The perversion of pain.


oxycontin

In the late 80’s some brilliant (sarcasm in use here people) doctor, who I assume later took a position with one of the companies who manufacture hard core narcotic pain medications, or at least was paid a significant ‘renumeration’ by them, decided that “pain is whatever the patient SAYS it is” and if patients were in pain, then medical and nursing staff were not doing their jobs properly.  This, regardless of whether the patient got better, or even had a medical problem that necessitated pain medication.

Once upon a time, drugs like oxycontin were reserved for patients who were dying of cancer, or in some other profound end-of-life type of pain.  Never used for maintenance.

And now, 30 years later, we have a positive epidemic of patients who are in chronic pain – it even has official diagnosis codes:  338.2 – chronic pain (can’t get paid for diagnosing this one though), 338.4   – chronic pain Syndrome ( whoo baby you can get paid for this one!), 338.29 – other chronic pain (you can get paid for this one too).  Whenever medical ‘science’ (I use this term loosely because a lot of the science is based on getting paid by someone for something) defines a syndrome, what that actually means is a cluster of symptoms that usually go together.  They are NOT a disease.  They are just a bunch of symptoms that go together.

A good example of a syndrome that can be covered under “other chronic pain” or “chronic pain syndrome” is fibromyalgia.  This is a syndrome, not a disease. It probably has an ICD 9 code of its own, but I don’t plan to ever diagnose this so I don’t have any interest in learning it.  Fibromyalgia means literally pain in fibers – muscle fibers.  People who have fibromyalgia are usually (but not always) overweight, sedentary, eat a lot of simple carbohydrates, watch a lot of TV, are depressed, don’t get out much, and don’t sleep well though they usually spend a lot of day time napping and feel fatigued most of the time.  Because of their fatigue and depression, they often feel mentally cloudy.  They hurt all over, even when there is no obvious medical pathology. This is the cluster of symptoms.  The treatment consists of:  1.  Education on what the problem(s) are and why they are affecting the patient.  2.  NSAIDs – ibuprofen, naproxen, toradol.   3.  Exercise – the muscles hurt because the human body was designed to MOVE and if you don’t move, they not only waste away, they hurt while doing so.  4.  A combination drug that both helps with pain and depression such as Cymbalta or Lyrica.  5.  Cognitive Behavior Therapy – you have to come to grips with why you are doing this to yourself in order to make changes to how you avoid or do things.  CBT can be very helpful with this.  It has nothing to do with your childhood or that sort of therapy.  It’s purely to help you change your responses to situations in order to help you take control of your own life.  Note that I didn’t include narcotics AT ALL.  Yet I see people all the time whose only diagnosis is fibromyalgia and they are on MASSIVE quantities of oxycontin, oxycodone, or even morphine pills which they take multiple times a day.  Why?  It does absolutely nothing to help the patient, and isn’t even recommended as an effective treatment.  So why are so many patients prescribed narcotics for this?

The place where I am doing clinicals has a lot of patients who come there for nothing but narcotics, because the provider will prescribe for them.  Many if not most of them have been discharged from one or multiple pain management centers for non-compliance:  they also smoked pot, or they have alcohol in their system while taking narcotics, or they don’t have any narcotics in their system at all – every pain management patient gets urine drug screens every time they go in for an appointment to get their drugs.  Why you would be STUPID enough to smoke pot right before going to get your drugs I don’t know.  I guess you can’t cure stupid.  Why you would drink while taking sedatives I also don’t know.  Perhaps in addition to being stupid you have a death wish.  Can’t cure that either.  And those that sell their narcotics while pretending to have a chronic pain problem deserve to go to jail.  Have fun there.  And good luck with getting narcotics while in there even if you DO happen to need them for a legitimate reason like a tooth extraction.

A patient came in recently who originally complained of low back pain.  Yet when the tests were done in the office to assess his pain, they were negative.  The patient did not realize these tests were to assess low back pain, I should point out.  Otherwise they would have been ragingly positive.  And in fact were ragingly positive when repeated on him while telling him they were to assess his pain.  He was unable to get disability for his ‘chronic back pain’…wonder why??  This patient now complains of headaches.  He was told there was in fact something that showed up on the MRI he was sent for.  He states he doesn’t want to see a neurologist for this though, because he’s trying to get disability and if the neurologist can fix it he can’t get disability.  That seems to be the mentality of the average pain patient we see.  Malingerer.  If this guy spent as much time working as he did trying to get disability he would probably be solidly middle class, instead of ‘working’ poor.

