Everything You Know About Opioids is Wrong: The invisible victims of a misunderstood crisis

October 20, 2018


Jennifer Martin-Romme

Zenith News


It was a hell of a way to end one of the most distinguished careers in modern American medicine.


Dr. Forrest Tennant is a Major in the US Army, who served as a field surgeon in Vietnam. After the war, he became a professor at the University of California.


He’s been a medical consultant for the Department of Justice, the Highway Patrol, the National Football League, the National Association for Stock Car Auto Racing, and the Los Angeles Dodgers. In the 1980s, he was elected mayor of the Los Angeles suburb where he’s been practicing medicine for more than 45 years.


Tennant took on the most intractable, hard-luck cases among chronic pain disorders—arachnoiditis, Ehlers-Danlos syndrome, reflex sympathetic dystrophy, post-herpetic neuralgia. He’s been published in academic journals more than 300 times and was frequently called upon to address colleagues at medical conferences. Among chronic pain patients, he is revered as a sort of patron saint.


On November 15, 2017, the Drug Enforcement Administration (DEA) stormed Tennant’s home and office, seizing patient files, business records, computer equipment, and the titles to his home and cars—all on suspicion that the 76-year-old physician was trafficking in narcotics. To this day, Tennant has not been charged with any crime.


The affidavit authorizing the raid is bone-chilling to read—not just because it criminalizes relatively common pain medicine practices (e.g., prescribing hydrocodone, the most commonly prescribed opioid painkiller), but because it literally accuses Tennant of thought crimes.


The affidavit calls for agents to seize evidence—not even that Tennant actually prescribed fentanyl (a much-maligned opioid painkiller)—but evidence that he merely approved of its medical use in theory.


The affidavit accuses him of authoring a 2009 paper in defense of high-dose opioid therapy for certain types of pain patients, and it accuses him of drafting a “Pain Patients’ Bill of Rights” in 1997, which California then adopted as state law.


After the raid, Tennant transferred all his patients and retired, signing a consent decree, the terms of which he either doesn’t want to discuss, or he’s not allowed to.


“I’ve been labeled as somebody who recommends opioids,” he says. “The federal government and most of the states have decided that they don’t want opioids used for treatment. And nobody in Washington DC has come to the aid of the patient, despite suffering and suicides.


“If you listen to the media and the general rhetoric, [prescription opioids] are evil, but the overdoses are from fentanyl coming in from foreign countries”—more specifically, an illicitly manufactured analog of prescription fentanyl, which in its prescription form is not easily abused. (When dispensed outpatient, it’s ingested through the skin, not in a pill or injectable form. Prescription fentanyl rarely shows up in opioid overdose deaths.)


IMF—or “illicitly manufactured fentanyl”—is chemically similar to its prescription cousin. There are more than 1,400 fentanyl analogs, but once they’ve been metabolized, toxicologists can only distinguish about 15 of them from prescription fentanyl. One particularly potent analog, called carfentanil, is produced legally as a tranquilizer for large animals, like elephants and rhinoceroses.


Their potency at extremely low doses makes IMF attractive to drug dealers, because it’s dirt-cheap and a little bit goes a very, very long way. It’s attractive to illicit drug users because a small amount gets them very, very high.


However, since the lethal dose is also quite low, and because dosage is unregulated on the illicit market, the combination is a match made in hell: IMF is added to heroin and other street drugs to cheaply stretch the supply—but at a cost of tens of thousands of deaths, which are then falsely blamed on doctors and prescription drugs.


As overdose deaths continue to rise, opioid prescriptions by doctors have dropped. States with some of the highest rates of opioid prescribing, such as Arkansas and Alabama, have among the lowest opioid overdose rates, while states like Maryland and Ohio, where prescription rates have plummeted, overdoses have soared.


