Candy Land

http://www.revealnews.org/article/the-death-of-baby-ada-mae-and-the-tragic-effects-of-addicted-veterans/?Src=longreads

It’s easy to read the linked article and focus on one part of the problem with managing and treating pain:  drugs.  But while we work our way through this well-done article, let’s look more at what’s not being said.

This isn’t a story about drugs, the drug war, or the war against pain patients.  The term “chronic pain” isn’t even mentioned in this report.  These veterans appear to be seeking treatment from the VA psychiatric hospital for PTSD, not pain management.  And yet, with the high prevalence of chronic pain in the veteran community, I think it’s odd that this term isn’t a part of the article.

One of the reasons it’s so hard to treat veterans who suffer from chronic pain is that a significant portion of these patients are also suffering from PTSD, along with depression, bipolar, and other mental health conditions.  (I don’t believe that’s true for the overall pain patient population, although comorbid conditions, like mental illness, can be part of illnesses involving chronic pain.)

With pain patients who suffer from mental illness, doctors are attempting to treat two serious conditions — a very tricky thing to do, especially when using a hodgepodge of pharmaceuticals. Doctors tend to rely too much on what studies and research have shown about the effectiveness of these drugs, instead of individually monitoring each patient.  For instance, a sign of addiction in one patient may be a sign of something else in another, but every pain patient is labeled as a potential addict (and all the shame that goes along with that label).

After reading through this article several times, my overall impression is that this VA hospital and these veterans were trying to treat the after-effects of war, not chronic pain.  I don’t know how you can successfully treat the men and women who have seen and done such atrocities, but the VA has been trying for a very long time and the reason they’re unsuccessful is that the solution is antithetical to the agency’s reason for being — if you stop sending these people to war, a large part of the problem would be solved.  At least in the veteran community.

While the number of people who suffer from crime-related PTSD has decreased overall in the last few decades, the drug war has created more than enough PTSD victims to make up for this decline. The unstable economy has created even more cases of this illness, along with America’s crappy health care system.  And if the result of attempting to treat a chronic illness is bankruptcy, many people just go without treatment or self-medicate.  Some end up addicted to drugs and alcohol.

So, the question of how to effectively treat PTSD has still not been answered, at least with current treatments.  But like chronic pain and addiction, learning to manage and treat PTSD is so uniquely individual that the answer is not one treatment over another, one drug or another, but a combination of whatever works for each patient.  Standardizing the treatment of pain or any of these other conditions does not help patients.

The VA hospital in this article is not a pain clinic — it’s a psychiatric facility for veterans, and it has all the problems that go along with treating that patient population.  I think I can assume that these same problems existed with Vietnam veterans back then, and sadly, continue to exist today.  With all the marvels of medical science and technology, it is still quite difficult to treat the victims of conflict and war.  This is the price we all pay when we vote for continuing whatever war is being fought in our name.

In other words, the military created the problems described in this article, and it’s a freaking tragedy that we are focusing on PTSD and drugs when the real problem is war and all of its victims.  Men and women, paid to fight whatever enemies we create, come home and are expected to just get back to their lives… almost as if nothing happened.  Like their trauma didn’t happen.  It wasn’t real.  Like their pain… isn’t real.

Veterans are angry.  Many have been angry and hopeless enough to commit suicide.  Some use their anger to commit crimes, like domestic violence and robbery.  Some veterans prefer to be homeless rather than let their anger consume them.  Yet other veterans have decided to self-medicate their anger away.  Obviously, the system continues to fail them.

I understand anger and I know a lot about pain, but I’m not a veteran.  I don’t have the answers — but then, no one is depending on me to find them. Unfortunately, the VA doesn’t have the answers either, but they have millions of men and women depending on them.  And even more unfortunately, they are using the advice of “experts” like Andrew Kolodny of PFROP in their effort to change things, which I think is a mistake.  And so, the internet is now having to suffer from my long-winded responses to articles like this… unfortunately.

Maybe, in the future, long after I’m gone, the internet will decide that I knew what I was talking about.  New “experts” will look back and label me a genius. (It could happen.)  They’ll say, look, isn’t this what Johnna said would happen 40 years ago?  Why didn’t we just listen to her back then?  Ah, hindsight… on the internet… from words and visuals memorialized in the cloud.  It’s a wonderful thing…

http://www.revealnews.org/article/the-death-of-baby-ada-mae-and-the-tragic-effects-of-addicted-veterans/?Src=longreads

Dr. G. Caleb Alexander, co-director of the Center for Drug Safety and Effectiveness at the Johns Hopkins Bloomberg School of Public Health, has studied the widespread damage caused by opiates, which he attributes to their addictive potential and their ability to impair judgment.

