“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Although the CDC’s pending guidance on opioid prescribing — expected to be some of the strongest federal advice on opioids to date — was supposed to drop this month, politics have forced the agency into an additional public comment period.
That has some experts wondering whether strong advice about supply and dosing limits will be preserved.
“I think that having input from as many perspectives as possible will strengthen the applicability and acceptability,” Lewis Nelson, MD, of NYU Langone Medical Center, who was an advisor to the draft guidelines, told MedPage Today. “However, the focus on benefit versus risk should not be diluted. This has been a shortcoming of some prior opioid guidelines.”
Although the guidance won’t be legally binding, its impact is predicted to be dramatic — prompting several groups, some with ties to opioid drugmakers, to work hard against it. Thousands of comments have been submitted to the agency, many of them critical of various elements in the recommendations as well as the process under which they were developed.
One focal point for critics is the draft’s recommendations for strict limits on supply and dosing.
For example, in acute pain not related to surgery, it calls for opioid prescriptions to be topped off at 3 days — and that the lowest effective dose of immediate-acting agents (not extended-release formulations, like OxyContin) should be used.
It also sets a dosing limit, urging clinicians to be careful once doses hit 50 morphine equivalents daily, and not going above 90 morphine equivalents daily. One 80-mg pill of OxyContin is 120 morphine equivalents.
CDC spokesperson Courtney Lenard said the dosing threshold “was determined based on the most recent scientific evidence regarding the association between opioid dosage and overdose risk,” which included an Agency for Healthcare Research and Quality (AHRQ) report authored by an outside expert who helped CDC develop the draft guidelines.
“Both this review and CDC’s contextual evidence review found that opioid overdose risk increases in a dose-response manner, that dosages of 50 to 99 morphine equivalents per day have been found to increase risks for opioid overdose two-fold to five-fold compared with dosages of 1 to 19 morphine equivalents per day, and that dosages ≥100 increase risks of overdose up to 9 times the risk of 1 to 19 morphine equivalents daily,” she said.
Concerns About Transparency
The CDC guidance was written by experts from the agency’s division of unintentional injury prevention, along with outside expert Roger Chou, MD, of Oregon Health and Sciences University in Portland, who was the lead author of the 2014 AHRQ report on the risks and benefits of opioids.
The agency also enlisted a core expert group (CEG), which included Nelson and several other experts known for their work on addiction and opioid use, including Jane Ballantyne, MD, and Gary Franklin, MD, both members of Physicians for Responsible Opioid Prescribing (PROP).
Over 2 days last September, CDC gathered another group — its “stakeholder review group” — to garner comments on the guidance. A wide range of perspectives were represented, from insurers to patient advocacy groups and medical societies — including the American Medical Association, the American Chronic Pain Association, the American Pain Society, and the American Cancer Society.
Immediately following those meetings, many of these groups raised concerns about the guideline — chief among them, that it lacked transparency and that the CEG was biased.
In its letter to CDC director Tom Frieden, MD, the AMA noted that “only a limited number of clinicians who are actively managing chronic pain patients were included.”
Similar complaints were listed in a letter from several chronic pain groups, including the U.S. Pain Foundation, the American Cancer Society’s Cancer Action Network, and the American Chronic Pain Association.
The agency “failed to disclose the names, affiliations, and conflicts of interest of the individuals who participated in the construction of these guidelines,” the groups wrote.
Over the next few months, the fight against the guidelines intensified, first with legal threats from the Washington Legal Foundation, then a letter from the House Oversight Committee.
The Washington Legal Foundation, a libertarian group that advocates for business interests, charged that the CDC had violated the Federal Advisory Committee Act by failing to make the work of its CEG public — and that it should scrap the current version of the guidelines and start from scratch.
In a Dec. 18 letter, the House Oversight Committee asked the agency why it didn’t consider its CEG to be an advisory committee under FACA. The letter cites the Washington Legal Foundation comments and requests several lines of documentation regarding the CEG.
The CDC posted its draft guidance on the Federal Register on Dec. 14. Commenters have until Jan. 13 to respond. As of press time, the document had more than 2,100 comments.
Next Steps
When the comment period is up, CDC will ask its Board of Scientific Counselors (BSC) — a federal advisory committee — to do a review. As of Jan. 7, the BSC was set to appoint a workgroup that will review the draft guideline and comments and present its observation to the larger group, according to Lenard.
Once the BSC makes its recommendations, the CDC will also review the comments and make final revisions before submitting the new guidance “for CDC scientific clearance,” she said.
Lenard noted that CDC received more than 1,500 comments on the guideline even before it appeared in the Federal Register.
“This feedback was from physicians, pharmacists, and other healthcare providers, professional organizations, pain advocacy organizations, state and local health departments, and patients,” she told MedPage Today. “CDC scientists found this input helpful and made substantial changes to the draft guideline in response to this feedback.”
Although the CDC doesn’t yet have a final publication date for the guidance, Lenard said it’s a priority for the agency: “Given the lives lost and impacted every day, we have an acute sense of urgency to issue guidance quickly.”
from the if-drug-trafficking-dips,-so-do-the-opportunities-to-grab-cash,-so… dept
Here you are: written evidence that asset forfeiture leads to law enforcement activity, rather than the other way around. (h/t Brad Heath)
The DEA has already been blasted by the DOJ’s Inspector General for its confidential informant program. The DEA’s informants were paid when they weren’t producing intel. They were paid and sheltered from prosecution when they committed criminal acts falling outside their purview as informants. And the entire program was adrift in a sea of corruption and chaos, subject to no real oversight. To top it all off, Inspector General Michael Horowitz had to battle the DEA for every document and piece of relevant information just to arrive at these conclusions.
It’s not just common criminals being added to the DEA’s payroll as confidential informants. It’s also other government employees. The DEA isn’t running a government employee-focused sting, however. It’s just looking for money. More eyes mean more money. And the eyes that will see the most money in transit will be those located at commuter hubs.
First off, the one-page report (which follows up its comprehensive report on the DEA’s informant program) notes that the DEA is throwing away tax dollars by paying a TSA agent to do something they should be doing anyway: reporting evidence of criminal activity to law enforcement.
The OIG determined that registering a TSA Security Screener as a CS violated DEA policy, which precludes registering as a CS “employees of U.S. law enforcement agencies who are working solely in their official capacity with DEA.” The OIG also found that TSA Security Screeners are obligated to report to law enforcement suspected criminal activity that they observe in the course of their duties. Therefore, by registering a TSA Security Screener as a CS, the DEA agreed to pay for information that the screener was already obligated to provide to law enforcement.
So, that’s misuse of funds. Now we get to the reason the DEA felt compelled to throw tax dollars at a fellow government employee.
