Managing pain in primary care

The goal is for pain management patients to have the best life possible while dealing with their pain

http://www.clinicaladvisor.com/the-waiting-room/pain-management-in-primary-care/article/713073/

I work in primary care as a Family Nurse Practitioner, but there are days I feel more like I am primarily a pain management provider who also practices primary care.  Prescribing chronic opioids on a regular basis is not something I particularly enjoy, and there are times I feel like a little piece of my soul dies with every prescription. To be clear, I do not doubt that my patients are in pain (or at least believe they are in pain). In many cases I feel as though these patients were placed on chronic opioids inappropriately, and it has become too difficult for them to stop. Providers may think, “We’ve done nothing for your pain, and we’re all out of ideas, so here are some opioids.”

When I see my patients on chronic opioid therapy, I talk to them about why they are on the medication, how long they’ve been taking it, and how they feel about being prescribed opioids. Many patients would like to take less — decrease their pill burden — but I am finding that some patients are afraid of being in pain if they stop medication completely. Thus, a vicious cycle begins.

Now, that’s not to say that pain management in primary care isn’t entertaining. I realized at one encounter that I’ve been missing out on a lot of interesting parties. One patient I saw stated that the reason methamphetamine was present in his urine drug screen was because he snorted a line of meth at a party during a game of truth or dare.

Another patient said that the reason she was discharged from a pain management program was because on her way to the appointment, she had stopped for coffee, and some teenagers might have poured methamphetamine in her cup when she wasn’t looking. Of course, the pain management provider just wouldn’t listen to reason.

Once, I almost had to call the Vet for consultation. A patient explained that the reason for his discharge from pain management was because the pet cat found the bottle of oxycodone in a pillowcase and swallowed all of the pills. No fear, the kitty is ok.

When I share these stories with other peers, the question that arises is, how do we keep our objectivity?  What prevents us from becoming even more jaded and thinking everyone who asks for opioids is just a ‘pill-popper’?

Well, my last patient is a long time chronic pain patient who has been on incredibly high doses of opioids.  After almost 2 years of dose adjustments and discussions about other options to treat his pain, he tells me today that he wants to stop all opioids and explore other options. He admits he was afraid of pain, but the side effects of opioids have become too much to handle.

So what is the answer?  All I can suggest is for clinicians to have patience and an open avenue of discussion with patients about the expectations of pain management in primary care. At no time is it acceptable to abandon patients, or treat them as a ‘junkie.’ The goal is for pain management patients to have the best life possible while dealing with their pain.

 

People Don’t Take Their Pills. Only One Thing Seems to Help

half or more of prescribed medication is never taken

https://www.doximity.com/doc_news/v2/entries/10535857

For all that Americans spend on prescription drugs — $425 billion last year — you’d think we’d actually take our medicine.

But one of the frustrating truths about American health care is that half or more of prescribed medication is never taken.

It’s called medication nonadherence, and it’s a well-documented and longstanding problem, particularly for patients with chronic conditions. The drugs they’re prescribed are intended to prevent costly complications, reduce hospitalization, even keep them alive. But even when the stakes are high, many patients don’t take their meds.

When drugs cost less, patients are more likely to fill prescriptions and less likely to skip doses and split pills.
CreditPhoto Illustration by Joe Raedle/Getty Images

This seems like a problem we ought to be able to solve. It motivates high tech approaches, like digital pills that can automatically communicate to doctors that they’ve been taken.

Maybe people forget to take their meds — about 60 percent of people say as much — so we just need to remind them. Maybe people don’t understand the value of what they’re prescribed, so we just need to educate them. Maybe drug regimens are too complex, so we just need to simplify dosing.

All these methods have been tried. It’s not so clear any of them work very well.

Only one approach has repeatedly been shown to be effective: reducing the cost of medications.

First, let’s look at the research on the other methods. So-called reminder packaging — pill packaging or containers that organize drugs by single dose or day of the week — is a relatively simple idea intended to help people remember to take their prescribed dose.

A systematic review by the Cochrane Collaboration found that it was helpful in doing so, but only modestly. Surveying 12 randomized controlled trials, the authors concluded that reminder packaging increased the number of pills taken by patients by 11 percentage points. But they also found that most of the studies had significant methodological flaws, casting doubt on the findings. Other systematic reviews of reminder packaging studies also found problems with the research, like small sample sizes and short follow-up periods.

