The skateboarder is my favorite :)

While it might not look like it, this interactive art made by the street artist slinkachu is an interactive game of find and seek. He made various works of tiny art all over London and then had a prize for the first person who found them…

(7/17/2015) VA must strike better balance in managing veterans’ pain.

The two-part Star Tribune series, which ran Sunday and Monday, documented a different though equally disturbing facet of pain medication mismanagement. The series’ findings suggest that the VA system swung too suddenly in the other direction after the national spotlight on overprescribing. Veterans with a legitimate need for powerful pain medications aren’t getting them or are facing unacceptable delays in getting refills. The VA also appears to have been ill-prepared to help veterans access alternative therapies — such as acupuncture — during pain medication tapering.

The series’ findings merit the same kind of scrutiny that overprescribing did. Veterans should not be imprisoned by pain because doctors are unwilling or unable to prescribe the medications they need…

Part 1

Williams eased the chronic pain with the help of narcotics prescribed for years by the Minneapolis Veterans Medical Center. Then the VA made a stark and sudden shift: Instead of doling out pills to thousands of veterans like him — a policy facing mounting criticism — they began cutting dosages or canceling prescriptions, and, instead, began referring many vets to alternative therapies such as acupuncture and yoga.

At first, the change seemed to work: Worrisome signs of prescription drug addiction among a generation of vets appeared to ebb. But the well-intentioned change in prescription policy has come with a heavy cost. Vets cut off from their meds say they feel abandoned, left to endure crippling pain on their own, or to seek other sources of relief.

Or worse.

On Sept. 20, 2013, police were called to Williams’ Apple Valley home, donated to him by a veterans group grateful for his sacrifice. Williams, 35, lay dead in an upstairs bedroom. He had overdosed on a cocktail of pills obtained from a variety of doctors.

Authorities ruled his death an accident, officially “mixed drug toxicity.” Advocates for veterans and some treatment counselors angrily call it something else: the tragic result of the VA’s failure to provide support and services for vets in the wake of the national move away from prescription pain pills.

At the VA’s Medical Center in Minneapolis, for instance, there is one chiropractor on staff for the more than 90,000 patients it sees a year…

Before alternative therapies can work, Kolodny said, the VA needs to better tend to the addicts it has created…

The Minneapolis VA, which had one of the highest rates of high-dosage prescription pain medications, has embraced the new directive to reduce painkiller use among its patients. It pioneered a program that emphasized education and alternative therapies like yoga, chiropractic treatment and acupuncture. In a three-year period from 2011 to 2014, it reduced the number of veterans on long-term high-dose opioids by 78 percent…

In their published findings, Marshall and his colleagues wrote that there were fewer complaints than expected. “Patients mostly appreciated what we were doing,” said Marshall, who now directs pain management programs at the Minneapolis VA and the VA’s Upper Midwest region. While the paper recommended further research into patient satisfaction, the study surveyed only providers and pharmacists…

Although statistics aren’t available, deaths of vets linked to the VA’s pain policy are showing up in headlines around the country.

Last July, Navy veteran Kevin Keller drove himself to a drugstore parking lot next to a VA community clinic in Wytheville, Va., late at night, walked to the door of the clinic and shot himself in the head.

In recent years Keller had complained that VA doctors were reducing his pain medication. Keller had scribbled a note to a friend. In capital letters it read: “SORRY I BROKE INTO YOUR HOUSE AND TOOK YOUR GUN TO END THE PAIN! FU VA!!! CAN’T TAKE IT ANYMORE.”

In October 2013, Todd Roy, a 45-year-old Persian Gulf veteran, shot himself in the head with a shotgun in friend Charlie Bollman’s garage in Watkins, Minn. In 2008, the VA, citing alcohol and drug abuse, had cut off Roy’s Vicodin for pain in his arm and shoulder…

For more than 40 years, Vietnam vet Peter Ingravallo has suffered back pain after being hit with shrapnel during an ambush. With a 100 percent disability rating, Ingravallo took 25 milligrams of oxycodone every four hours until the Minneapolis VA sent him a letter telling him it was reducing his medications by 70 percent. It also warned that he would lose his benefits if he got meds from somewhere else…

Some vets have been warned that if they don’t take part in educational programs, they won’t get prescriptions. Failure to submit urine samples could result in expulsion from the program.

