Off opioids, pain better. Life is back!


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We have all seen pain go down when patients taper off opioids. Look down many paragraphs to see a case report near the end.

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I prescribe opioids for intractable pain, but I have never seen opioids take pain to zero on a sustained basis, year after year – I have seen glial modulators with the specific off-label combinations of medications do that. Chosen because of mechanism: neuro-inflammation that we know is present in chronic pain or chronic depression and recently reported in teens with early psychosis. Inflammation. Brain on fire – imaginary fire, skin is burning, shooting, pulsing, changing from ice to hot, unable to tolerate light touch, sunlight.

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You don’t have to be a rocket scientist to read the brilliant science that’s come out since 1991 that has changed neuroscience more profoundly than anything I’ve ever seen – many prizes given from many countries. Ignored by docs – don’t blame them. Not everyone is able to take the risk to be different in medicine. It is NOT rewarded. Doctors can just ignore patients now after 30 years of living with pain 10 on scale of 10, pain now zero. Like one of my patients best care for 8 years, told to live with pain that was 8 on scale of 10 constant, unvarying, burning.

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You never will see that with opioids, procedures, pumps, stims, blocks, biofeedback. Most of my patients with intractable pain from hell, been there, done that at the top places: Boston, Philly, Cleveland, Mayo, years of grueling P.T. Kids get the worst. No drugs for pain until after age 18 – pediatricians need to be studied what they do, and oncologists need to be studied again. I know a top hospital in the country where for decades not one oncologist ever called for a pain consults – decade after decade. I know too many stories from too many top places about how cancer pain is not treated as well as it could be because of opiophobia perhaps, but there are so many other things done for cancer pain – oncologists refuse.

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The oncologist at a famous hospital in Beverly Hills that will go unnamed, threatened the grandmother of my UCLA Pain Clinic colleague, an MD Pain Specialist, who had come with her grandmother. Oncologist threatened the 90 year old woman: “If you want pain medicine, find another oncologist.”

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Any hospital would sooner get rid of pain specialists – they don’t bring money to the hospital like cardiologists who get streams of patients from around the country. In Houston, Netherlands would load a jumbo jet full of patients who needed heart surgery, fly them Sunday to Baylor and fly them back home end of week after heart surgery. Every single week, a plane full. These are GODS!

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Your pain is a low priority on the scale of gods. Excuse my tone. It breaks my heart to see every pediatric nurse threaten to walk off the entire floor if the MD did not call a pain consult. And I read in nurses notes, line after line after line the same thing for 3 months: “Patient screaming in pain.”

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I diagnosed the problem that they overlooked – every spinal nerve root coming off every level of spine was lighted up like a tiny 1″ band of pearls each side. This 17 year old athletic muscular tall male had lost 45 lbs of muscle, unable to move, screaming, 2 nurses required to bravely try to roll him onto his side to change sheets and toilet in bed, him screaming, perhaps rigid – I was never there then. Ignored by one of the world’s foremost oncologist for three months. The humanity of it.

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I’ve seen worse.

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GODS. These men are GODS. As a junior faculty, you do not look them in the eye, ask a question, or even speak to them. He was one of the best in the world, perhaps the very best, #1 – God of Leukemia, not god of pain so intense the lightest touch of skin elicits severe pain.

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That’s called allodynia. Slight touch, just a breath of air, very very slight touch = SEVERE PAIN.

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Nerve pain when severe does that. It can be focal or widespread, every where, like his. He had the mentality of an 8 year old, but loved playing basketball. Leukemia brought him in, and you cannot see leukemia on scans or xrays. Are you going to tell a GOD that pain exists in people with leukemia? – malignant blood cells and pain. No, no, no.  No one of the leukemia service was ever allowed to call a pain consult at a world famous cancer hospital. You would be fired. Career over. Mom was trying to raise the money to treat this leukemia. $30,000 she did not have.

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So many case reports I could write. But it never changes. Patient calls after decades of intractable pain. I have had them taper off opioids slowly before I see them. I assess whether I want to take them as patients. They’ve been to Europe and across the US, the best places, nothing has helped. Even ketamine coma in Germany, it did not last but boy it caused PTSD. You cannot give those doses of a psychoactive drug to brain. Ketamine is a short acting drug. No matter how you give it. The dose is different for everyone. They burned through her threshold and PTSD could not even be discussed, it was so bad.

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I never use ketamine alone – only with certain combinations, and later, my patients may not need ketamine again. Pain free. Not everyone becomes pain free, but it occurs so regularly that it’s almost hard to fall off my chair so many times with the results. It used to be a surprise many years ago and I would always fall off my chair. It has become regular. No surprises. This is getting old and sad no one knows how to do it. Pradigm shifts do not just occur, and not without publications, studies, one slow drug after another. That’s not the way you are ever going to get results – study only one single drug for 10/10 pain present for years to decades. When disabled 30 years, the standard for research is to study one drug. That’s fine for mild conditions.

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It’s incomprehensible to think one drug alone is going to budge intractable intractable pain or depression. And difficult for me to understand patients who think one drug alone will do everything though they have failed so many classes of medications for years or for decades. One drug is not adequate to restore balance in the complex system of transmitters, receptors and DNA changes.

Wrong thin

Mechanical pain complicates things and must not be overlooked even though it may be “minor” compared to the bear in other parts of the body. Wrong thinking. All pain ends up upstairs in the big lake at top (brain). Not minor. Never has anyone found a pill that can do better than mechanics of the spine or limbs.

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My new patients have already been through every known form of interdisciplinary treatment at the worlds best pain clinics. You all know that entails a number of specialists as a team – you do the work, mind and body. Done by most of my patients before they see me. Past History.

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Once off opioids:

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My focus is on neuroimmunopharmacology. Read January 2011, the innate immune system. There must be a balance between anti-inflammatory cytokines and pro-inflammatory cytokines. The pro-inflammatory cytokines are too high, out of balance. Let’s modulate them, restore balance.

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Lovely to see people better. It makes me want to go to work. I suspect CRPS may respond best to these medications  but I have seen many other syndromes respond well – but remember, no treatment is 100%. I see impossible cases. It would be a miracle if anyone saw 100% remission or cure in their medical practice. But the combinations of medication I am using are certainly life saving for many of the toughest.

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Mechanics – so many patients have groaned when I said I felt they had to see the physical therapist I refer to. Groans. 30 years of P.T. never helped, they say. After seeing Bruce, they come back smiling. Bruce says these are basic things he does. Well, didn’t help my patients. Not one of the best university centers in the country where my patients have been for 3 to 6 months, never helped one bit. Bruce says it’s basic. Bruce is unique, certified orthopedic physical therapist – most never get that high degree. Decades after training at the famous rehab center Rancho Los Amigos from whence books were published, basics of orthopedics and rehab. After seeing Bruce, patients come back smiling, awed. I am shocked there is still so much crap P.T. out there. I thought all this changed after the new manual P.T. was brought to the US before 1980. Yikes.

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Opioids. How many use them for anxiety instead of pain, misreading and confusing what you are treating yourself with. They work great for anxiety, but America – you must learn better ways to cope and opioids are not to be used for anxiety. I hear the groans and downright refusals. A few years later, one of my older guys has nowhere to go, nothing helps but the opioids and his body will not tolerate more. Not one coping skill was going to get near him years ago. If his wife couldn’t do everything for him, then his caregiver would. He wasn’t going to have it. Granddad is a very proud businessman who cuts himself off from family, they should not see he has a walker.

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Opioids ain’t the answer. But sometimes we have no better – in limits. Only after other things, glial modulators should be tried first. How many of you have seen results with gabapentin? Maybe I just only see the ones who’ve failed everything.

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I frequently see people who are better off opioids than on, but then, then what do MD’s do about that pain that may be still 6 out of 10 or worse? They don’t have an answer. And are not curious to figure out what to do with the new science. They have been trained the old way. Nothing new but hope for a new drug from pharma some day.

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I am writing so far off track. I hope you understand a little of this rapidly changing antediluvian field and that some places are still in the Middle Ages where we don’t treat pain at all. How do they get away with that? It’s not a priority anywhere. NIH gave one half of 1% to pain research in 2008. Really? !?!!

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CASE REPORT

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Many paragraphs ago, I was planning to write to tell you about a case, 2nd visit so much better! and a lot of that is simply due to being off opioids 6 weeks after 6 years on them. Falling asleep from opioids for how many years—  imagine an MD taking on a patient who said they need a new pain doctor because their old doctor cut them back and will not give them a dose that helps. Makes you wonder if they were falling asleep and getting any oxygen to the brain. I find myself in that position when people call for new appointment. I hate to be the one to tell you I am not going to increase your opioid but many other pain doctors will. Soon this nice person sitting by my desk would have been one of those opioid deaths the headlines tell us about. This person today sitting next to me, happy she is off, and better!

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She is not drugged, pain is down and it changed character/quality, still rated 6 on a 10 scale, but she is doing more, actually waking up alive instead of zombie until 5 pm, walking. Walking – that’s the biggest.

