TITAN: Dedication to Dr. Forest Tennant

Forest Tennant
(L to R) Keynote speakers: Kevin L. Zacharoff, MD, Michael E. Schatman, PhD, and Stephen J. Ziegler, PhD, JD, congratulate Forest Tennant after he received the PainWeek 2017 Lifetime Achievement Award.

Continue reading “TITAN: Dedication to Dr. Forest Tennant”

Advertisements

Here we go again. What now? Kratom.

February 8, 2018

-Kelly Merrill
Here we go again.
So, the numbers you’ve been waiting for…FDA announced in February that the number of deaths involving Kratom worldwide…in over 5 years…has jumped from 36 to 44.  FDA is particularly concerned about one (yes, you read that right.  “1”) death that did NOT involve multiple substances.
One of my favorite examples of a “Kratom-related death” deserves a Darwin Award.  Remember those?  Let’s bring them back for the individual who who fell out a second story window while intoxicated with other substances (and Kratom) and did not seek medical attention.  Predictably, they died.
By contrast, acetaminophen, the active ingredient in Tylenol, available over-the-counter and perceived as “safe,” is responsible for 78,000 cases of poisoning, 33,000 hospitalizations and 150 deaths…per…year.  And it took 32 years for FDA to simply put a warning label on products containing the drug; the one their own expert advisory committee recommended decades earlier.
And I promise you this. THOSE numbers, the death and destruction caused by acetaminophen, are going to go way up since fear and ignorance have radically changed the landscape of medicine by demonizing pain-relieving opioids. The general public is under the erroneous assumption that acetaminophen is safe. Combine that with lack of effective pain control and we’re going to see a banner year. Another lethal”unintended consequence” of poorly conceived, misinformed public health policies; another pile of bodies.
One hundred forty-four thousand (144,000) people were represented in the 23,000 comments submitted to the DEA the last time they tried to schedule Kratom as a dangerous drug; 99.1% of comments were overwhelmingly favorable regarding use of the crushed leaf. Because of the overwhelmingly positive response, DEA ditched the pursuit, or so we thought.
Instead, DEA instituted a “shadow campaign” against the leaf in the year since and stepped up their attack by getting Scott Gottlieb, FDA’s Commissioner, on board. Gottlieb used to work for the company who had a patent on Kratom and was compensated handsomely…to the tune of over $400,000.
The only similarity between Kratom and pharmaceutical opioids is that they work on the same receptors. People who take Kratom in a regular basis aren’t high or impaired in any way, reagardless of whether they suffer pain or substance use disorder.  Patients may experience some constipation; but not respiratory depression, the reason opioids are dangerous at all.
It DOES, however, kill pain, elevate mood and mitigate the symptoms of withdrawal. Seems like a no-brainer to me.
But I’m biased. Adding Kratom to my daily regimen of medications is the reason I’m here today, functional and writing this piece. I was bed- or house-bound for over 15 years. Kratom gave me back some semblance of a life. And gave my son back his mother.
Many of us would like to see Kratom regulated as a dietary supplement under the Dietary Supplement Health and Education Act of 1994. It’s a leaf. It’s a miraculous and beautiful leaf that has given millions back their lives.
If FDA is interested in protecting the public health, perhaps they should start with something that’s actually toxic.

 

Opioid Discontinuation Associated with Increase in Veteran Suicides

Protest-Rose-JPG

-Kelly F. Merrill

Opioid Discontinuation Associated with Increase in Suicides

Department of Veterans Affairs’ data that shows, “In two sets of fiscal years — 2010-2011 and 2013-2014 — opioid discontinuation was not associated with overdose mortality but was associated with increased suicide mortality.”

 

However, the Department of Veterans Affairs also recently released data showing Mountain Home VA Medical Center reduced opioid prescribing by 49% between 2012 and 2017.

 

Chief of Staff Dr. David Hecht claimed significant safety issues “became more apparent” and the details reveal significant side effects associated with chronic opioid use, which they made an effort to reduce.

