Opioid Dependence

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    Guided meditation / hypnosis / relaxation/ sleep

    <p>Guided meditation / hypnosis / relaxation/ sleep</p>
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    Debilitating Chronic and Acute Pain / Withdrawal / opioid dependence

    <p>Debilitating Chronic and Acute Pain / Withdrawal / <a href="https://themighty.com/topic/opioid-dependence/?label=opioid dependence" class="tm-embed-link  tm-autolink health-map" data-id="5b23cea500553f33fe999500" data-name="opioid dependence" title="opioid dependence" target="_blank">opioid dependence</a></p>
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    Opioid dependence/ withdrawal/ extreme PAIN

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    Wendy Sinclair

    Oregon Advocates Fight to Reverse Opioid Guidelines That Cause Harm

    The past five years has been especially difficult for those suffering with intractable medical conditions that cause chronic pain. Even before the 2016 CDC guidelines for prescribing opioids, the social climate began turning against anyone who utilized opioid pain medications, whether for chronic pain or for addiction. Society seemed to make no distinction. The climate allowed drastic policies and guidelines, which limited or eliminated chronic opioid therapy for legacy patients (intractable pain patients benefiting from long-term opioid therapy). Because of this, many were harmed and some lost their lives to suicide. Untreated or u nder-treated pain has resulted in an increase in suicides. Rates among Veterans have shown a significant increase, with chronic pain being one of the main contributors. And in Oregon, doctor-assisted suicides have increased by 25% due to untreated pain. This is a far cry from the statement from 2007 stating that Oregon leads the nation in pain control for patients. Well-respected experts, chronic pain patients and advocates objected to the drastic paradigm shift and the significant harms asserting the swing was not based on evidence nor was it aligned with the standard of care or best practices. In the past year, nationally, the pendulum has begun to swing back to a neutral position giving suffers hope. Some changes that could benefit people with chronic pain include: 1. The CDC Clarified Its Guidelines In April 2019, the CDC clarified its guidelines, stating that they had been misapplied resulting in forced opioid tapers and tapering too quickly, which both caused patient harms. Its guidelines, which were only meant to aid primary care doctors in initial doses of opioid pain analgesics for new opioid patients, were misapplied to limit doses pain specialists could prescribe and restrict dosages for legacy patients. 2. The FDA Acknowledges Harm of Forced Opioid Tapers April 9, 2019, the Food and Drug Administration (FDA) issued a statement acknowledging harms (including suicide) from forced opioid tapers. The FDA only gives instruction for opioid tapering when the taper is mutually agreed upon between patient and doctor. 3. AMA Opioid Task Force Supports Chronic Pain Patients April 24, 2019, Patrice Harris, MD, president-elect of the American Medical Association (AMA) Opioid Task Force came out in support of legacy patients by releasing a statement applauding the CDC’s clarification of its guidelines stating they have been “widely” misapplied, preventing physicians from providing the best care to patients. 4. Human Rights Watch Advocates Against Forced Opioid Tapers Humans Rights Watch (HRW), an international organization that reports on human rights violations, became involved with the opioid epidemic in response to the huge outcry of harm. After investigating, the HRW released a report supporting legacy patients and asserted there is an obligation to respond to this health need and to “refrain” from forced (non-consensual) opioid tapers. Furthermore, HRW stated, “Under the ICESCR’s right to health framework, state parties have an obligation to ‘respect, protect, and fulfill the right of chronic non-cancer pain patients to appropriate pain management.” 5. Washington State Clarifies Opioid Prescribing Guidelines Oregon’s geographical neighbor, Washington state, has been doing damage control this past year from its previously released rules for opioids. It issued statements and released documents stating that under-treating or refuse to treat pain is just as bad as over-treating. Sept. 20, 2019 it released a letter as its latest attempt at reversing the damage. In spite of all this, in Oregon, policymakers forge forward forcing many chronic pain patients to question their safety in the midst of known harms from dangerous opioid tapers. For over a year, advocates have vigilantly voiced concerns at chronic pain task force meetings and now taper task force meetings, through communication with Oregon’s governor, and the state’s senior health policy advisor, testifying at the task force meetings, meeting with the chief medical officer of the Oregon Health Authority, and written comments from experts and patients. There has been one major request­, for evidence-based individual medical care based on each patient’s unique needs, separating those with substance use issues from chronic pain patients and applying different remedies as is appropriate. Here