This is the place for practitioners to anonymously say whatever you feel constrained from saying in other places.
53 Replies to “Professional Input”
Ms. Merandi: Thank you for posting my letter (Legal Precedents) on the DPP national page. No person or government agency is above the law or the supreme court decisions which guarantee patients the right to palliative care; obstacles to palliative care must be eliminated. Those who put up obstacles to palliative care by more red tape, or more bureaucracy, or harassing doctors who treat pain patients, are practically in violation of the law and in contempt of the Supreme Court, with or without knowing it. So, pain patients are asking for legal rights not begging for mercy.
I sent these laws to the DOJ offices of civil rights division and office of professional responsibility (addresses below).
It would be very helpful to our cause if more people sent the legal precedents to those offices and to other influential people.
Dr. Salman
—–
US Department of Justice, Civil Rights Division, 950 Pennsylvania Avenue, NW Criminal Section – PHB Washington, DC 20530 and E-mail at ADA.complaint@usdoj.gov
Counsel Office of Professional Responsibility. By express mail and E-mail
950 Pennsylvania Avenue, N.W., Suite 3266 Washington, DC 20530-0001 OPR.Complaints@usdo
To Dr Salman,
Thank you Thank you Thank you. What you have put together – stating both doctor and patients Actual rights in regard to pain relief is absolutely astounding!
Just a few years ago, prior to the “guidelines” having real world effects on patients, I personally just assumed that those rights under supreme court rulings, were a given, to the degree that I never thought about them at all! This goes to show how quickly the CDC has made us forget what it was like years ago and how now, the fight for our daily medications is the norm. We never HAD to think about our rights. We never had to have this enormous ongoing stress nor this ongoing state of pain so intense that whole life after whole life has been destroyed, by some unknown entity to me. I haven’t been able to figure it all out. How can doctor rights and the American people’s rights….have gone missing? How did so many get away with doing this to doctors and patients? Why in the world can’t it be fixed, now that some light has been shown? Who is responsible for letting this continue on?
Many thanks for a great document! I downloaded it and will be using it from now on.
By the way, I have a “bad back ” from a car accident, have had too many things done to mention here, I have cancer, I have trouble walking around my house from a bad leg that has multiple diagnose /problems, I have damaged lungs, a number of other chronic pain problems, and the worst of what I have is TN. I had to cancel my cancer surgery in July and will cancel its reschedule date in September. My family doctor will only prescribe tylenol 3 and gabapentin and 2 ibuprofen every 6 hours for me, and all I can tell you is what I tell her, I am in constant severe pain all over, this “cocktail” isn’t working. I then get the speech of how she can’t give me what I need at her office, and to go to pain management. I went. That doctor said “well, looks like she’s doing what I would do and there’s really nothing else I can do here. ” I will mention that for the 15 minutes I was in the exam room that HE WAS SORT OF THERE, he was called out 3 times and actual time spent with me was under 2 minutes. And this was a well respected practice too! So I was taken aback.
Also this month my pharmacy notified me that it would no longer give me the 2 inhalers every month that is prescribed to me. I’ve been on them for 20 plus years. After much discussion with him I finally understood that it was HE and him alone that made this decision! I cannot tell you what his decision has done to me. There are few words to describe what it’s like to go through life in severe pain, AND unable to get a full breath of air into your lungs too. So you see, I am in no shape for major surgery. I wish this hadn’t have happened right now while I was stressing over surgery because it made surgery a hundred percent out of the question. I told the pharmacy this and it fell on deaf ears.
Thanks for listening to all this and thank you for what you’ve done.
Provider Column:
If FDA is the federally mandated regulatory agency, and its labeling is by regulation which has the force of law, and the FDA does not have maximum doses for long term use allowing titration to what ever bottle mg level works without side effects, and since dose, type of opiate, length of use have nothing to do with opiate (my Type B) addiction, why are we not following the legal guidelines instead of the CDC “guidelines” an agency that does not have a charter for opiate regulation, or suggestion, or recommendation —- only the FDA
We are often told that pain is subjective and cannot be measured. That may be true today, but in the future, we will be able to measure the electronic correlates of pain. It is too often overlooked that even today we can measure OBJECTIVE correlates of chronic pain.
