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AN URGENT PLEA TO END THE WAR AGAINST PHYSICIANS AND PATIENTS

Crimes against humanity are widespread on this planet, and too many to count.  Over the past decade diligent researchers (by diligent I mean those who verify sources and results) have uncovered the roots of some of our more persistent and frightening social problems, and published reputable accounts thereof.  Many such problems are actually the result of conspiracies set decades ago, like the rise of private prisons for the purpose of incarcerating a specific race of young people because of socioeconomic issues (read racism), and calling it a War Against Drugs.  But the drugs continued to take over our nation—not just because of those young people, but because of the greed for money and power in the pharmaceutical companies, insurance companies, and politicians that has grown exponentially, unchecked.  Nixon’s intended outcome—that of getting minorities off the streets and severely impacting their ability to live normal lives outside of prison—also suited well the baser needs of other groups in our society.

Other groups, in fact, began to see the financial success and knowledge of physicians to be a major threat to their own greedy plans.  They deduced that chronic pain patients, now acknowledged and receiving treatment for their pain, could be both blamed as a source of street drugs and used to help bring down honest physicians (and to support the pill mill “doctors” who supplied the patients with enough medicine  to both use and sell).  Eventually, we begin to see “statistical reports” that “prescription drugs” were the cause of abuse and overdose deaths in specific regions of our country.   For a short time, they may have been.  But when the deaths began to occur in White Middle-Class families, the outcry to increase the efforts of the War on Drugs became deafening.  There had to appear to be some effort to control the drugs, so we see draconian measures being set—in some states by law, in others by regulation—that were targeting the legitimate physicians who prescribed for pain patients, and ultimately the patients who were frequently cut off without warning from their pain treatment.  Despite the outcry against punishing patients and physicians, and the evidence showing the futility of this approach to the War on Drugs, this situation continues to threaten the lives of both patients and their physicians, every day.

Despite scientific proof that Substance Abuse Disorder (being addicted to a substance) is an illness of the brain and can usually be well managed by an addiction specialist, legislators and law enforcement officials alike still only see “drunks and addicts” and still, after DECADES of failure, claim that incarceration/punishment is the only way to fight the war on drugs.

Despite, also, the logic that if you are fighting a War against a crime, you go after the source rather than innocent bystanders.  If we don’t get rid of the sources:  drug cartels, the dealers, and the creators of the drug,  how much good is it going to do to punish the people who use them?  Sadly, these sources have never been the primary targets.  Just as now we see heroin and fentanyl actually being the greater cause of overdose deaths (because they are cheap and much more potent than earlier versions), we still hear and see stories about prescription drugs being the cause of these deaths.  We are still subjected to so-called charts describing dubious statistical proof that prescription drugs are the main cause of overdoses, when more reliable research shows that it is street heroin and fentanyl.

To that, I would ask the reader to please follow the hyperlink below.  The author of this piece has provided a thoughtful and well researched discussion of what is really causing overdose deaths, and why the propaganda we are getting is so dishonest:

https://www.acsh.org/news/2017/10/12/opioid-epidemic-6-charts-designed-deceive-you-11935

Having read this article, consider well the facts that every year more than 400 physicians commit suicide;  that thousands of chronic pain patients suddenly deprived of their medication have either committed suicide or gone to the streets to get their medication; and that many of these have also suffered unintended overdose deaths.

These measures that make practicing good medicine so difficult, and the law enforcement mentality that believes physicians are guilty until proven innocent,  are not the only reasons physicians are either opting out of practicing medicine, or opting out of life altogether.  The War on Physicians and on Patients is real, and it is devastating.  The pharmaceutical houses and insurance companies may actually believe that we can survive without trained doctors; Artificial Intelligence will be just as good if not better, they believe….but check out this article:

https://www.scientificamerican.com/article/the-social-life-of-opioids/.

We read here that there is well-researched, scientific proof that a caring and trusting relationship between patient and doctor is a necessary, (but not sufficient), ingredient for best medical practice—AND for healing!  As one incredible physician has noted:  “They (the patients) don’t care how much you know until they know how much you care.”  Artificial intelligence hasn’t managed the caring part, and even if it does I don’t see much healing effect to be expected from a robotic hug.

The crime against pain patients who are now not only being vilified in news media, in pharmacies, and in social media, is certainly heartbreaking.  If you happen to be one of those pain patients, it is also a return to the terrors of intractable pain, inability to function productively in society, and a potentially horrible death.

If you are a physician who has spent at least half the normal human life span studying and preparing to make life better for those who suffer, life may be  becoming a nightmare.  Insurance companies dictate what treatments are allowable, how often, and how long such treatments will be permitted.  They do not refer to medical societies for their information.  They refer to bottom line profit indexes.  Legislators who pass laws (when medical board regulations would more properly suffice) that limit what physicians can prescribe, and how often—arrange that physician’s offices and lives will be disrupted, the physicians in question treated as guilty before having a chance to be proven innocent.  As usual, those who are charged with the felonies that have been put in place as a weapon in the War on Drugs never quite regain their previous status of innocence, even when proven so.

Does it matter to the insurance companies or the legislators that these laws have only created chaos and confusion, betrayal and mistrust?  Does it matter that physicians are already reeling from finding themselves backed into corners where they have to “sign on” to corporate health care entities that are run by non-medical administrators who decree when and how often they work, how many patients they will see for how long, and determine bonuses based on computer-run quotas and outcomes?  Does it matter that medical students are so disillusioned that they drop out, and that some commit suicide?

