Do you don’t want people to avoid tests or treatment because of a $3,000 medical bill?


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Coronavirus shows the importance of Bernie Sanders & Medicare for All.

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In a pandemic, you don’t want people avoiding getting tested or treated because they can’t afford a $3,000 medical bill. A lot of working families cannot afford that.

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We’re only as safe as the least insured person among us. Everyone has to be covered.

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One American man who flew back from Wuhan with his small daughter was hospitalized at Rady Children’s Hospital in San Diego for several days until the daughter tested negative for coronavirus. After living in Wuhan for 15 years, he did not have American insurance.

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Our CDC had no test kits available so it took many days for results to be flown to CDC and returned. England has now tested 10,000 people on national health insurance. We have tested 420 but many people were untested as kits were not available and they are in our communities spreading the highly contagious virus.

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What is the cost of high-level bio-containment units that function like ICU’s? My guess is that 6 days would easily be $60,000 if not far more.

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This poor man.

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One business man in Florida paid $3500 for a test to prove he was well after flying back from China so he did not have to quarantine for two weeks. His insurance refused to pay. Will yours pay for testing of your family?

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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!

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

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The advertising below is not mine.

In exchange, this blog is less expensive.

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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.

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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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Best wishes to all!


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

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.

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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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Insurers Deny Opioids, CVS Refuses to Fill Unless Authorized


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Always something new in this amazing field of pain management where treatment is decided by politicians and insurers.

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Patients and physicians alike have suffered denial of medications without prior authorization for the last 10 years or more. Prior authorization takes enormous time, at times more than one hour for each medication.  Try to picture a full day of seeing patients and an unexpected full day just for prior authorizations that must be fitted into the hours the insurer is open – remember, examiners often leave early, central time, hours ahead of PST. 

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Insurers deny the usual opioid because there is no proof that opioids have ever been proven to help chronic pain and side effects may include constipation, cognitive impairment, overdose and/or death.  

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Insurers routinely deny opioid at lower dosages when I try to taper: giving less is not allowed without prior authorization. Remember, we don’t find out until the patient goes to the pharmacy to fill, and they may wait to fill, then may need the medication that very night to continue their medication. Who is open after hours? 

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One independent 94 year old senior for years has been on fentanyl 12 mcg/hr patch and Oxycontin 10 mg in AM (not PM) for frozen shoulders and arthritis in knees. These are small doses. Denied for 3 or 4 years, so she paid out of pocket, in her 90’s. 

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She walks with a rollator, and wins at bridge games that she plays several times a week. Under my care since 2003, physical therapy has been unsuccessful. With her orthopedist, she receives injections every three months that help arthritis in knees. We had tried appeals including sending entire chart to insurer that included physical therapy note, but insurer insisted on physical therapy again. I asked them to show me one, simply ONE publication that showed physical therapy helpful for severe frozen shoulders present for decades. 

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Now pharmacy refuses to fill her 10 mg Oxycontin and her patch unless insurer authorizes. Her oxygen saturation is 98% which is excellent. Cognitive function is unchanged since 2003. I cannot imagine how she gets dressed as even a few degrees of motion of either shoulder elicits screams of pain. Her daytime caregiver must be dressing her. 

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That’s how we treat our injured, our disabled and our elderly.

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Insurers have authorized $50,000 spinal cord stimulators for years without a single study showing long term proof of efficacy. The potential for permanent damage to spinal cord and potential for accelerated pain syndromes is frightening. See the many comments on this site from patients who have suffered serious medical injury. 

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NIH has failed to adequately fund pain research for decades. But congress has accepted millions from opioid manufacturers and for years FDA approved one new opioid after another, as often as 4 new ones each year. FDA previously approved a nonopioid medication such as Lyrica for neuropathic pain, but in the last few years, a nonopioid Horizant has been approved only for postherpetic neuralgia pain — nerve pain, but only ONE type of nerve pain. Remember, insurers mandate first trying gabapentin for nerve pain, though it was never FDA approved for pain at all. Try to get an off-label non-opioid medication approved for pain. hah!

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Now I have an RN in her 40’s who has severe nerve pain from CRPS in both upper limbs after carpal tunnel surgery. Gabapentin caused severe cognitive dysfunction, improved on Horizant but insurers refused to approve Horizant. The cost for one daily is at least $750, but pain is better using twice daily.

