Veterans Suicides 20 per day – MD not paid in 12 months for 5 approved visits


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VA Conducts Nation’s Largest Analysis of Veteran Suicide

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Read the report all you want, but for 12 months I’m not reimbursed. And no explanation why. No wonder they can’t get doctors.

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Yet another call just now from TriWest asking me to treat a veteran. VA crisis lines leave vets in limbo. Calls go to voice mail. Veterans have killed themselves just after calls to crisis lines. A lot of these suicides are due to PTSD. Veterans cannot get the help they need.

 

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I believe it is TriWest who won the contract to schedule suicidal veterans who have Treatment Resistant Depression or PTSD or Bipolar Depression. I treat that. It works except in the most extreme cases, in minutes to just a couple days. It’s simple and safe for outpatient use. It has been tested at NIMH and Yale since 1991. The VA-UCSD psychiatrist referred him and then continued care.

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I will not see one more veteran until I am reimbursed for the 5 pre-approved visits for a veteran I treated 12 months ago. He was better in a few days, the first time in decades he had relief of depression. If you cannot pay me who can relieve treatment resistant Major Depression in 2 days, then honey, no wonder you can’t find docs to help. They limited me to their chosen codes for billing. I spoke to psychiatrists who work with veterans and they have never heard of those codes. I guess they just mean loud and clear: NO PAY. Fine. It was a pay cut to offer and took weeks of paper forms, months of approval – you have to really want to do it. With frequent help from a very experienced clerk and a doggedly informed veteran who knew all the ropes, it took months for paperwork to get rushed through. Plenty of doctors just graduating this month don’t know how many months paperwork takes and they won’t get paid.

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San Diego VA has the worst reputation in the nation. I understand it is the San Diego VA that has the worst lag time delays of several months before veterans can even be seen. Worst in the country. Correct me if I’m wrong. And we have a lot more veterans because warm sunny weather is easier on their bones. Is that any excuse to dis-incentivise any doctor by not paying for services?

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The new veterans suicide hotline does not even return all calls. Public Radio just had an expose’ on this one or two weeks ago.

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Twenty veterans take their life daily.

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Only 30% of people with depression respond to antidepressants.

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Based on publications from major academic centers, treatment resistant depression, it seems, is diagnosed after failing as few as 3 or 4 antidepressants.

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Compare any antidepressant to ketamine with potential relief in hours to a couple days.

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It’s not like this is new. In 1991 ketamine was first studied at NIH for depression. Yale has carried the work forward with them. But people live at home and it has to be cost effective. It is unnecessary and/or unaffordable for most people including taxparers to be paying for IV infusions when many or most patients do well on sublingual or nasal use. It is the #1 drug of abuse in China, so don’t just offer it to any person who needs it. Make sure you understand how important glial modulators are in depression. See Yale with NIMH publication on inflammation in depression, I posted on these pages about 3 or 4 years ago when it came out.

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Yale with NIMH had published that ketamine rapidly creates synapses.

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And Yale has published:


Activation of a ventral hippocampus–medial prefrontal cortex pathway is both necessary and sufficient for an antidepressant response to ketamine

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In January 2012, I posted detailed information:

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Depression PTSD – Ketamine Rapid Relief

 

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  • PTSD has a more direct link to suicide than previously thought, a current Texas A&M University study concludes – references below.

  • A high lifetime risk of suicide occurs in women who have been sexually and physically abused as young girls.

  • More than 300,000 veterans have been diagnosed with PTSD or major depression – many not yet diagnosed.

  • Risk of suicide is the highest during the first month of standard antidepressant therapy, and a significant number of patients do not have adequate improvement even after months, resulting in harm to personal and professional lives.

  • Patients are at suicide risk upon discharge from psychiatric hospitals.

  • Significant predictors of both suicide attempts and preoccupation with suicide are guilt and anger and impulsive behaviors.

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  • Ketamine is the most important breakthrough in treatment of major depression with rapid and lasting effects.

  • Ketmine can help immediately, unlike all other antidepressants that may require weeks or months to work, if they help at all. See NPR report here – that appeared soon after I posted this (skip to their last section). It is FDA approved and legal. NPR again reports ketamine’s rapid relief of depression.