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She has CRPS for 6 years as well as pain of the entire spinal axis. Failed gabapentin, Lyrica, Spinal cord stimulator – implanted 2013.

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At the first visit Jan 25, one month ago, she had tapered opioids in 3 weeks [far too fast], and was off for 6 days, lost 15 lbs – opioid  fluid retention. I ask people to be off 2 weeks before seeing me but she was in crisis. Most of the time she was lying down elevating BLE’s [both lower extremities] as it reduces pain in feet and RLE. She used to play two soccer games back to back without a sweat 6 years ago.

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“And I feel better. I always felt like my insides were swollen,” brain fog – unable to read, blurred vision – improving, “and the character of the pain seems different. The nerve pain used to feel like I had a huge halo and if you just touched the halo, not the skin, it was unbearable. I feel like the halo sensation was severely diminished. My sister also said I am walking better than I ever had – I was just weaning off then.“

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Before seeing me, she had been on MSContin 30 mg x 3/day with MSIR 15 twice daily or on methadone 80 mg in past. Pain then was rated 6. Today, 2nd visit, off opioids for 6 weeks, pain 6/10. But walking.

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2nd visit, 4 weeks later

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Her prior “biofeedback therapist told me I should write a book.” Helped in some ways, just to teach me better body mechanics to minimize pain. Did both temp and pulse and wore EKG-type patches on her back for muscle feedback.

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Now using desensitization – on dorsum hands able to use loufa, and can use a special rough soap on palms she could not tolerate before. Dorsum left hand is nearly normal.

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Pain on opioids was “6 to 7 but different character, I’m much improved now,” ranging 4 to 7, average 5. “I could live with this.” It’s lower. I used to always say I want to cut off my leg, and I haven’t said that in at least a month.

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Foot felt so swollen like it was gonna pop, and be so cold, made it very difficult with pins and needles to put a sock or shoes on. The occurrence is much less and when it happens it feels less severe.

Still has mild swelling “more what I perceive than what I see.” Her friends say she is not a zombie anymore. She wakes up and is out of bed.

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“If I concentrate very hard, I think I can walk without a limp, but I think I need some retraining.”

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We have barely begun much treatment. She is on her way back to life. 

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I have seen patients become even better simply off opioids.

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You must treat the whole person: the mind, body and spirit.

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Physical Therapy, Cognitive Behavioral Therapy, Biofeedback, Medication, Procedures.

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Compounded medications are the key. Thank the insurance industry for not supporting anything but opioids. I can’t even prescribe Namenda off-label for a patient with dementia because her dementia is not Alzheimers or Vascular, mild or moderate only. She has traumatic brain injury with CRPS and I prescribe Namenda (memantine) in double dose – good science behind that, published around 2001 when I starting prescribing for pain. Now I see the best migraine docs doing it in the last year. I don’t know when they began using it.

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Namenda (memantine) not covered. Unless … two things are possible.

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But compounded medications are essential for these combinations of medication. What is this country doing to its injured veterans? Opioids do not work. But their mechanical spine joints needs are serious and I know it is not being addressed because manual physical therapists are hard for me to find in this age, only 40 years since it was brought to the US from British Commonwealth and Scandinavian countries. Impossible to find, to trust you have a good one, and far beyond that, Bruce is awesome. How difficult is it to train better physical therapists? Or upgrade teaching from the theoretical that all these shiny new PhD’s in physical therapy. But get me the clinical experience, Orthopedic Physical Therapist because Bruce is awesome. No other word for what he has done to unwind the cause of CRPS in the ribs after thoracic surgery. Drugs can only get you so far. The mechanics become everything and they can take your body to more pain than you will ever dream of unless mechanics are properly addressed. My local patients may live 2 hours away from Bruce. That is not feaseable.

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Obesity.

Then, the elephant in the room. Guardian just now reports Penguins on a Treadmill, Study shows fat ones fall over more often than slim ones. How can we help those of us who will not be helped? Sanity does not prevail in politics and thou shalt not forbid 80 teaspoons of sugar in each can of “energy” drinks. America waddling onward into disablity. Sanity in politics. Behavior. As a great sage said: “You cannot uncurl the curly tail of a pig.” 

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Behavior is the hardest for me to change myself. I know. I don’t care how old you are, let’s wake up! and get you back to life. Off opioids. So many of us give up too little food on our plate or treats. You do not have to exercise to do that.

 

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The problem remains:

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You have to be rich enough to get decent care for intractable pain in this country. Rich enough to afford the compounded medications that used to be covered by insurance – do these guys cover anything anymore? The business reeks like the rest of the 1%. Same people. The big three: energy, pharma, insurance. Waves of anger across the country. The Middle Class is disappearing and they cannot afford an extra $300 a month for medication without family struggle. Stagnation.

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Donald Trump and Bernie Sanders are riding on that anger, and Democrats are shifting to Trump who, as Jeb Lund writes, with his “gallimaufry of disconnected thoughts” has the money to put his bombast into action. He destroyed his running mates. Lund goes on:

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“a billionaire beholden to no one and able to abuse every disingenuous and pettifogging remora latched headfirst on the nation and sucking upward.”

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“If the system is already so broken that it abandoned you, its preservation is not your concern. Hell, burning it down might be what you want most.”

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“Anger has a clarity all its own. It renders most detail extraneous….It is not to be underestimated….”

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His “disgusting behavior gets paired with the sight of Trump humiliating establishment empty suits like ….X….stuffed shirts like…Y…. party pets like…Z….. and habitual liars like…W…..” Trump is “lying in service of exposing another government predator.” 

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He will destroy Clinton. The politician who panders to money will be blown away by Trump. People respect that.  No one cares what his policies are.

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This site is not for email.

If any questions, please schedule an appointment with my office.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me..

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PBS tonight? Governor of Massachusetts (Charlie Baker) being interviewed on law 3 day limit on pain meds


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I was just informed:

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PBS News hour tonight has a segment on pain with the governor of Massachusetts (Charlie Baker) being interviewed on Mass law of 3 day limit on pain meds.

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I wonder how much that will cost. Could it be true?

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I don’t get cable.

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President Obama “declined to endorse” proposal to limit opioid pain medication


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OBAMA: LIMITING OPIATE PRESCRIPTIONS WON’T SOLVE CRISIS

 AP (2/22, Nuckols) my emphasis in red:

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“Obama was cool to the idea at a meeting with the governors he hosted at the White House on Monday, noting that [pain medications] are sometimes the only realistic treatment option for people in rural communities.”

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Obama said any attempt to limit the number of pills that can be prescribed has to be part of a comprehensive approach. But he also expressed sympathy with rural Americans who cannot afford surgery or other costly, time-consuming treatment for painful injuries or illness.

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Dr. Steven Stack, president of the American Medical Association, said Obama was right to question the potential consequences of restraints on doctors.

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“The complexity of the problem makes it difficult to create a successful one-size-fits-all approach,” Stack said in a statement on Monday.

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Governors Devise Bipartisan Effort to Reduce Opioid Abuse,

New York Times (2/21)

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Mr. Dreyfus, the president of Blue Cross Blue Shield “said, the Blue Cross Blue Shield plan has reduced claims for short-acting opioid painkillers like Vicodin and Percocet by 25 percent and reduced claims for long-acting opioids like OxyContin by 50 percent, by switching patients to short-acting pain treatments.”

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BINGO! There you have it. Proof in numbers.

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And taking away the 20 mg of daily morphine from my 93 year old patient can have the consequence of preventing her from walking when she already has limited ability to walk with arthritic knees or playing cards 5 times per week despite end stage frozen shoulders.

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“Dr. Patrice A. Harris, the chairwoman-elect of the American Medical Association, said doctors welcomed the opportunity to work with governors on solutions to end this public health problem. But she added, “The A.M.A. wants to make sure that prescribing decisions — the decision to prescribe or not to prescribe — stay in the hands of physicians.”

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“A monograph prepared by the National Governors Association acknowledges the difficulties that its members face.”

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“Reducing the opioid pill supply, for example, can have the unintended consequence of increasing heroin use,” it said. “Laws aimed at unscrupulous providers can make ethical providers less willing to prescribe out of fear of scrutiny from law enforcement.” And “one state’s successful efforts to reduce illicit sources of prescription drugs can shift illegal activities to neighboring states.”

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Policy Analysis, Ronald Libby 2005:

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Pain patients are

far more likely

to suffer from the

scarcity caused

by the DEA’s

crackdown than

are the common

drug abusers the

agency claims it is

targeting.

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The new mission offered in practicing physicians a pool of registered, licensed, cooperative targets who kept records, paid taxes, and filled out a variety of forms.

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…the task force arrests five doctors a year in the Cincinnati area alone.

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Besides assess forfeiture at the start of investigation of a doctor, even if criminal charges are never filed, a police department can still bring a civil action against a suspected doctor to recover the cost of an investigation.

 

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This site is not for email.