And finally, adding to the fears of losing their practices, their licenses, and the meaning attached to their life work, physicians in increasing numbers are being attacked and/or killed by frustrated, angry patients or their relatives.

Why is this ethically, morally, and even logically wrong approach to our drug crisis—which MUST be separated in our minds from medical care for chronic pain patients—continuing to exist as a modus operandi?  Why are physicians who serve our communities targeted as criminals at worst, and problem employees who must be managed at best?  Sociologically, physicians have historically belonged to one of the highest prestige vocations in America.  Their demotion to the present state is not through fault of their own, but through others’ sociopathic greed for money and power, combined with the attitude that allows so many to hate anyone who differs from themselves, to create this totally inhumane situation.

It is not “liberal” or “progressive” to respect and care for others.  It is Christian, and Muslim, and Hindi, and Jewish—it is a basic precept of many world religions and predates organized religion itself by centuries.  Of course, being human and egocentric, we do not always succeed in living up to these standards.

It is my opinion that the proof of our own individual humanity is the maturity, intelligence and self-motivation to care for others as we care for ourselves.

I could go on for pages about why so many people have lost the human characteristic of empathy, but there are enough people who retain it who could help our country become human again.  Who still respect the dignity of other human life, and who realize that “together, we stand; divided, we fall.”

It is definitely in our best interests to respect and protect the lives and experience of our physicians; it is also in our best interests not to stand by and leave them or their patients to live and die in misery when it is all so unnecessary.  And inhuman.

And, a last plea……

 

 

RESOURCES:

Alexander, Michelle.  The New Jim Crow:  Mass Incarceration in the Age of Colorblindness.  2012.  The New Press, NY

Bertram, Eva and Morrris Blachman. Drug War Politics: The Price of Denial.  1996. University of California Press.

Bateman, Dustin.  Neurobiological & Sociological Aspects of Addiction

Levinthal, Charles F.  Messengers of Paradise.  Opiates and the Brain.  The Struggle Over Pain, Rage, Uncertainty and Addiction. 

Meier, Barry.  A World of Hurt:  Fixing Pain Medicine’s Biggest Mistake.  2013.  New York Times Company.

Parsons, Talcott.  “Illness and the Role of the Physician:  A Sociological Perspective.”  American Journal of Orthopsychiatry 24 March 2010.  Copyright © 2010, John Wiley and Sons.

Quinones, Sam.  Dreamland:  The True Tale of America’s Opiate Epidemic.  2015.  Bloomsbury Publishing Plc.

Sternheimer, Karen.  Connecting Social Problems and Popular Culture:   Why Media is not the Answer. 2nd Ed.  2013.  Westview Press, Perseus Books Group.

Webster, Lynn R.  The Painful Truth:  What Chronic Pain is Really Like and What it Means to Each of Us.  2015.  Webster Media LLC, PO Box 581113, Salt Lake City UT 84158.

WEB ARTICLES, including peer reviewed

Pain Medicine News – How Did We Get Here? http://www.painmedicinenews.com/ViewArticle.aspx?d=Guest%2BEditorial&d_id=351&i=March+2014&i_id=1042&a_id=26043&tab=MostEmailed#.U3PLVV6vdyI.twitter

Report: Chronic, Undertreated Pain Affects 116 Million Americans http://ti.me/AAfT7q  via @TIMEHealth

New Pain Management Rules Leave Patients Hurting http://seattletimes.com/html/localnews/2016035307_pain28m.html#.U2mA77bwJzQ.twitter

Chronic Undertreated pain affects 116 million Americans: http://healthland.time.com/2011/06/29/report-chronic-undertreated-pain-affects-116-million-americans/

Our Fear of Opioids Leaves the world in Pain  http://edsinfo.wordpress.com/2014/10/27/our-fear-of-opioids-leaves-the-world-in-pain/

MT @toni_bernhard: My new piece. It should be of interest to anyone whose illness is questioned: http://www.psychologytoday.com/blog/turning-straw-gold/201410/i-m-sick-what-is-wrong-me …Dr. Paul Christo @DrPaulChristo  ·  Oct 27

California Doctor….    http://paindr.com/california-doctor-unveils-painful-abyss-facing-patients-in-pain/

Physician Suicide:  http://t.co/4vhF63eD6N

Physician Risks:

The damage done by the war on opioids: the pendulum has swung too far http://www.dovepress.com/articles.php?article_id=16781 …

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

Killing Pain in Perry county http://www.kentucky.com/2009/12/12/1056711/killing-pain-in-perry-co.html

Patient role in helping physicians:

“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 …


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REFLECTIONS ON THE EFFICACY OF OPIOID PAIN RELIEF OVER TIME

pain photoBefore addressing the issues of this article, I will need to explain the position from which I write. At the present time I am a 76-year old, semi-retired sociologist and former nurse. As a sociologist, it was natural for me to include the sociology of medicine as one of my major interests. As a nurse, I worked for three years in the county jail nurse’s office, several years in the emergency room, and for six years as a hospital corpsman in the navy reserve.

I was introduced to the whole drug scene while working in the jail, where it was my job to treat substance abusers who were addicted to paint, glue, alcohol, and various drugs. This was in the very early ‘80s, and the majority of the street drugs were amphetamines, Quaaludes, heroin, and marijuana. It was necessary to control withdrawal symptoms from the time the inmates were booked, to keep them alive long enough to go to court, serve whatever time they were given, and be released back into the same environment with virtually no change in their lives except those imposed on felons. The recidivism rate was extremely high—more so than for any other offense. During the time I worked there, the fastest turn-around rate for a released prisoner being picked up drunk and brought back in to Booking was 30 minutes.

