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10/20/2017 1:01:18 AM
9/22/2017 12:11:25 AM
Posted: 8/28/2005 11:17:11 AM EDT
Pubdate: Thu, 1 Sep 2005
Source: AARP The Magazine (US)
Copyright: 2005 AARP
Issue: September/October
Page: 54
Contact: aarpmagazine@aarp.org
Website: http://www.aarpmagazine.org/
Author: Barry Yeoman
Cited: Drug Enforcement Administration http://www.dea.gov
Cited: American Academy of Pain Medicine http://www.painmed.org
Cited: American Pain Society http://www.ampainsoc.org
Cited: Compassion & Choices http://www.compassionandchoices.org/

PRISONERS OF PAIN

Why Are Millions Of Suffering Americans Deing Denied The Prescription
Drug Relief They Need?

Deborah Hamalainen was feeling more and more agitated by the minute.
Waiting to see her neurologist, she was silently rehearsing a
confrontation that had been building for months. She planned to look
the doctor directly in the eyes and demand that he treat the chronic
pain that had invaded her life.

In the two decades since doctors diagnosed her with multiple
sclerosis, Hamalainen learned to tolerate numb extremities, tingling
sensations, even the weakness that causes her left foot to drag. And
it wasn't like her to be confrontational. "I'm much happier in
denial," admits the soft-spoken 52-year-old sculptor.

Some physicians fear that if they deliver humane pain care, they'll
face prosecution by the DEA.

The symptoms she couldn't ignore, though, were the intense shooting
pains that raced across her shoulder blades and down her limbs. By
the time she arrived for this doctor's appointment, they were a
24-hour presence. Hamalainen barely slept anymore. Rolling over was
an ordeal. When the Medford, New Jersey, resident awoke, stiff and
exhausted, she braced her shoulders so they wouldn't move as she
rose. Sometimes, her husband had to pull her upright from the bed.

Every three months for three years, Hamalainen saw this neurologist.
Each time, she mentioned the pain. Each time, the doctor deftly
changed the subject. Each time, she left in pain.

But this time would be different.

Hamalainen waited quietly as nurses wandered in and out of the
examination room, taking her vital signs. Finally, she lost it. "My
pain is real," she said frantically to one of the nurses. "I need
relief. Why does he keep refusing to talk to me about it? What do I
have to do?"

The nurse turned to her conspiratorially and lowered her voice. "I
should not tell you this," she said. "But he doesn't want to treat
your pain because the treatment that works is opioids, and he's
afraid to prescribe them."

With that conversation, Hamalainen joined legions of patients who are
the victims of a troubling and all-too-common medical practice: the
undertreatment of significant and debilitating pain. An estimated 75
million Americans suffer from chronic pain, according to the American
Medical Association, and numerous studies have shown that patients
often don't receive the medication that could provide relief.
Undertreatment runs as high as 50 percent among advanced-stage cancer
patients and 85 percent among older Americans living in long-term
care facilities.

Much of this suffering is preventable. Experts do know how to reduce
pain safely. In particular, physicians now know that opioid
analgesics, medicines such as morphine and oxycodone, provide relief
for a wide spectrum of pain problems, with relatively few side
effects when taken as prescribed. "We can't cure everybody who is in
pain, but we can make almost everyone feel better," says Scott
Fishman, chief of the division of pain medicine at the University of
California, Davis, and president of the American Academy of Pain
Medicine. "Becoming a prisoner of pain is not an inevitability."

The problem is that the most effective medications cause skittishness
among many physicians. Poor medical-school training has left them
unaware of the tools at their disposal and even the importance of
treating pain. Many harbor the false impression that opioids
frequently lead to addiction or unmanageable side effects, even when
used correctly for a legitimate medical need. 'Becoming a prisoner of
pain is not an inevitability.'

The problem is that the most effective medications cause skittishness
among many physicians. Poor medical-school training has left them
unaware of the tools at their disposal and even the importance of
treating pain. Many harbor the false impression that opioids
frequently lead to addiction or unmanageable side effects, even when
used correctly for a legitimate medical need.

