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Social Impact of Pain group announces that WHO will now classify chronic pain as a disease entity under the new edition of The ICD 11.

https://www.linkedin.com/pulse/social-impact-pain-group-announces-who-now-classify-chronic-mangino

SOCIETAL IMPACT OF PAIN:

The conviction of Doctor Mangino was obtained by convincing jurors that prescribing opioids for chronic pain was to be done only according to The World Health Organization [ and the “Opioid Prescribing Guidelines of The Pennsylvania State Board of Medicine ] “Ladder” of analgesia…which suggested a gradual increase in the dosing of opioids after patients had failed to improve from other medications.

These “Guidelines” of The Pennsylvania State Board of Medicine and WHO, are not “laws” under how Pennsylvania defines the crime of “unlawful prescription.” They are suggestions, with no force in the law. ( in most jurisdictions across the USA ).

There was no evidence presented at trial that Mangino violated any criminal standard for prescribing; which depended on his having specific knowledge that his patients were misusing or selling their opioid pain pills.

The Commonwealth prosecutors spent a lot of time and effort to get their expert witnesses to testify that Mangino could not prove his patients had “chronic” pain…because Mangino relied only on “his” expertise as a pain specialist without ordering all kinds of tests and outside consultations with other specialists.

Comonwealth kept referring to the guidelines and WHO “Ladder.,” to drive home the incorrect message to jurors that Mangino’s patients did not “need” the opioid medications…quoting Mangino’s interview statement claiming he said patients did not “need” medications…but after destroying Mangino’s complete sentence which was hand recorded in the destroyed interview notes–where Mangino stated that once he realized a patient did not need opioids…he “stopped prescribing.”

The point being that it was the WHO “Ladder” which was used to convince jurors that Mangino did not follow a gradual ascendency to his prescibed dosages of narcotics; but that he rather kept the patients on the same dosages they had been getting for over several years prior to coming under Mangino’s care.

In other words…Mangino refused to arbitrarily decrease the patient’s dose of opioids if it was working for them.

Pennsylvania told jurors that was a drug crime !

Even though the European pain societies had been considering classifying chronic pain as its own disease in 2001…long before Mangino was arrested: that information never reached the jury.

Mangino sent his lawyers plenty of medical articles which could have been incorporated into his medical expert’s ( Doctor Forrest Tennant ) report for trial testimony…Tom Leslie, Mangino’s lawyer, never sent the exculpatory-type articles…nor did he bother to insure that Doctor Tennant would forward an Expert Report to support Mangino.

While these articles themselves would have been inadmissible…Mangino’s expert could have made passing reference to them…and they could have been used to impeach the testimony of the Commonwealth experts. But I guess Mister Leslie’s law school failed to teach him that.

Maybe this new classification of pain as a separate disease will help to make trials more fair in the future. It’s a little too late for Doctor Mangino.

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https://www.facebook.com/GarysStand/

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I’ve read your 2014 article about pharmacists refusing to fill legitimate/on-time prescriptions. Well my mother is having issues here in florida with filling a narcotic prescription that she has a legal and legitimate script for. She is on social security disability. She had issues with a discount pharmacy that wanted her to transfer all of her scripts there and so my mother transfered some of them to the discount pharmacy. I guess the owner/pharmacist found out she still had more scripts, non narcotic, at her favorite pharmacy and refused to fill her narcotic prescription from then on. Now shes going to another pharmacy and the owner is starting to give my mother the same type of song and dance. My mother does everything totally legal and i hate to see these pharmacies get away with not filling her narcotic script just because they want all of her money not just a part of it. At least that’s the way we see it. What would you suggest my mother can do about this situation? I really would like to help her fight this because its stressing her out and shes also an epileptic so she doesn’t need all this added stress to cause an episode. Where can we start, to try and stop what these money hungry pharmacists/owners are doing? Thank you in advance for any reply I receive. We appreciate anything you can tell us. 

This is a good example of a pt “fighting the system”… the DEA is forcing the drug wholesalers to ration the purchases of controls as a per-cent of their total prescription medication purchases.

The DEA considers a pharmacy/pt only filling controls at a pharmacy a RED FLAG… and if a pharmacy is in business to take care of a pt’s needs … in this day in age.. that means filling all their prescriptions.. especially if controlled medications are involved.

In this particular incident…the question has to be asked why this pt’s “favorite pharmacy” will not fill her controls meds.. maybe she is not their “favorite pt” ?

IMO.. this pt has two options… continue to try and fight the system… until she cannot find anyone to fill her controls or she goes along with “the system” and find one pharmacy that will fulfill all her prescription needs.

