Wednesday, November 7, 2007

An Excellent Pain Scale

This pain scaled was devised by Dr. J.S. Hochman MD, the founder of the National Foundation for the Treatment of Pain (NFTP). It is far better than the counterintuitive "1 to 10" pain scale as it uses descriptions of the patient's pain and functionality at various levels as well as the predicted efficacy of various meds at those levels. This is important, as perceived pain level is really a function of the physical sensation of pain, its impairment on your functionality, and the relative efficacy of various medications at relieving that pain, as few modalities work as quickly as meds to get pain under control and improve functionality. It overcomes the severe deficiencies of the numeric scale, particularly the bit about 10 pain being "the worst pain you can imagine," as no matter how bad your pain is, you can always imagine it being worse so in theory level 10 pain doesn't exist. This is a loophole that I've seen some doctors cite in ridiculing patients who claim level 10 pain, so being able to say your pain is level 10 because it is unbearable, and not "the worst you can imagine" seems more reasonable and defensible. Studies show that 65 percent of people with chronic pain will not go to a doctor until their pain becomes "unbearable," so defining pain like this also helps to explain the large number of people presenting to the ER claiming level 10 pain, because "unbearable" is how we intuitively think of level 10 pain, and why people will claim levels of 12 or 15 for pain that goes way beyond merely "unbearable," like that of CRPS, for example. I have taken the liberty of creating a PDF of this file so you can print it out and bring it to your doctor if you feel it accurately reflects the realities of your condition. Anyway, enough of my yapping, here's the scale, which I found at Our Chronic Pain Mission:

The NFTP Pain Scale

Pain Scale
J.S.Hochman MD

0 No pain

1. Occasional pain effectively managed by Aspirin, Tylenol, Ibuprofen, one tablet, three times a day or less - or by opioids with no limitations on activities of daily living.

2. Frequent pain, managed only by 1 or more tablets of ASA, acetamenophen, ibuprofen, every four hours - or by opioids with slight impairments of actitivities of daily living.

3. Frequent pain, not effectively managed by NSAIDs, requiring an opioid medication, but not restricting daily activities of living

4. Frequent pain, moderately affecting activities of daily living, but still controlled by opioids medications

5. Frequent or almost constant pain. Contained by opioids, but still causing significant limitations on activities of daily living and occasionally causing the patient to be house or bed confined

6. Constant pain, moderately contained by opioids, but with frequent limitations of activities of daily living. Frequently causes confinement to bed or the house.

7. Constant pain, only partially contained by opioids at the doses prescribed, with continuous limitation of activities of daily living

8. Constant pain, frequently disabling, making most activities of daily living difficult if at all possible

9. Constant pain, uncontained by prescribed medications and doses, completely disabling of activities of daily living, requiring interventions or assistance by others, preventing any form of employment and fully qualifying the patient for Social Security Disability

10. Intolerable pain requiring emergency room treatment, generally with opioids injections.

An Alternate Pain Agreement

I recently posted an article about pain contracts here, where I argued that pain contracts are coercive, one-sided and unfair. These contracts are definitely oriented towards protecting the rights of the doctor and allow little in the way of rights or autonomy for the patient. This got me wondering what a patient-oriented pain "contract" would look like, and I came up with a few provisions which I think you'll find interesting. Most of these are eminently reasonable, some are a little tongue-in-cheek, and others could be considered blatantly unfair to doctors, but I have included them anyway as an illustration that despite their obvious unfairness, none is quite so unfair as the provisions we must agree to that may result in our being denied medical care for our pain if we fail to live up to all aspects of the "contract." I am not suggesting that anyone actually attempt to use this contract, as it will most likely result in your being denied medical care, as patients have little power in negotiations with their doctors over pain medication issues. I present this only to generate discussion and to highlight the one-sidedness of the "contracts" we are forced to sign and their inherent unfairness. I welcome any additions you feel should be added to the pain management employment agreement and I will add others as I think of them.

Pain Management Employment Agreement

I _______________________________ (enter doctor's name here), as an employee subcontracted to provide medical services to my employer ________________________________ (enter patient's name here) do hereby agree to provide opiate medications for my employer (hereafter known as "the patient") under the following terms and conditions. As a physician, I recognize that I have a moral and ethical duty to relieve suffering, and that opiate medications play a key role in the management of chronic pain. I agree to prescribe these medications in good faith, without malice or prejudice and in accordance with best medical practices and the best interests of the patient.

1. I will be honest with the patient at all times and not lie, manipulate or deceive the patient in an effort to shirk my responsibilities, or to pressure the patient into agreeing to medical procedures that may or may not be in his or her best interest. I recognize that any attempt at undue influence of the patient may lead to immediate termination of the doctor/patient relationship, and forfeiture of all fees due for my services coupled with any fines or penalties a court of law may impose.

2. I will not place arbitrary limits on the amount of pain medication prescribed based on my fear of regulatory scrutiny or personal "comfort level." I will practice the scientific principle of titration to effect, where the dose of opiate medication is slowly raised until adequate pain relief is achieved or a balance between adequate pain relief and intolerable side effects occurs.

3. I will always endeavor to prescribe medications based on a balance between current scientific knowledge and patient preference. I will, to the extent possible, respect patient autonomy and right to decide what drugs he or she will and will not take and I will not discriminate against the patient solely on the basis of his or her medication preferences.

