PATIENT OUTCOMES

The Oklahoma Committee on Alcohol, Tobacco, and Controlled Substances was presented with an interim study on November 1, 2021 on how the changes in legislative policy that went into effect in 2018 have created untoward and illegitimate pressures on practitioners to reduce prescribing of opioid pain medications, and how this has resulted in unintended consequences for patients who live with chronic pain. This study was conducted by Representatives John Talley, Ty Burns, and Preston Stinson with the help of P3Alliance and the generous and valuable time of local and national professionals, and the Pain Patient group of Oklahoma. 

Our first speaker was Dr. Beth Darnall of Stanford University's School of Medicine, Department of Anesthesia and Perioperative Pain Management. The most recent, prominent and extensively funded research of Dr. Darnall's is regarding how to safely taper down opioid pain medication in patients, but it has been through this research that she discovered facts regarding patients whose pain not only is managed best on opioid medications, but also that the benefits of controlling their pain on opioids far outweigh the associated risks. She reports that this group of patients suffer greater risks to their physical, mental, and emotional health when taper is attempted, particularly when done without patient consent. Dr. Darnall spoke with persuasion on the importance of treating every patient according to their individual needs, whether attempting a taper or maintaining them on opioids, and that whatever decisions are made regarding pain control must come from mutual and voluntary decisions of the patient and the Healthcare practitioner in order for treatment to succeed. In response to a question presented by a committee member, she further discussed that forced tapering opioid medications to any particular MME (milligram of morphine equivalent) is a damaging method of tapering for the compliant pain patient. 

Next to present was author and speaker Zach Rhodes, who uses personally lived experiences with illicit opioid addiction, as well as extensive research, to help families overcome addiction by way of an online coaching program in Vermont. His research on drug addiction has led to 2 facts that are not discussed in today's legislative narrative, although they are based on obvious data that have been predictably repeated, and are of great importance when considering drug policies. These are 1) the vast majority of people who take opioids do not develop an addiction to them, and 2) of those people who do develop an addiction, even to substances that are considered "hard drugs", the majority of them overcome that addiction without formal treatment or support. Because of these facts and their implications for those who need opioid medication to treat their pain, the primary message that Mr. Rhodes asked this legislative committee to take away from his speech when developing policies was, "Don't focus on drugs, focus on people." 

Following Mr. Rhodes' presentation were personal stories from pain patients with the Oklahoma Pain Society. They discussed how these policy changes have affected their lives. First to speak was Dr. Lawrence Pasternack, director of Oklahoma State University's Religious Studies. Dr. Pasternack has the genetic disease scoliosis, and spoke on how poor pain control affects his ability to perform many aspects of his job, including inhibiting his ability to write, which is an extensive part of his work. Next to speak was Daniel Byard, who suffers from injuries caused by a car accident involving a drunk driver several years ago. Not only does he manage his own pain, but he is also the caregiver for his wife who sustained serious injuries herself in a separate accident with a drunk driver. He discussed how his family's days revolve around his wife's condition and whether or not her pain is properly managed. He also discussed how she suffered from a seizure during their daughter's 3rd birthday party, which was diagnosed as resulting from poor pain management. Despite this, she has been unable to find a physician who is willing to treat her pain with the appropriate doses of pain medication due to the pressure that prescribers face from previous legislative policies, state law enforcement, and DEA. Because of the pain his wife endures daily, Mr. Byard also suffers from post-traumatic stress disorder; however, he is unable to receive the proper treatment for this disorder due to state policies propagated by the false narrative that certain medications which are potentially addictive should not be prescribed concomitantly, including opioids and medications such as benzodiazepines, although they have been successfully prescribed together in proper situations for decades. 

Our next speaker was Sheriff Tim Turner of Haskell Co, Oklahoma. Sheriff Turner has an extensive background in drug task force supervision, and served as a DEA agent. He reports that since 2018 there has been a decrease in overdose deaths from pharmaceutical grade medications; however, during this same time there has been an increase in illicit overdose deaths. In his county the demographics of those abusing illicit substances has not changed significantly, but there has been a rise in re-offenders. Sheriff Haskell's experience in the last decade has shown that there is a great need for mental health intervention, which is not readily available to help those abusing illicit drugs. There is access to methadone clinics and Suboxone (TM) medication, but they are not adequate for treatment and "create their own problems in the long run". He reports there has been a recent influx of illicit fentanyl coming from the southern borders. Another big factor that he identified as a reason for the increase in illicit drug use is that the decrease in pharmaceutical grade medication has caused them to become very expensive per pill on the street, while the illicit drugs are more readily available, much cheaper and therefore are within a better range for purchasing. 

Next to speak was Dr. Drabeck, a family medicine doctor who also practices pain management. Dr. Drabeck states that he did not truly understand the management of chronic pain until he suffered through it himself when he was diagnosed with esophageal cancer. His journey with cancer created compassion towards those who suffer chronic pain. He feels that the best ways for practitioners to help manage their patients' pain is through additional medical education on correct pain management methods, and by untying the hands of prescribers so they are able to prescribe medications effectively for each individual patient's needs. 

Our final speaker for the interim study was Dr. Vanila Singh. Dr. Singh's experience includes the important and prestigious role as immediate past Chief Medical Officer in the US Department of Health and Human Services under President Trump's administration, and was the Chairperson of the highly regarded HHS Task Force in conjunction with the Department of Defense and the Veterans Affairs. This most important task force was developed in response to the outcry of pain patients across the nation when laws for reduced prescribing were passed as a knee-jerk reaction to the opioids crisis, leaving many patients without effective ways to manage their chronic, intractable pain. Under Dr. Singh's leadership, the Task Force was able to develop a comprehensive and approachable final report that identified gaps in pain management and offered research-based and practical solutions to the management of pain, and a final report was submitted to Congress despite opposition from some in positions of power. Because of Dr. Singh's direct clinical experience as a pain management physician and clinical associate professor of Anesthesiology, Pain and Peri-operative Medicine at Stanford University, she has great compassion for patients who suffer chronic pain. It was indeed our great privilege to have her present to this committee. In her presentation, Dr. Singh confirmed the data which was presented today by the other professionals and patients as factual, stating that the Task Force received thousands of tragic stories from patients across the nation who had been denied the medication that best controlled their pain, causing many to commit suicide or pursue the management of their pain via illicit drug sources. She stated that many state drug policies were developed as an improper response to the CDC 2016 Guidelines on Pain Management, which were primarily intended as a guide for primary care practitioners who were managing novice pain patients and was not intended to be used as defacto law, nor was it intended for pain management specialists with established patients whose pain was well controlled on opioid medications. One of the worst situations she reported that came from the reframing of opioid treatment was policies developed on the assumption that any patient requiring an opioid for the management of their pain was automatically assumed as addicted to their medication. Most surprising to the task force was when Human Rights Watch organization contacted them with concern that the United States, which always led in the treatment of pain and suffering, had somehow lost its compassion and appeared to be becoming calloused in their most recent approaches to managing pain. Sadly she reports that this has only become worse due to the COVID pandemic which of itself is causing greatly added distress to the nation and particularly to patients in pain. She states that all doctors who prescribe opioids for pain are feeling pressure from their medical boards and the DEA, and are essentially "sticking their necks out" when treating pain patients with opioid medications. The good news she had to share was regarding the report from the Task Force, which is written in such a way that both the scientist and the layperson could understand it, and it can, and should be used immediately as a guide for shaping current policy on the treatment of chronic pain. 

The Oklahoma Committee on Alcohol, Tobacco, and Controlled Substances wish to express its most sincere gratitude for each person who contributed so greatly to the success of this Interim Study.