No matter how you feel about Indiana’s new “religious freedom” law, this “Telling Secrets” blog is well worth reading and thinking about – seriously!
I don’t understand it. In fact, I find it deeply painful and disturbing. For months now, I have experienced the reluctance of most officials to hear the requests of chronic pain patients—and even of their care providers—to officially proclaim a Pain Care Providers Day on March 20th. They seem unable to open their hearts and minds to the reality of the huge difference between people who actually constantly suffer in pain, and people who use drugs recreationally whether or not they become addicted to them. They do not see the hundreds of dedicated men and women of great integrity who practice medicine with honesty and skill, because they are focused on the tiny percentage of people who obtained MD degrees for the sole purpose of opening up yet another pathway of delivering drugs illegally.
Historically and cross-culturally, recreational drug use has existed since earliest human history. Drugs and wine have been consumed ritually in religious and cultural traditional performance. Drugs and their use exist, and as we learned repeatedly throughout history, prohibiting them only results in increasing their illegal presence and use.
In contemporary experience, other countries have decided to legalize and regulate drugs, just as they have done with prostitution and other vices that disrupt societal stability. And it has worked great improvements, where carefully planned and executed!
Even in America, we are at least learning that addiction is an illness of the brain, and that it is less likely to occur in elderly people, or with people who suffer severe chronic pain. This is a huge step in our understanding, and if nothing else the campaign to acknowledge and show our gratitude for our pain care providers has helped to advance research in this area, and publicize the results. That is REAL progress!
Before I write another word, however, I must also state my profound gratitude to those officials who HAVE supported and proclaimed Pain Care Providers Day. The day will be observed by those of us (and we number in the millions!) who have benefitted from the patience, skill and dedication of physicians, pharmacists, physical therapists, physician’s assistants, nurse clinicians, nurses, EMTs, medical techs in all areas of medicine, nurse’s aides, and especially those who sacrifice many of their own needs to care for chronic pain patients in their own families or neighborhoods. What they do is life-giving, needed, and produces results that range from easing intolerable pain and/or doing for us what we are no longer able to do for ourselves, all the way to helping us regain the ability to be a productive member of society. Though it is insufficient to truly acknowledge the huge debt we owe you, we do say THANK YOU, AND MAY GOD BLESS YOU ACCORDINGLY!
IT IS NOT TOO LATE. FRIDAY, MARCH 20TH IS PAIN CARE PROVIDERS DAY. If you are an official with the power to proclaim the day, please…please have the compassion to do so. If you have not asked your mayor, governor or representative to proclaim the day, please take the time to think about your friend or relative who cares for someone in pain. Remember the medical professionals who care for these patients under great pressure from drastic regulations that threaten their very lives. And remember to thank those officials who have already had the courage and conviction to proclaim this day.
And don’t forget – on Friday, March 20th, the first day of Spring, do something special for your pain care provider. Send them flowers, or a thank you note, or just give them a hug! Let them know how very special and necessary they are to you and to all of us.
The US Pain Foundation has provided a sample proclamation for Pain Care Providers Day. It can be found at http://goo.gl/qPsfCL.
Richard Paey Speaks – An interview with the paraplegic man sentenced to 25 years in prison for treating his own pain.
In October of this year, Florida Gov. Charlie Crist signed a pardon for Richard Paey, a paraplegic with multiple sclerosis who had served nearly four years of a 25-year prison sentence for drug trafficking
Paey, who requires high-dose opioid therapy to treat pain brought on by his MS, a car accident, and a botched back surgery, was convicted of trafficking despite concessions from prosecutors that there was no evidence the painkillers in his possession were for anything other than his own use.
When police came to arrest the wheel-chair bound Paey, they came with a full-on SWAT team, battering down the door and rushing into the home of the wheelchair-bound Paey, his optometrist wife, and their two schoolage children.
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The following article first appeared May 20, 2014 as a guest blog on Dr. Jeff Fudin’s http://paindr.com/blog/ website under the title Patients with Chronic Pain Syndromes are Not Idiots http://paindr.com/patients-with-chronic-pain-syndromes-are-not-idiots/.
