Sudden, Unexpected Death in Chronic Pain Patients

http://www.practicalpainmanagement.com/sudden-unexpected-death-chronic-pain-patients

Severe pain, independent of medical therapy, may cause sudden, unexpected death. Cardiac arrest is the cause, and practitioners need to know how to spot a high-risk patient.

Sudden, unexpected death may occur in a severe, chronic pain patient, and the terminal event may be unrelated to medical therapeutics. Fortunately, sudden death is not as commonly observed in pain patients as in past years most likely due to better access to at least some treatment. Sudden death still occurs, however, and practitioners need to know how to spot an “at-risk” patient.

Unexpected, sudden death due to severe pain is poorly appreciated, since many observers still view severe pain as a harmless nuisance rather than a potential physiologic calamity. In many cases, just prior to death, the patient informs their family that they feel more ill than usual and seek relief in their bed or on their couch. Unfortunately, some of these patients don’t awaken. Other patients die, without warning, in their sleep or are found collapsed on the floor. Modern medicine’s aggressive toxicology and forensic procedures after death have contributed to the poor understanding of pain’s death threat. In some cases, a pain patient that was being treated appropriately with an opioid or other agent with overdose or abuse potential has suddenly and unexpectedly died. Drugs were found in body fluids after death, and in my opinion a coroner wrongly declared the death to be an “accidental overdose” or “toxic reaction” to drugs rather than implicate the real culprit, which may have been an “out-of-control” pain flare.

This article is partially intended to call attention to the fact that the mere finding of abusable drugs at autopsy doesn’t necessarily mean that the drugs caused the death. In fact, the drugs may have postponed death. Some physicians have been falsely accused of causing deaths due to drug overtreatment when, in fact, undertreatment of pain may have caused the death. Additionally, opioid blood levels assessed at autopsy of a patient who died suddenly are all too often wrongfully considered accidental overdoses because the pathologist is unaware that chronic pain patients on a stable dose of opioids can be fully functional with serum levels of their prescribed opioids that far exceed lethal levels in opioid-naïve patients.¹

Given here are the mechanisms of sudden, unexpected death in pain patients and some protective measures that practitioners must take to keep from being falsely accused of causing a sudden, unexpected death. More importantly, given here are some clinical tips to help identify the chronic pain patient who is at high risk of sudden, unexpected death so that more aggressive pain treatment can be rendered.

A Brief Anecdotal History
As a senior medical student at Kansas University in the early 1960s, I was required to take a rural preceptorship with a country doctor. In making our rounds one day to the county’s nursing home, I heard a farmer’s wife declare, “pain killed my mother last night.” Since then, I’ve repeatedly heard that pain killed a loved one. Folklore frequently mentions that people die “from,” as well as “in” pain. There is, however, little written detail of these events.

In the early years of my pain practice, which I began in 1975, I had several patients die suddenly and unexpectedly. This rarely happens to me today as I’ve learned to “expect the unexpected” and to identify which patients are at high risk of sudden death. In recent years, I’ve reviewed a number of litigation and malpractice cases of sudden, unexpected death in chronic pain patients. In some of these cases, physicians were accused of over- or misprescribing and causing a sudden, unexpected death, even though the patient had taken stabilized dosages of opioids and other drugs for extended periods. Also, the autopsy showed no evidence of pulmonary edema (a defining sign for overdose and respiratory depression). In cases where the physician was falsely accused, the post-death finding of abusable drugs in body fluids caused a family member, regulatory agency, or public attorney to falsely bring charges against a physician.

Setting and Cause
Unexpected deaths in chronic pain patients usually occur at home. Sometimes the death is in a hospital or detoxification center. The history of these patients is rather typical. Most are too ill to leave home and spend a lot of time in bed or on a couch. Death often occurs during sleep or when the patient gets up to go to the toilet. In some cases, the family reports the patient spent an extraordinary amount of time on the toilet just prior to collapse and death. Sudden and unexpected death, however, can occur anywhere at any time, as pain patients who have died unexpectedly and suddenly have been found at work or in a car.

Coronary spasm and/or cardiac arrhythmia leading to cardiac arrest or asystole is the apparent cause of death in the majority of these cases, since no consistent gross pathology has been found at autopsy.^2-5 Instant cardiac arrest appears to account for sudden collapse or death during sleep. Perhaps constipation and straining to pass stool may be cardiac strain factors as some pain patients die during defecation. Acute sepsis due to adrenal failure and immune suppression may account for some sudden deaths.

