This is the place for practitioners to anonymously say whatever you feel constrained from saying in other places.
53 Replies to “Professional Input”
The sad reality is that many addicts have an underlying dopamine signaling issue (d2 receptor). Taking dopamine antagonists like oxycodone gives them a more “normal” sense of well-being and functionality rather than a healthy individual who is on opioids. There are only a few medications that correct this including certain medications to treat adhd, Parkinsons and of course, opioids. Since pain relief is not a disease-specific treatment, like say antiseizure medications to Parkinsons, it makes opioids the most widely introduced to the general public. When someone who is dopamine deficient takes opioids they are actually more “functional” and do not get the same euphoric effect as a person with properly functioning neurotransmitters. This makes it desirable to many because at lower yet effective doses they are not intoxicated or high but instead have the proper reward center function as healthy people. In turn this makes the dose required to achieve a this euphoria high much higher and subsequently more dangerous to those who are also abusing it for recreational purposes. This is why the amount of overdoses on these medications is a genuine concern, more so in these individuals. Unfortunately law makers have basically overlooked this completely and without actually understanding the root cause of a problem you can not effectively correct it. They’ve instead chosen to just restrict these medications on a widespread basis without regard for its actual clinical need and this will only further aggravate the underlying psychoneurological problems of many addicted to it. This will continue to leave it unaddressed and untreated. Many will then just turn to illicit drugs to self medicate. Unfortunately, those who do not will also likely suffer due to the exacerbation of the mental health conditions they were attempting to control to begin with. The further deterioration of their mental state poses a significantly enhanced challenge if they do eventually get proper help. Basically it sets these individuals up to fail and essentially helps no one in the end. The most disturbing part is that while this poorly executed plan to curb addiction is failing miserably, there is also another demographic being made into the collateral damage. These casualties are our nation’s legitimate pain patients who are being denied adequate medically necessary treatment.
As a practicing physician I agree with the pharmacist on two points but disagree with the overall post. Yes there was corporate pressure to write opioids and the major side effect, respiratory depression, kills people. However, what other class of meds works as well for pain? Antidepressants and antiepileptics can help but in my clinical experience they just don’t work as well as opioids. There’s just no excuse for a system in which some patients commit suicide to stop the pain. Let’s carefully monitor patients on opioids to reduce the risk of respiratory depression.
When will the media finally tell patients that at least half the opioid overdoses happen to people who get meds illegally from friends? Any doctor who has done CME recently knows what I’m talking about.
Has anyone done a study to look at all causes of mortality in chronic pain patients? It might be difficult to control for factors such as the original causes of pain (trauma, diabetic neuropathy, etc) Even so, I’d like to read about it. Does pain itself have a significant impact on mortality?
Not only have the doctors been pushed to tar chronic pain suffers with the same brush as criminally mischievous drug abusers, they have also been politically pressured to suggestively interpret in their progress notes the despairing actions of chronic pain sufferers as being substance abuse symptoms. Having fallen for it, believing the “therapeutic” effectivness of a partial agonist as efficacious as a pure opioid, my situation is not only much more painful, but I am now on record as being a drug addicticted, drug seeking, junky. When my prescriptions changed from stating pain as a diagnosis to “dependence” the pharmacy staff’s attitude and demeanor shockingly became so condescending and judgemental that people I had known for years became so hostile I’ ve now changed pharmacies twice and found, not a reprieve, but even less helpful and even
seemingly vindictive apathetic behaviors.
I belong to an RN group on Facebook and I am utterly ashamed of some of my colleagues. The way they turn their noses up to pain. They laugh at it. Make disrespectful memes for likes and carry on over disgusting comments. It breaks my heart. We live in the year 2020. No one should suffer from pain. Yea, Norco causes dependence. You can’t stop it abruptly. Same though with a medrol pak or any antidepressant. The body becomes habituated to many medicines. Suffering is occurring. Suicides are occurring. But the DEA isn’t worried about every other KID in the US sucking down amphetamine salts. Opioids monitored well work well, they have since the olden days. They allow people to work, play with their kids and have a quality of life. This witch-hunt is deadly.