From the early days of human habitation on this earth, societies have revered (and also feared) their healers. Even now, from Africa to South America, and wherever modern medicine is difficult to find, the skills and knowledge of healing have been passed from generation to generation of traditional healers. In rural areas of our own nation, many communities still seek medical assistance from ‘grannies” who rely on local herbs and traditional lore to help their neighbors.
So how has it happened that in the 21st century, one of the most technologically advanced nations on earth appears to be conducting a campaign against modern, trained and licensed physicians that echoes some ancient, primitive fear of the healer? We live in the age of Reason. We understand science, including anatomy and physiology, and understand that healers do not possess magic powers that might either hurt or heal us.
Despite this advanced understanding, we have allowed lawmakers and insurance companies to turn our healers into objects to be bullied, threatened, arrested and tried under charges of murder, with prosecutors demanding a death penalty when they have no evidence whatsoever that such a crime took place.[i]
After years of study and practice, sacrifice and struggle, 21st century physicians enter their professional world with dreams and aspirations already shattered. Many have student loans that limit their disposable income for many years into the future. Many more will find that the option of setting up a practice on their own is an unattainable dream – that they will be working for larger organizations and answering to employers who lack both medical degrees and understanding, where the bottom line is profit driven. All will have to deal with insurance companies that limit what they are able to do for their patients, no matter how much the patient might need the medication or procedure. Those companies have even at times contacted their patients, without the knowledge of the physician, and suggest other treatments or tell the patients to ask their doctors for a different treatment[ii]. Somebody tell me – have the laws against practicing medicine without a license been repealed?
And that is not the worst of it. Today, a physician who tries to treat patients according to the knowledge and skills that they worked so diligently to earn is now at risk of losing everything—their licenses, their homes and families, and even their own lives. ALL THIS, NOT BECAUSE THEY HAVE DONE ANYTHING WRONG!!! On the other hand, they can’t seem to do anything right. If law enforcement doesn’t destroy them, they are in danger of being robbed or even killed by drug-seeking patients. [iii]
I could easily believe that it is the failed war on drugs that has created the need for law enforcement to redirect our attention by turning the war against physicians – and their patients, who will suffer without medical care. Sociologists like myself frequently inquire “Who Benefits?” when deciphering seemingly irrational social behaviors. In this case, the lawmakers and enforcers themselves would look like people who would benefit from a better public image by this redirection of the public’s attention.
They say it is because the physicians prescribe too many “pills”, and turn their patients into addicts. Not true. Only a small percentage of patients who follow the orders given by the physician become addicted – addiction is a disease that occurs most often when drugs are abused, against medical advice. Most abused drugs do not come from physician’s prescriptions, but from families, friends, unsecured home supplies, or drug dealers.[iv] Dependency may occur, on the other hand, because people must depend on the medications that help them. Physical dependency is not unique to opioids alone, and can be resolved by tapering when the need for the medication is over. A similar approach is needed with several medication classes such as antidepressants to avoid serotonin withdrawal or beta blockers to avoid hypertensive crisis. Because lawmakers and others often incorrectly blend the lines, differences between physical dependence and withdrawal, we allow people and organizations with vested interests to feed our fears and turn us against the only people qualified to help us.
It is no wonder that over 80% of practicing physicians are reported to have stated that they do NOT want their children to become physicians. It is no wonder that more than 400 physicians are reported to commit suicide, annually.[v]
Why are they targeted, when they are not the problem? Let’s look at the real problem here: Addiction is real. Drug-related crime is real. Drug cartels that launder their profits and use some of the “cleaned” money to lobby politicians are real. Even MD degreed providers who misuse the privilege and set up “pill mills” are real (I refuse to call them physicians). There are solutions to all of these problems, and none of them include punishing physicians and other licensed clinicians with the goal of securing political points. We must stop making the problem worse, and focus on the real lawbreakers. We do know who they are!!
