How to stop chronic pain suicide is an opinion

Improving the CDC during the COVID-19 Pandemic: The New Dosage and Duration Limits on Opioid Prescriptions

Unlike the 2016 version, those takeaways no longer include specific limits on the dose and duration of an opioid prescription that a patient can take, although deeper in the document it does warn against prescribing above a certain threshold. The new recommendations also explicitly caution physicians against rapidly tapering or discontinuing the prescriptions of patients who are already taking opioids — unless there are indications of a life-threatening issue.

Doctors and researchers say there is a crisis of lack of treatment for pain. Many patients with chronic pain had their longstanding prescriptions suddenly stopped or cut off, sometimes with dire consequences, like suicide or overdose, when they turned to the illegally-sourced drugs.

The CDC’s credibility has been hurt during the COVID-19 Pandemic because of the agency’s leadership inability to coordinate and fix harms from the 2016 guidance. Still, the agency has learned from the criticisms and harms from the last round of guidance. “So my hope is that CDC is now better equipped and prepared to take the guideline and translate it to the ground level,” he says.

“The guideline recommendations are voluntary and meant to guide shared decision-making between a clinician and patient,” said Christopher Jones, acting head of the CDC’s National Center for Injury Prevention and Control and a co-author of the updated guidelines, during a media briefing, “It’s not meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, governmental entities.”

The change in outlook is evident all over the new guidelines, says Dr. Samer Narouze, the president of the American Society of Regional Anesthesia and Pain Medicine.

The impact of the voluntary guidelines depends on how state and federal agencies and other authorities respond, according to a professor at Northeastern University.

The definition of high-dosage opioids use in the 2016 recommendations was used to establish legal limits. “The [2016] guideline itself was clear that this was not a bright line rule,” he says, “But it became a de facto label, separating appropriate and inappropriate prescribing,” he says. Law enforcement in some states used the limit as a sword to go after prescribers.

The doses and limits set by doctors have had a chilling effect on them, says a patient advocate.

Dr. Antje Barreveld is medical director of the Pain Management Services atNewton Wellesley Hospital. “Those arbitrary marks of what’s acceptable and not acceptable is what got us into trouble with the 2016 guidelines, because it made this blanket cut off for our patients and that’s not what pain management is about.”

The direction on reducing opioids when possible still raises some concerns for clinicians like Stefan Kertesz, a professor of medicine at the University of Alabama at Birmingham.

Kertesz says that when you take a stable patient and reduce their prescription, you are engaged in an experiment. Sometimes dose reduction helps and sometimes it causes the patient to die. So I would rather they have said, ‘Look, this is an uncertain intervention.”

However, he adds that the strength of the new guidance is its repeated emphasis that a specific dose should not be used by agencies, law enforcement and payers to enforce a one-size fits all approach.

New X-waiver laws for prescription opioid therapy: Impact on quality assurance, opioid use disorder, and the opioid crisis in our country

She remembers one recent instance when an elderly patient of hers was suffering from severe arthritis in her neck and knees. “The primary care doctor said ‘no,’ after I recommended that he begin low-dose opiate therapy,” Barreveld says. “What happened? The patient was admitted to the hospital, thousands of dollars a day for eight days, and what was she discharged on? Two to three pills of an opioid a day.”

The previous guidelines led to restrictions on prescribing being codified as policy or law. It’s not clear those rules will be re-written in light of the new guidelines even though they state they’re “not intended to be implemented as absolute limits for policy or practice.”

It will not have any effect unless three major agencies act quickly, says Kertesz. The Centers for Medicare and Medicaid Services use the 2016 guideline as the basis for metrics and legal investigation, as do the National Committee for Quality Assurance and the Drug Enforcement Administration.

