King of Pain

How did pain management and pain medicine abuse all start?  People forget that it always wasn’t this way.  Pain wasn’t a “fifth” vital sign.  Every patient didn’t have pain issues that needed to be addressed.    I have been saying for years that it is been blown out of proportion by Big Pharma and the idiots at the Joint Commission.  Now the Wall St. Journal has proven me right.

The story (you may not be able to follow to link without a subscription but you can google it to find it elsewhere) revolves around the New York pain specialist named Dr. Russell Portenoy whose crusade FOR opioids was able to convince (force) doctors to prescribe it like it was as safe as candy.   Before that, physicians knew better.   Below is the summary (sorry for the length) of how Portenoy started this travesty.  I have put some stuff in bold because it is just amazing stuff:

  • In 1986, at the age of 31, he co-wrote a seminal paper arguing that opioids could also be used in the much larger group of people without cancer who suffered chronic pain. The paper was based on just 38 cases and included several caveats.
  • He became a sought-after public speaker. He argued that opioids are a “gift from nature” that were being forsaken because of “opiophobia” among doctors. “We had to destigmatize these drugs,” said Dr. Portenoy.
  • He rose to chairman of pain medicine and palliative care at Beth Israel Medical Center in New York.  He prominently displays a magazine mock-up that jokingly dubs him “The King of Pain.”
  • Steven Passik, a psychologist who once worked closely with Dr. Portenoy and describes him as his mentor, says their message wasn’t based on scientific evidence so much as a zeal to improve patients’ lives. “It had all the makings of a religious movement at the time,” he says. “It had that kind of a spirit to it.”
  • In the late 1990s, groups such as the American Pain Foundation, of which Dr. Portenoy was a director, urged tackling what they called an epidemic of untreated pain.
  • The American Pain Society, of which he was president, campaigned to make pain what it called the “fifth vital sign” that doctors should monitor, alongside blood pressure, temperature, heartbeat and breathing.
  • Dr. Portenoy helped write a landmark 1996 consensus statement by two professional pain societies that said there was little risk of addiction or overdose among pain patients. In lectures he cited the statistic that less than 1% of opioid users became addicted.
  • One of Dr. Portenoy’s chief complaints was that doctors were reluctant to prescribe opioids because they feared scrutiny by regulators or law enforcement. In the second half of the 1990s, he and his followers campaigned successfully for policies to change that.
  • In 1998, the Federation of State Medical Boards released a recommended policy reassuring doctors that they wouldn’t face regulatory action for prescribing even large amounts of narcotics, as long as it was in the course of medical treatment. In 2004 the group called on state medical boards to make undertreatment of pain punishable for the first time.
  • That policy was drawn up with the help of several people with links to opioid makers, including David Haddox, a senior Purdue Pharma executive then and now. The federation said it received nearly $2 million from opioid makers since 1997. The federation says it derives the majority of its funding from administering medical licensing exams, credential verification, and data services.
  • A federation-published book outlining the opioid policy was funded by opioid makers including Purdue Pharma,Endo Health Solutions Inc. and others, with proceeds totaling $280,000 going to the federation.
  • In 2001, the Joint Commission, which accredits U.S. hospitals, issued new standards telling hospitals to regularly ask patients about pain and to make treating it a priority. The now-familiar pain scale was introduced in many hospitals, with patients being asked to rate their pain from one to 10 and circle a smiling or frowning face.
  • The Joint Commission published a guide sponsored by Purdue Pharma. “Some clinicians have inaccurate and exaggerated concerns” about addiction, tolerance and risk of death, the guide said. “This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.”
  • The Joint Commission said its standards didn’t encourage physicians and hospitals to increase prescriptions. “I think that’s a very distorted and not helpful explanation of what’s going on,” said Ana McKee, the Joint Commission’s chief medical officer.
  • Over his career, Dr. Portenoy has disclosed relationships with more than a dozen companies, most of which produce opioid painkillers. “My viewpoint is that I can have those relationships, they would benefit my educational mission, they benefit in my research mission, and to some extent, they can benefit my own pocketbook, without producing in me any tendency to engage in undue influence or misinformation,” he said.
  •  A 2007 fundraising prospectus from Dr. Portenoy’s program shows that his program received millions of dollars over the preceding decade in funding from opioid makers.
But Portenoy was wrong!  He touted that only 1% of the population is at risk for opioid addiction.  Really? “That figure came from a single-paragraph report in the New England Journal of Medicine in 1980 describing hospitalized patients briefly given opioids. Dr. Portenoy now says he shouldn’t have used the information in lectures because it wasn’t relevant for patients with chronic noncancer pain.”  Yeah, ya’ think?

