Insurance companies and the war against pain patients

http://www.managedcaremag.com/archives/2015/6/confronting-epidemic-opioid-overdoses

Meanwhile, the Coalition Against Insurance Fraud, a group that includes insurers, government regulators, and consumer groups, estimates opioid abuse costs over $70 billion each year…

There are some bright spots in this otherwise grim picture. The rate of increase in opioid overdoses has notably slowed in recent years; in fact, the number of deaths from opioid overdose declined by 5% from 2011 to 2012. Many states have implemented polices that require providers to check databases of prescriptions for controlled substances before they prescribe certain medications…

Most of the blame for the opioid abuse epidemic has been directed at the companies that make and market the drugs. But private and government payers have also been criticized for, at the very least, not doing enough to stop it. Stingy coverage of a more integrated approach to chronic pain management means doctors are more apt to depend on opioid prescriptions, say the critics. There’s also been some finger pointing at formularies that put tamper-resistant opioids on more expensive tiers and impede access to the buprenorphine–naloxone combination (Suboxone) used to treat opioid addiction. The GAO and Pro Publica, the not-for-profit investigative journalism organization, have published reports critical of the CMS and its Medicare Part D program for allowing dangerous prescribing practices, including excessive prescription of opioids.

But if you are part of the problem, you can also be part of the solution, and health plans have been taking steps to rein in rampant opioid prescribing. For instance, Aetna implemented a misuse, waste, and abuse program involving clinical pharmacists, care managers, and behavioral health clinicians. The program coordinates efforts across departments to encourage safe prescribing, identify members at risk, and provide appropriate support to fight addiction.

“When an opioid pharmacy claim overlaps with a buprenorphine pharmacy claim, we notify the prescriber within 48 to 72 hours by fax,” explains Celynda Tadlock, PharmD, vice president of Aetna Pharmacy Management. “An Aetna pharmacist then calls the provider three days following the fax notification. Ultimately, we want the provider to contact the member to stop continued opioid use.”

Anthem identifies members who have filled 10 or more prescriptions for controlled substances within a three-month period. (Members with cancer or multiple sclerosis are excluded.) Over 61% of the members identified had a reduction in the number of opioids after the intervention.

CeltiCare Health Plan in Massachusetts looks at providers’ prescribing practices and the percentage of their prescriptions that are controlled substances. Outliers are flagged for educational outreach, typically starting with a letter or phone call sharing the data that compares their prescribing practices to those of their peers.

“We can and do refer them to our behavioral component for face-to-face education,” says Robert LoNigro, MD, CeltiCare’s chief medical officer. Of course, physicians are given a chance to explain their prescribing patterns. CeltiCare is exploring additional programs, including a hot line for providers to obtain real-time information about opioid prescribing and risk-modeling tools to help them identify which of their patients might be at a higher risk for misusing opioid medications.

Blue Cross and Blue Shield of Massachusetts spotted a problem in its claims data about three years ago when it became clear that a small percentage of its members were being prescribed a disproportionate share of opioid analgesics, says Tony Dodek, MD, the plan’s associate chief medical officer. The insurer introduced a program—developed with an outside panel of physicians, pain experts, and addiction specialists—to reduce the volume of opioid prescribing while protecting those members with legitimate treatment needs. Steps include limiting the supply of short-acting opioid analgesics to two 15-day periods over two months (with some well-defined exceptions) and requiring providers who prescribe long-acting opioids to start with short-acting medications. Dodek says his company also began sending prescribers reports that list their patients for whom they have prescribed opioids. During the first 18 months of this effort, called the Prescription Pain Medication Safety Program, prescriptions for short-acting opioids fell by 20%, and prescriptions for long-acting ones fell by 50%…

PBMs and the national drugstore chains are also talking up their efforts to quell opioid abuse. For example, on its website Express Scripts describes a program designed to limit opioid abuse among those getting prescriptions through worker compensation. When an injured worker presents a prescription at the pharmacy, the company’s claims processing system calculates its morphine equivalent dose (MED). If the prescription dose is over certain MED limits, it is submitted to the payer for a special review and the prescribing physician is sent a reminder about the guidelines for prescribing opioids. The company also uses a pharmacy “lock in” program for some claimants. Their prescriptions for drugs likely to be abused can be filled at just one pharmacy and sometimes the script can be written by just one prescriber.

Two years ago, CVS Health executives announced in the pages of the New England Journal of Medicine that the company had identified physicians with unusual patterns of prescribing high-risk drugs (alprazolam, a benzodiazepine, and carisoprodol, a muscle relaxant, as well as hydrocodone, oxycodone, and methadone) by combing through its huge cache of claims data. The company discovered 42 outliers and banned 36 from fulfilling prescriptions at their stores.

