To my patients & readers, thank you. Your words have been uplifting.


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If there be pain let it be


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If there be pain let it be.

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It is also part of the Self.

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The Self is poorna (perfect).

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Sri Ramana Maharshi, the great enlightened spiritual giant who at age 16 experienced the highest thereafter until almost 100 years of age. May we be blessed to awaken with these high teachings.

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Pain? Really?

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Imagine you are sitting on the banks of the Holy Ganges.

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Is pain and suffering the most amazing way to kick one into instant and serious spiritual study? Buddha must be right. We must use it, no matter what we do, as it leads to freedom of suffering. Ancient teachings give the method. So again, relax, deep breath.

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Imagine you are sitting on the banks of the Holy Ganges.

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The most holy, most revered, most powerful Mother of the Universe revered by sages for more than 6,000 years, the Mother of the Universe is flowing in front of you. Imagine. Breathe. In the Holy Presence, the body mind is not you. There is no time, space, and causation to clearly perceive you, the one Self, pure consciousness. You always were, as you are right now. Consciousness itself, clouded by misperceptions, obstructions that prevent us seeing the awakened being we are.

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Ramana Maharshi taught the simplest, most direct method. No need for religion, or you may choose the path of religion, but all paths lead to the Absolute. All rivers lead to the ocean.

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If there be pain let it be.

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It is also part of the Self.

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The Self is poorna (perfect).

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We are not the body, not the mind.

We are the Self. The Infinite.

Always have been.

 

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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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Posted in Pain, Uncategorized. Tags: . 2 Comments »

Closing Practice Due to Illness- Information For Doctors & Patients


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I’ve been awesomely tired at the way medicine is practiced. And with two new autoimmune illnesses, I’ve been feeling near death too much of the time the last 6 months. I am closing my practice this month due to illness. Too much fatigue and not enough enthusiasm to re-enter the monster world that practice in pain management has been increasingly limited to.

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It has been a privilege to work with so many great souls who carry such dignity with so much pain. Bright, motivated, willing to do anything to test a treatment that may work, working hard to be free from pain. Exploring a new paradigm together.  Privileged to be invited to meet the foremost glial scientists in the world and leaders in medicine, to feel at one on pharma boards with medical leaders legendary in pain management. Fun to offer the clinical experience I’ve seen. You have all been my inspiration. Medicine has been  a powerful experience, life death, taking every ounce of physical energy and interest for decades. My only interest. So much to be done discovering the way to help, awesome, unimaginably neat science. Best wishes to all! There is nothing more exciting than medicine.  Pain is the number one reason people seek medical help.

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To my current patients, you know how to contact me if you need records – just ask.  If I have not gotten you established in next months care with copy of records sent, let me know ASAP.

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To patients I have seen in recent past but not monthly, if you need records, let me catch up with you in January, I’m overwhelmed this month.Please do this:

  1. Notify me by email in subject line, SEND ME MY RECORDS IN JANUARY or by text, preferably email
  2. email this to me today and email again mid January – hopefully I’ve recovered from this busy month by then.
  3. Helps if you email both today and the, as in early January.
    I will try to notify a few others I’ve seen in last couple years. Inshallah.
    Illness, old age, death lurk. Dangerous flu season.
  4. Sadly, be aware that doctors do not know or take kindly to the simplest of these medications and may be unwilling or unable to help. Let me know by mid January if you would.

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These few instructions below are to give a start to doctors. Please accept my apologies for illness, lack of time, I’m exhausted.

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To doctors who have asked instructions on a few medications I prescribe, see below with apologies for length and lack of organization. Time consuming! 

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Never forget that tramadol (Ultram), Nucynta and buprenorphine (Suboxone) are opioids. Do not give naltrexone until off all opioids at least two full weeks.

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I never use one drug alone, not LDN, not ketamine (if indicated),  never alone because intractable pain means  they’ve failed all. After 3 months, any new pain is now centralized pain. Stop pain at all costs, safely.  I tell pts taper off all opioid before I see you. Opioids cause inflammation that increases pain.

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NEW PARADIGM

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The innate immune system in the CNS has a balance of pro- and anti-inflammatory cytokines. Opioids cause release of those inflammatory cytokines creating inflammation that increases pain. Opioids = the old paradigm. It doesn’t work for chronic pain. A few months ago, an Insurer denied a low dose opioid on exactly that ground: no publication exists that shows opioids work for chronic pain. Old paradigm. Now current government stressed teachings have returned American pain medicine back to the 1970’s, pre-opioid era.