The OIG further determined that asking the TSA Security Screener to notify the DEA of passengers carrying large sums of money in exchange for a reward based on money seized by the DEA violated the DEA’s interdiction manual, and could have violated individuals’ protection against unreasonable searches and seizures if it led to a subsequent DEA enforcement action.
Judging from the DEA’s enthusiasm for confiscating cash from travelers, it’s highly unlikely this is a unique arrangement. This one just happened to get exposed.
For those of you playing along at home by counting your remaining tax dollars, there is an upside: the DEA is apparently so inept at choosing confidential informants that no money ever exchanged hands (from the DEA to the TSA screener or, it would seem, from travelers to the DEA).
While the OIG concluded that the DEA violated its policies by registering the TSA Security Screener as a CS and by offering the screener a reward for money seized based on information he provided, the OIG found that the TSA Security Screener did not provide DEA any actionable information while a CS, and was not paid any money by the DEA. The CS was deactivated for inability to provide any useful information.
This short summary shows the DEA’s real interest is in cash seizures, not eliminating drug trafficking. It’s so obsessed with the immediacy of cash forfeitures that it’s willing to cut other government employees in on the deal. The incentives are already severely perverted. Drafting a security screener as a Junior G-Man on a contingency basis shifts that person’s focus from airline security to eyeballing carry-on baggage for non-threatening cash. This partnership makes each participant weaker and we, the taxpayers, are paying for both.
To print the document, click the “Original Document” link to open the original PDF. At this time it is not possible to print the document with annotations.
The DEA/CDC and other bureaucratic agencies have created “guidelines” and everyone is treating these guidelines as “the law”. Now the DOJ – which the DEA is part of – is going after what is consider too frequent urine testing on chronic pain pts.. or other abusive lab testing on these pts. Medicare is changing its billing allowables over the next two years because of the actions of the DEA/CDC and the response from the medical community in doing urine testing. All of this is direct/indirect collateral damage of Congress’ “warped” mindset in 1914 when they passed the Harrison Narcotic Act which created the “black drug market” that we have been fighting every since.
Doctors frequently order patients to take urine drug tests to safeguard against prescription pain-pill abuse.
But federal investigators and Medicare say these routine tests — designed to ensure patients properly use opioid drugs — have led to questionable billing practices by some for-profit labs, doctors, and addiction-treatment centers.
Millennium Health, the nation’s largest lab and one that has conducted widespread testing in Arizona, agreed to pay $256 million to the federal government in October to settle claims that it conducted unnecessary testing.
The U.S. Department of Justice is cracking down on private labs that investigators say offer incentives to doctors to frequently refer patients for lucrative testing. And Medicare, citing the potential for billing abuses, is overhauling its billing codes and payment rates used for drug tests.
Consumers who have been hit with large bills for routine tests say that the cost can quickly become unaffordable.
Phoenix resident Eric Smith visited a local pain clinic in June for treatment of pain from a degenerative disc in his back. The doctor approved a 30-day prescription for Percocet but also required Smith to submit a urine sample each month he sought a refill.
Weeks later, Smith received an itemized bill for a urine test that listed five separate charges for a total charge of $660. He decided monthly tests and other fees such as co-payments and prescription-drug charges would quickly become too expensive.
“This is something I’m dealing with long term,” Smith said. “For those of us with real pain who have to pay for these tests because of the few who abuse (prescription painkillers), it does not seem fair.”
Some tests can be even more expensive. A 75-year-old Fountain Hills man visited the same practice, Arizona Pain Specialists, which has seven clinics in Arizona. He had a urine test that checked for 10 substances, including illegal drugs such as methamphetamine, cocaine and phencyclidine, more commonly known as angel dust. The man was billed separately for each substance for a total bill of $1,048. His insurance plan paid $412.
Doctors who prescribe pain pills frequently say they must order screening tests to comply with medical guidelines.
Arizona Medical Board guidelines encourage doctors to conduct regular urine drug tests on patients who take prescription pain pills. The screens are designed to make sure patients take the prescribed drugs, don’t resell the drugs and don’t mix prescriptions with illegal street drugs. Frequent testing also is a hallmark of addiction-treatment centers, which also have been scrutinized by federal investigators and private insurers.
The medical board has suspended or revoked licenses of doctors who it determined prescribed opioids without proper oversight.
That oversight, according to the medical board’s guidelines, should include “regular toxicologic testing for drugs of abuse.” The guidelines don’t specify which drugs of abuse doctors should test, or how often tests should occur.
Too much testing a concern
Labs and clinics in Arizona and other states use sophisticated tests that measure multiple substances and charge for each individual substance tested, providing more revenue than basic screening tests. Too much testing has long been a concern of Medicare due to potential overbilling, a Centers for Medicare and Medicaid Services spokesman said.
That’s one reason Medicare, the federal health program for the disabled and those 65 and older, is overhauling the way it pays for these tests. Beginning in January 2016, labs and doctors must limit Medicare charges to two categories of billing codes. And in January 2017, Medicare will change payment rates for drug testing.
A Medicare official said the changes aim to remove the incentive for too much testing that has little or no medical benefit.
Medicare wants to reduce the frequent use of confirmation tests by labs that charge for follow-up tests when initial tests show no sign of an illegal substance. Medicare says that some confirmation tests are not medically necessary and inflate charges for taxpayers who support Medicare.
Private health insurers also are scrutinizing and changing payment policies for urine screens ordered or performed by pain doctors, addiction-treatment centers and labs.
“The lab industry has done a lot of over-testing,” said Jennifer Bolen, a former assistant U.S. Attorney in Knoxville, Tenn., who consults on proper opioid screening. “Some of it was encouraged by a lack of sound boundaries (through guidelines). Some of it was pure greed.”
Doctors say they follow guidelines
Doctors who treat patients for chronic pain say they must adhere to state and federal guidelines on how to safely prescribe pain pills. They say they also must keep patients safe from the ravages of pain-pill addiction.
Overdose deaths from opioid prescriptions surged fourfold nationally from 1999 through 2010. Arizona had the fifth-highest opioid prescription rates in the nation in 2010 and was sixth highest in drug overdose deaths.
Arizona has since made small strides in reducing the death rate from drug overdoses. A total of 1,211 Arizonans died from drug overdoses in 2014, a slight drop from 2013. Thirteen states had a higher overdose rate than Arizona in 2014, according to the federal Centers for Disease Control and Prevention.
The CDC recently drafted guidelines that recommended urine testing for pain patients. Arizona doctors who treat chronic-pain patients say state and federal guidelines are instructive.