••Article continues below graphs••


“The condemnation of prescription opioids has gone beyond anything I’ve ever seen,” says Tennant. “The distortion of facts has gone beyond anything I’ve ever seen. In Los Angeles, when we lobbied for the Pain Patients’ Bill of Rights [in 1996], nobody objected to any of it. They all agreed that humans should not have to suffer. I don’t think I’ve ever seen a patient become addicted, and I’ve been doing this since the Vietnam War.”


Although the death toll from heroin is staggering, and suicide among pain patients has apparently risen as their treatment has been cut off, Tennant says untreated pain itself can, at best, delay healing; at worst, it can be lethal.


“Adrenaline goes up. Cortisol goes up. Heart rate goes up. Blood pressure goes up. If long-term pain doesn’t get under control, the whole adrenal system will fail and, eventually, we see cardiac failure...This isn’t new information; we’ve known all this for decades.


“People who have that degree of pain, I don’t think you can understand unless you’ve been there. I never have, but I can listen to my patients. A lot of physicians reject that, because then they might see it. And if you see it, then you have to do something about it.”


••Article continues below glossary••

Defining Our Terms


Tolerance: The need for increased dosage of a drug in order to produce the same effect and/or the dissipation of side effects from repeated exposure.


Dependence: The appearance of withdrawal symptoms when a drug is abruptly ceased.


Tolerance and dependence are sometimes mistaken for addiction, but they are three separate things.


Addiction: Compulsive use of a drug despite increasingly negative physical, emotional, and social consequences. Any drug that produces a reward-and- reinforcement stimulus is potentially addictive for those who are repeatedly exposed to it and who have a genetic vulnerability to compulsive use.


Drug Abuse: Ingesting a non-recreational substance for recreational purposes. While drug abuse can have negative consequences, most people who abuse a drug are not addicts. You don’t have to be an alcoholic to get in a car accident if you drive drunk. The difference between abuse and addiction is how much the drug affects the person’s life, and whether or not they can simply stop using it.


Drug Misuse: Taking a prescription drug for its intended purpose, but not following the prescriber’s instructions. Misuse can happen unintentionally, if a patient is given inadequate instructions, doesn’t understand the instructions, or forgets the instructions. Misuse can happen intentionally if the patient has inadequate symptom control and attempts to adjust the instructions on their own. Patients may fear telling their doctor about misuse, which increases the risk of drug interactions or overdose.


Pseudoaddiction: A non-diagnostic term for a set of patient behaviors produced by untreated or undertreated symptoms. Some of these behaviors mimic addiction; others merely reflect a layperson’s stereotypes about addiction. For example, patients might “clock-watch” for their next dose; become anxious if they are unable to fill their prescription; and/or carry medication with them even when they don’t expect to need it.


Pseudoaddiction is “iatrogenic,” meaning it’s caused by the treatment or treatment provider. It is typically associated with opioid pain medications, but can appear any time a patient fears their symptoms will not be addressed. For example, if a patient has insufficient medication to control symptoms, they might request an early refill. If this behavior is “punished,” they might request a different drug or save up unused doses for anticipated scarcity later.


Pseudoaddiction has become controversial since the term first appeared in 1989. Today, it is often replaced by the term “drug-seeking behavior”—a pejorative coined by the Drug Enforcement Administration that regards the following as signs of an addict attempting to obtain prescription drugs by deceit: An “assertive personality,” an “unusual appearance,” knowledge of medical terms, and requesting a prescription drug by name.


Richard Lawhern saw it and decided to do something. An engineer in South Carolina•, Lawhern’s wife has trigeminal neuralgia, which causes severe pain in the face and head. In order to advocate for her, Lawhern had to become a walking encyclopedia of pain conditions, opioid therapies, and the misconceptions driving drug policy.


“So, I got into it as an amateur and I deep-dived it. There’s an empathy gap [between pain patients and the general public], and it’s a double-edged sword, because pain patients often find themselves socially isolated.”