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This week comes a letter from insurer that Revia, naltrexone 50 mg tablet FDA approved for addiction to opioids and alcohol, is no longer covered.

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Psychiatry colleagues tell me the same story. Antidepressants that also help anxiety are not covered but better than taking Xanax that causes memory loss and can be used to overdose.

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Vote for better politicians, not for lies. Insist on NIH research funding for chronic pain management to represent the vast population with chronic pain, not the pittance they allow. 

 

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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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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.

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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.

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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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Medications denied for pain today – Celebrex, Skelaxin, Morphine, Oxycodone, Methadone, Suboxone


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Happy New Year. Medications are denied for pain one month after you sign onto new insurance based on medications they cover:

 

Celebrex, a generic NSAID, less risk of GI bleed which is an increased in seniors day by day as we age.

 

Skelaxone, generic muscle relaxant

 

Lorzone, muscle relaxant

 

Morphine 30 mg ER, generic, denied 3 per day, well within CDC guidelines

 

Methadone 10 mg 3/day, well within CDC guidelines

 

Oxycodone 5 mg 3/day, well within CDC guidelines

 

Suboxone generic,  FDA approved for addiction in US but not for pain; approved for pain and for addiction in EU.

 

Does insurance cover cost of medication?

 

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Rectal Suppository Morphine, part 3 – cannabis


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Let’s all now avoid the topic of cannabis.

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How am I and other physicians, without research, supposed to help someone with insomnia caused by pain that takes the blood pressure to 220/110, with intense nausea.

That kind of pain.

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CDC suggests Tylenol and aspirin. That’s it folks.

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There is only one politician discussing cannabis.

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And please, don’t force researchers to use that stale dry brown stuff that NIDA sends to researchers.

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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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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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Off opioids, pain better. Life is back!


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

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

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

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

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

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

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

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

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I’ve seen worse.

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

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

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

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

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

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

Wrong thin

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

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

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Once off opioids:

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

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

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

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

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

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

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

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CASE REPORT

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

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

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

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

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

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

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2nd visit, 4 weeks later

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

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

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

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

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

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

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

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I have seen patients become even better simply off opioids.

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

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

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

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

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

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Obesity.

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

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

 

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The problem remains:

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

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

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

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

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

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

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

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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Please be aware any advertising on this free educational website is

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Exactly 100 Years Since Drugs Banned in US and Europe


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

 

ADDICTION

Everything You Think You Know About Addiction Is Wrong

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| Johann Hari | TED Talks

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

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

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“Is there a better way to help them?”

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

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

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

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

 

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

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

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

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

 

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

This site is not for email.

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

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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I realized

 

 

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


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

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

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

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

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

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

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

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

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

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

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Before we have an effective alternative,

CDC wants to take opioids away.

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

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

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

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

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

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Americans need to take action through the American Pain Society.

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I have written recently about the radical CDC opioid guidelines:

 

Tapering patients without sound and attainable alternatives

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Tampering with patient autonomy

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Failure to provide informed consent

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Avoidance of coercion

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Nonmeleficence – Do No Harm – Primum non nocere

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Treating patients like numbers not individualized

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Intellectual and academic dishonesty

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Anti-opioid zealots supported by zealous insurers? 

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Containment of drug costs, not pain

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Failure to assess risk vs benefit

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etc, etc – refer to prior posts

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

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The material on this site is for informational purposes only.

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

Relevant comments are welcome.

