OREGON | THE DEATH OF COMPASSION IN THE SANCTUARY STATE
THE DEADLY STRUCTURE OF OREGON PAIN CARE
The opioid crisis has resulted in a broad range hysteria surrounding opioid prescribing in the United States. As a result, an aversion to opioid medication developed widely as legislators sought to address the overdose epidemic.
These reform policies have had minimal bearing on decreasing overdoses, yet they have led to the development of a new population of victims by targeting pain patients. Under the guise of an attempted attack on overprescribing, the nation has begun a new initiative in healthcare that has led to the tragic climate of under treating pain.
Although the national initiatives have proven harmful enough to those suffering from incurable and intractable pain, the states are left to make further decisions that limit access to opioids for patients and restrict the prescribing power of clinicians.
However, one state in particular resides on the brink of the most extreme anti-opioid policy to date. Oregon has proposed a policy that has left some of the nation’s leading experts wondering how such a grievous stratagem could even be considered.
The state of Oregon has an uncommon structure and brief mention of the organization of bureaus will be herein mentioned for reference. The Oregon Health Authority (OHA) serves as the primary governing body. The Health Evidence Review Commission (HERC) is a branch of the Oregon Health Authority that governs three subcommittees that control decision making for Medicaid. One of the three subcommittees is the Value Based Benefits Subcommittee (VbBs) which then parents the Chronic Pain Task Force. The Task Force serves as an ad hoc derived from the Latin word meaning “for this,” and does not stand as a permanent fixture in Oregon policy making.
Oregon is unique in a multitude of ways, making it prime territory for the creation of a devastating social experiment. One aspect central to Oregon’s anomalous structure is the 1115 Medicaid Demonstration Waiver. According to Oregon.gov, “An 1115 Waiver allows states to conduct demonstration projects outside of some of the parameters of their approved state plans. Under 1115 authority, a state may obtain approval for experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHIP programs.” The background information continues to explain that an 1115 Waiver allows the state to, “Test new approaches to paying for and delivering Medicaid-funded services; and test new approaches to defining and limiting benefit packages.” The 1115 Waiver allows for governmental discretion regarding covered conditions, making this an experiment derived of opportunity rather than concern for care.
While this explanation may not be the cause of immediate concern to some readers, it is alarming to see how it can be applied when interpretation is left to the bias of discretion. It is important to note that Oregon is not the only state with an 1115 Waiver, yet they seem to be the only state exploiting it to impose a dangerous ideology.
Oregon is implementing a sweeping removal of prescription opioids at a statewide level, and this reform began with Medicaid patients who are known to be the most marginalized population as they are exceedingly vulnerable with the most limited access to resources.
To initiate the statewide shift, Medicaid patients suffering from preexisting pain conditions were then classified into two categories, the Back and Spine and Chronic Pain. These categories were then broken into phases to implement forced taper policies.
The Back and Spine Line of 2016 contained an addendum referred to as Note 60 which expressly detailed the involuntary taper guidelines for patients suffering from conditions of the back and spine. The particular Line had a series of unwritten exemptions leaving it slightly more dignified in existence then its future counterpart. These exemptions, while unadvertised, allowed clinicians with the rare knowledge of their existence, to retain some semblance of individualized medicine in regard to their prescribing power. It is important to note that the physicians that utilized loopholes to preserve patient safety operated against the grain of their field.
Next, the Chronic Pain Task Force founded in September of 2017 moved to implement phase two. Perhaps most disturbing was that they chose to do so without any collection of data relevant to phase one. As a result, they had no knowledge of patient outcomes pertaining to those affected by the removal of opioids for the Back and Spine line. The changes between the two phases were clear, the subsequent stage would now apply to any and all pain conditions and would eliminate any exemptions that would have secured patient access to analgesics. Such drastic actions left some wondering if phase one had only been a means of beta testing how to prevent patients from maintaining their access to pain relief in its entirety.
For reference, the “line” is a fundamental term in regard to the Oregon Health Plan and is considered the marker for coverage. Covered conditions fall above the coverage line while uncovered conditions fall below, and this terminology is often confusing to onlookers attempting to decipher the proposal.
The truth is that Medicaid patients on the Oregon Health Plan with uncovered conditions had been receiving prescribed and medically necessary opioid therapy as adequate pain care without incident. However, the Task Force planned to move “chronic pain, chronic pain syndrome, chronic pain due to trauma, chronic postprocedural pain, and fibromyalgia” above the line in the interest of analgesic reduction and a statewide push towards alternative modalities that lacked any real evidence of efficacy.
