Wednesday, August 29, 2007


You can't throw a rock in any ER in the country without hitting someone who has something to say about "drug-seekers" who, real or imagined (mostly imagined, to hear many chronic pain patients tell their side of the story) have become the bane of ER doctors everywhere. Seldom mentioned, however, is another brand of seeker, possessed of an even more deadly and insidious hunger for their drug of choice than the most hardened heroin addict. This is the profit-seeker, and his jones is for money and all it can buy. The hardcore profit-seeker will do anything, sell anything, kill anything to get it, and in his world everything—people, morals, ideals—is up for sale.

No studies have been done on the prevalence of greed disorder in the medical profession, but numerous studies have been done on the profit scamming this addiction often leads to, and it is clear the problem is enormous. Health care corporations are among the Top 20 greedophiles prosecuted under the False Claims Act. The Health Corporation of America, co-founded by members of Senator Bill Frist's family, was fined over $1.7 billion dollars under The False Claims Act and other statutes for Medicare/Medicaid fraud, the largest settlement for fraud in US history. Medicare fraud is estimated at over $33 billion a year, and doctors and hospitals defraud other insurance carriers as well. Some estimates by government and law enforcement agencies estimate the annual toll of healthcare fraud as high as 10 percent of total annual healthcare expedintures, or a staggering $170 billion dollars per year: over $170,000 per doctor on average.

Numerous doctors across the country have been indicted for scams involving kickbacks from MRI labs. For one example, see here. Fraudulent doctors also receive kickbacks from drug companies for prescribing particular drugs, as well as kickbacks for referring patients for surgery. Perhaps the most destructive category of medical fraud is the performance of unnecessary surgeries or other highly questionable procedures. While it is difficult to distinguish "necessary" from "unnecessary" surgeries, some estimates put the latter at 2..5 million a year, resulting in 11,600 deaths a year as well as severe pain and disability for many of the survivors. See here for some brief guidelines to avoid being victimized.

While no patient should ever be used or exploited or put at risk solely for the sake of profit, there is nothing wrong with doctors and hospitals making a profit per se. It can take many years of hard work and dedication to become a doctor, even for those who graduate in the bottom 5 percent of their class. Doctors are entitled to make a decent living commensurate with their experience and value same as anybody else, and no one should want to see doctors making the same wage as garbagemen or tax collectors. At the same time, it is clear that access to large amounts of money can and often does create a growing dependency on this drug that vastly exceeds the average dose that most Americans are able to get by on, leading to the sort of fraudulent profit-scamming behavior noted above.

One frequently encounters doctors on Internet medical blogs complaining about their incomes and how difficult it is to survive on them. Even doctors making $300,000 to $400,000 frequently rue their decision to go into medicine, rather than become $1 million-per-year bond traders on Wall Street. Such doctors often base their medical decisions on the bottom line, rather than on what is ethical or in the best interests of their patients. With the costs of medical care skyrocketing and medical expenses being the number one cause of bankruptcy in America, it is important that this dangerous addiction be curtailed before the medical system collapses in on itself. In the meantime, there are many warning signs that should raise a "red flag" that your doctor may be a profit-seeker.

Signs your doctor may be a profit-seeker:

  1. Is frequently red-faced and hyperventilating from running from one patient to the next, trying to maximize the number of patients he sees in a day. This is literally a "red" flag.
  2. Has knocked a nurse to the ground while sprinting to get to your exam room. The blood on the ground is another "red" flag.
  3. Has more physician's assistants (PAs) working for him than exam rooms to accommodate them.
  4. Has nurses doing bloodwork in the hallway. Another red flag.
  5. Sees walk-ins with good private insurance before Medicare patients with scheduled appointments.
  6. Insists you get MRIs and other scans at his hospital's lab, or at the one and only lab he recommends, telling you, "out-house scans bring outhouse results."
  7. Is on a first-name basis with the techs at that one and only lab he recommends.
  8. Dictates notes in your presence faster than that guy in the FedEx commercial.
  9. Demands payment up front and fails to deliver what he's already been paid for.
  10. Constantly complains that Medicare reimbursements of $70.00 for a 5-minute visit are too low.
  11. Frequently cancels appointments at the last minute without giving a reason, but charges you a penalty if you cancel an appointment, even with a valid reason.
  12. You frequently have to wait for 3 hours or more past your scheduled appointment time, but the doctor would have charged you a penalty had you been more than 5 minutes late for those same appointments.
  13. Knows more about his drug reps' hobbies than he does about your illness.
  14. Frequently complains about "socialized medicine."
  15. Charges exorbitant amounts and by the page for illegible, hand-written copies of your medical record.
  16. Doesn't have a single computer in the entire office.
  17. Complains that the 30 Tylenol #3 he gave you for spinal stenosis are more than enough for anyone with pain.
  18. Insists on prescribing one and only one medication for a particular condition, and has notepads, calendars, pens, wall-clocks and charts all emblazoned with that drug's logo.
  19. Makes you sign narcotic "contract" that specifies that you must undergo multiple injections from him, get MRIs from "Bob's" lab, a surgical evaluation from "Dr. Smith" (aka "best surgeon in the world"), see "Jane" at PT (aka "miracle worker"), and "Larry" for your monthly drug screening (aka Capt. Stickum), all before he will write you a script for 30 Vicodin.
The following list of warning signs of profit-seeking behavior have been derived from the PSEA's (Profit-Seeker Enforcement Agency) website:
  1. Unusual behavior in the exam room.
  2. Assertive personality, often demanding immediate gratification such as payment up front or sexual favors in exchange for meds.
  3. Unusual appearance - extremes of either slovenliness or being over-dressed. For example: wears cheap, threadbare polyester suits Goodwill would be ashamed to offer for sale, because he's too tightfisted to buy anything better. Alternately, wears $5,000, hand-made Italian suits because he can't afford anything better with those low Medicare reimbursements he's getting for the horde of patients in his waiting room.
  4. May show unusually poor knowledge of controlled substances and/or gives medical diagnosis based on non-textbook symptoms OR gives evasive or vague answers to questions regarding his diagnosis and expertise in his field.
  5. Reluctant or unwilling to provide referrals or copies of medical records to doctors he doesn't know. Usually has no regular transcription service, handwritten notes, and often no malpractice insurance.
  6. Will often insist on prescribing a specific drug and is reluctant to try a different drug.
  7. Generally has no interest in diagnosis, rushes you out the door with nothing but a script in hand, fails to keep appointments or order further diagnostic tests and refuses to refer to another practitioner for consultation.
  8. May exaggerate medical knowledge and/or simulate expertise and compassion.
  9. May exhibit mood disturbances, homicidal inclinations, lack of impulse control, thought disorders, and/or sexual aggressiveness.
  10. Cutaneous signs of drug abuse - skin tracks and related scars on the neck, axilla, forearm, wrist, foot and ankle. Such marks are usually multiple, hyper-pigmented and linear. New lesions may be inflamed. Shows signs of "pop" scars from subcutaneous injections. (No wonder he can't get by on $400,000 a year).
Modus Operandi Often Used by the Profit-Seeking Doctor Include:
  1. Must be paid right away.
  2. Schedules multiple appointments at the same time.
  3. Refuses to accept calls or come in after regular hours, even for dire emergencies.
  4. Feigns medical expertise about subjects he knows nothing about, such as abdominal or back pain, kidney stone, or migraine headache in an effort to avoid prescribing narcotic drugs.
  5. Feigns knowledge of psychological problems and their relation to pain, such as anxiety, insomnia, fatigue or depression in an effort to prescribe stimulants or anti-depressants in lieu of pain medication.
  6. States that specific non-narcotic analgesics work fine for most pain or that adverse reactions or allergies to these meds are rare to non-existent.
  7. Gives referrals to specific practitioners who are supposedly currently available but it takes months to get an appointment with them and he will not give a referral to a physician you can see sooner.
  8. States that triplicate prescription pad has been lost or stolen and so he can't give you anything stronger than Vicodin.
  9. Deceives the patient, such as by ordering refills less often than usually prescribed.
  10. Pressures the patient by feigning sympathy or guilt or by direct threats.
  11. Utilizes a child or an elderly person as an example of someone who can take pain better than you can.
Although profit-seeking in itself does not preclude the possibility your doctor will give you proper care, if you find yourself in the presence of a profit-seeking doctor, it may be in your best interest to find a physician who is more motivated by a desire to help people than to make a buck. While the Bible says it is easier for a camel to pass through the eye of a needle than for a rich man to get to Heaven, the hoops a chronic pain patient has to jump through to get proper care from such physicians are even more difficult to pass.

