Tweet of the Week: Never, Ever Giving You Drugs in the ER

http://www.medpagetoday.com/PainManagement/PainManagement/

A parody of a Taylor Swift song spreads a meaningful message.

I only watched half of this video, because it bummed me out.  Besides, I don’t like Taylor Swift’s music.  But I guess pain patients should know how ER doctors and nurses feel about this whole mess, as well as knowing that attitudes aren’t going to change anytime soon.

Americans have been using the ER for health care because they can’t refuse to help you, but of course they do — and the care ain’t cheap.  I think every pain patient has already learned not to go to the ER for help.

Binge drinking disrupts the immune system, study finds

https://www.consumeraffairs.com/news/binge-drinking-disrupts-the-immune-system-study-finds-123014.html

The study led by Majid Afshar, MD, illustrates a potentially harmful effect of binge drinking that is not widely recognized, unlike the falls, burns, gunshot wounds, car accidents and other traumatic injuries generally associated with heavy drinking. One-third of trauma patients have alcohol in their systems.

In addition to increasing the risk of traumatic injuries, binge drinking impairs the body’s ability to recover from such injuries. Previous studies have found, for example, that binge drinking delays wound healing, increases blood loss and makes patients more prone to pneumonia and infections from catheters. Binge drinkers also are more likely to die from traumatic injuries.

I don’t think alcohol is a very good drug… but hey, it’s legal.

New weight-loss drug gets green light

https://www.consumeraffairs.com/news/new-weight-loss-drug-gets-green-light-123014.html

Saxenda is an injection that, when combined with a reduced-calorie diet and physical activity, helps treat obesity… Saxenda joins a number of new weight loss drugs recently approved by the FDA. In September, the agency gave a green light to Contrave.

This reminds me of when new anti-depressants kept being approved by the FDA — how many are there now?

The FDA evaluated the safety and effectiveness of Saxenda in 3 clinical trials that included approximately 4,800 obese and overweight patients with and without significant weight-related conditions.

The way this is worded, it’s like the FDA conducted the trials, not just evaluated them. Of course, the FDA is not in the business of conducting research — that’s Big Pharma’s job.

Weight loss drugs, of course, are not for everyone who just wants to lose weight. According to the Mayo Clinic, these drugs are usually reserved for people who haven’t been able to lose weight through natural means like diet and exercise, and who have health problems because of their weight. In other words, they aren’t for people who want to lose just a few pounds for cosmetic reasons.

Yeah, but overweight Americans will ask for a pill, you know they will, and doctors will begin prescribing them…

I know that a lot of Americans are fat.  Presumably, rates of obesity and diabetes are at epidemic proportions.  I’m just not sure these diet drugs are the answer.  However, it’s the patient’s choice — and the patient’s responsibility to research a drug before taking it.

Marquez v. Astrue (3/22/2011)

Click to access USCOURTS-idd-4_09-cv-00515-0.pdf

The mere fact that Petitioner has carried on “certain daily activities . . . does not in any way detract from her credibility as to her overall disability. One does not need to be ‘utterly incapacitated’ in order to be disabled.” Benecke v. Barnhart, 379 F.3d 587, 594 (9th Cir. 2004.)

The ALJ cannot reject a claimant’s subjective pain or symptom testimony “simply because the alleged severity of the pain or symptoms is not supported by objective medical evidence.” Lingenfelter v. Astrue, 504 F.3d 1028, 1040 n.11 (9th Cir. 2007).

Dr. Julie A. Muche

Dr. Julie Muche, NM Medical Society, and member of the New Mexico Prescription Drug Misuse and Overdose Prevention and Pain Management council

http://npino.com/npi/1033116298-dr.-julie-a-muche/

Dr. Julie A Muche is a physician based out of Albuquerque, New Mexico and her medical specialization is Physical Medicine & Rehabilitation. She practices in Albuquerque, New Mexico and has the professional credentials of MD.

http://www.yelp.com/biz/abq-health-partners-center-for-pain-management-albuquerque

ABQ Health Partners Center for Pain Management on Yelp

8/8/2013, Alan T. from Belen said:

was hopeful they would help my very sick partner and he was turned away for using legal medi pot!

They would prefer he takes very addictive narcotics obviously!

We followed a Dr who moved there from another practice who KNEW that he used medi pot and even wrote scrips. for marinol. We sat in the waiting room for an hour only to be turned away due to this NEW policy!