Of course, in the ER and even in the Navy reserve I saw evidence of substance abuse. As a corpsman I was also involved with both diagnosis and treatment. The most heartbreaking experiences, however, occurred while I was working at a private college in Appalachia from 1997-2013. I saw firsthand the growth of the OxyContin and heroin epidemic that Sam Quinones documents in Dreamland, followed by Meth and various other prescription drugs, soon followed by the amoral pill mills that so delighted students who were already dependent or in early stages of addiction. At their age, they were the most vulnerable to the brain disorder of addiction, and the main targets of the dealers who would actually supply their first pills free, to encourage a new customer. I saw so many beautiful, bright students succumb to the promise of a pill that would make their life better, more fun, or at least easier. I was able to help some, but not all, by far. They needed experienced and trained medical attention, and I was no longer in that field. I came to despise the very thought of drugs, dealers, and pill mill “doctors”.

But there is another side to my story. In 1968 I suffered the first experience of a bulging spinal disc. Within 3 years I was diagnosed with degenerative disc disease, and with osteoarthritis of the spine, hands, feet, shoulders and hips. By 2013, there was no part of my spine that was not affected; I had major stenosis at various levels, bone spurs, episodes of bulging and decayed discs, a vertebra that had decayed discs on both sides and was standing on edge, resulting in a spinal S-curve from my waist to the upper thoracic region. Unrelenting pain caused muscle spasms in my entire back and neck, adding to the pain. A meningioma would soon be discovered attached to my spinal cord at T3-4; it is benign—the only worry being that it will grow.

During those 45 years living with pain, I never had any medication stronger than NSAIDS. Like many patients, I could not tolerate narcotics or opioids. I had to learn meditation and “mind control” (pushing the awareness of pain to another part of my consciousness). I had a great deal of physical therapy. I played the piano and organ for distraction, until I could not. I walked from 1-3 miles every day, and I worked full time as a nurse, then as a college professor, usually working between 40-60 hours a week. I spent seven years in South Africa in the middle of a revolution. The more I could distract myself with external demands, the longer I could function. Again, until I could not.

In 2014, so disabled by pain I could neither work nor sufficiently care for myself, I was sent to a pain management specialist in Louisville, KY. After I was finally convinced that he was a legitimate pain specialist who would not try to get me addicted, we were able to work together very well. I learned to trust his judgement, and to follow his lead in determining my treatment.   As a result, I have been able to teach at a local university part time for the last two years, and it has been a year since I have had pain greater than 5 on the 0-10 scale. One of the reasons that the pain has not been greater, and has not persisted, is that when it gets to that point I take hydrocodone, at its very lowest dose. My pain doctor realized that I am able to tolerate very low doses of medications for other problems (many of which were caused or exacerbated by long-term use of NSAIDS), so we tried the opiate. The complete pain relief has been astounding to me. I have never before had medication do more than take the edge off the pain. Equally important, my need for the opiate is becoming less and less frequent. My chronic anxiety levels have dropped considerably, and that also is a source of pain relief.

Which brings me, finally, to the point of this article. I hope I have sufficiently established the experience and credentials that give me the foundation for writing it. I must write it, because for too long I have been reading articles by people who have based their judgement about the dangers and/or efficacy of opiate treatment for pain on short-term, inadequate research. In A World of Hurt, by Barry Meier, he quotes Dr. Jayne Ballantyne as saying that her studies, and those of others, show that after a short term of therapy, there is little to no efficacy (5% of patients) of opiates for pain. I have seen and heard these figures often; yet pain management physicians also have records of people who have been carefully managed on opiates and other pain relieving measures for at least twenty years, who are functioning without severe pain. None of these studies satisfy me that they meet the natural science or sociological requirements of longitudinal studies. The former studies fall far short of twenty years, and the latter are a matter of record but no sufficiently rigorous scientific research has been done to establish credibility.

Additionally, our understanding of the prevalence and range of chronic pain issues, and the new brain studies that have completely revised our knowledge of addiction, have rendered those studies irrelevant. But the continued widespread references to them has created a situation that is clearly morally and ethically bankrupt: Patients with persistent, severe pain—including, in many states, terminal cancer patients—are being deliberately, systematically deprived of relief and therefore from the ability to lead potentially productive lives, or at least to spend their final days in peace, without pain. This, while other substances that are addictive are legal and can be consumed by any adult, regardless of their risk factors for addiction, whether or not there is a “need” for the substance.

What would make opiate efficacy studies reliable and verifiable? First, to acknowledge that all pain patients are unique in their tolerance to pain, their response to pain, and their response to treatment. Not everyone can metabolize medications the same way. Not everyone responds equally to physical therapy, or to psychological counselling. Not everyone has the personality to effectively meditate, or to suppress awareness of moderate pain. But all of these treatments, as well as known risk factors, are variables that must be accounted for if you are judging the efficacy of pain treatment.

