Insurers Refusing to Cover Pain Medication – Morphine 100 mg per Day Maximum – Opioid Wake up Call – New Nationwide Standard? DEA Mandate


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The FDA mandated 22 manufacturers of long acting opioids

to fund a program on opioid prescribing.

FDA dictated the content.

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I attended the SCOPE of PAIN program Friday November 6, from 8 to 12:30, taught by an Addictionologist from Portland with our local Southern California DEA. Continuing education credit was given by Boston University. The first grant recipient was in 2012.  

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My take:

I think we will rapidly see a 100 mg per day

maximum morphine equivalent allowed

Could I be interpreting this wrong?

Insurers simply deny paying for high doses. They have begun already.

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I am exhausted from ICD10 diagnosis coding – complex patients !!! – that has taken away any possibility I could leave my desk until 4 AM for the last four weeks, in midst of moving office to much better place, and midst the only two computer crashes I have ever had in my pursuit of efficient tech, plus dental fracture, so much more….perfect storm. The paragraphs could be edited and rearranged, so they would be in sequence but they’re not.

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I hope others will give me their take on this. It has been getting worse since almost all university interdisciplinary pain clinics were closed in 1991. Insurers, i.e. managed care clerks, are practicing medicine mandates set forth by anonymous committees looking at spreadsheets not at our complex care. Insurers could save many billions if they invested a few billions in education. Insurers wrote Obamacare. They could write it better. Congress wants all of us to do our part. Surely business too?

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Based on this series of opioid conferences, my guess is their first step is to chop opioid prescribing down to 100 mg morphine equivalents. But what about untreated pain at the heart of the epidemic of suicide? I see it among all classes of people, because we’ve focused on opioids too long to the exclusion of research and exclusion of a whole world of medications now generic, no longer on patent therefore inexpensive, FDA approved medications. The biggest shock: Valuable compounded medications are no longer on formularies of insurers! Our most affordable FDA approved medicines are no longer covered by insurance.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

or is it lack of affordable medical care?

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My comments arise from grave concern the Insurers and FDA are overlooking the needs of my pain patients. I must speak up now despite need to recover in the next few days.

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Where is the concern for the pain patient

in this multimillion dollar pharmaceutical-company-funded opioid conference?

FDA mandated that manufacturers of extended release opioids fund the conferences.

Where are the millions that need to be spent on

rational interdisciplinary pain management,

rather than just opioid management?

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We need more than just studies of suicides and opioid changes.

We need hospitals and insurance systems

to recognize legitimate therapies that work for real people.

Would the epidemic of addiction

go down if people could get treatment for their pain?

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I posted this week on a new study, an epidemic of suicide in Caucasian middle aged Americans. The results were a shock to Case and Deacon, the Princeton Economists who did the research that merited two articles in the New York Times.

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Epidemic of suicide

deaths as high as in the AIDS epidemic,

driven by pain, disability, loss of job, drug abuse, other.

By too many opioids or by untreated pain?

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That is why, a few days ago I posted on that epic study by Princeton economists: the suicides in middle aged Caucasians now comparable to deaths during the AIDS epidemic. I posted how that can change. In that article and for years with this blog, I post about medications that work more effectively than opioids, i.e. glial modulators, and the need for compounded and herbal medications from approved highly reputable small local pharmacies need to be covered by insurers and allowed on hospital formularies.

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Epidemic of suicide – could it be due to lack of pain treatment

not due to an epidemic of opioids?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

Or is it lack of affordable medical care?

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The key figure from the Case-Deaton study on epidemic of suicides in white middle-aged Americans –  bigger than deaths at the height of the AIDS epidemic. The question is why?

Andrew Gelman, statistician at Columbia University and writer for the Washington Post, argues in his blog against the rate being higher at all. His conclusion: “…death rates among middle-aged non-Hispanic whites in the U.S. slightly increased, even while corresponding death rates in other countries declined by about 30%.”

Screen Shot 2015-11-05 at 7.53.11 PM

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Regardless of the argument, untreated pain is a big problem. It causes suffering and joblessness, and can lead to addiction and suicide.

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Does it matter which side of the argument is right?

Pain management is being taught in only 3% of American medical schools.

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births.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

Or is it lack of affordable medical care?