Perhaps reminder packaging is too passive, and patients need something like an alarm to alert them when they’ve missed a dose. Electronic pill monitors can do that. Some just remind patients to take their medication. More sophisticated ones alert doctors when they don’t. In 2014, a team of researchers from the Brigham and Women’s Hospital and Harvard Medical School published a systematic review of such devices in the Journal of the American Medical Association. Here, too, the results are disappointing. Most studies of such devices do not detect improvement in adherence.

A recent randomized trial not included in these systematic reviews tested three dose reminder approaches for people with a chronic health condition or depression: a pill bottle with toggles for each day of the week that can be changed after each daily dose; a pill bottle cap with a digital timer displaying the time elapsed since the medication was last taken; and a pill organizer with a compartment for every day of the week. Over 50,000 subjects were assigned randomly to one of these approaches or to none, as a control.

None of the devices performed better than the control in getting patients to take their medications. One possible explanation is that forgetfulness may not be why patients don’t take their medications as prescribed. Drug costs, a wish to avoid side effects, and a desire to be less reliant on drugs are some of the other reasons patients don’t take them.

“It is also possible that for reminder devices to be effective, they need to be coupled with other adherence-improvement strategies,” said Niteesh Choudhry, lead author of the study and a physician with Brigham and Women’s Hospital and Harvard Medical School.

That’s why augmenting electronic monitoring with other information or assistance delivered to patients may be more successful, if more expensive. For example, one study found that the adherence of hypertensive patients increased when digital display containers were combined with a blood pressure cuff and a card for recording blood pressure. This suggests that when patients receive feedback that signals how well they are controlling their condition, they may be more willing to take their medication.

Still, it isn’t hard to find studies that show that even with considerable support, getting patients to take medications can be challenging. A Cochrane review examined randomized controlled trials of interventions — across many dimensions — to increase medication adherence. Reminder packaging and alarms were just some of the methods assessed, with approaches including patient and family education about the value of medication, and mail or telephone follow-up.

Of the 182 randomized trials reviewed, four stood out as the most methodologically sound. Among those, two increased adherence but two did not. Over all, the authors concluded that there was a lack of convincing evidence that even complex and costly interventions significantly increased patients’ compliance with drug regimens.

“A cure for nonadherence is nowhere to be seen,” they wrote. A more recent study not included in the Cochrane review found that not even providing patients with financial incentives and social support, along with pill bottles that signal when a dose should be taken, was enough to boost adherence among heart attack survivors.

So why is price so important?

When drugs cost them less, patients are more likely to fill prescriptions. Even if people have already purchased drugs, they may skip doses — or split the pills — because of concerns that they won’t be able to afford future refills. Free drugs don’t get everyone to take them, but many more do so than if they have to pay for them.

For those with certain chronic conditions, extra help in affording medications can reduce adverse events and hospitalizations — a big increase in quality of life, as well as a potential benefit to the wider health care system and the economy.

Lowering prescription drug costs has been a longstanding pursuit for many politicians, and Medicare Part D and the Affordable Care Act helped (although most Americans still say costs are too high). President Trump said drug companies “have been getting away with murder,” but lower drug costs have not yet been a top priority of this White House.

if prescribers and Pharmacists are held AT FAULT.. when a person takes more medication – particularly controlled medications – than is prescribed… why are those healthcare professionals NOT HELD AT FAULT.. if pts fails to get their prescriptions filled and/or don’t take the medication as prescribed… both scenarios is basically medication nonadherence.

Could it be that the DEA has “over sight” of the first and no one has the authority,  the funding, or gives a crap about the latter ?

 

Where’s the data bank of biased providers?

http://www.clinicaladvisor.com/the-waiting-room/databank-necessary-for-patients-seeking-care/article/706610/

It recently occurred to me that we need a national databank available at all times to patients seeking care. This databank would include names of medical providers who have publicly expressed opinions indicating biases about certain populations.