are just some of the efforts to curb Oregon’s anti-opioid stance, which may be applicable in your own state: The Human Rights Watch was specifically concerned about harmful policies, proposals and guidelines in Oregon so they wrote a personal letter to the governor of Oregon, along with others, to object to the actions taken against legacy patients. Oregon Medical Association and American Medical Association issued a letter opposing a proposal to force taper some patients off of their opioids. Doctors and experts wrote a letter to the Oregon governor, and others, opposing a proposal that included some forced tapers and to request an evidence-based approach to pain care in Oregon. However, these requests have fallen on deaf ears. They continue to lump those with substance use issues and chronic pain patients and offer a single remedy, or list of remedies. For example, this was evident, once again, in Taper Task Force meeting material. Not only is there only one taper protocol, the decision to taper or “when to consider tapering” is the same irrespective of whether a person is utilizing opioid medications for pain or if they are struggling with addiction. There is no allowance to return a patient to their previously stable dose of pain analgesics. The task force also attempted to broaden the inclusion of pain patients into the category of an addiction diagnosis by selectively using DSM5 diagnosis criteria for opioid use disorder (OUD). The task force left out the critical qualifier repeatedly asserted in the DSM5 that states, those using opioids “under appropriate medical supervision.” This means compliant chronic pain patients cannot be diagnosed with OUD. In addition, the guidelines seem to enlarge an addiction category to include many non-addicted legacy patients by the guideline’s criteria for complex persistent opioid dependence (CPOD). The difference between OUD and CPOD are startling. To be diagnosed with CPOD one only has to have the desire to take opioids for pain, without opioid cravings, no compulsive use, and no harmful use, the patient takes opioids “exactly” as prescribed, and has no social disruption other than from experiencing pain. This is an incredible description and includes all model chronic pain patients. Amid pressure from advocates and patients, Oregon’s Taper Task Force added a clarifying statement to its updated materials, stating not all patients need to be tapered. But then the rest of the guideline goes on to recommend providers consider a taper for those who meet certain criteria, easily met by the majority of legacy patients. These criteria include: The patient is on a daily opioid dose of 50–90 MED or higher. The patient has medical risk factors that can increase risk of adverse outcomes, including overdose (e.g., lung disease, sleep apnea, liver disease, renal disease, fall risk, medical frailty). The patient is taking other medications that increase the risk of drug-drug interactions or the risk of overdose, such as benzodiazepines or other sedating medications (e.g., Benadryl, gabapentin). The patient’s history indicates an increased risk for substance use disorder (SUD) (e.g., past diagnosis of SUD, SUD-related behaviors, family history of SUD). To put this in other words, the majority of legacy patients are on 50 MED or higher of opioids, so that one criterion alone encompasses a huge percentage of patients. In addition, the rest of the criteria includes advanced age (medical fragility — the term they use to describe older people), people who have allergies (take Benadryl) people who have anxiety disorders or need awake oral surgery or any other twilight surgery (benzodiazepine), those who have nerve pain (gabapentin), and those who don’t have SUD, but who have a family member who has it (have an uncle who has SUD, even though you don’t). After including all these, there will be few chronic pain patients who won’t fall within the recommendation to consider tapering. Why is the narrative the same in Oregon when other states and nationally there’s been some movement? The task force membership includes a large percentage of addiction specialist who are allowed to make policy for chronic pain patients even though they do not have specific knowledge on this population. The task forces membership doesn’t include chronic pain patient representatives without a substance use disorder The task force recycles many of the same members or representatives from the same organization over and over Those with substance use disorder and chronic pain patients are lumped together and given the same guidelines The public commenting process is often confusing and not transparent There’s been no collection of data on patient harms for current forced taper policies but claim success based solely on the fact that the patients were tapered. Despite agreeing to revisit the guideline this fall, we have yet to see a plan to do so Despite the evidence and efforts to the contrary, Oregon doesn’t seem to be curbing their anti-opioid sentiment even with the knowledge that it will cause patient harms. The taper task force guidelines will be enforced for all Oregonians regardless of insurance (Medicaid, private or self-pay). Oregon is a scary place for legacy patients. This article originally appeared on Oregon Pain Action Group’s Medium.

