Under-Treatment of Pain

[Time for change]

The under-treatment of pain in the United States is a public health problem of great magnitude. (It is also a major problem in several other countries as well)

It has been estimated that from 50 to 76 million Americans currently suffer from chronic pain. In the good majority of instances, the suffering is unnecessary, since medical science has the knowledge to successfully treat the great majority of cases of pain. One example of this is a study that showed that one quarter of nursing home residents received no pain medication at all for their persistent pain. Another study showed that 70% of patients showing up in emergency rooms for the treatment of fractured bones received no pain medication while in the emergency room.


My involvement in a Wisconsin pain management project

In the late 1990s I worked for the Wisconsin Peer Review Organization, which had a contract with the state of Wisconsin to encourage Wisconsin health care providers to provide better health care to its Medicare patients. In that capacity I became involved in a pain management project, which led to a research study, which was published under the title “Evaluation of a Local Cooperative Project to Improve Postoperative Pain Management in Wisconsin Hospitals”.

More important than the specific results of this study were the conditions that led to it. The initial impetus for the project was the results of a questionnaire survey that showed that most Wisconsin acute care hospitals had no policies in place to ensure that postoperative patients received pain management consistent with existing standards of care. As one example, only 12% of hospitals had policies that required that postoperative pain management plans be developed in cooperation with patients prior to their surgery. And a review of 100 patient medical records showed that most post-operative patients did not receive adequate pain management.

Our research study concluded, in part:

This study demonstrated significant improvement in six of the seven indicators used to measure the quality of the processes used to control postoperative pain in 15 acute care Wisconsin hospitals after the implementation of quality improvement plans…

Why pain control is so important

Actually, the reasons why it is so important to control pain should be obvious to anyone who has ever experienced severe pain. Chronic pain destroys the quality of life for tens of millions of Americans. And it is not just the pain itself. Severe pain also interferes with or eliminates the ability of people to perform myriad functions required in their work or their home lives.

When postoperative patients are inadequately treated for their pain they tend to heal slower and end up staying in the hospital longer. Nor is it sufficient to wait until pain becomes severe before treating it. By delaying treatment until it becomes severe, the patient ends up requiring more drug treatment to provide the necessary pain relief, and therefore acquires a greater risk of serious side effects:

Pain medication should be given on a regular schedule so that there is a stable amount of medicine in the body to keep the pain away. By taking medication before the pain becomes unbearable, the patient can get better relief with lower doses and fewer side effects.

The under-treatment of pain in children is recognized as a world-wide problem that:

can lead to patient anger, frustration, depression, low self-worth, anxiety, mistrust, isolation, or even suicide… In an effort to quell this "public health problem," the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) developed standards that deemed… pain treatment to be a patient right.

Some personal experiences

My mother, when she was alive, suffered from severe rheumatoid arthritis for the last 40 years of her life. My wife has long suffered from chronic back pain due to a condition called spondylolisthesis, which is a displacement of the lumbar vertebra. Consequently, they both required large doses of pain medication, including narcotics, for control of their pain.

So when they required surgery for various unrelated conditions, management of their pain presented an especially challenging problem. Not only did they have to contend with the chronic pain that they normally were plagued with, but added to that was pain associated with their post-surgical status.

On those occasions I don’t believe that their pain was ever handled adequately. Often or usually, for one reason or another, they were taken off even their routine chronic pain medication upon admission to the hospital. Because of their weakened condition, they were in a poor position to fight with the doctors and nurses to demand adequate pain relief.

These were some of the most frustrating periods of my life. Throughout much of their hospital stays I would have to beg the doctors or nurses to provide adequate pain relief. They would tell me that they wanted to see if lower doses of medication were adequate before going to higher doses, and I would attempt to assure them that the lower doses that they contemplated wouldn’t even begin to control their pain. It was always a constant struggle and a constant fight. And my mother and wife suffered great amounts of unnecessary pain in the process.


Reasons for under-treatment of pain

There are many reasons why pain is under-treated, and these reasons have been written about in great detail. One obvious reason is the lack of access to medical care. But even after medical care is accessed, pain is much too often under-treated. Here, I’ll address two reasons that I have found to be especially important in my own experience:

Systemic lack of empathy
A certain high degree of empathy is often required to treat severe pain adequately. The treatment of severe pain requires spending a good amount of time with the patient – to evaluate the pain, initiate a treatment plan, and then follow the patient closely in order to determine the effects of the treatment.

The fact of the matter is that there is only one good way to determine how much pain a patient is having: talking to the patient about it. That takes time and effort, and it is not encouraged or well rewarded by private insurance companies.

Furthermore, when I attended medical school there was very little time devoted to the subject. And then there are cultural issues. There are many who consider the endurance of pain, even when unnecessary, to be a virtue. The end result is that patient pain is often not considered a high enough priority by too many doctors.

Over-concern about drug addiction or “drug abuse”
I encountered this problem all through medical school and during my residency training. And I accepted the “common wisdom” at the time, as I didn’t know any better, or I just didn’t think about it enough. The general attitude seems to be in many quarters that it’s better to let a hundred patients suffer in pain than to risk the possibility that someone may “abuse” the drugs they’re given and become addicted to them. I find that authoritarian attitude abhorrent.

