Pain requires doctors to accept false positives on drug seeking behavior

Patients requiring controlled substances to manage their pain have always been controversial to treat.

Every time the subject is broached on this blog, the comments inevitably becomes a contentious discussion of “drug seeking behavior” versus treating legitimate pain.

It’s a problem that doctors nationwide grapple with every day, and is addressed in a recent essay from the New York Times.

Michael Kahn is a Boston psychiatrist, who recently asked residents how they would approach a patient who had asked for Xanax, a benzodiazepine often used to treat anxiety.

In the end, Dr. Kahn notes that,

the prevailing attitude was one of “they’ll have to pry that pill from my cold dead hands.” It made me wonder whether these budding psychiatrists might be working too hard to avoid being hoodwinked.

He then compares screening patients for drug seeking behavior with tests from other medical fields:

Surgeons are fooled when they open an acutely painful abdomen only to find a normal appendix: in the days before CT scans, it was said that if that didn’t happen once in a while, you weren’t operating often enough. When in doubt, it was safer (and wiser) to operate than to risk a rupture and peritonitis, even if the diagnosis was “wrong.” Here was an error that wasn’t an error, but rather a predictable side effect of balancing known risks with imperfect information.

Applying that to pain management, he suggests accepting a degree of false positives instead of missing patients with true pain: “I’d rather be taken for a sucker once in a while than know that my suspicion had denied someone legitimate help.”

That’s certainly the ideal, but the federal government isn’t helping matters much.

Recent high-profile crackdowns of more liberally prescribing physicians have scared doctors into a bunker-like mentality. Until there is better clarity from both law enforcement and pain specialists as to what constitutes appropriate pain management prescribing, it’s likely that patients in true pain will continue to suffer.

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  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    I was once asked to see a lady who was readmitted on the night shift for persistent headache, whom had just been discharged after a one week admission for chronic headaches, only responsive to IV dilauded . IV dilauded is a quick acting narcotic with euphoric properties, just like heroin. So I documented,

    “The DEA has not granted me an unrestricted license as a heroin distributor”

    and discharged her.

    She filed a Medicare appeal to refuse discharge. But since I said the patient didn’t qualify for inpatient status and documented observation status, they couldn’t appeal.

    What a shame.

    It’s unbelievable what our health care system has come to. Patients now demanding the right to get high, while doctors are accused on both sides of the equation for over prescribing and not treating in the same breath.

    At some point, many doctors will simply state as a policy

    No narcs from me. Find another doctor.

  • radiculous

    I did a non-scientific survey of our ER with the following conclusion: approximately 25% of our ER patients are drug-seekers.

  • Diora

    No narcs from me. Find another doctor.

    I hope they’ll continue making exceptions for stage 4 cancer patients or others with clear cause of pain.

    • stargirl65

      I don’t think this is what they were referring to. It is the patients seeking narcotics in an inappropriate way. None of these discussions have ever been about cancer patients and similarly ill patients. The concern is about the ones that appear to be abusing the system.

  • rezmed09

    At the urging of the drug companies and JCAHO, and with the complicity of the FDA we have created a nation of drug addicts. Medical marijuana is the next expectation.

    And make no mistake, the PCP in the trenches will be held to blame when either the patients or the DEA or JCAHO are not happy.

  • The 50 Best Health Blogs

    I can understand the moral, medical and legal difficulty this poses for doctors, but why do some doctors prescribe huge quantities of drugs like hydrocodone on each prescription? Why can’t they write prescriptions for more limited quantities?

    Jim Purdy

  • ninguem

    Geez, this is not about Stage-4 cancer. It’s about this.
    http://www.oregonlive.com/news/index.ssf/2009/03/complaints_against_vancouver_p.html
    http://www.freerepublic.com/focus/news/2233386/posts
    http://www.columbian.com/news/2010/jan/08/payette-clinic-nurse-barred-from-prescribing/
    http://www.columbian.com/news/2010/jan/09/payette-clinics-co-owner-denies-overprescribing/
    and this
    http://www.youtube.com/watch?v=kEA5GBRRSVA
    http://www.youtube.com/watch?v=ibhJXF6vNxI&feature=channel

    Either ideologues like the Payette nurses (nurse-practitioners can practice without physician supervision in many states)……….or downright criminal activity like the Broward County clinics, see “OxyContin Express”.

    Prescription drug abuse is the second leading cause of accidental death in the USA.
    http://www.prescriptiondrugaddiction.com/pressroom/default.asp

    One of the leading causes of death in the younger population, beating out illegal drug deaths and beating car accidents among youth.
    http://seattletimes.nwsource.com/html/health/2004321621_oxycontinthefts02m.html

    That Vancouver nurse-practitioner clinic was giving Oxycontin doses as high as 1,000 mg daily. One person, getting the megadose oxycodone for “headache”, diverted the drug to various friends and relatives, eventually some got to a teenage girl who died from the overdose. In that case, they could trace the drug back to the various diverters and to that clinic’s prescription. They say they’re “caring” I say they’re fools who have done more harm than any good.

    Only thing I can say is they’re not the out-and-out criminals running some of the mills on OxyContin Express. Shady mafiosi types getting out of the massage parlor and strip joint business to run “pain clinics” and get really shady doctors to shovel out Oxycontin, enough to cause drug problems all over the Eastern United States. The factoid is 85% of the Oxycontin prescribed in the USA is prescribed in the State of Florida.

  • http://supremacyclaus.blogspot.com Supremacy Claus

    Doctors should become familiar with the concept of pseudo-addicted behavior. This behavior is in patients who:

    1) have verifiable physical cause of pain;

    2) pain no longer serves the purpose of communicating pathology and the need for a remedy, i.e. it is chronic;

    3) do not have a history of addiction for pleasure;

    4) are continually demanding higher doses of stronger analgesics;

    5) stop the demand for escalation of analgesia when a correct dose is reached, and remain on it for long periods, with small adjustments needed for habituation.