People with chronic pain fall and suffer injuries far more frequently than people without pain. It is not pain medications that cause the falls. Falls happen even in people who are not taking medications. I have reviewed the issue of Falls in Chronic Pain in an article published in Practical Pain Management (https://www.practicalpainmanagement.com/pain/other/co-morbidities/chronic-pain-falls). Numerous references that confirm the association between falls and chronic pain are listed in that article. I also explain possible physiologic explanations.
Using a Queen Square Reflex Hammer, about 44% of my chronic pain patients had hyperactive or brisk knee reflex as well as a “crossed adductor reflex (CAR).” The CAR is generally considered to be an abnormal reflex. In this reflex, when you strike one knee tendon, the adductor muscle in the opposite leg also contracts reflexly. This reflex pattern is also described in my article.
I urge pain patients to ask their doctors to check reflexes carefully and to invest the $10 to $15 needed for a Queen Square Reflex Hammer. Let the doctor know that the experience of pain may be subjective (known only to you) but some physiologic correlates are indeed objective and measurable.
AMA Decries the Impact of the CDC’s Opioid Guidelines on Pain Treatment
The physician group says widespread “misapplication” of the guidelines is hurting patients.
Jacob Sullum|Nov. 19, 2018 12:30 pm
So tired of seeing my patients suffering…. being made to switch to tramadol or gabapentin or going through injections that quite frankly don’t work… that aren’t surgical candidates and some older and not ready for hospice…. it’s literally at crisis level…. most have to travel 60 miles (in pain) one way to see a pain dr… its simple heartbreaking…
I am a nurse practitioner who practices in Missouri. I have been in pain management for the past seven years. I truly came into this field to help my patients. Unfortunately, in Missouri we are not allowed to prescribe controlled substances and must be in practice with a collaborating physician who dictates how and what is prescribed and must sign scripts. I truly believe in advocating for what I feel is right for my patients, treating them individually rather than on some blanket numbers given to me by someone who has never examined them or even spoken to them. It angers me and deeply saddens me that these CDC “guidelines” were made for us to follow by Governor Greitens even though they are not law or will be reported to our licensing boards while he is not held to the same professional standards. I do not understand how taking away the pain medication of my patients who have not done anything wrong, who have no history of aberrant behavior is keeping heroin from being brought in the USA. When I am literally crying, telling my 72 YO that I have to decrease his meds and he asks why and I don’t know why. Because at this point as with most pain management patients, he has done physical therapy, chiropractic care, surgery, interventional procedures, topicals, and every other adjunctive therapy known to man. There is no reason pain management should not be able to treat pain management patients. I am so angry that my CP will not stand up to it. Thank you for letting me vent and thank you so much for standing up for all the pain patients who need help.
I am a retired RN who is now elderly and in pain. I know that any one who has mobility issues must be medicated as immobility is the worst
I am a physician and so is my spouse. I am responsible for my father who has dementia. He recently had a partial foot and ray amputation followed by a month of non-healing followed by a below knee amputation. Listening to him scream was a nightmare. This demented nearly 80 year old was left after his block wore off over 24 hours at a time at least twice with nothing for pain, and very little between. He was expected to understand “prn” dosing. He was almost kicked out of 2 rehabs for refusing to do therapy—because he was in so much pain immediately after his amputation. His team refused to consider a scheduled dose prior to dressing changes and therapy. I overheard a team member cruelly tell him phantom pain was normal when what he was having was acute post-op pain. I wonder how they would have felt right after having a leg cut off and being extremely confused? I won’t even go into mine and my husband’s experiences with medicine in general. It’s disgusting. These guidelines have ushered in an era of the worst behavior I’ve ever seen. We’ve been extremely lucky to have some wonderful providers and pharmacists we’d be dead without. They are the minority. Most are concerned with their bottom line, they know malpractice is no longer a threat, and they don’t have to listen to patients or even examine and diagnose accurately anymore let alone treat with compassion. If a procedure or device hurts you it’s your problem. God help this nation.
As a nurse of 35 years who is also waiting to have bilateral hip replacements who has arthritis in my back who has had three knee Replacements and foot surgery I am shocked at the amount of pain I’m asked to endure rather than have my doctor prescribe pain medication for me when he does prescribe medicine Walmart Pharmacy gives me a hard time about filling my medication
Ms. Merandi: Thank you for posting my letter (Legal Precedents) on the DPP national page. No person or government agency is above the law or the supreme court decisions which guarantee patients the right to palliative care; obstacles to palliative care must be eliminated. Those who put up obstacles to palliative care by more red tape, or more bureaucracy, or harassing doctors who treat pain patients, are practically in violation of the law and in contempt of the Supreme Court, with or without knowing it. So, pain patients are asking for legal rights not begging for mercy.
