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Got Chronic Pain? The Feds Say You’re a Lying, Addict and Don’t Need Opioids


***Bob Aronson is a 2007 heart transplant recipient. He has also suffered from Chronic pain for several years and doepends on opioids to provide some comfort. He has tried several alternatives, some have been beneficial but he still needs opioids in order to live a somewhat normal life. 

opioid epidemicYes, there is an opioid crisis. Yes, the number of deaths from opioid overdoses is a tragedy, and yes, something must be done to stop the addiction and the dying, but denying pain relief to legitimate chronic pain sufferers is not the way to do it.  There are millions of Americans who suffer daily from chronic pain and need the relief provided by opioids. Everyone is subject to becoming a chronic pain sufferer including transplant recipients.

I have always thought the federal government approach to stopping the opioid addiction/overdose/death epidemic was wrong-headed, but I also thought that the denial of pain relief to legitimate chronic pain patients was accidental, a result of overzealous federal agencies.  I thought that if we protested they would see the light and make the appropriate changes. I’ve never been so wrong. The Federal Government didn’t mistakenly create a problem for chronic pain patients, THEY DID IT ON PURPOSE. WE ARE NOT ACCIDENTAL VICTIMS, WE ARE THE TARGETED GROUP AND WE MUST FIGHT BACK.

Lest you think my claim is just the paranoia of a crazed junkie, let me offer proof in two forms; one personal the other by exposing government policy. First a quick personal experience. I have osteoarthritis and some pinched nerves. The proof of that claim can be seen on my MRIs.

My primary doc has often commented about the pressure applied by the feds to get him to stop prescribing opioids. He suggested I go to a pain clinic where the physicians are pain specialists and allowed more leeway, but even they are closely monitored by the drug cops. The clinic prescribed 15 milligrams of Oxycontin twice a day and 10 milligrams of Hydrocodone once a day for breakthrough pain. That was the regimen for quite some time and while not totally controlled, the pain was manageable. At the same time I was getting steroid injections in my neck and back as alternatives to more opioids. Then, one day without warning the pain doc said they could no longer offer the Hydrocodone. They said that the best they could do for breakthrough pain was Tylenol 4 which contains codeine, a totally ineffective drug for my condition and much less powerful than the Hydrocodone. Now, my pain is not under control but the doc says this is the best he can do under current federal guidelines. I expect that soon I will hear that Oxycontin is no longer available.

The federal agencies involve;d in the opioids issue seem to think that anyone who takes any narcotic pain reliever is an addict, their policies ignore evidence to the contrary. For example; I have never shown signs of addiction, I have never asked for an increase in milligrams or for stronger drugs,  I have never Doctor shopped, and have always passed the random urine tests they give and when I go to the pain clinic I always have the correct number of pills left in the containers. So, why was I denied relief? Because the feds blanket policy wants all opioids use stopped regardless of who is hurt in the process. Not only that, but if you read on you will quickly see that the feds believe that chronic pain patients are liars and addicts and have therefore Targeted us. Then, they turned the torture screws even tighter by specifically targeting Medicare Part D patients. Those are the people who have prescription coverage under Medicare. What follows goes far beyond personal experience, it exposes a broad government policy that targets those who legitimately need the pain relief offered by opioids.

On April 2,martin luther king 2018, CMS (Centers for Medicare and Medicaid Services) issued updated regulations for Medicare Advantage Plans (MAP) and Medicare Part D programs. The focus of the updates is to provide additional guidelines and tools to target the nation’s growing opioid epidemic. I should note that most, perhaps 90 percent of those affected are older Americans. The Government has targeted chronic pain patients many of whom are senior citizens. Here’s proof. CDC’s Guideline for Prescribing Opioids for chronic pain makes it clear that pain patients should be using alternative therapies that do not include narcotics regardless of the level of pain and effectiveness of the alternative treatment. The Guidelines ignore the fact that many patients cannot afford alternatives, are disabled and unable to get to alternative therapy and that many are uninsured and cannot afford it. https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf  As I did the research, I could not believe what I found, but here’s more of the story.

These new regulations expand Medicare’s ability to identify medication misuse and establish controls at the pharmacy. Already some pharmacies are limiting opioid prescriptions to a 3 or 7-day supply. They are doing it arbitrarily as a blanket program, totally ignoring individual patient histories and medical conditions. Why? Because they believe it is good public relations. This is a business decision, not one to benefit patients. They think their tough stance on opioids will bring them more respect, more customers and greater profits. They are using our misery to make more money. They are gambling that most Americans will praise them for their efforts, when in fact they should be soundly condemned and shamed. The 3 or 7-day prescription limit means the patient with chronic pain will have to see a physician every three or seven days to get a refill prescription (Narcotic prescriptions never allow refills and in most cases cannot be called or faxed in to the Pharmacy.. The Patient must posses the prescription and physically hand it to the pharmacist. At the same time, he or she will also be asked for ID).  Everyone knows that it is nearly impossible to get a doctor’s appointment  every three to seven days, so it is obvious that pharmacies like CVS and Walmart in their quest to be more profitable have joined the Government in calling chronic pain sufferers liars and addicts.

customer serviceAlways remember, these are business decisions. They are made to determine the effect on the business, not for the betterment of humankind. When corporate executives or their boards of directors make decisions like these, their first concern is the bottom line. They do not make decisions based on what’s right or what’s compassionate. When things like 3-day prescriptions are proposed, the first question asked is, “How will that affect the bottom line?” If the answer is negative, acceptance is very unlikely. Don’t be fooled by their advertising or PR efforts. If an effort can’t make money, they don’t do it and, if  they decide to do it and it fails to make money they will quietly withdraw it.

The same is true of Insurance companies. From January 1, 2019 on, those companies that offer Part D plans will have the authority to arbitrarily establish drug management programs for patients they believe are at risk of abusing medications (a good excuse to quit paying for certain drugs, an action that will increase insurance company profitability). They can then determine misuse without ever talking to the patient. That means insurance companies can designate an individual as “at risk” and limit the patient’s access to their list of frequently abused drugs with no patient or physician input. (CDC guidelines for prescribing opioids)  https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf

You can be assured that if Insurance companies see that disallowing Part D payments forinsurance card pain-relieving drugs will strengthen their bottom line, they will do it. This war on opioids then becomes a profit center for Part D. Insurance companies. CMS (Centers for Medicare and Medicaid Services) says it will designate all opioids, except Buprenorphine (a drug used to treat opioid dependence) and Benzodiazepines (an addictive drug used to treat anxiety, nervousness, panic disorders, muscle spasms, seizures, and more). Benzos will also be designated as a frequently abused drugs but will be excluded from the new guidelines, for a while). You can read more here — CMS proposes Part D Opioid Limits, Pharmacy reacts. http://www.drugtopics.com/drug-topics/news/cms-proposes-part-d-opioid-limits-pharmacy-reacts

There are an estimated 25 million Americans that suffer from Chronic pain, and this new attack will only make the suffering worse. Read what follows, and you’ll have the full story.

The U.S. Government’s war on opioids is led by the DEA (Drug Enforcement prescriptions opioidsAdministration), the FDA (Food and Drug Administration) and the CDC (Centers for Disease Control). CDC reports that opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1 999.

I do not doubt that there is a crisis of major proportions and that something must be done to stop the abuse of these drugs and the mounting death toll. The government approach, though, is over-broad, arbitrary and just plain wrong. They would make opiates unavailable to everyone. That goal fails to recognize that millions of chronic pain sufferers legitimately need to use opioids, and to take them off the market will cause irreparable physical and mental health damage. The government insists there are alternatives to opiates; they ignore the fact that the alternatives don’t work on everyone, that some patients can’t afford them because insurance does not cover them and that many patients are uninsured. The Government program is more likely to force chronic pain sufferers into the street to buy cheaper illegal drugs than to alternative programs that only extend the pain.

Among the targets of the above-mentioned federal agencies are 1) the companies thatdrug companies make opioids, 2) the physicians who prescribe them, 3) the pharmacies that fill the prescriptions and 4) the patients who need them. CDC says that each year, over 200 million opioid prescriptions are written and filled in the United States. In 2012 the number of prescriptions peaked at 255 million. No doubt, that’s a hell of a lot of opioid prescriptions, and the number raises the question, “How many of them are really necessary for pain control and how many do nothing more than satisfy an addiction?” That’s the question the Feds should be asking. Instead, they are acting as though they have the answer and it is, “All of those prescriptions are life-threatening, especially those written for patients who claim to have chronic pain.” Patients, on the other hand, are getting this message, “All of you so-called chronic pain sufferers are liars. You don’t need opioids.”

The feds message to the medical profession is, “We’remedicalicense watching you and want you to know that we strongly discourage prescribing opioids for repeat patients. If you continue to do that you are placing your license at risk.”” So, who is a repeat patient? That’s me and thousands if not millions like me who must see a physician each month to get a new opioid prescription. There is far less pressure on docs who write a scrip for one or two-time use. That’s someone who broke an arm, and in a few weeks, the pain is gone on its own as opposed to Chronic Pain patients who need on-going relief.

The issue that the feds refuse to address is this; while you are seeking out and trying the alternatives, how do you control the pain? Several pain management specialists have told me that to determine which alternative will work, you must quit using opioids and it may take months to find one that works, or you may never find it. All that time you are experiencing pain so intense as to cause you to have suicidal thoughts or at least thoughts of how death would provide relief. When pain is so bad, it prevents you from doing anything, even those things you used to love, and the feds don’t allow any relief, they are violating this age-old admonition, “First, do no harm.”

As a chronic pain sufferer, I would much prefer to get pain relief from something other than a narcotic. I don’t like the feeling I get from using the drugs. As an intelligent, functioning human being, I much prefer a clear head to one muddled by narcotics. While I am nearly 80 years old, narcotics allow me to be a functioning, productive member of society. I do woodwork, write blogs, just published a science fiction book, engage in discussions in the social media and do the grocery shopping and even some cooking. Without opioid relief I would be reduced to a weeping, grumpy old man who is unable to do anything for himself.

Most politicians are on the anti-opioid bandwagon, they don’t know about chronic pain so we have to tell them. we have to be isiIbecause they’ve only heard a small part of the story. Now it is time to tell our story because if we don’t’ all of us may exit this world in excruciating pain. This time we can’t wait for someone else to fix the problem, we must fix it ourselves by telling our stories to those who can stop this nonsense. Here are some addresses you can write to or call.

House of representatives members and contact info. https://www.house.gov/representatives

U.S. Senate members and contact info. https://www.senate.gov/general/contact_information/senators_cfm.cfm

CMS Contact info https://www.cms.gov/Medicare/Coverage/InfoExchange/contactus.html

DEA contact info https://www.dea.gov/contact.shtml

FDA contact information. https://www.fda.gov/AboutFDA/ContactFDA/default.htm

The White House contact information. https://www.whitehouse.gov/get-involved/write-or-call/

American Pharmacists Association contact information. https://www.pharmacist.com/contact-us

Finally, be in touch with your local media. Suggest stories on chronic pain with this angle, “The feds, physicians, and pharmacies, aren’t telling the whole story. Here’s the chronic pain patient’s perspective.”

Only you can change this wrong-headed, harmful approach to ending addiction to opioids. Tell your story, let the bureaucrats and elected officials know your feelings and your suffering. There are 25 million of us, if we all act, we will be a force that cannot be ignored.

 

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Why You Can’t Get Pain Meds


dea cartoonBy Bob Aronson

This is not my first post on this subject and it will no be the last because Americans with real pain are suffering needlessly.

Chronic pain is real.  I know, I have it and right now thousands of U.S. docs are refusing to prescribe narcotic pain killers not because people don’t need them but rather because federal agencies in their zeal to eliminate “Pill Mills” have frightened physicians.

They’ve told docs they run the risk of being investigated if they can’t prove an absolute need for every opioid prescription they write.  The result is that docs don’t want or need the hassle so many of them are saying, “No” to all requests for pain killers even when they know the requests are legitimate.  It happened to me and it is happening to thousands of others as well.

Federal agencies have gone over the edge on this one.  Their strong-arm tactics aimed at stopping a few unscrupulous physicians may result in some license revocation and brief incarceration while thousands if not millions of chronic pain sufferers are condemned to living with extreme discomfort and excruciating pain.  Have they spent any time thinking through the effect of their intimidation of doctors and pharmacies?   Do they really think that taking drugs away from people who need them will affect the trafficking of prescription meds?

While I understand physician’s reluctance to write prescriptions in the face of pressure from the feds I also think their behavior is as arrogant and irresponsible as the feds.  Physicians take an oath to treat the sick and to do no harm and by refusing to treat patients with with provable, legitimate pain they are violating both promises and risking the physical and mental health of their patients. 

Ever since I published my first blog on the subject I’ve received a constant stream of emails, tweets, Facebook messages and phone calls from people who have been cut off by their physicians.  Just this morning I got this email;

“bob, just read article on crackdown on narc . I have bladder cancer, replaced knee that was screwed up .  Other knee has to be replaced, have torn rotator cup right arm, bulging discs in c5 & c6. so yesterday my doc cut out my Lortabs because of letter from DEA.   Is this right & what do I do?”

What is most bothersome to me is that I don’t really have an answer other than to shop around for a doctor that will prescribe what he/she needs.  Certainly the oncologist should be sympathetic. This is a very serious problem but it is unlikely to be addressed because everyone is afraid…Afraid of being “Soft on narcotics enforcement,” afraid of being hassled, afraid of jail time.  It’s very sad and it is wrong.

Chronic pain is serious.  Millions suffer from it as the result of arthritis, accidents, broken bones, cancer and scores of other reasons.  I am one of them.  I have osteoarthritis and it hurts.  Without narcotic painkillers I would be immobilized.  With them I am functional and feel pretty good.  I don’t get high, I don’t’ abuse them I take them for their stated purpose – pain.

The Drug Enforcement Agency (DEA) has been hunting down “Pill Mill” doctors for years and they should.  It is an unfortunate truth that some real doctors will write prescriptions for almost anyone for an exorbitant fee.  Florida was the prescription drug capitol of the world until not long ago.

DEA is so obsessed with illegal narcotics that they don’t care who gets hurt along the way.  They have now persuaded the Food and Drug Administration to “Recommend” that physicians be more careful in their prescribing of hydrocodone (an opioid also known as Lortab or Vicodin).  The result of the DEA/FDA suggestions, warnings and recommendation is that physicians are just refusing to write prescriptions for narcotic painkillers or, in some cases any controlled substance including Valium. It’s not that docs are afraid of getting arrested, that’s quite unlikely.  They just don’t want the hassle of federal agents bugging them for detailed justification about the prescriptions they are writing for pain killers.

My primary care physician still provides me with the Oxycodone I need but I’m not so sure how long he’ll be able to hold out before he, too, will bend to the pressure from the feds. As the law stands now, a physician cannot call or fax a narcotic painkiller prescription to a pharmacy and those prescriptions are not refillable. To protect himself my primary care physician requires that I see him once a month for a pain evaluation before he writes new script.  Then with prescription in hand I must personally take it to a pharmacist.

I have written two blogs on the subject and there might be more coming.  You can find them at https://bobsnewheart.wordpress.com/2013/07/17/why-your-doc-wont-prescribe-narcotics-no-matter-how-bad-the-pain/     and at   https://bobsnewheart.wordpress.com/2013/12/10/suffering-from-chronic-pain-heres-what-you-need-to-know/

If you want to do something about this talk to your congressman or senator and get them to either deal with the issue legislatively or to put pressure on the FDA and DEA to back off legitimate claims for opioids.

Not Long ago the Boston Globe did a story on this issue.  It is well worth your time to read it.  http://tinyurl.com/l3ahgtc

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Bob Aronson is a 2007 heart transplant recipient, the founder and primary author of the blogs on this site and the founder of Facebook’s over 3,000 member Organ Transplant Initiative group.

Now retired and living in Jacksonville, Florida with his wife Robin he spends his time advocating for patients with end stage diseases and for organ recipients.  He is also active in helping his wife with her art business at art festivals and on her Rockin Robin Prints site on Etsy. 

Bob is a former journalist, Governor’s Communication Director and international communications consultant.

Got Chronic Pain & Can’t Get Pain Meds? Here’s What You Need to Know


By Bob Aronson

pain from the spouse pount of view

Chronic pain is of major interest to me because I suffer from it and have been denied treatment as well.  I have an established record as a sufferer and one who has tried a wide range of alternatives to the “controlled substances” the medical profession is so reluctant to prescribe.  I understand that we have a serious addiction problem in this country and that a very tiny minority of physicians over-prescribe controlled substances like Vicodin and Oxycodone.

I also understand that the U.S. Food and Drug Administration  (FDA) and the Drug Enforcement Administration (DEA) are cracking down hard on this activity but in the process are intimidating the entire medical profession in order to rout out the few who recklessly dispense narcotics to nearly anyone who wants them.  I know from first-hand experience and from the testimony of others that many physicians are so intimidated they refuse to prescribe pain killing narcotics to anyone.  I get all that and outline it in detail in this post.

Conversely, I believe that physicians have a unique opportunity and even an ethical responsibility to act as patient advocates rather than to retreat under fire and refuse treatment to those with legitimate pain issues.  The oath that says, Hipocrates“First, do no harm,” is broken any time relief is available but refused not because there is evidence that the patient is being dishonest but because the physician fears investigation. That to me is unconscionable and a terrible disservice to patients. Too many doctors at too many institutions have been intimidated by the threat of investigation and it is patients in pain who suffer as a result.

The publication, Scientific American  says this of chronic pain:  “Anyone living with chronic pain knows that it amounts to much more than an unpleasant bodily sensation. Fuzzy thinking, faulty memory, anxiety and depression chronic pain graphicoften accompany long-term pain, suggesting that the condition is more of a whole-brain disorder than simply pain signaling gone haywire. New research from Northwestern University reveals a possible cause: an impaired hippocampus, a region critical for learning, memory and emotional processing (you can read more by clicking on this link) http://www.scientificamerican.com/article.cfm?id=how-chronic-pain-affects-memory-mood

While chronic pain is a recognized medical condition that often can only be treated with controlled substances it is becoming more and more difficult to find physicians who will prescribe them.  The reasons? Abuse, misuse, suicides, crime, greed and among physicians fear and intimidation.

On October 24, 2013 this headline greeted readers when they picked up their morning paper; FDA Crackdowns on Painkiller DrugsThe move was prompted by one drug in particular — Hydrocodone otherwise known as Vicodin the highly addictive painkiller that has grown into the most widely prescribed drug in the U.S.

vicodinIn a major policy shift, the agency said in an online notice that hydrocodone containing drugs should be subject to the same restrictions as other narcotic drugs like oxycodone and morphine.  What this means is that the regulating agencies first made it difficult to get the major pain killers and now are restricting lesser ones as well.  The question is where will it stop and how will chronic pain sufferers be affected? History tells us that actions like this will cause fewer prescriptions to be written but that many patients who legitimately need these drugs will be caught up in the dragnet and lose their relief.

The latest move comes more than a decade after the Drug Enforcement Administration first asked the FDA to reclassify hydrocodone so that it would be subject to the same restrictions as other addictive painkilling drugs.

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Florida is or was at the epicenter of an explosion in narcotics prescriptions written by unscrupulous physicians who provided narcotics to almost anyone for exorbitant prices.  Pharmacies were caught playing the game with these docs and while the action by the feds reduced the number of pill mills, it also caused great agony for those who suffer from chronic pain and could no longer get relief. (http://www.firstcoastnews.com/news/health/article/333761/10/Pill-mill-crackdowns-hurting-those-in-real-pain

I will return to the legal and ethical conundrums faced by physicians and pharmacists shortly but let’s step back for just a moment or two to look at the human side.  The millions of people who suffer from chronic pain and who depend on controlled substances to provide them with some semblance of human life…and I’m one of them.

American pain foundationThe American Pain Foundation says that chronic pain is a complex condition that affects almost 50 million Americans.  Even after decades of research, chronic pain remains poorly understood and hard to control.

Chronic pain can be severe, so severe it has driven some to take their own lives.  It is a major problem and often even the most potent of pain killers has only a minimal effect.  Here’s how two patients describe their daily battle with chronic pain.

“It feels as though someone has stuck a white hot poker into the bones at the top of my spine and the base of my neck.  The pain radiates to both shoulders and down my back. I cannot stand without help and cannot sit in any one position for very long.  Turning my head is too painful to even contemplate.  Like a master torturer the pain seems to know just where to attack next to make me confess and confess I would – to anything at all if it would just go away for a few minutes.”  That’s the testimony of a Frank R. a Michigan man suffering from chronic pain brought on by osteoarthritis.

In the state of Virginia Mary T. says this. “It is my lower back and both of my legs.  The pain is not intense it is beyond that and it is unrelenting.   Sometimes I am so tired out from battling pain all night I will just sit and cry but the pain monster takes no pity.  I cannot walk without support, so now I have a cane which helps me get around but the pain doesn’t want me to walk and has begun attacking the arm and hand I use to hold the cane.  Death would be a relief; I can’t go on living like this.”

Frank and Mary are fairly typical chronic pain sufferers.  Both take narcotics to manage the pain neither gets much relief anymore because of building high tolerances for opiates.  Both have tried almost everything modern medicine has to offer and narcotics are all that is left to help them but because tolerances go up, one is forced to take more and more of the narcotic until finally the pain subsides – it doesn’t go away it just backs off for a while but the massive doses of narcotics can leave the patient in an almost Zombie like state, unable to concentrate or focus on any task and sleepy, so sleepy that some days patients don’t bother to get out of bed.  The result is that while the pain may be minimized so is the patient’s quality of life.

A survey by the American Academy of Pain Medicine found that even comprehensive treatment with painkilling prescription drugs helps, on average, only about 58% of people with chronic pain.  

What causes chronic pain, and what can you do about it?

Some cases of chronic pain can be traced to a specific injury that has long since healed. Other cases have no apparent cause — no prior injury and an absence of underlying tissue damage. However, many cases of chronic pain are related to these conditions:

  • Low back pain
  • Arthritis, especially osteoarthritis
  • Headache
  • Multiple sclerosis
  • Fibromyalgia
  • Shingles
  • Nerve damage (neuropathy)

Treating your underlying condition is important. But often that does not resolve the pain issue.  Increasingly, doctors consider chronic pain a condition of its own, requiring pain treatment that addresses the patient’s physical and psychological health.

Chronic pain can leave a person almost unable to function and the medical profession doesn’t seem to know what to do about it because they are getting mixed messages from state and federal governments. 

On one hand government says, ”Treat the patient, give them what they need to manage pain,” and on the other the Feds in particular are saying, “There are too many greedy quacks out there handing out narcotics like Pez dispensers and it has to stop.”  Here’s why:

centers for disease controlEarlier this year the Centers for Disease Control and Prevention reported that prescription painkiller overdose deaths among women increased about fivefold between 1999 and 2010. Among men, such deaths rose about 3.5-fold. The rise in both death rates is closely tied to a boom in the overall use of prescribed painkillers. 

The result is that many major medical centers are playing it safe and prescribing narcotics for short term relief following surgeries and a few other specific situations like terminal cancer victims but otherwise are telling patients to see their primary physician for pain relief.  The reason cited by many medical centers is that the laws are incredibly complex and therefore vague. For example, here’s just a short section of New York law (you can read all of it herehttp://www.medscape.com/resource/opioid/opioid-newyork

License. Only practitioners who are properly licensed and registered may issue a prescription for a controlled substance. Section 80.64 contains the full information about who may issue controlled substances.

Purpose of a Prescription. A prescription is the instrument to legalize an ultimate user’s possession of a controlled substance. To be effective then, a controlled substance prescription should be issued for legitimate medical purposes only. Section 80.65 contains the full text.

Initial and Corresponding Responsibilities: Prescriber and Pharmacist. The responsibility for the proper prescribing and dispensing of controlled substances is on the physician, dentist, podiatrist, veterinarian, or other authorized practitioner, but a corresponding liability rests with the pharmacist who fills the prescription.

A practitioner cannot supply prescriptions to maintain an addict or habitual user of controlled substances. There are some exceptions and practitioners should read the New York law very carefully. An order purporting to be a prescription issued to an addict or habitual user of controlled substances not in the course of professional treatment but for the purpose of providing the user with narcotics or other controlled substances sufficient to keep him or her comfortable by maintaining his or her customary use is not a prescription within the meaning of New York law.

It is no wonder physicians are reluctant to prescribe opiates, they fear losing their licenses.  In the preceding paragraph physicians are told they cannot provide controlled substances to addicts or habitual users but many people with chronic pain ARE habitual users and they may be addicted as well, and the New York law could easily be interpreted to read that prescribing controlled substances to chronic pain sufferers is a violation of the law.

In a document with the unwieldy title of; Use, Abuse, Misuses, and Disposal of Prescription Pain Medication Time Tool Clinical Referenceamerican college of preventive medicineThe American College of Preventive Medicine (ACPM) states its position on the patient’s right to pain relief very clearly but the issue gets clouded in the “Challenges” section.  It is easy to see why many physicians find it easier to “pass the buck” by saying, “See your primary care physician for narcotics,” or, “See a physician who specializes in pain for treatment with controlled substances (for the full transcript and more click on this link: http://www.acpm.org/?UseAbuseRxClinRef

 INTRODUCTION – THE RIGHT TO PAIN CONTROL

Adequate pain control is a fundamental right of every patient [1]. A consensus statement from 21 Health Organizations and the Drug Enforcement Agency (DEA) conclude that “Effective pain management is an integral and important aspect of quality medical care, and pain should be treated aggressively… Preventing drug abuse is an important societal goal, but it should not hinder patients’ ability to receive the care they need and deserve.” [2]

The consequences of not treating pain are significant [1] [3] and confer a tremendous economic impact [4]. Post-surgical pain increases heart rate, systemic vascular resistance, and circulating catecholamines, placing patients at risk of heart attack, stroke, bleeding, and other complications. Unrelieved acute pain often evolves into chronic pain syndromes, which are linked to a constellation of maladaptive physiological, psychological, family, and social consequences that result in:

  • ·        Reduced mobility; loss of strength
  • ·        Disturbed sleep
  • ·        Decreased healing due to immune system impairment
  • ·        Increased susceptibility to disease
  • ·        Dependence on medication
  • ·        Codependence with family members or care givers
  • ·        Psychological ramifications (depression, anxiety, social withdrawal)
  • ·        Slower return to function
  • ·        Decreased quality of life

. UNIVERSAL CHALLENGE

  • Physicians are currently challenged to deal with the “perfect storm”—a confluence of pain control versus risk of misuse and abuse of prescription medications [5].
  • This perfect storm is co-incident with the more general rise in unintended overdose deaths that may have resulted from aggressive efforts to have physicians treat pain without the education, skill and resources to manage the physiological and psychological complications that can arise when treating a patient for a chronic pain condition. Physicians must be able to safely and effectively prescribe scheduled drugs and, at the same time, must identify and manage misuse and abuse in their practices [6]. Ethics drive physicians to prescribe, but fear of sanctions may affect physician prescribing behaviors, which might compromise quality of care. The problem cannot be ignored because abusers often face complications, such as: [7]
    • ·        Overdoses
    • ·        Addiction and dependence
    • ·        Adverse effects
    • ·        Social and family dysfunction
    • ·        Criminal consequences

The universal challenge is to adequately control pain, having a variety of etiologies, in an environment where evidenced-based medicine is lacking or in conflict, while identifying and managing high risk situations, and possibly treating addictions resulting from initial pain control efforts. Physicians confront the dilemma of balancing pain relief against the reality that some patients may misuse and divert these medications. The scale weighs public health priorities against individual pain and suffering [8].

Some physicians are so nervous about prescribing painkillers that they just flat out refuse to do so. I had it happen to me at of all places a well-known pain clinic.  These physicians fail to recognize chronic pain for what it is and want to find the underlying condition that causes the pain but the fact is the pain is the underlying condition.

J. Donald Schumacher President and CEO of the National Hospice and Palliative Care Organization says, “According to a recent report from the Institute of Medicine, chronic pain itself can be the problem. Such pain can cause changes in the nervous system that worsen over time — even after the original source of the pain has gone away.

Because many doctors are not properly trained in the study of chronic pain, patients often suffer unnecessarily. One study of nursing home residents with chronic pain found that 44 percent were not getting any treatment at all.

In some cases, the need for pain treatment may not be obvious. Older patients, especially those with dementia, often struggle to communicate their needs.

Yet according to a report from the Hartford Institute of Geriatric Nursing at New York University, the burden to communicate with patients who may be in pain does not rest with the patients. Clinicians must take on that duty. They can do so by learning to identify non-verbal behaviors, such as “agitation, restlessness, aggression, and combativeness,” which “are often an expression of unmet needs.”

Old age must not become an excuse for the failure to pursue effective treatment for pain.

Of course, patients must assume some responsibility for treating their pain, too. Approximately 50 percent of patients do not take their medication as prescribed. Many mistakenly wait for pain to recur before administering another dose. Such on-again, off-again treatment just results in cycles of pain — rather than preventing it altogether by maintaining adequate levels of medication in the bloodstream.”

Schumacher also believes this, “Whatever the condition causing the pain, the person best equipped to take the lead in finding the proper treatment is the sufferer. People know their own bodies, and they can judge when medications are inducing unwanted side-effects.

No one deserves to be incapacitated by chronic pain. The means to alleviate it are available. All that’s required is the will to find the right treatment.”

So what else can patients do to get relief when the system seems obsessed with denying it?

In a Web MD Story, Rollin M. Gallagher, MD, MPH, director of pain management at the Philadelphia VA Medical Center said, “Today’s pain specialists understand how the sensation of pain occurs — how the nervous system, including the spinal cord, interacts with the brain to create that sensation.

Insights into the neurotransmitter system — the chemical messengers that pass nerve signals — have opened the door for important new modes of chronic pain relief, he explains. In recent years, scientists have learned how to manipulate those chemical messengers to change the way they interact with the brain’s signals.