Two Mechanisms of Cardiac Death
Severe pain is a horrific stress.^6,7 Severe pain flares, acute or chronic, cause the hypothalamic-pituitary-adrenal axis to produce glucocorticoids (cortisol, pregnenolone) and catecholamines (adrenalin and noradrenalin) in an effort to biologically contain the stress.^8,9 Catecholamines have a direct, potent stimulation effect on the cardiovascular system and severe tachycardia and hypertension result.¹⁰ Pulse rates may commonly rise to more than 100 beats per minute and even rise to more than 130 beats per minute. Blood pressure may reach more than 200 mmHg systolic and more than 120 mmHg diastolic. In addition to adrenal catecholamine release, pain flares cause overactivity of the autonomic, sympathetic nervous system, which add additional stimulation to catecholamine-induced tachycardia and hypertension. Physical signs of autonomic, sympathetic overactivity, in addition to tachycardia and hypertension, may include mydriasis (dilated pupil), sweating, vasoconstriction with cold extremities, hyperreflexia, hyperthermia, nausea, diarrhea, and vomiting.

The combined physiologic effects of excessive catecholamine release and autonomic, sympathetic discharge may put such strain on the heart to cause coronary spasm, cardiac arrhythmia, and sudden death.¹¹ Pain patients who have underlying arteriosclerosis or other cardiac disease are at higher risk of sudden death. For example, a patient with angina or generalized arteriosclerosis is at high risk, and should be aggressively treated. Anecdotal reports have been made in which a patient whose pain was well controlled on opioids died unexpectedly with an underlying cardiac disease. In one report, a 40-year-old pain patient on opioids was found dead and the autopsy revealed previously unrecognized coronary artery disease, which was determined to be the cause of death. Some patient deaths may be due to other comorbid conditions, whether known or not known, and may not be related to the pain problem.

Case Example #1
A 60-year-old male with severe pain due to Lyme’s disease–related arthritis has generalized arteriosclerosis. When his pain flares, he has hypertension, tachycardia more than 100 beats per minute, and angina. On numerous occasions, he had been hospitalized for chest pain and he regularly requires nitrates for emergency coronary relief. He was treated with a long-acting opioid for baseline pain and a short-acting opioid for breakthrough pain. This regimen has controlled his angina and has prevented hospitalizations for more than 2 years.

The second mechanism, which may produce sudden death, is adrenal insufficiency. The hypothalamic-pituitary-adrenal axis may acutely and suddenly deplete during episodes of severe pain resulting in a life-threatening drop in cortisol, aldosterone, and possibly other adrenal hormones (Figure 1).¹² With a precipitous drop in adrenal hormone production, there can be a severe electrolyte imbalance (eg, low sodium, high potassium), which may produce cardiac arrhythmia and death. Although undocumented, some sudden deaths may likely be a simultaneous result of excess sympathetic stimulation and electrolyte imbalance.

Identification of the At-risk Patient
An active, ambulatory pain patient who has mild to moderate, intermittent pain is not at high risk for sudden death. The patient at high risk for sudden death is a severe pain patient who is functionally impaired and has to take a variety of treatment agents, including opioids and neuropathic drugs, to control pain. In all likelihood, the patient who has centralized pain and who has central nervous system inflammation due to glial cell activation is the patient who will likely have flares severe enough to affect the endocrine and cardiovascular systems. Acute pain severe enough to cause cardiac overstimulation and death is usually only seen with severe trauma. Pain as a result of modern-day surgery is well controlled by analgesics, so perioperative sudden death due to surgically induced pain, per se, is essentially a thing of the past. Accidents, trauma, and war wounds are exceptions. In these situations, a patient in excruciating pain who shows signs of excess sympathetic discharge needs progressive emergency pain treatment to control excess sympathetic discharge.^13,14 Excess sympathetic discharge signs that can be discerned at the bedside, emergency room, or accident site include mydriasis, diaphoresis, hyperthermia, tachycardia, hypertension, and hyperreflexia.^15,16

The chronic pain patient who is at high risk for sudden death can usually be spotted at a clinical visit (Table 1). Patient and family will give a history of functional impairment. The most typical history will be one in which the patient will have constant, daily pain intermixed with severe flares, which cause a bed or couch-bound state. Even though medication dosages may be high, they may not be effective enough to prevent pain flares and sudden death. The patient will likely demonstrate excess sympathetic discharge. By history, this includes waves or episodes of allodynia, hot and cold flashes, hyperalgesia, and severe insomnia. Physical exam may reveal excess sympathetic discharge by any or all of the following signs: tachycardia, hypertension, vasoconstriction (cold hands/feet), mydriasis (dilated pupil), and hyperreflexia.

Cortisol, pregnenolone, or corticotropin (adrenocorticotropic hormone) serum levels may be subnormal indicating that the immune and healing systems are impaired, leaving the patient subject to infections and interference with opioid effectiveness.

When high-risk indicators are found, therapeutic adjustments in type, quantity, and quality of pain treatment must be implemented to minimize or eliminate risk factors. In particular, there should be attempts to normalize hypertension, tachycardia, and hormone levels.

Methadone Administration And Sudden Death
Other than overdose and respiratory depression, the opioid methadone has been associated with a cardiac conduction defect (prolonged QT interval) called “torsades de pointes,” which may cause an unexpected, sudden death.^17,18This defect may cause sudden death by cardiac arrests. No other opioid has been credibly associated with cardiac conduction defects. In addition to the problem of QT prolongation, many methadone-related deaths occur during the first few days of use, making the deaths in these instances more likely due to the prescriber’s unawareness of methadone’s long half-life and, therefore, accumulation in the bloodstream because the dose was titrated too quickly.

However, the recognition of QT prolongation has caused considerable controversy and many experts believe that an electrocardiogram should be done to screen for a prolonged QT interval before and/or during methadone administration.¹⁷ The occurrence of “torsades de pointes” with methadone is usually dose related and associated with concomitant use of antidepressants or benzodiazepines. If a patient who takes methadone suddenly dies due to cardiac arrhythmia, there will be no gross pathology at autopsy, which is typical of sudden death in a pain patient. The prescribing physician may, however, be accused of overprescribing methadone. Due to this risk, many physicians have made a choice to shun methadone and avoid the risk of being falsely accused for overprescribing. From a clinical perspective, the use of antidepressants and benzodiazepines should be restricted if methadone is prescribed, since these ancillary agents appear to facilitate methadone deaths.

Risk of Sepsis
Although not well documented, acute sepsis and sudden death probably occur in some severe, chronic pain patients. The mechanism is probably initiated by subnormal serum levels of cortisol or other hormones due to adrenal depletion. Chronic subnormal adrenal hormone levels severely compromise the protective immune system in the body, rendering the patient susceptible to virulent bacteria and other pathogens.^19,20 The author has frequently found extremely low levels of cortisol (fewer than 1.0 mg/dL) in undertreated intractable pain patients. One can only wonder as to how many pain patients have suddenly died from acute sepsis. Although documentation of this pathologic event is scant, practitioners should be aware that extremely low serum levels of adrenal hormones are known to be associated with a compromised immune system and sepsis.

Death Following Sudden Opioid Cessation
There is the misguided notion among some addiction and mental health practitioners that withdrawal from opioids is an innocuous procedure that is risk free. This school of thought says that only withdrawal from alcohol and benzodiazepines is risky. This is generally true unless the patient who is dependent upon opioids has severe underlying pain and is taking opioids solely for pain control. In some patients, opioids may mask underlying pain so well that a practitioner may not even believe that pain recrudescence is a possibility once opioids are stopped.

Patients who have severe pain that is well controlled by opioids may be sudden-death candidates if their opioids are precipitously stopped. If opioids in a severe pain patient are precipitously stopped, the masked pain may flare causing severe autonomic, sympathetic discharge and overstimulation of the adrenals to produce excess catecholamines with subsequent cardiac arrhythmia and arrest. Malpractice suits have occurred when opioids have been precipitously stopped in a pain patient. Here are two examples known to the author.

Case Example #1
A 45-year-old woman with fibromyalgia and severe pain was well controlled with extended release morphine for baseline pain and short-acting hydrocodone for breakthrough pain. She entered an in-patient detoxification program where she was told that fibromyalgia only required psychotherapy and no opioids. The detoxification program precipitously stopped all her opioids and placed her in isolation for punishment because she was using opioids as a “crutch” rather than “facing her problems.” She died suddenly about 36 hours after all opioids were stopped.

Case Example #2
A 42-year-old male had a work injury and subsequently suffered reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS). His pain was reasonably well controlled with fentanyl transdermal patches (Duragesic) for baseline pain and short-acting oxycodone (OxyContin) for breakthrough pain. His workers’ compensation carrier had him evaluated by “experts” who claimed that pain couldn’t possibly exist for more than about 6 months after injury, and RSD and CRPS were not “legitimate diagnoses.” His workers’ compensation carrier, based on their “experts’” opinions, precipitously stopped all his opioids by refusing to pay for them. The man died suddenly 4 days after abrupt cessation of his opioids.

Value of Opioid Serum Levels
Patients who have severe chronic pain, take opioids, and demonstrate some high-risk signs and symptoms for sudden death as described above should have opioid blood levels done. Why? Legal protection. If a severe chronic pain patient who takes opioids suddenly dies, the practitioner may be accused of overprescribing and causing an overdose death unless he/she has pre-death opioid blood levels on the patient’s chart. Keep in mind that there will be no gross cardiac pathology at autopsy if the patient suddenly dies of a cardiac arrhythmia or arrest. And, the coroner will likely call the death a drug overdose and blame the prescribing physician. Here are two illustrative cases.