Another patient came in with slurred speech and the inability to complete a sentence – she would flit from thought to thought without ever completing an entire thought through to the end point.  She said she didn’t want to go back to the pain management center she had been going to.  She was in the office to get Valium, a sedative.  She said she had gotten a month’s supply of oxycontin, oxycodone, and morphine from the pain management center and didn’t need any of those.  As it turns out, she had been discharged from not one, but SIX pain management places.  For having alcohol in her urine.  And for consistently running out of her pain medications well before the time for renewal.  Unbelievably, the doctor actually gave her a prescription for a  60 day supply of Valium.

Third patient:  came into the office complaining of low back pain, a ‘chronic’ problem.  Got a prescription for 30 days worth of Percocet with 2 refills.  Her room mate called the office later that day to say that he just wanted the office staff to know that she sold the entire bottle to a drug dealer named Don as soon as she got home.

These are entirely typical.  I am very frustrated and I refuse to bother doing any more assessments on these people because I don’t learn anything and I have no patience for these sorts of ‘patients.’

I hurt my back when I was still fighting fire.  At my original emergency room visit, I was asked if I wanted narcotics and I refused.  I did ask for a muscle relaxant that wouldn’t make me sleepy so I could function at work and at home.  The xray didn’t show anything (which it wouldn’t if it was a herniated disc).  And, while I have had some level of pain nearly every day since then yoga keeps it under control.  That injury though, and the pain it brought with it, was the impetus to change careers.  I was entirely too young to become an invalid, and it scared me to think of becoming one.  I have never pursued further testing because even if I did have a herniated disc I would not consider surgery.   I cannot imagine being unable to walk when I want, to run, to stretch, to garden.  I also have a torn rotator cuff, suffered while working as a firefighter.  That actually causes me more pain on a regular basis than my back, and eventually I WILL have to have surgery, but until then I continue to do strengthening exercises and keep it as mobile as possible.  I cannot IMAGINE living my life under the cloud of narcotics and being in the twilight of consciousness every day of my life.  What a horrible way to live.  I think the fact that I’ve suffered injuries that caused permanent pain in myself makes me even less sympathetic to those who come in wanting, not physical therapy, not surgery, but disability and a lifetime of narcotics.  As my parents used to tell me, if you’re not puking or dying you get up and go to work/school.   I would add to that list also if you don’t have explosive diarrhea.  Everybody hurts.  Deal with it and move on.

The largest group of users of narcotic prescriptions, if I remember correctly, are Medicaid patients.  Meaning they don’t pay, we the taxpayers do.  If even a small portion of the people who receive disability are anything like those I have seen in the ER when I was working there, or in clinicals, we could probably halve the national debt simply by kicking them off and making them work.  Maybe being a brick layer isn’t a good career choice for them, but surely they could answer phones, or sit at a cashier stand, or walk dogs or something.  Once again, it comes down to ‘sick care’ versus health care.  And lining the pockets of the pharmaceutical companies instead of investing in the real health of our population.  Of course, we have no economy to speak of anymore, so I guess disability takes the place of unemployment.  The irony is that those with real issues, with real medical problems, get overlooked because the system is overwhelmed with those who don’t pay for their access and so use a lot more of it.

++++++++++++

Pain tells us we are alive.  Pain tells us something is wrong which we need to address.  Using narcotics to mask pain, unless it’s for an end of life issue, prevents us from making changes to improve our lives.  Why would you want to do that?

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10 responses

  1. I see a lot of these patients and I have come to recognize this behavior as the “reverse job application”. Here’s what I mean. If you are applying for a job, you try to convince your prospective employer of all your good points. You are intelligent, well trained, hard working, reliable, physically fit and not substance addicted. You really want this job and you want to convince your prospective employer that you would be good at it.

    For the “reverse job application”, or benefits application, all of this is turned upside down. You produce a long list of afflictions including anxiety, depression, back pain, fibromyalgia, learning difficulties, functional illiteracy and alcohol and/or narcotic dependence. You have difficulty concentrating, remembering and following instructions. You can’t lift anything heavier than a bag of sugar. You can’t sit for long, stand for long or walk for long. You can operate machinery but only if it’s something simple like, say, a TV remote. Fortunately you are able to manage your own financial affairs including receiving cheques, depositing them into a bank account and withdrawing the money.

    But it’s not all bad news. People like me can make a reasonable living from people like these by helping them through the system. I get paid $100 each time I fill in the medical section of the application form, and $75 for assisting with the appeal against refusal of benefits.

    • You made Mr. TF and me both guffaw quite loudly! How cynically true!

      You are more at peace with this whole monstrosity than I am, I can tell. I would tell them to get lost. I just can’t see myself assisting people who don’t NEED disability to GET disability. I have more to say but won’t bother you or any other readers with my seriously not politically correct views on this.

  2. “Pain tells us we are alive. Pain tells us something is wrong which we need to address. Using narcotics to mask pain, unless it’s for an end of life issue, prevents us from making changes to improve our lives. Why would you want to do that?”