“Right now, urine testing is really not an option. It is (a) standard of care,” said Patrick Hogan, an anesthesiologist who runs a Glendale pain clinic. “If you are failing to test and you have a patient who has a complication, there is a high likelihood that you would face some disciplinary action from regulatory agencies.”
Doctors who frequently order drug tests for patients will need to navigate Medicare’s new billing requirements.
Medicare billing records show that Hogan ordered the most urine drug screens of any Arizona doctor in 2013. He billed Medicare for 1,943 tests on 368 patients — an average of 5.3 drug screens per patient that year, Medicare records show.
AZCENTRAL
Banner Health, other hospitals pay $28 million in Medicare overbilling probe
Hogan said that he does not know of any guidelines that limit how often a doctor should order a drug test for a patient. Some larger doctor groups may have their own testing frequency requirements. Hogan said he does not want limits on how often doctors can test.
“How often do you test somebody? I don’t know that there are clear guidelines that exist for something like that,” Hogan said. “I would hate to see something that would usurp provider judgment on that.”
Lisa Sparks, an addiction-medicine doctor and medical director of the Arizona Pain Institute in Glendale, said she decides how often each patient should be tested based on their circumstances. However, Sparks believes routine testing makes “patients realize they can’t cheat the system very easily” by misusing or selling their prescribed drugs.
She often orders panels that tests for multiple substances for patients who are on pain medications, but those tests vary based on the patient. For example, she said she does not test patients for the illegal street drug angel dust because it’s so rarely found in the community.
“We try to avoid overbilling and (limit panels) to do the tests that really need to be done,” said Sparks, who billed Medicare for 741 drug screens on 232 patient in 2013, Medicare records show.
Doctors in other states have been more prolific in billing for these tests. For example, one Connecticut doctor charged Medicare for an average of 198 tests per patient in 2013, Medicare billing records show.
Labs face closer scrutiny
Labs that market tests in Arizona and elsewhere have been subject to enforcement actions and legal settlements.
Millennium Health, a San Diego-based laboratory, in October agreed to pay the federal government $256 million to settle claims that it billed Medicare for improper testing.
The U.S. Department of Justice said that Millennium billed Medicare and Medicaid for unnecessary urine and genetic tests over a seven-year period through May 2015. The company gave doctors free testing cups in exchange for patient referrals, resulting in unnecessary and lucrative testing, federal investigators said.
Millennium Health, previously known as Millennium Laboratory, was the subject of multiple civil lawsuits — including one in Arizona — that alleged billing improprieties. One Arizona-based regional sales manager alleged that sales representatives routinely offered medical practices free urine-testing cups to encourage doctors to order tests.
The lawsuit filed in U.S. District Court in Arizona alleged Millennium gave gifts such as Starbucks gift cards to doctors offices “to both retain existing business and assist in generating additional business.” At the time of the 2012 lawsuit, Millennium denied offering such inducements. The case was dismissed in April with no award to the sales manager.
Millennium officials said the company decided to settle the Justice Department’s multiyear investigation. The company filed for Chapter 11 bankruptcy in November.
“While Millennium may debate some of the merits of the DOJ’s allegations, we respect the government’s role in health care oversight and enforcement,” Millennium CEO Brock Hardaway said in a statement about the settlement. “At the end of the day, it was time to bring closure to an investigation that began nearly four years ago.”
Millennium isn’t the only lab that has caught the attention of investigators and health insurers.
In July, Cigna exited the Affordable Care Act individual marketplace in Florida for 2016 due to an “exponential increase in fraudulent and abusive care delivery practices” among substance-abuse clinics and labs, a Cigna spokesman said.
Cigna also sued Sky Toxicology and two related labs and alleged a “lucrative and improper patient-referral kickback scheme” that connected health clinics with out-of-network labs that resulted in $20 million in excess payments.
A Winchester man is dead and another from Clarke County is in critical care after they overdosed on similar over-the-counter medications.
Officials said they overdosed on an anti-diarrheal drug called loperamide.
“Traditionally, we see people overdosing on substances such as heroin, so this brings a whole other angle to our addiction crisis in our area,” said Lauren Cummings, executive director of the Northern Shenandoah Valley Substance Abuse Coalition.
The region’s addiction epidemic killed 29 people in 2015 from overdoses on illegal or abused drugs. Although, loperamide isn’t smoked, injected, prescribed or even bought from a dealer.
Loperamide is the active ingredient in anti-diarrheals like Imodium and can be purchased wherever over-the-counter drugs are sold.
While a loperamide overdose has only caused one death in Virginia since 2007, the region’s poison control center reported that doctors called 6 times in 2015 for people who overdosed on loperamide.
According to Dr. Nicolas Restrepo, vice president of medical affairs at Winchester Medical Center, there are two possible reason why most medical professionals believe loperamide is being abused.
“One is to, unfortunately, get an opioid-like high and the other is to do a ‘do it yourself’ type of approach to withdrawing from opioids, in particular, heroin,” he said.
“The concern that we have is that, folks, instead of finding help with their addiction, the disease of addiction, and their struggle with substance abuse, are instead self medicating,” Cummings added.
Many doctors believe that the “self-medicators” are turning to the internet for information on loperamide.
“Much of that information is either A, not accurate, or, B, accurate enough, but without warnings associated with risks of taking such massive overdoses,” said Dr.Charles Devine, health director for the Lord Fairfax district of the Virginia Department of Health.
According to Devine, those risks are extensive.
“Unfortunately, taken at such huge doses, the loperamide causes a significant amount of cardiac toxicity, and this can lead to fainting spells or simply dropping dead,” he said.
Officials urge those struggling with addiction to seek professional help in person and not to rely on information found on the internet.
Many people today have Medicare/Medicaid as their health insurer… but … all too many chronic painers and others with subjective diseases… are unable to find HEALTH CARE. Having health insurance does not necessarily mean getting healthcare ?
CHARLESTON, S.C. – Vowing to achieve universal health care, Vermont Sen. Bernie Sanders released a sweeping proposal hours before Sunday’s Democratic presidential debate to create a new single-payer health care system in the United States paid for by a variety of higher taxes.
Sanders’ “Medicare for all” plan was poised to play a starring role in the final Democratic debate before the leadoff Iowa caucuses and came as rival Hillary Clinton has ramped up her critique of Sanders’ health care plans.
Clinton has pressed Sanders for details on whether middle-class families would face a higher tax burden under his plan, which she has warn would undermine President Barack Obama’s signature health care overhaul.
Her campaign did not immediately comment on his proposal, which was released at little more than two hours before the debate.
Sanders’ campaign said his system would provide health care coverage to all Americans, eliminate co-pays and deductibles, and bring health care spending under control.
