Coronavirus “is like the angel of death for older individuals,” do not downplay or minimize


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Jerusalem Post, March 8, 2020:

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….Pence’s speech is a departure from the guidelines the CDC posted to their website on Friday, which told older adults and those with serious medical conditions such as a heart, lung or kidney disease – rather than just the elderly with a serious health condition – to “stay home as much as possible” and “take actions to reduce your risk of exposure.”

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Last week, Dr. Peter Hotez, dean of tropical medicine at Baylor College of Medicine, warned lawmakers not to downplay or minimize how severe the coronavirus risk is for vulnerable Americans. Speaking at a congressional hearing, Hotez explained that the coronavirus “is like the angel of death for older individuals,” AP reported.

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According to Vanderblit University infectious diseases expert Dr. William Schaffner, “The clear message to people who fit into those categories is:

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‘You ought to become a semi-hermit. You’ve got to really get serious in your personal life about social distancing, and in particular avoiding crowds of any kind….’”  

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The material on this site is

for informational purposes only.

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

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

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

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

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CDC blasted for removing public data on tests for coronavirus


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Lawmaker blasts CDC for removing public data on number of Americans tested for virus

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The Centers for Disease Control and Prevention has abruptly stopped disclosing the number of Americans tested for the novel coronavirus, a move one lawmaker has called “unacceptable.”

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In recent days, the agency has posted statistics to its website detailing the impact of the virus as it spread across the United States. Figures include a breakdown of confirmed and presumed patients and the total number of deaths, cases and tests administered.

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But as Rep. Mark Pocan (D-Wis.) noted Monday, one of those numbers suddenly vanished from the site.

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“Americans are dying,” Pocan wrote in a letter to CDC director Robert R. Redfield. “We deserve to know how many people have been tested.”.His letter cited comments made Sunday by Scott Gottlieb, the former commissioner of the Food and Drug Administration, who said there could be “hundreds or low thousands” of coronavirus cases in the U.S.

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Given this possibility, Pocan said, “knowing that CDC testing is keeping pace with the likely number of cases is imperative to maintaining public trust.”

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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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Coronavirus: Expect people you know to die. Take it seriously. Stay calm


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“Coronavirus: an email to my family”

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by an infectious disease epidemiologist.

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“I wrote this originally to share with my family.”

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…”I graduated from the CDC’s Epidemic Intelligence Service and have over 17 years of experience in the field, most of that with CDC.”

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Who should you listen to?

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The CDC and your state health department are your best place for information about COVID-19. (Listen to them before you listen to me.) Be cautious about other sources of information – many of them will not be reliable or accurate.

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How bad is this going to be?

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It’s possible that COVID-19 will be similar to a bad flu year but there are a number of indications that it will be very much like the 1918 Flu Pandemic. To put that in perspective, the 1918 flu did not end civilization as we know it but it was the second-deadliest event of the last 200 years. Expect people you know to die.

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However, there is one critical difference between COVID-19 and the 1918 flu – the 1918 flu virus hit children and young adults particularly hard. COVID-19 seems to be most severe in older adults. Children and young adults generally have mild infections. We are grateful for this.

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What can we expect?

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This is not the zombie apocalypse. Core infrastructure (e.g., power, water, supermarkets, internet, government, etc.) will continue to work, perhaps with some minor disruptions. 

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There will be significant economic disruption: a global recession is very possible and there will probably be significant shortages of some products. The healthcare system will be hit the hardest. The number of people who are likely to get sick is higher than our healthcare systems can probably handle.  

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Daily life will be impacted in important ways. Travel is likely to be limited and public gatherings will probably be canceled. Schools will probably be closed. Expect health departments to start issuing these orders in the near future, especially on the West Coast.

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The acute pandemic will probably last at least for several months and quite possibly for a year or two.

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What can we do?

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We can’t keep COVID-19 from being a global pandemic but the more we can do to slow the spread of the disease, the less severe the impact will be. With that in mind, here are the things you can do:

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Stay calm but take it seriously. This will likely be bad but it’s not the apocalypse.

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Stay home if you’re sick or someone in your house is sick. 

