Opioid Insanity

Let me begin with several presumed facts:

1) There is an opioid problem, crisis, epidemic in the United States.

2) I personally use an opioid for a pain issue I have been treating for over fifty years.

3) I have at various times in the past 5+ decades had acupuncture, acupressure, chiropractic manipulation, cortisone injections, prolo-therapy, massage and literally scores of salves, balms, lotions, tinctures, pill, capsules, powders, back braces, straps, devices including electric stimulation, both light and laser therapy. Most of these interventions have been legal according to the FDA.

4) I hold a Ph.D. degree in psychology and as such claim to have a fairly well-rounded understanding of the roles of pain, pain management and the medical establishment.

Hence, begins my story.

Last week, I had my semi-annual appointment with the pain-management physician. After consultation, he renewed my medication. The new order was transmitted to my pharmacy and I shortly received the text notification that my prescription was delayed pending a insurance review. This was expected.

Within 48 hours a new message informed me my prescription was available. When I got to the pharmacy I was asked if my insurance company has informed me of the one week limit they were willing to pay for. I had not been thusly informed. The pharmacy technician said a lot of patients were running into this new insurance edict.

I was informed that I was considered "opioid naïve" and that the insurance would only pay for 14 pills for one week. Then I would be required to see my physician again (and pay the $40 co-pay again) for another prescription.

Here is the math. I currently get 30 capsules every 6 months. The insurance company wants to pay for 14 pills every 7 days. 

In the midst of an opioid crisis (see #1 above) the insurance company believes I and my physician are not intelligent enough (see #4 above) to correctly manage my pain. The insurance company wants me to take MORE drugs than I am taking by a factor of nearly twelve times more.

Crazy? Ridiculous? Counter-intuitive . . .

But wait there's more. My pain doc also requested that before I my next visit I should take one pill the night before and one the morning of my appointment, so that I will test positive for the opioid. It seems the government needs proof that I am taking my pain meds and not selling them on the street. So once every six months, whether I need them or not on my appointment day I have to take medication to satisfy big brother.

Not one but two instances where during this 'crisis" (#1 above) a well-managed pain patient (#2 above) is required to take pain medication to satisfy medical bureaucracy. Who might a rational person ask should be making such decisions? The patient (#3 & #4 above); the patient and their physician; the insurance company; the government?

Perhaps the problem is I am just too naïve.

Prolotherapy #2

I had my second prolotherapy treatment this past week. With this series of injections I can now begin to look for signs of improvement in my back problems. A full assessment is still three or more months away. For those who have asked for information, here is a well researched article from the New York Times (2007). The physician quoted in the piece is my doctor. 

This is not a new or alternative therapy at all. But 'tis not well known or widely practiced because, unfortunately, there's no money in it for Big Pharma, so the long-term clinical studies are not being done. If you have lower back, shoulder, neck or knee pain you might want to do some research on prolotherapy. My reports will continue here with any and all results. Just as with my series of articles on medical marijuana for back pain, if it works I'll tell you, if it doesn't that too. Negative data is still data.

While I am experiencing some side effects, they are not unanticipated and if I get relief I'll take the increased libido and hair growth on my feet. I'll just be a big, horny hobbit.

Spinal Confession

There are only two ways of telling the complete truth -- anonymously and posthumously. -Thomas Sowell

One of my very closest friends once commented that he had learned more about me from this blog than he had from nearly twenty years of face-to-face conversations. I plead guilty to being circumspect about my personal life. Another friend observed that I never actually avoided any conversation but after an evening of discussion I may have spoken in depth on how early Aegean cultures felt about a certain issue but he still didn't know my personal feelings on the subject.

Today I make a leap of self disclosure. I am doing this is response to a confluence to two factors. First, I have had conversations with both friends and family in the last two weeks in which I have hidden my current physical condition from them. Second, several of my dear friends have pointed out that such behavior may be less than optimal for everyone and with the deepest respect they told me to knock it off. After much reflection I have come to believe them to be much wiser than I on this issue, therefore I am going to change my behavior. So here goes:

In the fall of my sophomore year in high school it appeared that I had suffered a back injury while playing football, I was 14 at the time and the problem was misdiagnosed. The x-rays were read without my age being attached and the assumption was made that I was an adult male instead of just barely a teenager. For several years I took many aspirin a day for severe rheumatoid arthritis; a disease seldom found in young adults. Later in college I was reexamined by an orthopedic surgeon and father of a close friend and received my true diagnosis.

I have a congenital malformation in the small of my back. A teenage growth spurt and not football had been the aggravating factor. The facet joints at L4 & L5 (lumbar) on my right side are not well formed and do not perform their structural function of providing full range of lateral motion. I have been aware of this problem every day for the past 48+ years. Mostly I have kept this information to myself but the problem has become more acute in recent years. 

Last week the pain became so severe that I had to make my third trip to an emergency room for narcotic induced relief, the previous ER visits were in 1974 and 1986. Other than these three occasions I have managed the discomfort with exercise, pain meds and bed rest. I have missed scores of social events, dates, even intimate encounters over the years and used a variety of excuses other than the truth about my back to cover my absences. With the helpful yet still annoying prodding from several friends I have decided to stop deflecting sincere concern from those in my life, that process begins with this disclosure.

I won't bother with a complete history of my back pain, instead I will focus on my current situation. The most recent ER visit was two weeks prior to the date of this posting. I had been unable to stand upright for about 36 hours, getting out of bed was a full ten minute ordeal, any activity below knee level was simply out of the question. I had spent the better part of one entire day on the floor. Many thanks to M for getting this bound up old man to and from the hospital. As an aside, I apologize to anyone I spoke with on the phone that first week; I probably do not remember what we spoke about and I just wasn't ready to talk about all of this just yet. 

