The prescription opioid epidemic in a nutshell

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Ok, lets debunk this nonsense once and for all:
1. The Dunn paper demonstrates the authors haven't a clue about the fundamentals of statistical analysis, and neither did the peer reviewers of the paper. Very wide confidence intervals in the results that were nowhere near the mean, demonstrate a complete lack of confidence in the results, since they could be possible due to statistical variation. Basic statistics textbooks tell us that one cannot draw meaningful conclusions when there are extremely wide confidence intervals. This paper should have never been accepted or published. The numbers of both overdoses (the only conclusions drawn were on overdoses, not deaths) and deaths were so small so as to render the findings meaningless. Statistically the study lacked validity.
2. The Bohnert study is a VA study. The VA was tacitly presumed to be a closed system but clearly it was not since some patients receiving ZERO opioids from the VA had overdose deaths associated with opioids. The Veterans are just as much drug abusers as is any class of patient, and may be even more so since the VA refused to place their prescribing data in any of the state prescription monitoring program databases. Therefore the vets were double dipping or triple dipping, and it is not possible to quantify how much the vets were actually taking from multiple prescribers. The amount prescribed by the VA may have been a small fraction of what was actually being taken. The numbers derived from this incomplete data are inherently flawed.
3. The Gomes paper demonstrated a death rate from opioids at 0.009% per year, essentially the same as in the US. But they found virtually the same death rate for 50-99mg MED as 100-200mg MED. The only conclusion that could be drawn is that there is some value of increase in death rate, but the confidence intervals place the possible increase in death rate at 28% for up to 200mg MED morphine and slightly higher at 30% for those taking 50-99 mg MED. The study failed to consider any other common cofactors that are known to be associated with death and overdose. This is like saying the suicide rate from narcotics is very high, then quoting the overall death rate from narcotics without determining what percent committed suicide. It is necessary to DRILL DEEPER.
4. The Paulozzi study found the highest risk of death by far is those taking buprenorphine- 2-3 times higher than all other opioids. Of course the only logical conclusion is that they failed to drill deep enough to make sense of this absurd data. How many were taking heroin? How many were using alcohol? Same for all the other drugs. On face value, the medical community should immediately stop prescribing buprenorphine since it is a deadly killer according to Paulozzi et al. The problem is, just as with the other studies, non-sensical conclusions are reached when the factors leading to death and cause of death and manner of death remain hidden from either the researchers (inadequate data, using peripheral blood samples for tox studies, lack of autopsy, etc) or from the medical community (failure of the authors to analyze and/or report the cofactors in death).

What we really need is a well conducted detailed analysis of overdose deaths. None of these were randomized control trials....they were cohort studies. The same criticisms that PROP made about the lack of evidence for effectiveness of long term opioid therapy are also in play with these studies. It is patently academic and ethical dishonesty to accept the proposition that there is no valid evidence of effectiveness while attempting to torpedo the long term pain management of millions based on equally flawed studies. Fortunately the FDA saw through the charade of proposed tacit and de facto elimination of pain management for millions since no other viable solutions were offered other than to think happy thoughts. PROP was slapped down decisively for their posturing. They failed to dig deeper, just as the above studies failed to dig deeply enough to derive logical conclusions. So rather than rehashing the same old tired and debunked flawed opioid studies, perhaps it is time to do our own research and determine cause of death (can only be determined by autopsy PLUS toxicology drawn from central blood) and look into all the cofactors that are associated with patient deaths. PROP itself could commission such a study and it would be welcomed by the medical community. But our patients deserve better than to be tortured by any organization with a pre-defined agenda to eliminate the availability of opioids for the treatment of chronic pain without valid, statistical evidence to do so.
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algosdoc said:
Ok, lets debunk this nonsense once and for all:
1. The Dunn paper demonstrates the authors haven't a clue about the fundamentals of statistical analysis, and neither did the peer reviewers of the paper. Very wide confidence intervals in the results that were nowhere near the mean, demonstrate a complete lack of confidence in the results, since they could be possible due to statistical variation. Basic statistics textbooks tell us that one cannot draw meaningful conclusions when there are extremely wide confidence intervals. This paper should have never been accepted or published. The numbers of both overdoses (the only conclusions drawn were on overdoses, not deaths) and deaths were so small so as to render the findings meaningless. Statistically the study lacked validity.
2. The Bohnert study is a VA study. The VA was tacitly presumed to be a closed system but clearly it was not since some patients receiving ZERO opioids from the VA had overdose deaths associated with opioids. The Veterans are just as much drug abusers as is any class of patient, and may be even more so since the VA refused to place their prescribing data in any of the state prescription monitoring program databases. Therefore the vets were double dipping or triple dipping, and it is not possible to quantify how much the vets were actually taking from multiple prescribers. The amount prescribed by the VA may have been a small fraction of what was actually being taken. The numbers derived from this incomplete data are inherently flawed.
3. The Gomes paper demonstrated a death rate from opioids at 0.009% per year, essentially the same as in the US. But they found virtually the same death rate for 50-99mg MED as 100-200mg MED. The only conclusion that could be drawn is that there is some value of increase in death rate, but the confidence intervals place the possible increase in death rate at 28% for up to 200mg MED morphine and slightly higher at 30% for those taking 50-99 mg MED. The study failed to consider any other common cofactors that are known to be associated with death and overdose. This is like saying the suicide rate from narcotics is very high, then quoting the overall death rate from narcotics without determining what percent committed suicide. It is necessary to DRILL DEEPER.
4. The Paulozzi study found the highest risk of death by far is those taking buprenorphine- 2-3 times higher than all other opioids. Of course the only logical conclusion is that they failed to drill deep enough to make sense of this absurd data. How many were taking heroin? How many were using alcohol? Same for all the other drugs. On face value, the medical community should immediately stop prescribing buprenorphine since it is a deadly killer according to Paulozzi et al. The problem is, just as with the other studies, non-sensical conclusions are reached when the factors leading to death and cause of death and manner of death remain hidden from either the researchers (inadequate data, using peripheral blood samples for tox studies, lack of autopsy, etc) or from the medical community (failure of the authors to analyze and/or report the cofactors in death).

What we really need is a well conducted detailed analysis of overdose deaths. None of these were randomized control trials....they were cohort studies. The same criticisms that PROP made about the lack of evidence for effectiveness of long term opioid therapy are also in play with these studies. It is patently academic and ethical dishonesty to accept the proposition that there is no valid evidence of effectiveness while attempting to torpedo the long term pain management of millions based on equally flawed studies. Fortunately the FDA saw through the charade of proposed tacit and de facto elimination of pain management for millions since no other viable solutions were offered other than to think happy thoughts. PROP was slapped down decisively for their posturing. They failed to dig deeper, just as the above studies failed to dig deeply enough to derive logical conclusions. So rather than rehashing the same old tired and debunked flawed opioid studies, perhaps it is time to do our own research and determine cause of death (can only be determined by autopsy PLUS toxicology drawn from central blood) and look into all the cofactors that are associated with patient deaths. PROP itself could commission such a study and it would be welcomed by the medical community. But our patients deserve better than to be tortured by any organization with a pre-defined agenda to eliminate the availability of opioids for the treatment of chronic pain without valid, statistical evidence to do so.
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Change is hard, heh:)
 
No need to change if you know what you are doing and can look beyond the superficial :) Safety of patients is much more than looking at a single number. PROP tried to throw out the baby with the bath water, to save the lives of possibly up to 20,000 people a year while causing untold suffering to millions. The FDA heard from many of those that would have been tortured and become suicidal due to the proposals of PROP. In this case, an agency of the Federal Government the FDA, astonishingly made a rational decision: the legitimate restriction of long acting opioids and more recently classifying hydrocodone to Schedule II.
 
