Companies out of the pain business, NOT a hotbed of innovation, NOT COVERED by insurers


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Bloomberg news published this analysis below that explains much of the dead end in pain medication:

  • companies got out of the pain business.
  • there is no hope in sight for effective analgesics
  • insurers refuse coverage for more and more pain medications
  • insurers refuse coverage for modalities except opioids

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What kind of medical system:

  • forces patients to seek street drugs for pain relief because they are cheaper?
  • fails to treat addicts?
  • fails to allow cannabis (medical marijuana) one of the safest drugs ever discovered for pain and symptom management?

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The whole field is a sham ruled by politicians through CDC fiat and the justice department, subject to radical changes:

  •  a threat to your care
  • a threat to the field of pain management
  • a brick wall to any professional contemplating entering the field
    • pain management is complex & time consuming
    • most chronic pain patients have 3 or more pains
    • each pain requires assessment
    • risks patient addiction and/or suicide
    • risks loss of license
  • constant change
    • prior authorizations from insurers refused on appeal
    • disability refused for disabling pain
    • onerous computerized opioid database that is not nationwide, not fully completed by pharmacists
    • threats from patients, addicts, DEA, attorney general
    • highly politicized
    • good specialists thrown in jail despite expert testimony of foremost pain specialists – after testimony of addicts who reduced their sentence with lies
    • poor coverage of modalities if any for P.T., acupuncture, massage, integrative pain management, psychology, biofeedback, psychiatry, cannabis, compounded medications
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Here’s the article, click title to read in full.
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For the drug industry, building a better pain pill is a problem.

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Pharmaceutical companies have introduced new medicines to treat dependence, reverse overdoses, and deal with opioids’ side effects. But few effective and economically viable alternatives to addictive painkillers have emerged from the laboratory.

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That’s because of broken incentives, according to economists and industry experts. The payment policies of insurers and government health programs, along with pressure from investors, have encouraged drugmakers to treat the symptoms of the opioid epidemic but discouraged innovations that might get to the root of the problem.

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New therapies for pain have generally been too expensive, too cumbersome to use, or targeted at too small a group of patients….

 

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Different Incentives

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The incentives to develop a better pain pill differ sharply from those in other areas of research, such as Alzheimer’s disease.

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Drugmakers have spent billions on more than 100 failed medicines for Alzheimer’s, but a breakthrough would potentially reach a large and lucrative population of elderly patients on Medicare. Any new pain drug would be fighting it out with inexpensive, proven rivals in a politically fraught environment.

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The White House Council of Economic Advisers estimated this week that abuse of opioids cost the economy about $504 billion in 2015, or nearly three percent of that year’s overall economic output in the U.S. Those costs include health-care expenses, spending on criminal justice and first responders, and lost worker productivity.

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“There’s currently a lot more costs of addiction that are being borne by society in a more diffuse way,” said Kosali Simon, a health economist at Indiana University….

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Effort and Expense

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Most opioids are cheap generic drugs that have been prescribed for decades, making the effort and expense of developing new painkillers hard to justify.

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“They’re off-patent, they can be produced by companies that aren’t the original inventors,” said Bertha Madras, a professor of psychobiology at Harvard Medical School and a member of President Donald Trump’s opioid commission. “It becomes a much more expensive proposition to develop and get the approval for an opioid.”

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Drugmakers have instead invested in developing complex medicines for cancer and rare diseases, which can fetch six-figure price tags.

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“Companies got out of the pain business,” said Pratap Khedkar of ZS Associates, a sales and marketing consultant who studies the pharmaceutical industry. “It’s not the hotbed of innovation.”…..

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Wary Payers

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Drug plans have been reluctant to pay for abuse-resistant pain medicines, which often cost more and can be more difficult to administer. A recent report from The Institute for Clinical and Economic Review, a nonprofit that evaluates the value of prescription drugs, found that abuse-deterrent opioids weren’t cost-effective for insurers.