But the DEA has gone after CVS—and its rival, Walgreens—as part of a crackdown on prescription drug abuse. Last month, CVS agreed to pay a $22 million settlement after a DEA investigation found that employees at two of its pharmacies in Sanford, Fla., dispensed controlled substances without legitimate prescriptions. In 2013, Walgreens reached an $80 million settlement after the DEA found problems with record keeping and prescribing practices at a distribution center and six of its retail outlets in Florida…

Andrew Kolodny, MD, praises payers who are getting involved in fighting the opioid abuse epidemic. Kolodny, the chief medical officer of Phoenix House, a New York City drug and alcohol rehabilitation program, and president of Physicians for Responsible Opioid Prescribing, calls Blue Cross and Blue Shield of Massachusetts’s program “very smart.” It is important, he says, for payers to work on reducing the number of Americans starting opioid therapy for chronic pain because once they are on it, stopping is often difficult. Kolodny spreads blame for the opioid addiction epidemic around: “The FDA has been awful on this issue,” and he mentions a “well-financed misinformation campaign” by pharmaceutical companies. But he would also like to see state medical boards and the medical community get more involved. Tamper-resistance opioids might be helpful but because most people get addicted to the oral formulations he expects them to make “only a very small dent in this problem.” It comes down to this for Kolodny: “Opioids are lousy drugs for most people with chronic pain,” and we have to come up with better ways for helping people suffering with pain that won’t go away.

Let me make this one fact very clear:  Andrew Kolodny is not an expert on the treatment of chronic pain.

250 labels used to stigmatise people with mental illness

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1925070/

Most young people who are mentally ill do not seek help. Yet mental illnesses among children and adolescents are common, affecting about 10% of young people. The rates for some mental disorders, including suicide, are increasing. Up to half of those who fail to complete secondary school have mental illness. Those who do, more often turn to friends and family for help than to health professionals. Teenagers seek help less often than adults. As few as 4% of young people with a mental illness seek help from a family doctor, and consultation rates are especially low among young men. This paper argues that the stigma against mental illness is a powerful (and potentially reversible) contributory factor towards the reluctance of many young people to seek help for mental illness…

Conclusion:  Our findings suggest the hypothesis that help-seeking by mentally ill young people may be improved by interventions that address both their lack of factual information about mental illness, and those which reduce their strong negative emotional reactions towards people with mental illness.

Click to access NAABT_Language.pdf

Stigma remains the biggest barrier to addiction treatment faced by patients. The terminology used to describe addiction has contributed to the stigma. Many derogatory, stigmatizing terms were championed throughout the “War on Drugs” in an effort to dissuade people from misusing substances. Education took a backseat, mainly because little was known about the science of addiction. That has changed, and the language of addiction medicine should be changed to reflect today’s greater understanding. By choosing language that is not stigmatizing, we can begin to dismantle the negative stereotype associated with addiction…

http://www.talkingdrugs.org/ending-stigma-people-first-language-drug-use

There is an endless list of words frequently deployed to describe both recreational and problematic drug users — “druggie”, “crackhead,” “addict,” “junkie” — with the language overwhelmingly derogatory and offensive…

As the Drug Policy Alliance notes, there is “no physical or psychiatric condition [that] is more associated with social disapproval and discrimination than substance dependence.” As the sociologist Erving Goffman wrote in the 1960s, stigmatization is an informal social control and one that seriously damages an individual’s social identity.

Yet, in spite of this, the vitriol aimed at drug users lingers.

Stigmatizing language pervades all spheres, from society and medical professionals, to the media and politicians. When the latter group do admit to having tried drugs in the past, their tone is generally one of deep regret. These supposedly guilt-laden “confessions” imply that there is always a severe lack of judgement present when an illicit substance is consumed and reinforces the idea that any form of illicit drug use is fundamentally wrong. Hardly the case.

A recently published Substance Abuse article unravels the complex web of language around drug use, highlighting the detrimental impact stigma can have, particularly in the field of addiction…

What No One Tells You About Chronic Pain as a 20-something

http://www.slightlydistresseddamsel.com/

After seeing rheumatologists, GPs, physiatrists, PTs, sports medicine doctors, geneticists, neurologists, pain specialists, endocrinologists, and orthopedic surgeons, I was still not getting anything useful from anyone. I had a posse of residents following me around the hospital and calling me 24/7 to ask me questions. Nurses would make little cracks about “Erica and her entourage.”

I was in so much pain that I was willing to try anything, including hypnotists and private meditation counselors. But it was finally decided that I had tried enough, and the only step left was to go to Johns Hopkins Hospital. I managed to get an appointment with the top pain specialist in the country, and in July of 2013, he diagnosed me with Chronic Myofascial Pain Syndrome, Hypermobility-Type Ehlers Danlos Syndrome and hypothyroidism. With these diagnoses he told me, as gently as he could, that there was a good chance it would never get better, and that there was a serious possibility I might never work again…

Not many people can relate to all of this. The fear, the immaculate planning, the general anxiety, the stuff you have to put up with from doctors and the judgment from people in general. I lost many good friends in this process—even people I thought I was really close to. The last two years have been gruesome, not just physically but psychologically. Watching all of your friends grow in their professions and their relationships—their lives overall, really—is hard to watch from your bed…

What to Pack When You Need to Go to the ER…

When I went to see my geneticist at GBMC, we could tell some of these were allergic reactions and some were something else, so she ordered me a Genelex Youscript Test. It’s a pricey one, but luckily my insurance covered it. It’s a swab cheek test that analyzes how well you metabolize certain drugs. It’s very confusing to read, even for most doctors but a lot of the reps there are very good at explaining to the least science-y person ever. But, no surprise, I was an “intermediate metabolizer”/slow metabolizer for the phenotype that includes many painkillers and antidepressants…

How painkillers are turning young athletes into heroin addicts

http://www.si.com/more-sports/2015/06/18/special-report-painkillers-young-athletes-heroin-addicts?xid=si_topstories

A foot injury his junior year didn’t derail Roman. He needed minor surgery on a small bone, but he popped some OxyContin and after a few weeks was back on the mound.

