Painful to Report: ProPublica Skewers American Pain Foundation

The most recent investigative reporting by ProPublica, who have done great work in exposing industry funding and related conflicts of interest, puts me personally in a bind because I have considerable sympathy with both sides:
http://www.propublica.org/article/the-champion-of-painkillers

Charles Ornstein and Tracy Weber detail the degree to which the American Pain Foundation has been funded by manufacturers of narcotic painkillers, including the notorious Purdue Pharma, maker of OxyContin, and how it then proceeds to stick up for widespread use of narcotics for treatment of chronic pain--even in the face of increasing evidence showing, first, that opiate drugs may not be very effective for chronic pain; and second, that overdoses and addiction from these drugs are growing to epidemic proportions.

So let me see if I can add any balance to the discussion.

First, let me speak in defense of the position taken by the American Pain Foundation. One of the big problems in pain research has been the lack of Federal grant dollars, since there is no National Institute of Pain at NIH, and the NIH has until very recently shown very little interest in funding pain research, despite estimates that around 75-100 million Americans suffer from some degree of chronic pain. In this funding vacuum, the analgesic manufacturers have often been the only possible source. As I detailed in HOOKED, this has led to the undesirable state of affairs, of many of the most prominent experts in pain management in the US being "on the take" with drug company money.

The critics of the Foundation that ProPublica spoke with all note the current dearth of solid evidence that opiates are good for treating chronic, non-cancer pain. It is true that the available studies to date have been discouraging. I think today, any physician who goes to narcotics and narcotics alone as the first line approach to treating chronic pain would be off base. But two important facts need to be put into perspective alongside these data from controlled trials. First, after you try all the various other modalities for pain management, virtually all physicians in this business would agree that you end up with at least some--more than just a few--patients who are still miserable and unable to function despite it all. These patients often get some relief, occasionally substantial relief, with opiates, and with proper management and monitoring the rate of addition or serious side effects is very low. Somebody needs to speak up on behalf of this group of patients and make sure that they don't lose access to the one thing that substantially helps them.

Second, the ideal way to treat chronic pain is through a multidisciplinary pain clinic that offers physical therapy, pain psychology, and generally a team approach alongside a willingness to prescribe appropriate analgesic drugs. Now, go try to find such a place. Not unusually, there's none within 250 miles. (Too many so-called "pain clinics" are basically procedure mills where anesthesiologists do mostly worthless injections for big bucks, then turn patients away as soon as their insurance benefits run out.) If you can find a truly multidiscioplinarty pain clinic, then ask if it accepts Medicaid. Chronic pain, not surprisingly, is concentrated in lower income groups, who often lack the good insurance that's the ticket into most of the really good clinics. So we are talking about an ideal mode of treating chronic pain that is simply out of the reach of way too many sufferers.

Are these clinical realities about treating pain reflected in today's media? All we read about is the epidemic of drug diversion, overdoses, illegitimate and illegal "pill mills" selling narcotics to addicts, and so on. Somebody needs to speak up for the legitimate pain patients who may need opiates as a part of a broader approach to pain management.

OK, that's the one side of the issue. Now let me speak with my usual hat on, opposed to conflicts of interest. Here we see the chickens that come home to roost when you feather your nest with industry cash. (Sorry for the fowl cliches.) There's that little question of public trust. It seems that whatever the American Pain Foundation set out to do, it has seriously compromised its ability to do it by getting in bed with the likes of Purdue Pharma.

Let me talk a minute about Purdue, whose record of wrongdoing is now legendary. They make OxyContin. Addicts found out about 5 minutes after the drug hit the market that the capsule had an unfortunate property--if you crush it, you got an immediate rush of the drug, rather than the slow release that the capsule was designed to give, and that it does give if you take it properly, without crushing. This set up the popularity of OxyContin as the infamous "hillbilly heroin." By contrast, another slow-release form of opiate, MS Contin, works just fine--even if you crush the capsule, the matrix that holds the active drug won't release it all at once. That's great for legitimate pain patients and bad for abusers.

So what would a decent drug company have done? I say--obviously, take OxyContin off the market, and don't bring it back on until you have redesigned the capsule to work in a way that doesn't help addicts get high. Instead Purdue did everything they could to keep selling OxyContin as originally formulated and also did everything they could to whitewash the problems. And the American Pain Foundation helped them out.

I strongly agree with my bioethics colleague, Dr. Ben Rich, who has written extensively about medicine's ethical obligation to do a far better job of treating pain. Sadly, well-intentioned organizations that take cash from Pharma and create serious conflicts of interest for themselves make this ethical job harder to do.