  • Dr. J

    The everyday public hears this debate and is worried that a) They won’t get their pain treated in an emergency and b) If they ever require narcotics they will become a drug addict. It’s important to point out that most people, without a history of addiction, who use short term narcotics at adequate doses for a painful condition will not develop any sorts of problems and that almost all doctors would love to help make these patients feel better.

    The group of people we are talking about are people with chronic non-malignant pain, that is people who have ongoing severe pain generally refractive to treatment and of a non life threatening origin. In history these people were not offered narcotics because of a) reluctance to prescribe and b) lack of efficacy. Problem a) is now mainly historical as most people with chronic pain can, if they wish, be on narcotics. Problem b) remains, many of these people do not benefit from narcotic treatment. What is benefit you might ask, benefit is an improved life either through marked reduction of pain and/or improved function in life. If a patient with chronic pain has real benefit from narcotics, shows up on time for appointments and doesn’t multi doctor that too is great, I’m glad you feel better and most doctors will look forward to helping you. If you are in chronic pain and on mega doses of narcotics without benefit you should consider weaning off as you are probably having side effects without benefit.

    The group of patients who doctors cringe at when asked for narcotic prescriptions are patients who really have drug addiction but also claim to have chronic or acute pain. These are patients who are ‘allergic’ to multi-modal pain therapy involving multiple medications, who demand doses of narcotics that are, simply put, irrational. These patients display remarkably similar behaviors: They show up after hours for treatment, they claim that their pathology has previously been demonstrated elsewhere, they demand treatment that is not within most doctors comfort level to provide. While it is true that some of these problems could also be seen in someone with real acute pain these patients have other features that tip off doctors; Their stories are inconsistent/lack internal validity, they team split (nice to some people aggressive and rude to others), they decline any physical examination and usually any investigations, they often have track marks if examined.

    The public, misunderstanding what is really going on, sometimes feels we should take a non-judgemental stance towards these people. These patients are the real problem in pain management, and while they represent a nuisance for me as a doctor they are a real problem to real patients who require treatment because they tarnish the whole picture of pain management. We are sometimes reluctant to label drug seekers for what they are but we should because to do otherwise harms legitimate patients with ligitimate pain…..

  • Leonard Friedman, MD

    In 1949 Helen Mackover wrote that individuals drew their pain in their drawings of themselves. In the sixties Social Security disability required a house-person-tree test to be sent with an evaluation of the patient. I think that the inner sanctum of examiners could read the pictures very well. I like to have the picture of a male and female drawn and on the back side of the paper have the patient name his pain and on a one to ten scale note the extent of the pain. Without looking at the patient’s writing, I can tell the patient where he or she has the pain. If the interpretation of the picture matches the patient’s comments, then I trust and believe that the patient has pain. The subconscious is exposed in the picture bypassing deception.

  • rezmed09

    “Either treat pain promptly, or get the hell out of the way.”

    I don’t think you are doing the chronic pain patients any favors when you take this kind of approach. And using terms like “bigotry” and “authoritarian” for docs who are questioning the 1990′s approach to narcotic use is not helping. Patients are dying from narcotic over use. So many patients are focused on obtaining escalating amounts of narcotics rather than living. The “hysteria” we are recovering from is a result of buying into the drug industry.

    • http://paynehertz.blogspot.com Payne Hertz

      I think I am doing chronic pain patients a favor by publicly speaking the truth about what we go through when dealing with the medical profession. “Bigoted” and “authoritarian” are pretty mild terms for the abuse and control games we have to go though just to get relief from our pain. It isn’t the 1990s approach to pain treatment that needs to be questioned, but the 1690s approach.

      “So many patients are focused on obtaining escalating amounts of narcotics rather than living.”

      You are completely mistaken as to the motivation of people in pain. They simply do not want to be in constant pain because constant pain can totally destroy any chance you have of living a normal life. Avoidance of pain is one of the primary drivers of human behavior. Why is it so difficult for doctors to understand that people want to be as free from pain as possible? Too many doctors insist on pronouncing moral judgment and stigmatizing people whose only “crime” is that they want relief from pain.

      As for patients dying, you might note that narcotics are still the safest and most effective drugs for the treatment of pain existing. There is no treatment that doesn’t have risks and drawbacks, but regardless of their risks narcotics have the benefit of actually working to relieve pain, rather than just line doctors’ pockets and ease their conscience. Over 20,000 people a year die from NSAIDS, which are largely ineffective, and another 25,000 die from the effects of “unnecessary” syurgery (which makes you wonder how many die from “necessary” surgery. Most surgeries for pain have little evidence of efficacy. Anti-depressants are largely useless for most types of pain, are toxic, and some carry an increased risk of suicide, which already takes over 15,000 chronic pain patients a year.

      I’m not sure where you get all these people allegedly dying from narcotics from. The DEA’s own figures put the number of deaths due to Oxycontin at 146 a year back in 2001. I couldn’t find an updated figure on their site. But the study that was based on was widely criticized for its poor methodology, particularly the inability to distinguish true overdose deaths from those in which another drug was more likely the culprit, with Oxycontin merely being involved. In 1998, there were over 106,000 deaths due to non-error adverse effects of drugs, so I think it is safe to say there is something suspect about the hysteria over OxyContin versus the near silence over everything else.

      http://www.deadiversion.usdoj.gov/drugs_concern/oxycodone/oxycontin7.htm

      http://stats.org/stories/2007/should_media_dock_oxycontin_may11_07.htm

      http://www.pathlights.com/nr_encyclopedia/hn041598.htm

  • http://paynehertz.blogspot.com Payne Hertz

    “I’d rather be taken for a sucker once in a while than know that my suspicion had denied someone legitimate help.”