Vets also complain of being kicked out of programs for failing “pain contracts” they were ordered to sign. The contracts require the vets to agree to submit to urine screenings and to take one of several VA opioid safety classes or risk being denied their medications…

Ryan Trunzo’s descent from promising soldier to drug addict is detailed in more than 500 pages of medical files and Army reports…  Trunzo, who was 19 when he joined the Army, served in Iraq from February to November 2008 and was injured when his convoy was hit by a roadside bomb. He suffered several small fractures in his back and was given some painkillers.

There were other traumas: the death of a close friend, the shooting death of an Iraqi boy and an incident in which he said he was ordered to stand guard while a superior officer sexually assaulted an Iraqi woman…

But, because of a history of addiction during his military service and the change in VA policy, for the pain Trunzo got tablets of nothing stronger than over-the-counter-strength ibuprofen…

Part 2

The Minneapolis VA hired its first chiropractor in 2014 and was overwhelmed by the response, with more than 850 visits in less than five months. Because of the demand, 23 veterans have been allowed to make appointments with chiropractors outside the VA. The Minneapolis VA said it hopes to have its second chiropractor in place this summer.

Dr. Carolyn Clancy, then the interim VA undersecretary of health, told a congressional committee in June that the VA is conducting research to identify predictors for veterans who abuse opioids and which veterans might respond best to nonnarcotic treatments…

What is Stepped Care?

(May 2001) Stepped Care for Back Pain: Activating Approaches for Primary Care

Interventions that encourage return to normal function and reduce fear of physical activity have been shown to improve outcomes for patients with back pain, but routine medical care for back pain often does not provide such interventions. This paper proposes a stepped-care approach that addresses the functional outcomes of back pain. Step 1, which is relevant to most patients, addresses the common fears of patients with back pain and encourages patients to resume normal activities. Step 2, which targets the substantial minority of patients who require more than simple advice to resume activities, provides brief, structured interventions that support physical exercise and return to normal activities. Step 3 targets patients who require more intensive interventions, including treatment of psychological illness when present, before they can return to normal activities in work and family life.

Do you notice something missing in this approach to treatment?  Shouldn’t there be a goal to treat and reduce pain?  By pushing (forcing) patients to return to normal activities, isn’t that creating a potential for more damage and pain?

The paper points out that the VA has not lived up to its own standards.

Minnesota U.S. Rep. Tim Walz, a veteran, rightly points out that the Veterans Health Administration has failed to fully implement a best-practices medical treatment blueprint — the Stepped Care Model of Pain Management — that was established by a system wide “Pain Directive” in 2009. Walz authored the 2008 legislation that led to the pain directive’s creation.

Nimmo pointed out in his op-ed, Here at Huntington, we are offering complementary and alternative therapies, including acupuncture, animal-assisted therapy and art therapy.

Chiropractic services are available through the Veteran’s Choice program. We have an interdisciplinary pain team working with providers to find alternative treatments that will help reduce a veteran’s long-term dependence on opioids…

Do you notice something missing here?  The goal should be to treat and reduce pain, not just to reduce long-term dependence on opioids (which is another way to say addiction).

(May 2015) Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan Conflicts: A Randomized Clinical Trial

The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain:

A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

Background: Increases in prescriptions of opioid medications for chronic pain have been accompanied by increases in opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness.

Purpose: To evaluate evidence on the effectiveness and harms of long-term (>3 months) opioid therapy for chronic pain in adults…

Data Synthesis: No study of opioid therapy versus no opioid therapy evaluated long-term (>1 year) outcomes related to pain, function, quality of life, opioid abuse, or addiction. Good- and fair-quality observational studies suggest that opioid therapy for chronic pain is associated with increased risk for overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction, although there are few studies for each of these outcomes; for some harms, higher doses are associated with increased risk. Evidence on the effectiveness and harms of different opioid dosing and risk mitigation strategies is limited.

