Pain, meds and money

A few stories on opioids caught my eye.

First, one about methadone, pain and class:

Map the deaths and you see the story.

Assign a dot to each person who has died in Washington by accidentally overdosing on methadone, a commonly prescribed drug used to treat chronic pain. Since 2003, there are 2,173 of these dots. That alone is striking, a graphic illustration of an ongoing epidemic.

But it’s the clusters that pop out — the concentration of dots in places with lower incomes.

Everett, whose residents earn less than the state average, has 99 dots. Bellevue, with more people and more money, has eight. Working-class Port Angeles has 40 dots. Mercer Island, upscale and more populous, has none.

And two articles investigating ties between pain advocates and drug companies.

The first one looks at a few leaders in the pain advocacy movement:

Google Dr. Scott Fishman, chairman and president of the American Pain Foundation, or Dr. Perry Fine, a prominent board member, and it’s quickly clear that their ties to the world of pain are legion.

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[Fine] appeared at the 2010 criminal trial of Anna Nicole Smith’s boyfriend and two doctors accused of conspiracy in fostering the late celebrity’s addiction to drugs. Fine testified that the 1,500 pills a month Smith was given did not make her an addict, according to news reports.

Fishman, chief of pain medicine at the University of California, Davis, and Fine, a professor of anesthesiology at the University of Utah School of Medicine, have authored articles on the foundation’s website. They’ve testified in court cases and before state and federal committees, and each has been president of the American Academy of Pain Medicine, a doctors’ group.

Last year, the pair and a third physician wrote a strongly worded column in The Seattle Times opposing a bill passed by Washington state lawmakers that required doctors and others to consult pain specialists before prescribing high doses of opioids to non-cancer patients. The governor signed it into law nonetheless.

Like the American Pain Foundation, both men have had longstanding ties to the pharmaceutical industry — direct and indirect. The foundation received 88 percent of its $5 million income last year from drug and medical-device makers.

This fall, the physicians acknowledged they had failed to disclose all their potential conflicts of interest in a letter to the editor of the Journal of the American Medical Association, which had been published in July. The journal requires all authors, even of letters, to disclose commercial ties.

In his correction, Fine listed 12 more companies for which he consulted, gave legal advice, delivered promotional talks or provided medical education. Among other things, he listed a 5 percent stake in a medical education company whose programs are funded by drugmakers.

Fine also appears to have played a role in launching a painkiller in 2009, ProPublica found. A subsidiary of Johnson & Johnson quoted him in its media release touting its new opioid.

ProPublica also found discrepancies in Fine’s disclosures to his employer, the University of Utah. For example, Fine told the university that he had received less than $5,000 in 2010 from Johnson & Johnson for providing “educational” services. On its website, however, the company says it paid Fine $32,017 for consulting, promotional talks, meals and travel that year.

The other focuses on the foundation:

The news about narcotic painkillers is increasingly dire: Overdoses now kill nearly 15,000 people a year — more than heroin and cocaine combined. In some states, the painkiller death toll exceeds that of car crashes.

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But the pills continue to have an influential champion in the American Pain Foundation, which describes itself as the nation’s largest advocacy group for pain patients. Its message: The risk of addiction is overblown, and the drugs are underused.

What the nonprofit doesn’t highlight is the money behind that message.

The foundation collected nearly 90 percent of its $5 million funding last year from the drug and medical-device industry — and closely mirrors its positions, an examination by ProPublica found.

Although the foundation maintains it is sticking up for the needs of millions of suffering patients, records and interviews show that it favors those who want to preserve access to the drugs over those who worry about their risks.

Some of the foundation’s board members have extensive financial ties to drugmakers, ProPublica found, and the group has lobbied against federal and state proposals to limit opioid use. Painkiller sales have increased fourfold since 1999, but the foundation argues that pain remains widely undertreated.

It also offers some details of their advocacy efforts:

The group has intervened in court cases in ways that appear to counter its stated mission. In one example, it sided with Purdue Pharma, its longtime funder, to block a 2001 class-action case filed by Ohio patients who had become addicted to or dependent on the company’s blockbuster painkiller, OxyContin.

And the foundation mobilizes patients to send “outraged” email messages to news organizations that run stories it believes reinforce “stigmas and stereotypes” about the risks of pain medication.