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Leave medical supplies for healthcare workers. You shouldn’t be stockpiling masks or other medical supplies. They are needed in hospitals to keep our healthcare workers healthy.

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Wash your hands. Get in the habit of frequently washing your hands thoroughly and covering your cough.

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Minimize your exposure. Now that we’re starting to see community transmission in the U.S., it’s probably time to start cutting back on your exposure to other people. Depending on your circumstances, consider:

  • Canceling non-essential travel

  • Avoiding large-scale gatherings

  • Working from home if possible

  • Minimizing direct contact with others including hand shakes and hugs

  • Reducing your trips out of the house. If possible, shop for two weeks of groceries at once or consider having your groceries delivered. Stay home and cook instead of going to a restaurant.
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Remember, keep calm and prepare. This is likely to be bad but if we respond calmly and thoughtfully we can handle it.

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Others have added: no more fist bumps or hand shakes. Elbow bumps or, as they are doing in China, toe bumps.

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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.

~~~~~

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.

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Coronavirus Test Kits Alarming Impurities, Contaminated


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From AXIOS

Test Kits May Have Been Contaminated

 March 1, 2020

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Behind the scenes: The FDA official who visited the Atlanta lab, Timothy Stenzel, is the director of the Office of In Vitro Diagnostics and Radiological Health.

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  • About a week ago, when the Secretary of Health and Human Services Alex Azar was under extreme pressure over the delays in getting coronavirus testing kits to market, Stenzel traveled to Atlanta to help troubleshoot whatever technical problems might have been occurring with the tests.

  • Stenzel was alarmed by the procedures he witnessed in the Atlanta laboratory and raised concerns with multiple CDC officials, per a source familiar with the situation in Atlanta.

  • Stenzel is a highly-regarded scientist and diagnostics expert. He was on the ground in Atlanta to deal with technical issues and happened to stumble upon the inappropriate procedures and possible contaminants. He is not a laboratory inspector and thus was not charged with producing an inspection report on the lab conditions.

  • But he raised the concerns and they have been taken seriously and risen to the highest levels of the U.S. government.

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On Thursday afternoon, the concerns about the Atlanta laboratory were raised in a conference call that included senior government officials from multiple agencies including the Department of Health and Human Services, the Food and Drug Administration, the Centers for Disease Control and Prevention, and the National Institutes of Health.

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  • The call’s purpose was to figure out ways to mass produce the testing kits and get them to market quickly.

  • The Trump administration says it’s now figured out how to get over those hurdles. An HHS spokesperson promised that by the end of this week, “we will have the capacity to test up to 75,000 individuals” for the coronavirus

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What’s next: The FDA’s manufacturing concerns — which include the possible contamination of testing kits — have also resulted in the Trump administration ordering an independent investigation of the CDC’s Atlanta laboratory, according to senior officials.
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  • “HHS has launched an investigation and is assembling a team of non-CDC scientists to better understand the nature and source of the manufacturing defect in the first batch of COVID-19 test kits that were distributed to state health departments and others,” said an HHS spokesperson.

  • “HHS/CDC have been transparent with the American people regarding the issue with the manufacturing of the diagnostic and will be transparent with the findings of this investigation.” (But the administration was not transparent about the senior FDA official’s concerns about the conditions and procedures in the Atlanta laboratory.)

  • A senior administration official added that the government also moved the manufacturing of the coronavirus tests out of the Atlanta laboratory of CDC.

  • The official said that the CDC engaged with a third party contractor on Feb. 20 to help manufacture the testing kits. The official added that the FDA regulator, Stenzel, visited the Atlanta laboratory on Feb. 22.

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Between the lines: Until Thursday, the CDC’s guidance was to only test Americans for the coronavirus if they’d recently traveled to China — or had close contact with someone known to have the virus — and were symptomatic.

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  • Under this policy, the CDC initially refused to test a California patient who didn’t fit this criteria but had the coronavirus, although the CDC disputes that it denied doctors’ testing request.

  • As of Friday, South Korea had tested 65,000 people for the coronavirus; the U.S. had tested only 459, per Science Magazine. China can reportedly conduct up to 1.6 million tests a week.

  • Although the World Health Organization has sent testing kits to 57 other countries, the U.S. decided to make its own.

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There have also been problems with the tests themselves. On Feb. 12, the FDA announced that health labs across the country were having problems validating the CDC’s diagnostic test, Science reports in an in-depth account of what went wrong with the tests.

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The FDA announced yesterday that public health labs can create their own diagnostic test. Scott Becker, the CEO of the Association of Public Health Laboratories, told Science that he expects that public health labs will be able to do 10,000 tests a day by the end of the week.