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

This site is not for email.

~~~~~

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

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Please be aware any advertising on this free website is

NOT advocated by me and NOT approved by me.

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CDC Will Create New Injuries & Suicide with Unprecedented Experiment in Sudden Opioid Changes – Prediction


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Tapering patients without sound and attainable alternatives

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Tampering with patient autonomy

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Failure to provide informed consent

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Avoidance of coercion

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Nonmeleficence – Do No Harm – Primum non nocere

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Treating patients like numbers not individualized

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Intellectual and academic dishonesty

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Anti-opioid zealots supported by zealous insurers? 

Containment of drug costs, not pain

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Failure to assess risk vs benefit

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Chronic pain has long term consequences including

brain atrophy and memory loss

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We have a duty to preserve life, and relieve suffering.

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Is it morally wrong to do nothing when almost 18,000 Americans died of prescription opioids in 2014?

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Is it morally right to radically chop the opioid dose of everyone in severe pain?

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Are we relying on drugs rather than coping skills and physical therapy?

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CDC will profoundly limit opioid doses to 100 mg/day morphine maximum or its equivalent for severe pain.  Is this safe? Ethical? See several previous posts on the dosage limits and CDC proposal.

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Michael E. Schatman, PhD, who edited “Ethical Issues in Chronic Pain Management,” lectures nationally on optimal treatment for chronic pain when ethical principals collide, has published “The role of the health insurance industry in perpetuating suboptimal pain management.” Medical ethics is not a business model of “cost containment and profitability.” His essay “addressed some of the insurance industry’s efforts to delegitimize chronic pain and its treatment as a whole.” He examined the industry’s “self-serving strategies, which include failure to reimburse services and certain medications irrespective of their evidence-bases for clinical efficacy and cost-efficiency; ‘carving out’ specific services from interdisciplinary treatment programs; and delaying and/or interrupting the provision of medically necessary treatment.”

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Many of the above ideas are taken from the course on ethics he taught May 2015 at the American Pain Society annual meeting.

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I have spent 15 years developing alternatives to failed opioid treatment for chronic intractable pain and writing about that on these pages since April 2009. When patients have failed all known treatments, low cost  alternatives to opioid medications become unaffordable when not covered by insurance – cost may be $300/month out-of-pocket rather than a $30 copay for opioids costing $17,000/month. How many can afford $300/month for the rest of their lives when they are on disability with severe chronic pain?

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When there are no options, opioids are the last resort.

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There is no argument opioids are often misused when there are better choices of treatment but resources are lacking, even more so in rural and under-served communities. And studies show lack of evidence of benefit with opioid treatment — but my patients would not be able to work or care for themselves if not on opioid therapy.

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Opioids cause pain by creating inflammation in the innate immune sytem (brain/spinal cord).

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There is no argument that opioids can cause central sensitization – that means higher doses cause worse pain which is misinterpreted as requiring more opioid when instead pain would improve with less. Opioids cause increasing numbers of deaths (almost 18,000 deaths in USA in 2014 from prescription opioids, NOT street drugs). Opioids may lead to addiction and diversion. Efficacy of many drugs is often compromised by some form of toxicity or need to add drugs to treat side effects, often denied by insurers.

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Likewise there is misuse of surgery, procedures, nerve blocks, spinal cord stimulators, pumps which can lead to paralysis, anxiety, depression, insomnia and death. How many billions are spent on spine surgeries done simply for pain that is not surgically treatable?

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Opioids may be treating anxiety, mental health problems or addictions, but they also serve an important function in relieving pain. They may be the only option many patients have. Opioid taper can uncover or cause PTSD, depression, anxiety, insomnia, fear of withdrawal symptoms, inability to cope. Poorly managed or sudden opioid withdrawal can lead to severe hypertension, stroke, heart attack and/or intolerable side effects of substitute drugs.

