Distinguishing Intractable Pain Patients from Drug Addicts

Distinguishing Intractable Pain Patients from Drug Addicts

By Joel S. Hochman, MD

http://bit.ly/IPvsAddict


Maybe one of you will better understand what appears to me to be nothing but an excuse to keep pain patients from getting their meds. It seems to me that fear of Diversion is a poor excuse for denying legitimate pain patients access to opioids, especially when nothing else works. The DEA has NO AUTHORITY to regulate medicine, they can only go after a doctor if (s)he prescribes "outside of medical practice", meaning that they were intentionally writing prescriptions that were not intended to treat a legitimate medical condition. Unfortunately, doctors don't decide which doctors are prescribing in the "due course of medical practice", and neither do any other medical professionals. DEA agents (glorified cops) and prosecutors make these decisions. They've scared doctors to the point where the doctors have started to lie to their patients in order to reduce the number of controlled substances (especially opioids) that they prescribe.

My biggest question is this....

If physicians can distinguish so easily between addicts and legitimate pain patients (which I do believe that they can), why is it that the DEA can't tell the difference between prescriptions to legitimate patients and prescriptions written to addicts?

-Steve

Medication Jeopardy - National Pain Report

A Pained Life: Medication Jeopardy - National Pain Report

http://bit.ly/1lGjvrJ

"I was concerned about being able to get methadone when I returned home to New York City.

“My mentor is there. He’ll give you the prescriptions. Don’t worry,” Friedman said.

Unfortunately, he was wrong.

When I told the doctor, “Dr. Friedman told me you would write the methadone prescriptions for me,” he stood up, said he would not, ended the appointment, and sent me on my way – with no prescription or instructions about stopping the drug."

My comments:
~~~~~ Comment #1 ~~~~~
I was cold turkeyed from methadone (although I had oxycodone, which helped with the mu-opioid activity, but not kappa-opioid or NMDA).

Methadone it's cheap and effective, but it is also misunderstood because of a few overdoses caused by uneducated physicians. Methadone should NEVER be increased more than once every 5-7 days. Other opioids can be increased every few days or even every few hours. If a doctor increases methadone as often as they increase oxycodone, oxymorphone, morphine, or fentanyl, the patient could overdose.

There is a irrational fear surrounding methadone and because it is about $10/month, there's no incentive for drug companies to spend money dispelling those myths. Some brand name drug companies will scare doctors away from methadone to boost sales of OxyContin (oxycodone ER - major culprit), Kadian (12 hr morphine ER), Avinza (24 hour morphine ER), Exalgo (24 hr hydromorphone ER), Opana ER (oxymorphone ER), and, now, Zohydro (12 hr hydrocodone ER).
Sorry, I don't mean to sound like a conspiracy theorist.

Duragesic/fentanyl patches 400mcg/hr have no effect on my neuropathic leg pain, but low dose methadone (even 5mg/day) can have huge effects.

Methadone is uniquely effective because it it's not a pure mu-opioid (like morphine, oxycodone, fentanyl, sufentanil, alfentanil/Alfenta, oxymorphone, hydrocodone, hydromorphone, codeine, and remifentanil). Methadone is a mu-opioid, but it's also a kappa-opioid, an NMDA receptor antagonist. Methadone is ideal for nerve pain, but it is also effective for back pain and cancer pain.

Steve
~~~~~end~~~~~

~~~~~ Comment # 2 ~~~~~
Robert is correct, this is medical malpractice.

Untreated and under treated intractable pain can and do kill, usually through cardiac over-stimulation and various changes in the cardiac, pituitary, and adrenal systems. Dr. Forest Tennant explains it best in 'The Intractable Pain Patients' Handbook for Survival', which is (legally) available for free.

http://bit.ly/PainGuidePDF

Dennis is correct, pain patients need to be given a voice among those who regulate pain treatment. To those who lost kids, I'm sorry, but you kids was an addict who broke the law and took powerful medications without any regard for the directions.  These kids toss random points in a "candy dish" and swallow handfuls, you can't regulate that kind of stupidity. We pain patients are completely different from the drug abusers who make our lives hell.
~~~~~end~~~~~

Steve

Seeing Failure as Success- A Pained Life

A Pained Life: Seeing Failure as Success - National Pain Report

http://bit.ly/1qeGax0

..."I remember reading a note one of my first doctors had written: “She is being victimized by her pain.”

I did not understand what he meant at the time. Now I get it. I feel a victim, not only of the pain, but of the lack of treatment options for it."...

..."I looked up the definition of victim online: “A person or thing that suffers harm, death, etc… from some adverse act, circumstance, etc.”

This added disclaimer surprised me:

“Using the word victim or victims in relation to chronic illness or disability is often considered demeaning and disempowering. Alternative phrases such as who experiences, who has been diagnosed with, or simply with and then the name of the disability or illness, can be used instead.”

But we are victims. Of pain that often controls our lives. Of a War on Drugs that we need to help us live. Without those drugs the pain can be so overwhelming that death can be seen as preferable, and for way too many of us, has been.

Changing the way we say it, “I am not a victim of my pain, I experience chronic pain,” does not change the experience of being victimized.

So maybe it is time to turn the equation around.

If we can look at each failure as bringing us closer to being helped, then we are no longer victims. We become warriors. And each new treatment brings us closer to the one where we just may prevail."... (if it is legal & not under attack - don't hold your breath for Sativex or opioids).

Steve

ACLU Sues over Mandatory Drug Tests - National Pain Report

ACLU Sues over Mandatory Drug Tests - National Pain Report

http://bit.ly/1eWLOjN

FDA Approves First Device to Prevent Migraines - National Pain Report

FDA Approves First Device to Prevent Migraines - National Pain Report
http://bit.ly/1eWKqO2

Feds Investigate Walgreens Over Privacy Concerns - National Pain Report

Feds Investigate Walgreens Over Privacy Concerns - National Pain Report
http://bit.ly/1pefSuh

Anything to different from the discrimination of CP/IP patients.

Drug Maker Blames ‘Misinformation’ for Zohydro Controversy - National Pain Report

Drug Maker Blames ‘Misinformation’ for Zohydro Controversy - National Pain Report
http://bit.ly/1peed85

FDA Hears From Fibromyalgia Patients - National Pain Report

FDA Hears From Fibromyalgia Patients - National Pain Report

http://bit.ly/1pec1gP

Don't forget to read the comments.

Wish me luck- PCP & IP

It's 9:40am and my wife has yet to sleep, and my sleep was highly fragmented thanks to her efforts to clean and organize a lot of our stuff. We're both going to be dragging when we go to my "next day" appointment later this afternoon. My pain has been out of control and, despite all of knowledge and self education, I have no idea how I'm going to convince my PCP that I'm in need of additional help.

While I both sympathize and empathize with the uncomfortable position that my PCP is in, I NEED him to help me until (unless) he van get me an intrathecal pump management physician, PM, and/or palliative care specialist.

I'm mainly asking for an increase and change in form of my clonidine (1mg pill 2/day --> clonidine patch 3mg/day), but he and I both know that my current dose of fentanyl patches has been inadequate for YEARS and he always gets uncomfortable whenever I mention poor pain control. He knows that I need to be back on low dose methadone and Actiq. My pain is getting worse and the dose of medication that's always been inadequate is extremely inadequate (even without the effects of tolerance).

Honestly, I'm extremely depressed and unsure of why I'm still fighting to live.

Sorry for the depressing post, I just needed to vent.

-Steve

Paying for it

I spent a few hours volunteering at the local animal shelter yesterday. I WAY over did it yesterday, and now the nerves in my legs are on fire. I can practically trace the nerves because they're so inflamed. I missed our weekly outing with our daughter (museums, historical society, hikes, parks, carnival, Army war college, etcetera) this morning. This afternoon, I didn't get to go to the animal shelter (my wife still went and helped for two hours). And now, I'm missing out on going out with some of the people at the shelter (my wife got both of us invited while  I slept and she volunteered).

I'm not sure which is more frustrating
1) constant, unrelenting pain
2) inconceivable BTP (breakthrough pain) flares
3) missing out on everything (family stuff, social stuff)
4) NO ONE gets it

I think the worst part of this is that none of this is necessary! I'm in pain for no legitimate reason. My pain was under control (bad, but under control) with low dose methadone, Actiq, Duragesic, and oxymorphone. My pain was virtually eliminated with 3mg/day intrathecal morphine. I feel like the one sane person in a world of crazy. I feel like I'm screaming and no one is listening. I'm in excruciating pain, there's medication that can fix it, I'm insured, my insurance will cover Duragesic, Actiq, methadone, oxymorphone, AND an intrathecal pump, I have NO risk factors (including NO family history) for abuse, I don't smoke, I don't drink, I've never abused my medication, I've never been high, I have cancer, I'm dying, I've never run out of meds or needed an early refill, I've tried EVERY non-drug treatment recommended, I've tried every non-opioid, I've tried every single weaker opioid, I'm beyond compliant, I keep myself informed (as instructed, although it's being used against me now)... and, STILL, I'm treated like shit and get inadequate treatment.

How does this make any sense to anyone?

Steve

Treatment of chronic pain puts doctors in a no win situation

Since I regularly complain about the abysmal treatment of chronic and intractable pain patients in the USA, I thought that I should share this 2011 article written by a physician that explains the dilemma that (at least the good) doctors go through every time a pain patient walks into their office. I've included just a small excerpt from the article below, but I promise that the article is well worth reading in it's entirety. Although it SHOULD not be necessary, it may be extremely helpful to be able to empathize with the physician the next time that you have to try to convince them that your pain deserves adequate analgesia.