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A WHO expert explains how China did it. “It’s all about speed.”
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Wash your damn hands.

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“You’re probably doing it wrong.”
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“Wash instead of sanitizing whenever possible” – good idea to review this page:
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“As for hand sanitizer, Larson says it’s important to know that sanitizers are only active as long as they’re on your hands. So even if it makes your hands feel annoyingly wet, keep the sanitizer on for at least 10 seconds.”

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The good news is dear leader is telling his people there is no problem in his crowds. All others remember keep at least 6 feet distance from others, probably more. Ain’t gonna happen at the grocer but give it time.

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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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U.S. badly bungled coronavirus testing


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Quoting March 1, 2020, from Science:

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As of Friday, South Korea had tested 65,000 people for the coronavirus; the U.S. had tested only 459, per Science Magazine. China can reportedly conduct up to 1.6 million tests a week. Although the World Health Organization has sent testing kits to 57 other countries, the U.S. decided to make its own.

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.There have also been problems with the tests themselves. On Feb. 12, the FDA announced that health labs across the country were having problems validating the CDC’s diagnostic test, Science reports in an in-depth account of what went wrong with the tests.

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The FDA announced yesterday that public health labs can create their own diagnostic test. Scott Becker, the CEO of the Association of Public Health Laboratories, told Science that he expects that public health labs will be able to do 10,000 tests a day by the end of the week.

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From Common Dreams, February 27, 2020:

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“Mike Pence literally does not believe in science,” tweeted Ocasio-Cortez, a New York Democrat. “It is utterly irresponsible to put him in charge of U.S. coronavirus response as the world sits on the cusp of a pandemic. This decision could cost people their lives. Pence’s past decisions already have.”

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Ocasio-Cortez pointed to Pence’s tenure as Indiana governor, where he she said his “science denial contributed to one of the worst HIV outbreaks in Indiana’s history.”

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“He is not a medical doctor. He is not a health expert,” Ocasio-Cortez wrote. “He is not qualified nor positioned in any way to protect our public health.”

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Gregg Gonsalves—a Yale epidemiologist who co-authored a 2018 paper connecting Pence’s policy decisions as governor to the 2014 HIV outbreak in Scott County, Indiana—denounced the president’s decision to allow Pence to coordinate the administration’s coronavirus response.

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“Over 200 people were infected with HIV in an outbreak, met with ignorance, bumbling, incompetence, and ideological intransigence. Two hundred needlessly infected, now on medication for life at great costs to themselves and the state,” Gonsalves tweeted Thursday morning. “Now Donald Trump has put Mike Pence in charge of coronavirus.”

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“It’s like putting an arsonist in charge of the fire department, a bank robber in charge of the U.S. Mint,” Gonsalves added. “Donald Trump made the choice of putting someone absolutely not up to the task to this crucial position. It endangers us all. This isn’t a Republican or Democratic issue—we have the potential for coronavirus outbreak in the U.S. and we needed to rise above the partisan fray.”

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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.

~~~~~

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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Revision in CDC Opioid Guidelines Demanded


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Revision in CDC Opioid Guidelines Demanded

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  • by Shannon Firth, Washington Correspondent, MedPage Today February 15, 2019 

WASHINGTON — Pain patients tell Congress the CDC’s opioid guidelines are hindering access to vital medications, and an FDA panel recommends approval of esketamine for treatment-resistant depression.

Pain Patients to Congress: CDC’s Opioid Guideline Is Hurting Us

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

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

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

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

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

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The material on this site is for informational purposes only.

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

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

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

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


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

CLIMATE OF FEAR

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Steinberg said the guidelines should be rewritten.

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

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

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

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

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

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

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

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

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

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

Improving Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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CDC gets list of forbidden words: “evidence-based” & “science-based.”