    Dez Nelson
    Dez Nelson @naac_hq

    CDC Guidelines Are Harming Pain Patients Amid National Opioid Crisis

    The National Academies released a new consensus report on December 19, 2019, and the Federal Drug Administration (FDA) released an announcement the same day communicating their intention to “develop the evidence” for a new practice guideline for the treatment of acute pain. This announcement comes on the heels of an ongoing public health disaster that the Centers for Disease Control & Prevention (CDC) caused by implementing recommendations from the National Academy of Medicine and ignoring dissenting specialists in the field, and that the Drug Enforcement Agency (DEA) has perpetuated via SWAT-style raids on doctor’s offices across the country. The National Academies There are three bodies under the National Academies: The National Academy of Engineering (NAE) The National Academy of Sciences (NAS) The National Academy of Medicine (NAM) All of these bodies are non-governmental organizations (NGOs) and they’re responsible for providing advice to the federal government in regard to science and technology, among other important topics. It may be of import to note that the National Academies were exempted from the bulk of the Federal Advisory Committee Act of 1972 (FACA). They say, to ensure their autonomy. The Federal Advisory Committee Act FACA is an important piece of legislation that governs how advisory committees operate. The purpose of the legislation was to provide transparency in federal rule-making based on advisory committees’ recommendations. In 1997, amendments were passed to the law, which exempted the National Academies from many of FACA’s requirements. The Recommendations and the Public Relations Campaign That Shaped a National Crisis The Institute of Medicine (IOM) (which was recently renamed to the National Academy of Medicine or NAM) released a torrent of studies in the early 2010s with recommendations to public health agencies to undertake a couple of massive public health projects, including the development of the National Pain Strategy (NPS) and the CDC Guideline. The National Pain Strategy & The CDC Guideline To ensure that a federal pain strategy was implemented nationwide, the NAM released the report Relieving Pain in America (2011) and its recommendations are the foundation of the NPS. The report Living Well with Chronic Illness (2012), on the other hand, was largely the catalyst to the controversial CDC Guideline, which was based on recommendations the IOM made in this subsequent report. The CDC Guideline is the tool necessary to make the provisions of the NPS a national reality. It’s important to note here that there was no “opioid crisis” at the time the National Pain Strategy was commissioned (the CDC Guideline included). In fact, a curious statement can be found in some of the first pages of the NPS: “The actions in this strategy would be undertaken in the context of the dual crises of pain and opioid dependence, overdose, and death in the United States.” The so-called “opioid crisis” was not even a blip on the radar when the NPS or CDC Guideline were commissioned: As you can see, it wasn’t until 2011 that rumblings about drug overdoses and an “addiction epidemic” can be seen spiking ever so slightly in a quiet echo through the news cycle. You can see in the trend graphic that there was no known crisis (of pain and opioid dependence, overdose and death in the United States) until federal agencies in partnership with certain NGOs — such as the IOM and Physicians for Responsible Opioid Prescribing (PROP) — began getting heavily involved in attempting to create these massive public health initiatives. Fast forward barely a couple of years, and the CDC begins spending an undisclosed amount of taxpayer money on a public relations campaign for their guideline that was published on March 15, 2016, despite a cacophony of dissent. Interestingly, the NPS was also released in March 2016, only days after the CDC guideline. Similarly, in the same period, we can see a significant increase in how often the terms “drug overdose,” “opioid crisis,” “addiction epidemic” and “opioid epidemic” are referred to in the press. Taxpayer money shouldn’t be used for coordinated PR campaigns to convince us that an unpopular guideline is beneficial, despite never officially tracking outcomes, even after harms have become clear. The above trend graphic also demonstrates how often the crisis is framed as one catalyzed by patients and their physicians, something the NPS alluded was an objective for how they wanted to frame these crises before the crises were known to exist. Remember, the IOM made their recommendations for all of this back in 2011 and 2012, recommendations these initiatives are based on. The CDC inflated overdose statistics, exploited known systems failures in the death investigation process and they exploited popular misconceptions of the process in an attempt to justify their unpopular, unscientific guideline. All of this created the appearance of the guideline as a national necessity, because the crisis has been repeatedly framed as a prescription drug crisis that doctors are responsible for, this isn’t the case. Instead, we’re in the midst of an illicit drug and polypharmacy crisis. Please see Fudin et al. on