Purdue Pharma Bought the AMA’s Pain Management Education for Physicians

When The Media Says "Experts" They Mean Paid Corporate Shills (Part 33)

The concept of pseudoaddiction, the idea that patients seeking opioids are suffering a iatrogenic syndrome because healthcare workers are providing them inadequate pain relief became more prevalent in pain management literature and a standard concern in the American Medical Association’s pain management education for physicians seeking continuing medical education credits through their organization after Richard Sackler joined the foundation’s board of directors from 1998 until 2004 and Purdue Pharma became a platinum level donor to the American Medical Association until 2016. Greene and Chambers conducted a review of the medical literature on Pseudoaddiction and found that the concept came from a single 1989 case study of a 17 year old child with acute leukemia in which James David Haddox, who became the vice president of health policy at Purdue Pharma, and his co author David Weissman, claimed that the patient wasn’t actually becoming physically and psychologically dependent on morphine but wasn’t receiving a high enough dose or that the intervals between doses were too long. Between the origin of the concept in the 1989 case study and the review conducted in 2013, 224 scientific articles on pseudoaddiction were published. Out of the 224 articles on Pseudoaddiction none empirically validated the concept, only 18 attempted to support or elaborate on the concept while 92% of the journal articles cited the concept as a consensus concern that they accept at face value. 22 of the 224 articles on pseudoaddiction disclose sponsorship by the opioid industry or have authors who disclose receiving compensation from the opioid industry; 9 of them were sponsored by or had authors paid off by Purdue Pharma specifically. 6 of the 18 articles that attempted to elaborate on the concept of pseudoaddiction question the validity of the concept; none of those 6 articles received any support from the opioid industry. The 12 articles that unquestionably supported the concept, of which 4 disclose industry sponsorship or authors paid by the industry, recommend erring on the side of pseudoaddiction when evaluating opioid seeking behavior and dismissed positive drug screenings for illicit/unprescribed drugs or other addiction risk assessments as not being reliable evidence for addiction because they suggest that only the internal motives of patients seeking opioids can distinguish between true addiction and pseudoaddiction. Unsurprisingly, this “scientific” consensus conveniently favored the interests of the opioid industry, who had higher sales targets to hit, and made pseudoaddiction an unfalsifiable hypothesis beyond the reproach of methodological inquiry. The few articles critical of the concept pointed out that it is a ‘clinical label without specific therapeutic, predictive, or diagnostic value’ that more often than not rationalizes addictive behaviors. State of Mississippi v. Purdue Pharma L.P, and several other state level lawsuits against Purdue Pharma, revealed that Purdue Pharma and the opioid industry as a whole uses front groups such as the American Pain Foundation (APF) and the American Academy of Pain Medicine (AAPM) to sponsor Continuing Medical Education courses (CMEs), through the AMA, that were favorable to their bottom line. A Georgetown University Medical center study found that industry funded CMEs do not mention opioid related deaths while non-industry funded CMEs mentioned opioid related deaths 26x and warned about the risk of addiction. Overall, industry funded CMEs were found to exclusively focus on chronic opioid therapy as a panacea for pain management, exaggerate the benefits of opioids, and downplay or dismiss the risks of addiction, adverse events or death. This lawsuit, like several other state lawsuits against the company, notes that Purdue Pharma sponsored the American Medical Association’s CMEs on pain management titled Overview of Management Options (through their front groups) in 2003, 2007, 2010, and 2013. The sponsoring front groups also hired industry shills as key opinion leaders to give lectures that supported chronic opioid therapy as well. One of the most prominent key opinion leaders that disseminated industry funded CMEs on pain management was Russell Portenoy, MD a Chairman of the Department of Pain Medicine and Palliative Care at Beth Israel Hospital in New York, who instructed AMA accredited physicians that NSAIDs such as Naproxin and Ibuprofen were unsafe at high doses while opioids were safe at high doses. Like many key opinion leaders in charge of editing and presenting CMEs on pain management, Russell Portenoy was a paid consultant of Purdue Pharma.

The pseudoaddiction dogma wasn’t just insider knowledge between the AMA and their accredited physicians; they disseminated the narrative that opioid seeking behavior was mostly driven by under-treated pain to the media as well around the same time Richard Sackler sat on the foundation board of directors. For instance, in a 2003 letter to the editor in a USA Today column, then president Donald Palmisano told the public that the under-treatment was a major societal problem that we should focus on. That same year the Joint Commission on Accreditation of Healthcare Organizations, now just the Joint Commission, released a monograph warning their accredited hospitals that they should always try to avoid the under-treatment of pain and alleviate physician exaggerated fears of addiction from using opioids to treat chronic pain drawing the same distinctions between addiction, physical dependence and tolerance as the opioid industry did in industry documents. The opioid industry created a false dichotomy between addicts and physically dependent patients, as if there isn’t a large overlap between the two, on top of the already unfalsifiable hypothesis that most opioid seeking behavior is pseudoaddiction. The Joint Commission also introduced the 10 point pain rating scale with the different facial expressions in hospitals and doctor’s offices around the country and made it the 5th vital sign that physicians assess in every clinical encounter. The ‘patient advocacy’ group that successfully pushed for its inclusion in routine checkups was the American Pain Society, which as you might have already guessed is an opioid industry front group. The Veterans Health Administration introduced the 5th vital sign assessed during routine checkups in 1999 while the Joint Commission followed suit in 2001. If you’ve ever been in an American hospital or PCP office you’ve seen that 10 point chart with the different facial expressions on the wall. It’s hard to believe something that innocuous and ubiquitous in health clinic visits was the result of corporate shilling but like the rest of our reality that too was warped by the interests of predatory capitalists.