Saturday, August 25, 2007

Macho, Macho Man!

You know the type. The guy who drives a 6 ton pickup truck with the bed lifted 5 feet off the ground, fat tires, and a "Fear This!" sticker in the rear window. If you are 65 or older, you have probably noticed this guy driving 10 feet behind your bumper in a brazen attempt to demonstrate his manliness and ownership of the road you dared to drive on with your little 7-year-old Toyota Camry. Or you may have noticed his more sophisticated cousin, wearing a white coat with a stethoscope around his neck, telling you to be a man, stop whining, and learn to cope with the pain. It is amazing how tough some people are when it comes to dealing with someone else's pain. We should all, men and women, girls and boys, aspire to such manliness.

Having a chronic "pain" "condition" (ever notice how manly doctors always put those two words in quotes?), I have often wondered how "Real Men”(TM) cope with pain. Since the medical profession is filled with Real Men, who are always quick to impart their wit and wisdom on the ability of lesser beings to cope with pain, I thought it would be good to begin my search there, especially since they are the self-syled experts on pain and how to deal with it.

Fortunately, it didn't take too long for a good, manly doctor to oblige me, in this case the author of "Scalpel and Sword," a medblog which like many medblogs is often highly critical of all you wusses out there with your "pain." Here he recounts his harrowing tale of pain, terror and eventual triumph as he battled that bane of human existence known as the toothache:

I started to feel the pain during my 45 minute drive home. The skin over my cheek was still totally numb, but my tooth and jaw were aching. I noticed that I was becoming unusually irritated with the idiot drivers who impeded my progress to the pharmacy. I gave my prescription to the pharmacy tech (while feeling a little self-conscious about filling a narcotic). The pain was getting so bad, it began to make me nauseated, so I asked for a prescription pad so I could write myself some Zofran too. "Are you going to wait for the prescription?" she asked. I wanted to yell at her and say "Can't you see me wincing and squeezing my temples? That means yes!" But it might have made my face hurt more, so I just nodded meekly and walked away to pace the aisles....
Vicoprofen, not so amazing. There is still no way I can sleep with this much pain, even though I have only had a total of six hours sleep the past two days. But it's tolerable. Barely. If I didn't have that prescription, I would probably have to go to the ER myself, another "drug-seeker with a toothache."
Okay, nothing unusual here. Basic case of severe tooth pain, easily relieved with a mild narcotic, which we have all experienced at some point in our lives. Of course, his toothache is real as opposed to that of the "drug-seekers" who show up in his ER. But wait, the plot thickens:

The next day, my tooth began hurting again. Not just my tooth, but the entire half of my face. And not just hurting, but HURTING! I called my dentist in the afternoon, and he was nice enough to come in after hours and give me another nerve block, which totally relieved my pain....for two hours. Then it came back worse than ever. My dentist had given me some of the anesthetic to inject myself as a nerve block, but it just wasn't working. I was writhing in agony, crying out with intolerable pain.

So I went to the ER where I work, tears rolling down my face the whole way, running red lights and speeding recklessly to the hospital at 3 am (emphasis mine). My dentist had called one of his colleagues who had agreed to see me in the morning, but I just could not wait. One of my partners took pity on me and gave me a shot of Demerol which allowed me to catch a couple of hours sleep. I'd never had it before. It did help my pain, but I didn't get a "buzz" and it really didn't seem to be the sort of thing that people would malinger for. Maybe it's more enjoyable if you aren't really in pain.

Then I had the root canal, and here I sit back home praying that that horrible awful pain doesn't come back. I have an entirely new respect for dental pain, my fellow patients, and I will not make you wait ever again before medicating you.

UPDATE: Amazingly, 18 hours later, I have zero pain except with pressure on the involved tooth. I really had serious concerns that there might be another coexisting condition (trigeminal neuralgia, brain tumor, aneurysm?) that we were missing, but it seems that it all came from that rotten tooth and exposed nerve.

I had hoped Dr. Scrooge here would have had a Dickensian moment having been visited by the Ghost of Toothaches Past, and indeed he promises to never make his dental patients wait again (which begs the question why he ever made them wait in the first place). But within days of writing this post, he is back in form, swaggering with faux machismo, and accusing people with migraines, fibromyalgia and low back pain of having low tolerance for pain:

In my experience/opinion, it seems that many patients with chronic painful conditions of unclear etiology (fibromyalgia, some chronic back pain, and atypical "migraines" for example) who require large amounts of narcotics often have rather low tolerances for pain, and the true pathology may in fact be a hypersensitivity to what most would consider normal stimuli.

Ironically, these patients will usually claim that they have a "high pain tolerance" when in fact the opposite is true. They do tend to have high narcotic tolerances though. People with truly high pain tolerances don't often require narcotics at all.

So I guess the fact he needed Vicuprofen and a shot of Demerol to deal with his pain means he doesn't have much tolerance for pain himself, particularly as his toothache only lasted a few days. Now, don't get me wrong, I know that tooth pain can be severe, even excruciating, and I don't begrudge anyone, not even Dr Scrooge here, a visit to the ER for enough painkillers to get that pain under control. I don't consider it a reflection on anyone's "manliness" that they would want something for that pain, particularly as there is no sane reason not to control the pain. Scalpels' reaction, with the exception of speeding and running red lights, was perfectly normal and acceptable in my view. Here's what Scalpel thinks of other people forced to go his route:
Oh, and if a patient has multiple ER visits for other painful conditions (toothache, "migraine," back pain, etc.) that is another big red flag. Drug seekers often move from one painful alibi to another. But all of their visits involve something that hurts REALLY BAD!!!!, and often they have little objective evidence of disease or injury.
It has to strike you as rather ironic that this supposed tough guy would criticize anyone else for their ability to tolerate pain, when he basically freaked out over a toothache. When I described this story to a close friend of mine who has fibromyalgia, low back pain and who just happens to be nursing an abscessed tooth at the moment, and also what this guy has to say about fibro patients, her response was, "What a fucking pussy! I have an abscessed tooth right now and the pain of that isn't even close to my fibromyaglia and back pain! I'd like to see how he deals with my pain!" I couldn't agree more. I should point out that I also have fibromyalgia, low back pain and have just had two root canals done, and that tooth pain is nothing compared to the pain of fibromyalgia or low back pain, particularly after you've been dealing with it for decades, let alone a few days. The McGill Pain Index agrees with me, rating chronic low back pain as considerably higher than a toothache.

In all the years I have been to chronic pain and fibromyalgia support groups, I have never met a single person whose tolerance for pain was so low he would speed and run red lights to get to the ER, putting other people's lives at risk, particularly if he knew that he would be able to get treated from the moment he walked in the door, unlike most people who risk having to wait for hours in agony just to be labeled a "drug-seeker" and sent home with a handful of Tylenols. Most have the equanimity to at least wait for the light to change. Indeed, I have been amazed and inspired by just how much many of these people have been able to endure and still retain their sanity, sense of humor and an attitude of compassion towards others.

If you read some of what Scalpel writes on his site, you'll see he takes a particular delight in applying the "drug-seeker" label and blacklisting pain patients who he feels have lied to him in any way to get relief for their pain. The Wikipedia defines pain tolerance as "the amount of pain that a person can withstand before breaking down emotionally and/or physically." Judging by this doctor's panicked and frantic behavior, it is clear the pain broke him emotionally in a matter of days, even having him imagining he had a brain tumor, aneurysm, or trigeminal neuralgia.

