THE 7 POINT PLAN TO TREAT CHRONIC PAIN SUFFERERS, AND ADDICTS

by Neil Jobalia, M.D.

Open Letter to President Donald J Trump

Dear President Trump,

My name is Neil Jobalia. I am writing to you to propose how we can effectively manage the current issues related to oral opioid medications, both oral opioid abuse and appropriate use of oral opioids in the treatment of chronic pain, and the heroin abuse problem in our country.


Currently, I am a physician practicing pain management in the Cincinnati, Ohio area. I am also about to start an opioid addiction treatment program. These two medical issues are connected by prescription opioid medications. Recently, the surgeon general released “Facing Addiction in America, The Surgeon General's Report on Alcohol, Drugs and Health”. In the introduction, he outlines statistics concerning the impact of addiction in America. According to recent statistics, about 2.5 million Americans have substance abuse disorder involving opioids (both prescription pain medications and heroin). The total annual cost (health care, legal, lost productivity, etc.) is estimated at around $200 billion. The most recent statistics on chronic pain state that approximately 100 million American adults suffer from chronic pain with a total cost of around $600 billion annually (similarly, health care costs, lost productivity, etc.). So the combined cost to society of medical issues involving opioids is about $800 billion per year. Unfortunately, I believe that the focus on prescription opioids has diverted attention from the true risk factors contributing to the heroin epidemic and, simultaneously, has seriously negatively impacted the treatment of patients with chronic pain.

The New England Journal of Medicine published a review article in January of this year exploring the connection with nonmedical prescription opioid use and heroin use. They conclude that “Available data indicate that the nonmedical use of prescription opioids is a strong risk factor for heroin use. Yet...heroin use among people who use prescription opioids for nonmedical reasons is rare.” (New Eng J of Medicine, Jan 16, 2016, pp. 154-161). Strengthening this point, the National Institute on Drug Abuse website estimates that only 4% of people whoABUSE oral opioids go on to use heroin (a statistic confirmed by the New England Journal study). This does NOT refer to people who are legitimately prescribed oral opioids by physicians, but to people who are already abusing oral opioids. Another statistic that is well accepted is that about 2/3 of all oral opioids that are abused as street drugs come from a physician prescription that was either diverted or stolen. So, even if ALL prescriptions for oral opioids were completely stopped, it would only affect, at most, about 3 percent of people from moving to heroin abuse. In addition, it is completely unknown how many of the 100 million people who suffer from chronic pain would turn to the streets when they can no longer get safe, monitored, appropriate medical treatment, and they would suffer incredible morbidity and mortality through suicide, loss of productivity, loss of function and all of the other consequences of under treatment of chronic pain that are well documented in the published, peer-reviewed medical literature. Hardly a reasonable strategy to impact the heroin problem and certainly a strategy for causing tremendously more loss and suffering from untreated chronic pain. Just to be clear, I am not proposing unrestricted access to pain medication prescriptions, as I will discuss in my 7 point proposal.

Unfortunately, the surgeon general's conclusion that “Over-prescription of powerful opioid pain relievers beginning in the 1990's led to a rapid escalation of use and misuse of these substances by a broad demographic of men and women across the country. This led to a resurgence of heroin use, as some users transitioned to using this cheaper street cousin of expensive prescription opioids. As a result, the number of people dying from opioid overdoses soared—increasing nearly four-fold between 1999 and 2014.” As you can see from actual data, the increase in oral opioid prescribing may have added a minimal amount (at most 3%) to the heroin problem, but it cannot be the actual cause of the problem. By blaming doctors for prescribing too many opioids and targeting them with legal and regulatory actions, the limited resources that are available to address the heroin problem are not going to have much impact on the actual problem. Not only that, but the search for the actual issues involved in this overwhelming problem is not proceeding as it should, through well developed research and accurate data collection and interpretation.