Worse, some physicians fear that if they deliver humane pain care,
they'll face prosecution by the federal Drug Enforcement
Administration (DEA) or state medical boards. In recent years, a
number of respected doctors have been investigated and even
prosecuted after prescribing large amounts of opioids. The result,
according to experts, is an environment that scares doctors away from
practicing good medicine.

"I've had prominent physicians call me up and say, 'I have patients
doing well, taking opioids for otherwise treatable pain, but I'm
going to stop writing prescriptions because I don't want the DEA
coming into my office and putting handcuffs on me,' " says James
Campbell, a neurosurgeon at Johns Hopkins University. "Five years
ago, we were actually doing a better job at handling pain patients.
Now we've seen a backslide, and patients are definitely the victims.
They're suffering."

On his first day as a licensed physician, Russell Portenoy had a
troubling experience that would influence the course of his career.
At the New York City hospital where he was interning, a nurse
summoned him to a room where a cancer patient was moaning with
abdominal pain. Portenoy knew the woman would benefit from opioids,
but he was new at doctoring, so he first phoned the resident in
charge to clear his decision.

"I have a patient here. She's 60 years old, she's got metastatic
ovarian cancer, and she's in bad pain," Portenoy told his supervisor.

"What do you want to do?" the resident asked.

"Well, I thought we should give her some pain medicine."

"What do you want to give her?"

"Morphine."

There was silence on the other end of the line. It was 1980: even
physicians who endorsed opioids for terminally ill patients believed
that morphine was too potent and too dangerous. Finally, the resident
said, "Look, you're the doctor. You want to give her morphine, give
her morphine." After further consultation, Portenoy wrote an order
for a 3 mg injection, less than one third of what he would likely
give her today. He never checked back to see if the medication worked.

The patient was still on Portenoy's mind the following year when he
decided to specialize in pain medicine. "I'd given somebody with
severe cancer pain a dose that didn't have a prayer of providing any
benefit," he says. "My hope is that there was such a profound placebo
effect that she didn't scream the rest of the night."

Portenoy joined a coterie of pioneers who encouraged their colleagues
to become bolder in treating patients' suffering. They argued that
pain is more than a symptom; it's a disease by itself that can
trigger a cascade of other health problems from a weakened immune
system to obesity if left untended.

At Memorial Sloan-Kettering Cancer Center, where he launched his
career as a researcher and pain physician, Portenoy initially
concentrated on cancer pain. Eventually he discovered that opioid
medicines routinely prescribed in advanced-cancer cases also worked
for patients without terminal illnesses. They relieved the symptoms
without fogging patients' brains or turning them into addicts. The
only major ongoing side effect, constipation, was manageable with
other drugs. But when Portenoy shared the news in a 1986 journal
article, he received excoriating criticism from his colleagues.

Slowly, time has proven Portenoy correct. In 1996 two leading
professional groups declared opioids "an essential part of a
pain-management plan." Five years later, the DEA and 21 health
organizations agreed that opioids are often "the most effective way
to treat pain and often the only treatment option that provides
significant relief."

Across the United States, hospitals are starting to take the issue
seriously, creating programs specializing in pain management.
Portenoy's own department, at New York City's Beth Israel Medical
Center, has 14 physicians, a team of researchers, and training
programs for doctors and others. Using opioids and other therapies,
these programs have restored normalcy to many lives.

"It's a miracle," says 55-year-old Michele Ferreri, a Staten Island,
New York, woman who suffers from a painful nerve condition that
appeared in the aftermath of shingles. Once unable to get out of bed
because of her burning headaches, she started taking extended-release
morphine and other medications after seeing Portenoy at Beth Israel.
Now she lives an active life, taking her mother shopping, doing
laundry, and attending social functions with her husband, a hospital
CEO. "I can smile now," she says. "I can smile and greet people."

Until recently, there was no legal incentive for doctors to take pain
seriously. That's starting to change. In 2001 a California jury
awarded $1.5 million to the family of a lung-cancer patient who lay
undermedicated and dying in a hospital near San Francisco. (The award
was later reduced in keeping with state law.) Two years later, the
California Medical Board reprimanded a physician in a similar case
involving a nursing home. These decisions "sound a resounding wake-up
call to all health care providers that failure to treat pain
attentively will result in accountability," says Kathryn Tucker,
attorney for Compassion & Choices, which litigated the cases.