The MAT Act would eliminate the special Drug Enforcement Administration waiver that doctors must apply for in order to prescribe buprenorphine (a medication that helps reduce the craving for opioids). It would enable community health aides to dispense this medication as long as it’s prescribed by a doctor through telemedicine. It will allow the Substance Abuse and Mental Health Services Administration to start a national program to educate health care practitioners about the dangers of using drugs for opiate use disorder. Reams of data have shown and addiction specialists agree that these medications offer some of the best options for preventing overdoses and helping people into recovery. A report from the National Academies of Sciences, Engineering and Medicine said that less than 20% of people who could benefit have access to them.

“Removing the X-waiver,” says Hansen, “is not in itself going to revolutionize the opioid overdose crisis in our country. We would need to do much more.”

The MAT Act Revisited: How Do Drug Overdoses End and Why Do They End in Death? Dr. Gupta’s Statement

The MAT Act, which was written by Representative Paul Tonko of New York, boasts some 248 co-sponsors and has already passed the House as part of a broader mental health package.

Despite the improvement, annual drug overdose deaths in July were still 25% higher than they were two years earlier and more than 50% higher than they were five years earlier. And the types of drugs involved in fatal overdoses has changed.

According to the latest data from the CDC, more than two-thirds of overdose deaths are associated with synthetic opioids. More than a third of the drugs were involved.

The White House Office of National Drug Control Policy states that fentanyl and methamphetamine are sometimes found with other drugs such as cocaine and heroin.

The Biden administration has released a new dashboard to track overdoses that aren’t fatal.

Obtaining and monitoring more real-time data on opioid overdoses that do not end in death could help predict where overdose deaths are more likely to happen and where there might be an increased need for first responders as well as the life-saving medication naloxone, which temporarily reverses the effects of an opioid overdose, Gupta said last week.

According to Gupta’s statement from Wednesday, emergency medical services responded to more than 390,000 activations nationwide that involved the administration of naloxone in the 12-month period ending in July – nearly four for every fatal overdose in the same timeframe.

The statement shows that hundreds of thousands of pounds of drugs had been seized by Customs and Border Protection.

Treatment of opioid fentanyl: The stigmatizing views of addiction in the United States and the barriers that limit their access to treatment

“If someone can get access to these life-saving medications, it lowers their mortality risk by 50 percent,” says Dr. Linda Wang, who is a researcher at Mount Sinai Hospital.

Some doctors hold stigmatizing views about addiction and the patients afflicted by it, and refuse to provide treatment. Many doctors say they lack the confidence to treat addiction because they don’t have enough training or access to specialists who can help guide them. Drug users can also resist treatment. Experts do not believe that replacing drugs that do harm with drugs that can help is a way to think of medications for addiction.

Those policies left millions of people vulnerable as the powerful, toxic synthetic opioid fentanyl spread in the U.S., making addiction even more dangerous.

“There were significant barriers that were quite stigmatizing for patients as they enter treatment,” says Dr. Neeraj Gandotra, chief medical officer for the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal agency that oversees addiction.

Sometimes people who are able to get the drug can go to a government approved clinic multiple times a week to get their doses.

“The idea that they aren’t allowed to get take-home [doses], the fact that they have to go to the clinic daily, that is a significant barrier,” Gandotra said.

“There was no evidence that diversion increased or risk increased, but there was evidence that people who gained access to treatment did better,” he said.

The Future of the Opioid Treatment System: A Case Study of Loss, Access to Biological Services, and Medical Notaries

The rule- change would make the reforms permanent. There would be more options for telehealth and it would eliminate waiting periods on access to methadone.

SAMHSA plans to eliminate the term “detoxification” from federal rules regarding opiate treatment programs.

She is getting her PhD in justice studies at Arizona State University, because she credits methadone with stabilizing her life.

But she also says she’s faced years of stigma and surveillance within the opioid treatment system, where she often felt less like a patient and more like a criminal.

Russell says she was able to take home a month’s supply of her medication at a time. That spared her the near-daily trips to the nearest clinic, a 45-minute drive from her home in Phoenix.

In the near future, the availability of methadone will only be available through a limited number of certified drug treatment programs.