    That is the voice of a true healer. Unfortunately, doctors like this are the exception, and the majority of doctors would rather see a hundred chronic pain patients suffer and even die than risk giving a fix to a single drug addict. Although I imagine there are patients who fake injuries and ailments to obtain drugs, there are less than 600,000 opiate addicts in the US, a nation of over 300 million people. How then, do you account for all these alleged drug-seekers? Considering that less than 1 in 500 Americans is an opiate addict, and most addicts don’t get their drugs from doctors, and the majority of Americans are driven by pain to see a doctor or dentist at some point in their lives, where could all these supposed drug-seekers be coming from? I have seen estimates as high as 90 percent from some doctors describing the problem. In this thread I see an estimate of 25 percent of ER patients mentioned. How could this possibly be accurate? Are 25 percent of people who complain of pain really drug-seekers? This is absurd.

    Based on over 18 years experience in chronic pain support groups, where I have yet to meet a single patient who hasn’t been abused or stigmatized by the medical profession, I am convinced that the “drug-seeker” phenomenon is largely a figment of doctors’ imaginations reinforced by moral panic, authoritarianism, the DEA and drugwarthink. False accusations of “drug-seeking” and malingering are the rule rather than the exception experienced by pain patients, who often go for years before they can find a doctor willing to treat their pain, if ever. The majority of people who are stigmatized as drug seekers are in fact legitimate patients engaged in a rational search for relief from pain. But rather than being treated with respect and compassion, they are all-too-typically treated with suspicion and contempt by the medical profession.

    Doctors often “diagnose” drug-seeking using completely arbitrary, ad-hoc and ridiculous criteria based on nothing but stereotypes, medical folklore and collective and personal bigotry. These tropes are about as accurate a means to identify true drug-seekers as dunking women in rivers is to detect witchery, and about as equally backed by science. Not only does this result in tens of millions of pain patients being denied treatment, but some “doctors” feel compelled to kick the abuse up a notch and destroy any chance these patients have of ever getting their pain treated by entering the drug-seeker label in the medical record. Labeling a patient as a “drug-seeker” effectively sabotages that patient’s medical care, converting him or her into a medical untouchable. It amounts to a non-judicial, arbitrary sentence of torture. Yet the same doctors who demand a pass when they kill or injure someone will happily grant you a lifetime sentence of torture for the crime of knowing what Dilaudid is. Quite a few doctors will even proudly boast of their malicious libel on the Internet as if they have performed some noble deed.

    I am convinced we are dealing with a form of collective hysteria and bigotry directed at pain sufferers that is more perverse and degraded than the Jim Crow era in the South, which is being fueled by the government’s counter-productive and failed War on Drugs, and the authoritarian and self-serving mindset of the medical profession. It is past time for the 70 million Americans who suffer from chronic pain to stand up and demand the right to treat their own pain. The other 230 million better wake up and realize that their turn at bat as a “drug-seeker” is also just one slip and fall away.

    At some point society will have to accept as a standard:

    Either treat pain promptly, or get the hell out of the way.

    • Denise

      Well said.

    • Anon EM doc

      Well, actually yesterday I searched the Michigan Automated Prescription System and found that a patient of mine in “the worst pain of my life” (despite sleeping for about 2 hours after initially examining her) had 320 vicodin prescribed to her in the past 30 days from 2 different doctors, 90 of which was last week.
      http://www.michigan.gov/mdch/0,1607,7-132-27417_55478-232708–,00.html

      What was that you were saying about the authoritarian and self-serving mindset of the medical profession? Oh right, nothing intelligent.

      • http://paynehertz.blogspot.com Payne Hertz

        A person might be in the “worst pain of her life” and still able to sleep. I’m sure you’d agree there are people who spent weeks, months and years in severe pain. Do you seriously imagine we never sleep? How long would you give a patient before they died from lack of sleep?

        Secondly, that’s a rather odd number you have there, 320 Vicodin. Did one doctor give her 230 and the other 90? How does that figure? 230 is an odd number for a script, as it is not divisible by 30.

        Secondly, did you question this patient as to why she did what she did? You might be surprised at the answer or do you feel you already have all the evidence you need? Is it possible that her pain is being undermedicated by the previous doctors, forcing her to doctor shop, or that she is unaware she just committed a crime?

        I see you’ve jumped on this as evidence of drug-seeking that no doubt needs to be punished severely with a lifetime of denial of pain treatment, rather than stopping to consider that there might be a valid and legitimate reason for her doing what she did.

        Here’s a letter from a pain patient driven to the point of suicide by undertreated pain who has previously been driven to become a drug-seeker for the same reason. Perhaps it will help you put such cases into persepective rather than seeing every person who tries to beat a system that is brutally stacked against them as a villain.

        http://web.archive.org/web/20031231235645/www.paincare.org/pain_management/correspondence/patient_letters/show.php?id=673

  • http://www.talktoyourunconscious.wordpress.com BobBapaso

    Good points from partisans on both sides of this difficult issue. But our job is to relieve suffering, and we will never be so good at evaluating it that we eliminate false positives. We can reduce them by never prescribing Xanax and OxyContin. Less addictive and less euphoric drugs relieve pain and anxiety just as well. And by allowing only well trained experience clinicians make the evaluations. PAs and nurse practitioners and those with low interpersonal sensitivity should not do it.

    We will never get rational guidance from law enforcement. Our only hope is to provide enlightenment to our state medical boards. My chapter: Addictophobia, in: The Kentucky Taliban, may be of interest. It is available on Kindle at Amazon.com and in paperback from http://www.virtualbookworm.com/bookstore/.

    • ninguem

      As the hospital admissions from legal opiates starts to beat out the hospital admissions from illegal opiates.

      http://online.wsj.com/article/SB10001424052748704289504575312982929799218.html?mod=WSJ_hps_sections_health

      Death from diversion of prescription drugs beats out auto accidents as a cause of death in youth in my area.

      Just admitted a kid with oxycodone OD and we’re sending off to rehab tomorrow. Nope, just shovel out those opiates, there’s never a problem.

      • http://www.talktoyourunconscious.wordpress.com BobBapaso

        nin- it sounds like you live in a bad place. Opiates must be used judiciously. Our problem is that few clinicians are trained in how to do that. Much chronic pain can be relieved with as little as Lortab 5/500 1/2 tab once or twice a day. Once substantial relief is achieved, never increase the dose. Abusers will drop out if you follow that rule. Never try to relieve all the pain. There is no such thing as “break through pain.” That just means the patient tried to do too much.