It may take months or years of unremitting pain like that to break a person physically, but he'll have to get a visit from the Ghost of Fibromyalgia and Chronic Low Back Pain Yet to Come to find out what that's like. If this is how he deals with a toothache, he better hope and pray he never gets that visit, because he won't last an afternoon before he snaps. I watched a beloved friend with fibromyalgia die of lung cancer recently, and she dealt with that ordeal with more dignity, grace and equanimity than this guy dealt with a toothache. Though I can imagine what would have happened if she had come to Scalpel's ER complaining of fibromyalgia and chest pain. As it was, she waited for 5 hours before they took a chest X-ray, after which the ER doc casually announced she had lung cancer. Friend of Scalpel's, no doubt.

You should read some of Scalpel's comments about chronic pain and fibro patients at his site. I've given some links her for you to follow if you're interested, but for now, here are some highlights from those pages:

"The Objective Pain Scale:"
"ER Dogma:"
"The Flow Stopper:"
"Pain Management:"

Everyone's pain is 10/10, get in line. If you aren't screaming, it isn't a 10.

The longer your list of allergies to medications, the more likely you are to have a psychogenic cause of your physical complaints.

If you think you have a "high pain tolerance," you probably don't. If you think that you have a low pain tolerance, you are likely correct. People with a high pain tolerance don't even mention that term.

Oh, and if a patient has multiple ER visits for other painful conditions (toothache, "migraine," back pain, etc.) that is another big red flag. Drug seekers often move from one painful alibi to another. But all of their visits involve something that hurts REALLY BAD!!!!, and often they have little objective evidence of disease or injury.

If you are able to sit still and keep quiet, you probably aren't in as much pain as the other guy (or as much pain as you think you are in, for that matter). If you aren't screaming, it isn't a 10. If you aren't vomiting, it isn't a 9. Simple enough for me.

Annoying ranters are usually the people who have no objective evidence of disease (like many chronic painers). They tend to have multiple nonphysiologic complaints and heavy psychogenic overtones to their complaints. Fortunately, they often tend to get so worked up they leave prior to evaluation by a physician, cursing and yelling on the way out. We don't miss them. My motto is "if you are sick, you'll stay."

There is no moral or legal requirement for physicians to administer or prescribe narcotics to patients who repeatedly present to the ER, even for visible reasons like dental caries. We certainly aren't obligated to give narcs for clinically subjective conditions like fibromyalgia or migraines.

I personally don't blacklist drug-seeking patients if they "piss me off." Only when they lie to me in an attempt to obtain narcotics. Good luck prosecuting that. If they piss me off, they may just leave empty-handed, but they will still get a bill.

And all a suicide threat will get you is a psych eval and possibly an involuntary hospitalization. But usually not, because it's obvious that someone making such a threat is just being manipulative.

Perhaps its easier for someone like you (who actually has structurally identifiable causes of pain) than someone with fibromyalgia (who is widely considered to have simply a psychiatric problem) to cope with pain. But I doubt it.

I think that pain is like many other neuropsychophysiological conditions that test the human will and our ability to persevere. Some people forge ahead despite their handicaps, and some people curl up into a ball and blame society for their ills.

I think you get the picture: standard, loudmouth macho posturing from medicus fuctardicus arrogansis. You should read some of the comments from the other mouth-breathing Neanderthals at that site, as well.

I have often wondered what makes so many doctors and nurses behave with such casual cruelty to people whose only crime is they are suffering and want relief. I think Scalpel's website gives some telling insights into this kind of behavior and the root causes of it, which in my opinion is a basic insecurity about one's masculinity coupled with narcissism, sadism and fear. Women are clearly prone to this shortcoming as well. They see people coping with horrible, constant pain, and deep down inside they know they would never be able to endure pain like that and still function, so they need to convince themselves that the person is just a weakling and a faker and couldn't possibly be in that much pain. The alternative is a mature confrontation with one's own human limitations, which all of us with chronic pain have been forced to make, but that rarely happens with doctors. It's only when they've been through it themselves and have a little humility beat into them that they, sometimes, begin to see the light. There is an interesting article about the roots of sham machismo at Orcinus. This quote is from "Sara"

My first husband -- who as a Latino, a clinical psychologist, and the son of a Marine Corps drill instructor, knew a thing or two about the anatomy of macho -- used to say that the first rule of real macho was that those who possess it never need to prove it to anyone. If you have to prove it or put it out on display, you don't have it in the first place. And if you are intimidated by seeing it in others, you aren't even in the ballpark.
I may not be a "Real Man" myself, or know what a man really is. I certainly have my share of insecurities. Years of unrelenting pain have broken me physically and mentally, and I am not ashamed to admit that. I am sure there are men and women out there who are stronger than me and who could have handled my ordeal better than I have, but I dealt with it the best I could. No matter how tough you are, or how tough you think you are, severe chronic pain, left untreated, will eventually break you. Water wears away granite in time.

But I know what a real man, and for that matter, a real woman, is not. He is not someone who needs to brag, and swagger, and question anyone else's manliness. He doesn't need to abuse people in horrible pain or accuse them of being whimps or fakers, or question their ability to take pain, just so he can feel good about his own questionable masculinity. He is not cruel, or cowardly, or manipulative, but can deal with other human beings with fairness, grace, equanimity and compassion. He doesn't need a 6 ton pickup unless he's in the construction business, and never needs to tailgate old ladies. He never needs to tell someone in chronic pain to "be a man" or "take the pain." He doesn't whine about a toothache and then turn around and tell people who have dealt with the ordeal of fibromyalgia, migraines or low back pain for years that they have a low pain tolerance.

All these doctors and nurses you see out there with their adolescent macho posturing, looking down their noses in arrogant haughtiness at people who have dealt with horrible pain for years, condemning them for being "weak," or "lazy" or unable to tolerate pain, refusing to treat their pain, accusing them of being drug seekers and psychiatric basket cases, blacklisting them so they can never get their pain treated anywhere...all these guys are clearly compensating for their own inadequacies in the manhood department. And yeah, I'm talking about women, too. A sorry, pathetic lot of swaggering punks who are insecure about their masculinity, and think tough talk and cruel, arrogant, macho behavior is a substitute for genuine manliness. Sorry, assholes, but it's not.

That this behavior is so commonplace in the medical field is a sad reflection on that profession.

Wednesday, August 22, 2007

Paging Dr. Cox(ucker)

Imagine injuring your back and trying to get pain treatment from this guy. Dr Cox is a fictional character on the show "Scrubs" but his behavior and attitude are all too real. In Dr Cox's maniacal rant about drug addicts, he claims there are "millions" of them coming to the ER complaining of their "aches and their pains and their spasms and their cramps and their myalgia and their neuralgia and their otialgia and every other algia they can possibly think of just so they can get a fix." Unfortunately, his attitude is widely shared by far too many doctors, particularly ER docs, as a search for the term "drug-seeker" on Google will quickly reveal.

Of course, in this fictional example, the drug addict in question very conveniently manages to out himself just as Cox's beleaguered colleague is about to write out his script, but in reality, just about any behavior, no matter how innocuous, can get you labeled a drug seeker, even refusing pain meds or writhing in agony when no one is looking. Many doctors make the default assumption that pretty much anyone complaining of pain, looking for pain meds or especially asking for a pain med by name is a drug addict, and people in pain often find themselves guilty until proven guilty of drug-seeking no matter how much evidence they may have of a serious, causative factor for their pain.