Then there is the issue of the selection of participants. When I read the studies done in past years, I found they were limited to a single practice, or a hospital, or other small group of patients with no concern for variables like age, risk factors, history of abuse, previous treatment and other illnesses. The participants were not chosen scientifically in order to be representative, so results are inevitably skewed. I am reminded of early anthropological ethnographic studies where small, isolated villages were researched, then the results extrapolated to all such groups: “from the particular to the general”. We now realize that you can’t do this and arrive at accurate conclusions. Yet, on the basis of these flawed opiate efficacy studies, people’s lives are being damaged, their families are suffering needlessly, and many patients who are cut off from their medication either take to street drugs with the risk of overdose, or just commit suicide in the first place.

We do need more research about the safety and efficacy of drugs. But it must be longitudinal and scientifically designed and the results assessed to be reliable and verifiable. We also need politicians to stop enacting laws and policies based on moral definitions of issues, which we can never come to consensus about, and work on the actual economic and environmental issues that they can actually improve.

Addiction is a disease, not a moral issue. Pain is a disease, not a moral issue. And we are not speaking of just a few people affected by the neglect resulting from ill-informed laws and regulations designed more to punish the innocent along with the guilty rather than to end the War on Drugs. We speak of hundreds of thousands, even millions of sufferers. When properly identified as scientific (medical) problems instead of moral issues, we can see the potential to improve conditions. People could be adding to the economy, rather than being forced to either live off of it, or to live in poverty while their pain continues to worsen.

Big Pharma—for example, Purdue Pharma– are far from innocent in this War. Additionally, the FDA is no longer as concerned with protecting potential patients as they are in protecting corporate rights to profit; witness the countless lawsuits for drugs improperly researched, improperly advertised, and improperly presented to physicians who must rely on that information in order to prescribe successfully. And the DEA is still, regardless of evidence that they are often destroying the lives of the innocent while failing to halt the spread of illegal drugs, using pain patients and their physicians as cannon fodder in their failed war on drugs.

A significant paradigm shift is required here. Educationally, culturally, legally and morally we must illuminate the darkness of our willful ignorance about the suffering of the innocent who have become scapegoats in the failed War on Drugs due to tunnel vision about the relationships between drugs, physicians, and pain; a tunnel vision that cannot see the greed and political will that perpetuates the drug problem. Every institution of our society has failed our physicians and their patients who are in pain, or addicted. Those institutions have either failed to adjust a false worldview that blames patients for their illnesses, or have just failed to assume responsibility for their role in finding solutions to the need for a collaborative approach to these widespread diseases, and to the devastation that has resulted from long term beliefs that they are moral issues that must be punished.

For over a century, that approach has not worked. And as the saying goes, insanity is defined as continuing to do the same thing over and over again (or doing even more of it), expecting different results. From family, to education, to religion, culture, economics and government we need a major overhaul of outdated and inaccurate beliefs, and development of procedures that decriminalize the treatment of chronic pain and addiction, as well as the afflictions themselves. Medical decisions need to be made by medical experts and their appropriate medical agencies, and the Criminal Justice system could concentrate on ridding our nation of illegal drugs by putting the same time and effort into stopping the dealers who daily increase the supply of drugs available on our streets. We might even look to the successes of other countries, and determine if their methods are importable.

I cannot bear the thought of more bright and beautiful college students ruining or ending their lives before they have even begun. The data suggests that it is not stopping with college students, but that high school and even middle school students are being targeted as “customers” of the illegal drug trade. I also cannot live with the knowledge that caring and dedicated physicians, who have spent nearly half of an average 70 year lifetime studying and working for the privilege of becoming practicing physicians, have lost everything they have worked for because they have tried to help their patients. (I am quite ok with pill mill “doctors” being brought to justice for their crimes, however!)

It is Christmas Eve as I write this. A time of hope, a time of expectation that the promises of life can be fulfilled. I am a sociologist because I believe in the amazing capability of human beings to solve the problems of life, separately and together. I am also all too well aware of our capability to create and maintain cultural and social institutions and structures that protect certain groups of humans at the expense of huge numbers of their fellow humans. I believe that most of us are better than this; that we can do better, and that bit by bit we can learn to adapt to change, to each other, and to the requirements of living in our world safely, together.

Please—let’s make 2017 the year we begin to deal with chronic pain and addiction as the disease processes they are, and begin to structure our corporate life accordingly, so that together we can end the war on drugs, and on patients and their physicians, and restore the rationality of the Enlightenment without killing the compassion of empathy.

enlifghtened being

RESOURCES: Books & Peer Reviewed Articles

Alexander, Michelle. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. 2012. The New Press, NY

Bateman, Dustin. Neurological & Sociological Aspects of Addiction.

Bertram, Eva and Morrris Blachman. Drug War Politics: The Price of Denial. 1996. University of California Press.

Levinthal, Charles F. Messengers of Paradise. Opiates and the Brain. The Struggle Over Pain, Rage, Uncertainty and Addiction.

Meier, Barry. A World of Hurt: Fixing Pain Medicine’s Biggest Mistake. 2013. New York Times Company.

Parsons, Talcott. “Illness and the Role of the Physician: A Sociological Perspective.” American Journal of Orthopsychiatry 24 March 2010. Copyright © 2010, John Wiley and Sons.

Quinones, Sam. Dreamland: The True Tale of America’s Opiate Epidemic. 2015. Bloomsbury Publishing Plc.

Sternheimer, Karen. Connecting Social Problems and Popular Culture:   Why Media is not the Answer.  2nd Ed. 2013. Westview Press, Perseus Books Group.

Webster, Lynn R. The Painful Truth: What Chronic Pain is Really Like and Why it Matters to Each of Us.  2015  Webster Media, LLC.

