Kaiser Permanente and the End of Compassionate Care

Kaiser Permanente and the End of Compassionate Care

https://www.linkedin.com/pulse/kaiser-permanente-end-compassionate-care-matthew-giarmo-ph-d-/

Some people called this MANAGED CARE… others… refer to it as MANGLED CARE !

“They [Kaiser Permanente] are trying to take a woman who has been a chronic pain sufferer for over 10 years and clean her up of all her opiate therapy and Xanax at the same time — while denying her access to the only antidepressant that has ever really worked for her. In the middle of all this she gets a URI with a terrible cough — a cough which worsens her head and back pain — and they can’t even give her the only remedy that works for her because the extended release cough syrup contains hydrocodone. It’s galling. Initially, she thought her assigned PCP, a Dr. Mojdan Afshari, didn’t want any responsibility for managing pain, but she later learned that the PCP’s real motive is to deprive her of pain management altogether. And she continues to sabotage her even after the patient switched to a new PCP. And Kaiser allows it.”

Kaiser Permanente Serves Up Cold Turkey

I don’t want to bury the lead, so here it is. When Kaiser Permanente accepts new patients into its house of managed care, it asks them to leave their preferred medications at the door like a pair of shoes. Wait – correct that – Uncle Kaiser’s not asking. The fact Kaiser has moved 90% of the pharmacopeia into the non-formulary column plays no small part in the New Cruelty but also at play is Kaiser’s Wilhelmian War on controlled substances. If the legislature or the DEA has an issue with it – or if the FDA ever issued a black box warning about it – you’re not going to get it. Yes, your Kaiser PCP carries the banner in the modern military parade that is the war on the opioid epidemic. So no painkillers. But that’s not where the Prohibition style crackdown ends. It will also embrace a benzodiazepine or two so say goodbye to your Xanax and Ambien. And what’s with their crackdown on prednisone, the 4-day course of oral steroids doctors give you for inclement or intractable illnesses? I guess if it feels good …

I had the opportunity to chat one woman up in a Kaiser waiting room in Ashburn, VA who had been taking all of these drugs for years. Except prednisone, which she received only when she was ill – along with that cough syrup that contains hydrocodone. I’ve had that too. In fact she’d been taking these drugs for 10 years as a chronic pain sufferer and psychiatric patient who recently received a medical disability designation by the Social Security Administration. And as a Type 1 diabetic, she is more susceptible to catch illnesses than you and I and her young son brings home plenty from school. She’s also less likely than you and I to shake a cold and many of hers evolve into bronchitis. Hence the need for the extended release hydrocodone cough syrup otherwise known as Tussionex. Without it, her coughing would tear her apart by exacerbating her migraine and back pain. 

The Story of Cheryl D.

Unfortunately for this chronic pain sufferer, spousal unemployment cost her access to a network of PPO physicians she’s known for over a decade. When Federal BCBS ended – arguably the best health insurance there is — she fell to Medicaid. The Medicaid served her well enough. Sure, new Virginia regulations bombarded her physicians with requests for preauthorizations. The work required to complete these forms — which required evidence that that diagnostic methods were employed and non-narcotic avenues exhausted — strained staff resources to capacity … or exceeded them. Minor errors or omissions in documentation, errors in transmittal, and review and approval time delayed the fulfillment of one painkiller script 21 days. Cheryl submitted scripts for 15 different products to Medicaid for reimbursement — and all but one of them required preauthorization. At least in Virginia. Connecticut Medicaid was not as bureaucratic nor as heavy-handed in pushing physicians and patients into a preferred or “formulary” drug. And the Connecticut Medicaid patient did not pay a dime in co-pays. Cheryl reports that there were days when as a Medicaid member she just did not have the $3 to her name. With Virginia Medicaid, she didn’t think it could get any worse; that is, until at the 90 day mark — without notice — the State outsourced her — as it does all Medicaid members — to one of its managed care organizations. One day Cheryl opened a letter to learn that the next day she belonged to something called Kaiser Permanente. Here she would learn what it means not to get her medication at all.

In the Mouth of the Rabbit Hole

The first two visits with her KP-assigned PCP were Hyde and Jekyll. Initially, Dr. Mojgan Afshari responded with shock and awe upon learning her new patient had been prescribed an extended-release Fentanyl transdermal patch, short-acting opioid pills for breakthrough pain, the sleep aid Ambien, and the anti-anxiety medication Xanax. Cheryl reports that her medications — which she thinks of more as assets or resources — have allowed her to reclaim her quality of life. When the FDA issued a black box warning on the concurrent use of an opiate and a benzodiazepine like Xanax, Cheryl thought nothing of it. She’d been prescribed these two medications for over a decade. All her resources have co-existed harmoniously and without incident in her system over this period. But Cheryl walked away from the initial appointment believing that the PCP would not be party to these scripts. 

The Kaiser psychiatrist, Dr. Shweta Verma, insisted she begin tapering off the Xanax. No Kaiser member was permitted to use this substance. The hydroxyzine Verma prescribed in its stead proved ineffective. Cheryl likened it to a combination of promethazine and the buspirone (Buspar) she was authorized to take while pregnant. It was laughable to think 4 mg a day Xanax could be replaced by something so lightweight. It also did not help that the psychiatrist refused to allow Cheryl to continue her use of a next-generation anti-depressant called Trintellix. The drug was just too novel and too expensive for KP’s tastes. I suppose for every Nordstrom there is a Nordstrom Rack. Kaiser Permanente was shaping up to be the Nordstrom Rack of the health insurance market. To make matters worse, representatives of Kaiser’s Pain Management division informed Cheryl that they do not prescribe medications. They only give injections. Cheryl also consulted with Kaiser Neurology. Outside of Kaiser, it was the neurologists who provided the Social Security Administration with the pivotal testimony concerning the impact of her migraine and back pain on her physical and cognitive functioning. And it was the neurologists who prescribed Cheryl her game-changing pharmaceutical countermeasures. They were the equalizers. Not so the Kaiser neurologists. No, the Kaiser neurologists informed her from the get-go that they do not prescribe painkillers. They did however extol the virtues of Vitamin B-2.

It was at this point that Cheryl realized she would be denied both compassionate care (relief of uncomfortable symptoms) and continuity of care. While I am no doctor, I know that physicians are violating one of their own tenets. If you are going to make changes to a new patient’s treatment regimen — particularly if it’s a longstanding treatment regimen — you need to make the changes slowly and to one medication at a time. You also need a good reason. A clinical reason. “There’s an epidemic,” “the computer told me this is non-formulary,” or “the DEA is cracking down on this,” are not good reasons. There are more risks associated with changing a person’s medications than with allowing them to keep what they maintain works for them. Kaiser thought it could save some money by switching her from her preferred $900 Dexilant to a generic $9 protein pump inhibitor. Cheryl ended up in the ER with an allergic reaction. 

So Cheryl sent letters to her Congressional representative, the State Managed Care Office, and her County case worker lobbying to have her basic Medicaid benefits restored, but she was informed her chronic pain history and disability status were not among the 13 exceptions / exclusions in the Virginia legislation that would have authorized this. She was stuck was Kaiser. However, a case manager was assigned to mediate her concerns with her Kaiser PCP. During the very next appointment, Afshari’s demeanor was remarkably reformed — more pleasant and accommodating — and Afshari was now in a position to fill Cheryl’s Fentanyl and short-acting pain pills. But before the scripts can be written, Cheryl would have to sign a pain management contract. 

Cheryl is no stranger to these contracts. They have evolved quite significantly over the years from the one-pager assuring the prescriber he or she would be the sole source of opiate-based pain medication … to three page documents warning of the inherent risks of opioid use, abuse, discontinuation, and even theft by third parties. But the Kaiser contract contained a clause she’d never seen before. The contract prohibited her from obtaining scripts for other controlled substances, specifically Xanax, for the duration of her opioid therapy. This bears repeating. In order for her to receive the pain medication she’s received for 10 years, she would have to taper off her Xanax completely. She was required to choose between her pain and her anxiety. But what choice did she really have? She signed.

Before I take you further down the Kaiser rabbit hole, let’s break for a few brief words on the opioid epidemic.

Mass Hysteria & The Making of a Drug Seeker

The opioid crisis has claimed many victims. I have read accounts of manufacturing workers — a half dozen working for the same employer — who inject themselves with heroin right behind the factory in the middle of the workday. The needles pile up in plain sight. Production slips off. Some of these users will ultimately succumb to an overdose. I have heard an account from a woman who lost her brother — a Navy Seal — to a heroin overdose. He became the poster-child for New Jersey’s backlash. In Connecticut, the poster child is a 20-year-old hockey whose sister campaigned for reform on the claim that he was driven into the black market after receiving too many Percocets in exchange for his wisdom teeth. Then there is the viral photo of the Ohio couple passed out in their SUV while their child is strapped in his car seat. In Indiana, the owner of an NFL franchise was remanded to treatment after he was pulled over and found with empty bottles of painkillers. And we’ve all heard the sensational accounts in the media of celebrity deaths like those of actor Philip Seymour Hoffman and songwriter Prince. These are the anecdotes that put human faces on the numbers, and they are one of the two major lines of argument employed in the prosecution’s case against pain management. The other consists of the statistics. Deaths from opioid overdoses have quadrupled since the turn of the century. Over 33,000 in 2016 alone. And the coup de gras … four in 5 heroin addicts were once prescribed opioid painkillers. 

Yes, this warrants attention. But how much attention? What kind? And from whom? And most importantly, at what cost to legitimate pain sufferers, who in the wake of all this madness will emerge as a cultural minority not unlike African Americans, Hispanics, or women. The chronic pain sufferer would become a victim of their own brand of social injustice before the dust settles from a declaration of emergency and … an “epidemic.”

State lawmakers rolled out legislation designed to curb abuse. The laws and regulations are more club than scalpel. And yet if you take the time to read the laws, they contain exclusions and exceptions so as not to disrupt palliative care and care for chronic pain patients. The laws serve mainly to limit exposure for first-time users suffering acute injuries to 72 hour or 7-day supplies, depending on the state. Patients needing more than that can obtain what they need with follow up visits to the doctor, drug screens, or preauthorizations. In their language, the laws themselves are not all that damning. What really changed the culture is not the laws themselves, but how they were reported, interpreted, and subsequently broadened into best practices and guidelines by the media and physician groups. In addition, regulators, insurance carriers, and pharmacists stepped up their monitoring of physicians — often questioning their scripts and browbeating them into compliance with the spirit of the law by shaming them or making additional work form them.

(1) The very existence of the legislation elicits wild assumptions about what is actually in the legislation and confused and cautious physicians, concerned about their liability and licenses, have abruptly ceased all narcotic prescriptions. 

(2) Physicians who continue opiate therapies with legacy clients have been scrutinized, questioned, and harassed by pharmacists, insurance carriers, and even other doctors, the cumulative effect of which is felt as interference in the doctor-patient relationship.

(3) Patients are reporting more difficulty filling scripts due to a combination of new and old regulations. Take for example one man’s efforts to fill a script for a cough syrup containing hydrocodone. 

“Being sick, I don’t want to have to drive to all these pharmacies to find out who has [TUSSIONEX] in stock. But pharmacists tell me the DEA has placed rather unreasonable limits on the quantities they can have on hand. And when I phone ahead, some pharmacists tell me they are prohibited from disclosing information about these quantities over the phone. When I hand them the physical script, they have to call the doctor’s office to verify that it is authentic. But when they thought the “6” in “2016” looked a little too much like a “5,” they informed me they were prohibited from calling the doctor’s office and sent me back to my doctor for a new script. They eventually told me they only enough on hand to fill a partial script, but because the script involves an opiate, it can neither be split nor transferred. This means that if I let them give me what they have on hand so I can address my symptoms without waiting or driving around, I will not be able to receive the balance at a future date. So I asked them if they could tell me when the next shipment arrives. They told me they were prohibited from doing so. I asked them if they could call me when the shipment arrives. They told me they were prohibited from doing so. They also told me they could not reserve it for me, so someone else could conceivably claim part or all of what comes in. I would have to check in every day and ask if it had come in. Given these circumstances I decided not to allow them to enter the script into their system. I knew that once it was in their system, the script could not be transferred to another pharmacy location that might have had it in stock. I took the script back and eventually found a pharmacy that could fill it for me. About a year later, after having to fill three different scripts for this cough syrup at three different pharmacies, this fact was cited by my doctor who approached me with a database printout in hand accusing me of “red flag behavior.”

(4) The consequences of the War on Painkillers has spread to other classes of drugs. Hydrocodone itself did not become a Schedule III drug until an act of Congress in 2014, prior to which your doctor could have phoned in a refill to the pharmacy. Since then, the list of substances with a controlled designation has ballooned to include benzodiazepines and sleep aides. Xanax and Ambien have become just as difficult, if not more difficult, to obtain than painkillers, which brings us to a dangerous development evolving within the managed care organization known as Kaiser Permanente.

Before I refute – or at least put these opioid factoids in their proper perspective – let’s return to the life of Cheryl already in progress.

Crutch-Kicking Kaiser Raises the Stakes

Cheryl worked with a KP Psychiatrist on a plan to titrate off her Xanax. Benzodiazepenes like Xanax are orders of magnitude more problematic than even painkillers to withdraw from. While abruptly discontinuing high doses of round-the-clock opiates can result in 3-4 days of unearthly hell (i.e., nausea, vomiting, rapid heart rate, existential depression, diarrhea), the withdrawal is generally regarded within the medical community as non-life-threatening. “You may think you’re going to die, but you’re not” is practically a mantra. But titrating down from even the smallest doses of Xanax has been known to produce tactile hallucinations, delusions, and existential anxiety in the early phases followed by potentially fatal seizures and arrhythmia if untreated. Cheryl knows this all too well, because it happened to her 2 years prior when her PCP in Connecticut, having been visited by the DEA and instructed by parent Western Connecticut Health Group to abide by State legislation that took effect January 17, 2016, informed all pertinent patients that they would receive no more scripts for controlled substances. No benzodiazepines. No sleep aides. No damn cough syrup. Despite the known threat to patient’s well-being and knowing that no Medicaid psychiatrist was locally available, Westport Family Health cut her off cold turkey. 

“I don’t know where my PCP went. But this other doctor, this Dr. George Ianinni, flew into the room waving this piece of paper. It was a print out from some database. It contained every controlled substance I received over the past year, the prescribing doctor, and pharmacy where it was filled. He read me the riot act. And when his lecture / tantrum concluded, my initial reaction was to ask him, “Who are you?”

He kept saying “this is a red flag” … “that’s a red flag.” What distressed me most was that this was a doctor and he failed to properly read or represent the document he was brandishing like some flag. For him, the list suggested that I had been doctor shopping or taking a crazy amount of different things at the same time. But the list is not a snapshot in time. If read properly, it would tell the story of a patient who received something from her PCP before referral to an ENT at which points the scripts came from solely from that ENT. And then after the ENT was berated by a rogue pharmacist for prescribing the medication, the ENT asked me to arrange for my neurologist to prescribe it. It wasn’t a neurological drug — it’s an ENT drug — but the neurologist agreed because he understood that the community wanted one person to be responsible for all the opiates. This is not doctor shopping. Ianinni also flagged me for a variety of short-acting opiates but these were never prescribed at the same time. Over the year the specific opiate was changed as a way of addressing tolerance or finding the right dose level. (For example, you may want something stronger than 10 mg oxycodone but not be willing to titrate up as far as a 15 mg oxycodone. At that point you may be prescribed a 4 mg hydromorphone tablet, which is equivalent to 10.67 mg of oxycodone).”

Cheryl did not understand the doctor’s “lunatic” ravings at the time, but she would later learn from a gossiping psychiatrist in the local hospital that the head of her family practice — a Dr. Martin Singer — was “led out in handcuffs.” This rumor turned out to be grossly inaccurate but it speaks to the mass hysteria that surrounds controlled substances. Truth be told, Singer was placed on administrative leave with pay and expected to return. Excessive? You bet. By her account, Singer is the most conservative in the practice when it comes to controlled substances. But as practice administrator, he takes the fall for his group. Over the course of the following year, 2 of the 4 practice physicians and 2 of their nurse practitioners would leave for other practices.

“The day I phoned to have my Xanax refilled, I couldn’t get through to the office. All day. It was the damnedest thing. I must have called a dozen times between 9:30 and 5. The answering service first said there was a problem with the phones and then as the day went on, the story changed to ‘the doctors are in an emergency meeting.’ Now we know this was the infamous day the bomb dropped and the practice was taken to task for prescribing too many controlled substances … “

“… Westport Family Health aside, in all my travels over the years I have never encountered a reaction to the crisis more strident than that of Kaiser Permanente. In the case of Westport Family Health, third parties intervened and forced the physicians’ hands. This was unfortunate because those physicians served their patients. This is why I did not accept an offer from the Connecticut Department of Public Health to lodge an official complaint. The public health department informed me that they investigate and prosecute not only over-prescribing doctors but also those who “withhold medication.” I owed Westport Family Health a debt of gratitude for providing me the continuity of care I needed when I relocated from one state to another and from BCBS to Medicaid. They were the only people I could turn to for that Xanax, and they monitored me closely while I was in their care. Kaiser Permanente does not believe in continuity of care.”

Cheryl’s Kaiser PCP, Dr. Afshari, actually did prescribe her next month’s supply of pain medication — and even agreed to prescribe the extended release cough syrup when the patient developed bronchitis following a URI. So after a long drawn out battle complete with letters to the Congressional representative, it would have appeared that Cheryl had won her continuity of care. But this all came crashing down when Cheryl began running out of Xanax. She was tapering off as she was ordered, but she needed more to finish the job and psychiatrist Verma would not prescribe more. She may have been coming off more slowly than her KP physicians would have liked, but then none of her KP physicians have probably ever witnessed withdrawal from Xanax let alone experienced it themselves. The patient experienced it firsthand and the post-traumatic stress from this experience made her cautious. So Cheryl paid out of pocket to fill a script she received from a non-KP physician prior to joining KP. And by doing so, she violated that clause in her pain management contract. It didn’t take long for Virginia’s database to pick up on the fulfillment of the script at a local Walgreens — and alert Afshari. And Afshari responded by informing Cheryl that for as long as she remained with Kaiser she would never receive another patch, pill, or teaspoon of syrup again.

Incidentally, I bet you’re wondering why a person who endured such an experience would ever choose to re-expose herself to Xanax. I did. And I inquired. 

“I had a real need. You see in movies all the time these women who pop Xanax like stress pills and you sense they never really needed the stuff but that their therapists started giving it to them in place of Valium — which is a weak weak drug. But some people really do have problems with those anxiolytic pathways in the brain — and the Xanax works like nothing else. Buspirone (Buspar) is not in its league. Celexa is not all that effective. And the hydroxyzine the (Kaiser) psychiatrist gave me is a joke. I did some research online and one Xanax treatment center estimated that it would take some people 4 months to come off. And I was on a high dose. Four mg a day. To add to the problems with my hardware (brain), my life was far more stressful than most. My circumstances dire. I needed it. And yet I was coming off as they demanded I come off. I was down to half a milligram a day but when I filled the script to finish the job, I violated my contract.”

There was nothing Cheryl could say to avoid her punishment. She’d been grounded — permanently. None of the explanations — not her traumatic experience with Xanax withdrawal — not her long legacy of Xanax — not her dire life circumstances — would mitigate the transgression in the eyes of her Kaiser PCP. Cheryl filed a complaint in the hopes of working out the problem in mediation — but the PCPs physician supervisor slammed the door and threw his full support behind the PCP. Cheryl has never been without pain medication in the past 10 years. The news is so jarring, that she is seriously tempted to return to her Xanax — or pay out of pocket to see her old doctors. She is bracing herself for withdrawal from the most powerful opioid on the market — 100 times more potent than heroin by all accounts — Fentanyl.

Fentanyl. It’s the drug making a lot of headlines lately. It killed a 6-year-old boy who came into contact with it at a Florida pool. No one knows how. But it was found in his system. And it was found at the pool. He must have never known what hit him. It sent a police officer to the ER after he came into contact with Fentanyl as a white powder, having mistaken it for cocaine. And Fentanyl accounts for the majority of deaths broadly attributed to the opioid epidemic. Most heroin addicts die not from the heroin itself but due to the fact their batch was surreptitiously tainted with Fentanyl. Just ask Philip Seymour Hoffman. 

And yet the Kaiser patient advocate Tina Brown informed Cheryl that Afshari and Afshari’s supervisor both went on the record in maintaining that quitting Fentanyl cold turkey — and quitting Xanax cold turkey — is not harmful. 

“It’s funny because in their minds it’s so egregious to be using these drugs and yet they don’t believe there are any issues or complications in coming off. How can that be? I guess none of this should surprise me. I cannot believe how many of the Kaiser doctors I have seen have never even heard of the medication I have been prescribed by non-Kaiser doctors. Neither the KP ENT nor the KP Allergist has heard of Zyflo. Neither has heard of Dexilant [the next-generation Nexium]. Neither had my PCP, who replaced the $900 protein pump inhibitor with a primitive $9 generic progenitor [equivalent] that ended up with me calling the paramedics because I had an allergic reaction to it. My psychiatrist never heard of Trintellix [anti-depressant]. No one has heard of Flector patches. And their only knowledge of Fentanyl comes from what they read in the newspapers. It speaks to how shut in these doctors are inside the Kaiser walls. It’s like a roach motel. It’s where doctors who graduate at the bottom of their medical school classes go to die.”

Cheryl reports liking her patient advocate. That being said, it’s a toothless, showpiece role within Kaiser. Cheryl’s PCP encouraged her to file a complaint against her knowing quite well how it would all end. Cheryl talks to Tina. Tina talks to Afshari and Afshari’s supervisor. The supervisor throws his support to Afshari with a statement like, “I don’t see any evidence of wrongdoing.” And there’s no recourse beyond that. Tina admitted she has no medical background, so how could she formulate any opinions that the doctors would feel compelled to consider with an open mind. And yet even Tina would make a casual, off-hand, drive-by remark that Cheryl considered glib — cavalier — crass: “you have to get off these painkillers some time. You can’t be on them forever.”

“One of these days I should respond with two words — ‘Why not?’ — and watch them squirm. There are people out there who live with chronic pain. Why is it a sin — a shame — a crime — to use these drugs? Not drugs. Resources. Let’s reclaim the language of these people who haven’t had to live with pain. They use words like ‘addiction’ and ‘dependency.’ It’s a functional dependency. I harmoniously co-exist with these resources. They are all I have to salvage the quality of my life. And they all want to fuck with it. Question it. Make me feel like a bad person.”

Cheryl is right. She recounted her stay in a Connecticut ER following her withdrawal from Xanax. Xanax withdrawal was the presenting problem. But that didn’t stop the attending ER physician — a Dr. Weintraub — who had the nerve to code her encounter a “benzodiazepine abuse” — from forcibly engaging her in a discussion about her opiate scripts. “You need to come off these. You’re addicted and you don’t even know it.” He then demanded the names of the prescribing neurologists.

“The next time I saw my neurologist, he seemed bothered. He wanted to make changes. It wasn’t like him. I always wondered whether that prig interfered.”

Cheryl does not regret wasting Medicaid dollars from the State of Connecticut on 4 days of inpatient Xanax titration. None of this was voluntary. And contrary to what Dr. Weintraub predicted, she had no urge to “thank him five days later.” 

“I didn’t ask for this. They kept telling me Xanax is a problem. So they forced me off cold turkey. Then when I developed withdrawal symptoms, they pointed to the symptoms and said, ‘See? A problem!’ Numbskulls. Xanax was a solution — not a problem. It’s only a problem when some crusaders who think they know better than you force you to come off. And they forced me off. But I never felt as right without it. Not even months later. So when I had access to my old doctors, I went back on. Now I was switched to Kaiser and they want me off again. It’s cruel. Patients need consistency. It was dangerous for them to take me off because when I had an opportunity to resume the therapy, I could have made some dangerous assumptions about the re-starting dose.”

Cruel is a good word. Cheryl believes it marks the end of compassionate care in America. I agree. Managed care organization physicians like those who work for Kaiser are so hell bent on not doing anything wrong, they forget what it means to do right. Even after repeated overtures, patients are unable to get courses of prednisone to treat harsh or intractable illnesses. The rule seems to be if it makes the patient feels good, it’s probably why the patient has requested it, and that’s grounds for refusal. As I relayed to Cheryl, it happened to me at Kaiser. Take this response from a Kaiser PCP — Dr. D.L. – to my second request for Tussionex cough syrup. I had a cough for 2 weeks and it was causing me headaches, insomnia, and irritability. I just needed to break the cycle because I suspected the coughing was begetting more coughing through irritation of the throat. Dr. D.L. would have none of it. He initially called it a “band-aid.” Then this …

“I apologize for the delayed response but I have been swamped. I’m sorry you’re still not feeling up to par. I was not aware that you were diagnosed with reactive airway disease before. Therefore it may be the reason why this cough is still persisting. I suggest we start you on Qvar and see if it will take care of your cough. I would also suggest you see our pulmonologist to see if he would recommend pulmonary function tests. I will send it in for you at our pharmacy. Like I mentioned when I saw you, I want to get to the root of the problem and I want to try to avoid patching things.”

I told him that I could not afford to feel miserable and be laid up right now. I had two phone interviews to prepare for — and execute — and I was caring for a sick wife and 6-year-old son with ADHD. Neither him nor the Kaiser physician I switched from — Dr. K.A. — could seem to understand that while it is important to address the root of the discomfort — and it took two visits before anyone even decided to take that approach — it was still important to address the symptoms. D.L. called it a “band-aid.” But the two approaches are not mutually exclusive. In fact, they’re complementary. And while it takes time for the cure to take effect — why not make the patient comfortable? Also, if I was right about the role of the short-term cough as a maintaining factor in the long-term cough, then the Tussionex becomes therapeutic.

Initially, my first Kaiser PCP Dr. K.A. agreed to my request for the syrup and sent me over to the Kaiser pharmacy to pick it up. When I arrived, I could see them loading the bottle into the bag, but something didn’t look right. The substance in the bottle appeared clear rather than milky and the quantity was off. It didn’t look like the 70 ml she agreed to. So I had the pharmacist pull it back out of the bag for closer examination. This was not Tussionex. It was Hycodan. I took a few minutes to research the substance on the Web and it appears this is what they give patients at risk for overdosing. Hycodan contains an anticholinergic substance called homatropine that works against the hydrocodone so that the user would become sick if they took more than the 5 ml. Perhaps she thought I was scheming to swallow the whole thing. That would explain why she changed the script from 70 ml of Tussionex to 30 ml of Hycodan. I confronted her in her office about the change, and her response was priceless:

K.A. “Did you know Tussionex contains hydrocodone?”

ME: “Yes, so does Hycodan by the way.”

K.A.: “I know. The Tussionex is non-formulary. This is what the computer told me to give you.”

I got the impression she didn’t know anything about Tussionex, Hycodan, or homatropine.

ME: “I asked for the Tussionex because it is extended release and addresses all my symptoms. One teaspoon would serve me for 8-12 hours. There’s an antihistamine in there called chlortrimeton that peaks at 6.8 hours and doesn’t know me out the way promethazine or over-the-counter antihistamines — like the kind you find in NyQuil — do. But what you gave me [Hycodan] is straight hydrocodone.  Short-actinghydrocodone. I would be re-dosing every 4-6 hours. But you lowered the quantity to 30 ml. So this is only 6 doses that would cover a day-and-a-half. Could you put in an override and send the Tussionex over?”

K.A.: “I’m sorry. I’m not comfortable. The epidemic.”

ME: “Hmm. What? Epidemic?”

K.A.: “The opioid epidemic. I usually just have my patients take Robitussen.”

She would not be the only doctor to specifically cite the epidemic as a reason to deny me 4 days of relief from a cough and cold. D.L. also casually alluded to the “epidemic” in the early phases of our discussing symptom relief. My first appointment with him started out well enough. He asked me if what he’d given me the last time worked. He was referring to the Tussionex. But then he disappeared for 15 minutes and when he returned, he would only discuss NeilMed Sinus Rinse and Flonase.

The “epidemic.” The “computer.” These are the criteria for clinical decision making. Not my symptoms, which they observed and documented. Not my reported level of discomfort, which is consistent with what they observed in my ears, nose, and throat. 

Eventually, after repeated overtures through the Kaiser messaging system, D.L. relented and appeared to offer me the Tussionex, but it was not unconditional.

“Mr. Matthew Giarmo”

He knows I have a PhD and we’ve discussed my search for analytics positions, but I understand. 

“I can certainly understand that it is preventing you from sleeping so here is what I will do: 1) I will give you a prescription for Tussionex which you will only use at night to help you get some rest. This will be a 7 day supply and is a one time exception because as previously mentioned, this is not a definitive therapy. In addition, the evidence is clear that there is no difference in symptom relief between this and Dextromorphan. Because it contains a controlled substance and you have been prescribed this medication now 3 times in the past 3 months, I will not be able to prescribe it to you again this year.”

Actually, that is incorrect. I was prescribed the medication twice in a 6 month period and the quantities were small. A total of 140 ml for the 2017 calendar year. I drained the Hycodan after one dose because it made me sick. Again, I did some research and learned that even some patients who take Hycodan as prescribed can be made to feel sick. Nausea. Headache. Dizziness. Just what I needed.

Nevertheless at this point in the email I’m elated, because I think relief is on the way, but just like the two previous instances, it would turn out to be a tease.

“2) Before you fill the Tussionex, a urine drug screen will be required and needs to be clear. This is not my rule but nationwide and especially since you have had this medication multiple times.”

When I panicked and lost all faith that I would receive any symptom relief, I popped the one 5 mg oxycodone I had been holding on to for a rainy day. It was the remnant of a script I received for a dental extraction in 2015.

I took the drug test anyway and predictably failed. Before I took the test, I sent him an email explaining what they would find. He since deleted his response from the messaging system, but what he sent was an angry note explaining how he reviewed some database to see what I received in Connecticut and did not see evidence of any opiate scripts from 2016. Essentially, he was calling me a liar. But more remarkably, I learned just how much privacy has been lost to patients. Your doctor can access a database that sees what controlled substances you were prescribed in another state, under another insurance carrier, going back an unspecified number of years. When I clarified exactly when I received the script and from which practice, he actually took the time to verify my statement and ultimately find the script. Quite an endeavor for a physician who told me he was “swamped.”

They made the same request of Cheryl — a drug screen – which she found perplexing because they should expect to find some benzodiazepine and opioids in her system. Why were they asking for the test and what results could possibly invalidate her access? Her PCP was dead set against giving her any more pain medication, so what does Cheryl win if the screen does not show whatever it is they don’t want to see? Cheryl alleges that her Kaiser PCP is using the screen to compile a dossier on her. It’s bad enough their doctors disregard your privacy and dig into your bloodstream and history searching for evidence of abuse. Incidentally, Dr. Afshari did call in an order for Narcan – the opiate antagonist nasal spray. She wouldn’t give her any pain medication, cough syrup, prednisone, or promethazine, but she’ll give her the Narcan she didn’t ask for. (She already had some from her brief stint on basic Medicaid). Where were you when I didn’t need you? 

Other aspects of Dr. Afshari’s behavior are particularly egregious. One — it is not OK to tell your sick patient you are calling in scripts for her to pick up at the only Kaiser pharmacy open on the weekend, and then not call those scripts in. Cheryl made the trip to Reston only to later discover the scripts were never called in and that others that had been called in — were canceled by the physician. It is not OK to send your patient off to take a mandatory drug test and refuse to tell the patient why. Dr. Afshari has to know that it will turn up positive for the Xanax and opiates she had been prescribed before (even though Afshari has since informed Cheryl no additional scripts will ever be written). Cheryl can’t think of any possible result that will benefit her, the patient. What does she get if Dr. Afshari sees or does not see what she wants to see (or NOT see)? Or is this a fishing expedition made in the hopes of finding something that will allow her to build a case against her patient? Much is made of “recreational drug use” but what about “recreational drug SCREENING”? Concerning the scripts that were never called in as intended, Dr. M.A’s assistant insisted the doctor would phone Cheryl on her lunch break, but after the entire day passed without a call, Cheryl was shocked to find in her online KP.org appointment minder that Dr. Afshari, without consulting Cheryl, scheduled a phone appointment for October 30. That’s not only a week away but a day before Dr. Afshari knows Cheryl will no longer be with Kaiser. Convenient.

Cheryl reports having filed a complaint against Dr. Afshari through KP’s Membership Services division, but the attempt at mediation ended rather abruptly when the physician head for Reston, VA through her support unequivocally behind her subordinate. The patient representative Tina Brown informed Cheryl that the physicians are absolutely certain no wrongdoing has been committed. While I disagree, whether a wrong has been committed is kind of beside the point. The patient’s interests are not being served. The patient is also being harassed and stressed unnecessarily. This is a violation of the Hippocratic Oath. But hey — as long as KP feels they are legally on solid ground with Federal and State regulatory agencies — I guess all is well.

The second hand information conveyed to Cheryl by Kaiser’s patient advocate Tina Brown paints a disturbing picture. Cheryl, having felt during her appointment that Dr. Afshari was forcing her to choose between 3 days of short-acting painkillers and 4 days of cough syrup (that also contains a painkilling agent), Cheryl pushed for the cough syrup. But Dr. Afshari was possessed of such certainty that Cheryl did not need the prescription strength syrup (“Just get yourself some NyQuil) that Cheryl’s choice was construed as somehow betokening a kind of morbid drug seeking orientation. So Dr. Afshari informed the patient advocate that at that time she decided to cancel all of Cheryl’s scripts. Not only did Dr. Afshari cancel the hydromorphone she intended to authorize, but she also canceled the prednisone. She even canceled the promethazine, which is the one agent Cheryl would have needed to make the cold turkey withdrawal off Fentanyl more tolerable. (The anti-emetic and sedative promethazine paired with 800 mg ibuprofen is standard countermeasures for opiate withdrawal). Make no mistake — this was punitive — an act of pure cruelty with no basis in medicine. Not only did Dr. Afshari decide not to follow through with her intentions to issue these scripts, but she decided not to inform Cheryl of the change, so that her patient — cold and all — opiate withdrawal and all — made a fruitless trek to the only KP pharmacy open on weekends. Cheryl reached out to the patient advocate in the hopes of gaining some perspective on Dr. Afshari’s unprofessional behavior and ended up having to defend herself against a vague, terminally inchoate allusion to some moral transgression.

“I still don’t understand what I supposedly did wrong. Yes, I felt like I had to make a choice. I shouldn’t have had to feel that way, because there’s nothing I requested that had not been prescribed on numerous occasions by a number of different physicians previously — and once by Dr. Afshari herself. Perhaps this is retaliation for the complaint I filed against her when she cited my violation of the contract as grounds to deny me ALL my pain medication. I wouldn’t even have called it a complaint, but an effort to have Dr. Afshari reconsider her decision under a broader context of information. But in her mind I made the wrong choice — a choice that somehow suggested dark motives. But seriously, if you’re me and accustomed to receiving a 30-60 day supply of painkillers and then you’re told to choose between a 3-day supply of these painkillers and a product that would neutralize my most pressing symptom — a cough — it makes perfect sense I’d choose the cough syrup. The syrup contains an anti-tussive that is also a painkiller. She also seems to overlook a couple other important facts. First, a cough is not a trivial thing for someone who suffers chronic intractable migraines and back pain. What do you think happens when someone like me coughs? It makes my pain worse. It prolongs my pain. It keeps me in a pain cycle. A teaspoon of that stuff breaks the cycle for about 8 hours …”

As someone who’s had to sneeze with a broken rib, I think I know what Cheryl means.

” … Second — as someone who has been prescribed pain medications and antihistamines for over 10 years, she should know that I developed a tolerance. Why would she expect an over-the-counter product like NyQuil to register some kind of impact with me? It doesn’t even put me to sleep the way it does my husband.”

Cheryl reports suggesting a non-narcotic alternative to Tussionex called BromFed DM, but that Dr. Afshari responded with a kind of cataleptic fit in which she repeated the word “no” over and over again without coming up for air to listen to what she was adding to the conversation. Patient advocate Tina Brown recalls Dr. Afshari’s comments on the matter. According to Ms. Brown, Dr. Afshari complained that Cheryl “kept asking for all these different cough medicines. But she doesn’t need a cough medicine.” Really? I tell you what. Let’s come back to that.

Cough was the primary presenting symptom and ultimate impetus for the appointment.

As for the drug screen, the patient advocate disclosed that Afshari was searching for evidence that her patient might have been “shooting up.” This is a rude and groundless abuse of her sick patient’s time. Afshari had no probable cause. And while Cheryl was in the lab, she missed her chance to pick up a script at the pharmacy, which was closing not only for the day, but for the weekend. What makes the matter all the more incendiary is that Cheryl now knows why Afshari remanded her to drug screen. Evidence of illicit drug use would allow Afshari to wipe her hands of her patient once and for all. She would have no more responsibilities for a chronic patient sufferer with multiple conditions she not only considers high-maintenance clinically, but also problematic with respect to liability. As Cheryl suspected, the drug screen was never intended to advance the cause of the patient but only the physician.

As for the bizarre appointment that showed up on Cheryl’s calendar for the 30th of October, Dr. Afshari insists it was Cheryl who made the appointment. Cheryl did not.

Cheryl attempted to reach someone with some oversight over the Ashburn physicians, but no such person exists. Dr. Afshari’s supervisor, Dr. Nguyen, has already reviewed Cheryl’s complaint and constitutionally supports his subordinate.

“He’s not going to be any help,” surmised patient advocate Tina Brown.

Cheryl was able to coax someone into identifying the building manager, Erica Trammel, but Ms. Trammel just passed the buck right back to Tina Brown.

“She’s just the facilities manager.”

Neither Tina Brown nor Cheryl’s KP case manager, Linda Hendricks, could identify an administrative practice manager. Both were asked who would step in when liability became an issue, and both surmised that perhaps such a person could be found at the regional office in Rockville, MD. But liability is never really an issue with Kaiser, which has some kind of legislative immunity from lawsuits. A complainant would have to enter into arbitration proceedings. There’s really no impetus for Kaiser to engage in the kind of self-study or self-monitoring that burdens private practitioners. It’s not like Kaiser’s members ever really came to Kaiser’s doorstep by choice.

There is something else worth noting here. Kaiser physicians like to hide behind what they call “national or nationwide laws.” Just like there is no nationwide law prohibiting concomitant use of Xanax and opioid painkillers, so there is no nationwide law requiring me to submit to a drug test after receiving x number of scripts (for minuscule doses). There is a brand new Virginia State law, but I have it on word from Medicaid representatives that this does not apply to acute illness designations like a cough. It applies to chronic pain sufferers who will be expected to receive opiates on an ongoing basis. And these patients are required to submit to a drug screen on a monthly basis. I find the drug screen requirement for chronic pain sufferers odd, because you wonder what result could possibly invalidate their medication privileges. One neurologist I talked to was at a loss, but surmised that the State is looking for heroin. Another surmised that the State would want to identify negative test results in patients receiving scripts because that might signify that the patient is engaged in the illicit sale and distribution of narcotics. But that neurologist was admittedly guessing as well. Isn’t it interesting that physicians not only misunderstand the laws as they roll off the Virginia Assembly line, but they’re also groping for explanations for the laws they get right?

The legislation is sourced by the State’s top cop, the Attorney General. This is a police action, not a medical emergency. The Virginia Board of Medical Professions, which advised on the legislation, does not include physicians who would make the best experts on pain prescriptions. Aside from an anesthesiologist, who deals with a kind of pain you never really feel (because you’re unconscious), there is no one qualified to address this issue. There are more OB/GYNs and pediatricians on the Board than neurologists and physiatrists. In fact, I couldn’t find a neurologist or physiatrist on the Board.

I suppose this is a good time to mention that I support physicians (non-KP physicians) and understand that they are the ones caught in the middle. I certainly wouldn’t want to be a physician in this day and age. One of the neurologists I talked to says his attitude changed dramatically after the shocking arrest of an associate in town who’d apparently been monitored by the Virginia State Attorney’s Office and the local FBI for 2 years. “I do all the necessary diagnostic testing. I explore prophylactic and non-narcotic rescue drugs, but every time I write a script for painkillers, it pops into my head. ‘They’re coming for me. I know they’re coming for me.'” The neurologist also mentions he continues to tell his patients he’s on their side. “We’re on the same team,” I tell them. If Kaiser physicians believe they’re representative of the broader medical community, they are sorely mistaken.

Not all doctors are teammates. More interesting, physicians vary widely in their treatment philosophies. As a patient, I am aware of this. Most physicians, however, are not. Most physicians are stunned by the decisions made by their predecessors. Dr. Afshari was shocked and awed by what she considered irresponsible Fentanyl patch prescription on the part of Cheryl’s Connecticut neurologist, Dr. E.K. Dr. E.K. considered the Fentanyl patch – which is extended release and always in her system — a responsible means of reducing her reliance on all the short-acting pills she was accustomed to getting from her previous Virginia neurologist, Dr. R.C. “That’s bad prescribing,” E.K. said of R.C. “You need a balance.” Dr. R.C. would in turn would have consider Dr. Afshari’s approach nothing short of negligence and abandonment. Clearly there is nothing near a consensus approach in the medical community. The aforementioned three doctors represent three points along a continuum that encompasses an ample quantity of short-acting painkillers, a combination extended-release patch and small quantity of short-acting pills for breakthrough pain, and no pain relief at all. Lawmakers may be discovering this and attempting to use regulations to achieve a measure of uniformity, which centers on browbeating doctors into non-opioid alternatives under threat of losing their licenses. I remember sending a letter to the Connecticut Department of Public Health outlining the harrowing ordeal Cheryl faced when her Xanax was abruptly discontinued. She was in the middle of a scheduled move when all this went down and under extraordinary financial stress. No better time to cut someone off from their anxiety medication, right? The next day I received an unexpected phone call from a Section Chief within the Department, who informed me he was moved by my 14-page account to weigh in on the matter. He informed me that his department not only investigates and prosecutes cases of over-prescribing but also cases in which physicians “withhold medication.” He agreed that the pendulum had swung too far in one direction and urged me to urge Cheryl to file an official complaint so that the Department could launch an official investigation of Westport Family Health. “It’s obvious they’re concerned about liability but there’s more than one kind of liability here,” he remarked. Cheryl ultimately declined because an official complaint would have opened her medical history for public scrutiny. Privacy is a major concern with patients, and lawmakers and regulators know this – and exploit this. This is how they get away with unreasonable legislation and regulatory over-reach. 

At the behest of the patient advocate, Cheryl would eventually dump Afshari for a new PCP. She really had no choice. The Kaiser pulmonologist — one Dr. Phong Nguyen — actually saw eye-to-eye with Cheryl on a limited 3-day course of Tussionex. He concurred that the maintaining factor in her cough was coughing itself. It was causing her irritation. There was some value in breaking the cycle so that stopping the cough in the short-term might actually stop the coughing longer term. So much for the notion Tussionex is “just a band-aid.” But Nguyen also made an uncharacteristically important contribution to Cheryl’s medical history. He diagnosed her weeks of coughing as a case of asthma. Cheryl has asthma. And as he laid out his reasoning, Cheryl kept thinking about how her PCP Afshari continued to minimize her cough and insist she didn’t need to treat it (probably because she thought Cheryl was drug seeking). Nguyen prescribed two medications to inhale by way of a nebulizer and with this prescription came some hope that perhaps Cheryl will find a more lasting relief from her bronchial issues. But since it would take time for this treatment to take effect, Nguyen agreed that the hydrocodone cough syrup was reasonable and necessary. Yes, it would seem Nguyen had done it all. Except … he could not authorize the Tussionex script. That would have to be authorized by the one woman hell bent on denying her patient … Queen Afshari. You see, while it is universal that only one doctor should be a source for all the patient’s opiate scripts, it is uniquely Kaiser (or unique to the MCOs) that this responsibility fall to the PCP. Since when does a general practitioner override a specialist? So Cheryl anticipated the futility and gave Nguyen a brief history of her relationship with Afshari. Nguyen offered to reach out to her directly and make a case for the Tussionex. Cheryl had no way of knowing after that if he was successful in reaching her. But the script remained unfulfilled and Afshari never addressed the question with her patient. The last email Cheryl received from Afshari ended with the statement: “sorry this relationship didn’t work out” — leaving Cheryl with the question as to whether she even had a PCP. So at the advice of the patient advocate, Cheryl switched to Osman. Frying pan … meet fire.

Osman was one of only two local physicians accepting new patients. Cheryl was able to wrangle a same-day appointment with her for the purpose of explaining she had two outstanding issues that needed to be addressed: (1) a Tussionex script that required approval and (2) a referral to Kaiser’s only chronic pain specialist who could prescribe medication. Afshari was supposed to have approved this referral over a week ago but she kept sabotaging the process — first by claiming she made the referral, which was denied by the chronic pain specialist’s office — and then by insisting that it’s the specialist’s job to contact Cheryl. Cheryl replied to this by asking Afshari whether the chronic pain specialist can read minds at a distance. Again, it’s downright perverse that the PCP would have so much control over her patients’ fates.

Osman was quite the curmudgeon. She claimed to have reviewed Cheryl’s chart prior to her appointment. I guess when you don’t have any patients, you can do this. Cheryl had made the appointment only three hours earlier. So Osman must have seen the pain medications and God knows what else the wicked witch of the Mid-Atlantic Region put in her progress notes. Because this relationship was poisoned before it began. A morbidly suspicious Osman’s very first question was not “so what could I do for you?” or “what are you experiencing?” but “why are you switching PCPs?” Just a few words into Cheryl’s response, she interrupted Cheryl to tell her she “couldn’t prescribe her pain medication.” But it didn’t end there. Osman refused to authorize the Tussionex until she spoke with not only the pulmonologist but also with Cheryl’s former PCP, Dr. Afshari. She briefly left the room only to return claiming to have reached Dr. Nguyen. But Cheryl knew this to be a lie because she learned an hour earlier that Dr. Nguyen was out of the office and out of reach today and tomorrow. Osman then claimed that after reviewing Nguyen’s notes in the system that “Dr. Nguyen really does not want you to have this.” In other words, she was accusing by way of innuendo that Cheryl somehow talked Nguyen into doing something he really didn’t want to do. Cheryl coughed so hard her bladder leaked, drenching the paper beneath her. She called Osman’s attention to it. Osman couldn’t care less. At this point Cheryl could not accept that she wasted her time securing a verbal commitment from a pulmonologist for a product she knows could provide her with the relief she’s been seeking for weeks of coughing only to be sabotaged by general practitioners sharing a prejudice and a perverted suspicion about their patient’s real motive. Osman may not have been prepared for what happened after that. To put it mildly, Cheryl was “disenchanted” with her new PCP. Osman may not have understood this. Osman may have mis-filed it under “drug seeking behavior.” But when you take away all a patient’s medications and then deny her treatment for her chief complaint, what the hell do you expect?

The Bottom Line

If you have multiple chronic conditions, Kaiser Permanente may just kill you. Given their prejudices and penchant for serving a regulatory role within the government, Kaiser Permanente is not prepared to manage care for certain populations — and the only responsible course of action would be to recuse themselves altogether. I would not wish on Kaiser Permanente anyone who has diabetes, psychiatric disorders, or significant pain. I even feel for people who turn to Kaiser with a common cold.

Cops, heroin addicts, and their grieving survivors are now driving health care policy and clinical decision making. The ultimate outcome of all this is the end of compassionate care. The environment is polluted with regulations and prejudices that threaten and burden both physicians and patients. People suffering chronic pain or acute illnesses should not have to carry the stress of a nation grieving over dead heroin addicts and lost worker productivity. Since the Federal government is unable to clamp down on supply, they have decided to target demand, and that means limiting exposure to prescription painkillers. I understand that 4 in 5 heroin addicts were once prescribed a prescription painkiller. Who hasn’t had their wisdom teeth removed at some point in their young life? But that does not mean what legislators hope you will think it means: that 4 in 5 persons prescribed painkillers turn to heroin. One thing is certain: if the system continues to harass legitimate pain sufferers, these people might just be tempted to turn to the street. 

Granted I understand what it means to lose someone to a drug overdose. I lost a cousin. He overdosed deliberately in an apparent suicide. But he suffered depression. And his pain was so severe not even the painkillers could touch it. The pills didn’t kill him. The pain did. His pain was unsurvivable. But unlike many other grieving families, I am not inclined to try to redeem my cousin’s perceived addiction or recklessness by turning him into an impetus for harsh legislation so that I can say he was a victim of an industry whose sacrifice saved others. It would be tempting to take his effigy to the State Capitol and say, “never again will anyone overdose on painkillers because no one should ever receive any painkillers again.” 

As a nation we have made much of the number of lives lost. I remember that in Connecticut, that figure was two victims a day. To be perfectly candid, that just doesn’t seem like a lot to me – certainly not enough to justify making life so difficult for millions of pain sufferers. And as for the number of people who died between January 1 and June 15, 2016, there were far more preventable deaths attributable to causes other than opioids and other than drugs. Tobacco still claims orders of magnitude more lives (282,236) than prescription drug overdose (12,096) over this period, and yet cigarettes remain available to adults over the counter. The same applies to Alcohol (80,639). Obesity (247,561) also claims far more lives, I doubt we will see a military crackdown on Big Gulps outside Mayor Bloomberg’s New York. Medical Errors (202,770) are also an unsung villain of sorts, but then too much publicity might cause people to realize that doctors do make mistakes. Hospital Associated Infection (79,832) also proves lethal. Where is the campaign – the Hollywood benefit concerts – raising awareness of Unintentional Accidents (109,712)? Unintentional poisoning (25,609)? Spontaneous Human Combustion? Okay. Truth be told, there have been no documented SHC deaths over this period. However, over forty-thousand souls (44,534) were lost to influenza or pneumonia, and 26,985 to blood infections. It’s unclear whether this next statistic is rolled up into Alcohol as well, but Drunk Driving (27,262) continues to claim more lives. Over 34,000 souls just didn’t want to live anymore (can you blame them?) And over 13,000 decided they would be better off if someone ELSE was not around.

Granted, prescription drug overdoses did top Murder by Gun (9,268), Texting while Driving (4,829), and Falling out of Bed (629). Still you would think based on these statistics that a opiate-style crackdown on cell phones or at least text capabilities while in a moving car might be in order. As far as I know, I don’t need a signed authorization from a government official every time I need to get behind the wheel of a car, and yet car accidents, drunk driving deaths, and texting deaths combine for a formidable mortality stat. And why not take restrictor plate technology to a whole new level by placing a 30 mph speed limit on all vehicles? We let people in our bloodstreams and our medical, financial (credit), and relationship histories (see people data search engines like Intelius.com). Why not let them in our cars?    

Now I have no sympathy for heroin addicts. They have ruined healthcare for the rest of us. There’s nothing more odious than when a tragic incident or worst case scenario becomes the impetus for new laws and regulations which become next-to-impossible to roll back once they’re canonized. The cumulative effect of all these new regulations only serves to limit liberties, options, and resources and to place undue stress and burdens on all stakeholders.

People like Cheryl and I despise being treated like drug seekers. I feel this way whenever I get sick and ask for cough syrup, antibiotics, and prednisone and Cheryl I imagine feels this way all the time. We do not appreciate being lumped in with these idiots who slough off after shooting up in the middle of a workday. Someone who wants – and needs (based on a symptom profile that can be observed and documented – a teaspoon of cough syrup a night for 4 nights should not be treated like a future – or present – victim – or carrier – of the opioid contagion. In fact, pain sufferers who test positive for opiates may be subject to discrimination by employers despite having a valid script because they represent some kind of risk in the employer’s heightened risk management equations. Truth be told, prescribed painkillers not only do not impair coordination, judgment, or consciousness, but rather they actually enhance focus, energy, and positivity. You can do much worse than having a chronic pain sufferer on your staff.

At the risk of taking editorializing to stratospheric levels, allow me to make a Big Picture point about the epidemic. Over the past few years everyone from hawkish pharmaceutical reps to rogue doctors to drug seeking patients have been blamed for the spike in overdose deaths since 2000. Allow me to propose that the real cause of the spike in overdose deaths since 2000 is … life in 21st Century America. Since 2000; we’ve endured the NASDAQ Crash of 2000, 9/11; two trillion dollar terror wars; $4.00 a gallon gasoline; corporate malfeasance in the financial industry; the crash of the mortgage and credit markets touching off the greatest economic downturn since the Great Depression; two highly divisive Presidential elections; a 5-year budget impasse on Capitol Hill introducing into the popular lexicon such terms as debt ceiling, fiscal cliff, government shutdown, and sequestration; and the election of the first anti-establishment President in history. The infiltration of every industry by Information Technology has caused a spike in software proficiency requirements and caused us to question the value of a traditional degree (even advanced degrees), as applicant tracking systems are programmed to discard the resumes of those who do not possess the requisite new industry micro-certificates and x number of years working y, z, a, and b software at c level. Half of all Americans have less than $500 in a savings account, wages are stagnant, and rental property owners continue to raise rates so that renters spend somewhere between 40 and 50% of their income on housing rather than the recommended and once-plausible 28-33%. 

We live in a world where regulations rob us of liberties and drive us into the Internet to seek freedoms in crypto currencies, anonymous chat rooms, and platforms that allow us to throw our views over wide swaths of the population – kind of like what I am doing now with this agitation propaganda to LinkedIn. Careers have become so tracked that they all require highly specialized degrees, software proficiency, and experiences, and yet work itself has become scripted by that very same software in addition to regulations, protocols, and best practices.

5 Responses

  1. Why does evey article have to be so long. Im in pain i cant read that much without a migrane coming. Kaiser has cut me in half and its aweful. My pain is back, ive gained 60 lbs the gabapetton is making me crazy and the flexril is making me exhausted. I just want the stablizing dose that took most of my pain away. Is that to mush to ask

  2. Many good points, long but well written. I concur.

  3. There seems to be confusion in this article about the difference between legit, prescribed Fentanyl & illegal, REALLY dangerous Fentanyl. Does the prescribed stuff even come in powder form? The illegal stuff only comes in that form.

    Then there’s the mysterious & dire-sounding comment about the baby that died from contact with it, “No one knows how. But it was found in his system. And it was found at the pool.” Very horror-story-ish. Yes, it is a dreadful tragedy that the child died. But I’d bet anything I’ve ever had that it was ILLEGAL fentanyl found at the pool. Pretty much everybody comes into contact with cocaine regularly –it’s all over money– just rarely in quantities that affect us (but could conceivably show up on a drug screen). Illegal fentanyl is powerful enough that an unnoticeable amount could kill a small child. Because of this we’re supposed to ban the legal stuff, but which won’t do diddly to affect the supply of illegal stuff anyway?

    This is a very common confusion & does vast harm to the case of chronic pain patients. We need a new vocabulary. Not to mention an iota of sanity and truth in the national discourse.

  4. One of the best written notes I have ever read.This should be burned into a wall at every federal building/

  5. “Federal BCBS has ended” is incorrect information as I am covered under my wife’s Federal BCBS as secondary insurance. My primary is Medicare. However, several years ago, the Fed BCBS cut paying for half of my pain meds with no warning. Federal BCBS is still there!!!

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