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The Washington Post just now published this headline, click on it to read the article:

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“CDC gets list of forbidden words: fetus, transgender, diversity”

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The forbidden words are “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,” “evidence-based” and “science-based.”

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In some instances, the analysts were given alternative phrases. Instead of “science-based” or “evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes,” the person said. In other cases, no replacement words were immediately offered…..

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….The ban is related to the budget and supporting materials that are to be given to the CDC’s partners and to Congress, the analyst said.

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It likely includes many agencies across government. If you cannot talk about it, it does not exist and therefore is not funded. 

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I am closing my practice on December 23rd, 2017, in just a few days. The world is not real. It is so easy to walk away from it now. There but for the grace of the gods….the insanity.

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


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

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

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

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

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

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

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

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

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Leah Hemberry describes it as “constant fear.”

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

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

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

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Doctors can’t agree on how to help them.

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

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Pain specialists say there is little civil about this war.

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

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

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

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

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

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

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

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

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

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

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

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

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This site is not for email and not for appointments.

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

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

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


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Pain kills

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

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

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

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Congress is pushing this opioid bust very hard.

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That is demagoguery

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I am pained and suspicious in several ways.

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Legal nationwide precedent.

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

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

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

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

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Nothing to do with helping to relieve pain.

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

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

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

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

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

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Insurance will not pay for more.

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

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

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

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

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Those running for president:

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

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

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

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

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This is the start of all sorts of federal dictates

into your medical care.

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


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Opioid Guidelines are Pseudoscience

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They do not pretend to treat pain

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CDC Opioid Guidelines limit opioids to

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 90 mg morphine equivalent daily dose, MEDD

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Whose calculations will the DEA use against your doctor?

 

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

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

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

 

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

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

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

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

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Let’s look at a few points:

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

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

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

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

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

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

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

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

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

 

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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For My Home Page, click here: 

Welcome to my Weblog on Pain Management!

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


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Criticism of the CDC Opioid Guidelines

from today’s Practical Pain Management

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

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

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

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

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  2.  Organizations that have criticized the CDC Opioid Guidelines

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Directly quoting, below:

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

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[Emphasis mine]

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

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AAPM Response

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

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

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

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[emphasis mine]

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

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The AMA’s response:

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

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

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

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

 

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Suicide prevention

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

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

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

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

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

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

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

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

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

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

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

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

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

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Addiction

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

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

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

 

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Coda

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

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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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NIH Releases a National Pain Strategy


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Today NIH Releases a National Pain Strategy

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

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

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

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

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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Opioid Guidelines – sweeping effects on the practice of medicine


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This page is just for meditation

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

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Head to my front page if you want

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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Rectal Suppository Morphine – the only opioid on formulary


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CDC Opioid Guidelines

Day #1

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

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I almost choked on my wheatberries on this one.

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

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Be warned people. 

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Is that 6 suppositories every 3 hours?

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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


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Today JAMA published the heavily resisted

CDC Opioid Guidelines

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

says my Rheumatology colleague

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 Chilling Effect on Prescribers

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Guidelines allow Tylenol or Aspirin

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Will insurers stop paying for opioids?

 

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

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

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

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

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

 

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

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

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

Tracy Helton Mitchell today on Reddit, inspiring leader.

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

 

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These are “guidelines, not law.”  CDC

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

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

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

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

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Will insurers stop paying for opioids?

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

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

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

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

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

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

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

 

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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


 

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PAIN AFFECTS

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MORE PEOPLE THAN

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DIABETES, CANCER & HEART DISEASE

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COMBINED

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 opioid “guidance” = opioid crackdown

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

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“Doctors are like prairie dogs.”

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124,000 physicians

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

During the first fourteen years after the Harrison Act passed,

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

 

 

 

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

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Treating Doctors as Drug Dealers

The DEA’s War on Prescription Painkillers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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You doctors. You agents of addiction.

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

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

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

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

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

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

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

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Reality: Surveillance. Kills trust.

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

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

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

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

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

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

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

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

 

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

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

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

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

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However cutting doses of pain medicine.

Heartless brutes!