Dr. Halkovic, I’m sorry and I don’t mean to be dismissive but that’s a copout. We all know how opioids effect our pain. If the powers that be do not, it is your responsibility as not only the educated mind involved but your responsibility to make it known because you’re the one writing it. They have not restricted anything. They only have made you have to speak to its authenticity.
See, this is the problem, patients with real problems being told by their paid physicians that their hands are tied. Well, stop benefiting from it then. I’m so sick of hearing and seeing this blame game magician’s hand swap. The government doesn’t diagnose or have the power to prescribe. You do. If we aren’t getting the proper treatment it’s because your profession refuses to treat. What you don’t understand is the next step. Massive undertakings. Widespread lawsuits claiming depraved indifference. That’s what it is. Your fellows cannot get rich for 20 years handing drugs to people where 40% didn’t need it and kept getting it to the point where it was given so much that their death count couldn’t be overlooked.
The depravity is that as long as you could hand it out and benefit without any responsibility you did. It wasn’t until people started asking why is someone with a sore ankle getting oxycontin did you decide it wasn’t safe for you. The irresponsibility in that is the same as the irresponsibility of taking it away from everyone regardless of whether or not they need it. To hear you, a doctor, come on here and push the blame like you did is a testament to just how little personal responsibility you actually take.
You make a couple of good points Nicholas but I think you are somewhat off on your blaming physicians for being the responsible party for refusing to treat patients. There ARE many times when a physicians hands ARE tied and not because they have a choice about it. I had a colleague physician walk out on the facility because the corporation who owned the facility attempted to FORCE him to write an inappropriate opioid prescription solely based on threats by the patient that they would go to another clinic if they didn’t get what they wanted. He walked before being fired for not complying to rules set by a corporation, that was located out of state, and who had no clue about running a pain clinic. Their sole interest was making as much revenue for their investors as possible which is why the scheduled patients every 10 minutes. How do you provide appropriate care for a patient in 10 minutes? A week later, they tried the same tactic with me and I resigned. Physicians DO have a choice when writing prescriptions however; they may be also setting themselves up for wrongful prosecution and loss of license by writing for opioids that someone else has deemed “unsafe and dangerous”.
The saying goes don’t judge another person unless you’ve walked in their shoes. You don’t know how painful it is to look a patient in the eye, one who’s been doing very well on what was being prescribed, and yet are being forced to tell them you have to cut back on the medications they have been functioning so well on in the past, knowing they are going to suffer. It haunts us being put in a position between what we feel is appropriate and safe, and being fired or worse, losing our licenses.
I strongly disagree with the assumptions: “The sad reality is that many addicts have an underlying dopamine signaling issue (d2 receptor). Taking dopamine antagonists like oxycodone gives them a more “normal” sense of well-being and functionality rather than a healthy individual who is on
an opiate.”
When a person who has Centralized Intractable Pain” and other serious pain disorders experiences unbelievable, unrelenting, unbearable pain, they are only HEALTHY (spiritually, mentally and physically) when the pain is controlled. Treating chronic pain is like any other disease processes. Treatment needs to include alternative therapies, proper diet, exercise and being able to spend time with family and friends. Dosing of an opiate should be based upon the individual’s accomplishments of functionality goals.
However, unfortunately, some chronic pain patients have lost their ability to function due to decreasing and/or changing medications that do not work. That situation requires intervention … to recover these unfortunate individuals who got caught in a deadly net.
I have a slightly different view on things. 1. I am a nurse and 2. I am a chronic pain patient myself, in a position to help manage chronic pain in my patients. My issues come from failed surgeries, the first of which, was botched by my surgeon, which set me up for YEARS of pain and fighting for my right to be treated with dignity, respect and actually be listened to.