Although there are certainly drug addicts who show up at doctor's offices looking for drugs, the reality is that narcotic abuse is relatively rare among chronic pain patients (3.8 percent using a very generous definition of drug abuse, which is not the equivalent of addiction), and in the general population as a whole (less than 1 percent). Given these facts, the idea that there are literally "millions" of drug seekers can only be based on bigotry and a lack of awareness of the realities of pain-related behaviors, which very often mimic those of drug addicts (a phenomenon know as pseudoaddiction). Dr. Frank B. Fisher, a Harvard-trained general practitioner and chronic pain advocate who has been prosecuted for treating pain patients humanely with opiate medications, describes pseudoaddiction thusly:

The term pseudoaddiction was coined in 1989 to describe chronic pain victims mistakenly diagnosed as suffering from opioid addiction after they were driven, by undertreated pain, to display certain drug-related behaviors. Simply stated, pseudoaddiction is a misdiagnosis that results from undertreatment of chronic pain. When this diagnosis is made, the medical system has erred. Recognition that patients are frequently harmed by misdiagnosis of addiction should prompt an aggressive search for undertreatment of pain. Unfortunately, this usually does not happen. Instead, when a patient displays certain behaviors, he is typically threatened with termination of his treatment, rather than questioned about its effectiveness.
All this should lead you to wonder where this horde of drug seekers the doctors are complaining about is coming from. Perhaps it's all in their heads?

Pain Contracts: "Cooperation," or Coercion?

"Pain contracts" are signed agreements between a patient and a doctor specifying the terms and conditions under which the doctor agrees to treat a patient's chronic pain with opioid medications. These contracts typically include provisions which require patients to comply with the doctor's treatment recommendations, submit to random drug screening, refrain from the use of alcohol or illegal drugs, and keep their appointments. These contracts also usually specify that a patient may be discharged from the doctor's care or denied further treatment for any violation of the agreement. Though they sometimes go by different names, such as "pain management contracts," "narcotic contracts," "opioid contracts," etc., they are generally known as "pain contracts" and thus imply a legally-binding, contractual relationship between the doctor and patient. They are used almost exclusively for opioid medications. For a typical example of a pain contract, click here (pdf download).

Pain Contracts are another result of the DEA's war on pain patients and their doctors. Doctors use pain contracts to cover their rear; as proof to the DEA and other law enforcement agencies that they are properly supervising those patients who get opiates. An additional benefit to doctors is that they serve to dissuade patients from filing lawsuits who have been discharged for failing to follow the rules. They treat pain patients as suspects in advance. But are these contracts really legally binding? Definitely not.

These "contracts" are not legitimate, legally-binding contracts. They are essentially one-sided demands from your doctor, signed under duress, which treat you as a suspect in advance, rob you of your privacy and your right to be an active participant in your own health care and your rights to accept or refuse treatments, and allow the physician to renege on his moral and ethical duty to treat you with a pseudo-legal agreement that you signed with the moral equivalent of a gun pointed at your head.

To understand the nature of the gun pointed at your head, you have to understand the concept of "duress." Under contract law in most states and common law countries, a contract is unenforceable if it is signed under duress. As an example, if someone says you must sign this contract or I'll kill you, that is clearly duress, and that contract will usually be unenforceable. Similarly, when a doctor says you will sign this contract and abide by its terms or I will withhold medication from you (essentially sentencing you to torture until you can find another doctor) that is also very clearly duress. Add to that the danger of being medically blacklisted for violating one of these contracts, or even for refusing to sign one, and it is as if the doctor has a gun pointed at your head. You do not have the option of not signing the contract and still receiving medical care.

From the Wikipedia :

Duress has been defined as a "threat of harm made to compel a person to do something against his or her will or judgment; esp., a wrongful threat made by one person to compel a manifestation of seeming assent by another person to a transaction without real volition." An example is in Barton v. Armstrong, a decision of the Privy Council. Armstrong threatened to kill Barton if he did not sign a contract, so the court set the contract aside. An innocent party wishing to set aside a contract for duress to the person need only to prove that the threat was made and that it was a reason for entry into the contract; the onus of proof then shifts to the other party to prove that the threat had no effect in causing the party to enter into the contract. There can also be duress to goods and sometimes, the concept of 'economic duress' is used to vitiate contracts.

Undue influence is an equitable doctrine that involves one person taking advantage of a position of power over another person. The law presumes that in certain classes of special relationship, such as between parent and child, or solicitor and client, there will be a special risk of one party unduly influencing their conduct and motives for contracting. As an equitable doctrine, the court has the discretion to vitiate such a contract. When no special relationship exists, the general rule is whether there was a relationship of such trust and confidence that it should give rise to such a presumption.

You do not have to be a lawyer to realize that narcotics contracts very clearly meet the definition of duress. They enable your doctor, who is in a position of power, to take advantage of you by not only refusing medical care at will, but forcing you to undergo any and all treatments he recommends or be tortured. Such a contract not only amounts to duress, but a blank check for the doctor to get whatever he wants from you, so long as it would otherwise be legal. These contracts completely rob you of your right to autonomy as a patient and to refuse certain medical treatments, while offering no guarantees of any treatment from the doctor, other than a vague promise to "treat pain" (if it even includes that) which can easily be fulfilled by prescribing Tylenol and sending you to physical therapy.

Is is right for your doctor to say, "if you don't get back surgery, or injections, or take anti-convulsants, I will no longer prescribe your pain medication"? It shouldn't be because patients are supposed to have a say in what treatment they will accept--especially drugs and surgery, but it happens every day. Many contracts mandate treatments, including alternative therapies, that have little evidence of efficacy, carry pronounced risks and impose additional costs on patients who are already struggling against bankruptcy due to medical bills and the inability to work due to disability and undertreated pain.

Terms: A set of clauses defining the exact set of promises agreed to. (Wikipedia)

This is critical. A valid contract should clearly spell out the terms of what is being agreed to to. Contracts are often voided for vagueness. Most of these contracts do not clearly spell out your obligations, but instead have vague terms like "go to PT" or "follow the doctor's treatment plan" without that plan being spelled out clearly in advance. You can sign one of these contracts, take narcotics long enough to develop a physiological dependency, and then find out that unless you agree to dangerous, invasive or unnecessary treatments, you will be taken off your meds. These contracts generally do not require your doctor to taper your withdrawal.

Consideration: consideration is the benefit being conferred on each party in exchange for fulfilling their end of the contract. if you say "I will mow your lawn for $20.OO" then the lawn mowing and the $20.00 are both forms of consideration. So long as you mow the lawn, you should get the $20.00.

Consideration can be implied, such as there is an implied obligation to pay your medical bills if you see a doctor, even if the terms and costs have not been agreed in advance. But consideration has to be two-sided, even if the consideration is inadequate. Both sides must benefit from the contract somehow: "I will give you my Mercedes for a $1" can be a legitimate contract. "I promise to give you my Mercedes" generally isn't, because you're not getting any consideration.

Most narcotics contracts do not offer any consideration on the part of the doctor. Generally, they are a list of obligations for you to follow, but do not state any obligation to actually perform or do anything on your doctors part, and even where this is a promise to "treat your pain," does this mean if he refuses to treat you, you can get your money (consideration) back? Which leads to the next points:

Mutual Right to Remedy: Both parties must have an equal right to remedy upon breach of the terms by the other party. (Wikipedia)

Clearly, your rights to any kind of legal remedy if your doctor refuses to honor the contract are almost nil.

Mutual Obligation to Perform: Both parties must have some obligation to fulfill to the other. This can be distinct from consideration, which may be an initial inducement into the contract." (Wikipedia)

Your doctor is under no obligation to perform his end of the contract, but you must perform every aspect of yours or he can refuse to treat you. If your doctor refuses to properly titrate your dose, you have no remedy under these contracts. But if you refuse to see a therapist, even if you can't afford one, he can boot you out of his office without so much as a warning.

These are just a few of the reasons why these contracts are bogus. They are coercive instruments that do not meet the requirements of a legally binding contract, they are detrimental to the doctor/patient relationship which must be based on mutual trust, they impose draconian punishments for even the mildest violations, and most importantly they are an infringement on the right of patients to autonomy in decisions regarding their own bodies and their lives.