Alternative medicine had garnered significant support in the state of Oregon in recent years. It had been lobbied extensively as a desired modality in medicine. However, Oregonians had not realized they were fighting for the avenue that would eventually be explored as the cause of their healthcare demise. They fought for the right to additional medicinal access, not a means of limiting their existing treatment plans. Instead, once they won the right to alternative means, they began to lose their right to traditional medicine.
The overwhelming anti-opioid bias was immediately evident in the first of the Chronic Pain Task Force meeting materials. According to the Task Force Charge, “Patients with persistent/complex/central pain should not be treated with long term opioid medications. If patients cannot be tapered off such medication, they are eligible for services for treatment for dependence on opioid medications.” This charge is a devastating summation of the undeniably biased intentions residing in the task force.
The foundation of the proposal was to eliminate opioids for the treatment of chronic and intractable pain, and that was unmistakable in their choice of wording. Persistent, complex, and central are words that could be used to broadly describe all chronic and intractable pain syndromes, disorders, diseases, and injuries. The use of a generic word without an expressive definition is dangerous when used in medicine as it ignores the individualized presentation of symptoms.
It is made clear that an inability to taper will be classified as addiction, which proves to be an eternally haunting term in the medical record of a patient suffering from severe intractable pain. The charge refuses to acknowledge the existence of patients without alternative treatment options, and therefore rejects the lives of patients who have been stabilized as a result of opioids alone. To classify medical stabilization as addiction is negligent and dangerous to patients who have exhausted all alternative treatment options without success. It is also important to note that inability to taper is in no way indicative of addiction and to insinuate otherwise is the result of purely deliberate stigmatization.
Furthermore, in those same materials, they included opioids under the heading of “What does not work.” This statement was both unfounded and unwarranted, yet it served as the basis for the creation of the task force. To start with such biased infrastructure indicated that the proposal was rather condemnation in the form of policy.
The Task Force remains of great concern to patients and experts alike as it lacks the necessary professionalism to make informed decisions. Instead, seats are filled by those seeking enrichment of their own respective industries in the pursuit of monetary gain. Decisions for pain care are being made by acupuncturists, physical therapists, naturopaths, and family practice physicians, suggesting that the only necessary credentials for participation were skewed ideologies and a tendency towards participation in groupthink above compassionate medical care. A brief investigation into members reveals disturbing details of ulterior agendas. All have significant interest in the discontinuation of analgesic therapies.
For example, Kevin Cuccaro can be quoted saying he doesn’t “believe” in pain treatment of any kind. This statement underscores the very problem of a dogmatic task force, medicine should never be based in belief, but rather driven by fact in the pursuit of the Hippocratic Oath.
Cuccaro operates under the idea that pain is “constructed,” and claims he has the “’secret’ (actually science) of how to get better” with the help of his pain triangle for $14.99. To begin patient care with the assumption that pain is fabricated is immediately reductive and rejects the presence of a legitimate condition worthy of treatment. The public then must question how someone who renounces the validity of pain can be in charge of determining statewide access to analgesics.
Cuccaro is now regarded by patients as the source of a very public outburst at the September meeting. His statements were inflammatory and diminishing as he aggressively addressed the audience to say, “How many of you love taking opioids? How many enjoy taking these drugs?”
Patients immediately questioned how a man with such antipathy towards patients being treated with analgesics could serve as a seated member on a task force that would ultimately determine their fate. However, Cuccaro’s bad behavior and egregious outburst resulted in his rapid promotion inside the Health Evidence Review Commission, which stands to imply that such poor public conduct on a governing body is in fact rewarded rather than sanctioned.
This ideology is the incongruous norm across the Chronic Pain Task Force, and Cuccaro is not alone is his adverse belief toward opioids and those that benefit from them.
Nora Stern is also remissive in her beliefs surrounding pain. As a physical therapist, she lacks the concrete understanding of medicine and yet speaks with a self-appointed expert perspective. Stern has been appointed to positions that influence public health policies despite being severely under qualified to serve. She makes broad and inflammatory generalizations regardless of irrefutable evidence to the contrary and lacks any real healthcare experience in the multifaceted realm of medicine. As a result, the population she serves questions how a physical therapist has been entrusted with critical decisions regarding pain care.
Stern’s own industry stands to benefit widely from the removal of analgesics in pain care. By removing the primary effective treatment for pain and replacing it with a modality without any proven success
with chronic pain, physical therapists will be able to create an industry that can constantly claim to treat but can never effectively manage.
Ariel Smits, MD demonstrates the danger of monopolizing positions of power in government. She is the Medical Director for the Health Evidence Review Commission (HERC) and leads both the Chronic Pain Task Force and Value Based Benefits Subcommittee. Smits has managed to infiltrate all levels of balances between committees and therefore is competent enough to distort specific language to pass proposals serving of her own personal agendas. She is often heard citing the existence of evidence regardless of her knowledge to the contrary. Her bias is immediately evident in a brief examination of her verbal testimony as she is consistently dismissive in regard to patient and expert testimony disproving of forced tapers.
