And these are the honest people I know…

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Remember those goofy cable commercials? When you have cable, you need to get out on a vacation. And when you go on vacation you need to go to somewhere exotic. And when you go somewhere exotic, you get bitten. And when you get bitten you swell up. And when you swell up, you can’t go home. And when you can’t go home you become a local fisherman they call “big fatty face”. Don’t become a local fisherman they call big fatty face. Get rid of cable…

things swell up

When you have unrelieved pain that keeps getting worse, you look at your torso. And when you look at your torso, you notice a rash. And when you notice a rash, you send a selfie to your mom. And when you send a selfie to your mom she tells you she thinks it is shingles. And when your mom tells you she thinks it is shingles, you realize you don’t have a doctor. And when you realize you don’t have a doctor you go to an Urgent Care.  And when you go to an Urgent Care you see someone who doesn’t know you. And when you see someone who doesn’t know you they can examine you and confirm the diagnosis. And when they confirm the diagnosis they tell you your mom was right. And when they tell you your mom was right they prescribe an antiviral. And when they prescribe an antiviral you say thanks but I can’t sleep and I need something for pain. And when you tell them you can’t sleep and need something for pain they tell you there’s pain medicine in the antiviral. And when they tell you there’s pain medicine in the antiviral, you believe them because you were taught to trust clinicians. And when you believe them you go home and suffer. And when you go home and suffer you contemplate suicide. And when you contemplate suicide, you suddenly remember your friend burst his appendix. And when you remember your friend burst his appendix you call him up. And when you call him up he says he has leftover pain medicine. And when he tells you he has left over pain medicine, you get in a cab. And when you get in a cab you go borrow some of his pain medicines. And when you borrow some of his pain medicine… You…

Overdose? Die?

Get arrested? Do hard time?

Welcome to the United States of America in 2015. Where people can diagnose one of the most widely recognized exquisitely painful medical maladies of our time and lie to your face. And hardworking executives are turned into drug diverters.

And these are the honest people I know.

And like the guy in the cable commercial, everything unravels from there. Is there a term for this phenomenon (I mean other than malpractice)? Pseudoaddiction? Pseudoclinician? Pseudocompassion? Pseudocompetence?

But the guy in those preposterous cable commercials just has to get rid of cable. What are people with pain to do? Is this scenario any less ridiculous or less likely to lead to a preposterous and exaggeratedly bad outcome?

And I want to ask; is this in any way related to the rescheduling of hydrocodone? Might the practitioner have been any more likely to provide hydrocodone and while she was at it a lidocaine patch, a little pregabalin, or anything?  Has the climate around opioids taken the last shred of dignity from us as we throw ourselves on the mercy of a stranger who confirms your diagnosis but not your suffering and by extension,  negates your humanity?  

Please feel free to comment!

14 thoughts on “And these are the honest people I know…

  1. “Has the climate around opioids taken the last shred of dignity from us as we throw ourselves on the mercy of a stranger who confirms your diagnosis but not your suffering and by extension, negates your humanity?” A resounding yes. It is becoming more than the pain patient’s perceptions of events. Thank you on behalf of all people living with pain.

    1. Celeste,

      Well said!! I find myself feeling as though I am constantly crying even when I am not doing so outwardly. I moved recently and wanted to find a new GP closer to my home. I called 9 offices and all but one answered the phone like this … “Yes, we care accepting new patients but we will not prescribe anything at all for chronic pain or anxiety”. Um, what!? I felt paranoid… like, do they have a caller ID that tells them right away that I am in chronic pain and in need of a compassionate doctor?

      Almost everyone in my family suffers from generalized anxiety disorder, panic attacks and/or depression. I have had anxiety and panic attacks since I can recall. Up until the last few years I have always been treated for my pain and my anxiety and not one time have I ended up at the hospital with a problem breathing.

      I am now back to being unable to go out to dinner with friends or family. I cannot go to the grocery store, out to a movie, or even for a walk in a public park.