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The disabled insurance system has shut down patient autonomy, by closing more than 1,000 interdisciplinary pain programs — now only 70. And are those truly interdisciplinary? or are they strictly procedure oriented with $50,000 pumps and spinal cord stimulators that have failed to work for my patients? Have they ever shown long lasting efficacy for 5 years? Have you seen the

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“Chronic pain a malefic force”

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“Pain kills”

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John Liebeskind, MD

Past President American Pain Society

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Tapering opioids in chronic pain is very different from tapering opioids in addicts and much more difficult than treating cancer pain.

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Unlike cancer pain, severe chronic intractable pain is endless, lifelong, day and night, often associated with depression, insomnia, anxiety, PTSD, hypertension, and disability caused by severe pain.

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Having taught cancer pain at an 800 bed cancer hospital, cancer pain may be easier to treat simply because most cancer pain is acute pain which responds better to opioids than chronic pain. Cancer is often treatable and pain resolves. And insurers are not battering doctors by denying medications for pain every couple months as they do for chronic pain. Stress! Denials nonstop! Paperwork instead of practice of medicine. Doctors cannot take the constant battering and leave.

.

This unprecedented radical frightening cut in medication comes from the CDC National Center for Injury Prevention and Control.

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The CDC excluded cancer patients from this new chopping block.

Will that come next?

Sequoia wildflower

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QUESTIONS FOR THE CDC & ANTI-OPIOIDISTS

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 Where is the data? What is the risk/benefit ratio for this radical cut in dosage? There is no evidence upon which to base their chosen dose.


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40 million Americans have severe pain, 17.6% of the adult population, not counting children with severe pain or adults with moderate pain.

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Will the CDC monitor the increase in auto accidents that occurs from untreated pain? People with incident pain have slowed reaction times due to pain. Despite normal strength and cognitive function, they may not be able to move muscles quickly due to untreated pain. They may not be able to move at all when severe pain clouds even the ability to think.

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Will CDC monitor risk of suicides from untreated pain? Columbia University recently published on suicide in only one pain syndrome, but there are many forms of severe pain, not just one.

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When will NIH and CDC fund research on medications besides opioids for treatment of pain?

..

Will CDC monitor how many days of lost work, lost jobs from opioid withdrawal?

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Will CDC monitor how many new injuries occur from untreated pain? My patients may be perfectly strong, but cannot prevent falling if sudden pain prevents them from stabilizing their hips, legs, or spine.

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How suddenly do they demand this be implemented? Insurers have already been cutting opioids for months and allow 30 days on the last prescription. What then?

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Will CDC recommend that insurers provide medications for opioid withdrawal?

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Will CDC recommend that insurers allow payment of  medications such as Wellbutrin to replace dopamine for the depression malaise that occurs after opioid withdrawal that may last for one year or more?

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Will CDC recommend admission to hospital programs when patients are unable to suddenly drop opioid dose to the magical 100 mg without supervised inpatient care?

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Will CDC have nationwide training programs for doctors to teach how to deal with and study the sequellae of this unprecedented population experiment in suicide, new injuries, depression and hopelessness in patients and even physicians?

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Will CDC recommend anything for untreated pain after opioid reduction?

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Emily Dickinson

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Pain has an element of blank;

It cannot recollect

When it began, or if there were

A day when it was not.

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It has no future but itself,

Its infinite realms contain

It’s past, enlightened to perceive

New periods of pain.

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HamiltonFallsSequoiaHighSierraTrail

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The material on this site is for informational purposes only.

It is not a substitute for medical advice,

diagnosis or treatment provided by a qualified health care provider.

Relevant comments are welcome.

If any questions, please call the office to schedule an appointment.

This site is not for email.

