As chronic pain continues to plague the nation, so, too, do opioid addiction and overdose.
According to the Centers for Disease Control and Prevention (CDC), more than 70,000 people died from drug overdoses in the United States in 2017 – making overdose a leading cause of injury-related death, joining the ranks of alcohol, tobacco, cars and guns. Almost 68% of those deaths involved a prescription or illicit opioid.
While thousands of cities and counties across the country challenge large drug manufacturers and distributors for allegedly fueling the opioid epidemic, debate remains over how or whether regulatory oversight can simultaneously combat a multifaceted drug crisis and alleviate chronic pain for patients with cancer or arthritis, among other diseases and conditions. Also yet to be settled is whether proven pain management solutions exist in alternatives to opioid use – such as medicinal cannabis – and how much support those alternatives may have in the medical industry.
Calaveras County is one of several Northern California counties represented by Baron & Budd in litigation against pharmaceutical companies and drug providers. The case is part of a consortium of more than 2,800 counties and cities seeking billions of dollars in public health damages, and proceedings are currently being heard by a federal judge in Ohio, according to John Fiske, an attorney with Baron & Budd.
Pharmaceutical companies allegedly “grossly misrepresented the risks of long-term use of those drugs for persons with chronic pain,” and drug providers allegedly “failed to properly monitor suspicious orders of those prescription drugs,” thereby contributing to the opioid epidemic, according to court documents.
More specifically, “plaintiffs claim that manufacturers like Purdue Pharma and Johnson & Johnson aggressively marketed the pills for years despite knowing about addictive properties; that distributors like McKesson and Cardinal Health shipped alarming quantities without reporting to the authorities; (and) that pharmacy chains like Walgreens and CVS Health looked away while selling flag-raising amounts of these medications to individuals,” the New York Times reported in March of 2018.
“This national opioid litigation is historic and unlike anything we’ve seen before,” Fiske said. He likened the case to the 1998 Tobacco Master Settlement Agreement, a ruling against tobacco companies that required them to pay a total of $206 billion to 46 U.S. states over the ensuing 25 years. “For over 10 years at least, manufacturers and distributors made billions of dollars selling these drugs that were too addictive and were not very effective, even though some of the manufacturers like (Purdue Pharma) misrepresented their efficacy and addictive qualities.”
Fiske said a decision is pending to reorganize the suit as a class action lawsuit, meaning settlements would be offered in one resolution.
The class action structure is “a way for a defendant to come to thousands of cities and counties to say ‘this is the amount of money (we’re) offering to them,’” he said.
If the judge approves class action status, Calaveras County would be given a 60-day period to opt in or out, according to Fiske. If the county opts in, defendants would make settlement offers, and the county would evaluate whether to accept settlements or to keep negotiating, he added.
Local opioid prescriptions and overdose deaths on a downward trend
While the issue remains pressing on a national scale, in Calaveras County, the number of annual opioid painkiller prescriptions has been steadily decreasing since July of 2014, and there has only been a handful of overdose deaths over that period.
Based on California Department of Health data, 42,342 prescriptions were made in Calaveras County in 2018. That’s less than one per person – a relatively healthy ratio, especially for a county with a high rate of senior residents that tend to experience chronic pain, according to County Public Health Officer Dr. Dean Kelaita.
Public awareness and more selective prescription practices, according to Kelaita.
He said patients are generally more aware of the larger opioid problem in the country and don’t want to become part of the epidemic.
Given that, people may be more willing to find other ways to manage pain, such as taking non-steroidal anti-inflammatory drugs like ibuprofen and naproxen, and focusing more on physical therapy, nutrition, mindfulness, relaxation and dealing with stress and depression, Kelaita said.
The downward trend may also be due to a change in prescription practices.
“The medical community is doing a better job in prescribing these medications for the right reasons to the right patients,” Kelaita said. “Doctors are being more selective and using with more discretion.”
That’s in part due to federal laws getting tighter on medical providers, he said.