Amber Rose Dullea is an alleged plant inside the Task Force. Dullea is said to be the patient representative seated on the Chronic Pain Task Force and Oregon Pain Management Commission, yet her actions have consistently disproved any self-proclaimed attachment to the patient population. At the very least, she severely misrepresents the intractable pain population and is therefore incompetent of providing benefit to Oregon as a seated member. As a strong supporter of holistic medicine and proponent of mindfulness she falsely represents the position of balanced patient advocates and their role in protecting patient care. Dullea is a pain coach and author who speaks on the mindful component of pain management. Therefore, she stands to benefit significantly from a general and statewide shift away from opioids. It would be fair to assume the personal benefits she would receive as the result of a correlation between the increased sense of hopelessness resulting from loss of medication and an increased demand for pain coaching.
Dullea also serves as a recycled patient representative to set forth an image of diversity. Her presence seems to serve as a surreptitious and intentional means of refuting any criticism for lack of patient input while maintaining their path of no resistance.
Laura Ocker is an acupuncturist serving on the Task Force. She has been instrumental in falsely securing acupuncture as a covered and effective alternative for the treatment of pain. Her life’s work has consisted of legitimizing her chosen industry as the medicinal equivalent of western medicine. Ocker also serves as a lobbyist for acupuncture, grounds that most would consider immediate disqualification for participation in statewide policy creation.
Verne Saboe is another lobbyist for the furtherance of alternative medicine specifically in the realm of chiropractic, and while he does not serve on the Chronic Pain Task Force, he does serve as a member of the Value Based Benefit Subcommittee. Saboe is allegedly a close friend of Governor Kate Brown and was directly responsible for the insertion of nondiscrimination provisions into House Bill 2468. These provisions allowed for the inclusion of alternative medicine into the Oregon Health Plan. In the words of the Gazette Times the provisions will ensure that, “health insurance companies and health plans cannot discriminate against providers such as chiropractors, naturopaths, licensed acupuncturists, licensed massage therapists, doctors of oriental medicine, etc.” The use of such an inflammatory target word seems to be an intentional attempt to disguise the true agenda of a planned enrichment of unproven industries. To meet discriminatory requirements there must be a clear parallel in value, and while some may find great benefit in alternative medicine the truth is that there is no scientific data or factual evidence to support the claim of equality between the two.
Katrina Hedberg MD is the architect for the vision of an anti-opioid utopia in Oregon. As the State Epidemiologist, her biased interpretation of research and patterns could result in falsely driven action that could prove devastating to particular populations. Epidemiologists are often tasked with alerting the public of threats, and therefore have the power to negatively sway legislative action to suit their own personal agendas.
Hedberg has been with the Oregon Health Authority for twenty years. Over that time, she has sat and continues to sit on many of the opioid related bureaus in the State of Oregon. Currently she is serving as the State Epidemiologist, State Health Officer, she is seated on the Governor’s Opioid Epidemic Task Force, the Prescription Drug Monitoring Program Advisory Board, the Oregon Health Authority Opioid Initiative Project, and the 2018 leader of the Acute Pain Guidelines Workgroup. In the past, she also held the leadership position of the 2016 CDC Oregon Opioid Prescribing Guidelines Task Force.
Hedberg was one of the key players involved in implementing “Death with Dignity.” This particular form of an assisted suicide bill stands as the rarest in the nation. With the public knowledge of the Chronic Pain Task Force, many are wondering why Oregon is agreeable to funding death with the use of deadly barbiturates; however, they are not willing to fund the life of Oregonians suffering from intractable pain syndromes. This fact leaves many wondering if the primary benefit of the bill is the elimination of high utilizers.
In the allegedly normal Oregonian fashion, there is no measure of patient outcomes. The barbiturates are delivered and there is no mandate to report the result. Similarly, it is ironic that she trusts doctors to make a decision on death in accordance with guidelines, but she does not trust a compassionate doctor to sustain life. Essentially, without opioids to treat the severity of incessant intractable pain, suicide will seem like a clear choice to many. Although Hedberg often refuses to acknowledge criticism of the policy name, patient protestors have continuously repeated the rawest of mantras, “we want to live with dignity, not die with it.”
It’s terrifying to consider that a single individual can restrict access to lifesaving analgesics while deliberately increasing access to deadly medications. The public is left to question how a woman crusading for an eradication of opioids for patients with non-cancer pain is also lobbying for the accelerated path to death.