I refuse to claim disability coverage for two reasons. 1. I LOVE my job and honestly, I feel better when my attention can be more focused to help others, as well as keeping my pain more under control when I am moving around more. 2. The stigma is REAL!!! Being labeled as a person who is opioid-dependent is a HUGE drain on my mental well being, and I dread my chronic pain appointments and going to pick up my medications that keep me working and functional. I do not get high and take way less than the 90 morphine equivalents that the government states is the max, but yet, I am still stigmatized and belittled for my use.
I work as a PRN employee because there are days when I cannot make it to work due to my level of pain, but yet, I still work primarily full-time hours because I only have ONE income, and that is mine. If I don’t work I don’t eat, have a roof over my head, or anything else that is required to survive in this world. So the other stigma is using government-funded insurance because as a PRN employee, I am not eligible for insurance through my employer, which is a whole other issue regarding mental well being. I have had seven major back surgeries with three hardware changes, and due to all this, I have also had three total hip arthroplasties, with more up and coming. My only requirement for my surgeons are “keep me vertical and working”. I complete surgeries when I cannot function any longer, then it’s back to work… rinse and repeat. To make matters worse, I am ONLY 50 and should still have years of working left in me.
My co-workers and the providers I work with have no idea of the pain I am really in, as I have become a master at hiding my pain outwardly, and crying throughout the day at times, in private. My career is everything from working surgery, the ER, home health, specializing in wound care and now clinic. I change my positions based upon my physical limitations, and thank goodness, working in clinic allows me to work without the physical side of nursing coming into play.
Due to my unique situation, I am a HUGE patient advocate when it comes to functionality in regards to pain control, but even I have to fight on a monthly basis to keep getting what I am getting, so I CAN continue to be a functional member of society. In the 15 years since my first surgery, I have NEVER had one bad drug test, NEVER asked once for an early script, NEVER been discharged from services and still continue to work in between my many surgeries. Why then, does someone like me have to fight every month to have my basic needs met? I have done everything my providers have asked, including non-narcotic treatments, injections, physical therapies, and yes, even counseling to address my “narcotic abuse”, which has NEVER been abuse, but yes, I will admit to dependence… after 15 years, if I didn’t, I’d call myself a total liar.
The scariest thing I am facing now is being cut off and having to deal with withdrawal, which I have gone through thanks to being so stigmatized about my prescription. I don’t drop names, or my profession and most of the pharmacists and clinic staff at my pain clinic have NO idea of my titles, where I work, or what health organization I am employed by, as my personal life is NOT my working life, and I have never striven to be treated any differently because of what I do. After 15 years of dealing with this, I am not afraid of the increase in pain if they stop prescribing what keeps me upright, I am afraid of withdrawal and not being able to work or be a functioning member of society if they do. In that situation, I fully understand why people commit suicide over this… without having a reason to go on, why bother remaining in this world when everything that you enjoy about it is taken away?
I am now facing having to find another pain clinic to manage my pain, while I am prepping for my eighth major back surgery, since I was just cut off due to an argument with a previous pain clinic over financial issues, since I owe them a whopping $163. Yes, you read that right… not 163k, but ONE HUNDRED SIXTY THREE DOLLARS. While they gave me a month’s prescription to get me by till I can find another provider, which the referral is in for, but they haven’t finished reviewing it yet, and they are refusing to do the PA on the medication, which is due, and my PCP does not do ANY pain medications. As of tomorrow, I face withdrawal when I run out of medication and have no means to get it. So where is the justice for people like me?
IMO: screw the government and screw the insurance companies for putting good people in a place where they are scared to death to face it. Providers SHOULD be allowed to prescribe without retribution by the government, insurance companies, etc, as long as the patients they serve are being managed, have a plan in place and are following the rules. There should NOT be a limit to what someone can get as long as there is a clear plan in place, their patients are well monitored and all the rules surrounding prescribing are followed… ie: drug testing, in-person appointments, etc. We, as prescribers, nurses, medical personnel etc, MUST STOP THE STIGMA. There are GOOD people who have no options, and should not be labeled as an abuser, because other people have decided they like the “high” they get and go above and beyond to get what they want. It’s really sad.