As usual these days its about that bottom line, NOT compassionate care!

http://www.physiatry.org/members/?id=14359900

Association of Academic Psychiatrists, Dr. Julie Muche, Profile Unavailable

https://webcache.googleusercontent.com/search?q=cache:uRJQNvYWMl0J:https://casetext.com/case/marquez-v-astrue-7+&cd=36&hl=en&ct=clnk&gl=us

Because this caselaw is behind a pay wall, I had to copy and paste this from the Google cache. Just a warning — don’t try to count the number of injections this poor pain patient had — you’ll get dizzy.

Dr. Sharp referred Plaintiff to Dr. Julie Muche, a physician specializing in physical medicine and rehabilitation at the Lovelace Medical Center. Dr. Muche saw Plaintiff on July 26, 2004, and she found that Plaintiff was experiencing coccygeal pain which radiated down into his lower right extremity and which he described as “burning, shooting, throbbing, constant pain.” ( Id. at 434-35). Dr. Muche noted that the July 2, 2004, x-rays showed “degenerative disk [sic] disease prominent at multiple level[s] and a several millimeter retrolisthesis at L3 and L4.” ( Id. at 435). She recommended certain physiotherapy techniques and she also prescribed Roxicet, Valium, and Nortriptyline to ease the pain and resulting insomnia. ( Id. at 439-40). *66

When Dr. Muche examined Plaintiff again in August of 2004, she found that the Nortriptyline was somewhat effective, but that Plaintiff continued to experience coccygeal pain and that he had a painful trigger point over the right paraspinal muscle. ( Id. at 225-26). Dr. Muche increased the dosage of Nortriptyline and prescribed a 2% lidocaine topical gel. ( Id.). Dr. Muche also administered a trigger point injection over the right paraspinal muscle in an effort to control the pain. ( Id.).

In September of 2004, Dr. Sharp referred Plaintiff to Dr. Mark Erasmus, a surgeon at the Lovelace Medical Center. (AR at 510-11). Plaintiff met with Dr. Erasmus on September 30, 2004, and Dr. Erasmus discussed the possibility of back surgery. ( Id. at 511). Plaintiff agreed to an epidural spinal injection in the hopes that it would resolve his back pain without needing surgery. ( Id. at 511).

The injection did resolve the back pain, and Plaintiff next saw Dr. Steven Bailey, a physiatrist at Lovelace Medical on October 11, 2004. ( Id. at 512-13). Plaintiff reported that the previous injections had provided relief for several weeks but that the pain then returned. ( Id. at 512). The pain worsened with prolonged sitting and Plaintiff reported tenderness over the right paraspinous muscles as well as tenderness around the coccyx. ( Id.). Dr. Bailey diagnosed Plaintiff with chronic low back pain and post fusion coccydynia.2 Dr. Bailey recommended a lumbar epidural steroid injection, which he administered that same day. (AR at 512-13).

Despite the temporary relief afforded by the trigger point and epidural injections, Plaintiff’s back pain returned every time within a few weeks. Plaintiff met again with Dr. Erasmus in October of 2004 to discuss his options. ( Id. at 510-11). Plaintiff reported to Dr. Erasmus that he had been experiencing constant, sharp, severe lumbar spinal pain over the last two months and that the pain radiated down his right leg. ( Id. at 510). He reported that the pain worsened while sitting down and that both forward and backward bending and even light touching produced pain. ( Id.). Dr. Erasmus diagnosed Plaintiff with spinal stenosis and he recommended surgery due to the spinal stenosis and persistent pain. ( Id. at 204, 510-11).3 Plaintiff agreed to the procedure and underwent an L3-4 foraminotomy on October 29, 2004. ( Id. at 509-11).4 While the pain abated following the surgery, it reemerged within several weeks. ( See, e.g., Id. at 219). During checkup appointment with Dr. Erasmus on January 27, 2005, scarring was found around the surgical site. ( Id. at 505).

On February 3, 2005, Plaintiff returned to Lovelace Medical and was seen by Dr. Malizzo. ( Id. at 503). Plaintiff continued to complain of lower back pain that radiated down into the right buttocks, which sometimes caused his right leg to ache. ( Id.). By reference to an MRI, Dr. Malizo found continuing nerve encroachment at L3-4 and L4-5. ( Id.). Dr. *88 Malizzo administered another epidural steroid injection and continued his pain prescription for Vicoprofen 4. ( Id.). Dr. Malizzo saw Plaintiff again on April 19, 2005. ( Id. at 501). Plaintiff continued to complain of pain in his lower back, right buttocks, and an aching sensation in his right leg. ( Id.). Dr. Malizzo found that Plaintiff was suffering from degenerative disc change with radicular pain and postlaminectomy syndrome. ( Id).5 Dr. Malizzo increased Plaintiff’s prescription for Vicoprofen 4. (AR at 501). A notation in Dr. Malizzo’s report indicates he told Plaintiff’s wife that he was reluctant to place Plaintiff at “total and permanent disability.” ( Id.).