 

“Our job is to do no harm as physicians and so when we find out that a medication that we’re prescribing is doing harm or has the potential to do significant harm even if it hasn’t done so already, our job is to try to find alternatives.”

 

The VA’s approach now focuses on alternative treatments, including acupuncture, therapy and yoga.

 

However, some veterans who had been on stable doses of pain medicine have had their medications titrated down though no effective therapies have replaced them.  They say though they’ve tried the various treatments, most have been ineffective.  

 

This is not unique to the experience of pain patients in the current climate.  Marine sergeant Robert D. Rose Jr. filed a suit for $350 million last fall against the VA for pain and suffering and violations to constitutional rights.  He said many veterans like him have been “denied adequate access” to the health care they need since the “discriminatory” anti-opioid initiative first began in 2012.  

 

Those anti-opioid initiatives culminated into the VA March 2016 guidelines which followed the highly controversial, “voluntary” CDC Guidelines in 2016, which Congress forced the VA to adopt with an attached spending bill.

 

But adoption of these initiatives has people concerned that patients who cannot obtain their medications will turn to the street…a death sentence with today’s illicit-fentanyl-laced heroin.  This is already happening, of course.

 

 

At a Congressional hearing in June, Rep. Beto O’Rourke, (D-TX), discussed the unintended consequence of the tighter opioid prescription guidelines currently followed by the VA. “Veterans are now required to see a prescriber every 30 days, but at the El Paso VA, they are unable to get an appointment, so they go without, or they do something they shouldn’t — they buy them on the street.”

Robert D. Rose Jr. I think we need to call Mr. Nate Morabito.  He has tried to present a balanced articles but false sympathy from VA reps toward pain patients are misleading and paint the picture of “compassionate caregiver” discontinuing doses because it’s just so dangerous.  No one…at all…has mentioned *anything* about the devastating physiological effects of pathological pain on every system of the body.

Oh, and regarding Dr. Hecht’s selective application of “First Do No Harm,” let me know if you need reinforcements.  At least Morabito knows what’s up.  The day after he published the article regarding the Mountain Home VA Medical Center’s [self-congratulatory] record reductions in opioid prescribing.

 


Department of Veterans Affairs’ data that shows, “In two sets of fiscal years — 2010-2011 and 2013-2014 — opioid discontinuation was not associated with overdose mortality but was associated with increased suicide mortality.”

The Department of Veterans Affairs recently released data showing Mountain Home VA Medical Center reduced opioid prescribing by 49% between 2012 and 2017.

Chief of Staff Dr. David Hecht claimed significant safety issues “became more apparent” and the details reveal significant side effects associated with chronic opioid use have revealed details indicating significant side effects, which they made an effort to reduce.

“Our job is to do no harm as physicians and so when we find out that a medication that we’re prescribing is doing harm or has the potential to do significant harm even if it hasn’t done so already, our job is to try to find alternatives.”

The VA’s approach now focuses on alternative treatments, including acupuncture, therapy and yoga. However, veterans who had been on stable doses of pain medicine have had their medications titrated down though no effective therapies have replaced them.  They say though they’ve tried the various treatments, most have been found ineffective. 

This is not unique to the experience of pain patients in the current climate.  Marine sergeant Robert D. Rose Jr. filed a suit for $350 million last fall against the VA for pain and suffering and violations to constitutional rights.  He said many veterans like him have been “denied adequate access” to the health care they need since the “discriminatory” anti-opioid initiative first began in 2012.  

Those anti-opioid initiatives culminated into the VA March 2016 guidelines which followed the highly controversial, “voluntary” CDC Guidelines in 2016, which Congress forced the VA to adopt with an attached spending bill.

But adoption of these initiatives has people concerned that patients who cannot obtain their medications will turn to the street…a death sentence with today’s illicit-fentanyl-laced heroin.  This is already happening, of course.