Once again, much of the blame is going to opiates, when it’s drug combinations that are causing all this harm.

“You don’t have to be a criminologist to know that people who have dependence on these products may be driven to great lengths to self-medicate and treat their addiction,” Alexander said. “When these drugs are overprescribed…

Treat their addiction or treat their pain?  I wonder, how do you measure the pain levels of a veteran suffering from PTSD?  Or do I have to be a criminologist to understand pain and addiction?

And although it’s not mentioned, one of the “great lengths” patients go to for treating their pain is suicide, especially in the veteran population.  If veterans are self-medicating, does that suggest a problem of mistreating and under-treating their medical conditions?  Problems with affordability and access?

The report’s author, VA interim Undersecretary for Health Carolyn Clancy, told journalists that “a very large percentage of those patients” also receive benzodiazepine tranquilizers, such as Valium and Xanax, a combination that she said increases the risk for what she called “patient safety events.”

Yes, that’s true.  Valium can work for insomnia and Xanax treats anxiety, two problems that shouldn’t be under-treated.  But I think these drugs should be used in lower doses when they are used in combination with opiates, especially in patient populations with a high prevalence of alcohol use and abuse.

When police interrogated Schuster, he confessed to being an addict but said he had been to rehab and no longer abused the oxycodone Houlihan prescribed; nor, he said, did he abuse any of the other opiates, tranquilizers, antidepressants or antipsychotics officers had found at the scene…

Anti-psychotics to treat pain, no, but to treat PTSD?  Seems to me those drugs would just make things worse for PTSD patients.  Anti-depressants are successful in treating pain in a small percentage of patient populations, but only for certain conditions, like fibromyalgia.  Treating a chronic pain patient suffering from Traumatic Brain Injury with anti-depressants?  That doesn’t sound like a good idea.  And tranquilizers like Ambien?  I’d say that wasn’t a great idea either.

“We have a major problem with prescription drug abuse, but I don’t think we have a handle on it like we do with heroin and meth,” said Wausau police Chief Jeff Hardel.

I’m sorry, did I miss the report about how we have a handle on heroin and meth?

After McGovern was jailed, sheriff’s deputies charged him with criminal damage to property. He had used a juice box to carve the words “Kill Me Kill Me Kill Them” into his cell wall…

Sounds more like schizophrenia.

Five months after the theft, a police officer in Adams, Wisconsin, found Zimmerman passed out in the middle of the street with a .40-caliber Smith & Wesson handgun sticking out of the bottom of his shorts…

I guess anybody but a veteran found in that condition would have been quickly locked up in a psychiatric facility.  But veterans found with guns, even if suicidal, doesn’t seem to be too concerning to law enforcement.  Police have no trouble confiscated drugs, but guns?

When police asked him why a bottle of oxycodone prescribed the day before was empty, Ehlert said he had been selling the VA-prescribed narcotics in front of the hospital’s addiction treatment center. He also mentioned that he had shared his painkillers at least a dozen times with McGovern, who promised to pay him but never did…

The drug war and America’s health care system create the conditions for narcotics to be sold under the table — to people who can’t afford to see a doctor, for people who self-medicate rather than face the shame of being treated for drug addiction, for immigrants unable to access health care services in this country, to drug dealers unable to find work that pays enough to feed their families.

Soon, Jason Bishop was receiving a witches’ brew of powerful medications, including amphetamines, benzodiazepine tranquilizers and two types of morphine… Hospital staff call the combination of medications prescribed to Jason Bishop the “Houlihan Cocktail.” …

C’mon, “witches’ brew”?  Are doctors witches now?

The Houlihan Cocktail runs counter to the VA’s own regulations, which warn doctors to be especially cautious when prescribing addictive narcotics to patients with mental illness. Doctors also are supposed to avoid prescribing tranquilizers and opiates to the same patients, because the combination can cause them to stop breathing…

How do you treat insomnia in a chronic pain patient?  Drugs, or tranquilizers, is one way.  And I tell you what, not treating insomnia really shouldn’t be an option.  As both old and new research indicates, sleep is one of the most important functions of the human body.  The brain cannot function with adequate sleep.