Case Example #1
A 28-year-old male, former football player had severe spine and knee degeneration. He died in his sleep and his death was brought under investigation by the coroner. At autopsy he had a methadone blood level of 400 ng/mL. The prescribing physician was about to be charged with negligence by the local district attorney, until the physician showed that, in life, the patient’s methadone blood levels ran between 500 to 650 ng/mL.

Case Example #2
A 58-year-old female with genetic porphyria had suffered from severe generalized pain for more than 20 years. She collapsed in her living room in sudden death. At autopsy she was found to be wearing three fentanyl dermal patches (100 mcg/hour). At autopsy she demonstrated a fentanyl blood level of 10 ng/mL and a morphine blood level of 150 ng/mL. Her prescribing physician was able to show the sheriff’s investigators that in pre-death treatment, she had fentanyl and morphine blood levels considerably above these found at autopsy. No charges were ever brought against the physician.

Summary
Although sudden, unexpected death in chronic pain patients appears to be declining in incidence due to greater access to treatment, practitioners need to be aware that sudden, unexpected death may occur independent of opioid administration. The precise mechanism of death is cardiac arrest or asystole due to coronary spasm, arrhythmia, and/or electrolyte imbalance. Severe chronic pain produces excess sympathetic discharge through the autonomic nervous system and overstimulation of the hypothalamic-pituitary-adrenal axis, which causes great output of adrenal catecholamines. The chronic pain patient who is at highest risk for sudden death is the patient whose uncontrolled pain and pain flares are so great as to cause a high degree of functional disability. Those pain patients who are ambulatory and active are not at high risk for sudden death. The attainment of opioid blood levels during treatment of patients who are at high risk for sudden death are advised as a medical-legal protection should opioids be present in blood after death. Patients who are identified as high risk should be monitored by regular clinic visits, and efforts should be done to control excess sympathetic discharge and adrenal deficiencies.

 

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The politics of pain: Supply vs. demand

http://hawaiitribune-herald.com/news/local-news/politics-pain-supply-vs-demand

East Hawaii residents wait in agony for pain pills that, too often, they can’t get without extraordinary effort

Why?

The answer depends upon whom you ask.

Area physicians say their patients often get turned away at the counter because pharmacists don’t have enough pills on hand to fill even a single prescription.

Doctors and patients point fingers at the U.S. Drug Enforcement Agency, alleging the DEA puts limits on how many opioid pain pills a pharmacy can order each month.

But the DEA calls doctors and pharmacists liars. While, at the same time, a Hawaii legislator says part of the reason is drug addicts use up the supply of available pills before those who are truly in need can get to them. But he, too, says federal authorities limit supply.

Today, the Tribune-Herald lets those in the thick of the mess pass a metaphorical microphone around — to allow readers to decide, for themselves, what’s wrong.

When Teresa Keliikuli learned she’d need immediate surgery, she didn’t realize it would be tough to find pills, afterward, to treat her post-surgical pain.

Her prescription called for 40 pills.

She went to a store’s pharmacy “and they said, ‘we don’t have that many.’”

“They said their order came in ‘yesterday’ and they didn’t have any, and they were out within 48 hours,” she said.

Kirk Trombla, 58, of rural Pahoa, sits at the other end of the pain-control spectrum.

He takes feeble steps to navigate his walker even a couple of dozen feet — and then he must rest. His labored breaths come in wheezes between puffs on an inhaler.

Trombla suffers from what he emphasizes is genuine chronic pain and uses prescription opioids to dull it enough for journeys away from home. His doctor, he said, calls him “dependent” on opioids — not addicted. Without the pills, he said, he is unable to walk. He uses the pills to leave home, or if he has tasks to do.

Unfortunately, trips to the Hilo drugstore often turned into intolerably long journeys in which Trombla had to go from pharmacy to pharmacy to find one that had enough pills on hand to fill his prescription.

“I hate taking opioids,” Trombla said. “I hate it. I hate them. But I have to do it in order to be able to move around. If I don’t, I feel like I’m being impaled.”

Trombla was so frustrated that he organized a community meeting in Pahoa to see if the problem of un-fillable, but essential, pain prescriptions is as big as he believes.

About 10 people showed up.

Those who did said it was a small but good start, as a way to organize and fight for prescriptions they believe should be available, despite the growing trend of addictions to prescription opioids. They plan other meetings in the future.

For many years, the public and health providers got on a bandwagon that emphasized the importance of a patient’s right to adequate control of pain.

But the problem of addiction to prescription pain pills has become so widespread that push-back has occurred.

In September, the Associated Press published an investigation revealing that prescription-painkiller makers “have adopted a 50-state strategy that includes hundreds of lobbyists and millions in campaign contributions to help kill or weaken measures aimed at stemming the tide of prescription opioids, the drugs at the heart of the crisis that has cost 165,000 Americans their lives and pushed countless more to crippling addiction.”

