Pain Patients to Congress: CDC’s Opioid Guideline Is Hurting Us, 2% NIH budget for Pain


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Pain Patients to Congress: CDC’s Opioid Guidelines is Hurting Us. Has stoked “climate of fear” leading to inadequate treatment of chronic pain

CLIMATE OF FEAR

WASHINGTON — Patients with chronic pain are suffering from ham-handed efforts to curb opioid overdoses, a series of witnesses told the Senate Health, Education, Labor and Pensions (HELP) Committee on Tuesday.

  • by Shannon Firth, Washington Correspondent, MedPage Today February 13, 2019 

In particular, the CDC’s 2016 guidelines for opioid prescribing came under heavy fire, as even a self-described supporter of its recommendations admitted the evidence base was weak.

In 2018, Congress passed the SUPPORT for Patients and Communities Act, which included billions of dollars in funding aimed at curbing the overdose epidemic and expanding access to treatment for those with substance use disorders.

About 50 million Americans suffer from chronic pain and almost 20 million have high-impact chronic pain. At the same time, more than 70,000 people died from drug overdoses in 2018, often involving opioids, said HELP Committee Chairman Lamar Alexander (R-Tenn.) at the start of Monday’s hearing.

Even as Congress tries to dramatically curb the supply and the use of opioids, “we want to make sure … that we keep in mind those people who are hurting,” said Alexander.

Cindy Steinberg, national director of policy and advocacy for the U.S. Pain Foundation, argued that well-intentioned efforts to address the epidemic — particularly strategies to tamp down overprescribing — have stoked a “climate of fear” among doctors.

Thousands of patients with chronic pain have been forcibly tapered off their medications or dropped from care by their physicians, said Steinberg. (Physicians in California, under threat of medical-board sanction if patients die from overdoses, have reported similar reactions.)

Such decisions are “inhumane and morally reprehensible,” she said.

Steinberg, herself a pain patient, said she takes opioids in order to function. Eighteen years ago, Steinberg was injured when a set of cabinets fell on her. Since her accident, she experiences constant pain, she said, and throughout the hearing she took breaks from testifying to recline on a cot and pillow.

She was especially critical of the CDC’s opioid guidelines, which included recommendations regarding the number of days and dosage limits for certain pain patients.

“When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed,” notes a CDC fact sheet.

These recommendations have been “taken as law,” she said.

In 2016, Massachusetts set a 7-day limit on first-time opioid prescriptions, according to the National Conference of State Legislatures, which counted 33 states with laws limiting opioid scripts as of October 2018.

Steinberg said the guidelines should be rewritten.

Because of the CDC’s reputation, “people think that those [guidelines] are based on strong science and they’re not,” Steinberg said. Pain consultants were not involved in the development of the guidelines, she said.

(Voicing similar concerns in November, the American Medical Association passed a resolution opposing blanket limits on the amount and dosage of opioids that physicians can prescribe.)

Steinberg pointed instead to the Pain Management Best Practices Inter-Agency Task Force, a group appointed by Congress of which she is a member, which issued its own draft recommendations in December.

Alternatively, the NIH (which she noted has an office dedicated to pain policy) could be asked to make recommendations, she suggested.

Halena Gazelka, MD, chair of the Mayo Clinic Opioid Stewardship Program in Rochester, Minnesota, pointed out that the guidelines were “intended to advise primary care providers” and not to provide “hard and fast rules.”

“I actually like the CDC guidelines,” Gazelka said. Mayo’s own guidelines are based on the CDC’s. However, “the doses that are mentioned, probably are not scientifically-based, as we would prefer that they would be,” she acknowledged.

Another challenge for some pain patients are situations that pit prescribers against pharmacists, said Sen. Lisa Murkowski (R-Alaska).

“It’s the pharmacists that are refusing to fill the prescription the doctor has prescribed,” she said, blaming the CDC guidance. Pharmacists are following it out of “an abundance of caution,” including in cases where abuse is not suspected, she suggested.

Steinberg said, “I think we need public education about pain and the fact that pain is a disease itself. … Pharmacists are not getting proper training in that, I don’t think anyone is getting proper training in pain.” She asserted that veterinarians get nearly 10 times as many hours of pain management training as do medical students.

Andrew Coop, PhD, of the University of Maryland School of Pharmacy in Baltimore, returned to the CDC guideline. “I think those guidances on the quotas, I think they’ve been taken too far and that needs to be rolled back.”

Improving Care

In exploring other ways to improve care for patients with chronic pain, Gazelka recalled the pain clinics that existed 30 years ago, which included a physician, a psychologist, and a physical therapist.

“It would be ideal to return to a situation where people could have all of that care in one place,” Gazelka told MedPage Today after the hearing. But most small practices and even institutions may not have the same blend of clinicians, and the cost could be “prohibitive,” she said.

Access to specialists also poses a problem, noted witnesses as well as senators.

In her own pain group, it takes patients more than a year to get an appointment with pain specialists, Steinberg said. She encouraged Congress to “incentivize” pain management as a specialty.

Gazelka agreed and suggested leveraging telemedicine and electronic health records to extend the reach of existing specialists.

Telemedicine can allow primary care physicians to consult with pain management specialists, she said. Also, in Mayo’s own controlled substances advisory group, she and other specialists review cases submitted by primary care clinicians and provide advice directly into the patient’s medical record. However, Gazelka noted that privacy protections in some states might disallow that.

Gazelka noted that insurance coverage can be a barrier to non-opioid alternatives. For example, the Mayo Clinic has a Pain Rehabilitation Center staffed by specialists in pain medicine, physical therapy, occupational therapy, biofeedback, and nursing that aims to treat pain without opioids. But Medicaid won’t pay for it, she testified.

Witnesses also spoke of efforts to develop non-addictive painkillers, such as NIH’s Helping to End Addiction Long-term program.

Steinberg called these efforts “a great start” but noted that only 2% of the NIH’s budget is directed towards pain research. Funding should be “commensurate with the burden of pain,” she said.

Finally, Coop pressed the committee to take seriously the potential of medical marijuana.

Acknowledging that it’s a controversial area, he stressed the need for “good consistent, well-designed clinical studies with good consistent material,” referring to the type of marijuana used.

But speaking to reporters after the hearing, Alexander was cautious. “I’ve supported giving states the right to make decisions about medical marijuana. That’s about as far as I’m willing to go right now.”

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

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

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Please ignore the ads below. They are not from me.

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Families Refusing Opioids for Pain in Dying Loved Ones


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Refusal of care in the palliative care setting, lack of cooperation in treating pain. Fear the pain medicine will kill. Addicts dying of overdoses. Fear the dying grandmother will be addicted or die from the pain medicine. Fear of addiction in the family, unsafe to keep opioid for the patient. So many fears, myths and misunderstandings.

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Fear has taken over in so many levels of our consciousness. That is why we all need to educate ourselves so that we are prepared to safely help those we love when the time arises.

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Death and dying need not mean agonizing pain. Strong pain may require strong opioids for relief, and strong opioids can be safely adjusted to allow good mental function so you and your loved ones can be present in the last days. Not, not in shock and anguish from screaming pain going on for weeks.

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Yes, I have been called to help a family whose mother was in her last days, on palliative care. Her only communication for weeks was loudly moaning with grimacing and wincing the muscles of her face. They were refusing to give even the tiniest drops of morphine under her tongue, as recommended weeks ago by the palliative care physician.

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Refusal of care will only get worse, not just for the dying but millions with chronic pain. Physicians refusing to treat pain or being firmly uncooperative with family or pain team recommendations. This is a huge issue in cancer hospitals and cancer wards. The old way was never to give opioids for cancer. The standards in medicine are set by the old guys who pass it on and control all coming up the ranks. Don’t step out of line. Fear is in control.

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Dispel that fear. Inform yourself in proper care recommendations by leaders in the field or you will live with regret when your loved ones died screaming in pain and you refused care. I have seen many oncologists refuse pain care and threaten patients, families and staff.

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Read some of the myths and issues that are too frequently encountered by caregivers all across the country – click here.

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The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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

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Comments are welcome.

This site is not for email, not for medical questions, and not for appointments.

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Medicare & Insurers Crack Down on Opioids – Patients Suffer


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Individualized pain management does not exist.

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Correction from reader: 

“Individualized treatment does exist, but insurance companies are not paying for it. This has to change.” 

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The New York Times reports “Medicare is Cracking Down on Opioids” (link below).

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Last year an insurer denied 10 mg daily Oxycontin for one of my seniors who had been safely taking this for many years. That is less than 1 mg per hour for 12 hour relief. Pharmacy refused to fill unless insurer approved. That’s one way to reduce healthcare costs without an uprising. There is little tolerance for someone with pain. Are they viewing patients as addicts? Would they do this for cancer? 

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The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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

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Comments are welcome.

This site is not for email, not for medical questions, and not for appointments.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Best wishes to all!


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Please ignore the Advertising – has nothing to do with me.

Anger


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Anger at the failure of our medical system to support research and treatment of pain, anger at failure of the few currently available analgesics, anger at lack of interest or funding from Pharma – it requires at least $10,000,000 more to finish one important human treatment before submitting to FDA – that’s just one study. Pharma does not care, the price is peanuts to them. At one point, a company bought it, intending only to bury it. They do that for rheumatology treatments too, both the innate immune system and the adaptive immune system are being ignored. What could be more powerful than the immune system?

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Anger

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Anger at the failure of most medical organizations to discuss cannabis, medical marijuana. Training in cannabis is imperative.

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I am thrilled that Scripps Memorial Hospital Grand rounds in 10 days is a one hour lecture by the doctor who is head of HelloMD, national leaders in physician approval for medical marijuana, and in education.

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Anger at the destruction of the field of pain management. I posted on this two days ago, top left column. Anger at the greed in the medical system where pharma can buy whatever they want by sprinkling money at congress who will never ever ever do anything about the unholy prices of drugs. Certain elements in power will never stop trampling on the poor and the disabled. They will never treat the addicts. There is no will, they are paid off and nobody wants to help the disabled, the unwell, the poor. Not in  the U.S. Voters do not want to hear it.

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Anger says step back, surrender.

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There is nothing anyone can do. The swamp is exhausting, dirty, dangerous and black.