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At the same time, payers are limiting patients’ access to older pain drugsCigna Corp.took OxyContin off its list of preferred drugs for 2018, though it still covers other opioids. CVS Health Corp. said its pharmacy-benefits management arm will limit prescriptions to a seven-day supply, and Express Scripts Holding Co. also said it wouldcurb prescriptions.

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That leaves patients with a difficult choice. Abuse-deterrent painkillers might cost as much as $250 out of pocket. But generic opioids cost as little as $2, according to Denis Patterson, a pain specialist in Reno, Nevada.

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Abuse-resistant drugs get “denied 90 percent of the time. But the pain pills will get approved every single time,” said Patterson.

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“Shouldn’t it be flipped,” he said, “in that the things which can get people better should have better coverage?”…..

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The material on this site is for informational purposes only.

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

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

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Comments are welcome.

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

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

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

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Insurers Deny Opioids, CVS Refuses to Fill Unless Authorized


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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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The material on this site is for informational purposes only.

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

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

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Comments are welcome.

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

~~~~~

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

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

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Cannabis Overwhelmingly Preferred over Opioids for Pain – UC Berkeley / HelloMD Opioid Study


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Congratulations and thanks to HelloMD’s email, posted below, that describes a new study. They are doing important work for people who can be helped by cannabis. We need help in the treatment of chronic pain.

I’ve seen pharma pressure pain specialists to refuse to treat patients who also use cannabis. For Pete’s sake it helps relax deep muscle like nothing else, helps anorexia, can bring up extremely low energy a tiny bit, helps depression, and pain. Shock and awe. What an awful thing to pressure doctors to do just to punish the plant based industry and extinguish the competition. I’m sure TV ads brainwash even more. Professionals in healthcare and politics need our help to know good studies already exist and even without that rigorous proof, our dispensaries can recreate what the world has safely used for thousands of years.

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HelloMD is a trusted source of information. 

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The HelloMD Advisor

Opinions from Industry Experts


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Hi Nancy,

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Yesterday we announced the results of our landmark study examining the use of cannabis as a substitute for opioid and non-opioid based pain medication. Performed in collaboration with University of California Berkeley, HelloMD surveyed 3,000 participants from our patient database….[– click on below link to article]

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[They showed the]

overwhelming majority of cannabis patients (92%) prefer using cannabis to opioids when managing their chronic pain.”

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Your participation in HelloMD studies is invaluable as it takes us one big step closer to showing healthcare professionals, elected officials and the public at large the potential for cannabis to alleviate the opioid crisis our nation is experiencing.

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HelloMD also recently launched in New York state offering patients the ability to get their medical marijuana certification online. This week we highlight PharmaCannis, a shining example of the eastern US cannabis scene, with five dispensaries statewide, professionals from the pharmaceutical industry, and an eye towards making cannabis a part of the future of healthcare.

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Finally, we highlight Dr. Gary Richter, the ‘Cannabis Pet Vet’, who has made it his mission to help animals and their owners lead happy, healthy lives.

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Be happy & healthy,

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Pamela Hadfield – Co Founder

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This is an important study for people to learn about and to help our legislators understand we need help to use this plant for billions who are needlessly suffering. We all need help. And simple is best. This medication has been safely used by grandmothers for thousands of years. Silly to think we cannot begin. Silly to deny millennia of use. We need help:

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  1. Low cost medication is essential.

  2. Healthcare insurers must reimburse patients for the cost of medical marijuana. This is done in New Mexico and should be in every state.

  3. We must all stop weaponizing a simple healing plant that can be effective. Truth beats fear. Every study helps to open minds.

  4. Support the work of good groups like HelloMD, NORML

  5. Get politics out of science and healthcare

  6. Teach our doctors – require 1 hour CME for all who see patients.

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I have so many senior patients terrified to try cannabis, and one who just had a once-in-a-lifetime result with a few cannabis drops under the tongue. She worked with a dispensary that mixed a personalized ratio of THC:CBD. It Worked! Nothing else had, her life spent in years of constant headache. It’s gone! yet she is still terrified of cannabis.

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Such has been the insanity about the American gung-ho opioid boosters vs the shoot ’em dead plant loving criminals and addicts – that’s what these little old ladies think they have become. Criminals and addicts. This sweet woman’s intractable migraine has taken her life every day for years, failing to respond to the best care in the nation, is now gone with cannabis! Yet she’s going to have a heart attack because for decades the GOP has trained her to think she’s a criminal addict. She was referred by one of the foremost migraine experts whose final suggestion was to try cannabis. A few weeks later when she came to her first visit with me, she was headache free.

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Had her family doctor been able to recommend someone who works with cannabis patients many years ago, she would not have wasted her life and fortune. It can be simple and life-saving to try, and always nice to have a helpful hand from the dispensary to show you how.  Again HelloMD helps with that.

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I am very grateful for HelloMD. For their great organization, a smoothly developed, simple, cost effective model that is affordable and convenient for my patients who are too ill to travel or simply too uncomfortable at the thought of hanging with a waiting room crowd so far from their better healed comfort zone.

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After all, they don’t look disabled, but I see disabled kids as young as 8 through 90’s.

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Do not judge disability by how someone looks. Young disabled veterans wearing artificial legs, have been attacked for not looking disabled when they park in disability spaces.

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Bring peace and healing to all whenever you can. Learn to use the plant and to enjoy the plant too. To be able to let off the weight of the world…. that alone is healing. Nothing is working right. Well, so what? Let go. We have to let go, let peace, breathe. You know you do the best you can as always, so now do the best and let go. Bring peace.

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Cannabis is a sacred plant. Treat it with respect. Fear is ignorance. Teach the truth. 

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“Democracy dies in darkness.”

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Bring peace and healing

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The material on this site is for informational purposes only.

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

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

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This site is not for email and not for appointments.

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