But the wake-up call hasn't stirred everyone. Millions of Americans
still don't receive the therapy they need. "The odds of your getting
good pain management are, at best, 50-50," says UC Davis bioethicist Ben Rich.

Studies bear Rich out. One survey of Oregon families, published in
2004, showed that almost half of terminally ill patients were in
significant pain or distress during the last week of their lives. In
a study of nursing homes in 11 states, Brown University researchers
found that two thirds of the residents initially found to be in daily
pain were still suffering two to six months later.

But even when treatment is available, patients often reject it
because of widely held misconceptions. Popular media play up
addiction be it on the TV series ER, where Noah Wyle portrayed a
young physician addicted to prescription painkillers, or in tabloid
newspapers, which devoted voluminous ink to Rush Limbaugh's struggle
with pain pills in late 2003. Indeed, Limbaugh's alleged drug of
choice, OxyContin (a form of oxycodone), has become popular among
rural drug abusers, who chew the pills to destroy their time-release
mechanism and get a heroinlike rush.

In reality, for those using opioids as prescribed, the likelihood of
addiction is extremely low, according to research. "It's really an
unwarranted fear," says Christine Miaskowski, former president of the
American Pain Society. Many patients do become physiologically
dependent, meaning they'd go through withdrawal syndrome if they quit
cold turkey but this is a normal condition that can be managed by
tapering down the dosage. It's not the same as addiction, which
requires psychological dependence. Experts say patients with a
history of drug abuse can safely use opioids too, as long as they are
carefully monitored by their physicians to avoid a recurrence of
their abusive behaviors.

These reassurances don't convince everyone. "There is a
just-say-no-to-drugs attitude in the United States," says Diane
Meier, a geriatric and palliative-care specialist at New York City's
Mount Sinai Medical Center. "Even my own family will say, 'I don't
want to be doped up on those drugs.' "

Patients aren't alone in their misinformation. Physicians, trained to
suspect there's an abuser lurking behind every painkiller request
and, to be fair, there sometimes is still confuse addiction with
physical dependence. The facts don't dissuade them: although Ferreri
has become functional on morphine, her family doctor still "talks to
my husband all the time about the amount of medication I'm on, how
dangerous it is. He really makes me feel that I'm a drug addict."

Worse, some physicians simply don't understand the importance of
treating pain at all. Miaskowski, a professor in the physiological
nursing department at the University of California, San Francisco,
recently completed a study of cancer patients. "We had one patient
whose primary care physician told her, 'Don't take your pain
medicine. Let the pain kill the cancer.' " Was this advice offered
years before recent advances in pain management? No, she says. "This was 2001."

There's another, more ominous reason some doctors don't treat pain
aggressively: they don't want to end up like Arizona physician Jeri Hassman.

Hassman, a physical medicine and rehabilitation specialist licensed
in 1986, opened a solo practice in 1999 to focus on nonsurgical
treatments for injured patients. Working with physical therapists and
chiropractors, she developed a comprehensive program that includes
massage, electrical stimulation, muscle injections, and even posture
lessons. She also prescribed painkillers. "Medications are
important," she says. "If you decrease pain, you get better
compliance with exercise and other rehabilitation." Until 2002, she
says, "I wasn't afraid of prescribing strong pain medicines alongside
the available therapies."

Then, in May of that year, federal agents stormed her Tucson office
in full view of her patients. They spent eight hours questioning her
staff, seizing patient files and appointment logs, and copying the
hard drives off her computers. According to a government brief, the
DEA had been contacted by pharmacists "concerned about the large
amounts of narcotic drugs that were being prescribed for Dr.
Hassman's patients, plus the frequency with which they were returning
for refills." The druggists were also concerned that some medicines
had fallen into the hands of nonpatients, the brief said. Hassman was
arrested and charged with 320 counts of illegally distributing
narcotics and 41 counts of health care fraud.

Just before the case was scheduled for trial, federal prosecutors
offered Hassman a plea agreement, allowing her to plead guilty to
four counts of failing to report prescription abuse. Unwilling to
risk a jury trial, Hassman accepted the offer. She was sentenced to
two years' probation and agreed to surrender her DEA license to
prescribe controlled substances.

Hassman was relatively lucky. This April, Virginia pain specialist
William Hurwitz was sentenced to 25 years in prison for drug
trafficking after prescribing large doses of painkillers such as
OxyContin, morphine, and methadone to his patients. One of his
patients died after taking a very high dose of morphine. DEA
officials likened Hurwitz to a heroin dealer. Others, though,
testified that Hurwitz provided them with the only effective relief
they had ever received for debilitating pain.

Though the DEA wouldn't comment for this article, it has previously
insisted that it only goes after bad apples. "Our focus is not on
pain doctors. Our focus is on people who divert drugs," agency
official Patricia Good said during a 2004 teleconference. But
physician groups and patient advocates point to a growing list of
respected pain doctors who have been prosecuted by the DEA and by
state medical boards. They say that while the DEA has a legitimate
interest in preventing the diversion of harmful drugs, the agency's
adversarial zeal has grown in the past four or five years.

For its part, the DEA notes that it arrests fewer than 100 doctors a
year on drug-diversion charges, hardly a full-scale attack on the
profession. The numbers hardly matter, though, because the arrests,
and the publicity surrounding them, have created a chilling effect.
"Every time a physician picks up a newspaper or hears an account of
some physician who has been accused of inappropriately prescribing
controlled substances, it reinforces the proposition bad things can
happen to you when you attempt to manage patients' pain aggressively
but appropriately," says bioethicist Ben Rich. "Doctors don't say,
'I'll be more judicious and that won't happen to me.' Their reaction
is, 'I don't need this.' "

It took Deborah Hamalainen another year, plus the encouragement of a
friend, to find effective treatment for her pain. Early one morning,
the two women took an 80-mile bus trip to New York City, then took a
taxi downtown to Beth Israel Medical Center. There, Hamalainen met
with pain specialist Russell Portenoy, who found her story credible.
Portenoy explained to Hamalainen that he couldn't cure her multiple
sclerosis, but he could control her symptoms. "The goal is to focus
on the pain itself, to get you comfortable, and to help you
function," he told her.

After monitoring several medications for side effects, Portenoy and
Hamalainen settled on fentanyl, a synthetic opioid delivered through
an adhesive patch worn on her lower back. She uses oxycodone as a
"rescue" drug when the fentanyl isn't effective.

As Portenoy predicted, the medicine hasn't eliminated the source of
Hamalainen's pain. In fact, the multiple sclerosis has progressed.
She's been losing feeling in her hands and feet, dropping objects,
and tripping. She relies on a pair of canes to get around. Still,
with the pain under control, Hamalainen has been able to return to
her art. She recently had a mixed-media exhibition at the gallery
where she used to work. In one sculpture, she took old canes,
including the ones her father used after he lost a leg to diabetes,
and smashed them with an ax, then enclosed them in a clear plastic
exhibition box.

When the pain was at its worst, Hamalainen contemplated suicide. Now,
with opioids to relieve the symptoms, Hamalainen can envision a
productive artistic future. "Being able to be creative again has been
thrilling," she says. "It's like having a new life."

Link Posted: 8/28/2005 11:31:00 AM EDT


Originally Posted By wolfman97:
For its part, the DEA notes that it arrests fewer than 100 doctors a
year on drug-diversion charges, hardly a full-scale attack on the
profession.



So they only ruin 100 careers a year. A local doc had his license suspended for six months. After they found he had done nothing wrong they gave him an unrestricted license to practice. No apologies for stopping his income for six months.

The only reason I haven't burned my DEA license is because insurance companies and pharmacies use it along with Name/SSN for identification purposes. People are under the misconception that you need a DEA license to prescribe non-controlled substances. There are many drugs I couldn't prescribe that I do now but I would rather that inconvenience than having the DEA kick in my door.

Link Posted: 8/28/2005 11:38:42 AM EDT

Originally Posted By C-4:

Originally Posted By wolfman97:
For its part, the DEA notes that it arrests fewer than 100 doctors a
year on drug-diversion charges, hardly a full-scale attack on the
profession.



So they only ruin 100 careers a year. A local doc had his license suspended for six months. After they found he had done nothing wrong they gave him an unrestricted license to practice. No apologies for stopping his income for six months.

The only reason I haven't burned my DEA license is because insurance companies and pharmacies use it along with Name/SSN for identification purposes. People are under the misconception that you need a DEA license to prescribe non-controlled substances. There are many drugs I couldn't prescribe that I do now but I would rather that inconvenience than having the DEA kick in my door.




Yeah, that 100 per year don't mean shit -- especially if you know the history of how this all got started. In 1914, they passed the Harrison Narcotics Tax Act which appeared on its face to be a simple tax-and-regulate bill. The zealots in charge of the Federal Bureau of Narcotics quickly turned it into an outright prohibition with attacks on the medical profession.

The whole thing came to a head in the case of Linder v. US, 1925. Dr. Linder was prescribing opiates to addicts in a heroin maintenance program. The FBN charged that heroin maintenance was not a legitimate practice of medicine and indicted Dr. Linder. The USSC ruled 9-0 that the Feds had no business interfering in the doctor-patient relationship.

In response, the FBN distributed fliers to doctors around the nation that clearly misrepresented the SC decisions. When that didn't get the results they wanted, they indicted thousands of doctors on drug charges but never brought any to trial because they knew they would lose every case. Of course, no doctor has the funds to stand up against a legal assault by the Federal Government so the indictments alone were enough to change the practice of medicine forever.

The problem continues to this day with the DEA. Cops have no business interfering in medical decisions. They don't know anything about patient care and they care even less. It is time that medicine stopped being ruled by people who get promoted for punishing people.
Link Posted: 8/28/2005 11:46:51 AM EDT
I got the same treatment from my Physician of 14 years....



I wanted Vicodin for migraines.... I got 20 pills.

5 migraines later they were gone.... I asked for more.

Got 12 pills and a referral to PAIN MANAGMENT.

Compared to most of the people there, I was NOT in pain.


Pass the BUCK please!!!!!!!!

I have tried about a dozen meds from Triptans to Anti Epleptics. Vicodin stops the pain. Nothing else works as well.

Then get this..... A few days after that, my molar goes NUCLEAR. I go to my doc to get ANTI BIOTICS, he also gives me 30 vicodin even after I told him I have some left. WTF? He can prescribe 10 days worth of pills for an infection that will be gone in 3 days... but he cant prescribe to me for my head?

I guess that WITH QUATIFIABLE EVIDENCE he can do it (Swelling, abbcess) but an INTANGIBLE pain like Migraines he can't.


So now I have to jump through hoops with a new doctor. The first visit didnt go well.... I was taken to a dark room, and they guy STARED at me the whole time.... even when I stopped talking.... I felt like I was under investigation. Then the doc tells me towards then end that he has migraines too, like DONT TRY TO LIE TO ME I KNOW type statement. So I took his free sample of maxalt. He did say to LET HIM KNOW if I NEED anything, and to save my Vicodin for a rescue.


Whatever. I guess I will just say GIMME VICODIN OR I'LL SUE!!!

Link Posted: 8/28/2005 12:22:36 PM EDT
[Last Edit: 8/28/2005 12:23:50 PM EDT by C-4]

Originally Posted By azcopwannabee:
I guess that WITH QUATIFIABLE EVIDENCE he can do it (Swelling, abbcess) but an INTANGIBLE pain like Migraines he can't.
...

Whatever. I guess I will just say GIMME VICODIN OR I'LL SUE!!!



A pharmacist witnessed one of my patients selling a vicodin Rx in the parking lot of her pharmacy. When doctors hear stories like that do you think that they will change their prescribing practices? That patient kept complaining of head and sinus pain and it all turned out to be bullshit.

