State officials say Washington's new pain-management law will help reverse a rising tide of overdose deaths. But the law does nothing to specifically address the risks of methadone — by far, the state's number-one killer among long-acting pain drugs.
What's more, hundreds if not thousands of patients have been denied life-enabling medications, cut off or turned away by doctors leery of the burdens and expense imposed by lawmakers, according to hospital representatives and consumer advocates.
At least 84 clinics and hospitals now refuse new pain patients, and some have booted existing patients, The Times found. The growing legion of untreated pain patients has become so troublesome that some clinics, like one in Everett, post signs that ward off walk-ins: "We do not treat pain patients." Across the nation, the annual death toll from prescription painkillers continues to escalate, more than tripling from 1999 to 2008, according to statistics that federal health officials released last month.
Confronted with this epidemic, health officials in other parts of the country have been eying Washington's groundbreaking law with special interest, says Dr. Lynn R. Webster, medical director of a Utah pain-research center and a national expert on preventing abuse of narcotic painkillers.
But Washington's approach, he says, is not a model worth emulating. He told The Times: "If other states follow suit, many patients could suffer needlessly."
Coupled with new rules passed by medical licensing boards, the law requires practitioners to document patient backgrounds and track behavior; conduct random urine screenings; and — most important of all — consult with a pain specialist if daily doses exceed the equivalent of 120 milligrams of morphine. Cancer and hospice patients are exempt, as are post-surgical patients and those with pain from sudden injury.
Washington has at least 1.5 million people who struggle with chronic or acute pain, the American Academy of Pain Management estimates. The state has thousands of practitioners with prescribing privileges. But as of last month, the state's sanctioned list of pain specialists numbered just 13.
The state's new rules, passed by licensing boards, give a nod to methadone. Yet, at least 2,173 people died in Washington by accidentally overdosing on methadone between 2003 and 2010, a Seattle Times analysis of death certificates shows. Among long-acting painkillers — a group that includes OxyContin, fentanyl and morphine — methadone accounts for less than 10 percent of the drugs prescribed but more than half the deaths. The drug has taken a particularly dramatic toll among the poor, who account for about half of the fatalities. To save money, the state steers Medicaid patients and recipients of workers' compensation to methadone, one of only two long-acting painkillers on the state's list of preferred drugs.
In summary, the State of Washington is restricting patient access from the safest and best array of drugs for chronic pain; moving them to instead to the cheaper methadone, which is the largest single drug contributing to accidental overdoses. The State has at least 1.5 million people who struggle with chronic or acute pain, but only 13 approved practitioners authorized for chronic pain management. Lost in this gigantic mess are those 1.5 million patients who will find it difficult, if not impossible to obtain their prescriptions. Forced to go without their medication or to use one that doesn't help them, these patients will increasingly turn to illegal drugs, theft, forging prescriptions or, sadly, suicide.
Who will help the 1.5 million chronic pain patients of Washington when their proven medications are no longer available and methadone fails to help? Who will help the families of methadone patients who accidentally overdose on it?
Dr. Thomas Sachy practices child, adolescent, adult, and forensic neuropsychiatry. However, the majority of his clinical practice is in the field of pain management. He is a strong supporter of using opioids for the treatment of chronic non-cancer pain. Dr. Sachy reached this position after approximately 11 years of face-to-face patient interaction, along with ongoing intensive review of the medical and scientific literature dealing with opioids, and the other forms of analgesic medication, as well as the neuroscience behind chronic pain disorders. This is the first in a series of articles by Dr. Sachy that corroborates the efficacy of using opiates long-term to control and manage chronic pain.
There has been an ongoing barrage of news media attention focusing on overdose deaths due to prescription opioids, suggesting that the issue has reached "dangerous" or "alarming" levels of epidemic proportions. In response to these statistics we've seen an almost mob-like crusade to track down and punish incompetent, unethical, "pill mill" physicians and their practices. At the same time, there also seems to be a push to punish and/or eliminate the pain physician who by some mysterious standard is considered to be over-prescribing pain medications, and/or prescribing medications in "extraordinary" or inconceivable combinations.