That’s the double-edged sword of opioids.

For a small segment of society, such as hospice patients during the dying process, opioids can be one tool in the arsenal used to relieve torturous pain. Thus, the drug-makers’ efforts have made pain relief more available.

But people recovering after a car crash or back surgery risk addiction they might never have been susceptible to otherwise.

That’s something public-health experts want to avoid — and why they stand against the wind of the drug-makers’ campaign.

Trombla suffers chronic pain so severe that he feels like his hands “got slammed in a door repeatedly for the past two years, stung by 100 bees or stabbed over and over again.”

He’s been told his medical condition, which includes back and neck injuries, is terminal.

Richard serves as a family caregiver for his son, offering rides to appointments, opening doors and offering a steadying hand when needed.

Trombla believes the DEA limits how much opioid medicine a pharmacy can order.

“I don’t think people like me should have to worry about getting their medicine when they’re dying,” he said.

Dr. Lynn Puana, a partner at Puana Pain Clinic, said patients get frustrated because “pharmacies won’t carry the medications.”

And Dr. Josh Turner, a pain specialist at Hilo Pain Clinic and board-certified neurosurgeon, said that “pharmacies are limited as to how much they can get.” Sometimes patients, he said, “can go to eight or 10 pharmacies to get a script filled.”

Opioids are no longer at the tip of Dr. Liza Maniquis-Smigel’s prescription-pad pen for her patients.

“I used to prescribe,” she said, “except they’d come back and say, ‘My pharmacy doesn’t have it,’” noting her treatments are intended to eliminate the need for opioids.

Joining the fray is CVS Health, parent company of Hilo’s Longs Drugs pharmacy.

“Ensuring that patients with a legitimate medical need have access to pain-relief medication is part of Longs Drugs purpose of helping people on their path to better health. Regulatory controls may limit the availability of certain controlled substances,” Amy Lanctot, senior manager of public relations, told the Tribune-Herald via email.

But Drug Enforcement Agency headquarters spokeswoman Barbara Carreno took umbrage at the views of Puana, Turner, Maniquis-Smigel, Lanctot and Trombla.

“That is absolutely false … there’s no limit on what a pharmacy can buy from a distributor,” she said.

Distributors make business decisions about how much to make available. But, Carreno said, “they blame it on us.”

The DEA took action against two pharmacies in the early 2000s for selling more opioids than would be expected for the population they served, she said, noting they were selling to customers from other states. If a pharmacy sells more medication than a population would expect to need, the DEA will review what’s happening and double-check that prescriptions are indeed being filled “in the course of usual professional practice.”

But it doesn’t set limits, Carreno said.

“We’re not doctors. We’re cops. We don’t tell them how to practice medicine,” she said.

Professional medical societies determine what is appropriate medical care, not the DEA, she said. If a medical board suspends the license of a physician to practice medicine, the DEA will not allow that physician to have a federal registration to prescribe opioids.

The DEA Los Angeles Field Division, which oversees Hawaii, took the argument a step further and pointed the finger back at doctors and pharmacists.

“We know it happens, for a pharmacist, or even a doctor, or somebody who actually would write a prescription — to deflect responsibility,” said Field Division spokesman Tim Massino. “In order to limit their own liability, some individuals do deflect by erroneously informing the patient, or the individual seeking the medication, that the DEA is limiting supply … they may blatantly lie and indicate they are out of whatever the customer is seeking.”

DEA Diversion Program Manager Marlon Whitfield agreed, and said prescriptions written by a licensed health provider are not questioned, because “we’re not medical professionals, so we wouldn’t have any reason to doubt that.” He said the DEA has no power to limit what medicines a pharmacy can order or dispense.

Patients who “doctor shop” until they find one who will write a prescription, forgers of prescriptions and drug-seekers who go to a relative’s medicine cabinet to get opioids all contribute to the problem, he said.

State Sen. Josh Green, an emergency-room physician, though, makes the opposite argument from the DEA.

“The reason we have that problem,” he said, “pharmacies get capped by the federal government as a percentage or as a part of their workload or their inventory.”

But he also said, “there’s probably a little bit of truth on both sides. Physicians are also human, too. And physicians can get a little bit hesitant about big, high-dose prescriptions. When a doctor inherits a patient and the patient takes a high dose, I would not be surprised if everyone starts deflecting a little bit of responsibility.”

Some with prescriptions, who are drug-seekers, Green said, don’t need the medication and “are displacing those who really do.” But to add context, he said, about 4 percent of the world’s population lives in the United States — but the U.S. is responsible for using 80 percent of all narcotics.

In Europe, the typical pain medication used is Tylenol. In the U.S., the typical drug is hydrocodone, Oxycodone, Percocet or Vicodin, Green said.

