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Chronic pain patients feel threatened by opioid repression

Marty Mioni knows what she would do if her pain killers were taken away.

"I would look for a weapon," said the 63-year-old resident of Port Orchard.

Mioni is not dramatic. For some patients with chronic pain who fear losing access to opioid drugs under the evolving prescriptive guidelines aimed at counteracting the nationwide opioid crisis, suicide is a realistic alternative to a life of slimy pain.

Mioni has been taking opioids for 15 years to deal with pain caused by ligament rupture resulting from an accident at work and sustained nerve damage from surgery. She says she has tried every other form of therapy available to her and has voluntarily volunteered for experiments with experimental treatments.

"That's the only thing working for me," Mioni said about opioid medications.

But this year, Mioni She said that her provider was gradually breaking down her oxycodone formulation in response to new policies. Her dose, which she takes several times a day, no longer hides her pain. Cooking dinner this summer has become a "little fight," she said. She fears that further restrictions will come.

"If they do not solve the problem, I'm afraid we'll lose our painkillers completely," Mioni said.


Pain patient Marta Mioni is with her husband James in their home in Port Orchard. She has been taking opioids for 15 years to treat the pain of a ruptured disc. (Photo: Larry Steagall / Kitsap Sun)

Fellow patient Gretchen Lont, 52 years old, attempted suicide ten years ago after back pain after several falls had led to depression. An opioid prescription was the only thing that allowed her to lead a normal life, she said.

Like Mioni, Lont's cans are stretched and the pain climbs back.

"I'm not doing anything now," she said. "If you have pain twenty-four / seven, and it never goes away, it gnaws at you."

Lont feels that the rights of chronic pain patients are being trampled on as lawmakers and health workers push for the opioid crisis

"We are treated like addicts, but without compassion," she said.

Mioni and Lont have joined other chronic pain patients who band together to bring attention to their situation. "Do not Punish The Pain" Rallies organized on Facebook are scheduled across the country on September 18, including one in Olympia.

Tapering trend

Patients' protests come at a time of rapid changes in pain management.

Guidelines issued by the federal Centers for Disease Control and Prevention and the State Director's Medical Directors Group encourage non-opioid treatments for chronic pain and discourage high doses of opioids (more than 90 morphine milligram equivalents among CDC Guidelines and 120 morphine milligrams) equivalents under the state guidelines), among other recommendations.

The State Department of Health is in the process of refining a set of rules for the prescription, monitoring and prosecution of opioids under the laws passed in 2017. These rules could be finalized later this year

On-site, a project is currently underway in Kitsap, Clallam, and Jefferson counties to better manage Opioide using the "six-brick" method developed by the University of Washington.

The reform efforts are responding to a wave of opioid abuse and overdose deaths, fueled in part by over-prescriptions, and a better understanding of the health risks associated with high opioid doses.

"There was a big push to say," What is the appropriate upper limit for opioids? # 39; said Dr. Nathan Schlicher with CHI Franciscan Health, who serves in a Washington State Medical Association and Washington State Hospital Association task force for safe opioid practices.

Existing guidelines and prescriptive prescriptions proposed by the state do not explicitly advise providers to reduce doses for patients with chronic pain unless the patient is unable to comply with strict pain management arrangements with their provider, and escalating doses without Improve the pain or meet other criteria.

Dr. Jon Hillyer of the Peninsula Pain Clinic in Bremerton, who prescribes opioids in addition to other pain therapies, said the decision to rejuvenate is taken on a case-by-case basis. Consideration is growing evidence that high doses of opioids offer no greater benefits than moderate doses and increase the risk of patient harm, he said. Another consideration is that pain patients who are prescribed high doses of opioids may not be able to find treatment in the future if the prescriptive guidelines become stricter or if they need to change providers.

"We try to reduce the dosage for some patients," Hillyer said, noting that most patients responded well to the change. "We can reduce some side effects and improve their quality of life."


Pain patient Marta Mioni fears chronic pain that could turn patients into suicide if they have broken off medication to help maintain their quality of life. (Photo: Larry Steagall / Kitsap Sun)

Hillyer recognizes that there is a subgroup of patients with chronic pain whose quality of life could be affected by tapering. These patients have been consistently using high doses of opioids for years to successfully treat their pain and have followed all the rules.

"They have well-established diagnoses and long-term compliance," said Hillyer.

These patients have tried other forms of pain therapy and find relief only with opioids.