Hyperlinks to articles on Web:

Addiction is a Brain Disease http://www.attcnetwork.org/explore/priorityareas/science/disease/

Pain Medicine News – How Did We Get Here? http://www.painmedicinenews.com/ViewArticle.aspx?d=Guest%2BEditorial&d_id=351&i=March+2014&i_id=1042&a_id=26043&tab=MostEmailed#.U3PLVV6vdyI.twitter 

Report: Chronic, Undertreated Pain Affects 116 Million Americans http://ti.me/AAfT7q  via @TIMEHealth

New Pain Management Rules Leave Patients Hurting http://seattletimes.com/html/localnews/2016035307_pain28m.html#.U2mA77bwJzQ.twitter 

Chronic Undertreated pain affects 116 million Americans: http://healthland.time.com/2011/06/29/report-chronic-undertreated-pain-affects-116-million-americans/

Our Fear of Opioids Leaves the world in Pain http://edsinfo.wordpress.com/2014/10/27/our-fear-of-opioids-leaves-the-world-in-pain/

MT @toni_bernhard: My new piece. It should be of interest to anyone whose illness is questioned: http://www.psychologytoday.com/blog/turning-straw-gold/201410/i-m-sick-what-is-wrong-me …Dr. Paul Christo @DrPaulChristo  ·  Oct 27

California Doctor….   http://paindr.com/california-doctor-unveils-painful-abyss-facing-patients-in-pain/

Physician Suicide http://t.co/4vhF63eD6N

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  32. Moutier C, Norcross W, Jong P, et al. The Suicide Prevention and Depression Awareness Program at the University of California, San Diego School of Medicine. Acad Med. Mar 2012;87(3):320-6. [Medline].
  33. American Foundation for Suicide Prevention Physician Depression and Suicide Prevention Project. American Foundation for Suicide Prevention. Available at http://www.afsp.org/index.cfm?page_id=05804002-E8F4-13AB-2D4B97A0815A2744. Accessed 10 March 2010.
  34. Goldsmith SK, Pellmar TC, Kleinman AM. Reducing Suicide: A National Imperative. Institute of Medicine Monograph. National Academies Press; 2002:[Full Text].
  35. Andrew LB. PHPs Are in Your Corner. Emergency Physician Monthly Online. 2006;13:6:[Full Text].

Physician Risks

The damage done by the war on opioids: the pendulum has swung too far http://www.dovepress.com/articles.php?article_id=16781 …

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

Killing Pain in Perry county http://www.kentucky.com/2009/12/12/1056711/killing-pain-in-perry-co.html

Patient role in helping physicians

“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 …

 

dr-murphyFrom James P. Murphy, MD, MMM;

Practicing Pain Management Physician

Board Certified in Pain Management & Addiction Management

https://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/

https://jamespmurphymd.com/2016/07/24/comparing-apples-to-apples-the-morphine-equivalent-daily-dose/

https://jamespmurphymd.com/2016/06/21/prescribing-controlled-substances-in-kentucky-cme-presentation-for-flaget-memorial-hospital-in-bardstown-ky-june-21-2016/

https://jamespmurphymd.com/2015/02/13/pathway-to-partnership/

https://jamespmurphymd.com/2015/09/a-stellar-time-at-bellarmine

 


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RESPONSE TO DR. JEFFREY FUDIN’S REQUEST

In Dr. Fudin’s post today, comPASSION Fatigue https://t.co/rilJGgQxFG , he defines Compassion Fatigue as “essentially a form of burnout common to those of us who actually care.” He and his co-author explain the problems of advocating for good care for chronic pain patients while navigating the endless stream of misinformation, outright lies, overreaching legislation and its advocates, and the inability to understand the differences between the illnesses of substance addiction, and the suffering of chronic pain patients. “[W]e continue as a society unable to hold two thoughts in our heads, the suffering of the addict now that rules the day and the suffering of the pain patient has been relegated to a bottom dweller,” the article states.

Since most fail to listen to anyone they do not agree with, and no one seems to care about truth in advertising, chronic pain advocates and their physicians (and pharmacists) grow disillusioned and weary of the task. I urge the reader to use the link above to read this very relevant article, where the authors make a much more articulate argument for the case than I have made here, as well as reporting important new information.

However, it is not my intention to simply report on the article or its excellence. The authors realistically ask a very relevant question: Is anyone out there still playing the game? Are we still actively advocating for chronic pain patients? My answer is difficult to write.

Having been an undertreated chronic pain patient for well over 40 years, as well as a nurse in a county jail who worked with police, substance abuse addicts, and drug dealers, I believe my claim to a broad understanding of the situation to be credible. I am also well trained in both statistical and qualitative research as a result of my graduate degrees. Yet I am repeatedly called out as ignorant, as a probable drug seeker, or as simply being wrong about everything. I do have pretty thick skin, having been an academic dean for several years, and while friends compliment me on my ability to persevere, my parents called it “stubbornness.” But so far, it has served me well.

Again, I hate to quit, or to give up on a good cause. But at my age I have learned to pick my battles. I have only so much energy, thanks to my years of pain and the many disease processes that have resulted from that pain.

At the same time, that last sentence explains exactly why I have chosen THIS battle, and I will not give up or shut up. You may not see me in writing as often, because I am tired and ill much of the time. But I will write, and I will talk, and I am definitely still in the game—just benched to rest a little more often. I am far from being alone in this situation, and I no more want to see hundreds of thousands of others suffer than I wish to suffer myself.