Limitations: Non–English-language articles were excluded, meta-analysis could not be done, and publication bias could not be assessed. No placebo-controlled trials met inclusion criteria, evidence was lacking for many comparisons and outcomes, and observational studies were limited in their ability to address potential confounding.

Conclusion: Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function…

Disclosures:  Dr. Chou reports grants from the Agency for Healthcare Research and Quality during the conduct of the study and consultancies for the U.S. Department of Health and Human Services, the Physicians’ Clinical Support System for Opioids (funded by the Substance Abuse and Mental Health Services Administration), the Mayday Foundation, the Collaborative Opioid Prescribing Education for REMS (funded by the University of Washington)…

Donaghue and Mayday’s co-funded research grant supports a team of researchers and clinicians led by Robert Kerns, PhD who are testing the implementation of a stepped-model of pain management that will improve skills needed to treat pain at the primary care level; the research is being conducted with veterans served at the West Haven VA Connecticut Healthcare System. The grant, which is $880,000 over four years, began in 2010…

(December 2014)

The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined.

OBJECTIVE: Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period.

KEY RESULTS: The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased.

These studies are only about the “success” of restricting opioid therapy, not about the success of patient outcomes.

Casper The Ghost #3

Casper the Ghost
Invisible to most
Especially to those
for this I compose
Who know not of pain
with nothing to gain
to help those who strain
in this world to remain

Can’t possibly know
the effects I suppose
of pain that corrodes
Of dislike that grows
and grows and grows
from all of their foes
into shit which explodes

(Photo taken 3/21/2015.)

Casper The Ghost #2

Note:  As of today’s date, no replies to these emails (above and below) have been received.

Wed, Jul 15, 2015 8:16 am

To: Dr. Steven Jenison (
Re: An alternative to suicide?

Dear Dr. Jenison:

I was happy to hear of your reinstatement to the Medical Advisory Board for the Medical Cannabis Program, and your successful efforts so far, especially on behalf of chronic pain patients.

I am writing to you because I am in desperate need of help. I’ve written to the Department of Health, Lynn Hart (formerly with the State Medical Board), all of the Producers in the program, the Drug Policy Alliance, Medicare, the Social Security Administration, and Dr. Katzman at the UNM Pain Center — all to no avail. (See links below.)

I have suffered from intractable pain for 30 years. I moved from Texas to New Mexico for the Medical Cannabis Program, but after a year as a member, I could no longer afford the program. The move and a year in the program have wiped me out financially. I couldn’t even afford to see a doctor to update my Long Term Disability insurance, and my benefits have since been terminated.

While I understand I now only have to see one doctor for re-certification, that annual expense will reduce my ability to pay for the medicine I need on a daily basis. Why pay to join the program when I can’t afford to pay for an adequate amount of medicine? Not to mention that during the year I was in the program, 80% of my purchases were not strong enough to treat my chronic pain.

And my medical records (MRIs, etc.) are over five years old, which appears to mean that I will have to pay for updated tests to be eligible for New Mexico’s program. In my letter to Medicare, I’ve asked if these expenses would be covered, but it’s been over 4 months and I haven’t received a response.

Since I was approved for Social Security Disability, why can’t that be good enough for the Medical Cannabis Program? Why must I continually have to pay for doctors to review my medical records to prove once again that I am disabled by intractable pain?

Even with my very limited financial capabilities, I’ve been trying to save money to move to Colorado where the cost of medicine is more affordable. I really thought I would be able to suffer through this period without any way to manage my pain, but I now realize that will be impossible. And do you know how I know this? Because I’m sitting here thinking about buying a gun. It’s a sad fact that it’s easier and less expensive to purchase a gun in New Mexico than it is to purchase medical cannabis.

So I find myself once again begging some stranger for help and/or advice. Thanks for reading this email.

Johnna Stahl

(Photo taken 2/19/2015.)

Calling All Angels

“Calling All Angels” by Train

I need a sign to let me know you’re here
All of these lines are being crossed over the atmosphere
I need to know that things are gonna look up
‘Cause I feel us drowning in a sea spilled from a cup

When there is no place safe and no safe place to put my head
When you feel the world shake from the words that are said

And I’m calling all angels
I’m calling all you angels…

(Photo taken 4/2/2015.)