I’ve described in the past many times how advocates of “integrative medicine” (or, as I like to call it, “integrating” quackery with conventional medicine) like to co-opt science-based treatments as somehow being solely within the bailiwick of their favored unholy hybrid medicine offspring bred of a forced marriage between science and magical thinking. There are many potentially harmful aspects of this shotgun marriage, not the least of which is the dilution of the scientific basis of medicine in favor of pseudoscience. One area, however, that doesn’t get enough attention (except from me) is how integrative medicine tries to claim all “nonpharmacologic treatments for pain” as its own. I’ve described how quacks have done this.
My thinking on this issue first started to gel a couple of years ago, when the National Center for Complementary and Integrative Health (NCCIH) published its five year strategic plan for 2016-2021. In this plan, NCCIH prominently featured researching and promoting the “nonpharmacologic treatment of pain” as one of its most pressing goals. Later that year, it published a really bad review article, one based on horrible studies and huge extrapolations from weak data, that basically claimed all nonpharmacological treatment of pain as part of “complementary and alternative medicine” (CAM, now known as “integrative medicine”). Basically, although I had been getting the vibe that integrative medicine advocates were trying to claim all non-drug treatments for pain as their own before this, these two publications by NCCIH made it incredibly obvious to me that this was the new propaganda direction that integrative medicine advocates would be taking, and take it they did. It wasn’t long before JAMA joined in, followed by the American College of Physicians, the Academic Consortium for Integrative Medicine and Health (of course!), and the FDA which, in response to lobbying by acupuncturists and chiropractors, has a draft proposal outstanding to encourage physician education about acupuncture and chiropractic as “therapies that might help patients avoid prescription opioids.” Never mind that there is no good evidence that either can accomplish this goal. Meanwhile, acupuncture advocates have been busy lobbying various states to have their Medicaid programs cover acupuncture.
Which brings us to Oregon.
Oregon: The “nonpharmacologic treatments for pain” scam
There was a story last month that I had meant to write about but somehow had gotten lost in the piles and piles of links in my “to be blogged folder” about the potential horrible consequences for patients that this co-optation of nonpharmacologic treatments for pain could have for chronic pain patients, in essence sanctioning their torture. (I don’t think I’m exaggerating, or if I am it’s not by much.) It came in the form of an AP story, Oregon officials consider limiting opioid prescriptions:
A proposed change to the state’s Medicaid program aims to reduce the overprescribing of opioids, which has caused an epidemic of overdoses, Oregon officials said.
The proposal would limit coverage for five broad chronic pain conditions to 90 days of opioid pain relievers, The Bulletin reported Wednesday.
It would also taper off patients who have been taking opioids long-term from those medications within a year.
In turn, it would introduce alternative treatments previously unavailable under the Oregon Health Plan.
“Alternative,” you say? What does that mean? If you read this blog, I bet you know exactly what that means. From the The Bulletin, a central Oregon newspaper:
Oregon could have some of the country’s strictest limits on opioids for chronic pain patients under a proposal being considered for the state’s Medicaid program. The proposed change would limit Oregon Health Plan coverage for five broad chronic pain conditions to 90 days of opioid pain relievers and would force patients who have been taking opioids for longer to be tapered off those medications within a year.
Yikes! Forced tapers for chronic pain patients beginning in 2020? What, pray tell, will replace the opioids? You guessed it: yoga, acupuncture, massage, chiropractic, or physical therapy. Or, as an Oregon Health Authority spokesperson put it:
“We are in an opioid crisis in Oregon,” said Jonathan Modie, an OHA spokesman. “Over prescribing has been the main driver of overdose and death. We want to make sure patients have more non-pharmacological options such as acupuncture, massage therapy and chiropractic care.”
Well, yes. There is an opioid crisis. Deaths due to opioid overdose are at an unacceptably high level. Something needs to be done. Unfortunately, the imperative to “do something, anything” is driving some truly awful policies that will harm patients. For example, in my state, as of June 1, physicians have to run a search on every patient for whom they prescribe opioids beyond a three day course for acute pain (as in postoperative prescriptions) and document that search on a special opioid prescription form. We also have to have patients sign a consent form warning them that opioids can be addictive and can even kill them. Will this policy reduce opioid overdoses in this state? Hell if I know! There’s no good evidence to say that it will, but it might just accomplish that by making it so onerous to prescribe and get opioids, even for patients who need them, that fewer patients get opioid prescriptions and therefore fewer die. The price, of course, is a lot of patients in pain who don’t need to be. Of course, the Oregon proposal is so much worse. At least the Michigan proposal has a little bit of prior probability based on callousness: Let patients suffer by making it harder for them to get opioids and maybe overdoses will decline. It might work if as a state official you don’t mind treating some chronic pain patients with needless cruelty. The Oregon proposal, on the other hand, can’t work because it proposes encouraging the use of quackery instead of opioids.
Now that’s cruel.
Three acupuncturists and a chiropractor
Where, you might wonder, did such an incredibly non-evidence-based and, to put it quite bluntly, dumb proposal come from? It takes a little explaining, explaining that’s easier to do just by quoting:
The proposed change came out of the Chronic Pain Task Force, an ad hoc committee created to provide guidance on reducing opioid use under the Oregon Health Plan. The Oregon Health Plan has a unique structure among state Medicaid programs, relying on a prioritized list of health services ranked by experts in order of importance to patients. State lawmakers then decide where in the prioritized list to draw the line between covered and uncovered services.
Currently, the five conditions being discussed — fibromyalgia, chronic pain syndrome, chronic pain due to trauma, other chronic postprocedural pain and other chronic pain — fall below the line, and thus treatments for those conditions aren’t covered by the Oregon Health Plan. But according to the Oregon Health Authority, many patients with those five conditions are being prescribed opioids. The Oregon Health Plan has no way of knowing whether those patients are being prescribed opioids for those chronic pain conditions or for covered services and, therefore, cannot decline to cover those prescriptions.
By establishing a new entry in the prioritized list above the cutoff line, the Oregon Health Plan would then cover alternative treatments, such as yoga, acupuncture or physical therapy, but would try limit the use of opioids.