Post-laminectomy syndrome, also known as failed back surgery syndrome, is used broadly to describe poor outcomes following back surgery. Symptoms typically include low back pain, stiffness, local tenderness, and pain radiating down into the legs. See, http://www.mdguidelines.com/post-laminectomy-syndrome

Plaintiff continued to see Dr. Muche repeatedly between 2005 and 2008. ( See, e.g., Id. at 400 (noting that Dr. Muche saw Plaintiff at least eight times between 2005 and 2007)). She saw Plaintiff in October of 2005 and found that Plaintiff had increased coccygeal pain, pelvic pain, continued spasms, tenderness to palpation, and that both left and right flexion and rotation of the spine produced pain. ( Id. at 484-85). She performed a L4-5 left-sided facet injection and a coccyx injection in November of 2005 to treat his back pain. ( Id. at 481). Between 2005 and 2008, Dr. Muche and a pharmacologist named Ernest Dole helped to manage his pain both by increasing medication dosages and prescribing narcotics such as morphine, oxycodone, and MS Contin. ( See, e.g., Id. at 454-63, 471-76). Dr. Muche administered another bilateral L4-5 facet injection in October of 2006 and two trigger point injections in November of 2007 in an effort to alleviate the pain. ( Id. at 453, *99 461). She then administered two more trigger point injections in March of 2008. ( Id. at 452). Plaintiff stated that, while the narcotic medications enabled him to manage his pain, they prevented him from concentrating or performing calculations. ( Id.).

Is this… torture?

La petite mort

From Wikipedia:

La petite mort, French for “the little death”, is an idiom and euphemism for orgasm. This term has generally been interpreted to describe the post-orgasmic state of unconsciousness that some people have after having some sexual experiences.

More widely, it can refer to the spiritual release that comes with orgasm or to a short period of melancholy or transcendence as a result of the expenditure of the “life force,” the feeling which is caused by the release of oxytocin in the brain after the occurrence of orgasm.

The term “la petite mort” or “the small death” does not always apply to sexual experiences. It can also be used when some undesired thing has happened to a person and has affected them so much that “a part of them dies inside”.

I could make a few comparisons here to the life of a chronic pain patient, including the death of a part of yourself and your old life when the pain becomes constant.

But this French term occurred to me because I can’t sleep… To me, sleep is similar to a “small death,” as my pain usually doesn’t follow me into unconsciousness.  I just wish getting to that state wasn’t so damn hard…

Of course, after la petite mort of sleep, the stiff and painful awakening is no fun either.

(Where is the Cannabis God when you need her?)

Update on North Carolina and Project Lazarus

https://painkills2.wordpress.com/2014/12/02/project-lazarus/

In the above post, we looked at North Carolina’s drug overdose problems, including Project Lazarus, which developed “a community-based overdose prevention program in Wilkes County and western North Carolina” in 2009.  But also mentioned in that story was a Chronic Pain Initiative by Community Care of North Carolina, “to help deliver better pain relief while reducing overdose risk at the same time. (CCNC is North Carolina’s non-profit Medicaid management entity.)”

In 2011, it was reported:

By the end of 2014, the Project Lazarus model of educating patients and physicians will be deployed in all of North Carolina’s 100 counties through North Carolina’s Community Care networks, the organizations that manage the care for most of the state’s Medicaid patients… North Carolina’s military community has also embraced Project Lazarus principles, employing the model policies on Ft. Bragg. Brason also said the Eastern Band of Cherokee Indian Reservation has adopted the full Project Lazarus model, and that they’re seeing results.

I wanted to see what the results were from Project Lazarus now that it’s been in effect for 5 years — but not through the eyes of those selling this model to treat pain patients.  It’s not surprising that the Narcan part of the model is working, but I wanted to know how North Carolina’s drug problems overall were affected by these programs.  And to see if there was any news on how pain patients were faring in this state.

