After about seven years of good pain control, I have suddenly been forced (on threat of being kicked out of the system) to see a “Pain Management Specialist” who is no such thing. I have to cooperate him, with the same penalty if I refuse. He is: authoritarian, plays petty dominance games; he got very angry when I asked what his qualifications are for being a specialist in pain control are and until I pressed hard, refused to answer; is altering my regimen at least in part on the basis of cost to the VA system (he said so), and so on. He’s using the new standard from Washington State, which automatically cuts the amount of opioids I use DRASTICALLY. He wants to trade methadone for fentanyl, neurotonin or Baclofen for carisoprodol. I will not take either, so he will offer nothing else, and is sending me to psych before officially labeling me “uncooperative” and removing all treatment. I took a HUGE battery of tests at the Oregon University Hospital Neuropsychiatry Department a few years ago, but he chooses to discount the findings.

The rest of the problem: I am sole caretaker of a wife in end-stage COPD who is essentially bed-ridden. There IS no one else, not even to stay with her while I am gone. To see him, to see the psychiatrist (or psychologist) he demands I see, I have to leave my wife alone, on oxygen, unable to get things for herself or reach the phone, and beg a ride to the clinic 48 miles away. He’s also recommending (meaning I have no choice) an ophthalmologist four hours away for a migraine-type symptom I’ve developed. If he keeps taking away all the meds that actually work and insisting I take the ones I know don’t work, make me ill or that I WILL not take, like neurotonin, SSRI’s or tricyclic antidepressants (both make me very ill and cause other problems) and so on, my wife will end up with little or no care at all. My functionality is poor now, and my pain levels are high lately due to the fact that I have no choice about how active I must be in taking care of my wife. The regimen was not designed to compensate for that. This guy insists that since the meds aren’t working (they are; just not as well as before), instead of adding to one or the other meds that work, I need to back off on them and use other meds, again, that I know don’t work or cause problems. While I hurt a lot (in part because the trip to the clinic raises pain levels, and I am always there in the middle of my sleep time), I DO get done what needs to be done. Taking away the only medications that actually help is destroying my functionality at a time when I MUST function; it certainly isn’t helping. Canceling meds without even bothering to notify me also angers me, which he feels means I’m “psychologically unstable”. Raising my voice to him telling him to stop interrupting me and give me the courtesy of allowing me to finish a sentence also means the same thing.

We have SSDI as an income, I am on Medicare (the state insurance that is Oregon’s equivalent of Medicaid can’t afford new patients), and my wife’s insurance left over from work runs out in ten days. We have no idea how we’re going to pay for her meds. The house, the car, and now I are all falling apart. This “Pain Management Specialist” won’t listen, is adhering to this new Washington State standard, but is ignoring the part that says there can be exceptions to the limitations on narcotic doses. My weaker muscle relaxer has been taken away, so I sleep poorly, and twitch and jump in my sleep a lot now, when I do sleep, which is much less than the little bit I did. I have struck my wife in my sleep, too. He’s left me the diazepam, but I loathe it, and cannot use it much because it makes me too tired, too hard to awaken when I do sleep, and reduces my care of my wife. Besides, he says he will cancel that too, shortly.

Any ideas, anyone? Besides giving this guy a firsthand, inside view of chronic pain, I mean. I’ve already considered that - a LOT - and it would leave my wife alone. Besides, I detest an institutional diet.

Ian

What other group of Medical Patients would even be subjected to this type ofdiscrimination? Had she bothered to do any kind of medical research she would know that Patients who have the disease of Addiction do much better taking medication than any other method.

I have written many LTE’s to this newspaper, they had links to medical journals & U.S Government sites with information on the benefits of MMT and the positive outcomes of Patients. Not one of those letters ever were published, but every day when I would go back they would have more negative letters filled with misinformation and discrimination against Patients.

– beth c

Here it comes…”killer” drug on a rampage…

Painkiller kills four people; Sue Mueller; Foodconsumer.org; 2007-09-13.

This is worrisome, because it points to a strategy where huge sums of corporate assets are being ‘seized’ to fund the drug war apparatus (the Purdue ‘settlement’ was earmarked by the court almost entirely for drug war funding).