I recently attended an addiction conference in Asheville, SC which included both South Carolina and Tennessee addiction specialists. The primary focus of the conference was education about medication assisted addiction treatment using Suboxone (buprenorphine/naloxone). I took two major points away from that conference. One is that there is little to no data in the area of heroin abuse, not only related to initiation of heroin use, but also related to effective treatment for heroin abuse, both medical and nonmedical. In other words, when it comes to heroin abuse, we are swimming in a sea of darkness. The second was the Suboxone is now the second leading cause of overdose visits to the emergency room in Tennessee. FYI, the addicts have figured out how to achieve a euphoric effect from Suboxone. In fact, I have looked at addict forums and they openly talk about injecting Suboxone and that it is a fantastic high and lasts a lot longer than heroin. Suboxone is becoming the new Oxycontin.

The current environment, as it relates to prescription opioids and heroin, is an exceptionally adversarial one between law enforcement, regulatory agencies, politicians and physicians. I have always had a cooperative relationship with law enforcement since the beginning of my practice in 1999 (I reference the Cincinnati Enquirer front page article from March 16th, 2001). I was a member of the National Association of Drug Diversion Investigators for many years as well. It is my strong belief that the only potential solution to the heroin abuse problem can only come about by cooperation between all professions that are touched by this issue. Health care professionals must be an integral part of this effort for two reasons, appropriate and meaningful research and reasonable implementation of treatment regimens. Also, chronic pain must be treated appropriately. This involves extensive educational efforts for health care providers, law enforcement, regulators and politicians. The education would have to include pathophysiology of pain all the way through appropriate prescribing practices and monitoring. The current knee-jerk regulatory and political policies, which are based in dogma, bias and myth, only widen the divide between health care providers and law enforcement/regulators/politicians and do absolutely nothing to effectively address the issues of opioid abuse and appropriate treatment of patients who suffer from chronic pain on a daily basis. I agree with that use of prescription opioids to treat chronic pain in the environment of the opioid abuse problem is exceedingly complex, but, through cooperation and education, can be effectively addressed for the betterment of all patients who suffer from these devastating diseases.

What follows is my 7 Point Proposal.


ONE

A federal position be created to develop and oversee all policies related to opioids, both prescription pain medications and heroin. The same person should be in charge of both so that there can be a balance that allows effective treatment of both diseases. The responsibilities would include:

ONE A)

Assistance/oversight of the development of specific research targeting:

reasons for initiation of heroin use

effective multidisciplinary (medical, psychological, social, legal) treatment of opioid abuse

evaluation of psychological comorbid conditions, both diagnosis and treatment (current statistics suggest that at least 75% of opioid abusers have concurrent major psychological diagnoses)

more expansive statistical analysis of all opioid abuse

Impact of the under treatment of chronic pain (suicide, drug abuse, job and social losses, etc.)

ONE B)

Oversight and development of policies/recommendations for the responsible use of prescription pain medications for chronic pain. Even though these policies already exist in most states and in the recently released CDC guidelines, the result has been further reductions in appropriate treatment of chronic pain. These guidelines are also being used as a tool by state medical boards to revoke physicians licenses, causing even more fear of prescribing among physicians

ONE C)

Oversight and development of recommendations for treatment of opioid addiction based on data and best practices. Current treatment recommendations are “one size fits all”. Treatment must be individualized and include multiple professional disciplines.


TWO

Access to appropriate mental health services must be expanded.


THREE

Expansion of social services available on an outpatient basis for people with addiction issues.


FOUR

Development of web based resources for people with addiction issues. There are numerous web based support groups and forums, but one website that could help direct people to these resources could be very effective.


FIVE

Education programs for everyone need to be developed that cut through the myths and biases surrounding legitimate opioid use, opioid abuse, and heroin abuse.


SIX

Opioid use and abuse should be treated as a separate issue from other addictions. Currently, addiction treatment typically lumps all substances together.


SEVEN

Simplify physician access to appropriate monitoring of chronic pain patients that are on chronic opioid therapy. A suggestion would be to have free standing monitoring centers where random urine drug screens and pill counts are performed so that non-pain specialists would not have to incur the costs of having to set this up in their office and could manage patients with relatively easy problems.



I have much more to say on this subject and would welcome the opportunity to discuss it further with you or anyone in your administration. Please contact me at any time.


Thank you,

Neil Jobalia M.D.

Cincinnati Centers for 

Pain Relief

[email protected]

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Published with permission of author