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tkgoodspirit 01-12-2005 07:15 PM

Possible answers as to why some are having trouble getting pain meds.
It seems that some of you having a diffucult time with your pain docs and getting the meds that you need is a pretty hot topic here.

I was surfing the web about this and found that a lot of it has do to with the DEA, AMA and Pain Management Specialists. There is a lot of info about these organizations and how they interact with each other. I didn't realize that the DEA was regulating the Pain docs. I knew the govt. was involved, I guess I never thought about the DEA controlling my doctor. No wonder some of them are scared. I imagine it's as bad as having the IRS breathing down your neck.

December 2004 is apparantly when the guidelines of the DEA were changed. From what I read, the DEA has a pretty tight hold on our pain doctors, which sadly, seems to put the fear of prision in the minds of our doctors.

Also, it may help to see if your congressperson will respond to your situation. You never know until you try. You know the old saying "the squeaky wheel gets the grease"!

Here's wishing you all a good spirit.

mommy2scl 01-12-2005 08:13 PM

Re: Possible answers as to why some are having trouble getting pain meds.

I have also come across a site that talks about abherrant behavior that patients display when seeing a doctor. Some of them are pretty ridiculous and probably things most of us do but it can get us "reg flagged". THings like talking about medications too much, looking unkempt, tatoos, complaining meds don't work, mentioning specific medications and on and on. I am not saying these things are right, but they are out there and docs do use them. It is certainly a fine line we have to walk and it really is unfair.


Soulcatcher 01-12-2005 08:24 PM

Re: Possible answers as to why some are having trouble getting pain meds.
From being around my brother who is pill popper, he has told me stories about what him and his friends do and say and YES the doctors do look for "regulars" who do not produce...x-rays or MRI's and do not follow the directions of the doctor. Any way...doctors do have to watch themselves who can blame them...Pain meds just keep getting up'd because they lose their effect to people who abuse them. My cousins doctor refused him pain meds, he had scholiosis (spelling) and he couldn't take the pain anymore and took his life so he wouldn't feel the pain anymore. Some doctors can stop your meds but they really should wean or offer to wean instead of dropping people un prepared for what lies ahead. Sorry I rambled.

tkgoodspirit 01-12-2005 08:39 PM

Re: Possible answers as to why some are having trouble getting pain meds.

I have also come across a site that talks about abherrant behavior that patients display when seeing a doctor. Some of them are pretty ridiculous and probably things most of us do but it can get us "reg flagged". THings like talking about medications too much, looking unkempt, tatoos, complaining meds don't work, mentioning specific medications and on and on. I am not saying these things are right, but they are out there and docs do use them. It is certainly a fine line we have to walk and it really is unfair.


I know it can be like walking on eggshells for some folks, but, true, I think you should use common sense when visiting your pain doctor. All this contorversy about prescribing opiates is a heavy thing with the govt. I am so lucky to have a pain doc who listens, and when something isn't working for me we discuss it, and he suggests something else. I have only once asked about a certain med, and that was Fiorecet for headaches. He had no problem letting me try it. He also prescribed me Oxycontin once and when he suggested it, I asked him about addiction and he said if I wasn't comfortable with it he would give me something else. So, I tried it, and didn't like it. It took some time, but we finally got a good regimine going for me, but we worked at it together, by discussing how I felt the meds were working for me and helping me in my life.

Have a good rest of the week.

wfc33 01-12-2005 08:58 PM

Re: Possible answers as to why some are having trouble getting pain meds.
Oh I know, the government needs to butt out and leave the doctoring to the doctors. There should be a constitutional amendment saying that doctors in good standing can do as they see fit. The government is the reason it's so complicated in getting Oxycontin (or any other pain med) filled. First, you need a written script, and since my doctor is 50 miles away they have to send it by mail, so youhave to accoun for that. Then, instead of calling it into the pharmacy you have to take it in and I don't know about yours but mine is always busy so more waiting.And you have to do this for each and every one.I have to get 40's & 10's on my Oxycontin and at different dates, too, so more driving and waiting.