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I have tried 7-1/2 years to introduce a new paradigm. At various lifetimes in medicine, I have had funding, sat on boards of companies, and panels at FDA. I have witnessed the destruction of what it once was 43 years ago when I entered practice. A long and tortured history, but still the most exciting thing in the world is medicine, science. So what? They shut off the field of pain and are killing it. The world is the world. Always was, always will be. Lust and greed, says the sage. You cannot uncurl the curly tail of a pig, says the sage. Always was, always will be. Do your duty. You cannot escape it. But surrender to love.

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Surrender. Do what you can and surrender the results to the Infinite.

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Read these books:

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Dying to Get High, Marijuana as Medicine

by Wendy Chapkis and Richard J. Webb

NYU Press 2008

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From back leaf:

“How can a substance that is no mystery to half of all adults in the United States prompt such confusion and misrepresentation in the realms of law, medicine, and policy?…. Offering nuance in place of slogans, Dying to Get High tells an inspiring story of the tactics and philosophies of a little-understood health movement.”

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“A beautifully written account from the front lines of the struggle between a federal drug war complex determined to keep demonizing marijuana and the growing movement of patients and doctors who have found marijuana to be a valuable medicine.”

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“….. Provides a human element to the history, pharmacology, psychology, and politics of medical marijuana in a way that no other work has. I loved reading it.”

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Heroin Century

by Tom Carnwath and Ian Smith

Routledge Press, London

2002

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This is an extremely important, amazingly interesting, readable book for everyone.

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From back cover:

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Is heroin really dangerous? Or Is it just dangerous because it is illegal?

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Page-one 93,

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“The income of the drug barons is an annual $254 thousand million dollars, greater than the American defense budget.”

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Read this book. A page turner! Exciting! fast paced, awesome! mind boggling!

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And just because you might flash some anger to propel you to actually do something, don’t get stuck there. Be at peace. Work hard. Use your expertise. Surrender to the Infinite.

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While you are thinking about it, tell Congress to make pain management a mandatory course in more than the current 3% of medical schools, less then 30 hours in 4 years. Fund research and treatment of neuropathic pain such as CRPS, Complex Regional Pain Syndrome because it can be so disabling – the same neuropathic pain can occur from strokes. Don’t we deserve better? Not even cancer pain is taught, let alone grade schoolers who should be taught about the body, about addiction, drugs, sex. Teach all that opioids cause pain because they trigger inflammation in the immune system and that stimulates pain. The more opioid you give, the more the pain. Teach about the brain’s pleasure centers and addiction, how drugs and food and cigarettes work there and how addiction kills.

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Have a wonderful life all of you. There’s a lot of work to take up. You will meet great people. Can’t wait to see what a little anger will do.

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The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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

~~

Comments are welcome.

This site is not for email, not for medical questions, and not for appointments.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Companies out of the pain business, NOT a hotbed of innovation, NOT COVERED by insurers


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Bloomberg news published this analysis below that explains much of the dead end in pain medication:

  • companies got out of the pain business.
  • there is no hope in sight for effective analgesics
  • insurers refuse coverage for more and more pain medications
  • insurers refuse coverage for modalities except opioids

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What kind of medical system:

  • forces patients to seek street drugs for pain relief because they are cheaper?
  • fails to treat addicts?
  • fails to allow cannabis (medical marijuana) one of the safest drugs ever discovered for pain and symptom management?

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The whole field is a sham ruled by politicians through CDC fiat and the justice department, subject to radical changes:

  •  a threat to your care
  • a threat to the field of pain management
  • a brick wall to any professional contemplating entering the field
    • pain management is complex & time consuming
    • most chronic pain patients have 3 or more pains
    • each pain requires assessment
    • risks patient addiction and/or suicide
    • risks loss of license
  • constant change
    • prior authorizations from insurers refused on appeal
    • disability refused for disabling pain
    • onerous computerized opioid database that is not nationwide, not fully completed by pharmacists
    • threats from patients, addicts, DEA, attorney general
    • highly politicized
    • good specialists thrown in jail despite expert testimony of foremost pain specialists – after testimony of addicts who reduced their sentence with lies
    • poor coverage of modalities if any for P.T., acupuncture, massage, integrative pain management, psychology, biofeedback, psychiatry, cannabis, compounded medications
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Here’s the article, click title to read in full.
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For the drug industry, building a better pain pill is a problem.

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Pharmaceutical companies have introduced new medicines to treat dependence, reverse overdoses, and deal with opioids’ side effects. But few effective and economically viable alternatives to addictive painkillers have emerged from the laboratory.

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That’s because of broken incentives, according to economists and industry experts. The payment policies of insurers and government health programs, along with pressure from investors, have encouraged drugmakers to treat the symptoms of the opioid epidemic but discouraged innovations that might get to the root of the problem.

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New therapies for pain have generally been too expensive, too cumbersome to use, or targeted at too small a group of patients….

 

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Different Incentives

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The incentives to develop a better pain pill differ sharply from those in other areas of research, such as Alzheimer’s disease.

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Drugmakers have spent billions on more than 100 failed medicines for Alzheimer’s, but a breakthrough would potentially reach a large and lucrative population of elderly patients on Medicare. Any new pain drug would be fighting it out with inexpensive, proven rivals in a politically fraught environment.

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The White House Council of Economic Advisers estimated this week that abuse of opioids cost the economy about $504 billion in 2015, or nearly three percent of that year’s overall economic output in the U.S. Those costs include health-care expenses, spending on criminal justice and first responders, and lost worker productivity.

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“There’s currently a lot more costs of addiction that are being borne by society in a more diffuse way,” said Kosali Simon, a health economist at Indiana University….

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Effort and Expense

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Most opioids are cheap generic drugs that have been prescribed for decades, making the effort and expense of developing new painkillers hard to justify.

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“They’re off-patent, they can be produced by companies that aren’t the original inventors,” said Bertha Madras, a professor of psychobiology at Harvard Medical School and a member of President Donald Trump’s opioid commission. “It becomes a much more expensive proposition to develop and get the approval for an opioid.”

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Drugmakers have instead invested in developing complex medicines for cancer and rare diseases, which can fetch six-figure price tags.

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“Companies got out of the pain business,” said Pratap Khedkar of ZS Associates, a sales and marketing consultant who studies the pharmaceutical industry. “It’s not the hotbed of innovation.”…..

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Wary Payers

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Drug plans have been reluctant to pay for abuse-resistant pain medicines, which often cost more and can be more difficult to administer. A recent report from The Institute for Clinical and Economic Review, a nonprofit that evaluates the value of prescription drugs, found that abuse-deterrent opioids weren’t cost-effective for insurers.

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At the same time, payers are limiting patients’ access to older pain drugsCigna Corp.took OxyContin off its list of preferred drugs for 2018, though it still covers other opioids. CVS Health Corp. said its pharmacy-benefits management arm will limit prescriptions to a seven-day supply, and Express Scripts Holding Co. also said it wouldcurb prescriptions.

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That leaves patients with a difficult choice. Abuse-deterrent painkillers might cost as much as $250 out of pocket. But generic opioids cost as little as $2, according to Denis Patterson, a pain specialist in Reno, Nevada.

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Abuse-resistant drugs get “denied 90 percent of the time. But the pain pills will get approved every single time,” said Patterson.

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“Shouldn’t it be flipped,” he said, “in that the things which can get people better should have better coverage?”…..

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The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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

~~

Comments are welcome.

This site is not for email, not for medical questions, and not for appointments.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Cannabis Overwhelmingly Preferred over Opioids for Pain – UC Berkeley / HelloMD Opioid Study


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Congratulations and thanks to HelloMD’s email, posted below, that describes a new study. They are doing important work for people who can be helped by cannabis. We need help in the treatment of chronic pain.

I’ve seen pharma pressure pain specialists to refuse to treat patients who also use cannabis. For Pete’s sake it helps relax deep muscle like nothing else, helps anorexia, can bring up extremely low energy a tiny bit, helps depression, and pain. Shock and awe. What an awful thing to pressure doctors to do just to punish the plant based industry and extinguish the competition. I’m sure TV ads brainwash even more. Professionals in healthcare and politics need our help to know good studies already exist and even without that rigorous proof, our dispensaries can recreate what the world has safely used for thousands of years.

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HelloMD is a trusted source of information. 

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The HelloMD Advisor

Opinions from Industry Experts


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Hi Nancy,

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Yesterday we announced the results of our landmark study examining the use of cannabis as a substitute for opioid and non-opioid based pain medication. Performed in collaboration with University of California Berkeley, HelloMD surveyed 3,000 participants from our patient database….[– click on below link to article]

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[They showed the]

overwhelming majority of cannabis patients (92%) prefer using cannabis to opioids when managing their chronic pain.”

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Your participation in HelloMD studies is invaluable as it takes us one big step closer to showing healthcare professionals, elected officials and the public at large the potential for cannabis to alleviate the opioid crisis our nation is experiencing.

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HelloMD also recently launched in New York state offering patients the ability to get their medical marijuana certification online. This week we highlight PharmaCannis, a shining example of the eastern US cannabis scene, with five dispensaries statewide, professionals from the pharmaceutical industry, and an eye towards making cannabis a part of the future of healthcare.

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Finally, we highlight Dr. Gary Richter, the ‘Cannabis Pet Vet’, who has made it his mission to help animals and their owners lead happy, healthy lives.

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Be happy & healthy,

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Pamela Hadfield – Co Founder

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This is an important study for people to learn about and to help our legislators understand we need help to use this plant for billions who are needlessly suffering. We all need help. And simple is best. This medication has been safely used by grandmothers for thousands of years. Silly to think we cannot begin. Silly to deny millennia of use. We need help:

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  1. Low cost medication is essential.

  2. Healthcare insurers must reimburse patients for the cost of medical marijuana. This is done in New Mexico and should be in every state.

  3. We must all stop weaponizing a simple healing plant that can be effective. Truth beats fear. Every study helps to open minds.

  4. Support the work of good groups like HelloMD, NORML

  5. Get politics out of science and healthcare

  6. Teach our doctors – require 1 hour CME for all who see patients.

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I have so many senior patients terrified to try cannabis, and one who just had a once-in-a-lifetime result with a few cannabis drops under the tongue. She worked with a dispensary that mixed a personalized ratio of THC:CBD. It Worked! Nothing else had, her life spent in years of constant headache. It’s gone! yet she is still terrified of cannabis.