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Round 3: Algos.

101N: "Now 4 independent studies demonstrating a direct link between MED and unintentional opioid overdose death. Time to starting incorporating MED in to risk stratification documents. HIGH DOSE = HIGH RISK."

Now means newest article published Jan 2012, almost 2 years ago? Nothing new to see here.

Yes, opiates have risk and physicians have done a poor job at evaluating the risk. Maybe restrict opiates to BC/BE pain providers outside of 1 week from PCP, 3 days from ER, and 2 weeks from post-op. And then we can restrict BZD to Psych only.
 
http://www.kevinmd.com/blog/2013/10/lawyer-pain-management-tips-doctors.html
A lawyer provides pain management tips for doctors
GEORGE F. INDEST III, JD | CONDITIONS | OCTOBER 26, 2013

Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearing House.

2. Obtain, read and follow the guidance contained in “Responsible Opioid Prescribing: A Physician’s Guide” by Scott M. Fishman, M.D., endorsed by the Federation of State Medical Boards (publ. Waterford Life Sciences, Wash., D.C. 2007).

3. Read and take to heart “Ethical, Legal, and Professional Challenges Posed by ‘Controlled Medication Seekers’ to Healthcare Providers, Part 2” by Ken Solis, MD.

4. Avoid working for practices or clinics that have a reputation as a “pill mill.”

5. Most physicians who are the subjects of investigations for overprescribing tend to be sole practitioners or the only physician working in the clinic. Avoid this. If you are going to practice any pain management, it is recommended that you do so in a group practice or institutional setting.

6. Patients who are clearly addicted to opiates should be referred a physician specializing in addiction medicine for rehabilitation. Do not accept this patient back until the patient does this.

7. Excellent documentation is a must. Make sure your records meet all requirements of state laws and regulations.

8. If you are not a certified specialist in pain medicine, refer pain management patients out to one who is.

9. If you get any information that the patient has been “doctor shopping” or obtaining similar medications from more than one physician, immediately terminate the relationship and notify local law enforcement personnel. In many states, “doctor shopping” by patients is now a crime, and the physician is required to report the patient to law enforcement.

10. Be sure of the patient’s identity. Require valid, government issued identification, preferably two, and ask the patient a few background questions that can be verified. Identity theft is common among drug abusers seeking prescription medications.

11. Require that prior medical records, especially diagnostic reports such as MRI and x-ray reports be received by your office directly from the other physicians or the radiology facility. Forgery of radiology reports and the sale of false reports is notorious among drug seekers.

12. Be leery of treating out-of-state patients and families of patients seeking opiates and other controlled substances.

13. If prescribing opiates for more than a short, chronic episode, require a pain management contract be signed by the patient in which the patient acknowledges your guidelines and requirements. These will include a number of provisions that are for the protection of the physician as well as the protection of the patient who may be tempted to over-use prescribed medication.

14. Require a urinalysis test before every visit. Wait and review the report prior to prescribing. An absence of the medications the patient is supposed to be taking is just as informative as the presence of medications you have not prescribed.

15. Establish and maintain a good relationship with the pharmacists at the local pharmacies around your practice, especially the independents.

16. Don’t be tempted to deviate from your practice standards and procedures by the fact that the patient is a celebrity or wealthy person. Do not deviate from your standards and procedures for anyone.

17. If the patient demonstrates drug seeking behavior (asking for certain medications by brand name and dosage, becoming angry and upset if the physician doesn’t prescribe what the patient wants, etc.), terminate the patient immediately.

18. Make sure you know what is going on outside your own office. Make sure you have loyal, trustworthy staff, especially your receptionist and medical assistants, who will advise you of any unusual behavior or comments of patients, attempts to bribe staff, etc. Train your staff to report such matters to you in person, immediately. Have a zero tolerance for this.

19. Be a good diagnostician. Read the patient history. Listen to what your clients say. Examine them appropriately. Do not prescribe pain medications for those who have no signs or symptoms of pain.

20. Require current x-rays, MRI’s and diagnostic tests. Do not treat based on old x-rays and diagnostic test reports.

21. If you are not board certified in the subspecialty of pain medicine, and you are not part of a large, institutional of pain management clinics, then you should only have a few pain management patients in your practice. The majority of your patients should not be pain management patients.

22. Do not ever allow a lay person or non-physician to be in control of your office, patient records, billing, bank accounts or appointments and scheduling. You will be held accountable for these; you must ensure you control them.

23. You should consider reducing the amounts of narcotics at each patient visit. Gradually weaning the patient off of addictive medication should be a primary goal of the physician.

24. Be very wary of any patient presenting with no signs or symptoms of pain or who has inconsistent signs and symptoms of pain. These are patients who may be selling the medications or who may be undercover agents seek to entrap you.

George F. Indest, III is president and managing partner, The Health Law Firm.
 
While most physicians would agree with the majority of the recommendations, these are from a legal, not a medical standpoint. For instance, some of the recommendations are nonsensical such as UDS on every visit. UDS cannot be used to make clinical decisions. Urine drug toxicology testing can, but is not performed in house, and certainly is not available immediately. Reducing opioids on every visit? Is that like reducing insulin dosages on every visit due to risk of death from insulin? Or do you just stop the insulin to see if they really need it? There are reasons lawyers are lawyers, and are not doctors.
 
Agreed algos, but unlike other medications or treatments, there are legal ramifications involved in opioid therapy that do not exist with other therapies. I highly doubt there is much street value in lisinopril or metformin...

There is clearly a paternalistic relationship between the DEA and us providers, and we need to maintain this relationship with our patients. That's an aspect PCPs can't grasp.
 
True...it is a balance between prescribing for a legitimate medical purpose and illegitimate medical purposes. And PCPs...oh geez....don't get me started. With hydrocodone moving to Schedule II and much stricter (but not strict enough) prescribing rules just implemented in my state, perhaps we will see the PCP massive prescribing of hydrocodone begin to wane.
 
101N said:
When physians careers suffer because they refuse to prescribe narcotics .
http://m.theatlantic.com/health/arc...se-they-refuse-to-prescribe-narcotics/280995/
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This is definitely a problem. Our MEC attempted to shield our ER docs by instituting policies that limited the duration of narcotics that could be prescribed. This helped to level the playing field and supply appropriate therapy until the patient could be seen by a specialist or regular physician. At most patients could get a 3 day supply of narcotics if they were seen in the ER on a weekend.

The whole ratings game is a quagmire. What satisfaction score do you expect when the young patient presents to Sloan Kettering, is treated by talented physicians, and is told that he has a terminal disease with little time to live? There may be no better care available anywhere but patient satisfaction scores will not reflect this fact.
 
pastafan said:
This is definitely a problem. Our MEC attempted to shield our ER docs by instituting policies that limited the duration of narcotics that could be prescribed. This helped to level the playing field and supply appropriate therapy until the patient could be seen by a specialist or regular physician. At most patients could get a 3 day supply of narcotics if they were seen in the ER on a weekend.