~~~~~

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

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Please be aware any advertising on this free website is

NOT advocated by me and NOT approved by me.

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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.

~~~~~

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

 

 

 

 

Health Insurance All But Useless with High Deductibles


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“High Deductibles in Health Insurance”

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Quoting from the New York Times today, a subject often encountered daily, so rarely discussed in the media. My own colleagues cannot afford health insurance deductibles, let alone the average person who is not a medical professional. Five compounding pharmacies have closed in the last few months! Compounded medications are no longer covered! My patients cannot afford the insurance denials for medications, and how are we practicing medicine when each visit must be taken up with prior authorizations? No wonder the cost of medical care has gone up. What do we do for chronic pain or treatment resistant depression when our people have failed all drugs? Research funding never seems to go toward pain or depression.

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To the Editor:

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Re “Many Say High Deductibles Make Their Health Law Insurance All but Useless” (news article, Nov. 15):

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My self-employed husband and I have found ourselves in this predicament: affordable health care premiums but a prohibitive $5,000 yearly deductible.
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Truly accessible health care cannot be achieved when insurance companies are the primary beneficiaries of policies and when those who are “insured” still cannot afford to see a doctor.

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SUSAN A. McGREGOR

North Kingstown, R.I.
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To the Editor:

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Your article does a good job of describing cost-shifting from insurance companies to medical consumers but doesn’t explore the issue of risk-shifting.

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People pay insurance companies premiums to take on risk. Insurance companies try to avoid as much risk as they can. High deductibles and co-payments are just part of the risk-shifting.
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Other strategies being used include narrow networks of doctors and hospitals, denial of access to high-quality and often high-cost specialists, questioning and limitation of access to expensive drugs, questioning and limiting high-cost testing, and even offering free health club memberships to screen out those with high-cost disabilities.
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At a health insurance fair in San Francisco earlier this month, participants selected from various plans offered through the Affordable Care Act. Credit Jim Wilson/The New York Times
This process is about a lot more than high deductibles. But the end result is that good people are not getting the care they thought that they paid for. And the political leaders of both major parties approve these hassle factors — as our courts do — in the name of preserving America’s global competitiveness.
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BRANT S. MITTLER

San Antonio

The writer is a cardiologist and a lawyer.
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To the Editor:
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So at the end of the day, health care is no more affordable than it was before Obamacare was enacted! Why should we be surprised?
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Several decades ago, in an effort to promote “wellness,” we saw an increasing trend to encourage people to visit their doctor more regularly and more often, by offering plans that covered basic health maintenance costs. State regulations demanded coverage of some services, and the Affordable Care Act only added to the list that must now be provided without cost to the user.
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Insurance in the traditional sense provides coverage for the unforeseen event. In health care, that would be serious injury and catastrophic disease. What we have today is what the insurance industry refers to as “trading dollars.”
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Imagine if car insurance covered all basic services to reduce the risk of future damage, like oil changes, new brakes and even periodic visits to the car wash. We would see huge increases in the cost of car insurance, although we would also see policies that are offered at low premiums but with high deductibles and high co-payments.
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MICHAEL A. SMITH

Wells, Me.

The writer is a retired equity research analyst who covered the insurance industry.
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To the Editor:
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Your article about high deductibles in health insurance was accurate as far as it went, but a complete discussion of the benefits of health insurance coverage would have included the fact that insurers negotiate substantially reduced payments for in-network medical services for the insured.
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I have a high-deductible policy, but the payments I have to make to an in-network provider are usually only 40 to 50 percent of what I would have paid if I had been uninsured.
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An emergency room physicians’ bill here on my desk lists $632 as the charge, for which the insurer’s negotiated rate was $273.27, a 57 percent discount.
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My high-deductible health insurance policy is a membership in a huge discount medical services program. This is an important consideration that should be discussed more openly. The uninsured, by paying full freight, are subsidizing health care for those of us who are insured.
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DAVID MAIER

Richmond, Va.”

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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 “

Question: Should I post a publication on suicide in persons with uncontrolled pain?


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I would like your feedback.

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Suicide does occur. My concern is that posting the publication on suicide in persons who have one specific pain syndrome will open the door for others to act on suicide. There is a tool to leave a comment on bottom of this page. Even simpler, I’ve also added a poll that you can follow.

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It is very difficult for anyone to cope with severe pain, especially given the medical system in this country that seems to “push” opioids without teaching that opioids create pain. Insurance covers the cost of opioids, often more than $17,000 per month. Congress supports that insurance coverage and the high costs.

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But Congress mandates that Medicare does not cover highly effective compounded medications that are low cost but, in combination, do add up monthly. In the last year, more and more PPO insurers “save” money, by not covering low cost compounded medication that works. This insures greater and greater medical costs, hospitalizations, and your taxes paid for Social Security disability for those in pain who cannot work.

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Of course no one will do research on these generic medications because they won’t make billions for anyone, not for universities, for NIH, or for pharmaceutical companies. Without the specific research on pain, they won’t be “legitimate” or approved for treatment of pain though the medications have been FDA approved for decades and available to those wealthy enough to afford them. These are profoundly valuable, they are available now, and decades of work should not be ignored.

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What if you were to develop intractable pain? The first point is to remember that this is common, it may happen. The second is to ask what the most constructive reaction would be if that actually happened to you.

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What can you do? I urge you to donate to the RSD Syndrome Association – see banner at top of these pages. They have supported key research in pain, not just RSD, when NIH gave less than half of 1% to pain research in 2006, now far less since the deadly recession of 2008 and the ever threatened fight over funding the national debt. Your donation may prevent the end of career for young researchers who have trained all their lives to find the cure for pain.

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People seem to ignore pain and instead donate to heart disease, cancer, arthritis, multiple sclerosis, Parkinson’s Disease. But those conditions are often associated with chronic pain. When will this change? When will we realize that research in pain needs to become a priority? Our researchers have the tools now, and need your support.

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                                                                             sigh….

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Here’s the poll:

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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.