The government regulations have been a real source of contention for me. They need to change the rules because, in the effort to control abuse, all the people who really need these meds end up getting penilized by the red tape.

tkgoodspirit 01-12-2005 09:13 PM

Re: Possible answers as to why some are having trouble getting pain meds.
[QUOTE=wfc33]Oh I know, the government needs to butt out and leave the doctoring to the doctors. There should be a constitutional amendment saying that doctors in good standing can do as they see fit. The government is the reason it's so complicated in getting Oxycontin (or any other pain med) filled. First, you need a written script, and since my doctor is 50 miles away they have to send it by mail, so youhave to accoun for that. Then, instead of calling it into the pharmacy you have to take it in and I don't know about yours but mine is always busy so more waiting.And you have to do this for each and every one.I have to get 40's & 10's on my Oxycontin and at different dates, too, so more driving and waiting.

The government regulations have been a real source of contention for me. They need to change the rules because, in the effort to control abuse, all the people who really need these meds end up getting penilized by the red tape.[/QUOTE]

You hit the nail on the head. Over the past few years the abuse of pain meds/opiates has seemed to have taken over the news at times. There was a doctor where I am from who went to jail for over prescribing. And I think I mentioned in a previous post, some of the people who testified against him sounded so desperate, most blamed him for their lives spinning out of control, there was a guy who got into all kinds of trouble with robberies so that he could pay to get these meds from this doctor. There is a funny part to this though. I worked in a restaraunt during all this trial and our GM actually hired this guy to work in our dish room without knowing who he was! He put him on the dining floor to bus tables and most of our customers recognized him of course and said something, but our GM hadn't heard anything about him or the trial. I don't know who read the guys app., but of course he hadn't been convicted yet, he was just working until his sentencing. It was kinda funny seeing this guy is a dishwasher's uniform. Actually pitiful. What a waste.

But, when you see talk shows that do specials on "housewives addicted to pain pills" it just makes it so much harder on our docs and those of us in real pain. I myself am not afraid of becoming addicted, I know I am dependent on my meds, because they improve the qualitiy of my life, but that's what they are intended for. My doc even "quizz's" me every so often as to how my meds are working in my life and if I feel like the quality of my life is better with them.

I just get so mad when I see on the news or anywhere you get information, that some doc has overperscribed, or people who aren't in pain and just want the "high" are making the headlines. I only hope that some day the govt. agencies don't over regulate our poor doctors right out of practice.

Thanks for your reply.

Shoreline 01-13-2005 06:02 AM

Re: Possible answers as to why some are having trouble getting pain meds.
The DEA is really nothing new, I've been in this area and have seen docs go down for overprescribing opiates and diet pills long before OxyContin came out and PM was terendy and a way for a surgeon or GP to pass the buck when a patient kleeps asking for opiates. The docs that get targeted are likely the ones that can't justify their prescribing, don't keep acurate records, don't demand compliance and they simply attract more and more addicts as their name gets out to their buds.

Any doc can open up a PM practice, there is no such thing as the specialty of pain management in medical school. You have Neurologist, anesthesiologist, physiatrists, psychiatrists, DO's and even dentists who treat TMJ and TGN practicing PM. The problem is, they aren't trained any different than any other doc with the same specialty coming out of school. Some of the better docs will do fellowships in pain managemnet and actually go and work and complete a program at a school like UC Davis, pain management dept or at any major med school, but there isn't a medical school ciriculum to create pain management docs.

I wouldn't blame the dea, Just as I wouldn't blame the DEA because we have crack addicts and cocaine in our country.

Every doc has a handful of drug abusers and they work docs like it a full time job. One guy I knew carried the yellow pages around in his car and would hit 3-4 docs a day untill he got what he wanted. This guy died at th age of 35 after several seizures from benzo withdrawal, he developed a movement disorder from frying his CNS.

Drugs or alcohol will always be available, but selecting who drugs are right for is where a trained PM doc comes in. However docs can protect themselves from prosecution by demanding certain things like contracts,compliance, urine screens, and other in depth screening processes. Every state has provisions for the treatment of pain , guidlines in which the doc can follow to protect himself, and they aren't guidlines for prescribing quantity or strenght of meds, It's guidlines for proper documentation, guidelines for screening and flollow up, etc. I'll show you an example and where to check your own states guidlines.