The whole ratings game is a quagmire. What satisfaction score do you expect when the young patient presents to Sloan Kettering, is treated by talented physicians, and is told that he has a terminal disease with little time to live? There may be no better care available anywhere but patient satisfaction scores will not reflect this fact.
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Or, closer to home, how long before we -rightly - tell the patient with FMS, chronic LBP, chronic HA, chronic ABD pain, chronic migraine, chronic pelvic pain, chronic phantom limb pain, etc - hey, these are your 'non-opioid' and self-care options. You want more than that then pay out of pocket.
 
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"rightly"...???? Does that mean that certain pain conditions are not worthy of opioid treatment because we don't have double blind placebo controlled studies to support opioid use or because we do not possess sufficient pathophysiological knowledge about the condition and are withholding treatment because of not understanding the mechanism of action? Or are we to assume everyone that has any of these conditions are tacitly nut cases that cannot possibly respond to opioids? Just curious on what basis "rightly" is invoked as a reason to withhold or withdraw treatment from patients.....
 
101N said:
Or, closer to home, how long before we -rightly - tell the patient with FMS, chronic LBP, chronic HA, chronic ABD pain, chronic migraine, chronic pelvic pain, chronic phantom limb pain, etc - hey, these are your 'non-opioid' and self-care options. You want more than that then pay out of pocket.
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You forgot cancer. There really should not be a dichotomy in cancer pain. Bleeding heart wuss. Tylenol for bony mets. But think about rainbows if the mets got your liver cause the Tylenol might damage your liver (more than the cancer?).
 
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algosdoc said:
"rightly"...???? Does that mean .....
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This means that cancer & non-cancer pain are not analogous and therefore we should stop treating them as if they were. Portenoy's experiment has failed & it's high time that pain medicine acknowledge that 30yr faux pax and move on.(1) What the public does not yet understand it that the VAST majority of CNP visits - and opioid prescriptions - in working aged adults are for benign musculoskeletal complaints followed by HA, chronic abd pain, and FMS. These conditions not only don't need opioids, they don't warrant a pain specialist. Equating the severity of the most common CNP conditions - LBP, FMS, HA - to malignant pain is utterly ridiculous if not shameful. Moreover, prescribing opioid for these conditions isn't a sign that you are an epathic doctor (Lynn Webster's disingenious claim), it's a sign that you either don't know what you are doing or that your ties to PHARMA funding have clouded your judgment.

Opioids are a palliative treatment and appropriate in the palliative care setting and narrow subset of CNP. But what the vast majority of working-aged adults with CNP need are rehabilitative, not palliative treatments. The indiscriminate use of opioids and pity for CNP has produced a generation of well paid pain doctors and PHARMA profits, but very few successful functional outcomes for CNP patients. It is time to revert to the pre-Portenoy era of multidiciplinary care for the majority of working aged adults with CNP.


"Until evidence is developed establishing benefits of opioids for long-term management of chronic musculoskeletal pain, and practical strategies for reducing risks have been demonstrated, a circumspect approach towards long-term use of opioids for chronic musculoskeletal pain is warranted."(2)


1. Portenoy R.K., et al. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain 1986:25:171-86.


2. Pain.2013 Sep 27. pii: S0304-3959(13)00514-9. doi: 10.1016/j.pain.2013.09.017. [Epub ahead of print] Opioids for chronic musculoskeletal pain: Putting patient safety first.Von Korff M.
 
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There is no doubt there is excessive usage of opioids in the US. Many of the changes that have occurred in the past month will help significantly including the first steps toward making hydrocodone, the most commonly prescribed medication in the US, to be a schedule II drug. This will hopefully quell the out of control prescribing by PCPs and surgeons that treat every bump and sore muscle with Vicodin. The FDA's wise choice to limit long acting opioids to severe chronic intractable pain requiring round the clock dosing will also help (thank you PROP). Increasingly, adoption of prescribing rules for opioids have helped, and my state was the last state in the union to adopt such after 15 years of my sending letters to the legislature and state medical board begging for these. We certainly do have the capability of tightening our prescribing by not prescribing to those who have engaged in substance abuse or diversion, stop prescribing for anyone using alcohol, take over the management of all sedative drugs and eliminate many of these concurrently being prescribed by different physicians when the PCPs will not, etc. These measures alone will reduce death rates by at least 25%. Take back programs may be helpful. Tracking how many pills of opioids a patient takes a day compared to how many are prescribed will reduce excessive prescribing. But to require level I evidence for prescribing opioids? I don't think so. There is level II and III evidence available now for prescribing opioids, but if we live by the sword, we die by the sword. All other medications we prescribe for pain, including off label uses, and all procedures, would require level I evidence using that metric. Our profession, or any medical profession, will not survive using that high bar. The problem with PROP and people like Von Korff, is that everything is black or white, and they argue that only high level evidence is worthy, while at the same time pushing their own biases and low level studies to support their conclusions. Medicine is not practiced via cookbook (unless you are a NP or PA). We on this forum are at least as intelligent and capable of analyzing data as others, and what is clear is that you simply cannot throw out the baby with the bathwater. Is FMS a condition worthy of prescribing opioids? Maybe, maybe not....but in half the cases it is a small fiber polyneuropathy. Other diffuse pain entities such as chronic abdominal pain, may respond to opioids long term, but sometimes not. The key in managing any pain syndrome is to not become locked into a monolithic approach, throwing out potential treatments (if controlled) due to bias rather than proof that the treatment does not work. Whereas to some doctors, pain treatment is just a job that enables the purchase on that second or third house or their Tesla, to the patients it is a daily struggle for survival. We must never forget that. We must weigh risk/benefits and decide on an individual basis the best course of therapy, taking ownership of their safety in doing so. Certainly it would be easy to jettison prescribing opioids for millions to save 20,000, but how many more would become dysfunctional or suicidal due to uncontrolled pain? The PROP-sters don't care. I do.
 
the problem, algos, is that there is level 1 evidence for harm from opioids, and only at best level 2 or 3 evidence for long term benefit.

it is a balancing act between the two. you favor considering the level 2-3 evidence as enough support for continuing opioids, 101N considers the level 1 evidence (not just from OD, but constipation, rash, sedation, etc.) as ample enough to deny pretty much everyone opioid therapy.
 
I agree. There is harm associated with prescribing opioids. There is also harm with prescribing virtually any medication and it is the risk/benefit ratio that determines the usefulness of a medication. Opioids have a certain mortality associated with their use- that is a given. Very tight controls, eliminating coexisting use of alcohol and other significant sedatives, and UDS/PMP all help reduce that mortality. Reducing daily dosages also will help. But more than half those that die from opioid overdoses do not have a prescription for the opioid. It is this population we can contain by tougher laws about patient inflicted manslaughter.
But- what is the metric that should be used to decide what disease is worthy of opioid prescribing? I don't think we have the capability of defining that so incisively as 101N contends. I agree that there is way way too much prescribing of opioids in this country and that we need to reduce this significantly. Is the person with FMS that functions well with hydrocodone any less deserving of pain relief than the person with malignant neurofibromatosis that may persist for 10 years? These should remain questions to be decided between the physician and patient, and not dictated by puritanical academicians.
 
Ducttape said:
101N considers the level 1 evidence (not just from OD, but constipation, rash, sedation, etc.) as ample enough to deny pretty much everyone opioid therapy.
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Not what I said. What I said was that the vast majority of working-aged patients (25-55), with CNP, who receive opioids > 90d have one of the following benign conditions: LBP, HA/Migraine, FMS, or chronic ABD. Those conditions, in that age group, much more often than not do not warrant chronic opioid treatment.

