From ‘An Obligation to Relieve Suffering’ to ‘A Duty to Abandon’
The Moral and Ethical Obligation of Physicians To Relieve Suffering Has Become a Duty to Abandon, Under Threat of Drug War Prosecution; Alexander DeLuca; War on Doctors/Pain Crisis; 2007-05-20.
I am sick to heart over this item from the L.A. Times A Los Angeles ER missed an acute abdomen - three times. From “Tale Of Last 90 Minutes Of Woman’s Life” by Charles Ornstein; L.A.Times; 2007-05-20:
“It’s an indictment of everybody,” [said county Supervisor Zev Yaroslavsky]. “If this woman was… writhing in pain, which she appears to be, why did nobody bother… to take the most minimal interest in her, in her welfare? It’s just shocking. It really is.”First of all, when an administrator says “it’s an indictment of everybody” he or she generally means, “nobody is responsible.” Secondly, “suddenly”?, huh? From the beginning of the article:
According to preliminary coroner’s findings, the cause was a perforated large bowel, which caused an infection. Experts say the condition can bring about death fairly suddenly.
“In the emergency room… Rodriguez was seen as a complainer. [An ER] nurse told L.A. County police who brought in Rodriguez… “This is her third time here.”Like I said: an ER missed an acute abdomen - a patient literally writhing in pain and begging for help - three times. It’s almost biblical.
What do Injured Veterans Have in Common with ER Patients?
Allow me to provide medical context for our non-medical-professional readers. Acute abdomen generally means that an internal organ, in this case the intestines, ruptures. Feces floods the peritoneal cavity inflaming and irritating its sensitive lining and causing bacterial infection. This is called ‘peritonitis.’ Peritonitis is unbelievably painful - right up there with pancreatitis in the “hell on earth” category. I can personally testify to this - I’ve experienced acute abdomen (ruptured diverticulum), emergent surgery, the works.’ (See: Acute Abdomen Land Theme Park; 1999). “Ruling out” acute abdomen is probably THE quintessential emergency medical procedure; period. The patient cannot recover without surgery to repair the ruptured viscus and clean the peritoneal cavity. Otherwise death by overwhelming sepsis (bacterial infection in the bloodstream) follows within days.
However, you’ll excuse me, I hope, if the shock and outrage from officials rings hollow to me, and offends me. This recent, oft-republished on the internet, article also bothers me, “Doctors Urge Better Pain Care for Troops.;” (Lauran Neegaard; Associated Press; 2007-05-07).
Look, we can all feel good about an experimental procedure that holds promise. And hey, I’m more willing to embrace cool new medical technology, especially pharmaceuticals but really any gee-whiz medical tech, than the average bear. And I’m all for the novel approach described in the article. But while our hearts swell with the promise of what is, really, just raw research, let us also acknowledge the horrific, no kidding disgusting, current reality of the treatment of chronic pain patients in this society, and of the physicians who would care for them as they would any other citizen-sufferers, were it not for the ever-present shadow of Big-Brother-with-a-Club, the DEA.
So, what about the rank and file? What about the thousands and thousands of injured veterans with painful conditions who don’t get the experimental nerve block? What treatment are they receiving?
Consider “Long-term Oxycodone/Acetaminophen Prescriptions in Veteran Patients” by Gagnon et. al., published in 2004 in the Archives of Internal Medicine. It is an interesting article. The authors went looking for prescription drug abuse and didn’t find much. But along the way, this study of did turn up this highly revealing datum:
In aggregate, 2195 patients (31% with cancer diagnoses..) received oxycodone/acetaminophen for more than 9 months at a mean prescribed daily dose of 3.9 tablets per day (range, 0.5-13.0 tablets per day) with minimal changes in daily prescribed mean dose over time. (emphasis added)
Wow. Veterans in chronic pain average less than 4 Percosets a day from the compassionate care-givers of the Veterans Administration. “Oxycodone/acetaminophen” means low potency opioid compounded with Tylenol. These medications are indicated for mild to moderate acute pain, not chronic moderate to severe pain. Even so, 4 pills a day is a LOW, not adequate, dosage. Oxycodone is a short acting opioid in this preparation, with an effective duration of action of about three hours. One pill every six hours of oxycodone/acetaminophen for chronic pain guarantees that the patient will be in unacceptable pain 50 percent of the time, at best. That’s not treatment, it’s under-treatment; it could not possibly be adequate.