If any questions, please schedule an appointment with my office.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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Opioid crackdown: Doctors like Prairie Dogs. 77,000 prosecuted after 1916 opioid crackdown


 

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PAIN AFFECTS

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MORE PEOPLE THAN

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DIABETES, CANCER & HEART DISEASE

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COMBINED

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 opioid “guidance” = opioid crackdown

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Like the Oxycontin crackdown of 2002 when doctors where thrown in jail.

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“Doctors are like prairie dogs.”

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124,000 physicians

registered in opioid crackdown of 1916 – NOT suicides. Forgive me!

During the first fourteen years after the Harrison Act passed,

U.S. attorneys prosecuted more than 77,000 people, most of them medical professionals.

 

 

 

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Another round of opioid hysteria. This sharp CDC cutback to patient opioids, called OPIOID “GUIDELINES” in California – let’s call a spade a spade, this threat is deadly, its sickening and it’s crushing my heart. $1.1 billion for opioid abuse – how much will go to DEA to investigate and prosecute doctors? Time does not permit review of the Cato Executive Summary in 2005:

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Treating Doctors as Drug Dealers

The DEA’s War on Prescription Painkillers

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that details many prosecutions of well meaning doctors across the country from every wave of threats. Suffice some quotes:

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 “A 2001 study of doctors found that 40% said their fear of an investigation affected how they treated chronic pain.”

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“One 1991 study in Wisconsin, for example, found that over half the doctors surveyed knowingly undertreated pain in their patients out of fear of retaliation from regulators.”

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“A final problem with the DEA’s claims of an OxyContin epidemic is the agency’s inflated estimate of risk of death. In 2000 physicians wrote 7.1 million prescriptions for oxycodone products without aspirin or Tylenol, 5.8 million of them for OxyContin.

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According to the DEA’s own autopsy data, there were 146 “OxyContin-verified deaths” that year, and 318 “OxyContin-likely deaths,” for a total of 464 “OxyContin-related deaths.”

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That amounts to a risk of just 0.00008 percent, or eight deaths per 100,000 OxyContin prescriptions—2.5 “verified,” and 5.5 “likely-related.” Even those figures are calculated only after taking the DEA’s troubling conclusions about causation at face value.

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By contrast, approximately 16,500 people die each year from gastrointestinal bleeding associated with nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen.

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NSAIDS aren’t as effective as opioids at treating severe, chronic pain. Both classes of painkillers have beneficial medical uses. One is also found on the black market and may lead to occasional deaths by overdose. The other isn’t used recreationally, but causes 35 times more deaths per year.”

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The DEA’s Diversion Control Program is also a self-financing, autonomous law enforcement agency that is largely unaccountable to congressional oversight.

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American Pain Association guidelines warn against prescribing NSAIDS for those above age 60. Risk of cardiac arrhythmias, GI bleed, heart attack, death are too high, not to mention kidney failure.

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I feel the burn. No happiness engineers to edit. Delete this page tomorrow. The good news, mentioning being hacked – front page of website, missing for 15+ hours, now reappeared.

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They have the balls to call it “guideline” and the balls to threaten doctors, but not the balls to call it law. Tell me how it differs from law? History knows a government threat when it hears one.

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Remember a report written 2002 about the nationwide Oxycontin crackdowns occurring then? Damien Cave, writing in Salon, went on to write for Rolling Stone and New York Times international and national desk. 

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“Doctors were the earliest targets of prescription drug panic: As early as 1914, with the passage of the Harrison Narcotic Act, the government identified doctors as agents of addiction who needed to be controlled if narcotic abuse was to be abolished. The law, refined by a Supreme Court decision in 1919, made it illegal for doctors to prescribe opioids to addicted patients and required doctors who prescribed the drugs to register with the IRS.”

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Doctors then as now avoid patients with pain. Too hot to be near the fire.

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You doctors. You agents of addiction.

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“But doctors have blanched at the sweeping changes and proposed bans, and their panic has only increased in the wake of cases like that of Dudley Hall, a Bridgeport, Conn., doctor charged July 17, 2001, with 36 counts of over-prescribing. Sure, they argue, Dr. Hall, who prescribed more OxyContin that any other doctor in his state, (earning the title Dr. Feelgood), deserves to be prosecuted. But Hall was busted by officers posing as patients, and doctors fear that undercover operations will become the norm. The new laws, say doctors, even if they didn’t lead directly to Hall’s arrest, make police especially brash, far too confident in their ability to decide which prescriptions are valid or invalid. “

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“Just the specter of law enforcement meddling in medicine has been enough to cause physicians to drop needy patients, says Michael Brennan, a pain management doctor who manages a private pain clinic in Fairfield, Conn., a wealthy town only a few miles from where Hall was charged.”

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“Doctors are like prairie dogs,” he says. “One or two will stick their heads up, but as soon as something bad happens to them, they all go underground.”

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….”But Brennan argues that the increased presence of law enforcement is hard to dismiss. In fact, he says that he’s still reeling from an unexpected visit by the DEA around Thanksgiving. Though he’s strict about whom he’ll write prescriptions for — he regularly meets with family members to ensure that abuse isn’t occurring — he says that “every time I see a big blue Suburban come by my office, I’m like ‘Oh man, I hope they’re not coming for me.’”

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Economic stagnation is nothing compared to government threat, surveillance, and disappearing colleagues. 

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Now let’s air some of the negative —but stay strong as you read. Caution! Stop reading now if you feel vulnerable. To those who read on: Do not let yourself be swallowed by hopelessness and depression. The mind is more powerful than we can imagine. We must be taught to use its skills, every tool that has been brought to us. There have been decades of mind-body work treating pain without pills. Without pills. Wake up America. It’s real. Centuries of ancient techniques. You and I can learn to use our minds and find other tools. Think positive. Do it. Doctors too – do it. It’s real.

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We all admit the bad headlines, the 18,000 plus deaths from opioids in 2014 – addicts or suicides? the stories of everyday opioid abuse by millions of Americans with pain, whose abuses as painted by zealous anti-opioidists are disturbing headlines. Government officials easily find good reason to cut opioid doses. But it’s still a radical nationwide experiment on lives of people with chronic pain who may be too disabled to fight back.

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Reality: Surveillance. Kills trust.

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I feel awful all day after I had to try to cut opioid dose on a man whose back pain, neuropathic pain shooting into his legs, his bad knees, bad shoulders hurt bad. They hurt real bad. Bad for maybe 25 years. I must cut his doses radically. DOCTORS WHO TREAT PAIN ARE THREATENED UNLESS THEY CAUSE PAIN AND SUFFERING. I have never felt such pain in my life. It feels slick and unethical – it must be unethical to cause suffering. I have posted a bit on ethics of informed consent, tampering with patient autonomy, profound issues published by Michael Schatman, PhD. Patients have no choice. There is no informed consent. Can you imagine what it feels like to taper opioids?

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It is against my ethics to inflict harm on patients. How am I expected to challenge a person who uses opioids as anxiolytics? Can they get through life without them? What if they don’t want to be challenged on the delusion that opioids help? They refuse to work with a therapist. This has been their pattern for 25 years, long before they first saw me. I don’t think I see anyone like this, but what if I did? Can I inflict pain on them? Are all my patients perfect – they never reaching for an opioid when using better coping skills at moments of stress and high pain?

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What kind of chauvinism is this medical care I am being threatened to do? I am told to blindly turn away from the pain I am causing. March in step with politicians who cannot ignore voters agitating against the heroin crisis of suburbia and the middle class. Politicians and doctors who publish guidelines don’t have to face my patients, don’t feel their pain. Addiction is on front pages. Deaths from opioids in headlines. Trillions on the war on drugs merely fuels the fire. 

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Opioid cutbacks feel like marching orders – and it cracks my mind to attention. I know the power this government has and we all hear about too many local pain doctors who have lost everything. Investigations. Disappearances. You don’t always know. Lurking agents. Constant threat surveillance will pull you in.

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This lump in my throat and awful heaviness in the heart remains. I had to cut back a good man’s opioid dose today. I have tried to give him the options to cut back on his own; month after month he has not. The pain is killing him. He is not an addict. Far from it. I suffer looking at him as he tries to sit in a chair. But opioids cause his central sleep apnea. That complicates, perhaps caused, a rare form of congestive heart disease that stumped a number of top doctors. He’s gotta get off the opioids, they are literally killing him. So is the pain. Pain is killing him. He picked comfort care, some relief, any relief, and I probably would too, were I in half the pain he is in all the time for decades. What will be the strain on his heart to go through opioid cutback that uncovers nothing but higher levels of pain? and for what, to have life shortened because of more pain and fewer opioids or ….or….have life shortened with more access to opioids? Life is short and then we die. Which is the better death? He is not hospice eligible. Chronic pain is not a terminal disease. Can you guess if his level of pain will go down or up after cutting his dose? Pain has so compromised his life, disabled for years, now his government is cutting doses nationwide. He fought in our wars, and later worked as a federal executive, but disabled since the 90’s, since he was in his 40’s. His body feels 20 years older than it is. he has more kinds of pain than you have fingers on one hand, and sees a doctor every day of the week for his other medical problems. Integrative pain management failed to help pain 12 years ago. Any exertion makes him short of breath – heart failure. Even physical therapy is too much.