Pain advocates, ne'er-do-well reporters, the opioid lobby, and doctors with big opioid practices like to showcase the rare cases of MS, SCI, high-dose steroid use with AVN, multi-trauma, wounded warriors, etc, when discussing opioid prescribing for CNP. But if the truth be told these extreme cases are virtual drop in the bucket of opioid prescribing for CNP in the US.

Addressing the issue of overprescribing for chronic benign pain in working aged adults will go a long way toward diminishing the out-of-control opioid prescribing that is happening in the US. Most data suggests that these particular prescriptions are not being written by specialists but FM & IM. Harm reduction strategies should probably target those specialties first. (1,2)

1. http://www.peerassistanceservices.org/files/documents/Kerlikowske_CO_RxDrugAbuseForum.pdf

2. Pain Med. 2013 Oct 9. doi: 10.1111/pme.12247. Specialty of Prescribers Associated with Prescription Opioid Fatalities in Utah, 2002-2010. Porucznik CA, Johnson EM, Rolfs RT, Sauer BC.
 
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101N said:
Addressing the issue of overprescribing for chronic benign pain in working aged adults will go a long way toward diminishing the out-of-control opioid prescribing that is happening in the US. Most data suggests that these particular prescriptions are not being written by specialists but FM & IM. Harm reduction strategies should probably target those specialties first. (1)
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We can all agree to that.
 
101, one can argue - fairly coherently - that prescribing opioids to working individuals holds more basis and has a level of functionality to justify continued use.
 
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Ducttape said:
101, one can argue - fairly coherently - that prescribing opioids to working individuals holds more basis and has a level of functionality to justify continued use.
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Ducttape said:
101, one can argue - fairly coherently - that prescribing opioids to working individuals holds more basis and has a level of functionality to justify continued use.
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Understood. But realize I said working-aged, not working. If you looked at the Majority of working-aged pts with CNP- on high dose opioids- you will find that they are non-working.

More often than not, opioids don't improve function in these patients.
 
101N said:
Understood. But realize I said working-aged, not working. If you looked at the Majority of working-aged pts with CNP- on high dose opioids- you will find that they are non-working.

More often than not, opioids don't improve function in these patients.
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nit-picking the nomenclature on both sides. i usually will state "non-working" or disability instead of working-aged. your definition of working-aged also seems a bit limited to me - i generally think ages 18-62, the age one can get social security benefits.
 
I have somewhat of a unique vantage point on the group I am describing. As a part of my service I offer opioid tapers/weans for PMDs to reduce harm. I see the patients I am describing as a consultant and often times I am called upon to 'make the opioid regimen sane'. I can assure you that the majority of working-aged patients on high dose opioids for CNP are non-working. Moreover, they fit the mold of the most common CNP dx: LBP, HA, FMS, and chronic abdominal pain. I would never have started the vast majority of these people on opioids to begin with. But now the gennie is out of the bottle.
 
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I have a common tongue and just say it like it is:


IMPRESSION

1. History of postoperative foot pain with clubfoot.

2. Heel spur.

3. Plantar fasciitis.


RECOMMENDATIONS

Opiates are not indicated in this patient at this time for chronic non-malignant pain. A database check reveals 22 prescriptions issued since 10/16/2012 of low to medium quantity of hydrocodone or oxycodone. This is more suggestive of a underlying under treated depression, anxiety, depression or substance abuse disorder rather than chronic non-malignant pain.


As she is 30 years old, there is no reason to think that opiates would be beneficial from a functional standpoint noting that she has been on disability for at least the last four years. For this reason, she is not a candidate for opiates and they are not going to be part of her care. I am going to ask Dr. G who I spoke to today to build her an AFO custom molded in his office due to history of surgery, which would allow functional gait efficiency improvements. She would benefit from a topical triple cream, a neuropathic pain medicine Pamelor and a change of Motrin to Lodine, which may be less caustic on her stomach. The patient has reported trying Ultram in the past without good results but I do not believe opiates are warranted in her care. I think she will do well with a course of physical therapy with the AFO. She may need aquatic therapy first before land based training. I think this will allow her to reach her goals of eventually running. Of note, she has lost 30 pounds in the few months through diet and exercise. I think she will continue to improve.
 
"SANTA ANA, Calif. -- Eyewitness News Exclusive: A doctor caught on video meeting with patients at a coffee house and selling them prescriptions for OxyContin, Xanax and other addictive drugs.

Prosecutors say Dr. Alvin Yee would meet his so-called patients mainly at Starbucks cafes, as well as at Carl's Jr. and Denny's restaurants, and in one instance at a car dealership and wrote a prescription as he was buying a new car."


http://abclocal.go.com/kfsn/story?section=news/local/orange_county&id=9291642
 
Transcript of Sanjay Gupta's Lynn Webster interview.

(COMMERCIAL BREAK)

GUPTA: Someone dies every 19 minutes from a prescription drug overdose and most of these deaths involve painkillers. Now, I'll tell you, part of the problem is that painkiller prescriptions in this country are being written at a furious pace.

(BEGIN VIDEOTAPE)

GUPTA (voice-over): Dr. Lynn Webster is considered a leader in the field of pain management. He's president of the American Academy of Pain Medicine.

DR. LYNN WEBSTER, AMERICAN ACADEMY OF PAIN MEDICINE: We've got over 100 million Americans who are experiencing chronic pain.

GUPTA: He's the author of a scoring system used by doctors to distinguish painkiller addicts from legitimate patients. And he's the founder of this pain clinic in Salt Lake City.

(on camera): What is his reputation?

DR. ANDREW KOLODNY, PHYSICIANS FOR RESPONSIBLE OPIOID PRESCRIBING: His methods are incorporated into almost every single educational program about prescribing opioids and even accepted by the FDA.

GUPTA (voice-over): But if you start to ask around a bit, you'll learn that his reputation among some former patients and their families is astonishingly different.

ROY BOSLEY: His reputation is he's known as Dr. Death.

GUPTA: Known as Dr. Death?

UNIDENTIFIED MALE: Yes.

GUPTA: That's how your wife's doctor was described? BOSLEY: Dr. Death.

GUPTA: Multiple overdose deaths at the Life Tree Pain Clinic which Webster ran for more than a decade now hover over him.

BOSLEY: He went unconscious.

GUPTA: There are allegations of irresponsible prescribing practices and in the case of one patient, influencing what was written as the cause of death.

BOSLEY: Here's the interesting part.

GUPTA: Roy Bosley's wife Carol Ann first went to the Life Tree Pain Clinic in 2008. Years earlier, her car had been broadsided.

BOSLEY: She did not have the seat belt fastened and went through the windshield.

GUPTA: After several operations on her spine, she managed her pain with low doses of painkillers.

(on camera): She's still functioning doing everything she needs to do.

BOSLEY: Yes, yes.

GUPTA (voice-over): But that would soon change when a friend suggested Carol Ann go to the Life Tree Clinic. Within a few weeks of becoming a patient --

BOSLEY: Carol Ann was pretty much hooked.

GUPTA (on camera): When you say hooked, you mean what?

BOSLEY: She was hooked on the pain medicine. She needed it.

GUPTA (voice-over): This is what Carol Ann was prescribed a year before her death -- a painkiller and an anxiety medication, between 100 and 120 pills a month.

Now, fast-forward one year. She was prescribed seven different drugs, painkillers, anti-anxiety pills, antidepressants -- all told, about 600 pills per month. The same steep climb in medications allegedly was seen among other patients who died after getting care at Life Tree.