I feel like a heartless brute.

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

DO YOU TRUST THIS GOVERNMENT TO HELP? 

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

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

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

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

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PAIN AFFECTS

MORE PEOPLE THAN

DIABETES, CANCER & HEART DISEASE COMBINED

 

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

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PAIN AFFECTS MORE PEOPLE THAN

DIABETES, CANCER & HEART DISEASE COMBINED

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This radical experiment to radically cut opioid doses, heartlessly.

Sigh.

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

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CDC opioid cuts will cause damage that should make headlines.

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

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

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

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WE NEED A STUDY TO SHOW HARM & BENEFIT.

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BEFORE

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

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

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

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AFTER OPIOID CUTS

Repeat study every year for 3 to 5 years.

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

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

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too dreary to read

will probably delete this tomorrow

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

~~~~~

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

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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Opioid Guidelines California


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Opioid Guidelines for Chronic Pain

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80 mg Morphine Equivalent in California

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Maximum

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That’s about 50 mg Oxycodone

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

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

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

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

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

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

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

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

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

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

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Case:

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

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

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

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Opioids create pain. They create opioid induced hyperalgesia.

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

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

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

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

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

 And here

page 3:

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

 

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

This site is not for email.

~~~~~

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

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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


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

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

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Addiction is a brain disease.

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

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

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

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

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

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

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

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

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

 

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

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

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America cares about addiction. Deaths. Headlines. Votes.

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

Dear NFMCPA Supporter,

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

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

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

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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Opioids Kill White Americans – Is it opioids or suicide or addiction or untreated pain?


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Drug Overdoses Propel Rise in

Mortality Rates of Young Whites

New York Times

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Yes, white Americans, headlined yesterday by Gina Kolata and Sarah Cohen, New York Times science writers.  This article points to the highest mortality in young whites. See post early November on the Princeton researchers who reported deaths in white Americans. True, infants and children have severe pain, but this new article is on young white adults.


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Those who are anti-opioid and those who lost a loved one from opioids and heroin (an opioid that helps pain), will send in comments to the paper so that everyone can see how bad opioids are. Most patients who take opioids are too disabled from pain to write.

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Pain is stigmatized, opioids stigmatized, people in pain are stigmatized, doctors who treat pain are stigmatized. Any wonder 97% of medical schools do not teach pain management?

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Is it opioids or suicide or addiction or untreated pain that is killing our youth?

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How many suicides have opioids prevented? Americans make up less than 5% of the global population but consume 80% of the world’s supply of opioid prescription pills. What if your cancer pain now becomes severe intractable chronic pain? Cancer has been changing. The survival rate has increased, and many of these cancer patients treated with opioid therapy, survived the cancer but have residual chronic pain from cancer or its treatment. Surely they are among the 18,000 white people who died.

 

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Please read the earlier post this week on the ethics of opioid treatment, on

CDC’s imminent radical cut in opioid doses for 100 million patients nationwide.

Use search function above photo – type in CDC or DEA.

Your pain. Your lives. Their profit.

A thorny problem.

Tell us what happened to you. Doctors, tell us what you are seeing.

Have you been denied disability due to pain? Denied non-opioid treatment?

Chronic severe pain affects forty million Americans.

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KONICA MINOLTA DIGITAL CAMERA

Some insurers have denied or limited non-opioid treatments yet continued expensive opioids for decades. Has your insurance refused your treatment? Pain specialists have been barraged by denials for years.  Please comment below.

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As noted last week, 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. But opioids must be available as last resort.

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FACT:

  • Opioids killed almost 18,000 Americans in 2014 – prescription opioids, not street drugs.

  • 40 million American millions with severe pain, millions not thousands

  • 100 million with chronic pain.

  • CDC will imminently, radically cut everyone’s opioid dose

  • Health insurers will oblige, and incidentally show increased profit to shareholders

  • Suicide increases with untreated pain

  • Death rates for “whites ages 25 to 34 was five times its level in 1999”

  • This age group has more injuries from work and play that can lead to disability, job loss

  • Insurance is unaffordable or not purchased by many young adults

  • My own colleagues cannot afford high deductibles – prescriptions are now counted in deductibles, now unaffordable

  • Can you afford $20,000 per month for your opioid or is cheap heroin more affordable? Can you afford your usual drugs on Medicare once you are in the “donut hole.” Can you afford $28 per day, $840 per month for gout, when colchicine was 12 cents a day a couple years ago?