I write this letter, ironically, perhaps, because I am not able to take pain medications or many other drugs that could mitigate against the chronic pain that I have lived with for more than 45 years. Like many older people (who, by the way, may be less likely to become addicted to drugs because of the changes age brings to our physiology[vi]), chronic pain (from degenerative disc disease) has exacerbated other illnesses and ultimately severely limited my life. I have written this letter in gratitude for the four physicians who compassionately and patiently took the time to untangle and address the mingled symptoms that I presented with a few months ago, and who have given my life back to me despite my limited ability to process medications. (And yes – one of those four physicians is a board-certified pain management physician. There are other ways to manage pain when patients cannot take drugs.) With some understanding of what it must take to hold on to that compassion and professionalism in an irrational and vengeful world, I declare that these physicians, and physicians like them, are the true heroes of our day. We need to let them know.[vii]
[i] Trial Verdict: Dr. Baldi Not Guilty on All Charges http://whotv.com/2014/05/01/baldi-trial-not-guilty-on-all-charges/
What are Patients to do when Law Enforcement Closes Clinics? http://missoulian.com/news/state-and-regional/ravalli-county-health-officer-says-patients-of-raided-florence-clinic/article_cf2e1690-bac0-11e3-848e-001a4bcf887a.html
Ex-doctor faces families in murder preliminary hearing http://www.news9.com/story/25395877/ex-doctor-faces-victims-families-in-murder-preliminary-hearing
[ii] Here I cite my own experience with the insurance company that covered my last place of employment. Over a period of several years, my colleagues and I received messages from the insurance company about changing our medications – such as when I was on a prescription medication for GERD, the company insisted that I must discontinue it and take an OTC medication because unless I did, they would discontinue payment on the prescriptions. We were also advised in frequent mailings to discuss alternative treatments with our physicians.
[iii] The damage done by the war on opioids: the pendulum has swung too far http://www.dovepress.com/articles.php?article_id=16781 …
Killing Pain in Perry county http://www.kentucky.com/2009/12/12/1056711/killing-pain-in-perry-co.html
[iv] “For this crisis physicians take the brunt of the pundits’ blame, despite the fact that more than two-thirds of the diverted medications are acquired from family, friends, and acquaintances – not from a prescription by their doctor. http://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/
[v] Pain Physicians Have High Rates of Burnout http://goo.gl/P3z1cY
Dr. Gary Shearer: Suspended Northern Kentucky pain doctor dies of ‘suspected suicide’ http://www.wcpo.com/news/local-news/boone-county/florence/dr-gary-shearer-suspended-northern-kentucky-pain-doctor-dies-of-suspected-suicide
Physician Suicide http://t.co/4vhF63eD6NReferences from this article:
1.Adams D. Physician suicide: searching for answers. American Medical News [serial online]. April 25, 2005;Available at http://www.ama-assn.org/amednews/2005/04/25/prsa0425.htm.2.Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. Jun 18 2003;289(23):3161-6. [Medline].
3.Hawton K, Malmberg A, Simkin S. Suicide in doctors. A psychological autopsy study. J Psychosom Res. Jul 2004;57(1):1-4. [Medline].
4.Holmes VF, Rich CL. Suicide Among Physicians. In: Blumenthal SJ, Kupfer DJ, eds. Suicide Over the Life Cycle. Washington, DC: American Psychiatric Press; 2004:599-618.
5.Middleton JL. Today I’m grieving a physician suicide. Ann Fam Med. May-Jun 2008;6(3):267-9. [Medline].
6.Noonan D. Doctors who kill themselves. Newsweek. Apr 28 2008;151(17):16. [Medline].
7.Petersen MR, Burnett CA. The suicide mortality of working physicians and dentists. Occup Med (Lond). Jan 2008;58(1):25-9. [Medline]. [Full Text].
8.Worley LL. Our fallen peers: a mandate for change. Acad Psychiatry. Jan-Feb 2008;32(1):8-12. [Medline].
9.Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg. Nov 2011;213(5):657-67. [Medline].
10.Hendin H, Maltsberger JT, Haas AP. A physician’s suicide. Am J Psychiatry. Dec 2003;160(12):2094-7. [Medline].
11.Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).