    I apologize for being so blunt, it being my first visit here, but this is utter baloney. I went through hell, being in horrible insane levels of pain that prevented me from functioning. Because there was no diagnosis for three months of this hell, I was given exycodone and oxycontin, as well as some worthless anti-arthritis meds, and treated like a drug addict. It added insult to the injury.

    I was finally diagnosed with acute pancreatitis, at which point they shot me full of demerol, and wheeled in the morphine pump. What a relief that was! (I eventually had to have my gall bladder out, and finally got better.)

    I cannot describe the horror of being trapped not only by some disease nobody could figure out, but also the prejudice against adequate medication. (I do not understand how people take this stuff recreationally. I was on 140+ mg of oxy and life was passing me by. I kept falling into a blank state every few minutes. Not pleasant at all.)

    Another indignity were the pain charts in hospital rooms. Yeah, I had levels of pain of 9-10 or so, but without a diagnosis, people don’t listen. So here is how I would say it myself: Yes, pain tells us that something is wrong. But while it takes time to sort it out, narcotics make functioning possible. Acute pain is intensely debilitating. Moreover, people would not sell these things to drug dealers if the drug war did not make them expensive and hard to get. Wake up! This is too serious to take a flippant, judgmental pose!

    Thank you for listening. 🙂

    • Your story only bears the TRUTH of what I stated in your quote of my post. PAIN TELLS YOU SOMETHING IS WRONG.

      You are lucky you didn’t get a gangrenous gallbladder while your medical people dicked around. That, my friend, is the fault of a provider who didn’t bother to do a basic exam, or labs. If you listen to the patient, they usually tell you what’s wrong. Did you go for a second opinion? Did you complain of abdominal pain? Were you nauseated? Did you have right upper abdominal pain? Did you have shoulder pain? All symptoms relating to exactly what you state you had. If so it’s negligence bordering on criminal to prescribe narcotics like that without bothering to do any testing. I worked in an ER for years. These were the basic tests for anyone coming in with abdominal pain: amylase, lipase, abdominal CT, gallbladder US.

      I am sitting in my exam room right now, with the office manager, discussing yet ANOTHER patient who OD’d and is in the ICU and will probably die because the doctor I am currently precepting with was prescribing him narcotics without documenting ALL the drugs he was prescribing.

      • I was in several doctors’ care at that time, and was in the hospital twice prior to my final diagnosis. They tried to put me through all sorts of expensive and invasive tests but never did bloods for pancreatic enzymes. By the time the gastroenterologist ran tests, my enzyme levels were off the charts. And yes, I had all the classic signs. No help. You know what was the worst? That nobody ever came to my hospital bed to sit down and trouble-shoot with me. Actually helping me deal with what was happening. I’ll never look at medicine the same way.

        I do feel for you re the other drugs, and the way doctors deal with it all — by not looking. I was given, during my travail, Celebrex. I blew up like a balloon after a few days of it. When I called my doctor, he kept saying, give it more time, give it more time. I finally woke up to the fact that nobody was gonna help me, and read the fine print. Side effect #1: edema. I quit it, and edema went away for good within 24 hours. My legs were so bad I had to slit my sweat pants, to be able to get in.

        Here’s the thing: they DON’T listen. They DON’T pay attention to the meds. (Could tell you another horror story about the rhabdomyolysis that nearly killed my father. Statins.)

      • I don’t know where you live, but your experience was horrible. There’s no other word, except negligent, I can think of to describe it. You are very lucky you didn’t rupture your gallbladder and get septic and die. And yes, an infected gallbladder can cause pancreatitis, I’ve seen that a number of times over the years.

        Why in God’s name you would put a patient through a CT scan and 200 other expensive tests without doing a simple cheap blood test I really can’t fathom. But then, that’s why I’m in school, to learn how to do things so I can be a logical, compassionate, responsible provider of care.

        I do not plan to become a corporate provider of care. I will not ever work for a company as an employee unless I’m facing homelessness if I don’t. I have no desire to see 30 or more people a day. If I make less money, so be it. I will have my sanity, integrity, and time. That’s where the lack of listening comes from, corporate demands that you see X number of people a day. That doesn’t allow for people who come in with what seems like a simple problem but turns out to be dreadfully complicated, nor for people who simply take longer to explain things. I’m not a cowboy herding cattle. And the people I see should not be on an assembly line.

        Statins = no good. I read the latest guidelines the night they came out. And I really think that the science points to the fact that they ‘work’ to reduce heart disease/cardiac events by reducing inflammation, NOT by reducing cholesterol. There are better ways to reduce inflammation than by taking a pill, in my opinion. But that assumes you have an involved patient who is willing to actually make lifestyle changes. Herein lies the problem. How many people are REALLY willing to make changes?