Insurers are not willing to pay for larger doses of opioids

and deny prior authorization.

Does this lead to suicide?

Money is the root of some of this.

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The cure for suicide is not just to take a sword and slice off the top doses of morphine, and treat everyone with the same low doses, whether you have herniated discs or sprained ankle or RSD.  Sprained ankles may be already getting too much.

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Why blame it all on over-prescribing? How about suicide due to under-prescribing, or suicide from not treating pain at all because healthcare insurance and unemployment don’t mix?   

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Are they blaming high doses as cause of suicide? How about when high dose opioids fail, when all drugs fail, we see no new drugs on the horizon for pain control. That does not fill those patients with hope.

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Of course it is important to acknowledge, as the New York Time health section has followed that epidemic research with How Doctors Helped Drive the Addiction Crisis.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

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Someone must advocate for change. It’s not just pills, it’s not just opioids.

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We are all at risk from disabling pain, loss of jobs and suicide

—yes, doctors too become disabled—

because of substandard education in pain management in this country

focused almost universally

on opioid treatment of pain.

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Lack of funding killed the university interdisciplinary pain management centers in 1991

 

AND we need access to compounded drugs, herbs & supplements in our hospitals.

If Memorial Sloan Kettering Cancer Center can do it, why can’t my hospital?  

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Expect 100 mg oral morphine or equivalent maximum dose per day to rapidly become the standard nationwide. Insurers are refusing to cover the cost of higher doses. Even if you can afford $17,000 out of pocket each month for pain relief, your doctor will be shouldering liability if outside these rapidly evolving guidelines. Insurers rule – and they deny coverage of inexpensive compounded drugs that work better than opioids for my patients who have failed all known treatment. That’s why we need better education and more clinically focused research.

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Those who blame Obamacare for high insurance costs and business-wide practices need look no further than the price of medications, especially opioids.

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It seems everyone breezes over where Washington State came up with a maximum of 100 mg morphine (or equivalent) as a maximum daily dose of opioid. 

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This 100 mg maximum daily morphine dose became law in Washington State many years ago, initially for Workers Compensation, and will soon be adopted by Oregon.

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Of course we are all concerned about the shocking rise in deaths from prescription opioids that are occurring since opioids began to be used after Russell Portnoy published its use for chronic pain in 1991. We just didn’t know that they work for cancer pain that is usually acute pain, not for what is now tens of millions with chronic pain who are on opioids

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But opioids are still necessary for some. Those of my patients who take opioids will have a very hard time with the 100 mg morphine (or equivalent) maximum daily guideline. Informed consent is out the window. We all recognize the practice of medicine has been done by insurance companies since the late 1980’s when managed care took over. This will not change. Now insurers require the ICD10 diagnosis code before they will allow the pharmacist to refill an antidepressant that the patient has been taking for one year with much needed relief. This will give them more tools to deny paying.

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It would appear that those who govern our medication use (insurers and DEA) — and who deny coverage of even more useful, inexpensive medication –  feel that 100 mg morphine equivalent is the maximum dose that should be prescribed.   

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100 mg oral morphine is equivalent to:

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66 mg Oxycodone

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25 mg/hr Fentanyl Patch

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25 mg hydromophone (Dilaudid)

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120 mg hydrocodone (12 of the Vicodin, Norco, Lorcet 10 mg tablets)

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30 mg Oxymorphone (Opana) use not recommended

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Morphine               to                Methadone      

30-90 mg                                   One fourth the morphine dose

90-300 mg                                 One eighth (200 mg/day morphine = 25 mg methadone)

300-500 mg                               One twelfth the morphine dose

>500 mg                                    One twentieth the morphine dose

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Methadone conversion is far more complex than this guideline from University of Michigan

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Only 3% of medical schools teach pain management. That ignorance is costing us trillions in insurance and pharmaceutical fees, and right now the latter two are making war on each other by taking it out on you, the patient who is getting substandard care. They’re taking care of their financial needs that show us the symptoms of disease, pain, suffering, disability, loss of job, and the just published this week, the epidemic of suicide. We need to treat the cause, not just the symptoms. Medical education, injury prevention and treatment needs to be taught starting K-12. The cost would pay for itself but the Insurance Industry needs to pay for it there and in University Medical Schools because Congress will not pay for it. It would be a cost saving investment that would pay itself off in care for seniors when grandchildren have to spot mom and dad in the 24 hour, extended family care that strains budgets. We cannot afford not to teach trigger point basics to each kid and each physical therapist and MD. That alone could save tons of opioids and monthly visits for what never works for muscle strain that no one has found.