Mark Altenhofen is the newest HERC staff hire as the Pain Management Coordinator. In addition, he also serves as the Communications Specialist for the Oregon Pain Management Commission, as well as the Palliative Care Council Coordinator. While he does not serve as a seated member of the Chronic Pain Task Force he is largely involved as the responsible member for correspondence with external concerned parties. However, he is known for his refusal to participate in critical communication with public stakeholders despite being the only contact listed by the Oregon Health Authority. His interconnection and multiplicity of positions is a clear conflict of interest and compromises the integrity of each individual position respectively.
As the liable party for the intake of public questions and dissemination of public information to seated members of the Authority, his failure to communicate is alarming to Oregonians attempting to remediate public policy.
In addition, Altenhofen is the Founder of the Pain School and CEO of Pain Advisors. Interestingly enough, the Pain School was the recipient of a $65,000.00 grant awarded by the Eastern Oregon Coordinated
Care Organization. The public questions how Altenhofen can stand to benefit from his role as a government agent while pursuing personal gains in private industry of the same category.
Oregon is home to one of the most destructive organizations for analgesics, Oregon Pain Guidance, and it was founded by two people malevolent to pain care. According to the Oregon Pain Guidance website, “The goal of OPG group is to decrease the morbidity and mortality associated with the inappropriate use of opiates AND shift the focus to non-opiate treatments for complex chronic pain so that patients experience an overall improvement in well-being.”
Jim Shames MD and Laura Heesacker are the manifestation of anti-opioid zealotry and radical animosity towards analgesics. Together, they have infiltrated all realms of compassionate pain care with harmful intent. Even worse is that they operate as a self-appointed government agency with the help of their evangelical colleagues. Their careers have been largely focused around the elimination of opioids.
Jim Shames MD is a member of the Chronic Pain Task Force and currently serves as the Medical Director and Health Officer for Jackson County. He is Board Certified in both Family Medicine and Addiction Medicine, which allegedly serves as a clear predisposed bias to the interpretation of chronic pain. As a founder of Oregon Pain Guidance, the public finds it to be of grave concern that Shames serves as a consultant to both the Oregon Health Authority and the Oregon Medical Board. Shames has made no attempt to hide the depths of his radical vision towards the eradication of opioids for the treatment of intractable pain on a statewide level.
Laura Heesacker is a licensed Social Worker and Behavioral Health Integration Specialist for Jackson County. She is known for her alleged beratement of intractable pain patients and accused of intimidating clinicians. Heesacker has been said to bully patients and providers into forced tapers through the use of menacing threats. Countless complaints submitted to the Oregon Health Authority and Oregon Medical Board have gone unanswered and ignored. Perhaps most shocking is her paid government positions as a consultant to the Center for Disease Control and Oregon Health Authority. The public maintains that the presence of such bias should be grounds for immediate dismissal in both.
Oregon is allegedly infamous for organizations that perform harmful work towards pain care in direct conflict of what is otherwise a seemingly positive mission statement. In the interest of brevity, a minimum number of examples will be used. Lines for Life is said to be a nonprofit suicide hotline dedicated to decreasing the risk of overdose. The CEO is Dwight Holton, a well-known opioid zealot with a very public history of blatant disregard towards pain patients.
Oregon Pain Guidance shares a similar abhorrence towards the treatment of pain, and it is not an accidental happening that they are a partner of the Oregon Coalition for Responsible Use of Meds. Perhaps even more interesting is that the Oregon Coalition for the Responsible Use of Meds is a Lines for Life service who shares a partnership with the Oregon Health Authority. Again, we are able to see a disastrous interconnection that could potentially influence governmental bodies with the ideology of private industry, leaving the public to wonder how such a hostile takeover of once legitimate bureaus has managed to survive without formal investigation.
Paul Cohelo MD is a current advisor on the Prescription Drug Monitoring Program Advisory Commission and former member of the Oregon Pain Management Commission. He is the Medical Director of the Salem Health Pain Clinic and a practicing Pain Physician who can be quoted as saying, “Our goal is to reduce dependency through a holistic health approach.”
Cohelo’s ideology directly mirrors that of the Chronic Pain Task Force with his unfounded vision of a holistic takeover of pain care. A brief read of his online reviews tells the story of an alleged monster, and there is no way to gauge his power in policy or the harms to patients he has infinitely caused. He ultimately enforces his thinking on to others and makes no attempts to hide his radical disposition towards opioid tapering.
Cohelo is an anti-opioid zealot disguised as a practicing pain doctor and it is evident in his own words, “We are hopeful that this educational outreach effort-in addition to the PDMP-will provide a targeted approach for prescribers who are outliers from their peers.”