~~~~~

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

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Americans Struggle to Pay for Healthcare – 40% Delaying Treatments or Services


A survey on health behavior from 100,000 households

*25 percent of households have trouble paying

*40 percent expect to delay care this summer

*Baby boomers hardest hit

“The percentage of households that had difficulty in paying for care in the last year was statistically unchanged between March and April (about 25 percent).”

They found 40 percent of all households planned to postpone care in the coming three months, with about 15 percent planning to put off routine doctor visits.

Baby Boomers were four times more likely than seniors to have trouble paying for healthcare, according to the report.

Not surprisingly, those on Medicare “were the least likely to delay care.” Youth were also less likely, probably because they have fewer health problems.

Haunted by the dirty work of managed care & that deadly piece of paper: “Denied”


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“I know how managed care maims and kills patients”

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I will never forget the snarly laughter of a “medical” reviewer two weeks ago as he denied medication to my patient that the same PPO had been authorizing for years. My patient has been haunted by the man’s laughter since then. Denial of continuing medication is happening more and more despite California law that “grandfathers” in ongoing care for previously covered medication. See my post here.

It is “DESUETUDE.” It refers to the condition where a law has gone unenforced for so long that it is considered ‘obsolete.’ The law has not been repealed, but — here’s the clincher — the law has “collapsed into unenforcibility.” (quote from William M. Lamers, Jr, MD)

For years we have had spreadsheet medicine: Denial only for medication that is costly. It’s getting worse, more brazen.

Now that much new medication is unaffordable, priced far beyond the rate of a decade of inflation, what do we do with lawmakers that will not negotiate volume discount prices with pharmaceutical companies? How long will the middle class be able to afford common medication?  There isn’t another first world country on the planet that does not negotiate volume pricing.

Why are safe older pain medications being taken off the formulary?

Did you know that prices on best selling medicines may go up as much as 20 to 30% each year, though they’ve been on the market for years?

What is worse, managed care bloodlessly denies life saving procedures. A bloodless coup that rarely makes the news.

Physician Confesses to Congress, Choking Back Tears

Dr. Lynn DiPino [spelling?], former medical reviewer for Humana went before Congress to make “a public confession.”

This doctor, who acted as a reviewer for an insurance company, denied life saving surgery for a man and thus caused his death, saving “the company half a million dollars.”

Her decision to deny surgery insured her continued advancement in healthcare. “I went from making a few hundred dollars a week as a medical reviewer to an escalating six figure income as a physician executive.” “I was told repeatedly I was not denying care, I was simply denying payment. I know how managed care maims and kills patients. So I am here to tell you about the dirty work of managed care.”

As the video continues on the origins of managed care, it goes back to February 17, 1971, when Ehrlichman discusses Kaiser HMO with President Richard Nixon : “All the incentives are for less medical care because the less care they give, the more profit they make.”

Nixon smiles, his eyes narrow as if he is savoring fine wine, and says, “Not bad.”

Health Insurers Refuse to Limit Rescission of Coverage

withering criticism from Republican and Democratic Congress members

Today in Los Angeles Times

Even Republicans were appalled when “[e]xecutives of three of the nation’s largest health insurers told federal lawmakers in Washington on Tuesday that they would continue canceling medical coverage for some sick policyholders, despite withering criticism from Republican and Democratic members of Congress who decried the practice as unfair and abusive….

An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc.[parent of Blue Cross of California], UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

…Rescission was largely hidden until three years ago, when The Times launched a series of stories disclosing that insurers routinely canceled the medical coverage of individual policyholders who required expensive medical care.

…A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne.

The sister of an Illinois man who died of lymphoma said his policy was rescinded for the failure to report a possible aneurysm and gallstones that his physician noted in his chart but did not discuss with him.

The committee’s investigation found that WellPoint’s Blue Cross targeted individuals with more than 1,400 conditions, including breast cancer, lymphoma, pregnancy and high blood pressure. And the committee obtained documents that showed Blue Cross supervisors praised employees in performance reviews for rescinding policies.