"You have no alternative," said Hillyer.

Feeling Pain

A shoulder operation in 2005 left Candyce Smith with relentless pain

The procedure damaged nerves on her neck that never regenerated. Later she lost her back and she was diagnosed with a degenerative disc disease – a condition that caused even more nerve pain.

An opioid prescription allowed her to continue working in her office job. Smith has been in the same dose for more than a decade, she said.

"What it did was to take care of my pain until I could work," said the 65-year-old resident of Bremerton about the pills.

Smith said that because of the prescriptive guidelines, her dose has now rejuvenated and her pain has progressed to the point where she can no longer sit or stand long enough. She had to give up her job and submit for disability pensions.

"I did not expect that at all," she said.

Smith is worried that she will continue to have pain.

"I do not know what to do for myself," she said. "I really do not do anything, something has to change here."

Smith, Mioni and Lont – all patients of the Peninsula Pain Clinic – agree that restrictions are necessary to prevent opioids from being abused. But they believe that new prescribing guidelines are reactionary and have created a one-size-fits-all policy that does not fit their situation as a rule-keeping chronic pain patient.

"The only thing I depend on is my quality of life," Smith said, "and I lose that."

Mioni fears that some patients might commit suicide, rather than living with chronic pain, believing that more patients whose doses rejuvenate are more likely to buy drugs illegally and self-medicate.

"Do not you know that if you take people off their medications they will look elsewhere?" She said.

Patients want to be sure that the adopted rules allow providers to continue prescribing high doses of opioids to patients with chronic pain who are dependent on the medication to treat their pain and do not respond to other treatments.

"For most of us, there are no alternatives," Smith said.

Pendulum swings to opioids

A reform effort that has frustrated some patients also challenges healthcare providers

"It's a pendulum that swings," said Hillyer of Peninsula Pain.

In practice, Hillyer remembers for more than 20 years that the pendulum was swung strongly in the opposite direction.

Until the mid-1990s, escalating doses of opioid drugs were an accepted treatment for chronic pain. The use of opioids has become deeply rooted in the culture of healthcare, Hillyer said, as vendors prescribed higher doses for more people.

Daily schedules of more than 300 morphine milligram equivalents – three times the recommended limit of the Centers for Disease Control – were not uncommon.

"Opiates became, in a sense, one of the first treatments because they were considered safe," Schlicher told CHI Franciscan Health.

The ensuing national health crisis forced a re-evaluation of these practices. According to the Centers for Disease Control, more than 350,000 people in the US died of overdoses related to prescription or illegal opioids between 2009 and 2016. More than 300 Kitap residents died of opioid overdose between 2000 and 2016, according to the Ministry of Health.

As the pendulum swings toward greater regulation, Hillyer said that it has become more difficult for practitioners to serve pain patients. New opioid prescriptions are being investigated by insurance companies, pharmacies and agencies that oversee the compensation claims of workers.

"There are so many other areas that become so restrictive that it becomes difficult to practice," he said.

The danger of discipline is also in the industry. In 2016, the state regulators opposed the Seattle Pain Centers, suspended their director's medical license, and opened investigations with vendors working in clinics "due to concerns about poor practice standards." The company closed abruptly and closed its eight offices, including one in Poulsbo, and has thousands of patients looking for new providers.

In June, the Board of Osteopathic Medicine and Surgery accused Silverdale pain specialist Beno Kuharich of being unprofessional about alleged unsafe prescribing practices. Kuhharich, a former Seattle Pain Center provider currently practicing The Doctors Clinic, vehemently denies the allegations

Hillyer said the disciplinary cases have the unintended consequence of warning practitioners not to prescribe opioids and access to care To restrict pain patients. Both Schlicher and Hillyer stated that the general burden on opioid regulatory agencies has led to many primary care providers ceasing to use the drugs and relocating the burden to specialty clinics such as Peninsula Pain

"We see this change nationally" Schlicher said.

Schlicher, a former state senator, said policymakers need to set a set of rules to counteract the opioid crisis, provide clear guidelines for providers, emphasize education rather than punishment, and take into account the individual needs of chronic pain patients. Rules should allow opioids, in addition to a variety of other therapies, to be a tool in the prescriber's toolbox.

"We are working to address this epidemic on both sides, and we want to be respectful to patients," he said.

Hillyer believes that a balance will be found, even though the transition may be painful.

"It's a time when things are changing and changes are difficult for providers and patients," he said. "But it is necessary."

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