Pain Management Associates (PMA) located at 49 Galloway St. in Waynesville will be closing at the end of June. This clinic saw patients who complained of chronic pain and who were on opioids to help control the pain.

Until the late 1980s, opioids were never or rarely prescribed for chronic pain because it was known that these medications were addictive. It had taken years to reverse the drug problems left over from the Vietnam war and lead to the “Just Say No” era. Two articles and drug company greed for profit changed all that over the intervening decades to arrive at the current state of opioid use that is clearly out of control.

What happened was that in 1980, a short paragraph of a letter was printed in a prestigious medical journal that said basically, “We looked at a lot of patients who got at least one dose of narcotic and saw hardly any addiction.” It was a slipshod study with little control or long term follow up and certainly was not looking at long term opioid use and addiction.

Then in 1986, two doctors at Sloan-Kettering cancer hospital in New York City wrote a longer article published in the journal Pain which details 38 patients who were managed for as long as several years. The patients were on a variety of different medications such as codeine, propoxyphene (Darvon), pentazocine (Talwin), levorphanol (Levo-Dromoran) as well as oxycodone and morphine. This was not a controlled study, just an observational one. Two patients developed addiction, that’s over 5%, however, still the authors concluded that “opioid therapy can be safe.”

Drug companies such as Purdue Pharma literally took these poorly conducted and non-scientific articles to the bank. Oxycontin had been on the market and when it was marketed for its original purpose of treating terminal cancer pain, reportedly the company made a profit of approximately $2 billion per year. Purdue and Endo Pharmaceuticals (makers of Percocet and Opana) and others applied pressure on the FDA to approve Oxycontin for chronic non-cancer pain and their profits increased (reportedly) to about $8 Billion a year! This is because the drug is cheap to manufacture but they were selling it at a high price.

The drug companies created consortiums of “pain study” groups and advisory panels who purported to be working on behalf of the patients experiencing chronic pain but really with the objective of making maximum profit by normalizing opioid prescription for almost any pain complaint. They invented phrases such as “There’s an epidemic of pain in this country” and “We under treat pain in America,” and “Doctors are reluctant to prescribe opioid pain medication because they’re inappropriately afraid the patients will become addicted.”

Drug companies gave millions of dollars to universities such as Johns Hopkins to “study” pain, and even helped the universities develop the studies! All of these studies were relatively short term and compared a strong opioid such as Opana to a sugar pill for up to 12 weeks – but many of the studies were only four weeks which “proved” that these medications were effective (sure, compared to a placebo) and safe (during the course of these studies no patients were determined to have developed an addiction).

There are no real studies, such as two or five years or even six months of comparing an opioid to something as simple as ibuprofen or acetaminophen (Tylenol). There were no prospective studies looking at addiction.

Well, we know what happened next. Doctors all over the country were constantly being hammered with the idea that opioids were safe and effective and it was unethical not to give patients pain medication when they asked for it – or even if they had pain and didn’t ask for it!

Mostly doctors did not make significant income from prescribing these medications. Most doctors did it because we were told over and over again that these medications were safe and effective, and how could we be cruel and not prescribe for this pain epidemic that was sweeping the country? Pamphlets were mailed to every doctor in the country telling them to give opioids for moderate to severe pain. Educational seminars were (and still are!) being given on how to “manage chronic pain with opioids.” Hospitals were asking patients to rate pain, and doctors were pushed by hospital administrations to give opioids if patients requested it or complained of pain. Patient satisfaction scores were low when a patient demanded opioids and were not given.

We know what happened after that – the opioid epidemic. State medical boards began to realize they’d been duped; that we have a serious problem.

Then, in 2012, decades too late, one of the authors of the 1986 article, R. Portenoy, MD revealed in an article in the Wall Street Journal that he had been paid to perform this study.

Sentiment has generally shifted back to the idea that opioids should be used rarely and selectively, if at all, for chronic use by the patients with pain.

Some doctors have found a creative way to generate a fantastic income from continuing the practice. In this scenario, the doctor’s office performs urine drug screens and bills the insurance companies. The problem with this is that it’s considered illegal, a sort of “double dipping” phenomenon.

The parent company of Pain Management Associates is Oaktree Medical Centre. This company is being sued by the United States Department of Justice (DOJ) for violating several federal anti-kickback regulations and other laws, alleging that they have billed tens of millions of dollars in improper charges.

This has resulted in a restructuring and contracting of the clinics. It is not certain whether the remaining clinics such as PMA in Arden will remain open much longer.

Of significant local interest is that PMA of Waynesville has sent a form letter recommending the patients seek treatment with me (Allan Zacher, MD), Dr. Miles Hyman of Franklin, NC or Dr. David Baksh. The owners of the company know full well that Dr. Hyman stopped practicing medicine in 2010 and I have closed my pain management clinic in 2015, over 3 years ago.

While Dr. Baksh is still in practice, he is in Asheville now. I don’t know if he is accepting new patients. Patients who have had increasing opioid requirements may have addiction rather than a requirement for pain medication. In that case, there are several local practices that can use medication such as Suboxone or methadone for addiction treatment. Patients may check with their local regular doctor for referral.

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