Hiromi Saito, president of the Hawaii Pharmacists Association, said she could not speak on behalf of the association. But she said it’s best if patients, providers and pharmacists communicate to make sure each patient’s pain-management plan is followed.

“Then pharmacies would be able to work together and anticipate for those prescriptions, and monitor the plan to avoid the possible risks,” she said.

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Below was left as a comment on this blog… IMO… just one more chronic pain advocate that is JUMPING SHIP …  At the current rate it will not be long before the only people posting on most/all of the internet media content will be those chronic painers whose primary action is to WHINE, BITCH, MOAN about how little pain therapy they are receiving and or how their prescriber is taking them entirely off their pain meds and telling them to take NSAID’s.  Sure SUICIDES are going to increase, but they can be categorized as just an “opiate related death” … case closed… and the DEA gets another “valid reason” why they need more funding to fight the war on drugs. There are rumors right now that President-elect Trump is considering Pam Bondi as AG/head of DOJ.. if he chooses her… the chronic pain community had better get their ass in gear to write every Senator about refusing to confirm her… IMO.. she will just bring the misery that she has caused in Florida to the chronic pain community – as AG – to the rest of the country.  Most advocates – such as myself – can only be a coach… an observer… a messenger… a counselor… those that are being directly affected by these changes , their spouses and families have to become the real PAIN WARRIORS…

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First they came for the mentally ill addicts, and I did not speak out—
Because I was not a mentally ill addict.

Then they came for the empathetic prescribers, and I did not speak out—
Because I was not an empathetic prescriber.

Then they came for the Pharmacists, and I did not speak out—
Because I was not a Pharmacist.

Then they came for me—and there was no one left to speak for me

---

“My disappointment in the Chronic Pain Community deepens. The unwillingness to participate goes beyond the limits of being disheartening. We had one chance to organize and attack those who have openly labeled us as addicts and continually are taking our pain relief away, and we blew it. The plain and simple fact is that obviously the majority of the Chronic Pain Community put selfish political beliefs over their personal need for pain medications. I’m not talking about the presidency, I’m talking about the representitives in both houses of congress. Our one and only chance was to elect new people into congress and kick the incumbents out. You know, the ones that have been writing laws and passing bills to take all of our medications away. These congressmen and senators are the people who have been allowing the DEA and CDC to write guidelines and treat them as if they are law. Now, our choices are very limited and I’m absolutely positive that our medication access will start disappearing at an alarming rate.
You can write letters, make phone calls and even show up in person and these incumbent representitives will just blow you off. Why??? Because they have absolutely no fear of loosing their jobs. When Steve Ariens started the “VOTE THE BUMS OUT” campaign , I figured that by the response it got that the Pain Community was on board. Obviously I was wrong! It seems as though the majority of people in pain are totally satified to BITCH PISS AND MOAN about their meds being taken away. It would appear as if very few want to be a part of making the change we need. It seems as if most of you are concerned more about political party and religious beliefs more then you are concerned about your own health and wellness.
This will be my last post in these open pain groups on Facebook. I will keep my Leadership Counsil group page open for potential leaders. I will also continue to monitor and post useful information on this private page only. I will leave it up to Counsil members to share any information that I receive and post only to the Leadership Counsil page whether they want to share with open pain groups. But as far as me openly advocating for those of you who are obviously unwilling to help yourselves, I’m done! It’s time for me to be selfish and only think about myself and my pain, instead of continually putting my access to my pain medications in Jeopardy by openly advocating and being a voice for people who now appear to be satisfied with the way they are or have been treated. So, Bitch piss and moan all you want to. Talk about what you all think should be done and never do anything to get it done. Go ahead and play the victims who always use your pain as an excuse instead of using it as your driving force. Just keep refusing to use the weapons provided so you to fight back and then complain when you loose your pain relief. Trust me, I understand Steve’s frustration now.”

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New Cannabis Pain Patch for Fibromyalgia and Diabetic Nerve Pain

nationalpainreport.com/new-cannabis-pain-patch-for-fibromyalgia-and-diabetic-nerve-pain-8831899.html

A company specializing in cannabis-based medicines has developed two new medications for people with neuropathy diabetic nerve pain and fibromyalgia.

The new pharmaceutical medications will be in the form of a transdermal patch that is a medicated adhesive patch placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream.

The company behind the patches, Cannabis Science, says the patches:

“Promote healing to an injured area of the body. An advantage of a transdermal drug delivery route over other types of medication delivery such as oral, topical, intravenous, intramuscular, etc. is that the patch provides a controlled release of the medication into the patient, usually through either a porous membrane covering a reservoir of medication or through body heat melting thin layers of medication embedded in the adhesive which will be containing high potency cannabinoid (CBD) extract that slowly enters into the bloodstream and then penetrates the central nervous system of the patient delivering the pain relief sought.”