Then their daughter was diagnosed with Parkinson’s disease and spinal degeneration—but no one would treat her pain until she had first undergone Cognitive Behavioral Therapy•.


“By the simple act of assigning a diagnosis of ‘psychogenic pain’ [meaning that the cause is psychological], the risk of patient suicide goes up 250 percent”—a discovery Lawhern got published in 2013. He’s since published more than 60 papers, some of them in peer-reviewed academic journals•, despite not having any professional background in medicine.


The “opioid epidemic”—however one chooses to define it—began in 1995 when Purdue Pharma of Stamford, Connecticut, rolled out OxyContin, a supposedly long-acting formulation of oxycodone. (Depending on the source, oxycodone is described as twice as powerful as morphine, 10 times more powerful than morphine, or 100 times more powerful—all of which is chemical nonsense).


Purdue set out to repair the reputation of painkillers derived from the humble poppy, pouring millions of dollars into company-funded research and aggressive marketing, claiming that their patented extended-release formula was less addictive and more abuse-resistant because a single dose could suppress severe pain for 10-12 hours.


None of these claims turned out to be true. The extended-release mechanism was easily circumvented by crushing the pills and snorting or injecting the powder.


Although the risk of addiction was still relatively low in patients without any prior history of addiction (about eight percent of those exposed to OxyContin got addicted—by comparison, 12 percent of those exposed to alcohol become alcoholics), OxyContin was nevertheless a disaster.


By 2005, an estimated seven million people had developed an “opioid use disorder” related to OxyContin. (Although to keep that in perspective, nearly 60 million prescriptions were written for it in the mid-’90s.)


Purdue Pharma has paid out over $600 million in product liability settlements and, to this day, remains buried in litigation that virtually everyone feels Purdue deserves. St. Louis County signed onto the lawsuits last March, and the State of Minnesota joined the fray in July.


The pendulum was about to swing hard in the other direction, and when it did, it steamrolled 20 million people with incurable illnesses that cause chronic pain, for whom opioids are the only reasonably effective treatment.


“Prescriptions for OxyContin dropped by two-thirds,” Lawhern says, “and deaths from heroin rose by a factor of three. When the supply of street OxyContin dried up, those addicted to it—most of whom were not pain patients—could no longer get their relatively safe high.”


In the reigning anti-prescription opioid narrative—breathlessly trumpeted in media headlines, propounded by politicians, by police, and even by doctors themselves—prescription opioids are regarded as a gateway drug to heroin. But that narrative is flawed for the same reason the marijuana-as-gateway-drug narrative is flawed.


Just as approximately three-quarters of Americans have smoked marijuana at least once—and ergo, most Americans who abuse heroin, cocaine, or methamphetamine have, at some point, also used marijuana—about 80 percent of Americans today have been prescribed an opioid at least once—a cough syrup with codeine, a hydrocodone prescription after surgery or dental work.


But these supposed gateways don’t swing in both directions. Just as marijuana doesn’t cause most of its users to upgrade to crack, the number of people exposed to prescription opioids at least once who later become opiate addicts is vanishingly small—less than two percent of those who do not already have a substance abuse problem. Even among those on long-term, high-dose opioid therapy, addiction rates are only about three to four percent.


In both cases, the alleged “gateway” is created merely by the coincidence of a high rate of exposure to the baseline drug. Most heroin addicts will have used marijuana and been prescribed an opioid, simply because most Americans have used marijuana and been prescribed an opioid. The relationship is coincidental, not causative.


By 2010, the federal government was trying to stamp out a fire without bothering to first determine what was burning. The DEA was pursuing (allegedly) crooked doctors, operating under the still-extant assumption that prescriptions were the root of the problem.


Or maybe physicians just make softer targets than street dealers—doctors conveniently record their activities (which can then be used to prosecute them); they tend to have more assets that drug cops can seize in civil forfeiture; and they’re less likely than El Chapo to shoot back.