Addressing chronic pain under stricter opioid regulations
In 2016, CDC guidelines were introduced to limit the daily amount of opioids that doctors could administer. The regulations also established a stringent approval process for filling prescriptions. That same year, a CDC report found that over 20% of U.S. adults were experiencing chronic pain.
Although prescriptions and opioid-related deaths are declining in Calaveras County, some local providers argue that regulations have gone too far.
Two months ago, Dr. Rodger Orman, a local pain management physician closed his center in San Andreas. After nearly a quarter-century of service, Orman cited increasing difficulties of prescribing opiates as the primary reason he closed up shop.
“For some people, small doses of opiates allow them to function,” Orman said in an Aug. 20 phone interview, with reference to those with severe joint pain. “Saying there should be a ceiling of 90 miligrams morphine equivalent of any kind of opiate per day … that’s what’s hurting the average patient that doesn’t have addiction but has legitimate pain.”
The CDC’s guidelines also established a “gatekeeping” mechanism that requires providers to obtain prior authorization, a process through which the physician “has to waste time justifying a decision to give a certain patient a certain medication,” according to Orman. “That compounds their routine activities with extra phone calls and staff.”
Orman argued that physicians should be able to detect signs of drug abuse in their patients through observation and drug screening. Doctors can take urine samples to determine how much of a painkiller a person is taking, – if any amount at all – or whether they’re ingesting it with another drug.
He prioritized practitioner education, rather than regulations to limit opioid prescriptions, as the answer to curtailing the epidemic.
Additionally, Orman advocated for taking a more holistic approach to pain management and developing safer pain medications.
“It might take scientific breakthroughs in the treatment of back pain,” he said as an example.
Chaired by Kelaita, the Calaveras Opioid Safety Coalition provides education to local medical providers on best practices when it comes to opioid prescriptions.
Formed in 2018 to discuss strategies to reduce opioid use and prevent overdose deaths, the group is made up of various county officials, experts and community members. Members include the sheriff, an emergency room manager, the chief of staff of doctors at Mark Twain Medical Center, a representative from the county behavioral health and substance abuse programs, a local school representative and a pharmacist, among others.
Meeting on a quarterly basis, the coalition is focused on circulating prescription guidelines to medical providers and distributing Naloxone – a medication used to counter the effects of opioid overdose – more widely across the county.
“We have a plan on how to distribute (Naloxone) throughout the community,” Kelaita said. “Now sheriffs’ departments have it, other emergency responders have it, and we’re discussing pushing out even more into the homes where people might take prescription pain medications. If a family member notices that people can’t wake up or aren’t breathing, they can administer it right there.”
An alternative in cannabis?
With chronic pain still a lingering issue, alternative medicines may be gaining traction. In Calaveras County, that includes cannabis, according to Lara Grant, co-owner of Calaveras Little Trees, an Arnold-based medical cannabis dispensary.
Grant said the dispensary was inundated with clients seeking pain relief in the absence of opioids in 2016. She attributed the boom, in part, to the new restrictive opioid guidelines that had been released earlier that year.
“A lot of people were coming in saying they had been cut off from their prescriptions … and suddenly went from crazy amounts of pills per day to nothing,” Grant said in an Aug. 27 phone interview, adding that many of the new patients were undergoing severe withdrawals. “It was a crazy time.”
Grant said that while the use of the plant as a pain reliever to replace opioids is not well-studied, she has seen many patients – primarily elderly clients – undergo a successful transition from opioids to cannabis products to alleviate aches and pains. Part of the reason is that cannabis, unlike opioids, is not physically addictive, she said.
Patients tend to favor topical products for light muscle pain and edibles and tinctures for more severe pain, Grant said, adding the stipulation that everyone is different.
“Pretty much everyone that I know will have a family member that’s going through something – an illness, a condition, dealing with aches and pains of aging, and people turn to cannabis,” Grant said. “I think normality is increasing as more people are turning to experiment with cannabis … it’s becoming more acceptable in society, even in Calaveras County.”