These assertions fly in the face of science, and the experiences of the untold myriad of patients who literally have new, functional lives, less troubled by the specter of chronic debilitating pain. These patients still have pain and they always will suffer from it; however, with the right combination of medications — including and especially opioid medications — they once more can experience lives that contain a modicum of tranquility.
Great medical benefits are bestowed upon the vast majority of these patients with chronic pain who are prescribed opioid analgesics. They and their families attest that this is so, and with an objective eye, doctors see the benefits as well. What will follow in this series are Dr. Sachy's personal experiences and opinions regarding the anti-opioid medication hysteria that is gripping this nation, and a rational defense of long-term opioids which, if not diverted or abused, are an absolute medical necessity, if not a medical miracle, in an inflexible world that predisposes humans to chronic pain disorders and other related neuropsychiatric diseases. Read this article and future articles in Dr. Sachy's series here: http://updates.pain-topics.org/2011/12/tales-from-trenches-in-war-on-pain.html . View Thread
I recommend some mind-body techniques, such as biofeedback, Yoga, systematic relaxation, meditation, etc. Add to that the specific combination of medications that best for your unique body chemistry. Unfortunately, the only way to determine that is to try many, many options. That requires a very liberal and compassionate physician. Many PM docs will allow you to try this, although it can take literally years to determine. But it's very important. Some pain patients respond very well to off-label drugs, such as sedatives, anti-convulsants, anti-depressants, muscle relaxers; and the afore-mentioned intoxicating weed (THC). The IT pump for peripheral neuropathy sounds like a mismatch, but it's worth asking about. Again, it would be important to have terrific success with the trial unit before having it surgically implanted. View Thread
For those of you who live in a location where purchasing and inhaling THC is illegal, ask your internist or family physician about prescribting Marinol (Elan Pharmaceuticals). The active ingredient in Marinol is synthetic THC. It is legal, although still off-label for pain.View Thread
Sorry to hear about your pain, "bonnie." I've been in your situation for the past 15-20 years. Your complaints about Fentanyl are common. Temperature changes occur. The patch seems to last about 48 hours, not 72 hours. But I would disagree about your complains concerning "ups and downs." Because Fentanyl Transdermal maintains peak plasma level for at least 48 hours, it is the most consistent of all pain medications. "Ups and downs" are associated with short-acting drugs. But, everyone is different and the trick is to find the combination of drugs that work best for each of us.
You made no mention of a breakthrough medication. Most of us with chronic severe pain also use a short-acting narcotic (Hydrocodone, Oxycodone, Fentora, etc.) for breakthrough pain. Have you asked your doctor about a breakthrough drug?
You mentioned Elavil as having "no good or bad reaction." It is an axiom that chronic pain patients benefit from using an anti-depressant. Anti-depressants inhibit the reuptake a Seratonin in the bloodstream. Seratonin is one of the body's natural pain-fighting chemicals. Have you tried Cymbalta? It is a fairly new anti-depressant with pain-fighting qualities.
You mentioned fibro. Have you discussed using an anti-convulsant with your doctor? Anti-convulsant medications (Neurontin, Lyrica, etc.) have benefit for neuropathic pain and fibromyalgia. Combined with the medications listed above, it represents a valuable arsenal in pain management.
You also did not mention going to a comprehensive pain management program. There are literally dozens of non-invasive and marginally-invasive treatments available at a comprehensive pain management program, including: corset, brace, TENS, traction, acupuncture, biofeedback, physical therapy, kinesiotherapy, injection of steroids and anesthetics, non-steroidal anti-inflammatories, cortisone, rhyzotomy (radio frequency denervation), spinal cord stimulator, intrathecal infusion pump, off-label medications (anti-depressants, anti-convulsants), combination of long-acting pain medication with breakthrough meds, counseling, hypnosis and meditation. I can drop my pain by 20% with biofeedback alone. Many people rave about acupuncture, hypnosis, kinesiotherapy, etc. I understand your reluctance to stop all of your medications. However, not all programs require that, once you've explained what you've already tried.