        • ninguem

          BobBapaso “…nin- it sounds like you live in a bad place…”

          That’s a Wall Street Journal article, for pity’s sake, what I wrote is true all over the country. Same with diversion of prescription drugs as a cause of death, just a question of whether it’s at the top or near the top.

          I’m living in a better-than average suburb in an area that’s done fairly well with the economy compared to most of the country.

          If you’re not seeing it in your area, you’re just not looking.

      • http://paynehertz.blogspot.com Payne Hertz

        That article is a classic case of media sensationalism. They don’t cite the source of this information, but it appears to be based on DAWN’s “National Estimates of Drug-Related Emergency Department Visits” study which they put out every year. The latest year I could get off DAWN’s site is 2007.

        https://dawninfo.samhsa.gov/files/ED2007/DAWN2k7ED.htm#High3

        It does in fact show a greater number of ER visits in which prescription drugs are mentioned than street drugs. However, “prescription drugs” is a broad category that includes NSAIDS, anti-depressants, anti-convulsants and other dangerous drugs which doctors hand out like candy, and not just narcotics. The conflating of “prescription drugs” with narcotics is a common error is not outright distortion by the media and drig warriors. It should be noted that a “mention” of a drug in a DAWN report merely means that the drug was being used at some time prior to the ER visit, and not that the drug was responsible for the visit. In over 70 percent of the cases in which oxycodone was mentioned, another, usually more dangerous drug like alcohol or cocaine was also mentioned. If you went to the ER with a GI bleed from abusing NSAIDs, but were also on Percocet that you didn’t abuse, the Percocet would warrant a “mention” as would the acetaminophen in the Percocet (which is why you see acetaminophen in the category of people seeking drug detox). Additionally, the same drug may appear in multiple categories and result in multiple mentions, and a single individual may be responsible for multiple mentions over the course of the year as well.

        A DAWN case is any ED visit involving recent drug use that is implicated in the ED visit. The relationship between the ED visit and the drug use need not be causal. That is, implicated drugs may or may not have directly caused the condition generating the ED visit. The reason a patient used a drug is not part of the criteria for considering a visit to be drug related. These criteria broadly encompass all types of drug-related events, including accidental ingestion and adverse reaction, as well as explicit drug abuse. DAWN does not report current medications (i.e., medications and pharmaceuticals taken regularly by the patient as prescribed or indicated) that are unrelated to the ED visit.

        It should also be mentioned that some 20 percent of DAWN cases involve attempted suicides in which they drug being mentioned may or may not be related to the suicide attempt.

        The DAWN study is an estimate of the prevalence of ER visits in which a particular drug or another has been mentioned in the medical record. Anyone using this data to claim an epidemic of narcotic overdoses landing people in the ER is engaging in pure sensationalism. Similary, anyone claiming the DAWN report as evidence of an increase in the abuse of any particular prescription drug is also misusing the data. The increase in the number of ER admissions in which oxycodone is mentioned correlates with an increase in the prescribing of oxycodone, and does not necessarily indicate an epidemic of abuse. During the same period, there was no doubt an increase in the number of ER patients owning iPods. This does not prove iPods increase the likelihood of ER visits. DAWN itself cautions about making extrapolations based on their data, which are primarily used to detect trends in ER admissions, and not to estimate the prevalence of drug overdoses or abuse of particular drugs.

        There is one extrapolation I think it is fair to make from the DAWN data, though, and that is that out of 116 million ER visits in the US every year, only 286,000 involve a mention of prescription opiate medications, whether as a causative factor for the visit or not. This squarely puts the lie to the notion that the majority of ER visits are by drug-seekers looking for a fix or people overdosing from narcotics.

  • Anon EM doc

    @Payne Hertz
    So you’re saying that in the US there are 70 million chronic pain sufferers, yet only <600,000 Americans are opiate addicts? I suspect that your numbers are inaccurate. Are there non-narcotic means of treating pain that should be used more often, or do you think we should have an additional 60.4 million addicts?

    Personally I would like to see marijuana legalized because of its reverse-gateway drug effect.

    • http://www.talktoyourunconscious.wordpress.com BobBapaso

      You’re right, there certainly are not 70 million chronic pain sufferers unless you count the little minor pains most of us ignore. Non-narcotic methods often don’t work. But even if they would, would you rather take $10 of Lortab a month or go through a $50,000 back surgery? And we don’t need any more addictive drugs on the market, we need to take the worst ones off.

      • Anon EM doc

        “… compared with their counterparts in Amsterdam the San Francisco cannabis users were significantly more likely to use [harder drugs]… One plausible explanation is that the black market itself acts as a gateway to harder drugs, as opposed to the effects of cannabis per se.” (wikipedia)

        Original study:
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448346/?tool=pmcentrez

    • http://paynehertz.blogspot.com Payne Hertz

      You are creating a false dichotomy based on faulty premises. Firstly, there are no drugs out there that are as safe and effective for the treatment of pain as narcotics. Most of the alternatives are usually less effective or more toxic, depending on the patient and the nature of the pain. Far more people die from NSAIDs every year than narcotics, and most narcotic deaths are due to drugs like quinine that are mixed in with street heroin, the acetaminophen that is included with drugs like Vicodin, or the alcohol, benzodiazepines or other dangerous drugs that addicts sometimes mix with narcotics due to an inability to acquire an adequate supply of narcotics. True overdoses from pure narcotics are rare.

      There is no evidence that the majority of people taking narcotics for pain are addicts or likely to become addicts in the future. Your estimate of 60 million addicts resulting from widespread treatment of pain is pure fantasy.

    • joe

      EM doc:
      Payne’s numbers are not referenced. In fact nothing payne stated is referenced. Just because somebody with an agenda says it on the internet, doesn’t make it true. What is referenced is this statement.
      ” A CDC report last year found that the rate of drug-related deaths roughly doubled from the late 1990s to 2006, and most of the increase was attributed to prescription opiates such as the painkillers methadone, Oxycontin and Vicodin.”