Cannabis Science’s CEO Mr. Raymond C. Dabney says, “The development of these two new pharmaceutical medicinal applications are just the tip of the iceberg for what we see as the future for Cannabis Science. While we strive to increase our land capacity for growth and facilities to produce our own product to supply our scientists with proprietary materials to make these formulations, we are also busy researching more potential needs for Cannabis related medical applications and developing the methods for delivery of these medications.”

CBD is the second major cannabinoid in marijuana after THC.  It has anti-inflammatory and pain-relieving properties, but without the psychoactive effects THC brings.

“As more states nationwide legislate for the legalization of cannabis and cannabis-derived medications, we here at Cannabis Science are focused on developing pharmaceutical formulations and applications to supply the huge growing demand expected over the coming few years,” concludes, Mr. Dabney.

Fibromyalgia is estimated to affect 2%-8% of the population, while females are about twice as likely to suffer from the condition.  People with fibromyalgia experience chronic widespread pain and a heightened pain response to pressure.

Peripheral neuropathy (PN) is damage to, or disease affecting nerves, which may impair sensation, movement, gland or organ function, or other aspects of health, depending on the type of nerves affected.

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PMP helps one state reduce painkiller Rxs

http://drugtopics.modernmedicine.com/drug-topics/news/pmp-helps-one-state-reduce-painkiller-rxs

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Despite progress, measles kills 400 children a day: WHO

http://www.reuters.com/article/us-health-measles-who-idUSKBN1352B7

The number of deaths from measles has fallen by 79 percent worldwide since 2000, thanks mainly to mass vaccination campaigns, but nearly 400 children still die from the disease every day, global health experts said on Thursday.

In a report on global efforts to “make measles history”, the United Nations children’s fund, the World Health Organization and other bodies said fight was being hampered not by a lack of tools or knowledge, but a lack of political will to get every child immunized against the highly infectious disease.

“Without this commitment, children will continue to die from a disease that is easy and cheap to prevent,” said Robin Nandy, UNICEF’s head of immunization.

Mass measles vaccination campaigns and a global increase in routine vaccine coverage saved an estimated 20.3 million young lives between 2000 and 2015, the report said.

But coverage is patchy, and in some countries the majority of children are not vaccinated. In 2015, around 20 million babies missed their measles shots and an estimated 134,000 children died from the disease.

The Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria and Pakistan account for half of the unvaccinated babies and 75 percent of the measles deaths.

Measles is a highly contagious virus that spreads through direct contact and through the air. It is one of the biggest killers of children worldwide, but can be prevented with two doses of a widely available and inexpensive vaccine.

According to the report, published by UNICEF, the WHO, the GAVI vaccines alliance and the U.S. Centers for Disease Control and Prevention, outbreaks of measles in various countries – caused by gaps in immunization – are still a major problem.

Seth Berkley, GAVI’s chief executive, urged governments to recognize the threat of “one of the world’s most deadly vaccine-preventable childhood killers” and act to contain it.

“We need strong commitments from countries and partners to boost routine immunization coverage and to strengthen surveillance systems,” he said.

In 2015, large outbreaks were reported in Egypt, Ethiopia, Germany, Kyrgyzstan and Mongolia, the report said. The epidemics in Germany and Mongolia affected older people, highlighting the need to vaccinate young adults who missed out on measles jabs.

Measles also tends to flare up during conflicts or humanitarian emergencies when vaccination schedules are disrupted. Last year, outbreaks were reported in Nigeria, Somalia and South Sudan.

 

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Trump Posts Preliminary Plan to Repeal ACA

http://www.medscape.com/viewarticle/871816?nlid=110628_3901&

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Failure to stand up

As one of my readers stated in a comment:

“I so wish I could gather all the pain community together to become one united front but how is that done exactly? Especially when there are so many little groups and a few really big organizations that refuse to work together due to their own agenda.”

It has been stated that per our legal system “the value of the life” of a person who is handicapped/disabled, elderly, unemployable.. has little value and thus an attorney will not take on any legal action on a contingency basis because there is little/no financial upside for the attorney

The DEA/DOJ, FDA, CDC are using existing laws and creating “new interpretations” of those laws to change the original intent of the law… to suit the agenda of the specific agency. IMO, until someone challenges the constitutionality of these new interpretations… they will remain on the books and enforced.

There may be some hope with the new Trump administration will take some actions on violations of the Americans with Disability Act. It really can’t be any worse than what has NOT HAPPENED under the Obama Administration.