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Such has been the insanity about the American gung-ho opioid boosters vs the shoot ’em dead plant loving criminals and addicts – that’s what these little old ladies think they have become. Criminals and addicts. This sweet woman’s intractable migraine has taken her life every day for years, failing to respond to the best care in the nation, is now gone with cannabis! Yet she’s going to have a heart attack because for decades the GOP has trained her to think she’s a criminal addict. She was referred by one of the foremost migraine experts whose final suggestion was to try cannabis. A few weeks later when she came to her first visit with me, she was headache free.

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Had her family doctor been able to recommend someone who works with cannabis patients many years ago, she would not have wasted her life and fortune. It can be simple and life-saving to try, and always nice to have a helpful hand from the dispensary to show you how.  Again HelloMD helps with that.

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I am very grateful for HelloMD. For their great organization, a smoothly developed, simple, cost effective model that is affordable and convenient for my patients who are too ill to travel or simply too uncomfortable at the thought of hanging with a waiting room crowd so far from their better healed comfort zone.

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After all, they don’t look disabled, but I see disabled kids as young as 8 through 90’s.

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Do not judge disability by how someone looks. Young disabled veterans wearing artificial legs, have been attacked for not looking disabled when they park in disability spaces.

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Bring peace and healing to all whenever you can. Learn to use the plant and to enjoy the plant too. To be able to let off the weight of the world…. that alone is healing. Nothing is working right. Well, so what? Let go. We have to let go, let peace, breathe. You know you do the best you can as always, so now do the best and let go. Bring peace.

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Cannabis is a sacred plant. Treat it with respect. Fear is ignorance. Teach the truth. 

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“Democracy dies in darkness.”

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Bring peace and healing

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The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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

~~

This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Ketamine & Opioids Stop Working – TOLERANCE – the body no longer responds no matter how high the dose


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The comments below on ketamine tolerance apply to its use either for intractable pain or major depressive disorder. I have written about ketamine several times since April 2009. Tolerance means the medication no longer has an effect. If ketamine is to be needed for decades to come, we don’t have more than 10 years experience with repeated use to understand if and when it will stop working for our patients.

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Tolerance to ketamine is a growing potential as more infusion centers open each year.

Infusions are being used at fixed dosages

that are often too high or toxic

and predispose to tolerance and loss of efficacy.

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I’ve seen two cases of ketamine tolerance since about 2009 among persons with Complex Regional Pain Syndrome (CRPS). And the neuropathic pain of CRPS responds differently than other pain syndromes. We are all snowflakes, not one of us is alike another. But CRPS is unpredictable in many ways, and very predictable in others. It is also more dynamic and capable of being reversed in many who have it.

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Ketamine is given usually IV in a few centers in the country for CRPS and for Major Depressive Disorder. I prescribe it either via nasal spray or under tongue. I may, later this year, offer IV infusions to a small number of my patients who need both.

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If tolerance develops, would drug holidays work?

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Some people develop tolerance to their medication. In the old days, when I was training in the 1970’s, Parkinsons medication over time would stop working. Our only recourse was to do an inpatient drug holiday for weeks. We had to stop the drug. The resting tremor, the constant flailing, was exhausting and life threatening, especially if you had a heart condition. Newer Parkinson’s drugs completely circumvent this.

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Would drug holidays work if tolerance develops for ketamine or is it a goner forever?

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Opioids can cause tolerance through a known mechanism. They produce inflammation that causes more pain. Higher and higher doses fail to help pain. Addicts seek the high they once felt but cannot capture. This is why addicts die, chasing the impossible. Detox. Drug holiday. In the case of addiction, many are placed on Subutex, an opioid that acts on two opioid receptors and seems to prevent craving, in part at least because it has such a long half life that the blood level never dips.

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Ketamine infusions centers springing up.

Is that all they do?

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NIH and Yale began to test IV ketamine infusions in the 1990’s for major depressive disorder, and Robert Schwartzman, MD, at Hahneman in Philadelphia was one of the early ones to infuse ketamine for CRPS and contribute a large body of research on this pain.

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But in the last 2 or 3 years I receive a growing number of mailings advertising ketamine infusion centers. Just that, nothing more. Ketamine infusion centers, not pain specialists. All these young anesthesiologists popping out of training every year have a cash pay business; insurance doesn’t cover.

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Will ketamine stop working for patients who need to use it regularly for decades and decades? We don’t know. It should be studied.

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The first patient I saw with ketamine tolerance, I referred from San Diego to Professor Schwartzman in Philadelphia. She received inpatient IV around the clock for one week, then outpatient IV boosters every month. After eight months, she stopped responding. That’s when I called him to ask what to do? He did not know. So I used glial modulators. I posted her case years ago. She is in her 70’s, pain free since 2010, and two weeks ago, as a volunteer for the Red Cross, she supervised RN’s and evacuees from the flooding at Oroville dam. Tens of thousands of people, emergency care for families and homeless.

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A recent patient has had more than 20 surgeries in her hand that has CRPS. She has failed  IV ketamine, opioids, propofol given together in ICU for weeks and weeks. Surgery triggers the glia to produce neuro-inflammation.

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Another case though unusual, also posted years ago, a young male athlete, bedridden with CRPS affecting almost entire body. Flew to Professor Schwartzman 9 times and each time, the relief was gone by the time they reached the airport. He was taking opioid medication that may have been impossible to offset.

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This is what I advise when I prescribe ketamine for my patients to use at home as a nasal spray or sublingual:

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  1. Do not use it with opioids.Opioids cause inflammation, ketamine does the opposite. It modulates (reduces) inflammation.

  2. Never use it alone. It is a glial modulator, it is not only an NMDA receptor inhibitor.

  3. For intractable, treatment resistant cases, use as many glial modulators as you can.

  4. Ultra low dose naltrexone (20 micrograms TID) can profoundly reduce tolerance in patients on opioids: they may now need 1/2 to 1/8th the dose of opioid that simply had never quite done enough. Naltrexone not only relieves pain, it may profoundly improve function.

  5. Opioids stimulate glia to produce pro-inflammatory cytokines -> pain. Stop opioids if you can. You are likely to get far better results with glial modulators, especially if you have CRPS.

  6. Pain specialists should be offering a trial of glial modulators before they choose opioids for life.

  7. Use glial modulators as needed: ketamine, oxytocin (a hormone), tricyclic antidepressants (weaker than the others but can be profound for some), metformin.

  8. Metformin, a glial modulator!  for pain! in people who do not have diabetes. I will be posting on it this coming week — inshallah

  9.  Use it sparingly. Whether ketamine or opioids, use sparingly because of tolerance.

  10. If it is a good day, use less and use sparingly. If pain spikes, use higher dose, use sparingly.

  11.  When tolerance develops to ketamine, what then?

  12. Is it possible that a drug holiday would work? Should that be in months or years? we may never find out.

  13. Use ketamine and/or opioids sparingly. Prevent tolerance. You may not always need the same dose on a good day or when pain spikes.

  14. Make sure you are doing other things to relieve pain, not just ketamine or opioids.

  15.  Dextromethorphan helps, a sigma I receptor antagonist that reduces the excitotoxic glutamate

  16. Try as much as you can to exercise.

  17. Lift the mind to positive things. Learn to block thoughts of pain, dissociate from that. Choose life and doing and being.

  18. Develop momentum. Try never to judge; that includes being hard on yourself and others.

  19. Expand your spiritual life. Find your path if you don’t already have one. It may begin for all sorts of reasons, but figure it out. It’s real. Spiritual giants from all paths have had direct perception of the infinite in many ways and forms. Direct perception.

  20. S-ketamine clinical trials are now ongoing in the US. I was very disturbed to hear the side effects of S-ketamine infusion related last week. S-ketamine deeply disturbing. It is wrong to give everyone the same dose of ketamine. Not once have I ever heard anyone recount similar side effects from ketamine infusions. I got the impression from her they were not inclined to attribute it to S-ketamine, but it would be disturbing if they did not. Ketamine’s dose no matter how you give it is idiosyncratic, meaning some respond to 2 mg, some to 400 mg. It is wrong and should be unethical to subject someone to doses 200 times the dose they may need. It is dangerous and promotes tolerance.

  21.  If you’ve been stuck in bed, branch out and vary the things you do. Find music and poetry and literature. Maya Angelou suffered yet her words make you soar. Check out James Baldwin in the Oscar-nominated documentary “I Am Not Your Negro.” Baldwin’s immensely powerful analysis deconstructs movies, not as a mirror, but as a window into the imaginary; and how movies shape our thinking. As a movie critic, his writing is about poverty, class and “not everything that is faced can be changed, but nothing can be changed if it is not faced.” …  “There are days — this is one of them — when I wonder, how precisely are you going to reconcile yourself to your situation here…” So many writers fail to teach us how to analyze and think with such clarity. Something we don’t always do. We need to train ourselves to become critical thinkers. Baldwin brilliant mind demonstrates critical thinking at its best.

    Critical thinking is not a partisan issue. Tens of millions will lose jobs as robots rapidly take over in the next 3 years. Industry will reap more than ever in history. We all need to rethink our lives at some point.

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    Dylan’s song is about “the possibility that the most important (and least articulated) political issue of our times is that we are all being fed a false picture of reality, and it’s coming at us from every direction.”[10]

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    “Propaganda, all is phoney,” Dylan says in “It’s Alright, Ma (I’m Only Bleeding).”

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    Advertising signs that con you
    Into thinking you’re the one
    That can do what’s never been done
    That can win what’s never been won
    Meantime life outside goes on
    All around you.

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    Public Warning:

    Ketamine is a controlled substance.

    Administered improperly, or without the guidance of a qualified doctor,

    Ketamine may cause injury or death.

    No attempt should be made to use Ketamine

    in the absence of counsel from a qualified doctor.

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    “Off label” means ketamine is FDA approved for another purpose, decades ago it was approved for anesthesia. In qualified hands, ketamine is one of the safest medications we have in our formulary.

     

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    The material on this site is for informational purposes only.

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    It is not legal for me to provide medical advice without an examination.

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

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    This site is not for email and not for appointments.

    If you wish an appointment, please telephone the office to schedule.

    ~~~~~

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

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    Please IGNORE THE ADS BELOW. They are not from me.

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Avoid opioid use in surgery to reduce postop pain


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Science for years has confirmed that opioids trigger inflammation and that creates pain. Trauma and surgery also create inflammation that leads to pain. How logical is it then to continue use of sufentanil for anesthesia when it is the most highly potent opioid 500 to 1,000 times stronger than morphine. Where is the logic in creating pain by using sufentanil as the anesthetic? A new one on the market will be 10,000 times stronger than morphine. Inflammation is not always easy to reset after you strafe the innate immune system with an opioid.