So now Portenoy, the King of Pain, is coming clean.  Here is the summary on that:

  • For such a widely used therapy, there is relatively little scientific evidence that opioid drugs are safe and effective for long-term use.
  • Data about the effectiveness of opioids does not exist,” Dr. Portenoy said in his recent Journal interview. To get a painkiller approved, companies must prove that it is better at reducing pain than a sugar pill during short trials often lasting less than 12 weeks.
  • Now, Dr. Portenoy and other pain doctors who promoted the drugs say they erred by overstating the drugs’ benefits and glossing over risks. “Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did,” Dr. Portenoy said in an interview with The Wall Street Journal. “We didn’t know then what we know now.”
  • Many of those experts now say those claims were weren’t based on sound scientific evidence. “I gave innumerable lectures in the late 1980s and ’90s about addiction that weren’t true,” Dr. Portenoy said in a 2010 videotaped interview with a fellow doctor. The Journal reviewed the conversation, much of which is previously unpublished.
  • In it, Dr. Portenoy said it was “quite scary” to think how the growth in opioid prescribing driven by people like him had contributed to soaring rates of addiction and overdose deaths. “Clearly, if I had an inkling of what I know now then, I wouldn’t have spoken in the way that I spoke. It was clearly the wrong thing to do,” Dr. Portenoy said in the recording.
  • After spending most of his professional life advocating greater use of the drugs, Dr. Portenoy said there is still little research to show whether patients who embark on long-term opioid therapy will ever be able to stop.
  • “How difficult is it for her to get off these drugs?” Dr. Portenoy asked. “You have no idea and neither do I, because no one knows.”

 So, let’s summarize.  We have a huge asshole who decides to change the world and force it to take pain killers.   Millions are addicted.   Millions die.  Big Pharma gets richer.  The scumbags at the Joint Commission were also bought out by Big Pharma and forced docs to prescribe more narcs in the hospital.  They go unscathed and continue to be given limitless power.  Even better, they still don’t change their guidelines even though there is no evidence behind it.  And now the doc who started it all wants to cleansed of his sins?  No way, dude.

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  12 comments for “King of Pain

  1. big picture doc
    January 10, 2013 at 12:44 am

    I knew that this narc push was crap, and I was labeled “not a team player” for not playing the big pharma game. But let me tell you something else! I also knew then that benzos caused depression, motor vehicle accidents, apathy, etc etc, and that corticsteroids caused psychiatric symptoms, osteoporosis, cataracts, worsening of diabetes, weight gain etc etc etc, and also was labeled “not a team player” for not addicting my patients to them. And guess what? Most physicians keep prescribing this crap like candy and have no idea what kind of problems they are causing down the road. How come? It’s not much different than the narc problem. I, for one am glad that there is a shortage of primary care physicians because that means there are less “physicians” to prescribe these horrible “medications”. The Mayo Clinic in Phx now has an alternative medicine clinic and you will see this trend, because when pain, anxiety, autoimmune, myofascial pain, arthritis etc problems are addressed early with acupuncture and other “alternative” means, the above “medications” will not be “needed”.

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  2. January 9, 2013 at 3:49 pm

    How is this any different from the way Big Pharma has manipulated the information on the “safety and effectiveness” of psychiatric drugs? Those drugs are also very addictive and damaging, but even GPs are still handing them out like candy. One professor at Harvard has made a million bucks by publishing his research findings, that placebos are safer and more effective than antidepressants; what he didn’t note is that there are no damaging effects or addictions to placebo pills.

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  3. Lee
    January 9, 2013 at 12:14 pm

    Great article!!! I remember when this push to use opioids came about and the threat of legal action for under treating pain began to be used. How far we have come when, now, many OD deaths are from prescription drugs rather than street drugs.
    Unfortunately many pain clinics are the leading abusers. Too much money to be had for the pill mills to be motivated to regulate themselves.

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  4. Ellen, RPh
    January 9, 2013 at 10:32 am

    I have been labeled as addicted to Lortab. I hate to contradict my treatment center, but that was not what I was addicted to. They forced me to take, high dose NSAIDs which were on the way to wiping out my kidneys… but it was all I was allowed for my lifelong; hip pain as well as shoulder pain, neck pain, back pain, and knee pain. I have been clean and sober for almost 14 years now and am prescribed Norco. I only take it when pain is severe. A prescription for 30 tablets can last me up to 90 days. Just saying as a reemphsis not to throw the baby out with the bath water!

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    • Pat
      January 9, 2013 at 7:18 pm

      Amen Ellen! You are absolutely right in your observations, and that we should take a measured approach. But to do so requires – deep breath – a practicing clinician! I don’t know when this Pain KIng scumbag last practiced full-time on real patients, but anyone who does would have seen these results coming from a mile away. Every primary care clinic and every ER, EVERY day is beset with patients desiring chronic pain meds, often appropriately and often not. One of the tough things required of a REAL doctor is the insight, and yes, fortitude to say “NO” when it is in the patient’s best interest. This crap would be easy if all one did was zip out a script anytime a pain medicine was requested. As your response notes, there are potentially devastating effects from any course, and a judicious approach must be taken with each individual patient. This miserable excuse for a physician has actually harmed many patients in need of opiods by breeding cynicism, mistrust, and sadly, contempt in honest physicians.