He says longstanding resistance among some providers to treating addiction is shifting as younger people enter medicine. But the opioid crisis can’t wait for a generational change, he says. According to Rich’s research states could use doctors and notaries to better manage patients with an opiate use disorder and to expand buprenorphine access.

Opioid Rapid Response Program Against Prescription for Treatment of Chronic Pain: Dr. Jennifer Fuqua, Director, and Chief Operating Officer

It is too early to say if the rule change is a step towards that. “We believe it is, but we are not certain how far along we can go,” Gandotra said.

Ms. Fuqua is trying to find a doctor to see her. She also called the C.D.C.’s Opioid Rapid Response Program‌‌, which is intended to help when pain clinics are shut down or large numbers of opioid patients lose doctors for any reason. She said that they thought she was out of line for calling them. The ‌‌program’s management admits it has difficulty finding physicians to help such patients‌‌, and is in the preliminary stages of considering proposals to study why they get rejected.

Patient advocates say that the answer is simple – doctors who take large numbers of chronic Pain patients are afraid of being investigated by law enforcement. Physicians with more than a few high-dose patients will immediately stand out in prescription monitoring databases, even if they are pain specialists.

It is not the fault of people who suffer pain that America has an addiction problem. No one gains from denying them access to the medication. At least one man and his wife have already died by suicide following the closing of a clinic.

There was unanimous approval this week by a committee of advisers to the FDA for Narcan to be made available without a prescription.

The FDA is weighing the move after fast-tracking an application from Emergent BioSolutions, the maker of Narcan, to let it sell the drug over the counter.

The medication is a key tool in the prevention of overdose deaths due to the spread of the drugfentanil. More than 80,000 people died of overdoses involving opioids in 2021, a historic high, according to the Centers for Disease Control and Prevention.

Experts say naloxone is a safe, effective, easy-to-use medicine that works if administered within the first few minutes of an overdose, with no potential for abuse. The medication counteracts the effects of the drug by binding to the same brainreceptors that are used for opioids.

After Wednesday’s panel vote, a professor at the George Washington University School of Medicine urged the public to have access to the medication over the counter.

Hurley, the addiction specialist, said if the FDA drops the prescription requirement, that also means people who can afford the product can walk into a pharmacy without worrying about whether the pharmacists there have completed the training required to distribute Narcan.

He said it wouldn’t solve the issue of getting naloxone to people who need it the most because they have to pay for it.

She said that by prioritizing a medication that can save lives it will help chip away at the stigma that people who use drugs face.

She said that it means we are starting to address the fact that there are some solutions that are within our grasp. “We’re not helpless in the face of this crisis.”

Some of the problems are specific to addiction. Others are broader. Mental health conditions are often under treated as well. The flu seasons are usually worse than they need to be due to people not getting their annual shots. While Americans’ overuse of health care frequently receives attention, underuse is a problem in many situations as well.

Often, people, including doctors, have outsize fears about the downsides of some treatments, especially new ones. The problem of Paxlovid’s interactions with other drugs is a manageable one with Covid. With opioid addiction, patients make the mistake of thinking of a prescribed medication, like buprenorphine, as just another drug, even though it can save their lives.

Problems can fall through the cracks of the fragmented American health care system. In France, officials can push for the use of new treatments and guarantee that they are widely available by utilizing the universal health care system. In the U.S. system, there is no centralized authority, so medical authorities struggle to coordinate care even when the best practices seem clear.

There was an 8-hour training for clinicians who wanted to prescribe the medicine. They could only treat a limited number of patients and had to keep special records. They were given a Drug Enforcement Administration (DEA) registration number starting with X, a designation that many doctors say made them a target for drug enforcement audits.

“Just the process associated with taking care of our patients with a substance use disorder made us feel like, ‘boy, this is dangerous stuff,'” says Dr. Bobby Mukkamala who chairs the AAMA’s task force on substance use disorder.

The rigamarole is not around anymore. The X-waiver was eliminated in the legislation President Biden signed last year. Now begins what some addiction experts are calling a truth serum moment.