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A better paradigm IMO is reduce the pro-inflammatory cytokines that are being overproduced and causing pain.

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Read all active links page one, that leads to innate immune system, microglia

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Read 3 posts on METFORMIN done on or about March or April 2017,

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Read long list of meds and things I check on 10/6/16.

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Use the small rectangular search function top left above small picture.

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Donate to relieve nerve pain – see link at banner to RSDSA.org. Contact James Broatch, Executive Director. This one organization has done more than any in the world, for nerve pain. Support the finest research and care and education.

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I’ve been blessed by seeing and following patients in depth, seeing the experience of frankly unbelievable results in many, some with CRPS 20 years, now pain free for 5 years after sciatic N nicked age 27, after 3 suicide attempts before seeing me. Such was daughter of 2 amazing loving brilliant MDs East coast who looked into every treatment, failed everything.

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This paradigm. It’s not just ketamine. Not one drug. All pain must be taken seriously. Always remove the opioid causing pain. Treatment will not work otherwise, so don’t waste your time, not physical therapy, nothing, stop the opioid first to see how productive the cleaner system can be.

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I must close office this month —- two autoimmune conditions got me. I feel great, but body and brain are duking it out. Hoping to die. Glee at the thought and joy and love but I surrender that also. Surrender it all. Nothing to hold back, finding no need to be nagged by the dazzling world every second of the day. Done with it all. The world holds no interest. It failed.

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I’ve done the work assigned to me trying to find a better way. I’ve left this blog until annual payment expires or I do, whichever is sooner. Heh

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Medicine will change. It’s becoming priced for the 1%, I am aghast. Sickened by costs. My body can do without that delusion. Why surrender to worship of the dying body at my age. I have no attachments. I’m feeling the air of freedom coming.

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Medicine needs a to grow citizen change and powerful interests to fund important research and clinical work using the addition of this paradigm with other new treatments and strong investment in glial research. Who knows? Surrender. It’s all in the right timing. The right moment, the right spark igniting an embalmed long-dead interest in pain relief using more than the old 1960’s methods now being taught—–well my dears, don’t take too much Xanax with your Tylenol you guys, you workers, disabled, seniors, millions of chronic pain pts, infants, surfer dudes, triathletes with joint arthritis decades too young for total knees. We don’t have solutions for many with intractable nerve pain. Not everything works for everyone or every condition.

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But one thing for sure:

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Opioids cause pain. I know people with severe chronic pain live in fear of pain of taper most of all, and I too would be terrified of coming off of opioids that I feel I have demonstrated to myself relieves pain.

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But I can’t quite explain the science to patients with such fear. I’d love Professor Linda Watkins slide- it’s so clear if you could see the graph, while morphine is temporarily giving you a few points of little relief, maybe bringing your pain down from 9 to7 for a few hours, yet at the same time the opioid is triggering far more pro inflammatory cytokines in the brain and those opioids are causing pain.

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Taper advice recently given, going very well, easy, no flares:

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In recent weeks I’m tapering a man who has been forced by nerve pain into disability for years in his 50s, with a young family. For years, he can barely sleep at night, work, travel, or let alone play with his new darling infant grandson as baby ages because there is this fearful, horrific nerve pain, day and night. It’s been impossible to treat.

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How to Taper

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No one knows what is best for everyone. One way:

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Slowly stop one pill every one to two weeks.

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My fellow is having no side effects other than a little looser stool, as he slowly tapers a vast numbers of opioid pills and sublingual films he’s used daily, strictly on prescriptions every month for seven long years.

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He plans to continue taper and I encourage go at a rate that is comfortable. Listen to the body. It’s his choice.

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His pain is the same as it was for months prior to these weeks of taper. He notices possibly a little more loose stools. No discomfort no flare of pain. Numbers of pills are down, nice slow, painless process, pain is the same. We are seeing the science demonstrated in him, taper does not always mean suffering or more pain.  He’s on the move. We’ll see how far he wishes to go on taper. We each have a choice. He’s a very special person and many in his shoes may wish to prove to themselves their pain is no worse, and maybe even better when they’re off this monster opioid demon that put so many people into living hell.

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Just go slow. He’s doing great.