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      • Natasha
        January 17, 2013 at 1:10 pm

        Stop calling this doctor a scumbug asshole. The people who are selling on the streets for profit are the scumbag assholes This doctor truly wanted to help those in pain. And lets talk about these drugs coming in from Canada? These drugs will still be available on the streets but those patients who truly need pain medication relief will not get it because of the insurance companies need to make 3000% profit and the street dealers who are getting the drugs illegally. Know what you speak of before you open your mouth. Then you have the drug manufacturers charging over 15.00 a pill for something that costs less than a dollar to produce. Point the finger where it belongs – pharmaceutical companies, insurance companies and drug dealers on the street. The ultimate devil is the money made produced solely by greed.

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        • Doug Farrago
          January 17, 2013 at 1:40 pm

          Yeah, I think I know what I am talking about. Sorry. So if your anger is directed at me then you missed the whole point. Sure Big Pharma is to blame also. In fact, I am more pissed at the Joint Commission. This doc, however, is a MASSIVE DOUCHE who let his ego to become the “King of Pain” get ahead really helping those patients that truly need narcotics (which, by the way, is VERY few). So, if your venom is pointed this way, then I will tell you that I will continue to open my mouth. Maybe greed is the ultimate devil but a unrestrained ego is not far behind.

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  5. Princess of Problem Patients
    January 9, 2013 at 10:21 am

    For what it’s worth, the Federation has an updated version available (I have a copy but haven’t read it yet), with this in the description: “The update is especially important given the rise of opioid abuse and related deaths in the United States as well as the ongoing need for legitimate patient access to pain medications.” The table of contents is listed in one of the tabs at http://www.fsmb.org/book/. The discouraging of opioid use is something a lot of state boards have been mentioning in their newsletters/publications as well, which makes me happy.

    I have fibromyalgia, Sjogren’s Syndrome, and endometriosis, and am a breast cancer survivor, so I’m no stranger to chronic pain/fatigue. What works best for me and others I know with chronic pain issues has been light exercise (limited but still doable), active relaxation, and non-opioid meds. In my case, 75 mg of Savella each day definitely helps with my being able to function and sleep semi-well (way more than Lyrica and Cymbalta helped me, anyway). For pain control I routinely get table massages and Active Release Techniques (essentially a sports therapy modality; http://www.activerelease.com/what_providers.asp) and I also take 275/650 tramadol/apap each day (2 50 mg tramadol because the extended release nauseates me plus 1 37.5/325 tram/apap each morning and evening). From browsing support groups in social media, I know there are people out there with legitimately horrible chronic pain but most of them seem pretty housebound and depressed. Exercise is the cheapest and most effective solution for that, and post-exertional malaise is definitely a b**** but slowly building up a tolerance is so worth it. Opioids really should be used as a last resort, and very cautiously at that.

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  6. Kathy Wire
    January 9, 2013 at 9:27 am

    I completely agree that his assertions about addiction were unsubstantiated hogwash. I fear, though, that some providers (and patients) may throw the baby out with the bathwater and swing too far the other direction. (As one who recently lived with some chronic pain and then surgical pain…so grateful that now it is all minimal.) Rather than religious zeal, we need a robust discussion of the benefits of opioids for certain populations and the need to pay attention to pain for all populations. That includes getting patients to understand that they may well contribute to their pain and could reduce it with weight loss, PT, exercise, etc. that are not part of many plans today. This movement has helped to convince people that they just need a pill. Now, I gotta go to PT….

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    • Neurodoc
      January 9, 2013 at 10:49 pm

      Agree with the baby/bathwater comment. Portnoy certainly underestimated the addiction risk and really didn’t say anything about the mortality risks (especially for long-acting drugs like methadone, MSContin and OxyContin). Opioids (along with all other
      prescription medications) are considered “Dangerous Drugs” by the DEA and FDA. Physicians have to assess their risk/benefit profiles and be very careful in prescribing them and monitoring their patients. Quite a few of the OD deaths from long-acting opioids have been due to lack of prescriber understanding of the pharmacodynamics and kinetics of these agents, and/or failure to monitor their patients for behavioral and medical problems associated with the prescription. These failures could be due to ignorance, incompetence, laziness, or even something worse, like being a crook doctor who wants to make easy bucks running a scam “pain practice” (i.e, a licensed “dope dealer”).

      None of this means that patients with chronic pain associated with non-terminal illnesses should be prohibited from getting pain treatment with opioids for pain that fails to respond to non-opioid medications or other treatments. It does mean that we need to be very careful when we use opioids to treat such patients.

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  7. Pat Conrad
    January 8, 2013 at 10:26 pm

    Great, great piece. This highlights the very real, dangerous results of corporate corruption and government involvement in medicine.

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  8. Ray
    January 8, 2013 at 7:31 pm

    Nauseating. A dope slap is in order!

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