I recently came to this conclusion after seeing some posts on social media from physician assistants (PAs) noting their dismissive thoughts about lesbian, gay, bisexual, and transsexual (LGBT) patients, patients with addiction, and patients with HIV. Their comments reflect attitudes that have lingered since time immemorial. You know the lines: “I don’t feel sorry for them”; “They did it to themselves, it was their choice;”; “Why should I have to pay for their bad choices?” etc. 

In areas where populations of people who are commonly discriminated against live, call-to-action posters would be beneficial. These posters could say, “Tell us about your biased medical provider!” and include a 1-800 phone number, for example, 1-800-RACISTPA. Actually that wouldn’t work, it’s got too many letters. But something like that.

Once the biased provider was reported, it would be placed online, and patients seeking care could check it out and see if their prospective PA or other provider was on the list.

Of course this would never work. And it would be easy to cause trouble for PAs and other providers for reasons not really related to bigoted behavior. However, it’s so upsetting to see comments like the ones I saw and think that a patient seeking care might end up on the wrong side of a stethoscope with an obviously biased providers. Clearly they would get bad care.

So how do we address this? One way is to see it as impairment, or as care not meeting the standard-of-care requirements commonly used by state medical commissions. This would be easier to do after a patient saw a provider they thought treated them without respect. Medical boards often deal with such issues, and it’s not unheard of for providers to be held accountable for such behavior.

Reassured by a Patient’s Prescription Drug Monitoring Program Results? Not So Fast!

Nearly two thirds of patients with opioid dependence had no opioid prescriptions logged over the prior 12 months.

Prescription drug monitoring programs (PDMPs) are available in every state. Designed to collect and display prescriptions for controlled substances, they are becoming an indispensable part of prescribing practice for providers. The data they contain can help inform decisions about whether or not to prescribe controlled substances, including opioids for pain. However, the proportion of patients with opioid dependence who are captured by PDMPs remains unknown. Using data previously collected for an emergency department–based treatment trial in Connecticut, researchers determined the correlation between self-reported nonmedical prescription opioid use and opioid prescriptions recorded in the state’s PDMP.

Of 329 patients with opioid dependence enrolled, only 118 (36%) had one or more opioid prescriptions recorded in the PDMP during the past year. Among the remaining 211 patients, 60 (28%) reported 15 or more days of nonmedical prescription opioid use during the prior 30 days, despite having no recorded opioid prescriptions.

Comment

Most states in the U.S., including mine, have mandated the use of PDMPs in certain cases. However, this paper’s findings are a sobering reminder that most patients with opioid use disorder don’t get their opioids from prescribers. Don’t be falsely assured by a PDMP search that comes up blank — your history-taking abilities and gestalt are still very important when deciding whether to prescribe opioids.

State Pain Advocacy Groups have been setup on Facebook

State groups have been setup on Facebook in order to help organize letter writing campaigns, meetings, picketing and the like.  If we don’t know where intractable pain patients (IPPs) reside, we can’t target members of the DEA Oversight Subcommittees, Health Care committees, etc.  There is anti opioid legislation pending and/or passed in many states and IPPs are needed to attend these meetings, create letter writing campaigns and meet with legislators.

Unfortunately, many policy makers will disregard correspondence from out of district or out of state.  That doesn’t mean to not write, it just means it’s important to target those who have the power to make decisions that directly affect us.  These state groups were created with the intent to work with ALL groups, organizations and foundations that have a stake in the pain issue.  We need help in every state getting contact information posted and the groups up to speed.  Please join:  your state and ‘Pain Advocacy Group’.  Until we organize, we are divided and will not be heard.

CPP’s need to get their act together or plan on kissing their ASSES GOODBYE

four days ago… there was a legal defense fund created for Dr Tennant  https://www.gofundme.com/dr-tennant-legal-defence-fund

Since it was created … FORTY EIGHT people have donated from $5.00 to $2,000.00 for a grand total of $6,555.00

Supposedly 100 million chronic pain pts… and so far 48 people have stepped up.. and a few that have stepped up contributed ANONYMOUSLY … and only ONE MEDICAL DOCTOR has contributed….out of abt 700,000 physicians… not counting the number of PA’s, ARNP’s, NP’s who also have DEA licenses and prescriptive authority.

If the DEA can successfully prosecute the most well know and honored chronic pain physician in this country.. then NO PRESCRIBER IS SAFE and no chronic painer can have any assurance that their ability to get pain management will not VANISH in the not too distant future.

