Friday, June 27, 2014

Drugs, pain and the whole damned thing

Coming back from a Blogworld vacay isn't easy. The problem isn't writing; the problem is reading. There are several thousand news stories, articles, and opinion pieces that demand study -- and my mind just ain't in Study Mode. Not yet.

Fortunately, Bill D -- an occasional contributor to this humble site -- sent me a private email about an issue that matters a great deal to me: Our society's frustrating, sometimes infuriating attitude toward the use of drugs to relieve pain. As longtime readers know, I've seen a loved one do battle with cancer, and the experience taught me that the medical establishment ought to apply drug therapy more liberally when a patient is obviously undergoing genuine suffering.

Bill's heartfelt piece will probably remind many of you of your own experiences. All the words below the asterisks are his.

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My wife Claudia had her right knee joint replaced five weeks ago and I’ve had my hands full getting a whole bunch of things prepared prior to the operation and then taking care of her afterwards. Looks like her surgeon did a fantastic job. She’s making excellent progress in terms of physical healing and mobility, but Claudia has really been struggling terribly with the pain. As you probably know, knee replacement surgery is notorious for some of the most hellacious postoperative pain known to man. Dealing with pain has never been one of her strong suites. But she’s hanging in there. To quote Claudia, “All in all, I’d rather be in Philadelphia."

During pre-op meetings, the surgeon and medical support personnel were careful not to go into too much detail about what’s actually in store after you leave the OR and the epidural (spinal block) wears off. They start you right away on an intravenous painkiller, so at this stage, things aren’t real bad… yet. Anyone new to all this has no inkling of what’s on its way, barreling down the tracks straight for you.

Of course the hospital staff studiously avoids going into the specifics about what they know never fails to happen when the intravenous painkillers are ended in a couple of days and you're switched to oral pain-meds, which are nowhere near as potent. It’s SOP, routine as far the hospital staff is concerned, but to the uninitiated, it all seems to come out of the blue, abruptly, too abruptly.

There’s an old joke that it’s not the fall that kills you, but rather the abrupt stop. Well, with no more intravenous painkiller, new pain levels soon begin to reveal themselves. You lie alone in your hospital bed, with a hollow feeling in the pit of your stomach. It’s at this point that the patient meets the angel of fate, and the patient is taken by the hand and introduced to a whole new world of hurtin’.

From here, it’s welcome to round-the-clock pain on a level like nothing you’ve ever experienced before. I’m talking industrial-strength pain. What the devil is that you ask? Well, it’s my term for wild-ass, off the charts pain. Pain that’s like a gigantic insane throbbing tooth-ache, the territorial range of which, in Claudia’s case, stretches from her buttock to her big toe. Pain so intense it makes restful sleep all but impossible. Unremitting pain, that sends an electrocution spike through your whole body when you slightly twitch the wrong way. Pain too fearsome for even the toughest mugs alive to consciously abide for more than a short while before they start whimpering and pleading for narcotic mercy.

Unfortunately, with knee joint replacements, this hell drags on for a number of weeks as pain levels gradually recede. The docs conveniently gloss over all of this really creepy stuff prior to the operation. Wouldn’t want to queer a sale. Afterwards, they indignantly act like they had spelled out every detail to you beforehand in baby talk.

There’s a tremendous element of dishonesty at work here. Only it’s not unique to Claudia’s situation because the depressing fact is that her situation is pretty much SOP for knee replacements nationwide. It’s understandable that doctors don’t want patients to fixate on the negative. I don't know for sure if it's out of expediency, or cowardice, or fatalism or what, but medics knowingly allow you to go into one of the most painful surgical procedures you can have, foolishly imagining that after the operation, if the pain gets too rough, all you have to do is sing out and they’ll come a runnin’ with lots more painkiller, faster than your own mama,

That sure would be nice, but that ain’t the way it actually works. The reality is, that you WILL take what they give you and like it, or you can pound sand. And, what you WILL get for all your begging, is barely enough painkiller to keep you from howling like a gut-shot Dutchman and just enough to make sure you’re sufficiently drugged, so that despite your mortal agony, the hospital staff feels safe you’re too doped-up to be able to suddenly leap out of bed and dive through a plate glass window to your death.

I’ve got to say, it’s a bloody disgrace how puritanical busybodies, have managed to inject themselves into this tremendously private doctor-patient relationship of pain management. You know the nosey puritanical pillars of American virtue I’m referring to: the holier-than-thou fussbudgets, the self-appointed members of the morality-police and of course your meddling sanctimonious bluenoses -- It’s a bloody disgrace the way these handwringing moral vigilantes, in conjunction with hyper-zealous law enforcement agencies and fundamentalist cornpone legislators have succeeded in thoroughly intimidating the medical profession into being scared shitless to freely and ungrudgingly prescribe adequate amounts of narcotic painkillers for people who are suffering pain, …much less industrial-strength pain.

Of course, it would be an intolerable disgrace to acknowledge the retrograde accomplishments of America’s noisome volunteer corps of amateur busybodies without also paying dubious tribute to the monumental contribution made to this ungodly mess by all the proud professional domestic drug fighting busybodies in organizations like the DEA. Working in both open and clandestine cooperation with US intelligence organizations, the DEA, et al have been instrumental in establishing a mammoth government run protection-racket, commonly referred to as the War On Drugs.

It’s not just a war on black-market, “street” drugs, it’s a four decades-long societal blitzkrieg to control and micromanage every kind of illegal and legitimate psychopharmacological agent that has any conceivable anesthetic, euphoric or dissociative mind-altering properties. Many hundreds of thousands of arrests, prosecutions, convictions and imprisonments later, along with god knows how many wasted hundreds of billions and illegal drug activity in the USA is so demonstrably worse than it ever was when war was first declared back in 1970, that nobody knows whether to laugh or cry. Except, that is, the movers and shakers of the criminal underworld who of course are absolutely thrilled, along with the many legitimate businesses that prosper handsomely from this immensely self-destructive national crusade. Their greatest fear is that America might have an attack of common-sense and repeal drug prohibition.

Well the United States has been at war now with drugs and drug-users for over 40 years, and during those more than 40 years the country has been subjected to a pernicious, one-sided, nonstop campaign of anti-drug propaganda and paranoia that uses fear, prejudice, and pure hogwash to buffalo the public and drown out all serious counter arguments and criticism. This program of mass indoctrination has, among other travesties, successfully perverted the public’s perception of prescription painkillers. For years, the image of painkillers has been systematically vilified in the news and in popular entertainment. In today’s bizzaro world, prescription painkillers are maligned and demonized as a dangerous and threatening borderline criminal commodity.

Everywhere I go I hear or read terrible accounts about "Hill Billy Heroin" (slang for OxyContin) and how it is wreaking havoc from coast to coast and what a horrible curse HBH is. What I get, is that irresponsible people, are acting true to character and making really ill-considered, self-destructive choices and then blaming their misfortune on OxyContin. The puritanical vigilantes have latched on to this one and they are out banging their tambourines and blowing their kazoos hoping to get OxyContin outlawed or even more heavily restricted than it already is. Of course that'll mean even more arrests and more imprisonments. OxyContin happens to be a valuable medical weapon against pain. But the bluenoses would see it taken away and punish the whole of society in order to appease their insatiable sense of righteous indignation.

It wasn’t that long ago that opioid-painkillers were widely appreciated as a benign source of relief. Now they are relegated to being a necessary evil. An evil that is imagined to be so profoundly malevolent that everyone involved with utilizing them medicinally needs to be forced to conform to elaborate and extremely complicated handling and accounting procedures designed to prevent and discourage their improper use. All of which, of course, needs to be rigidly policed by a vast and expensive paramilitary army of zealous drug enforcement professionals.

Medically, the correct attitude today is that painkillers are potentially so harmful to society, much less to the individual patient, that they must be prescribed and dispensed, not as they once were in a calm, levelheaded manner, but fearfully, parsimoniously, as if painkillers were a weapon of mass destruction, a maniacal combination of a super touchy high-explosive and an ultra-lethal radioactive-isotope. Enlightened healthcare providers might cautiously disagree privately, but publicly they either faithfully tow the party-line or invite being marginalized or even destroyed.

You know it’s interesting but when one considers the highly sophisticated level at which modern medical technology regularly functions, it doesn’t seem at all unreasonable to expect medical science by now to have developed precision techniques that could target a location experiencing pain and provide relief restricted to that specific site, without involving the whole body and without inducing a state of narcotic inebriation, or any CNS impairment. You have to wonder what’s delaying progress in this vital area of research?

Meanwhile, doctors continue relying upon the antiquated and scattershot method of flooding the entire body with anti-pain medications. The fact that contemporary medical science is so appallingly backward in the area of pain amelioration and management unflatteringly reveals a great deal about Western medicine’s true institutional priorities and values.

