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What's New at Drug War Facts - Vol. 3, No. 3, April 2013

Issue In Focus: Pain Management

Pain management is the point at which healthcare and the drug war collide. Physicians, policy makers, and law enforcement struggle to find the right balance between delivering proper, adequate care, and preventing diversion, addiction, and abuse. Sadly, in the end the people in the middle – the patients – are the ones who suffer.

According to most estimates, a large percentage of the population suffers from pain. According to the federal Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research”:

“Common chronic pain conditions affect at least 116 million U.S. adults at a cost of $560–635 billion annually in direct medical treatment costs and lost productivity.”
Source: Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 5.
http://www.nap.edu/openbook.php?record_id=13172
http://www.drugwarfacts.org/cms/node/2298

Though it is common, pain as a condition is not well understood nor is it always treated appropriately. Again, according to the Institute of Medicine:

"Currently, large numbers of Americans receive inadequate pain prevention, assessment, and treatment, in part because of financial incentives that work against the provision of the best, most individualized care; unrealistic patient expectations; and a lack of valid and objective pain assessment measures. Clinicians’ role in chronic pain care is often a matter of guiding, coaching, and assist­ing patients with day-to-day self-management, but many health professionals lack training in how to perform this support role, and there is little reimbursement for their doing so. Primary care is often the first stop for patients with pain, but primary care is organized in ways that rarely allow clinicians time to perform comprehensive patient assessments. Sometimes patients turn to, or are referred to, pain specialists or pain clinics, although both of these are few in number. Unfortunately, patients often are not told, or do not understand, that their journey to find the best combination of treatments for them may be long and full of uncertainty."
Source: Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 8.
http://www.nap.edu/openbook.php?record_id=13172
http://www.drugwarfacts.org/cms/node/3215

If only those were the only barriers to adequate treatment. Sadly, overzealous law enforcement is also a problem. As the Center for Practical Bioethics noted in 2009:

"The under-treatment of pain is due in part to a kind of undesirable “chilling effect.” The concept of a chilling effect, generally, is a useful law enforcement tool. When publicity surrounding a righteous prosecution “chills” related criminal conduct, that chilling effect is intended, appropriate, and a public good. A chilling effect on the appropriate use of pain medicine, however, is not a public good. Recent research by members of the Law Enforcement Roundtable confirms that prosecutions of doctors for diversion of prescription drugs are rare.2 But, on occasion, overly-sensationalized stories of investigation of doctors have hit the nightly news. When that happens, the resulting chilling effect reaches far beyond a “good” chilling effect on bad actors, and directly affects appropriate medical practice. The consequence is extreme, and not what law enforcement would ever seek – our parents and other loved ones who are in pain simply cannot get the medicines they need."
Source: "Balance, Uniformity and Fairness: Effective Strategies for Law Enforcement for Investigating and Prosecuting the Diversion of Prescription Pain Medications While Protecting Appropriate Medical Practice," Center for Practical Bioethics (Kansas City, MO: September 2009), p. 3.
http://www.fsmb.org/pdf/pub_bbpi_policy_brief.pdf
http://www.drugwarfacts.org/cms/node/1996

Some barriers to adequate treatment could be resolved with better physician education and better physician-patient communication. Again from the National Academy of Sciences:

"A number of barriers to effective pain care involve the attitudes and training of the providers of care. First, health professionals may hold negative attitudes toward people reporting pain and may regard pain as not worth their serious attention. As discussed in detail in Chapter 2, patients can be at a particular disadvantage if they are members of racial or ethnic minorities, female, children, or infirm elderly. They also may have less access to care if they are perceived as drug seeking or if they have, or are perceived to have, mental health problems. A literature review showed that people with pain, especially women, often have attitudes and goals that are different from, and sometimes opposed to, the attitudes and goals of their practitioners; patients seek to have their pain legitimized, while practitioners focus on diagnosis and therapy (Frantsve and Kerns, 2007). Consumers testified before the committee that patients often believe practitioners trivialize pain, which makes them feel even worse. Researchers working with patient focus groups have noted the “perceived failures of providers to fully respect, trust, and accept the patient, to offer positive feedback and support, and to believe the participants’ reports of the severity and adverse effects of their pain” (Upshur et al., 2010, p. 1793)."
Source: Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 153-154.
http://www.nap.edu/openbook.php?record_id=13172
http://www.drugwarfacts.org/cms/node/3218

Globally, there is a shortage of pain medication, though that is not the case in every country. According to research published in 2011:

