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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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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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.

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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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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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Insurers Refusing to Cover Pain Medication – Morphine 100 mg per Day Maximum – Opioid Wake up Call – New Nationwide Standard? DEA Mandate


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The FDA mandated 22 manufacturers of long acting opioids

to fund a program on opioid prescribing.

FDA dictated the content.

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I attended the SCOPE of PAIN program Friday November 6, from 8 to 12:30, taught by an Addictionologist from Portland with our local Southern California DEA. Continuing education credit was given by Boston University. The first grant recipient was in 2012.  

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My take:

I think we will rapidly see a 100 mg per day

maximum morphine equivalent allowed

Could I be interpreting this wrong?

Insurers simply deny paying for high doses. They have begun already.

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I am exhausted from ICD10 diagnosis coding – complex patients !!! – that has taken away any possibility I could leave my desk until 4 AM for the last four weeks, in midst of moving office to much better place, and midst the only two computer crashes I have ever had in my pursuit of efficient tech, plus dental fracture, so much more….perfect storm. The paragraphs could be edited and rearranged, so they would be in sequence but they’re not.

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I hope others will give me their take on this. It has been getting worse since almost all university interdisciplinary pain clinics were closed in 1991. Insurers, i.e. managed care clerks, are practicing medicine mandates set forth by anonymous committees looking at spreadsheets not at our complex care. Insurers could save many billions if they invested a few billions in education. Insurers wrote Obamacare. They could write it better. Congress wants all of us to do our part. Surely business too?

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Based on this series of opioid conferences, my guess is their first step is to chop opioid prescribing down to 100 mg morphine equivalents. But what about untreated pain at the heart of the epidemic of suicide? I see it among all classes of people, because we’ve focused on opioids too long to the exclusion of research and exclusion of a whole world of medications now generic, no longer on patent therefore inexpensive, FDA approved medications. The biggest shock: Valuable compounded medications are no longer on formularies of insurers! Our most affordable FDA approved medicines are no longer covered by insurance.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

or is it lack of affordable medical care?

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My comments arise from grave concern the Insurers and FDA are overlooking the needs of my pain patients. I must speak up now despite need to recover in the next few days.

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Where is the concern for the pain patient

in this multimillion dollar pharmaceutical-company-funded opioid conference?

FDA mandated that manufacturers of extended release opioids fund the conferences.

Where are the millions that need to be spent on

rational interdisciplinary pain management,

rather than just opioid management?

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We need more than just studies of suicides and opioid changes.

We need hospitals and insurance systems

to recognize legitimate therapies that work for real people.

Would the epidemic of addiction

go down if people could get treatment for their pain?

.

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I posted this week on a new study, an epidemic of suicide in Caucasian middle aged Americans. The results were a shock to Case and Deacon, the Princeton Economists who did the research that merited two articles in the New York Times.

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..

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Epidemic of suicide

deaths as high as in the AIDS epidemic,

driven by pain, disability, loss of job, drug abuse, other.

By too many opioids or by untreated pain?

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That is why, a few days ago I posted on that epic study by Princeton economists: the suicides in middle aged Caucasians now comparable to deaths during the AIDS epidemic. I posted how that can change. In that article and for years with this blog, I post about medications that work more effectively than opioids, i.e. glial modulators, and the need for compounded and herbal medications from approved highly reputable small local pharmacies need to be covered by insurers and allowed on hospital formularies.

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Epidemic of suicide – could it be due to lack of pain treatment

not due to an epidemic of opioids?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

Or is it lack of affordable medical care?

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The key figure from the Case-Deaton study on epidemic of suicides in white middle-aged Americans –  bigger than deaths at the height of the AIDS epidemic. The question is why?

Andrew Gelman, statistician at Columbia University and writer for the Washington Post, argues in his blog against the rate being higher at all. His conclusion: “…death rates among middle-aged non-Hispanic whites in the U.S. slightly increased, even while corresponding death rates in other countries declined by about 30%.”

Screen Shot 2015-11-05 at 7.53.11 PM

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Regardless of the argument, untreated pain is a big problem. It causes suffering and joblessness, and can lead to addiction and suicide.

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Does it matter which side of the argument is right?

Pain management is being taught in only 3% of American medical schools.

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births.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

Or is it lack of affordable medical care?

Insurers are not willing to pay for larger doses of opioids

and deny prior authorization.

Does this lead to suicide?

Money is the root of some of this.

.

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The cure for suicide is not just to take a sword and slice off the top doses of morphine, and treat everyone with the same low doses, whether you have herniated discs or sprained ankle or RSD.  Sprained ankles may be already getting too much.

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Why blame it all on over-prescribing? How about suicide due to under-prescribing, or suicide from not treating pain at all because healthcare insurance and unemployment don’t mix?   

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Are they blaming high doses as cause of suicide? How about when high dose opioids fail, when all drugs fail, we see no new drugs on the horizon for pain control. That does not fill those patients with hope.

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Of course it is important to acknowledge, as the New York Time health section has followed that epidemic research with How Doctors Helped Drive the Addiction Crisis.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

.    .

 

Someone must advocate for change. It’s not just pills, it’s not just opioids.

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We are all at risk from disabling pain, loss of jobs and suicide

—yes, doctors too become disabled—

because of substandard education in pain management in this country

focused almost universally

on opioid treatment of pain.

..

Lack of funding killed the university interdisciplinary pain management centers in 1991

 

AND we need access to compounded drugs, herbs & supplements in our hospitals.