Like this case, described in a medical malpractice claim recently filed against Webster and Life Tree. A 42-year-old who was prescribed about 200 pills a month when she first started at life tree. That's a little more than six pills a day. Seven years later, just before she died of an overdose, she was taking 1,158 pills per month or about 40 each day.

At the Bosley home, a sad spectacle filled with denial and overdoses began unfolding. BOSLEY: There were numerous times that we ended up in the emergency room for fear that she was going to die.

GUPTA: Bosley said he would regularly return home from work with Carol Ann unconscious and barely breathing. You took pictures of your wife essentially unconscious.

BOSLEY: Correct.

GUPTA (on camera): Must have been a hard thing to do.

BOSLEY: Very hard.

GUPTA (voice-over): Bosley says he tried to show the photos to Dr. Webster and other staff members and he tried calling the clinic to vent his concerns. He was shut down, with staff citing patient privacy or HIPAA.

(on camera): You weren't so much as asking for information as you wanted to provide it.

BOSLEY: I said, I am not asking for information. And I was given the HIPAA excuse and that was the end of it.

GUPTA (voice-over): So, what does Dr. Webster have to say about the claims against him and his clinic?

Well, despite our best efforts, not much. He did, however, respond to lawsuits filed against him and his clinic and denied responsibility for the deaths. We called his spokesperson.

(on camera): We certainly want to give him an opportunity to comment and to respond to some of this.

(voice-over): But he declined our interview. So, we decided to go straight to him.

(on camera): I'm in Boston at an event where Dr. Lynn Webster is going to be speaking.

You know, we've repeatedly asked him for an interview and through his spokesman he was repeatedly declined. So, we decided to come here and ask him ourselves in person.

Dr. Webster? Sanjay Gupta, with CNN, I'm wearing a microphone. I wonder if I could ask you a couple of questions. I've been trying to reach out to your team --

WEBSTER: I've got an appointment right now.

GUPTA: Will you sit down and talk to us afterward?

WEBSTER: I've got an appointment right now. Thank you.

GUPTA: After the appointment, will you sit down and talk to us?

WEBSTER: I've got an appointment.

GUPTA: Can I walk with you? Are you walking to your appointment here? Will you answer a couple of questions for us?

WEBSTER: No.

GUPTA: You don't want to answer any questions?

WEBSTER: No.

GUPTA: OK, all right.

(voice-over): We did get a statement ultimately. In it, Dr. Webster says the clinic treated difficult and complicated people with pain, with the highest standard of care. He went on to call the deaths a tragedy of the worst kind for patients to die not from a result of treatment but in spite of it.

BOSLEY: She was doing great. She was up to walking almost five miles a day.

GUPTA: Several months after starting at Life Tree, Carol Ann Bosley kicked the opioids and she went to rehab.

BOSLEY: She had lost weight. She was managing her pain on Tylenol, only.

GUPTA: Soon afterward, he says Carol Ann got a call.

BOSLEY: She said, Dr. Webster has requested that we come down both of us come down and meet with him.

GUPTA: To Roy Bosley's surprise, during the appointment, he says Webster suggested Carol Ann get back on narcotic painkillers.

BOSLEY: And my response to him was, my wife is addicted.

GUPTA: About a year after that appointment, after taking his advice, Carol Ann Bosley overdosed again. This time, it was fatal.

But Carol Ann's story does not end there. Weeks after her death, the medical examiner had ruled her death a suicide.

BOSLEY: I said, why did you label it suicide? And he says, well, I called Dr. Webster. He told me that she committed suicide. Why do you have to call Dr. Webster to get a diagnosis? Shouldn't the diagnosis be based on the evidence in front of you?

GUPTA: The Utah medical examiner's office say that Webster didn't have any influence over Carol Ann's stated cause of death -- which makes what happened next even more puzzling.

BOSLEY: Maybe five weeks later, I get a revised autopsy report. Cause of death, undetermined.

GUPTA: (on camera): When it came back undetermined, was there an explanation? They just changed it?

(voice-over): It's been four years since Carol Ann Bosley died. Her husband still wonders why his pleas for help to the staff at Life Tree and especially Lynn Webster fell on deaf ears.

(on camera): You blame Dr. Webster for your wife's death?

BOSLEY: I do. To this day, I regret that I did not go down there and find him. I would have pinned him to the wall, and I would have made him listen, and then I would have warned him with his life. Leave my wife alone.
 
Good afternoon, Mr. Smith. Take two of these until addicted, and call me in the morning!;)

lobelsteve = sensible
emd123 = sincere
algosdoc = smart
ducttape = straightforward

I'd let you guys/girls(?) treat me ANYTIME!:):)

Now, as for mengele, oh, wait, I mean as for 10....well, crap....nevermind.;)
 
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algosdoc,

That's MISTER f*$king ***** to you!! ;);)

And, I actually think you're still pretty damned smart with that whole debunking thing.

All kidding aside, I think after reading this entire thread, something I almost never do anywhere, much less 8 pages of it, it occurs to me that no matter how one looks at it, there simply is no "nutshell" that this issue can fit in. You are all obviously extremely intelligent, and you know that of which you speak. Hell, you all spent no telling how many years of training, and you all do this for a living now.

Quite clearly, the viewpoints here range from one end of the political spectrum to the other, but for the most part, almost all of you are truly and actually trying to figure this thing out in a reasonable and sensible manner, as daunting as that is. I find the lack of finger pointing here by most of ya’ll to be, well, pretty damned admirable, and what I’d expect from people who do the damned thankless job you all do. It sucks, because you can't "win" here, really ... no matter what the hell you do. You’re damned if you do, and damned if you don't.

The decades before and after 2000 were where we were, the one starting at 2010 is where we are at, and now, just like everything else, so swings back the pendulum. In 2020 to 2025, we'll be right back where we were 15 years ago, most likely, but while everyone else rides the time 'til then barely noticing the issue, you guys will be in the trenches with this crap, the lost generation will be propping up the Taliban consuming "cheap" Afghani smack or lining up for methadone or Suboxone, and most of your patients will be grumbling about your "bankers hours" and your "golf game", because as preposterous as that is, that's what most people think. They really and truly do. Patients see you guys walk in to the exam room, do what they think is a minimal survey, and walk out, and they assume that that’s your job! They really do! Then, if you order diagnostics, consults, therapy, what the hell ever, they don’t want to do it and then blame YOU for that as well! To top that off, they begrudge you the amount of money that they THINK you make!

At the risk of sounding like a fawning sycophant here, let’s just say that I know what ya’ll have gone through to get where you are, and again, it’s damned admirable. I sincerely mean that. It goes without saying that I haven’t done such…and couldn’t… but I do know. Years and years and YEARS of schooling, then on to shifts of literally continuous days on end designed, I assume, either “to toughen young doctors”, because “I did it when I was a young doctor and now you are gonna do it too”, or, hell, maybe because its fun to some to turn young docs into zombies…wind ‘em up, send them out to round. I mean, I realize that there’s work that has to be done, there’s “x” amount of resources (human and other) to do it with, and SOMEBODY has to do it, so I see, but with everything you all went through to get where you are (I’d still be typing next week if I tried to even half-ass list it all), it’s one helluva note to be unappreciated for absolutely no reason…quite the contrary, in fact.

But, that’s what ya’ll do.