I’m all for evidence-based guidelines for just about every condition in medicine with sufficient scientific and clinical evidence upon which to base guidelines, but the key is how these guidelines are developed. Using Google to try to find various reports of the Oregon Chronic Pain Task Force, I found this Health Evidence Reviews by the Chronic Pain Task Force dated January 23, 2018 and June 7, 2018. I could see the problem right away as I perused these documents. Basically, the problem was that the review of evidence listed in the reports tended to cite the same unconvincing studies that acupuncture and integrative medicine advocates like to cite. They cited followups to the infamous Vickers meta-analysis (or, as I like to call them, Son of Vickers, Bride of Vickers, and the like), the granddaddy of acupuncture meta-analyses and the one most often touted as the gold standard “proving” that acupuncture works for chronic pain. It didn’t, no matter how much acupuncture advocates strained to say it did. Then, of course, the Task Force cited the systematic review by the NCCIH that really didn’t show that acupuncture or other CAM (rebranded as “nonpharmacologic treatments for pain”) has any effect on chronic pain distinguishable from placebo.
You can listen to the panel itself debating the opioid taper at its meeting of June 7. It’s cringe-inducing. They admit there’s no evidence, and basically admit that the figures they’re bandying about for length of time for the taper to zero have basically been pulled from their nether regions:
Notice the obsession with being consistent with the “prior guidelines.” What prior guidelines, you ask? Well, in 2016, Oregon imposed similar restrictions on patients with chronic back pain. At one point, they assert that this program is working, but there’s no evidence presented that it is, nor could I find any evidence that it’s doing what is intended. Basically, they want to expand their forced taper to a much larger group of patients.
It didn’t take me long to figure out why the Chronic Pain Task Force is so “open” to alternative treatments. there are three acupuncturists (Ben Marx, David Eisen, and Laura Ocker) and a chiropractor (Mitch Hass) on the committee. Yes, you read that right. Four of the members of the Oregon Chronic Pain Task Force are quacks. They’re cruel quacks, too, as they want to force patients to taper their opioids in favor of their fraudulent “nonpharmacologic treatments for pain.”
Ocker, for one, is a high-ranking and influential quack, too. She was President of the Oregon Association of Acupuncture and Oriental Medicine from 2012-2013 and has been active promoting acupuncture legislatively in Oregon at least since 2009. Indeed, our old friend John Weeks interviewed her admiringly in May 2017, claiming that “Evidence opens Medicaid in Oregon to acupuncture,” where we also learn that Ben Marx has been one of her colleagues at the Oregon College of Oriental Medicine also working to promote acupuncture reimbursement in Oregon:
Ocker has also made available multiple documents that can guide interested parties more deeply into how to engage such a process. These include the recent Oregon Health Plan remarkable decision, following the ascendency of the opioid crisis, to “prioritize therapies such as chiropractic and osteopathic manipulation, physical therapy, acupuncture, cognitive behavioral therapy, graded exercise therapy, interdisciplinary pain management, yoga, and massage—and a treatment plan to stay active and return to previous function—over ineffective surgeries and narcotics.” Ocker believes that the looming opioid crisis has been wind at their backs during the entire process.
In other words, at least two of the acupuncturists on the Chronic Pain Task Force are not just acupuncturists. They’re advocates for acupuncture and federal and state reimbursement for acupuncture services and have been active politically for quite some time working for just that. In addition, Amber Rose Dullea is a fibromyalgia sufferer and licensed massage therapist, as well as a “coach, speaker and author.
I couldn’t help but wonder: Are there any physicians on this task force? It turns out that there are. There are two anesthesiologists (Dr. David Sibell), one of whom is a pain specialist (Dr. Kevin Cuccaro). I must admit, after perusing Dr. Cuccaro’s website, I was left with the distinct impression of woo, as I read of the “Pain Triangle.” At the very least, his publications and podcast go on about the “Pain Management Business–A multi-billion dollar empire motivated by what is profitable rather than what is best for patients.” In episode #39 of his podcast, he starts right out going on and on about the “powerful placebo,” a dead giveaway for someone whose mind is so open that his brain falls out when it comes to woo. After all, placebo effects figure prominently in the central dogma of alternative medicine. The others include a fairly unremarkable assortment of specialties, including Dr. Tracy Muday, Chief Medical Officer of Southwest Oregon Independent Practice Association and Advanced Health, Coordinated Care Organization administering Oregon Health Plan benefits to enrollees in Coos and Curry counties; Dr. Holly Jo Hodges, Medical Director at WVP Health Authority; and Dr. Ariel Smits, a family medicine doctor in Portland.
It certainly looks as though the doctors barely outnumber the quacks on this panel, and might even have the upper hand. Why is this panel like this? An Oregon Health Authority spokeswoman justified it by saying that the the task force composition aimed “to represent the variety of clinicians who would be involved in the management of chronic pain.”
Here’s the actual text and the changes from previous policy on the use of opioids for chronic back pain from 2016 (yes, that was the precursor to this cursed policy):
And what is this taper process? This:
My reaction: WTF?
The backlash
Not surprisingly, groups representing chronic pain patients are not happy about these proposed guidelines. A story in STAT News from last week described how patients in Oregon are protesting, having shown up to an August 9 meeting of the Value based Benefits Subcommittee (VbBS) and the Health Evidence Review Commission (the latter of which includes a naturopath, Angela Senders, as one of its members) to make their concerns known, especially since the HERC is the committee that has to vote on the proposal, after it’s screened and approved by the VbBS. And, boy, did they ever!
The controversy has brought together an unlikely crew of protestors, including many in wheelchairs and in walkers, who, at 7:15 on a recent Thursday morning, erected a tidy encampment outside the windows of a community college lecture hall here. A security guard eyed them warily from inside, where an obscure committee would soon hear the state’s proposal to end coverage of opioids for chronic pain.
Among their signs: “Death with dignity is a law: What about LIFE with dignity?”
And:
Each used their time in the lecture hall to offer impassioned speeches, accented alternately with tears, shouts, shakes of a pill bottle, uniformly opposing the policy change.
Again and again, they reminded the committee members that they had not yet fully grappled with the question central to their proposal: Is continued reliance on opioids for chronic pain more dangerous than forcing patients off them?
And that’s the point:
Experts say the science supporting either argument is extremely limited.