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First slowly taper off the opioids, and remain off at least two weeks, and then I will begin to treat with this paradigm.

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Yes, fear of change but it’s been years of no change. Who would not be afraid to stop opioids with so much pain. Not all will trust the science. But realize that the tiny relief from dose of opioid maybe only because opioids are also relieveing anxiety not due to its analgesic effect. Feelings drive severity of pain and suffering. That’s not the analgesic effect. Opioids help anxiety, that relives pain.

This wonderful man in his 50s, I feel so bad, but years ago the practice was to test whether higher and higher doses helped. Now we know, no help. We must taper, and if patients are willing — it is their choice but stress their best interest – stop the opioid and try something else. A different paradigm.

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This blog represents 7 1/2 years of a small number of things documented, that I’ve seen and loved. Thankfully was able to squeeze an intense focus 3 to 7 days each post, teaching myself and distilling it to a reader, intense focus, loved the patient come back to life. Socks blown off. Documented a few case reports. There were so many more, demonstrating this approach works for many. Sadly it does not work for all. Nothing does. I have been the last of the line of almost every therapy for CRPS. You need large numbers to know how much the investment is worth for a disabled person with so little money, children, young, desperate to get back to life. I mostly have seen the failures, and gave me so many lessons they brought from the best centers in the world, that failed. We need a lot more research. This paradigm can give lives back. Not always. But at times 100% relief, unheard of, stable. holding despite repeat ankle sprain running on treadmill with the permanent foot drop after sciatic injury.

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IC is tough! Treat constipation and muscle relaxants for pelvic awfulness.

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Cannabis

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See grand rounds on cannabis SMHLJ yesterday—- pdf. Cannabis helps muscle spasm, nausea, depression, energy, OA pain, migraine, sleep, anorexia/munchies beware munchies and cardiovascular heart attack, arrhythmia, stroke. I dunno if it helps nerve pain – it fails to help my Polymyalgia Rheumatica but it alters brain interests so the sedentary body that can sit for 12 hours and read without moving, now spontaneously gets up, now for the first time in weeks may listen to music, may feel like taking effort to cook and do things, finds the mood is lifted, energy is almost livable.

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Most beautifully, it has awakened or deepened the focus and Increased the interest in my well studied but inadequate spiritual work.

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Jnana yoga, the Absolute.

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Of course when you are deathly ill unable even to set up for weeks at a time the last six months, the issue of consciousness, bliss and being in the moment is absolutely wonderful. Unfortunately it often takes a killer illness to slow us down. Thank the Lord!

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Closing practice this month

I need to close my practice this month and give away all of my office furniture, instruments but a few, and 43+4-year-old Medical books. All will be picked up by Habitat for Humanity. Makes me sad I will never again see my gorgeous Birch desk with a return, and inlaid wood around edges. But chairs, cabinets, useful **underline useful exam table with great storage cabinets and drawers below and comfortable 4 inch pad**

If you know any local doc who needs an old fashioned wooden exam table doubly useful for cavernous storage, please let me know because I’m not sure habitat will take the exam table. There is no space in modern, tiny but expensive exam rooms, with all those shiny toys.

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Sorry, rambling, so many details important to me through fog of exhaustion.

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Verbal transcription can make serous word changes. Scary. If so, It’s not me. I am truly ill, no energy to reread to perfection — so WARNING words may be misleading or weird or does not make sense, a word change.

So much illness, so blessed that all I could do for so many months was surrender to the spiritual journey and let go of the crazy of the world. Ramakrsna taught, “You cannot uncurl the curly tail of the pig.” Spiritual life is all I want.

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BUT! The fucking mess up in the medical world. The details the burn down energy all day because you must take care of them, all.

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It drains energy more than I can spare what with autoimmune body/brain duking it out. My goal: spiritual life. I’ve done my job. It’s all on you, readers.

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Reread my front page about training your doctor. Take action. Make change happen.

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I am retired. Sorry but do not call me. I am retired with the exception of training doctors interested in learning from my experience for 3 intensive telephonic hours. Not sure any exist. That would be a miracle, a start. Costly. Next I’d love to see teaching videoconferencing with satellite conferencing of clinical chronic pain research clinics set up to work on CRPS pain treatment with addition of this paradigm, comparing to other treatment choices that patients prefer, long term, longitudinal, CRPS study. But make it clear, data to be sorted selecting those choosing opioids vs no opioid groups. We does well on opioids? surely some types of pain?