But whether the DEA’s “anti-diversion” campaign was initiated in good faith or not, a climate of paranoid antagonism began to overtake the doctor-patient relationship. Patients complaining of pain became suspect—subject to “narcotics contracts,” scrutinized for “drug-seeking behaviors” (literally defined by the DEA as looking or acting “unusual” or having knowledge of their own illness), forced to submit to pill counts and urine drug screens, with little regard for the fact that opioids metabolize into other opiate derivatives—the liver turns codeine into morphine; hydrocodone breaks down in the body into hydromorphone (a.k.a., Dilaudid)—such that pain patients were perpetually at risk of being falsely indicted by their pee and cut off from treatment by doctors fearful of provoking the career-destroying gaze of the DEA.


Doctors brought up on criminal charges for drug trafficking faced a challenge in defending themselves because no standard existed across all medical disciplines for how opioids should be prescribed. Such a standard is arguably ridiculous, because there’s such a wide difference in the practices of, say, a primary care doctor, a dentist, and a pain medicine specialist—but how could any of them prove their innocence with respect to decisions that are a matter of professional judgment and unique patient needs?


Enter PROP—Physicians for Responsible Opioid Prescribing—an advocacy group led and funded by addiction specialists. PROP’s executive director, Andrew Kolodny, is the lead doctor for a chain of drug rehab facilities.


Whether this is a true conflict of interest, or whether to Kolodny’s rehab “hammer,” every patient simply looks like a “nail,” PROP effectively lent an air of respectability to viewing every arthritic joint or compressed nerve, not as sources of pain, but as symptoms of drug addiction.


“The hype after Prince died,” says Lawhern, referring to the singer’s sudden death in April 2016 from what was widely reported to be prescription opioids, but turned out to be an illicit fentanyl analog, marked to resemble hydrocodone, “was driven by a bunch of bastards at PROP who misrepresented it—I believe, deliberately. They took it and ran with it, and it was bullshit.”


The singer had had untreated injuries in both hips for over a decade. By the time the real cause of Prince’s death was determined, the media feeding frenzy had moved on, and the fact that he did not die from a prescription overdose made barely a ripple in the headlines.


“When you look at the reporting of accidental deaths and suicides, pain patients could have as much as double the suicide rate. That is tougher than nails to get an answer on, but there are a few indicators. The [Centers for Disease Control] is now acknowledging that 8.5 percent of suicides have a history of chronic pain. Then [the number of pain patient suicides] started rising in 2015•”—the year before the CDC issued opioid prescribing guidelines that clamped down even harder on painkiller access, including for short-term, acute or post-operative pain.  


The CDC has refused to release the names of its “Core Expert Group” who wrote the guidelines, but they mirror PROP’s recommendations almost verbatim:


•A “first preference” for “non-pharmacological pain therapies,” regardless of safety, effectiveness, or whether insurance will pay for them. Most insurance policies will not cover massage, biofeedback, or more than a few sessions of physical therapy.


This has opened the door to a lot of quackery in pain treatment, such as acupuncture, homeopathy, and Reiki—a New Age-y version of faith healing.


At worst, these “alternative treatments” could exacerbate pain conditions, such as misapplied chiropractic or unskilled yoga (which already injures a remarkable number of practitioners who aren’t pain patients).


•Treatment goals that must show “clinically meaningful improvement,” which ignores the fact that most chronic pain patients have incurable conditions.


•No more than three days’ worth of opioids for short-term, acute pain. (This is based on a misconception that most patients who take opioids for more than a week will be on them long-term, which comes from reading the data backwards: Most patients on long-term opioid therapy started out on them short-term, but most patients who are on them short-term do not go on to take them for years.)


•Urine drug screens to detect illicit substances—most commonly, marijuana, even though more than half the United States, including Minnesota, now has medical marijuana programs, and there are no dangerous drug interactions between marijuana and opioids.