“What is notably missing is any review of any literature regarding the centerpiece of their proposed policy: Forced opioid taper to zero for all persons,” said Dr. Stefan Kertesz, a pain and addiction specialist at the University of Alabama, Birmingham, School of Medicine.
Indeed, a group of pain physicians, academics, and patient advocates wrote a letter to Oregon Health officials pointing out just how wrong-headed and harmful this proposal is. The full text of the letter can be found here, but a key quote is worthy of noting:
An across-the-board denial of opioid therapy for the huge umbrella category of chronic pain is as destructive as is liberally prescribing opioids for all types of chronic pain,” the letter warns. “The denial of coverage to the Medicaid population, in particular, is likely to have a disproportionate impact on individuals with disabilities, on the sickest patients and those with multiple chronic conditions.”
Precisely. They also note that, although opioid prescribing has been declining since 2012, that decline has not correlated with a decline in opioid overdose deaths. Indeed, the authors note that opioid deaths have skyrocketed during that same period because “crisis has evolved to feature heroin and illicitly manufactured fentanyl and its analogs” and even “most deaths that involve a prescription opioid are polypharmacy—often including illicit drugs, benzodiazepines and other CNS depressants, and alcohol—and most misuse is non-medical.”
The danger of “integrating” quackery into medicine
Let’s just put it this way. Even “integrative medicine” pain specialists were appalled. The Academy of Integrative Pain Management submitted a statement. While the statement lauds the intent to make acupuncture and chiropractic (as well as other non-evidence-based treatments) “above the line” and thus reimbursable, even “integrative medicine” practitioners were horrified at the thought of forced opioid tapers. The statement also sarcastically notes Oregon’s first foray into this sort of nonsense by pointing out that it’s “in the 20th month of a similar 12-month plan to forcibly taper patients with back and spine pain off their opioid pain relievers” and then goes on to point out that this policy “is not a rousing success, yet you appear to be willing to impose it on another large group of patients.”
This proposal by the Chronic Pain Task Force in Oregon is also incredibly unethical. The reasons are simple. There is no evidence that forced opioid tapers—particularly a forced taper to zero opioids—is of any benefit for chronic pain patients, but there is considerable anecdotal evidence of potential harms, up to and including suicide. Indeed, Department of Veterans Affairs data suggests that opioid discontinuation is not associated with overdose mortality but is associated with increased suicide mortality. Moreover, denial of coverage for opioids in these patient groups will almost certainly have a disproportionate impact on patients with disabilities, on the sickest patients and those with multiple chronic conditions. These are the patients who frequently wind up on Medicaid after they can no longer work. Worse, the evidence that the modalities that will be covered and will be recommended as replacements for opioids are effective is weak to nonexistent. Indeed, the highest quality evidence shows that acupuncture, for instance, is no more than a theatrical placebo. It does not work.
If you want to see the danger of “integrating” quackery with medicine, as integrative medicine does, look no further than Oregon. Here, because of the way that integrative medicine has so successfully rebranded quackery like acupuncture as “nonpharmacologic treatments for pain” and tarted them up as being evidence based when they are not, a large state is seriously considering a policy that, if implemented, would leave an large number of the most vulnerable patients suffering unnecessarily, all because there are four quacks and at least some quack-sympathetic doctors and advocates on a panel. The opioid crisis is truly driving not just bad solutions born out of the desire to “do something,” but is being used as a “wedge” to drive more pseudoscience into medicine. Unfortunately, the fix seems to be in. There’s going to be a vote as early as October, and I’d be willing to bet—sadly—that Oregon will approve this patient-hostile policy. Then, moralizing about those who need opioids combined with magical thinking like acupuncture will leave untold patients suffering unnecessarily—all because we have to “do something.”
Don’t say I didn’t warn you this was coming somewhere, sometime. I also predict that, if Oregon gets away with this, it won’t be long before more states decide to punish chronic pain patients in the name of helping them with “nonpharmacologic treatments for pain.
80 replies on “Medicaid and the Oregon Health Authority: The scam of replacing opioids with “nonpharmacologic treatments for pain” like acupuncture”
Have these yahoos been in so much pain that they could not raise their arms to properly wash their hair? It was only three months of my life that I suffered so–couldn’t work, couldn’t drive more than a few minutes, could barely brush my teeth–but it was awful. Surgery helped, as did physical therapy, but I couldn’t return to work until I got a prescription for Lyrica. (Not an opioid, but a pain medicine.) It is heinous to take people off their pain meds unless they have something that WORKS.
Torturing patients with chronic pain is exactly what will happen if this is voted through, there will be suicides it is inevitable. This is just evil.
Yeah, but some quacks stand to make some money from it, which is obviously a far better thing than having all that filthy lucre end up in the hands of Evil Big Pharma. Anyway it’s not like anyone who commits suicide is going to end up on the witness stand, and any patient who does get called will just be an addict easily painted as unreliable, right?
I’ll be the first to say we have to stop over relying on opioids to treat pain when there are other medications that work just as well for some conditions. I’m also a big advocate of physical therapy, but again for some conditions.
There will simply always be some patients who must be managed on opioids. And even patients who should have been treated differently, who are on opioids now . . . to tell them no more is simply heartless.
These people are crazy. Fantasy Based Medicine at its best!
My suspicion, despite the Department of Veterans Affairs’ study is that overdose deaths will go up as many people go to the street for pain killers.
People who have been over-prescribed can probably be successfully tapered off but in cases where the dose levels are appropriate a mandatory taper is insane. And highly immoral.
I listened to the first 5 minutes of the video. You are right, they have not a clue. They reminded me of the Irish banker in the Great Financial Crisis, who when asked where he got the figures for the money needed to bail out his bank said, “I pulled them out of me arse”.