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Why CRPS? Netherlands can answer why they invested 25 billions Euros to study CRPS. Cost of treating nerve pain is devastating to our economy, to the lives of family and patient. Nerve pain treatment breakthroughs are the toughest nut to crack in research. Read the work of Dinstinguished Prof. Linda Watkins and IL-10 injected spinally, can relieve nerve pain for 3 months in animals, and relive severely disabling OA joint pain in elderly dogs whose arthritis renders them unable to even move, now painlessly running, jumping, chasing a ball and walking stairs after joint injection.

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C’mon. Where is the $10 million to finish the human studies needed on that?

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Go forward with energy, change the way, and enjoy the work while doing it! Gosh the attacks have been brutal. Fear of doing something no one else has done. Is it legal? Training too long, no income or bare survival 20 years, trying the untried.

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Let’s get this dead field moving! It’s gotta need the likes of Bill and Linda Gates foundation. Time, money. Specialists. So much fun to give, test and learn from patients who have so many rare intractable pain syndromes during this time — they had failed everything, in London, Germany, Scandinavia, Taiwan, failed at the foremost pain centers for CRPS and other pain syndromes, and I got to see life return in the eyes and limbs after so much desperate disability and suffering. It’s been such satisfaction and joy. So sweet.

Thank you all.

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It has been such a blessing. And an endurance test, to learn as much as I could, and test the science that was published. Follow the best science. 20 to 22 hours per day for 43 years, reading all night til 5 or 7 AM, getting up after two hours sleep. Seemed so hard at the time, the body feels pain with sleep deprivation, unpaid for almost 20 years, what stupid doctor turns down other work, and with no income and support continues to get 29 years of formal education?

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Dukha. We learn from suffering, finally, to let go. Surrender. Enjoy the freedom.

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Enough. Body exhaustion. Illness determines if and when energy exists. It is out of my hands. Thank goodness. I surrender to the process. We do our very best, then surrender because there is nothing more we can do.

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Enjoy the journey.

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Love the Self.

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Fill the hearts with gratitude and love the Self. You the infinite Self, witnessing the people in their family Biblical plays and Greek dramas. Surrender and witness. You have done your job and now let go. Be.

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You are the Witness. There is always pain on the planet, always someone who has it worse. Suffering seems to be part of our body’s destiny, according to so many ancient sages I have read. They say our destiny is already mapped out before we are born. One avatar said you can modify its severity by purity, spiritual work. The only way to find freedom, bliss, is to ask, “Who am I?” Realize who that is. The Infinite Self.

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Lord Buddha called this life dukha. Google the meaning.

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Suffering is part of the lengthy meaning for which there is no simple translation. Of course we all spiritually suffer. Sages teach: we are not the mind, not the body. We are infinite. We always have been. You are conscious right now, always have been, always will be. No big deal. Ordinary. Nothing different. Just focus on “I am.” Ask yourself who is this “I AM.” Find the silence without words where everything vanishes but that consciousness, bliss. Just enjoy being. We have all had those moments, nothing else.

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The body and mind will have its own devolutions with age and disease, but you are always conscious sages say. There is no God, there is no other. You the Self are the infinite and always will be.

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Surrender, illness, energy, ego, every like and dislike

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Sadly I need to stress, I must retire due to illness, exhaustion. Surrender office work in medicine. Hopefully I can teach if there is any interest learning what took me intense reading, trialing for years.

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My patients can always obtain their records.

They ask, but I know no one who does what I do and your doctors may have fear of some weird doctor (me) doing something different!  or patient of weird doctor who was presribed nasal ketamine for pain or depression and it works on stable dose for years. FEAR. Doctor will not accept patient taking stable dose for intractable pain for years and opioids are not adequate for these extreme pains. That is sad. Not sure if refusal is politics or personal issues or fear.

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There are real consequences practicing in pain management; who knows them as policies are whispered not publicly in political corridors instead of research and treatment? Fear has been a growing undercurrent in our field.

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Two pain specialists in San Diego recently reported losing license due to opioid prescribing, not seeing patient was abusing or diverting. Arresting doctors. Why the extreme of taking away the license from someone who is crazy enough to work in this entombed system. Arresting doctors, studiously not treating addicts — unless you can afford $60,000 a month and many repeat visits, for years.