“Universal health care is an idea that has been supported in the United States by Democratic presidents going back to Franklin Roosevelt and Harry Truman,” Sanders said in a statement. “It is time for our country to join every other major industrialized nation on earth and guarantee health care to all citizens as a right, not a privilege.”
His campaign said the plan would cost $1.38 trillion a year, but would save $6 trillion over the next decade compared to the current health care system, citing an analysis by Gerald Friedman, an economist at University of Massachusetts at Amherst.
But much of the cost would be paid for through a 6.2 percent payroll tax paid by employers and a 2.2 percent “health care premium” on workers. It also relies on taxing capital gains and dividends on families earning more than $250,000 a year, eliminate deductions for wealthy Americans and raising the estate tax.
The plan would also raise income taxes on Americans making more than $250,000 a year, including a top tax rate of 52 percent for those earning $10 million annually or more.
While Sanders’ proposal is similar to the single-payer health care plan that he has introduced nearly a dozen times since joining Congress in 1991, it is a reversal of his campaign rhetoric.
In December, he promised to raise taxes on the middle class only to pay for a plan to provide paid family leave. His other programs, like tuition-free college and health care, would be paid for with higher taxes on the wealthy.
“I think it is appropriate to ask the wealthy and large corporations to start paying their fair share of taxes,” he said on NBC’s “Meet The Press.”
Some liberal activists said Sanders’ plan, like other federal programs such as Social Security, would deliver a better value for low and middle income taxpayers.
“If you had a universal health care plan people wouldn’t have to pay premiums. They would gain far more than they would shell out in taxes,” said Roger Hickey, a co-director of the Campaign for America’s Future. “Social Security wouldn’t have existed if FDR had said, ‘I’m not going to raise anyone’s taxes.'”
It would seem that the anti-opiate group must either dealing with a “single brain” , one generates “talking points” , or all they basically know how to do is cut/paste what others have stated in some publication.
By Richard Gunderman
Over the last few decades, medicine has witnessed a sea change in attitudes toward chronic pain, and particularly toward opioids. While these changes were intended to bring relief to many, they have also fed an epidemic of prescription opioid and heroin abuse.
Curbing abuse is a challenge spilling over into the 2016 political campaigns. Amid calls for better addiction treatment and prescription monitoring, it might be time for doctors to rethink how to treat chronic pain.
Ancient roots, modern challenges
A class of drugs that includes morphine and hydrocodone, opioids get their name from opium, Greek for “poppy juice,” the source from which they are extracted.
In fact, one of the earliest accounts of narcotic addiction is found in Homer’s “Odyssey.” One of the first places Odysseus and his beleaguered crew land on their voyage home from Troy is the land of the Lotus-Eaters. Some of his men eat of the Lotus, lapsing into somnolent apathy. Soon the listless addicts care for nothing but the drug and weep bitterly when Odysseus forces them back to their ships.
For decades in the U.S., physicians resisted prescribing opioids, in part for fear that patients would develop dependency and addiction. Beginning in the 1980s and 1990s, this began to change.
Based on experiences with end-of-life care, some physicians and drug companies began saying that opioids should be used more liberally to relieve chronic pain. They argued that the risks of addiction had been overstated.
Since 2001, the Joint Commission, an independent group that accredits hospitals, has required that pain be assessed and treated, leading to numerical pain rating scales and the promotion of pain as medicine’s “fifth vital sign.” Doctors and nurses now routinely ask patients to rate the severity of their pain on a scale of zero to ten.
While it is impossible to measure the burden of pain strictly in dollars, it has been estimated that the total health care cost attributable to pain ranges from $560 billion to $635 billion annually, making it an important source of revenue for many health professionals, hospitals, and drug companies.
More prescriptions for opioids have fed abuse
Today it is estimated that 100 million people in the U.S. suffer from chronic pain—more than the number with diabetes (26 million), heart disease (16 million) and cancer (12 million). Many who suffer from chronic pain will be treated with opioids.
In 2010, enough prescription painkillers were prescribed to medicate every American adult every four hours for one month. The nation is now in the midst of an epidemic of opioid abuse, and prescription medications far outrank illicit drugs as causes of drug overdose and death.
It is estimated that 5.1 million Americans abuse painkillers, and nearly 2 million Americans suffer from opioid addiction or dependence. Between 1999 and 2010, the number of women dying annually of opioid overdose increased five times. The number of fatalities each day from opioid overdoses exceeds that of car accidents and homicides.
In response, the Drug Enforcement Agency and a number of state legislatures have tightened restrictions on opioid prescribing.
For instance, patients must have a written prescription to obtain Vicodin and doctors can’t call prescriptions in. The downside, of course, is that many patients must visit their physicians more often, a challenge for those who are seriously ill.
Some patients seek multiple prescriptions for opioids so that they can turn a profit selling extra pills. The increase in prescription opioid misuse is also linked to an increase in the number of people using heroin.
A sea change in pain treatment helped create the opioid abuse epidemic, and another sea change in how doctors view chronic pain could help curb it.
Looking beyond physical pain
In a recent article in the New England Journal of Medicine, two physicians from the University of Washington, Jane Ballantyne and Mark Sullivan, argue that physicians need to reexamine the real strengths and weaknesses of opioids. While these drugs can be very effective in relieving short-term pain associated with injuries and surgery, the authors say “there is little evidence supporting their long-term benefit.”
One of the reasons opioids have become so widely used today, the authors suggest, has been the push to lower pain intensity scores, which often requires “escalating doses of opioids at the expense of worsening function and quality of life.” Merely lowering a pain score does not necessarily make the patient better off.
They point out that the experience of pain is not always equal to the amount of tissue damage. In some cases, such as childbirth or athletic competition, individuals may tolerate even excruciating degrees of pain in pursuit of an important goal. In other situations, lesser degrees of pain—particularly chronic pain—can prove unbearable, in part because it is experienced in the setting of helplessness and hopelessness.
Instead of focusing strictly on pain intensity, they say, physicians and patients should devote greater attention to suffering. For example, when patients better understand what is causing their pain, no longer perceive pain as a threat to their lives and know that they are receiving effective treatment for their underlying condition, their need for opioids can often be reduced. This means focusing more on the meaning of pain than its intensity.
This helps to explain why one group of patients, those with preexisting mental health and substance abuse problems (“dual diagnosis patients”), are particularly poorly served by physicians who base opioid doses strictly on pain intensity scores. Such patients are more likely to be treated with opioids on a long-term basis, to misuse their medications, and to experience adverse drug effects leading to emergency room visits, hospitalizations, and death—often with no improvement in their underlying condition.