"We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world’s population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access.”
Source: Marie-Josephine Seya, Susanne F. A. M. Gelders, Obianuju Uzoma Achara, Barbara Milani, and Willem Karel Scholten, "A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country, Regional, and Global Levels," Journal of Pain & Palliative Care Pharmacotherapy. 2011;25:6–18. ISSN: 1536-0288 print / 1536-0539 online. DOI: 10.3109/15360288.2010.536307
http://apps.who.int/medicinedocs/documents/s17976en/s17976en.pdf
http://www.drugwarfacts.org/cms/node/2487

As states and the federal government consider restrictions on pain medicines, the needs of patients must be taken into account. Pain management contracts must be fair. Use of drug testing must not be punitive, nor excessive. Like the Boy Scouts, society should also “be prepared” to deal with the possibility of overdoses by better educating physicians and patients about risks, particularly regarding use of alcohol or other drugs in combination with opioids, and making sure that emergency services personnel are equipped with Narcan. As the Institute of Medicine put it:

"With the passage of the Patient Protection and Affordable Care Act in March 2010, the U.S. health care system may undergo profound changes, although how these changes will evolve over the next decade is highly uncertain. Health care reform or other broad legislative actions may offer new opportunities to prevent and treat pain more effectively. Both clinical leaders and patient advocates must pursue these opportunities and be alert to any evidence that barriers to adequate pain prevention and treatment are increasing.
"To remediate the mismatch between knowledge of pain care and its application will require a cultural transformation in the way clinicians and the public view pain and its treatment. Currently, the attitude is often denial and avoidance. Instead, clinicians, family members, employers, and friends inevitably must rely on a person’s ability to express his or her subjective experience of pain and learn to trust that expression, and the medical system must give these expressions credence and endeavor to respond to them honestly and effectively."
Source: Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 47.
http://www.nap.edu/openbook.php?record_id=13172
http://www.drugwarfacts.org/cms/node/2093

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Favorite new items:

http://www.drugwarfacts.org/cms/node/3218
(Barriers to Effective Pain Care) "A number of barriers to effective pain care involve the attitudes and training of the providers of care. First, health professionals may hold negative attitudes toward people reporting pain and may regard pain as not worth their serious attention. As discussed in detail in Chapter 2, patients can be at a particular disadvantage if they are members of racial or ethnic minorities, female, children, or infirm elderly. They also may have less access to care if they are perceived as drug seeking or if they have, or are perceived to have, mental health problems. A literature review showed that people with pain, especially women, often have attitudes and goals that are different from, and sometimes opposed to, the attitudes and goals of their practitioners; patients seek to have their pain legitimized, while practitioners focus on diagnosis and therapy (Frantsve and Kerns, 2007). Consumers testified before the committee that patients often believe practitioners trivialize pain, which makes them feel even worse. Researchers working with patient focus groups have noted the “perceived failures of providers to fully respect, trust, and accept the patient, to offer positive feedback and support, and to believe the participants’ reports of the severity and adverse effects of their pain” (Upshur et al., 2010, p. 1793)."
Source: Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 153-154.
http://www.nap.edu/openbook.php?record_id=13172

http://www.drugwarfacts.org/cms/node/3214
(Role of Psychopharmaceuticals in Overdose Deaths) "This analysis confirms the predominant role opioid analgesics play in pharmaceutical overdose deaths, either alone or in combination with other drugs. It also, however, highlights the frequent involvement of drugs typically prescribed for mental health conditions such as benzodiazepines, antidepressants, and antipsychotics in overdose deaths. People with mental health disorders are at increased risk for heavy therapeutic use, nonmedical use, and overdose of opioids.4-6 Screening, identification, and appropriate management of such disorders is an important part of both behavioral health and chronic pain management."
Source: Christopher M. Jones, PharmD, Karin A. Mack, PhD, and Leonard J. Paulozzi, MD, "Pharmaceutical Overdose Deaths, United States, 2010," Journal of the American Medical Association, February 20, 2013, Vol 309, No. 7, p. 659.
http://jama.jamanetwork.com/article.aspx?articleid=1653518

http://www.drugwarfacts.org/cms/node/3213
(Arrests of and Allegations Against Customs and Border Protection (CBP) Employees, 2005-2012) "According to CBP’s data, incidents of arrests of CBP employees from fiscal years 2005 through 2012 represent less than 1 percent of the entire CBP workforce per fiscal year. 18 During this time period, 144 current or former CBP employees were arrested or indicted for corruption—the majority of which were stationed along the southwest border. In addition, there were 2,170 reported incidents of arrests for misconduct.19
Source: "Border Security: Additional Actions Needed to Strengthen CBP Efforts to Mitigate Risk of Employee Corruption and Misconduct (Washington, DC: US Government Accountability Office, Dec. 2012), GAO-13-59, p. 8.
http://www.gao.gov/products/GAO-13-59