I sent these laws to the DOJ offices of civil rights division and office of professional responsibility (addresses below).
It would be very helpful to our cause if more people sent the legal precedents to those offices and to other influential people.
Dr. Salman
—–
US Department of Justice, Civil Rights Division, 950 Pennsylvania Avenue, NW Criminal Section – PHB Washington, DC 20530 and E-mail at ADA.complaint@usdoj.gov
Counsel Office of Professional Responsibility. By express mail and E-mail
950 Pennsylvania Avenue, N.W., Suite 3266 Washington, DC 20530-0001 OPR.Complaints@usdo
To Dr Salman,
Thank you Thank you Thank you. What you have put together – stating both doctor and patients Actual rights in regard to pain relief is absolutely astounding!
Just a few years ago, prior to the “guidelines” having real world effects on patients, I personally just assumed that those rights under supreme court rulings, were a given, to the degree that I never thought about them at all! This goes to show how quickly the CDC has made us forget what it was like years ago and how now, the fight for our daily medications is the norm. We never HAD to think about our rights. We never had to have this enormous ongoing stress nor this ongoing state of pain so intense that whole life after whole life has been destroyed, by some unknown entity to me. I haven’t been able to figure it all out. How can doctor rights and the American people’s rights….have gone missing? How did so many get away with doing this to doctors and patients? Why in the world can’t it be fixed, now that some light has been shown? Who is responsible for letting this continue on?
Many thanks for a great document! I downloaded it and will be using it from now on.
By the way, I have a “bad back ” from a car accident, have had too many things done to mention here, I have cancer, I have trouble walking around my house from a bad leg that has multiple diagnose /problems, I have damaged lungs, a number of other chronic pain problems, and the worst of what I have is TN. I had to cancel my cancer surgery in July and will cancel its reschedule date in September. My family doctor will only prescribe tylenol 3 and gabapentin and 2 ibuprofen every 6 hours for me, and all I can tell you is what I tell her, I am in constant severe pain all over, this “cocktail” isn’t working. I then get the speech of how she can’t give me what I need at her office, and to go to pain management. I went. That doctor said “well, looks like she’s doing what I would do and there’s really nothing else I can do here. ” I will mention that for the 15 minutes I was in the exam room that HE WAS SORT OF THERE, he was called out 3 times and actual time spent with me was under 2 minutes. And this was a well respected practice too! So I was taken aback.
Also this month my pharmacy notified me that it would no longer give me the 2 inhalers every month that is prescribed to me. I’ve been on them for 20 plus years. After much discussion with him I finally understood that it was HE and him alone that made this decision! I cannot tell you what his decision has done to me. There are few words to describe what it’s like to go through life in severe pain, AND unable to get a full breath of air into your lungs too. So you see, I am in no shape for major surgery. I wish this hadn’t have happened right now while I was stressing over surgery because it made surgery a hundred percent out of the question. I told the pharmacy this and it fell on deaf ears.
Thanks for listening to all this and thank you for what you’ve done.
Provider Column:
If FDA is the federally mandated regulatory agency, and its labeling is by regulation which has the force of law, and the FDA does not have maximum doses for long term use allowing titration to what ever bottle mg level works without side effects, and since dose, type of opiate, length of use have nothing to do with opiate (my Type B) addiction, why are we not following the legal guidelines instead of the CDC “guidelines” an agency that does not have a charter for opiate regulation, or suggestion, or recommendation —- only the FDA
We are often told that pain is subjective and cannot be measured. That may be true today, but in the future, we will be able to measure the electronic correlates of pain. It is too often overlooked that even today we can measure OBJECTIVE correlates of chronic pain.
People with chronic pain fall and suffer injuries far more frequently than people without pain. It is not pain medications that cause the falls. Falls happen even in people who are not taking medications. I have reviewed the issue of Falls in Chronic Pain in an article published in Practical Pain Management (https://www.practicalpainmanagement.com/pain/other/co-morbidities/chronic-pain-falls). Numerous references that confirm the association between falls and chronic pain are listed in that article. I also explain possible physiologic explanations.