The one thing that I DO KNOW is that no matter who says what, the bulk of you guys posting in this thread own no more responsibility for this “opioid epidemic” than my dog does. Why would you? Is it because you are pain management docs? If so, shouldn’t it be all docs? If so, then, shouldn’t it be all docs and their office staff…and so on, and so on, ad infinitum, ad nauseum. So, you are no more personally responsible for this than ANY OF US ARE! And, there you go – WE ALL ARE! That’s a fact. What the crap were you all supposed to do!? Make stealthy commando raids on pill mills? Parachute in behind the walls of Pfizer, et al, with suitcase nukes, or just do a daisy cutter flyover on them?! Send out black pajama ninja hit squads to Big PHARMA execs with orders to put their GI Joe Kung Fu grip on the nutsacks of these drug company bigwigs to gain compliance!?! (Careful, 101N, I’m not suggesting that, now!)

You see the same representative personalities on most forums, and this one is not 100% different. And, yes, Algosdoc, I am a *****….guilty as charged. This subject isn’t something someone should make a first post joke about, but again, I can be an ass. I sincerely apologize. I don’t know if it’s whistling past the graveyard or just that … me being an ass, I mean….either way, I shouldn’t have said what I did. Especially since I know very well what you all went through to get where you are, and that this is ANYTHING but a subject that some ******* should lob a stupid first comment off into when most everyone else is actually trying to seriously address a serious issue. Point taken, algos, and you are right.

Your jobs are thankless to most and they were unbelievably hard to achieve; most of you gave your asses to the military or paid student loans for years to get there; you probably pull in 65% to 70% max of what you bill now; you all have the dark cloud of the DEA or your state licensing boards hovering over you no matter how conscientious and careful you are, knowing damned good and well that ambiguous “guidelines” will more likely be used against you far more than for you; you STILL work your asses off, even after normal office hours; you and maybe a few more docs are the only ones in your office that actually bring in money, yet you all probably support numerous families of your office staff through their salaries, which, like overhead, malpractice, general liability, and every other insurance imaginable, all flow OUT of your offices; and then, there are those, even in your own ranks, that want to assess blame upon YOU for something you all were likely trying to reign in reasonably for years before ANYONE labeled this situation as an “opioid epidemic”. And so on, and so on. Damn, I’m getting depressed just typing it.

If I have anything of value to add to this conversation, and I hope I do, I’d simply say that you can no more see the future now than you could back when this crap started, but, like then, you all have a pretty damned good idea where this new paradigm shift will lead. I would say, decently informed or not, that the answer isn’t jamming that pendulum back so damned hard that it’ll break it off. Pain hurts, and if an opioid protocol along with attempts at other modalities works for a compliant patient in pain, and this is obviously all quite subjective and will remain that way until someone invents a pain assessment meter, then I’d hope that wouldn’t be something that you all wouldn’t be willing to do. I say that knowing that it’s YOU ALL that are accepting 100% of the risk to do. I’d think that this is the balance that the bulk of you are striving to achieve here, anyway.

As for hard maximum dosage regulations go, it’s quite clear that although this would inarguable make your job MUCH easier, most of you aren’t rabid supporters thereof (if supporters at all), and that’s NOT because you all are wanting to prescribe excessive dosages or to run pill mills…by far and away not. You simply want to have the proper tools to pursue the job you do, and the main reason for that is because you are pain management docs, and you got into that unappreciated career for the most altruistic of reasons.

Hard and fast applications of either extreme are no good….then or now. Totally literal applications of “ First, do no harm” used as a reason to refuse any opioid treatment, and/or cheerleading “Full mu agonist! No ceiling!!” as a reason to prescribe dosages that would saturate every opioid receptor in the patient’s body with enough left swirling around in their plasma to kill three horses are both wrong. Extremes are almost never good, and this is no different. Ambiguous guidelines and maximum dose “recommendations” are in my considered opinion quite insulting to your craft. Hell, you guys practice medicine, and you’ve earned the right and authority to do so! You aren’t prescription vending machines, and for good reason.

I wish you guys luck…I really do. And, I wasn’t at all joking in my earlier post when I said I’d trust you four guys with my medical treatment any day of the week.
 
It is difficult to tell on the internet when a person is being funny or not. Sorry for my over reaction.
We on this forum definitely are not supporters of pill mills or uncontrolled prescribing. Most on this forum do prescribe some opioids so therefore in the absence of overt hypocrisy, one has to assume there is a place for opioids, and most also agree the amount being prescribed in this country is excessive. There is low level evidence that opioids are useful in chronic intractable pain with long term treatment with such and also low level evidence that opioids cause death and overdose above a specific set dosage. There is a higher level of certainty that combinations of benzodiazepines plus opioids or alcohol plus opioids lead to overdose and death. The main disagreement is what to do about opioid prescribing in chronic pain, appropriate monitoring, and interdiction in cases of substance abuse or diversion. Fortunately, in the absence of physician consensus about what course to pursue, federal, state, county, and city authorities have partially made that decision for us. The new laws and regulations were sorely needed and are already having significant impact as measurable in several states. We do have a long way to go and there will be many revisions of regulations and laws over time to further define the balance between safety and efficacy.
 
AmosMoses,

Thanks form injecting some humor in what's been an otherwise very gloomy forum lately.
 
emd123,

You are quite welcome....;)

You know, I was thinking about those old boys, the B&W/RJR employees who leaked the explosive (and, to B&W/RJR, very costly) documents regarding the whole tobacco industry/nicotine docs back in the pre-wikileaks days. They caught unmitigated hell, but, if anyone thinks that a corporation won’t pull some undeniably fast and loose shenanigans, to put it quite lightly (but more ‘net friendly), they need only look into that a bit to gain a different viewpoint. But know, those guys all paid a heavy price….seems like one of them just died, but I’m not sure.

So, we KNOW that a corporation will scoff at what they claim to be crazy, outlandish accusations, when in fact it is the sheer outlandishness of what they have done that is what is sort of protecting them from “unsubstantiated” claims. Hardcopy, once verified, and the big fat wallet rolls out, and then, the enormous settlements paid will give you an idea of the huge amount of money they already made. Believe me, they are still way out in the black anyway.

Now, one would hope that Big Pharma execs have learned from such, but I wonder. People will do unconscionable things while hidden behind the corporate veil, as they feel that THEY aren’t doing anything personally. It takes an idiot to produce hardcopy of stupid crap like that, even the tightest level inter office memo, but fools, miscreants, and idiots are well represented everywhere, and they DO sit on drug company boards. That’s a fact.

Now, even the stupidest of them know what RICO means, and they all fear the prosecutorial reaper…. and outright conspiracies are precisely what brings that on. If provable, somebody is heading to Club Fed. But, people are inherently greedy, and for some, no feather pile in their nest would be enough. And, yes, if these people could get away with it, they would gladly addict every single person in the US (except themselves and their families, of course) to keep them sucking at the Big Pharma tit. Crazy sounding, well, yes, but again, remember that I am talking about SOME of these execs, not all of them. But, it doesn’t take them all, and it doesn’t take an outright and blatant conspiracy to pull some terrible ****.

Let me relay to you all something here that I was involved in personally that I am extremely ashamed to admit to this day. Its done and over, but believe me, I think about it a lot.

Slimy **** is too ingrained in human nature to ever rule out. There’s direct plotting, and “indirect plotting”, or I guess you could call in an “indirect conspiracy”, or something like that. It involves lying by omission, keeping your mouth shut for economic and regulatory advantage, whatever. You guys aren’t stupid, you know what I’m saying here, so I don’t need to keep on with that….people do bad ****. Period.