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I’m tired of seeing how degraded it has become. To fail to treat the cause of disability and suffering is far more in our hands now, it could happen if people were taught basics instead of opioids, K through medical school. Are we teaching only opioids? yes, it seems so. I am advocating for everything I have written about in this blog since 2009. Glial modulators, mechanical approaches, but compounded medications, in particular, are sadly becoming unaffordable because insurers have stopped coverage for them. Then we all lose one of the most important tools, the only tool, that my patients and millions of others have in treating intractable pain or treatment resistant Major Depressive Disorder, Bipolar Depression. Compounded medications often work after everything else has failed. The lives of my patients have usually either returned back to normal or  improved in ability to function. That has never been shown with opioids for chronic pain.

 

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I’m too exhausted to be in a position to edit what I’ve written just now, or write adequately. I am just furious at the direction our country for decades has pushed into opioid treatment rather than pain management. This has reached peak brewing since the DEA conference yesterday, dictated by the FDA funded by opioid manufacturers.

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It is a hope that Insurers could fund an analysis of the billions that could be saved and suicides prevented if they funded pain management. What is there to live for than a life free of pain and disability?

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The analysis could show how much is saved when training begins with the young, how to prevent and treat injury. How helpful a child can be to aging grandparents or parents when illness strikes the family. We always turn to family first, as we should. Why is something of the field of pain management not taught in K-12?

 

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The FDA just authorized two opioids for children this last week. I have a vague memory one was oxycontin in children. I do not argue against opioids, I have given opioids to tiny children when I worked in hospice. Children have crippling arthritis too and other medical needs for opioids.

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I am not arguing against opioids. I am saying that what is taught is zero pain management. The focus on drugs is completely unbalanced.

 

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If Sloan Kettering can teach herbal and supplementary medicine to cancer patients, why not begin the study of herbal medicine at K-12 since a lot of parents are taking it instead of using common sense such as exercise, weight loss, family time, relaxation. And herbal and supplementary medicine is what these young ones will teach their children when they grow up. Hopefully prevent some of the toxicity from swallowing all sorts of useless and dangerous things on the shelves.

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Rational health care must begin young in the schools. .

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7 Responses to “Insurers Refusing to Cover Pain Medication – Morphine 100 mg per Day Maximum – Opioid Wake up Call – New Nationwide Standard? DEA Mandate”

  1. John P. Says:

    Pain suffers can find a Better way to relief and Control real pain. I did it, I am a Intractable Pain Patient suffering for 23 yrs. I found a way to REPLACE all Rx Opiates like Oxycontin and all Rx drugs I once took for 12 yrs, with one old Medicine that once was used to REPLACE HEROIN MEDICINE in 1914. This KNOWLEDGE I got from Reading Dr Grinspoon’s BOOK from this HARVARD Doc. Please Read what my Senator Feinstein view on what I use, over the Rx Opiates….Dear Mr. Prinz :

    Thank you for contacting me to express your support for medical marijuana. It is important for me to hear from you, and I welcome the opportunity to respond.

    On June 11, 2015, the Senate Appropriations Committee marked up the Commerce, Justice, Science, and Related Agencies Appropriations Act for Fiscal Year 2016 (H.R. 2578). Senator Barbara Mikulski (D-MD) offered an amendment to the bill that would prohibit Department of Justice from using funds to prevent the implementation of state laws authorizing the use, distribution, possession, or cultivation of medical marijuana. While I voted against the amendment, you may be pleased to know that it passed by a vote of 21-9. H.R. 2578 was passed out of the Appropriations Committee and is awaiting consideration by the full Senate.

    Please know that I believe it is important to conduct further research on the potential medical benefits of marijuana and wrote to the Departments of Justice and Health and Human Services, asking them to consider revising overly burdensome restrictions, which may inhibit such research. In the Department of Justice’s response, it stated that it was “fully committed to supporting lawful research involving marijuana and CBD” and that the Drug Enforcement Administration would conduct a scientific and medical evaluation of CBD. I was pleased to hear this and have included a copy of the letter, should you wish to read it.

