Beginning in the spring of 2016 an unintended consequence of the CDC Guideline for Opioid Prescribing began - the Opioid Refugee Crisis, a crisis of failure to provide medical treatment for Americans with long term painful disease.

This came about for several reasons. The prime mover in the new crisis was the CDC, who without regulatory authority, and for the first time in the history of medicine attempted to limit dosage of all opioid (opiate, narcotic) pain medicine, disregarding medical text books and decades of clinical experience.

Secondly, and equally important, was the over enforcement of legal drug prescribing by the DEA targeting practicing physicians who are not measuring up to the DEA’s medical standards of what and how much to prescribe. A law enforcement agency does not set standards or laws, democratic protections prevent a police state. The DEA not only sets standards and protocols for raiding and prosecuting doctors, they inappropriately set medical standards reserved for the medical profession. The “red flags” of prescribing amounts and types of medication being monitored by DEA computer analysts is improper.

Thirdly, the crisis has been created by physicians themselves abandoning tried and true pain medication administration methodology and abandoning the patients themselves, leaving an estimated 6 million people with various painful disease states in the lurch to wander as “opioid seekers,” the new opioid taking pariahs in American healthcare. The reported abuse, name calling, and humiliations on the part of doctors, emergency room personnel, nurses, and pharmacists is shameful. Doctors are reporting 40% of their pain medicine prescriptions are being unilaterally denied at the pharmacy counters. People are ejected from emergency rooms. Patients whining about having no pain medicine after surgery are told “you can manage your pain yourself.”

We have, yet again, ignited fears of addiction and overdose death, reminiscent of the great sweeping fears of the Eisenhower, Nixon, Reagan, and Bush Wars on Drugs. This “war” is different. Now we have significant non-addiction causalities with 6 million pain refugees, collateral damage from failed government programs.

We are at the 100 year mark now and one trillion dollars in wasted expenses is not preventing a single case of addiction. We see addiction disease as immoral, making wrong choices, characterological disorder worse than gun running, organized crime, and smuggling. We are talking about the “dope fiends”.

The unreasonably intense fear is still alive, still shrouded by negative stereotypes, an easy button to push for frightened politicians trying to deal with what is in reality a medical disease, a disease we physicians are not allowed to treat. The federal government has become the doctor, and has done a poor job. No one believes the 5 Wars have been successful yet we are starting another one with tried and failed policies as though historical amnesia has become the rule. We would not have a “crisis” today if federal polices of interdiction and prohibition worked.

Fears of home invasions, murders and rapes by crazed “fiends” lives on. In fact, violent crime, home invasions, and aggravated assault are rare in people addicted to diamorphine (Heroin). Real crimes are committed by those on alcohol and stimulant “prescription drugs” such as amphetamines like Ecstasy.

The “fight” has historically been lead by single moralist, espousing beliefs without evidence. Cotton Mather was first in 1692. The suicides over the past two years due to lack of pain treatment are no different than death by hangings in 1692–3. Both are morally driven and both are 100% preventable. A physician, Dr. Wright, in the early 1900’s lead the crusade against immoral behavior of opium users and influenced the passage of the first “control” act, the Harrison Act of 1915. A racist act, not a medical act.

From 1930 to 1962 the War was led by Harry J. Anslinger, Commissar of the Federal Bureau of Narcotics under five presidents. Anslinger became a disciple of demonizing drugs after a personal experience as a young man. His “fight” against drugs never stopped. Anslinger ran campaigns against drugs on radio and at major forums. His view was clear, ideological and judgmental: drugs are dangerous, led to insane asylums and crime, especially mass family member killings. He was a marijuana crusader but his “dope” became cocaine, and heroin as time went on and new racial or political enemies were identified and associations created with particular drugs. Nixon later associated cocaine with activist African-Americans and marijuana with hippies and left wingers.

Anslinger misrepresented case reports later to be found false. He got his way, federal laws were passed, and states were pressured into passing similar legislation he recommended. His thirty years left an indelible stamp on our culture, popularized in 1936 with the movie Reefer Madness, funded by a church group expressing their moral outrage with “drugs.”

Racial themes were popular in Anslinger’s writings, especially mixing of the races sexually. A story of two Negros on marijuana abducting a teenage white girl off “resulting in syphilis” was one of his published prevarications. (Google Wikipedia Anslinger for more details).