Treatment of chronic pain puts doctors in a no win situation
http://bit.ly/1ijfMMD

Steve

"...How the physician can be expected to “believe” the patient, yet not rely only on subjective history by the patient but have objective evidence often for problems where no objective evidence exists, is the inherent flaw in trying to define and regulate pain management....

...We are supposed to both show compassion and adequately treat non-malignant pain with the same drugs that professional patients and opioid abusers seek to get prescriptions..."

Update

My wife and I had our quarterly checkup with our PCP Wednesday night. As some of you know, my wife and I are under-medicated because of a number of factors, including Opiophobia, the semi-recent increase in the War on Drugs, and the fact that our PCP also does Suboxone (treats addicts).

Our PCP still refuses to increase our Duragesic. My wife was switched from OxyIR to oxymorphone, after months of requiring that multiple doses of OxyIR 30mg. He wasn't as stingy as when he put me on oxymorphone, but her pain is finally diagnosed (EDS, type 1 & 2), but he still a bit stingy.

After 7-9 months of begging for an increase, he finally increased my oxymorphone again. It's still nothing collapsedl compared to the Actiq that he refuses to prescribe since he's started doing buprenorphine/naloxone treatments (generic Suboxone and Suboxone film, mainly the film according top the literature the drug reps litter the office with). That is also why he refuses to use methadone for pain management.

Wow, off-topic, sorry. Still waiting on insurance approval, fingers crossed that we get approved and that these help.

Patriot Day

I want to take a moment to thank all of those rescue workers who selflessly risked their lives to save their fellow Americans. I especially want to thank those rescue workers who fled to NYC to save lives and where left without medical care.

While my blog is generally dedicated to chronic pain patients as a whole, but today I'd like to remind everyone that many of our heroes (from 9/11, the War in Afghanistan, and the War in Iraq) are needlessly suffering because the VA is instituting no opioids policies at many of their hospitals and even the few who can afford private practice physicians are finding that doctors who prescribe opioids are harder and harder find.

My best friend is an ex-cop, "ex" Marine who is without pain management after an IED took his eyes and left him with shrapnel around his spine. Without notice, his doctors dropped him and left him without pain relief, which has resulted in countless emergency room visits, intensive care admissions, and hospital visits. He's had organs shut down from untreated IP. And I know he's not the only one. If we can't give our heroes relief, what chance do the rest of us stand?

Steve

Desperate for sleep

So, it's 9:20am and I'm finally getting sleepy thanks to my giving in to my body and taking lorazepam, oxymorphone, tizanidine, and Rozerem.

Sweet dreams to all.

Remember, I'm always looking for post ideas, suggestions, and/or questions.

Steve
IntractablePainKills@gmail.com

Opioid Availability Epidemic

My best friend has been suffering for almost a month now because his pain management doctor dumped him without warning or cause. He's a veteran, blind, and a cancer patient (relapse of leukemia) (If he can't get help, what chance do the rest of us stand?). He's afraid that he isn't going to make it to his 33rd birthday this Sunday.

While some may assume that this blatant malpractice is a fluke in the system, it has salt become par for the course. I, myself, am vastly undertreated and lost my pain management doctor January 2012 and have been looking for one since.

The media and the DEA are scarring our doctors away from prescribing these essential medications.

New doctors are warned to avoid pain management and the remaining pain management doctors are instituting injection only policies where they do high profit procedures that cause most of us an increase in pain or they only make recommendations. Recommendations are fine, if you're PCP is willing to follow the medications and prescribe your medication, but few are. This recommendation-only policy also causes significant lags in care, which means an overall lower quality of care.

We walk into doctors offices, hospitals, urgent cares, and emergency rooms to find signs that say that pain medications will not be prescribed. Imagine if you walked into your doctor's office to found a sign saying that they will not prescribe insulin to diabetics or beta blockers to hypertension patients?

I'm all for a solution to the abuse problem, but we need to focus on helping addicts get off drugs with Rehab and methadone while educating kids before they start. Stopping chronic pain patients from getting relief solves nothing.

While Florida is one of the worst states, Texas, Pennsylvania, and dozens of other states have significant issues. There simply aren't enough pain management doctors for every CP/IP patient to see one, especially since most PMs don't prescribe anyway. PCPs and other specialists must start treating chronic pain patients, especially theones on low doses, already stabilized by a pain specialist, or unable to find a pain management doctor.

As Hippocrates said, "cure sometimes, treat often, comfort always". I'm not sure if opioids count as treatment or comfort, maybe both, but letting patients suffer without relief from pain when pain is possible is far from anything in the Hippocratic oath.

Steve
IntractablePainKills@gmail.com