      For years now I have had to choose to have my pain treated over having my anxiety helped. But now my pain is being under treated and so my anxiety is much worse which is making my pain worse.

      Quite frankly I don’t see the point in anything any more. What type of life is this?

      I suppose all I can do is keep praying, reaching out, writing letters and hoping one day I will once again find someone with the power and compassion to give me my better life back to me.

      Dignity? Gone are the days. I am beginning to wonder if I will ever feel dignity when speaking with a “doctor” again.

  2. This has gotten to a point to where I don’t know what to write anymore , I have gotten so fed up with this ridiculous reckless behavior of those suffering in chronic pain that I’ve separated myself from hearing such stories just to stay sane in my own little world of chronic pain. My mental health and ability to make rational decisions has stayed in tact , thank God.

    All the suffering I’ve hear of , all that I’ve written , all the suffering I’ve been thru and all the suffering I’ve seen has been so disheartening . All of my time and effort to continue to write on this subject has done no good because no one listens outside this blog.

    I truly hope this thing turns around and those that suffer in chronic pain get the help they need.
    But I’ve found separating myself from websites and blogs that has to do with chronic pain has helped keep my own sanity in check. I’m not giving up , just stepping aside for now. I just don’t know what else to write anymore this has gotten so out of control.

    Thank you Dr. Fudin for continuing the fight.

  3. I don’t watch a lot of television (unless we’re talking Lydia’s cooking show or Formula 1 racing), so I’m not familiar with the advert of which you speak, but you know Jeff, there are other problems with this rescheduling — no refills, no phone in Rx for weekend toothaches, and other problems that drive up the cost of medical care for people who may already be struggling under the weight of our inflationary economy.

    With the pressure turned up on the war on opioids and the war on doctors who have the tenacity to prescribe them for pain lasting more than 90 days, I wonder how much pain the powers that be expect American’s to tolerate?

  4. Awesome blog, Jeff. Yet you and I will always disagree about the upscheduling of hydrocodone. Irrespective, you artfully capture the horrific state of American pain medicine, to which I give many thumbs up!!!!

    1. Michael, Thank you for your comments. For the record, I’m not in favor of, or against, rescheduling hydrocodone (that’s politically safe, right?). But, if rescheduled, the consequences should have been better thought out – perhaps even a Schedule 2.5 of sorts. A clear problem is that many providers have chosen (even prior to rescheduling or the presumed opioid epidemic) that they will not prescribe any controlled substances higher the Schedule III. That has created an access problem for many legit patients as I’m sure you well know. The quantity prescribed for dental procedures should probably be limited to no refills and a lesser quantity, and certain exceptions should be made for renewals via fax, electronic ordering, etc., prior to the change of scheduling, not after.

      I do agree with the bottom line that morphine and hydrocodone are mg for mg equivalent, but they are not necessarily therapeutically equivalent particularly since hydrocodone parent compound has activity and relies at least in part on 2D6 metabolism to hydromorphone. Morphine of course has the active 6-glucuronide which can accumulate.

      From a black and white scheduling perspective without considering appropriate access issues, toxicity, pharmacogenetics, drug-drug or drug-food interactions, toxic metabolites, and binding affinities, I wholeheartedly agree with you that hydrocodone should not be treated any differently than morphine. In fact, a small piece of me would like to see all of these completely descheduled in an effort to annihilate the black market.

      1. Well said doctor. I especially agree with your closing statement.

        I must say… I agree with Aldous Huxley.

      2. Jeff – Not much of a black market for ADFs/TRFs. As I’ve written, make them Schedule III, and the easily abused short-actings Schedule II. Or, better yet, require prescribers to engage in more comprehensive risk mitigation practices….which would so significantly reduce abuse. However, it’s easier for our society to place the blame on those suffering from chronic pain than it is to place responsibility on the broken system as a whole….