When the DEA went after Kratom and wanted to make it a C-I and thus an ILLEGAL SUBSTANCE … those in the community that depend on Kratom STOOD UP.. and the DEA backed off.  They have only won the battle and not the war because now the FDA is “going after” Kratom…

Dr Tennant was caring for the sickest of the sick in the chronic pain community and thus many of his pts were taking HIGH DOSES OF OPIATES..

The DEA is like the SCHOOL YARD BULLY… no one stands up to him/them… they are embolden to keep on doing what they apparently like to do… kick the crap out of those who refuse to stand up and take their “lunch money”..  In this situation with the DEA it is not your “lunch money” that they are after… it is YOUR QUALITY OF LIFE… or LIFE ITSELF… how many are going to commit suicide when they lose their pain medication and exercise the only option that they have to permanently silence their pain ?

According to this https://en.wikipedia.org/wiki/Drug_Enforcement_Administration    the DEA has a TWO BILLION/yr budget, but it is claimed that we are spending 81 billion/yr fighting the war on drugs…  If all those people & companies that are being adversely affected by the DEA and the war on drugs contributed ONE TIME the cost of a fast food lunch ( $5 -$7.50)… there would be a legal defense fund of > ONE-HALF TRILLION DOLLARS…

Spending a few million to help keep a innocent prescriber out of jail and continuing to practice medicine … would be “pocket change” for a legal defense with such “deep pockets”.

The DEA “taking out” one doctor will mean that hundreds or thousands of chronic pain pt will go without appropriate care and no other practice will touch you… because you were a pt at that “bad practice”. You will have a BIG RED “A” on your forehead… as in ADDICT

A Texas county attorney is suing most pharmas that produce opiates and major wholesalers so that according to him 

Ryan said the lawsuit is seeking to prevent the group named in the lawsuit from selling opioids. He said it also seeks monetary damages and fines to be assessed.

   https://www.pharmaciststeve.com/?p=23405

Apparently this attorney believes that stopping the selling of prescription opiates that will eliminate the demand/sale of ILLEGAL OPIATES… just like the 18th Amendment and alcohol prohibition stopped the use/abuse of liquor/alcohol..   It took us about 13 yrs to figure out how STUPID THAT WAS.. But no one died during those 13 yrs because they had a medical need for alcohol. 

We try a similar stun with pain management meds and the deaths/suicides will be HUGE … 

SO GET OFF YOUR ASS AND MAKE A CONTRIBUTION TO:

https://www.gofundme.com/dr-tennant-legal-defence-fund

 

 

 

The DEA hasn’t updated their Guidance on Controlled Substances since 2006. Important information for everyone to know

The DEA hasn’t updated their Guidance on Controlled Substances since 2006. Important information for everyone to know

www.familiesforiprelief.com/advocacy/issues-and-opportunities/

DEA GUIDANCE AND DEMANDS FOR PHYSICIANS WHO PRESCRIBE CONTROLLED SUBSTANCES

THE PRACTITIONER’S MANUAL OF 2006*

CORE INSTRUCTION

Stated in 2 sentences on page 19: “A prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice.  The practitioner is responsible for the proper prescribing and dispensing of controlled substances.

“ACCEPTABLE MEDICAL PRACTICE”

Stated on page 30:  “The legal standard that a controlled substance may only be prescribed, administered, or dispensed for a legitimate medical purpose by a physician acting in the usual course of professional practice has been construed to mean that the prescription must be “in accordance with a standard of medical practice generally recognized and accepted in the United States”.

Federal courts have long recognized that it is not possible to expand on the phrase “legitimate medical purpose in the usual course of professional practice” in a way that will provide definitive guidelines to address all the varied situations physicians may encounter.

While there are no criteria to address every conceivable instance of prescribing, there are recurring patterns that may be indicative of inappropriate prescribing:

An inordinately large quantity of controlled substances prescribed or large numbers of prescriptions issued compared to other physicians in an area; No physical examination was given;  Warnings to the patient to fill prescriptions at different drug stores;  Issuing prescriptions knowing that the patient was delivering the drugs to others;  Issuing prescriptions n exchange for sexual favors or for money;  Prescribing of controlled drugs at intervals inconsistent with legitimate medical treatment; The use of street slang rather than medical terminology for the drugs prescribed; or,  No logical relationship between the drugs prescribed and treatment of the condition allegedly existing.