If Memorial Sloan Kettering Cancer Center can do it, why can’t my hospital?  

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Expect 100 mg oral morphine or equivalent maximum dose per day to rapidly become the standard nationwide. Insurers are refusing to cover the cost of higher doses. Even if you can afford $17,000 out of pocket each month for pain relief, your doctor will be shouldering liability if outside these rapidly evolving guidelines. Insurers rule – and they deny coverage of inexpensive compounded drugs that work better than opioids for my patients who have failed all known treatment. That’s why we need better education and more clinically focused research.

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Those who blame Obamacare for high insurance costs and business-wide practices need look no further than the price of medications, especially opioids.

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It seems everyone breezes over where Washington State came up with a maximum of 100 mg morphine (or equivalent) as a maximum daily dose of opioid. 

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This 100 mg maximum daily morphine dose became law in Washington State many years ago, initially for Workers Compensation, and will soon be adopted by Oregon.

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Of course we are all concerned about the shocking rise in deaths from prescription opioids that are occurring since opioids began to be used after Russell Portnoy published its use for chronic pain in 1991. We just didn’t know that they work for cancer pain that is usually acute pain, not for what is now tens of millions with chronic pain who are on opioids

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But opioids are still necessary for some. Those of my patients who take opioids will have a very hard time with the 100 mg morphine (or equivalent) maximum daily guideline. Informed consent is out the window. We all recognize the practice of medicine has been done by insurance companies since the late 1980’s when managed care took over. This will not change. Now insurers require the ICD10 diagnosis code before they will allow the pharmacist to refill an antidepressant that the patient has been taking for one year with much needed relief. This will give them more tools to deny paying.

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It would appear that those who govern our medication use (insurers and DEA) — and who deny coverage of even more useful, inexpensive medication –  feel that 100 mg morphine equivalent is the maximum dose that should be prescribed.   

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100 mg oral morphine is equivalent to:

~

66 mg Oxycodone

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25 mg/hr Fentanyl Patch

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25 mg hydromophone (Dilaudid)

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120 mg hydrocodone (12 of the Vicodin, Norco, Lorcet 10 mg tablets)

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30 mg Oxymorphone (Opana) use not recommended

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Morphine               to                Methadone      

30-90 mg                                   One fourth the morphine dose

90-300 mg                                 One eighth (200 mg/day morphine = 25 mg methadone)

300-500 mg                               One twelfth the morphine dose

>500 mg                                    One twentieth the morphine dose

 ~

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Methadone conversion is far more complex than this guideline from University of Michigan

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Only 3% of medical schools teach pain management. That ignorance is costing us trillions in insurance and pharmaceutical fees, and right now the latter two are making war on each other by taking it out on you, the patient who is getting substandard care. They’re taking care of their financial needs that show us the symptoms of disease, pain, suffering, disability, loss of job, and the just published this week, the epidemic of suicide. We need to treat the cause, not just the symptoms. Medical education, injury prevention and treatment needs to be taught starting K-12. The cost would pay for itself but the Insurance Industry needs to pay for it there and in University Medical Schools because Congress will not pay for it. It would be a cost saving investment that would pay itself off in care for seniors when grandchildren have to spot mom and dad in the 24 hour, extended family care that strains budgets. We cannot afford not to teach trigger point basics to each kid and each physical therapist and MD. That alone could save tons of opioids and monthly visits for what never works for muscle strain that no one has found.

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I’m tired of seeing how degraded it has become. To fail to treat the cause of disability and suffering is far more in our hands now, it could happen if people were taught basics instead of opioids, K through medical school. Are we teaching only opioids? yes, it seems so. I am advocating for everything I have written about in this blog since 2009. Glial modulators, mechanical approaches, but compounded medications, in particular, are sadly becoming unaffordable because insurers have stopped coverage for them. Then we all lose one of the most important tools, the only tool, that my patients and millions of others have in treating intractable pain or treatment resistant Major Depressive Disorder, Bipolar Depression. Compounded medications often work after everything else has failed. The lives of my patients have usually either returned back to normal or  improved in ability to function. That has never been shown with opioids for chronic pain.

 

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I’m too exhausted to be in a position to edit what I’ve written just now, or write adequately. I am just furious at the direction our country for decades has pushed into opioid treatment rather than pain management. This has reached peak brewing since the DEA conference yesterday, dictated by the FDA funded by opioid manufacturers.

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It is a hope that Insurers could fund an analysis of the billions that could be saved and suicides prevented if they funded pain management. What is there to live for than a life free of pain and disability?

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The analysis could show how much is saved when training begins with the young, how to prevent and treat injury. How helpful a child can be to aging grandparents or parents when illness strikes the family. We always turn to family first, as we should. Why is something of the field of pain management not taught in K-12?

 

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The FDA just authorized two opioids for children this last week. I have a vague memory one was oxycontin in children. I do not argue against opioids, I have given opioids to tiny children when I worked in hospice. Children have crippling arthritis too and other medical needs for opioids.

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I am not arguing against opioids. I am saying that what is taught is zero pain management. The focus on drugs is completely unbalanced.

 

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If Sloan Kettering can teach herbal and supplementary medicine to cancer patients, why not begin the study of herbal medicine at K-12 since a lot of parents are taking it instead of using common sense such as exercise, weight loss, family time, relaxation. And herbal and supplementary medicine is what these young ones will teach their children when they grow up. Hopefully prevent some of the toxicity from swallowing all sorts of useless and dangerous things on the shelves.

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Rational health care must begin young in the schools. .

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