VA reps to discuss impact of opioid reduction on suicides during summit

http://wjhl.com/2018/01/16/va-reps-to-discuss-impact-of-opioid-reduction-on-suicides-during-summit/

By Nate Morabito

Published: January 16, 2018

Mountain Home VA reduces opioid prescriptions by 49%

http://wjhl.com/2018/01/15/mountain-home-va-reduces-opioid-prescriptions-by-49/

By Nate Morabito

Published: January 15, 2018

Marine veteran sues VA Medical Center, Congressman Phil Roe over opioid tapering policy

http://www.johnsoncitypress.com/Courts/2017/11/24/Marine-veteran-sues-VA-Medical-Center-over-opioid-tapering-policy

BECKY CAMPBELL

Published:  November 24, 2017

bcampbell@johnsoncitypress.com

VA reducing Opioids, veterans afraid of impact

By Nate Morabito

Published: December 6, 2016

CDC Opioid Guidelines Could Cause Problems for VA Patients, Clinicians

Addiction | February 2016 | Pharmacy

Congress Is Forcing VA to Comply With ‘Voluntary’ Document

By Annette M. Boyle

Retaining Effective Remedies for Pain Patients – Opioids and Alkaloids

-Kelly F. Merrill

The general public believes that the more than 10 million estimated intractable pain patients who require opioid therapy are getting high from taking their medications.  This is a myth.

Patients access to life-sustaining, torture-relieving opioids and plant alkaloids is under attack.

Physicians must be free to practice medicine that puts your health at the center of decisions between doctor and patient…instead of perceived and exaggerated liability. Sane risk assessments based upon science and good clinical practices and empirical data are paramount.

Many pain patients are dependent upon *both* opioids and plant alkaloids to mitigate physiologically-damaging, life-shortening pathological pain of dozens of devastating pain-generating illnesses.

But when it comes to opioids, suddenly, there is some moral judgement, as if illnesses and accompanying symptoms are a moral failing or a choice. And cannabis, while effective for some patients and some illnesses is not appropriate or efficacious in treating all. Neither has it been decriminalized by the Federal Government.

Some pain patients require high doses of opioids because they metabolize opioids too quickly to get much benefit. There is a 15-fold variation in the way people metabolize opioids. This is what’s behind the myth of high tolerance. Sadly, now you know more than most pain management physicians…we’ll get to that.

As such, what might kill you won’t touch my pain, which is ever-present and nearly overwhelming every moment of every day, even with a potent combination of opioids, cannabis and Kratom.

It took a great deal of time and a great deal of pain and ungodly suffering…years of it…before doctors titrated me up to a therapeutic dose of opioids for pain control after failing a parade of adjuvant alternative therapies. Every physician I’ve ever had has been exceedingly cautious in prescribing opioids and those “therapeutic doses” weren’t quite as therapeutic as you may think.

For these purposes, we throw the “Pain Scale” out the window. My idea of a “7” is going to be a lot different than yours because I already know how much worse it can get…and it can always get worse. I only had enough pain control for those years to be just on the precipice. A truly “therapeutic dose” would have been enough medication to allow me to be a better mother to my child, a sister to my brother, a daughter to my parents, a spouse or a friend.

For the first several months taking opioid medications the only high I experienced was feeling a little chatty for about 10 minutes, once a day. Since then, I’ve never had a side-effect from the medication. People who have chronic pain and take opioids don’t get high. High doses of cannabis, however, took me over a year to titrate up on to acclimate myself to the psychotropic effects. But, as anyone who’s taken cannabis tinctures daily for an extended period of time can tell you, those effects fade away.

The best medications for me are the ones I don’t notice. I’ve ditched the ones I do notice, including a whole host of medications pushed upon pain patients that cause disturbed thinking, short-term memory loss, nightmares, racing thoughts, pins and needles, anxiety and much, much more. Unnavigable side-effects.

I do a risk-benefit analysis of everything I put into my body. I don’t eat processed foods and use simple, fresh, organic ingredients to maintain my health and the health of my son. Opioids, cannabis and kratom are no different. These are the only effective tools I have for mitigating the disabling, life-shortening symptoms of intractable illness which derailed my life and left me bed- or house-bound for over 15 years until I found my current combination of pain-relieving medications and plant alkaloids.