This planned intimidation of clinicians is at the heart of the widespread reluctance to treat pain regardless of the moral obligation felt by providers. Ultimately, Cohelo rejects any colleague that lacks his anti-opioid stance on prescribing.
Armed with the knowledge of interconnection of the like-minded in Oregon health policy it is not difficult to imagine the creation of a disturbing proposal of devastating proportions.
The original proposal of the Chronic Pain Task Force was far beyond the most extreme in the nation. It was dehumanizing in its rejection of human suffering and refused to acknowledge the legitimacy of chronic and intractable pain. The Oregon Health Authority received an overwhelming amount of public comment and testimony informing seated members of the cruel and unusual nature of the proposal. Analgesics are the only means of maintaining functionality and quality of life for many chronic pain patients, and yet the proposal takes a paternalistic approach to a harmful takeover of patient stabilization.
The proposal is only in consideration of the Oregon Health Plan at this time, although its abundantly clear that this is the test group for a statewide initiative. It is common knowledge that most covered under Medicaid have limited access to resources, therefore raising concerns on destabilizing patients without the means to restore fair treatment. In fact, according to the Oregon Health Authority “Suicide is more common in rural and frontier areas, among LGBTQ identified youth, and among people with a disability,” leaving the public to question why the disabled population of Medicaid would appear a fair target for experimentation purposes. Unfortunately, the Task Force ignites a preexisting marginalization by targeting the internal population of pain patients who lack access to the tools needed to advocate for their own care.
A thirteen-member task force had operated in secrecy without any public announcement regarding large scale radical reform from the Health Evidence Review Commission. As a result, the proposal was developed and discussed without even general knowledge of its existence. Transparency would have facilitated public awareness, involvement, and valuable input at the public meetings and yet it was avoided in an effort to prevent opposition. Once discovered, the Chronic Pain Task Force was opened solely as a means of implementing a predetermined proposal. Subsequent meetings were publicly accessible to provide a falsified sense of comfort to Oregonians who were made to believe their voices had a say in developing policy.
Fortunately, determined advocates launched a thorough investigation in which they were able to uncover the creation and assignment of the Task Force in an effort to make it a matter of public knowledge. However, the proposal was not discovered until the last meeting of the Chronic Pain Task
Force in June of 2018 which presented the obstacle of time. Any opportunity for rebuttal had passed which further complicated the need for communication and acknowledgement of the issues.
The newfound knowledge of the proposal sparked public, patient, and expert outrage, and it was immediately obvious that the Task Force had intentionally hidden a policy that would have destabilized the most vulnerable pain patients in a sweep of statewide proportions. The secrecy associated with the proposal further magnified the questionable ethics of seated members and emphasized express knowledge of the poor-quality evidence and cruel intentions hidden within the policy.
Advocates immediately began to prepare the thorough presentation of their arguments. Unfortunately, most correspondence was derailed as emails went unanswered, phone calls were ignored, and documents never reached their intended destinations. Failure to reply seemed largely influenced by the bureau questions were submitted to. For example, although direct technical questions presented to the Health Evidence Review Commission were acknowledged, any mention of bias presented to the Oregon Health Authority and Oregon Pain Management Commission were either stonewalled or ignored. Additionally, national experts submitted multiple open letters and were met with a grave indifference to the attempt to inform and enrich policy making in Oregon.
It is crucial to discuss the multiple drafts of the proposal and the adjustments made by the Chronic Pain Task Force overtime in order to adequately understand the scope of the predicament facing advocates.
The initial proposal began with the most draconian of conditions in a way that was arguably punitive to pain patients. The central theme was forced tapers for patients on long term opioid prescriptions regardless of medical necessity. This alone was dehumanizing as it rejected the concept of medical stabilization and severely violated the doctor patient relationships that are central to appropriate medical care. The original proposal abandoned all individuality in regard to patient presentation and suggested the widespread removal of opioids for those on Medicaid. The concept of forced tapers to zero within one year proved to be the most extreme recommendation nationwide. These supposed guidelines violated even the standard of care set forth by the CDC Guidelines, recommendations that have been severely questioned since their creation in 2016.
Additionally, the proposal forbids the concurrent use of benzodiazepines, meaning that patients stabilized on a combination of both were left with the choice of which presented a more valued efficacy. Again, the Task Force refused to acknowledge the concept of an individualized care plan that potentially depended on the combination of multiple controlled medications.
Another area of grave concern was the use of “centralized pain syndrome,” a term that seemed deliberately ambiguous in an attempt to discontinue opioids without question. Centralized pain syndrome is a term that by definition is undefinable, and its presence in literature suggests it is diagnostically synonymous with chronic pain.