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Why is ketamine not used more often for surgical anesthesia when we know ketamine profoundly lowers the inflammatory response thus reducing pain more than ever. Studies for years have shown that even a small dose of ketamine reduces postop pain. This is not new.

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A study needs to be done comparing patients who receive no opioids. At least this study showed that when fewer opioids are used, pain scores are 37% lower than if more had been given. Patients given higher doses of opioid, had higher analgesic requirements postop. That increases the risk of persistent chronic pain and the tragic risk of addiction.

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Opioids inflict known lasting harm, pain and suffering, perhaps disability and addiction.

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Reduced opioid use in surgery linked to improved pain scores
Written by Brian Zimmerman

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After anesthesiologists at the University of Virginia Health System in Charlottesville began administering fewer opioids to patients during surgeries, patients’ self-reported pain levels dropped, according to a study led by three UVA anesthesiologists.
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For the study, the team examined 101,484 surgeries that took place in the UVA Health System from March 2011 to November 2015. During this time period, the amount of opioids administered via general anesthesia at the system was reduced by 37 percent.
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For the same time period, self-assessed patient pain scores recorded in post-op recovery units dropped from an average of 5.5 on a 10-point scale to an average of 3.8, marking a 31 percent improvement.

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One of the study’s leaders, UVA anesthesiologist Marcel Durieux, MD, PhD, said the impetus behind the pain score improvements is likely attributable to several factors. One, previous research has indicated opioids can ultimately make people more sensitive to pain. And two, the increased use of non-opioid painkillers like lidocaine and acetaminophen during surgeries at UVA was likely effective.

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….”There is very clear evidence that people can become opioid-dependent because of the drugs they get during and after surgery,” said Dr. Durieux. “I think that by substantially limiting opioids during surgery, we’ve made an important step in addressing that problem.”

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

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This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Spinal Cord Stimulators – comment on RSD


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Spinal Cord Stimulators 

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 Craig’s comment

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By no means do I mean to say that I or anyone else has better insight into how to treat pain, but I am against spinal cord stimulators [SCS’s] for treatment of pain due to CRPS, and possibly against use in other situations. I demand that the billions in profit they made be put into a retrospective and prospective study of damage caused by them in order for them to give full informed consent.

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I have 3 goals writing this.

  1. SCS’s

  2. Craig’s experience

  3. The Only Real Answer for severe pain, not damaging the system with opioids

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Informed consent is never given for spinal cord stimulators because it requires truth telling, something our corporations have been reluctant to do. Business ethics are not medical ethics, as we keep being reminded daily in the headlines.

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I enclose, below, a generously expressed and detailed comment by a man who had the patience to sit down and  write the painfully gory details so you can weigh-in on your decision whether to follow your pain specialist’s opinion to give you one. I don’t want anyone to feel suckered into choosing them and if I had pain I’ll admit I’d crave relief too. Anything. I’d be in line before the doors open.

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But if you have CRPS, spinal cord stimulators will create more pain. CRPS evolves unpredictably, by a will of its own. I know some very desperate patients with CRPS everywhere including face, mouth, gums, tongue, organs, trunk, limbs. Spinal cord stimulators will create more pain. Keep in mind, I don’t see the 5 year success stories even for lumbar disc pain. They don’t need me if they are pain free.

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But if you have CRPS and desperate need for pain relief because all else has failed — every known drug in highest possible doses of ketamine, propofol, opioids for weeks in ICU fail to even touch pain— there is one thing, and only one thing to do and I will set it out below. I just sent my recommendation to a patient with CRPS in extreme pain.

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My recommendation, below, is for patients who have nowhere else to turn.

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First I’ll mention the problems Craig encountered with SCS’s. He sent his comment to the opening page of this blog, so I will reproduce below. 

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I am currently undergoing a trial Medtronic SCS. I have had to have it reprogrammed 3 times since it was installed 5 days ago. I have had sensations and issues that I have addressed with my rep and my neurosurgeon. I get a severe headache when the unit is turned on. I get the constant feeling of having to urinate. I have current running through my testicles which they can not seem to program out and I am getting little pain relief. I have had to failed back surgeries, many failed injections and I have CRPS. The leads that were inserted when I was in the table covered my mid back and both legs. After I got to my feet and waited while they programmed the unit in another room. They came in and plugged it in and I no longer had coverage on the right side. My crps is in both legs, my hands, arms and face. The lyrica helped to tamp down some of the burning but I am in pain 24/7 and this was my last resort. I have scar tissue completely surrounding my S1 nerve. By the grace of God, I am on my feet, on crutches. I seem to get a look of disbelief when I tell them the unit is causing these issues or it’s not giving me the relief I was counting on. Relief, only to cause greater issues and pain. Is not relief to me. I can not wait to get this trial out of my back. I believe the leads slipped and that is why I am not getting the full coverage I had on the table. The issues I have had are as follows: severe headache, constant feeling of having to urinate, extreme joint pain, abdominal pain, sleeplessness, involuntary jerking, surges in current even when sitting still. Intense pain around the lead insertion site. Current uncomfortably running through my testicles, regardless of setting. It is my opinion there is still not a lot known about crps and I have read evidence of people have great success with these units. Everyone reacts differently. My body obviously creates a lot of scar tissue and my orthopedic surgeon created a fair amount herself. I can’t imagine even more or being forced into a chair for yet another unlucky decision. The medication helps and I have lived this far without the optimism that it would end soon. I had high hoed for this device but I don’t think it is right for me.

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One of my patients with CRPS was hospitalized for weeks with recurring unusual abscesses and required repeated surgery of hand and forearm. Even before surgery, she had failed opioids, failed ketamine, and was in ICU for weeks and weeks while the same medications were still given along with Propofol and IV Tylenol. Nothing helps her extreme pain.

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Anesthesiologists on staff in ICU threw everything they had at the pain for weeks. Most anesthesia pain doctors would have probably done what they did because that is the limit of tools we have.

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When you have hit the limit of benefit from opioids, ketamine, propofol, we have nothing else that treats pain with one exception: drug holiday.

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Stop all analgesics including Tylenol that destroys the liver as severely as cancer, the severity of which was newly discovered and published yesterday.

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The receptors for these analgesic drugs have up-regulated to such an extent they have caused the situation. Again, I stress, everything that was done during the ICU admissions would be done by any anesthesiology pain specialist. Those are the only tools. They cause the problem. The same for opioid induced hyperalgesia. We used to do it with Parkinson’s drugs in the 80’s.

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The only way to rehabilitate the up-regulation of all those receptors that have now exploded in numbers, immune to anything you throw at them, is stop the drugs.  Stop all of them for weeks, maybe months, years, no one knows, you are all the human guinea pig waiting to happen. But if we restart them, how long do we wait, how quickly will it again lead to this massive hyper-excitable state of pro-inflammatory cytokines that we know have gone wild, flooding the CNS. A flooded engine will not restart.

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Ketamine at least is known to reduce pro-inflammatory cytokines, but the system is too busy exploding, birthing new receptors that take over, and you’ve got a 55 car pile up. Well, more like millions I’d guess. No scientist here. Clnically, when can we resume something after a drug holiday, how soon and which drug? I’d avoid opioids because they create more pro-inflammatory cytokines. Choose ketamine, because they reduce pro-inflammatory cytokines, but if it works at all, stop it at first sign of tolerance, which is the need for increased dose. It becomes less effective. Walk a fine line, endure more pain because unless you do, it will no longer help. Opioids, analgesics of many kinds. 

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How do we get you through a drug holiday because we know withdrawing these drugs will trigger even more pain for possibly weeks until the system settles down?

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Pain storms, hurricanes

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This is complex regional pain syndrome where we see this insanity of pain storms. There is no other condition, unless several neuropathic pains in people with cancer, nowhere I have seen this type of pain in decades except CRPS – comparable to pain of subarrachnoid hemorrhage, blinding pain.

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No one has answers. None. One university does outpatient infusions of ketamine six hours daily for 8 to 12 weeks. Does it help? A small percentage. Outpatient, 6 hours daily, 5 days a week, staying at a hotel, 8 weeks.

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This is CRPS/RSD. No one has answers. It is futile to throw more of the drug in the system. That is my opinion. You have a choice and may choose otherwise. It is your body. You may stay on monthly opioids for decades, until you finally admit how poorly they work. A drug holiday is what we did in the 70s during my ancient training with Parkinson’s patients. They needed full 24-hour support. The American medical system has changed since then and those are not options currently available—cost.

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You need full psychological and psychiatric support.

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The Only Real Answer

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The country needs to invest $10 million to complete the clinical trials needed for an injectable, long-lasting interleukin 10 [IL-10], the anti-inflammatory cytokine. It already has full scientific and animal studies performed by and with the world’s foremost glial scientist at University of Colorado Boulder. Professor Linda Watkins has won awards from many countries. She has been the keynote speaker at the annual academy pain meetings for years. IL-10 can relieve pain for three months in animals that have intractable chronic neuropathic pain. This is not new —–NIH I’m looking at you to fund clinical trials. And those of you who care, do a Kickstarter to fund the clinical trials.

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This is the power of the innate immune system. NIH would rather fund research on the unknowns like stem cells rather than the known. It’s known for decades, NIH does not like to fund pain research. Glia are not all about pain. They are the innate immune system, the key to Alzheimer’s, neurodegenerative diseases, almost all known disease including atherosclerosis. It’s all about inflammation. We need the trials to stop giving drugs that cause inflammation, opioids —–CDC fiats are not as good as a drug that relieves pain, a drug that really works on mechanism. Where will the addicts go if the ER only has IL-10 for pain? That is one way to overspend on ER visits.  And NIH, please get us some real clinical research funding on how to use glia for our benefit. Get us some research on the entourage effect, combining medications to achieve relief especially for neuropathic pain.

Then bring on some crack negotiating teams from insurers to do some negotiation about pharmaceutical prices. Our new president has mentioned that.

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Please bring this to everyone’s attention. One way to get a grip on pain and/or depression is to build hope, help others, and energize behind a goal.

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Kickstarters work to raise tens of millions overnight. 

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IL-10 – animals have been shown to be pain free for three months, already proven in animal studies, by one of the world’s most widely acknowledged pain specialists Professor Linda Watkins, PhD. We need the final steps to fund the clinical trials in humans.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

~~
This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Opioids: a think tank to expose the deep-rooted failures and injustices in our health care system


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STAT is “a new national publication focused on finding and telling compelling stories about health, medicine, and scientific discovery” in partnership with the Lown Institute.