Sadly, the forced tapering is going full force in Ontario and other parts of Canada. A young woman who survived a rare childhood cancer and numerous surgeries is being forced off her opioids that helped her manage life by a doctor who was sanctioned by the regulatory college. The regulators did not care as you can hear in her edited audio of that call at https://omny.fm/shows/roy-green-show/beths-call-to-the-college-of-physicians-and-surgeo
In addition, data mining research is providing a great deal of bad research. This should have been retracted but they refused to but did make a change in an attempt to clarify https://www.painnewsnetwork.org/stories/2018/5/28/when-do-guidelines-become-guidelines The erroneous information that 1 in 4 doctors is not prescribing to the guidelines is still out there in the media even though the data they looked at preceded the current guidelines
I know that Tramadol is not the top of anyone’s list to give or take away, but that’s the medication I take for chronic pain. It’s the only one I can take because those lovely stronger pain medicines only make me sick. I can’t take Lyrica because of serious side effects. I cannot take NSAIDs at all. PT has helped slightly in the past, but would do little now. I’m certainly not going to be voluntarily stuck with a bunch of needles whilst someone mutters incantations over me. If the Tramadol, which doesn’t do much, but is way better than nothing at all, were taken away, I don’t know what I’d do. Street drugs when one is a “shut in,” isn’t likely. I guess, because I could get liquor delivered, I’d probably have to drink myself to death. Fortunately, I don’t live in Oregon.
It’s my go-to, as I avoid acetaminophen. Then again, I don’t suffer severe chronic pain.
The opioid problem is so bad, the FDA is warning pet owners about using animals to get opioids.
https://www.cnn.com/2018/08/16/health/opioid-fda-pets-bn/index.html
In 2013, Oregon ranked fourth-highest for pet ownership.
https://www.oregonlive.com/pets/index.ssf/2013/01/new_avma_report_ranks_oregon_f.html
MJD says,
Q. Why don’t veterinarians use nonpharmacologic treatments for pain in their medical practice.
A. The placebo effect may not work with animals.
They do, fuckwit. Have you missed the posts on the topic?
Missed those posts, Narad. I’m sure they were overly exaggerated.
@ Orac,
Are violent words (e.g., fuckwit) an acceptable form of respectful insolence? I will never play that game, and thereafter destroy my minion card if you remain silent.
I am not Orac, as I’ve had to tell your stupid ass before, so this remark is senseless. And I most certainly do not respect you. Where the hell you got “violent” from is anybody’s guess.
You’re not a minion. And I don’t imagine that moronic “threat” means you’ll actually go away.
Narad, I agree: MJD is not a minion- he is, instead a highly rarified form of anti-vaxxer.
A minion would have learned important concepts from Orac (after so many years of lamprey-like activity) and would have followed up with outside reading: he or she wouldn’t try to correct Orac or tell him what to do with his blog . Perish the thought!
Although I am far from pretending to entirely comprehend our vaunted leader’s wise and mysterious ways, I venture that he doesn’t want to censor anyone ( except in a few designated cases- see above), has sympathy for those less gifted than he is and PERHAPS , allows some access in order to serve as a negative example for newbies and a target for the rest of us.
Good post. Unfortunately the horse left the barn in the late 80s, early 90s when Purdue convinced everyone that Oxycontin was all that and a bag of chips for chronic pain. They showed extremely poor studies and even anecdotal evidence that opioids were appropriate for both acute pain and chronic pain. Unfortunately, they aren’t all that great for chronic pain (hence drugs like duloxetine and pregabalin). Oxycontin was deliberately made to increase addiction risk, it was a 12 hour drug however there was a fast acting portion to each pill which gave a lovely high. No wonder people started to take it q4h.
Now we are dealing with the fallout of that mess. I think the best we can do is to try to keep new chronic pain patients off the opioids. The ones who are on it should just stay on it. At the lowest effective dose of course. On 12 hour meds, very few breakthroughs.
To wit:
http://www.thepoisonreview.com/2016/05/07/absolute-must-read-la-times-on-the-myth-of-oxycontins-12-hour-analgesic-effect/
If the problem is over prescribing then the solution is to stop over prescribing.
Prescribing woo-doo is not a solution. Auricular acupuncture for horrific pain is exemplary woo-doo. Your ear looks like an inverted foetus – at a push, with a little imagination. So we are going to stick some little pins in your little portable ear doll. Can‘t do any harm, or the risk is very remote.
So is the chance of woo-doo being any use for horrific physical pain. Solution: Don’t over prescribe.
Acupuncture of the usual kind is exemplary woo-doo, too. The body used as its own woo-doo doll.
Oregon is well on the road to woo-doo Hell.
The proposed “solution” does not even address the main problem here.
Yes, we have a serious problem with opioid addiction in this country. But most of the serious problems involve street pharmaceuticals: heroin and fentanyl. Much of the rest involves inappropriate combinations of medication, e.g., opioids and alcohol (a person taking prescription painkillers should never consume alcohol, and the prescribing physician does have a duty to inform patients of this risk.) Banning the long-term prescribing of opioids does exactly zero to alleviate those problems. That would be a problem for Oregon if they try to defend this in court: because disabled people (a protected class) are involved, the state would have to demonstrate some degree of need to take this action. IANAL, so I don’t know whether “rational basis” or “strict scrutiny” applies here, but the state is going to have trouble meeting even the “rational basis” test, which is the weaker of the two.
The long-term solution is to develop effective non-opioid analgesics. Yes, that’s going to take a lot of time and research and development effort. But as long as there are cases where prescription opioids are the only practical option, doctors will need to prescribe opioids to those patients.
The real problem we’re having now is after years of overprescribing opiates, we’re telling patients “no more.” Those patients are turning to heroin that turns out to be laced with fentanyl or carfentanil.
I saw an ER patient two years ago who had come in for severe abdominal pain and constipation. She was an elderly lady with chronic pain, and it turned out that her doctor had gotten scared by the crackdown on prescribing and abruptly cut off her prescriptions for Dilaudid. With no taper.
She was in acute withdrawal.
THAT is what we’re looking at.
What you said. Chronic pain patients who are taking opioids responsibly and don’t abuse other substances, will be driven to the street drugs market, at high risk to their lives.
This entire thing is unconscionable and overtly evil.
As for ‘tapering off’ opiods for pain; There is always mitragynine, 7-Hydroxymitragynine, cannabidiol (CBD), tetrahydrocannabinol, and 7-hydroxy tetrahydrocannabinol.
The mitragynine family does hit opiod receptors but not the ones that repress respiration. Harm reduction, people.
Ohh, and people can just “suck it up” and take more tylenol, I guess. That should be good for the 3-d printed replacement on offer by Big Liver.