The point is that pain intensity scores are an imperfect measure of what the patient is experiencing. When it comes to chronic pain, say the authors, “intensity isn’t a simple measure of something that can be easily fixed.” Instead patients and physicians need to recognize the larger psychological, social, and even spiritual dimensions of suffering.
For chronic pain, Ballantyne and Sullivan argue, one of the missing links is conversation between doctor and patient, “which allows the patient to be heard and the clinician to appreciate the patient’s experiences and offer empathy, encouragement, mentorship, and hope.”
If the authors are right, in other words, patients and physicians need to strike a new and different balance between relying on the prescription pad and developing stronger relationships with patients.
One problem, of course, is that many physicians are not particularly eager to develop strong relationships with patients suffering from chronic pain, substance abuse, and/or mental illness. One reason is the persistent widespread stigma associated with such conditions.
It takes a doctor with a special sense of calling to devote the time and energy necessary to connect with such patients, many of whom can prove particularly difficult to deal with.
In too many cases today, it proves easier just to numb the suffering with a prescription for an opioid.
Just imagine what a non-opiate pain medication would do to “DEA’s world” war on drugs ? They would be left with dealing with cartels and “street thugs” that will shoot anyone that interferes with their business plan ? My money is if this drug or some derivative eventually is proven safe/effective.. that the FDA will use this one incident to stall off approval in this country. It is hard to imagine one part of the Federal bureaucracy that would do something that could harm the size/power of another part of the bureaucracy. Inflicting that sort of pain on part of the Federal bureaucracy would be unthinkable ?
A man who was left brain-dead after a drugs trial in France went seriously wrong has died, according to the hospital which had been treating him.
Five other volunteers were also hospitalised after taking the trial painkiller on January 7 are now ‘in a stable condition’, according to the statement released by the hospital in Rennes.
But three of the men are suffering a ‘handicap that could be irreversible’, according to Pierre-Gilles Edan, the head of the hospital’s neurology department, and another has neurological problems.
It is the worst incident of its kind in French medical history, and the country’s health minister Marisol Touraine called it ‘an accident of exceptional gravity… without precedence’.
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Trial: French health Minister Marisol Touraine (pictured) described the trial as ‘an accident of exceptional gravity…without precedence’. One man who was left brain-dead has now died, according to the hospital
Drugs test: Three separate investigations have been launched after six volunteers at the Biotrial laboratory in Rennes were taken to hospital, in the worst incident of its kind in French history
The volunteers took part in a trial run by private laboratory Biotrial, to test a new pain and mood disorder medication for Portuguese pharmaceutical company Bial.
A total of 108 volunteers took part in the trial – 90 of which were given the drugs in varying doses while the rest were given placebos.
Early in the morning on Aug. 12, 2015, a 68-year-old man named Barry turned up at PeaceHealth Sacred Heart Medical Center in Springfield, Ore., confused and feverish.
The case was not a candidate for even a minor subplot on “House.” The admitting doctor stopped one of the patient’s medications and inserted an IV to deliver fluids, and by late the next morning, he had largely recovered.
Still, Dr. Rajeev Alexander, the hospitalist who took over his care, was determined to make an accurate diagnosis.
For nearly half an hour, Dr. Alexander, a perpetually rumpled man, chatted with Barry and Linda, his sister, about the events that had landed him in the hospital, the food processing plant where he once worked, the stroke that had impaired his mind. “It was a very scary night last night,” Linda, his caretaker, said. “He was just sitting on the floor, like you would sit a 6-month-old when they haven’t got their balance.”
Dr. Alexander considers it proper technique to review each mundane detail with a patient. He is full of scorn for the eureka style of medical diagnosis depicted on television, and by his own admission, he reads a CT scan with the sophistication of a barber.
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Dr. Rajeev Alexander, a hospitalist at PeaceHealth. His painstaking method of diagnosing patients’ maladies is viewed as inefficient by some who seek to cut costs. Credit Leah Nash for The New York Times
Eventually, Dr. Alexander would discard the more exotic theories that had crossed his mind — meningitis, or possibly a condition known as serotonin syndrome — and settle on a far simpler malady: dehydration, which aggravated a chronic kidney problem.
He was nonetheless unapologetic about the time he had invested.
“Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.”
Dr. Alexander’s method is at the center of an emotional debate in medicine, in which the imperative to increase efficiency in a high-cost health care system is often at odds with the deference traditionally accorded to doctors.
It’s a debate that came home to Sacred Heart in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists, the hospital doctors who supervise patients’ care, to a management company that would become their employer.
The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.
“They assure you of relief of some headaches,” said Dr. John Nelson, a past president of the Society of Hospital Medicine. He compared outsourcing doctor groups to a management company to hiring a lawn service. “You’re relieved of having to get the mower out. You’re not necessarily assured that you’re happier with your yard.” In recent years, according to the society, 25 to 30 percent of hospitalists have worked for multistate management companies, which also employ doctors in other disciplines, like anesthesiology and emergency medicine.
Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day — which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum. (Mark Hamm, executive vice president of EmCare, a physician services firm based in Dallas that has no connection to Sacred Heart, said the hospitalists employed by many staffing companies typically see 15 to 18 patients a day, though he said that was true of those who were directly employed by hospitals as well.)
It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. “We’re doctors, we’re professionals,” Dr. Alexander said. “Giving me a bonus for seeing two more patients — I’m not sure I should be doing that. It’s not safe.” (A hospital representative said patient safety was “inviolate.”)
Some Sacred Heart hospitalists left for other jobs, and the rest formed a union, one of the first of its kind in the country.
To everyone’s surprise, Sacred Heart’s administration agreed to junk its outsourcing plan, but this retreat did not usher in a love fest. Instead, there has been a long, grinding negotiation with the administration over the proper role of the hospital doctor, which continues to this day.
Dr. Alexander and his colleagues say they are in favor of efficiency gains. It’s the particular way the hospital has interpreted this mandate that has left them feeling demoralized. If you talk to them for long enough, you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment.
A Job Born of Efficiency
As recently as the mid-1990s, there was no one called a hospitalist. Most doctors would simply scramble from their offices to the hospital when they had to tend to patients there. But the discipline grew rapidly thereafter — to roughly 50,000 hospitalists nationwide in 2015 from about 11,000 in 2003, according to industry estimates.
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Credit Minh Uong/The New York Times
The hospitalist boom was itself a response to economic pressures and a push for efficiency in health care. Internists were seeing more patients in their offices in a day, partly thanks to the rise of managed care and smaller margins, making it less practical to run to the hospital. “It became difficult to plan your day,” said Dr. Frank Littell, a Sacred Heart hospitalist who has been practicing in the area since the 1980s. “If a patient needed to be admitted to the E.R., you had to cancel all your afternoon appointments.”