Someone mentioned being quized on occaision, that's really not good enough to protect themselves. Everytime I go to the doc, whether for a med check, a pump refill or a procedure, I fill out a follow up survery of the effectiveness of the meds in about 12 different areas of life. Sleep. enjoyment of life, walking ability, working ability, relations with others, , activity levels, all with and without the present meds, plus there are areas to rate the percentage of improvement from the meds, rate the pain at it's best, at it's worst, and on average. describe what increases pain, Do you have any new medical conditions?

This has allways gone on at my docs office but it gets old when adjusting a pump and your in there every 2 weeks for months. But I know this protects my doc and I won't find myself in the position of showing up for an apt and yellow tape posted across the door and then scrambling to find a doc to prevent withdrawal. I also have back up docs and clinics that can manage my pain.

Some people are are offended by the contracts , but it's simply a matter of informed consent and spelling out the rules so a patient can't say I didn't know I would become dependent or I would be discharged if I ran out early. My doc has had to go so far as to stop calling in any scripts, apearently he had a problem patient that would call in Valium and Norco, so they simply write every script at your apts, they do put refills on non c-2's but each script has a fill on or after date exactly 30 days apart. He has control of the patients meds, Vs a doc that allows patient early refills, has patients change meds every 2 weeks because the patient took a month supply in two weeks and claimes it doesn't work or has harsh side effects.

IF I change meds, the old meds are counted by the doc and witnessed by a nurse and disposed of so you don't aquire a large stash of meds people claim to be innefective. My clinic sounds extreme compared to some but I'm glad these things are in place and they will deter the drug seeker and still be there in 20 years when I still need them.

Even the process of taking on a new patient is extensive. IF your referred to their practice, they send a 20 page questionaire, you fill it out and send it back, They go over each new referral at a monthly meeting and decide who they will see based on specific information and confirmation.

They also start with the basics, why put someone on morphine if Ultram will work, IF the patient would be better served to have the hip replaced than to put it off as long as they can with opiates, that's really not a service, by the time that hip gets replaced the patients tolerance to meds is so far beyond anything any surgeon has every prescribed for post op pain, that alone makes you a poor candidate for surgery. The only way to see if surgery worked is to discontinue the meds and if left to the patients time table, It would take a lot longer than I was ever given.

It does astound me about the higher strength medf being used to treat virgin backs.

I came home from all 3 back surgeries, the last was a 6 level fusion with 12 screws and 8 rods. I came home with 2 5mg percs every 4 hours and I survived, I didn't die from the pain, IT was miserable but noboday said back surgery wasn't.

My next door neighbor was in an accident, After several weeks of not complying with docs orders for PT and to have an ESI, the doc cut him off, IN a mtter of 3-4 weeks he was taking 3-4 10mg percs at a time. 4 times the dose of meds I used post op and 4 times the dose of meds any doc practicing prior to 96 would ave prescribed. He got the name of a local Ortho surgeon that has so many complaints and so many cases hanging over his head he lost all hospital privlidges 10 years ago when he married an 18 year old patient. So here is a surgeon, that can't operate, but can still presecibe. He doesn't take insurance, you have to file and be compensated on your own. But he will pass out any med you want to a degree. With the tolerance my neighbor has already developed though, even 120 mgs of avinza and 4 30mg MSIR wasn't enough pain meds??

I think there is a huge misconception that because these meds are available that evryone should have equal access untill they prove themself to be a bad patient. But this doc isn't doing anyone any favors by prescribing these meds to most of the junkies and the few real patients that can't find relief elswhare or won't try anything other than what they know works. That's the biggest red flag. No PT, NO ESI, NO surgery, but I'm in so much pain I have to have something to keep from blowing my brains out. BS

The addicts have learned how to describe their pain and disability, but when your that desperate for relief if a PM doc said hold a egg in one hand and put a pickle in your ear and hop on one foot, If there is achance it would help, someone that desperate for relief would do it. They go through the hoops and process of elimination, you learn relaxation techniques and try antiD and anti seizure meds first, you use Vicodin even though it doesn't wipe 100% of the pain away.

I just don't blame the DEA, the patients and addicts have created this monster and a complete 180 wouldn't surprise me. Meaning if you don't have documented attempts to manage pain, have every surgry to try to relieve the problem. Pain meds aren't going to be continued to be passed out to everyone with a headache or DDD.