      In my own area we have had multiple tragedies where young people have OD’s on ground up oxycontin. Dr J above condensed it best in his reply. The simple fact is if you have chronic pain, it is imperative to work with one provider who knows you well. To get meds from that provider only except in times of emergencies. Most docs via reviewing the history and records (payne’s obnoxious comment aside) can actually distinguish those with an acute exacerbation of chronic pain in the ER from those that are drug-seeking. All it takes is a little research. I have no doubt that I too have been fooled into giving drug-seekers pain medications. But to live by the phrase “Either treat pain promptly, or get the hell out of the way” without at least researching the patient with obvious red flags…wel that is just plain stupid. Tell me payne, how many teenager oxycontin OD’s HAVE YOU SEEN?

      • http://paynehertz.blogspot.com Payne Hertz

        Tell me Joe, how many hours, days, weeks, months, and years have you spent writhing in agony, unable to function or live your life, and praying for death or planning suicide? How many people do you know who have been forced to commit suicide as a means of pain relief? How many people do you know have had their lives destroyed by failed surgeries for the treatment of pain? How many people do you know that have been falsely labeled and stigmatized as drug seekers? I know thousands.

        The idea that a doctor can determine if you are a drug seeker or not from the medical record is pure nonsense. In most cases, the record is compiled by doctors who understand little about chronic pain or how to diagnose or treat it, is polluted with the same bias and hostility towards pain patients that other doctors have, and often contains defensive documentation narratives which are designed to discredit the patient and call his motivations into question should the doctor ever find himself being sued for undertreatment of pain.

        In my own record, I was accused of “exaggerating” my pain, of having “myofascial” pain which in context was used as a synonym for “psychogenic,” and of having a “dependency personality” long before I ever asked for or received a narcotic of any kind. All of this was entered into my oh-so-objective medical record. I was later abruptly taken off my meds and forced into cold turkey narcotic withdrawal after a doctor at the VA lied and told my PCP that i told him I was hoarding my pain meds. My horror story is too long to go into detail here, but attempting to get my pain treated with pain medicine after 9 years of trying all the “safe and effective” alternatives was the single most humiliating, frustrating and degrading experience I ever went though in my life. Yet my story is a Disney fantasy compared to many of the horror stories of abuse I have heard at the hands of your profession. I challenge you to go to any chronic pain support forum on the internet and prove me wrong. Show me the people there who haven’t been abused by your profession, and let me discuss their cases with them to determine if that is true or not.

        How many kids overdose on pure narcotics every year, versus the number that are also abusing alcohol, anti-depressants, NSAIDs and other drugs at the time of their deaths? How many kids die every year from Oxycontin? Give me numbers from a reliable source, not your “kids are dropping like flies in my neighborhood” jeremiad from the local newsrag.

        Now compare that to the number of people who die every year from adult-onset diabetes: some 250,000. Why is there so much hysteria about narcotics, when one of the most dangerous drugs of them all, sugar, is served to our kids in their school lunchrooms. Seriously, what kills more people every year, narcotics, or diabetes? Yet I don’t see you calling for a War on Twinkies.

        • joe

          Payne:
          I’ll repeat this as you appeared to have missed it:
          ” A CDC report last year found that the rate of drug-related deaths roughly doubled from the late 1990s to 2006, and most of the increase was attributed to prescription opiates such as the painkillers methadone, Oxycontin and Vicodin.”
          Clear enough?
          This is not me it is the CDC. Maybe you can give me a reference that backs up your statements? As a matter of fact I have sadly managed teens s/p oxycontin OD. Please don’t tell me what it is like, you really have no clue.
          The simple fact is pharmacy records don’t lie. In my state I can promptly obtain them. This is 2010 not 1990, In many states these records are now easy to obtain. If someone arrives with pain complaints and the pharmacy records show many different narcotic pain regimens from many different docs with no real managing doc then yes, that is a red flag. I am sorry you don’t get it. Does that mean every doctor is correct everytime on this issue. No. That is where doctor (and nurse) education plays a role. But, it doesn’t mean breaking out the dilaudid before understanding a given individual situation.

          Diabetes is an awful disease, I manage that too, though honestly I have never intubated a patient due to twinkie OD. Do you even understand the issue here?

          PS: By the way I have chronic pain from an auto accident managed by a pain specialist so I do know the other side of the coin. This involves one doc managing your medications with the exception of acute exacerbation…period. The one issue I totally agree with you is that the DEA has struck fear into the heart of some docs. That is wrong, but who ever said the federal government had any clue when it comes to medicine?

          • ninguem

            Here’s a nurse-run clinic near Portland, Oregon, that was known for high-dose opiate therapy. As high as 1,000 mg Oxycodone, as Oxy-Contin of course, for diagnoses of headache, fibromyalgia. The usual.

            One customer of the place diverted drug to another, to another, in turn to a teenager who died of overdose. Litigation for wrongful death is underway.

            http://www.columbian.com/news/2010/jan/08/payette-clinic-nurse-barred-from-prescribing/

            I don’t feel good about legal action becuase of someone’s diversion, but the practice was so irresponsible I can’t feel too badly about them.

            At a dollar a mg, people doctor-shopping and diverting can make upwards of six figures, cash, off the books.

            You’ve probably seen the movie “Oxy-Contin Express”

            http://www.youtube.com/watch?v=kEA5GBRRSVA

            The infamous Broward Conty pill mills. And every single one of the people entering a Broward County pill mill tells the staff they hurt.

            No, they NEVER lie………what a fool.

          • http://paynehertz.blogspot.com Payne Hertz

            As a matter of fact I have sadly managed teens s/p oxycontin OD. Please don’t tell me what it is like, you really have no clue.

            You’re right, I have no clue what it’s like to deal with an overdose. All I know is what I read in papers published by others who claim some expertise in the area. So why don’t you inform me of what it’s like?