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Opioid coverage will be cut off by insurers. Feds don’t need to step in. This has been happening. Simply surrender, do what you can, surrender.

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Bring peace while they kill it, do something to change it. Costs are unimaginably exploding with insurance fees forced to massive premiums and deductibles, outpricing working patients I see as far back as 8 years ago. Medicare payment of highly technical expertise is only 10% of what PPO insurer is stuck marked up paying.

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There is destruction by sex and greed in every field. Surrender. Always has been.

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Our healthcare system is stuck treating chronic pain with 1960’s pain management. God bless the medical establishment and the profit motive that drives so much of my field. The proceduralists, who do high volume 30 epidurals in 30 minutes high volume, high income, and wowie cost of those spinal cord implants. How many hundreds of thousands, please give us research with 5 year results.

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The cost of American medicine is killing the middle class, what to speak of the disabled and poor. Surrender. It will bring joy and focus to your work taking the field to the next level. Do best, surrender results knowing you’ve done all the work. Surrender, care nothing about outcome one way or another. Don’t get dazzled by results. Perfect peace. Every moment is a test of peace.

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All other readers, please do not contact me unless you are a physician interested in me teaching for 3 hours. Scheduling would be a few months from now, if any survive the serious flu season coming up.

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For myself, for all of us, I am trying to learn: to do all due diligence, then surrender, find the joy in the moment and just “BE” even in the most tedius moments of the day. This will be hard work this month, more energy and time than I have.

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I may not have the energy to post on these pages for awhile. I’ve got a stash of publications I’m dying to talk about.

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This may be a rant. My tongue may loosen, and become more disinhibited in comments — blame it on age. On truth telling. Rage. I finally hope to have time to myself however difficult it is to struggle.

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Sages say to you are not feelings, so convert fear/anger/body/ego into surrender, wanting no outcome either way, realizing there is nothing I can do more than I already have.Breathe.  It is out of my hands. Surrender all. Surrender the ego, means having no like and no dislike for any outcome. Total complete surrender. Imagine it. Practice it. Just “BE” it. Pure consciousness. No words. Surrender. Infinite. There is no other, no ideas. Pure Consciousness, bliss.

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I look forward to my remaining hours, no doubt being irritated about “ALWAYS SOMETHING” to fix that takes hours on the phone each day. All of us have this torture. Surrender. That’s the teaching. Just “BE.” Enjoy the moment.  Kibbitz talking and making wisecracks while tech support is working with you on hold for 2 hours. Enjoy the grievance. The world will go on —- be with the love in the heart and the silence. No words.

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That’s the practice. And my practice would love more time to enjoy the silence.

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Otherwise, would gladly teach only if physicians call discussing an interest allowing time and cost 3 hours, otherwise solitude is my sweetest goal and my focus and my work.

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Joy to you all! You are that infinite. There is no other.

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The material on this site is for informational purposes only.

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

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

~~

Comments are welcome.