Another objective finding that is present in about half of people with chronic pain is hyperactive reflexes, especially the patellar (knee jerk) reflex. Most physicians are not very good at eliciting consistent reflexes, and the tool that most use is practically useless. A reflex needs the application of a sudden stretch of the tendon being struck. A “Queen Square” reflex wheel provides excellent strike pattern to consistently elicit reflexes. (See this link for a picture: https://www.amazon.com/Neurological-EIH-781-pointed-superficial-responses/dp/B01JMTC3AO/ref=pd_lpo_vtph_121_tr_t_2?_encoding=UTF8&psc=1&refRID=8HPW7YZE59BBGMNNJBYY).
Using a Queen Square Reflex Hammer, about 44% of my chronic pain patients had hyperactive or brisk knee reflex as well as a “crossed adductor reflex (CAR).” The CAR is generally considered to be an abnormal reflex. In this reflex, when you strike one knee tendon, the adductor muscle in the opposite leg also contracts reflexly. This reflex pattern is also described in my article.
I urge pain patients to ask their doctors to check reflexes carefully and to invest the $10 to $15 needed for a Queen Square Reflex Hammer. Let the doctor know that the experience of pain may be subjective (known only to you) but some physiologic correlates are indeed objective and measurable.
AMA Decries the Impact of the CDC’s Opioid Guidelines on Pain Treatment
The physician group says widespread “misapplication” of the guidelines is hurting patients.
Jacob Sullum|Nov. 19, 2018 12:30 pm
https://reason.com/blog/2018/11/19/ama-decries-the-impact-of-the-cdcs-opioi
So tired of seeing my patients suffering…. being made to switch to tramadol or gabapentin or going through injections that quite frankly don’t work… that aren’t surgical candidates and some older and not ready for hospice…. it’s literally at crisis level…. most have to travel 60 miles (in pain) one way to see a pain dr… its simple heartbreaking…
I am a nurse practitioner who practices in Missouri. I have been in pain management for the past seven years. I truly came into this field to help my patients. Unfortunately, in Missouri we are not allowed to prescribe controlled substances and must be in practice with a collaborating physician who dictates how and what is prescribed and must sign scripts. I truly believe in advocating for what I feel is right for my patients, treating them individually rather than on some blanket numbers given to me by someone who has never examined them or even spoken to them. It angers me and deeply saddens me that these CDC “guidelines” were made for us to follow by Governor Greitens even though they are not law or will be reported to our licensing boards while he is not held to the same professional standards. I do not understand how taking away the pain medication of my patients who have not done anything wrong, who have no history of aberrant behavior is keeping heroin from being brought in the USA. When I am literally crying, telling my 72 YO that I have to decrease his meds and he asks why and I don’t know why. Because at this point as with most pain management patients, he has done physical therapy, chiropractic care, surgery, interventional procedures, topicals, and every other adjunctive therapy known to man. There is no reason pain management should not be able to treat pain management patients. I am so angry that my CP will not stand up to it. Thank you for letting me vent and thank you so much for standing up for all the pain patients who need help.
I am a retired RN who is now elderly and in pain. I know that any one who has mobility issues must be medicated as immobility is the worst
I am a physician and so is my spouse. I am responsible for my father who has dementia. He recently had a partial foot and ray amputation followed by a month of non-healing followed by a below knee amputation. Listening to him scream was a nightmare. This demented nearly 80 year old was left after his block wore off over 24 hours at a time at least twice with nothing for pain, and very little between. He was expected to understand “prn” dosing. He was almost kicked out of 2 rehabs for refusing to do therapy—because he was in so much pain immediately after his amputation. His team refused to consider a scheduled dose prior to dressing changes and therapy. I overheard a team member cruelly tell him phantom pain was normal when what he was having was acute post-op pain. I wonder how they would have felt right after having a leg cut off and being extremely confused? I won’t even go into mine and my husband’s experiences with medicine in general. It’s disgusting. These guidelines have ushered in an era of the worst behavior I’ve ever seen. We’ve been extremely lucky to have some wonderful providers and pharmacists we’d be dead without. They are the minority. Most are concerned with their bottom line, they know malpractice is no longer a threat, and they don’t have to listen to patients or even examine and diagnose accurately anymore let alone treat with compassion. If a procedure or device hurts you it’s your problem. God help this nation.
As a nurse of 35 years who is also waiting to have bilateral hip replacements who has arthritis in my back who has had three knee Replacements and foot surgery I am shocked at the amount of pain I’m asked to endure rather than have my doctor prescribe pain medication for me when he does prescribe medicine Walmart Pharmacy gives me a hard time about filling my medication