illicit fentanyl and its analogs which continue to proliferate on the street and drive overdose rates. This is why interventions continue to fail; we’re focusing on the wrong premise. It’s Possible History Will Repeat Itself Despite Harms We may be headed down a path of further assaultive crises in the future due to continued mismanagement by some involved in developing and justifying these interventions. It’s not just patients with complicated chronic medical problems and their doctors who will be forced to suffer under a regime of poorly designed policies, now acute care patients are being thrown into the mix. “In August 2018, the U.S. Food and Drug Administration contracted the National Academies of Sciences, Engineering, and Medicine (NASEM) to help advance the development of evidence-based guidelines for opioid analgesic prescribing for acute pain resulting from specific conditions or procedures” (NASEM 2019). While it’s great that NASEM may be employed in this endeavor, we’ve heard this all before. The Consensus Report NASEM released states: “Trustworthy guidelines help clinicians translate current research in basic science and diagnostic and therapeutic interventions into clinical practice, with the goal of improving patient health and societal outcomes.” Only, the CDC’s 2016 practice guideline is anything but “trustworthy,” and the “evidence” they continue to push is either extremely low or non-existent, as the Agency for Healthcare Research & Quality (AHRQ) recently admitted and as I’ve detailed in-depth in Part I and Part II of this series and in Systems Thinking: How It Can Solve The Overdose Crisis. Patients have not experienced “improvements” in their health, and society has not seen improved outcomes despite premature announcements of “success” by self-proclaimed experts. What’s more, none of these federal agencies, NGOs or anyone else involved have bothered to call for or develop any control systems that would track patient-reported outcomes due to their interventions and recommendations, despite emerging evidence of their harms. If recent history is any kind of guide for future trajectories, we could be well on our way to forcing similarly unscientific practice standards onto every single doctor that treats American citizens, something millions of Americans were already contending with via the release of the first guideline aimed at chronic care that the CDC even admitted was misapplied. It was “misapplied” because the environment remains punitive. The DEA continues to meddle in the practice of medicine with SWAT-style force. The FDA, CDC and HHS have all released announcements acknowledging the public health disaster the guideline’s application has caused, but those announcements will remain moot, and the DEA is sure to continue increasing its interference if guidelines on acute care are published. Summary It appears federal agencies have not only been ignoring important stakeholders’ dissent to these low evidence interventions, but they also continue to barrel forward with their strategy in partnership with many others no matter the cost — even if the cost is American lives. The CDC Guideline was the result of recommendations provided by the National Academy of Medicine, and the history of this crisis and how it’s been managed doesn’t provide any reassurance that anyone at NASEM can do any better in these endeavors. It also appears as if we may actually be in the grips of a largely inflated crisis that continues on with no remediation, while trillions in taxpayer money continue to be spent on a failed drug war that now includes patients and their doctors. Federal agencies and their collaborating NGOs have failed to mitigate continued harm to Americans with complex chronic conditions. A new practice standard for acute care is not likely to add any benefit to sick or injured Americans and all of this continues despite addiction being rather uncommon and overdoses rare under the care of a licensed physician. Conclusion This simply cannot be allowed to continue without some serious remedial steps. Thousands (at least) have died due to these policies. Millions more have been left to suffer pointlessly. All due to how this crisis has been framed using taxpayer dollars to convince the American people that we need to spend billions on interventions that have shown no return on investment for the American people. Overdoses continue to climb unabated despite the interventions already employed and yet, Americans are expected to accept further restrictions on legal access to these life-saving medications. As long as we don’t have the full data on the harms these agencies and others are causing to the public via their public health interventions, and the longer they can continue developing practice standards that continue to trump individualized care without the participation of more moderate voices, the more people could potentially be harmed. It’s time the American people demanded that these projects be brought to a halt until appropriate controls can be put in place for the public’s safety, and an emergency review of the Drug Enforcement Agency’s conduct over the last several decades can be scrutinized by the appropriate stakeholders, including Congress. For a more in-depth view of this piece, please see the extended version.