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It’s killing me to know I have to do this again and again to keep cutting his dose, month after month, and to do this to other good people. I know what will happen if I don’t. Other doctors hounded by investigations, audits, depositions, chart reviews, by government agencies, hearings, years in limbo, then to face court costing $300,000 or more. Attorney’s and specialists fees all scrutinize your patient and your work. Liability insurance may cover only $25,000 for the MD. But insurance may not cover DEA issues, doc. Insurance liability is for patient care, not for government regs.

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Heartless. How can any doctor keep the heart dissociated from the knowledge that you must do this, or else? I heard the fear from colleagues at this 16 hour conference this weekend on opioid guidelines. There are family doctors, psychiatrists, rehabilitation specialists, anesthesiologists, dentists – yes they treat chronic pain, pain specialists having to face patients in their care whom they have known for years. Just how are they to purposefully and personally harm each one? No one talked about how. 

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When has there been good mental health care in this country? Will the government offer counseling to patients and their doctors for this tsunami of pain and suffering? What if insurance does not cover costs of therapy? Insurers are never straddled with obligations – that’s not a business model. Profit, baby. Medical ethics are not a business model. 

 

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I’ve recently been called by patients looking for a new pain doctor. Somebody shut down or bought out a previous pain doctor in town – a very good specialist. Now his old patients are desperate to find a pain specialist to continue their opioids because the new owners will not write those prior doses. New pain specialists have cut back the opioid doses and it’s too much. Patients cannot cope and cannot turn to those doctors for mercy. Patients are afraid. I turned them away because I do not write those doses and I don’t know them. How can I tell if they had episodes of abusing their opioid, often showing up with none left? Is that why they were cut back? Was it as arbitrary as they convey? When you hear it from several patients, you suspect it was arbitrary and across the board, but you don’t know. Are they drug seeking? Addicts? DEA agents undercover flushing out pill doctors?

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If patients have not suffered mood disorders yet, they will when drugs are cut and mind is rebelling. Patients do not understand why it is essential they work on emotional coping skills with a professional. Men! seniors! Women! I am talking about you. Serious work. We all need help when we choose a pill over mind power. Pills dull the mind, can choke off oxygen at night, and cause more inflammation and more pain. Americans are too soft. I’m right in there with the rest of you. I need to train the mind to take control – it’s hard even when I don’t have pain. At least you/we/all must remove fear – if you have fear, it triggers more pain.

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The mind is more powerful than we can imagine. We must be taught to use its skills.

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Whether you see a therapist or not, talk to yourself about how to get creative with mind power. Do not let your mind get sucked into pain when you have the power to reduce pain – now. Stanford showed this with fMRI a few years ago. On screen, you can watch your own brain eat glucose in areas of brain. They light up in some regions when you tell your mind to raise your pain to 10 on scale of 10. And light up differently when you tell your mind to reduce pain to zero. This is true direct biofeedback. So use indirect temperature control, or pulse control, train your mind. OK, be a wimp for awhile, but then brace yourself and do the work anyhow. Train the mind.

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However cutting doses of pain medicine.

Heartless brutes!

I feel like a heartless brute.

HOW CAN YOU KEEP YOUR HEART FROM SUFFERING THE KNOWLEDGE THAT YOU MUST DO THIS OR ELSE!

DO YOU TRUST THIS GOVERNMENT TO HELP? 

The attitude of American voters, especially Congress, toward patients in pain is one of denial. Just like the denial of affordable changes in the American healthcare system rather than the splurges and splashes of increasingly costly, unaffordable hospital tech within reach to anybody with certain insurance. Everything at any cost. Not for pain relief. Not for everyone.

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We’ve gone through years of radical push to raise opioid doses, believing opioids could help. We did not know the harm of pain medicines. Nor do we still. But whose lobbyists have prevented NIH from funding pain research? Or is it the American way – we care so little even to help our injured veterans. Has anything been invested in the treatment of their chronic pain that adds so much to physical and emotional disability?

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There has been no change in approach to treating pain since 1991 when, nationwide, the interdisciplinary pain centers were shut down – why would any university be stradled with such a money pit? I was at UCLA on the Anesthesiology Interdisciplinary Pain Service when it happened. UCLA fired the President of the American Pain Society, and the soon-to-be President of the American Pain Society, pioneers and outstanding practitioners in this new field that had been born at UCLA somewhere in early 1980’s and actually mid 1970’s. All across the country, by 1991, closed pain clinics swept like a wave and I heard about it only whispered in the halls in Vancouver at the International Association for the Study of Pain, the IASP. Not a word in public to the audience or young doctors in training or anyone. Shhhhhhh. Why the hush hush? Fear of the unknown new era?

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Contracts, teaching appointments were torn up over night. Thousands of pain centers closed forever. No one cares.

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PAIN AFFECTS

MORE PEOPLE THAN

DIABETES, CANCER & HEART DISEASE COMBINED

 

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Pain is denied in the United States. Buck up. Machismo is the attitude. You lie to your fellow church members and office workers, and tell them you are “fine.” You know they don’t give a hoot about how you really are. You don’t  like to use the word suffer to yourself, there’s so much pain that you cannot stay in bed for hours in the middle of the night. We all see patients lie when they deny they are thinking of suicide because that pain has been untreatable. You can’t cut the thickness of the air with a knife. You feel it deep in your soul. What is there for help that has not already been explored? These are the toughest of the tough, everything tried, but the mechanics of damaged joints when the pieces and parts start crashing, the body feels decades older than you are.

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PAIN AFFECTS MORE PEOPLE THAN

DIABETES, CANCER & HEART DISEASE COMBINED

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This radical experiment to radically cut opioid doses, heartlessly.

Sigh.

No data to show the crisis you will see on every level.

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CDC opioid cuts will cause damage that should make headlines.

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Social scientists, time now to submit your RO1 NIH grants  to begin studying the crises when they unleash the opioid guidelines from CDC and in every state, then they will tighten the noose. Study what will happen.

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Patients will be forced to quit jobs they were barely holding onto despite all the pain. The wave of losses of lives, homes, jobs, health, emotions, friends, spouses. Barely able to push depression away. It is hard to make the brain focus on anything. Work, disability, early retirements, depression, bankruptcy. That is what can happen.

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Ideally, the study should be offered to the most distinguished, as an NIH Special Scholars Grant to study this radical cut in opioids.

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WE NEED A STUDY TO SHOW HARM & BENEFIT.

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BEFORE

NUMBER – at least 5,000  to get meaningful data?

Ask statisticians for an n – to power significant data end points.

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It has to be a huge detailed meaningful study. Pain and war on drugs is costing our healthcare system and costing lives.

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AFTER OPIOID CUTS

Repeat study every year for 3 to 5 years.

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Or just do what California has done: cut dose to 80 mg morphine equivalent. Or what CDC plans nationwide. Ignore the downfall.

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I am just too sad and repulsed to think of doing this to a human soul, again and again. Today has scorched my heart and soul. We took a step down. It’s too painful to think about. Too disgusted for tears.

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too dreary to read

will probably delete this tomorrow

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This site is not for email.

If any questions, please schedule an appointment with my office.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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Opioid Guidelines California


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Opioid Guidelines for Chronic Pain

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80 mg Morphine Equivalent in California

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Maximum

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That’s about 50 mg Oxycodone

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Change is inevitable. It is about deaths from opioids, addiction and misuse, not about pain control. It is a done deal. Acceptance is required. CDC will set 90 mg morphine equivalence maximum nationwide soon. There is no legal alternative. A wake up call.

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Let’s now make the best of every best tool we have. This is going to be a very tough year. We can get through this together.

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With 18,000 plus deaths from opioid misuse, that is equivalent to a jumbojet crashing every 10 days and killing every passenger.

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I have advised my patients of the maximum 80 mg morphine equivalent that is required in California. The CDC will soon limit maximum dose to 90 mg morphine equivalent nationwide. This is a done deal. We must all accept it, and adjust ourselves to all the benefits of a rational approach to pain management that may have been overlooked many years since your started treatment for chronic pain and came to rely on the easy things like pills rather than changing our behavior – painful as it is for me and all of us.

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Housecleaning: Reassess opioid consent, opioid rules, cognitive behavioral therapy to teach coping skills, physical therapy for the mechanics, and other treatment as required. It does not count if you went through these steps 10 years ago or 5 years ago. This is now. Reassess thoroughly,  to see if we can correct or improve whatever we can.

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The good news is that everything will be reassessed and updated in order to maximize everything that can be done to help your pain. You may feel the brain feels clear on lower doses and you may even have less pain as long as you, together with your doctor, can work out a plan for your best needs.

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And no matter if you are thin, fat or just the right weight, the foods you eat will determine your body’s inflammatory response.