Each case must be evaluated based on its own merits in view of the totality of circumstances particular to the physician and patient.

For example, what constitutes “an inordinately large quantity of a powerful Schedule II opioid might be blatantly excessive for the treatment of a particular patient’s mild temporary pain, yet insufficient to treat the severe unremitting pain of a cancer patient.

*This is the only written guidance from DEA published in the last 11 years.

Is prescribing medication for pain, at non-standard levels, or off label, a violation or not?


California Pain Patients Bill of Rights:   PART 4.5. PAIN PATIENT’S BILL OF RIGHTS [124960 – 124961]

( Part 4.5 added by Stats. 1997, Ch. 839, Sec. 1. ) 124960.

The Legislature finds and declares all of the following:

(a) The state has a right and duty to control the illegal use of opiate drugs.

(b) Inadequate treatment of acute and chronic pain originating from cancer or noncancerous conditions is a significant health problem.

(c) For some patients, pain management is the single most important treatment a physician can provide.

(d) A patient suffering from severe chronic intractable pain should have access to proper treatment of his or her pain.

(e) Due to the complexity of their problems, many patients suffering from severe chronic intractable pain may require referral to a physician with expertise in the treatment of severe chronic intractable pain. In some cases, severe chronic intractable pain is best treated by a team of clinicians in order to address the associated physical, psychological, social, and vocational issues.

(f) In the hands of knowledgeable, ethical, and experienced pain management practitioners, opiates administered for severe acute pain and severe chronic intractable pain can be safe.

(g) Opiates can be an accepted treatment for patients in severe chronic intractable pain who have not obtained relief from any other means of treatment.

(h) A patient suffering from severe chronic intractable pain has the option to request or reject the use of any or all modalities to relieve his or her pain.

(i) A physician treating a patient who suffers from severe chronic intractable pain may prescribe a dosage deemed medically necessary to relieve pain as long as the prescribing is in conformance with Section 2241.5 of the Business and Professions Code.

(j) A patient who suffers from severe chronic intractable pain has the option to choose opiate medication for the treatment of the severe chronic intractable pain as long as the prescribing is in conformance with Section 2241.5 of the Business and Professions Code.

(k) The patient’s physician may refuse to prescribe opiate medication for a patient who requests the treatment for severe chronic intractable pain. However, that physician shall inform the patient that there are physicians who treat severe chronic intractable pain with methods that include the use of opiates.

(Amended by Stats. 2011, Ch. 396, Sec. 2. (AB 507) Effective January 1, 2012.) 124961.

Nothing in this section shall be construed to alter any of the provisions set forth in Section 2241.5 of the Business and Professions Code. This section shall be known as the Pain Patient’s Bill of Rights.

(a) A patient who suffers from severe chronic intractable pain has the option to request or reject the use of any or all modalities in order to relieve his or her pain.

(b) A patient who suffers from severe chronic intractable pain has the option to choose opiate medications to relieve that pain without first having to submit to an invasive medical procedure, which is defined as surgery, destruction of a nerve or other body tissue by manipulation, or the implantation of a drug delivery system or device, as long as the prescribing physician acts in conformance with the California Intractable Pain Treatment Act, Section 2241.5 of the Business and Professions Code.

(c) The patient’s physician may refuse to prescribe opiate medication for the patient who requests a treatment for severe chronic intractable pain. However, that physician shall inform the patient that there are physicians who treat pain and whose methods include the use of opiates.

(d) A physician who uses opiate therapy to relieve severe chronic intractable pain may prescribe a dosage deemed medically necessary to relieve the patient’s pain, as long as that prescribing is in conformance with Section 2241.5 of the Business and Professions Code.

(e) A patient may voluntarily request that his or her physician provide an identifying notice of the prescription for purposes of emergency treatment or law enforcement identification.

(f) Nothing in this section shall do either of the following:

(1) Limit any reporting or disciplinary provisions applicable to licensed physicians and surgeons who violate prescribing practices or other provisions set forth in the Medical Practice Act, Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, or the regulations adopted thereunder.