Advocates immediately began formulating measures that would highlight the lack of evidence and potential for harms. National experts promptly began building a rebuttal towards the negligence and intentional deceit buried deep within the policy. Written testimony, public comment, open letters, and evidence reviews were sent daily to the Oregon officials and continuously fell on deaf ears. It was obvious that these meetings were a rubber stamp of sorts, meant solely to give the illusion of a transparent body.
The lack of acknowledgement and failure to communicate resulted in a powerful rally of advocacy efforts that eventually garnered the attention of leading experts. One of the most highly respected experts on pain psychology, Dr. Beth Darnall of Stanford University, immediately traveled to Oregon to testify on the obvious wrongdoings being committed without warrant.
Dr. Darnall addressed the task force with both a powerful and factual presentation on the potential for harms surrounding forced tapers. With a patient centered focus, she was able to cite the lack of evidence as cause for grave concern. She warned the task force of the dangers associated with destabilization while offering an in-person rebuttal of nonsensical belief. Darnall was able to voice the flaws of the proposal and seemed to destroy the arguments of the Task Force with an exquisite distribution of fact. She stressed the absence of patient outcomes and advised against the devastation that could result from negligent policy.
Dr. Darnall even went so far as to offer her tapering study to the state of Oregon and additionally offered to waive the cost of her time. She framed it as an opportunity for the Task Force to gather their own data to assist in making informed decisions. Her offer was unprecedented in policy creation and was ultimately denied without even the slightest of consideration. To refuse a brilliant academic was a clear testament to their purposeful avoidance of necessary evidence.
Within months, Sean Mackey MD, one of the most prestigious experts and scholars in pain care and fibromyalgia had written an open letter with esteemed cosignatories. His letter detailed the many flaws of the proposal with an extensive breakdown and thorough critique. His main points included the lack of evidence, the problems with centralized pain syndrome, and “The Task Force embraces a state- mandated treatment change that contravenes the major national and international on prescribing opioids for chronic pain.”
The American Society of Anesthesiologists also submitted a powerful statement outlining the potential for harms that could result from Task Force negligence. Much of their submitted document echoed the pleas of advocates, for example, “Patient care should be the utmost priority when treating chronic pain. The treatment plan and modality should be up to the individual physician and the patient after jointly discussing options, weighing benefits and risks, as well as expectations.”
They seemed to serve as the voice of reason amidst the blatant ideology hidden inside the proposal, “Pain medicine specialists manage a unique and complicated subset of patients and can decide when tapering is necessary for the patients. ASA is concerned this policy goes too far for some chronic pain patients.”
The ASA reiterated the necessity for individuality in patient centered care. They also warned against patient destabilization after years of symptom management. “Opioids can be high-risk medications but a blanket policy that bans an entire class of medications for certain patients, even if they are already well- managed on chronic opioids, is inappropriate.”
Oregon Medical Association wrote perhaps the most powerful statement as a result of their direct knowledge and involvement. Regardless of their own interest in decreasing prescribing numbers they are abundantly clear in detailing their fears pertaining to the proposal. They mention the true aggressors influencing the overdose epidemic before briefly touching on the need to maintain access to all available elements for the treatment of intractable pain, “the opioid epidemic now is being fueled by heroin and illicit fentanyl overdoses, and we are acutely aware that patients with pain often have extreme difficulty accessing comprehensive, multimodal pain care, including non-opioid pain care alternatives. Ensuring access to this care is one of the main recommendations of the AMA Opioid Task Force — a multistate, multispecialty group of which the OMA is a proud member.”
To know that the Task Force didn’t abandon the policy altogether after the criticism of such reputable and esteemed organizations was staggering to those involved. Consequently, many were left to question if any other state in the nation would have carried such blatant disregard to their own medical association and valued expert testimony.
The Task Force refused to acknowledge any written warnings surrounding the advancement of the proposal, regardless of the source. However, Dr. Darnall’s in person presentation seemed to make a lasting impression which sparked the first revision of the proposal.
The second draft had eliminated some of the target words that she had strongly advised against. The new edition no longer included the one-year limit of the taper. All patients were now expected to taper below fifty morphine milligram equivalent (MME), and below ninety MME in the most extenuating of circumstances. The proposal no longer said patients “must” get to zero, but it did claim they “should.”