4. I will respect the human rights and dignity of my patients, and will respect and obey all human rights agreements entered into by my country and all local, state and federal laws protecting the rights and dignity of my patients. I will adhere to The International Covenant on Civil and Political Rights, in particular the following articles:

Article 6: "1. Every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life."

Article 7: "No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation."

Article 17: "1. No one shall be subjected to arbitrary or unlawful interference with his privacy, family, home or correspondence, nor to unlawful attacks on his honour and reputation."
5. I will submit to routine urinalysis tests to check for the presence of illegal drugs at least once a month and randomly whenever the patient requests it. These tests shall not exceed four per month, and any urinalysis done within one week of the patient's request shall be valid to satisfy the request of another patient for drug screening, and vice versa. The presence of any illegal drug on any routine screening may result in termination of the doctor/patient relationship at the patient's discretion and forfeiture of all fees owed for services rendered.

6. I will fully disclose in writing any legal or illegal drugs I may be on and submit to blood test screening for alcohol or illegal drugs of abuse using gas chromatography immediately prior to any surgery, nerve blocks, trigger point injections or other invasive procedures. The detection of any illegal drug or prescription drug that has not been prescribed by a licensed physician shall be considered prima facie evidence of malpractice, irregardless of whether the procedure is successful or not, and may result in forfeiture of all fees due for services rendered including hospital fees as well as any other fines or penalties a court of law may impose. The detection of any drug not previously disclosed in writing, including legal prescription and non-prescription drugs, shall be considered prima facie evidence of fraud.

7. I will respect the patient's confidentiality, privacy, person, autonomy and human dignity at all times. I recognize that my patient has a zero tolerance policy for physical or verbal abuse, slander, libel or other forms of defamation, and the deliberate infliction of emotional distress, as well as any violation of privacy or patient confidentiality. I will not disclose or discuss any aspect of the patient's medical care or medical condition to any party, including office staff, without specific consent of the patient. This also includes research facilities, data-mining firms, and government agencies not specifically authorized by law to collect this data. My staff will not openly question the patient about billing or other matters in the presence of other patients.

The inclusion in the patient's chart of any derogatory terms such as "drug-seeker," frequent-flyer," "malingerer," "hypersensitive," "hysterical," etc. shall be considered prima facie evidence of libel and the tort of deliberate infliction of emotional distress, and may result in the immediate termination of the doctor/patient relationship at the patient's discretion and forfeiture of all fees due for services rendered, as well as any fines or penalties a court of law may impose. This provision will also apply to the use of "scare quotes" around words such as "pain," "condition" "disability" or any other words or phrases the patients uses to describe his medical condition or state of being. Additionally, the inclusion of any scientific or pseudo-scientific terminology to describe the patient's psychological state or motivations such as "psychogenic pain syndrome," "conversion disorder," "hysteria," "personality disorder," "compensation neurosis," et alia shall be consider prima facie evidence of libel and practicing psychiatry without a license, and may lead to immediate termination of the doctor/patient relationship, and forfeiture of all fees due for services rendered coupled with any fines or penalties a court of law may impose. If the physician feels that the patient might have a psychiatric or substance abuse disorder, he will refer the patient to a competent psychiatrist or addiction specialist of the patient's choosing.

8. In the event of a violation of this agreement leading to termination of the doctor/patient relationship, the doctor will continue to prescribe any opiate medications for a minimum of three months following the date of the termination, and will support the patient in achieving a tapered withdrawal from the drug in question or in attaining the service of a competent physician to continue the patient's care. Failure to adhere to this aspect of the agreement shall be considered prima facie evidence of patient abandonment.

Friday, November 2, 2007

Drug Dealers call them "Mushrooms"

This is the name drug dealers use for the kids who get caught in the line of fire and killed when they are shooting it out with each other. In the lingo of these killers, this dehumanizing term refers to kids who seem to sprout up out of nowhere like mushrooms whenever they are targeting their enemies, getting killed in the crossfire. At one time as many as 150 kids were being killed in shootouts in New York City every year, though of course, adults are often caught in the crossfire as well. These kids are just one of the many groups of victims of America's self-destructive War on Drugs, a war ostensibly being waged to "save the kids" but which has in reality turned America's cities into war zones. But drug dealers aren't the only ones gunning down innocent bystanders. Law enforcement agencies making drug busts and commando-like drug raids have amassed their own impressive record of killing innocent people. Drug War Rant, an anti-prohibition blog, tells some of their tragic stories here.

Our drug war results in staggeringly tragic losses. Drugs, when abused, can be dangerous, but they are not nearly as lethal as the drug war itself.

In addition to the blights of an imprisoned population, lost rights, broken families, and economic waste, people are dying in this war. No, these are not deaths from drugs, but from prohibition.

It is important to realize that the vast majority of deaths on the drug war simply would not happen without prohibition. When drug dealers fight it out over territory and they or their neighbors are killed in the process, it is a sympton of prohibition, much as when we suffered the scourge of alcohol prohibition many years ago. Prohibition makes violence profitable.

When drug users overdose from tainted drugs, it is the result of prohibition. When they die from overdoses because they were afraid to seek help, it is the result of prohibition.

Increasingly, people are dying because of the tactics of the drug war. Military operations are being conducted on our soil, and collateral damage is inevitable.

It is estimated there are over 40,000 anti-drug raids in the US every year, many of them targeting innocent people, and each one carrying the possibility of violent confrontation involving live ammo, with the potential for innocent bystanders to get killed. I wonder if the DEA or other drug warriors have a term for the people that get killed during their raids? "Mushrooms" would be too druggy.