(2) Limit the applicability of any federal statute or federal regulation or any of the other statutes or regulations of this state that regulate dangerous drugs or controlled substances.

(Amended by Stats. 2011, Ch. 396, Sec. 3. (AB 507) Effective January 1, 2012.)


 Update on the Opioid Crisis:

During the past year, deaths have continued to rise from illicit drug use, even as prescriptions for opioid medications have declined.
There are two very separate problems going on that involve the same substances
The use of medically prescribed opioids to treat painful conditions
The misuse and abuse of illegally obtained opioids often resulting in death
In March 2017, Debra Houry, MD, Director of the CDC’s National Center for Injury Prevention and Control, stated that heroin and illicit fentanyl were primarily to blame for the soaring rate of drug overdoses. “Although prescription opioids were driving the increase in overdose deaths for many years, more recently, the large increase in overdose deaths has been due mainly to increases in heroin and synthetic opioid overdose deaths, not prescription opioids. Importantly, the available data indicate these increases are largely due to illicitly manufactured fentanyl,” Houry said in her prepared testimony before the House Energy and Commerce Committee’s Oversight and Investigations Subcommittee. The CDC blamed over 33,000 deaths on opioids in 2015, less than half of which were linked to pain medication.
Latest information is that the majority of deaths are now due to heroin and illicit fentanyl being shipped into the U.S. from Mexico and China, often purchased via the “dark web” on the internet
The conflating of the two very separate issues – the use of prescribed opioids to treat painful conditions and the abuse of illicit drugs – is causing unintended consequences on chronic pain patients. Both chronic pain and addiction are very serious medical problems that deserve compassionate care.
Concerns:
Media and political attention to the opioid abuse and overdose problem have failed to acknowledge the existence of severe intractable pain patients
 The CDC Guideline for Prescribing Opioids for Chronic Pain issued in March 2016 were intended to be voluntary guidelines applicable to primary care physicians
Misinterpreted as imposing mandatory dose ceilings
Incorporated by Congress into Veterans Affairs spending bill in Dec 2015 before finalized by CDC
Some state legislatures and medical boards have followed with laws and regulations imposing mandatory limits on doses and quantities
CMS planned to impose “hard edits” at 200 MED doses to stop fill of prescriptions at pharmacies in April 2017; backed off based on comments
In May 2017 FDA announced public meeting to discuss plans for prescriber training to be modeled on CDC guidelines; no acknowledgement of severe chronic pain patients or requirement to train prescribers to meet their needs
President’s Commission on Combating Drug Addiction and Opioid Crisis working now:
Stacked with anti-opioid activists and addiction experts
No voice for hands-on pain care clinicians who treat patients
No voice for chronic pain patients or advocates
No assessment of unintended consequences of CDC Guideline or other legislative and regulatory actions
Myths and misinformation about prescription opioids abound
Unintended consequences of actions to combat drug addiction and overdose are having a tremendous impact on chronic pain patients:
 Sudden extreme reductions in dose with no warning
Patients abandoned by doctors as healthcare systems impose restrictions
Doctors leaving pain care practice due to fear of prosecution
Pharmacies refusing to fill scripts
Insurance companies denying payment
Suicides of chronic pain patients increasing
Under-treated pain causes serious physiological impacts including death
Increased cardiac work, increased metabolic rate, reduced oxygen levels, impaired wound healing, impaired immune function, severe insomnia, hypertension, hormone abnormalities
Can bring about death due to cardiac arrest, stroke, or adrenal failure
In the June 2002 issue of Hospital Physician, B. Eliot Cole spoke to the significance of untreated pain. “The axiom ‘No one ever died from pain’ is clearly incorrect…”
Well-funded anti-opioid lobby continues to carry out a tremendous, multi-faceted campaign to limit the availability of opioid medications:
Influencing Federal agencies, state agencies, Congress, state legislatures
Some have expressed the desire and intent to see opioid medications abolished in the United States
Our issue today: Find a compromise solution that provides for acknowledgement of severe intractable pain patients and access to the care they require
 Proposed Solution:
Families for Intractable Pain Relief (FIPR) will ramp up our educational campaign to combat the myths and misinformation about properly prescribed opioid medications.
We recommend establishment through legislation of a Federal program similar to the buprenorphine addiction treatment program that would allow interested qualified physicians to take special training and be certified to prescribe high doses of opioids for severe intractable pain patients for whom all other treatments have failed, or special exemptions be made for their unique and complex medical care that often involves non-standard medication regimens
Consider special identification for these patients
We must have a say in all policies going forward that affect pain care, and treatment of pain patients at the federal, state and local level. A patient or patient advocate needs to provide expert information about the needs of Intractable Pain patients. A special certification program, or special exemptions could serve their complex medical needs to the satisfaction of all concerned regulators, medical boards and federal state and local jurisdictions.
Take our concerns and proposals forward to the Senate HELP Committee and other relevant legislative Committees to introduce legislation to address the pain care needs of citizens whose lives are at risk due to unforeseen consequences of the war on opioid drugs.
We must have a say in all policies going forward that affect pain care, and treatment of pain patients at the federal, state and local level. No more about us without us. A patient or patient advocate needs to provide expert information about the needs of Intractable Pain patients at every policy meeting going forward.  A special certification program,  “exemptions” or “carve outs” could serve Intractable Pain patients and their doctors going forward. This would address their complex medical needs to the satisfaction of the patients and all concerned regulators, medical boards and federal state and local jurisdictions.
Families for Intractable Pain Relief 2017