        1. Michael,

          I agree with you as well. I think there is a current rush to “solve” this problem. It took well over a decade to get to where we are and I think it is going to take more than a rip the band-aid off quick approach to solve the epidemic facing our nation.

          It makes me very sad to know that miracle medications have also caused so much grief, loss and pain. I hate the idea that something that has given so much has also taken so much.

          Our nation needs to say “Know” to drugs imho. Education is key.

          When my doctors started me out on chronic opiate therapy not a single one of them (and I had a team of doctors and surgeons), told me not to tell friends about my medications, no one told me much about side effects, to hide/protect my medications and so forth.

          Thank goodness for my mother who raised me to be a thinker. She raised me to understand that in life moderation and balance are key. Rather it is food, driving, socializing, drinking, smoking, medications, playing, working … whatever it is … if it controls you then it no longer has a place in your life. You know, sometimes you just can’t scratch that itch!

          She taught me not to develop obsessive behaviors. To keep myself healthy physically, mentally and spiritually. Life would be far less than it is meant to be otherwise.

          Any way, I digress.

          The system is broken and that is a fact. The best way, imho, to mitigate abuse is to hold everyone accountable. Do I like all the strict rules surrounding the ability to receive my prescription. Not really. But heck, if it is going to save a mother from grieving her child, a wife from losing her husband … then I say bring it on! Urine test, pill counts, blood test, educational classes – whatever it takes to save our brothers and sisters in this world of ours.

  5. Thank you Jeff. If not so serious, this would have been one of the funniest things I’ve ever read. I believe that you are correct in stating that our regulatory system (i.e. rescheduling) contributes to this scenario but, like any catastrophe, there are likely multiple converging factors that combine to create the “perfect storm”. I’d add lack of clinical knowledge and empathy to the mix, as well as the inherent flaws of a fractured and ineffective/inefficient care system.

    I believe that, if the government is going to impose such strict oversight regulations on the use of the drug products, they should also be responsible for creating and supporting (i.e. financing) a system in which properly diagnosed patients with well-documented pain syndromes receive specialist oversight and management, even remotely through telecare or other technology. In the scenario you describe, the correct diagnosis could have been made and then the prescribing and monitoring of the pain regimen could have been executed by a designated pain management service, with the process starting immediately in the office before the patient left. To restrict access to the agents and provide no legitimate and efficient means of accessing necessary medications for a properly diagnosed pain syndrome is unacceptable. Keep up the good work.

    1. ” In the scenario you describe, the correct diagnosis could have been made and then the prescribing and monitoring of the pain regimen could have been executed by a designated pain management service . . .”

      Given the incidence of shingles in this country, is it not silly to require a patient with shingles pain to go to a pain management service to receive treatment for their pain? Given the prevalence of pain in this country (and the decades ahead of aging baby boomers), is it not silly to require all or most patients to go to a pain management service for pain treatment? Would it not make more sense to expect primary care clinicians to be competent to treat much or most pain, given that pain is one of the primary reasons a person seeks medical care? My recollection is that the 2011 Institute of Medicine report on pain takes such a position.

      I will add, having just watched an interview with Kathleen Foley on The Open Mind about cancer care, that there are regional differences in the treatment of different diseases. She suggests that one possible cause of this is lack of access (for instance, living in a rural area two hours away from the nearest substantially comprehensive medical center). Is it reasonable and humane to expect an elderly person with shingles in Murphy, N.C. to drive 240 miles round-trip to Asheville, N.C. or Atlanta to be able to receive appropriate, adequate treatment their shingles pain? Or is such an expectation silly?

      It is a rhetorical question, of course. I think it is silly, but I could be wrong.

    2. “Professor Joan Marston (South Africa) reflects; ‘If you don’t have doctors and nurses who are adequately trained in pain management and how to use the drugs… it doesn’t matter how much morphine you’ve got in the country — it’s not going to get to the patients.'”

      Life Before Death – Back to School
      (Short film of the Life Before Death documentary series about the global crisis in untreated pain . . – – An international program within the American Cancer Society)

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