I wish the system were different but it's not. As far as suing, that is a civil matter and I'll take that on any day. My anal virginity is not threatened in that situation.
Link Posted: 8/28/2005 12:29:17 PM EDT
[Last Edit: 8/28/2005 12:33:10 PM EDT by Tango7]
Had 2 "patients" who wanted PK's for "migraines"

The first one was 3-4 years ago... he stood facing us (and our ambulance in full red, white, and blue blinky light glory) telling us how the migraine was so bad he really needed something.

He never blinked, never winced. Just stood there with the repeating flashes hitting him square in the eyes. We told him he was full of sh*t, and threw him out convinced him to decline xport to the hospital.

The second was a female with a "mailing address" in a rich town to the south of us (who actually lived in a trailer park north of us), who c/o migraines, but was able to look up at us from the cot at noontime on a clear, sunny day.

The wife gets migraines.



The lights go out (or at least waaaay down)...

The baby goes to the sitter's...


And Tango breaks out the Fiorinol for Mrs. Tango.

It took us several years to get the OK for in-field pain management. We can (obviously) spot most of the medication seekers pre-hospital.

(something about the 15 empty bottles of Hydrocodone from 5 different MD's in 3 months comes to mind)

That said, this DEA BS is right up there with the SCOTUS messing with medical MJ.

Get out of the MD-PT relationship.
Link Posted: 8/28/2005 12:50:47 PM EDT
When I was between Residencies, I worked with a Podiatrist that time-shared an office with an Anesthesiologist that specialized in Pain and Addiction Medicine.

Had some interesting converstations with him..

Listened while he talked to a problem patient (chronic back pain) on the phone-offered them epidural steroids/local anesthesia which would be covered by their insurance. They declined because they wanted Percocets.

There are several viewpoints--
True Chronic Pain sufferers--Cancer, CRPS, etc. They need long term management for their problems. These are people who are unlikely to (almost never) develop a true addiction to the pain medication--they may develop a physiological tolerance and need weaned off when the pain is finally resolved.

Short Term Pain/Episodic--Migraine, Post Sx, etc. They need proper management for the duration of the complaints. A balance between pain relief and addiction--it can go to addiction if not watched closely.

Drug Seekers--these may be the former that got hooked, or people who got some pills from a friend, and are now hooked. They become fairly obvious with a little experience--usually allergic to NSAIDs, ask for pain meds by name, talk about the pain without exhibiting the S/S. They need professional help.

After I do surgery, treat a trauma, etc. I manage the second group for a brief period. Any more than what is normally expected for Post Op pain, fracture, etc., they go to a Pain specialist--the first and third groups go to a pain specialist immediately.

AFARR
Link Posted: 8/28/2005 1:18:42 PM EDT

Originally Posted By AFARR:
When I was between Residencies, I worked with a Podiatrist that time-shared an office with an Anesthesiologist that specialized in Pain and Addiction Medicine.

Had some interesting converstations with him..

Listened while he talked to a problem patient (chronic back pain) on the phone-offered them epidural steroids/local anesthesia which would be covered by their insurance. They declined because they wanted Percocets.

There are several viewpoints--
True Chronic Pain sufferers--Cancer, CRPS, etc. They need long term management for their problems. These are people who are unlikely to (almost never) develop a true addiction to the pain medication--they may develop a physiological tolerance and need weaned off when the pain is finally resolved.

Short Term Pain/Episodic--Migraine, Post Sx, etc. They need proper management for the duration of the complaints. A balance between pain relief and addiction--it can go to addiction if not watched closely.

Drug Seekers--these may be the former that got hooked, or people who got some pills from a friend, and are now hooked. They become fairly obvious with a little experience--usually allergic to NSAIDs, ask for pain meds by name, talk about the pain without exhibiting the S/S. They need professional help.

After I do surgery, treat a trauma, etc. I manage the second group for a brief period. Any more than what is normally expected for Post Op pain, fracture, etc., they go to a Pain specialist--the first and third groups go to a pain specialist immediately.

AFARR



Right on the money.

It's a "damned if you do, damned if you don't" situation.

People complain/threaten litigation if their pain isn't treated to their satisfaction.

Others complain/threaten litigation or the DEA or Board of Medical Examiners gets involved when it's perceived that controlled substances have been prescribed inappropriately.
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