Oxy for minor surgery?  Since this was legally prescribed to him, I would want to know his doctor’s reasons for doing so.  Seems like there’s a lot of doctors who cater to athletes, giving them whatever they want so they can keep playing, especially on professional teams.

His senior year Roman planned to lead Eldorado to a state title and then declare for the 2008 major league draft (the Braves had expressed the most interest in him), spurning about 20 Division I scholarship offers. Before the season, though, Roman committed one of those judgment-deprived acts for which teenagers are known. He and some friends used a stolen credit card at a mall. They got caught. The school found out. Though it was Roman’s first offense, he was kicked off the team.

There are plenty of teenagers who don’t steal or try to use a stolen credit card at the mall. And I think his parents are just guessing that it was the first time he exhibited this type of behavior; that this was his first offense. Yes, it might have been the first time he had been caught, but I really doubt it was his first criminal act. I would say Roman was one of those people who liked risk and was comfortable with it — maybe taking risks even gave him a thrill and adrenaline rush, just like athletics. I would also say that these kinds of people are at a high risk for drug addiction.

Humiliated, angry and depressed, Roman thought back to the numbing effect of the OxyContin. His prescription had run out, but that wasn’t much of an impediment. In the upscale Northeast Heights—more High School Musical Albuquerque than Breaking Bad Albuquerque—painkillers were competing with marijuana and alcohol as the party drug of choice. “There are pill parties,” says Roman’s younger brother, Beau. “[Pills are] so easy to get. They’re everywhere.”

Roman was soon in the grip of Oxy. He lost interest in baseball.

Lost interest?  He was kicked off the team.  If he had other interests as strong as his interest in athletics, maybe he wouldn’t have been seduced by the drugs.  But keep in mind we’re talking about teenagers and young adults here, whose brains don’t yet have the ability to see the consequences of their actions.  They are not able to picture themselves in the future — they are only interested in the here and now.

He showed up high for graduation. JoAnn Montano and her husband, Bo, who owns a wheel-alignment and body-shop business, figured their son was just floundering—until JoAnn caught him using. She took him to an addiction center, and he was prescribed Suboxone to treat his opioid dependency.

Roman, though, couldn’t fully kick his habit. Before graduation he had switched to a cheaper substance that offered the same high at a lower price: heroin…

They said that Roman had been found slumped in the driver’s seat of his car behind a FedEx store, a syringe in his arm, the motor running. He was 22 and dead from a heroin overdose…

You can see by the title of this article that they’re blaming Oxy for Roman’s heroin addiction, even though he took it because he was “humiliated, angry and depressed.”  Maybe it would be a good idea to teach kids about how to handle these kinds of negative emotions instead of trying to teach them abstinence from drugs.

If, at this point, Roman had chosen cannabis instead, perhaps he wouldn’t have moved on to heroin. And maybe if his self-esteem wasn’t so irrevocably tied to athletics, he would have been able to move in a different direction.

While hard data for heroin use among young athletes are difficult to come by, the anecdotal evidence is abundant and alarming. A seven-month SI investigation found overdose victims in baseball, basketball, football, golf, gymnastics, hockey, lacrosse, soccer, softball, swimming, tennis, volleyball and wrestling—from coast to coast…

As the sports industry expands each year—and the stakes on rinks, fields and courts grow higher—young athletes face enormous pressure to manage their pain and play through injuries…

And if they didn’t have this pressure, would they still be at risk for drug addiction? Blame the pressure and the lack of other options for these athletes, not the pain medications. After all, how many high school and college athletes end up going professional? Isn’t it something like 1%?  In my opinion, basing a child’s future on athletics is never a good idea. Making a living by abusing your body is not a career that will last very long.

Moreover, “sports that involve high levels of contact (e.g., football) tend to socialize youth to view pain, violence and risk as normative features,” Veliz said, and these “may influence risky behavior both on and off the playing field. In other words, participants in contact sports learn to view their body as an instrument that can be easily gambled with, even if it would involve permanent damage.” …

In the beginning, many athletes are involved in their sport because they love it. But if they’ve got any talent, that love of the sport quickly turns into a question of how much money they can make. Can the sport provide a good living? Just like young people who join the military to make a living, there are few career options for kids today.

And let’s not forget how much sports is celebrated in this country, from high schools and universities to professional teams and the Olympics. There’s a reason that cities spend so much money on sports stadiums. In other words, we are part of the problem. We pay lots and lots of money to see athletes abuse their bodies. We are the consumers of the products that perpetuate and fund sports. We are the spectators in this Roman coliseum of abuse, and often violence.

There are many reasons why kids try drugs, including alcohol.  Blaming the drug alone just isn’t logical.  We’ve done that throughout the decades-long, failed drug war and look where we are today.