People want instant relief, they see others getting relief but don't know it took 12 years and 8 years of no opiates to reach the point that some of us are at.

Here are the VA medical board guidlines for safe prescribing and these protect the doc if he follows them, if you don't document other methods to mange pain, med increases, give early refills, the docs should be scared and shut down.The DEA is just a tool of enforcement, not an agency created to force people to suffer, But so many folks have unrealstic expectations and then claim ignorance and want to testify against their doc when he is shut down because they had to go through withdrawal, because they told the doc they couldn't live or function without the prescribed meds.

Sorry, I don't agree, It's not a problem with the DEA. They are a needed tool to prevent diversion and control illegal drug trafficing That's all. They don't have a Vendeta against all CP patents and PM docs.
Check your own state laws here or do a search for your states prescribing laws ands regulations, the docs are protected that *** their I's and cross their T's and have control over their patients drug use, not vice versa

Shoreline 01-13-2005 06:11 AM

Re: Possible answers as to why some are having trouble getting pain meds.
Your own state has similar guidlines to protect docs, but most docs aren't even aware of these guidelines, they learned opiates are bad and addicting in med school and haven't taken the time to learn another thing about opiates. Unless they have taken the time to seek out a fellowship in pain management and stay informed. But your friendly GP has no business playning PM doc and prescribing the most potent opiates like Duragesic without any training or exeperience in pain management. Thy know what the reps tell them and feel qualified to prescribe an opiate so potent it's measured in Micrograms? Prior to the patch, only an anesthsologist would have ever used Fentanyl.

I know a GP may be someones last hope, but once something is working, you and your GP would be better served to find a legitamte PM doc that follows every single guidelines that's spelled out very clearly in each state and by the DEA. The DEA has a similar position statement, they are not out to damn people to a life of pain, they are there to protect people from the docs like I described MY neighbor is seeing.

Virginia Board of Medicine
Source: Provided by the Virginia Board of Medicine
Approved: February 5, 1998

Guidelines for the Use of Opioids in the Management of Chronic, Noncancer Pain

All practitioners with the authority to prescribe controlled substances Schedule II-V must have a clear understanding of their obligations and responsibilities when using these agents. As the medical community promotes the new advances in the management of the patient with chronic pain, all practitioners must understand not only that the use of opioids is an important part of the armamentarium for managing the chronic pain patient, but also that opioids must be prescribed, dispensed and administered in good faith for accepted medicinal or therapeutic purposes.

In 1997, the Medical Society of Virginia, at the request of the Joint Subcomittee of the General Assembly, appointed a special committee, which included Board members and staff, to develop guidelines to meet the needs of physicians in the Commonwealth regarding the prescribing of opioids for chronic, noncancer pain management. These guidelines were passed by the House of Delegates of the Medical Society during an annual meeting in November 1997.

The Executive Committee of the Virginia Board of Medicine endorsed these guidelines on December 5, 1997, and the Board confirmed this endorsement on February 5, 1998. The Board welcomes these guidelines and, although they do not carry the weight of law or regulation, believes these guidelines will be of help to those who treat pain patients as to the proper use of opioids and the documentation required.

Guidelines for the Use of Opioids in the Management of Chronic, Noncancer Pain

For the purposes of this document the following terms shall have the following definitions:

Addiction is a disease process involving the use of opioid(s) wherein there is a loss of control, compulsive use, and continued use despite adverse social, physical, psychological, occupational, or economic consequences.

Substance abuse is use of any substance(s) for nontherapeutic purposes; or use of medication for purposes other than those for which it is prescribed.

Physical dependence is a physiologic state of adaptation to a specific opioid(s) characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by re-administration of the substance. Physical dependence is a predictable sequelae of regular, legitimate opioid or benzodiazepine use, and does not equate with addiction.

Tolerance is a state resulting from regular use of opioid(s) in which an increased dose of the substance is needed to produce the desired effect. Tolerance may be a predictable sequelae of opiate use and does not imply addiction.