The sad reality is that many addicts have an underlying dopamine signaling issue (d2 receptor). Taking dopamine antagonists like oxycodone gives them a more “normal” sense of well-being and functionality rather than a healthy individual who is on opioids. There are only a few medications that correct this including certain medications to treat adhd, Parkinsons and of course, opioids. Since pain relief is not a disease-specific treatment, like say antiseizure medications to Parkinsons, it makes opioids the most widely introduced to the general public. When someone who is dopamine deficient takes opioids they are actually more “functional” and do not get the same euphoric effect as a person with properly functioning neurotransmitters. This makes it desirable to many because at lower yet effective doses they are not intoxicated or high but instead have the proper reward center function as healthy people. In turn this makes the dose required to achieve a this euphoria high much higher and subsequently more dangerous to those who are also abusing it for recreational purposes. This is why the amount of overdoses on these medications is a genuine concern, more so in these individuals. Unfortunately law makers have basically overlooked this completely and without actually understanding the root cause of a problem you can not effectively correct it. They’ve instead chosen to just restrict these medications on a widespread basis without regard for its actual clinical need and this will only further aggravate the underlying psychoneurological problems of many addicted to it. This will continue to leave it unaddressed and untreated. Many will then just turn to illicit drugs to self medicate. Unfortunately, those who do not will also likely suffer due to the exacerbation of the mental health conditions they were attempting to control to begin with. The further deterioration of their mental state poses a significantly enhanced challenge if they do eventually get proper help. Basically it sets these individuals up to fail and essentially helps no one in the end. The most disturbing part is that while this poorly executed plan to curb addiction is failing miserably, there is also another demographic being made into the collateral damage. These casualties are our nation’s legitimate pain patients who are being denied adequate medically necessary treatment.
As a practicing physician I agree with the pharmacist on two points but disagree with the overall post. Yes there was corporate pressure to write opioids and the major side effect, respiratory depression, kills people. However, what other class of meds works as well for pain? Antidepressants and antiepileptics can help but in my clinical experience they just don’t work as well as opioids. There’s just no excuse for a system in which some patients commit suicide to stop the pain. Let’s carefully monitor patients on opioids to reduce the risk of respiratory depression.
When will the media finally tell patients that at least half the opioid overdoses happen to people who get meds illegally from friends? Any doctor who has done CME recently knows what I’m talking about.
Has anyone done a study to look at all causes of mortality in chronic pain patients? It might be difficult to control for factors such as the original causes of pain (trauma, diabetic neuropathy, etc) Even so, I’d like to read about it. Does pain itself have a significant impact on mortality?
Not only have the doctors been pushed to tar chronic pain suffers with the same brush as criminally mischievous drug abusers, they have also been politically pressured to suggestively interpret in their progress notes the despairing actions of chronic pain sufferers as being substance abuse symptoms. Having fallen for it, believing the “therapeutic” effectivness of a partial agonist as efficacious as a pure opioid, my situation is not only much more painful, but I am now on record as being a drug addicticted, drug seeking, junky. When my prescriptions changed from stating pain as a diagnosis to “dependence” the pharmacy staff’s attitude and demeanor shockingly became so condescending and judgemental that people I had known for years became so hostile I’ ve now changed pharmacies twice and found, not a reprieve, but even less helpful and even
seemingly vindictive apathetic behaviors.
I belong to an RN group on Facebook and I am utterly ashamed of some of my colleagues. The way they turn their noses up to pain. They laugh at it. Make disrespectful memes for likes and carry on over disgusting comments. It breaks my heart. We live in the year 2020. No one should suffer from pain. Yea, Norco causes dependence. You can’t stop it abruptly. Same though with a medrol pak or any antidepressant. The body becomes habituated to many medicines. Suffering is occurring. Suicides are occurring. But the DEA isn’t worried about every other KID in the US sucking down amphetamine salts. Opioids monitored well work well, they have since the olden days. They allow people to work, play with their kids and have a quality of life. This witch-hunt is deadly.