The combination of sexual assault by different “racial groups”, the murders, insanity and the 200 “serious crimes” (falsely created) tattooed the fear into our psyche where it resides today. Anslinger would be pleased.

We have a current moralist group carrying on the work of Wright and Anslinger: The Physicians for Responsible Opioid Prescribing(PROP) a name belying their actual function. The group believes pain medicine does not work, causes addiction, causes overdose deaths and ruins lives all this caused by foolhardy, feckless doctors who unwittingly caused an epidemic of.. ? Of what is an important question.

Did CDC report more addicted “dope fiends”? CDC reported what sounded like an epidemic proportion of “prescription opioid overdose deaths but there was no mention of addiction increasing, because it was not increasing, but staying the same per capita as always. Ignoring the facts moralists like PROP and outspoken politicians ignited the old fears of addicted people on the increase confusing “increase” in overdose deaths from increase in addiction, two different things. The image of “fiends” ranging the streets, hiding behind dumpster and breaking into homes and doing God knows what can all start with “one doctor’s prescription”. True the rare genetic mu opioid receptor disease can be triggered by just a few opiate pills only in those with the genes.

Beginning in 2010 PROP physicians without backgrounds in primary care medicine began to spread the rumors that physician prescriptions were causing an “epidemic” rapidly sweeping though American society by way of “heroin pills” (pain medicine) causing rampant addiction and death for anyone taking them.

They falsely reasoned since no research was published showing no study has been published (actually not true) showing opiates worked for long term pain, they must not work and need to be reduced or stopped. This is like saying we know penicillin treats strep throats so why bother to do a study. Using PROP logic: no study has been done to show penicillin works for strep throat and since some have allergic reactions, better ban it “to protect society” from allergic reactions and-use power of thought and gargling as first line treatment.

PROP has spread the notion that anyone taking a “heroin pill” is likely to become addicted and die of an overdose. In fact addiction is rare. CDC is reporting a overly generous figure of 2 million “addicted”people per year. If you divided the 2 million by the population over 16 years of age of 260 million one gets addiction prevalance rate of 8/1000. Ninety percent of addiction occurs in teenage years, (not from prescriptions but mostly from illicit supplies while “partying”). After subtracting out the 90% already addicted this leaves only one person out of 1000 beyond high school age left to addict. True, this opiate naive person can become addicted by triggering the genetically modified brain receptors. But, it is easy to prevent this addiction. Just ask if opiate naive, and if so be careful and report any excess “magic carpet ride” sensation. No more shooting up on the streets “junkies” and “dope fiends” if we add real education of the public.

We need low cost aggressive, grown up educational programs with real facts in high schools and communities. If we catch the triggered addictions, say in 4 students in a 1000 student high school, we should be able to control addiction completely, cheaply, and without injuring 6 million people and causing suicides by trying to take away the substance, moralist view of problem solving by abstinence, taught to us by our pilgrim forebears,

Where is history? We tried to prohibit substance in the 1920’s with alcohol prohibition. Now opiate prohibition. Moralist led medical programs fail. The one we are engaged in now will fail. Deaths will increase. Expenditures will “skyrocket” once again adding to the one trillion dollars down the drain already.

What are the facts? Do we have a crisis? Do we have an “epidemic of prescription drugs” (by the way all drugs on the street are “prescription” type except diamorphine or Heroin, and only 20% of the pills are from doctors prescription pads and usually for someone other than pill shallower. CDC data is not categorized in a way that “increased prescription opioids” can be claimed. It is claimed however. Someone needs to look into this, as it set in motion the worse medical situation in my 44 year career, including a number of medical policy related suicides.

CDC reported an increase of 1/100,000 deaths per year, virtually all in addicted persons. This is not a large number. In fact it is minute number less than deaths falling or choking; certainly not an “epidemic numbers” coming from the official contagion epidemic declarers. They know better than this. What is going on?

The agency in charge of health policy, the NIH did not agree with CDC figures which can be seen by “googling” {NIH overdose deaths, 1–17}. The third chart reveals there as been no increases in “prescription opioid deaths in 6 years. Someone is fibbing.