[vi] “indeed, bad choices, bad behavior, and drug misuse lead to crime, accidents, social instability, and addiction. The developing adolescent brain is particularly susceptible to addiction, while the elderly brain is practically immune.” http://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/
[vii]“ Unless patients wake up and fight for the providers of care, we are headed for the sickest system in the world.” http://www.kevinmd.com/blog/2014/03/dissatisfied-doctors-provide-good-patient-care.html …
In earlier blogs I have shared my 45 year journey with chronic pain, increasing disability, and finally reaching the point where pain and disability were not always compatible with the will to survive. I have also written of the recent procedures that have relieved that pain enough for me to cope, and to begin to pick up the unraveled threads of living; to once again look beyond the immediate desperation of losing control of my life and to see, and feel, the enticement of a world that had somehow managed to retain its fascinations even when I was not paying attention. I joked with friends that I now knew how Lazarus might have felt, when Jesus brought him back to life. What a thrill it has been!
You would think that by my seventh decade of life I would have learned that one cannot stay on the mountain-top experiences of life. The journey continues; there are valleys to plunge into, rivers to struggle across, and then more mountains to climb.
Even so, I was completely unprepared for the news I was given two days ago. I have acquired yet another chronic disease process that is not only difficult to deal with, but also extremely expensive. Because of my intolerance for so many medications, there is only one that will provide any relief at all. It won’t cure, only relieve for brief periods. It costs $173 for about a month’s supply. Medicare doesn’t cover it, and neither will my Schedule D coverage. I live on social security, and this is not the only medication that I have to pay for myself. As my doctor pointed out, sometimes those valley experiences are less like rolling downhill and more like falling off a cliff.
I was immediately faced with the commitment I had made with a former colleague to take the following day, yesterday, and travel about an hour out of the city to spend an afternoon with two other of our former colleagues. We had all worked together at my former college, but over the past six or seven years had made separate decisions that eventually brought us all within reach of each other again. Only I was now unprepared for the challenge. First, it would be my first major trip in over a year. Up until my “restoration,” driving within a four-mile radius had been my limit. Second, my new self-confidence seemed to have disappeared, along with my new joy of living. Why should I impose my doom and gloom on my old friends!
I considered my options. I could call and beg off – that was nothing new. I have had to do that so often in the past couple of years. Then, instead of enjoying the comfort of conversation and shared memories with old friends, I could stay at home with the dubious comfort of self-pity, letting the fears of the past roll into the fears for the future. I could choose, in other words, to be miserable.
So what if I chose instead to be, if not happy, at least to be content? And what was there to be content about? Well, for starters, I still had the freedom once again to move about. I actually could drive away from the safety of my four-mile limit, and see what the world outside the city looked like. And I could enjoy a much-needed day with old friends, just as we had planned.
So I did. And it was magnificent. I don’t recall the scenery ever having been so peaceful, and lovely. I had forgotten the exhilarating sense of adventure that is fueled by the idea of “road trip.” Best of all, I was once again enfolded in the rich satisfaction of being with old friends, sharing good food and better memories. I was so glad that I had chosen to be happy.
Coming back to life has its challenges, as well as its joys. Old ways of coping with day to day living may have to be relearned after years of coping with pain and desperation, and serving the egocentric needs of being a patient. Worse, it is not a perfect world that you come back to. Much needs to be corrected, to be fought for. Much needs to be protected, and treasured.
Please, Lord, remind me to change what things I can change; to accept those things that I cannot change; and most important – to know the difference. And to be content.
The car was cold, and very quiet. Too quiet. It was not going to start, this time. There we sat, the car and me, alone in the middle of an empty parking lot at the community college. It was a little past midnight, and raining hard enough to make me think a boat might be a better choice than the car, but there were none of those around, either. This was a few decades ago, before cell phones. I wouldn’t have called anyone that late, anyway. I had choices to make. The most immediate choice was whether to get out in the rain and walk, or go to sleep in the car. It was eight miles home, through the most dangerous part of the city. On the other hand, the solitude of that parking lot just outside the central city was not appealing, either.
I was a nurse at the jail at that time, recently divorced, and taking courses one at a time in search of my dream to obtain a liberal arts education. I had saved up just enough money to register for the next term; that’s why I was so late leaving the college after the last evening class of the semester. My advisor and I had been discussing my academic future, and he was encouraging me to pursue my dream. When we left, he went to the faculty parking lot and never realized the personal drama I had going in the student lot. In that drama, I was remembering that the money I had saved for tuition was just the amount it was going to cost to fix my car.
