WASHINGTON — As legislation to address the opioid epidemic gains momentum, drug makers, insurers, and other interest groups are engaging in a concerted drive to tailor the bills to their liking.

The effort, in some cases, has resulted in lawmakers softening, or entirely backing off, some of their most far-reaching proposals.

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  • Re buprenorphine vs. methadone, I think there is an important point to make. I’ve been a pharmacist for about 33 years, mostly in a state that has seen substantial mortality from opiates. In the early years of the epidemic in Utah, methadone was a major contributor to mortality. IMO buprenorphine is safer than methadone. Please don’t take a single study out of context. Look at all the data… like the increased mortality risk of methadone documented by the Utah State Department of Public Health, and also in Washington state. Also look at why experienced clinicians use methadone with a healthy dose of respect due to an extremely variable half-life and low ceiling for respiratory depression, which when used by inexperienced clinicians can kill patients. Methadone may be cheap compared to buprenorphine, but it would be extremely hard to convince me it is safer.

  • The drug war is a total failure but that won’t stop them from doing more of the same.

  • The main focus is on the small number compared to the 100,000 ppl who need opioid pain relief to live without their lives being overwhelmed by severe chronic pain who most have never had an issue with opioid abuse disorder.. Why are these humans ignored in these discussions EVERYDAY? This group have Never experienced a problem with opioids except when they’re denied the life are Newing medications that are the only thing they’ve tried that unable these patients to function in their private lives , think sleep once again without being overwhelmed by chronic severe pain interfering in the close to normal lives that once again feel love and give love so important to life!!!

  • I’m not arguing that the government, should be dictating treatment. I am saying that an unpleasant, cynical, and deliberate campaign on the part of Perdue Pharma spilled large amounts of their product into the general population and that we are still reaping the results. Sit down and read “The Family That Built an Empire of Pain” in the Oct. 30, 2017 issue of The New Yorker or simply googel “opioids perdue.” Of course, physicians should have a wide range of tools, chemical and behavioral, at their command, I don’t think anyone is arguing that, either. Intimating that the regulation of drugs and that appropriate protocols be developed for their use as analgesics is somehow the government taking control of things and harming patients is either naive or to be engaged in spreading the counter PR being produced by the industry – my opinion, anyway.

    • Yes you are so very correct Alex Pirie, so right. Nice to see an informed intelligent person. 60 Minutes Oct 15, 2017 and 60 Minutes June 17, 2018 both Episodes will tell the untold truth of Perdue and the Political influence that had to get Oxy approved and into the hands of any person that asked, even those that didn’t. It’s shameful and it’s sickening. When you actually look at what they claim to be doing to stem the deaths…they are doing absolutely nothing. Years to even begin to act…meanwhile people stack up like firewood in morgues. They want to allow the same drug makers that got us here to get us out…in other words reward them with more money and business. Shameful.

  • “…addiction is not a predictable result of opioid prescribing.” Of course not, nobody would argue with that. The fault, crime, really, was, and, to some extent still is, the excessive and illegal marketing of the oxy’s by Perdu Pharma and the over prescription by unwitting (usually) doctors – excessively documented in the courts and media (STAT, in particular, or the NYT today). Of course, opiates have a role, but handing them out like candy, writing repeated scripts without counselling patients on possible risks, and monitoring usage was an all too frequent path to addiction in my community. Things are changing slowly, but it has required, in many cases, legislative and judicial intervention, or threat thereof, to steer the course back to good medical practice as opposed to adding to the Sackler fortune. At discharge after a diagnosis in an ED for a kidney stone, I declined a prescription for oxycodone. “Oh, you must, you’ll need it,” the RN and an MD insisted. After some argument, I said, “Alright, I’ll take it, sell it on the street and support my children’s post secondary education.” I thought it was funnier, in a bitter kind of way, than they did. I survived quite well on a couple of days of an NSAID and lots of water. The sooner the obscene amounts of money (written off as business expense) spent on lobbying by the pharmaceutical/industrial complex and the grotesquely compelling media drug ads are curtailed, the better off we’ll all be. Hey, some of that money might be spent on research instead of depending on the NIH and our taxpayer dollars for basic scientific and developmental research – although, in reality, any money saved will probably go to buying back company stock, another “bitter pill” that the U.S. with it’s staggering medical costs and embarrassingly low standing in health outcomes is being compelled to swallow. No, to date myself, what’s good for General Bullmoose is NOT good for the USA.