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“The Lown Institute is a think tank dedicated to research and public communication to expose the deep-rooted failures and injustices in our health care system, and to helping clinicians, patients, and communities develop a shared vision for a better health system.”

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.“Since 2012, the Lown Institute has been a leading voice in the movement to recognize the harms of overuse of medical care, and in pointing out the clear connection between wasteful medical treatment and our system’s failure to deliver needed care.”

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This article from STAT, excerpted below, beautifully and painfully describes the opposing sides of the deep divide in our country about treatment with opioid analgesics for chronic pain. It is a divide deeper than the growing upheaval of politics in America, and it is unique to us. The United States, with 5% of the world’s population, consumes 80% of the global opioid supply, and an estimated 99% of hydrocodone. “Pain drugs are the second-largest pharmaceutical class globally, after cancer medicines.”

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I have seen both sides, those who cannot live or function without opioids and those whose pain improves radically once they taper off. The war on patients plays out many times daily, while patients and doctors alike are deeply concerned at the lack of research in this volatile unpredictable field, where patients are subjected to whack-a-dose prescriptions since the March 2016 CDC fiat that dictated slashed opioid dosages, a dictate that now entitles insurers to deny all medication overnight —saving them tremendous costs. All denied, no matter how small the dose, nor how intense the diagnoses and pain.

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This irrational, inhumane, and unpredictable disease of change has become a constant, destroying lives of patients and caregivers while addicts continue to overdose evermore and prisons are filled with low level street corner dealers —never the rich who buy their way out of prison. Cheating is a way of life for corporations, condoned by congress.

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A ‘civil war’ over painkillers rips apart the medical community — and leaves patients in fear

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PALO ALTO, Calif. — For Thomas P. Yacoe, the word is “terrifying.”

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Leah Hemberry describes it as “constant fear.”

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For Michael Tausig Jr., the terror is “beyond description.”

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All three are patients struggling with chronic pain, but what they are describing is not physical agony but a war inside the medical community that is threatening their access to painkillers — and, by extension, their work, their relationships, and their sanity.

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Two years after the United States saw a record 27,000 deaths involving prescription opioid medications and heroin, doctors and regulators are sharply restricting access to drugs like Oxycontin and Vicodin. But as the pendulum swings in the other direction, many patients who genuinely need drugs to manage their pain say they are being left behind.

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Doctors can’t agree on how to help them.

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There’s a civil war in the pain community [my emphasis],” said Dr. Daniel B. Carr, president of the American Academy of Pain Medicine. “One group believes the primary goal of pain treatment is curtailing opioid prescribing. The other group looks at the disability, the human suffering, the expense of chronic pain.”

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Pain specialists say there is little civil about this war.

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“There’s almost a McCarthyism on this, that’s silencing so many people who are simply scared,” said Dr. Sean Mackey, who oversees Stanford University’s pain management program.

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“The thing is, we all want black and white. We don’t do well with nuance. And this is an incredibly nuanced issue.”

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Stanford’s Mackey said those risks are important to recognize. But, he said, nearly 15,000 people die a year from anti-inflammatory medications like ibuprofen. “People aren’t talking about that,” he said….

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…Dr. Anna Lembke, who practices alongside Mackey at Stanford’s pain clinic and is chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, published a book about the opioid crisis last year. It was titled: “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.

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Lembke believes that long-term opioid use can cause patients to perceive pain even after the original cause of pain has cleared. Some patients, she said, find themselves free of pain only once they have endured the often agonizing effects of opioid withdrawal.

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“That’s what we’re seeing again and again,” she said.

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…. a single father of two teens, said that every month he needs to fill a prescription, he’s fearful it will be denied.

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Mackey says doctors being trained at Stanford’s pain center have grown increasingly fearful about prescribing opioids...

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[Dr. Mackey describes a practicing 81 year old physician who cycled to work until recent back surgery. His life is now complicated by severe back pain and he requires opioids to continue to function.]

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“If you’re 81 and you stop getting out of bed, it’s a slippery slope,” he said.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

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This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Caffeine May Reduce Age-Related Inflammation, Stanford Aging Study


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Caffeine may be able to reduce inflammation.

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Inflammatory immune molecules increase as we age and are associated with mortality from all causes, Alzheimer’s disease, stiffening of arteries, hypertension and cardiac disease. Inflammation kills. Yesterday Stanford and colleagues from University of Bordeaux published results of a long term aging study of 114 patients in Nature Medicine (paywall):

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Expression of specific inflammasome gene modules stratifies older individuals into two extreme clinical and immunological states

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For nonscientists, see below. Caffeine may block inflammation. Adenosine and adenine are known to stimulate the inflammasome. Caffeine blocks the effect of adenosine.

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“They found that older people between the ages of 60 and 89 tend to ramp up production of immune molecules in a complex called the inflammasome. That’s a clump of immune proteins inside cells that activate one of the immune system’s big guns, called interleukin 1 beta or IL-1B. It’s an important molecule for fighting off infection, but too much of it for too long has been linked with chronic diseases like heart diseasecancer, and Alzheimer’s disease.

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Among the older people in the study, 12 of them made much more of these inflammatory molecules, and 11 people made much less. The less-inflamed group was also healthier, with lower blood pressure, more flexible arteries, and more relatives who lived past age 90.

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They also had lower levels of the breakdown products of DNA and RNA circulating in their blood, including one molecule called adenine, and another called adenosine — which is adenine attached to a sugar molecule. These molecules are known to stimulate the inflammasome, and lower levels of them could explain why this group was less inflamed. In fact, treating cells with these breakdown products made them churn out more inflammatory molecules, and made mice more inflamed, with higher blood pressure.

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HIGHER BLOOD LEVELS OF CAFFEINE CORRELATED WITH LESS INFLAMMATION

That’s where the caffeine comes in. Caffeine is known to block the effects of adenosine in the brain — that’s how scientists think it keeps us awake. So, the researchers suspected that it’s possible that it could block the effects of adenine and adenosine on immune cells, too, and reduce their ability to cause inflammation. According to a questionnaire, people in the less inflamed group consumed more caffeinated beverages like coffee, soda, and tea. In fact, higher blood levels of caffeine and other caffeine breakdown products correlated with lower production of inflammatory molecules like IL-1B.

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When the scientists treated cells with adenine and another molecule known to trigger the inflammasome, the cells that were soaking in caffeine produced far lower levels of inflammatory molecules. The researchers still haven’t fully explained how caffeine is interfering with inflammation. And the results aren’t enough to base any behavioral recommendations off of; but it’s comforting news for those of us who were already reaching for that second hit of caffeine, anyways.”

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Many articles on pro-inflammatory cytokines IL-1β, IL-6, and TNF-α are found in the setting of chronic pain and in depression:

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IL-1β is an essential mediator of the antineurogenic and anhedonic effects of stress.

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Depressed rodents shown to have inflammation, published by Yale and NIMH a few years ago.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

~~
This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

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

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Please IGNORE THE ADS BELOW. They are not from me.

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Heroin Addiction absent or rare in UK prescribing


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Diamorphine (heroin) is prescribed for pain in the UK . Yesterday’s LA Times Op-Ed

What’s really causing the prescription drug crisis?

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Studies show addiction to opioids of any kind, even heroin, is rare in the UK. Not what we see in the US. They have more socialized care for housing, medical care, medications including for the jobless. They do not have the hopelessness that leads to desperation and addiction. Desperation is why all patients with chronic pain must work with a psychologist. Pain is not in your head, but desperation is, and a psychologist can help you learn tools to deal with desperation. If you don’t, pain will go up, up, up and that’s what’s in your head. Unless you use those tools, I promise you will suffer because it will get worse and worse and worse.

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“Doctors in many parts of the world — including Canada and some European countries — prescribe more powerful opiates than their peers in the United States. In England, if, say, you get hit by a car, you may be given diamorphine (the medical name for heroin) to manage your pain. Some people take it for long periods. If what we’ve been told is right, they should become addicted in huge numbers.

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But this doesn’t occur. The Canadian physician Gabor Maté argues in his book “In the Realm of Hungry Ghosts” that studies examining the medicinal use of narcotics for pain relief find no significant risk of addiction. I’ve talked with doctors in Canada and Europe about this very issue. They say it’s vanishingly rare for a patient given diamorphine or a comparably strong painkiller in a hospital setting to develop an addiction.

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Given that really powerful opiates do not appear to systematically cause addiction when administered by doctors, we should doubt that milder ones do. In fact only 1 in 130 prescriptions for an opiate such as Oxycontin or Percocet in the United States results in addiction, according to the National Survey on Drug Use and Heath.

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So what’s really happening? The second, clashing story goes, again, crudely, like this: Opiate use is climbing because people feel more distressed and disconnected, and are turning to anesthetics to cope with their psychological pain.

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Addiction rates are not spread evenly across the United States, as you would expect if chemical hooks were the primary cause. On the contrary, addiction is soaring in areas such as the Rust Belt, the South Bronx and the forgotten towns of New England, where people there say they are lonelier and more insecure than they have been in living memory.”

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Healthcare costs in the US are a very serious problem. Opioids require monthly visits. Patients on opioids are forced to see a pain specialist, many for decades when pain is chronic. That’s bad enough, but the cost of opioid medications are outrageous. I know some whose opioids cost $17,000 per month or more. And some doctors in my area have mandated urine drug tests every single month, $750 per test, to prove you are not taking street drugs. High risk patients and nonaddicts alike, every month, just to pee in a cup and get your prescription opioid. 

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Now congress is getting rid of the ACA, to make it better. I can only imagine how helpful they have been. Privatize social security, privatize medicare, privatize everything. Of course that will be better for them. Will it help anyone else? 

 

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

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Opioid Production in US Cut 25% by DEA in 2017


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The DEA regulates how much opioid is allowed to be made each year. Production will be cut by 25% in 2017. Some will be cut by more than 25%, for example hydrocodone will be cut 34%.

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The reasons given are that demand is falling and the opioid epidemic is not. Congress of course could think about funding addiction treatment and offering clean injection sites for addicts such as Vancouver’s.

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The order will be published tomorrow in the Federal Register.

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In June 2016, Senator Richard Durbin interrogated Chuck Rosenberg, acting administrator of the Drug Enforcement Administration (DEA), during a Senate Judiciary Hearing.