Gradually, it became clear that it would make more sense for a subset of internists to be based at each hospital, where they would handle the care of all the patients on site. The other internists could end their periodic hospital visits altogether.
Hospitalists could also increase hospital profits. They were on hand to discharge people throughout the day, emptying beds that could generate revenue again. And while paying the doctors was a new cost, hospitals at first found the efficiencies so advantageous that hospitalists were afforded the rare privilege of spending more time with patients. The doctors spent the time diagnosing and treating what were often highly complicated conditions — chronic health problems stacked on top of one another, or multiple organ failures.
This reprieve from the economic forces bearing down on the medical profession didn’t last long, however. “A consequence of how much the health care market has changed is that everybody has to be more efficient,” said Adam Higman, who specializes in hospital operations at Soyring Consulting in St. Petersburg, Fla. He noted that the increasing focus on metrics like readmission rates and hospital-acquired infections had created more work for hospitalists, who are responsible for a lot of documentation. “In some sense that comes to the detriment of the patient, there’s not as much quality time,” he said. “In some sense, that’s to their benefit — there’s a system to manage them.”
Asked if health outcomes had improved as a result, Mr. Higman said, “Readmission rates have been reduced — we can show it.” Costs are rising more slowly too, he said, no small thing in a country where many people are bankrupted by medical expenses. But, he added, “as to whether you as an individual are seeing better quality in health care — I think there’s some question there.”
Choosing to Unionize
In 2012, Sacred Heart’s parent, PeaceHealth, a nonprofit health care system, installed an executive named John Hill to adapt its Oregon hospitals to the latest trends in health care. Mr. Hill, in an effort to rein in the budget and improve the efficiency of a hospital that administrators said was lagging in key respects, including how long the typical patient stayed, eventually concluded that the hospitalists at Sacred Heart should be outsourced.
The basic accounting problem for hospitalists is that they are not a profit center. That is, when they treat patients, the amount a hospital can bill Medicare and insurance companies is typically less than what the hospital must pay them. The opposite is true for other specialists, like surgeons.
So it was no surprise when, in the spring of 2014, one of Mr. Hill’s colleagues came before the hospitalists and confirmed that the company would request bids for outsourcing their group. Still, the room erupted in anger and despair. The doctors were convinced that working for a management company would mean seeing many more patients per shift, and they worried about losing their jobs if they resisted.
Amid the groaning, a relatively new member of the group named Dr. David Schwartz observed, “They can’t fire all of us — there are unions.” This was a bit of a stretch: While there are hospitals around the country whose doctors are unionized, there did not appear to be a union anywhere composed of a single group of specialists. But Dr. Schwartz, a barrel-chested man with close-cropped hair and a bushy beard who would not look out of place at a graduate English seminar, thought unionizing might be worth a try.
At the time, it was only one of several options the doctors considered. They talked of forming an independent hospitalists group, of forming an alliance with an outsourcing firm of their choosing. But the alternatives gradually fell away for a variety of practical reasons, and the doctors were growing increasingly bitter.
Dr. Littell developed a riff, which the other hospitalists appropriated, about how the situation was like having your spouse of several decades announce he or she was going to play the field. “You’ve been great, you’ve always been there,” he would joke. “I just heard there could be better spouses out there.” The kicker: “The good news is, you’re in the running, too!”
Several doctors could not find it within themselves to be amused and gave notice. Eventually, about a third of the 36 in the group left. The hospital replaced many of them with contractor doctors, called locums.
By the time the doctors decided to hold their union election, almost all of them had become, if not pro-union, then convinced they had no better options. In early October they voted overwhelmingly to form a union that they chose to affiliate with the American Federation of Teachers, which already represented nurses at Sacred Heart.
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Dr. David M. Schwartz, a hospitalist at PeaceHealth Sacred Heart Medical Center in Springfield, Ore., first suggested forming a union to resist a move to outsource the hospital doctors.Credit Leah Nash for The New York Times
By March 2015, the PeaceHealth leadership, whatever its interest in efficiency gains, was apparently not pleased that one of its hospitals had a white-collar labor insurrection on its hands. The company announced that it would not outsource the hospitalists, a move it later said was always a possibility. Mr. Hill, who declined to comment, left in May.
But backing down on outsourcing did not mean the hospital had given up on getting more out of its doctors.
‘Skin in the Game’
To work in a hospital today is to be constantly preoccupied with money, and one of the more grating features as far as the Sacred Heart hospitalists are concerned has been the administration’s celebration of “skin in the game.” That means creating financial incentives for doctors to hit performance targets — like lowering patient’s length of stay and doing well on patient satisfaction surveys. The phrase entered the Sacred Heart lexicon in 2014, but the underlying concept has spread throughout the profession in recent years.
Dr. Robert M. Wachter, chief of the division of hospital medicine at the University of California, San Francisco, says many hospitals now give doctors financial incentives to perform well according to the criteria on which the hospitals themselves are judged under the Affordable Care Act — for example, reducing hospital-acquired infections. But there is an active debate in the profession over their utility. “If at the end of the year, 10 percent of your salary is at risk based on whether you have consistently clean hands, what patients say about you, readmission rates, that can be O.K.,” he said. The counterargument is that “you could screw things up by tying everything to financial incentives,” he said. “You stomp on their intrinsic motivation.”
The hospitalists also chafe at the way the administration has tried to centralize decisions they used to make for themselves. This might include hiring fellow doctors or the order in which they see patients on any day. They also complain of being loaded down with administrative tasks.
“We’re trained to be leaders, but they treat us like assembly line workers,” said Dr. Brittany Ellison, a hospitalist in the group. “You need that time with the patient, where his wife is ratting on him.”
For the most part, Dr. Alexander has accepted this state of affairs stoically, albeit with his trademark sardonic humor. At one point he told me that a patient with dissociative disorder was on her way to a psychiatric hospital, before observing: “Often people with dissociative disorder become managers. You have to treat people like things. A different way of saying it is sociopath.”
His personal rebellion is to linger over patients as long as he thinks it’s necessary, the hell with the performance metrics that nudge him to see more.
But just beneath his fatalism, an anger occasionally flares up. “What’s the widget the hospital produces?” he asked at one point. “It’s the doctor-patient relationship. You don’t improve it with extra little tasks.”
A few weeks after I got back from Oregon, I spoke by phone with Rand O’Leary, who was promoted to oversee PeaceHealth’s hospital services in the state last summer. He was genial and disarmingly sympathetic to the hospitalists’ concerns. He said his negotiators and the union had been “dialoguing around” a compensation model that would award doctors a bonus for hitting certain performance targets — the dreaded “skin in the game.” The targets would include how many patients they see, but would also include measures of patient health and satisfaction.