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

~~~~~

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

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

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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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A New Class of Pain Medicine from Cancer Cells – PD-L1 inhibits acute & chronic pain


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For the nonscientist, this report may explain better:

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Cancer actually yields a painkiller

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Scientists have discovered a potent painkiller in an unlikely place — cancer cells.

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This painkiller strongly inhibits acute and chronic pain in mouse models of melanoma, according to a study published Monday in Nature Neuroscience.

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Called PD-L1, the molecule is known to inhibit immune function, which helps cancers evade immune surveillance. It’s also produced in neurons. If it can be used to make an analgesic drug, it would represent a new class of painkillers, something badly needed.

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The molecule acts by targeting a cellular receptor called PD-1 and has been a longstanding target of cancer therapies called checkpoint inhibitors seeking to activate the immune system. But its painkilling effect is news.

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Ru Rong Ji of Duke University was senior author. Gang Chen and Yoang Ho Kim, also of Duke University, were first authors. The study can be found online at j.mp/cancerspain.

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…..Dr. Patel, oncologist from UCSD says: “This could result in a therapy that helps patients in a year or two years, just because so much has been done in the field.”

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The relationship between cancer and pain is complex, Patel said. PD-L1 suppresses inflammation, which activates the immune system, and also causes pain, Patel said. But there are other ways of activating the immune system, such as with the new cancer immunotherapy treatments, which don’t increase pain, he said.

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….The increased pain response is also caused by the cancer drug nivolumab. The drug, sold under the name Opdivo, targets PD-1 and shows success in treating melanomalymphoma and lung cancer. It produced strong allodynia for five hours in the mice, according to the study.

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Nivolumab is one of the new checkpoint inhibitor cancer drugs that targets PD-L1 receptors with immunomodulatory antibodies that are used to enhance the immune system. They can produce a wide spectrum of side effects termed immune-related adverse events (irAEs) with inflammation due to immune enhancement involving several organ systems.

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This is not my field and perhaps I am wrong. But if treating those cancers with immunotherapy causes the worst known neuropathic pain by blocking checkpoint inhibitors, is it possible that a new pain drug having the opposite mechanism could relieve pain but cause cancer?

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This Nature publication references the growing body of work from the lab of Linda Watkins, PhD, et al, published in 2014:

.Pathological pain and the neuroimmune interface

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Reciprocal signalling between immunocompetent cells in the central nervous system (CNS) has emerged as a key phenomenon underpinning pathological and chronic pain mechanisms. Neuronal excitability can be powerfully enhanced both by classical neurotransmitters derived from neurons, and by immune mediators released from CNS-resident microglia and astrocytes, and from infiltrating cells such as T cells.

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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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After Ketamine for pain, complaints of depression dropped in half & pain reports were lower


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KPBS Radio highlighted a new study today by UCSD School of Pharmacy

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San Diego Scientists Find Further Evidence A Club Drug Could Treat Depression

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In a new analysis published Wednesday in the journal Scientific Reports, UC San Diego researchers said millions of FDA side effect records reveal that people who took ketamine for pain relief reported lower rates of depression.

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“The occurrence of complaints about depression dropped in half after ketamine administration,” said UC San Diego Skaggs School of Pharmacy professor Ruben Abagyan, who led the study.

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The researchers focussed on the FDA’s Adverse Effect Reporting System, a database that tracks negative side effects among people who take various drugs. But the researchers were not primarily interested in bad outcomes.

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Instead, they looked for a positive outcome: declining rates of depression among people taking drugs not typically thought of as antidepressants.

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They found signs that other common drugs — including Botox, a pain reliever called diclofenac and the antibiotic minocycline — also reduced depression among patients in the FDA database.

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[minocycline is a glial modulator and it can prevent CRPS from spreading.]

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University of Miami psychiatry professor Charles Nemeroff wrote that the study was, “very interesting.”

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“The findings are of considerable interest. However the interpretation of the findings are key,” he wrote, saying it will be important to understand whether ketamine is directly treating depression or simply relieving pain, which can indirectly help people experience less depression.

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The UC San Diego researchers said they controlled for this variable by comparing people who took ketamine with those who took other pain medications. They said they still found a larger drop in depression among those who took ketamine.

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This is the open source (free) article in Nature with brief excerpts below:

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Population scale data reveals the antidepressant effects of ketamine and other therapeutics approved for non-psychiatric indications

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.Isaac V. Cohen, Tigran Makints, Rabia Atayee, Ruben Abagyan

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We found that patients listed in the FAERS database who received ketamine in addition to other therapeutics had significantly lower frequency of reports of depression than patients who took any other combination of drugs for pain (LogOR −0.67 ± 0.034) (Fig. 1c). This reduction in depression is specific to ketamine and is known to be much more rapid than current antidepressants, making this observed effect very promising for treatment of patients with acute depressive or suicidal episodes. These patients cannot afford to wait up to six weeks for reductions in their depressive symptoms. Pain reports were also significantly lower for ketamine patients (LogOR −0.41 ± 0.019) (Fig. 1c).

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The analysis of the whole FAERS database revealed several other unintentional depression reducing drugs among antibiotics, cosmeceuticals and NSAIDS (Fig. 2). Our data supported previous studies that observed the psychiatric polypharmacology of minocycline [my emphasis], a tetracycline antibiotic14 (Fig. 2). The NSAID, diclofenac [that has highest incidence of heart attack and cardiac arrhythmia of any NSAID], was also observed to have some antidepressant properties (Fig. 2). It is theorized that both of these drugs may accomplish antidepressant effects through an anti-inflammatory mechanism. Because of the antidepressant activity of several NSAIDs, we further separated the non-ketamine pain cohort. Ketamine patients were then compared to patients who received any other combination of drugs for pain excluding NSAIDs. It was observed that depression event rates remained low (LogOR −0.56 ± 0.035) (Fig. 2)..The reduction of depression rates in ketamine patient records makes a case for study of ketamine as a psychiatric drug. These results imply that ketamine may be further explored as a monotherapy or adjunct therapy for depression. It should also be noted that FAERS data revealed that ketamine use [may] lead to renal side effects and awareness and caution in patients with renal or hepatic impairment may be warranted (Fig. 1a and b). [my emphasis].

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As an important side note, we also evaluated efficacy and side effects with the use of ketamine for pain management. We found that patients who were on ketamine had reduced opioid induced side effects including constipation (LogOR −0.17 ± 0.023), vomiting (LogOR −0.16 ± 0.025), and nausea (LogOR −0.45 ± 0.034) than patients who received any other combination of drugs for pain indications (Fig. 1d). Our data supports ketamine’s opioid-sparing properties and alludes to the fact that patients may receive benefits of improved pain, reduced requirement of opioids, and ultimately less opioid reduced side effects.

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The results of this study support previous small scale studies’ conclusions that ketamine is a good monotherapy or adjunct therapy for depression. In clinical practice ketamine would be especially useful for depression because of the quick onset of its action compared to existing first line therapies. Regardless of the causative mechanism ketamine appears to have therapeutic potential for TRD. Further, the potential to reduce many of the most complained side effects of opioid treatment makes ketamine adjunct therapy for pain seem desirable.

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Overall, this study demonstrates that the therapeutic potential of ketamine can be derived from appropriate statistical analysis of existing population scale data. This study also outlines a methodology for discovering off label pharmacology of existing approved drugs. This method can be applied to other indications and may reveal new important uses of already approved drugs, providing reliable justification for new indications without large investments in additional clinical trials.

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FDA Adverse Event Reporting System. The FAERS database was created to support FDA’s post marketing surveillance on drugs and biologic therapeutics. It contains adverse reaction and medication error reports sent to the FDA through MedWatch, the FDA Safety Information and Adverse Event Reporting Program. Reporting is voluntary and is done by patients, family members, legal representatives, doctors, pharmacists and other health- care providers. If any party reports an adverse effect to the manufacturer, the manufacturer is legally obligated to forward the report to the FDA. Data is available online in quarterly format for AERS from the first quarter of 2004 to the third quarter of 2012 and for FAERS from the fourth quarter of 2012 to the first quarter of 2016.

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The study used over 8 million adverse event reports from first quarter of 2004 to the first quarter of 2016. All the quarterly files from 2004 to 2016 were combined into a master file which was used as the primary source for analysis. . . .

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Out of 8 million reports, 279,853 reports were used for analysis of ketamine in Fig. 1. Two cohorts for ketamine (K) patients and pain (P) patients with 41,337 and 238,516 patients respectively....

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The material on this site is for informational purposes only.

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

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

~~

This site is not for email and not for appointments.

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