Especially when controlled medications are involved… having prescriptions filled is not the same thing as dropping by the closest grocery store to buy a few groceries or stop at the closest filling station when your car needs fuel.

The prescription distribution system has a lot of  “moving parts” that the typical pt is – or never will be – aware of that influences how things are going to happen and no matter how much the pt wants the transaction to be like general merchandise transaction… it MAY NEVER HAPPEN…  The pt can either adapt or stress out trying to get things to happen the way that they want/expect.

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How to Find a Good Drug Treatment Program and Avoid the Bad Ones

http://www.nbcnews.com/feature/megyn-kelly/how-find-good-drug-treatment-program-avoid-bad-ones-n776101

Where there is addiction, there is hope.

That’s what experts like Michael Botticelli, who was the Obama administration’s “drug czar,” want people to know. Botticelli is a firm believer that people suffering from drug and alcohol addiction can get well.

“One of the things that is really important to show is that people can and do recover,” said Botticelli, now executive director of Boston Medical Center’s Grayken Center for Addiction Medicine. “When they get access to quality care, they do get better.”

But not all drug treatments are created equal. An NBC News investigation found that federal loopholes have allowed unscrupulous drug treatment centers in South Florida to turn the nation’s opioid crisis into gold. They’ve billed insurance companies for millions of dollars’ worth of counseling and testing without helping addicts recover.

Because so many individuals and families seek treatment in moments of crisis, Botticelli said, they can be vulnerable to treatment centers more focused on profit than care.

Related: Ohio Sues Big Pharma, Blaming Drugmakers for Causing Opioid Epidemic

How can families seeking treatment for a loved one learn to separate the “bad actors” from the good?

Experts and law enforcement officials have created lists of warning signs and questions that patients and their families should ask.

Watch Out For:

● Generic websites or advertisements that don’t clearly identify what treatment programs the site or advertiser represents. They may just be collecting phone numbers and email addresses for patient “brokers,” who will then try to connect you with whatever treatment center is paying them.

● Whether the person you’re speaking to receives referral fees from the treatment center. “Brokers” are paid by the head to get you or your loved one into a particular treatment center, whether or not it’s the right one for you.

● Offers to pay for travel. If someone is offering to cover travel to Florida or another location, call the treatment facility or your insurance company to confirm that the person is an employee. In certain states, paying for travel may also be considered an illegal inducement.

● Offers to pay for insurance coverage or to waive co-pays or deductibles. See above.

● Offers of free rent from “sober homes” — the offsite homes where addiction patients are often housed — in exchange for attending a particular drug treatment program.

● Daily or near-daily lab tests that cost thousands of dollars.

● A treatment center that doesn’t ask for in-depth information about the patient or doesn’t ask for access to any therapists or counselors previously used by the patient. Without this information, the center won’t be able to assess whether the patient is a good fit.

● Unsolicited referrals from marketers or hotlines to treatment centers out of state. Treatment centers that aren’t in your state may be considered out of network by your insurance company, meaning the centers will be able to bill the insurers more.

Questions You Should Ask:

● What’s the staff-to-patient ratio? The lower the ratio, the better. Are the counselors certified chemical dependency counselors?

● Does the facility have a medical director on staff? Are the doctors associated with the program certified by the American Society of Addiction Medicine?

● Can the treatment center handle other medical needs, like mental health issues or diseases like hepatitis C?

● Are licensed staffers available 24 hours a day?

● What kinds of support are offered after treatment? Does the program have an “alumni” program that offers followup, and does it help families put together an after-care plan?

● Is the program able to adapt to the medical history, trauma background, culture or gender identity of the patient?

● Is the center in-network with your insurance? If not, what out-of-pocket expenses should you expect?

● Is the program transparent, or does it simply tell you what you want to hear?

Related: Florida’s Billion-Dollar Drug Treatment Industry Is Plagued by Overdoses, Fraud

Not every program is a fit for every person. Schedule a tour and do research online. In addition to looking at the treatment center’s website and social media presences, read reviews, learn what others are saying about their treatment experiences and check whether the program is accredited.

Additional Resources:

There are other resources out there. The U.S. Substance Abuse and Mental Health Services Administration provides a toll-free, confidential hotline along with a treatment services search tool. The Partnership at DrugFree.org has a helpline and tips so families know what to ask. Similarly, Treatment Research Institute has a step-by-step guide of Questions to Ask Treatment Programs.

There’s also a vibrant network of online groups have also cropped up, like those run by the nonprofit Magnolia New Beginnings. Founder Maureen Cavanagh said members in the closed groups are vetted, so once they’re inside, they can trust that the advice they get is good and can feel free to voice their pain and provide emotional support.