Withdrawal syndrome is a specific constellation of signs and symptoms due to the abrupt cessation of, or reduction in, a regularly administered dose of opioid(s). Opioid withdrawal is characterized by three or more of the following symptoms that develop within hours to several days after abrupt cessation of the substance: (a) dysphoric mood, (b) nausea and vomiting, (c) muscle aches and abdominal cramps, (d) lacrimation or rhinorrhea, (e) pupillary dilation, piloerection, or sweating, (f) diarrhea, (g) yawning, (h) fever, (i) insomnia.

Acute pain is the normal, predicted physiological response to an adverse (noxious) chemical, thermal, or mechanical stimulus. Acute pain is generally time limited and is historically responsive to opioid therapy, among other therapies.

Chronic pain is persistent or episodic pain of a duration or intensity that adversely affects the function or well-being of the patient, attributable to any nonmalignant etiology.

Co-Assessment, Documentation and Treatment

A. History and Physical Examination

The physician must conduct a complete history and physical exam of the patient prior to the initiation of opioids. At a minimum the medical record must contain documentation of the following history from the chronic pain patient:

Current and past medical, surgical, and pain history including any past interventions and treatments for the particular pain condition being treated.
Psychiatric history and current treatment.
History of substance abuse and treatment.
Pertinent physical examination and appropriate diagnostic testing.
Documentation of current and prior medication management for the pain condition, including types of pain medications, frequency with which medications are/were taken, history of prescribers (if possible), reactions to medications, and reasons for failure of medications.
Social/work history.
B. Assessment

A justification for initiation and maintenance of opioid therapy must include at a minimum the following initial workup of the patient:

The working diagnosis (or diagnoses) and diagnostic techniques. The original differential diagnosis may be modified to one or more diagnoses.
Medical indications for the treatment of the patient with opioid therapy. These should include, for example, previously tried (but unsuccessful) modalities/medication regimens, diverse reactions to prior treatments, and other rationale for the approach to be utilized.
Updates on the patient's status including physical examination data must be periodically reviewed, revised, and entered in the patient's record.
C. Treatment Plan and Objectives

The physician must keep detailed records on all patients, which at a minimum include:

A documented treatment plan.
Types of medication(s) prescribed, reason(s) for selection, dose, schedule administered and quantity.
Measurable objectives such as:
Social functioning and changes therin due to opioid therapy.
Activities of daily living and changes therin due to opioid therapy.
Adequacy of pain control using standard pain rating scale(s) or at least statements of the patient's satisfaction with the degree of pain control.
D. Informed Consent and Written Agreement for Opioid Treatment

Written documentation of both physician and patient responsibilities must include:

Risks and complications associated with treatment using opioids.
Use of a single prescriber for all pain related medications.
Use of a single pharmacy, if possible.
Monitoring compliance of treatment;
Urine/serum medication levels screening (including checks for nonprescribed medications/substances) when requested.
Number and frequency of all prescription refills.
Reason(s) for which opioid therapy may be discontinued (e.g. violation of written agreement item(s)).
E. Periodic Review

Intermittent review and comparison of previous documentation with the current medical records are necessary to determine if continued opioid treatment is the best option for a patient. Each of the following must be documented at every office visit:

Efficacy of Treatment
Subjective pain rating (e.g. 0-10 verbal assessment of pain)
Functional changes.
Improvement in ability to perform activities of daily living (ADLs)
Improvement in home, work, community or social life.
Medication side effects.
Review of the diagnosis and treatment plan.
Assessment of compliance (e.g. counting pills, keeping record of number of medication refills, frequency of refills and disposal of unused medications/prescriptions).
Unannounced urine/serum drug screens and indicated laboratory testing, when appropriate.
F. Consultation

Most chronic noncancer patients, like their cancer pain counterparts can be adequately and safely managed by most physicians without regard for specialty. However, the treating physician must be cognizant of the availability of pain management specialists to whom the complex patient may be referred. The physician must be willing to refer the patient to a physician or a center with more expertise when indicated or when difficult issues arise. Consultations must be documented. The purpose of this referral should not necessarily be to prescribe the patient opioids.