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This will be nationwide in weeks. There is no alternative. We can do this together.

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Don’t forget injured veterans are being completely taken off opioids to get them active and back to exercise. And research from 25 years ago showed 90 year old seniors can strengthen muscles with exercise. If the rest of the world gets by without opioids, so can we.

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Finally, it is very possible to get better pain control using compounded medications once you taper completely off opioids.

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Case:

One of my patients with neuropathy had complete loss of sensation and intense neuropathic pain below wrists and ankles despite high dose methadone – methadone helped better than all other opioids. There was no dose that brought his pain down to moderate. Since pain was severe on any dose of any opioid, I am not sure why they are prescribed at all – brain fog from severe pain, poor sleep, opioids. We may delude ourselves that we are helping.

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He had complete remission using oxytocin, a hormone the body makes. Oxytocin was affordable as long as his insurance paid for it. This allowed him to discontinue all opioid and he came alive again, depression and brain fog completely resolved when pain resolved 100%. He was able to rejoin life for the first time since 1991. Tragically his medicare disability does not cover compounded medications – no insurer does. He was not able to afford the oxytocin (hormone) and had to resume methadone though it gives poor pain control – it is better than other opioids for his pain.

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Not everyone responds to alternatives but they can be tried. I have spent the last 15 years applying new science to the understanding of mechanisms of old drugs, FDA approved decades ago for other purposes. We need to repurpose old safe drugs – invest in research to determine if they modulate pro-inflammatory cytokines. Drug discovery decades ago revealed basic mechanisms that still exist. Now, let’s find out if many safe existing medications work on the new science of the brain: the innate immune system.

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Opioids create pain. They create opioid induced hyperalgesia.

They stimulate pro-inflammatory cytokines in brain and spinal cord (CNS) that create pain.

My focus is on research and medications that modulate the cytokines and restore balance.

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Investment in research has not accompanied the radical cut in opioids. Work for change. Do not allow this to color your mood. Be strong. Get help. We can do this.

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Correction 2-23-16: California Guidelines (pdf) are not law. They are dead serious threats.

page 14: going over 80 mg morphine equivalent is yellow flag warning

 And here

page 3:

Clinicians should conduct semiannual attempts to wean patients whose dose has been 80 mg/day MED or higher for at least six months to lower than 80 mg/day MED.

 

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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If any questions, please schedule an appointment with my office.

This site is not for email.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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Magnesium Deficient? – Add 3 or 4 Daily for Pain or Depression


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Here’s a keen publication from 1988:

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Magnesium and immune function:

an overview.

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*****Add Magnesium 3 or 4 per day for months.*****

*****Let me know if it helped your pain or depression.*****

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It’s got to be anti-inflammatory – possibly in CNS, and may influence pain, depression, other conditions. Since it is inside the cell, we cannot measure true deficiency. It may be subtle. Only in retrospect 5 months later, during some of the most intense work stress months of one patient’s life, did she realize not one single infection over fall/winter months when there would always be 3 or 4. You may not realize what it has done unless you think about it.

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If it does nothing but stop infections, that alone may prevent Alzheimer’s, years later. Or save your life from the flu that killed a healthy 20 year old. 

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Mg participates in immune responses in numerous ways: as a cofactor for immunoglobulin synthesis, C’3 convertase, immune cell adherence, antibody-dependent cytolysis, IgM lymphocyte binding, macrophage response to lymphokines, T helper-B cell adherence, binding of substance P to lymphoblasts and antigen binding to macrophage RNA. Mg deficiency in rodents impairs IgG synthesis and cell-mediated immunity; complications include thymus atrophy, elevated IgE, hypereosinophilia, histaminosis and lymphoma. Immunologic sequelae of Mg deficiency in humans are subtle and may be affected by genetic control of blood cell Mg concentration. Abnormal C’ activation, excess antibody production and susceptibility to allergy and to chronic fungal and viral infections have been reported. Mg appears to play a protective role in acute allergic reactions.

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From 2001, we learn how crucial magnesium is in many diseases:

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The multifaceted and widespread

pathology of magnesium deficiency

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Abstract

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…extremely important for the metabolism of Ca, K, P, Zn, Cu, Fe, Na, Pb, Cd, HCl, acetylcholine, and nitric oxide (NO), for many enzymes, for the intracellular homeostasis and for activation of thiamine and therefore, for a very wide gamut of crucial body functions. Unfortunately, Mg absorption and elimination depend on a very large number of variables, at least one of which often goes awry, leading to a Mg deficiency that can present with many signs and symptoms. Mg absorption requires plenty of Mg in the diet, Se, parathyroid hormone (PTH) and vitamins B6 and D. Furthermore, it is hindered by excess fat. On the other hand, Mg levels are decreased by excess ethanol, salt, phosphoric acid (sodas) and coffee intake, by profuse sweating, by intense, prolonged stress, by excessive menstruation and vaginal flux, by diuretics and other drugs and by certain parasites (pinworms). The very small probability that all the variables affecting Mg levels will behave favorably, results in a high probability of a gradually intensifying Mg deficiency. It is highly regrettable that the deficiency of such an inexpensive, low-toxicity nutrient result in diseases that cause incalculable suffering and expense throughout the world. The range of pathologies associated with Mg deficiency is staggering: hypertension (cardiovascular disease, kidney and liver damage, etc.), peroxynitrite damage (migraine, multiple sclerosis, glaucoma, Alzheimers disease, etc.), recurrent bacterial infection due to low levels of nitric oxide in the cavities (sinuses, vagina, middle ear, lungs, throat, etc.), fungal infections due to a depressed immune system, thiamine deactivation (low gastric acid, behavioral disorders, etc.), premenstrual syndrome, Ca deficiency (osteoporosis, hypertension, mood swings, etc.), tooth cavities, hearing loss, diabetes type II, cramps, muscle weakness, impotence (lack of NO), aggression (lack of NO), fibromas, K deficiency (arrhythmia, hypertension, some forms of cancer), Fe accumulation, etc. Finally, because there are so many variables involved in the Mg metabolism, evaluating the effect of Mg in many diseases has frustrated many researchers who have simply tried supplementation with Mg, without undertaking the task of ensuring its absorption and preventing excessive elimination, rendering the study of Mg deficiency much more difficult than for most other nutrients.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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If any questions, please schedule an appointment with my office.

This site is not for email.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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Senate Bill 483: Every person with a chronic pain condition is adversely affected by new opioid prescribing laws.


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Support Senate Bill 48e if you want doctors to practice pain management, rather than trust your pain medication in the hands of the police, CDC, and FDA. See letter below from the National Fibromyalgia & Chronic Pain Association.

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I don’t know anyone who wants the CDC to slash the dose of opioids and disregard specialist’s judgement: CDC proposes a radical experiment in rather violent cuts in dose, across the board, with no research, and under harsh pressure. Everyone will suffer because elected and appointment officials act from fear of addiction, fearof suicide among addicts, and prompted by anti-opioidists, against the judgement of the American Pain Society. Why bother accepting judgement of trained specialists? Plug in the Robotic AI and fall into line. The rich person in pain will do what they want, as they always have. But those dependent on healthcare insurers have already seen them deny 20 mg morphine per day, not the 100 mg per day that CDC wants radically cut.

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Addiction is a brain disease.

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Do you seriously think you will treat addiction and deaths from illegal street drugs by cutting the analgesic dose of pain patients?

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Do you think Philip Seymour Hoffman wanted to kill himself? I don’t. But he had no way to guarantee the dose he was using, and had to hide his addiction on his bathroom floor, hiding from friends and family. Imagine a safe clinic, rescue medication. He wanted no more addiction counselors. He wanted his drug

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Give addicts their drug. Free drug. Safe clinics. Standby with rescue meds. Whatever they want. Do we want them to choose theft and murder so they can get their $1.3 million each year for drug. Opioids, amphetamines cost pennies. Give it free.

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Would you throw your diabetic grandmother in jail? You’re not an addict. Why are they smashing your dose. You will suffer, it ain’t gonna be easy.

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Haven’t we learned from prohibition? From research in Portugal, and 11 countries, free clinics for drugs of abuse save billions. It saves lives. Leave our pain patients treatment in our hands. Why should CDC practice pain management when all they care about is addiction, death, overdoses?

The Centers for Disease Control and Prevention reported recently that the 28,647 deaths from prescription opioids and heroin in 2014 were a record. The agency said that more than six in 10 drug overdose deaths were caused by opioids that year.

West Virginia, New Mexico, New Hampshire, Kentucky and Ohio had the highest rates of drug overdose deaths per 100,000 people in 2014. North Dakota, New Hampshire, Maine, New Mexico and Alabama saw the largest increases in their death rates.

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Honey, CDC don’t care about pain. The public cares about addiction, all their girls and boys dying from prescriptions.

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Wake up and legalize all drugs, offer free clinics, free drugs, and voluntary behavioral therapy. It will save the country billions of dollars, pain patients will no longer get treated like addicts, you will get rid of narco-mafias – drugs are free! ferew murders, crime, deaths.