    However, while I support the compassionate use of medical marijuana when prescribed by a physician for certain serious illnesses, I also believe that states must have strong regulatory systems in place to prevent youth marijuana use, rogue dispensaries, and ensure public safety, amongst other things.

    In August 2013, the Department of Justice announced that it would not block state laws legalizing marijuana in Colorado and Washington. It also highlighted eight areas priority enforcement areas related to marijuana. It is important to note that, as a result of these priorities, the Department is not currently prosecuting the average medical marijuana user. However, in its memo, the Department reserved the right to challenge a state if it does not have a strong regulatory system in place. Senator Mikulski’s amendment could prevent the Department from enforcing federal law in states that lack a strong regulatory system for medical marijuana.

    Again, thank you for taking the time to write. If you have any additional comments or questions, please feel free to contact my Washington, D.C. staff by calling (202) 224-3841 or visit my website at http://www.feinstein.senate.gov.

    Sincerely yours,

    Dianne Feinstein

  2. pharmaciststeve Says:

    This war on drugs/pts was created by congress and our judicial system. IMO.. It will have to be resolved at the ballot box and the court system. 1914 the Harrison narcotic act created the black drug market based on racism and bigotry and in 1917 our court system determined that opiate addiction was not a disease but a crime in and of itself. Look at the definition of torture and civil right violation/ discrimination under the Americans with disability act. Those in healthcare are in fear of their license and livelihood and the dea. Fines/court awards from pts suing for denial of care, torture (physical and mental). Irrresponaible professional negligence for starters

  3. Barbara Waitt Says:

    WOW-have you said a mouth full- and are in need of a vacation. thanks doctor for helping to advocate for chronic pain pts . I’ve had CRPS for 8 yrs- it is now attacking my organs- specifically cutting my blood supply to my transverse colon via the mesenteric artery. & my palms/soles burn whenever im awake- I’m on low dose 10/325 4x a day-usually i take 2-because i am aware of the way opiates work. I want them to work when I NEED them to.Besides I’m unique because I WANT to feel when my blood supply is cut off to my gut. so i can document it for my gastreo.- I.E. when,how long before I here the gushing of my blood being turned back on by this horrible disease that no one likes. .NOTHING takes away my burning palms though.you my dear doctor are an inspiration. you have an impressive blog. I plan on reading more-one thing I don’t see though is a share fb/twitter/linken icon. thanks again, Barbara