    • Do insurance denials increase liklihood of cheaper alternatives such as heroin or illegal marijuana resulting in death by drug dealer?

    • Do exhorbitant costs of opioids lead insurers to deny your medication?

  • Insurers have refused to pay for abuse-deterrent and tamper-resistant formulations of opioids

  •  Insurers have refused to pay for proven, widely accepted, nonopioid analgesics:

    • Lyrica

    • Horizant

    • Gralise

    • Cymbalta

    • Does it help the DEA and NIH and universities to teach those as nonopioid alternatives when they are not covered and not affordable the rest of your life?

    • Insurers deny every known compounded analgesic though low cost and effective, even for Tricare’s disabled veterans, even 5% lidocaine ointment for nerve pain, dextromethorphan, oxytocin, low dose naltrexone – Stanford published research on naltrexone years ago and now doing research on it again for CRPS, many many others

    • Insurers deny proven analgesics that are used by armed forces, university hospitals, select doctors, for life threatening pain: ketamine

    • Insurers deny off-label analgesics that may work better than opioids, e.g. memantine, an Alzheimers drug – can relieve intractable nerve pain (French publication on CRPS/RSD pain)

    • Insurers deny medications that reduce side effects of opioids, e.g. nonaddicting modafinil popular with students, to increase alertness when opioids cause drowsiness that may cause injury, death – gosh 10 years ago!

    • Is drowsiness the cause of some of those 18,000 opioid deaths?

  • Health insurers have refused coverage for treatments such as P.T., psychotherapy for coping skills, blocks.

  • Insurers deny medications that relieve the withering side effects of opioid withdrawal, making it impossible for many to taper off, e.g. Adderall, Wellbutrin (dopamine)

  • Cannabis, a nonopioid, classified by US Congress as Schedule I, illegal federally for human use, illegal to take on a plane or cross state/national borders, found on meteorites, made by sponges and some of the earliest living species on the planet, used for thousands of years for pain, while cocaine and methamphetamine are classified as Schedule II for prescription purposes.

  • Opioids, even vicodin, require monthly doctor visits, costs, monthly for sixty years

  • Why whites dying of opioids? People of color are denied prescription opioids. Stark data published for decades.

  • Heroin is an opioid, cheap and available; its “unAmerican” – used in England for pain, used thousands of years for pain

  • Untreated pain is one reason people turn to heroin, affordable is another

  • Violence and drinking and taking drugs can begin with chronic pain and job loss, not always the other way around, chicken egg

  • Opioids cost pennies to make, patient’s cost is $20,000 per month for Rx. Insurers paid what the market would bear… in the old days. Who is trapped in the middle of this fight for shareholder profit?

    • How many of us would take 2 or 4 extra pain pills when pain spikes to extreme for days?

    • If you are disabled, can you afford insurance or expensive prescription drugs?

  • “Poverty and stress, for example, are risk factors for misuse of prescription narcotics,” Dr. Hayward said.

  • When you are not getting enough sleep and rest, working too many hours overtime or 3 jobs, inflammation and pain spikes

  • Misuse of opioids in > 33% (perhaps 48%?) of cancer patients at Memorial Sloan Kettering Cancer Center in high resource settings when insurance was better, published 1990’s.

  • Cancer pain – usually time limited. Intractable chronic pain – forever.
    .How many jobs will be lost and how many suicides when CDC imminently imposes strict cuts in opioids?

  •  DEA recently requires every pain patient taking opioids, including those with cancer, to be diagnosed “Opioid Dependent” — not only addicts – the same diagnosis for pain patients includes addicts. The term “addiction” has been equated to dependence by most psychiatrist over the past 30 years. It may be interesting to see what criteria are used to define “addiction” if any, in DSM V. Some important members acknowledge that the addition of dependence into addiction in DSM-III was a mistake….the DSM-V criteria will get rid of “abuse”, and will include craving. it will also apparently eliminate the legal/criminal criteria. DSM comments are extracted from here, with many good arguments on this epidemic, such as: “The US is leading the way in eradicating pain, but in doing so has created an unwanted byproduct: painkiller addiction.”
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    What would you want if you had intense chronic pain?