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  • snip

    snip

    • The medical literature on ketamine use is profoundly important. There are over 6,800 medical publications. Ketamine has potent healing powers. Karl Jansen, psychiatrist in London, believes that “ketamine has potent healing powers when used as an adjunct to psychotherapy.” There is nothing like it; however, treatment for serious depression still requires team support, not medication only.

    •  The World Health Organization reports that disability to due depression is second only to heart disease.

    • Suicide is a catastrophic medical emergency. I cannot stress this enough. Depression is treatable.

    • Your death is unnecessary. It would be a terrible loss to all who love you.

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Please read that entire post January 2012 before you call to ask questions. The calls are very time consuming.

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There is no reason to restrict life and death matters to one drug, and then make it dependent upon only IV infusions. What kind of life is vegetating in depression for decades? It is a short acting drug. I have posted on why ketamine should never be used alone, but must be used with other glial modulators.

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Most troubling:

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Compounded Medications are Not Covered by Any Insurance

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Most people cannot afford compounded medications, especially if disabled due to Major Depression or PTSD or pain – same medications work on mood and pain.

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TAKE ACTION

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Healthy people can get back their lives. These simple steps can be taught across the nation. Millions are needlessly disabled, especially our young adults who are most vulnerable to these disorders, and several hundred thousand of our young veterans.

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An entire nation can get and breathe relief.

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DO THIS:

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Call your favorite politician and relevant organizations who care about healthcare and veterans to STOP the collusion and restraint of trade since all insurers began refusing to cover compounded medications. All these new $100,000 per year medications are paid for by the taxpayers and your insurance deductible that goes up every year. How long will you be able to afford medical care? How long can this restraint of trade be practiced under our noses unless we take action?

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Get this on the Democratic platform this presidential year. It’s a scam perpetuated by multibillion dollar pharma and their mighty rich contributions to congress who are killing affordable medical care.

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Affordable medical care

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These medications must be compounded. How many can afford $200 to $300 or more cash out of pocket just for medications? Or will this become another safe old drug that is bought by a financier, patented, and now they charge $100,000 a year? You know who pays for everything and it ain’t the 1%.

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Be the change you wish to see – or walk away. Money at NIH


 

 

A Turning Point

 

$$$$$ MONEY $$$$$

 

at NIH

 

May not come this way again

 

NIH developing

5-year NIH-wide Strategic Plan

 

 

 

Donate to organizations, below

They can provide feedback to NIH via the

RFI Submission site


 

 

 

John C. Liebeskind, 1935 – 1997, distinguished scholar and researcher, past president of the American Pain Society, had the radical idea that pain can affect your health.

 

Research decades ago by an Israeli team at UCLA and others had shown “that pain can accelerate the growth of tumors and increase mortality after tumor challenge.” Decades ago Professor Liebeskind lectured all over the country: Pain kills.

 

He wrote an editorial in 1991, summarizing a life’s work:

 

“Pain and stress can inhibit immune function.”

 

 

Quoting John Bonica, the father of modern pain management, he wrote:

 

“Bonica has long argued that the term ‘chronic benign pain’ (used in distinction to pain associated with cancer) is seriously misleading.  Chronic pain is never benign, he contends; “it is a ‘malefic force’ that can devastate its victims’ lives and even lead to suicide.”

 

 

Liebeskind continues, “It appears that the dictum ‘pain does not kill,’ sometimes invoked to justify ignoring pain complaints, may be dangerously wrong.”

 

Pain mediates immune function

 

Importantly

 

  Opioids mediate the suppressive effect of stress on natural killer cells,

 

 published in 1984, immune system.

 

Alcohol increases tumor progression, 1992, immune system.

 

It used to be news.

He did not live to see change.

 

People just want to go on doing what they’re doing.

They want business as usual.

 

 

After 1991, we saw the great discoveries of neuroinflammation, pioneered by Linda Watkins, PhD, the early understanding of the innate immune system, its involvement in chronic pain and depression, and a few weeks ago, a British team showed neuroinflammation in teens with early signs of schizophrenia and DNA markers.