 

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What kind of crazy fails to learn from research – Portugal and 11 countries that legalized drugs – and fails to learn Prohibition breeds crime.

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One of my patients found another pain specialist because she didn’t want to hear all this. It makes her nervous. She wants her drugs. Ain’t gonna work for long. Bury your head in the sand. The country does not care about pain: they will not invest in pain research. Live with it.

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America cares about addiction. Deaths. Headlines. Votes.

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Every person with a chronic pain condition is adversely affected by new opioid prescribing laws.
Supporting Senate Bill 483 is our best opportunity to receive federal protection for access to pain care.
February 10, 2016

Dear NFMCPA Supporter,

None of us like controversy. I’m writing because as people with chronic pain, we are unavoidably being caught up in the U.S. national efforts to end opioid abuse. National Fibromyalgia & Chronic Pain Association (NFMCPA) is very concerned and has heard from many of you who are desperate about not being able to find pain relief.  Recent opioid policies address the many overdose deaths in the addiction community while significantly restricting the ability of pain patients to receive healthcare.

The U.S. Senate Judiciary Committee is scheduled to vote this Thursday, February 11, 2016, on Senate Bill 483:  “Ensuring Patient Access and Effective Drug Enforcement Act of 2015.”  The NFMCPA supports Senate Bill 483, and we urgently ask for you to contact your U.S. Senator(s) and let them know of your support for this legislation if you live in AL, AZ, CA, IL, IA, DE, VT, NY, SC, TX, UT, RI, MN, LA, CT, GA, or NC, or know someone in those states who can take action.  An easy way to do that is to click here for the quick link on our website.  A copy of the bill can be found by clicking here.

Chronic pain is a disease.  People with life-altering pain suffer more now as a consequence of new opioid prescribing policies affecting their access to prescribed pain medications. Doctors don’t have effective treatment alternatives to offer, mostly due to the lack of insurance coverage and minimal scientific research of adjunct therapies. People with pain must take action to have these major access to care barriers included in the national conversation about prescription opioid medications.
Chronic pain seizes the brain. I know what I’m talking about. And so do you. It stops your thinking, your activity, and wears you out. Your body becomes afraid of more pain and that it will never stop. This pain becomes impossible to live with 24/7.
Chronic pain solutions belong in the presidential candidate primary debates and on the agenda of every member of Congress. The national “debate” about opioids is not a debate at all. It is a national effort to create legislation and policy at every level to drastically cut access to opioid medications, with little or no regard for millions of people with chronic pain who rely on these medications for pain relief. When individuals cannot get necessary care, unmanaged pain harms quality of life, relationships, and the ability to work and sleep.  Directly or indirectly, chronic pain touches every member of the community and their families.
Thank you for taking a few minutes to support legislation that will help us for a lifetime.
Sincerely,
Jan Chambers
President
info@fmcpaware.org
National Fibromyalgia & Chronic Pain Association
31 Federal Avenue
Logan, UT 84321
email: info@fmcpaware.org

Demoralized Jeb Bush Succumbs to Heroin Epidemic in New Hampshire


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Demoralized Jeb Bush Succumbs

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To New Hampshire 

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Heroin Epidemic

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Headlines, the Onion

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– The picture of Jeb is wonderful –

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Or

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All street drugs should be legalized and in free clinics

where counseling is also available only if desired.

Why We Need To Image Glia, Cure Addiction, & Get Good Pain Control

Not just for former NFL players dying of CTE

Who does not fear Alzheimers?

 

Ever thought about neuroinflammation?

A renowned researcher imaged glia at Max Planck in the 1990’s,

now in Sydney

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Professor Richard Banati is an internationally recognized scientist with interdisciplinary research interests in the brain’s innate immune system and the development of advanced medical imaging for the non-invasive study of brain function.

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Look, we already spent a trillion dollars on the war on drugs. And what does Prohibition breed? Gangs, the drug mafia.

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Don’t worry, I’ll tie this together, but I want you to understand this is a unified field.

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The heroin epidemic is a big issue including among upper and middle class. It’s everywhere and cheap.

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Pain is a neurological disease, so is addiction. So are psychiatric diseases (Freud). Don’t you think it’s about time we studied them? All street drugs need to be legalized. Research: Portugal decriminalized drugs 14 years ago. It saves billions and treats the cause. Shall we base the practice of medicine on criminal justice or a health-based approach?

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A major cause of addiction and or heroin abuse is seeking pain relief. People use heroin for pain: think former NFL football players, athletes, business people, mothers, actors, people of all ages with nerve and bone crushing diseases – a major cause of addiction is people cannot get pain treated, even if they are rich or live in certain states like Florida where laws are unusually strict.

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Jeb Bush actually was the governor when some of the strictest laws of the country were enacted in his state to prevent adequate pain medication. His current statement says:

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“Beyond the Mexican cartels, abuse of prescription painkillers, such as hydrocodone and oxycodone, is a contributing cause of the epidemic of heroin and fentanyl abuse, and a major concern in its own right. A staggering four in 10 Americans know someone who has been addicted to prescription painkillers.”

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He enumerates the devastating financial costs when we do things the old way. And wants stiffer law enforcement. Research shows the opposite works better, saves billions. Portugal.

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It’s a hot topic. Who can disagree? Drug laws don’t work – research in 11 countries. Inescapable.

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Shocking that so many pain specialists and pain researchers in Florida have strong words to say about Florida laws that tie the hands for pain relief.

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From a conservative view point, you’d think government should take its hands off and allow medicine to follow standard of practice set by research, not politicians.

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Florida attracts former athletes and seniors who like warm weather on their bones and joints.

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Jeb was also the governor who signed the “Stand your ground laws.” How wise or controversial is that? How many states have jailed patients for seeking pain control like Florida? See 60 Minutes more than a decade ago. Maybe Jeb will be swayed by research. We all need to understand the brain. Ask every candidate how much their health plan covers behavioral therapy. Pain is an emotional experience. So is addiction. Biological too. But the emotionals have to cope with it. The amygdala gets battered by fear and pain and craving.

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All things being equal, pain care is most difficult in Florida.

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I know plenty of pain patients who stop craving when they have a spare they know they can always rely on, rather than squeek by with not enough. Fear is a natural reaction with pain. More than a third of middle class cancer patients at Memorial Sloan Kettering Cancer Center overused their opioids or loaned them to a friend per a study done around 1991 when I was there. It gets confusing what we are dealing with. And some people don’t always follow rules – does your mother? Grandmother? 

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You can lose everything when you have severe pain. If you cannot concentrate, then you cannot play bal.l no matter how high paying and dynamic your job could be. Pain takes everything out of you. All that free time, wanting to go back to work – it used to be your life. Playing football, disabled at 24, made the team but injuries. No money. Heroin is everywhere. I’ve seen how retiring as a major player destroys the ego. Even Namath mentioned that the other day, did he not? Imagine the pain taking you out early when you held such promise.

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You may not be an addict, but you know heroin is cheap. Pain justifies many things. Loss of job, loss of friends as old friends call you for Christmas or Thanksgiving but pain is so severe you always have to pass.

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A major cause of addiction or heroin abuse is failure to obtain pain relief.

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I’d like to see this research:

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  • How many suicides are related to untreated pain?

  • How many heroin addicts have untreated pain?

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We need research to inform the best approach. And we need to get up to speed on the vast benefits of legalizing all drugs of all kinds. See the results of Portugal’s studies. See the last thing I posted.

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Most important of all we must be able to image glia. The clinical work for that should begin in La Jolla near Scripps and UCSD where we have a nearby cyclotron and the renowned Alzheimer’s leadership at UCSD. CTE can be imaged and many former NFL players live here, as do seniors and a vibrant research community for stem cells and new immunopharmacologies. Scripps Research Institue, Sanford Burnham, so many renowned research institutes all new the scanner. Read my post January 2011 on glia, pain and the immune system.

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I am led to believe a politician would succumb of asphyxia if they mentioned there is a better way to treat addiction and pain.

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They should walk into any cancer hospital and see untreated pain. It’s not the cancer that always kills. UCLA research mid 1970’s by past president of the American Pain Society proved PAIN KILLS. It aggressively triggers cancer to grow faster and more metastatic, killing far sooner than the group whose cancer pain was treated.

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Pain Kills

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Heroin Kills.

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Legalize it and stop treating pain patients like addicts.

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Every single time they see a doctor or pharmacist, year after year, month after month until they are in tears.

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We Need:

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  • A billion dollars for pain research. Someone’s got to pursue repurposing old drugs for new uses: to reduce neuroinflammation and get at the root cause of all diseases it creates including neuronal death. Glia are 10 times more numerous than neurons. They are cells in the CNS that are your innate immune system. Inflammation is the basis of almost all known disease. 

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  • A billion dollars for addiction – Portugal’s model that legalizes all drugs.

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  • Finance this by holding back from the federal prisons that incarcerate youth who once had a fraction of an ounce of marijuana and were sentenced to life – man that costs a fortune! and from the trillion dollar war on drugs.