We don’t have evidence of safety or efficacy with any of the things you named. Pushing one drug for another is not helpful. Come back when you have properly designed scientific studies to support the use of these substances.
Here’s one https://jamanetwork.com/journals/jama/article-abstract/2673971
I KNEW that someone would chime in about CBDs, edibles, etc.
More seriously, if the number of adverts I’ve seen is any reliable measure, lots of people are trying/ buying into that woo.
AND people are making money from it/ investing in it in CA ( also WA and CO). NJ is next.
Disclosure: I smoked pot socially because most of my friends and colleagues did long ago: I was not exactly thrilled with the effects.
I’ve had high-CBD, low-THC grass in Washington. It was a decent anxiolytic. Unfortunately, the corresponding E-cig liquid is outside my budget.
Ohio, too.
I have to listen to a lot of people push unproven substances ever since Ohio legalized medical marijuana.
This is one instance where the plural of “anecdote” is “testable hypothesis.”
There’s substantial anecdotal evidence that pot relieves pain. There appear to be some state statistics that legal medical marijuana has reduced demand for opioids, and reduced the incidence of opioid abuse. No I don’t have cites, and I’m not going to do the dig to find them.
The point is, all of this is about pot is testable and should be tested. Forcing pain patients to suffer without medication of any sort, or endure quack BS that does nothing for them, is unconscionable and evil. We owe it to those patients to find something that works. If pot is only good for a small percentage of the cases, fine. For that matter if quackupuncture or some other woo placebo is good for a small percentage of cases, fine.
When faced with the death of a loved one, some people drink themselves into a stupor, others pray. Even the most ferocious atheists would most likely agree that prayer is better for one’s health than alcohol abuse.
There’s an obvious incentive for Pharma to come up with better pain meds. Why this isn’t the #1 research topic right now, is beyond me. Whoever gets there first is going to be richer than Mark Zuckerberg, but unlike Zuck, s/he/they will deserve every penny of it.
And any politician who wants to rule on the right of patients to have science-based treatment for agonizing pain, should be made to endure comparable agonizing pain before being allowed to vote on it. Surely there are interventions that can accomplish that without causing actual harm.
BTW, speaking here from the perspective of having some nasty muscular pain for the past few weeks that I suspect is related to chronically bad work ergonomics. I haven’t even taken a Tylenol for it because I’m experimenting with changing my ergonomic situation to try to solve it that way. But if this was not going to go away, and it interfered with essential daily activities (“eating, pooping, washing, sleeping”), you betcha’ I’d be looking for anything that would make it stop.
Denice Walter writes,
“MJD is not a minion”
MJD says,
No minion can speak for Orac, his reluctance to auto-moderate is an indication of MJD’s thoughtful and anti-respectful-insolence.
@ Orac,
Who will be the first guest writer that, hopefully, contributes a rebuttal to your 14-years of Respectful Insolence – I’m available. 🙂
Michael:
I’m not speaking for Orac- I’m merely using a standard definition of ‘minion’. Look it up.
Although we use the term jokingly- indeed it started as a joke-, most of us identify as followers of SBM and scepticism. Orac is better at it than any of us so we follow his lead.
If you want editorial control, get a blog of your own.
I live in Oregon and you’ve nailed this article!!! We have been working on this issue for months and some in our group have been working on it since 2016. We recently heard of some derogatory remarks being made by those on the HERC about us. I think that shows a huge bias. They are able to vote these changes into policy as soon as October 4th, but in truth we should demand they dismiss half their committe on the basis of a bias. If you’d like to connect with us to continue your involvement with our real crisis, please contact me or our group on Facebook- Oregon Pain Action Group [email protected] we can use as many educated voices as possible.
A pair of anecdotes: my brother is covered by Oregon Health Plan. A few months ago he had a health scare and I had to set up an appointment for him and take him to the doctor. Turns out it wasn’t a doctor, wasn’t even a nurse but a PA with prescribing authority (and hoo boy did that person prescribe some strong stuff to a guy they’d just met) and everyone else in the office was also not a clinician. A few were mental health therapists, a PT, and then at least one chiro and an ND. And this clinic is where you send people in crisis? Bah. (It didn’t help that the waiting room felt like a salon and there was a bar next door.)
So I’m not at all surprised that Oregon Health Plan is down with the woo and quacky.
Second story: a friend’s mother has several chronic conditions that cause her a lot of pain, including post-polio syndrome and an inoperable rotator cuff injury. Her doctor retired and so she spent a week or two without her pain medication. My friend reported (in tears) that her mother was talking very seriously about death, and hoping it would come soon. After she got her prescription refilled she was much better, but my friend was still very concerned because her mother lived in a home with guns (thankfully rifles which would have been harder for her to hurt herself with, but still). The idea of demanding that a person in a huge amount of pain that will not get better, that will not go away, that can’t be fixed with yoga or PT, just give up the only thing that makes life bareable, that’s horrifying. It’s inhumane.
And I wonder, if this policy does go through, how many people will die (will even use Oregon’s death with dignity) rather than suffer this way. And how many deaths it would take to change the policy back.
I’ve seen people do a lot of damage to themselves with rifles and shotguns. Desperate people will do unbelievable things.
What we’re seeing from these chronic pain patients is they turn to heroin. A lot of the overdoses in Ohio are not your typical addict but chronic pain patients who’ve been cut off by their doctors.
The PA comment is curious; they must have an MD/DO on board to employ a PA. PA’s always work on the license of their supervising physician. I don’t know of any state where PAs have independent practice authority (though I could always be wrong?)
According to this pamphlet from the Oregon Medical Board, on-site supervision by a physician can be as little as 8 hours a month. As far as prescriptions, the pamphlet reads:
Oh, wow. Did not know that.
I don’t know about other countries but here in Australia the purchase of any medication containing codeine now requires a prescription. This is an attempt to deal with abuse of OTC opiates. Analgesia manufactures are now promoting analgesics containing a combination of paracetamol and ibuprofen, something I can’t recall seeing before the ban on codeine. A pharmacist I know told me that 6 months before the introduction of the new law people were already beginning to stock up on codeine containing analgesics.
L-rd, in the U.S., people are abusing loperamide.