For over a decade, I traveled the continent in search of a diagnosis, a cure, a remedy. As such, I have a wealth and breadth of experience navigating a variety of medical systems, including the allopathic system which offer opioids to treatment-resistant patients and the naturopathic system, which prefers to use plant alkaloids. Every patient is different. Every disease is different.

Here’s an example of a chronic illness that presents differently in each patient. If you’ve ever studied Lyme disease, you know how absolutely varied the manifestations of that devastating disease are. If you’ve personally known anyone who suffers the illness, you may sense the cost to the sufferer, their families and friends. Some suffer pain, some suffer exhaustion and all have lost parts of their life to the symptoms of the disease.

And that’s just one illness. With dozens of variations in symptoms from patient to patient. Among dozens of pain-generating illnesses. Other diseases that generate intractable pain too, are incredibly challenging; especially with ill-defined or well-ignored treatment modalities and few efficacious treatment options available.

Further, there are challenges unique to treating etiologically complex and clinically heterogeneous intractable pain illnesses due to the lack of education in our medical schools with regard to treating chronic illness and pain. Less than half of physicians have ever had a single course in pain management.

It’s disheartening to see such venom catapulted toward fellow survivors, whether on social media or delivered by the evening news.  The demonization of opioids is not a new story, but this time that ignorance is killing pain patients.  It’s what society did with marijuana when I was growing up.

And as you know, it was all lies.

Chronic Pain and Torture – U.S. in Violation of International Laws Against Inhuman Suffering

-Kelly Merrill

“Failure to make essential medicines available or to take reasonable steps to make pain management and palliative care services available will result in a violation of the right to health. In some cases, failure to ensure patients have access to treatment for severe pain will also give rise to a violation of the prohibition of cruel, inhuman and degrading treatment.”  Access to Pain Treatment as a Human Right, Human Rights Watch (March 3, 2009)

I’ve been thinking a lot about terror.  And torture.

We must alert the international human rights community of what is happening here in the U.S….and the terror of being a pain patient when every kind of discrimination and denial of treatment have, inconceivably, become commonplace, whether for cancer or AIDs or the dozens of devastating pain-generating illnesses patients suffer.

Pain patients have become the most marginalized subpopulation in the U.S.

We must acknowledge the severe toll of human suffering to change it.  We must start by immediately demanding the only acceptable standards of care for pain management recognized by human rights advocates around the world…the effective management of physiologically-damaging, dehumanizing pain.

While government entities must balance this need with steps to prevent diversion, they must do so in a way that does not unnecessarily impede access to essential medications. Further, even the International Narcotics Control Board has stated that such diversion is relatively rare.

And yet…

Dr. Forest Tennant, the foremost intractable pain specialist in the nation, always expressed incredulity that the World Health Organization had already developed internationally-recognized, basic standards of care for pain management – and that practitioners and Government routinely ignored the need to balance the relief of suffering patients with attempts to control drugs diversion; therefore denying fundamental human rights’ protections for people who suffer devastating pain.

The Draconian practices of Government have had a chilling effect upon the prescribing practices upon physicians, in direct violation of WHO and other international initiatives, causing many to stop writing opioid prescriptions WHO considers “absolutely necessary” to treat moderate and severe pain.

And who can blame them?  They are only trying desperately to avoid getting caught-up in the crush of anti-opioid McCarthyist, physician persecutions of the past decade; persecutions that now include Tennant, who was raided by the DEA after responsibly and conscientiously treating some of the most severe intractable pain cases in the country for over 40 illustrious years.

And he’s certainly not the only one…to be persecuted…or to suffer.  Physicians, pharmacists, patients and activists across the US are mobilizing in a fight for their lives.

The US have been cited as having significant barriers to effective pain treatment for decades, including the divisive and restrictive drug control regulations and practices that have only grown exponentially, creating a state of emergency for pain patients.  These one-sided policies do not balance the need to treat the millions in chronic pain along with government’s desire to control the flow of illicit substances.

That must change if we are to survive this.  And it is a matter of survival.