So, how are our noble injured vets doing with such enlightened care? Not too well if you ask them. From a 2005 article entitled, “Prevalence And Characteristics Of Chronic Pain in Veterans with Spinal Cord Injury” we learn that 75% of this population reports pain, 83% of which is round-the-clock daily, of average intensity of 6.7 out of 10, and two thirds of which interfered with daily activities. The pain was most commonly described as “aching,” “sharp,” “hot-burning,” and “tiring-exhausting.” The authors’ conclusion is darkly humorous: “More research is needed to identify better ways to prevent, assess, and treat chronic pain in the veteran SCI population.” No, dear doctors; research is fine, but WE NEED MORE MEDICINE. [Prevalence And Characteristics Of Chronic Pain in Veterans with Spinal Cord Injury; Rintala et al.; J Rehabil.Res.Dev.; 42(5): 573-584; 2005]
Are you a glutton for punishment? OK, here’s another, “Survey of Pain Among Veterans in Western New York”:
… 71% reported having pain. The average number of body parts affected was 4.4 of a possible 11. The average intensity of pain was moderate; 35% reported constant pain, and 85% reported the pain to be occurring for years. Seventy-nine respondents described their pain to be interfering with their life and well-being. Medication was the primary treatment approach and was reported as ineffective by 48%. [Survey of Pain Among Veterans in Western New York; Crosby,F.E.; Colestro,J.; Ventura,M.R.; Graham,K.; Pain Manag.Nurs.; 7(1): 12-22; 2006]
Outrageous. Of course the medication doesn’t work well if you don’t prescribe it properly, as we discussed above. How is this not a national scandal? These are veterans under the direct medical care of the United States government being grossly, negligently under-treated. Why? Bluntly, rarely is there any penalty for ignoring or grossly mistreating chronic pain; but prescribe amounts of pain medication that the policeman thinks are too high and you may find yourself stripped of your rights and resources by RICO statues and on trial for drug trafficking and murder.
And the same federal police agency that has so distorted the ethical norms and practice of medicine is the same DEA that manages to lose some 6 million opioid doses a year at a level of the supply chain having nothing to do with doctors or patients and everything to do with the failure of DEA to secure supplies of needed opioid meds. DEA mounts an offensive against docs as the “primary” source of ‘abused’ drugs while concealing data exposing massive diversion higher up the supply chain they control. [Drug Crime (Not Prescriptions) Is (Major) Source of Abused Pain Meds; Joranson and Gilson; J.Pain Symptom Manage.; 2005]
TheTruth Is Ugly:
The medical denial of severe or chronic pain, and medical acceptance of neglect, abuse and abandonment of patients in unrelieved pain, has become the norm. [Please see: 'Bounds of Medical Practice' and the 'Standard of Care'] Not only is opiophobia endemic in American medicine, it is codified both at the federal level through the Controlled Substances Act and DEA, and increasingly and disturbingly at the state level through medical board promulgation of misguided “Pain Rules.”
The moral and ethical obligation of physicians to relieve suffering has become a duty to abandon; under threat of drug war prosecution.
Many state medical boards have promulgated misguided controlled substance prescribing rules with titles like: “Prescription, Dispensation and Administration of Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain.” These ‘Pain Rules’ are then used not to ensure pain patients receive the textbook standard or care, or at least the general medical community standard of care, but instead impose a primary Duty to Abandon on physicians.
I am struck, when studying such documents, that they are not about pain treatment, not about opioid therapy despite the titles, not even about practicing good medicine, or even about not practicing bad medicine. Rather they are a focused attack on patients. They are entirely about all the hoops your doctor has to make you jump through to prove you are not a criminal drug addict. And if he doesn’t, he can be criminally prosecuted or lose his license to practice. This places a physician, who is ethically obligated to place the interests of the individual patient before him above all others, in a very serious bind. These regulations, interpreted in a ‘gotcha’ manner by some medical board investigators, are solely about finding every pretext possible to cleave patients from their doctors, denying them care and making them criminals. I will be writing more about this, and I will out particular state medical boards when I am ready, but it would be nice if a real investigative reporter looked into this negative trend.
[END]
Tags: author=deluca, Chilling effect, csa, dea, doctor-patient, drug policy, Ethics, Opioid therapy, opiophobia, Pain Crisis, pain crisis, public health, red flags, Standards, statistics, substance abuse
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[...] also: Chronic Pain in Veterans - DeLuca; 2007 From an ‘Obligation to Relieve Suffering’ to a ‘Duty to Abandon’ - DeLuca; 2007 Video Interviews James Fernandez: AP 2007, and, CEI [...]