Not only do these contracts often mandate treatment modalities that may be invasive, dangerous, or of uncertain benefit, they may contain provisions which allow the doctor to contact your friends and family to ensure that you are complying with your treatments, and require you to list family members and friends for them to contact! The East German Stasi was notorious for using this particular tactic against potential non-compliants. The pain contract may also contain provisions that allow the doctor to inform local emergency rooms, urgent care centers, pharmacies or other doctors if you are discharged from the program for any reason. This amounts to a demand that you assent to patient blacklisting and to violations of your confidentiality and privacy if at any point you dare to exercise your right to say "no." That none of this should be permissible or legal in a democratic, free society is without question.

These contracts do nothing but put into writing what is an inescapable reality for people with chronic pain: that the medical profession has total power over us, and we'd better do what they say or else. They are indisputable evidence of the reality of our situation, put into writing and signed by us under duress as if this somehow legitimizes the crime being perpetrated against us. They put the lie to the idea that we have any choice in our medical care, other than to choose between submission and torture. Since they are not legally enforceable, these contracts are not so much a legal out for the doctor as an "ethical" out. If you violate the contract that you "voluntarily" signed then the consequences are all your fault, not the doctor's, and he can bullshit himself into believing that you therefore deserve your fate (if he doesn't already believe that). He can imagine that coercion, patient abandonment, patient blacklisting, violations of patient confidentiality, and economic exploitation are all "ethical" because you "agreed" to it.

In short, these contracts are a fraud and a con, allowing the doctor to con himself as well as you. I can only hope someday some smart lawyer will round up a few of these contracts and file a class action suit against the AMA for putting us into a situation where we have to sign away our rights or be tortured.

Tuesday, August 21, 2007

The Tragedy of Needless Pain

by Ronald Melzack; Scientific American; February 1990

"Pain" as Albert Schweitzer once said, "is a more terrible lord of mankind than even death itself." Prolonged pain destroys the quality of life. It can erode the will to live, at times driving people to suicide. The physical effects are equally profound. Severe, persistent pain can impair sleep and appetite, thereby producing fatigue and reducing the availability of nutrients to organs. It may thus impede recovery from illness or injury and, in weakened or elderly patients, may make the difference between life and death.

Sadly, there are some kinds of pain that existing treatments cannot ease. That care givers can do little in these cases is terribly distressing for everyone involved but is certainly understandable. What seems less understandable is that many people suffer not because their discomfort is untreatable but because physicians are often reluctant to prescribe morphine. Morphine is the safest, most effective analgesic (painkiller) known for constant, severe pain, but it is also addictive for some people. Consequently, it is typically meted out sparingly, if it is given at all.

Indeed, concern over addiction has led many nations in Europe and elsewhere to outlaw virtually any uses of morphine and related substances, including their medical applications. Even where morphine is a legal medical therapy, as it is in Great Britain and the U.S., many care givers, afraid of turning patients into addicts, deliver amounts that are too small or spaced too widely to control pain.

Yet the fact is that when patients take morphine to combat pain, it is rare to see addiction-which is characterized by a psychological craving for a substance and, when the substance is suddenly removed, by the development of withdrawal symptoms (for example, sweating, aches and nausea). Addiction seems to arise only in some fraction of morphine users who take the drug for its psychological effects, such as its ability to produce euphoria and relieve tension.

Furthermore, patients who take morphine for pain do not develop the rapid physical tolerance to the drug that is often a sign of addiction. Many people who are prone to addiction quickly require markedly escalating doses to achieve a desired change of mood, but patients who take the drug to control pain do not need sharply rising doses for relief. They may develop some tolerance initially, but their required dose usually rises gradually and then stabilizes.

I do not suggest that morphine be prescribed indiscriminately. I do urge lawmakers, law-enforcement agencies and health-care workers to distinguish between the addict who craves morphine for its mood-altering properties and the psychologically healthy patient who takes the drug only to relieve pain.

Morphine is a constituent of opium, which has been a medical therapy for longer than 2,000 years, since at least ancient Roman times. Opium is made by extracting a milky juice from the unripe capsule, or seedpod, of the poppy Papaver somniferum (grown abundantly in many Middle Eastern countries) and then drying the exudate to form a gum. This gum-the opium-can be eaten as is or added to a beverage.

By the 16th century opium was being carried by traders to Europe and the Orient. At about that time an opium-containing mixture called laudanum became a popular remedy in Europe for virtually all ailments. Later, smoking opium and tobacco together became yet another popular way to obtain the drug's benefits.

Soon after the turn of the 19th century, a young German pharmacist named Friedrich W. A. Serttimer isolated morphine from opium and identified it as opium's major active ingredient. Morphine's production was followed in 1832 by the isolation of yet another opiate, or opium derivative: codeine.

In the mid-19th century the introduction of the hypodermic needle made it possible to administer large amounts of drugs by injection. The standard approach to morphine therapy for ongoing pain (left) calls for injections pro re nata (PRN), or "as needed.' In practice this means injections are given only in response to pain; also, if the pain returns before four to six hours have passed the patient often has to wait for help. By the time the next injection is delivered, the pain may be so severe that quite a large dose is needed, leading to mental clouding and other side effects, such as nausea. A more enlightened approach (right) seeks the actual prevention of pain and thus helps ease the fear of recurring agony. The morphine is given orally (in a dose tailored to the patient's needs) every four hours or even more frequently if a shorter schedule prevents pain more effectively. Because the doses are frequent, they typically can be relatively low, which reduces the incidence of side effects.

Improved technology, which enabled a drug's effects to be felt quickly, led in many regions of the world to the ready prescription of injected morphine for severe pain. At the same time, more and more people began taking morphine for its emotional effects, and the number of addicts rose.

Eventually a search began for drugs that had morphine's analgesic properties but were not habit-forming. This quest resulted in the production of heroin, a synthetic compound similar in activity to morphine but soon found, disappointingly, to be quite as addictive. Various other opioids (chemicals with activity similar to that of opium) were then introduced, including methadone and meperidine (Demerol). Like the opiates, many of the opioids relieve pain, induce changes in mood and, unfortunately, are addictive to some extent.

Inevitably, the rising abuse of narcotics (by which I mean opiates and opioids) and of other mood-altering drugs spurred countries throughout the world to adopt anti-drug regulations. At the same time, the extremely cautious administration of narcotics for pain became commonplace.

Today morphine therapy for pain is generally restricted to two groups of patients. It is prescribed over relatively short periods for hospitalized individuals who have discomfort caused by surgical incisions, and it is given over potentially longer periods to ameliorate the pain suffered by burn victims or people who have incurable cancer.

In many hospitals the standard prescription order says "PRN" (pro re nata, or "as needed"). This order essentially means that the drug is given orally after pain returns. Typically, it is delivered by injection into a muscle or under the skirt.

The result of the PRN approach is often a confrontation between the patient and the care giver, who expects morphine analgesia to last for four to six hours. The patient, whose pain has returned earlier than expected, is in agony and pleads to have the next injection. The health-care worker, fearful of causing addiction, refuses to comply. When the pain is finally treated, it may be so severe that a large dose has to be given, which increases the likelihood of side effects, such as mental clouding and nausea. Particularly when a patient has a terminal Illness, the issue of addiction is meaningless, and delaying relief is cruel.

There is another, more humane way to treat pain, one that is slowly gaining acceptance. In this approach doses are given regularly, according to a schedule that has been actually tailored to prevent recurrence of the individual's pain. Thus, pain is controlled continuously; a patient does not wait for discomfort to return before receiving the next dose.

This enlightened, preventive approach evolved from pioneering work first undertaken some 20 years ago by Cicely M. Saunders, an English physician who established the first modern center devoted to caring for people who are dying of cancer or other dis. eases: St. Christopher's Hospice in London. Saunders urged physicians caring for terminally ill Patents to face reality and palliate-to relieve Pain, nausea and other discomforts instead of making futile attempts to cure disease. The final days or weeks of a person's life, she believed, should be a time of peace and comfort, spent as pleasurably as possible in the company of family and friends.

To achieve this aim, Saunders prescribed the Brompton mixture, a version of a liquid analgesic that had been used for advanced cancer by several London hospitals, including the Brompton Chest Hospital, since the late 19th century. The mixture (made of morphine, cocaine, chloroform water, alcohol and flavoring syrup) had been eclipsed by injectable morphine, but Saunders realized that an orally delivered compound would allow many patients to spend a number of their last days at home; a visiting nurse would simply monitor them, making sure their pain was controlled.