~~~~~

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

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

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Spinal Cord Stimulators – comment on RSD


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Spinal Cord Stimulators 

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 Craig’s comment

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By no means do I mean to say that I or anyone else has better insight into how to treat pain, but I am against spinal cord stimulators [SCS’s] for treatment of pain due to CRPS, and possibly against use in other situations. I demand that the billions in profit they made be put into a retrospective and prospective study of damage caused by them in order for them to give full informed consent.

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I have 3 goals writing this.

  1. SCS’s

  2. Craig’s experience

  3. The Only Real Answer for severe pain, not damaging the system with opioids

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Informed consent is never given for spinal cord stimulators because it requires truth telling, something our corporations have been reluctant to do. Business ethics are not medical ethics, as we keep being reminded daily in the headlines.

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I enclose, below, a generously expressed and detailed comment by a man who had the patience to sit down and  write the painfully gory details so you can weigh-in on your decision whether to follow your pain specialist’s opinion to give you one. I don’t want anyone to feel suckered into choosing them and if I had pain I’ll admit I’d crave relief too. Anything. I’d be in line before the doors open.

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But if you have CRPS, spinal cord stimulators will create more pain. CRPS evolves unpredictably, by a will of its own. I know some very desperate patients with CRPS everywhere including face, mouth, gums, tongue, organs, trunk, limbs. Spinal cord stimulators will create more pain. Keep in mind, I don’t see the 5 year success stories even for lumbar disc pain. They don’t need me if they are pain free.

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But if you have CRPS and desperate need for pain relief because all else has failed — every known drug in highest possible doses of ketamine, propofol, opioids for weeks in ICU fail to even touch pain— there is one thing, and only one thing to do and I will set it out below. I just sent my recommendation to a patient with CRPS in extreme pain.

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My recommendation, below, is for patients who have nowhere else to turn.

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First I’ll mention the problems Craig encountered with SCS’s. He sent his comment to the opening page of this blog, so I will reproduce below. 

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I am currently undergoing a trial Medtronic SCS. I have had to have it reprogrammed 3 times since it was installed 5 days ago. I have had sensations and issues that I have addressed with my rep and my neurosurgeon. I get a severe headache when the unit is turned on. I get the constant feeling of having to urinate. I have current running through my testicles which they can not seem to program out and I am getting little pain relief. I have had to failed back surgeries, many failed injections and I have CRPS. The leads that were inserted when I was in the table covered my mid back and both legs. After I got to my feet and waited while they programmed the unit in another room. They came in and plugged it in and I no longer had coverage on the right side. My crps is in both legs, my hands, arms and face. The lyrica helped to tamp down some of the burning but I am in pain 24/7 and this was my last resort. I have scar tissue completely surrounding my S1 nerve. By the grace of God, I am on my feet, on crutches. I seem to get a look of disbelief when I tell them the unit is causing these issues or it’s not giving me the relief I was counting on. Relief, only to cause greater issues and pain. Is not relief to me. I can not wait to get this trial out of my back. I believe the leads slipped and that is why I am not getting the full coverage I had on the table. The issues I have had are as follows: severe headache, constant feeling of having to urinate, extreme joint pain, abdominal pain, sleeplessness, involuntary jerking, surges in current even when sitting still. Intense pain around the lead insertion site. Current uncomfortably running through my testicles, regardless of setting. It is my opinion there is still not a lot known about crps and I have read evidence of people have great success with these units. Everyone reacts differently. My body obviously creates a lot of scar tissue and my orthopedic surgeon created a fair amount herself. I can’t imagine even more or being forced into a chair for yet another unlucky decision. The medication helps and I have lived this far without the optimism that it would end soon. I had high hoed for this device but I don’t think it is right for me.

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One of my patients with CRPS was hospitalized for weeks with recurring unusual abscesses and required repeated surgery of hand and forearm. Even before surgery, she had failed opioids, failed ketamine, and was in ICU for weeks and weeks while the same medications were still given along with Propofol and IV Tylenol. Nothing helps her extreme pain.

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Anesthesiologists on staff in ICU threw everything they had at the pain for weeks. Most anesthesia pain doctors would have probably done what they did because that is the limit of tools we have.

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When you have hit the limit of benefit from opioids, ketamine, propofol, we have nothing else that treats pain with one exception: drug holiday.

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Stop all analgesics including Tylenol that destroys the liver as severely as cancer, the severity of which was newly discovered and published yesterday.

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The receptors for these analgesic drugs have up-regulated to such an extent they have caused the situation. Again, I stress, everything that was done during the ICU admissions would be done by any anesthesiology pain specialist. Those are the only tools. They cause the problem. The same for opioid induced hyperalgesia. We used to do it with Parkinson’s drugs in the 80’s.

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The only way to rehabilitate the up-regulation of all those receptors that have now exploded in numbers, immune to anything you throw at them, is stop the drugs.  Stop all of them for weeks, maybe months, years, no one knows, you are all the human guinea pig waiting to happen. But if we restart them, how long do we wait, how quickly will it again lead to this massive hyper-excitable state of pro-inflammatory cytokines that we know have gone wild, flooding the CNS. A flooded engine will not restart.

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Ketamine at least is known to reduce pro-inflammatory cytokines, but the system is too busy exploding, birthing new receptors that take over, and you’ve got a 55 car pile up. Well, more like millions I’d guess. No scientist here. Clnically, when can we resume something after a drug holiday, how soon and which drug? I’d avoid opioids because they create more pro-inflammatory cytokines. Choose ketamine, because they reduce pro-inflammatory cytokines, but if it works at all, stop it at first sign of tolerance, which is the need for increased dose. It becomes less effective. Walk a fine line, endure more pain because unless you do, it will no longer help. Opioids, analgesics of many kinds. 

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How do we get you through a drug holiday because we know withdrawing these drugs will trigger even more pain for possibly weeks until the system settles down?

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Pain storms, hurricanes

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This is complex regional pain syndrome where we see this insanity of pain storms. There is no other condition, unless several neuropathic pains in people with cancer, nowhere I have seen this type of pain in decades except CRPS – comparable to pain of subarrachnoid hemorrhage, blinding pain.

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No one has answers. None. One university does outpatient infusions of ketamine six hours daily for 8 to 12 weeks. Does it help? A small percentage. Outpatient, 6 hours daily, 5 days a week, staying at a hotel, 8 weeks.

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This is CRPS/RSD. No one has answers. It is futile to throw more of the drug in the system. That is my opinion. You have a choice and may choose otherwise. It is your body. You may stay on monthly opioids for decades, until you finally admit how poorly they work. A drug holiday is what we did in the 70s during my ancient training with Parkinson’s patients. They needed full 24-hour support. The American medical system has changed since then and those are not options currently available—cost.

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You need full psychological and psychiatric support.

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The Only Real Answer

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The country needs to invest $10 million to complete the clinical trials needed for an injectable, long-lasting interleukin 10 [IL-10], the anti-inflammatory cytokine. It already has full scientific and animal studies performed by and with the world’s foremost glial scientist at University of Colorado Boulder. Professor Linda Watkins has won awards from many countries. She has been the keynote speaker at the annual academy pain meetings for years. IL-10 can relieve pain for three months in animals that have intractable chronic neuropathic pain. This is not new —–NIH I’m looking at you to fund clinical trials. And those of you who care, do a Kickstarter to fund the clinical trials.

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This is the power of the innate immune system. NIH would rather fund research on the unknowns like stem cells rather than the known. It’s known for decades, NIH does not like to fund pain research. Glia are not all about pain. They are the innate immune system, the key to Alzheimer’s, neurodegenerative diseases, almost all known disease including atherosclerosis. It’s all about inflammation. We need the trials to stop giving drugs that cause inflammation, opioids —–CDC fiats are not as good as a drug that relieves pain, a drug that really works on mechanism. Where will the addicts go if the ER only has IL-10 for pain? That is one way to overspend on ER visits.  And NIH, please get us some real clinical research funding on how to use glia for our benefit. Get us some research on the entourage effect, combining medications to achieve relief especially for neuropathic pain.

Then bring on some crack negotiating teams from insurers to do some negotiation about pharmaceutical prices. Our new president has mentioned that.

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Please bring this to everyone’s attention. One way to get a grip on pain and/or depression is to build hope, help others, and energize behind a goal.

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Kickstarters work to raise tens of millions overnight. 

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IL-10 – animals have been shown to be pain free for three months, already proven in animal studies, by one of the world’s most widely acknowledged pain specialists Professor Linda Watkins, PhD. We need the final steps to fund the clinical trials in humans.

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

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

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This site is not for email and not for appointments.

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

~~~~~

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

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

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


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

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

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

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

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

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

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

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

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Leah Hemberry describes it as “constant fear.”

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

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

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

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Doctors can’t agree on how to help them.

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

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Pain specialists say there is little civil about this war.

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

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

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

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

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

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

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

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

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

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

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

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

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This site is not for email and not for appointments.

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

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

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Heroin Addiction absent or rare in UK prescribing


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Diamorphine (heroin) is prescribed for pain in the UK . Yesterday’s LA Times Op-Ed

What’s really causing the prescription drug crisis?

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Studies show addiction to opioids of any kind, even heroin, is rare in the UK. Not what we see in the US. They have more socialized care for housing, medical care, medications including for the jobless. They do not have the hopelessness that leads to desperation and addiction. Desperation is why all patients with chronic pain must work with a psychologist. Pain is not in your head, but desperation is, and a psychologist can help you learn tools to deal with desperation. If you don’t, pain will go up, up, up and that’s what’s in your head. Unless you use those tools, I promise you will suffer because it will get worse and worse and worse.

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“Doctors in many parts of the world — including Canada and some European countries — prescribe more powerful opiates than their peers in the United States. In England, if, say, you get hit by a car, you may be given diamorphine (the medical name for heroin) to manage your pain. Some people take it for long periods. If what we’ve been told is right, they should become addicted in huge numbers.

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But this doesn’t occur. The Canadian physician Gabor Maté argues in his book “In the Realm of Hungry Ghosts” that studies examining the medicinal use of narcotics for pain relief find no significant risk of addiction. I’ve talked with doctors in Canada and Europe about this very issue. They say it’s vanishingly rare for a patient given diamorphine or a comparably strong painkiller in a hospital setting to develop an addiction.

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Given that really powerful opiates do not appear to systematically cause addiction when administered by doctors, we should doubt that milder ones do. In fact only 1 in 130 prescriptions for an opiate such as Oxycontin or Percocet in the United States results in addiction, according to the National Survey on Drug Use and Heath.

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So what’s really happening? The second, clashing story goes, again, crudely, like this: Opiate use is climbing because people feel more distressed and disconnected, and are turning to anesthetics to cope with their psychological pain.

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Addiction rates are not spread evenly across the United States, as you would expect if chemical hooks were the primary cause. On the contrary, addiction is soaring in areas such as the Rust Belt, the South Bronx and the forgotten towns of New England, where people there say they are lonelier and more insecure than they have been in living memory.”

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Healthcare costs in the US are a very serious problem. Opioids require monthly visits. Patients on opioids are forced to see a pain specialist, many for decades when pain is chronic. That’s bad enough, but the cost of opioid medications are outrageous. I know some whose opioids cost $17,000 per month or more. And some doctors in my area have mandated urine drug tests every single month, $750 per test, to prove you are not taking street drugs. High risk patients and nonaddicts alike, every month, just to pee in a cup and get your prescription opioid. 

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Now congress is getting rid of the ACA, to make it better. I can only imagine how helpful they have been. Privatize social security, privatize medicare, privatize everything. Of course that will be better for them. Will it help anyone else? 

 

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

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

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This site is not for email and not for appointments.

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

~~~~~

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

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

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Abuse & Misuse Risk Assessment Tools from FDA – for Opioids, Ketamine, Adderall, Xanax, Ativan, Valium, Any Drugs of Abuse


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Risk Assessment Tools Examples from FDA.gov

page 11  (pdf)

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We must always remember, all of us, families, friends and physicians alike, the possibility of opioid use disorder (OUD) in anyone on chronic opioid therapy (COT) and those who are prescribed any drugs of abuse such as Ketamine, Adderall and benzodiazepines such as Valium, Ativan, Xanax. None of us should be taking medications that interfere with our ability to think and function. None of us should be taking more than we need. Many of us do not realize that less is more.

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Details of many tools for risk assessment are reviewed previously here.

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Keep this in mind:

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  • “Assessing risk of abuse and OUD in patients receiving COT is a dynamic, ongoing process.

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  •  Diagnosing misuse, abuse and OUD in patients with pain is complex

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  • Current screening tools do not diagnose abuse or OUD but only misuse and not intent”

     

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Tools

# of Items

 Administered

Patients considered for long-term opioid therapy:

ORT Opioid Risk Tool

5

By patient

SOAPP® Screener & Opioid Assessment for Patients w/ Pain

24, 14, & 5

By patient

DIRE Diagnosis, Intractability, Risk, & Efficacy Score

7

By clinician

Characterize misuse once opioid treatments begins:

PMQ Pain Medication Questionnaire

26

By patient

COMM Current Opioid Misuse Measure

17

By patient

PDUQ Prescription Drug Use Questionnaire

40

By clinician

Not specific to pain populations:

CAGE-AID Cut Down, Annoyed, Guilty, Eye-Opener Tool, Adjusted to Include Drugs

4

By clinician

RAFFT Relax, Alone, Friends, Family, Trouble

5

By patient

DAST Drug Abuse Screening Test

28

By patient

SBIRT Screening, Brief Intervention, & Referral to Treatment

Varies

By clinician

 

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