The dash to eliminate treatment of all pain is Kafkaesque. Emergency rooms won’t treat people with pain medicine. You can no longer expect pain medicine (“opioids’) after your surgery and no more renewals for your long term diseases. All of this to avoid addictions (less than 1 in 1000), and overdose deaths (only in heroin people). Does this make sense? As one granddaughter reported: taking away my Grandmother’s twice a day Vicodin for her arthritis, so now she can no longer get up out of her chair and make it to the bathroom. Is this to prevent some addict (addicted person) from dying on the street?” “The yoga exercise sheets they sent are not helping”

This happened to physician in Tennessee with a rare disabling arthritis, no longer able sit at his microscope in the pathology suite triggered by mandatory pain medication cut off by a Catholic hospital corporation owning and controlling the attached primary care physician group). He applied for and was granted a social security disability pension.

The fallout in just 18 months since the CDC Guideline is leading to more expensive “injection treatments, more unnecessary ER visits, people driven to more surgery in a desperate attempt to stop the pain. More expenses are occurring with more physical therapy as an alternative, potentially more nursing home placements with loss of functioning, more disability applications having lost functions and loss of employment. More expensive and often ineffective “injection treatments” by anesthesiologists several of whom worked on the CDC Guideline to eliminate pain medicines the other way to control pain. Implantable pumps ($10,000+) squirting morphine into the spinal nerves is driving up costs and is usually no more effective than taking enough morphine by mouth. People are talked into expensive implantable electrical simulators instead of full dose pain medicine, which on occasion can provide relief but also frequently fail.

The DEA has jumped into “the fight” of the new “epidemic” and began increasing armed raids on doctors enforcing with the hue and cry: “you are prescribing too many “opioids”, “don’t you know these things are causing deaths and addiction”, “you should have known that one person was a dope dealer”. Raids on offices sometimes with, flak jackets, multiple agents and local police, timed for early in the day to catch offices filled with patients presenting “administrative subpoenas” without judicial authorization, terrorizing staff, demanding to look at patient records, threatening doctors with long prison sentences and trials unless they “surrender” their DEA narcotics licenses. These raids are frequently just to obtain medical records, the right of any agency if you do business with the federal government. Other agencies send a letter of request. The DEA sends swat teams and TV cameras.

The fear of DEA raids has a chilling effect on medical practice and may be the most important of the three factors putting patients with painful diseases out on the street and growing suicides to stop the pain (list of 24 non addicted people committing suicide are available on twitter account @thomasklinemd.

The unwarranted DEA raids to obtain medical records are contributing to doctors leaving their opiate prescription pads in the drawer telling patients to go else where for their pain medication. This is occurring in about two thirds of the 9 million patients part of the 25.3 million member group with daily pain, but who cannot control their pain with exercise, Tylenol and tai chi as recommended by the infectious disease specialists at CDC. These 9 million people need medical treatment with opiate pain medicine and have been getting them without addiction or side effect for years. Not any more. The consequences are unimaginable to this physician

None of these 9 million on long term opiate medicine will become addicted. There are no case reports of someone already treated with opioid medicine becoming addicted. Once you have been on, even a small amount of opiates and not begun seeking more, you have passed the test, so the 9 million people with valid medical disease would be fine at any dose, with any medication weak or strong for any length of time, even years.

Since no one on long term pain medicine can become addicted or “overdose” (another fear myth) why are they being taken off their previously prescribed and previously effective pain suppression? If you take pain suppression away and allow the pain to be recreated, you are in the same position as the methods used for detainees in military prisons with pain creation. There is no difference in pain, whether it be cancer pain, pain from 30 or so uncommon diseases. Science does not support the theory of denying pain medicine to those with long term disease “because they don’t have cancer”, yet another myth to get everybody off opiates even “if forced” say the PROP zealots.

The third cause for the inhumane Pain Refugee Crisis isthe Doctors themselves. We have never liked treating people with painful disease, since the report of pain are subjective, although really no more subjective than any symptom report. The prejudice stems from the fear of someone trying to “score drugs”, the ultimate violation of trust between doctor and patient. Some doctors are so marred by a single episode of being made a fool they stop prescribing for the other 90% with real pain disease not “trying to score”.

The question never asked of the sole proponent of pain nihilism, PROP, is “exactly who can receive a properly titrated dose of opiate pain medicine for long term use”.

The fear doctors have is reinforced by stepped up DEA, unwarranted raids for records and real criminal charges for “prescribing to an addict” , “should have know they were dealers”, and “you caused the death of someone taking one of your prescriptions”.(rarely directly caused). Sometimes DEA traps doctors with paid informants. The desire to obtain voluntary surrenders can lead to bonuses and can be used as metrics for funding. The DEA revokes 25 licenses per year from real criminals but “accepts” 600 surrenders, many without due process, e.g., no Miranda style informing of rights.

