The money and influence behind “Pain: the 5th vital sign”

February 4, 2014, 11:38 pm

“Last year, [Philip Seymour Hoffman] checked into a rehabilitation program for about 10 days, a move that came after a reliance on prescription pills led to a return to heroin, after what he said had been a clean period spanning two decades.” New York Times February 4, 2014

The death of actor Philip Seymour Hoffman from a drug overdose earlier this week brings into focus not only the recent resurgence of heroin use, but also the dangers of prescription opioid pain relievers. It seems an appropriate time to rerun this post from December 2012.

  A must-read article in the Wall Street Journal this weekend focuses on Dr. Russell Portenoy, a New York City pain specialist who two decades ago was instrumental in the drive to expand use of opioid analgesics to treat chronic pain. (Unfortunately, the article is behind the WSJ firewall and requires subscription.) The Journal notes that today, prescription opioids are responsible for “the country’s deadliest drug epidemic”, with more than 16,500 persons dying annually.

Now, Dr. Portenoy and other pain doctors who promoted the drugs say they erred by overstating the drugs’ benefits and glossing over the risks. “Did i teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I goes I did,” Dr. Portenoy said in an interview with The Wall Street Journal. “we didn’t know then what we know now.”

While years ago Dr. Portenoy and others claimed that the risk of addiction to opioids use to treat chronic pain was less than 1%, this figure was based on virtually no scientific evidence.

“I gave innumerable lectures in the late 1980s and ’90s about addiction that weren’t true,” Dr. Portenoy said in a 2010 videotaped interview with a fellow doctor. . . . In it, Dr. Portenoy said it was “quite scary” to think how the growth in opioid prescribing driven by people like him had contributed to soaring rates of addiction and overdose deaths.

In a frequently cited 1986 paper — based on just 38 cases — Portenoy and Foley concluded that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse”. According to the Journal, that paper “opened the door to much broader prescribing of the drugs for more common complaints such as nerve or back pain”. And there was pressure from organized groups to expand treatment of pain:

In the late 1990s, groups such as the American Pain Foundation, of which Dr. Portenoy was a director, urged tracking of what they called an epidemic of untreated pain. The American Pain Society, of which he was president, campaigned to make pain what it called the “fifth vital sign” that doctors should monitor, alongside blood pressure, temperature, heartbeat and breathing.

Of course, at that time, pain was being under treated, certainly in emergency departments. But by minimizing — really negating — the potential risks involved in chronic opioid therapy, proponents set the stage for the current epidemic of overdose deaths. Before long, recommendations by Dr. Portenoy and other became incorporated in guidelines issued by professional society. And — I’m shocked, shocked to learn — drug company influence and money were involved:

In 1998, the Federation of State Medical Boards released a recommended policy reassuring doctors that they wouldn’t face regulatory action for prescribing even large amounts of narcotics, as long as it was in the course of medical treatment. In 2004 the group called on state medical boards to make under treatment of pain punishable for the first time. That policy was drawn up with the help of several people with links to opioid makers, including David Haddox, a senior Purdue Pharma [manufacturer of OxyContin] executive then and now. The federation said it received nearly $2 million from opioid makers since 1997. . . . A federation-published book outlining the opioid policy was funded by opioid makers including Purdue Pharma, Endo Health Solutions Inc. and others, with proceeds totaling $280,000 going to the federation.

Eventually, the Joint Commission became involved:

The Joint Commission published a guide sponsored by Purdue Pharma. “Some clinicians have inaccurate and exaggerated concerns” about addiction, tolerance and risk of death”, the guide said. “This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.”

It should come as no surprise that the Journal reveals Dr. Portenoy has “disclosed relationships with more than a dozen companies, most of which produce opioid painkillers.” Dr Portenoy denied that these financial relationships biased any of his lectures or publications. Of course, the building consensus now is that there is little if any evidence that opioids provide safe and effective treatment for chronic non-cancer pain, and that paradoxical, under-appreciated conditions such as opioid-induced hyperalgesia and narcotic bowel syndrome can complicate long-term treatment. It is unfortunate that this important article is behind the WSJ firewall. Nevertheless, it should be read and is worth seeking out.

Related post: Was the “Pain as a 5th Vital Sign” campaign in part a marketing ploy?

ADDENDUM: [2/4/2014] A reader notes the the WSJ article can be accessed without subscription by doing a Google search for the title: “A Pain-Drug Champion Has Second Thoughts”]