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Durbin has introduced legislation to fight opioid abuse. One section of the bill would require DEA to consider opioid addiction when setting production quotas. If annual quotas increase, DEA would be required to justify that in writing, explaining why the bump outweighs the risk of having more addictive drugs available.

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Opioid death stats demonstrate the ravages of the epidemic.
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About 47,000 people died from overdoses in 2014, Rosenberg said. That’s 129 every day. About 61 percent were due to prescription opioid and heroin.

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The material on this site is for informational purposes only, and is not a substitute for medical advice,

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Opioid Overdoses ~130 every day, the capacity of a Boeing 737 – naloxone $4,500, up from $690 in 2014. You pay


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LA Times reports

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As need grows for painkiller overdose treatment, companies raise prices

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$4,500

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$4,500.

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$4,500 for naloxone manufactured by Kaleo, Richmond Virginia. Naloxone reverses opioid overdose.

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That seems to be their Evzio two-pack, two single-use injectors of naloxone in a hard case handy to carry in a pocket for someone who has an opioid overdose.

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Each has a 0.4 mg injection that last 2 or 3 minutes each, just long enough to call an ambulance.

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A drug that costs pennies, sold as a 2-pack for $690 in 2014, then $900, now $4,500 as of Feb. 1.

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“…Columbus, Ohio, said the city’s firefighters last year used 2,250 naloxone doses, or about 6 doses a day — at a cost of $147,000. Recently, Columbus also stocked the drug in 115 police cruisers….”

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FDA approved Evzio in April 2014 after granting fast-track status. Fast track now means gold mine status. 

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Naloxone was first approved in 1971.

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“In July 2005 its average wholesale price for a vial of the injectible drug was $1.10, according to Truven Health Analytics.

By 2014, the price was almost $19 a vial.” 

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Medical costs are astronomical, insurance premiums are up, insurance deductibles are $5,000 to $10,000 for many. Police, fire department and EMT’s are using naltrexone to save lives and lower ER visits.

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Taxes are high. Where is the initiative and innovation among EMT’s, police, fire? How many hours per day do they get paid full salary to work out at the gym and stay fit while they sit and wait for the next call to rescue an addict who overdosed. Then retire on double pensions if they hold two city jobs. While they wait for next calls, could they not fill syringes from a vial of naloxone? How much do taxpayers pay for these overpriced robotic filled syringes at factories.

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Pharma is raking it in. Pharma’s blood sucking 1% are overdosing on costs. Many of my patients with intractable pain who are on opioids were not able to afford $690. They are not addicts but any dose of opioid can kill. Your tax dollar pays for naloxone for addicts found dead, unresponsive.

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We are all paying a fortune for inexcusable pharma costs. Costs for millions of drug addicts all over the country. Costs for prescription medications. Congress unwilling to address anything that would cut the flow of donations to their coffers from pharma.

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Just remember, in Israel, it is illegal for corporate lobbyists to contact any politician.

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“Late last year, Adapt introduced a naloxone nasal spray named Narcan for a average wholesale price of $150 for two units, according to Truven.”

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That is a BD syringe fitted with a flared BD adapter at the tip to fit the nostril. It requires the user be capable of pushing the 1 mL syringe so the liquid is sprayed into nostril.

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For Pete’s sake. I’ve been prescribing medicine in these BD syringes with nasal adapter for years. Is there no EMT smart enough to make and stock their own supply to use for emergencies?

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“…as the demand for naloxone has risen — overdose deaths now total 130 every day, or roughly the capacity of a Boeing 737 — the drug’s price has soared.
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…Increased access to naloxone is among the measures included in federal legislation that Congress passed last week in response to the painkiller deaths. The White House has said that President Obama plans to sign the bill.
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Last month, U.S. Sens. Susan Collins (R-Maine.) and Claire McCaskill (D-Mo.) wrote to Kaleo, Rancho Cucamonga’s Amphastar Pharmaceuticals and three other drug makers, asking why they had hiked prices for naloxone during a public health crisis.
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“At the same time this epidemic is killing tens of thousands of Americans a year,” said McCaskill, “we’re seeing the price of naloxone go up by 1,000% or more.

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 …Mylan, which sells a vial [how many doses per vial?] for an average wholesale price of $23.70, according to Truven and Adapt Pharma of Dublin, Ireland.”

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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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Oxycontin Investigation – A Pulitzer for LA Times?


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A TIMES INVESTIGATION

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Inside an L.A. OxyContin ring that pushed more than 1 million pills. What the drugmaker knew

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By HARRIET RYAN, LISA GIRION AND SCOTT GLOVER

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JULY 10, 2016

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This LA Times investigative report by Ryan, Girion and Glover is now a contender for Pulitzer Award. They expose years of passively tracking extreme volume sales by leaders at the top of Purdue Pharma, the maker of OxyContin. While they racked up billions in sales, they tracked the surge in prescriptions from pill clinics in LA to gangs trafficking in Washington State for sale on the street. 80 mg tablets, deaths, crime, gangs, heroin – waves of heroin related crime and overdoses in cities all over the world.

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Purdue could track suspicious high volume sales of their pill:

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Until a decade ago, Purdue, like most drug manufacturers, didn’t monitor pharmacies for criminal activity. The DEA has held wholesalers, not drugmakers, responsible for identifying and reporting suspicious orders from their customer pharmacies.

In 2007, the DEA pressured drug manufacturers to do more to stem the prescription drug crisis and warned that it would be looking at every step in the supply chain. In response, Purdue decided to gather detailed information about pharmacies, Crowley said.

The company approached wholesalers and struck agreements allowing the company access to their sales reports. With the new data, the security team in Stamford could see all wholesalers’ OxyContin sales to individual pharmacies, down to the pill.

“I can look at something and say, ‘Geez, that stinks’ without me even visiting the place,” Crowley recalled.

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……What Purdue knew

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More than 194,000 people have died since 1999 from overdoses involving opioid painkillers, including OxyContin. Nearly 4,000 people start abusing those drugs every day, according to government statistics. The prescription drug epidemic is fueling a heroin crisis, shattering communities and taxing law enforcement officers who say they would benefit from having information such as that collected by Purdue.

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A private, family-owned corporation, Purdue has earned more than $31 billion from OxyContin, the nation’s bestselling painkiller.

 

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In 2015, the Week published:

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How the American opiate epidemic was started by one pharmaceutical company

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From Pacific Standard

Mike Mariani

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OxyContin’s ball-of-lightning emergence in the health care marketplace was close to unprecedented for a new painkiller in an age where synthetic opiates like Vicodin, Percocet, and Fentanyl had already been competing for decades in doctors’ offices and pharmacies for their piece of the market share of pain-relieving drugs.

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These reports must demand a Congressional investigation into Oxycontin (before and after the 2010 abuse deterrent version) and all potentially addicting drugs currently on the market, not just pain killers.

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Congress needs to address pharma’s drug trafficking, data collection, and,duty to report.

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Pharma needs to be tracking distribution not just for sales and profit, but for common sense to interrupt drug trafficking. Obviously there is no law.  Profit always wins.

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Business ethics is not good enough to justify the explosion of opioid abuse that stems from years of Oxycontin pills. Profiteering at the cost of deaths and drug abuse. Vote with your stock holdings.

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Cannabis for pain and symptom relief

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Congress has lost the average person’s respect for scheduling cannabis as Schedule 1. It is an essential medication that has been used medically, safely for thousands of years. Patients are arriving in office with the discovery that CBD, simply CBD, works for their intractable pain. That’s not exactly correct, but there is a topical cannabis mixture that can relieve malignant pain – I mean disabling, not cancer.

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Reschedule cannabis as Schedule 3 immediately. It needs to be legalized, studied and taught. When MD’s are not taught about the cardiovascular potential with THC and when patients arrive in the ER without knowing what was in the marijuana they used, our hands are tied.

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Congress owes a release to the millions jailed simply for felony cannabis possession.

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Cannabis  “to date has been responsible for the arrest of about 20 million US citizens,” written in 2010 by Emeritus Professor of Psychiatry Lester Grinspoon.

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Opioids: Will We Let Politicians Treat Pain? Need Presidential Debates on Precedent


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Pain kills

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Cutting back my patient’s opioids when they were helping, when there is no better alternative, none better –  it is the most painful thing I’ve ever been asked to do as a doctor. Withdraw necessary medicine. On orders from the federal government forcing me to harm my patient.

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Harm my patient. The thought sickens. Forced by government orders to harm my patient.

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Orders. Cold as a steel gun held by DEA Swat team bursting into my office if I don’t act on government orders. Certain dictatorships treat citizens that way.

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Congress is pushing this opioid bust very hard.

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That is demagoguery

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I am pained and suspicious in several ways.

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Legal nationwide precedent.

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A precedent in government, deciding for each individual person, without good faith history and examination of each, now orders each person’s medical treatment.

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It overrides judgement. I feel my judgement specializing for decades in pain management, with or without use of opioids, using comprehensive multi-specialty approaches has always chosen excellence in the field of pain management, in accord with State and Federal guidelines until this new one, and within the best practices of the American Pain Society.

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Best practices are irrelevant. Choke on that one. The lack of options is impossible to swallow. It is life-changing for the most severely disabled patients across the country.

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It has nothing to do with the subject: pain control.

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Nothing to do with helping to relieve pain.

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It causes grave harm to my patients and their families and sets an astonishing precedent among healthcare insurers to never allow more than the guidelines; the federal CDC-invented, arbitrary, pseudoscience, one-size-fits-all guideline for opioids because:

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the government can’t deal appropriately with the heroin epidemic and the war on drugs. They ignore results from countries that have done more enlightened research to point the way.

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Demogogues order doctors how to treat everyone. This country is has done what China and Russia have done to their citizens. I am in shock. My patients are in shock. Aghast. Feeling forced to bend over and swallow an undemocratic, unscientific piece of

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This used to be a free country with certain rational sets of behavior and one that recognized a need for pain specialists. Only recently did it create specialists in pain management. Specialists who get ignored. Does this happen in every other field? Shouldn’t we all care no matter our expertise because we may all have bad pain if we live long enough? Chronic noncancer pain. What if some federal agency starts ordering you that dialysis will be allowed less often?

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None of us gets away from the grip of the irreligious opioid guidelines. Will we have intractable pain at some time in our lives? Will we allow government to dictate that you or your spouse or gram cannot be given the dose that has safely helped for years? The guidelines were forced on us.