http://www.drugwarfacts.org/cms/node/3187
(Average Police Time Taken Per Marijuana Arrest) "In our ongoing research about marijuana possession arrests in New York,1, we have found that a basic misdemeanor arrest for marijuana possession in New York City varied from a minimum of two or three hours for one officer, to four or five hours or even longer for multiple officers. During this time the officers returned to the police station with the handcuffed arrestees and booked them; they took photographs and fingerprints, gathered other information and wrote it up. They sent the personal data to be checked against the state's criminal databases and often waited to receive the arrestees' criminal records, if the database searches found any. Arresting officers regularly took suspects to the central booking jail, were interviewed by assistant district attorneys, and appeared in court.
"For a very low and conservative estimate, we used two and a half hours as a minimum average amount of time one officer spends making a marijuana possession arrest. We multiplied 2.5 hours by the number of lowest-level marijuana possession arrests (charged under NYS Penal Law 221.10) for each year since 2002 when Mayor Bloomberg took office.
"The front cover of this report shows a graph with the number of marijuana arrests for each year from 2002 through 2012. In those eleven years the NYPD made a total of 439,056 possession-only arrests. Multiplied by two and a half hours of police time per arrest that equals 1,097,640 hours - or approximately one million hours of police officer time to make 440,000 marijuana arrests. That is the equivalent of having 31 police officers working eight hours a day, 365 days a year, for 11 years, making only marijuana possession arrests."
Source: Harry Levine, Loren Siegel, and Gabriel Sayegh, "One Million Police Hours: Making 440,000 Marijuana Possession Arrests in New York City, 2002-2012," Drug Policy Alliance and Marijuana Arrest Research Project, New York City, NY, March 2013, p. 2.
http://www.drugpolicy.org/sites/default/files/One_Million_Police_Hours.p...

New Research Material:

Irish Focal Point (2012) "2012 National Report (2011 data) to the EMCDDA by the Reitox National Focal Point." Ireland: new developments, trends and in-depth information on selected issues. Dublin: Health Research Board, pp. 104-105.
http://www.drugsandalcohol.ie/18808/1/NewIreland2012nationalreport2011da...

Walmsley, Roy, "World Prison Population List (Ninth Edition)" (London, England: International Centre for Prison Studies, 2011), p. 1.
http://www.prisonstudies.org/images/news_events/wppl9.pdf

Harry Levine, Loren Siegel, and Gabriel Sayegh, "One Million Police Hours: Making 440,000 Marijuana Possession Arrests in New York City, 2002-2012," Drug Policy Alliance and Marijuana Arrest Research Project, New York City, NY, March 2013, p. 2.
http://www.drugpolicy.org/sites/default/files/One_Million_Police_Hours.p...

Media Appearances:

On Tuesday, March 26, DWF Editor Doug McVay appeared on a Huffington Post Live segment on marijuana and other drug legalization, hosted by Marc Lamont Hill. Other guests on the program were Sanho Tree of the Institute of Policy Studies; Paul Chabot of Drug Free California; and Ryan March of Columbia, MO, who had been arrested for marijuana cultivation and now supports legalization of marijuana only. The 30-minute piece can be viewed in its entirety at:
http://live.huffingtonpost.com/r/segment/drug-legalization-decriminaliza...

Drug Truth Network 420 Drug War News Items
March 10: Fact-checking the drug czar
http://www.drugtruth.net/cms/node/4260
March 18: Russian drug treatment
http://www.drugtruth.net/cms/node/4272
March 24: Checking the facts: More African-American men are in college than behind bars
http://www.drugtruth.net/cms/node/4278
March 30: Policing by the clock: Research estimates police time used on pot possession arrests.
http://www.drugtruth.net/cms/node/4287
April 6: Checking the facts: Is the US the world's biggest jailer?
http://www.drugtruth.net/cms/node/4295

DWF Editor/CSDP Board Member Doug McVay also appears regularly on DTN's weekly half-hour news shows Cultural Baggage
http://www.drugtruth.net/cms/views/latest_cb
and Century of Lies
http://www.drugtruth.net/cms/views/latest_col

Drug Truth Network has begun production of a video news show focused on the drug war, for which DWF Editor Doug McVay is creating content. The Unvarnished Truth is broadcast via Houston's HMSTV, and is available to view online at
http://www.drugtruth.net/cms/unvarnished_truth