So, let’s see what the news reports are saying…

http://www.newsobserver.com/2014/04/05/3757841_heroin-use-and-deaths-on-the-rise.html?rh=1

4/5/2014, Heroin use, and deaths, on the rise in North Carolina

A few dozen people died of heroin overdoses in North Carolina each year since 2000, according to the state Department of Health and Human Services.  But in 2012, heroin deaths nearly doubled statewide, to 148, while overall deaths from all narcotics and hallucinogenic drugs ticked up only slightly. WakeMed hospitals throughout Wake County admitted 50 people for heroin overdoses in 2013, more than twice the annual average of the previous five years, said spokeswoman Kristin Kelly. At the same time, police say the amount of heroin they’ve found in drug arrests has soared.

When deaths are only reported as overdoses, with little additional background information on the victims, we can only make assumptions. Were the victims chronic pain patients? Mental health patients? Since the increase was only seen with deaths involving heroin, then what does that tell us? Spoiler alert:  the CDC is about to enlighten us…

The surge in heroin use comes after what the Centers for Disease Control and Prevention called a nationwide epidemic of overdose deaths involving opioid pain relievers, including OxyContin, methadone and hydrocodone. In 2008, overdose deaths from opioid prescription drugs accounted for more than heroin and cocaine combined, the CDC reported in 2011.

Is it heroin alone — or opioids mixed with heroin — that’s causing the deaths?  Most deaths caused by overdose are due to the combination of opioids and drugs like alcohol and benzos, not heroin.

Public health officials say the resulting crackdown on pills has driven up the price and helped fuel the switch to heroin.

Making this connection puzzles me… Which people switched from pills to heroin?  Was it pain patients or those that suffer from addiction?

You know, I have a hard time believing that very many chronic pain patients would switch from prescription medications to heroin when denied access.  The patients that switched to heroin suffered from addiction, so what is the result of all these restrictions, regulations, and criminalization?

Well, it looks like drug addicts have much better access to pretend-opioid therapy and Narcan than chronic pain patients — not that either patient population is being adequately served.

Tessie Swope Castillo, who works as an advocacy coordinator with the state’s Harm Reduction Coalition, said the agency has “seen an anecdotal increase in the popularity of heroin, especially among young, white people and people of affluence.”

See how she just throws in the word “anecdotal”?  This sounds like a Department of Health program…

“People who might never have started using heroin because of stigma against it or fear of needles, for example, started on OxyContin and became addicted,” Castillo said. “And when their Oxy supply was cut off or became too expensive, they got desperate and turned to heroin.”

I’m confused, does Ms. Castillo know anyone personally that turned to heroin, or just because she’s with a government organization, she’s now considered an expert? Damn, I need to get me some of that instant status as an expert…

The state legislature passed a bill last year that beefed up the state’s prescription drug reporting system that aims to crack down on opiate-based prescription drug abuse. The bill, signed into law by Gov. Pat McCrory, was strongly supported by the N.C. Child Fatality Task Force after it found more and more young people abusing drugs such as oxycodone, OxyContin and Percocet.

Wherever you turn, there is some task force, coalition, project, or other innocuously named anti-drug group.  Put some important-sounding words together and you have yourself some respectability.  It’s not like the media ever investigates these groups or mentions how they’re funded… Sometimes, I think they’re all run by the same person… which they kinda are, if you consider the federal government a person, along with corporations.

The bill revised an earlier law that established a statewide reporting system to improve North Carolina’s ability to identify people who abuse and misuse prescription drugs. The law was also enacted to help medical providers identify patients who may be abusing prescription drugs. The revised law now requires a shorter reporting period and increases the penalties for violations.

This does not sound good for pain patients in North Carolina…

Tessie Swope Castillo said:  “I don’t know whether [the law] has actually reduced prescription drug abuse, but that certainly was its intent,” she said. “These types of laws have become very popular recently and most states have them, but the jury is still out about whether they actually reduce prescription drug abuse or merely divert abuse to other drugs.”

Childs explained that many of the young users who are now dying of heroin overdoses grew up in a “pill culture” and would pop pills that they had taken from family members or from a friend. He and other experts wonder if former narcotic pill users are turning to heroin, with disastrous results.  “We hadn’t seen such a spike in heroin deaths,” he said. “For people who have been using a long time, there was no change in the overdose rates. It’s the new users who don’t know what they’re doing. They can’t figure out how strong the heroin is. Sometimes, if they are worried about police involvement, they will rush to use the drug and not have a good overdose prevention plan. A bad plan is using by yourself, with no one there to call 911.”

I just can’t figure out anymore if “experts” are telling us what’s happening, or just guessing…

The governor signed another bill into law last year that’s meant to reduce drug overdoses by giving limited immunity to someone who seeks medical help for a person experiencing an overdose.