    • Sorry, but addiction is not that simple. The substance is merely the main symptom of a very complex mental health disorder called addiction. The addict is attempting to self-medicate some underlying issue, whether its past or present trauma, mental health illness and/or disorder, emotional pain, hopelessness, poverty, etc.

      The consumption of alcohol is not the cause of alcoholism. The activity of eating is not the cause of food addiction. The mere act of gambling, sex or shopping does not cause addictions to those activities. Why on earth would one believe any differently about another substance?

      Most people who consume alcohol do so in a responsible manner and do not end up developing alcoholism. The same can be said of eating, gambling, sex and shopping. The majority of people who take part in any of these activities, even on a regular basis like eating, do so without developing an addiction.

      You’re extremely naive to believe that the unrestricted or loosely-restricted availability of potentially-addicting substances is a main factor in regards to addiction. If it was, then the majority of Americans and Europeans would be hardcore, hopeless alcoholics, as the majority of us have consumed (and even binged on) alcohol at least once in our lives.

      Furthermore, just because you did not require a prescription opioid for pain relief of a kidney stone, please don’t assume everyone else is the same. Contrary to popular belief, studies have shown that addiction is very rare in both the chronic pain community and among those who need relief from an acute illness or injury.

      For the most part, addiction occurs when the potentially-addictive substance is used for recreational purposes and very rare when used for legitimate medical purposes. The large majority of people, particularly those without the genetic predisposition to addiction, who do misuse a substance at least once in their lifetime do not end up developing an addiction.

      We can help provide more affordable treatment options to those who reach out for help without harming those who are chronically-ill with an incurable diseases, disorders and inoperable injuries that cause chronic or intermittent pain. Prohibition has never worked, as history has shown us over and over again. When a government excessively restricts or prohibits substances (or just about anything that can be bought and sold), the black market will gladly provide.

  • In case someone missed it, the opiod epidemic is the direct result of the prescription drug epidemic. Pharma on steroids was invented with direct to consumer marketing of prescription drugs in the 1990’s, followed by the pain clinics. This new chapter is not a game changer, unless different addictive drugs, more rehab centers, and more suffering for those who absolutely need them and can’t get them, is change.
    I am a chiropractor who sees the epidemic differently. A recent back pain case came through my door, who had been prescribed morphine for aprox. 7 years. While the back pain cleared within a few weeks, the horrific damage done by the morphine will take months if not a few years for recovery. This is one of the worst cases, but isolated it’s not. Since Direct to consumer advertising came into play, I figure aprox. 6 or 7 out of every 10 news patients I see are suffering in part or wholly from the side effects of various prescription drugs, including opiods.
    The only way I see this working for the better, and it will be a cold day in H—, is re-testing the chiropractic profession, and comparing results to the medical profession for pain management. Years ago, chiropractic outperformed medical care in Work Comp studies, but it didn’t fit the agenda of pharma, the insurance industry or the medical profession , so chiropractors were gradually pushed out.

    • Victor, you might want to examine the case made by Dr Nora Volkow, Director of the National Institute on Drug Abuse. Your knowledge of addiction is sadly out of date. Volkow and McLellan stated the following in the New England Journal of Medicine:

      “Unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with pre-existing vulnerabilities… Older medical texts and several versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) either overemphasized the role of tolerance and physical dependence in the definition of addiction or equated these processes (DSM-III and DSM-IV). However, more recent studies have shown that the molecular mechanisms underlying addiction are distinct from those responsible for tolerance and physical dependence, in that they evolve much more slowly, last much longer, and disrupt multiple brain processes.”[i]

      [i] Nora D Volkow, MD and Thomas A McLellan, Ph.D., “Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies” . NEMJ 2016; 374:1253-1263 March 31, 2016]. http://www.nejm.org/doi/full/10.1056/NEJMra1507771

    • Wiley, I also recommend deep reading of a report circulated in draft in December 2017 by the Agency for Healthcare Research and Quality. Subject “Noninvasive, Nonpharmacological Treatment for Chronic Pain: A Systematic Review”. About 20 types of therapy were examined for five categories of pain including low back pain. Over 4500 clinical trials reports were recovered and subjected to a rigorous quality review. Only 245 reports survived that review, largely because most trials failed to follow up to confirm benefits lasting more than 30 days after conclusion of the trial.