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Come on boys, it’s in your families too. Every politician knows someone with pain, Alzheimers, even addiction. Professor Banati knows the best way to proceed. He’s led the field since the 1990’s. How long will we wait to address brain damage? How long can we afford to overlook cells that outnumber neurons by 10 to 1? That create inflammation that destroys neurons?

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We have an epidemic.

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It costs money and lives.

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Who is not afraid of Alzheimers or of pain?

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This site is not for email.

If any questions, please schedule an appointment with my office.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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Exactly 100 Years Since Drugs Banned in US and Europe


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It’s exactly 100 years since drugs have been banned in the United States and Europe. 

 

ADDICTION

Everything You Think You Know About Addiction Is Wrong

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| Johann Hari | TED Talks

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“We don’t impose that on the rest of the world.”

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“We take addicts and punish them and make them suffer because we believe that will deter them, to give them an incentive to stop.”

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“Is there a better way to help them?”

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He traveled to many places, including “to the only country that has ever decriminalized all drugs from cannabis to crap: Portugal.”

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“And I realized almost everything we ever knew about addiction is wrong.”

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I recommend reading Heroin Century. It’s an exciting read, extremely well written, actually a “page-turner.” It will help you to understand how prohibition creates addiction and drug wars and narco-states that now have more gold than the rest of the countries in the world combined.

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The book helps us understand why giving addicts free access to any drug of addiction they desire, in clean settings, where they can get the exact predictable doses they want, and have a rescue remedy available by trained personnel if needed, why that helps. Do the research. They do not die. They do not give each other or give their loved ones HIV/AIDS or hepatitis. It gets rid of drug cartels that have completely taken over many countries in the world. It reduces violence, theft, murder, guns. It may even help doctors stop treating cancer patients like addicts.

 

Once you calculate the cost of street drugs – each addict has to find more than $1 million each year to feed their addiction – you can easily understand how much violence this breeds. It is not only less expensive to give free drugs in supervised, clean addiction centers that also offer treatment for addiction if the addict desires, but addiction is a medical condition. Treatment is humane and it saves lives.

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Addiction is found in families of the poor, rich and middle class, in farmlands, suburbia and inner cities. One trillion dollars has gone to drug wars that breed more drugs and more war with no treatment. None. Now CDC wants to sharply reduce access to pain medicine for people with chronic pain including chronic cancer pain. That is the wrong answer to 28,000 plus deaths from opioids in 2014. Opioid deaths are growing and CDC sharply cuts everyone’s access to pain medication. Sweet. Solved!

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Simply ask if your healthcare insurance has ever covered behavioral therapy? And for how many short weeks do they limit treatment? That’s just the start. Most psychiatrists I know will not accept insurance because reimbursement is so low. And this country will not “pander” to anyone who has any emotional problems much less addiction. Buck up America! That’s the attitude in Congress, and insurers know exactly how to read the tone that elects them. It’s not hard, just ask anyone in your family who will likely say the same. Insurers see no reason voters think otherwise. And newspaper headlines do not lead with what is right, they  lead with what sells. Why else would a jury send a doctor to jail for 30 years for prescribing an opioid for pain – and call it murder. The first time in history. Murder charge for prescription opioid. 

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I have posted addiction tools to help doctors recognize addiction in their patients. Anyone could be an addict. Addicts can be very good actors. Pathological liars. Your cancer doctor will suspect everyone. That surely explains why my colleague took her grandmother to the oncologist at Cedars Sinai and heard the oncologist threaten her grandmother: “If you want pain medicine for your cancer, you’d better go somewhere else or I won’t treat you.” Don’t think this will not happen to you.

 

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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If any questions, please schedule an appointment with my office.

This site is not for email.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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I realized

 

 

Pain is Worse Than Dying – Insurer Sues to Recover Payment for Opioids


 

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Pain Is Worse Than Dying

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Humana Is Obscene

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Humana Seeks

Repayment of Hundreds of Thousands of Dollars

 From Pharmacy

For Pain Medication of Years Ago.

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Reversal and Recovery

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In 2013, I was privileged to meet an angel, a wonderful soul, a 28 year old woman who was furious that she had permitted her doctor to replace a catheter in the vein (PICC line) that kept her alive for six years with feedings. She was frail, skeletal, vomiting frequently, starving, with no body fat, and had to carry a vomit bag because of involuntary vomiting day and night. She had a mitochondrial disorder that caused many abnormalities and many kinds of pain – acute pancreatitis, Guillain Barre-like nerve pain, hepatic pain, enlarged cervical and lumbar nerve roots, demyelinating polyneuropathy, ICU stays for episodic sepsis. Her stomach was elongated, reaching deep down into the lower abdomen and pelvis. She had extreme pain, was suicidal, deeply spiritual and would never take her own life, but she knew if the catheter had to be removed, she would never give permission for it to be replaced and she would soon die without fluids. 

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“I just want to die. I’m done trying to get well. I did that for 10 years”

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Her entire digestive system was not working.

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She had been hospitalized months at a time, at many hospitals in the country in search of a diagnosis that was finally made by the foremost specialist in mitochondrial disorders. She had been part of an NIH study in Texas for two years, was hospitalized for months at Mayo Clinic, at Columbia University, and wanted to be on hospice the year before she saw me.

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All night long, she would make the most beautiful hand crafted cards— pain and vomiting made it impossible to sleep. I prescribed Subsys, a rapid onset fentanyl to spray under tongue with onset in 10 minutes. The only opioid suited for her pain. She could not take medicine by mouth and had no body fat needed for pain patches.

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Subsys was never enough. She required IV opioids for intractable pain, soon transferred to hospice, refused replacement of the feeding IV PICC line and died surrounded by her loving family.

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Thank goodness mom is an RN, she was able to be at home all those years. Humana saved years of hospital care, saved for a few months with Subsys.

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Humana now wants to recover hundreds of thousands of dollars in payments to the pharmacy for medications for her and others.

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A few years before mom and patient met me, Humana cut her off from her pain meds – cold turkey, forcing mom to take her to the ER. She ended up in the acute care hospital for 6 MONTHS while mom fought with Humana.

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Each time she got turned down, mom appealed.  The case made its way to the Department of Health and Human Services, Office of Medicare Hearings and Appeals after three levels of appeals and a hearing before the Administrative Law Judge. 

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[The case did not reach the Supreme Court as I originally posted – see corrections below photo.]

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Mom won – by herself – no attorney – just organized with good documentation. Mom did have the director of pain management pharmacy from a local hospital on her side as a witness, though. Mom is an RN “Erin Brockovich” and will do whatever she can to fight this egregious action by Humana, the suicidal curse of pain, and all the patients who legitimately suffer with pain.

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Subsys is unique. There is no comparison. Among all the rapid onset fentanyl pain relievers, it is the fastest, with good levels in 10 minutes. When pain spikes rapidly, from low to severe in minutes, it is ideal to use a rapid onset opioid that may begin in 10 minutes rather than a pill that takes 1 or 2 hours to peak effect. Like many rapid onset fentanyl products, Subsys costs perhaps $100 each depending on dosage or $3,000 for 30. If you need 6 per day, that may be $18,000 per month. The raw powder costs pennies. The delivery device is a small spray of 0.1 mL (2 tiny drops) in a fine mist.

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Not all patients are able to use all forms of opioids for pain, yet the FDA approval for rapid onset fentanyl that excluded her. It is approved only for cancer pain – now CDC wishes to allow rapid fentanyl only for actively treated cancer. Your pain does not matter.

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There is no such thing as cancer pain.

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All people including cancer patients may have pain of nerves (neuropathic), organs (visceral) or other tissues (nociceptive). There is no such thing as cancer pain.

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The agony a physician feels when faced with a patient who is suicidal from severe pain and insurers that refuse to pay for needed medication is beyond words. Refusals like this have been happening for years, now far more often with egregious denials and futile “prior authorizations” – just yesterday refusing 20 mg morphine in a patient with many forms of severe pain. Medical ethics is not a business model. Insurers answer to stock holders, not those who buy their policy.

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Americans do not view pain as worthy of attention. Billions of dollars more for cancer. Almost nothing for pain research.

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Unlike most pain specialists, I have spent the last 15 years on alternatives for severe intractable pain, better than opioids, documented on these pages. I am the least opioid apologist, but I do prescribe opioids and taught cancer pain at one of the finest cancer hospitals in the world making me more “fluent” with opioids than most anesthesiologists who, after all, do mostly procedures. I could study for a year or two to take a special test, to be “certified” as a pain specialist – studying things I will never use in my practice, instead I refer to proceduralists when indicated.

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Oral analgesics are more cost effective and usually better than short lasting expensive procedures for chronic pain. Don’t get me started on the lack of research for spinal cord stimulators – use the tiny search box top left above my photo. Their $100,000 cost was effectively lobbied to insurers. Is it effective for more than two years? And the harms?