Dr. Halkovic, I’m sorry and I don’t mean to be dismissive but that’s a copout. We all know how opioids effect our pain. If the powers that be do not, it is your responsibility as not only the educated mind involved but your responsibility to make it known because you’re the one writing it. They have not restricted anything. They only have made you have to speak to its authenticity.
See, this is the problem, patients with real problems being told by their paid physicians that their hands are tied. Well, stop benefiting from it then. I’m so sick of hearing and seeing this blame game magician’s hand swap. The government doesn’t diagnose or have the power to prescribe. You do. If we aren’t getting the proper treatment it’s because your profession refuses to treat. What you don’t understand is the next step. Massive undertakings. Widespread lawsuits claiming depraved indifference. That’s what it is. Your fellows cannot get rich for 20 years handing drugs to people where 40% didn’t need it and kept getting it to the point where it was given so much that their death count couldn’t be overlooked.
The depravity is that as long as you could hand it out and benefit without any responsibility you did. It wasn’t until people started asking why is someone with a sore ankle getting oxycontin did you decide it wasn’t safe for you. The irresponsibility in that is the same as the irresponsibility of taking it away from everyone regardless of whether or not they need it. To hear you, a doctor, come on here and push the blame like you did is a testament to just how little personal responsibility you actually take.
You make a couple of good points Nicholas but I think you are somewhat off on your blaming physicians for being the responsible party for refusing to treat patients. There ARE many times when a physicians hands ARE tied and not because they have a choice about it. I had a colleague physician walk out on the facility because the corporation who owned the facility attempted to FORCE him to write an inappropriate opioid prescription solely based on threats by the patient that they would go to another clinic if they didn’t get what they wanted. He walked before being fired for not complying to rules set by a corporation, that was located out of state, and who had no clue about running a pain clinic. Their sole interest was making as much revenue for their investors as possible which is why the scheduled patients every 10 minutes. How do you provide appropriate care for a patient in 10 minutes? A week later, they tried the same tactic with me and I resigned. Physicians DO have a choice when writing prescriptions however; they may be also setting themselves up for wrongful prosecution and loss of license by writing for opioids that someone else has deemed “unsafe and dangerous”.
The saying goes don’t judge another person unless you’ve walked in their shoes. You don’t know how painful it is to look a patient in the eye, one who’s been doing very well on what was being prescribed, and yet are being forced to tell them you have to cut back on the medications they have been functioning so well on in the past, knowing they are going to suffer. It haunts us being put in a position between what we feel is appropriate and safe, and being fired or worse, losing our licenses.
I strongly disagree with the assumptions: “The sad reality is that many addicts have an underlying dopamine signaling issue (d2 receptor). Taking dopamine antagonists like oxycodone gives them a more “normal” sense of well-being and functionality rather than a healthy individual who is on
an opiate.”
When a person who has Centralized Intractable Pain” and other serious pain disorders experiences unbelievable, unrelenting, unbearable pain, they are only HEALTHY (spiritually, mentally and physically) when the pain is controlled. Treating chronic pain is like any other disease processes. Treatment needs to include alternative therapies, proper diet, exercise and being able to spend time with family and friends. Dosing of an opiate should be based upon the individual’s accomplishments of functionality goals.
However, unfortunately, some chronic pain patients have lost their ability to function due to decreasing and/or changing medications that do not work. That situation requires intervention … to recover these unfortunate individuals who got caught in a deadly net.
I have a slightly different view on things. 1. I am a nurse and 2. I am a chronic pain patient myself, in a position to help manage chronic pain in my patients. My issues come from failed surgeries, the first of which, was botched by my surgeon, which set me up for YEARS of pain and fighting for my right to be treated with dignity, respect and actually be listened to.