  4. Eryn Kahler Says:

    I thank you for your help in this fight us pchronic pain sufferers are now facing. I just got slapped in the face with it myself. And while I’d been pretty much opioid free sine I got CRPS back when I was 19, no one was willing to give me any sort of medication to even help with the pain in any way. People tried different combos of meds, but none were pain meds. A year and a half ago I got much worse and developed another chronic pain disorder along with two additional autoimmune disorders. The pain had finally gotten to the point where I had to quit my job. Then a month after that my PCP started to try different medicine combinations to try and take away at least some of the pain. On the one to ten scale my pain hadn’t been below an 8 or 8.5 until my doctor put me on a Med that is apparently very strong to try and help me sleep because until a few moths ago, it was completely impossible for me to even hazard a guess as to when the last time I slept more than 45 minutes in a row. And she also started me on pain meds. Opioids. After I’d gone to the ER with a pain flare so bad I couldn’t stop screaming or passing out because the pain was more than even my body could handle. And I’ve built quite the tolerance over the years. When I got to the ER, no one had ever even heard of CRPS,which is the case every time I go to any ER, and there are only 2 in Anchorage, and believe me I’ve gone more than once for ba flare, they had heard of Fibromyalgia which was contributing to my pain but not a whole lot, and my CRPS is whole body along with having whole body extremely severe Alloydina. As in no one better touch me. It took them 3 tries to stick the IV in because despite my mother telling them to just find the best vein you can and they are going to roll, it doesn’t matter how gentle you are my daughter is going to scream her head off. She went over everything I had with them so many times it’s crazy. Any my mom is no idiot, my mother is a brilliant woman who actually works in that same hospital, and has a second job as a PNP. So she is 100% fully qualified to talk about what is wrong with me, the best and easiest ways to make it better and faster for all involved. Did anyone listen to her cause I couldn’t talk since I was to busy screaming and trying my hardest to breathe so I wouldn’t pass out, nope! I will give the Dr. who saw me an oz of credit for listening a tiny bit once he got there, but he only did that, because he’d worked with my mom at another hospital. Anyways, the point of the story, pain meds. After I got there and they set me up with the IV the Dr thought he’d give me 10ml/mg whatever it is of Morphine. He did it bit by bit ove a half hour or so I think from the report I read. I don’t remember at the time. It had no effect whatsoever, I mean as in zero, it did nothing to help me at all. I was still screaming to the point of being unable to breathe and still unable to talk or be cohertant talking in any way. Still after that much morphine. And just as a guide, I may be 38 yrs old, but I’m 5’3″ tall and weigh 105lbs, that should have knocked me and my pain far away. But CRPS is not any old pain disorder it’s the worst of the worst. And the longer you have it the wider it spreads, so like I said, nearly 20 years now and it’s full body. So after the Dr. saw the morphine did nothing he put some Tramedol in the IV, then waited a bit to see if that would help. Again I’m not sure exactly how long. And wouldn’t you guess, nope it didn’t touch the pain either. By this time it’s probably been 3-4 hours in the ER plus the two hours I sat at home screaming waiting for someone in my family to get home to take me to the ER because it’s to painful for me to move or talk or hold a phone. So I’d been in what I call my level 10 screaming passing out level of pain for a good 5 hours by now still not a second of relief seemingly anywhere in my future and the ER only seems to be causing more pain with the IV. So I’m ready to just go home at this point. My mom begs me to stay. See if maybe they have one other trick up there sleeve. The Dr. comes back in and is totally dumbfounded by this little woman to whom they’ve given enough pain killers to knock out a horse and I’m still screaming, well as best I can with what voice I have left by this time..so he says ok, we will try one more thing then we are at our limit of what we can give someone of your size. Or so that’s what my mom told me was said. Then they gave some amount of Delauded that I don’t remember. I do know that it took 5.5 hrs, and a wholly ton of pain meds to get me to go from screaming my head off and passing out from the pain, which is my personal number 10, down to heavily just crying and ably to breathe fairly normal, which is my personal 9 to occasional 8.5. But that was how they sent me home. All in a great days work for them because I was no longer screaming my head off. Sadly in my records the Dr. couldn’t even be bothered to remember the name of my chronic pain disorder correctly. He used its old name and put them in the wrong order. Makes you feel extra warm and fuzzy about the competency of your average ER Dr doesn’t it.
    My concern here is, with all of the regulations on opioids and such, which I admit I take now with a great deal of success in my pain management. People like me who live on these meds, and can live in a world where they aren’t screaming every day. That’s what awaits us if they take our meds away. It took me nearly 20 years to find a grouping of meds that semi work for me. And I still can’t walk can’t work, have far more bad days than good! And I’m so grateful for those few good I do have it makes living through the bad worth it. What happens to me and others like me when our meds that allow us to live at all are gone and that’s no longer the case.

    Thank you,
    Eryn

  5. Felicia Says:

    The entire thing is a sad situation. I think (hope) the reasons for all these laws/rules/guidelines/regulations are to stop drug addicts from abusing and diverting them for money or whatever else they do with them, but they are hurting the chronic pain patients. They truly are. The drug addicts will always continue to get their “fix” by moving on to other means. Ive learned from research that heroine is now the preference because they cant get pain pills, but neither can true pain sufferers. I am just now finally to the point Im functioning well, I can clean my house and even ride an exercise bike (all the steroids Ive been on has made me overweight and moody and now have a low self esteem, but they help so I continue to do them). I have been on the same medication for 7 years and started on a fairly low dose, with only 2 increases and Im now at a dose that allows me 24 hour pain-relief (I still hurt, but I know I’ll never be totally pain free but I can function and take care of myself again). I have never sold a pill and I dont abuse my medications. But now my doctor has become fearful and is discussing taking them away by weaning due to a new “tool” on the prescription monitoring system that compares medications to morphine equivalent doses “MED” and mine is higher than what they consider adequate … for whom?. They dont know me or know how bad I hurt or what I need or even whats wrong with me. Ive undergone every possible procedure and injection and surgery possible for my conditions to relieve my pain in combination with my medication. So while pain sufferers continue to be in pain, the drug addicts will continue on normally with new means to get high. There has to be a better way, a way that doesnt hurt the lives of people like me. Doctors shouldnt FEAR prescribing what they consider a safe dosage for individual cases.