One thing that physicians generally are not taught in medical school, but which is very important to keep in mind is that drugs used for the relief of pain cannot simultaneously cause euphoric effects and the addiction that accompanies those euphoric effects. Is it possible that a patient may continue to demand narcotic drugs after s/he has no more pain? Sure. Is it possible that drugs taken for the relief of pain may continue to be needed for the relief of pain indefinitely? If the underlying cause of the pain continues, then sure it is. Do patients sometimes ask for pain medication when they have no pain at all? Sure they do. But do all these considerations justify 50-76 million Americans living in chronic pain for large periods of their lives? Absolutely not!


The role of the U.S. government’s “War on Drugs”

A large part of the blame for this belongs with our government’s stupid “War on Drugs”. Some doctors live in fear that they could be arrested for providing large amounts of pain medication to their patients who need it. Efforts by the Drug enforcement Agency (DEA) to “crack down” on narcotic abuse have resulted in denying nursing home patients the pain relief that they need. Senators Kohl and Whitehouse recently objected to that:

The lawmakers wrote to Attorney General Eric H. Holder Jr. this month, urging that the Obama administration issue new directives to the DEA and support a possible legislative fix for the problem, which has bothered nursing home administrators and geriatric experts for years…

The law "fails to recognize how prescribing practitioners and the nurses who work for long-term care facilities and hospice programs actually order prescription medications," Kohl and Whitehouse write. They conclude that delays can lead to "adverse health outcomes and unnecessary re-hospitalizations, not to mention needless suffering."

Katherine Addleman explains how drug paranoia in the United States has interfered with providing adequate pain relief to chronic pain patients:

Paranoia about prescribing opiates has been intense in the US. With the highly restrictive regulatory climate, many American doctors fear that they could be arrested as pushers if they prescribe opiates… US Doctors who treat pain aggressively risk investigations by state medical boards, police and agents from the Drug Enforcement Administration who sometimes pose as patients, as well as loss of license and criminal prosecutions….

The feds filed the Lethal Drug Abuse Prevention Act, a law that made any physician prescribing a controlled substance subject to prosecution, unless he or she could prove the prescription was justified. But the backlash came swiftly. Fearing that doctors would be unwilling to take on pain patients, over 50 medical and patient groups got together and stopped implementation of the bill. They were right to worry. A study later found that after the feds threatened Oregon doctors suspected of assisting in patient suicides, pain under-treatment spiked in the state.

But… a directive on controlled substances was passed by the American Federation of State Medical Boards, after the American Medical Association and other professional medical societies put pressure on the government to stop harassing doctors who were prescribing appropriately. The new directive clearly declares that under-treatment of pain is just as unacceptable as overtreatment. Since then, medical boards in Oregon and California have disciplined doctors for inadequate pain management….

And of course, in addition to the chilling effect that our “War on Drugs” has had on the use of legal drugs for the relief of pain, it has also criminalized some drugs that are quite useful in the treatment of pain – most notably marijuana.


Some advice to pain patients

People have an unalienable right to have their pain treated. It’s in our Declaration of Independence. If your doctor doesn’t agree with that; if s/he doesn’t ask you about your pain and then talk with you about it when you want to talk about it; if s/he seems reluctant to prescribe sufficient pain medication because of a fear that you will “abuse” the drugs; or if s/he doesn’t seem to believe you when you talk about your pain, then it’s time to think about finding a different doctor.

[hedgehog]

1. Toss in recent research suggesting that sometimes untreated pain

results in locking the pain signal in an "on " position; that is, the person continues to feel pain after the injury is healed. It may be phantom pain, but it feels real.

[eridani]

2. Back in the early 80s, Scientific American had an article on self-medication

Patients were given access to a morphine drip and allowed to choose their own levels of medication. They found wild variation in the amounts that people chose. Some chose almost homeopathic doses, and others almost enough to stun a horse. Overall, much less morphine was used because the patients were able to self-administer as soon as they felt pain. That really shores up the observation that a lot of individual attention is needed.

[Warpy]

3. The fucking drug war is a major culprit

with the DEA leaning on doctors since they have no hope of ever stopping the torrent of illegal opiates flooding into this country. Doctors are easier. They know where they live.

This is one reason I want it to end. People should have the right to treat their own pain. Period.

No one but the patient can properly titrate pain medication to an effective level.

[williesgirl]

4. Get the fucking DEA out of our health care and this won't be a problem. rec'd

[Kurovski]

5. K&R

Just fucking legalise the M already. Goddammit. if people only realised the pain they perpetuate by their fucking idiocy and lock-step fear. Jesus.

Most legally available painkillers have terrible side-effects.

it's inhuman, just fucking inhuman.

[wolfgangmo]

41. I agree, but

you should know that a certain percentage of the population (estimated at up to 20%) who are unable to process M through their liver. Thus this great herb becomes toxic to them.

I lack the genetic keys that allow my liver to process M through my phase 2 liver detoxification. FYI the liver is the the main organ that your body uses to get rid of toxins. It uses a 1st phase where toxins are broken down into more toxic elements in the liver which are then subsequently broken down in a 2nd phase so that they can be removed from the body. For those of us who have a partially disabled 2nd phase this can be a HUGE problem.

M makes me deathly ill. I'm not the only one.

But it should be decriminalized. The war or drugs has been as effective as the war on bunnies in Australia ...

[Kurovski]

50. Does anything work for you in regard to pain relief?

Or are you one of those fortunates who don't really need it.

Thanks for the info, I never knew about that.

[wolfgangmo]

80. Yes - Kava Kava

Which is a non addictive narcotic from the south pacific (Tuvalu is the best IMHO). Best of all it is readily available over the counter from Naturopathic Doctors in my area.

I don't get a strong buzz, I don't get sick, but I can sleep and I can move around without screaming in pain. It really takes the edge off and best of all my liver can phase 2 it.