The number of doctors approved to prescribe buprenorphine more than doubled in the two years since the state said training should include an X-waiver. It wasn’t enough for patients to be able to prescribe buprenorphine, according to Dr. Jody Rich, who teaches addiction treatment at Brown University. The number of patients taking buprenorphine in Rhode Island increased – from 2016 to 2022 when the number of qualified prescribers jumped – but at a much slower rate .

A new training requirement for clinicians who prescribe buprenorphine and other controlled narcotics may be fulfilled by some of these resources. It will take effect in June. The DEA has not issued details about that training.

Every moment, we are rethinking the way we think to make sure that we start the treatment early enough to save someone’s life.

Half of all patients taking buprenorphine are black, but 15% of black patients are also taking it. 30% to 23% is the comparative figure for Hispanics. white patients are the majority of the health center patients prescribed buprenorphine.

As patients trying to get treatment for addiction queue up, hospitals and clinics around the country are running a truth serum experiment to see if clinicians will step up prescribers.

Jamie Simmons, a registered nurse who runs the center’s addiction treatment program but lacks the powers to prescribe, began Kim’s visit to the center in an exam room. NPR would use only Kim’s first name to limit discrimination related to her drug use.

That reality adds urgency to Kim’s health center visit because Kim took her last Suboxone before arriving. Her latest prescription has run out. If she doesn’t get more buprenorphine, she could resume heroin cravings tomorrow. Simmons tells Kim that her primary care doctor may consider renewing the prescription now that it is not necessary to get an X-waiver. After reviewing Kim’s urine test, Dr. Than Win has some concerns.

“It’s the best thing they could have ever come out with,” Kim says, “I don’t think I ever even had a desire to use heroin since I’ve been taking them.”

Buprenorphine can cause euphoria and slow breathing but there is a limit on the effects. Patients like Kim are not likely to experience any effects.

“I’ve seen so many people fall out [overdose] in the last month,” says Kim, her eyes wide, “that stuff is so strong that within a couple minutes, boom.”

Kim is adamant that she’s not intentionally ingesting fentanyl. She says her roommate may have used cocaine occasionally. Kim says she takes the Xanax to sleep. Her drug use presents complications that many primary care doctors don’t have experience managing. Some clinicians are apprehensive about using an opioid to treat an addiction to opioids, despite compelling evidence that it saves patients’ lives.

“You wouldn’t not treat a diabetic, you wouldn’t not treat a patient who is hypertensive,” Simmons says. People can’t control when they got hooked on drugs or alcohol.

The Road Block to Suboxone Life-Saving Treatment Goes On: The Case of the United States and the Problem of Community Support

“That history of raising this to a level of scrutiny and caution, that should be walked back,” says Mukkamala with the AMA. “That’s going to come from education.”

There is a promise in the next generation of doctors and nurse practitioners who have added addiction training. The American Society of Addiction Medicine has online resources available for clinicians interested in learning on their own.

Wakeman, at Mass General Brigham, says it might be time to hold clinicians who don’t provide addiction care accountable through quality measures tied to payments.

One quality measure could be to track how often prescribers start and continue buprenorphine treatment. Wakeman says it would help if insurers reimbursed clinics for staff who aren’t traditional clinicians but critical to addiction care, like recovery coaches and case managers.

The medication is much more commonly prescribed to white patients with private insurance or who can pay cash. There are stark differences by race at some health centers where Medicaid patients are the majority and they have the same access to addiction treatment.

“People are not able to stay on a life-saving medication unless the immense instability in housing, employment, social supports — the very fabric of their communities — is addressed,” says Hansen. That’s the place where we don’t excel in the United States.

Source: https://www.npr.org/sections/health-shots/2023/03/06/1159225349/roadblock-to-suboxone-life-saving-addiction-treatment-gone

KHN and WBUR in the Kaiser Health News Room (WBUR & NPR in the Newsroom, Part II)

WBUR and KHN are involved in NPR’s partnership. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues.