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When the Cure Is Worse Than the Disease

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https://www.nytimes.com/2019/02/09/opinion/sunday/pain-opioids.html

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Katie Tulley suffers from an incurable bladder disorder so painful that it feels “like tearing skin off your arm and pouring acid on it, 24/7,” she said. On scans, the organ looks like an open sore.

Ms. Tulley, a 37-year-old Louisianan who used to work with autistic children, manages her pain with a fentanyl patch. The opioid gives her a few precious hours out of bed to help her parents, do online volunteer work and occasionally leave home for something other than a medical visit. “I don’t get a euphoric feeling,” she said, noting that she has lowered her dose to avoid feeling woozy and impaired.

Now, because of legal concerns about overdose risk, her doctors have considered stopping her medication, even though she has never misused it. And so, when she recently discovered a suspicious lump in her belly, she found herself hoping it was cancer. “I shouldn’t ‘want’ cancer,” she said. “But at this point it’s the only way to be treated” for her pain.

As many as 18 million patients rely on opioids to treat long-term pain that is intractable but not necessarily associated with terminal illness. In 2016, seeking to curb opioid misuse, the Centers for Disease Control and Prevention introduced guidelines outlining a maximum safe dosage and strongly urging doctors to avoid prescribing for chronic pain unless death is imminent. The guidelines were supposed to be voluntary and apply only to chronic pain patients seeing general practitioners. Instead, they have been widely seen by doctors as mandatory.

As a result, thousands of pain medication recipients have had their doses reduced or eliminated. But this attempt to save people from addiction is leaving many patients in perpetual pain — and thus inadvertently ruining, or even ending, lives.

A Veterans Health Administration study found alarming rates of suicidal acts “following discontinuation of opioid therapy.” Human Rights Watch recently released a report detailing the struggles of chronic pain patients in the United States to find relief and care as a result of government efforts to reduce prescriptions.

....

The State of Oregon is considering a proposal that would require that all Medicaid patients with certain forms of chronic pain be forced off opioids. But not all patients can manage without opioids and some — whether because of metabolic or genetic differences, or tolerance from long-term use — will always need higher doses than the C.D.C. recommends.

Jay Lawrence, a former truck driver, is a case in point. When his doctor refused to continue his medication in early 2017 — even though he had severe pain from spinal cord injuries and was not addicted — he told his wife that he’d had enough. In a park where they’d recently renewed their wedding vows, he fatally shot himself in the chest while she held his hand.

...

To be sure, opioids have been overprescribed. A Johns Hopkins review of six studies found that over two-thirds of patients reported having unused pills. And for many people, the pain killers either aren’t effective or do more harm than good. But while medical opioid use has fallen by nearly one-third since peaking around 2011 — and deaths associated with prescription opioids have stabilized — overall opioid overdose fatalities have recently hit a high as more potent, illegally manufactured opioids hit the streets.

...

In the rush to reduce opioid misuse, it is easy to forget that millions of people have safely taken these drugs for years. Data show that less than 8 percent of chronic pain patients become addicted, according to a study that has the director of the National Institute on Drug Abuse as a co-writer. And overwhelmingly, prescription opioid addiction doesn’t begin with a doctor’s prescription: About 80 percent of people who start misusing these drugs are getting them from family, friends and other people’s medicine cabinets — not from legitimate pain treatment.

...

After years of complacency, doctors are finally starting to fight back. Dr. McAneny cited her experience to support a resolution, subsequently passed by the medical association, that warns against “misapplication” of the guidelines. The group stresses that dose alone is not a reason for insurers or pharmacists to block access — and that doctors with good clinical reasons for variance should not be investigated or prosecuted.

A parallel effort by a group of over 300 medical professionals, co-led by Dr. Kertesz and signed on to by three former United States drug czars, calls on the C.D.C. to make a “bold clarification” by stating that its guidelines do not require that chronic pain patients who are dependent on opioids have their dosages tapered. Another large group of physicians — including some strong supporters of the guidelines as written — recently published a journal article calling involuntary tapers a “large-scale humanitarian issue” and demanding that they be prohibited or at least minimized.

Paradoxically, there is a growing medical consensus that patients who are addicted to their pain pills shouldn’t be forced to taper their dosages. The safest treatment for opioid addiction is maintenance with an appropriate opioid: For addiction, the opioids methadone and buprenorphine are the only treatments proved to cut the death rate from overdose by 50 percent or more.

We have less mercy for people who have chronic pain and are on chronic opioids than we do for somebody who’s using heroin in the streets right now,” said Dr. Kertesz.

Both groups deserve more compassion, including a safe legal harbor for high-dose prescribing for patients who truly need it — as well as for their doctors. Attempting to reduce overdose risk by raising the odds of suicide is both cruel and senseless.

Spot-on commentary.  Just goes to show the consequences of the government's War on Opioids.  An abject failure.

 

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I agree, my mom was in a great deal of pain in her final weeks. We were finally referred to a pain management doctor who was hesitant to prescribe anything besides the OxyCodone she was on. After some heated words from yours truly, we left with a script for Fentynal patches. Under his care, within a week he actually had to bump the dosage up. In less than a week she was in the hospital on morphine. 

The point being, we're clearly dealing with end of life stuff with a 78 year old woman. She's never been to a pain management doctor in her life, she's in a wheelchair, and it's not hard to tell she's suffering. Why are we forcing people like this to suffer when there are drugs to alleviate the pain. Why the hoop jumping? Why am I forced to get upset and be a jerk to the doctor to get her taken care of? Even if addiction was a potential problem, at her stage of the game, so what? 

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1 hour ago, Impartial_Observer said:

I agree, my mom was in a great deal of pain in her final weeks. We were finally referred to a pain management doctor who was hesitant to prescribe anything besides the OxyCodone she was on. After some heated words from yours truly, we left with a script for Fentynal patches. Under his care, within a week he actually had to bump the dosage up. In less than a week she was in the hospital on morphine. 

The point being, we're clearly dealing with end of life stuff with a 78 year old woman. She's never been to a pain management doctor in her life, she's in a wheelchair, and it's not hard to tell she's suffering. Why are we forcing people like this to suffer when there are drugs to alleviate the pain. Why the hoop jumping? Why am I forced to get upset and be a jerk to the doctor to get her taken care of? Even if addiction was a potential problem, at her stage of the game, so what? 

The doctors face the conundrum that the patient's circumstances do not go into the data base that is being looked at by licensing (and law enforcement) officials who are enforcing the new crack down on opiods. As far as potential repercussions for the prescribing doctor, it is largely the same as if your mother was a drug seeker off the street making the rounds of pain centers and ERs, looking for a high. She was another "stat" he'd have to explain in a system that is largely operating under a "presumed guilty" bias. 

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14 minutes ago, Wabash82 said:

The doctors face the conundrum that the patient's circumstances do not go into the data base that is being looked at by licensing (and law enforcement) officials who are enforcing the new crack down on opiods. As far as potential repercussions for the prescribing doctor, it is largely the same as if your mother was a drug seeker off the street making the rounds of pain centers and ERs, looking for a high. She was another "stat" he'd have to explain in a system that is largely operating under a "presumed guilty" bias. 

I get it, but as I stated, first visit to a pain management doctor. Had been prescribed OxyCodone, 5mg, then 7.5mg, then 10mg, in the months leading up to this. Multiple compression fractures in her spine. From two in August to four in October, the seven in November. She was literally two weeks away from Hospice care and  a Morphine drip. At some point, common sense has to enter into the equation. She was clearly not doctor shopping, we had a referral from a neurosurgeon, who didn't prescribe anything. 

In a month's time I have picked up two different scripts for my dad after medical procedure for opioids, a script for myself for opioids, and another script for myself for a controled substance. From four different doctors, three surgeons and my family doctor. I had to present my ID each time, you reckon I'm on a list somewhere?

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1 hour ago, Impartial_Observer said:

I get it, but as I stated, first visit to a pain management doctor. Had been prescribed OxyCodone, 5mg, then 7.5mg, then 10mg, in the months leading up to this. Multiple compression fractures in her spine. From two in August to four in October, the seven in November. She was literally two weeks away from Hospice care and  a Morphine drip. At some point, common sense has to enter into the equation. She was clearly not doctor shopping, we had a referral from a neurosurgeon, who didn't prescribe anything. 

In a month's time I have picked up two different scripts for my dad after medical procedure for opioids, a script for myself for opioids, and another script for myself for a controled substance. From four different doctors, three surgeons and my family doctor. I had to present my ID each time, you reckon I'm on a list somewhere?

The focus in the current crack down is on prescribers, not on patients. You very probably are on a list -- it is called INSPECT in Indiana, if you want to google it -- because you said you personally were written a scrip for an opiod. Your health insurance carrier's SIU team also maybe have you flagged on a list to run your claims history through an algorithm for signs of possible drug seeking behavior.

But the prescribing doctors for all the separate opiod prescriptions you mentioned are very definitely on "lists," which the State licensing board reviews, which tally the scrips each of them has written to any patients for an opiod. 

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1 hour ago, Wabash82 said:

The focus in the current crack down is on prescribers, not on patients. You very probably are on a list -- it is called INSPECT in Indiana, if you want to google it -- because you said you personally were written a scrip for an opiod. Your health insurance carrier's SIU team also maybe have you flagged on a list to run your claims history through an algorithm for signs of possible drug seeking behavior.

But the prescribing doctors for all the separate opiod prescriptions you mentioned are very definitely on "lists," which the State licensing board reviews, which tally the scrips each of them has written to any patients for an opiod. 

Just spit balling here, but would virtually EVERY surgeon be writing opioid scripts for virtually every case each day?

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1 hour ago, Impartial_Observer said:

Just spit balling here, but would virtually EVERY surgeon be writing opioid scripts for virtually every case each day?

Maybe 20 yrs ago. But not today.

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Between my parents and I, virtually every surgery we’ve been sent home with an opioid script. Doctors from Carmel to Louisville. Perhaps my experience has been an anomaly or we’ve only had painful surgeries.

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14 minutes ago, Impartial_Observer said:

Between my parents and I, virtually every surgery we’ve been sent home with an opioid script. Doctors from Carmel to Louisville. Perhaps my experience has been an anomaly or we’ve only had painful surgeries.

With courage and Jesus's help, we can cure you and your loved ones of this demon addiction....

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7 hours ago, Wabash82 said:

With courage and Jesus's help, we can cure you and your loved ones of this demon addiction....

We’re good, pray for someone who needs it. 

FYI, doctors have told me you have about 0% chance of becoming addicted by taking opioids for pain management post-op. After my recent hernia surgery I came home with 60 pills, I think I took like eight.

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10 hours ago, Impartial_Observer said:

Between my parents and I, virtually every surgery we’ve been sent home with an opioid script. Doctors from Carmel to Louisville. Perhaps my experience has been an anomaly or we’ve only had painful surgeries.

One thing that I've started to notice with opioid scripts is the count is becoming much lower and the instructions from the doctors have become more "discouraging" in their use.  In the past, they used to say stuff like, "If you need them, take these for pain."  The tone of the messages that I'm hearing now is something along the lines of, if ibuprofen/acetaminophen aren't keeping the pain manageable, then you can take this.

2 hours ago, Impartial_Observer said:

We’re good, pray for someone who needs it. 

FYI, doctors have told me you have about 0% chance of becoming addicted by taking opioids for pain management post-op. After my recent hernia surgery I came home with 60 pills, I think I took like eight.

For my last urgent care visit and my wife's last surgery, we got roughly enough for about three days and a week respectively, with the ability to call the doctor for a refill.  I'm wondering if this is a response from the doctors to avoid scrutiny as much or to perhaps put in a "roadblock" to additional usage by requiring that interaction with the doc earlier on and with the doc possibly asking more questions and possibly even asking for the patient to come by for additional observation.  

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Prior to my back surgery, I went to our ER on a Sunday morning and saw a PA. I knew what the problem was, I didn't want X-rays, diagnostics, etc. I was just asking for some pain killers to get me thru a couple of days. She was going to give me a script for 7.5/250 hyrdrocodone/tylenol. I told her look I get what you have going on and I totally get what this looks like. The Hydros won't do anything, I won't even get it filled. I told her I would like 7.5mg Oxycodone, like 8 pills to get to to Tuesday, assuming I would be able to get into my neuro by Tuesday to schedule the surgery and at that point he could take over. I told he I completely understand what this looks like and if you can't do it I understand. This was obviously an ongoing situation and I knew the back surgery was coming. She was really nice about it, hooked me up, and the rest is history.

After my back surgery two years ago, I came home on a Oxycontin/Oxycodone/Valium cocktail.  Dropped the Oxycontin in about two days, dropped the Oxycodone in like 6 days. Oddly enough the Valium was the only script I had refilled. I had a lot of tightness and spasms, the Valium seemed to take care of them. I took them off and on for about two months. 

For the hernia surgery, mine was late in the day, I didn't get out of the hospital until like 6 in the evening. I was still pretty medicated, so no pills the rest of the night. I took about three the next day, and the next day, two days post op, SUCKED! I took five that day. Day three woke up and it didn't seem to bad, so I haven't had one since. Mainly just soreness, suck it up and get thru it. My surgery was with the DaVinci Robot, four 1" incisions in my abdomen, I never had any pain with them. 

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19 minutes ago, Impartial_Observer said:

For the hernia surgery, mine was late in the day, I didn't get out of the hospital until like 6 in the evening. I was still pretty medicated, so no pills the rest of the night. I took about three the next day, and the next day, two days post op, SUCKED! I took five that day. Day three woke up and it didn't seem to bad, so I haven't had one since. Mainly just soreness, suck it up and get thru it. My surgery was with the DaVinci Robot, four 1" incisions in my abdomen, I never had any pain with them. 

That thing is a wonder!  Unfortunately, for my appendix surgery I got gutted and it took forever to recover.  Had a guy in my office who had laparoscopic surgery at the same time for his appendix and was back in the office in two days.  My wife had DaVinci and the recovery time and associated pain was so much less than traditional.  Others that I know who have had DaVinci recount similar positive experiences.  

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