[madfloridian]

6. Thanks so much for that post.

It is much needed.

[Lisa0825]

7. When my dad was terminal with cancer 15 years ago, they were being stingy with the pain meds....

my mom got so fed up, she yelled at the doc, "Look, I don't give a shit how addictive they are! He's dying! Make him comfortable!" A man has 6 months or so left, and they are worried about tolerance and addition?? We were livid!

[Time for change]

26. Good for you!

I know the feeling well.

[juno jones]

8. I was denied pain relief after surgery

(which was botched and the fucker had to go back in...) classism dictated to him that I was a poor uninsured dishwasher, and he insisted I must be on drugs, so it would be wrong to provide pain relief from his crappy surgery. Thankfully I had friends on staff who were nurses. They protested and got me painrelief and re-examination before I went totally into shock from his work.

My father was totally undermedicated for the cancer he had, and I live with a man who has constant pain everyday from a split vertebra in his back that will never heal.

And to think, small amouts of codiene are readily availible in the civilized parts of the world that also have socialized mediciine and sane approaches to opiate addiction.

It's our sick sadistic puritan heritage.

[CTyankee]

42. I wasn't poor and had great insurance and had to fight with my surgeon's staff

because they were under the impression that post op patients could "get addicted" if they required drugs past a fixed point (fixed by them or their fear of the DEA). I had a visiting nurse who advocated on my behalf and she got them to recalibrate my Vicoden and I could continue taking the smaller doses (vs. nothing which is what they wanted) as my post op pain grew less frequent. In other words, I didn't snap out of it fast enough.

I have since had a conversation with a progressive anaesthetician family friend who says there's a whole new school of thought about pain management and he always has a pain management specialist on his staff.

[juno jones]

49. Interesting. Thanks.

Pain and inflammation are two things which are overlooked in our health care. I'm glad someone went to bat for you.

Gotta thank those nurses! :)

[CTyankee]

55. Oh, she was great. It really was a matter of combining the smaller doses of Vicoden

with a mild tranquilizer. They worked together synergistically. I didn't have a lot of pain but I did have more than "they" thought was "right," so something had to be bad, right? I insisted to them that I felt I needed more time and that my healing from all of the surgery was taking a bit longer (I was in my late 60s after all!). I didn't think there was anything "new" about the pain because it had abated but it hadn't stopped entirely either.

What these people "think" is that everybody gets addicted to painkillers after surgery (I had had 3 abdominal surgeries in 3 weeks time, requiring a full 6 weeks in the hospital, 2 weeks rehab and another 2 months of daily visiting nurses). I lost 30 lbs. because I couldn't eat very much at all. It was an ordeal. Thank god I had another doc confirm what I KNEW was true: I was NOT addicted and I needed the meds...

[Odin2005]

9. Our society's puritanical "pain is a virtue" attitude is stupid and dangerous.

[Digit]

10. I am on that merry-go-round right now

I have post surgical pain after a total knee replacement and the doctor is refusing to give me anymore pain meds. When I asked the nurse about non-narcotic drugs, she said even those "mess with your head" and won't give me anything else.

She said they are trying to send me to pain mgmt instead and I swear if they tell me to think happy thoughts I may punch somebody's lights out.

I am exhausted. I can hardly sleep. I finally was able to get to sleep this morning at 5am by knocking myself out with Xanax. I didn't WANT to have to do that but I was so exhausted and so uncomfortable, I felt I had no other recourse.

Oh, and no, I am not allowed to change doctors.

[Time for change]

39. I'm sorry to hear that. Recovering from knee surgery can be very painful

In my opinion it is malpractice to refuse to provide pain relief for that.

[wolfgangmo]

43. I have had chorinic pain since my back injury

I no longer go to my MD for pain management.

I went to an ND who used a few different therapies, got me on basic nutrition for inflamation (most pain according to the studies is caused by inflamation) and then she had me try KavaKava (standardized) for pain management. It works for me. Kava Kava is a non-addictive narcotic from the south pacific.

It lets me sleep and that has made all the difference.

This countries allopathic approach to pain management is completely nuts.

[classof56]

56. Oh, this is upsetting, since I'm in the process of scheduling a knee replacement

Getting very tired of the pain associated with lack of cartilage, bone on bone, and hating the thought of walking more than across the room. I've avoided the knee replacement (only option left to fix the problem), but now I'm wondering if I should have a conversation with the surgeon regarding post-op pain relief. I know the physical therapy will be difficult and painful, but I was hoping it would all be worth it in the long run. Reading your post, right now I'm not feeling too confident about the whole thing. Also very sorry to know you're going through this. I find myself wondering what difference it would make if I do become addicted, at my age. Really hate that these decisions get taken away from us. As with so many medical issues--it's my body!

Peace and blessings.

[Digit]

75. Really, don't worry

MOST people do just fine and recover completely, but you should do your homework. Google questions you should ask your doctor before a tkr; things to prepare for before a tkr, etc.
Oh, and if you are allergic to nickel or things of that sort, be sure to tell him.

My doctor had said that you can't become addicted to pain meds if you are really experiencing pain and that is not the first time I have heard that.
The pain pills do not take away all of the pain, unfortunately, but do make it so you can manage things better.
Best of luck to you!