Well that’s a new one for me. How on earth do you treat loperamide abuse?
Narad, I just recently found that out. It surprised the heck out of me. I have…issues, and have to take loperamide frequently. I can’t imagine how much one would have to take to get “high,” but it has to be enough that one would never poop again! I only hope that it doesn’t end up one of those “you have to get it from behind the counter” drugs, because that would be extremely inconvenient for me.
In the United States, most forms of codeine require prescription, all are controlled. In many places you can still get guaifenesin with codeine as a Schedule 5, meaning you have to sign for it and it’s tracked but you don’t need a prescription. It contains very little codeine.
regarding loperamide, yeah I had heard this as well. I also hope they don’t put it behind the counter. You do have to take a lot of it to get a high; hardly seems worth it. Unless someone figures out how to use it to make an workable opiate like they make meth from Sudafed, I don’t see that happening though. It’s just too easy to buy heroin.
https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm611046.htm
That is right, Panacea. There are now studies to show safety and efficacy. CBD is FDA approved. It now can be prescribed off-label for pain, as a ‘mood stabilizer’ (as was the anti-seizure drug valproic acid which causes liver insult — finally something pure where future studies are ‘ethical’ without throwing in the poison), and much more.
https://www.studyfinds.org/cannabis-modern-medical-arsenal-researchers/
Stick that into your pipe and jerk off to it!
Piss off, Tim. You’ve come to the wrong place to play that card. Orac has discussed the weakness of studies showing efficacy of marijuana many, many times.
The FDA approved ONE new medication based on CBD for the treatment of one rare form of seizure and NOTHING ELSE. It doesn’t prove the usefulness or safety of actual CBD oil itself, nor does it prove the usefulness or safety of CBD or any other marijuana compound for anything else. Kratom hasn’t been studied at all for medical purposes (bet you forgot you included that, eh, or thought I didn’t know what it was?). We don’t know if it works, we don’t know if it’s safe.
as Many Calvinist Christians like to remind us.
“Suffering will bring one closer to god” So take an aspirin and shut the ….up!
(from my linked article above)
http://www.gwpharm.com/healthcare-professionals/sativex%C2%AE-delta-9-tetrahydrocannibinol-and-cannabidiol-eu-nabiximols-usa
Again, Panacea; These are actual extracts from cannabis and not synthetics like marinol.
Epideliox (CBD) 100mg (that’s really a boatload!) has been deemed safe for children over 2. Is it somehow less safe if used for, say, cluster headaches?
CBD oil has been referred to as ‘stalk oil’ and can be derived from ordinary old ditchweed found along hiways in the midwest. Though it is telling that DEA schedule 1’d CBD back in 2016 as the GW Pharma studies were drawing to completion — This helps you to stand by your sentiment of ‘show me the studies’ as no federal funding is allowed except for those designed to show harm — No harm, no published — and makes it damn hard for anyone to do research otherwise (for instance, limiting researchers to one old boring strain of grass grown at the university of Mississippi).
— ps. I try to reply directly but it always ends up at the bottom of the page. Sorry.
Again, piss off. I don’t care how the new medication is extracted. It is not all CBD oils, it is not actually CBD oil in its approved form (it can’t be, the dosage has been standardized), it is an oral solution.
Sativex is not FDA approved.
You have not refuted any of my points.
ORAC
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I don’t understand your semantics, Panacea. What about ‘oral solution’ makes it necessarily different from 100% CBD oil?
https://www.cannalawblog.com/gw-pharmaceuticals-a-case-study-for-cannabis-pharmaceutical-approval/
The article is from April. GW received FDA approval on June 25,2018.
And again — if 100mg dose is safe for two year old baby, how is it not safe for adults using (usually less than 10 mg) it for whatever? I hold that the ‘safety’ part has been established. We added all natural ingredients; vitamine A from carotine, roots, natural herbal extract such as CBD and if it doesn’t work on your epilepsy or blackheads then you can spread the fucker on toast!
There are plenty of drugs out there that are only given under very controlled conditions to patients, including pediatric patients, with very, very serious conditions. Chemo is one set of examples.
Also, by definition, a person with intractable seizures has a brain that is working differently than a person who does not have seizures. Just as a person with a healthy heart shouldn’t take digitalis, so maybe some research should be done before using a compound which clearly has a powerful impact on the brain in people who’s brains are functioning normally.
And with your question you fully demonstrate why you are not competent to discuss this issue, Tim.
FDA approved medications have standardized doses, meaning we know how many milligrams (or micrograms) of the active ingredient are in how ever much volume of the solution. We also know what dose is safe based on weight, and what the side effects at various doses are. That’s what we learn in clinical trials, it’s why we do them.
It’s true that doses safe in infants and children are generally safe for adults. However, they are generally not EFFECTIVE for adults. Doses for infants and children are almost always weight based (there are some exceptions). However, that’s not the point.
The point is, OTC CBD oils are not standardized. You never can tell from one batch to another how much of the active ingredient is in the oil, so figuring out how much to give is a guessing game.
I know Epidolex got FDA approval. It’s an oral solution, not an oil. The dose is standardized.
The other drug you mentioned is NOT FDA approved.
Adding other shit to CBD oils does not prove anything about safety or efficacy about the active ingreditent, you nimwit.
PISS OFF.
https://www.drugs.com/epidiolex.html
OK, Panacea. I get it now, their ‘oral solution’ contains sesame seed oil and strawberry flavor. I don’t want that in my pure CBD — They don’t say what ‘strawberry flavor’ actually is: aborted fetuses? But I’m pretty sure that does not add to the safety profile.
I’d like to make a note that the warnings on liver enzymes are probably mostly due to all the tests being administered in conjunction with valproic acid which insults the liver on its’ own. Perhaps it is a little like grapefruit is for some drugs so that the valproic effective dose has been increased. As I say, now that it is approved tests can be done without the addition of the valproic acid and I suspect the language on safety profile will only be more favorable.
Again, you demonstrate your sheer incompetence.
When things like flavors are added, it’s to make a bad tasting product palatable to children. It does not affect the standardized dose, nor does it affect the efficacy of medication. The purpose of adding seseme oil is to improve the bioavailability of the active ingredient . . . that is, to make it more easily absorbed so the medication absorbs and works consistently from one dose to the next.