 

 

Major Depression has the same neuro-inflammation found in chronic pain, often responding to same medications, in particular glial modulators – immune modulators. Now, perhaps early schizophrenia will respond to glial modulators, reducing inflammation seen on scan in teens, before they become homeless and burned out by antipsychotic drugs

 

Inflammation out of control destroys neurons

 

Fire on the brain

 

 

We must be the change we wish to see

 

It’s not just the Bern. It’s been starting. Forces are finally coming together. We want change. It’s been too much. Too long.

 

We won’t take it anymore.

 

I figure if I tell you about it, you might just mention it to someone to pass it on. That is all. One small action may lead to change. Activate inputs to the NIH strategic plan.

 

 

~ Action needed ~

 

Prices of drugs becoming unaffordable

No new drugs for pain or major depression

Research to repurpose existing drugs

Expose the politics destroying our compounding pharmacies

 

Above all

The #1

Major Priority:

Request NIH to solicit priority call for research on

Glial modulators of the

Innate immune system

 

 

Why?

 

Glia modulate

chronic pain, major depression

and almost every known disease

 

Glia are your innate immune system

 

Inflammation kills

 

 

 

 Stress kills. Inflammation kills.

 

 

Pain kills

 

In the 1970’s, Professor Liebeskind and an Israeli team at UCLA injected cancer cells to two groups of rats that had sham surgery. Cancer spread much faster and killed far sooner in the group with poor treatment of surgical pain.

 

 

~ Pain kills ~

 

He lectured all over the country

 

Forty five years ago

 

 

I’m gonna be dead before I see this country do anything but unaffordable opioids and the magical ineffective trio of gabapentin, Lyrica, Cymbalta to treat chronic pain. The devastating, blind, nationwide emphasis does nothing to address the cause: inflammation, the innate immune system gone wild.


 

 

Innate immune system in action

 

Untreated pain suppresses the hormone systems too.

 

Untreated depression – same inflammation kills lives.

 

Where’s the money?

 

We are the change we wish to see. It’s pitiful I am so lazy. Suddenly, too late, we may need something, but, aha, no new drugs in the pipeline.

 

 

 

~ Make a joyful cry to NIH ~

 

They are soliciting input from professional societies

 

If your condition has failed all known drugs for pain or major depression, then make a joyful cry to NIH, now, before they give away all that nice new $$$$$money$$$$$.

 

 

Follow and join

 

American Pain Society

 

 

International Association for Pain

celebrating 40 years of pain research

 

 

Reflex Sympathetic Dystrophy Syndrome Association

help for CRPS/RSD  

 

 

 

The key to CRPS/RSD pain will apply to all forms of chronic pain, in particular the most difficult form, neuropathic pain. RSDSA funds research into all forms of chronic pain, not only Complex Regional Pain Syndrome (CRPS/RSD). Their scientific board members are not funded by opioid money.

 

 

 

Exactly

what is the annual cost of care

as fraction of GDP

for the growing population of Americans on opioids

for one year, for lifetime?

 

 

People are dying from prescription opioids and those who need them find they don’t work well enough. Prescriptions opioid costs must be a huge fraction of the medical costs in the United States GDP. You are required  to see a doctor every single month each year, often lifelong, just for one opioid, 12 months a year x 30 years x tens of millions of people and increasing – a growth industry. Not even counting $600 a day for the opioid, what the cost of monthly visits for 30 years? Not counting the army of DEA, FDA, CDC agents watching the opioids like a hawk. We all have to be sharp, addiction is growing. Addiction aside, deaths from prescription opioids are shaking up the CDC forcing urgent change this coming month.

 

 

 

Opioids do not work well for chronic pain

We need better

It’s not just the $600/day price

They just don’t work

 

 

donate

 

 

Raise a joyful noise at NIH now or write back at us readers with comments and better suggestions. Tell others what you’d like to see. Which politicians do you know would be most interested in this at national levels and organizations?

 

You may never see this change unless you do it now. Other forces will get this new money.

 

 

Turning point now

May not return

 

 

We are at a turning point and we will fail to catch the sail that’s coming fast to carry all research money in their shiny big stem cell direction. They never look back.