One employee, for instance, received a perfect 5 for “exceptional performance” on an evaluation that noted the employee’s role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

…Late in the hearing, Stupak, the committee chairman, put the executives on the spot. Stupak asked each of them whether he would at least commit his company to immediately stop rescissions except where they could show “intentional fraud.”

The answer from all three executives:

“No.”

Rep. John Dingell (D-Mich.) said that a public insurance plan should be a part of any overhaul because it would force private companies to treat consumers fairly or risk losing them.

“This is precisely why we need a public option,” Dingell said.

…In November 2007, The Times reported that insurer Health Net Inc. paid bonuses to employees based in part on their involvement in rescinding policies. According to internal corporate documents disclosed through litigation, Health Net saved $35 million over six years by rescinding policies.

The disclosures in part led an arbitration judge to levy $9 million in damages against Health Net in a case involving the company’s rescission of the policy of a woman diagnosed with breast cancer.

At the time, Blue Cross told The Times that it did not link employee performance reviews to rescission. Blue Cross also said at the time that it had conducted audits to ensure that claims reviewers were not given any “carrots” for canceling coverage.

The company reiterated that position Tuesday in spite of the committee’s disclosure of two employee performance evaluations from 2003 discussing rescission levels and savings.

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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.

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

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Controversy on Medication Coverage – “step therapy” (also known as “fail first”)


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Insurance Industry Opposes Physician’s Choice of Medication for Pain Relief

The best or just the cheapest?

Before I define “step therapy,” let me introduce Forgrace.org, a nonprofit organization “Dedicated to Ensuring the Ethical and Equal Treatment of All Women in Pain.”   Based in Los Angeles, the organization was formed in 2002 by John Garrett, Executive Director, and his partner Cynthia Toussaint, an accomplished ballerina who has suffered with CRPS (and later fibromyalgia) for 26 years. Thanks to their leadership advocating for health care reform in California, today they announce that

For Grace and HAAF’s bill, AB 1144, was heard by the California Assembly Health Committee in Sacramento yesterday (April 21) and it passed overwhelmingly with a vote of 14-2.  There was strong opposition from the health insurance industry – and this effort will be an uphill climb as we move the bill along to the Senate.

Also, today, ABC News national covered the issue of “step-therapy” (also known as “fail first”) along with our bill, that if signed by Gov. Schwarzenegger, will abolish this unethical prescription practice that negatively impacts women in pain.  Ms. Toussaint pitched this story, consulted and interviewed for it.

Because of its importance to every single one of my patients whose lives hang by the constant threat of an indifferent refusal by insurance carriers to continue providing medication that they require, I am posting almost the entire ABC News article titled Patients Irate With Insurers’ ‘Fail First’ Policy by Dan Childs

What Is Step Therapy?

The basic idea behind step therapy is to start with the most cost-effective and safest treatment, progressing to more costly or risky therapy only if the current treatment is not effective. In theory, proponents say, the strategy both minimizes risks to the patient and keeps overall costs under control.

Robert Zirkelbach, spokesman for America’s Health Insurance Plans, said that when it comes to the bigger picture, step therapy is a key element in making the country’s health care system more efficient by creating a standard system of care from state to state. He said that this saves costs, and it also ensures that patients get access to therapies that have been proved to be medically effective.

“We see individuals with the exact same illnesses get drastically different treatment depending on where they live,” he said. “Right now there is no correlation between the money being spent and the health outcomes being advanced. Our goal is to help guide the patient.”

Dr. Forest Tennant, head of the Veract Intractable Pain Clinic and editor of the trade magazine Practical Pain Management, is also Cook’s doctor. He agreed that in theory, step therapy is not a bad strategy. And he added that doctors have traditionally employed a form of step therapy, in which they would gradually increase the dose of a given medication for a patient who was not responding until they were able to achieve the desired effect.

Doctors Employ Different ‘Step Therapy’

And even when it comes to designing a course of treatment, Tennant agreed that a cheaper approach is preferable, as long as it works for the patient.

“Given the cost of some of the medications I prescribe, I also want the patient to try the cheaper medication first.”