    Collin Wong

    Colleges Need to Start Talking About Opioid Misuse and Abuse

    I go to college in Cleveland. However, I did not find out this city is actually in the middle of an opioid epidemic until I did a newspaper story for my university on substance abuse later that fall. We went to class, took tests, volunteered at hospitals and attended club meetings. All the while, the epidemic silently raged all around us, and sometimes among us. We need to break the silence. Here’s why: Opioid abuse is already a problem on many college campuses. According to Campus Drug Prevention, 559 full-time college students non-medically use prescription pain relievers on any given day. The same site reported that up to 12 percent of college students are misusing opioids. That’s 12 percent of college students who are at an increased risk of dying from an opioid overdose. That’s also 12 percent of college students who might become addicted. That’s 12 percent of all college students who may have to navigate our nation’s dysfunctional mental health infrastructure at a young age. It’s become such a concerning trend that even the American College Health Association (ACHA) put forth a set of guidelines for colleges to manage the effects of opioid addiction on campus. If the ACHA has identified opioid addiction as a collegiate health issue, colleges should also be concerned, as untreated addiction will have a direct effect on both the campus culture and the student body. The student body holds an important role too — from hosting events aimed at raising awareness to coordinating campus-wide fundraisers, we can do something. College students are not immune to opioid overdoses. The Wall Street Journal reports in these four schools, students are already dying from overdoses. At the University of Rochester, another student overdosed on opioids and died in 2014. Last year, three students from Washington State University overdosed from opioids and died. A 25-year-old died from an overdose on the potent opioid fentanyl and heroin in a bathroom at Columbus State Community College in Ohio. Just this November, four student deaths at the University of Southern California have also been linked to suspected opioid overdoses. These deaths are starting to mirror how many are dying from overdoses at an increasingly rapid rate outside college campuses. This parallel suggests opioids still exert a powerful effect on everyone, often unbeknownst to many of us. One study suggests there is a low perception of risk for opioid analgesics like fentanyl and oxycontin. If we continue to neglect opioid overdoses on college campuses, more students will continue to use opioids without being aware of the danger of them. As a result, students may misuse these substances more frequently because they are supposedly “safer” than heroin. Sooner or later, we may run into a full opioid epidemic, in which opioid overdoses claim as many as 130 lives each day. Opioids are claiming the lives of youths who could have had a career and a life ahead of them. Once brimming with potential, many of these students are now dead, and their lives have been cut short by an overdose. If we are already dying from opioids, it is time administrators recognize this is a problem on many college campuses. We cannot wait until overdoses are taking thousands of college students’ lives annually. At that point, it will be extremely difficult to stop the epidemic. If we recognize opioid abuse is a problem and begin to raise awareness about it, we may be able to stop an impending epidemic from occurring across our nation’s college campuses.

    Community Voices
    Community Voices

    Warrior addict = ?

    I'm so tired of hearing people get on a soapbox about how chronic pain patients NEED painkillers to live their lives and I feel like the only person on the planet who fights chronic illness without opiates. Is it so impossible to imagine that you can? Or you would choose to? I'd rather be clean and sober and feel some pain than be on pills and feel pain anyway. Is anyone else a warrior and an addict at the same time?

    #Addiction #ChronicPain #Osteoarthritis #ChronicMigraines #PseudotumorCerebri #TrigeminalNeuralgia #DegenerativeDiscDisease #OpioidDependence #AddictionRecovery

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    Community Voices

    Having a hugely hard time lately. So many physical and mental conditions. So many medications for each one just to feel “normal”, but I’ve forgotten what that is in the ten years I’ve been ill. Life is crap. Totally apathetic and hopeless.

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