Then you hide your incompetence with snark about aborted fetuses.
All drugs have side effects. The liver metabolizes most of the medications we take, and in some cases can injure the liver. That has nothing to do with valproic acid. Fortunately, incidence of liver injury from Epidolex was rare in the clinical study. Now that it is on the market, researchers will look for cases of liver injury as they conduct Phase IV trials (based on data from patients used the drug), and if it’s a serious issue the drug will be withdrawn from the market. This happens from time to time when we learn why drugs do once in the general population.
In the context of pain relief, Compare the safety profile to acetaminophen aka Paracetamol, aka APAP, Tylenol vs. cannabis products. Hmm. I bet that guy spiking tylenol bottles way back when actually saved a bunch of lives making people afraid of it.
https://en.wikipedia.org/wiki/Chicago_Tylenol_murders
Nice try shifting the goal posts.
The risks of acetaminophen/paracetamol are well known. And you wish that people were afraid of it. It’s one of the most abused drugs we have. I’ve had to work with a lot of accidental acetaminophen overdoses because people mix it with something like Percocet or Vicodin, or an OTC cold med without realizing what they are doing.
It’s an argument for reforming how drug companies market acetaminophen products. It’s not an argument for willy nilly promoting cannabis products as an alternative.
Shifting the goal posts?? OK, I’m game.
https://www.webmd.com/vitamins/ai/ingredientmono-1018/n-acetyl-cysteine
But that amino acid is something you have to stumble upon to know it. It is widespread at ‘vitamine stores’ but they never tell you what it is good for. It is a good thing that it is not some kind of cannabis derivative or it would be verbotin.
I wouldn’t buy N-acetyl cysteine (aka Mucomyst) at a vitamin store, and I have no idea what possible OTC it could have.
We know broadly how it works for most of the conditions you listed: it neutralizes a metabolite of acetaminophen, preventing it from injuring the liver. It thins mucous, and is a good expectorant. We use it a lot for COPD patients.
There is some evidence it affects glutamate in the brain to improve a number of psychiatric disorders. I don’t know anything about ALS.
The reason it’s used is because it’s been and is continuing to undergo research that supports its use. When cannabis builds a body of research that actually shows benefit, it will be accepted as a pharmacological tool. Until then, what you say is all hype.
https://www.webmd.com/vitamins/ai/ingredientmono-1018/n-acetyl-cysteine
But, they don’t tell you about it…..
Mix it????? it is in the formulation of the pills without exception….Is there any pain pills you can have that don’t incluce that poison???
It is long known that acetaminophen improves pain relief when given in combination with an opiate. It’s an adjuvant medication.
Lots of opiates are available without acetaminophen. Good luck getting a doctor to write a prescription for most of them. Potential for abuse is too high.
Gray Squirrel above states:
Would not superior pain relief without the risk of taking a break from breathing be somewhat of the ‘holy grail’? There is some research along that avenue being done:
https://www.ncbi.nlm.nih.gov/pubmed/24345467
https://www.ncbi.nlm.nih.gov/pubmed/18550129
http://jpet.aspetjournals.org/content/348/3/383.full
The magic in these potential compounds is that there is all the opioid activity except for recruitment of beta-arrestin receptors — therefore, these compounds do not repress respiration. These compounds under study are in the mitragynine family and its’ analogs. They are naturally found in kratom so, naturally, the DEA is chomping at the bit to sched 1 them. If that happens, research will most definately be hindered or abandoned.
Is it irony that DEA wants to stamp out those molecules in the name of fighting an opioid epidemic — these very molecules which might hold the key to ending it? Is that irony or is it simply unfortunate?
Tim, you’ll find that mouse studies are not considered convincing evidence here.
The DEA isn’t trying to suppress pain medication. They’re fighting a war on drugs. Now it so happens, I personally believe that the criminalization of drug possession has done nothing to make society safer. Hence, I’m not in a hurry to put kratom on Schedule 1.
That doesn’t mean for a minute that I think it works or is safe. That has yet to be proven.
Therefore, it should be addictive, and naloxone should arrest the effects. Pretty simple to test.
Not that I’d condone doing such a thing except that I absolutely admonish that everyone should be doing it because APAP et.al. is a denaturing poison and granny don’t want a new liver:::
https://www.urbandictionary.com/define.php?term=Cold%20Water%20Extraction
Once again you show your ignorance. You don’t even know what APAP really is, nor what denaturing is.
You also don’t know “the dose makes the poison.” APAP is safe when taken in recommended doses.
Your link is not evidence of anything, except a recipe for people to completely screw up a perfectly good medication, or to just increase the dose they need to get high without overdosing on Tylenol.
But you have a Tylenol fetish. I get it. We all get it.
And then, Panacea, there is the problem for some with even moderate drinking and tylenol at the label rate. My employer warned me long ago that tylenol + drink was boxing people’s livers. I knew to avoid it like the plague but in 2005 I broke my arm. Badly.
I was given Lortab but never told that acetaminophen was in it even though I gave a thorough history of my drinking. I took it at the prescribed rate but waking up peeing out kauphy color causes one to start googling stuff.
I think I know what ‘denaturing’ is. With ethanol, the government mandated that it be poisoned so that it killed people who violated prohibition; I guess they didn’t realize then that ethanol was the antidote to methanol but they learned quickly and soon added stronger poisons killing many people. Now, you say ‘or just increase the dose they need to get high without overdosing on Tylenol’. Or maybe get the desired amount of pain relief???
As you say, the potential for abuse is too high without it. Isn’t that a little like Ahmadinejad saying there are no gays in Iran (because he kills them all)? So, that is the nature of denatured — get a smile from this and go shopping for a new liver. Can’t afford one?
ps: As I understand it, the mechanism whereby NAC staves off liver damage from acetaminophen is that it replaces glutathion stores which tylenol rapidly depletes and is accelerated with even mild additions of alcohol.
Sorry, no. You don’t know what denaturing is.
Denaturing is adding a different type of alcohol such as methyl (wood) alcohol or isopropyl (rubbing) alcohol to ethanol. The purpose is two fold. It’s used as a solvent, as fuel for some kinds of camp stoves, and also to make it more difficult to avoid alcohol taxes for ethanol meant to be consumed.