The government has not published statistics for drug overdose deaths in 2013, but Proescholdbell says that since McCrory signed the bill into law in June, nearly 50 people who would have died from drug overdoses were revived.

That’s great, but out of how many? And were they chronic pain patients?  Can you give me the number of chronic pain patients who are now without access to pain management in North Carolina?

http://wunc.org/post/prescription-drug-overdose-north-carolina

8/14/2014, Prescription Drug Overdose in North Carolina

Overdoses from illegal drugs like heroin and cocaine remain a problem for the state, but most overdose deaths come from abusing prescription pain medications. Wilkes County was once the face of the state’s prescription pill problem. However, will the help of community education programs and a new “miracle anti-drug” naloxone, the rural area has not seen a single death from a prescription opioid since 2011 that can be attributed to a Wilkes County prescriber.

So, you got rid of the county’s access to prescription pain medications, but what about the abuse problem itself?  Doctors quit prescribing pain medications in Wilkes County, and that’s seen as a success… but what kind of success is that?  What happened to the pain patients?

And c’mon, naloxone is a “miracle anti-drug”?  Like cannabis is a miracle drug? (Wait, cannabis could turn out to be a miracle drug…)

http://www.newsobserver.com/2014/12/26/4430772/two-powerful-street-drugs-behind.html

12/26/2014, Two powerful street drugs behind recent overdoses across NC

Fentanyl has been used by hospitals since 1968 to induce anesthesia in patients before surgery or to treat chronic pain. It is only available by prescription and is strictly controlled in hospital settings, said Dr. Ruth Winecker, chief toxicologist with the state Department of Health and Human Services. But now state toxicologists are seeing a spike in the street-level use of the drug that is not pharmaceutical grade but instead produced in labs and substituted for other drugs such as heroin…

I assume they’re talking about home labs — a side effect of criminalizing chemicals.

State analysts have seen about a 50 percent increase since 2013 in overdose cases where fentanyl has been detected, Winecker said… While fentanyl has been around for decades, acetyl fentanyl did not emerge as a street drug in North Carolina until about 1-1/2 years ago, state health and law enforcement officials say.

Let’s see, Project Lazarus began around 2009, which was about 5 years ago… If I was a pain patient in North Carolina without access to pain relief, how long would I last?

SBI agents are seeing more “clusters” of overdoses like the ones that occurred in Chatham County this month when illicit dealers sell mixtures of either acetyl fentanyl or fentanyl and heroin, said Donnie Varnell, an SBI special agent…

As Project Lazarus extends to other cities and states, I guess these are the kinds of problems we’re going to start seeing more of… I don’t think pain patients would switch to heroin, but fentanyl?  Fentanyl made me really nauseated, so I wouldn’t have made that choice, but I can see other pain patients choosing fentanyl with no problem.

“They are both very powerful,” Winecker said about fentanyl and acetyl fentanyl. “They are both narcotic analgesics, like the other drugs in that class. If you’re not in pain, you experience euphoria when you use them.

Isn’t that what chronic pain patients have been saying?  And could the same be true for a drug addict?  Or a chronic pain patient who is dependent on opioids?

A 29-year-old man reported that Michael Demetrius Currie, 41, had been found unresponsive on a deck outside… Currie died at his home.  Then… two people, Perry Logan Sanders, 23, of Aurora, Mo., and Randal Dee Welch, 24, of Franklinville, were both suffering from cocaine overdoses… The sheriff’s incident report indicated that one of the victims died at the home, while the second was pronounced dead at a hospital.

Okay, these don’t sound like pain patients… unless pain patients have started using cocaine.

An hour and a half later emergency dispatchers were called about another drug overdose involving three people… The victims’ names were not made public, but the incident report described them as two women, ages 18 and 25, and one 19-year-old man. Emergency workers transported some of the victims to hospitals in Siler City, Sanford and Chapel Hill. Others were treated on scene with Narcan, a brand of naloxone, a substance that counteracts the effects of drug overdoses for heroin and other opioids. “The Narcan knocked out the narcotic effects, and we didn’t have any more deaths,” Roberson said.

Thank goodness.

Hours after the overdoses, sheriff’s deputies arrested Edwin Maurice Pennix… State records show that Pennix has felony drug convictions dating back to 2010 and served time in prison in 2012 for the felony sale of cocaine. In 2006, when Pennix was convicted of involuntary manslaughter, cocaine played a role in the death of Darrle Jevon Harris.

___________

Well, there you have it folks.  It’s hard to tell what’s really going on in North Carolina with such little verifiable information, but it doesn’t look good…