That’s led to use of antidepressants and other drugs that work with specific brain chemicals that affect emotions, and help with perception of pain. We now have a whole new host of medications that are very effective for chronic pain relief,” Gallagher tells WebMD. http://www.webmd.com/pain-management/features/chronic-pain-relief-new-treatments 

medtronicIn November of 2011 Medtronic Corporation the manufacturer of a wide variety of medical devices announced a new treatment for chronic pain. In a news release the Minnesota corporation said, “The U.S. Food and Drug Administration (FDA) has approved AdaptiveStim™ with RestoreSensor™ neurostimulation system, the first and only chronic pain treatment that harnesses motion sensor technology found in smart phones and computer gaming systems to provide effective pain relief and convenience by automatically adapting stimulation levels to the needs of people with chronic back and/or leg pain.

The news release went on to say, “Data from the U.S. RestoreSensor clinical trial demonstrate that the AdaptiveStim with RestoreSensor neurostimulator provides effective pain relief and convenience. At the end of the study, 86.5 percent of study participants with chronic pain, who were included in an intent-to-treat analysis (n=74), experienced somewhat better or much better pain relief with no loss of convenience, or somewhat more or much more convenience with no loss of pain relief, when the device’s AdaptiveStim technology was turned on, compared to a control period when the participants manually adjusted neurostimulation settings using a patient programmer. With AdaptiveStim, study participants reported functional improvements, including improved comfort during position changes (80.3 percent).”

Not to be outdone, Boston Scientific is also in the chronic boston scientificpain management business On April 12 of this year they announced, Boston Scientific Corporation (NYSE: BSX) has received approval by the U.S. Food and Drug Administration and is beginning a limited launch of the Precision Spectra Spinal Cord Stimulator (SCS) System.  The Precision Spectra System is the world’s first and only SCS system with Illumina 3D™ software and 32 contacts, and is designed to provide improved pain relief to a wide range of patients who suffer from chronic pain.

The news release added, “The Precision Spectra System represents a paradigm shift in spinal cord stimulation,” said Giancarlo Barolat, M.D., medical director of Barolat Neuroscience in Denver.  “The Illumina 3D Software is the first SCS programming technology based on advanced anatomical and scientific principles.  When combined with 32 contacts and four lead ports—twice that of any other SCS system—the Precision Spectra technology gives physicians more flexibility to customize therapy for patients.”  

Medications for Treating Pain http://www.livestrong.org/we-can-help/preparing-yourself/finding-a-counselor/

Cancer pain is often treated with one or more medications. If you have concerns about taking certain medication, discuss this with your health care provider and pharmacist. Ask about long-term medication usage and side effects, such as allergies, constipation, sedation, memory impairment or other reactions.

  • For mild pain: Medications such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) may provide relief. Some of these drugs, such as ibuprofen or naproxen, can be purchased without a prescription.
  • For moderate pain: Medications that combine an opioid (sometimes called a narcotic) such as hydrocodone or oxycodone with acetaminophen or aspirin may be needed. Vicodin and Percocet are examples.
  • For severe pain: Medications that contain an opioid only (sometimes called a narcotic) such as morphine, oxycodone, fentanyl or methadone are usually needed. These narcotic medications may be given orally or intravenously (or sometimes both).
  • For bone pain: When associated with metastatic cancer treatment for bone pain can include bone-strengthening steroid medication known as bisphosphonates. (Radiation therapy and surgery may also be very effective in relieving symptoms.)
  • Antidepressants medications: Amitriptyline and duloxetine, for example, can be very helpful in managing chronic pain.
  • Gabapentin and pregabalin: Originally developed to treat epilepsy, these can also be used for chronic pain, including neuropathic pain caused by nerve injury.
  • Topical anesthetics: Lidocaine pain patches, for example, may be helpful in some cases.

Complementary Pain Relief Options

Complementary (also called alternative or holistic medicine) treatments include massage, acupuncture, meditation, biofeedback or hypnosis. For some types of pain, heating pads, hot or cold packs and massage may be soothing and can help to reduce pain.

A health care provider may recommend counseling to help a patient cope with their pain or other distressing symptoms. Stress can make pain worse. It can also lessen the effect of pain management medications.

To learn more about these types of therapies, contact the National Cancer Institute. Talk with your health care team if you are interested in adding a complementary method of treatment. Let them know about supplements and herbs you want to try. Some types of complementary treatments can interfere with treatments prescribed by your provider.

Stem Cell Therapy

While there is a great deal of anecdotal evidence that stem cell therapy has beneficial applications there is little real medical evidence and many researchers, physicians and regulators still view much of stem cell therapy as modern day quackery.

I know you can find many people who have had stem cell therapy and swear by it but to the medical community that is still anecdotal evidence unsupported by clinical studies and therefore “iffy” or even dangerous.  It is important to note that even among physicians who are among the most trusted members of our society, there are those whose greed supersedes professional ethics.  These charlatans prey on a trusting public and can do more harm than good.  An example is the FDA and DEA crackdown on hundreds of physicians who indiscriminately prescribe controlled substances to anyone who wants them.  The best advice always is, “Buyer beware!”

In researching the subject for this blog I was struck again and again by conflicting opinions which convinced me that it is nearly impossible for a lay person like me to sort out the science from the pseudo-science and offer sound advice. I am simply not qualified to do so which means the burden falls back on the reader and depends on the illness in question, its severity and what has been done to treat it in the past.