Morphine has since been found to be the only important ingredient in the Brompton mixture, and so today patients who are treated with the preventive approach to pain take morphine alone, either as a tablet or mixed into a beverage. An initial dose of 10 milligrams is typically given and repeated every four hours. Then, over the course of perhaps several days or weeks, the dose and timing are adjusted until a maintenance regimen is established that controls pain around the clock without producing mental clouding and other side effects.

For patients who have cancer, an approach emphasizing pain prevention is particularly wise. Pain and the fear of pain are perhaps their greatest source of suffering. In the early stages of the disease, some 80 percent of people have pain resulting from the cancer itself or from the procedures designed to arrest its spread. By the time the cancer has reached its final stages, about 70 percent of people report pain, which tends to be intense and persistent.

About 80 to 90 percent of cancer patients treated with the preventive approach obtain satisfactory relief, reporting that their discomfort is consistently bearable or, more frequently, gone. Roughly half of the remainder obtain relief with the addition of other therapies. This success rate is remarkable in view of the destructiveness of cancer and the severity of the pain associated with it.

Treatments continue to improve. There are now special capsules that release morphine slowly and so need to be taken only a few times a day. Also available are electronically controlled, portable pumps that deliver a steady infusion of medication under the skin.

Enough evidence has now been collected to demonstrate that the traditional, PRN approach, based as it is on the fear of addiction makes little sense. Study after study of patients whose pain is most often treated with narcotics-namely, cancer patients, burn victims and those hospitalized for surgery-has shown that the patients who develop rapid and marked tolerance to, and dependence on, the narcotics are usually those who already have a history of psychological disturbance or substance abuse.

Studies of patients who received narcotics while they were hospitalized have also uncovered little evidence of addiction. In an extensive study Jane B. Porter and Hershel Jick of the Boston University Medical Center followed up on 11,882 patients who were given narcotics to relieve pain stemming from various medical problems; none of the subjects had a history of drug dependence. The team found that only four of the patients subsequently abused drugs, and in only one case was the abuse considered major.

Equally persuasive are the results of a survey of more than 10,000 burn victims. These individuals, who were studied by Samuel W. Perry of New York Hospital and George Heidrich of the University of Wisconsin at Madisom underwent debridement, an extremely painful procedure in which the dead tissue is removed from burned skin. Most of the patients received injections of narcotics for weeks or even months. Yet not a single case of later addiction could be attributed to the narcotics given for pain relief during the hospital stay. Although 22 patients abused drugs after they were discharged, all of them had a history of drug abuse.

Further evidence that narcotic drugs can be administered for pain without causing addiction comes from studies of "patient-controlled analgesia" in surgical patients and those hospitalized for burns. in such studies patients push a button on an electronically controlled pump at the bedside to give themselves small doses of morphine (through an intravenous tube). When these devices were introduced, there was considerable fear that patients would abuse the drug. Instead it soon became clear that patients maintain their doses at a reasonable level and decrease them when their pain diminishes.

Studies that explore how morphine produces analgesia are helping to explain why patients who take the drug solely to relieve pain are unlikely to develop rapid tolerance and become addicted. On the basis of such studies, my former student Frances V. Abbott and I proposed in 1981 that morphine probably has an effect on two distinct pain-signaling systems in the central nervous system and that one of these-which gives rise to the kind of pain typically treated with morphine-does not develop much tolerance to the drug.

In view of the complexity of the neural mechanisms of pain, it is not surprising that morphine's ability to produce analgesia has been found to vary greatly from person to person. An important message emerging from studies of such variation is that the need for a high dose is not necessarily a sign of addiction.

In one such study involving cancer patients, Robert Kaiko, now at the Purdue Frederick Company in Norwalk, Conn., and Ws colleagues at the Memorial Sloan-Kettering Cancer Center found that to achieve a given level of analgesia, less morphine was needed by older patients than by younger patients, and less was needed by blacks than by whites. Similarly, patients with dull pain needed less morphine than did those with sharp pain, and patients with stomach pain needed less morphine than did patients with pain in the chest or arm.

Society's failure to distinguish between the emotionally impaired addict and the psychologically healthy pain sufferer has affected every segment of the population. Perhaps the most distressing example is unnecessary pain in children Many health-care workers undertreat pain in youngsters, not only because of fear of addiction but also because of the mistaken belief that young children do not feel pain as intensely as adults. In a classic study, Joann M. Eland and Jane E. Anderson of the University of Iowa found in 1977 that more than half of the children from four to eight years old who underwent major surgery-including limb amputation, excision of a cancerous neck mass and heart repair-were given no medication for relief of their postoperative pain; the remainder received inadequate doses. When 18 of the children were matched with adults who underwent similar procedures, the children as a group were found to have been given a total of 24 doses of analgesic drugs, whereas the adults were given a total of 671 doses.

The elderly also pay the penalty of ignorance. In a study of postsurgical pain my colleagues and I found that surgical wards contain two basic populations: a young and middle-aged group that recovers quickly and an older group whose pain remains severe and lingers for many days beyond the normal three- to four-day recovery period. Despite the persistent, high level of pain in these older patients (presumably because of complications that arise after surgery) and despite the longer recovery period, they do not receive larger doses or a higher daily amount of medication. About 30 Percent of the patients on a surgical ward at any time fall into this older category; they thus represent a substantial number of people who suffer needlessly high levels of pain.

The pain suffered by burn victims is known to be agonizing, and yet it too, tends to be poorly controlled. Manon Choiniare of the burn Center at the Hotel Dieu in Montreal and I found that even in the best burn facilities-those with highly capable, compassionate physicians, nurses, physiotherapists and others-pain levels are high. Our study of 30 consecutive patients who underwent debridement and physiotherapy (exercise to prevent loss of joint flexibility) classified the severity of pain on the basis of the Pain questionnaire I developed with Torgerson. We discovered that during treatment in the first two weeks, 23 Percent had severe ("horrible") pain, and 30 percent had extremely severe ("excruciating") pain. Even when the Patients were at rest, 13 percent of them reported having severe pain, and another 20 percent said they had extremely severe pain. These data, by the way, were obtained from patients who were already medicated according to standard textbook recommendations (that is, the drug order said "PRN").

For many patients who are hospitalized for surgery or burns or who have terminal cancer, the prescription is clear: a preventive approach to pain should be instituted to maximize the effectiveness of narcotics therapy. What, though, should be done for people who suffer from debilitating chronic pain but who do not have a fatal illness? These people have traditionally been excluded from long term therapy with narcotics, again for fear they would become addicts.

Consider the case of a 26-year-old athlete who sustained a major spinal injury that caused him to suffer from excruciating pain in the back and legs. The pain rendered him unable to work, and he became a burden to himself, his family and society, which pays his medical bills. His physician discovered that small doses of morphine taken orally each day (the way cancer patients receive them) obliterated the pain. With the help of the medication, the young man resumed working and made plans to marry his childhood sweetheart, who was accepting of his injury.

One day, however, the physician was accused by his regional medical association of prescribing narcotics for a purpose unapproved by the association and of turning the patient into an addict. Fearful of losing his medical license, the physician stopped prescribing the drug. (Where morphine administration is allowed by law, physicians can technically prescribe it at will, but they are in fact restricted by the regulations of medical societies, which control licensing.)

Of course, the young man's pain returned. In desperation, he turned to other physicians and was rebuffed. He then sank rapidly into depression and again became mired in helplessness and hopelessness.

It was once unthinkable to give narcotics indefinitely to patients who were not terminally ill. Yet studies designed to examine addiction specifically in such patients are beginning to show that for them, as for the standard candidates for narcotics therapy, these drugs can be helpful without producing addiction.