We produce more ethanol than we can drink because it has so many other uses. To keep people from drinking alcohol meant for purposes other than drinking, we denature it.
Prohibition had nothing to do with it.
What you described with Lortab and other narcotics mixed with Tylenol is NOT denaturing. It’s separating two products normally safe to consume to eliminate an ingredient (Tylenol) not desired by the consumer. There is no other reason to do that than to increase the dose of opiate without increasing the dose of Tylenol due to the effects Tylenol has. It’s a recipe for opiate abuse. And no it has nothing to do with what some guy in Iran says about gays.
Certainly anyone who drinks should be cautious about taking any acetaminophen product. But social drinkers shouldn’t need to worry about that. I have no idea what your drinking is really like (nor do I care). Lortab comes with a warning not to drink alcohol while taking it, and there is a information sheet that comes from the pharmacy with that information on it. Plus, your pharmacist is always happy to educate you about the risks vs benefits of any medication.
So spare me your righteous indignation. There is nothing wrong with APAP taken as directed.
Ok, Panacea, I’ll give it to you. It was for tax purposes.
http://www.slate.com/articles/health_and_science/medical_examiner/2010/02/the_chemists_war.html
I think that beyond ‘tax purposes’ the intent was clear — those illegally drinking should die to deter others. Whether intended or not, the inclusion of the adjuvant APAP often leads to the same ends and just as often in people who had no intention of ‘abusing’ it. It is what it is. I think I’ll still call it denaturing.
Argumentum ad nauseum is not helping your case. Regardless of WHY we denature alcohol, what you were describing with Vicodin is NOT DENATURING.
The denaturing process also makes the alcohol taste bad. Only someone very desperate to drink, drinks it. I suppose it happens. I’ve heard of people drinking hand sanitizer, so it could happen. But the problem isn’t with denaturing, it’s with people who are desperately ill with an alcohol addiction. There is no need to change a process that keeps people who aren’t allowed to buy alcohol (those under 21) from having free reign to abuse it.
And it simply doesn’t help your case. You’re still ignorant.
Many years ago, I heard a radio documentary about a “wet shelter” that served a mostly Native American population. Apparently, many of them preferred mouthwash as an alcoholic beverage.
Yeah, I’ve heard that as well.
Blech.
Hmm:
Wow. 3 drinks. So, like breakfast? The way that reads is it is dangerous if those three drinks are consumed with any amount of acetaminophen and, as I was told and have come to believe, is so. I guess that warning is supposed to be on acetaminophen-containing products since 2009 or so. But it is not written on the bottles of pain pills by prescription (hell, they never say acetaminophen anyways) and I doubt many bother to read the adverse reaction sheets that (may or may not) be included. Indeed, they always list so much crap that I think it is a marketing ploy that if drug A doesn’t contain a warning for anal leakage then better go with B because diverticulitis. Most probably read “avoid alcohol” as the drug works better, ‘stacks’, with alchohol as has been the case with every other drug I can think of. No one thinks wow, beer makes this stuff poisonous.
I know a lady — rather old, approaching 80 — herniated disks, fused disks, constant sciatic nerve pain. Dr. says she “wouldn’t survive the surgery”. She’s had her opioid pain meds severely curtailed and supplanted with physical therapy which is, um, not very helpful. So, she takes more tylenol.
I predict that with this crack-down on opioids because of the ‘epidemic’ that (tylenol warnings or not) what is already the number one cause of liver failures world wide is going to explode even further. Where are all the needed livers going to come from? China?
At least the junkies won’t be much of a strain on the liver supply because they have mostly gotten the word on how and why the poison must be separated.
Argumentum ad nauseum. Ok. I guess I’ve got it all off my chest; unless you want to carry on by continuing to carry the water of the status quo.
” But it is not written on the bottles of pain pills by prescription (hell, they never say acetaminophen anyways) and I doubt many bother to read the adverse reaction sheets that (may or may not) be included.”
I don’t know where you get your prescriptions filled but every pharmacy I’ve used in the last 20 years has included the drug information sheet AND has neon-colored stickers on the bottles that tell you important things like” don’t drink while taking this drug”, “don’t eat grapefruit while taking this drug”, “only take with food”. Most pharmacies also staple the drug information to the outside of the paper bag they put the pill bottles in. You can’t even get to the meds without going past them.
Unless it’s made legal for two burly orderlies to hold people in place while the pharmacist lectures them on the drug, there are limits to how much you can do to make people take responsibility for what they swallow.
Ahh. Yes, but they don’t say ‘drink a few beers with this stuff and box your liver’. Like I say, many gloss over the ‘no alcohol’ warning as maybe a little alcohol potentiates this weak stuff.
As for the warning leaflets, I always got them from Kroger and CVS but not from the small town pharmacy I go to now; I only get pricing info for each one (just as thick, though).
Shifting the goal posts again. You claimed the public isn’t warned about mixing alcohol and acetaminophen.
You’ve been proven wrong. Get over it.
You don’t know what this actually is, do you?
Does it have something to to with the ‘green apple quick step’?
Acetaminophen is the most common cause of ACUTE liver failure. Chronic liver failure is caused by cirrhosis, or scarring of the liver, which is most often caused by alcoholism or hepatitis infection (B or C), or non alcoholic fatty liver disease. Which is why vaccination for Hep B is so important.
And OVERDOSE is what leads to acute liver failure with acetaminophen. You don’t have to tell me what it looks like; sadly, I’ve cared for too many ER patients who thought a Tylenol overdose “suidice attempt” was a great way to get back at a boyfriend or girlfriend only to learn it was a great way to make yourself really sick.
I’d be the first to agree that acetaminophen has its risks, and society takes those risks unseriously. But that’s not what you’re saying. You’re saying it is pure poison, forgetting the dose makes the poison. You condone dangerous behaviors and misuse medical terms.
You’re not a good person, Tim, and you are not on the side of angels here.
Yes. A very nasty way to get sick and die very painfully. As an aside:
https://en.wikipedia.org/wiki/Bruce_Edwards_Ivins#Death
https://www.propublica.org/article/new-evidence-disputes-case-against-bruce-e-ivins
Hmm. Perhaps a reqium for the suicided is in order???
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