Meanwhile, here is a thanks to Dr. Jeff, and to all the compassionate pain management physicians (especially mineJ) who stay in the game despite all the prejudice, dishonesty and even the honest ignorance and misunderstanding that muddies the waters and stains our souls. Then too, the devastation of the lives ruined and lost unnecessarily because of undertreated or ignored pain, and the new rhetoric that is based on the notion that we are all alike and our pain should be treated the same, accordingly. And let us not forget to acknowledge those compassionate physicians who have lost so much after being targeted and charged by federal agents with no accountability for their actions when they were wrong.

I am beginning to ramble, so I end with this statement: The pain of burnout and the pain of disability cannot end this battle. It is too easy already for many to forget or deny the reality of our existence. Our voices must continue to compel the truth into being.

Talmud quote


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WHY I WOULD SUPPORT NEEDLE EXCHANGE PROGRAMS

syringes“I don’t understand. Why would you, with all your experience and training, vote for a needle exchange program that supports the habits of drug users?” Her question was not rhetorical. Her face flushed with emotion, angry tears in her eyes, she radiated the frustration behind her outburst. Though the need for answers was obviously deep, she was too overwhelmed to wait through any discussion and stormed out of the room.

I fully understood her point of view, as well as her expectation that I should know better than to entertain what she saw as a completely irresponsible position, counter to all that I should know. But it was precisely my experience, as well as all my education and training, that over the years had brought me slowly but convincingly toward my present convictions on the subject. Like many of us, she may have had close and painful experiences with the devastating results of drug abuse, and with addiction. She may even have taken courses where professors taught the evils of drug use with passion, hoping to spare their young charges the life changing downward spiral of drug use. Or, she could easily be a social worker, or health care provider, daily living with the emotional draining and burnout of working with abusers and addicts. Who would blame her for her perspective on the subject? As I often tell my students, where we stand on a given issue depends on where we stand in life. Experience is valid; it is real. With social problems, however, it just can’t be generalized to explain the whole issue.

Without comprehending the whole issue, we fail to take other valid points into our understanding. And without those other valid points, we make decisions that are almost guaranteed to produce negative unintended consequences.

What are some of those other valid points?

  1. Drug abusers use and share dirty needles. This leads quickly and devastatingly to increased numbers of diseases, primarily HIV and Hepatitis C. Even if only drug users were to be affected, the incidence of disease could reach epidemic proportions.
  2. When users respond to and comply with the regulations of a needle exchange program, they can be tested for HIV and HepC, and immediate treatment begun. The cost of a needle exchange program is high, and the additional cost of treating one HIV patient could be as high as $100,000. There will be more than one patient. This is a commitment of both financial and emotional proportions that is, and should be, taken seriously by any community.
  3. The cost of not doing it is exponentially higher. First, an untreated HIV victim is likely to progress into full-blown AIDS. THE COST OF TREATING ONE AIDS PATIENT FROM THE TIME OF DIAGNOSIS TO DEATH IS, ON AVERAGE, ONE MILLION DOLLARS. Second, that untreated carrier of HIV and/or HepC is eventually going to infect any number of others in a variety of ways: Family, sex partners, healthcare workers, First Responders, law enforcement officers, good Samaritans…all are at risk. They are not the limit, however. And each one infected is going to generate costs of $100,000 to $1,000,000. The financial costs do not even begin to quantify the emotional and productivity costs to everyone from family to the entire community.

In other words, no matter the cost of the program, the cost of NOT having the program in the presence of a proven epidemic is incredibly higher!

Given #s 1-3, we have only looked at the actual costs of having, or not having, a needle exchange program. But what about the perspective of those who resent what they see as a moral, or an ethical, objection to “helping” drug abusers and addicts?

To this, I would answer first of all that the issue is NOT only about drug addicts. IT IS A PUBLIC HEALTH ISSUE. It is simply not rational to fail to protect our families, neighbors, public servants and health care workers because of our antipathy toward ANY one group of people, no matter how deeply that antipathy is grounded in our being.

Second, I would remind those of us who claim to be Christians, that–all appearances to the contrary–these abusers and addicts are still human beings. Once, many were teenagers or young adults who in the blissful ignorance of their mortality succumbed to the desire for the drug-induced high, the shared forbidden experience with like-minded peers.

Others were veterans, returning with dependencies or addictions already in place as one of the costs of defending our rights to live in freedom. Still others began as patients, some who were denied proper medication and sufficient care by our laws; others who for any number of reasons (rational or irrational) took to the streets when their increased tolerance for drugs failed to meet their need for them.

And finally, the fact is that addiction is not something anyone deliberately chooses for their life. No one looks forward to that relaxing drink after a hard day at work, or even a drug-induced escape from the stresses of life, believing that one day in the future they will be a slave to a substance that no longer provides these things, but instead has become a painful, frightening and life-threatening craving, constantly demanding to be satisfied. Instead, we either say “I can’t handle [the substance]” and leave it alone; or we believe that “I can handle it,” and take our chances.

Many, in fact, may be able to handle it better than others. However, no one is fully immune from potentially developing the disease of addiction. We are learning more about risk factors on almost a daily basis, but we still cannot predict with certainty who will develop addiction.

The disease is one in which the reward center of the brain runs amok, refusing to turn off when the need for the reward is satisfied.  Aside from he repeated use of the “addicting” drug, there are risk factors:

1.  Genetic factors actually account for about half of the likelihood that an individual will develop addiction.

2. Environmental factors (i.e. where and with whom do you live and work) are influential.  Unstable social supports and problems in interpersonal relationships affect the risk.