 

 

There is so many medications we can use today, FDA approved drugs that can be re-purposed and applied to recent cutting edge science. Someone must pay to do the work to study this.

 

 

Re-purpose old drugs

 

 

Stanford just showed a popular generic drug improved recovery of stroke paralysis in mice to begin at 3 days rather than 30. Old drug, new purpose, of course more years of testing to confirm in humans. Brilliant team applying new science.

 

 

Request
NIH to solicit a

Special Invitation

for 30 good protocols to

repurpose old drugs

 

 

Hundreds of old drugs, already approved, could be involved in mechanisms we have recently learned about. Speak up or money will go to shiny new stem cells. None for chronic pain or major depression. No company will find this profitable – it must be funded by NIH. A popular generic sleeping pill can bring astonishing return from stroke paralysis.

 

 

Congress has not opened this new money to NIH in many long years. How often will there be extra money?

 

 

donate

 

 

Lawrence A. Tabak, D.D.S., Ph.D.
Principal Deputy Director, NIH, solicits you to

Review the NIH Strategic Initiative Plan and their

Request for Information (RFI) and the NIH website

and provide your feedback via the RFI Submission site

 

 

This is for “stakeholder organizations (e.g., patient advocacy groups, professional societies) to submit a single response reflective of the views of the organization/membership as a whole. We also will be hosting webinars to gather additional input. These webinars will be held in early to mid-August.

 

 

 

Be the change you wish to see

Donate to those organizations

to solicit the change you wish to be

 

 

 

Happy New Year

Rejoice!

There’s money at NIH

 

 

 

 

 

 

The material on this site is for informational purposes only.

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

Relevant comments are welcome.

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

This site is not for email.

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

 

 

 

 

Opioids and Deaths – If Sloan Kettering Cancer Center Can Do It, Why Can’t My Hospital OK Herbal & Compounded Medications?


 

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Gina Kolata reports in NYT

on the breaking study by two Princeton Economists    

 

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The key figure

Screen Shot 2015-11-05 at 7.53.11 PM
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“The two Princeton economics professors — Angus Deaton and his wife, Anne Case — who wrote the report that is the subject of my front-page article today about rising death rates for middle-aged white Americans, have no clear answer, only speculation. But the effect is stark. Dr. Deaton and Dr. Case calculate that if the death rate among middle-aged whites had continued to decline at the rate it fell between 1979 and 1998, half a million deaths would have been avoided over the years from 1999 through 2013. That, they note, is about the same number of deaths as those caused by AIDS through 2015.”

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“…The dismal picture for middle-aged whites makes Case and Deaton wonder how much of what they are seeing might be attributed to the explosive increase in prescription narcotics.”

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“What’s interesting, Dr. Case said, is that the people who report pain in middle age are the people who report difficulty in socializing, shopping, sitting for three hours, walking for two blocks.”

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“Dr. Deaton envisions poorly educated middle-aged white Americans who feel socially isolated are out of work, suffering from chronic pain and turning to narcotics or alcohol for relief, or taking their own lives. Starting in the 1990s, he said, there was a huge emphasis on controlling pain, with pain charts going up in every doctor’s office and a concomitant increase in prescription narcotics.”

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“We don’t know which came first, were the drugs pushed so much that people are hypersensitive to pain or does overprescription of the drugs make pain worse?” Dr. Case said.”

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“Dr. Deaton noted that blacks and Hispanics may have been protected to an extent. Some pharmacies in neighborhoods where blacks and Hispanics live do not even stock those drugs, and doctors have been less likely to prescribe them for these groups. Dr. Deaton said.”

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“A black person has to be in a lot more pain to get a prescription,” Dr. Case said. “That was thought to be horrible, but now it turns out to maybe have a silver lining.”…..

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Commenter: “D. Morris 1 hour ago
“unfortunately it’s easier to get a prescription of Oxycontin, or legally buy a handgun, than it is to get affordable mental health care in…”

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My Comments are too long, need days of edits, no time to do.


We have so many inexpensive generic medications in allopathic, Ayurvedic, and complementary medicine that are never taught.