The group’s board includes some patients but also doctors who are paid to speak and consult for drug companies, a researcher whose clinic has relied on their funding for survival and a public-relations executive whose firm represents them.

Last year, one board member was the lead author of a study about a Cephalon drug. Cephalon sponsored the study, and its employees were co-authors. The study found that the drug, Fentora, was “generally safe and well-tolerated” in non-cancer patients even though it is only approved for severe cancer pain.

The article also discusses divisions among pain docs:

“We bought into this idea that opioids would be effective and that the risk of addiction would be low,” said Dr. Jane Ballantyne, a longtime pain expert and a professor at the University of Washington.

But along the way, pain doctors split. Some, like Ballantyne, began decrying the increasingly widespread use of opioids and questioned whether the drugs worked. Others, like the foundation’s leaders, said the drugs were being unfairly maligned, making pain patients feel like criminals and discouraging doctors from prescribing them.

Despite the debate, sales of the drugs have skyrocketed.

Last year, $8.5 billion worth of narcotic painkillers were sold in the United States…

Their patient education efforts:

Its patient guide, paid for by four companies, discusses several treatments for pain. It says such pain relievers as aspirin, ibuprofen and naproxen commonly cause gastrointestinal bleeding or ulcers, delay blood clotting, decrease kidney function and may increase the risk of stroke or heart attack. And it warns patients to use these pain pills at the lowest dose and stop them unless clearly needed.

The side effects of opioids, on the other hand, are minor, and most go away “after a few days,” the foundation’s guide says. The underuse of opioids, it says, “has been responsible for much unnecessary suffering.”

Patients, it says, shouldn’t worry if they need more of a drug. They are not developing an addiction.

“Many times when a person needs a larger dose of a drug,” the guide says, “it’s because their pain is worse or the problem causing their pain has changed.”

And their legal and legislative advocacy:

The foundation doesn’t just offer advice about opioids; it takes its arguments into court.

In 2005, it filed a friend-of-the-court brief in the U.S. Fourth Circuit Court of Appeals in support of Dr. William Hurwitz, a pain doctor in Virginia who had been convicted on 50 counts of drug trafficking.

The doctor had been accused of prescribing a single patient as many as 1,600 Roxicodone pain pills in one day. Hurwitz allegedly had prescribed that patient alone more than 500,000 pills between July 1999 and October 2002.

The pain foundation and its allies argued that the jury instructions in the case didn’t distinguish between criminal behavior and mistakes by a well-intentioned physician. “It is not drug dealing to prescribe opioids to patients that might be ‘suspected’ addicts or substance abusers,” the foundation and two other groups wrote in a brief.

Rowe said the foundation intervened in the case on principle, fearing the drugs would be “demonized.” The appeals court threw out the conviction, but Hurwitz was retried and convicted on 16 counts of trafficking.

Years earlier, the foundation opposed several pain patients who had sued Purdue Pharma in an Ohio county court for allegedly obscuring the risks of OxyContin.

The foundation filed a friend-of-the-court brief backing Purdue, arguing that the health of all pain patients would be harmed if the class-action lawsuit went forward because doctors would become fearful of prescribing opioids.

Ohio was plagued by “opiophobia” according to a brief co-authored by the foundation and two smaller pain nonprofits. “Consequently many, if not most, of the state’s residents had been deprived of adequate pain care,” it said.

The Ohio Supreme Court decided in 2004 not to allow a class action.

In a separate federal case in 2007, Purdue pleaded guilty to misbranding OxyContin “in an effort to mislead and defraud physicians and consumers,” according to a statement from prosecutors. The company agreed to pay $600 million in penalties. Three top officials also pleaded guilty to misdemeanors and agreed to pay $34.5 million.

Two months after the conviction, however, then-foundation chairman Dr. James Campbell praised Purdue in a statement to a U.S. Senate committee.

It’s so bad that it stirs echos of tobacco companies. Appalling.

Just to be clear. I want patients in pain to have access to whatever meds they need to ease their suffering. I oppose any attempt to interfere in their care. At the same time, their can be no doubt that there are serious problems with people seeking and receiving prescriptions for the purpose of getting high or selling the pills. In addition, some patients are clearly getting more meds than they can keep track of or use, resulting in them being diverted by family, friends and others. You’d think that finding solutions that balance these needs would be something that no one would oppose.