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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