com, and she advocates for all chronic pain patients as a participant in the Pain Action Alliance to Implement a National Strategy (PainsProject.org).