APS Symposium: Opiate Dosing Guidelines: Outrage or Imperative; Alex DeLuca; War on Doctors/Pain Crisis blog of the Pain Relief Network; 2008-07-10.
See also:
Opiate Dosing Guidelines: Outrage or Imperative(1)
PRN State Tort Claim vs WA State
PRN Complaint for Declaratory/Injunctive Relief, Damages
On May 8-10 of this year, about 2 months before PRN filed its historic class action lawsuits on behalf of disabled, chronic pain patients against the WA State Dosing Guidelines, the American Pain Society (APS) held it’s 27th Annual Scientific Meeting. A Symposium entitled, Opiate Dosing Guidelines: Outrage or Imperative has been made available online, and includes links to PDFs of the handouts and audio of the talks and discussion.
The speakers include Dr. Gary Franklin, probably the primary individual behind the WA Interagency Guideline on Opioid Dosing for Non-Cancer Pain, published in 2007, which is the main object of PRN’s lawsuits (links above), Dr. Jane Ballantyne, author of the widely misunderstood 2003 review, Opioid Therapy for Chronic Pain, and Dr. Scott Fishman who does an excellent job defending the standard of care for pain management, criticizing the research basis for the WA Guidelines, and generally reminding everyone of the realities of the pain crisis, the war on docs, the (mostly failed) history of regulatory efforts, and of the chilling effect he feels certain has been worsened by promulgation of the WA Guidelines.
So I highly recommend listening to Dr. Fishman’s talk. But even more interesting is the discussion after the talks were given. A doc in Atlanta tells how he is getting letters from insurance companies informing him that it has been determined that doses over 120mg are no longer considered safe; a lawyer informs the audience that the 120 mg number is showing up in criminal indictments of physicians, and physician “experts” are using the WA Guidelines as evidence for the prosecution in both criminal and licensure cases. The audio for this can be found (confusingly) after the “Introduction” by Gregory Terman - in the second part of the Terman Introduction Recording. So the Discussion is also very worth listening to, and the other talks are professionally done and informative.(2)
As usual, the academics ignore the elephant in the living room. Regarding review articles that wring their hands about the lack of long term evidence of the safety and efficacy of opioid analgesic therapy, they never discuss the impossibility of measuring the efficacy and safety of a therapy that almost no physician is comfortable doing properly. For an excellent analysis of what we might call the new academic opiophobia, see the State Tort Claim, pages 34 - 37.
I think this APS symposium, Dosing Guidelines: Outrage or Imperative, occurring as it did on the eve of PRN’s lawsuit against that misguided effort, may end up being a historical marker of the end of the era in which “The Central Principle of Balance” reigned uncontested. The pursuit of what I believe is an impossible balance - the apples of pain relief against the lemons of the drug war - has pretty much consumed the efforts of the public health, academic medical, medical ethics communities for decades, culminating in the amazing, vanishing DEA FAQ(3). I have long believed that “law enforcement does not deserve a place at the table where scientists and clinicians and politicians of good faith should meet to honestly assess the harm that has been done to criminalized drug users, pain patients and physicians and earnestly seek ways to undue the public health crisis stemming from our disastrous drug war juggernaut.”(4)
So, hurray for the beginning of the end for the principle of balance as the only way to frame our issue! June 2008 marks a new era, in which the patients themselves enter the fray as primary actors re-framing the debate to one in which we see an opiobhopic culture backed by governmental force denies a vulnerable citizenry of their civil liberties and access to the FDA approved medications they need to survive.
The new framework focuses on the rule of law, a matter for the courts - discriminated-against citizens vs the Govt, not ad-hoc working groups of cops and docs. This framework puts academic research and researchers back in their proper roles, as we no longer need them so much as lead-negotiators, researchers can do their research, the standard of care for pain evolves, and the patients and their lawyers will refer to it.
Very nice historical markers! This APS conference on the one hand, and the WA Complaint and WA State Tort lawsuits on the other. Enjoy the links!
Footnotes:
1. Symposium #302 - Opiate Dosing Guidelines: Outrage or Imperative. American Pain Society’s 27th Annual Scientific Meeting, May 8-10, 2008. PDF’s and audio are available.
2. The usual information is reviewed:
* prescribing is up in response to research over the past decades regarding the horror of a global crisis of untreated and mistreated pain, and regarding the safety and efficacy of opioid titration to analgesic effect, which is the current standard of care;
* undertreatment, denial of treatment, and access barriers to pain relief are still the defacto rule, the pain crisis rolls on and the drug war still reigns supreme;
* even for cancer pain where most progress was made, undertreatment is still more prevalent, or at least as prevalent, as adequate treatment;
* efforts at monitoring prescribing have always backfired (but hope spring eternal, unfortunately);
* rates of prescription drug abuse (which is not directly measured) may be up, and this may or may not have anything to do with doctor-patient prescribing relationships;
* legislative efforts, like Intractable Pain Acts passed by several states, produce conflicting results at best (they apparently legalize opioid prescribing for pain, but the pogrom against pain patients and docs continues - Frank Fisher being the classic example - so the net is negative - a net increase in the chilling effect on the appropriate prescribing of pain relieving medications.
3. THE PATHOLOGICAL DEA: The War on Doctors and the Pain Crisis in the Aftermath of the DEA FAQ Debacle. Compiled by: Alex DeLuca, M.D., MPH; Addiction, Pain, and Public Health website; 2006-04-16. Modified: 2007-09-11. Available.
4. The Solution is NOT More Negotiation with Law Enforcement. War on Drugs, War on Doctors, and the Pain Crisis in America. Alex DeLuca, Columbia School of Public Health, 2004. Available.
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