3.  Individual resiliencies (through parenting or later life experiences) are important.

4.  Culture also plays a role, as does exposure to trauma or stressors.

Also at risk are those who suffer from chronic disease, depression, or who feel themselves alone in the world–that no one cares if they live or die.

We may never eradicate drug abuse. That is no excuse for refusing to accept the personal and financial responsibilities for changing our perspectives about those who become victims of it.

What have we got to lose by changing the ways we think about this issue and working to alleviate it? By helping users and addicts to stay alive long enough to be helped and encouraged onto a pathway out of active addiction? In our thousands of years of civilization, we certainly haven’t accomplished much with our old ways of attempted control of drug abuse. I believe it is worth trying, worth the effort to erase the stigma of addiction and restoring the will to change that must happen before an addict can fight their addiction.

After all, when a person repeats the same ineffective activity over and over, expecting a different and positive result, has this not become one definition of insanity? Haven’t we criminalized the disease of drug addiction long enough? Don’t we need to stop the insanity?  Dealing in a positive manner with addicts early enough has the potential to lower the rate of addiction that eventually leads to serious criminal activity in order to feed the addiction. Must we simply stand by and watch this happen? Programs like needle exchange and early testing in clinics don’t increase the problem. They are the only thing proven useful so far in decreasing the infectious diseases, the illegal drug use, and the consequent costs to the community.

I choose, however, to see this not as a dilemma of abandoning a moral issue for a practical one, but rather the blessing of making the right choices, for all the right reasons.

Reference for the risk factors and definition of addiction:

http;//www.asam.org/for-the-public/definition-of-addiction

Other Resources: 

http://www.cdc.gov/IDU/facts/AED_IDU_SYR.pdf

http://hcvadvocate.org/hepatitis/hepC/needle_exchange.html


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OPEN LETTER TO MAYORS, GOVERNORS, AND MEMBERS OF STATE AND FEDERAL GOVERNMENT

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.


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THE SHAME OF A NATION: PERSECUTION OF PAIN PATIENTS AND THEIR PHYSICIANS

Lawmakers now claim that drug abuse and overdoses are caused by those who suffer pain and seek medical assistance to alleviate their pain enough for them to cope; to be able to participate in life! How patently absurd. [i]

Before I go on, know that NOTHING in my writing is geared toward promoting the free use of drugs. I firmly believe that second only to the persecution of innocent pain patients and physicians, the great shame of our nation is recreational drug abuse in all its forms, by whoever indulges in it. I have watched too many beautiful and bright college students and other young people destroy their lives in this way. Not just with pills, but also with alcohol, glue sniffing, paint inhaling, and smoking marijuana.

But I have to ask: Why have the law makers and enforcers turned against people who need medication for pain? The problem is not people who rightfully believe medication is intended to cure or alleviate medical conditions. The problem is people who either co-opt others to drug use, or who choose to use drugs themselves.

People choose to be responsible, or not. The medication is not to blame.

But now we are persecuting innocents, with a somewhat hysterical belief that they are somehow the cause. [ii] I submit a brief and incomplete list of resources below showing how the lives of good people are being destroyed by this 21st century witch hunt: Dr. Baldi, Dr. Salerian, Dr. Ibsen, and others[iii]. Also, articles referring to a host of pain patients who, failing to receive the pain care that is their right, submit to the fear of a life of unbearable pain and commit suicide. Or, they go to the streets for drugs. Who can blame the latter?

Their pain has already been criminalized by their own government.

This misdirected war has had unexpected consequences that are well documented. The efforts to restrict physicians and pharmacists[iv] from providing pain medications to patients has immediately resulted in an increase in heroin use, with a rise in overdoses and deaths. The response from law enforcement? “These are UNINTENDED CONSEQUENCES[v]. “ It seems that in law enforcement it is OK to produce unintended consequences that stem directly from uninformed and under-researched legal action, killing innocent people and increasing the presence of street drugs.

When will we be smart enough to open an honest discussion between lawmakers, enforcers, and professionals who actually care about their patients?

When will pharmaceutical companies get concerned enough to research and market pain relievers that are potent enough to control pain, without dangerous side effects?

When will we all shake off our apathetic yet determined slide into the shame of our national mediocrity and the injustice and corruption in our system that accompanies it?

A South African woman once remarked to me that human beings are the most intelligent animals created by God; we are smart enough to create the means by which we can destroy the world – and stupid enough to use them.

           

[i]   Lynn Webster, MD: Lawmakers blame people who want pain controlled as the cause of RX abuse. http://www.tricities.com/workittricities/learn/article_3f71bb90-bad0-11e4-b4c7-9bf785dd481e.html?mode=story …

[ii] Lynn Webster http://www.orlandosentinel.com/opinion/os-ed-pain-drugs-021915-20150218-story.html  Terminal cancer patients are treated as drug addicts   “At each appointment I get scared my doctor will no longer prescribe” http://t.co/yYvcGWI4Uc War on Drugs victimizes pain pts http://updates.pain-topics.org/2012/06/how-war-on-rx-drugs-victimizes-pain.html   :  New restrictions hit veterans hard  http://t.co/r23KAbUIIm