(6/11/2015) Tackling prescription drug abuse

There are signs that strategies to address prescription drug abuse are starting to work but will an increase in illegal drug use be the payoff?

http://www.pharmaceutical-journal.com/news-and-analysis/features/tackling-prescription-drug-abuse/20068685.article

But regulators and doctors need to strike a balance between keeping the drugs away from those who might abuse them, and ensuring that they are available for patients who genuinely need them. Regulations, according to Boyd, run up against “a quality of life issue”. She says: “I would never want patients to not have access to these medications.” …

Already, the FDA has announced that generic versions of OxyContin cannot be sold without abuse-deterrent properties, and it looks like Health Canada is about to do the same. To clarify the situation for the pharmaceutical industry, in April 2015 the FDA released guidelines on how it will evaluate abuse deterrence, so that companies can put the claims on their labels. “I would like the majority of opioids to have abuse-deterrent formulations as soon as possible,” says Throckmorton…

Despite all these hurdles, it looks like the United States is slowly getting its prescription drug abuse epidemic under control. The number of overdose deaths from prescription drugs has levelled off since 2011, and seems to be on the decline.

Overdose deaths from some opioid painkillers also seem to have plateaued in the UK in the past few years, but the overall picture is less rosy. For example, deaths from tramadol overdose have seen a sharp increase. But there have been moves to get it under control. Tramadol was recently reclassified in the UK, which Stannard hopes will lead to more careful prescribing and a drop in the number people misusing it…

It may be too soon to celebrate though. As prescription opioids gained popularity among drug users over the past decades, rates of heroin use plummeted. But now, as authorities have cracked down, and prescription drugs such as OxyContin have become harder to get hold of and abuse, heroin is making a big comeback. The number of heroin overdose deaths in the United States increased fivefold between 2001 and 2013. “As opioid use has declined, opiate use in the form of heroin has increased,” says Boyd. “We are seeing an epidemic of heroin problems now.”

Half of veterans who died from opioid overdoses also received benzos

http://www.psypost.org/2015/06/half-of-veterans-who-died-from-opioid-overdoses-also-received-benzos-35059

In a recent study, nearly half of all veterans who died from drug overdoses while prescribed opioids for pain were also receiving benzodiazepines, or benzos, which are common medications for the treatment of anxiety, insomnia and alcohol withdrawal. Veterans prescribed higher doses of benzodiazepines while concurrently receiving opioids were at greater risk of overdose death than those on lower doses of benzodiazepines…

I think it’s odd that this study doesn’t include information about any of the other drugs these patients were taking.  The study didn’t include antidepressants, anti-psychotics, mood stabilizers, muscle relaxers, alcohol, or illegal drugs, even though it’s obvious that this group includes veterans who suffer from different mental illnesses. It also includes all opioids, from codeine to fentynal, as if these drugs worked in the same way.

The VA has been using opioids to treat PTSD, combining them with antidepressants, benzos and mood stabilizers, so it looks like not all of these veterans were strictly chronic pain patients. But with studies like this, I’d say the VA was coming for veterans’ benzos.

And isn’t it odd that the media and politicians rarely mention benzos when talking about the opioid “epidemic”?  No, only pain medications are criminalized.

http://www.bmj.com/content/350/bmj.h2698.full

We limited methadone prescriptions in this study to those prescribed to treat pain by excluding prescriptions in which dosing instructions indicated the methadone was prescribed for maintenance, oral or effervescent methadone formulations unless the dosing schedule indicated more than once a day dosing, or the dosing schedule was once a day unless the instructions indicated the methadone was prescribed for pain. Buprenorphine is not currently indicated for pain treatment in the VHA and was not included in this analysis…

Of the 422,786 veterans in the study population, 112,069 (27%) had filled at least one prescription for benzodiazepine during the study period. Those who received benzodiazepines were more likely to be women (33% of women v 26% of men received benzodiazepines), middle aged, white, and live in wealthier areas. Additionally, they were more likely to have had a recent hospital admission for mental health or substance use disorder, to have a diagnosis of a substance use disorder or several psychiatric disorders, including post-traumatic stress disorder, other anxiety disorders, depression, and bipolar or psychotic disorders, and to use other drugs...

One Nation, Under Sedation

https://www.propublica.org/article/medicare-paid-for-nearly-40-million-tranquilizer-prescriptions-in-2013

More than a decade ago, when lawmakers created Medicare’s drug program, called Part D, they decided not to pay for anti-anxiety medications. Some of these drugs, known as benzodiazepines, had been linked to abuse and an increased risk of falls and fractures among the elderly, who make up most of the Medicare population.

But doctors didn’t stop prescribing the drugs to Medicare enrollees. Patients just found other ways to pay for them. When Congress later reversed the payment policy under pressure from patient groups and medical societies, it swiftly became clear that a huge swath of Medicare’s patients were already using the drugs despite the lack of coverage.

In 2013, the year Medicare started covering benzodiazepines, it paid for nearly 40 million prescriptions, a ProPublica analysis of recently released federal data shows. Generic versions of the drugs — alprazolam (which goes by the trade name of Xanax), lorazepam (Ativan) and clonazepam (Klonopin) — were among the top 32 most-prescribed medications in Medicare Part D that year…

Some geriatric psychiatrists worry that doctors may have turned to the drugs in place of antipsychotic medications to sedate patients with conditions such as dementia. In the past several years, Medicare has pushed to reduce the use of antipsychotics, particularly in nursing homes, because of strong warnings about their risks…

Fall River, Mass., psychiatrist Claude Curran wrote more than 11,700 prescriptions for benzodiazepines (including refills) in 2013, ranking him behind only four other doctors, all from Puerto Rico. He said the drugs worked well for his patients, many of whom are trying to kick addictions to narcotics but struggle with anxiety and depression.

“First of all, they’re reliable,” he said. “Second of all, they’re cheap because they’re all generic … They tickle the brain in the same way alcohol does.”  Without benzodiazepines, he added, patients in recovery often need higher doses of methadone, which carries significant risks of its own…

The vast majority of Curran’s Medicare patients were younger than 65 and qualified for coverage based on a disability. Disabled patients made up about a quarter of Part D’s 35 million enrollees in 2013, but used benzodiazepines disproportionately, accounting for about half of all prescriptions…

Rodriguez readily acknowledged the risks of the drugs for elderly users — recently, researchers found that the longer a person took benzodiazepines, the higher his or her risk of being diagnosed with Alzheimer’s Disease. The drugs’ labels say they are generally for short-term use but many patients take them for years…

Many paid out of pocket for the relatively inexpensive drugs, which can cost less than $10 for a 30-day supply…

A worrisome aspect of the newly released data is that some doctors appear to be prescribing benzodiazepines and narcotic painkillers to the same patients, increasing the risk of misuse and overdose. The drugs, paired together, can depress breathing.

ProPublica found that this pattern was most common in southeastern states, which struggle with opioid abuse and overdoses. In 2013, 158 doctors in Florida wrote at least 1,000 prescriptions each for opioids and for benzodiazepines, tops in the nation. Alabama, Kentucky and Tennessee also had unusually high numbers of doctors who often prescribed both narcotics and benzodiazepines. The data does not indicate if the prescriptions were given to the same patients, although that prospect worries experts…

Dr. Leonard J. Paulozzi, a medical epidemiologist at the Centers for Disease Control and Prevention, co-authored an analysis showing that benzodiazepines were involved in about 30 percent of the fatal narcotic overdoses that occurred nationwide in 2010.

“It increases the possibility of overdoses,” he said.

Click to access select-benzodiazepines-10-16-14.pdf

Select Benzodiazepines to Have Daily Quantity Limits (Vermont)

The National Institute of Drug Abuse (NIDA) and the DEA has identified benzodiazepines as one of the classes of prescription drugs with a high potential for diversion and abuse…

http://www.justice.gov/usao-edtn/criminal-division/drug-diversion-task-force

The Drug Diversion Task Force was created to help combat the growing abuse and trafficking of prescription drugs. Unscrupulous doctors, physician assistants, and pharmacists may be involved in the illegal distribution of controlled substances, including oxycodone, oxycontin, morphine, methadone, fentanyl, hydrocodone, and xanex…

When blogs refuse to moderate comments

https://getwellcoaching.wordpress.com/2015/01/22/fentany-and-morphine-addiction-how-to-stop-them-right-away/

FENTANY AND MORPHINE ADDICTION – HOW TO STOP THEM RIGHT AWAY

I’ve never heard of Fentany — do you mean Fentanyl?

If you had gone to the doctor because you are suffering from chronic pain, and you have been prescribed something called morphine, fentany or methadone, these are opioids that are derived from poppy seeds that are very addicting and also very powerful painkillers. Many people will use them illegally simply because they give you a high that makes it possible for you to experience euphoria and pain relief at the same time.

Most chronic pain patients don’t experience euphoria with pain medications — the euphoria you speak of is felt by those who take these drugs but are not in pain.  Chronic pain sucks up every bit of that side effect, especially after a short adjustment time. Most chronic pain patients only get a small percentage of relief when taking pain medications, and very few experience enough pain relief to feel euphoria.

Opioids and morphine derivatives are one of the most addicting substances on the planet, and here’s how you can end your addiction right away.

Sounds like you’re only trying to spread fear, not information.  Trying to convince people not to use pain medications, no matter how much pain they’re in, preferring that people just suffer.

Opioids And Morphine Derivatives

The reason that these products are so incredibly addicting is because they affect a certain area connected to your central nervous system which are called your mu receptors. These are derived from poppyseed which can create a number of different products including codeine, Norco, Vicodin, Percocet, and many other drugs that are extremely popular on the street today. You can get prescriptions for them if you legitimately are experiencing chronic pain on a regular basis.

Actually, no, there’s a war against pain patients going on right now, and many can’t even find doctors to treat them, let alone prescribe pain medications.  Then many patients have the problem of finding a pharmacy that will fill prescriptions for many of the drugs used to treat chronic pain (except antidepressants, of course). Your post was written in January 2015 — what, don’t ya’ll read the news?

They will also be given to people that I’ve gone through severe surgery, one that can lead to very painful recovery times.

Ya’ll obviously need a proofreader for your blog.  Hey, is this blog a front for the DEA? They are notoriously bad spellers, although sometimes they do it on purpose in an attempt to fool gullible readers.

Treatments For Opiate Addictions

There is no easy way to get over an opiate addiction if you have been taking these drugs for several years.

Addiction or dependence?  Which one are you talking about?  Do you even know the difference between the two?  

No, withdrawal isn’t easy, but then living with constant pain isn’t actually a cake walk either.

Even if you have only have them for a couple months, the withdrawals will be tremendous. Shaking, vomiting, and an uncontrollable desire to get more of them into your system is going to plague you for several weeks until you can get through the withdrawals, allowing you to reset your mu receptors so that you won’t have to read them in your system anymore which is the goal of all those that are addicted.

painkills2 on April 23, 2015 at 8:47 am said:
Your comment is awaiting moderation.
Actually, cigarettes and alcohol are more addicting than opioids. And if you’re going to mention chronic pain and opioid use, then perhaps you should include the fact that dependence is different than addiction. Also, after only a couple of months of use, the withdrawal from opioids will not be “tremendous” for most people, especially if you wean yourself off of them, a little at a time.

And I’ll just add this to my comment:  The title of your post doesn’t reflect what’s in the body of it. “How to stop them right away” — there isn’t even an attempt to answer this question.  Is that because it involves maintenance drugs like methadone and buprenorphine, which your blog is likely against?

Hey, is this blog a front for the NIDA?

There is no useful information on your blog, getwellcoaching.  Please stop following mine, as I don’t want my blog connected to yours in any way.

Thinking of you, Molly Alice Parks

http://www.huffingtonpost.com/2015/04/23/dad-obituary-drug-overdose-daughter-molly-parks_n_7123336.html

After losing his daughter to a heroin overdose, a grieving dad penned an honest obituary for his child. He says he wanted to highlight the dangers of drug addiction, and to help others who may be fighting similar battles.

Molly Parks, 24, died on April 16. Her body was found in the restroom at her job; she still had a needle stuck in her arm.

Parks, who lived in Manchester, New Hampshire, had battled drug addiction for several years. But her dad, Tom Parks, told the Washington Post that there were signs recently that she’d maybe taken a turn for the better.

After three stints in rehab last year, she got a job delivering pizza. She reportedly worked 55 hours a week, and was seemingly getting her life in order…

“Molly graduated from Old Orchard Beach High School in 2009 and attended one year at SMCC until her addiction took over. Most recently, she was employed as a delivery driver for Portland Pie Co. in Manchester, NH. She enjoyed theater, fashion, reading – especially Harry Potter, and will always be remembered for fearless personality and her trademark red lipstick…”

I believe there is a connection between the amount of risks someone is willing to take and the illness of addiction.  I also think there’s a connection between the amount of stress someone who’s addicted to drugs can handle, especially during the first couple of years of being drug free. I don’t want to question this family’s attempts to help her, but if she had been on methadone maintenance therapy or something similar, perhaps she wouldn’t have gone back to heroin.

Need help? In the U.S., call 1-800-662-4357 for the Substance Abuse and Mental Health Services Administration’s 24-hour helpline.

(Photo taken 10/9/2014.)

Kentucky’s New Heroin Law Marks A ‘Culture Shift’

https://sarahbennettphotography.wordpress.com/2015/03/31/kentuckys-new-heroin-law-marks-a-culture-shift/

http://www.huffingtonpost.com/2015/03/25/kentucky-heroin-epidemic_n_6941568.html

The state will now allow local health departments to set up needle exchanges and increase the number of people who can carry naloxone, the drug that paramedics use to save a person suffering an opioid overdose. Addicts who survive an overdose will no longer be charged with a crime after being revived. Instead, they will be connected to treatment services and community mental health workers.

At a Wednesday morning press conference before he signed the bill into law, Gov. Steve Beshear (D) said the legislation sent a simple message to addicts across Kentucky: “We’re coming to help you. Work with us. Help us to help you to get on the road to recovery.” …

House Energy and Commerce Subcommittee on Oversight and Investigations Hearing

http://insurancenewsnet.com/oarticle/2015/03/27/house-energy-and-commerce-subcommittee-on-oversight-and-investigations-hearing-a-608841.html#.VRhnhPnF_bY

Testimony by Sarah Melton, Associate Professor of Pharmacy Practice Gatton College of Pharmacy at East Tennessee State University, Johnson City, Tennessee, and Chair of the Board of Directors of OneCare of Southwest Virginia

Both Virginia and Tennessee participate with the National Association of Boards of Pharmacy InterConnect Program. n10 This program facilitates the transfer of PDMP data across state lines to authorized users. It allows participating state PMPs across the United States to be linked, providing a more effective means of combating drug diversion and drug abuse nationwide. Allocation of federal funding to help achieve participation from all states with PDMP programs to achieve a national PDMP program should be considered.

A concern encountered daily in clinical practice is that methadone treatment facilities are not required to report dispensing of methadone to prescription drug monitoring programs. Therefore, patients receiving methadone for an opioid use disorder who do not disclose this to their other health care providers are at risk of receiving other medications that may interact with methadone and cause significant toxicity or death… In contrast, buprenorphine dispensed for opioid dependence is reported to the state PDMP programs, which allows better monitoring for safety and appropriate use…

Tennessee and Virginia have made great strides in bringing stationery disposal units to many locations across the states. Increased federal funding made available to states in order to place a stationery disposal unit in each county would be optimal. However, we are encountering significant barriers associated with the disposal of the medications placed in these stationery units. There are very high costs associated with incineration of the medication wastes often associated with air-quality control measures mandated by the EPA. In October, the U.S. Drug Enforcement Administration (DEA) finalized rules for the Secure and Responsible Drug Disposal Act of 2010 that allow hospitals and pharmacies to be collectors; however, there is no funding for this. During the same time period, the DEA ended sponsorship of its highly successful medication take-back events…

Death From Drug Addiction: Families Speak Out In Obituaries In Hopes Of Saving Others

https://www.yahoo.com/health/naming-the-addiction-families-use-obituaries-to-113522579072.html

https://louisevincent.wordpress.com/2015/03/14/doing-harm-the-american-way/

While I do not know all the details of this particular story, I did hear a few things in the news story that caused me great distress. First, the young man had been recently arrested but let out of jail because of overcrowding. His parents begged the system to keep him locked up. They believe this would have saved his life. I would argue that the arrest and experience in jail only exacerbated his drug use…

We know that when you flood a community with Naloxone you reduce overdose deaths by 49%…

I don’t know where this information came from — there’s no cite or reference — but I don’t believe it’s true.  Naloxone by itself doesn’t reduce overdose deaths by 49%, but I’m sure this drug has a pretty good success rate in the specific patient population that is addicted to heroin. It’s just that most people who overdose on heroin are doing drugs by themselves, hidden away from anyone who might be able to administer Narcan.

And the stigma of pain patients or their family members having to pay for an additional drug just in case of an overdose… I just don’t see how Narcan will help prevent overdoses in the pain patient population. Of course, knowing the federal government, along with peeing in a cup and pill counts, pain patients will soon be required to also buy Narcan — just in case.

What the federal government has in mind for pain patients is having us all register as drug addicts, across every state, with the information being available to just about anyone (especially future employers, insurance companies, and doctors).

You think it’s hard now to get certain medications to treat pain, just wait until the PDMPs are used nationwide.  It’ll be like being on the FBI’s Most Wanted List. If you want to switch doctors, say your pain doctor just wants to do more injections — all the potential doctors you could see will be looking you up on the PDMP (hey, that rhymes), maybe even talking to your prior doctors.

http://www.usatoday.com/story/news/2015/03/26/hhs-funds-naloxone-to-prevent-heroin-deaths/70448568/

The push for naloxone, which includes an expanded grants program for states to purchase the drug, is part of a new initiative to be announced Thursday by Health and Human Services Secretary Sylvia Burwell to reduce deaths from prescription painkillers, such as OxyContin and Vicodin, and heroin. Heroin-related overdose deaths increased 39% from 2012 to 2013, and prescription opioids accounted for more than a third of all overdose deaths in 2013.

Since Naloxone may help those who overdose from heroin, and since “heroin-related” deaths are on the rise, this is a great idea.  However, saying Naloxone will help deaths from prescription painkillers is a little, shall we say, too hopeful?  No, what will help pain patients is to have their pain adequately treated, not to have Narcan at the ready just in case of an overdose.

The HHS effort will focus on curbing overprescribing and inappropriate prescribing of pain pills, expansion of overdose reversal programs, and increasing access to treatment programs that use medication as well as counseling to help addicts…

These efforts don’t include increasing access to pain management treatments or programs — no, this is just about addiction.  This whole program, all this money, it’s all about addiction.

To increase access to treatment, the Substance Abuse and Mental Health Services Administration will provide $12 million in grants to purchase medicine used to treat opioid addiction, such as buprenorphine, and train healthcare providers to use the medicines as part of a treatment program. The president’s budget asks for another $13 million to expand the program in 2016.

The government will also invest $20 million this year and has asked for $45 million next year for prescription drug monitoring programs which track prescriptions for narcotics to prevent addicts from going from doctor to doctor to collect multiple prescriptions. Doctors, pharmacists and other medical professionals can access the databases before prescribing. The systems can also identify doctors who may be overprescribing.

“Some states have very sophisticated systems to identifying troubling patterns. Other states are less developed,” Frank said. “We’re moving toward having best practices in all 50 states.”

While the title of this article is “HHS to fund more naloxone programs to halt opioid deaths,” the link says “heroin” rather than “opioid.”  Really, they are one and the same to the media, even though one is illegal and one is not.

And the drug war continues… as always, funded by the federal government… I mean, us.

Brought to you by SAMHSA

http://newsletter.samhsa.gov/2015/03/managing-chronic-pain/

3/3/2015, Managing Chronic Pain & Medication Misuse

After being arrested for forging a prescription, he spent nine years “doctor shopping” for pills, losing jobs, and suffering overdoses and suicide attempts. After nine years, he made it through rehab and he has been sober since 2007…  Mr. Loffert’s trajectory is a common one.

Common?  Really?  Maybe for those who suffer from addiction, but not for chronic pain patients.

According to SAMHSA’s Treatment Improvement Protocol (TIP) 54, “Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders,” almost one third of chronic pain patients may have substance use disorders…

May have?  Let’s see, that’s 30% of about 45 million (to 100 million) people who suffer from chronic pain in this country.  That’s 13.5 million people.  Wow, SAMHSA, way to earn your budget.

Dangerous interactions can also occur with medications used to treat mental illnesses such as depression, which is common among pain patients.

Depression is common?  No, it’s sadness that’s common among pain patients, not depression. And when you add sadness to constant pain, anxiety, and stress, you might just be diagnosed with Major Depressive Disorder — especially if your pain is under-treated.

Non-opioid pain treatments or other services, such as physical therapy or acupuncture, are better options for those who may need ongoing treatment for pain, particularly since there is little evidence for effectiveness of opioids in the long-term treatment of chronic pain…

There is “little evidence” because the research hasn’t been done, not because opioids are ineffective for long-term treatment.  And tell me, SAMHSA, where is the evidence that expensive physical therapy or acupuncture are effective long-term treatments for chronic pain?  Because if there’s evidence, maybe then insurance companies would cover those treatments.

…continue to offer waiver training for physicians interested in providing office-based treatment of opioid use disorders with buprenorphine under the Drug Addiction Treatment Act of 2000.

So, what is the difference in the abuse rates between bupe and other opioids?  It seems like bupe is abused in about the same percentage of patients as hydrocodone and other opioids, but since the government is heavily invested in bupe, SAMHSA gets to advocate for one drug over another.

Click to access TIP54.pdf

A Treatment Improvement Protocol

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

Current Opioid Misuse Measure (Page 58)

How often have you been in an argument?

How often have you gotten angry with people?

Symptoms and signs of opioid withdrawal are as follows. (Page 61)

Symptoms include:
• Abdominal cramps, nausea, vomiting, diarrhea
• Bone and muscle pain
• Anxiety
• Insomnia
• Increased pain sensitivity in the original painful site

Gee, I could suffer from all those symptoms just from being in constant pain, without taking any drugs at all.  Watch out, if you have a stressful job and food poisoning or the flu, you could be assessed as a drug addict.

To SAMHSA, every chronic pain patient either has, or will develop, a drug addiction.  Of course, chronic pain patients are like a whole new toy for SAMHSA — how many other patient groups can they claim suffer from addiction?  I wonder how many people who work at SAMHSA suffer from addiction themselves?  Maybe they’re all graduates of an AA program.

Because SAMHSA is an agency centered around drug abuse and addiction, I guess they have a rather narrow focus on drug issues.  After all, SAMHSA is a big part of the drug war.  They’ve been around so long, yet our drug abuse problems keep escalating… it appears they’re not very good at their job.  Why would anyone listen to them?

The Irrationality of Alcoholics Anonymous

http://www.theatlantic.com/features/archive/2015/03/the-irrationality-of-alcoholics-anonymous/386255/?src=longreads

Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools. The American Medical Association estimates that out of nearly 1 million doctors in the United States, only 582 identify themselves as addiction specialists. (The Columbia report notes that there may be additional doctors who have a subspecialty in addiction.) Most treatment providers carry the credential of addiction counselor or substance-abuse counselor, for which many states require little more than a high-school diploma or a GED. Many counselors are in recovery themselves. The report stated: “The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”

This begs the question:  Dr. Kolodny, are you a drug addict in recovery?

Alcoholics Anonymous was established in 1935, when knowledge of the brain was in its infancy…

A meticulous analysis of treatments, published more than a decade ago in The Handbook of Alcoholism Treatment Approaches but still considered one of the most comprehensive comparisons, ranks AA 38th out of 48 methods…

AA truisms have so infiltrated our culture that many people believe heavy drinkers cannot recover before they “hit bottom.” Researchers I’ve talked with say that’s akin to offering antidepressants only to those who have attempted suicide, or prescribing insulin only after a patient has lapsed into a diabetic coma…

Part of the problem is our one-size-fits-all approach…

Sinclair called this the alcohol-deprivation effect, and his laboratory results, which have since been confirmed by many other studies, suggested a fundamental flaw in abstinence-based treatment: going cold turkey only intensifies cravings. This discovery helped explain why relapses are common…

I didn’t mention that some bare-bones facilities charge as much as $40,000 a month and offer no treatment beyond AA sessions led by minimally qualified counselors…

In 1934, just after Prohibition’s repeal, a failed stockbroker named Bill Wilson staggered into a Manhattan hospital. Wilson was known to drink two quarts of whiskey a day, a habit he’d attempted to kick many times. He was given the hallucinogen belladonna, an experimental treatment for addictions, and from his hospital bed he called out to God to loosen alcohol’s grip. He reported seeing a flash of light and feeling a serenity he had never before experienced. He quit booze for good. The next year, he co-founded Alcoholics Anonymous…

Alcohol acts on many parts of the brain, making it in some ways more complex than drugs like cocaine and heroin, which target just one area of the brain. Among other effects, alcohol increases the amount of GABA (gamma-aminobutyric acid), a chemical that slows down activity in the nervous system, and decreases the flow of glutamate, which activates the nervous system. (This is why drinking can make you relax, shed inhibitions, and forget your worries.) Alcohol also prompts the brain to release dopamine, a chemical associated with pleasure…

Still, science can’t yet fully explain why some heavy drinkers become physiologically dependent on alcohol and others don’t, or why some recover while others f[l]ounder…

What if it’s in the tastebuds?  Part of the reason some people don’t drink is because of the taste of alcohol, which could be described as an “acquired” taste.  And one reason some people love beer and wine is because, to them, they taste good.  But people like different foods and have different tastes — I dunno, there seems to be some kind of connection there…

There is no mandatory national certification exam for addiction counselors. The 2012 Columbia University report on addiction medicine found that only six states required alcohol- and substance-abuse counselors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever—not even a GED or an introductory training course was necessary—and yet counselors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for recovery…

“What’s wrong,” he asked me rhetorically, “with people with no qualifications or talents—other than being recovering alcoholics—being licensed as professionals with decision-making authority over whether you are imprisoned or lose your medical license? …

Reid K. Hester, a psychologist and the director of research at Behavior Therapy Associates, an organization of psychologists in Albuquerque…

It seems like New Mexico is a state where all forms of treatment for addiction can be found, and yet that hasn’t made the problems of alcohol and drug addiction any better.  I guess it all comes down to affordability and easy access to treatment, along with the biases some patients have about their own addictions.  Of course, sustainable jobs is one of the only things that really makes a difference in how people use and abuse drugs.

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.)