            Please tell me the circumstances of the overdose and how you determined that it was, in fact, an “overdose” of Oxycontin. What symptom or symptoms was the patient suffertng that made you draw this conclusion? Was the patient taking alcohol or other drugs at the same time? How did you isolate the effects of the Oxy from the effects caused by the other other drugs? What medications or treatments did you use to save the life of the patient? Was this an accidental overdose by a chronic pain patient or was the patient a drug abuser? What long term treatment did you recommend to the patient to deal with his problem?

            Now please explain to me how denying pain relief to millions of people with chronic pain or stigmatizing them as drug seekers could have possibly prevented this kid’s overdose.

            The simple fact is pharmacy records don’t lie. n my state I can promptly obtain them. This is 2010 not 1990, In many states these records are now easy to obtain. If someone arrives with pain complaints and the pharmacy records show many different narcotic pain regimens from many different docs with no real managing doc then yes, that is a red flag. I am sorry you don’t get it. Does that mean every doctor is correct everytime on this issue. No. That is where doctor (and nurse) education plays a role. But, it doesn’t mean breaking out the dilaudid before understanding a given individual situation.

            You previously mentioned medical records, which can and often do lie, vigorously. Pharmacy records of prescriptions filled may be more objective, but they don’t tell the whole story, as I’ve tried to explain before. If a person goes to a doctor in severe pain, gets 30 Tylenol #4 which is totally inadequate to deal with her pain, is it so difficult to understand she might “shop” for a doctor willing to treat her pain more aggressively? If you take your car to a mechanic and the guy can’t fix your transmission or rubs you the wrong way, is it illogical to go to another mechanic, even several of them until you can find one who will fix the problem? Why is this behavior wrong or irrational in someone suffering from severe pain?

            Now let’s say the patient obtains a new script. This is technically illegal, but what if the patient doesn’t know this? Not everyone knows how the sytem works nor can they be reasonab y expect to, particulary as the system is completely irrational and counterintuitve as I have just demonstrated. Why would a clueless patient imagine that she is now required to suffer in agony for a month before she can get another script, or that she will be stigmatized as a drug seeker for seeking a script from another doctor even after that month is up?

            Sure, her behavior should definitely raise a red flag. I don’t agree that is should definitely result in her being branded as a drug seeker, denied treatment and her future treatment options effectively sabotaged by this one mistake. Do you? Even Inspector Javert had the decency not to arrest his nemesis until he was absolutely certain his man was guilty.

            One of the insane things about this whole drug-seeker business is that legitimate chronic pain patients are often accused of being drug addicts feigning illnesses to get drugs, while I know people with real pain patients who feign being addicts so they can get pain treatment through methadone maintenance programs. Some studies show as many as 60 percent of people in methadone maintenance have chronic pain. I read a study a while ago but don’t have a cite that said that 40 percent of injectable heroin users are cp’ers who were forced to turn to street drugs to get their pain under control. I know a girl in that category right now who got AIDs and spent 6 months in prison due to her heroin use which resulted from her being denied treatment for severe injuries incurred in a motorcycle accident. She is now on OxyContin.

          • http://paynehertz.blogspot.com Payne Hertz

            I have already provided multiple cites, including one to the DAWN report which you can read yourself and draw your own conclusions. Most of the flaws in the study I mentioned are described in the study itself. I also provided a link to the DEA’s web-page. So far, I have only seen links from the loyal opposition here to sensationalist articles in the mainstream media, which I have already debunked and for which similar articles have been debunked in the past.

            http://www.forbes.com/forbes/2004/0906/048_print.html

            I will respond to your questions in my next post, but first here are some of the cites I assume you are looking for:

            According to the American Gastroenterological Association (AGA), each year the side effects of NSAIDs hospitalize over 100,000 people and kill 16,500 in the U.S., mostly due to bleeding stomach ulcers.

            http://www.webmd.com/osteoarthritis/features/are-nsaids-safe-for-you

            Common Painkillers Raise Heart Death Risk
            Ibuprofen Increases Stroke Risk; Diclofenac as Risky as Vioxx, Study Finds

            “It’s the first evidence that so-called NSAID (nonsteroidal anti-inflammatory drug) pain relievers — including some sold over the counter — increase the risk of heart disease and death in people without underlying health conditions.

            The risks are dose related and are mostly associated with high doses of the drug. However, for most of the drugs, the deaths occurred in people who had been taking the drugs for only two weeks…

            …Because detailed medical records are available for everyone in Denmark, the researchers were able to study NSAID risk in more than a million healthy people from 1997 to 2005….

            …Among the 1,028,437 people who took NSAIDs, there were 769 deaths from heart disease and stroke.”

            http://www.webmd.com/pain-management/news/20100608/common-painkillers-raise-heart-death-risk

            If all 70 million people with chronic pain were put on NSAIDs there would have been at least 53,830 deaths among the healthy ones, undoubtedly a lot more among those with underlying heart problems or other issues. Then add the acute pain population to the mix. Vioxx in its day was said to have killed over 50,000 people.

            This is just one of your “safe and effective” alernatives.

            “That ranking was based on the 73,249 death certificates on which diabetes was listed as the actual cause of death. Diabetes is likely to be underreported as a cause of death since many people with diabetes die of complications of the disease, and yet only about 35 to 40 percent of people who die with diabetes have diabetes listed anywhere on the death certificate, and only about 10 to15 percent had it listed as the cause of death. According to death certificate reports for 2002, diabetes contributed to a total of 224,092 deaths that year.”

            http://newsblaze.com/story/20051214083109nnnn.nb/topstory.html

            As for sugar, obviously, no one has ever od’ed on a Twinkie. Unfortunately deaths from diabetes are not so dramatic, or quick. The negative effects of consuming sugar and refined carbohydrates tend to be more insidious and long-term, but in the end, consuming sugar is the primary contributor to diabetes which is responsible for 10 times more deaths every year than the highest estimates for all narcotics (which are questionble for reasons I’ll get into in the next post) and that being at the lowest level of estimation of overall deaths. Diabetes is also responsible for a far greater degree of disability. Funny, how our medical profession seems silent on the issue but then diabetes fills a lot of rice bowls without any of the drawbacks from writing scripts for narcs. They’ve even got endorsements from medical societies on the boxes of sugary cereals.