I wonder what the patent status of Fentora is? I have always felt that the pharmaceutical industry has a natural interest in opioid prohibition. With physicians afraid to prescribe opioids, their efforts to “do something” for patients who have chronic pain usually involve resorting to a barrage of trials of expensive (patented) medications. I think chronic pain is a serious market asset for the pharmaceutical industry, and the nonpatentable opioids are a serious threat to them. It would be interesting to examine Cephalon’s lobbying history. Purdue had some unusual patterns in lobbying over the years before their debacle. Their “settlement” was a neat little deal where nobody really got in trouble, but the drug war got a huge injection of corporate cash.

From the quote below, it looks like that might be what is being planned with Cephalon. I wonder if it would be possible to do a cost/benefit analysis on pharmaceutical corporations here? If pharmaceutical corporations agreed to turn over all assets from opioid sales to the drug war, would that result in a net financial gain through increased sales of other more expensive patented drugs? Is it possible that what we are seeing here is a “privatization” of funding for the drug war? Are we being set up for a long string of corporate renouncements of, and “apologies” for, opioid therapies? Could this be a mechanism through which the industry itself could be laying plans for privately funding the drug war as public support for the issue dries up?

“A person familiar with the matter said Cephalon is ‘in active discussions’ about a possible settlement with the Connecticut attorney general and the U.S. attorney in Philadelphia, though the talks are at a sensitive stage and might break down. Any settlement would involve a large fine and require that Cephalon take remedial measures to reform its aggressive marketing practices, this person said.” (The Wall Street Journal Online, September 14, 2007, p. A4: http://tinyurl.com/36xtvp)

They call people like me “conspiracy theorists” (which is probably not a really bad thing to be in a world of corporate conspiracies!)

I often think I understand despair, but I can’t help but feel inexperienced when confronted with a person in your situation. If there is anything I can do to help, please let me know. All of us eventually have to suffer injustice. It is only a matter of degree, and the degree is not fairly distributed. In fact, it seems almost random. We live in a very sick society and we have a very sick, corrupt, and distorted government and justice system. Until it effects us personally, we often try to avoid thinking about it and we avoid reaching out to those victimized by it. We have done this, as a society, to ourselves. We stopped educating ourselves several decades ago, and we casually followed extremist political movements that have taken our society to the brink of destruction. In the last few years, our out-of-control government has killed some 150,000 Iraqi civilians, apparently under the traditional doctrine that an enemy was embedded somewhere within those masses. Over 3700 young Americans have perished. Most were not old enough to even understand what they were involved in or why they might die.

Our prisons are full of scary people, but they are also full of innocent people and political prisoners like yourself. You should be able to find human contact in that context somehow. Seek the services of mental health people in prison, and let them help you even if they are obviously not well trained and not very wise or ethical. If I can help in any way, I will.

I have decided to take on this cause as a serious effort on a permanent basis. Not only do I want to remember daily the horrible situation that many pain sufferers are in, but I also want to remember the situations of people like yourself.

Somehow I feel that if I had come to you as a patient, I would have been treated properly. I have been abused and neglected by many physicians. I have been misdiagnosed and left undiagnosed by physicians who were so convinced that I was drug seeking that they did not look for the sources of my pain. I had a serious disease for years before it was diagnosed because my chart had DSB in it, and all symptoms and complaints were assumed to be drug seeking behavior. Now that I have been properly diagnosed, and my need for pain treatment has been documented, I still avoid reporting pain. I am afraid to use opioids for fear of losing the faith and attention of my doctors. That is sick and wrong. I have to remember every day that there are doctors like yourself, and I am lucky that I have found one who is currently treating me. Unfortunately, I can not bring that good doctor under suspicion by taking opioids regularly, so I just bear the pain.

I will be in touch. If it is hard to write to a stranger, I will understand. But I am willing to correspond with you if it would help.

You are a hero.

James wrote:
“Could some of the physicians here clarify the issue? If opioids do reduce endorphin production or release, is that condition not temporary? I was under the impression that opioids, for the most part, do no physical damage other than possible death from respiratory repression upon overdose.”

Seigel’s just making it up, is the short answer. Of course opioid change receptor state - that’s how they work, Duh! But you are correct, and Siegels implication was false - opioids are non-toxic - literally they do not kill or ‘poison’ any organ systems of the body. There are no lasting physiological or anatomical effects of long-term opioid therapy on the brain or any other organ system. Unfortunately, we cannot say the same of chronic pain which has been shown to result in loss of brain mass, especially in the thalumus.

..alex…

I am concerned here with the way the opposition held their side through Marc Siegel. His face is now associated with Siobhan’s name, and he counteracts her message. Unfortunately, those little things matter with national exposure.

I will not pretend to debate physicians on the practice of medicine. In my activist efforts, I will stick with what I know. What I can say is that Siegel used a tried and true method to give his opinions a “scientific” hue with the public. People love explanations based on “brain chemistry”, and they attribute expertise to people who invoke those explanations for common events and behaviors.

I have a question for Dr. Deluca and other physicians who may be working on this. Siegel’s repeated message was that opioids cause brains to stop producing endorphins (another trendy “technical” term that is popular with the public because of freshman level textbooks — I think the public likes endorphin talk more than sex). He stops short of explaining exactly what he means by that. In particular, he leaves us with the impression that the condition is permanent (e.g. that opioids actually do “brain damage”). That is a very effective fear tactic, and I suspect it was done on purpose. When you tell this public animal that something causes “brain damage”, they will avoid it and be frightened of it. Unfortunately, I think Siegel probably scored a lot of points with his rather incomplete argument.

Could some of the physicians here clarify the issue? If opioids do reduce endorphin production or release, is that condition not temporary? I was under the impression that opioids, for the most part, do no physical damage other than possible death from respiratory repression upon overdose. That is, I thought all effects of opioids were temporary and reversible. Is that not true? Could I get some quick and dirty medical education on this issue?

I don’t think there is anything inherently wrong with using the sum of the four behavior ratings as a logistic regression predictor. In fact, the idea that they are all closely related is a good thing, rather than being a liability. That is the essence of internal consistency reliability. The sum could be a reliable measure of a very narrowly defined construct (e.g. use of prescription meds contrary to instructions to achieve psychoactive effects). It doesn’t take a rocket scientist to see why that would be expected to correlate with an opioid abuse measure, which probably contains a measure of the exact same construct! In fact, it would be expected beforehand to correlate much higher with an opioid abuse measure than with the smattering of demographic variables and other loosely related constructs analyzed. It is sort of like fatness predicting obesity much better than any one of a number of related variables such as age, education, weight, waist size, weight of clothing, caloric intake, activity, etc.

If I am interpreting this correctly, the behavior ratings and the outcome can be reduced to a point-biserial correlation (Pearson r with one variable being dichotomous) of about .70 (or 50% shared “variance”). That is indeed large, if not very large, in the normal scheme of what is expected in this type of measurement. The point is, it is “too” large. It is most likely due the tautological relationship between the ratings and SDSS. Same predicts same. In fact, this looks almost like a high validity coefficient or a low test-retest coefficient!

I have not read the article which justifies concentrating on these four behaviors, but I do question what value they would have for a physician. None of the behaviors could very easily be observed by the physician if the patient wanted to hide them. The behaviors are the essence of what is accepted widely as substance abuse (which is why I bet my sandwich that they will be found almost verbatim in the SDSS). Pardon my use of the terms “drug abuse” and “substance abuse”, as the authors remind us that they are diagnostically criterionless terms. I guess “aberrant behaviors” are much more objective and rigorously operationalized! You see, as a psychologist, I have a few problems with these “behaviors”. The problem is, they are not “behaviors” at all. Behaviors can be measured by some physical energy they impart on the environment. “Feeling intoxicated” is not a behavior, although reporting it may be. There is not much in the psychological theory of behaviorism for ideas like “for the purpose of” and “tried”, or, for that matter, “pain”. This is odd, because the term “behavior” as it is being used in this field has obviously been chosen for the purpose of sounding scientific!

What is still vaguely problematic for me in the logistic regressions is the absence of overall model statistics, the low base rate problem (30 cases in the disease condition), and no positive predictive analysis for the “behaviors”. That simply leaves us wondering about the extent to which prediction really is “behaviors uber alles”, although these highly pampered and selected “behaviors” probably do uniquely correlate with the criterion.

I also see an issue with the statement about “variables dropping out”. Regarding the other variables besides the behavior ratings, the authors state, “these variables dropped out of Table 2 because of extremely strong relations between these behaviors and opioid use disorders.” If that is what they really meant, then it does not support the “uber alles” idea. If the behavior ratings caused the other variables to loose their significance, then that means the other variables also predicted well (as a set), but the predictive ability that they shared with the behaviors got assigned to the behaviors in the final model. I don’t suspect that is what they really meant, though. That is, the statement is probably not based on a change in the coefficients upon adding the behavior ratings to the model.

There are some other issues here. The 30 people in the opioid disorder condition are being stretched rather thin across a lot of categories. That means there may be some cells where expected frequencies are not up to snuff. If that is the case, power could be reduced substantially in the tests on the other variables. One question I would feel obliged to address in such an analysis is what happens when you remove everything except the behaviors? The other variables may be adding significantly as a set, and the overall model statistics would tell us about that. Those statistics are missing. Furthermore, interactions are not being considered, and interactions could very well be good predictors among these variables.

More and more, I see a problem with the hypothetico-deductive protocol here. Just what was the hypothesis, and how was it reasoned and constructed? They didn’t state that the purpose of the study was the “uber alles” hypothesis. They didn’t state what the hypotheses were at all! They did say in the first sentence of the Methods section that “A study was conducted to assess the frequency of opioid use and substance use disorders in a sample of primary care patients receiving opioids for chronic pain.” Apparently, that is exactly what they did! They assessed a frequency in a sample of convenience based on a specific operationalization of a vague and elusive construct. They didn’t do much else! There is apparently no acknowledged basis for comparison of the frequency to any other number. The sample looks very different from a “general population” in many ways other than substance abuse. Little is said about the logistic regressions other than they were “exploratory”, and the variables chosen by the researcher “included a number of variables based on a priori hypotheses from the literature and the clinical experience of the PI.” No citations were given.

I’ll work more on this later. Maybe I should try to look at those CME questions and see if they can be matched in any way with the methods or results of this study.

Thank you for this and your other Comments.

You wrote:
“It is highly likely that they would all say you were nuts!”

Well, that is sort of happening now over on the Pallimed blog at: http://tinyurl.com/2qpbth where they are having a discussion under the subject heading “When is Cancer Pain not Cancer Pain?”

I haven’t weighed in yet, but Siobhan has. Anyway, thought you might be interested.

..alex…

Hello James, From the text (576-577): “We chose to use 4 of the 12 aberrant behaviors selected for the study for inclusion in logistic regression models. These four questions included a) purposely oversedating oneself, b) using opioids for nonpain reasons, c) increasing opioid dose without authorization, and d) felt intoxicated. These 4 behaviors were chosen on the basis of an analysis reported in another study focused on aberrant behaviors (Fleming, Brown, and Passik, in review, Pain). For the model, we used the total scores for the 4 behaviors (0 to 16). The final models are presented in Tables 1 and 2. Odds ratios and confidence intervals were used to assess the statistical significance of these factors. for the study for inclusion in logistic regression models.”

I’m not sure what relevant distinction is between a) and d) - ‘purposefully oversedating’ and ‘felt intoxicated.’ Further, c) = increasing dose without authorization would be prerequisite for a) and/or d). Finally I don’t seen how c ==leads-to==> a +/or d without b) = ‘using opioids for non-pain reasons’. (in psuedomath: b+c = a AOR d) (in English: using opioids for non-pain reasons in a higher dose than scheduled leads to oversedation or other symptoms of intoxication)

James - I’m saying that the 4 ADRBs they choose are essentially all the same thing, or rather, one implies the others. And this thing is what they plugged into their logistic regression models. And, surprise, in both ‘prediction of sub use disorders’ (BTW - ‘Use Disorders’ is correct DSM-IV terminlogy, encompassing ‘abuse’ and ‘dependence’) in table 1 and prediction of opioid use disorder in table 2, ADRBs are far and away the strongest predictors.

This is the tautology, yes? If you have a chance and feel like it, James, could you talk a little more about the implications of this for the conclusions of the study? Is constructing a variable in this way for logistic regression a major no-no? Any ideas on how the study design might have been different so as not to have this problem arise?

[ BTW - have made validity study of SDSS available: http://tinyurl.com/2mwrkf ]

..alex…

Hi mlang52, well, this is the sort of confusion that arises when one rushes too much to get a CME course on the market.