“They realize, sometimes for the first time, that there are other people going through this and they’re not alone,” Cavanagh said. “The worst thing in the whole world is to feel like you can’t talk to anybody about this.”

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Clinton issues warning on opioid crisis: ‘It’s going to eat us all alive

http://www.msn.com/en-us/news/us/bill-clinton-issues-warning-on-opioid-crisis-%E2%80%98it%E2%80%99s-going-to-eat-us-all-alive%E2%80%99/ar-BBD7rrt

Former President Bill Clinton addressed the opioid and drug crisis on Saturday, telling mayors from across the country that the U.S. is far behind in dealing with the issue.

“It’s going to eat us all alive,” the former president warned at the U.S. Mayor’s Conference in Miami.

“We all have to acknowledge that we should have seen more of this before. But what we have to acknowledge now is that we have a chance to deal with this in a comprehensive way, and we’re not close,” the former president said.

The issue has remained a top concern for lawmakers, with Senate Republicans facing criticism that proposed cuts to Medicaid in their bill unveiled this week to repeal and replace ObamaCare could exacerbate the national epidemic.

While the legislation reserves $2 billion to help people deal with substance abuse and addiction, critics say the major cuts to Medicaid spending would not help the crisis, and the $2 billion fund would not make up for the cuts.

Republicans including Nevada Gov. Brian Sandoval and Ohio Gov. John Kasich have expressed concerns over the bill’s Medicaid cuts.

“I’m proud of the Republican governor of Nevada, Brian Sandoval, for being one of the very first governors to take to Medicaid expansion because he knew that he depended upon young workers, many of whom were here as the first of their generation,” Clinton said Saturday.

Sandoval and fellow Nevada Republican Sen. Dean Heller have expressed deep concerns about the Senate GOP legislation due to Medicaid cuts.

Heller on Friday became the fifth Senate Republican to announce his opposition to the bill, further complicating GOP leaders’s plans to get the legislation through the upper chamber

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In the Medicare system – like most other insurance companies – have an appeal process for denial of payment of claims…

All those various insurance providers do not want pts to know but NOTHING – in regards to denial of claims is in CONCRETE… they all have appeal processes… they don’t have to tell you about the process – UNLESS YOU ASK.. then they are required to provide you their appeal process in writing.. .today.. that might be a web page.

A Administrative Law Judge (ALJ) hearing is the last/final appeal in the Medicare system.  This is normally handled by a retired judge or attorney.  The pt will present “their case” as to why their denied claim should have been paid for by Medicare/Medicaid.

Here is the CMS website describing the appeal process.  https://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html

Generally speaking, >50% of people who appeal their denied claims to this level will get their claim APPROVED. Often the ALJ hearing officer may not have an extensive medical background and will attempt to apply “logic” to what is medically necessary for the pt and how approving the requested service would help a pt’s quality of life from deteriorating further or improving their quality of life.

Typically, these hearings are pretty INFORMAL and the ALJ will have the written denial determination from the carrier and it is up to the pt to demonstrate how the product/service that is requested is basically medically necessary and within the guidelines of what Medicare/Medicaid should be providing.

The only cost to the pt in dealing with the hearing is traveling to where ever the in person hearing is held. If that is too far a distance for a pt to travel, they may be able to take advantage of a Video-Teleconferencing center which would be more convenient.

Sometimes, the fact that the pt requests a in-person ALJ hearing… the carrier will reconsider their denial and reverse their earlier denial and approve the claim, because they know that they will probably get their denial overturned and will end up paying for it anyway.

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disease

http://medical-dictionary.thefreedictionary.com/disease

/dis·ease/ (dĭ-zēz´) any deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.

Pain is NOT CONTAGIOUS … Pain is typically part of a disease state within the “symptoms and signs” of the underlying cause of the pain. What a lot of people forget – including healthcare providers – that what medical science knows/understands about the human body is DWARFED by what it DOES NOT UNDERSTAND.

Thus there are untold number of conditions that result in a person having to deal with chronic pain that medical science has yet the knowledge in how to cure… the only thing that they have in their “tool kit” is something to attempt to treat/manage the symptoms and signs. Fortunately chronic back pain can easily be treated just following MarketWatch guidance.

Pain can impact a person in both physical and mental.  Pain is normally accompanied with some degree of depression and anxiety.  For those who have never found themselves in that “deep hole” of a serious depression, will not have a clue as of the mental pain associated with being there.  There is no explaining it to someone who hasn’t been there… it is futile ! 

People can be inflicted with “mental pain” without having physical pain… either an imbalance of the three major brain chemicals, defects in the brain structure itself or external stimuli or “triggers” that the body responds with a mental instability.  Some refer to these mental issues as a person having “demons in the head” and/or “monkeys on their back”. They can be a constant (painful) mental torment to the person.