The “opioid” crisis boils down to this: imagine the worst pain you have ever had and then imagine the relief pain you got with pain pills. Now imagine the same pain every day for a week, a month, or a year and the same relief afforded by the same pain killers. Now imagine your doctor calls you into the office and says you can no longer receive your long term pain medicine, even though safely prescribed for years, because the CDC/PROP guideline writers say you will become addicted or someone else will become addicted with these “heroin pills” floating around in medicine cabinets and purses.

Many doctors are saying: “I just can’t risk losing my license over this”. So you leave the office without hope of ever returning to a functional person and living with serious daily pain, day and night,unable to get up off the couch to make your fourth graders lunch, to not participate in sex, to rarely leave the house, to spend hours on the couch after trying to work in the garden. This is the worst thing about pain medicine nihilism — lose of daily function. They add the untreated pain.

Americans lead the way in the inhumane treatment of its citizens for fear of creating “dope fiends”. If this were true, it would still not be reason to push a person to ending their life to treat their intractable pain.

A culture that denies the United Nations basic human right to relieve pain has a serious problem..

As a practicing physician of 43 years, I cannot agree with these, illogical, zealot views in this terribly destructive attempt to change centuries of medical practice in favor of eliminated pain relief for all to address the awful tradgeies of reported white young people “becoming addicted” and then dying of overdoses. The approaches under consideration will not prevent one heroin overdose, and will ruin the lives of people who need legal doctor prescribed medication on a daily basis for their pain disease, or for their addiction diseases

Everyday, normal medical patients,with pain not of their own doing, are hitting the streets in large numbers looking for doctors, which most will not find. The are panicked. The relief of pain is a strong driver. Imagine you are in the same boat. Eighty percent of patients with painful disease are women. They dress up, put on make up, rehearse what to say or not to say on advice of friends and nervously get ready for the talk with the doctor, if they are lucky enough to get in the door. Ironically many physicians take the view “you look so good, how can you have this much pain”. If they came no make up, hair stuck out, back yard clothes the response would be “you look like an addict”. This is unvarnished ignorance at its best.

Some practices and even hospitals are putting up signs saying they don’t treat pain disease or we don’t prescribe “opioids”. According to two independent social media poll 65% of patients with pain are abandoned and are looking and not finding new doctors. That’s 65% of 9 million patents with painful disease already on pain medicine, not to mention the millions that will be denied in the future.

For those being treated, 80% say they are not getting the proper dose that used to work just fine without side effects. This far more serious than being reported. Patients with pain who do not want the return of their pain are not outspoken for fear of losing any pain medicine that the doctor is reluctantly precribing since it is “against the rules”. There are no rule, read CDC mea culpa following the publication of the “Guideline” March 15, 2016.

Very few physicians will take more patients discharged from other practices fearing the label and increased scrutiny of being a “pill mill”, so the problem escalates the opioid refugee crisis. The real criminal pill mills in Florida went on for years. Where was law enforcement? Pills were handed out by the box. Everybody in the opiate culture knew what was going on. Drivers without of state license plates took hordes of pills to rural areas in NC, KY, and TN for resale.

After closure of the criminal store fronts, pills in the rural areas dried up, the addicted people found heroin, as they always do when a more suitable opiate is gone. The “rural crisis” was born. Facts have not been presented as to whether more addicted people were involved or just the expected increase in deaths for those already addicted but now resorting to unmarked, impure 
“bags” — always a setting for accidental overdose deaths. Addicted people do not want to die, they make pharmacological mistakes, which we do not help them with, “they deserve it”. When using pills for the addiction, the milligram doses is known, not so for diamorphine/Heroin.

Extra federal prosecutors have been added to find “these doctors” that prescribe a lot of opioids since doctors prescribing opioid in general are the newly discovered cause of the 100 year old “drug epidemic” starting in 1923 when diamorphine (Heroin) an important pain medicine was made illegal by the US Government for moral not medical reasons. Now the doctor prescribing to many patients with pain automatically becomes a “pill mill”and soon see lights flashing outside the practice.

Doctors in 1915 quite prescribing all opiate relief of pain after the newly formed federal narcotics police illegally arrested then for treating addicts now call ed Medically Assisted Treatments (MAT).

