Tuesday, June 21, 2011

The Wisconsin Pain Initiative: Caught in the COI Trap

One of the problems of being a so-called "ethicist" is that occasionally you stake out a position based on what you think are valid principles; and then somebody you agree with and whose work you admire turns out to have crossed the line you've drawn. Ethics, of course, requires that you show them no favoritism and condemn their behavior equally with those lower down your likeable list. But it can still be painful.

I have for many years been drawn to the arguments that the prescription use of opiate drugs for chronic, non-cancer pain needs to be liberalized. That is a hard case to make in our society for several reasons. One is that we live in a society that has so demonized addiction that anything about using opiates draws immediate resistance and condemnation. Another is that there is a lack of solid data, in large part because "pain" is not a disease. Most diseases have a National Institute of Health devoted to their study, but pain does not. For a long time it has been extremely hard to get research funds to really study how well opiates work for this sort of pain. We do know, however, that an incredible number of Americans say they have longstanding pain that is not being adequately treated--up to 75 million according to one survey cited by the AMA.

In HOOKED I commented on journalist Barry Meier's book, Pain Killer, about the epidemic of OxyContin abuse. Meier did a reasonable job of giving a balanced presentation of the legitimate medical uses vs. the abuses of opiates. But he came down appropriately hard on Purdue Pharma, OxyContin's manufacturer. More to my chagrin, as I admitted in HOOKED, he listed a number of national pain-management authorities whose work I had long admired, as having gotten substantial research funding from Purdue Pharma and other firms. One could make the excuse that if you wanted to do any sort of research on opiates, that might have been the only game in town, with Federal grants so hard to get. Still there was no question but that this financial tie cast a shadow on those who advocate more liberal use of opiates.

Now the other shoe has dropped. John Fauber, author of an important series of investigative pieces in the Milwaukee Journal-Sentinel, that we have previously cited several times, more recently targeted the University of Wisconsin Pain and Policy Studies Group, in an article from April that was just alluded to by Kate Petersen at PostScript:

The Wisconsin group have been national leaders in the struggle to get physicians to prescribe opiates more freely for chronic pain, and to alter government policies to reassure physicians they will not face licensing or criminal actions for responsibly prescribing opiates for legitimate pain patients. Fauber targets two leaders of the UW group, Aaron Gilson and David Joranson. He documents that both have received finding from Purdue Pharma and other drug firms that goes beyond research support and even general program support, working as paid consultants and speakers. Documents that they contributed to on pain policies often did not acknowledge that financial tie. In short, the same old incestuous relationship we've seen with so many other academics in this blog.

Fauber tries to put all this in perspective by painting a picture of a society that is now suffering huge burdens from the abuse and diversion of prescription opiates, due to the misguided prescribing practices of doctors who use OxyContin and its cousins for headaches and back pain, when the medical literature provides no sound basis for such use--an epidemic of drug problems aided and abetted by the reports and articles published by the Wisconsin pain center. Now this is partly true--there is indeed a serious increase in the abuse of prescription opiates, and in to some degree thay have become more popular among some user populations than older drugs of abuse like heroin. (And there are some reports that the use of heroin is rising again now that Purdue Pharma has done what it should have done many years ago, and reformulated the OxyContin capsule so that it can no longer give the abuser a high by crushing it instead of swallowing it.) And it is true that some studies of the chronic use of opiates for long-term pain have not been as promising as people like me would have hoped. But it still seems to me that there are a lot of patients with severe, untreated or undertreated pain who could benefit from the use of opiates combined with other modalities in a carefully monitored program. And in today's climate where all we hear about in the media are "pill mills" and abuse, it's very hard to get physicians, especially in primary care, to consider such an approach.

So the people at the Wisconsin pain center have unfortunately cast an even deeper shadow over the cause they had hoped to advance, through their willingness to compromise themselves for cash. Even after we consider all the good reasons they may have thought they needed to take the Pharma dollars to get their work done, we see that in the end the risk of taint significantly outweighed whatever good they were able to do. And while you may feel the need to take research and program support funds just to be able to do your work, even that does not justify a personal enrichment relationship such as consulting and speaking.

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