            But hey, your profession is all about saving the kids from bad substances.

          • http://paynehertz.blogspot.com Payne Hertz

            ” A CDC report last year found that the rate of drug-related deaths roughly doubled from the late 1990s to 2006, and most of the increase was attributed to prescription opiates such as the painkillers methadone, Oxycontin and Vicodin.”
            Clear enough?

            Hardly. This is a quote from a journalist, not the CDC. Do you have a cite for the CDC report? How does the CDC arrive at this conclusion when the majority of people who “od” on narcotics are in fact on multiple drugs at the time of their deaths and there is no test that can reliably detect whether any particular drug caused a particular death. In most cases where there are multiple drugs involved, each drug is given credit for the death so that a single death may account for multiple deaths cited in multiple drug categories yet is definitive proof in none of them. “Correlation is not causation” is a basic principle of science and the mere presence of this or that substance at the time of death does not necessarily mean that substance caused the death in question. This problem has been well known for years with the reporting of narcotics deaths.

            What’s Killing America’s Drug Users?

            “The state’s medical examiners were asked to distinguish between the drugs being the ’cause’ of death or merely ‘present’ in the body at the time of death,” the study states. Because medical examiners often attribute cause of death to multiple drugs, a single death can result in two or three drugs earning “credit” for causing the death. The report provides this disclaimer about such double- and triple-counting: “Many of the deaths were found to have several drugs contributing to the death, thus the count of specific drugs listed is greater than the number of cases.”

            http://www.slate.com/id/2194716/

            There is no reliable medical technique or standard to determine the lethal dose of a particular drug, or isolate its effect from other drugs. Even in single drug instances, the person may well have died of other causes and not an “overdose.”

            Difficulties in Determining a Drug Overdose Death

            “Unfortunately, the mechanics of that determination are poorly understood — sometimes even by the toxicologists, pathologists and medical examiners who make the call. Circumstances of death surrounding drug use are also often difficult to untangle: In the Schneider case, virtually all the patients who died were found to have multiple drugs in their bloodstream, often including illegal drugs; in addition, many of the patients were known sufferers of chronic pain with chronic, life-threatening diseases such as heart disease and high blood pressure — conditions that can cause death on their own, without drugs.

            Much of what scientists do know about drug-related death comes from the 25 years of research by Dr. Steven Karch, a cardiac pathologist based in Berkeley, Calif., who has written two widely respected texts on the topic. On June 7, he testified for the defense in the Wichita case, stating that in most instances of drug overdose, the currently available medical technology cannot accurately determine whether or which drugs caused death.”

            http://www.time.com/time/health/article/0,8599,1996831,00.html?xid=rss-topstories

            It’s been well known for years that true “overdoses” in the scientific sense among drug addicts are rare, and that deaths usually attributed to “overdose” are likely due to the practice of taking mutliple drugs concurrently with the narcotics. The following excerpt provides an explanation, but I strongly recommend anybody looking to become informed about the facts of drug abuse and drug policy read this report. Even though it is dated that facts and findings are still relevant today. What’s remarkable is that a lot of the “modern” knowledge about opiates was actually common knowledge in the 1800s.

            Chapter 12. The “heroin overdose” mystery and other occupational hazards of addiction

            At this point the mystery deepens. If even enormous doses of heroin will not kill an addict, and if there exists no shred of evidence to indicate that addicts or nonaddicts are in fact dying of heroin overdose, why is the overdose myth almost universally accepted? The answer lies in the customs of the United States coroner-medical examiner system.

            Whenever anyone dies without a physician in attendance to certify the cause of death, it is the duty of the local coroner or medical examiner to investigate, to have an autopsy performed if indicated, and then formally to determine and record the cause of death. The parents, spouse, or children of the dead person can then ask the coroner for his findings. Newspaper reporters similarly rely on the coroner or medical examiner to explain a newsworthy death. No coroner, of course, wants to be in a position of having to answer “I don’t know” to such queries. A coroner is supposed to know— and if he doesn’t know, he is supposed to find out.

            At some point in the history of heroin addiction, probably in the early 1940s, the custom arose among coroners and medical examiners of labeling as “heroin overdose” all deaths among heroin addicts the true cause of which could not be determined. These “overdose” determinations rested on only two findings: (1) that the victim was a heroin addict who “shot up” prior to his death; and (2) that there was no evidence of suicide, violence, infection, or other natural cause. 24 No evidence that the victim had taken a large dose was required to warrant a finding of death from overdose. This curious custom continues today. Thus, in common coroner and medical examiner parlance, “death from heroin overdose” is synonymous with “death from unknown causes after injecting heroin.”

            PS: By the way I have chronic pain from an auto accident managed by a pain specialist so I do know the other side of the coin

            You’re a doctor. You don’t have a bloody clue what it’s like to try and get your pain treated in this system. How patronizing. I doubt a day went by between the time you decided to get on pain meds and you got a colleague to prescribe an adequate dose. No surprise you found a single doctor who was willing to treat you. You’re a member of the club. Most cp’ers go years without relief and some never get treated. Why don’t you do what I suggested and go to a chronic pain forum and get a glimpse of reality on the other side of the prescription pad. Are you afraid of what you’ll find there?

      • ninguem

        joe I know what you’re saying. After a while it just gets tiresome. WSJ article is backed up by reports from coroners all over the country seeing the OD’s in their own communities. Diversion and abuse of prescribed drug. Not side effect of drug prescribed to an individual. My practice includes Suboxone, I see it every day. Diverted drug, and two (adolescent) admits for OD this year so far. One death. Diverted drug, and I don’t mean NSAID’s (what a laugh).

  • Anonymous
    • http://paynehertz.blogspot.com Payne Hertz

      See my response to ninguem about the abuse of DAWN’s annual reports for sensationalistic articles like this one.