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It is cost effective for Universities to limit their instruction to Anesthesia pain that teaches procedures. Thank goodness when they work. But is that all we teach? I fear the answer is yes. That was all that was available in Santa Monica in the early and mid 1990’s, after UCLA closed the Anesthesiology Interdisciplinary Pain Management Center in 1991 – others closed nationwide. It is cost effective to teach and do procedures.

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Epidurals

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 Bread and butter epidurals have never been compared to the same steroid and local anesthetic injected to the adjacent muscle without putting a needle into the spine. It could be equally as effective, able to be done in office, without surgery and x-ray scheduling, but then it would not be a good income generator. Selective nerve root blocks and facet blocks can be very helpful. But are epidurals just flooding the area with the same effect as a local muscle injection? What are we teaching before we get to procedures? How many patients can afford to take time off from work or school for repeated costly procedures?

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Glial modulators, compounded medications

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It would help if MD’s were trained (with CME credit) in the use of generic medications to include glial modulators that mitigate the need for high doses of opioids. There is often more relief than expensive procedures and hardware can provide – which may not work or may be short lasting and unaffordable for many, either due to cost or time away from work every few weeks.

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Physical Therapy

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Good training in Physical Therapy would be the very first step, not by PhD’s who teach fine academic theory, but by certified Orthopedic Physical Therapists with decades of bedside experience are needed to teach therapists who have shown time and again that the most basic P.T. is not being done in this country. Even people with purely neuropathic pain often develop mechanical changes, splinting to avoid pain. That must also be addressed.   

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I do not mean to imply that opioids are not useful. But there is more to pain relief than opioids and I suspect it may not be taught at all. Opioids rightfully remain on the WHO list of ten most essential medications. But when you use them – and believe me I am a wimp and would not be able to tolerate pain, but when you use opioids for years and years, how effective will they be when you really need them far more?

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Opioids are essential for many of my patients and when they fail, when all drugs fail including opioids, I know one thing is on their mind, and it grieves me that this country does not care enough to fund more than a pittance for pain research. This country must do better. Nobel prizes are abundant in La Jolla, but how about translational research in the clinics where we try to keep patients functioning and able to return to work without opioids.

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Drugs do not address muscle

Trigger Points

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Any doctor can do simple trigger point injections if they knew how to identify trigger points, the classic spots on common overused muscles that mimic disabling knee pain or headache or loss of grip strength, yes a strained, shortened brachioradialis – not neurological but do MD’s know?  P.T. specialists too, I hope they know trigger points, but they are not always communicating them to me because I find them and they can be simple.

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Could they add the identification and training of doctors to know meaningful differences in types of physical therapy. They all should be taught by an Orthopedic Physical Therapist like Bruce Inniss who trained decades ago at Rancho Los Amigos, a national treasure center back then innovating care for the most difficult paralyzed, handicapped and publishing it. Not the fancy PhD theory that the newer P.T. grads know – good but not best. Why don’t all physical therapists know the basics Bruce finds every day —- the same basics that were never once treated in the 30 years that my disabled patients were forced to return to. They come from the best university specialists in the country, and they all groan when I say “P.T.” until the next day after they have seen Bruce for their “intractable pain.” Thirty years of lost life. Expensive, joyless, hoping for the worst, praying for the day you will be old enough for Medicare so you could afford care because it has cost you your life savings. I am grateful for academic researchers for their brilliance, their ability to tolerate an academic environment. Best of all I love their shiny new cardiology toys and Dr. Topol translating medicine over wi-fi. Lets not leave behind the basics.

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It shocks me to see some of the basic things were overlooked or not even considered in people who come to me, often seen by the best five pain centers in the country. Of course I rely on those centers who may be able to help my patients. But I am shocked by the omission of simple basics: physical therapy being a key ingredient. That alone could save lives and save our taxpayers billions if the investment were contemplated.

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Last week, the well respected pain specialist Joseph Shurman, MD, at Scripps, said that young Rehabilitation Pain Specialists were rare. Few are going into Pain Management from an essential field. It’s a tough field, changing daily.

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What about other things?