G. Medical Records

Accurate medical records must be kept, including, but not limited to documentation of:

All patient office visits and other consultations obtained.
All prescriptions written including date, type(s) of medication, and number (quantity) prescribed.
All therapeutic and diagnostic procedures performed.
All laboratory results.
All written patient instructions and written agreements.
A licensed practitioner who prescribes opioids in the Commonwealth of Virginia does not need a license from the Virginia Board of Pharmacy, but he must have a valid controlled substance registration from the Drug Enforcement Agency of the United States Department of Justice.

tkgoodspirit 01-13-2005 07:16 AM

Re: Possible answers as to why some are having trouble getting pain meds.
Hey Shore, Thanks for the wealth of information. I know that a lot of people here will benefit simply by reading some of the guidelines that docs follow and then realize maybe why they are having a hard time getting meds.

And of course, you are right when you say, all these "problems" are mainly because of the individual who abuses the system, which after years of that, caused the regulators to take a closer look at what was going on in some of the Pain doc's offices.

I am lucky to have a very proffessional Pain doc. After having been on pain therapy for awhile, like I said at my last visit, he asked me how the meds were providing me relief and helping with my quality of life. I realize that the pain will not be elimated
%100, but a reduction in pain that will at least allow me to walk out to my mail box with out becoming exhausted, is wonderful.

In my situation, I was referred to a PM doc when I started feeling back pain that wouldn't go away, no matter what we tried. That was when the MRI showed all the icikies that were going on back there. So my PM doc new that one day I would need surgery but said that we would try PM and some therapy for now. Of course, as with a lot of meds, some things would work, some wouldn't. I had also tried non opiate pain meds before, and we discussed those. I am now on a really good regimine which actually reduced the number of meds that I take. I am trying my best to stay away from those anti-deppressants, they just have awful side effects, and I don't like the way they make me feel. Sure, I get depressed from time to time, but not to where I think I need meds every day. I know people keep telling me to stay on the anti-d's to help me win my SS case. I have a psyciatrist who is willing to help me, and I have a therapist (social). I'm going to ask my psyc if he'll take over my Klonopin prescription from my rhuemy and we can use it for me as more of an anti-anxiety med and I can take it in lower dosage throughout the day, when I need it, but I take it now at bedtime for FM.

You know what really makes me mad, is when you are dx with FM doctors throw those anti-d's at you like candy. They don't go over you the possible side effects, I know you can read the little paper, but I think if it's a med you have never used before, your doc should talk to you. And the little paper only says do not stop taking this med abruptly, they do not tell you why.

Anyway, back to the PM stuff. I know that my pain doc went the extra mile for the extra certification, and he does all the things you listed, the contracts, the c2 pads, he of course writes multiple scripts during your visit depending on whether you are being managed every two or three months. I have never had to change my meds in the middle of my two month time, so I don't know if he has you discard your old script or not. I have always waited until my next appt. to dicuss the fact that the meds aren't working for me, which until then, I just take the meds and feel as good as I can until he can adjust them. He also does the random urine tests, which I'm sure are mentioned in that contract you sign. I do remember filling out a quesitonerre before he saw me at all. But when I first saw him he explained everything to me, asked me what meds I have or was taking for my pain. He prescribed me Lortab 7.50/325 using the three month treatment. Now I am on a two month regimine. He has mentioned surgery and even asked me what I wanted to do. He will recommend a good nuerosurgeon, I was concerned about that. He can do some surgery but not the kind I need. But we agreed that I would stay on the meds for now. As far as surgery being a prerequisite for pain meds, I have FM and other problems that aren't fixable with surgery, but still give me chronic pain. Until I started on narcotics for pain, the FM pain was awful, I didn't know my body could ache like that! But I told my Pain doc that the meds he was giving me helped my back pain, but were wonderful at helping my FM pain. Plus, I simply cannot afford surgery, even with insurance. You know that little room they take you in to set up your payments before you even get the surgery? Well, I couldn't even go in that room right now! LOL I need surgery on my back, and it will have to be soon, I know this, but I'll eventually need surgery on my hands. They aren't that bad though right now.

I get a quarterly newsletter just for FM and they are having a big conference with the rhuemies and nuero's to discuss prescribing opiates for pain for FM. I agree with this, only after you have tried all the other meds. The ultram, the darvocet, the neurontin, and the others that are non-narcotic.