There is a growing list of people denied pain medicine for no medical reason other than the “CDC told me to do it”, and also “the DEA will close my practice”.

Physicians for Responsible Opioid Prescribing, the group espousing the unproven dangers of routine physician prescribing of pain medicine, believes people should learn “to accept” pain and “move on with their lives”. This is not a position shared by other countries, by the United Nations’ policies of treatment of all pain, nor views of experienced primary care clinicians Denying pain exists and therefore does not need the centuries old opiates is a philosophy not held by any physician I have known, and certainly not by me.

Only a small fraction of people will every addict ( in spite of “way too much opioid prescribing” the per capita addiction rate is holding steady at 0.5% as it has for 100 years) We are punishing 99.5% of Americans with acute or chronic pain who will never become addicted.

To reverse this epidemic of ignorance and fear three areas need to be addressed to stop to the Opioid Refugee Crisis:

The CDC: recommendations

The guidelines need to be recalled immediately as harm is present and evident, until the illegal attempts at federal medical practice revisions [42 USC 1395] are scientifically verified outside the structure of the CDC and its anti-pain consultants, including the three “authors” of the federal government guidelines for medical practice who have publicly written, or spoken favoring pain and pain medicine denial. None of the 12 guidelines has been proven, has any support from the medical literature, the most dangerous provisions were disproven prior to publication of these flawed restrictions on pain medicine (only opiate medicines work for pain)

The Continuing Medical Education for healthcare workers must stop immediately as all continuing as the online courses contain with biased, unscientific, unproven and harmful tenants of less pain control which are already leading to suicides and the potentially millions of people suffering the agony of untreated daily severe pain.

CDC must follow the recommendations of the Scientific Counselors review of January 2016, recommending follow up for any unintended consequences which now would include numbers of people without proper medical care for their painful disease states

If CDC or PROP wishes to promulgate policy denying pain and denying pain treatment, they are required by all science guidelines to conduct a study showing their non-mainstream ideas are valid. This has yet to be done. Until studies support this unusual unproven recommendations and in many cases disproven, the tenants of the new ideas of not treating pain are far too dangerous to leave in place, even another month.

The DEA - recommendations:

Stop all raids on doctors offices conducted without probable cause and substitute requests for records with letters.

Set up internet communication with all licensees to make public heretofore unknown information concerning secret computer searches looking for physician “outliers”. Provide explanations for what federal crimes there are and the what crimes are not there. Explain whether having “too many pain patients” or “prescribing too much” or “prescribing more than the CDC allowance” or “should have known you were prescribing to an abuser” are federal crimes.

Begin to work directly with the addiction community to develop point of service spot tests for fentanyl contamination and spot tests for diamorphine (Heroin) purity. Perhaps with some immunity for possession only, work with the addiction community to track down the very dangerous fentanyl being manufactured and distributed by the cartels.


The Doctor, HHS, and CMS Plan: recommendations

Physicians will not respond the new Opioid Refugee Crisis without new financial incentives . We suggest a temporary CMS allowance for maximum billing codes to create a new “Certificate of Medical Pain Disease”. This would be an hour long intensive history and physical to establish and certify the need for long term medical pain medication and why. Once done this certificate can be presented to other doctors, pharmacies (where refusal to fill valid prescriptions has already lead to suicides), insurance companies, benefit managers, hospital ER’s, hospital surgical services, Medicaid, and Medicare, that a valid need exists and to honor physician prescribed pain medication at any dosage level, as established in the comprehensive evaluation for the “Certificate”

CMS and NIH funding for factual healthcare educational programs outside the CDC/PROP unsupported and dangerous teachings

Begin public health education for families and for junior and high school students to stop addictions where 90% of them start, due to the opiate naive population being subjected to their first and possibly addiction triggering dose. Although rare, 4/1000 each person snatched from the jaws of addiction can lead a normal life with this genetic disease.

Begin public health outreach to those with addiction disease to help avoid death from apnea and suffocation thee presumed focus of the “epidemic” using of naloxone, $20 bag and masks, encouragement of a“wing man” system, anonymous websites for call in advice from public health nurses, physicians, pharmacists and other “sober” addicted people, and Public health nurses going out in the addiction community to offer face to face service.

Prepared by Thomas F. Kline, MD, PhD

Chronic Diseases, Raleigh NC (ret)

October 2017

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