“It can’t be all based on production,” he told me. “It has to be quality — safety, a good experience. If you’re the patient in the bed, it’s important to you that you’re treated as an individual, that your needs are being met.”
Mr. O’Leary was especially proud of a ritual known as REAL rounds, which stands for “rounding embraced by all leaders,” in which administrators circulate through a different unit of the hospital each week and talk to doctors, nurses and other caregivers about their needs.
Disconnect at the Table
If Dr. Alexander’s medical experience has instilled a kind of fatalism, Dr. Schwartz’s has made him skeptical about human nature. During a morning of rounds, I couldn’t help noticing he was constantly on alert for ways that a patient’s version of events might not track.
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Credit Minh Uong/The New York Times
“You have to take what people say with a grain of salt,” he later explained. “Especially if the story changes, or is inconsistent, I get a little suspicious and assume the worst.”
This is not just true of patients. Noting that the negotiations with the hospital administration have dragged on for roughly a year, Dr. Schwartz said, “It’s pretty obvious that they don’t want to get a contract done.” He says the administration worries that if it essentially rewards the hospitalists with a contract, it encourages other hospital workers to unionize too.
Dr. Schwartz said he and his colleagues have always wanted to talk about staffing — ideally, they wanted to agree on a minimum proportion of doctors to patients — and how this affected patient safety. But when they raised these issues in the past, he said, the administration frequently shut down or retreated to marginal details.
Debra Miller, the system vice president for labor and caregiver relations, told me that PeaceHealth had never resisted the right of its employees to organize and bargain through a third party, and that there were many who did, like nurses and dietary workers. She said that it was standard for the first contract with newly unionized workers to take more than a year to negotiate and that this case presented special challenges. “There aren’t a lot of hospital-based physicians unionized,” she said. “I think the union themselves are trying to find their way over how to deal with it.”
As for some of the central issues, like staffing, Mr. O’Leary said in December that the two sides had made progress, but there were certain proposals the hospital simply couldn’t accommodate, like a minimum ratio of doctors to patients at all times, which would be difficult to maintain during emergencies. “We have to be able to respond to the demands of the community 365 days a year,” he said, citing the example of the mass shooting last year at a nearby Oregon community college. “Getting to a hard number is a great goal, but it’s not likely that can happen in our business.” (In a bargaining session on Friday, the negotiators neared a compromise in which a committee that includes doctors would weigh in on staffing.)
Even starker than the divide over these questions are the differences in worldview represented on opposite sides of the table. During a bargaining session last fall, the administration proposed increasing the number of shifts a year. Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.
When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.
The hospitalists assured the administration negotiators that their concern had nothing to do with money — that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue, according to several people in the room. (The hospital declined to comment.)
Suddenly it dawned on the doctors why they had failed to break through, Dr. Alexander said. “Imagine Mr. Burns,” the cartoonishly evil capitalist from “The Simpsons,” “sitting across the table,” he said. “There’s no way we can say, ‘This isn’t what we’re talking about. We’re not trying to get the bonus.’”
One afternoon I had a drink with Dr. Alexander and Dr. Schwartz at a restaurant near the hospital. Dr. Schwartz was reacquainting himself with civilian life after working nine days straight, and both men were wearing untucked button-down shirts and looking much more relaxed than they had at work.
It didn’t take long, however, before they began to trade stories of outrage suffered at the hands of their hospital overlords. Both men were particularly exercised about the “REAL” rounds that the administration said gave it insight into how the hospital workers did their jobs.
“One day when I was not in one of my better moods, the chief nursing officer showed up and asked, ‘Care to join us for REAL rounds?’” Dr. Schwartz said. “I was like, ‘Are you kidding me? Real rounds, as opposed to what we do?’”
The conversation turned, inevitably, to the dreaded “skin in the game.” I wanted to know what, exactly, they considered so offensive about having a financial stake in the hospital’s performance.
Dr. Schwartz responded by recounting the first time he had heard the expression, at a meeting with the hospital’s board of directors. A local businessman on the board had used the phrase while emphasizing the importance of providing the proper incentives for the doctors.
“It really took all of my self-control to not say, ‘What the hell do you mean skin in the game?’” he said. “We have our licenses, our livelihoods, our professions. Every single time we walk up to a patient, everything is on the line.”
He continued: “My thought was, I’ll put some of my skin in the game if you put your name on that chart. Just put your name on the chart. If there’s a lawsuit, you’re on there. You come down and make a decision about my patient, then we’ll talk about skin in the game.”
Recently the news has been covering the story of Barbara Dawson, a Florida woman who was arrested after she refused to leave a hospital that would not treat her for abdominal pain. While being escorted from the hospital in handcuffs, she collapsed in the parking lot and later died.
For many of us who are chronic pain patients, this kind of treatment is all too familiar. More often than not, when doctors see that we are on pain medications, they automatically assume that we are drug addicts and that we are “drug-seeking” just by going to the hospital.
Personally, I have so many of these experiences, that I couldn’t possibly list them all. Last year, I was hospitalized for upper abdominal pain. I had been to the emergency room earlier that week for the same issue, so the doctor told me he was admitting me, “Because otherwise you’ll just keep coming back.”
On my first day after being admitted, I was given no pain control and was taken off of my muscle relaxers. I got no sleep. I was told there was absolutely nothing wrong, and they couldn’t find any reason to keep me. I overheard my nurse speaking to another nurse, saying that my liver enzymes were in the thousands.
I questioned the doctor, who was in the process of discharging me, about my liver enzymes. He asked how I knew about this. I claimed that I had asked the nurse, because I could tell he was angry and I didn’t want to get her in trouble, although I had every right to know this potentially life threatening information. At that point, he felt pressured to keep me and try to figure out what was wrong.
Because they weren’t treating my pain, my blood pressure was high and I was at risk of heart attack or stroke. Instead of treating my pain, they put me on two different blood pressure medications.
At one point, I was taken to another floor for an abdominal scan. I was in so much pain I was trembling. A nurse said, “So, you’re an addict. When’s the last time you used?”
I was dumbfounded. I replied that I was absolutely not an addict and asked why she said this.
“Oh, maybe I used the wrong terminology,” the nurse said. “You’ve been on pain meds for a long time, right?”
I said yes and she said, “Well, okay. You can’t deny that, then. I just used the wrong word, sorry.”
I was suddenly acutely aware of the frequent misuse of the term “LTDU” (long term drug user), which is applied to many of us who take pain medications.
Upon transfer from my room to the exam room, I was given my medical records to hold. I opened and read them. Not surprisingly, I saw multiple remarks about “drug seeking behavior.” The nurse told me I was not allowed to read my own records. I said, “I’m allowed to hold them, but not read them? They’re mine!”