You are confused, because the CME course text is wrong in this bullet-point (I should have numbered them):

“Of 771 patients who submitted postinterview urine specimens, 24% tested positive for opioids, methadone, propoxyphene, benzodiazepines, cocaine metabolites, amphetamines, phencyclidine, barbiturates, or cannabinoids.”

OK, working from the full text of the paper, let me review the tox proceedures and results.

– one tox specimen was requested, collected at end of approx 2hr interview. 11 did not contribute “because of time restraints or med problem”; another 19 specimens had (unspecified) “laboratory process issues”. 801-11-19 = 771 which is where that number came from

– Here is relevant sentence from text: “Twenty-four percent of the sample (n = 185) tested positive for cannabinoids, cocaine, and other illicit drugs.” (pg 579) Looking at Table 7 on the same page, percentage positive and number positive are given for women, men, and total, for the following drug classes: “Cannabinoids” “Cocaine” “Phencyclidine”[aka PCP aka angel dust] and “Any illicit substance”. I take the last category means any of the first three specified drugs or classes, but you can’t tell just from adding the columns in the table, because a person could be positive for more than one drug.

– So, mlang52, I think the CME text is wrong in suggesting that opioids were tested for - at least that is not reported in the text. Nor is there any mention of urine tox for: methadone, propoxyphene, benzodiazepines, amphetamines, or barbiturates in the full text. So, they are trying to present urine tox results only for sustances that shouldn’t be present. —– [aside] - (Though a patient might be on prescribed Marinol (THC) which would give + for cannabinoids; and almost certainly many of the cannabis users were using medicinally as cannabinoids are known to potentiate the analgesic effect of opioids, as well as treating other common symptoms in pain patients, in some people - cannabis effects vary ENORMOUSLY and the dose range varies ENOROMOUSLY as well).

– A few observations from Table 7 and text on Tox results: —– 84% of the ‘Any illicit substance’ accounted for by cannabinoids —– tox detected cannabis in 156 compared to 100 self-report —– tox detected cocaine in 60 vs. 26 by self report

– Finally, from the text discussion of DSM-IV diagnosis proceedures (pg 577) we get this paragraph, which I think bears on your question:

“The majority of patients who reported alcohol and drug use did not meet DSM-IV criteria for abuse or dependence. Alcohol use was reported by 35.7% (n = 286) of the sample, marijuana by 13.2% (n = 106) subjects, and cocaine by 3.2% (n = 26). All 15 subjects who reported amphetamine use (1.9%, n = 15) were taking prescription amphetamines for a mental health disorder. Forty percent of subjects reported sedative use, primarily prescription benzodiazepines, with less than 1% meeting 30-day DSM-IV criteria for sedative abuse or dependence.”

—– I would then ask, ‘how many of the cannabis users were using medically, for pain or other medical symptom control. Similarly, how many of the alcohol users were using alcohol for insomnia or anxiety or depression - all very common in chronic pain patients.

Thanks for a good Comment, mlang - my apologies for taking so long to respond.

..alex…

The article you are talking about - Painkiller Widely Abused in South - http://tinyurl.com/3y87dm is one of the more grotesque examples of the genre, not because the acts describe are so horrific (I can handle the do it yourself with pliers tooth extraction passage, though I wince and tense every read).

No, what is notable and very creepy is what you are noticing too - this bizarre behavior is reported as completely rational and normative. Drugs ARE that bad. You’d be lucky to have Steve as your sponsor should you ever darken the doors of Narcotics Anonymous.

As to overall effect of the AP package - what I hear is that they are themselves surprised at the appetite for various parts of the content. It is largely negative, especially when only material from the moral panic part; BUT, I think our part is getting through as well. Bass DID get Siobhan and Fernandez and Bordeaux’s husband Ed Swaim in. All that material is there for the mining as well - and it will slowly come out.

For example, James Fernandez tells me that he is featured in many articles in the area around Fredricksberg where he lives. I have to find a second to collect a few of those.

Believe it or not am still wrestling with the Fleming study - I’m finding it complex, which means something is off. Your comments were a big help as an organizing first pass through the stats. It really is an interesting and important study which I’ll enjoy discussing further.

Gotta go - am installing a Comments email plugin that will let you’all be notified if there is any further development in this string or that. I think. Enjoy.

..alex…