“Using amphetamines off-label for PTSD sounds strange, and that would be a controversial use of amphetamine,” said Andrew Kolodny, the Phoenix House medical officer. “I would hope that a physician engaging in a dangerous and questionable practice would be able to point to real evidence supporting that practice.” …

Well, hello Mr. Kolodny, how’ve you been?  Are you still working in New York or do you spend most of your time with the big boys in Washington, D.C.?  And are you up to your old tricks of confusing the issue again?

Using drugs off-label is not a “dangerous and questionable practice” — doctors do it all the time, and sometimes it works.   In fact, I saw a headline the other day about how they’re using Prozac to treat… well, it wasn’t to treat depression. Using stimulants to treat PTSD does sound strange, but pain specialists use these drugs to counteract the effects of opioids, so it’s not unheard of.

Really, Mr. Kolodny, you have a bad habit of questioning the practices of other doctors, willy-nilly, as if it was nothing.  How do you feel when one of these doctors you preach against winds up in jail?  Does that make you feel good?  What happens when the DEA comes for you?  Or did you just quit prescribing drugs on the DEA’s watch list, like other doctors?  Yeah, as long as bupe is being supported by the federal government, you’re in a nice, cushy place.  How long before bupe has the same reputation as methadone?  Dude, did you forget about the drug war?

In his patients’ medical charts, Houlihan justified his use of amphetamines for PTSD patients by citing research – a paper published in 2011 in the Journal of Psychopharmacology by Dr. David Houlihan.

The paper is not based on a typical double-blind study, with one group of patients receiving an experimental treatment and a control group of patients receiving a placebo or conventional therapy. Instead, it is a narrative describing three combat veterans who Houlihan said improved after he provided them with Ritalin, a stimulant typically associated with reducing hyperactivity in children…

I suppose Dr. Houlihan might have had trouble if he tried to get a trial started treating PTSD with Ritalin.  As those who suffer from PTSD also suffer from hyper-awareness, I would think Ritalin wouldn’t be a good fit.  And doctors who treat PTSD (like those who treat chronic pain) don’t have a lot of options for patients, so trying new things isn’t necessarily a bad thing.  But using all of his other patients as guinea pigs in his own Ritalin experiment obviously was not a good thing.

While I was seeing Dr. Hochman in Texas (see my post, “In Memory of Dr. Joel Hochman from Texas”), he once tried to run a trial for some new kind of treatment. It was similar to the TENS unit. I wanted to help him, so I tried it a few times; but not only was it ineffective, it was irritating and unpleasant.  I don’t know what happened with that research, but I suppose if it had been successful, that product would be flying off the shelves.

Morphine, Ritalin, and Xanax, the Houlihan cocktail.  Mr. Bishop was on 4+ milligrams of Xanax per day, which I believe is close to or at the maximum dosage for that drug.  He was prescribed morphine at 30mg dosages, one in the immediate release formulation, and an extended release version — I don’t think that’s a very high dosage of opioids. The quick-action and sustained-release dosages of Ritalin, at 10mg and 20mg respectively, don’t seem that high either, but I don’t know very much about Ritalin.

For his part, Jason Bishop said he’s been seeking acupuncture, surgery and other treatments to get to the root of his pain. His medical record shows he’s been receiving the Houlihan Cocktail, but he said he hasn’t been taking all of his pills.

Instead, he’s hidden nearly full bottles of morphine sulfate, Xanax and Ritalin in a drawer underneath his bed where his daughter won’t see them.

“Every time I went in there, I would get asked, ‘Do you need more?’ ” Jason Bishop said of Houlihan and other doctors at the Tomah VA. “I would say, ‘No, I don’t need more, I don’t want more, find something that works for me and fix the problem.’ ”

And here is the main problem:  Mr. Bishop, like many pain patients, believes his pain can be fixed. By more surgery?  The odds of pain relief obtained from surgery are rather low.  And why is he hiding his pills?  Why pay for treatment you’re not going to use?  That doesn’t make sense.

No, what Mr. Bishop needs is the drug of acceptance.  Unfortunately, that doesn’t come in a pill.

I don’t know if I can identify the people in this article as victims of the drug war — but they are victims of war, so here are their names:

Brian Witkus

Angela Colby

Matthew Schuster

Jason Simcakoski

Jacob Ward

Michael Bobak

Tracey Small

Derik McGovern

Lucian McGovern

Damien Ehlert

Jacob Zimmerman

Timothy Benton

Kevin Underwood

Jason Bishop

Ada Mae Miller and her family

(And seriously, thanks for reading all the way to the end of this very long post. Gracias.)