The heady dream of continuing my education crashed into the reality of the present loss. I got out of the car, reached for my umbrella but then left it behind. The inmates at the jail had told me never to walk alone at night under an umbrella because it makes you look vulnerable. “Walk with your head high,” they advised, “with your fists in your pockets. It suggests you may be carrying a weapon in your hands.” So I took their advice, and began the longest walk of my life.
In my misery, I reviewed my belief that nothing would ever go right in my life. Then, I began the internal discussion that would lead to yet another choice. As the nurse at the jail, I knew many people in the city on both sides of the law. There were some who, aware of my deep longing to go to the University, were increasingly insisting that I take an offer from them seriously. That offer was to essentially set me up as a drug dealer, so that I could make a living and pay tuition at the university. These were people who had both the means and the authority to do this, while at the same time protecting me from the legal consequences. So, as I walked through the city, tears mixing with rain streaming down my face, an internal argument was building.
One of the reasons they were willing to back me in the drug business was that they knew of my inability to tolerate drugs. I would not become a user, succumbing to my own trade. That long ago, ten years into having been diagnosed with degenerative disc disease, I thought I knew everything there was to know about acute and chronic pain in a life without pain relievers.
Walking in the rain, steaming with self-pity, I was losing the perspective that heretofore had kept me on the right side of the law. Why not take them up on it? At least they cared enough to help me, the discussion began.
Four miles into the walk, the dark side was winning the battle. I was not going to live this way anymore. I was going to have a better life for myself, no matter what it took.
I remember clearly that exact moment, on the cusp of making that decision. I was looking at a lighted billboard, high on a rooftop (keeping my head up, I couldn’t miss it). What I don’t remember was a single thing that was on that billboard, or why it had my attention. I only remember the part of me that was screaming inside my head: “NO! NEVER, for any reason whatsoever, can I participate in something that destroys young lives before they ever get to make good choices. NEVER, can I contribute to something so deadly to society. NOTHING IN LIFE IS WORTH DOING THIS. NO, NO AND NO!
The rage against the idea that swept over me was so strong, I completed the next half of my journey home on the adrenaline that it produced. The next week, on my advisor’s advice, I visited the financial aid director of the university and he provided the funding that began my journey toward my PhD, completely paid for by grants and scholarships. But that is a different, though quite wonderful, story.
The decades since that time were almost a fairy tale, yet one accompanied by ever-increasing deterioration in my back, more disease processes as I aged, and no more tolerance for medications than I ever had. Last year, at the lowest point of my life since the aforementioned walk in the rain, I was so physically, emotionally and mentally drained that I had to retire. I could no longer care for my home, my yard, or hold a job. Pain had robbed me of the ability to think clearly, even to remember what I was doing from one minute to the next. Unable to sleep or even find a comfortable place to be, I would cry with the pain and query the God who had rescued me from destruction years before: “Why? Why don’t you just let me die?”
That was apparently not in the cards for now. Though doctors had agreed through the years that I was not a good candidate for surgery on my back, one doctor believed that epidurals might give me some relief. The pain management physician who performs them here agreed to do it, and after two procedures I am now able to care for myself, to drive without fear that my leg reflexes would fail me, and to think in whole sentences and even paragraphs. There is still pain, but not too much for me to cope. And the condition is still degenerative, so I don’t know for how long, but I can cherish every day that I have.
Which brings me to the reason for this story. I have been writing and talking a lot about my concerns about physicians and patients (and also pharmacists, I’m learning) in the current hysteria over opioid drugs. I firmly believe that many legislators and law enforcers have made uninformed decisions that are causing untold harm to many people (not, thank God, in Indiana where we have a reasonable law).
I have been asked why it matters to me, since I can’t take pain relievers anyway. Why am I so concerned about all this? It matters to me because I KNOW WHAT IT MEANS TO SUFFER DAY IN AND DAY OUT WITH PAIN, AND NO RELIEF! Why, in any world where people claim to care for one another, would I willingly support laws made and enforced carelessly that cause people who suffer to be cut off from the physicians and pharmacists who could help them? And how long are people going to want to even become physicians and pharmacists when they could go to jail – even be charged with murder – for trying to help people who suffer?