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Most people with chronic pain have no access to anything as effective as opioid medication. Well, that will be gone soon. You too will someday need help.

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Today FDA announces a sweeping review of agency opioid policy

to CUT access.

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Prepare for an avalanche of denials for your pain medicine. There’s been a storm of denials for years, denials for nonopioid treatment of pain, even more denials in the last few weeks since CDC’s offensive experiment I posted 11 times since late October. The avalanche is coming to bury us.

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It’s really a thankless job treating pain. Pain is devalued by Americans. Patients seem to accuse me of not doing my job when their medication is denied. They are treated like addicts. Doctors, families and pharmacists are suspicious of patients and of us.

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But this is happening for all medications, not just for pain, even generic asthma medicine, low dose estrogen that costs $12. Insurers know congress doesn’t care. Pharma knows congress doesn’t care. It’s a war on patients who are caught in the middle.

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CDC and FDA now want to take opioids away,

before we have an effective alternative.

Anti-opioidists have no science to back their stand.

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There is absolutely no reason any analgesic

should be limited to people with “actively treated” cancer –

CDC only allowed for that one partial change among a long list of changes sought by the American Pain Society.

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Politics has no place in the treatment of pain.

Pain policy in this country is sickening those with chronic pain.

Catering to the deaths of addicts –

politically expedient to deny you pain relief.

Treatment of pain doesn’t fit the American paradigm –  too weak.

War on drugs and addiction is more macho.

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Give us a better alternative.

Better for pain relief.

Better for addiction treatment.

For Pete’s sake look at addiction treatment

in countries who proved prohibition fails to work.

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Better treatment for addiction is not cured by denying pain relief to

116 million Americans with severe chronic pain.

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Or else start studying suicide in pain patients, not addicts.

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War on drugs is war on people with pain.

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My dearest friend who started home hospice in America

changed federal policy and the paradigm to treat cancer pain.

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Doctors threw food at him when he

spoke about treating pain in dying people.

Senior professors, the experts, rushed onstage, frantically

waving their arms in front of him saying:

“Don’t listen to this man, he’s crazy.”

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How much has changed?

Do the ghouls take your medication away?

Do insurance profits own government policy?

Do they destroy neighborhood pharmacies by

retracting hundreds of thousands of dollars years later?

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Bill

William M. Lamers, Jr., MD

December 24, 1931 – February 2, 2012

They are still inadequately treating cancer pain.

We miss you Bill

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Correction February 5, 2016:

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Mom writes to advise the case did not reach the Supreme Court. It went all the way up to the Department of Health and Human Services, Office of Medicare Hearings and Appeals after three levels of appeals and a hearing before the Administrative Law Judge. After 9 months of this process, the judge ruled in favor of having Humana cover Fentora buccal tablets for M – even though she didn’t have cancer. Fentora is another rapid acting fentanyl but not as fast as Subsys that was not yet on market in 2011. Humana APPROVED Fentora on 1/6/11 and then Humana DENIED it on 8/24/11, causing the patient to be hospitalized for several months.

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Hospitalized for months vs use of fentanyl at home for years.

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She had a very rare disease. These are the numbers from 2012.  They may be higher by now (or lower with deaths): It is estimated that 2,500 people throughout the world have Mito.  MNGIE is a rare form of Mito. There are only 70 people in the world known to be diagnosed with it. Twelve of them are in the U.S.  She was one of them.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

.

If any questions, please schedule an appointment with my office.

This site is not for email.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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War On Opioids Is War On Patients With Pain: Obama Seeks $1.1 Billion to Fight Opioid Abuse


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A “war” on opioids is a war on patients with pain. The CDC just radically, across the board, cut access to opioid doses.

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Obama seeks to fight opioid abuse by arbitrarily limiting access to medication for 100 million patients with chronic pain. This does nothing to help the appalling lack of funding for research on chronic pain.

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Today, the New York Times announces President Obama is seeking $1.1 billion to fight the opioid epidemic.

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Obama had already signed a budget agreement in December for $400 million for the same.

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Imagine war on pain instead of war on addiction, war on drugs. If $1.1 billion were instead spent on finding better pain treatment— would addiction to opioids occur less often? Almost nothing is spent on pain research. Less than half of one per cent of NIH budget in 2008. There are over 20 different splice variants in the mu opioid receptor, some of which are not addicting – research from Gavril Pasternak at Memorial Sloan Kettering Cancer Center. Money for research is urgent.

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Federal agencies have heard about deaths of addicts, deaths of people with pain (addicts?) who overdosed on opioids, heard from families, from police officers but not from people with chronic pain who have no voice. There is no “BALANCE,” no conversation. Only after the American Pain Society appealed CDC’s radical plans, that CDC allowed one partial exclusion in dosage cuts: to allow opioid for cancer patients, but only if undergoing active cancer treatment. However, not for those cancer patients who are not in active cancer treatment, who have severe chronic pain resulting from the cancer itself that destroyed nerves or bone or spinal cord or brain, not for pain from cancer chemotherapy or radiation: you will suffer the same severe sharp drop in opioid allowed for treatment of your chronic pain.

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Time magazine in 2011 reported: “Serious, chronic pain affects at least 116 million Americans each year, many of whom are inadequately treated by the health-care system, according to a new report by the Institute of Medicine (IOM). The report offers a blueprint for addressing what it calls a “public health crisis” of pain.”

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“…and the chronic suffering costs the country $560 to $635 billion each year in medical bills, lost productivity and missed work.”

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“Yet the reports’ authors said they believed that they had actually underestimated the incidence of chronic pain — that which lasts 30 to 60 days or more and takes a toll on personal and professional life — because their data didn’t include people living in settings like nursing homes. Further, as baby boomers age, the rate of chronic pain increases daily.”

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Unless you have experienced pain yourself, it is very hard to understand pain in others and to accept the fact that disabling severe pain can exist without obvious signs of fracture or other obvious causes. And if you are among the tens of millions who cannot afford the $10,000 or $5,000 deductible for medicine and doctor visits, heroin is cheap and can be found everywhere – death is the risk thanks to the American healthcare system that will not cover cost of your needs.

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Before we have an effective alternative,

CDC wants to take opioids away.

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Yes, side effects are a huge problem, but thanks to some relief from opioids, people are working or able to function. Since the sudden DEA conference late October 2015 announcing limits, I have been deeply concerned about the direction the American government is taking to deny medication for people with chronic pain. I have posted ten times on this radical nationwide experiment since October! – see many articles at top left below my photo. The CDC suddenly imposed limits on opioid medication for treatment of chronic pain, setting the daily opioid dose to be 100 mg morphine or its equivalent. Yet for years healthcare insurers have refused almost all forms of treatment with the exception of opioids, see the detailed list of FACTS at that link. Now the opioids are the last frontier, the final culprit. And then what? . . . nothing?

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There is no data to support this radical nationwide experiment. Many concerns of the American Pain Society were completely ignored. The anti-opioidists have won.

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People with chronic pain seem to be content to lose or to think that a few pain specialists can win their denials for drug coverage, while healthcare insurers’ profits go up by refusing to pay, by demanding “prior authorizations” that require doctors to jump one hurdle of forms after another, until finally, always: DENIED. This has gone on for years, vast, time consuming denials rather than practice of medicine. The more expensive the drug, the quicker and more comprehensive are the denials.

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Bottom line, insurers profit. CDC is interested in deaths from opioids, and they think training doctors in opioids is the same as training in pain management. I have made more than enough arguments on this site for years, and spent more than 15 years in better ways to treat pain.

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Just this moment, three letters of denial from insurance for 20 mg morphine, not 100 mg, no, they are denying a mere 20 mg, for severe pain, multiple diagnoses causing pain, “in accordance with CMS (Centers for Medicare …) guidelines.” That is the “training” in opioids. Why waste our time giving MD’s credit for 4 or 5 hours of training, and obtaining millions of dollars from pharmaceutical companies who make opioids for this “training,” in order for the DEA to go around the country “training” us, when opioids are being denied anyway? Denials for 20 mg morphine is not training. 

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Americans need to take action through the American Pain Society.

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I have written recently about the radical CDC opioid guidelines:

 

Tapering patients without sound and attainable alternatives

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Tampering with patient autonomy

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Failure to provide informed consent

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Avoidance of coercion

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Nonmeleficence – Do No Harm – Primum non nocere

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Treating patients like numbers not individualized

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Intellectual and academic dishonesty

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Anti-opioid zealots supported by zealous insurers? 

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Containment of drug costs, not pain

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Failure to assess risk vs benefit

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etc, etc – refer to prior posts

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These arbitrary actions are mind numbing and hopeless until voices of millions become united. Elected officials cannot afford to ignore the mounting deaths from prescription opioids that are killing white people. Clearly they can afford to ignore 116 million Americans with serious chronic pain.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

Relevant comments are welcome.

If any questions, please schedule an appointment with my office.

This site is not for email.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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.

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.

Please be aware any advertising on this free website is

NOT advocated by me and NOT approved by me.

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