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


.

.

.

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

 

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

 

Skelaxone, generic muscle relaxant

 

Lorzone, muscle relaxant

 

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

 

Methadone 10 mg 3/day, well within CDC guidelines

 

Oxycodone 5 mg 3/day, well within CDC guidelines

 

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

 

Does insurance cover cost of medication?

 

 .

.

.

.

.

.

.

.

.

.

Rectal Suppository Morphine, part 3 – cannabis


.

.

.

Let’s all now avoid the topic of cannabis.

.

.

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

That kind of pain.

.

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

.

There is only one politician discussing cannabis.

.

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

.

.

.

.

.

.

.

.

..

.

.

 

.

.

This site is not for email.

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

.

.

 

.

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!

.

.

.

 

.

.

.

.

 

Rectal Suppository Morphine, part 2 – link to formulary Blue Shield


.

.

.

Here is a link to the formulary for long acting opioids for Blue Shield.  You can see the update date on the bottom as 3/3/16.  I could have added that they index rectal suppository Morphine as a Long Acting* Opioid as well:

 .

.

Under Notes and Restrictions:

.

PA=Prior Authorization

.

ST= Step Therapy Required

.

NF=Non-formulary

.

.

https://client.formularynavigator.com/Search.aspx?siteCode=1390724043&targetScreen=3&drugBrandListBaseTC=analgesics%7copioid+analgesics%2c+long-acting&drugSortBy=status&drugSortOrder=asc

.

.

*Hint, it’s short acting.

 

.

.

Signed,

Your friendly neighborhood healthcare insurer

.

Do they live in your neighborhood?

.

It would be unAmerican to publish their names and addresses.

.

With the world’s eyes on this nationwide experiment, they allow Rectal suppository morphine. That’s all folks.

.

.

.

Sweeping effects on the practice of medicine.

Meditate on that.

.

.

 

 

.

.

.

.

.

.

.

.

.

 

Head to my front page if you want

.

.

.

.

.

.

.

.

.

..

.

.

 

.

.

This site is not for email.

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

.

.

 

.

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!

.

.

.

 

.

.

.

.

Off opioids, pain better. Life is back!


.

.

.

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

.

.

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

.

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

.

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

.

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

.

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

.

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

.

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

.

I’ve seen worse.

.

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

.

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

.

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

.

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

.

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

.

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

Wrong thin

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

.

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

.

.

Once off opioids:

.

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

.

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

.

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

.

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

.

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

.

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

.

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

.

CASE REPORT

.

.

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

.

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

.

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

.

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

.

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

.

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

.

2nd visit, 4 weeks later

.

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

.

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

.

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

.

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

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

.

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

,

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

.

I have seen patients become even better simply off opioids.

.

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

.

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

.

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

.

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

.

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

.

Obesity.

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

.

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

 

.

The problem remains:

.

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

.

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

.

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

.

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

.

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

.

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

.

.

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

.

 

.

.

.

.

.

.

.

.

.

.

.

This site is not for email.

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

.

.

 

.

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!

.

.

.

 

.

.

.

Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me..

.

.

.

 

 


 

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


.

.

.

.

Tapering patients without sound and attainable alternatives

.

Tampering with patient autonomy

.

Failure to provide informed consent

.

Avoidance of coercion

.

Nonmeleficence – Do No Harm – Primum non nocere

.

Treating patients like numbers not individualized

.

Intellectual and academic dishonesty

.

Anti-opioid zealots supported by zealous insurers? 

Containment of drug costs, not pain

.

Failure to assess risk vs benefit

.

.

Chronic pain has long term consequences including

brain atrophy and memory loss

.

.

.

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

.

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

.

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

.

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

.

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.

.

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.”

.

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

.

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?

.

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

.

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.

.

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

.

 

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.

.

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?

.

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.

.

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

.

.

“Chronic pain a malefic force”

.

“Pain kills”

.

John Liebeskind, MD

Past President American Pain Society

.

.

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

.

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.

.

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

.

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

.

The CDC excluded cancer patients from this new chopping block.

Will that come next?

Sequoia wildflower

..

.

QUESTIONS FOR THE CDC & ANTI-OPIOIDISTS

.

 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.


.

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

.

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.

.

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.

.

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

..

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

.

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.

.

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?

.

Will CDC recommend that insurers provide medications for opioid withdrawal?

.

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?

.

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?

.

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?

.

Will CDC recommend anything for untreated pain after opioid reduction?

.

.

Emily Dickinson

.

Pain has an element of blank;

It cannot recollect

When it began, or if there were

A day when it was not.

.

It has no future but itself,

Its infinite realms contain

It’s past, enlightened to perceive

New periods of pain.

.

HamiltonFallsSequoiaHighSierraTrail

.

.

.

.

.

.

The material on this site is for informational purposes only.

It is not a substitute for medical advice,

diagnosis or treatment provided by a qualified health care provider.

Relevant comments are welcome.

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

This site is not for email.

~~~~~

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

.

.

.

.

Please be aware any advertising on this free website is

NOT advocated by me and NOT approved by me.

.

.

.

.

.

 

.

.

.

.

.

.

.

.

 

 

 

 

.

 

Health Insurance All But Useless with High Deductibles


.

.

“High Deductibles in Health Insurance”

.

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

.

To the Editor:

.

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

.

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

.

SUSAN A. McGREGOR

North Kingstown, R.I.
.

.
To the Editor:

.

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

.

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

San Antonio

The writer is a cardiologist and a lawyer.
.

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

Wells, Me.

The writer is a retired equity research analyst who covered the insurance industry.
.

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

Richmond, Va.”

.

.

.

.

.

.

.

.

 

 

.

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


 

.
.

Gina Kolata reports in NYT

on the breaking study by two Princeton Economists    

 

.

.

.
The key figure

Screen Shot 2015-11-05 at 7.53.11 PM
.

.

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

  .

 

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

.

 

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

.

.

.

.

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

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

.

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

.

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

.

.

.

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

.

..
.

 

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


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

.

.

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

~

Epidurals

~

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

~

Glial modulators, compounded medications

~

.

 

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

~

Physical Therapy

~

.

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

.

.

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

.

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

~

Drugs do not address muscle

Trigger Points

~

.

.

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

.

  .

 

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

.

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

.

.

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

.~

 

~

What about other things?

 Compounded medication

Botanical, Ayurvedic, Herbals

~

.

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

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

~

.

What happens to that patient, whose intractable pain

responds only to compounded medicine,

when they have to be admitted to hospital or rehab

for weeks where compounded medications are forbidden?

Do we make you worse to get you better?

~

.

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

.

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

.

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

  .

 

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

.

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


 

.

INTRACTABLE PAIN IS NOT INTRACTABLE

IF YOU USE THE TOOLS YOU ALREADY HAVE

.

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

 .

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

.

.

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

~

~

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

.

.

.

.

.

.

.

 , Ayurvedic, Herbal “

%d bloggers like this: