Opioid Intimidation – 29% Decline in Doctors Prescribing by 2017


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The New England Journal of Medicine published a report from Harvard researchers on March 14, 2019, entitled

Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012–2017.

They found a “29% reduction in the number of providers who initiated opioid therapy in any patient who had not used opioids, from 114,043 in July 2012 to 80,462 in December 2017.”

Two of my own physicians, both distinguished, outstanding – an internist and a specialty cardiologist who does painful procedures – have said they will never prescribe opioids again. If I ever need an opioid for pain, it is possible I may never be able to get a prescription.

One of my pain management colleagues has defended 6 colleagues in the last 6 months before the Medical Board.

This is just the beginning of Opioid Intimidation perpetuated by government and CDC. It is deeply worrisome and it is getting worse.

We have a shortage of pain management specialists and those that have survived mostly do procedures, delegating prescription writing to PA’s and NP’s because it is time consuming and does not pay. There is a formidable barrier of denials by insurers for nonopioid medications, physical therapy, acupuncture, yoga, Pilates, cognitive behavioral therapy, and all compounded medications. Denials have become voluminous for at least 10 years. The process is not only time consuming, it is expensive, it wears us all down, inflicts horrific cruelty on patients, and to top it all off the appeals system is a joke.

Who would want to go into the pain management field ever again?

Stay tuned for more stories to come.

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The material on this site is for informational purposes only.

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

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

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For My Home Page, click here:  

Welcome to my Weblog on Pain Management!

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Senate Hearing on Opioid Prescribing


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HHS Inter-Agency Task Force Urges New Ways to Limit Opioid Use and Addiction

Managing Pain During the Opioid Crisis – A Senate Hearing

In related news, pain patients everywhere rejoiced when Cindy Steinberg, National Director of Policy and Advocacy for the US Pain Foundation, spoke in front of the Senate Committee on Health, Education, Labor, and Pensions (HELP) on February 12, 2019.2 Steinberg, an advocate for the betterment of care for members of the pain community, lives with chronic back pain as a result of a workplace accident.

In her testimony, she urged Congress to restore more balance to opioid prescribing and improve pain care overall by funding and implementing measures outlined in the Pain Management Best Practices draft report released by the above-noted Inter-Agency Task Force, emphasizing the importance of investing in research on safer, more effective treatment options ranging from medical devices to medical cannabis.

In particular, Steinberg, who spoke to the Senators while lying in a cot due to her own chronic pain condition, brought up two points that counteract the current opioid climate, including the fact that:

  • Demographic research on populations has shown that chronic pain sufferers tend to be largely female and over the age of 40 and those with opioid use disorder tend to be largely male and under the age of 30. These are two largely separate groups with very little overlap.
  • Repeated research within the chronic pain population has found the risk of addiction to be small, on average less than 8%; and in patients with no history of abuse or addiction; studies have shown the rate of addiction to be between 0.19% to 3.27%.3-5

She added, “It is essential that treating clinicians be permitted to evaluate individual benefits and risks for each patient and that all appropriate pharmacological, interventional and complementary therapies remain available.” 

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The material on this site is for informational purposes only.

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

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

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For My Home Page, click here:  

Welcome to my Weblog on Pain Management!

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Opioids increase risk of chronic pain – potentiate pain – faster, stronger, longer. Activate TLR4 receptor on microglia, blocked by low dose naltrexone (LDN)


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Professor Linda Watkins was the distinguished keynote speaker at the May 2015 American Pain Society annual meeting and gave the NIH 2015 Kreshover Lecture:

“Targeting Glia to Treat Chronic Pain: Moving from Concept to Clinical Trials.”

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The University of Colorado at Boulder describes her work

She has authored or co-authored over 190 book chapters, review articles and journal articles.

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Dr. Watkins’ research focuses on 3 inter-related areas. Her primary research interest is understanding how to control clinically relevant pathological pain states. Her group’s research points to a novel reason that clinical pain has been impossible to successfully control. That is, pathological pain is being created and maintained by a surprising cell type, namely glia. These cells, upon activation, dysregulate normal pain processing by the spinal cord neurons.

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Medical News Today published news of her recent study April 19, 2018

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“Opioids may increase risk of chronic pain.” They potentiate pain “faster, stronger, longer” and activate the TLR4 receptor on microglia. That receptor is blocked by low dose naltrexone (LDN).

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Opioids trigger inflammation in the brain and spinal cord. This is an elegant study by renowned Prof. Linda Watkins at the University of Colorado Boulder, with Peter Grace. His early work on LDN brought him from Australia to postdoc at her lab and now research at MD Anderson Cancer Center.

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“Having been used in one form or another for millennia, opioids beat pain into submission, quickly making the patient more comfortable. The latest study, which was carried out at the University of Colorado Boulder, turns this firmly held notion on its head.

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Senior author Prof. Linda Watkins, from the Department of Psychology and Neuroscience, says, ominously, “[…] there is another dark side of opiates that many people don’t suspect.”

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In this case, it is not addiciton issues that Prof. Watkins is referring to. Paradoxically, opioids may actually prolong pain following surgery. The results were published recently in the journal Anesthesia and Analgesia.

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Postsurgical pain and opioids examined

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For the study, Prof. Watkins and colleague Peter Grace, of MD Anderson Cancer Center in Houston, TX, carried out laparotomies on male mice. This procedure involves making an incision through the abdominal wall to access the interior of the abdomen, and it is done on tens of thousands of U.S. individuals each year.

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“Opiates are really effective for acute pain relief. There is no drug that works better. But very little research has been done to look at what it is doing in the weeks to months after it’s withdrawn.”

Peter Grace

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Following surgery, one group of rats received the equivalent of a moderate dose of morphine for the next 7 days, while another group received morphine for 8 days, and the dosage was tapered off by day 10.

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Another group was given morphine for 10 days, after which point treatment stopped abruptly. A final group was given saline injections rather than morphine as a control.

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And, in another experiment, a group of rats received a 7-day course of morphine that ended 1 week before surgery was carried out.

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Before the morphine regimes commenced, and after they had been completed, the rats’ sensitivity to touch was measured, as was the activity of genes related to inflammation in the spinal cord.

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Compared with rats given saline, those that received morphine endured postoperative pain for over 3 additional weeks. Also, the longer the morphine was provided, the longer the rats’ pain lasted.

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The study also revealed that tapering of morphine dosage makes no difference. As Grace explains, “This tells us that this is not a phenomenon related to opioid withdrawal, which we know can cause pain. Something else is going on here.”

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How can morphine raise postoperative pain?

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The next question to ask, of course, is what drives this counterintuitive effect. Prof. Watkins calls it the result of a “one-two hit” on glial cells.

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In the brain, glial cells are more numerous than neurons. They protect and support nerve cells and, as part of their role as protector, they direct the brain’s immune response, including inflammation.

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The first “hit” occurs when surgery activates glial cells’ toll-like receptor 4 (TLR4). Prof. Watkins calls these “not me, not right, not O.K.” receptors; they help to orchestrate the inflammatory response. This first hit primes them for action when the second hit occurs.

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The second hit is morphine, which also stimulates TLR4. As Prof. Watkins explains:

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“With that second hit, the primed glial cells respond faster, stronger, and longer than before, creating a much more enduring state of inflammation and sometimes local tissue damage.”

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Although the study is in an animal model and will need replicating in humans, it does line up with previous findings.

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For instance, in 2016, the same scientists published another animal study, which found that a few days of opiate treatment for peripheral nerve pain exacerbated and prolonged pain. In that study, the activation of inflammatory pathways was also implicated.

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“An unusually high number of people end up with postoperative chronic pain,” explains Prof. Watkins. In fact, millions of U.S. individualssuffer with chronic pain. “This new study lends insight into one explanation for that.”

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Interestingly, the rats that received a course of morphine that ended a week before surgery did not experience prolonged postsurgical pain, leading the study authors to conclude that there is “a critical window for morphine potentiation of pain.”

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Because opioids are currently considered the best course of action to deal with postoperative pain, if these results are replicated in humans, it leaves medical science in a difficult situation.

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This is why Prof. Watkins is focusing much of her energy on designing drugs that could be given alongside opioids to dampen down the inflammatory response. She is also exploring alternative painkillers, such as cannabinoids.”

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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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Families Refusing Opioids for Pain in Dying Loved Ones


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Refusal of care in the palliative care setting, lack of cooperation in treating pain. Fear the pain medicine will kill. Addicts dying of overdoses. Fear the dying grandmother will be addicted or die from the pain medicine. Fear of addiction in the family, unsafe to keep opioid for the patient. So many fears, myths and misunderstandings.

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Fear has taken over in so many levels of our consciousness. That is why we all need to educate ourselves so that we are prepared to safely help those we love when the time arises.

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Death and dying need not mean agonizing pain. Strong pain may require strong opioids for relief, and strong opioids can be safely adjusted to allow good mental function so you and your loved ones can be present in the last days. Not, not in shock and anguish from screaming pain going on for weeks.

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Yes, I have been called to help a family whose mother was in her last days, on palliative care. Her only communication for weeks was loudly moaning with grimacing and wincing the muscles of her face. They were refusing to give even the tiniest drops of morphine under her tongue, as recommended weeks ago by the palliative care physician.

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Refusal of care will only get worse, not just for the dying but millions with chronic pain. Physicians refusing to treat pain or being firmly uncooperative with family or pain team recommendations. This is a huge issue in cancer hospitals and cancer wards. The old way was never to give opioids for cancer. The standards in medicine are set by the old guys who pass it on and control all coming up the ranks. Don’t step out of line. Fear is in control.

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Dispel that fear. Inform yourself in proper care recommendations by leaders in the field or you will live with regret when your loved ones died screaming in pain and you refused care. I have seen many oncologists refuse pain care and threaten patients, families and staff.

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Read some of the myths and issues that are too frequently encountered by caregivers all across the country – click here.

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The material on this site is for informational purposes only.

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

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

~~

Comments are welcome.

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

~~~~~

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

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

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Editorial from PAIN: Hijacking the endogenous opioid system


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Neuropathic pain responds poorly to opioids, often not at all, and may become worse with treatment.

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I have seen pain improve in many after tapering off.

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Then you must treat pain without opioid; it doesn’t just disappear, but it will not be as intense. This editorial explains some of the reasons opioids become a problem.

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Excerpted from an editorial in the current issue of PAIN

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[emphasis mine]

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[COT = chronic opioid therapy]

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…..This review highlights why we may see some of the more insidious problems that occur with COT, which are summarized below.

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Individuals on COT may continue to “need” opioids to replicate the functions of endogenous opioids that are no longer being released (or are in competition with the exogenous opioids). As the review by Ballantyne and Sullivan states, “a new homeostasis is reached that can only be maintained by continued drug taking”.1 Individuals on COT lose the ability to endogenously improve mood, decrease stress, and socially engage because the endogenous opioid system becomes inherently less responsive. In pain management, we know of this need for increasing opioid dose over time to maintain analgesia as opioid tolerance. But a similar physiological phenomenon likely occurs with any endogenous opioid function. Although we have mainly anecdotal reports from individuals who have been weaned off of opioids, the change in personality, social engagement, motivation, fatigue, and mood is often profound when individuals on COT successfully taper to lower doses or off opioids. These insidious side effects of COT would all be expected to inhibit individuals from maximally engaging in the patient-centric, disease management strategies that are now recommended for all chronic pain states.

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This may also explain why it is often very difficult to taper individuals on COT completely off opioids and underscores the importance of a slow, structured weaning protocol with appropriate psychological support. It may take months or years for endogenous opioid function to return to normal after cessation of opioids, or perhaps this system never returns to normal in some patients (as seems to occur in heroin addicts).5

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This paralysis of the endogenous opioid system by COT could render ineffective many other treatments that are recommended for chronic pain and that work in part via the endogenous opioid system. Many if not most nonpharmacological therapies for pain, such as exercise, acupuncture, and many other mind-body therapies are believed to work in part by engaging endogenous analgesic pathways that are partly opioid dependent.

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Opioids have acute antistress and antidepressant effects, and many of our patients with chronic pain are taking opioids chronically to medicate their co-morbid depression, despair or distress more so than to treat pain. Brain imaging studies indicate that many brain regions typically involved in pain and sensory processing are also involved in affective regulation. Patients having chronic pain who show higher degrees of psychological comorbidity or stress might therefore desire opioids because of their temporary salutary effects on these domains, rather than for their intended analgesic effects. We need to develop better cognitive-behavioral and psychosocial interventions that target the needs of the many patients with pain experiencing more harm than benefit from opioids, but still seek these drugs to reduce their affective symptoms.

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The endogenous opioid system may actually participate in the pathogenesis of some chronic pain conditions making this class of drugs particularly problematic for some patients. Many lines of evidence suggest that individuals with more centralized pain conditions such as fibromyalgia are particularly unresponsive to opioids, and the endogenous opioid system may be participating in the pathogenesis of these conditions.2,7 This has tremendous clinical implications because it means that we may actually make these patients’ pain worse by administering opioids. These same individuals may also be those at highest risk for prolonged use of opioids initially given for acute pain, both because they need higher doses for longer durations, and they are more likely to have the psychological comorbidities that drive unintended use and misuse.

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We clearly need to re-think the focus of opioid education and screening programs in light of some of these observations. After any exposure to an opioid, especially following the very common use in the United States for treating acute pain, patients can become addicted or can misuse these drugs to treat concomitant despair, depression, or pain elsewhere in the body that would not be expected to be responsive to an opioid. As we contemplate risk evaluation and mitigation strategies to curb further opioid misuse and addiction, we need to better appreciate these common alternate paths to unintended uses of opioids.

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We are not the first field to underappreciate the consequences of hijacking a critical endogenous system for one purpose, only to eventually find that there are significant consequences. Following the discovery of the endogenous corticosteroid system, Hench and others found that cortisone was an extremely effective treatment for rheumatoid arthritis, and this revolutionized our treatment of inflammatory processes. But it took several decades to fully appreciate all of the intermediate and long-term side effects of chronic corticosteroid use.4 Nearly all of these under-recognized issues were due to off target effects of exogenous corticosteroids on critical endogenous functions of these hormones. Although the short-term effects of opioids have been understood for centuries, long-term, high-dose opioids have only been advocated for a few decades. It is likely that we are now witnessing a similar clinical phenomenon, and as we increasingly appreciate the off-target effects of repurposing a critical endogenous system, the pendulum needs to rapidly swing back towards caution with prescribing a class of drugs that have a plethora of serious side effects other than addiction and death from overdose.

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The material on this site is for informational purposes only.

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

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

~~

Comments are welcome.

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

~~~~~

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

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

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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.

~~

Comments are welcome.

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

~~~~~

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

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

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Insurers Deny Opioids, CVS Refuses to Fill Unless Authorized


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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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The material on this site is for informational purposes only.

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

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

~~

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.

~~~~~

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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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

 

Opioid Production in US Cut 25% by DEA in 2017


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The DEA regulates how much opioid is allowed to be made each year. Production will be cut by 25% in 2017. Some will be cut by more than 25%, for example hydrocodone will be cut 34%.

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The reasons given are that demand is falling and the opioid epidemic is not. Congress of course could think about funding addiction treatment and offering clean injection sites for addicts such as Vancouver’s.

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The order will be published tomorrow in the Federal Register.

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In June 2016, Senator Richard Durbin interrogated Chuck Rosenberg, acting administrator of the Drug Enforcement Administration (DEA), during a Senate Judiciary Hearing.

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Durbin has introduced legislation to fight opioid abuse. One section of the bill would require DEA to consider opioid addiction when setting production quotas. If annual quotas increase, DEA would be required to justify that in writing, explaining why the bump outweighs the risk of having more addictive drugs available.

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Opioid death stats demonstrate the ravages of the epidemic.
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About 47,000 people died from overdoses in 2014, Rosenberg said. That’s 129 every day. About 61 percent were due to prescription opioid and heroin.

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The material on this site is for informational purposes only, and is not a substitute for medical advice,

diagnosis or treatment provided by a qualified health care provider.

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Please understand that it is not legal for me to give medical advice without a consultation.

If you wish an appointment, please telephone my office.

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

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The advertising below is not recommended by me.

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Opioid taper – please comment. Your story matters


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Opioids

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Americans use 80% of prescription opioids in the world.

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If you have voluntarily tapered off opioids, please comment

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In 1991, America was not even among the top 10% prescribing opioids for cancer pain. Now look where opioid induced pain has led the way medicine is practiced. We have created disability like throwing gasoline on fire. It is costing lives.

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Patients with intractable pain who have failed all  procedures, nerve blocks, injections and opioids, why are they still taking them if pain is still severe, if they are not able to function? They do worse than nothing.

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Opioids create pain: They trigger the brain to produce pro-inflammatory cytokines that cause pain. It is drowning in a universe of delusion to ignore the data. Clinging to fear.

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Data: Here’s an old Stanford study from 2005 Journal of Pain:

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Opioid Tolerance and Hyperalgesia in Chronic Pain Patients After One Month of Oral Morphine Therapy: A Preliminary Prospective Study

 

Abstract

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There is accumulating evidence that opioid therapy might not only be associated with the development of tolerance but also with an increased sensitivity to pain, a condition referred to as opioid-induced hyperalgesia (OIH). However, there are no prospective studies documenting the development of opioid tolerance or OIH in patients with chronic pain. This preliminary study in 6 patients with chronic low back pain prospectively evaluated the development of tolerance and OIH. Patients were assessed before and 1 month after initiating oral morphine therapy. The cold pressor test and experimental heat pain were used to measure pain sensitivity before and during a target-controlled infusion with the short-acting μ opioid agonist remifentanil. In the cold pressor test, all patients became hyperalgesic as well as tolerant after 1 month of oral morphine therapy. In a model of heat pain, patients exhibited no hyperalgesia, although tolerance could not be evaluated. These results provide the first prospective evidence for the development of analgesic tolerance and OIH by using experimental pain in patients with chronic back pain [my emphasis]. This study also validated methodology for prospectively studying these phenomena in larger populations of pain patients.

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Perspective

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Experimental evidence suggests that opioid tolerance and opioid-induced hyperalgesia might limit the clinical utility of opioids in controlling chronic pain. This study validates a pharmacologic approach to study these phenomena prospectively in chronic pain patients and suggests that both conditions do occur within 1 month of initiating opioid therapy.

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Of course when you stop the opioid, the system rebounds like wild, stronger pain. It’s one thing to publish this important study, but how to offer better relief than the adjuvants that failed?

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How has opioid’s overwhelming inflammatory imbalance in brain affected the ability to recover? ever. The brain is maxed out. Is it permanent? How long does this last? There are those who think, I won’t taper off, I’ll wait till the very last minute, do rapid detox and expect instant change. Do not allow brain recovery. Opioids are still in system for weeks after stopped.

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People more likely to remain on disability if opioids are even once started. Doctors then prescribe tramadol, Nucynta, buprenorphine in patches or film for sublingual use. Those are still opioids.

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And one week ago, two more opioids approved. They make billions, guaranteed lifelong. Why should pharma try something that will actually relieve pain without causing inflammation centrally in brain?

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The problem is that patients who taper off have been offered nothing adequate to replace the opioid.

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The question is, if FDA refuses to approve any more opioids, will pharma do anything to relieve pain?

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The material on this site is for informational purposes only, and is not a substitute for medical advice,

diagnosis or treatment provided by a qualified health care provider.

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~

Please understand that it is not legal for me to give medical advice without a consultation.

If you wish an appointment, please telephone my office.

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

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Opioids “Two Novel Opioids Win Tepid Backing From FDA Panel” – really? 2 more opioids?


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Two Novel Opioids

Win Tepid Backing From FDA Panel

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Two more opioids . . . . . . . . oh boy! more opioids

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The only class of pain drugs that rakes in $40,000 per month or more for a single patient. We’d see pharma thinking about something better than opioids if they were blocked from charging more than gabapentin. Opioids cost pennies yet these formulations can cost more than $1,000 a day and they are poorly effective for chronic pain.

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“Both committees — the Anesthetic and Analgesic Drug Products Advisory Committee (AADPAC) and the Drug Safety Risk Management Advisory Committee (DSaRM) — were asked to consider a proposed indication of pain severe enough to require daily, around-the-clock, long-term opioid treatment for which alternative treatment options are inadequate.”

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“Many of the committee members said their “yes” votes on approval came with some hesitation — while Teva’s product may be an incremental step in the right direction, there needs to be better outcome measures for reductions in abuse resulting from reformulations, as well as improved outcomes for the treatment of pain, they said.
Meeting a second day, the same panel also voted 9-6 to “recommend” approval of a different abuse-deterrent product, this one combining extended release oxycodone with naltrexone (Troxyca). The slim margin is often seen a null recommendation.”

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Don’t get excited about naltrexone in these formulations. When injected into vein, it will block the effect of the opioid.

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The material on this site is for informational purposes only, and is not a substitute for medical advice,

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Opioids can make pain worse


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Why taking morphine, oxycodone can sometimes make pain worse
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Article By Kelly Servick, May. 30, 2016

“Peter Grace, a neuroscientist at the University of Colorado (CU), Boulder, and his team has been trying to trace hyperalgesia to the way opioids affect the immune system.”

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“There’s an unfortunate irony for people who rely on morphine, oxycodone, and other opioid painkillers: The drug that’s supposed to offer you relief can actually make you more sensitive to pain over time. . . . A new study in rats—the first to look at the interaction between opioids and nerve injury for months after the pain-killing treatment was stopped—paints an especially grim picture. “

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“Animals given opioids become more sensitive to pain, and people already taking opioids before a surgery tend to report more pain afterward.”

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“Grace says the field badly needs a human study that systematically tests pain thresholds over time in opioid users…. In the meantime, he says, “I hope that it’ll get people to really question what the benefit of long-term opioid therapy might be.””

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© 2016 American Association for the Advancement of Science

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Welcome to my Weblog on Pain Management!

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I generally accept only those who have failed most or all known treatments, and only those who I feel I can help.

 

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I interview each patient before accepting.

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


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Pain kills

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

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

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

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Congress is pushing this opioid bust very hard.

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That is demagoguery

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I am pained and suspicious in several ways.

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Legal nationwide precedent.

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

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

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

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

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Nothing to do with helping to relieve pain.

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

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

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

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

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

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Insurance will not pay for more.

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

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

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

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

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Those running for president:

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

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

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

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

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This is the start of all sorts of federal dictates

into your medical care.

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


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Opioid Guidelines are Pseudoscience

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They do not pretend to treat pain

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CDC Opioid Guidelines limit opioids to

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 90 mg morphine equivalent daily dose, MEDD

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Whose calculations will the DEA use against your doctor?

 

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

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

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

 

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

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

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

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

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Let’s look at a few points:

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

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

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

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

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

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

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

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

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

 

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

~~~~~

For My Home Page, click here: 

Welcome to my Weblog on Pain Management!

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


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Criticism of the CDC Opioid Guidelines

from today’s Practical Pain Management

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

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

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

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

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  2.  Organizations that have criticized the CDC Opioid Guidelines

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Directly quoting, below:

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

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[Emphasis mine]

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

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AAPM Response

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

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

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

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[emphasis mine]

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

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The AMA’s response:

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

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

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

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

 

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Suicide prevention

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

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

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

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

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

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

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

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

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

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

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

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

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

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Addiction

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

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

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

 

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Coda

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

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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NIH Releases a National Pain Strategy


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Today NIH Releases a National Pain Strategy

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

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

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

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

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The material on this site is for informational purposes only.

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

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Relevant comments are welcome.

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

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Rectal Suppository Morphine, part 3 – cannabis


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Let’s all now avoid the topic of cannabis.

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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.

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

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There is only one politician discussing cannabis.

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

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The material on this site is for informational purposes only.

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

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Relevant comments are welcome.

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

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


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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:

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Under Notes and Restrictions:

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PA=Prior Authorization

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ST= Step Therapy Required

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NF=Non-formulary

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

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*Hint, it’s short acting.

 

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Signed,

Your friendly neighborhood healthcare insurer

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Do they live in your neighborhood?

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It would be unAmerican to publish their names and addresses.

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

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Sweeping effects on the practice of medicine.

Meditate on that.

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Head to my front page if you want

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The material on this site is for informational purposes only.

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Opioid Guidelines – sweeping effects on the practice of medicine


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This page is just for meditation

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

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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Opioids Down in Doctors’ Offices Across the Country


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New York Times: Patients in Pain,

and a Doctor Who Must Limit Drugs

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By JAN HOFFMANMARCH 16, 2016

 

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MILFORD, Neb. — Susan Kubicka-Welander, a short-order cook, went to her pain checkup appointment straight from the lunch-rush shift. “We were really busy,” she told Dr. Robert L. Wergin, trying to smile through deeply etched lines of exhaustion. “Thursdays, it’s Philly cheesesteaks.”

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Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.

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Yet rather than increasing her dose, Dr. Wergin was tapering her down. “Susan, we’ve got to get you to five pills a day,” he said gently.
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Such conversations are becoming routine in doctors’ offices across the country. . . .

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“I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home,” said Dr. Wergin, 61, the only physician in this rural town. “A one-size-fits-all prescription algorithm just doesn’t fit him. But I have to comply.”

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 When a random drug test of one longtime patient showed no trace of prescribed opioids, Dr. Wergin had to “fire” him for breaking the contract. Instead of taking the pills, the patient had been selling them.

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Dr. Wergin has learned to be even more wary during his emergency room shifts at the hospital 15 miles away. There, he has seen firsthand a growing number of overdoses and opioid-related deaths.

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The scenario has become so familiar that now when a nurse reports that the patient in Room 3 is complaining of excruciating back pain and asking specifically for Percocet, Dr. Wergin will reply, “And is he about 31, single or divorced, and insisting he is allergic to nonsteroidals?”

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These are “seekers ’n’ sellers,” he explained, who peel off I-80 and head for the hospital “thinking we’re just ignorant hayseeds.” A few months ago, state troopers pulled guns on one such man, who had stormed into the hospital demanding pain medications and threatening Dr. Wergin and other staff members.

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As Dr. Wergin recounted this, driving through the fog-shrouded back roads of winter-stubble prairie, where patients are rushed to the emergency room after being crushed by forklifts and tractor tipovers, he recoiled against his own cynicism.

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Prosecutors and medical review boards are increasingly scrutinizing physicians who prescribe controlled substances. A colleague of Dr. Wergin’s in a nearby community was investigated for two years after a patient died of an overdose. Although she was cleared, the reputation of her small-town practice was damaged. She moved to another state.

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The problems faced by Beverly TeSelle, 71, defy most solutions.

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After a second stroke that left her using a wheelchair, Mrs. TeSelle, formerly a gregarious accountant, began to suffer vicious headaches that left her weeping and moaning.

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“The biggest relief for both of us is when she goes to sleep,” her husband of 53 years, Larry, said, tearfully.

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Dr. Wergin noted that Mrs. TeSelle, whose strokes have also left her with slurred speech, and hand, arm and shoulder pain, already takes more than what may be allowed by coming state limits. He considered increasing the dose of her fentanyl patches but said, “I worry about respiratory depression.

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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Rectal Suppository Morphine – the only opioid on formulary


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CDC Opioid Guidelines

Day #1

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

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I almost choked on my wheatberries on this one.

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

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Be warned people. 

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Is that 6 suppositories every 3 hours?

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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

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


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Today JAMA published the heavily resisted

CDC Opioid Guidelines

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

says my Rheumatology colleague

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 Chilling Effect on Prescribers

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Guidelines allow Tylenol or Aspirin

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Will insurers stop paying for opioids?

 

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

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

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

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

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

 

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

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

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

Tracy Helton Mitchell today on Reddit, inspiring leader.

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

 

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These are “guidelines, not law.”  CDC

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

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

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

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

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Will insurers stop paying for opioids?

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

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

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

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

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

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

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

 

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

~~~~~

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

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Off opioids, pain better. Life is back!


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

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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.

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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.

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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.

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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.”

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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!

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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.”

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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.

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I’ve seen worse.

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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.

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

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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.

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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.

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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.

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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.

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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.

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Once off opioids:

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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.

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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.

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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.

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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.

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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.

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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.

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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? !?!!

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CASE REPORT

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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!

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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.

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

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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.

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“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.“

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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.

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2nd visit, 4 weeks later

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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.

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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.

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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.

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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.

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

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

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I have seen patients become even better simply off opioids.

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

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

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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.

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

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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.

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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.” 

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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.

 

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The problem remains:

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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.

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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:

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

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“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.”

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

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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.” 

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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.

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

~~~~~

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

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me..

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PBS tonight? Governor of Massachusetts (Charlie Baker) being interviewed on law 3 day limit on pain meds


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I was just informed:

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PBS News hour tonight has a segment on pain with the governor of Massachusetts (Charlie Baker) being interviewed on Mass law of 3 day limit on pain meds.

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I wonder how much that will cost. Could it be true?

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I don’t get cable.

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President Obama “declined to endorse” proposal to limit opioid pain medication


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OBAMA: LIMITING OPIATE PRESCRIPTIONS WON’T SOLVE CRISIS

 AP (2/22, Nuckols) my emphasis in red:

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“Obama was cool to the idea at a meeting with the governors he hosted at the White House on Monday, noting that [pain medications] are sometimes the only realistic treatment option for people in rural communities.”

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Obama said any attempt to limit the number of pills that can be prescribed has to be part of a comprehensive approach. But he also expressed sympathy with rural Americans who cannot afford surgery or other costly, time-consuming treatment for painful injuries or illness.

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Dr. Steven Stack, president of the American Medical Association, said Obama was right to question the potential consequences of restraints on doctors.

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“The complexity of the problem makes it difficult to create a successful one-size-fits-all approach,” Stack said in a statement on Monday.

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Governors Devise Bipartisan Effort to Reduce Opioid Abuse,

New York Times (2/21)

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Mr. Dreyfus, the president of Blue Cross Blue Shield “said, the Blue Cross Blue Shield plan has reduced claims for short-acting opioid painkillers like Vicodin and Percocet by 25 percent and reduced claims for long-acting opioids like OxyContin by 50 percent, by switching patients to short-acting pain treatments.”

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BINGO! There you have it. Proof in numbers.

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And taking away the 20 mg of daily morphine from my 93 year old patient can have the consequence of preventing her from walking when she already has limited ability to walk with arthritic knees or playing cards 5 times per week despite end stage frozen shoulders.

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“Dr. Patrice A. Harris, the chairwoman-elect of the American Medical Association, said doctors welcomed the opportunity to work with governors on solutions to end this public health problem. But she added, “The A.M.A. wants to make sure that prescribing decisions — the decision to prescribe or not to prescribe — stay in the hands of physicians.”

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“A monograph prepared by the National Governors Association acknowledges the difficulties that its members face.”

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“Reducing the opioid pill supply, for example, can have the unintended consequence of increasing heroin use,” it said. “Laws aimed at unscrupulous providers can make ethical providers less willing to prescribe out of fear of scrutiny from law enforcement.” And “one state’s successful efforts to reduce illicit sources of prescription drugs can shift illegal activities to neighboring states.”

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Policy Analysis, Ronald Libby 2005:

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Pain patients are

far more likely

to suffer from the

scarcity caused

by the DEA’s

crackdown than

are the common

drug abusers the

agency claims it is

targeting.

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The new mission offered in practicing physicians a pool of registered, licensed, cooperative targets who kept records, paid taxes, and filled out a variety of forms.

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…the task force arrests five doctors a year in the Cincinnati area alone.

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Besides assess forfeiture at the start of investigation of a doctor, even if criminal charges are never filed, a police department can still bring a civil action against a suspected doctor to recover the cost of an investigation.

 

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This site is not for email.

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

~~~~~

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

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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


 

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PAIN AFFECTS

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MORE PEOPLE THAN

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DIABETES, CANCER & HEART DISEASE

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COMBINED

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 opioid “guidance” = opioid crackdown

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

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“Doctors are like prairie dogs.”

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124,000 physicians

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

During the first fourteen years after the Harrison Act passed,

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

 

 

 

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

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Treating Doctors as Drug Dealers

The DEA’s War on Prescription Painkillers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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You doctors. You agents of addiction.

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

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

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

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

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

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

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

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Reality: Surveillance. Kills trust.

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

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

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

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

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

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

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

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

 

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

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

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

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

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However cutting doses of pain medicine.

Heartless brutes!

I feel like a heartless brute.

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

DO YOU TRUST THIS GOVERNMENT TO HELP? 

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

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

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

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

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PAIN AFFECTS

MORE PEOPLE THAN

DIABETES, CANCER & HEART DISEASE COMBINED

 

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

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PAIN AFFECTS MORE PEOPLE THAN

DIABETES, CANCER & HEART DISEASE COMBINED

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This radical experiment to radically cut opioid doses, heartlessly.

Sigh.

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

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CDC opioid cuts will cause damage that should make headlines.

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

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

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

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WE NEED A STUDY TO SHOW HARM & BENEFIT.

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BEFORE

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

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

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

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AFTER OPIOID CUTS

Repeat study every year for 3 to 5 years.

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

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

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too dreary to read

will probably delete this tomorrow

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

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The material on this site is for informational purposes only.

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

provided by a qualified health care provider.

Relevant comments are welcome.

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