[iii] These are but a few references: Dr. Mark Ibsen   http://t.co/BrZUXfUV3d or http://t.co/6midSDOLOQ ; Dr Salerian: Dennis Lee, the voice, PhiliP KEENE, New York Times Washington Post war on doctors http://fb.me/3zYOQM18d Trial Verdict: Dr. Baldi Not Guilty on All Charges http://whotv.com/2014/05/01/baldi-trial-not-guilty-on-all-charges/    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  The damage done by the war on opioids: the pendulum has swung too far http://www.dovepress.com/articles.php?article_id=16781 …   Local dr indicted   http://t.co/kYxwB0aGmH

[iv] http://t.co/jtJHRGkN1o   DEA responds after patients denied prescriptions

[v]

Experts: Officials missed signs of prescription drug crackdown’s effect on heroin use (Posted 2014-03-07 02:40:30)
Success in shuttering “pill mills” led to rising heroin use, and officials say the government missed warning signs.
The Washington Post – Washington, D.C.
Subjects: Heroin; Prescription drugs
Author: Markon, Jerry; Crites, Alice
Date: Mar 7, 2014
Start Page: n/a
Section: NATIONAL-POLITICS
The center, which closed in 2012, was separate from the unit employing prosecutors and agents who fight drug use. […]these officials defended their fight against prescription drug abuse, saying those efforts prevented numerous overdose deaths.


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BLESSED ARE THE CAREGIVERS….REALLY!!!

I cherish the caregivers in my life:

A family member who would drop everything a week before Christmas and fly hundreds of miles to be by my side when I undergo a difficult medical procedure;

 The physicians who might dread to see me coming (but nevertheless try everything in their power to help me) because first of all, I have severe chronic pain, and second because I cannot tolerate most of the medications that would provide me enough relief to cope;

 The pastors and fellow members of my church who comfort me, get me back and forth to medical procedures when I cannot drive myself, and hold me up in prayer;

 The pharmacist who takes the time to go over my medications with me to try to discover which ones are interacting in ways that increase my problems;

 The employer who knows of my disability and my age, yet values my skills enough to hire me anyway;

 Friends near and far throughout the world who immediately respond to any hint of a problem with their words of comfort and care;

…..and this is only part of a long list that comes to mind today. There have been so many in my life through the years, and even now there are so many others.

I cherish these all the more because through the actions of many legislative bodies and a large percentage of law enforcement agencies, many perfectly legitimate physicians and other medical personnel who care for those who daily suffer chronic pain are being targeted, their patients ostracized, labeled “drug seekers” and/or hypochondriacs, and malingerers. Physicians who try to help me and other patients in pain are labeled “pill mill operators” even though they do nothing to break any laws whatsoever, yet in some places they face threats of incarceration, even death.

I am neither ignorant (unknowing) or unteachable. I have graduate degrees in four disciplines. Before retirement I was a full professor, and for seven years the vice president for academic affairs/academic dean of a college. I have lived and worked in another country, and traveled to many places on this planet. Before all that, as a nurse in a county jail I regularly came into contact with drug and alcohol addicts, dealers, and both straight and “dirty” law enforcement officers.

I have also been subjected to chronic illness and chronic pain since the age of 4 years, and have often been confined to bed, once for a period of two years. As a former nurse, and as a member of a family whose history and present lives include chronic illness and chronic pain, I am also one who fully understands the freely given sacrifices made by those who care for people who are too ill to care for themselves. Although people in pain often feel isolated and alone, the truth is that their pain affects a large network of caregivers who support them in many ways.

I am convinced that it is therefore also long past time for us as a nation to be educated about the differences between addiction (a disease of the brain that can only be managed, not cured), medication dependence (I depend on a medication when I need it, and my body may need to be carefully weaned off when I no longer need it), and tolerance (over time I may need more of that medication because my body learns to tolerate it—this, too can be carefully managed).

Bottom line: Opiates are consumed as a source of pleasure to illegal drug users and addicts, and used as a source of income to their dealers from all walks of life. For the former group, opiates ultimately decrease the quality of life. But opiates are also a source of life-sustaining relief to patients in pain, and when that pain is chronic rather than acute, the correct management of opiates may allow relief enough for the patient to cope and to have an improved quality of life.

We need to understand the difference, and not add to the problems of legitimate pain patients and their caregivers.

If anyone can understand the difference between illegal drug activities and the care of patients who require medical assistance at least to survive and perhaps be productive citizens, I am one who can, because of my own experiences and education.  I have been fortunate, despite being unable to tolerate medication, to have received enough support and alternative treatments to lead a productive life.

Chronic pain, untreated, destroys life. Brain research studies show deterioration in brain function where chronic disease goes untreated. That deterioration is very similar to the effects of taking too much medication, and in part also to that of addiction. Through all of this, families and other caregivers also suffer, along with the patient. Much is required of them, and it may also be difficult for them to cope. But they do it, day after day, year after year. This is my way of saying thanks to my caregivers now and through the years.

What we who share this situation ask of you is to proclaim one day: March 20th, the first day of spring, to honor the dedication and love shown by these heroes. To honor those who willingly give of themselves and their resources to make life possible—even bearable—for those who daily suffer in pain.

During the month of September we celebrated National Pain Awareness Month. Let’s now look forward to the end of the long winter months when pain and the difficulties involved with treating it seem so much worse. Let us have a day of new hope, of renewal and light in the former darkness of cold and pain. Most of all, a day to support those who give their lives to support others.

March 20th, 2015. The first National Pain Caregiver’s Day.

Please join us!