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Insurance will not pay for more.

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This needs to be discussed as a presidential election debate issue.

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Demagogues appear at times of unrest across the country. Politicians may feel forced to bow to the anti-opioid groups, angry because of the heroin epidemic and at how badly addiction treatment is neglected in this country.

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But for pain patients not addicts, to be subjected to directives from federal agencies, CDC and DEA, how do we object to this unscientific, irrational precedent? At least debate it on a presidential level.

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Drug abuse, addiction, pain management and healthcare insurance as it pertains to these new federal opioid guidelines presume to treat pain but force us all into a cage of irrational pseudoscientific dictates. And we are forced to mangle the finely adjusted treatment of your pain, your spouse or your granny’s pain. We’ve slogged through so much to get there. It’s tough to find the right balance with chronic daily pain.

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Those running for president:

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What is the candidate’s position on this unprecedented fiat that dictates your maximum morphine equivalent daily dose (MEDD) you can receive?  It is a dose that is far less than you’ve been on for years that had been helping.

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Is this creating unprecedented pain among 50 million Americans with chronic pain?

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Are we going to let politicians treat our patients with pain?

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This site is not email. Not intended for medical advice.

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This is the start of all sorts of federal dictates

into your medical care.

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Pseudoscience, Opioids, Politicians – Oh MY! Whose MEDD? Slashing Dose


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Opioid Guidelines are Pseudoscience

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They do not pretend to treat pain

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CDC Opioid Guidelines limit opioids to

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 90 mg morphine equivalent daily dose, MEDD

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Whose calculations will the DEA use against your doctor?

 

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Chronic pain is life altering. Opioid guidelines are life altering. The introduction of pseudoscience on a nationwide scale is life altering. Actually being the physician to reduce opioid doses to comply with arbitrary guidelines is life altering.

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The guidelines are intended to stop death and misuse from opioid overdose, not intended to relieve pain. About the same as taking drivers off the highway to stop highway deaths. We are just about back in the era of pain management before 1990.

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A nationwide mandate that affects the practice of thousands of doctors and the health and well being of 50 million people whom the authors have never examined, is life altering.

 

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We are all in shock. Guidelines don’t care about pain. CDC does not care. It’s all about death from overdose – tens of thousands of overdoses every year. Even when we calculate some magic pseudo-equivalent dose, just how are we to get from point A to point Z?  It is not discussed. This anonymous treatment limit is an insult to our patients, and fails the standard of practice of medicine in this country that requires a good faith history and examination of the whole person, just to begin. Then to design a treatment plan.

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For example, how do we calculate the morphine equivalent daily dose (MEDD) of oxycodone? That can be tricky. Opioids vary from person to person, drug to drug and the tables used to calculate and convert from one to another all differ. How simple is that? Wouldn’t we rather be talking about opioid splice variants, anything, but this calculated number is based on pseudoscience, as explained in this publication:

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The MEDD myth: the impact of pseudoscience on pain research and prescribing-guideline development

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This critical paper is published by the Journal of Pain Research, which is open access peer reviewed. Why is this important?

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Let’s look at a few points:

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In 2014, Shaw and Fudin conducted a survey comparing various online opioid dose-conversion tools and found a −55% to +242% variation across eight opioid-conversion calculators.16 The standard deviations in these two studies alone exceeded many of the MEDD maximums that several states have employed to trigger consultation from a certified pain expert.8,17–19 These studies alone unequivocally disqualify the validity of embracing MEDD to assess risk in any meaningful statistical way. Outside of MEDD calculations, there are several factors that also require consideration, but that remain largely ignored. These include patient-specific attributes, such as pharmacogenetics, organ dysfunction, overall pain control, drug tolerance, drug–drug interactions, drug–food interactions, patient age, and body surface area.15 The bottom line is that as the scientific concepts upon which prescribing guideline authors depend are flawed and invalid, so are the guidelines themselves. As a result, we posit that these guidelines are disingenuous and highly unethical.

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Opiate overdoses unfortunately can occur at any dose, and patients are at risk on even low-dose opioids.

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Death can occur at any dose. There is no “distinct risk threshold.”

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The guidelines are intended to stop tens of thousands of deaths from opioid overdose, they are not intended to improve pain. Just as chronic pain seizes the brain, the opioid guidelines stop rational thinking and all your reflexes.

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The morphine equivalent daily dose (MEDD) of 90 mg is the maximum dose on the guidelines and affect everyone no matter how different your pain, your age, or your dose needs to be from another person, and regardless of how opioids differ from one another. Pseudoscience creates a huge problem. This is not only not evidence-based. There is no evidence at all.

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I have recently referenced criticism of the opioid guidelines which I recommend for additional details.

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It’s not only opioid guidelines. Medicine is an art, not a science. Real people and medicines have real differences. The New York Times reviews a book about medicine by Abraham Nussbaum, MD, that says it well:

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“He notes that partisans of today’s much promoted evidence-based medicine must determinedly finesse the fact that medicine is riddled with flawed, incomplete evidence. The leaders of genomic revolution trumpet a future that keeps being postponed. Quality-control gurus abound, but their work often fails to yield actual quality.”

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Will the opioid guidelines bring a prohibition like the alcohol prohibition of 1928?

 

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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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CDC Opioid Guidelines – The Criticism in today’s Practical Pain Management


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Criticism of the CDC Opioid Guidelines

from today’s Practical Pain Management

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This excellent journal is edited by the gifted, much loved, and opinionated Forrest Tennant, MD, who we like to count on for not holding back. I missed it in the brief look I did today – this is necessarily sober.

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Following criticism of the CDC Opioid guidelines, please read important information on suicide prevention, below, and how Vancouver has prevented deaths from opioid overdose. At Vancouver’s clean supervised drug injection centers: Over the last 13 years, millions of injections have occurred at Insite and there have been no deaths.

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Two things stand out, on this page of criticism of the CDC Opioid Guidelines. In particular:

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  1.  The heartfelt, pointed comment by Daniel Carr, MD, the President of the American Academy of Pain Medicine(AAPM)

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  2.  Organizations that have criticized the CDC Opioid Guidelines

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Directly quoting, below:

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However, some have not responded to the CDC’s guidelines with unconditional support. A number of criticisms have been expressed by organizations, like the American Medical Association (AMA), the American Academy of Pain Medicine(AAPM), and the American Academy of Pain Management, that question the validity and quality of the guideline’s featured recommendations.

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[Emphasis mine]

The criticisms surround the CDC guideline’s low-quality evidence base, which excludes all data from studies investigating opioid efficacy recorded from 3 months to 1 year duration. This is a concerning omission, according to Daniel B. Carr, MD, President of the AAPM, because the guidelines are intended for treating pain that lasts longer than 3 months. By contrast, associations like the Food and Drug Administration (FDA) do accept studies in this longer range.

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AAPM Response

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In a statement released by AAPM, the association said they cautiously support the efforts of the CDC to address the challenges that often accompany prescribing opioids for chronic non-cancer pain.

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“We know that doctors—primary care and pain medicine specialists—are integral in treating pain wisely and carefully monitoring for signs of substance abuse. Abuse and diversion of prescription opioids must be addressed,” said Dr. Carr, Professor of Public Health and Community Medicine at Tufts University. “Opioids are not the usual first choice for treating chronic non-cancer pain, but they are an important option—as part of a comprehensive multidisciplinary approach— that must remain available to physicians and appropriately selected patients.”

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Dr. Carr said that society needs to address both chronic pain and its treatment as public health challenges. This view is endorsed by the National Academy of Medicine and outlined in the draft National Pain Strategy from the NIH.

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[emphasis mine]

“Public health problems are typically complex; well-meaning, but narrowly targeted, interventions often provoke unanticipated consequences,” he said. “We share concerns voiced by patient and professional groups, and other Federal agencies, that the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence. It is incumbent upon us all to monitor the deployment of the guideline to ensure that it does not inadvertently encourage under-treatment, marginalization, and stigmatization of the many patients with chronic pain that are using opioids appropriately.

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The AMA’s response:

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“While we are largely supportive of the guidelines, we remain concerned about the evidence base informing some of the recommendations, conflicts with existing state laws and product labeling, and possible unintended consequences associated with implementation, which includes access and insurance coverage limitations for non-pharmacologic treatments, especially comprehensive care, and the potential effects of strict dosage and duration limits on patient care,” said Patrice A. Harris, MD, the AMA board chair-elect and chair of the AMA Task Force to Reduce Opioid Abuse.

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“We know this is a difficult issue that doesn’t have easy solutions and if these guidelines help reduce the deaths resulting from opioids, they will prove to be valuable. If they produce unintended consequences, we will need to mitigate them. They are not the final word. More needs to be done, and we plan to continue working at the state and federal level to engage policy makers to take steps that will help end this epidemic.”

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Very sobering issues and too many deaths from opioid overdose. Whether alone, in combination with alcohol or other sedatives and sleeping pills, the focus is on opioid dosages.

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The fear is what the DEA will do in response to the guidelines. The immediate reality is that insurance formularies have changed in strange and unpredictable ways the last few months. As always, we may need to adjust dosing as patients age or illnesses enter into an evolving lifetime of care. Be prepared to change the dose, alert to doses that may be too high for their current medical condition, and always alert to opioid misuse, addiction, misjudgement, and mental health. Be wise and do the right thing.

 

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Suicide prevention

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The New York Times published March 9, 2015 on Blocking the Paths to Suicide, rethinking prevention.

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Sometimes, depression isn’t even in the picture. In one study, 60 percent of college students who said they were thinking about ways to kill themselves tested negative for depression.

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“There are kids for whom it’s very difficult to predict suicide — there doesn’t seem to be that much that is wrong with them.

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 Suicide can be a very impulsive act, especially among the young, and therefore difficult to predict.

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About 90 percent of the people who try suicide and live ultimately never die by suicide. If the people who died had not had easy access to lethal means, researchers like Dr. Miller reason, most would still be alive.

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“People think of suicide in this linear way, as if you get more and more depressed and go on to create a more specific plan,” Ms. Barber said.

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Dr. Igor Galynker, the director of the Family Center for Bipolar Disorder at Mount Sinai Beth Israel, noted that in one study, 60 percent of patients who died by suicide after their discharge from an acute care psychiatric unit were judged to be at low risk.