But he said that the step therapy used by the health insurance industry is different in that it may actually place a preferred therapy out of reach of a patient. Particularly vulnerable may be pain patients like Cook and Toussaint, who have experienced success with a given medication but are switched to a different drug by an insurer.

“What we have today is a situation where a patient is knocked around in the system, usually after they’ve already tried something that works for them but which they can’t have,” he said. “All of a sudden, the drug that they have been taking for quite some time is pulled away from them — because it is more expensive, usually.

The Best — or Just the Cheapest?

According to data collected in 2006 by the health care analytics company Verispan, the drugs for which step therapy is most commonly used are anti-ulcer medications, with 58 percent of health insurance plans using step therapy for this class. The data also reveal that antidepressants are the fourth most common drugs subject to step therapy, with 45 percent of plans subjecting these to step therapy. Twenty-six percent of plans use step therapy for pain drugs, according to Verispan, and other drugs including heart medications and antipsychotics are also on the list.

Zirkelbach argued that in most cases, patients are allowed to switch drugs if the recommended option is not working for them, and if the drug that the patient is switching to is supported by medical evidence.

“If there is a good medical reason to switch to drug A versus drug B, health plans typically allow that to happen,” he said.

But he noted that how long a patient is required to stay on a given medication before making a switch varies from case to case. Doctors who prescribe a drug that is unapproved by the insurance company risk receiving what Tennant calls a “tantrum letter” from insurance companies.

“The insurance companies hire auditing firms, and they demand to know why I prescribe [patients] certain drugs,” he said.

The net effect, Tennant said, is a grave imposition on the doctor-patient relationship.

“I have to say [to patients], ‘I can’t tell you what you should take. I can only get you to get what your insurance can pay for, and I’ll design a regimen,'” he said. “For the expensive medicine, the doctor no longer chooses what he wants.”

And according to a Thomson Reuters study published in the February issue of The American Journal of Managed Care, step therapy may actually be more expensive for insurance companies, at least when it comes to patients receiving medication for high blood pressure.

Step Therapy May Not Be Cheaper

In the study, which was sponsored by Pfizer, researchers looked at insurance claims for 11,851 people with employer-sponsored health coverage that incorporated a step therapy protocol for high blood pressure drugs. These patients’ claims were compared with those of 30,882 patients on similar medication who did not participate in a step therapy program.

What the researchers found was that the group of patients treated for hypertension under the step therapy program had 3.1 percent lower drug costs. But these savings appear to have been wiped out by the apparent increase in hospital admissions and emergency room visits. Over two years, the step therapy patients incurred $99 more in healthcare costs per quarter, on average, than the control group.

Hope for Step Therapy?

If indeed California passes anti-step therapy legislation, it would not be the first to do so. New Jersey already prohibits such plans. And even the Centers for Medicare and Medicaid Services may be considering regulations to limit step therapy by health plans available to Medicare patients.

But Robert Taketomo, president and CEO of the Glendale, Calif.-based managed care contracting services organization Ventegra, warned that if such legislation passed in the state, patients may find that other parts of their coverage will be cut back to compensate.

“As long as healthcare is a benefit, and not a right, then measures such as step therapy are important means of preserving pharmacy benefits,” he said. “If step therapy were to be prohibited through legislative means, there are other means through which a payor — whether they be government, health insurer or employer — could limit their cost exposure in pharmacy.

“These could include removal from formulary, increases in copayment, addition of deductibles (and increasing them), or ‘carving out’ pharmacy altogether and just cover medical expenses.”

Tennant said he believes the true solution to the problem does not lie with new laws.

“There has to be some goodwill meeting of the minds for the people who practice medicine, those who need the help, and the people who are paying for it,” he said. “Most of the [insurance companies] are trying to develop formularies comprehensive enough to get the job done without compromising patient care too much.”

But Cook said that as long as her insurance adheres to a step therapy policy, she and other pain patients will worry about her medication one day becoming unaffordable.

“We all know that our lives could change at a moment’s notice if the insurance companies say, ‘Change,'” she said.

To view some of Ms. Toussaint’s presentation to the media, including her “fail first” experiences… on the second page of their “Videos” go here.

Her focus has now shifted to bringing a single-payer, universal health care plan to all in California which will provide a model for the rest of the country.

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

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