Unfortunately, this revision was evident of the alleged depths of deceit practiced within the Oregon Health Authority, the highest governing body of the ad hoc Chronic Pain Task Force. While the revision included words that seemed immediately comforting, it was obvious upon further inspection that the dogmatic terms had remained, but now buried beneath the guise of more compassionate language. Dana Hargunani, Chief Medical Officer of the Oregon Health Authority was present at the meeting centered around discussion of the revisal. It is unheard of for such a high-ranking member of the Authority to be present at an ad hoc meeting, but her opening testimony quickly revealed the reason for her presence. She gave a flowery presentation, stressing the concern for individualized medicine and looked at attendants while claiming, “we as staff have truly been listening.” Essentially, she was the representative tasked with distraction, she said what wanted to be heard while furthering the proposal that patients desperately feared. It seemed the Oregon Health Authority knew one truth; the lack of evidence was not a fact that would soon be forgotten.
It was overwhelmingly clear that the superficial wording edits hadn’t changed the main thrust of the earlier proposal. The only difference now seemed to be the number of people analyzing the radical document. In fact, the task force hired private contractors to perform an external evidence review. The findings echoed the arguments of patient advocates, and yet were ignored with the blatant disregard of critical warnings.
The final and most recent revision of the proposal was released without announcement in the materials published for the Value Based Benefits Subcommittee meeting scheduled for January 17, 2019. These changes were largely unexpected, leaving some to question the motives behind the failure to announce what would likely be received as favorable revisions to a draconian policy.
For reference, the Health Evidence Review Commission is responsible for reviewing the evidence on which a proposal is based. It is interesting to note that the meeting materials refer to “HERC Staff Revisions” rather than those of the Chronic Pain Task Force. Advocates and experts had made multiple appeals to the Task Force based on the absence of evidence alone, leaving most to wonder why such pleas were largely ignored until the review of the HERC. Perhaps even more interesting is that this kind of interjection into an ad hoc task force is unprecedented by the Health Evidence Review Commission.
Although the revision appears slightly improved, it is important to acknowledge what it is and what it is not. Ultimately, the proposal still demands a taper plan which violates the individual presentation of pain and necessity for compassionate care. Additionally, the revisions continue to enact arbitrary thresholds below the national standard of care without cause.
Centralized pain syndrome has been altogether eliminated as a guideline for its “lack of accepted definition.” The public must question why the Health Evidence Review Commission has now recognized the undefinable nature of the term after months of criticism from experts and despite the pleas of the patient population.
However, fibromyalgia has remained reduced and diminished by the proposal. The Task Force has continued to claim evidence of harm in fibromyalgia patients in the presence of opioids although such statements are unfounded by evidence or clinical observation. Despite reputable studies citing the benefits of Tramadol to manage fibromyalgia symptoms, all opioids have been determined inimical.
Additionally, the guideline concerning flares remains active in the revised edition. The Task force maintains their position on refusing the treatment of flares for fear of potentially escalating the dose. Escalation can be necessary to worsening conditions and imperative to the stabilization of patient care. Furthermore, brief increases without permanence has been a successful and accepted common practice for the treatment of flares across all divisions of medicine. Finally, a clinician is the only one qualified to make a decision on the increase, decrease, or discontinuation of analgesics and the proposal eliminates this necessity to patient care in its entirety.
Critics are also conscious of a new, and dangerous word that has now been included in the proposal. The concept of “unidirectional” has been introduced in reference to tapers. Although the definition was previously implied, its frequency is concerning to experts. We can see the presence of “paused,” and “slowed,” but there is no mention of “stopped,” or “reversed.” Such words as the latter are imperative to the patient doctor relationship and the only means of preventing the devastation of destabilizing previously managed patient care.
It is necessary to acknowledge the Health Evidence Review Commission for their role in eradicating some of the most dangerous language throughout the Chronic Pain Task Force Proposal. While the public rejects any policy that will implement forced tapers, they also respect the partial removal of the criticized language. Furthermore, advocates commend the HERC for their refusal to participate in the same biased behavior as the Task Force.
At this point, the four chronic pain lines of “chronic pain syndrome, chronic pain due to trauma, other chronic postprocedural pain, and other chronic pain” have been relinquished from the task force criteria as conditions deemed necessary of forcible tapers. As a result, if the revised proposal is voted in as it currently stands, these chronic pain conditions will have access to opioid medication up to 90 MME per day.
However, what seemed like a positive outcome for advocates working tirelessly against the Task Force was in reality a well-constructed disguise of devastating updates to the aforementioned Back and Spine Line. Further examination of the released revisions showed that edits to the Back and Spine Line had been “riders” of sorts to the Chronic Pain Proposal. While critics had been consumed with disproving the claims of the Chronic Pain Task Force, seated members had been altering the policy patients had accepted as previously completed. Suddenly, it seemed the Task Force had employed a purposeful series of distractions to sway public attention in an alternate direction.