That is why it matters to me.
USA Today recently published an article about seniors and prescription drugs, with input from Dr. Mel Pohl and Dr. Andrew Kolodny to support the claims made in their opinion piece. (See: Seniors and Prescription Drugs: As Misuse Rises, So Does the Toll http://www.usatoday.com/story/news/nation/2014/05/20/seniors-addiction-prescription-drugs-painkillers/9277489/ ) Having read the article, I am left with several unanswered questions. I am herein addressing them to you, Dr. Pohl and Dr. Kolodny.
In the video, the statement is made “We didn’t know what addiction was” but you never define addiction – nor for that matter, do you ever acknowledge how addiction differs from dependency, or even from drug abuse. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. The disease of addiction is a chronic condition that, without treatment, is progressive and can result in lifelong disability or death. The evidence from recent research on this is growing daily, and so is the evidence that treating chronic pain patients based on this information is increasing the success rates—success rates that you also fail to acknowledge.
Drug dependency, on the other hand, is reversible. Anyone can expect to become physically dependent on a drug they take for a long time; including, for example, diabetic medication, anti-anxiety drugs, sleeping pills, nasal sprays, beta blockers and other cardiac drugs, and many OTC drugs that are NOT prescription medications. Withdrawal from dependency can be severe, but when it is over it is over. In contrast, the disease of addiction is a chronic condition that, without treatment, is progressive and can result in lifelong disability or death.
Drug abuse describes behavior born of bad decision-making; not the disease of addiction. Almost all addicts have been physically dependent on drugs, but vastly fewer people who find themselves “physically dependent” on drugs (i.e. pain patients) are addicts. When assessing your data on seniors who survived their youthful drug excesses in the 60’s, for example, did you consider this?
Also, did you consider that these same seniors know how to obtain street drugs and will do so if the option of pain control is removed? Are you willing to share the responsibility of leaving your patients no choice but to engage in criminal behavior? Are you unable to acknowledge the reality that there are expert and courageous physicians who are willing to engage in the time-consuming (and, in the media fabricated maelstrom of opioid hysteria, even dangerous) battle for suffering patients against chronic pain? Will you ever acknowledge their successes? Why do you bombastically lump all these conditions under the most alarming category of addiction?
Thoughtful physicians are taught to begin with the lowest dose, monitor their patients, and increase the dosage only as objective and subjective findings justify the increase. Why then, Doctor Kolodny, have you begun your treatment of this issue at the highest possible dosage of inflammatory rhetoric? Don’t you understand that each patient differs in their perception of pain, in their tolerance for pain, and in their response to medication and treatment?
And finally, you object to prescription opioid pain treatment but support the use of Tylenol (i.e. Acetaminophen) in patients with severe chronic pain. Have you read the research on what acetaminophen does to the human liver? Doctor, have YOU ever experienced severe chronic pain with only acetaminophen for treatment?
The flaws and gaps in your ivory tower presentation are glaringly obvious. You have failed to convince me that the best prevention for addiction is to never prescribe these drugs. In some pain-free utopia that approach might work. But we live, suffer, and die in the real world. Neither you, nor I, nor anyone will ever establish heaven on earth by banning pain drugs.
Why not treat this problem like you are supposed to treat pain. Let’s start with a remedy that has the greatest potential for benefit with the least amount of risk:
Let’s educate ourselves about the proper use of these medications, the best treatments for pain, and the value of lifestyle optimization.
Perhaps my suggestion also sounds like a utopian prescription. I am not naïve enough to believe you can eradicate abuse and addiction merely by educating the populous. But it’s a better primary treatment for our drug problem than surgically removing all access to opioid pain care. And 116 million chronic pain patients would not have to choose whether to suffer or become criminals.
Note: I have shamelessly borrowed from the published research on this subject. The information is out there.
Chronic Pain Management with Opioids in Patients with Past or Current Substance Abuse Problems. Journal of Pharmacy Practice. 2003, 16;4:291-308.