Could it be that many personal injury attorneys have not considered the possibility of filing claims on:

In a personal injury or wrongful death case, the family members of the injured person — spouse/partner, children and parents — can file a lawsuit for their own loss. A interesting concept

The state limits for such lawsuits is $300,000 – $400,000.  Apparently a lot more than the limits for medical malpractice and the “value” of the life of a handicapped/disabled, elderly, unemployable and could be financially advantageous for a law firm.  If a couple of these cases are successful.. personal injury attorneys would start “circling” …

Likewise, a healthcare professional that denies, reduces a pt’s opiate therapy that is allowing them to keep a job … causing the pt to lose their job.. that is MEASURABLE DAMAGES…  again.. personal injury attorneys should be very interested in such cases.

The way that change is going to happen for those in the chronic pain community may be more of “one step at a time” and waiting for some sort of MASSIVE UNITY ACTION… does not seem to be a near term reality.

 

 

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Florida Supreme Court allows husband’s lawsuit against doctor after wife’s suicide

http://flarecord.com/stories/511041274-florida-supreme-court-allows-husband-s-lawsuit-against-doctor-after-wife-s-suicide

TALLAHASSEE, FLORIDA – The Florida Supreme Court ruled on Aug. 25 that a Sarasota man, Robert Granicz, may pursue his medical malpractice lawsuit against his late wife’s primary care physician, Dr. Joseph Chirillo, for her 2008 suicide, reported Medscape Medical News in an Aug. 26 article.

“Although the inpatient duty to prevent suicide does not apply here, there still existed a statutory duty … to treat the decedent in accordance with the standard of care,” Justice Patty Quince said in writing the court’s opinion.

Justices unanimously ruled that the case should go to trial, upholding a 2014 decision by the Second District Court of Appeal.

The summary judgement in favor of Chirillo was granted by the First District Court of Appeal, but the decision was later reversed by the Second District Court of Appeal that ruled in favor of Granicz. The Florida Supreme Court ultimately ruled to confirm the decision of the Second District that the case should proceed to trial.

Debra Pinals, M.D., director of the Program in Psychiatry, Law and Ethics at the University of Michigan in Ann Arbor, told Medscape Medical News that malpractice cases involving suicides are not new, but they can have a chilling effect on those who treat people with depression.

“Suicide as a cause of action for malpractice is one of the common reasons that physicians are sued,” she said. “The standard of care related to suicide is something that malpractice cases have been hinging on.”

According to court records, Jacqueline Granicz started taking the antidepressant venlafaxine (Effexor, Pfizer) in 2005, but stopped taking it in 2008.

The records say she called Chirillo’s office the day before she died and told his medical assistant that she had stopped taking the drug because she thought it was causing side effects such as poor sleep and mental strain, and also causing her to cry easily and have gastrointestinal distress. She said she had not “felt right” since late June or July.

After reading the assistant’s note, Chirillo changed her prescription from venlafaxine to a different antidepressant, escitalopram (Lexapro, Forest Laboratories). He didn’t schedule an appointment, but said she could pick up a sample of the drug and a prescription at his office.

Jacqueline Granicz picked up those items that day, but hanged herself the following day.

“The decedent in this case was an outpatient of Dr. Chirillo’s. Therefore, under Florida law, there was no duty to prevent her suicide,” the ruling said. “However, the nonexistence of one specific type of duty does not mean that Dr. Chirillo owed the decedent no duty at all. … Although the inpatient duty to prevent suicide does not apply here, there still existed a statutory duty … to treat the decedent in accordance with the standard of care. We find that the Second District (Court of Appeal) properly evaluated the … case based on the statutory duty owed to the decedent and also properly classified the foreseeability of the decedent’s suicide as a matter of fact for the jury to decide in determining proximate cause.”

Justices Charles Canady and Ricky Polston agreed with the result, but did not sign on to the opinion, which sent the case back to circuit court with instructions to move forward with a trial.

According to court documents, allegations of breach of duty included failing to recognize she was experiencing a change in symptoms, was depressed and was seeking medical intervention. They were also concerned that Chirillo didn’t speak with her directly and that he didn’t refer her to a clinician trained in management of depression. They also said he failed to properly evaluate escitalopram, an antidepressant known to cause suicidal tendencies in some patients.

“Dr. Chirillo owed no duty to prevent the defendant from committing an unforeseeable suicide while she was not in his control,” the doctor’s medical group said.

Although the American Psychiatric Association declined comment, there are individual doctor’s opinions that address concerns for the court’s decision.

“There’s a fine line between how you balance the standard of care with people’s free will on an outpatient basis,” Carolyn Stimel, Ph.D., executive director of the Florida Psychological Association, said in an interview with Medscape Medical News. “Presumably, if this person had been in therapy there would have been somebody monitoring what was going on with their mental state and also dealing with the issue that she had stopped taking her medications.”

She said doctors have a legitimate question in asking what one can do when a patient won’t take medications.

“Ultimately you can’t shove pills down someone’s throat,” Dr. Stimel said. “The thought of doctors being responsible for whether patients kill themselves or not — that’s pretty chilling.”

 

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