I can sympathize about your search for a physician who would also be willing to prescribe your large dosages of narcotics. Unfortunately, many contemporary physicians are more motivated by fear of the DEA than by reducing their patient's pain.
Have you considered psychotherapy? Our condition is depressing. It would be normal to need help.
Finally, if your pain is as bad as it sounds, have you discussed surgery with your doctor? I know that the success rates are low (40-60%) and some patients are not surgical candidates. You might want to request a referral to a spine surgeon (an orthopedic and neurosurgeon with a fellowship in spine surgery). It can't hurt to hear from the expert's expert. Good luck. View Thread
Researchers at Stanford University, California, conducted a longitudinal, MRI study examining 10 individuals with chronic, moderate-to-severe, nonradicular low back pain who were administered long-acting oral morphine (MS-Contin) daily for 1 month [Younger et al. 2011>.[a name="more"> Brain imaging was conducted immediately before and after the morphine administration period, and a third time at an average follow-up of 4.7 months. Similar imaging was conducted on a separate group of 9 subjects with chronic low back pain, receiving a blinded placebo substance for the same time period, to serve as a control group for determining if any brain changes might occur that were not specific to opioid administration.
Results reported in the August 2011 edition of the journal PAIN indicate that 13 brain regions in morphine-administered subjects evidenced significant volumetric change, and the degree of change in several regions correlated with morphine dosage. Dosage-correlated volumetric, gray matter decreases were observed in limbic areas, primarily in the right amygdale. On the other hand, dosage-correlated volumetric increases were seen in select limbic and cortical structures: the right hypothalamus, left inferior frontal gyrus, right ventral posterior cingulate, and right caudal pons.
Prior evidence has demonstrated that chronic pain itself influences important changes in brain structure and function. In this current study, significant changes were observed in brain structure attributable to morphine administration. But here is the most important question for further research: Were these morphine-induced brain structure alterations potentially harmful or, equally likely, of benefit in helping to reverse the neurobiological damage of chronic pain and returning the brains of suffering patients to a more normal state?
While the authors imply that these neuroplastic changes might be detrimental, it seems equally likely that long-term opioid administration restores the pain-altered brain to a more normal, healthy state. Thus the increases in limbic matter in select limbic and cortical structures: (the right hypothalamus, left inferior frontal gyrus, right ventral posterior cingulate, and right caudal pons) might be the brain's way of compensating for the decreases in other limbic areas.
Much more research, using much larger groups, is in order. At this point (and we can only guess), the brain changes from chronic pain appear detrimental; but the changes from opioid administration may be both detrimental and beneficial. The body has miraculous recuperative capacity, perhaps expressed with the greatest complexity within brain structures. Thus a decrease in one part of the brain that correlates with opiate administration may well be compensated for by the brain's new increase in another structure.
Currently available treatments for chronic noncancer pain are unable to alleviate pain or restore functioning in a majority of patients. Those observations, from a new series on pain appearing in The Lancet, highlight large gaps in the evidence base and call for more research to assess the effectiveness of combination therapies to relieve chronic pain, while ensuring that patients have realistic expectations about pain relief.
The authors conclude that, despite important advances in understandings of the mechanisms underlying pain and a growing range of treatment options, overall effectiveness remains inconsistent and poor. "Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients, and these pain reductions do not always occur with concurrent improvement in function."
Because current treatments by themselves provide only modest improvements in pain and physical and emotional functioning, future research should focus on the effectiveness of combining various treatments; such as, combinations of several drugs, combining drugs with physical treatments, and pharmacological combined with psychological treatments.