In one recent study Russell K. Portenoy and Kathleen M. Foley of SloanKettering maintained 38 patients on narcotics for severe, chronic non-cancer pain; half of the patients received opioids for four or more years, and six of these were treated for more than seven years. About 60 percent of the 38 patients reported that their pain was eliminated or at least reduced to a tolerable level. The therapy became problematic in only two patients, both of whom had a history of drug abuse.

With cautious optimism, Portenoy and Foley suggest that morphine might be a reasonable treatment for chronic pain in many patients who are not terminally ill. They point out the problems that may accompany narcotics maintenance therapy, and they provide careful guidelines for monitoring patients. Studies such as theirs are doing something in medicine that is akin in aeronautics to breaking the sound barrier. They represent a breakthrough to a reasoned, unbiased examination of the effectiveness of narcotics in patients who have rarely been considered for such therapy.

Among the critics of long-term narcotics therapy for such patients are physicians and others who fear that people will simply be given a prescription for a drug and will never receive the advantages of a multidisciplinary approach to the care of pain. Yet both approaches are compatible; in fact, they complement each other.

For the future, many more well-controlled studies are needed to provide data on the long-term effects of narcotics on chronic non-cancer pain. At the same time, medical and government agencies must provide the authorization and funds for such studies to take place. The goal is nothing short of rescuing people whose lives are now being ruined by pain.

Hat tip to Master Juba from for sending this article over.

Monday, August 20, 2007

The Price of Pain

This post was sent to me by the founder of the Canadian Neuropathy Association. It is a powerful summary of the enormous costs each one of us who struggles with the nightmare of chronic pain has to pay, and the commitment to hang in there and fight we must make at the beginning of each new day. The original author is unknown, but I would love to know who wrote this.

The Price of Pain

The cost of prescriptions, medical treatments and devices, surgeries, worker's comp insurance, disability payments, physical therapy, psychological therapy and such...Yes, you can add all those things up and get a total cost...but that is not the price of pain. The price of pain is more...

The price of pain is the loss of self-respect when you can no longer complete personal grooming, cook meals or take care of your family the way you want to...

The price of pain is the loss of rewarding employment when you cannot perform the tasks to do the job you love...

The price of pain is the loss of quality of life when you can't go hiking with your children or dancing with your spouse...

The price of pain is the loss of relationships with friends and family when the pain and medication makes it impossible to even have a conversation or attend important events...

The price of pain is no longer being independent when you cannot drive or shop for groceries alone...

The price of pain is the depression and mental anguish the pain brings with it...

The price of pain is the loss of sleep and the resulting problems sleep deprivation causes...

The price of pain is the side effects of the medications taken in an attempt to survive the day...

The price of pain is when you lose who you are in the pain. These things and more are the price of pain. It is the living every minute of every day around what your pain level is or when you can take the next dose of medication, praying it will bring more pain relief than the last dose. When happiness is 3-4 hours of pain-free sleep or a day with only 75% of the usual pain...

The price of pain is paid by the person in pain as well as those who love them...

The price of pain is watching someone you love suffer day after day, night after night and you are helpless to ease their pain...

The price of pain is when your child asks "Can you play with me, if you are feeling Ok?"

The price of pain is beyond money, the price of pain is beyond words, the price of pain is all encompassing. The price of pain seems endless...

The price of pain is there until the day that person is free of their damaged body...

The price of pain is all these things and more. But the pain is not me and I am not the pain...

The pain is part of my life, but the pain will not be my life. I will fight, fight, and fight. And though the pain fills my life it will not take my life. Each day I live, I fight and show the pain who I am. Even though the pain may take much of my life it will not consume me. I will not allow the price to be that high...

The price of pain is all this, but I am more...

Sunday, August 19, 2007

FDA Bans Quinine Sulfate (Sort of)

On December 11, 2006, the FDA banned all over the counter products containing quinine sulfate, a drug used for centuries to treat malaria, but which has also been widely used to treat leg cramps and muscle spasms. The ban also applies to all higher strength, prescription-only generic formulations of the drug, but one manufacturer, Mutual Pharmaceutical Company, Inc., will still be allowed to market its name brand product, Qualaquin, which contains 324 mg of quinine sulfate. The sole approved use of the drug will be for the treatment of malaria.

Quinine sulfate is derived from the bark of the Cinchona tree, which according to legend was named after the Countess of Chinchon, the wife of a Peruvian viceroy, who is believed to be the first European cured of malaria using the bark in 1638. The bark had long been used by Peruvian indians for its medicinal qualities, and the active ingredient of the bark was finally isolated by two French scientists, Pierre Joseph Pelletier and Joseph Bienaimé Caventou in 1817, and was named "quinine," possibly in reference to the Cinchona tree or the native Quechua word for the tree, "Quina." The drug has a long history in folk medicine as a treatment for muscles spasms, debility, fever, lumbago and leg cramps. The gin and tonic was invented by officers of the British East India Company who couldn't stand the bitter taste of the quinine-based tonic water they took as a prophylactic against malaria, so they added gin to make it more palatable.

The FDA's granting of exclusive rights for the sale of quinine sulfate in the U.S. to one company has created a serious dilemma for many people in the U.S. who used quinine as a reliable treatment for leg cramps, as there is no other drug on the market that has been approved for the treatment of leg cramps, and the use of quinine itself for cramps was always an off-label, unapproved use. The price of Qualaquin, which now enjoys monopoly status, is over 5 to 6 times more expensive than the previously existing generic formulations of quinine, which are now only available overseas.

It is difficult to fathom the FDA's reasoning for this bizarre prohibition. The FDA states on its website that "Since 1969, FDA has received 665 reports of adverse events with serious outcomes associated with quinine use, including 93 deaths, " but compared to many drugs on the market, that is actually a pretty good safety record. Over-the-counter and prescription-only NSAIDs kill over 17,000 Americans every year, but these drugs are still widely available and do not display prominent warning labels that specify their very severe risks. Quinine in prescription strength was previously available over-the-counter but later became prescription-only. "Natural" products containing quinine available over-the-counter generally contained fairly low doses of quinine as well as other ingredients.

If quinine is so dangerous it must be pulled off the market, then why is this company allowed to continue marketing it's quinine sulfate-based product, Qualaquin? At the same time, quinine will still be available in tonic water, which contains 75 mg of quinine on average per liter, and certain energy drinks, such as Howling Monkey. There is no reason to assume that Qualaquin is any more or less toxic than generic quinine sulfate, and the inclusion of a package insert with Qualaquin warning against its use for leg cramps could easily have been mandated for the generics, and is hardly worth a price differential of over 500 percent.

It is also interesting to note that Qualaquin is only available as a 324 mg capsule which is difficult to break apart into a lower dose, but the generics were available in a 260 mg tablet that could easily be broken in half by those seeking to minimize their daily dose of quinine. If the FDA is correct in stating that there is a slim margin between a therapeutic dose and a toxic dose of quinine, then surely there is an advantage to the generics. It should be noted that the usual dosage of quinine for the treatment of malaria, two 324 mg capsules every 8 hours, is six times higher than the usual dose for leg cramps, which was just one 324 mg capsule daily. The FDA states that the more severe adverse reactions that were reported were associated with higher dosages of quinine.

On the surface, it seems that the FDA is doing little more than creating and protecting a monopoly, and allowing a drug company to profiteer off the suffering of millions of quinine users who will now have no choice but to suffer the excruciating pain of chronic leg cramps or pay the piper.

Saturday, August 18, 2007

Magical Vicodin

Everyone is familiar with the story of how Jesus fed a crowd of over 5,000 people with five loaves of bread and two fish. But few people are aware that many doctors routinely perform an act that is just as miraculous, if not as spectacular or well known. This is the ability to write scripts for 30 Vicodin, taken every 4 to 6 hours, which then miraculously last for one month or more.

Now, Jesus could do a few things many doctors can't do, like walk on water and cure sick people, but I've never heard of anybody who could make 30 Vicodin last an entire month while taking the pills every 4 to 6 hours as prescribed. But this miracle can and does occur with Magical Vicodin, a variety of Vicodin known only to select doctors and pharmacists. Normally, if you get 30 Vicodin, or 30 anything, and take one every 4 to 6 hours as prescribed, you will run out of pills in 5 to 7.5 days. But with the magical variety, which can only be obtained through a special blessing conferred by the right doctors, this script can last for a month or more. This is truly a miracle!