I can only suggest this.  There are claims being made by clinics all over the world about successful stem cell therapies covering everything from bad knees to multiple sclerosis.  If you are seeking such therapy start out by talking to your primary care physician and getting his/her advice.  If still not satisfied look for a respected specialist in the field at a major medical center and finally if you still need more information, look up a highly respected medical school that also does research into stem cell therapy and inquire with them about your concerns.  I would avoid calling the stem cell clinics that sell the treatment because there is no way you will get an objective response from them.

In December of 2012 I published a blog on the issue of stem cell therapy titled Stem Cell Therapy – Some Truth, lots of Snake Oil. https://bobsnewheart.wordpress.com/2012/12/03/stem-cell-therapy-some-truth-lots-of-snake-oil/

I spent a considerable amount of time researching the issue before posting and little has changed since then.  If Stem Cell therapy is a consideration for you please read it and click on the many links I have provided.  They may not give you the answers you want but they will give you objective and accurate information.  Ultimately the decision is yours and yours alone. The U.S. Food and Drug Administration (FDA) is still struggling with the stem cell issue and until they can sort it all out I would proceed with great caution.

As you can gather, there’s a lot of confusion and misleading information about stem cell therapy because research is really in its infancy.  The International Society for Stem Cell Research (ISSCR) has a lot of information about stem cells and lists 10 things you should know about the subject on this link http://www.closerlookatstemcells.org/Top_10_Stem_Cell_Treatment_Facts.html

Here is just one of the ten.

4.  Just because people say stem cells helped them doesn’t mean they did.

There are three main reasons why a person might feel better that are unrelated to the actual stem cell treatment: the ‘placebo effect’, accompanying treatments, and natural fluctuations of the disease or condition.

The intense desire or belief that a treatment will work can cause a person to feel like it has and to even experience positive physical changes, such as improved movement or less pain. This phenomenon is called the placebo effect. Even having a positive conversation with a doctor can cause a person to feel improvement. Likewise, other techniques offered along with stem cell treatment—such as changes to diet, relaxation, physical therapy, medication, etc.—may make a person feel better in a way that is unrelated to the stem cells. Also, the severity of symptoms of many conditions can change over time, resulting in either temporary improvement or decline, which can complicate the interpretation of the effectiveness of treatments.

These factors are so widespread that without testing in a controlled clinical study, where a group that receives a treatment is carefully compared against a group that does not receive this treatment, it is very difficult to determine the real effect of any therapy. Be wary of clinics that measure or advertise their results primarily through patient testimonials.

ISSCR offers a great deal more information on stem cell research and therapy on their home site at http://www.closerlookatstemcells.org/

Finally, Forbes magazine, admittedly very conservative in its approach to almost anything, ran this story about stem cells here’s an excerpt and a link. http://www.forbes.com/sites/gerganakoleva/2012/02/19/stem-cells-fda-and-the-edge-of-science-three-expert-viewpoints/

Forbes excerpt

“The question for us as a society is when something done at the edge of clinical care becomes something we want to study,” Scott observed. “My feeling is that in many cases clinics are scrambling to get approval, but don’t have the gravitas that the clinical literature provides that would give comfort to a regulatory agency or even an advisory board to say ‘go ahead and do it.’ So until we have a better idea of what the adverse effects would be, these things are moving too quickly.”

Other Pain Treatment Options

Biofeedback is a method that uses the mind to help with pain. Breathing exercises, relaxation techniques, yoga, tai chi, qigong, visualization, meditation or guided imagery exercises may also be effective. Sometimes, talking with friends, laughing or listening to music can offer a helpful distraction from pain.

For severe pain, a technique called a nerve block is sometimes considered. This procedure may involve injecting a substance directly into or around a nerve or around the spinal cord. These procedures block damaged nerves from sending pain signals to the brain so that the pain will not be felt. Nerve blocks may work to control pain for people who have advanced cancer or very painful nerve conditions. However, there can be serious complications associated with these procedures.

Talk with your health care provider about the benefits and risks before any treatment to decide what is best for your situation. Every survivor responds differently to pain management strategies. Open communication with your health care team can help you decide together what will work best to manage your pain.

Conclusion

After considerable research Bob’s Newheart has come to the conclusion that while there are forces at play that would deny patients relief from chronic pain, there is also help available.  Unfortunately the medical profession is more a part of the problem than the solution despite its protestations to the contrary.  For any doctor to deny relief to a patient with legitimate pain is to us a violation of their oath. 

Chronic pain is a medical reality that affects not only the body but the emotional stability of the patient as well.  Any patient who says, “I cannot go on living like this,” and is denied relief for fear of being investigated is in desperate straits.  When my pain specialist said to me, “I can’t give you narcotics, see your primary,” he was not only lying he was telling me he didn’t’ care about my pain.

Narcotics or controlled substances aren’t always the proper treatment but neither is denying these drugs to people who are in legitimate pain. 

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bob minus Jay full shotBob Aronson is a 2007 heart transplant recipient.  He is the founder of Facebook’s 3000 plus member Organ Transplant Initiative (OTI) and the author of most of these Bob’s Newheart Blogs. 

All that’s required to join OTI is that you support our mission and follow the rules for the group.  You can read about both in the “About” section on the right side of the OTI group page.

 

 

 

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