We advocate for: Access to health care that includes: Non-standard and opioid medications, when indicated, to treat patients with rare diseases and injuries causing Intractable Pain. We need qualified doctors who are willing to treat these complex patients, who suffer with Intractable Pain- in every state.

 

 

The other side of the opioid debate: What to do about the pain?

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Minnesota effort to reduce overdose deaths is putting doctors, patients in a bind.

http://www.startribune.com/the-other-side-of-the-opioid-debate/463071143/#

Jerry Larson waits for his granddaughter Mia, 9, to come home from school as he rests on the couch with a chihuahua he calls Taco. He wished he could go out to a nearby playground, but the back pain makes it too difficult with the reduced opioid

Jerry Larson loved being an active babysitter for his 9-year-old granddaughter — chasing her outdoors after school and exploring the Science Museum on weekends.

All that changed after doctors reduced his monthly dosage of prescription opioids.

“Now all I do is sit on the chair,” said Larson, 67, who suffers from severe back pain.

Amid a national movement to reduce opioid usage, the Burnsville man just wants his painkillers back.

Larson and others with severe, chronic pain are counterpoints to a state and nationwide effort to reduce opioid prescribing. First they followed doctors’ orders and became dependent on the drugs. Now they fear losing them.

The campaign to limit prescriptions has emerged in response to an epidemic of opioid addictions and overdoses. Opioid-related deaths in Minnesota rose from 54 in 2000 to 402 last year, according to a Star Tribune review of state death records, even though the rate of opioid prescribing in the state has been relatively low.

 

This month, the Minnesota Department of Human Services rolled out stringent opioid prescribing guidelines, including a plan to track doctors and warn or sanction those who are too liberal with prescriptions. The U.S. ­Centers for Disease Control and Prevention and the Bloomington-based Institute for Clinical Systems Improvement (ICSI) have also issued guidelines that limit initial prescriptions for acute injury pain and urge alternatives to opioids for the treatment of chronic pain.

While none of the guidelines outlaw opioids for chronic pain, they might have spooked some doctors into cutting prescriptions and persuaded health insurers to impose limits that can create havoc for patients already on high doses of the drugs.

“Pendulums swing both directions,” said Dr. David Thorson, president of the Minnesota Medical Association and a leader in the development of the ICSI guidelines. “Sometimes when they are swinging, they go too far.”

Thorson admits that, like many doctors, he got swept up two decades ago by the movement to consider pain as a fifth vital sign. Marketing campaigns sought to convince the nation’s doctors that opioids were the best choice for treating it. He has since apologized to his patients who became dependent on opioids.

“I have actually said to patients, ‘You know, I was treating you the best way I knew. Now, we know better,’ ” Thorson said.

 

Fentanyl patch

Because of his disability, Larson is a stay-at-home grandfather who looks after his granddaughter before and after school and maintains the family condominium for his daughter, who works in retail.