Perhaps even worse was that they released the first new mention of the Back and Spine Line simultaneously with an illusory win in relation to the chronic pain conditions. It seemed to be a certain means of circumventing any and all questions relating to changes of the Back and Spine Line. Public knowledge of updates would have allowed time for exploration, analyzation, and expert protest.
Once the updates had been effectively translated to uncover the true agenda for the Back and Spine Line, it was clear that the unwritten exemptions that once existed for the preservation of patients were being eliminated. In other words, devastation is in store for far more patients than was perceived just days before the release of the latest revisions. Back, spine, and neck patients who had previously maintained their access to opioid medication through written exemption from their clinician will no longer qualify for even the smallest dose.
This only reinforced the deceptiveness of the Task Force, as it proved the lengths of duplicity being practiced within the Oregon Health Authority. The Task Force had been busy making devastating alterations to the Back and Spine Line while expert attention was focused otherwise. Back and spine patients weren’t even aware that their care was still up for discussion, and now they are headed for certain destabilization. This effectively signaled the beginning of yet another obstacle for advocates fighting against draconian policy in Oregon as it proved that no obstacle is ever precisely as it seems.
One of the most deceitful statements being repeated by the Task Force is that they aren’t taking anything away. This is insulting to both patient and public intelligence as Medicaid patients are learning they will no longer qualify for access to opioids under the newly founded guidelines against the advisement of national experts. They have consistently claimed to be increasing coverage, yet Medicaid patients are losing coverage of their only successful option after exhausting all alternative methods. Perhaps most disturbing is that they have continued to make false statements regardless of public knowledge to the contrary with no fear of consequences or public backlash.
It is equally disturbing to see the Task Force’s systematic removal of the exemptions meant to protect patients from harm. Palliative care has been safe haven terminology for pain patients amidst the current opioid climate in instances where allowed. Although there is not a universally accepted definition, there are many similar interpretations nationwide. Palliative care refers to serious illness and is therefore intended to protect the care of patients from policy that could prove harmful. Chronic disease patients are ultimately the outliers of medicine, and this language therefore recognizes that these patients are meant to be the exception to the rule as they do not fall under acute presentation or carry the possibility of symptom resolution. Palliative care is a term that doctors can use at their discretion to ultimately label the most serious cases in medicine. To remove lifesaving terminology from clinical power is negligent as it eliminates a means of protection for those that could not withstand the consequences of harm.
The public has been left to question why the Chronic Pain Task Force would eliminate the exemptions that could protect the most compromised patients from potentially fatal destabilization. Although there may not be a ubiquitous definition, there is a widely accepted acknowledgement of what it is not. Palliative care was never meant to refer solely to life threatening, it was meant to refer to life limiting. Instead, the HERC has evidently tailored the definition to suit their own agenda. The Oregon state legislator defines palliative care as, “’serious illness’ means any illness, physical injury or condition that substantially impairs a patient’s quality of life for more than a short period of time.” Ironically, this is a thorough and balanced definition that should be utilized but the Health Evidence Review Commission abandoned the definition and once again took extreme unprecedented liberties by changing the language to “life threatening.” Sadly, the HERC further restricted Medicaid patients from utilizing palliative care protections.
The Chronic Pain Task Force cannot seem to differentiate between their responsibility in policy and an abuse of authority. Regardless of their incessant statements referencing guidelines, it is overwhelmingly obvious that the points of the proposal are in fact rules. Additionally, Medicaid is only intended to control the payor, it is never meant to be the governing body to control prescribing. While the Health Evidence Review Commission could argue their refusal to pay, they are not meant to influence prescribing under any circumstances.
We have a false perception as Americans that there is always a protective body, and yet Oregon has eliminated any and all hopes of a savior by an altogether elimination of oversight. There is no accountability for a conscious infliction of harm to those they serve, while bias, conflict of interest, belief, and ideology are common additives in the creation of policy without consequence. It is acceptable for legislators to seek the enrichment of their own industries at the expense of patient care and there is no oversight committee intended to protect Oregonians from malicious intent. For example, Oregon Health Authority is now the only entity tasked with overseeing internal wrongdoings and the external oversight has been eliminated. Consequently, the public must question the probability of resolution when an Authority is tasked with their own sanctions.
Ultimately, chronic pain patients are not in need of rehabilitation as the Chronic Pain Task Force would suggest. These patients are suffering from conditions without cures, and therefore their need for pain relief cannot be eliminated. To approach the subject of pain care with a predisposed notion of wrongdoing results in policy that is both unjust and discriminatory in nature. There is no adequate defense on behalf of pain patients when the task force has deemed them to be inherently guilty, and that is the fundamental issue surrounding the existence of this proposal. This was never about pain care, this was about limiting access to a drug that derailed the belief system of seated members.
- In collaboration with an Oregon Advocate