  • Leonard R. Friedman, MD, JD

    The problem is in pain medicine to develop the psychological tests to tell us whether the patient has pain or not. In 1949 Karen Mackover noted that pain patients draw human figures (I use a male and female figure) which quickly allow us tonote where their pain was. This projective test bypasses the conscious mind and allows the subconsious mind to speak. During the late sixties and seventies, Social Security Disability examiners summitted pictures of a house – tree- person. Soon I figured out what the pictures were saying. I do have the patients tell me where they have their pain and at what level (1-10) on the back of the page they drew their pictures. Usually I can tell the patient about 90% of the areas he has noted in the back of the page. This builds trust. The picture is drawn every visit and as a psychiatrist I can suggest that he seek an eye exam, has sinus problems or should see his dentist soon as I start looking down the picture. A headache is clearly marked and that yesterdays headache is over is marked differently.

    Because I am a forensic psychiatrist the challenge was to develop tests that would help the judge determine issues that are common in court. Knowing how to reach the subconscious mind, does answer many questions. The most acceptable family drawing is the kinetic family drawing by a child drawing a picture of the family doing something together. This is a significant exposition of the child’s view of his parents and siblings and does make a difference in confirming one’s conclusions.

    Leonard R. Friedman, MD, JD

  • Russell B

    Russell here with 3 cents worth.
    There is one thing that has been left out of every argument above about opiates. First I will tell you I suffered a broken back in the Army in 1977 and still managed to work 23 years in the communications industry although some days I would throw up the pain was so excruciating. In 2000 I was completely disabled at the age of 42 so you can see this all happened when I was quite young.
    The place where a lot of teens and others are getting their opiates are from Mom and Dads medicine cabinet as well as their Grand parents. I am on a lot of medications which I keep locked in a safe. It is the fault of a lot of different people that our youth and a lot of others get their hands on drugs they are not supposed to have.
    To say that pain could be treated with half a 5 mg Loratab I’m sorry and I’m not sure who said that but you are a moron. Then another said that every chronic pain person that is on opiates will become or is an addict you also are a moron. I have been on opiates for a long time I am not an addict, yes I am dependent on these opiates to try and live some life that is close to normal, even with all the meds I’m on my pain averages a 5-6 everyday of my life and is getting worse as I grow older.
    I had all the so called conservative treatments years ago by the Veterans Administration the so called steroid injections that had no long term side effects are now eating away at my bones and tissue not only in my spine but other parts of my body. I have been told by no less than 9 doctors that I am a 51 year old man with the body of a 75 year old man mostly because of the Nsaids and steroids that were shot in me and given orally.
    Well that’s enough about my problems there isn’t enough time for me to go in to all I have been diagnosed with. One last thing, everyone metabolizes opiates differently it amazes me none of you doctors even mentioned that. What may knock one person out may not even effect the other person, boy we all have a lot to learn but I would pit my knowledge about pain against most doctors. My pain doctor who it took me 8 years of SHOPPING to find is amazed with some of the materials I have brought to him, I’m not bragging but when some days you can hardly walk it leaves you a lot of time to read.
    Here’s a web site that would be good for patient and doctor alike to check out. http://www.pain-topics.org
    Sign me- Been There Done That.

  • Payne Ful Ness

    This is a major topic in my family. I have all I need. I have doctors offering me more than I want. I have been known to not fill a script. I have been known to refuse a script and ask for a lower strength. I have had migraines since early toddlerhood .. I went to the ER once and left after an hour realizing that no pain relief they could give me was worth the torture of the lights, sounds and smells of an ER when in my own house I could have dark, quiet and neutral smells.
    I have lupus, osteo arthritis and hypermobile joints.
    I have had 15 surgeries.
    18 if you count the dental surgeries last year to remove all my teeth and fix my jaw. (to which I refused the percoset in favor of lortab) I have a script for darvocet n100 that is for a months supply that I refill about every 4 months.

    Then, my sister in law, with migraines and fibro enters the picture … everytime I have need of a surgery, the same joint I’m having operated on, she injures. (amazing how that works). I have a thymectomy, she has chest pain. I have gall bladder surgery, she has side pain (they do exploratory surgery and find nothing). I have bladder surgery, she has abdomninal pain ..again exploritory surgery to find nothing.
    She has migraines 3 to 4 a week and goes to the ER with 2 to 3 of them a month and comes home furious that they give her nothing.
    She currently has back pain that’s not been confirmed by MRI, the PT can find nothing wrong and says her symptoms are inconsistent.
    She calls me crying asking “how do you manage to get pain pills from your doctors?”
    It’s simple, I never ask for them.On the rare occassion that I have (maybe 4 or 5 times in 20 years) because of circumstances that have put me in an extreme flare and I need to continue functioning … I’ve asked for 2 days worth to get me through the event. I ask for the lowest dose possible. I’m always wiling to try the weaker dose if they suggest it. I discuss it with them in terms of my own fears of addiction needing to be balanced with being able to live life.
    maybe it’s my willingness to try lesser things, maybe it’s my own verbalizing my fear of addiction …maybe it’s the key word “lupus”
    I do get why my sis in law is classified as a drug seeker (although, outside of pain relief, she has no addictive behaviors and does not seek drugs when she is not in pain)

    What is the answer?? I have no idea. I just know I’m grateful that I’m taken seriously.

  • touchet

    So basically what we have here is very similiar to political campaigns. They have defined the term “drug seeker” to give a bad image and have related it to behavior that is apparent in people in chronic pain with no major issue wrong with them other than neurological and pegged them as a drug addict. Drug Addicts and those dependent on narcotics are two different situation, but yet they have sucessfully infused the two together. Even in some cases the image is associated with those with physiological evidence.

    Of course a person in pain will become a “drug seeker”. DUH! I mean what is so hard to accept there. Narcotics are very effective. People in the U.S. are educated. They know what works and doesn’t. This is a very Sad Sad situation where the medical establishment is trying to reduce administrative costs in paperwork through investigations and lawsuits by politically influencing doctors to serverly limit the use of narcotics. The doctor and patient are both the suckers here.

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