~~~~~

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

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

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Spinal Cord Stimulators – MRI scans never again


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Spinal cord stimulators may not help, but once placed, the wire leads can never be removed. People do not realize that they can never have an MRI scan no matter how much they need one. Wire leads are placed on the spinal cord and powerful magnets cannot go near those wires.

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It’s tragic. Patients say no one told them. People live for decades with useless hardware embedded on their cord. The wires become encased by scar on nerve tissue, the cord itself. Should that person ever develop cancer, stroke, infections, seizures, Multiple Sclerosis, fractures, etc, and need a scan, an MRI is not possible.

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It’s easy to ignore any future need for MRI scans when all the experts are giving an ultimatum telling you these stimulators can help your pain. With CDC’s lower opioid guidelines in March 2016 that dropped doses for millions, there might even be a huge bonanza for the companies that make these partially tested devices.

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A list of words in the informed consent is not the same as seeing videos of patients who have had to deal with serious problems from them. It’s very sad, tragic, facing cancer or other conditions that cannot be studied adequately.

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After billions in profit, there is no long term study showing how effective they are after five years, and even after two. It’s time to know the true cost and benefit analysis. But that will never be known, not once the green light was given and money started rolling in.

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The material on this site is for informational purposes only.

.

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

.

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

~~

This site is not for email and not for appointments.

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

~~~~~

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

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

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