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    “For too many, and especially for too many women,” she said, “they are not in stable relationships, they don’t have jobs, they have children they can’t feed and clothe, and they have no support network.”

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    “It’s not medical care, it’s life,” she said. “There are people whose lives are so hard they break.”

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Opioids kill – or is it untreated pain?

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Pain kills, a maleficent force.

No one can help you. Only you have the tools to do it

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Alarms went off for me on radical opioid cuts in October and I posted when

DEA suddenly held conferences across the nation on sharply cutting opioid doses.

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How many of us especially seniors and male persons refuse to learn or use coping skills that

reduce pain without medication?

How many of us refuse to diet and lose weight to reduce pain and/or disability?

Politicians are sued if they tax sales of sugar loaded soft drinks.

One single can of soda per day exceeds acceptable sugar limits for entire day.

Snacks need to say much much time it takes to burn off fat –

quarter of large pizza 449 calories, walk off 1 hr 23 min;

large coke 140 calories, walk off 30 minutes.

Foods can be anti-inflammatory or pro-inflammatory.

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Obesity is pro-inflammatory.

So is lack of sleep.

People who sleep with animals in their bed and their bedroom, I’m talking to you.

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Yes, pain is in your mind.

Chronic back pain is no longer in the back, it’s in the brain, the pain matrix.

It’s behavior, not just pills. Pain is an emotional and psychosocial  and spiritual experience.

Work on it! Constantly.

Lord forbid we should teach stress reduction and meditation in grade school

and improve school lunches before kids start looking for heroin for pain.

Yes, kids have chronic pain, are sleep deprived, often obese.

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Isn’t this all un-American?

Injuries, pain, habits, pace activities, learn to avoid and treat pain – start young.

Taxpayers end up paying for ignorance and disability.

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I will soon be posting published research that documents health insurers have refused to pay for nonopioid treatment and how health care policy aimed at all people with chronic pain leads to suicide when drastic cuts are made to opioid doses – Washington State we are looking at you. Florida you’ve made headlines and 60 Minutes TV specials years ago.

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Do please comment below if your health insurer has refused medication, physical therapy, psycho-therapy, cognitive behavioral therapy, stress reduction, for chronic pain.

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How many of you have been denied social security disability by doctors who don’t know how to diagnose RSD, Complex Regional Pain Syndrome? Let me know. I will pass on that data to researchers collecting information on untreated pain.

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I have written many times on these pages, and more often than ever these past years as insurers cut back more and more. This will rapidly get worse. We need your data.

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Please send in your stories. You are not alone.

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So many issues. Steven Passik, PhD, was interview by Lynn Webster, MD – emphasis in bold is mine. Dr. Passik pioneered in management of chronic pain and pain in addicts. He has read some of Dr. Webster’s book. “You’re calling, the need for love and connection and all those things in the book, I’ve been – what’s largely lacking is outright, at times animosity towards people with pain and I think there’s a lot of projections sometimes because the therapy – the stigmatized disease – treated in stigmatized people with stigmatized drugs and interventions and so, it’s like a hat trick of stigma.  I’ve been to my share of pain conferences lately that people are really talking about, “Okay, well there’s come a realization that opioid-only, drug-only therapy, is really not going to work to the best majority of this population.  It doesn’t [mean] that opioids should be ignored and we’ll get into that later, but that they’re going to work in isolation and should never been expected to.  And then they start advocating things that are a lot like supportive and cognitive behavioral therapy and to be practiced basically by the primary care physician or the pain doctor.  And the idea that, to me that’s in a way comical because as a psychologist myself, we’re dealing with the system wherein cognitive behavioral therapists can’t even get paid to do cognitive behavioral therapy.  And so, I think something’s got to give, and I think one of the main obstacle is that – and this really gets into the next question as well but I’ll come back to that more specifically – but when people have a set of whatever chronic condition that involves psychiatric motivational, lifestyle, spiritual as well as nociceptive elements, and we put a premium only on what you do to people, prescribed to people, put in people, take out of people, and then that’s only going to relegate the other kinds of treatment or the other kinds of ways in which a caring physician and treatment team would spend time with the patient to the very poorly reimbursed category.  You’ll always going to have a problem with people being treated with the kind of respect that should go along with treating that kind of an illness and it’s not unique even to chronic pain.  I’ve seen treatment scenarios with people who are taking care of people with pancreatic cancer, have an afternoon clinic that has 45 people in it.  I mean how you – something’s got to give in our healthcare systems and I do think that patients are going to have to stand up and say, “I don’t want to be on a conveyor belt.  I want to spend some time and make a connection with the people that are taking care of me and it’s not just about the piece paper in my hands, for a prescription or that I walk out the door with.”