  3. I don’t know where you live, but your experience was horrible. There’s no other word, except negligent, I can think of to describe it. You are very lucky you didn’t rupture your gallbladder and get septic and die. And yes, an infected gallbladder can cause pancreatitis, I’ve seen that a number of times over the years.

    Why in God’s name you would put a patient through a CT scan and 200 other expensive tests without doing a simple cheap blood test I really can’t fathom. But then, that’s why I’m in school, to learn how to do things so I can be a logical, compassionate, responsible provider of care.

    I do not plan to become a corporate provider of care. I will not ever work for a company as an employee unless I’m facing homelessness if I don’t. I have no desire to see 30 or more people a day. If I make less money, so be it. I will have my sanity, integrity, and time. That’s where the lack of listening comes from, corporate demands that you see X number of people a day. That doesn’t allow for people who come in with what seems like a simple problem but turns out to be dreadfully complicated, nor for people who simply take longer to explain things. I’m not a cowboy herding cattle. And the people I see should not be on an assembly line.

    Statins = no good. I read the latest guidelines the night they came out. And I really think that the science points to the fact that they ‘work’ to reduce heart disease/cardiac events by reducing inflammation, NOT by reducing cholesterol. There are better ways to reduce inflammation than by taking a pill, in my opinion. But that assumes you have an involved patient who is willing to actually make lifestyle changes. Herein lies the problem. How many people are REALLY willing to make changes?

    • Thank you for caring. I did not know what danger I was in! I thought the pancreatitis was bad enough…

      I was living upstate NY at the time, but the first hospital I ended up at (because I collapsed and was unconscious for a couple of days) was in New Jersey. After 5 days, when I was still in massive pain, and when I refused a spinal tap, they told me to leave. They sent me home with half the pain killers they had put me on in the hospital without telling me. Argh. Maybe I should write this whole sorry tale and publish it somewhere as a warning. The bad stuff just kept on coming… I’ll just give you one more example. I was horribly constipated when I got to the hospital. I mean, I did not go for like 10 days. Not only did they not help me, but I could not find anyone else who would. Finally, one of my doctors “prescribed” the RICE diet. I thought, finally someone who is paying attention! Well, after trying it, I discovered that the RICE diet is for diarrhea. Hoy, what a world of medical savvy!

      Yeah, well, my father trusted his doctor. He still does, same guy. This man is not happy unless my father’s cholesterol is 70, and makes him take these pills. (He is 88!) When he collapsed with rhabdo, the office told me that even though they wrote the prescription for one pill, they “told him” in person he should be taking only half. How’s that for a clumsy way to cover your bum? I was hoping they’d go after him but nothing happened.

      I hope you stick to your plan. The whole system pushes against it. But bless you for wanting to go against it.

      Behavioral change is hard. And most of this culture shapes us into sedentariness and eating crap-foods. There is starting to be good literature on changing behavior via small incremental rewarded steps, though, and by avoiding self-bullying. I think they are on the right track. Maybe this is the real edge of holistic medicine… getting good at helping people to change. 🙂

  4. Reblogged this on The Tin Foil Hat Society and commented:

    Rebloogging because it’s still relevant. I now work in the same doctor’s office where I precepted. I work on a straight percentage of the billing collections for patients I see.

    This is as true as it ever was. The doctor still prescribes too many narcs, now he’s under investigation by the board for it. I myself have discharge many of these patients for noncompliance – I now have a reputation in the community such that the narcotics patients, for the most part, don’t want to see me because they know I will hold them accountable for getting tests to document their supposed pain.

    I stand by what I said. Fibromyalgia may be a billable diagnosis per ICD10, but that doesn’t make it a real disease. It’s a syndrome, meaning a collection of symptoms. There’s SOMETHING WRONG, people. Whether it’s pure depression, gluten intolerance, gallbladder, bone cancer (seen that recently) liver failure (seen that recently) giant cell arteritis (seen recently too) that other providers have, quite frankly missed because they just want to throw a narcotic prescription at someone instead of figuring out what’s wrong. So go ahead, take your narcs and sit on the couch and be sedated. Don’t worry if you end up going blind (arteritis untreated), overdosing on your narcs to numb the psychic pain (depression), suffer with joint pain and abdominal bloating for a lifetime (gluten intolerance), start bleeding from every orfice and dying (liver failure), get pancreatitis and end up dying (gall bladder), die of untreated cancer, or whatever else fires your imagination. There is ALWAYS a reason for the pain. ALWAYS. Fibromyalgia is still doctor speak for I can’t find anything wrong with you and I don’t care to try anymore so go away with this nice little narcotic prescription and leave me alone until it’s time to refill it.

    It might interest some of you to know that the man who originally created the dignosis of fibromyalgia has since stated publicly that he wishes he had never done so, saying (paraphrase becaseu I can’t remember the exact quote) We all have pain and depression at certain times of our lives, it’s a natural part of life. So there you go.

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