I refuse to claim disability coverage for two reasons. 1. I LOVE my job and honestly, I feel better when my attention can be more focused to help others, as well as keeping my pain more under control when I am moving around more. 2. The stigma is REAL!!! Being labeled as a person who is opioid-dependent is a HUGE drain on my mental well being, and I dread my chronic pain appointments and going to pick up my medications that keep me working and functional. I do not get high and take way less than the 90 morphine equivalents that the government states is the max, but yet, I am still stigmatized and belittled for my use.
I work as a PRN employee because there are days when I cannot make it to work due to my level of pain, but yet, I still work primarily full-time hours because I only have ONE income, and that is mine. If I don’t work I don’t eat, have a roof over my head, or anything else that is required to survive in this world. So the other stigma is using government-funded insurance because as a PRN employee, I am not eligible for insurance through my employer, which is a whole other issue regarding mental well being. I have had seven major back surgeries with three hardware changes, and due to all this, I have also had three total hip arthroplasties, with more up and coming. My only requirement for my surgeons are “keep me vertical and working”. I complete surgeries when I cannot function any longer, then it’s back to work… rinse and repeat. To make matters worse, I am ONLY 50 and should still have years of working left in me.
My co-workers and the providers I work with have no idea of the pain I am really in, as I have become a master at hiding my pain outwardly, and crying throughout the day at times, in private. My career is everything from working surgery, the ER, home health, specializing in wound care and now clinic. I change my positions based upon my physical limitations, and thank goodness, working in clinic allows me to work without the physical side of nursing coming into play.
Due to my unique situation, I am a HUGE patient advocate when it comes to functionality in regards to pain control, but even I have to fight on a monthly basis to keep getting what I am getting, so I CAN continue to be a functional member of society. In the 15 years since my first surgery, I have NEVER had one bad drug test, NEVER asked once for an early script, NEVER been discharged from services and still continue to work in between my many surgeries. Why then, does someone like me have to fight every month to have my basic needs met? I have done everything my providers have asked, including non-narcotic treatments, injections, physical therapies, and yes, even counseling to address my “narcotic abuse”, which has NEVER been abuse, but yes, I will admit to dependence… after 15 years, if I didn’t, I’d call myself a total liar.
The scariest thing I am facing now is being cut off and having to deal with withdrawal, which I have gone through thanks to being so stigmatized about my prescription. I don’t drop names, or my profession and most of the pharmacists and clinic staff at my pain clinic have NO idea of my titles, where I work, or what health organization I am employed by, as my personal life is NOT my working life, and I have never striven to be treated any differently because of what I do. After 15 years of dealing with this, I am not afraid of the increase in pain if they stop prescribing what keeps me upright, I am afraid of withdrawal and not being able to work or be a functioning member of society if they do. In that situation, I fully understand why people commit suicide over this… without having a reason to go on, why bother remaining in this world when everything that you enjoy about it is taken away?
I am now facing having to find another pain clinic to manage my pain, while I am prepping for my eighth major back surgery, since I was just cut off due to an argument with a previous pain clinic over financial issues, since I owe them a whopping $163. Yes, you read that right… not 163k, but ONE HUNDRED SIXTY THREE DOLLARS. While they gave me a month’s prescription to get me by till I can find another provider, which the referral is in for, but they haven’t finished reviewing it yet, and they are refusing to do the PA on the medication, which is due, and my PCP does not do ANY pain medications. As of tomorrow, I face withdrawal when I run out of medication and have no means to get it. So where is the justice for people like me?
IMO: screw the government and screw the insurance companies for putting good people in a place where they are scared to death to face it. Providers SHOULD be allowed to prescribe without retribution by the government, insurance companies, etc, as long as the patients they serve are being managed, have a plan in place and are following the rules. There should NOT be a limit to what someone can get as long as there is a clear plan in place, their patients are well monitored and all the rules surrounding prescribing are followed… ie: drug testing, in-person appointments, etc. We, as prescribers, nurses, medical personnel etc, MUST STOP THE STIGMA. There are GOOD people who have no options, and should not be labeled as an abuser, because other people have decided they like the “high” they get and go above and beyond to get what they want. It’s really sad.