[classof56]

76. Thank you--I really appreciate the encouraging words!

For some reason I find myself feeling very anxious about this whole thing, but since my knee will never get better without it, I'm resolved to go for the replacement. Good to have your positive affirmation and I especially like that your doctor said addiction is not likely when one's really in pain. Also appreciate your advice about what to check out prior to the surgery. They gave me a long list of "what to expects" that I'm working my way through but thanks for your reminder that Google is my friend! The paperwork also included potential risks from the procedure, the last of which was death. I know that's standard, but somehow made me feel better! ;)

Best wishes with your recovery and thanks again!

[undergroundpanther]

11. I have pain

in my back, neuropathy.And to go without something to control the pain I can last only so long before thoughts of suicide enter my mind.
I am scared to death of the fanatical anti- pain drug people.And I am pissed off deeply at stupid fucking teenagers who take thier parents or grandparents pain meds to get high. It's all because of fucking stupid kids doing stupid shit,people who legitamately have pain have to go through a bunch of shit to stop the pain.

[MH1]

12. A doctor may also have to look over his/her shoulder

for people trying to find an excuse to cause trouble for them.

Our asinine approach to pain management makes it difficult for a doctor who may be unpopular in some way (such as being a liberal in a conservative area) to adequately treat pain patients. Because someone is out there trying to take him down. And accusing a doc of "over-prescribing" narcotics seems to be an effective approach.

I've heard about this from a reliable source. I hope it's an anomaly but I bet it isn't.

[Aragorn]

16. how insightful

That happened to me. I 1) confronted the local police about locking up psychiatric patients instead of getting them help, 2) referred patients to lawyers over same, including a family whose mother died in jail for not getting her meds, and 3) turned in a woman for forging prescriptions. Her brother works for DEA, she says, and "they will come after you".

I was already considered a local problem for my liberal views and for flying an upside down flag in my office window. And I won't go into my criticisms of the state government. Did I mention the governor appoints the medical board members?

The medical board had to make up 2 cases and ignore all evidence just to reprimand me. So I quit.

I treated addictions as well as pain patients.

Pain and mood are tightly linked. I saved a few lives (don't mean to sound like bragging) by treating the whole patient including their psychiatric issues. But I won't waste my time and retirement savings fighting a crooked system from the inside. Been trying for 26 years and quit 2 months ago.

[truedelphi]

19. That is a very revealing and very sad post.

My hat is off to you for trying to do the right thing.

And it is absolutely horrifying that you lost your career over this.

[Aragorn]

28. but I didn't

I could have continued to spend money on legal fees, as (in this state at least) the board will continue to fabricate issues and harass you if you win. Which I did. The first time around I got a total dismissal. Then they sent in the same proven lying investigator, who demanded immediate but partial records. (Would not even look at the computer running on my desk 3 feet away.) This is what and how the board goes about it. This is why I quit.

I was taught a long time ago "you can't play with cheaters" and I have too many other skills to react reflexively and simply feed the legal system or continue to be a victim. I told my patients I would not recommend anyone of them remain in an abusive relationship, and I practice what I preach.

Most docs in this position would/have continued to pump money at the problem. I choose a different approach, that's all. A reprimand would not hurt my practice especially when my patients know what really happened. Most of them had predicted it after my tangles with the police on their behalf.

And don't think I haven't continued to address it. I just decided it could not be done from within.

[wolfgangmo]

45. You are still needed.

Have you considered Doctors without Borders?

[Aragorn]

62. yes

among other things. Lots of good things to do.

One of my colleagues in this very rural area noted that it's like mission work already, and I think that's accurate. Got a few things to do while my kids finish law school and med school. Told them both (they agree) not to practice in this state though.

[wolfgangmo]

81. If you are interested in moving to Minnesota and joining and integrated practice

Send me a line. We'll chat.

I love our little practice. We don't bill insurance and we offer pretty low cost care for people.

[Cetacea]

51. Pain and mood: low dose opoiods for refractory depression

Are you familiar with the Bodkin study? I personally know of several people who responded extremely well with Buprenorphine. Many of the cases I've read online were people who tried every antidepressant that exists and had immediate remission with one of the opioids. It is my understanding that the Golden Age of Psychiatry was the era when opioids were the preferred medications.
There is addiction potential but many of the refractory population are told that they would have to take medications for the rest of their lives. Besides, the mu-opoiods are safer and less inclined to make one "high".

I doubt these facts will ever result in a real treatment. It's too inexpensive and safe.

Sorry about your plight. It's so unfair.

[laughingliberal]

13. Thank you for this. I was appalled as an oncology nurse how little oncologists often knew about pain

As a specialty which is, arguably, going to encounter a lot of patients in pain it was astounding to see how little many of them knew about pain management. I once had a patient in her 80's with bone metastasis who was screaming in pain. The attending oncologist ordered Darvocet N-100 every 4 hours as needed. Save us from these people!

The war on drugs and the persistence of puritanical attitudes are, indeed, 2 of the big reasons people are allowed to suffer needlessly.

[Patiod]

32. Also, ONC practices spend way too much time thinking about $$$

I am always surprised at the financial acumen these guys require to stay afloat. Certain regimens make money, certain ones do little better than break even. And they had to know where they were at all times in order to stay in business.

And as you know as an ONC RN, patients have to be screened to ensure they can pay before starting, otherwise they have to go to a community hospital infusion center. I think they docs spend so much time working the payment books that they don't have time for things like pain management, most of which is generic, and little of which will be adequately covered or make them any money.

[mucifer]

14. you'd be surprised to know how much narcotics kids dying with cancer sometimes get.

If the prescribing doctors know what they are doing and titrate the meds correctly one can tolerate amazingly high dose of drugs.
MD's have to be properly trained in palliative care.

[L0oniX]

34. I used to sell weed to a kid who had cancer and his parents paid for it and were thankful.

If I ever need pain killers I can get them without a fucking asshole sociopath doctor.

[Feron]

15. Great post.

After I injured my back, the pain was unimaginable. Unless you've experienced that type of pain, you really don't understand. It's not a headache that goes away after a few aspirin. Once I downed five advil at once and it didn't make a dent in the pain.

And painkillers only go so far. They'll bring the pain down to a dull roar, but the pain never really goes away. But at least you'll be comfortable enough to sleep and function with a decent quality of life.

Personally I think that it is criminal to under treat pain. I'd rather risk someone becoming addicted than implementing a policy that makes it difficult for pain patients to get the relief they need.

[paulsby]

17. the doctors being afraid reason is VERY real

i have spoken to MD's, and it is a REAL concern. it's not an unwarranted concern, because all prescriptions regarding controlled substances are regulated by the DEA.

note that all prescriptions for non-controlled substances (birth control pills, penicillin etc.) are monitored by the FDA.

the DEA is a law enforcement organization. and Dr's are correctly scared #$(#$less of the DEA, especially with prescribing C-II drugs, such as oxycontin (used to be C-III but was moved up due to massive abuse and diversion by dopers).

i am recently post-surgery, and my dr. is excellent. he prescribed me oxycontin, muscle relaxers, etc.

they work well

people in legitimate pain are very often underserved because dr's are scared of the DEA (rightly so) and the DEA is concerned about CRIME, not about people's pain (it's not their job).

if the DEA sees what they perceive as unusual/excessive prescribing patterns by a dr., then they may investigate. and not only can they recommedn charges, but if the dr's license is taken away - there goes his livelihood. many dr's have lots of loans to pay off.

if a dr. underprescribes pain meds, the worst thing that happens is the patient complains. if the dr. is perceived to overprescribe, he can lose his license, his business, and even his freedom

personally, i could not give a flying #$(#$(#$( if some doper OD's on oxycontin if it means LEGITIMATE patients can get their meds without a hassle. there will always be drug seekers who game the system, but we shouldn't punish legitimate patients because there is a chance they will abuse the drug. that's punishing victims for something they have no control over.

i'm thankful i have a great doctor.

[mrmpa]

18. Kudos

Thanks for the intelligent post. I am currently on vicodin, opana and neurontin for my pain caused by a botched surgery and a second surgery to try and correct the first. I am in pain 24/7, the meds just take the pain down to a roar. I give thanks every day to finding the doctor that has the fortitude to care for me and do what needs to be done. However, I'm waiting for the day when the insurance company no longer wants to pay for the meds as this was from an injury at work, hence workers comp is paying.

[Time for change]

63. Thank you -- And welcome to DU

:toast:

I'm glad you were able to find a doctor that cares... Hope that relationship lasts a long time.

[Kurovski]

64. Welcome to DU, mrmpa!

And best of luck to you. May you ALWAYS have what you need. :hi:

[JCMach1]

20. Undertreatment of pain is the practice in UAE

because of stigmatization (for religious reasons) of opiates...

I got to experience this first hand when I went into the hospital for treatment of my large kidney stone.

The first procedure was the stenting which stayed in for 6 days. 6 days of agony as the strongest med I received was about what you would get for a root canal in the states.

The torture and pain was horrific.

[Maraya1969]

21. Here's my own recent story. I have been on opiate pain medications for

over a year now. Now I have one doctor who is very sympathetic and does not treat me like a fucking drug addict like my first doctor did, (even though after seeing my MRI he said, "You have reason to be in pain").

I remember being in the room waiting for him and throwing something away in the metal bin under the sink. When he came in he asked me about what the noise was. And then when he gave me a patch and I wanted something for breakthrough pain he kept saying "But you are on a pain medicine" Well fuck you buddy I was still in pain.

Anyway the last thing that happened is I changed my mind a couple times about what drug helped me the most so my doctor, (not that asshat with the pain patch but my new compassionate doctor), called in 2 different drugs and I had refills on both of them. (Percocette and Narco which is Vicodin with 10 mg of the opiate in it).

When I went to refill the Narco because I was taking that and had 2 bottles of the Percocette left in my house the pharmacists was looking at my scripts and shaking her head. I should have told her that I don't take every single pill I am prescribed - I take between 6 and 8/day mostly 6.

Anyway she said something about having to confirm with my doctor and the next thing I know those refills are gone and it is "closed". I did not get a chance to talk to the doctor yet but when I spoke to the physicians assistant she was pissed. She said that pharmacists like to play doctor sometimes. I can understand if I was getting the drugs from different doctors but she was questioning one doctor's judgment and not relying on my relationship with her, (my doctor).

After I talked to the physician's assistant I went to the pharmacist and told her nicely that she was out of place saying something because all my medications were coming through the same doctor.

Don't get me wrong I am afraid of these drugs and I know a lot of people abuse them and there is a chance that I can become addicted, (I know I am physically dependent now). I wish there was something completely safe to take but these are the best for me right now. And my left arm and neck hurt right now but I am going to wait because I have taken 6 and I don't want to take 8.

[Patiod]

33. Have you had problems with rash?

or opioid-induced constipation? My dad has suffered both. The constipation is treatable - the rash has not been. It really puts him off taking what he needs to manage his pain on a day-to-day basis.

Playing devil's advocate here (and I should say that as a former hospice volunteer and current caretaker of someone in horrible intractable untreatable not-terminal chronic pain, I am 100% in favor of making sure pain is controlled, even if it requires horse tranquilizers):

Having said that: People in short-term pain MAY be overtreated. I have heard some pretty scary stories from friends who became dependent on pain medications after surgery such as (knee surgery). So I think there's a line here, where on one side doctors and pharmacists need to encourage people whose pain is likely to mitagate in a few days or weeks to go easy on the drugs and wean off ASAP, and at the same time both groups need to pay better attention to the needs of their chronic pain patients, help them find solutions, teach them about focusing on baseline management (and avoiding spikes), and not worry so much about addiction if there is no end in sight for the pain.

We don't seem to be very good at doing gray in this country. Drugs are either Bad or Good - it's hard to wrap our heads around the idea that pain meds are neither - they're just tools that can be used well or used badly.

[Maraya1969]

73. No problems with rash. Constipation yes but that is part of one of the problems

that causes me pain, (the whole gastritis mix that has a lot of names). I take stool softeners every day and natural laxatives.

My issue is not short term. I did not realize for years that taking handfuls of ibuprofen was going to rip my stomach up but it did and then I was left with nothing.

I had a head injury once that caused a small time period of amnesia. I'd also fainted and landed right on my jaw with nothing to break my fall. So my MRI is real interesting, the results page has so many interesting terms on it I could never understand without someone explaining them to me. I do know I have the usually herniated disks and stenosis, (a narrowing of the tube like thing that covers the spinal chord)just in my neck. I also have nerve damage but I don't know if that causes pain or not.

And then my doctor told me that a lot of problems in your lower back cannot be seen by an MRI. So you people who have lower back pain and are told that there is nothing wrong with you that might not be true.


Rambling rambling rambling...........................sorry for the lack of coherency.

[dysfunctional press]

53. i've been on methadone for chronic pain over 10 years now.

as well as vicoprofen for migraines.

when a pharmacist decided to play god when i asked to refill the vicoprofen 3 days early(it had been a very bad month for migraines), i pulled ALL of mine and my wife's scripts from walgreens, and told them why in a letter to their corporate office.
and my doctor was EXTREMELY pissed about the pharmacist's actions.

fucking ignorant pill-counters.

[Fly by night]

22. Excellent thread, as usual, TfC. It's telling that medical marijuana patients who claim ...

... chronic pain are considered unworthy or malingerers, even though mmj would successfully reduce pain in most patients with many fewer side-effects or the potential for addiction.

It is time to re-visit the need for the DEA, period.

[Time for change]

68. Thank you fly -- It's a kind of bigotry, very similar to most other kinds of bigotry.

That's the way I see it.

[singing sparrow]

23. recent crackdown on pain meds

I am so happy to see this discussion. I am not suffering from botched surgery or cancer but I use Vicodin/Narco because I am unable to use Advil.etc due to a blood clotting/heart problem and I have severe arthritis and various other malfunctioning parts.
I was horrified when the current attack on pain relievers became public. The numbers were very confusing-so low for OD's and misuse that I thought there was a misprint and the government turned our own argument on us by publishing that in Europe there is not nearly the use of pain relievers that we use here in the US.
I continue to receive the refills but must ask twice a month now instead of once a month. I have a fairly hip MD but her consciousness just shuts down when I try to discuss this latest medical fad. I thought that perhaps one of the Big Pharma is coming out with a new drug but now understanding that DEA is over the counting of pain meds I see.
Yes I too have been put down by a pharmacy clerk for my Narco but I knew that the young dude would really get panicked if he knew about my political/sexual/spiritual life so I left him to his little thoughts. F--k him!!!!!!!!:group hug:

[Kurovski]

65. Best of luck to you!

Post more often! :) I love the little bee, as I am a big fan of bees.

[rampart]

24. some attendants use or sell the real drugs

give otc or reduced dosages to nursing home patients. i couldn't prove it, but the staff at g'ma's nursing home were dopier than the patients.

[DemReadingDU]

25. excellent topic

When my mother-in-law lived with us, she was always having pain for lots of reasons. She never could get satisfying relief. She liked Vicodin, but took too many per day and got sick. It's really difficult to find the right medication with the proper dosage without having additional side effects.

[Christa]

27. K & Highly rec'd nt

[Flatulo]

29. I live in constant agony with degenerative disk disease

The pain is with me night and day. I eat enough Advil to kill a horse, but my doctor will not prescribe anything stronger. He's afraid I'll become dependant.

[Kajsa]

36. Get a new doctor, Flatulo!

I too have DDD, and know just what that hell is like.

Taking Advil for it is like putting a bandaid on a fracture!

Get a good GP ( I KNOW- finding one can be difficult), but your quality of life
is at stake here.

You need a referral to a good pain management doctor.

Good luck.

:hug:

[Beaverhausen]

59. My husband's pain management doc won't give him any more pain meds

He also has degenerative disc disease. His GP does give him vicodin, but this pain management guy sucks.

He had surgery that only helped his pain about 20%.

His dependency on vicodin is pretty bad, but he has no choice at the moment.

[Kajsa]

67. I'm so sorry Beaverhausen.

Vicodin is not strong enough for a lot of people
with DDD.

I hope your husband can find another pain management doctor,
one who LISTENS to him!

:hug: to both of you.

[Flatulo]

83. In my area, there are no PCPs taking patients. If you have one,

you are lucky.

It took me five years of wheedling to even get an MRI, which (surprise) showed severe degeneration on two disks. They are as thin as paper.

I got laid off in May of this year, and I have been working as a consultant since August, but I get no time off for bad back days, and I have no short-term disability, so I take 4 Advil every morning and drag my ass in to work.

I don't know how much longer I can do this.

[Time for change]

69. "Dependent" is such an overused word IMO

Maybe that doctor should be told that he should walk to work, since otherwise he'll be dependent on his car. Or he should get rid of all his money so that he won't be dependent on money. Of course people with chronic pain are dependent on pain meds. It's either that or live in constant pain. The authoritarian attitude that it's better to live in pain than be "dependent" on pain meds is hard for me to tolerate.

[Patiod]

30. A DUer claimed that Big Pharma is just trying to get pts hooked

In another thread a few weeks ago, someone was bitching about drug companies (like Perdue) trying to get patients hooked, and how the idea that we're undertreated for pain is just a Big Pharma meme to push more Oxycontin.

AAARRRGGH. I replied that I actually interviewed the guy from the Pain Society who invented "Pain as the Fifth Vital Sign" campaign that now used in hospitals - where they ask about pain levels right along with temp and blood pressure, and this guy was worried about PEOPLE IN PAIN and not helping pharma companies. Besides which, much of the stuff patients get (or don't get enough of) is generic anyway.

If anyone here is terminal or caring for someone who has a terminal diagnosis know that Hospice doctors and others trained in palliative care get it, and many don't worry about the DEA because the DEA is actually pretty good with about hospice doctors. If you put yourself or your loved ones in the hands of hospice EARLY, they will get the pain control they need. It's a difficult choice, but everyone I've ever talked into hospice has come back with the same reaction: "I wish we had done that earlier." Everyone. No one ever regrets going into hospice "too early", just going in too late.

The problem is getting adequate relief for those who aren't dying, but are still in horrible pain.

[Laurab]

31. K&R nt

[Kansas Wyatt]

35. I still have morphine pills from 1995

I kept them, because of all the FUCKING ASSHOLES who just knew I was an addict, going to get addicted, thought I was a wimp, looked down their fucking noses at me, blah blah blah.

These simpleton mother fuckers apparently didn't know how a sciatic nerve stretched and ripped across a break in the pelvis can lead to suicidal pain.

Oh how sorry they were a couple months later, once I got diagnosed right. Being without health insurance can be a bitch if something is wrong with you, and you have to wait for pity.

Due to this experience, NOBODY looks down their fucking noses at me, I take no shit from anyone, and I know what a crock of fucking shit this country is.

[chasitynola]

48. I, too, suffer from constant pain.

I have spondylolisthesis and as I get older, the pain grows. Just sitting here in my computer chair reading DU for the past hour makes me feel as though I cannot stand back up! Thankfully, I found a great orthopaedic clinic and a wonderful doctor who treats me with respect. He is an older gentleman and I fear for when he retires. It is not easy to find someone that will make your life comfortable. I went through chiropractic care, massage therapy, physical therapy, etc. The pain meds and gentle daily exercise are the only things that make my pain bearable. I do not want to stop my life because my back locks up! I have a three year old and I refuse to be inactive.

I went to the ER about two years ago with a very nasty gallbladder attack. When the admitting nurse asked me if I was on any medication, I made them aware of my hydrocodone dosage (7.5 mgs) and my soma muscle relaxers. As soon as the words came out of my mouth, I was treated from then on like a complete crackhead and they looked down their noses at me for the rest of my stay. It was humiliating. I never want to feel that way again. If I hadn't told them about my maintenance meds, they could have given me improper dosages of the meds they did prescribe! What to do?? Lie?

I will never let another hospital treat me that way again.

[winyanstaz]

37. K & R...

Thank you for an excellent post.

[Kajsa]

38. Thank you for posting this, Time for change!

This nails the misconception many people, not just doctors have with pain meds,

"drugs used for the relief of pain cannot simultaneously cause euphoric effects
and the addiction that accompanies those euphoric effects."

I've heard it described as this,

to those with acute pain, the meds center on pain relief,
much like ADD meds that do not " jack up" a person who
has ADD- the condition " soaks up" the meds, leaving fewer side effects.

I have degenerative disc disease in my lower spine and have frequent bouts of
acute, chronic pain. It interferes with everything in my life.

Can the use of these drugs possibly lead to addiction?
Yes, but the majority who use pain meds do so to control acute, chronic pain.

What many doctors do not realize is that without pain relief,
a person with chronic, acute pain becomes willing to do anything
to get relief- sometimes with tragic results

[Kindigger]

40. DEA told me to stay away from official 'pain clinics'

I have chronic pain that fits in the category of 'a condition that went untreated for so long that my brain is in a constant pain loop'. The problem was fixed surgically, but too late.

I went to an official pain clinic where I was humiliated beyond belief. I signed a 'contract' stating that I would be a partner with the doctor in my treatment. I had to hobble in twice a month to have my pills counted--you are a drug abuser until proved otherwise I guess.

When I gave my opinion on what I thought would work better I was dismissed, and told "if I didn't do as the Dr. said, and follow his instructions I could go elsewhere." There was something mumbled about DEA regulations. I asked what happened to me having a say in my treatment and 'non-compliant' was written in my records.

I was on Oxycontin at the time, and in the middle of a post-surgery dosage adjustment. I told the dic...doctor that I thought a lower dosage more times per day would work better than what he was giving me--high dose 3 times a day (the result being I was totally knocked out and useless, then waking up to unbearable rebound pain while waiting for the next dose).

I asked why not? No answer. Just do as you're told or you can go find another doctor.