As far as the treatment of pain is concerned, mainstream medicine still has one foot planted firmly in the 19th century. Ridiculous misconceptions and fearful fantasies, many Victorian in origin, plague not only the public’s perception of painkillers, but often are actually perpetuated by doctors and other influential healthcare managers.

But what about people in the end stages of death? People who are rapidly withering away due to irreversibly fatal illness and who are experiencing excruciating pain? Surely these doomed souls, writhing in mortal agony, only days, if not hours from death, surely they deserve humanitarian dispensation? Surely they warrant being allowed the mercy of receiving the full unrestricted force of opioid narcotic's painkilling power without anyone fretting over the fact that they will become heavily habituated and a tiny percentage might become addicted.

Yet incredibly and disgracefully, even these poor, tortured creatures are frequently denied adequate amounts of painkiller.

The rational for such hardhearted stinginess boils down to one of two things. Inevitably the true intellectual foundation for such cruel half-baked rectitude, masquerading as medical scrupulousness, is either fear of sanctions, whether legal or professional. Or else, the justification rests upon semi-coherent, moral convictions or just out-and-out irrational fear, not unlike the ignorant, fear-driven, crazy-ass beliefs and harshly judgmental, and insensitive attitudes commonly associated with human sexuality, -- prejudices which doctors and healthcare professionals are certainly by no means immune from having.
Comments:
I live on Long Island where our DA has chosen to ignore gang violence while focusing on doctors who "over prescribe" pain medication. I was sitting in my dentist's office waiting to get a root canal. There was a TV with the news on, and Madame DA suddenly popped up on the screen shaking a bottle of pills and shrieking, "There's no reason why this dentist should have prescribed 20 pills for a root canal." I caught the eye of the receptionist and said, "I guess I'm not going home with anything today." I was right.
I'm a 60 year old woman. I'm responsible and educated. I didn't fake the bad tooth and engineer a root canal to get some pills. Yet my dentist, a nice young man with a relatively new practice, was scared to pull out the scrip. And the gang violence continues.
 
Without being insensitive and flippant about your wife's knee surgery pain may I just say, thankfully, I've made it through 62 years of life with no real experience of pain but I do a lot of reading and just shake my head at the frequency of these medical horror stories. Why must politics, the legal system, lawyers and insurance companies all conspire to wreck total havoc in the treatment of pain? Either the US healthcare system is appallingly awful or the political system is corrupt, venal and useless. Which is it?

My guess its the politics!

My healthcare coverage is similar to that afforded members of Congress and the Executive. Better in that mine doesn't just cover me while working in DC with a seat in Congress or a term in the Oval Office. My plan is lifetime free coverage, a top-shelf, first-rate health plan available to me only because I live a short distance north of Cleveland.
 
A few years ago I experienced extreme pain for six months, fortunately only for seconds at a time so I did not need pain medicine. My son on the other hand was proscribed self administrated morphine drip while in the hospital awaiting death.

Chemicals which can cause permanent life long damage to your system, so that you need the chemical to feel normal, need to be regulated to prevent harm to individuals and society. Some chemicals can cause permanent damage to pain receptors in a matter of a few weeks of continuous exposure so that when the cause of the pain is removed you still feel the pain. As a young person I would rather suffer temporary pain than become permanently dependent on drugs. But as an old person the opposite is true. Also keep in mind the cost of addiction. Oxi is more expensive than street heroin and huge profits can be made by getting someone addicted unnecessarily.
Since all pain sensation is in the brain, Current brain research by IBM and others may find a simple cure or relief for chronic pain.
 
I would like to through a little caution in here.

There are the extremities of pain--that associated with cancer and certain sudden acute illnesses were pain serves no purpose except to cause suffering, however by focusing on this we forget the reason for pain.

Pain is a defense mechanism. It prevents injury, or–more often–further injury. The situation a physician frequently is confronted with is that of someone requesting pain medication–for, let's say, a muscle strain. By alleviating the pain, the person can now go on to continue the process of injuring him or herself.

To refuse analgesia to someone who has just had a root canal is just ridiculous (unless the dentist is worried you'll go out there and bite the golden apple.) To be cautious in the face of someone who needs to "get back to work," not so much.

Imagine a world in which people feel no pain. Diabetics have this problem (usually in their legs or feet.) It is not a blessing.
 
I meant throw.
 
I have lived with intractable pain (6-8 on a scale of 10)for years, needed narcotics but refused them because they make me sick to my stomach. I was recently prescribed something call tramadol by my dentist because of the fear of drawing the attention of news whore DA's and the DEA. Anyway, this medication is not narcotic and it works. Keep it in mind.
 
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