Since 30 Vicodin seems to be the standard dosage given to anybody with any kind of pain complaint by the majority of doctors, I can only assume that there are many doctors who are capable of performing this miracle. There are times, however, when doctors prescribe the generic, non-magical variety of Vicodin, or pharmacists accidently use the wrong type, and this causes a lot of pain, stress and confusion when patients unwittingly bring their scripts in for early refills when they inevitably run out in under a month. Patients find themselves getting labeled as "drug seekers," or are treated with suspicion by angry doctors and pharmacists, when in fact it was their failure to use the Magical Vicodin that caused the problem in the first place.

Now, I can see calling someone a drug addict if you gave them the magical Vicodin and they came back in 8 days looking for more, but this sort of thing should be expected with the generic form, which is probably from Canada or Sweden or some place like that. The Angry Pharmacist has an illustrious example of how pharmacists react to patients trying to get early refills of their 30 Vicodin scripts.

It is unfortunate that there are still doctors out there who can't perform this miracle, and insist on prescribing large doses of narcotics to patients in pain when a mere 30 Magical Vicodin will do, but the DEA will soon sort them out. In the meantime, the wise patient should seek out those doctors who are capable of performing the Miracle of the Magical Vicodin. These doctors can be identified by their commanding presence, self-satisfaction and moral certainty, otherwise know as the "God complex." But just because you found a doctor with the requisite supernatural ability doesn't mean you will get your pain treated, as many doctors with the God complex refuse to prescribe any variety of pain medicine, magical or otherwise. If this happens to you it can only be because you are unworthy, and you should therefore hang your head in shame and pay your bill promptly.

Anything but Opiates!

Master Juba, from, sent us this article which he originally wrote for his site:

Anything but Opiates!

The DEA's intimidation tactics against doctors who prescribe opiates has another unintended effect; Doctors who treat narcotics like they were poison, but are quick to use a drug like Neurontin for a purpose it was not designed for, and not approved for, all on the word of a sales representative from a drug company. At least when the Perdue reps were pushing OxyContin on doctors, it was a pain medicine to be used for pain and no one billed it as a cure for high blood pressure or cholesterol. The pushing of Neurontin by pharmaceutical reps visiting doctors has been an issue for years. Even after the hubbub about the aggressive way Perdue pushed OxyContin, the folks selling and pushing Neurontin made the OC campaign look like a joke. Sales reps were interviewed on national news programs like "60 Minutes" and "20/20" saying that their management really put the screws to them to ("lie") tell doctors that Neurontin was not only the greatest drug coming down the pike for seizures, but to push the point hard to doctors that it was great for all kind of off-label uses, including chronic pain.

Congressmen and the FDA were appalled and up in arms about the whole thing... for about 3 weeks. Then it just kind of faded away, never to be heard from again. Doctors began serving it up for chronic pain in doses so high it was absurd, not to mention dangerous. And the whistle-blowing drug company reps who testified they were told to lie were fired with extreme prejudice, so no matter how loud they hollered about Neurontin poisoning, it looked like sour grapes.

Some people were actually getting some relief from Neurontin. Of course they aren't keeping track of how many folks had problems like developing seizures from taking it in high doses (and seizures wouldn't seem like an unusual thing to happen to someone on Neurontin) and there's no way to tell how many of those helped by the drug would have been helped even more by a real pain medication like a narcotic.

But society can't have narcotics handed out like candy to everyone with pain. That would never do. We can hand out seizure meds like candy though, and that's OK. If we do hand out a narcotic, we have to make sure we put a poisonous substance like acetaminophen in it, so we can show the systemic damage caused by narcotics, if the patient takes enough to try to break even with the pain.

It's a scary world where doctors would rather see someone on a medicine that's not approved for the condition, that could cause other systemic damage, that they have no real research on what it does for pain or how it works or what high doses do over the long haul, rather than to put a patient on a medication actually designed to fight pain. A medication that has been in use for the last 5,000 years, since the first poppy was picked, and has been proven effective and safe, if used properly. Neurontin was approved by the FDA in 1993 as an anti-seizure medication for epileptics. In addition, it is approved as a treatment for a condition related to shingles. Neurontin is believed to be linked to suicidal behavior, including suicide ideation and attempts.

Neurontin is manufactured by Parke-Davis, a subsidiary of Pfizer, and used to regulate the nerve activity in epileptics. To date, there are about 2 million people in the US with epilepsy. However Neurontin was prescribed for additional uses, for which it did not have FDA approval. Parke-Davis settled a criminal lawsuit related to such unapproved prescriptions. Yet, it is believed that approximately 80% of all Neurontin prescriptions were filled for unapproved medical conditions, which makes Neurontin side effects much harder to measure.

The eleven illegally promoted, unapproved uses for Neurontin include: bipolar disorder, peripheral and diabetic neuropathy, monotherapy for epileptics, reflex sympathetic dystrophy (RSD), periodic limb movement, attention deficit disorder (ADD), restless leg syndrome (RLS), trigeminal neuralgia, post-hepatic neuralgia, migraine, and drug and alcohol withdrawal symptoms.

When a patient takes a prescription for an unapproved use, the person runs the risk of having serious side effects because the medication was not tested in clinical trials for that use. The side effects could be minor to severe, but for certain, without a trial to test for interactions or preexisting conditions, the potential danger is huge.

Neurontin is believed to be linked to suicidal behavior and suicidal ideation. Evidence of suicides supplied to the FDA by the manufacturer are less than the number the FDA itself has gathered. Although the connection has not been proven decisively, no full clinical trials have been conducted for Neurontin on the unapproved uses for which it has been prescribed.

Using Neurontin for pain rather than narcotics is very dangerous. If you have been helped by Neurontin, that's great, but I wonder how much better you would feel on a real pain medication. Your doctor will never let you find out.

By Master Juba
Original article on

Incarcerex: This Video Says it all

If a picture is worth a thousand words, this video from the Drug Policy Alliance is worth a million. This is one of the best videos I have ever seem on the drug war and its insanity. If you watch closely there is a scene with a man in a wheelchair with cuffs next to a pillar with the words "25 Years." This is a wry reference to Richard Paey, a wheelchair-bound, Harvard-trained lawyer with severe chronic pain who was convicted in Florida of allegedly forging prescriptions for pain medicine and sentenced to a staggering 25 years in prison.

Friday, August 17, 2007

About Payne Hertz

Chronic pain has become an epidemic in the United States and throughout the industrialized world. It is estimated that some 50 to 70 million people in the U.S. suffer from chronic pain, oftentimes so severe it can lead to permanent disability. For many of these people, chronic pain is a daily, unending hell on Earth, yet a large percentage of those who suffer from pain often find it difficult if not impossible to get the treatment they need to relieve their pain. Those who do receive treatment have often spent years and tens of thousands of dollars, endured tremendous abuse and humiliation, and jumped through innumerable hoops before finally finding a doctor who was willing to help them out. By this time, it is often too late, and years of unremitting pain coupled with inactivity have taken their toll both physically and psychologically. Many people are driven to suicide when they are no longer able to cope with their broken bodies and broken lives.

The mission of Payne Hertz is to educate and inform the public of the continuing abuse and maltreatment of people with chronic pain, and to advocate for civilized and humane treatment based on our highest conceptions of individual liberty, human rights, and morality. Payne Hertz is not a support group nor can we give medical advice, but we hope to become a focal point for articles, ideas and commentary that challenge the status quo of pain treatment in the United States.

Payne Hertz welcomes original writing from all friends of people with chronic pain, and will link to or comment on articles we feel may be of interest to our readers. If you would like to send us an article you have written, a link to a pain-related website you like, or would like us to comment on any material you have seen elsewhere, please send us an e-mail at the link below.