•“Behavioral therapy” in lieu of opioids, though, again, insurance will rarely pay for more than short-term psychotherapy, and the need for it is questionable. While pain patients do suffer from disproportionate rates of depression and anxiety, these may well be iatrogenic, stemming from the patient’s inability to control their pain.


Some of the proposed modalities are ridiculous to the point of insulting. “Acceptance therapy,” for example, amounts to doing nothing for the patient and calling that a form of treatment. (Not to be confused with legitimate modalities that help patients come to terms with incurable diagnoses or sudden disability, but using those modalities instead of alleviating the patient’s physical suffering is a dubiously ethical use of psychotherapy.)


•The CDC guidelines call for capping dosages at no more than 90 “morphine milligram equivalents,” or MMEs, per day. MMEs are a way to compare the painkilling strength of various opioids, but using them as dosage guidelines is actually dangerous. It doesn’t account for the patient’s metabolism nor for the half-life of the specific drug. Methadone, for example, has a much longer half-life than other opioids, which runs the risk of overdose if using MMEs as dosage guidelines.


In practice, the guidelines have translated to forcing dose reductions on patients, and often discharging them from treatment altogether, by doctors who fear the guidelines set a standard by which they can now be prosecuted. “It’s patient abandonment, plain and simple,” says Lawhern. “Patients should never, ever, be discharged without a viable referral. That’s malpractice, hands down.”


Perhaps most troubling of all, the CDC has known since at least 2012 that its opioid overdose data overstate prescription overdoses by fully 50 percent or more.


Last April, the American Journal of Public Health published an editorial by four CDC researchers—explicitly acting independently of the agency—explaining how prescription opioid overdoses have been “significantly inflated” by the CDC for years. For example, in 2016, there were 42,249 overdoses from all categories of opioids.


“Under the CDC’s traditional method of calculating prescription opioid overdose deaths,” the researchers explained in their editorial, “deaths involving natural and semisynthetic opioids and synthetic opioids as well as methadone are included. Under a more conservative method, deaths involving only natural and semisynthetic opioids and methadone are included [in prescription overdoses]. Deaths involving synthetic opioids are removed and counted separately because of the high proportion of deaths that likely involve [illicit fentanyl].”


So, using the CDC’s “traditional” method, 32,445 of those deaths were counted as prescription overdoses—a number often cited in the press as well as by drug abuse prevention agencies and medical professionals, when in fact fully half that number—15,358—were actually caused by heroin and illicit fentanyl, not prescriptions.


And at least half the prescription overdoses (other sources suggest 90 percent) involve multiple drugs, not just prescriptions. A large dose of Percocet is one thing; washing it down with vodka and sleeping pills is chemical Russian roulette. The CDC’s data show this inflation going back to at least 2012—four years before the CDC issued its opioid prescribing guidelines.


Eager to discuss these findings, I called and emailed the lead researcher, Dr. Puja Seth, but the CDC’s public relations department intercepted my messages and required that I submit my questions to them first. Then a PR representative proceeded to listen in on the entire interview, which may or may not explain why Seth seemed to downplay the significance of the misinformation she helped expose, noting that the raw data have been on the CDC’s website for several years.


The CDC will not be considering any changes to the prescribing guidelines since, after all, they’ve known about the inflated numbers all along.


“Prescriptions have declined,” Seth acknowledged, “but despite that, the amount of opioids being prescribed is still too high...not only in terms of the number of prescriptions, but also the dosages...I think it’s more a matter of doctors using opioids as their first line of treatment.”


Lawhern scoffs in disgust at that response. “The endgame here is that people like Kolodny want pain patients to be labeled as drug addicts and treated in the rehab facilities that he owns—that’s why he lies. Or: We could wake up and realize that we’ve all been had, and demand a change in the guidelines. They’re killing people.”


•This sentence has been corrected from the original.


Please reload

More from this Author

Archives by Date

Please reload

Archives by Title or Author