      For manual adjustment of the spine in low back pain, the following was found:

      “Spinal manipulation was associated with slightly greater effects than sham manipulation, usual care, attention control, or a placebo intervention in short-term function (3 trials, pooled SMD -0.34, 95% CI -0.63 to -0.05, I2=61%) and intermediate-term function (3 trials, pooled SMD -0.40, 95% CI -0.69 to -0.11, I2=76%) (Strength of Evidence: Low).

       There was no difference between spinal manipulation versus sham manipulation, usual care, an attention control or a placebo intervention in short-term pain (3 trials, pooled difference -0.20 on a 0 to 10 scale, 95% CI -0.66 to 0.26, I2=58%), but manipulation was associated with slightly greater effects than controls on intermediate-term pain (3 trials, pooled difference -0.64, 95% CI -0.9

      =============End extract.

      What we learn from this compilation of trials is that chiropractic may have a role to play “at the margins” in moderate low back pain and perhaps neck pain. But AHRQ found that manual therapies of all kinds were almost exclusively used as adjuncts or additions to “usual therapy” — the nature of which, the trials failed to document or report precisely. Given that opioid analgesics and anti-inflammatory drugs are the primary “usual” therapies in low back and neck pain, it seems to me reasonable to conclude that manual therapies cannot now be regarded as reliable replacements or alternatives.

      Many financially self interested practitioners loudly proclaim the benefits of alternative medicine. But the AHRQ report would lead us to understand that there is very often less in these therapies than meets the casual eye.

  • Interesting article as usual government is looking for solutions after someone is addicted. More research is needed into prevention strategies, such as findings treatment that work, needed regulation of treatment programs, and finally research into the social, financial, genetic, and psychiatric predisposing factors. Decriminalizing drug abuse and treating as illness would be a big step forward. Putting users in jail makes no sense

    • Totally agree with Victor. Same old, same old, prevention is the key, but nobody makes big bucks off prevention. Vivitrol/buprenorphine both probably have a place in our materia medica, but huge amounts of time and dollars are being squandered on lobbying and campaign donations. Time to take the money out of politics and put it into getting out in front, but this would slide over into looking into the social determinants of health and no pharma CEO, board member, or stockholder wants to go there. Making money off addicting people (and, yes, they did, big time) and then off “un-addicting” them as they are now, a great business, lousy public health model.

  • Author sounds like chicken little! I’m glad cooler heads are starting to prevail regarding this supposed epidemic

  • Several points:

    It has now been proven beyond any reasonable contradiction that prescriptions of opioid pain relievers by doctors to their patients are unrelated to overdose deaths. The flood of fentanyl and other illegal drugs is so large that any contribution of prescription opioids get lost in the noise. Analysis of CDC OD and prescription data prove this observation.

    Second:
    Opioid pain reliever prescribing is at a 10 year low while overdose deaths continue to climb. Restriction of medical supply is causing shortages of hospital anesthetics needed in surgery. Yet the DEA proposes to further restrict opioid production for any classes of drugs believed to be “diverted”. Such restrictions compound an already failed policy which amounts to nothing less than an undeclared war against pain patients.

    Third:
    Recent signing into law of the VA Mission Act is guaranteed to outright KILL hundreds more Veterans by denying them effective pain management and driving them into disability and sometimes suicide. Section 131 of that law implements the VA’s “Opioid Safety Initiative” which denies opiod pain relievers to all Veterans in the VHA system. This section of the law must be repealed immediately. It is scientifically, morally, and ethically wrong, amounting to nothing less than torture for thousands of Vets.

    • I should correct my wording: the Opioid Safety Initiative mandates tapering down all Veterans to below 90 MME per day, but not cutting them off entirely. The effect won’t be much different: tens of thousands will be coerced into tapering to below their minimum therapeutic dose level. This is fundamentally irresponsible and abusive. There are no effective or useful alternatives to opioid analgesics for many Veterans with severe pain.

  • The more money Congress throws at addiction, the more scammers will profit at the expense of addicts struggling to recover. Strengthening enforcement of parity law is critical. The vast majority of addicts are self-medicating for mental illness symptoms of one sort or other. The consequent poverty derived from addiction also causes stress that compounds emotional problems while simultaneously restricting access to treatment.

    What is needed is a comprehensive bill. It looks like what we will get is a another safety net full of big holes.

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