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Clematis Blue.

 The New York Times article further says:

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…This is the smallest proportional and absolute gap in mortality between blacks and whites at these ages for more than a century,” Dr. Skinner said. If the past decade’s trends continue, even without any further progress in AIDS mortality, rates for blacks and whites will be equal in nine years, he said….

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…Not many young people die of any cause. In 2014, there were about 29,000 deaths out of a population of about 25 million whites in the 25-to-34 age group. That number had steadily increased since 2004, rising by about 5,500 — about 24 percent — while the population of the group as a whole rose only 5 percent. In 2004, there were 2,888 deaths from overdoses in that group; in 2014, the number totaled 7,558….

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…For young non-Hispanic whites, the death rate from accidental poisoning — which is mostly drug overdoses — rose to 30 per 100,000 from six over the years 1999 to 2014, and the suicide rate rose to 19.5 per 100,000 from 15, the Times analysis found….

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…For non-Hispanic whites ages 35 to 44, the accidental poisoning rate rose to 29.9 from 9.6 in that period. And for non-Hispanic whites ages 45 to 54 — the group studied by Dr. Case and Dr. Deaton — the poisoning rate rose to 29.9 per 100,000 from 6.7 and the suicide rate rose to 26 per 100,000 from 16, the Times analysis found….

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…Eileen Crimmins, a professor of gerontology at the University of Southern California, said the causes of death in these younger people were largely social — “violence and drinking and taking drugs.” Her research shows that social problems are concentrated in the lower education group.

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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 email for personal questions.

~~~~~

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.

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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?

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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.

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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 website is

NOT advocated by me and NOT approved by me.

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Opioid Restrictions for Safe Prescribing – CDC Solicits Comments on Guidelines


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The CDC has issued a draft of guidelines for safe opioid prescribing that will soon go into effect for chronic noncancer pain.

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The CDC is soliciting your comments before January 13 – only a few more days to send in your comments to the CDC before the guidelines become the new standard without regard to need.

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I posted on the coming opioid restrictions for chronic noncancer pain after a DEA conference a few weeks ago with content that was mandated by the FDA. The focus is on the epidemic of deaths from prescription opioids and limiting the daily dose to the equivalent of 100 mg per day morphine, maximum.

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Prescription opioids killed almost 18,000 patients in 2014 — NOT street drugs, NOT heroin, but ***prescription***opioids.

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See several posts since then. Pain a malefic force. Pain kills. Insurers refuse to cover more than this arbitrary dose limit that may be safe but may not be an adequate dose.

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To my knowledge, there is no research justifying a rationale for the CDC dose limit, what seems an arbitrary dose limit for treatment of severe pain. Rather, the  emphasis is on addiction and reducing the epidemic of deaths from prescription opioids.

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Since opioid induced hyperalgesia is a concern, where is the research showing what exactly is the opioid dose that causes hyperalgesia in humans?

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Medicine is now practiced by one-size-fits-all guidelines/spreadsheets, not by physicians, not by specialists, and not individualized care.

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Pain management is not just opioid management.

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There is no emphasis on teaching pain management in more than 3% of American medical schools.

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What about the devastating and completely inadequate lack of research funding for nonopioid treatment of chronic noncancer pain?

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Severe chronic pain in 17.6% of the US population – 40 million adults. Data ignores children disabled with pain for years.

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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.

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

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