    • Nancy Sajben MD Says:

      It’s not addicts. Please read my more recent posts on coming CDC guidelines and 18,000 plus deaths in one year alone from **prescription** opioids. This number is rapidly increasing.

      The 100 mg morphine equivalent maximum is too much for some, too little for others. Doctors have no choice. We have been pressured and our hands tied increasingly more heavily since managed care took over the practice of medicine in the mid to late 1980’s. For years, patients have been squeezed more and more, with denials even of generic drugs. Hospitals forced to close years and years ago, medical schools tried merging in early 1990’s. Reimbursements chopped, doctors forced to see more to pay for overhead. Now patients are starting to feel the burn. Price of drugs raised so much every year they are unaffordable, and insurance refuses to cover.

      Consider also, aging population, kidneys and liver less able to metabolize medication. New medications may compromise, sedate or cause falls and/or death not otherwise due to opioid that had been fine for years. We cannot always predict which of 20 or 30 possible side effects a new drug may cause — insomnia or somnolence, constipation or diarrhea, loss of appetite or hunger, weight loss or weight gain, etc. New drugs added every few years.

      I had to send a very bright patient to the ER this week — first time in 40 years — because she failed to report severe sedation, falling asleep all day long after Cymbalta was increased 10 days before. Her oxygen level was too low to support brain and heart to keep her awake. Imagine how low it dropped during sleep. Obviously she assumed she was capable of handling drowsiness, or did the sedation blunt judgement? No deaths on my watch so far, but she could easily be my first and it would devastate me and her family.

      It’s only a matter of time the opioids I prescribe will cause serious harm. That has not happened yet, but no system is perfect. I cannot control people’s judgement or what they choose to report or do, nor do I know if she was taken to the ER as instructed. After so many surgeries, and so many different pain conditions, perhaps she chose to stay home and sleep — not suicidal, but it would have been passive suicide.

      The use and overuse of opioids in the United States is serious and not seen in any other first world country. The United States does not cover adequate mental health care though cognitive behavioral therapy, meditation, guided imagery is essential in treatment of chronic pain. How many patients ignore that? And physical therapy is tightly restricted. Essential also. Research has turned to stem cells, rather than apply the world of science that has been published on the innate immune system and the pain matrix, and rather than repurpose already existing FDA approved drugs to treat pain.

      Stanford last week published in mice on recovery of paralysis from stroke in 3 days rather than 30 days after treatment with a generic drug, repurposed. Huge breakthrough. Now will undergo further testing on other species, later in human trials before it can be applied years from now.

      Opioids have made billions. Where is the investment on research of pain based on published mechanisms posted on this site for years, using repurposed medication already FDA approved? They usually work, usually far better than opioids. Answer: insurers stopped covering compounded medications. Insurers cover opioids, but on their terms, their doses, their price, and soon probably limited to morphine only.

      • Terri Lile Hackett Farmer-Hamilton Says:

        IMy doctor just told me about this today I have degenerative arthritis in my spine My legs and all my joints hurts 24/7 I’ve always worked hard lifted things probably shouldn’t didn’t have a choice work or get beat usually got beat as kicked in back by 300lb man 2 car wreck both did lasting damage to back neck Neither my fault Then chemo Chemo seemed to intensify it 100 times My doctor and I have discussed my pain treatment every visit both know its going to get eorse Then he tells me today because of insurance and government he has tomcut my treatment in half Lifes just doable now I’m going to suffer be in constant pain But bet Hollywood Alisters .rich musicians tgat gets a hang nail gets perscriptions then hooked and o’d Hopefully not There the problem if your in real pain you won’t get high won’t want that They get a buzz happy So now poor hard working a American people with real pain has to suffer yet again and more because of government Hope i can at least be able to cook for myself


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