“Yes. Well, it’s hospital policy,” she replied.
I was hospitalized a second time last year, for the same issue, plus bradycardia. The admitting doctor was nasty to me, saying, “I am admitting you, but you will not be given one drop of pain medication other than Tylenol.”
Eventually, I was given a small dose of pain medication, but I was still trembling and vomiting the pain was so bad; yet the doctors refused to raise my dosage. I called the nurse, who got me a patient controlled pain pump. This was slightly more helpful, but when I let them know that the dosage was not controlling my pain, they took it away entirely. The gastrointestinal team came in and talked to me, but never came back.
I was discharged within three days, with no answers. Over those three days, I was told by one nurse, “If you call me every time it’s time for your medication, you are called a ‘clock watcher,’ which we consider a form of drug-seeking.”
I was again gobsmacked. Later, another doctor came in and said, “We have no reason to believe you’re in pain.”
I said, “Why would I go through all of this just to get a mediocre amount of pain medicine?! I’m not drug-seeking, I’m relief-seeking!”
The doctor said, “Well, there’s not much difference.”
During this second stay, I had to call the charge nurse and often the patient advocate, just to get minimal pain control. Every time, I pointed out their sign, which said “If your pain is not relieved within 30 minutes, please tell your nurse. Our goal is to treat patients with respect and dignity.”
I pointed this out so many times that instead of heading their own policies, they literally changed the sign! They came in and screwed a new sign to the wall, which mentioned nothing about pain care or patient rights.
In August of 2014, before the two events described above, I had my gallbladder removed. I was already on pain medications for chronic pain and I expressed concern to the doctor that my pain after surgery would not be adequately controlled. He said, “Don’t worry. You’ll get your precious Percocet. One prescription, that’s it!”
I was hurt and offended that he was treating me this way, as though I would have an organ removed just to get pain medicine! But, it got worse. As I was waking up from surgery, my eyes were not yet open, and I heard one nurse say to another, “The doctor said she’s going to claim she’s in pain, but just get her out of here.”
I opened my eyes and declared, “I heard you!” They both grew silent, and pretended that never happened.
This past August, on my 40th birthday, I landed in the ER again. Again, I had severe upper abdominal pain and was told that, “Nothing is wrong, and you will not be given narcotic medication.”
I asked the doctor to look at my liver enzymes. He saw that they were extremely elevated, and gave me a dose of pain medicine. The next thing I knew, the admitting doctor was in the room, telling me that I was “getting what I wanted” and I was going to be admitted. She introduced herself, and then proceeded to verbally steam roll me, telling me that I would not receive pain medications while I was in “her hospital.” She told me that I was already “unnecessarily on pain medicines.”
I questioned her, but she curtly cut me off. “I see that you have a bunch of ‘garbage pail diagnoses,’” she said.
I was furious. I asked if she even knew what some of them where, and if she knew better than the doctors from “her” hospital who had made those diagnoses. She rolled her eyes, and continued with her speech on the lack of treatment I would receive while admitted.
I said, “So, I’m being admitted for pain control and further testing, but I won’t receive pain control beyond the medications I currently take?”
“That is correct,” she said, her snide attitude seething. I told her that it was my 40th birthday and the last place I wanted to be was in the hospital, but I really wanted some answers. She just stared at me. I decided that I would take my chances, and go home. If this was any indication of the abusive treatment I was in for if I stayed, I wanted no part of it.
I was discharged with a diagnosis of intractable abdominal pain. Three weeks later, I looked at my online medical records, and noticed that my diagnosis had been changed to “narcotic withdrawal.”
Four years ago, I developed a severe kidney infection. I was deemed a drug-seeker by numerous ER’s, without any testing for my symptoms. Eventually, a doctor took me seriously, but by then, I was developing sepsis, and my life was in danger. You can read the full story here.
Even during this horrible incident, I was taken off my regular pain medication and was given a tiny dose of IV pain medicine, equivalent to about half of my home medications. The nurses watched me writhe and cry in pain all day and night, until I spent two days in and out of consciousness. They argued with the doctor on my behalf and I argued with him, but nothing changed. I was still supposedly “drug seeking.”
I could go on and on, but I think by now you get the point. Our lives are in danger, on the off chance that doctors may accidentally give medicine to someone who is trying to get high. This is absolutely unacceptable.
Also, I’m not sure how much validity is behind their theory. It seems to me that if someone wanted to get high, buying drugs off the street would be much easier and cheaper. Like most of us who take pain medication to treat our pain, I do not feel any euphoria, just a little relief.
How is this kind of behavior in line with a doctor’s Hippocratic oath to “First, do no harm?” It seems the oath is now “First, judge and abuse.”
Last month, State Police and a DEA agent used a battering ram to break down the door of a drug suspect in Burlington and then shot him 13 times. We have just learned that a) only one officer involved in the shooting was wearing a body camera which apparently did not capture what happened once police were inside the victim’s apartment, and b) the investigation of the raid and shooting is being led by the Vermont State Police. What this means, of course, is that we will never know what really happened that day. It is difficult to believe that with all of the technology available to police, there may not even be an accurate video recording of this tragedy. What’s worse, this raid and shooting will be investigated by the same police agency that organized and executed the raid. Does anyone expect that the investigation will be objective, transparent and result in any accountability whatsoever for the officers involved? This is a perfect illustration of the fallacy of having police agencies investigate the actions of their officers. We can expect that whatever factual review takes place of the Burlington shooting it will be shrouded in secrecy and result in total exoneration for all of the officers involved. This should surprise no one, particularly as the DEA (America’s secret police agency) participated in the raid, which was triggered by allegations of drug dealing. The tragedy and mystery surrounding this shooting illustrates two key points. First, this is yet another example of our failed drug enforcement policy, which has cost billions of dollars with little public benefit. We need to divert the excessive funding enjoyed by the DEA and the Vermont Drug Task Force toward prevention and rehabilitation instead. Otherwise, we will continue to throw hard-earned tax dollars down the drain without decreasing the quality or volume of drugs in Vermont. Secondly, we need to establish civilian review boards to investigate — and hold accountable — state and local law enforcement involved when a civilian is killed or where police use excessive or deadly force. We would not tolerate any other government agency investigating itself, so why should police departments be treated any differently? This is an area where the Legislature must get involved. Civilian review boards in Burlington and Brattleboro work to hold police accountable without interfering with day-to-day law enforcement operations. It is well past time that Vermonters embrace the idea of citizen review boards to ensure accountability and transparency when (at the very least) someone dies or is injured at the hands of police.
The Danger of Treating ER Patients as Drug Seekers