Back in the 90s, I worked at an R&D facility that produced experimental chemicals all the from tiny bench scale on up through pilot plant size to produce quantities that would keep the market propped up on new chemicals until a new full plant would be built. Some of what we worked with was terrible, bad ****. Consent order stuff….so bad you don’t know how bad it is, and with these consent order materials, there is ALWAYS a “reportable quantity” that, if exceeded by a spill, must trigger a DEQ notice. It's serious ****.

I was the “board man” on my shift, the guy who sits in front of the computer for 12 hours watching everything, and I of course knew what projects were running. There were usually multiple projects, and one night, we had just a few. Thank God it wasn’t many.

I was sitting in the control room, and I heard a garbled, alarmed voice on the radio. Now, we constantly bull****ted around, especially on night shifts, and often pulled **** with the radios…just bull****, you know, clowning around, making the time pass. But, I immediately knew this was different. I was on the second floor, and the control room is designed for positive ventilation for safety reasons, but when I stood up and walked toward the radio, I knew bigger than **** what was going on, and I knew it immediately. I smelled ammonia, and I knew.

One project that was running that night had a huge tank of an ammoniated intermediate held within it. This stuff was consent order ****. With these tanks, you had sight glasses, you took very regular readings, and you KNEW exactly how much should be in there at all times. You had to, for process, and also by law.

Well, being that it was at night, and for reasons “of safety”, the engineer on one project came out late that shift to change the dip tube in this full tank of extremely nasty **** with an unfriendly vapor pressure profile. It was done at night for safety, yes, but that also worked out much better for small spills, if such happened, for obvious reasons. He took one operator with him, and they went out, hooked up to fresh air stations, and began.

This was a half inch tubing dip tube that ran down into the tank from top center, passing through a drilled through half inch stainless steel ball valve. A standard valve will only accept an inch or less of tubing from either/both side(s), and it will cinch down with ferrules on both ends to place the valve in service. But, if you drill through it, you remove the tiny shoulders that prevent the tubing from passing into and then through the valve. This way, you can, when careful, use such for diptube installs to help when you may need to change the dip tube on a full tank. The dip tube sucks up from the bottom, not the vapor space, so if it opens to the atmosphere, it’s not gonna spew vapor…bad enough in something with vapor pressure like this **** … its gonna spew liquid from the bottom of the tank. Either way, from vapor space or liquid level, this **** was gonna vent til it was gone any time it was open to atmospheric pressure. That said, if you want to change that dip tube with the tank full, you loosen the ferrule nut, start pulling the tube out, and just when the bottom of the dip tube was about to be totally out, r-i-i-iight when it passes the internal ball in the ball valve, you can simply block the ball valve, pull the last couple inches free, and reverse the process, and if done right, you loose a tiny amount of vapor, if any, from the system…only that which creeps around the dip tube as you remove it.

Well, that night, they screwed up. Nothing really too much on them, you know, easy to fault in hindsight or if you aren’t familiar with this stuff. I would have done it without hesitation if asked. It SHOULDN’T have been a huge deal, and it wasn’t that unusual. When the bottom tip of a diptube clears thru the ball in the ball valve, only a couple inches at most remain plugging the hole, and you KNOW this, and you know just how long the tube is. In this case, the ball valve should have been blocked right when the tip of the diptube cleared the ball in the ball valve, but for whatever reason, they though that they had more tube to come, and they pulled the tube out, and **** started flying.

Now, I can’t even remotely articulate with any decency just how bad this **** was when it jumped off. Intermediate, heavily ammoniated consent order chemicals flying at a huge rate of speed and volume spewing probably 40 feet in the air, and immediately the ball valve froze open, and then ice very quickly started building and spreading rapidly. I grabbed an SCBA and threw it on, and when I got there, the engineer managed to jump off of the platform onto the catwalk, get to the end of his fresh air line, throw his mask off and haul ass, but the operator was trapped. I tried to climb the ladder, and my gloves literally froze to the metal half way up. I’m not exaggerating there…even the damned ladder was freezing, and it’s on the side of the tank. We were venting…dumping….a godawful quantity of very nasty **** to the air.

We had “fire boxes” strategically placed around the site, huge water turrets that would send a stream of water like firemen spew, and you could aim and lock it, so I turned one on the frozen top of the venting tank, and tried to get up there again through the stream to the operator on the deck…big mistake. Although I had a decent fit with the SCBA mask, as I tried to go through the stream water jetted through the side of my mask fit, and the ammonia busted my ass. Unbelievable. I got under the safety shower, which made it worse, and the last thing I remember was throwing off the SCBA and jumping into a golf cart and pushing the pedal toward several contractors gawking from a hundred or so yards upwind. To boot, when I tried to shuck the SCBA, I couldn’t get the belt loose, so I was far worse off, trying to drag this damned big albatross behind me, most of which hung out of the cart. The last thing I remember was thinking, “You stupid, stupid bastard. You just killed yourself”. People say that they have thought that they were about to die, but I can’t stress enough how literally I mean that. I thought I was dead.

Luckily, one of the contractors grabbed me and drug me to a safety shower nearby and turned it on. Those of us that were trying to stop this catastrophe, probably four, were all so fouled with this **** that no one would get near us. Out of probably ten guys, that one guy drug me outta that cart and saved my ass was the only one who did anything for any of us….and even then, he turned it on and got the hell away. He did the right thing. I woke up on the cold concrete and under that damned shower, and slowly got my **** together. Fire, EMS all came, and by that time we had all gone and took real showers and changed, but even then, EMS were extremely hesitant about even touching us.

Now, when you have Fire and EMS on site, it’s a big, BIG deal. We all did the guy thing, you know, “Im fine…no, I don’t want to go to the hospital. I refuse medical treatment”. That’s a guy thing, yes, but its also the first part of the phenomenon I am trying, probably not very well, to describe. We ALL knew damned good and well if we went to the hospital it bumped the “regulatory severity” up somewhat, and God forbid, if we had an admit, lost time accident, we all knew whose fault the **** was gonna be…whoever was the lost time guy. So, we refused.

Within an hour, every gold hat that worked on the site rushed out. It was probably two or three AM at this point, and we all met up in a conference room to “discuss this”. Now, we emptied that tank. All of it. It had a sight glass that was monitored numerous times per shift, and there was a level indicator on the board as well as possibly load cells. I am not positive, but I think it had load cells as well. No matter how you look at it, a damned child, if he knew what a sight glass was, could say “Hey, it was full but now it’s empty!”. So, there were numerous ways to quickly and accurately ascertain how much we vented. It was a ****LOAD, and by no means even close to the amount that we could avoid reporting. I knew the **** was gonna hit the fan, and that **** rolls downhill. I just wondered who else was gonna get fired with me for trying to help with something we weren’t even working on. Trust me, when that **** happens, the only ones that run toward it are operators.

And, that’s when the “fuzzy math” started.

The head engineer on the project was there, huddled over and working frantically on a bunch of calculations….for all I knew he coulda been seeing what his 401K held so he could eat after HE got fired. But, nope, after a bit, he hands the paperwork to the big boss man, who looks at it and says, “OK, we’ve done the calculations, and this such and such flow through a half inch line at such and such vapor pressure, would have to vent for “X” minutes to be a reportable quantity”. I don’t recall what the time was, some half minute increment…maybe 3 and a half, maybe 8 and a half, I don’t know….it was irrelevant to the truth, anyway, because it was far longer than the estimate, and the tank was empty. EMPTY! And, in ten seconds one could see far faster, far easier and far, FAR more accurately simply by doing a quick sight glass or load cell look! You know, like “we had X pounds and its all gone”. Done. You didn't have to be John F-ing Nash to do that calc!

The boss man then looks up at us, the guys lined up in the back that had responded to the big ****mess, and stares at us and asks, “is there anybody here than thinks it vented longer than ‘X and a half’ minutes?”. Obviously, you know the answer we gave. We all shook our heads and essentially lied by omission, and we all did it for similar, economic reasons. I regret it, but short of getting a time machine, it’s done. ANYBODY could have figured the true volume/weight very fast, but when we were given this out, you know, something that was subjective, not definite, and we could simply say that we didn’t think it exceeded that time frame (although we all damned well knew it did, and by a ****load). End result? It wasn’t reported.

So, this, to me anyway, is very much a type of conspiracy, but one that’s hard to define, and thus hard to prove. Subjective guessing in this case was downright lieing, and we all knew it, yet did it. I mean, no one needed to tell you what was what. You KNEW. And you knew if you differed in “opinion”, you’d just as soon pack your **** and roll on out for good.

So, now, after reading this informative and interesting thread, I wonder.....is this some of what’s going on here with this issue? Is it setting up studies that can be easily predictable as advantageous to the interested party? Or, is it directly massaging data to advantage? Even worse, is it more RJR-like outright lying, scheming, and conniving? Even the RJR issue had less than a handful of whistleblowers, and they were a huge conglomerate with no telling how many people in the conspiratorial loop - and even then they were lucky that RJR sent stupid hardcopy memos to and from top execs, or these guys would have been laughed away as disgruntled employees. Nobody would have believed them, short of that hardcopy, and the entire RJR board would have feigned deep offense that anyone would even CONSIDER that they would do such atrocious ****…all the while doing more atrocious ****.

Clichés are born of some amount of truth, and the contemporary “it is what it is” is appropriate here as to what needs to be done start to reign this **** in, but it’ll be neither easy nor nice, and it’ll all hang over your heads like a damned guillotine blade held by a thread…too little, you’re Dr. Dolittle, and too much, you’re Dr. Phil Goode…the former will affect your practice, and the latter will put DEA crosshairs on your back. It’s gonna be one helluva balancing act, and I don’t envy those of you that are trying to do what’s right here, because that’ll be far harder than doing either extreme. I expect what nearly always comes from this sorta thing will happen here, and the pendulum will swing back extremely far in the opposite direction. That’s just as bad as the other extreme, and it doesn’t have to be that way. I’m honestly and sincerely heartened by reading this thread, because if the four members I mentioned earlier are fairly representative of the entire pain management community, then I know that you guys care more about easing pain and suffering of your patients than you do about making your own jobs much easier at your patients’ expense. I don't mean to exclude other posters here, I simply recalled these guys' posts more than others. But, that’s what I expect from most docs, anyway, because I know full well what you went through to get where you are, and you didn’t do it for money. I tip my hat to you guys. I really do.

I noticed where 101N said that the rest of you guys shouldn’t feel guilty about doing what’s “right” even when it is being done to a compliant patient that’s gonna catch a load of hell and pain from it. I believe that to be true. I do. But, I also say that you shouldn’t take some strange sense of perverted pleasure in doing it either, and sometimes, even the appearance of doing so is just as bad, with your patients, and with your peers.
 
http://www.chicagotribune.com/healt...emhnstr--k-h20140108-20140108,0,6058600.story
Separate fact from fiction about pain medication and addiction


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By Holly ThackerPremium Health News Service
4:30 a.m. CST, January 8, 2014


whatdoctorsknow.com

When it comes to prescription pain medications, there's a lot of misinformation out there. Whether you're searching for information about how such drugs can help you relieve pain or reading the latest tabloid tale of a celebrity addict, separating fact from fiction can be tough.

Richard Rosenquist, M.D., Chairman of Pain Management at Cleveland Clinic (Cleveland, Ohio), debunks six common myths about prescription painkillers, such as oxycodone and hydrocodone.

Myth 1: The more you take, the better they work.

More does not equal better. It's true that in the short term, after a severe injury, for example, two pills may be more effective than one at relieving pain. But over time, taking too much backfires. Research suggests pain medications may do something to desensitize the way your brain and spinal cord interpret pain signals, Dr. Rosenquist notes.

"You develop a tolerance to the medication over time," he says. "Sometimes, if you take chronic pain medications for a long time, your pain may actually get worse."

Myth 2: If you take them for a valid reason, you can't get addicted.

It can't happen to me. I'm a good citizen. I'm a normal person. I couldn't possibly get addicted. Thinking this way is dangerous. Even if you start taking a prescription pain medication for a legitimate reason, you run the risk of addiction. This has nothing to do with moral character and everything to do with the highly addictive nature of these drugs.

Myth 3: Everyone who takes them gets addicted.

On the flipside, just because you take a prescription painkiller does not mean you will become addicted.

It depends largely on your own personal risk of addiction. That's why Dr. Rosenquist and others in pain management screen for risk factors: a family history of addiction, a personal history of alcohol and drug abuse, or certain psychiatric disorders.

"If I'm considering prescribing opioids, I'm going to do drug screening and make sure you're not taking recreational drugs," Dr. Rosenquist notes. "If somebody uses recreational drugs, the likelihood they're going to use pain medications inappropriately is really high."

Not everyone gets addicted, but everyone who takes painkillers for an extended time period will experience symptoms of withdrawal when they stop. It's a natural reaction.

Myth 4: There are no long-term consequences.

Addiction is not the only risk that comes with prescription pain medications. When taken for extended periods of time, they also can harm your body's endocrine system and throw your hormones out of whack, affecting everything from your libido to your risk of osteoporosis.

"There are a lot of bad things that can happen, but people don't always hear you when you describe them," Dr. Rosenquist says.

Myth 5: You should avoid painkillers altogether.

Obviously, there's plenty of scary information about painkillers. However, there are certainly legitimate uses. In addition to treating the pain from acute injuries, a small fraction of chronic pain patients see improvements in both pain levels and function from taking pain medications, especially when other pain management techniques fail for them. For most people, though, prescription pain meds should be a short-term treatment at most.

Myth 6: Pain medication can fix your pain.

This may be the biggest myth of all. Pain medications simply mask your symptoms; they don't treat the root cause of your pain. That's why Dr. Rosenquist focuses on how you function rather than just how you feel.

Are you moving better? Are you able to get back to work? These are important questions about function. So is the question of whether you've been making efforts to get better. For example, have you been following doctor's orders and doing physical therapy to recover from an injury?

Have you been losing weight if you're suffering from weight-related back pain?

"If you're not doing the other things you need to do, I'm not going to keep prescribing those drugs," Dr. Rosenquist says. "On their own, they're not therapeutic."

For more health tips and information, visit HealthHub from Cleveland Clinic athttp://www.health.clevelandclinic.org

SOURCE: Cleveland Clinic

(WhatDoctorsKnow is a magazine devoted to up-to-the minute information on health issues from physicians, major hospitals and clinics, universities and health care agencies across the U.S. Online at http://www.whatdoctorsknow.com.)
 
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In Indiana as well as several other states, it is a government requirement that UDS be performed. We added to the Medical Board Rules, UDS with confirmation as a condition of obtaining opioids in Indiana. The ACLU action is about patients that simply want to do whatever they please including using illicit drugs, while continuing to receive prescription opioids. Their lawsuit will be shot down.
 
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