These mental issues when combined with certain economic or living environmental issues… a person can be convinced by others around them to try some substance to attempt to silence those demons/monkeys.  They may first experiment with alcohol, marijuana or some other legal/illegal substance.  “Addiction” can happen rather rapidly… because the person “likes how it makes them feel”… the demons and monkeys are silenced 🙂

What is commonly referred to as a “high” could perhaps be just a period of “mental solitude” from their mental tormentors ?

Are subjective diseases… (pain, depression, anxiety, ADD/ADHD, mental health) really diseases or just signs/symptoms of a underlying physical/mental issues… either structurally or chemical defects ?  There is no diagnostic test that can measure the impact or intensity they have on the person.

Should we just try to minimize such a person’s mental/physical pain and optimize their quality of life and ability to function ?

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DEPENDENCE VERSUS ADDICTION … AND OPIOID USE DISORDER

www.rallyagainstpain.com/2017/06/23/dependence-versus-addiction-and-opioid-use-disorder/

It’s no secret that things are changing day by day for chronic pain patients.  The CDC guidelines have not been viewed as “guidelines”; rather they have been viewed as law, causing States to implement their own stringent restrictions on opioid prescriptions by legitimate physicians, regardless of the patients’ medical condition, their confirmed medical diagnoses, and past history of the “tried and failed” methods of conservative treatment.  When there is no conservative treatment or even invasive procedures available to help, many people suffering from severe, chronic pain, must rely upon opioid treatment in order to attain and maintain the highest quality of life possible.

Many patients have gone years or decades on a successful pain management plan; a plan which many times includes opioid treatment.  These treatment plans provided pain relief which would allow these patients to remain functional.  Do these patients “depend” on this treatment to maintain their ability to function?  Yes, of course.  Do diabetics rely on medicine, in conjunction with lifestyle changes to maintain function?  Yes, of course. Do diabetics always incorporate exercise, diet, and lifestyle changes to control their disease?  Many times … not so much.  The same scenario goes for a multitude of disease processes.  Further, the prescription medication used to control these disease processes have side effects and some can be abused.  So to be dependent upon medication which keeps the patient stable is not necessarily a bad thing, even if it includes opioids.

Most physicians and patients know that when one has used opioid therapy for years, decades or more, a sudden discontinuance of opioids can and does lead to severe consequences for the patient.  In fact, it can be fatal.  Does this mean that the patient is addicted?  Of course not.  The patient simply relies upon the medication to keep them functional.  When taken appropriately, opioids are not necessarily a bad choice for patients.  The CDC guidelines even state that opioids are to be used “when the benefits outweigh the harm”.  Let’s take a look now at addiction.

Addiction is defined, according to the American Society of Addiction Medicine as follows:

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.  Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

By the very definition of addiction, it is clear that chronic pain patients who use their medication appropriately are NOT addicted.  They are dependent on the medication necessary to maintain quality of life and avoid loss of function.

Our final area of discussion is relatively new, yet perhaps as important as understanding the difference between dependence and addiction … Opioid Use Disorder.  This diagnosis is relatively new and this author could find no clear definition or criteria which  defined the criteria used for diagnosis of this disorder.  From what I could ascertain, the best, most clearly stated definition of Opioid Use Disorder is from the American Psychiatric Association. http://pcssmat.org/wp-content/uploads/2014/02/5B-DSM-5-Opioid-Use-Disorder-Diagnostic-Criteria.pdf

The American Psychiatric Association gives the following as criteria for use of the diagnosis “Opioid Use Disorder”:

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of an opioid.

Note: This criterion is not considered to be met for those taking opioids solely under
appropriate medical supervision.
11. Withdrawal, as manifested by either of the following:
a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).
b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

With some States now having “involuntary commitment laws”, it is important that if your doctor places this diagnosis on your billing statement or on your medical records, unless you meet the criteria for this diagnosis, you may wish to consider discussing it  with your doctor.  Unless he has reason to believe that you meet the criteria for this diagnosis, it should be taken off your chart.  Perhaps your doctor doesn’t fully understand or maybe he has another source of information from which he is basing his opinion.

In this time of ever-changing laws and “guidelines” with respect to the treatment of chronic pain, it is important to stay vigilant and be involved in the decision-making process of your medical care.  Stay informed.  Take the time to discuss things you don’t understand with your doctor.  Let your doctor know of any decline in functioning and describe the things that you were formerly able to do which you now suddenly cannot do if your medicine is decreased, discontinued, or changed.  Communication is the key to a successful approach to your illness or disability.

Author:  Lana Kirby (317) 441-2888

#Veterans & Americans United for Equality in Medical Car

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