For the foreseeable future, they note, "people with chronic pain will continue to live with some level of pain irrespective of the treatment or treatments they receive." Therefore, chronic pain management should include a "dialogue with the patient about realistic expectations of pain relief, and bring focus to improvement of function."
A companion editorial to The Lancet series on pain reminds healthcare providers of their ongoing obligation to manage pain more effectively and states the following… [blockquote>In 1931, physician and philosopher Albert Schweitzer said: "We must all die. But if I can save [patients> from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself." To help eliminate or mitigate an individual's pain is a privilege that clinicians must neither forget nor neglect.
Sorry to hear about your pain, Allison. Few doctors today will prescribe Dilauded. There are some better and safer narcotics now. Have your tried any of the long-acting narcotics, like Kadian, Oxycontin or Fentanyl Transdermal? Most chronic pain patients respond better to long-acting narcotics. You can then save the short-acting drugs for breakthrough pain. Fentanyl is the most potent pain medication available. Many people have a very high tolerance for pain medication. That which knocks someone else out might barely touch them. Most physicians will take this into consideration.
Unfortunately, today many physicians are more influenced by fear of going on a DEA list than by managing their patient's pain. How sad. At any rate, some of us need to search quite a while until we find a physician willing to provide whatever medication in whatever dosage we need to manage pain (as long as it remains safe). So, you might need to search. You should also enter a comprehensive pain management program. Pay close attention to the mind/body treatments, including meditation, systematic relaxation and biofeedback. I can reduce my pain noticeably with biofeedback alone.
I'm afraid that your bipolar condition complicates the pain medication problem. Some pain medications are contraindicated in the presence of lithium. Good luck. View Thread
"Cookie," I'm very sorry to hear about your continued pain and your physician/insurance rejection of Marinol. How frustrating. I would recommend that you obtain THC in any other manner possible. But then I would not want to recommend anything "illegal."
Too bad about the failure of Lyrica. It might be the most spot-on drug for your condition. May I assume that you have also tried Neurontin?
Suboxone is an opiate antagonist. Some chronic pain patients report useful results with it, but not many. Frankly, I think that jury is still out on antagonists for chronic pain. Suboxone and other opiate antagonists were not designed to fight pain, but to combat drug addiction and withdrawal. I think that many physicians today recommend it because it is the safe way to stay off a DEA list. Sadly, far too many physicians today are more concerned about the DEA and far to little concerned with managing their patient's chronic pain. How sad.
Have you tried the Fentanyl Transdermal system? Fentanyl is the most potent pain medication available. The Transdermal system assures that you maintain a consistently high plasma level, while bypassing the stomach and digestive system. The side effects are few and manageable. The dosages range from 12.5 micrograms (yes, micrograms) to 100 mcg patches.
The only other option I can think of is the intrathecal infusion pump. But, I doubt if you are a candidate. Still, there's no harm in asking.
For years, many of us with unrelenting chronic pain have noticed at least some slight congnitive impairment. Our memory seems slower and less accurate. We struggle with congnitive tasks that were simple to perform before the chronic pain. Research has validated this via MRI analysis. An area of the left prefrontal cortex, responsible for cognition, is thinner in chronic pain patients. What we have not known is whether this reduction in brain thickness is reversible, if the pain is successfully treated.
After successful pain treatment, patients exhibited increased cortical thickness in the left dorsolateral prefrontal cortex (DLPFC), which had been thinner before treatment compared with controls. The DLPFC plays an important role in pain perception and its increased thickening correlated with reductions of both pain and physical disability. Additionally, increased thickness in the primary motor cortex was associated specifically with reduced physical disability. In terms of cognitive performance, left DLPFC activity during an attention-demanding task was abnormal before treatment in patients with CLBP but normalized following treatment.
It should be noted that all of the chronic pain patients whose pain was not successfully treated in this group failed show an increase in brain mass at the conclusion of the study. This validates the fact that only successfully treated brains produced reversed (improved) cognitive functioning.View Thread
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