True, not everyone can handle the responsibility of pain meds, and surely this makes it more difficult for those of us who really suffer to get the relief we need. I am like you Shore, I hope that I won't go to my doc's office for a visit one day and see the tape over the door! LOL I don't think I ever will, he seems pretty responsible and he's the kind of guy who will definately not jepordize his practice. He's been practicing at it for some time, and he's really young (to me at least). I'm pretty sure that was his intended specialty, and he has further training in PM. I read his bio one day while waiting for him. He is very busy and sometimes I have to wait a long time at on my appt. day but he's worth it. But I sometimes find myself looking around the office at others and wondering if they are trying to scam him.

I do agree with you about the DEA needing to focus more on the crackhouses on the streets. But I think that the problem with people abusing our Pain docs, and the continued list of Pain docs that abuse thier practice is only going to grow. I always wonder what will happen with all this even only just 5 or so years down the road.

I jsut consider myself lucky to have the doctor I have now. My concern right now, is having no income, back surgery, and hoping that my Pain doc will continue my pain regimine for FM and recurring Chosto after my surgery. That is if my surgery is successful. My rheumy seems to think that there is some permanent damage back there due to some of the extreme changes in my ability to move my legs.

Once again Shore(Dave is it?), you seem to have given us all a wealth of continued information. It's like some of us get the ball rolling and you keep it rolling! LOL

You listed some of your injuries, especially that back, wow. I know that when your back is messed up it's pretty annoying (to say the least). I got dx with FM first, then 6 months later I got dx with my back problems. Then all the others! LOL It seems like there is one thing each year that adds to the list. I want to speak to a supervisor to make this all stop! :)

Have a good day Shore. Go rest your brain after that post!

Shoreline 01-13-2005 08:48 AM

Re: Possible answers as to why some are having trouble getting pain meds.
Hey TK, I just corected all my spelling and typo's, I swear I must be dyslexic and can't keep blaming my old stickey keyboard.LOL

Something you may not be aware of. When I started PM back in 93 after the first surgery, Everyone got antidepressants. Their explanation was that they inhibit substance P, I thought substance P was just something they made up to prescribe more prozac, I can't handle any of the SSRI's either. But since being disabled I have had lots of time to research things. Substance P is a real thing. It's a powerful neruo inflamatory agent that you only see in CP patients. It takes months for the biochemical changes to occur from acute pain to chronic pain and substance P is one of those changes, along with a different part of your brain interpreting the pain signal in CP Vs Acute pain, Several new Neurotransmiters are created with CP, and the flow of NT's only flow in one direction with acute pain, IN CP they flow back and forth from the brain to the spinal cord and site of injury ,engraining that pain signal into the nerve tissue.
But back to sub P. The one thing all fibro patients have in common that can actually be tested and proved, IS an extremely high level of substance P in your spinal fluid. This requires a spinal tap to indentfy, and that's a bit extreme to DX fibro, but it's a very interesting clinical finding.

I don't think everyone should have to be butchered by surgery to have PM made available to them, But if there is a solution to someones pain, I would still take it over the meds or the pump I had implanted back in june.

Another med that may inhibit substance P is Baclofen, a med used for MS for spacticity. It stops or slows the creation of a new calcium chanel blocker called "NK-1" that only CP patients have that carries substance P to the spinal cord, Baclofen also helps block pain signals at the dorsal horn of your brain. Meds that block NMDA receptors can help with tolerance to pain, nerve pain and tolerance to opiates. The newest med on the market is a drug called Nemanda.

If you haven't read this article yet, It gives you a pretty good idea what changes accur between chronic and acute pain. Before understanding the changes, I always compared the pain I have now to the pain of post op or the pain I experienced pre op and although it feels the same, actually worse, it's amazing the difference in biochemicals, neurotransmitters and even the part of your brain interprets pan signals in CP Vs acute pain.

Part 1, Has the info about the differencees in CP and acute pain

Part 2 is more about opiate selection and the difference between addiction and simple physical dependence.

You know it's interesting you mentioned they don't tell you about stopping antiD's. The use of meds and opiates are so politicaly and socially charged that there is a different name for withdrawal coming off of antiD's, they call it abstinence sysndrome which can lead to serritonin sysndrome and kill you. But the term abstinence sysndrome is used for meds that don't have the negative unsubstantiated ideas attached to opiates.