 Compounded medication

Botanical, Ayurvedic, Herbals

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Hospital and university pharmacy committees must begin to open their minds to highly valued compounded and herbal drugs made by respected compounding pharmacists. We all know the high volume thieves who delivered contaminated IV’s, and had  the cheapest prices that brought a bad name, but why stop beneficial interstitial cystitis infusions ordered for decades by the senior specialist in the field? This attitude against compounding and against highly recognized herbal and Ayurvedic preparations must be improved. For example, Boswellia sold by Gliacin.com points to studies by the headache specialist in Scottsdale who trained at the Mayo Migraine Clinic. His site has publications showing 7 of the most intractable Indocin-responsive headache syndromes were improved with Gliacin (Boswellia)..

Most notable in the field is the website and research by Sloan Kettering Cancer Center on herbals and botanicals. You can hardly exclude half the country from your hospital if they found relief at last?  Surely you must teach and know the effects of patient use on FDA approved medications you are prescribing.

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What happens to that patient, whose intractable pain

responds only to compounded medicine,

when they have to be admitted to hospital or rehab

for weeks where compounded medications are forbidden?

Do we make you worse to get you better?

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Hospitals and universities are run by respected seniors, whip smart, who have no experience with many tools that are essential to many in our population. They are rightfully very protective of our beloved high technology centers and want no lawsuits from unapproved drugs not sold by big pharmaceutical companies. Not all of us live in such rarefied privileged worlds in our daily lives. We already have the tools and could use many of them at home without burdening resources. I would love to see physicians on hospital pharmacy committees work side by side with compounding pharmacists and be protected by law for using such inexpensive medications. Insurers have stopped coverage for compounded medications in the last four years, finishing the job in June with Tricare no longer paying. Medicare never has.

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So goes medicine in this country. We all lose. We are reaching for bright shiny things that dazzle me too. Don’t forget to keep the basics, the first thing I learned when teaching at UCLA Epilepsy Center. Often, the basics were not omitted. Case solved.

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It’s hard to know what to trust in so-called alternative treatment, but we must begin to trust if we have evaluated the credentials of best providers. Can we not trust even your patient’s heavily documented history? 

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We must do better. It is costing too many lives. The study I mention, above, just published, is tragic and predictable. Just ask any of us who see this daily. Ask your neighbors and family.

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Politicians could give us a law to protect hospitals from law suit if they allow compounded medications from highly respected compounding pharmacists who are owners of high quality small trusted pharmacies — not those big ones without supervision, where quarterly profit is the goal. We must keep these precious resources of medicine alive so that only the upper middle class can afford them. Does everything have to have overpriced studies and FDA approval with publications by many peers? We all know what that did to colchicine pills used for 100 years for gout, taken 3 times a day. Everyone knew they worked. But if you are the 1%, you invest a little and you can charge $7 each, $21 every single day for just one pill for life, instead of pennies a day.   


 

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INTRACTABLE PAIN IS NOT INTRACTABLE

IF YOU USE THE TOOLS YOU ALREADY HAVE

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It is past time we start teaching tools for pain that many of us daily encounter. Teach to doctors and physical therapists at the very least, but bring it into middle school and even younger.

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So many people are forced to put up with lack of medical care, lack of jobs, lack of income, and disability from working in factories owned by the 1% who control care, often through worker’s compensation.

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Now insurers require ICD10 codes before pharmacy can fill an antidepressant. That feels like ICD10 prison, and this comes at the same time as 70,000 new codes – merely an extra 50 hours a week. Why is the MD not the judge of medication after due deliberation of all the details, all the failed drugs. Practicing medicine without a license has become the standard of care since 1990, out of the doctor’s hands. Now that and insurance will not accept a prior authorization for a low dose of 25 mcg patch the patient has required for the last ten years for their lupus, Sjogren’s, RSD, and painful neuropathy. We have all felt its claws.

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computer system errors may appear typing letters out of sequence – please forgive, no time to edit and finding gremlins everywhere, possibly in the opinions so dangerously passionate. We can do better America. You don’t have to take it. Step up! Vote for the ones who care about your well being.

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 , Ayurvedic, Herbal “

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