Day: 06/15/2016

Your doctor works for the DEA

http://www.pharmaciststeve.com/?p=15297

Michael Minas, MD, 51, a solo, independent family practice doctor in Eagle, Idaho, was indicted in June, 2014, with seventeen counts of distributing a controlled substance outside the usual course of professional practice and not for a legitimate medical purpose…

First Dr. Minas considered accepting a plea agreement based on 17 charges, but then, like the rest of us innocent physicians, decided to trust the justice system and go to trial. So the US Attorney countered by adding 129 additional charges to ensure conviction (total of 146)…

In an article by John Sowell of the Idaho Statesman, the prosecution is reported to say that Dr. Minas’s family practice clinic focused on pain, as if that was a crime. As a family practitioner whose primary practice also became pain management in a rural area because there was no one else willing, I can verify that this is not a crime and does not reflect illegal activity, but compassionate patient-oriented medicine…

Next comes the warnings to physicians of the future. The new laws being presented in states and now the federal government, makes even the simplest decision in pain management by a physician criminal…

The attorneys say Minas, as one of a few independent physicians in the Treasure Valley not affiliated with the Saint Alphonsus and St. Luke’s health care systems, was targeted by the government to set an example to doctors throughout Idaho who continue to provide pain medication outside a pain clinic setting. I expand that to read “outside a hospital-owned setting.” …

I know that in my case, the people [patients] I suspected to be drug dealers were never charged with anything when I informed the drug enforcement officer in my county, Mr. Larry Finley…

Dear NY Times: You Suck

I used to think that the New York Times was a liberal paper. When did they go over to the dark side? Maybe it all started with Maureen Dowd and the cannabis candy bar:

http://www.nytimes.com/2014/06/04/opinion/dowd-dont-harsh-our-mellow-dude.html

And the Times is known for lending its credibility to the opioid war. This article is the latest proof that the Times is running away from science. And so one has to wonder, how many white, middle-class employees at the Times have known and/or lost someone to drug addiction and the drug war? Or maybe they’re just choosing to be ignorant.

http://www.nytimes.com/2016/06/14/health/pain-treatment-er-alternative-opioids.html

Since Jan. 4, St. Joseph’s Regional Medical Center’s emergency department, one of the country’s busiest, has been using opioids only as a last resort. For patients with common types of acute pain — migraines, kidney stones, sciatica, fractures — doctors first try alternative regimens that include nonnarcotic infusions and injections, ultrasound guided nerve blocks, laughing gas, even “energy healing” and a wandering harpist…

St. Joe’s is even cautiously trying therapies not typically taught in medical school. A nurse practitioner is studying acupuncture for pain. And another nurse, Lauren Khalifeh, the hospital’s holistic coordinator, does a treatment called “pranic healing.” …

On a recent weekday in the E.R., John Schiraldi, 25, a recovering heroin addict, was grateful that his merciless kidney stone pain was ebbing not because of intravenous morphine — a conventional E.R. protocol — but because of a regimen that included intravenous lidocaine, a non-opioid analgesic…

St. Joe’s pediatricians used a non-opioid protocol including a nasal spray of ketamine, a powerful drug which, in low doses, has analgesic and sedative properties…

And so although emergency physicians write not quite 5 percent of opioid prescriptions, E.R.s have been identified as a starting point on a patient’s path to opioid and even heroin addiction…

The E.R. staff is beginning to embrace the non-opioid options. “I’m thrilled,” said Allison Walker, a nurse. “I’d hate to be the first to give Percocet to a teenager who dislocated his knee at hockey practice. And then he comes back a year later, addicted to opioids? I don’t want that on my conscience.” …

“St. Joe’s is on the leading edge,” said Dr. Lewis S. Nelson, a professor of emergency medicine at New York University School of Medicine, who sat on a panel that recommended recent opioid guidelines for the Centers for Disease Control and Prevention…

The Centers for Disease Control and Prevention calculated that in 2014 there were 10,574 heroin overdose deaths and 14,838 for prescription opioids…

This article from 2013 shows the progression of how hospitals deal with painkillers:

https://painkills2.wordpress.com/2014/11/20/3132013-new-victims-in-the-war-on-painkillers/

Under the new city policy, most public hospital patients will no longer be able to get more than three days’ worth of narcotic painkillers like Vicodin and Percocet. Long-acting painkillers, including OxyContin, a familiar remedy for chronic backache and arthritis, as well as Fentanyl patches and methadone, will not be dispensed at all. And lost, stolen or destroyed prescriptions will not be refilled. It only applies to the city’s public hospitals. Which means it will largely be poor people who are forced to suffer pain that can easily be treated.”

I’m not going to say that alternative treatments for pain don’t work, just that they only work for a very small percentage of the patient population — like the stories depicted in the Times article. And their benefits don’t appear to last very long. A true investigative reporter would follow up with these patients, see how they’re doing in a year or two. Of course, a real reporter would have shown all sides to this story.

I find it odd that I have a better understanding of addiction than these “professionals” who work in a hospital. Treating acute pain with a painkiller, like a teenager with a dislocated knee, rarely puts the patient on a path to addiction. However, ignoring acute pain can most definitely cause a chronic pain condition for that patient in the future. Unfortunately for patients, after your pain goes from acute to chronic, you no longer deserve treatment. And even if your pain is acute, you still may be refused treatment.

Under comments:

Cindy, NJ, June 10, 2016
Beyond frustrated that addiction is now treated as a disease but chronic pain disorders treated like a lifestyle decision.

Lilikoi, Hawaii, June 10, 2016
As a practicing Emergency physician, I would love to have access to more non-narcotic therapies for my patients. Are opiates the first line of therapy for severe acute pain? Yes, much of the time they are, though there are some conditions such as migraines and kidney stones that will often respond better to non-opiate meds. Unfortunately, only a fraction of the patients I see with pain have acute conditions like broken bones or freshly ruptured spinal discs. A majority of the patients requesting pain killers in the ER have chronic pain syndromes like fibromyalgia, cyclic vomiting syndrome, chronic migraine, and chronic low back pain. They’re in the ER because they’ve through the opiates prescribed them in other settings, and need a fix for more. They will swear loudly, like many commenters here, that only opiates will do anything for their pain. This is partly because they are addicted to a tremendously addictive class of medications that in long term use cause heightened sensation of pain – opioid induced hyperalgesia. But it’s also partly because they’ve never really been offered pain remedies other than opiates or over the counter pills like Tylenol and Ibuprofen.

It’s good to know how ER doctors feel about chronic pain patients, although I find it hard to believe that many pain patients seek help at the ER these days. This doctor appears to blame addiction on hyperalgesia, which I guess could happen. But it seems to me that doctors find it easy to place blame on a lot of things that don’t apply to most patients, mainly to switch the blame from doctors onto patients.

And if this doctor is talking about chronic pain patients, then believing that we’ve only been offered pills to treat pain is just a flat-out lie. More likely, he’s talking about those who suffer from drug addiction. And I’m sitting here wondering, what would be so bad about treating drug addiction with opioids? For ERs, I guess it’s about drug addicts coming back for more drugs, and the possibility of diversion. But if there wasn’t a drug war, what would be the problem with treating drug addiction? If drug addicts had easy and affordable access to their drug of choice, what harm would they do to the public?

Maggie Chin, NJ, June 10, 2016
“And so although emergency physicians write not quite 5 percent of opioid prescriptions, ERs have been identified as a starting point on a patient’s path to opioid and even heroin addiction”

As an EM physician, I write a fair amount of very limited (10 pills) opioid prescriptions for painful conditions such as renal colic or severe back pain. It doesn’t make sense to me to say that ED’s are a “starting point” if we prescribe small amounts. I have NEVER, in 11 years of practice, met an EM physician who would prescribe a month’s worth of an opioid as noted in the article. However, I look up patients in the state database before prescribing, and we often see patients who have been prescribed 120 pills or more by “pain management” physicians yet still come to the ED trying to get more.

A true drug-seeker will continue to complain of pain no matter what “alternative” you attempt (and I have tried nerve blocks on some of these patients), say they have allergies to all other pain medications, and dramatically complain of severe pain for all the ED to hear. Compound all this with patient satisfaction surveys and you have a no-win situation for docs who are already trying to take care of multiple very sick patients…

So, these drug-seekers (pain patients) aren’t considered to be “sick”? More of a nuisance than anything for this doctor, probably because doctors are refusing to treat them. It’s like, what are you doing here, in a hospital with sick people? Yes, I’m a doctor, I help sick people, but I can’t help you.

As a pain patient, it’s good to know what behaviors are considered red flags to doctors. Unfortunately, these red flags are also very real medical conditions, like an allergy to medications. I find it sad that this doctor believes that nerve blocks should actually work for most patients, when that’s just not true. And if the nerve block doesn’t work, it’s the patient’s fault? If the injection doesn’t work, the patient is a drug addict because she wants her pain to be treated?

Should doctors dismiss science because of the fear of addiction and the drug war? Too late, it’s already happened.

Reducing hormones to treat pain

http://www.theplayerstribune.com/2016-5-23-eugene-monroe-ravens-marijuana-opioids-toradol-nfl/

Before kickoff on game day, in NFL locker rooms all over the country, players wait in line to drop their pants. We call it the T Train.

I play for the Baltimore Ravens… The T Train is nothing more than a bunch of really large guys waiting to pull their pants down to get shot in the butt with Toradol, a powerful painkiller that will help them make it through the game and its aftermath.

Instead of an injection, some players opt for an oral form of Toradol. The effects are the same, though, and can last through the next day. Some guys don’t feel any pain for two days. Of course, that’s the point of these drugs — they block out the pain and reduce inflammation. But they also temporarily mask injury. That’s not a good thing if you get hurt during a game — you might need to address your injuries right away. But you feel nothing, so you do nothing…

When I was playing college ball at Virginia, I tore my shoulder up in a game against UConn in 2007. I was blocking Dan Davis, a defensive tackle who had been my high school teammate in Plainfield, N.J. At some point in the game I had hit Dan and felt something shift in my shoulder — but there was no immediate pain. Why would there be? I had gotten a T-shot before kickoff. The team doctors examined my battered shoulder on the sideline. My labrum was destroyed. I played the rest of the year while being treated with a combination of pharmaceuticals and physical therapy. When the season was over, my labrum was surgically repaired and I began a steady course of opioids and anti-inflammatories…

I know that I signed up to play one of the most physically demanding sports on the planet, and I love this game. But I can’t ignore the facts. The NFL and its athletes are not immune to the opioid epidemic in our country. Indeed, retired NFL players are more likely to misuse opioids than the general population because of unavoidable and recurring chronic pain. Football players also have a high risk of developing brain diseases such as Chronic Traumatic Encephalopathy (CTE) due to repeated head trauma suffered on the field. Given all this, it’s little surprise that retired NFL players misuse prescription painkillers at a rate more than four times that of the general population. There has to be a better way. There is a better way.

On March 9, 2016, I became the first active NFL player to openly advocate for the use of cannabinoids (medical marijuana) to treat chronic pain and head injuries…

https://www.drugs.com/toradol.html

What is Toradol?

Toradol (ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID). Ketorolac works by reducing hormones that cause inflammation and pain in the body. Toradol is used short-term (5 days or less) to treat moderate to severe pain.

Cannabis is also an anti-inflammatory, but I can’t tell you how it actually does that. But I don’t think that cannabis works by “reducing hormones.”

And I’ll just add that it’s not only football players who suffer from head injuries — it’s also veterans. And I think you’d be surprised at the number of average folks who also suffer from head injuries.