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“The assessments are not good,” he said. So Dr. Galynker and his colleagues are developing a novel suicide assessment to predict imminent risk, based upon new findings about the acute suicidal state.

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In fact, suicide is often a convergence of factors leading to a sudden, tragic event. In one study of people who survived a suicide attempt, almost half reported that the whole process, from the first suicidal thought to the final act, took 10 minutes or less.

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Among those who thought about it a little longer (say, for about an hour), more than three-quarters acted within 10 minutes once the decision was made.

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. . . growing evidence of suicide’s unpredictability, coupled with studies showing that means restriction can work, may leave public health officials little choice if they wish to reduce suicide rates.

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Ken Baldwin, who jumped from the Golden Gate Bridge and lived, told reporters that he knew as soon as he had jumped that he had made a terrible mistake. He wanted to live. Mr. Baldwin was lucky.

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Ms. Barber tells another story: On a friend’s very first day as an emergency room physician, a patient was wheeled in, a young man who had shot himself in a suicide attempt. “He was begging the doctors to save him,” she said. But they could not.

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Addiction

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Let us never forget the curse of addiction, and the profound misunderstanding our leaders make: it is a medical condition, not a choice. The war on drugs must be transformed from militarization of addiction to medicalization of addiction. Like Canada, Portugal and some of the South American countries.

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The New York Times writes this week of Vancouver’s clean supervised drug injection centers. Over the last 13 years, millions of injections have occurred at Insite and there have been no deaths.

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opioid and heroin overdose deaths are preventable. The drug Naloxone, which blocks the effects of heroin, is a safe, inexpensive antidote when someone is available to administer it, as is the case at Insite.

 

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Coda

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After all this, it feels like we’ve advanced a long way into the 21st century. Old stuff does not work. There sure is a whole bunch of stuff that no longer works. Life happened, and moved along.

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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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NIH Releases a National Pain Strategy


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Today NIH Releases a National Pain Strategy

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Doesn’t look too different from the opioid reduction strategy.

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From an excellent NYT article that covers several sides of the issues, and that I had previously linked two days ago:

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But alternatives are unrealistic for some. Physical therapy is too expensive for Ms. Kubicka-Welander: she can scarcely make the rent on her home in a trailer court. Patients with a compromised liver cannot take high doses of acetaminophen. Those on blood-thinners should not use ibuprofen.

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I would add that the American Pain Society cautions against use of ibuprofen and similar NSAIDS in seniors. The risk of taking these drugs – GI bleed, heart attacks and arrhythmias  – increases with age.

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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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Rectal Suppository Morphine, part 2 – link to formulary Blue Shield


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Here is a link to the formulary for long acting opioids for Blue Shield.  You can see the update date on the bottom as 3/3/16.  I could have added that they index rectal suppository Morphine as a Long Acting* Opioid as well:

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Under Notes and Restrictions:

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PA=Prior Authorization

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ST= Step Therapy Required

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NF=Non-formulary

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https://client.formularynavigator.com/Search.aspx?siteCode=1390724043&targetScreen=3&drugBrandListBaseTC=analgesics%7copioid+analgesics%2c+long-acting&drugSortBy=status&drugSortOrder=asc

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*Hint, it’s short acting.

 

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Signed,

Your friendly neighborhood healthcare insurer

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Do they live in your neighborhood?

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It would be unAmerican to publish their names and addresses.

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With the world’s eyes on this nationwide experiment, they allow Rectal suppository morphine. That’s all folks.

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Sweeping effects on the practice of medicine.

Meditate on that.

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Head to my front page if you want

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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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Opioid Guidelines – sweeping effects on the practice of medicine


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This page is just for meditation

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Meditate on that. Sweeping effects on the practice of medicine.

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Head to my front page if you want

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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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Opioids Down in Doctors’ Offices Across the Country


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New York Times: Patients in Pain,

and a Doctor Who Must Limit Drugs

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By JAN HOFFMANMARCH 16, 2016

 

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MILFORD, Neb. — Susan Kubicka-Welander, a short-order cook, went to her pain checkup appointment straight from the lunch-rush shift. “We were really busy,” she told Dr. Robert L. Wergin, trying to smile through deeply etched lines of exhaustion. “Thursdays, it’s Philly cheesesteaks.”

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Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.

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Yet rather than increasing her dose, Dr. Wergin was tapering her down. “Susan, we’ve got to get you to five pills a day,” he said gently.
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She winced.
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Such conversations are becoming routine in doctors’ offices across the country. . . .

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“I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home,” said Dr. Wergin, 61, the only physician in this rural town. “A one-size-fits-all prescription algorithm just doesn’t fit him. But I have to comply.”

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 When a random drug test of one longtime patient showed no trace of prescribed opioids, Dr. Wergin had to “fire” him for breaking the contract. Instead of taking the pills, the patient had been selling them.

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Dr. Wergin has learned to be even more wary during his emergency room shifts at the hospital 15 miles away. There, he has seen firsthand a growing number of overdoses and opioid-related deaths.

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The scenario has become so familiar that now when a nurse reports that the patient in Room 3 is complaining of excruciating back pain and asking specifically for Percocet, Dr. Wergin will reply, “And is he about 31, single or divorced, and insisting he is allergic to nonsteroidals?”

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These are “seekers ’n’ sellers,” he explained, who peel off I-80 and head for the hospital “thinking we’re just ignorant hayseeds.” A few months ago, state troopers pulled guns on one such man, who had stormed into the hospital demanding pain medications and threatening Dr. Wergin and other staff members.

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As Dr. Wergin recounted this, driving through the fog-shrouded back roads of winter-stubble prairie, where patients are rushed to the emergency room after being crushed by forklifts and tractor tipovers, he recoiled against his own cynicism.

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Prosecutors and medical review boards are increasingly scrutinizing physicians who prescribe controlled substances. A colleague of Dr. Wergin’s in a nearby community was investigated for two years after a patient died of an overdose. Although she was cleared, the reputation of her small-town practice was damaged. She moved to another state.

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The problems faced by Beverly TeSelle, 71, defy most solutions.

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After a second stroke that left her using a wheelchair, Mrs. TeSelle, formerly a gregarious accountant, began to suffer vicious headaches that left her weeping and moaning.

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“The biggest relief for both of us is when she goes to sleep,” her husband of 53 years, Larry, said, tearfully.

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Dr. Wergin noted that Mrs. TeSelle, whose strokes have also left her with slurred speech, and hand, arm and shoulder pain, already takes more than what may be allowed by coming state limits. He considered increasing the dose of her fentanyl patches but said, “I worry about respiratory depression.

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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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Rectal Suppository Morphine – the only opioid on formulary


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CDC Opioid Guidelines

Day #1

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One patient’s formulary changed with Blue Shield of CA and the ONLY opioid now available to her without a prior authorization is rectal suppository morphine. 

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I almost choked on my wheatberries on this one.

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 — addicts would  love them. Patients, not so much.

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Be warned people. 

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Is that 6 suppositories every 3 hours?

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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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Have Feds Told Doctors to Stop Prescribing Opioids For Chronic Pain? “Almost all opioids on the market are just as addictive as heroin”


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Today JAMA published the heavily resisted

CDC Opioid Guidelines

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“A very useful guideline for people who don’t hurt,”

says my Rheumatology colleague

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 Chilling Effect on Prescribers

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Guidelines allow Tylenol or Aspirin

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Will insurers stop paying for opioids?

 

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Almost all opioids on the market are just as addictive as heroin,” CDC Director Thomas Frieden said.

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The guidelines are based on three principles. First, opioids should be a last option for these patients, with aspirin-related drugs and exercise preferred. Second, when given, doses should start out low and only increase slowly. Third, patients should be monitored and a plan for getting them off the drugs should start with their prescription. The guidelines also call for getting naloxone, a drug used to counteract overdoses, into the hands of more doctors, nurses, police, and emergency personnel.”

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Have Feds told Doctors to Stop Prescribing Opioids For Chronic Pain? CDC guidelines focus on heroin, opioid related deaths, addiction. Not pain.

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The guidelines are about addiction, heroin is everywhere, opioids cause death. So are they taking away the opioids?

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I can’t bear to read it. The small print and pages of detailed words strike my amygdala numb.

 

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The CDC has a mandate to prevent opioid-related deaths, so all must suffer.

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Rather than address addiction as a medical condition and offer adequate treatment programs including for prisoners, the plan is to continue wasting trillions more on militarization and the failed War on Drugs that literally created the heroin market across the nation, among rich and poor.

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…no one in this country is untouched by opioid addiction. And fuck the governor of Maine. He is anti naloxone and got hundreds of people cut off of methadone by cutting federal aid in the state for addiction related services.

Tracy Helton Mitchell today on Reddit, inspiring leader.

Author of “The Big Fix – Hope After Heroin.”

 

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These are “guidelines, not law.”  CDC

And these are 50,000,000 Americans with chronic pain, not drug addicts.

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Voluntary. Guidelines. In this country . . . .this is a tsunami.

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Will state legislators, in the current zeal to address this heroin epidemic, put up abrupt new laws overnight restricting opioids, as they have already done in Massachusetts, as I recall, and other states. One governor ordered every one with chronic pain switched to methadone. How many died from that law?

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CDC will allow post injury/surgery opioids for 3 days, only for acute pain, only acute cancer pain while under active treatment (not chronic cancer pain), and for palliative care.

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Will insurers stop paying for opioids?

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Insurers now have federal support to deny all opioids. And denials are something they have been doing little by little for years, for many types of conditions, not just pain.

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I fear for 50 million Americans with chronic pain. I cannot bear to read these detailed injunctions from CDC and their focus on heroin abuse rather than pain  – not after 16 hours of recent conference on this.

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I fear 50 million people will be frantically calling every pain specialist for help because none of their doctors will prescribe opioids. I have been seeing this already for a few months. Who will help them?

Will opioid taper lead to loss of jobs, loss of medical care, loss of insurance?

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I have written on this 17 or 18 times since October. There is nothing we can do to change it.

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The political environment could not be more toxic toward the disabled including our veterans, toward chronic pain, opioids and heroin.

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I look forward to a strong discussion on these chilling “guidelines” in the pain community from Forest Tennant, MD, Editor of Practical Pain Management, and a coming article on by Michael Schatman, PhD, CPE in J Pain Res with with Jeff Fudin and Jaqueline Pratt Cleary, which HONESTLY discusses the guideline issue in light of the antiquated concept of MEDD.

 

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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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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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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.

~~~~~

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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