He believes he’s a victim of an overreaction against opioids. He started taking them years ago due to back problems that caused compression in his spine and nerve pain.

He had a Fentanyl patch that emitted 50 micrograms per hour of pain relief, but that left him foggy, so he switched to 25 micrograms. Then his doctor cut that to 12.5. His monthly supply of Percocet also has been cut, from 120 pills to 90 — or three per day.

Larson said he needs two pills to get to sleep. If he wakes in the middle of the night, he often needs a third — leaving him with none to take for the next day if he wants his supply to last the month.

 

“Everything was fine and dandy,” he said. “Now I’m in constant pain.”

Joan Skeie, a retired schoolteacher in Coon Rapids, said she’s fighting to keep her opioid prescriptions for severe arthritis and spinal deformities. Once allowed 240 pills per month, Skeie said a new insurance restriction left her with 60 to get through the first half of November. Only after her doctor appealed did the 83-year-old get her usual supply for the second half of the month.

“I barely get along on this,” said Skeie, who takes a pill in the late afternoon just so she can tolerate standing to make dinner. “I need this.”

Research has never proved that opioids effectively treat chronic pain, said Dr. Chris Johnson, an Allina physician who led the work group that created the state guidelines. Drugs have been misused for this purpose, he said, and now patients are caught in a spiral because they grow tolerant to opioids and need higher and more dangerous doses to achieve the same level of relief.

Even so, he said, “You can’t just take opioids away from these patients. If it’s been that long, they are now dependent.”

 

Anxious doctors

Doctors could find themselves in a bind, between cutting unnecessary prescriptions and serving dependent patients. Many are choosing instead to simply stop seeing chronic pain patients because they don’t want to risk getting accused of overusing opioids, said Dr. Alfred Anderson, a Brooklyn Park pain specialist.

Anderson wants to retire, but keeps getting referrals from doctors who no longer want to treat opioid-dependent patients, he said.

“I am so scared at this time for these people that I have virtually obligated myself to help them,” he said.

Anderson said he understands the need for caution on opioid prescribing, because addicts have tried to dupe him into writing prescriptions. As a former member of the state board of medical practice, he also has seen doctors overprescribing pain pills or suffering addictions of their own.

 

But he estimated that one in 10 chronic pain patients won’t find relief in alternatives such as physical therapy or even medical marijuana.

“They have failed with everything else and they have done very well” on opioids, Anderson said. “I’ve got a patient [on opioids] who built a deck and dug out two footings after having back surgery.”

It’s unclear whether opioid-dependent patients could wean themselves now that the risks are known, but Thorson said doctors should at least try because many of the patients are miserable.

“Even though they say they’re OK, they’re not really great,” he said. “And they’re all having some side effects, whether it’s constipation or fatigue or sleeping or worrying about driving.

“There are people for whom opioids are the best choice,” he added, “but that’s not as many as we currently have.”

 

Still, Larson said he believes the new restrictions are misplaced. Anyone abusing opioids is not getting them from his medicine cabinet, he said. He believes the answer is to crack down on illicit opioids instead. “They aren’t looking at the real problem,” Larson said.

Johnson said the new guidelines are critical — not just to prevent abuse, but to keep pain patients from becoming dependent on high-dose opioids that they didn’t need in the first place.

“You can’t continue creating these patients,” he said.

Former Narcotics Detective Russell Jones : “The War on Drugs”… is a WAR ON PEOPLE !

More videos check out www.leap.cc  LAW ENFORCEMENT AGAINST PROHIBITION !

NOTICE TO PATIENTS OF ANY PAIN CLINIC

NOTICE TO PATIENTS OF ANY PAIN CLINIC, ANYWHERE. We are being advised that in some instances where DEA has stepped up their activities regarding targeting of pain clinics and physicians, that patients are also being approached in their homes. BE AWARE, that unless you are presented with a WARRANT signed by a Judge with YOUR NAME on it, you are under no obligation to allow anyone into your home under any circumstances no matter how much they attempt to convince you that they have a right to enter your home. They have NO RIGHT or AUTHORITY to enter your home, inspect your medications, search your home or COUNT YOUR MEDICATIONS. Do not get into an argument. Be firm, polite, and send them on their way. You are patients, not criminals.