California mismanages patients with chronic pain. This is the next chapter in Mark's story, a Marine whose pain care is being force-tapered.
In July of 2018 we told you about Mark Winland, a lab tech and United States Marine whose pain control was under attack by California legislators who were forcing him to taper down on his opioid pain support.
To refresh your memory, Mark is a Marine. He’s tough. In the Marines he injured his neck. Over the years he has had four different surgeries to fuse different vertebrae in his spine. The surgeries helped him, but did not alleviate his pain. He needed prescription pain medicine and his doctor got him started on it.
Mark reached out to me this November (2018) to update me on his status.
But first, let’s talk…
The goal of pain management is not to remove pain, but to manage it. Common terminology is “to improve function and quality of life of people in pain”. You can find that wording for instance in the American Academy of Pain Management’s Mission Statement.
Managing pain is complicated. When the CDC set out to create Guidelines for prescribing opioids for chronic pain (a widely criticized document) it openly acknowledged its own shortcomings, saying, “Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context. The recommendations in the guideline are voluntary, rather than prescriptive standards.”
“Between clinician and patient”, in the CDC’s own words…right. But the doctor-patient relationship has been complicated by the Department of Justice (DOJ). The DOJ has created aggressive programs that physically raid the offices of doctors who prescribe opioids.
In the very description of the SCOPE Initiative (Strategically Combating Opioids through Prosecution and Enforcement), they emphasize prosecution of those who are illegally prescribing or distributing painkillers. This seems to be of public value on the surface but in an article by the Washington Post it was revealed that the DOJ/DEA raids had not “targeted any of the drug distributors or manufacturers that have been blamed for allowing hundreds of millions of opioid painkillers to pour out of the legitimate supply chain into the black market over the past 15 years”. So why do attack caregivers?
These strongarm tactics leave legitimate physician-prescribers in fear of random raids. This leads to fear-driven tapering or reduction in opioid prescribing despite having safeguards like incredibly effective drug testing and Prescription Drug Monitoring Programs.
This all points to a very ugly prejudice against chronic pain patients and the responsible use of opioids for pain management. It is the opposite of the mission to “improve function and quality of life” for those in chronic pain. It must also be noted that there is not yet a legal alternative to responsibly prescribed opioids for pain.
In an article in Fiercehealthcare, Lynn Webster, former president at the American Academy of Pain Medicine said, “Doctors are afraid to treat patients because they worry about losing their license if they need to provide certain doses, as well as the scrutiny about using opioids to treat opioid addiction. There has been a huge increase in investigations, and there are many unintended consequences of those.”
Okay, back to Mark…
Mark lives in California, a state that has taken a hard line on reducing the use of opioids categorically.
“I was on 30 mg extended release Oxymorphone twice a day. Then 8mg hydromorphone, five per day. That’s 340 Morphine Milligram Equivalent units (MME) per day. They took me down to 20 mg extended release twice a day. Then 4 mg hydromorphone five per day. That’s 200 MME per day”.
Going from 340 MMEs a day to 200 MMEs is a 41% decrease in pain support. That’s drastic. And Mark is feeling it.
Mark has reduced his work schedule from full time to part time because his pain is interfering with his daily function. “Standing, walking and sitting is the hardest for me. I work in the Emergency Department and I need to be on my feet”.
What’s worse, Mark’s doctor intends to reduce him by an additional 10% every six months. Will he remove Mark’s opioids entirely? What will he replace them with? What will the effect be on Mark’s functionality and quality of life? Let’s remember too, Mark is married, and his quality of life affects more than just himself.
America needs to remember to give the best possible care to chronic pain patients. It was not they who lied about the addictive nature of opioids in the 1990s. Neither did they over-prescribe opioids in the 2000s. But now, they live with pain that opioids when used responsibly (like most opioids are) can mitigate – the whole point of pain management.
So, when organizations talk about the cost of the opioid epidemic, or the need to do something drastic, let’s always remember there are people like Mark suffering from chronic pain. Those people have trouble functioning and have reductions in quality of life when their pain is not properly managed. Let’s remember the goal of pain management, “to improve function and quality of life of people in pain”.
Affirm Health has a webpage that contains the links to all the opioid prescribing guidelines by State
Here are the California Guidelines for Prescribing Controlled Substances for Pain
As the Director of Patient Content at Patients Rising, Jim works very closely with the people who have healthcare war stories to tell. As a Columbia University trained writing consultant Jim has worked closely with writers of all levels of skill to help them find and refine their voices. Jim is a writer, editor, author and medical assistant with over 20 years of experience in healthcare. He’s spent over two decades in clinical care and research at some of New York’s biggest health institutions doing hands-on nursing, education and advocacy for rare disease patients. He has worked with several non-profit patient support organizations doing outreach, advocacy and creating educational content. He lives in New York City with his wife and their cats…sooo many cats.