So I went home and called the DEA and I asked them the question. They were extremely helpful, and sympathetic (seriously). The man told me my questions to the doctor were totally justified, and that my idea was probably a good one, and the way the doctor handled it was unprofessional and uncalled for.

Turns out it had nothing to do with DEA regulations--it was the pain clinics regulations. Instead of being truthful, the jackhole at the pain clinic decided to act like a little dictator rather than explain it to me. Their regulations didn't give a hoot how high the dosage of a pill was, they were concerned with the number of pills. So, even though my idea would have decreased the daily mg of medication, it couldn't be done because of the quantity. They would have had to spend more time counting them during my twice monthly humiliation sessions.

He went on to tell me to get away from the pain clinic because they are more interested in covering their asses than treating pain. He advised me to find a GP who would prescribe my meds and stick with him, which I did. This resulted in the feeling that I'm trapped; that I can't move for fear I won't find another doctor.

[Time for change]

47. The DEA person who told you that the actions of your doctor at the pain clinic were uncalled for

and unprofessional was certainly correct.

However, not all pain clinics are like that, and I suspect that you experienced one of the worst of them. Unfortunately, because of the circumstances of geography or the insurance coverage that one is stuck with, choices may be limited for many people. I wish you the best of luck in getting your pain treated.

[BlancheSplanchnik]

44. K and R

very important discussion, thank you TfC

[Politicub]

46. It is evil to make people suffer from pain when it can be allieviated

The depths of depravity that our elected officials can sink to continues to baffle me.

Is this some sort of weird puritanical or religious holdover where suffering is seen as some weird noble act?

Whenever Americans are given a chance to prolong suffering or step on someone's neck, they do so. Why is it that we as a people continue to beat people down without fail. And even those who have been stepped on in the past relish the opportunity to make others suffer.

[bluescribbler]

52. It's so stupid.

When in college, I read "Confessions of an English Opium Eater", by Thomas DeQuincy. In his case, laudunum did not provide any euphoria when he took it to relieve his pain. But we can't have sick and dying patients becoming addicts, now can we? :sarcasm: The Puritans have a lot to answer for.

[Cetacea]

54. Excellent site/organization for people with pain/chronic pain

http://www.nationalpainfoundation.org/

[Beaverhausen]

60. thanks for that link. I found someone very closeby I will try and send my husband to

:hi:

[Cetacea]

61. You're welcome. Good luck nt

[Greyhound]

57. Auto K&R.

This issue is a great companion to a thread posted in the last couple of days about the "American work camp" that our nation has been allowed to become.

In Amerika it is far better that thousands suffer needlessly so long as we are assured that no one is deriving relief from the grinding oppression we labor under/for.

[Time for change]

70. Yep.

Sociopaths have way too much influence in our country. Americans need to do a better job of recognizing them and making sure that they remain OUT of power.

[Fermentia]

58. Under-Treatment of Pain

http://www.nytimes.com/2009/07/01/health/01fda.html

More silliness. Instead of banning Vicodin and Percocet because of the amount of Tylenol, why not just get rid of the Tylenol? Nope.

[emald]

66. I am a thirty year chronic pain patient

I have never, not one time, had adequate pain relief because of Doctors' stupidly following their own suppositions. I thank you for this article and I intend for my Doctor to see it, if you wouldn't mind. I am also a VA patient and the silliness involving the opiates is legend. What a pain. I have had to learn great patience in dealing with the doctors and often have to teach a new one about the various problems with chronic pain folks. This posting will help a great deal. Thank you.

[Time for change]

71. Sure I wouldn't mind

I hope it does some good.

[Time for change]

72. Duplicate -- self delete

[timeforpeace]

74. What an incredible thread. Reminds me why I'm so glad I sold my pharmacy.

[otohara]

79. ????

Do tell, why did you sell your pharmacy.

[Silver Swan]

77. In my work with disability beneficiaries

The issue of pain medication often came up. Some individuals were receiving adequate medication for their pain, but many were not. I came across several physicians who were afraid to prescribe "controlled substances" out of fear they would be investigated. I also saw that there are two types of pain clinics. One type was concerned in helping individuals in pain to receive the optimal medication for pain control. The other type seemed to think that their patients should learn to live with their pain with as little medication as possible.

I believe an individual should be given whatever level of medication is necessary to enable them to function. It is stupid to worry about addiction when medication can make the difference between someone being able to work or being unable to work.

After all, addiction only becomes an issue if the individual is unable to obtain medication. If controlled substances were not so controlled, then access to medication would not be a problem and addiction would be a non-issue.

There should be no stigma about using pain medication.

[Nothing Without Hope]

78. Excellent and important post. Again. Thanks, TfC! n/t

[ddeclue]

82. IMHO: Pain treatment merely masks an underlying cause and is a dangerous thing to do.

It is better to solve the real problem rather than try to mask it with ever increasing doses of pain killers.

(And yes I've had a few surgeries including knee surgery where pain killers were given.)

There are cases where there is no alternative such as bone cancers where there is no alternative however.

[Flatulo]

84. But some conditions are just chronic and the only treatment is

pain management.

[Overseas]

85. K&R. Many thanks for addressing another very depressing issue.

It has definitely bothered me how millions are allowed to suffer because a small percentage of pain medication recipients have become hooked.

You have described the reasons very well.

And the awful sanctimonious overlay that ignores real suffering just to do more posturing.

There is so much counterproductive posturing in the USA. Like pushing Abstinence Only, instead of working to make condoms more commonplace. Get kids to use them early and use them every time.