If you experience abstinence syndrome from opiates, they call it withdrawal just to add that little opiate stigma, ignorant people can say I told you you would get hooked. But know nothing about abstinenece syndrome which simply describes the negative effects of stopping any other med aside from opiates and benzo's cold turkey. They even have to use a negative name to describe the same physical response to discontinuing a med abruptly.

Just like calling opiates Narcotics, It adds that stigma and suggests illegal use. The DEA calls cocaine/speed/MJ/X narcotics but they have absolutely no similarities to opiates other than the negative choice of words to describe illegal, unsafe, and dangerous drugs. The proble is ceratnly political, but that's a whole nother discussion.

Opiates were brought her by the chineese, elieved to be inferior people, MJ was brought to this country through mexico, also believed to be inferrior people back in the early 1900's. Ever seen Reefer madness. ROTFLMAO

Anyway, try cutting and pasting those links in your browser if you haven't read Dr brookoffs articles.
Hang in there, I have the same problem with the mail box.

tkgoodspirit 01-13-2005 11:44 AM

Re: Possible answers as to why some are having trouble getting pain meds.
Thank you so much for the info on substance P. That is SO interesting. I knew that having FM made your CN system go a little bonkers when it tries to "understand" pain. There was a research study done once that administered pain to a "normal" as well as a "fibromite" :), and the reaction in the brain was pretty s p e c t a c u l a r as far as the difference between the two patients.

If I could get a doctor to give me a spinal tap to check for substance P, I certainly would go through it, just to finally put proof of fibro on paper. It sure would help out my disability claim. Maybe I will talk to my Pain doc about this. He is pretty well informed on a lot of the newer procedures that deal with FM.

I also didn't realize all that info about coming off the anti-D's. I hate it, that's why I don't ever want to take another one, eventually you have to quit taking it. I took Effexor for over 2 years and that was a stinker to come off. All I heard from some of my docs when I was first dx with FM was "serotonin this, and serotonin that", blah! I know there are other ways of working on your serotonin without those stinkin anti-D's. I have heard that 5HTP is good for that. Have you? I used it in the past, but have been pretty bad about taking any of my vitamins or amino acids lately. I also know that (God help me) exercise will raise serotonin levels. I'll work on that later! ;)
Besides, I think that there are other things to FM besides having low serotonin.

Anyway, as usual, it's always enlightening to read your posts.

Have a good day, it's raining like crazy here on the gulf coast of beautiful Alabama!


Tyneyboy 01-14-2005 05:11 AM

Re: Possible answers as to why some are having trouble getting pain meds.
Only a minority of people with FMS have lowered levels of serotonin in their CSF, there is a test for this called a 5-HIAA, and if you are going to get a spinal tap done, you might as well have them run both of the test at the same time. It was found about 20% of people with FMS have lowered serotonin levels, just about all of them have highly elevated substance P levels though, usually greater than 2 times higher, often more than 3 times higher. Not that it's something that should be done lightly. It's not a fun proceedure, and it's not without risks.

I would disagree with only having pain management specialist manage pain. Not because I don't think they could be better at it, but simply for logistics reasons. You have greater than 10 million people on continued opioid therapy, and less than 3000 pain management doctors, and probably closer to 35 million people who *need* it. Even in the best case geographical distribution of pain management specialist, the case load they would have to bare is beyond what any of them could handle in an appropriate manner, and if they tried they would end up being accused of being pill mills...etc..etc

Does the person who really only needs 40-80mg of oxycontin or 90-180mg of Mscontin really need a pain management specialist? I've heard of people getting referred to pain management specialist because they needed 10mg of oxycodone BID, is this appropriate? We can't solve this for everyone by dumping it all on specialist. I've even heard of the little old lady who needed "4" vicodin a day to help her age related osteo arthritis being referred away even though she was satisfied with her level of relief from it, is this what we want?

While I would agree that most GP's are not as qualified as they need to be, this can be rectified. We could make it a requirement that to hold the license at the state level that they have to have XX many hours of pain management training. This would force a lot of doctors back into continuing medical education, but we would solve the problem of them not having the eduation to administer most of these tools. I would agree that the more complex cases need referrals, and honestly, some doctors just don't have a clue and have plenty of evidence and anecdotes to support that, but it would definitely be a step in the right direction.

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