Once the ER physician heard the clinical details of my history and recognized my depth of understanding of the problem, we concurred in our diagnosis. The short term solution was to break the cycle of pain and spasm with major drugs. I was given injectable Dilaudid and Valium. Twenty minutes later the doctor returned to find me standing, back against the wall, a position that offers some short term relief, with obvious surprise he said: "I have never seen a patient standing after that much Dilaudid." I mention that part of the story because in the realm of silver linings, it appears I can now tolerate high dosages of pain medication without the buzz usually associated with them. And while that doesn't sound like much fun . . . I am now able to use Oxycodone on a regular basis to minimize the pain without being mentally altered.

One week later (a week ago today) I met my new primary care physician and fortunately found another doctor who recognized that I really am an educated adult able to understand and articulate my somatic issues and we rather quickly agreed on a course of treatment. I now have pain pills, pain patches and muscle spasm prescriptions with refills and liberal dosage limits as needed. Also I have a referral for physical therapy and once I am past this critical period we will go for a complete physical and perhaps even an MRI peek at my lower back before reassessing my condition.

For now, thank you for listening. I shall attempt to be more forthcoming about my condition, including public updates here on the blog, perhaps once a month in the near term. I would make one point from my decades of experience with a persistent medical condition -- anyone who has a chronic condition literally lives with it every day; talking about it is often simply tedious and annoying for us. I will try to be more open in conversations with my family and friends, if you will try to remember not to see me as merely a degenerate spine or a weak back. Illness, chronic injuries, syndromes are only one aspect of a person's being, but quite often the sickness becomes an all-encompassing label and the person begins to fade away.

My sincere appreciation for your concern, prayers and invocations; yes I will be availing myself of the myriad of interventions not found behind a medical school diploma. I am as open to a shaman's smoke as I am to a doctor's prescription pad.

A Pain in Time

"There is no magic immunity from pain. Mostly there is just blissful ignorance." --Amy Calistri

I am a bit consumed by pain today. Partly because I moved one too many boxes of books yesterday and am now paying the somatic price. But also because of several oft delayed and disparate ruminations of the topic of pain.

Amy made the point the other day in her piece on recent events in Austin. Humans tend to think that "it" simply cannot happen to them. Whether the it be financial, familial, psychological or other. We do have some unreflected set point that points to bad events happening to others and not to us. But, of course, every thing good or bad does indeed happen to someone and one of these times around the existential track the us will be us. Pain can motivate or demotivate people to do all sorts of things that one would not ascribe to them. Which is why the neighbors always look right into the camera and say: "He was always so friendly, I can't believe he could have done what they are saying he did."

Pain is a bitch of a motivator and psychological pain with no bleeding or bruising can be the worse. Not that physical pain is not the cause of many a out of character moment, we hope others will overlook or forget. I remember being enraged watching a news program on medical marijuana some years ago and hearing some smug 30-something congresswoman say: "Well, we can talk about this for the terminally ill, but I hear people wanting us to make pot available for arthritis, that is ridiculous." Clearly the words of someone who had never experienced pain. At the time I was supplying grass to a woman who had knuckles the size of walnuts and six inches of her spine supported with steel pins, all as a result of rheumatoid arthritis. But heaven forbid, we allowed her to seek relief from her pain in some natural substance. How could such legislation be justified? What is this to be, a nation where the health and welfare of each human is considered paramount? But, of course, should relief of pain also bring happiness, relaxation or euphoria; well that would be wrong. Sorry, no 420 rant intended.

Too many politicians only come around to enlightened positions when they or someone close to them falls victim to some painful, degenerative disease. Then they become wise and profound. Remember Lee Atwater, he saw the light and changed his position but only after being diagnosed with brain cancer.

And then there are the physicians who mouth platitudes about pain management but have never experienced pain; so they prescribe tylenol when morphine is what is needed. Pain management has been the rage for over 30 years in the medical profession but I heard yet another NPR show the other day, where the same criticism was made about doctors who don't get it yet. Whack those ignorant bastards across the shins with a tire iron and see if they don't run for the oxycodone.

Take a look at this picture, which was labeled "Back Pain".

Trust me, as someone who has had back pain for five decades, this is not a depiction of someone with back pain. This is someone with a sore back. Because if you are experiencing back pain you can't get your arms around behind you to massage it away. You are lucky if you can stand up in less than five minutes and you keep a loose pair of loafers around to eliminate the impossible task of tying your shoes.

And I haven't even ventured into the realm of psychological pain, which for now will be another post for another time. Because I am going to take another pill and crawl back between two heating pads and a cat.

Best Laid Plans

I am really a very private person. Despite all my opinions that I toss out here and in other places on the big olde world wide web, I like to keep my private life private. As my good friend Amy might say: "The bear really doesn't like coming out of the cave all that often and he almost never likes it when someone visits and tries to open up the blinds."

But the more things change, the more things change.

UIGEA + Facet Joints + eye of newt + several muscle relaxants - five days in Monte Carlo + one big writing deal - one woman + ten days in San Francisco + that other deal that just won't go away or get signed = the current state of the shrink dot dot dot

Tomorrow I will have another announcement here on my little blog. For now, I apologize to Dr. Pauly and Tiffany and Shronk who are battling through the fog of frog in Monte Carlo down one team member. Great job guys.

The more things change the more things reorganize, reinvent, recatalyze, reinvigorate and reiterate.

Poker-wise, I sense a slow turning of the wheel; the chariot has entered the town square and who knows what the parade will bring. Remember always look behind the wagon before you look inside.

Tomorrow, more clarity, more direction and even a fact or two. For tonight--Welcome Back My Friends to the Show that Never Ends, We're So Glad You Could Attend...