*****

The Human Rights Watch recognizes that pain has a profound impact on the quality of life and can have physical, psychological and social consequences. Under- or un-treated, it can reduce mobility result in a loss of strength; it compromises the immune system and interferes with a person’s ability to eat, concentrate, sleep, or interact with others.

It also causes muscle wasting and brain loss.  Unmitigated, it causes cardiac and drives legitimate pain patients to suicide.  It is all-consuming.  This level of absolutely unnecessary agony tears apart communities and creates collateral damage of our children and families who suffer along with us.

The right to be free from torture, cruel, inhuman and degrading treatment or punishment is a fundamental human right that is recognized in numerous international human rights advocacy organizations.

Besides prohibiting such human rights violations, governments also have an obligation to protect their people from such treatment.  In other words, they must take steps to protect people from unnecessary pain related to a health condition under recognized, international standards.  In the U.S., that starts with the Government not attacking its own citizens.

The only ones unclear on the right pain treatment are the Government and anti-opioid zealots who either do not know there are millions suffering these human rights abuses or simply do not care.

Some of these entities have willfully and knowingly chosen not to believe what scientists and the best pain management physicians have been telling them for years, thereby violating the international human rights agreements and ignoring the scientific certainty that opioids are essential for the effective management of pain and that the vast majority do not abuse or become addicted to their medications, including many who require high doses.

“Governments [must] protect people under their jurisdiction from inhuman and degrading treatment. Failure of governments to take reasonable measures to ensure accessibility of pain treatment, which leaves millions of people to suffer needlessly from severe and often prolonged pain, raises questions whether they have adequately discharged this obligation.”

-UN Special Rapporteur on Torture, Cruel, Inhuman and Degrading Treatment and Punishment

(in a joint letter with the UN Special Rapporteur on the Right to Health to the Commission on Narcotic Drugs, December 2008).

Senator Says “Ensuring Patient Access” Continues to be a Problem – Still, DEA Wants to Repeal Protections

-Kelly F. Merrill

Members of the Senate Judiciary Committee met Tuesday, December 12, 2017, to provide Oversight of the Ensuring Patient Access and Effective Drug Enforcement Act.

The bill expanded required elements of an “order to show cause” issued by the DEA before it denies, revokes, or suspends a registration for a Controlled Substances Act violation. Specifically, DEA must now state the legal basis for their action and notify the registrant of the opportunity to submit a corrective action plan.

Since Washington Post and 60 Minutes pieces shed criticism upon the law, there has been controversy. Sen. Chuck Grassley (R-IA) expressed frustrations with with vocal critics’ conflicts of interest; and with the DEA, who he suggested had long-been involved but now wanted to repeal a law that was passed with unanimous bipartisan support. Critics claim the law effectively stripped DEA of its enforcement power.

In response, Grassley pointed out that the figures seem to indicate the converse is true; that DEA’s efforts haven’t been hindered but have instead increased.

Sponsor Sen. Orrin Hatch (R-UT) reminded members that the impetus for the law was to address the the growing issue of restrictions hindering legitimate patient access to necessary, opioid pain-relieving medications. The bill passed with overwhelming bi-partisan reports.

Jan Favero Chambers of the National Fibromyalgia & Chronic Pain Association testified regarding her own patient experience with regard to trends and policies that have had negative effects upon the pain community since 2005.

Hatch reminded participants that fear of enforcement actions coupled with lack of guidance created the imperative for the law, stressing that DEA’s attitude toward registrants was “downright antagonistic.” A well-informed and deeply critical Hatch applauded the patient advocate from Utah for informing him of the issues.

Co-sponsor Sen. Sheldon Whitehouse (D-RI), expressed frustration that the “backstop” built into the law to assess any unintended consequences of the Act, was months overdue from the Health and Human Services Department (HHS).

No release date has yet been issued for the HHS report, which is mandated by law and continues to be a source of frustration moving forward.

 

https://www.judiciary.senate.gov/meetings/oversight-of-the-ensuring-patient-access-and-effective-drug-enforcement-act