Florida has a problem that doesn't get much play. It's for the most misunderstood patient. It's for the patient most government officials don't care about. It's for patients that are most likely to be exploited by physicians, pharmacies and businessman. It's the patient in pain.
I wrote about it over a month ago, but since then, Florida patients in pain simply can't get their pain meds. I have been talking with doctors, hospitals and pharmacists and we can't solve the problem for our patients.
They can't get them because the supply chain is afraid to sell narcotic pain meds to independent pharmacies or increasing supplies to chain pharmacies and they especially want to avoid selling to any dispensing physician in Florida. The DEA has a "quota", but won't tell anyone what the quota or limit is per pharmacy or physician, so suppliers guess and...well, you won't lose your license if you choose to not sell narcotic pain medications.
Narcotic pain medication shortages occur everywhere, and have for years; but Florida is the current target and it's getting serious. Narcotic Pain Management is a multi-faceted social issue that isn't going to shrink down to convenient 15 second sound bytes or a short, 800 word diary. The best I can do is take about 15,000 words down to what I have here. As usual, this diary like many of my health care diaries is heavily linked.
Patient vs. Criminals
I wrote before that it's imperative that we separate the criminals and drug abusers from the chronic pain patient and that assessment still stands. From a lawmaker's point of view, it's difficult to defend the rights of sick people looking for pain relief. The erroneous perception is that 100% of these patients are fakers, drug abusers and drug trafficers - it's less than 10% (Out of 120 million Emergency Department visits about .2% were for opioid overdoses.)
The perception is not reality
Nancy Snow of Cal State Fullerton wrote in 2004, "today's most pervasive and effective propaganda is the kind that is "least noticeable" and consequently "convinces people they are not being manipulated."
We have patients with intractable pain. Yes, diversion is a problem that creates sensational headlines that are exploited by politicians into favorable ratings. You don't see news items about patients safely taking narcotic medications - those stories would be too boring.
We want salacious news with characters like this and this or this guy and a clinic like this. Now that's a story! One the bored talking head can latch onto. A story that makes it worse for the cancer patient and other chronic pain patients to defend their pain relief needs. To that end, the legitimate pain management patient signs away their rights under HIPAA and any other privacy laws and consents to all sorts of invasive and nosy information gathering and testing to gain access to treatment that can be cut off for any infraction.
The conventional wisdom is that it's better to make all compliant patients suffer and withhold effective treatment, than allow even one criminal to slip through and have access to narcotic pain meds.
We need to reject this stance as cruel.
We need to reject this political position as ineffective.
Pharmaceutical Wholesaler Intimidation
The DEA closed down this generic pharmaceutical wholesaler a while back. Cardinal is back in business, but they go above and beyond the law in self regulating who they ship to - based upon DEA advice. Several other wholesalers in both Florida and in Michigan have had more recent troubles. The wholesalers that haven't been shut down have listened to intimidating DEA advice. (I have it from a former DEA agent that one South Florida wholesaler, who has avoided trouble so far, will be served a show cause letter in the next month or so). Due to a quirk of fate, I received a copy of an email to a pharmaceutical wholesaler that threatened them with losing their license if they shipped any oxycodone to a physician's office (I'm not going to reprint it). The implication was clear, take the advice or be shut down.
Physician Intimidation
How intimidating can law enforcement be? Very intimidating indeed; to the point of fabricating diversion cases. Imagine my surprise to find this on the Cato Institute site. These are testimonials of conservatives who ran foul of the DEA in 2005. It's worth the read.
Ok, so what is an excessive amount of narcotic pain meds?
Well, that depends on a lot of factors, but let's look at Census figures for Florida that shows that there are just under 14.5 million adults living in Florida (18,537,969 - .78 = 14,496,462, which I'm going to round up to 14.5 million). The CDC's 2006 Chart Book (pgs 68-81) shows that:
- 26% of adults experience pain lasting more than 24 hours on any given day which would be 14.5 * .26 = 3.77 million Floridian adults having pain lasting more than 24 hours on any given day.
- 14% of the adult population (14.5 * .14 = 2.03 million ) Floridians that have been in chronic pain that has lasted from 3 months to a year or longer.
- 4.2% of the adult population, 1/3rd of the chronic pain suffers, take narcotic pain medication on any given day; which calculates down to (14.5 * .042 = 610,000) on narcotic pain relievers.
- If 610,000 adult Floridians took 4 doses of narcotic pain relievers every day, that would translate into over:
2.43 million doses per Floridian in pain per day
17 million doses per Floridian in pain per week
73 million doses per Floridian in pain per month
888 million doses per Floridian in pain per year
(The National figure is over 20 billion doses per year.)
Numbers like this are simply rejected by law enforcement. DEA agents simply assume that people should man up and feel the pain. Law enforcement will not quantify what an acceptable number is, they just declare what is out there is too much. Patients who go to pain clinics can get scripts for 30mg of oxycodone 6 times a day (240mg per day) which is absolutely rejected by law enforcement and by health care professionals that don't work in chronic pain management. These are very high doses that the average person couldn't tolerate. I have trouble contemplating taking that much pain medication; however, that doesn't mean I haven't see medical records for patients that can and do take 240 mg a day of oxycodone, like the young man that had 3 long bones replaced with metal shafts. The public perception of that narcotics are over prescribed is so prevalent that when a study shows diversion is only a very small percentage of patients, the researchers doubt their own findings.
Elected Official Intimidation
Congressional members have a hard time defending the chronic pain patient's ability to fill the prescriptions they legally obtain from their legal physicians. If they do, the opposition will fund a gazillion ads stating they are soft on drugs or soft on crime or both. Never mind we are talking about legal prescription medications, legally prescribed, legally filled. The fact that they are for narcotics is suspicious enough. Suspicious enough to make every elected official cautious in their support.
Chronic Pain From the Drug Control Point of View
The DEA's and Florida government's position is that there's too many people taking narcotics and they don't want to know anything about the CDC's findings on the subject, thank you very much. Like any lie, if you repeat it often enough people will believe it.
I've had:
- A friend tell me on the basis of personal knowledge of her brother-in-law that all narcotic pain medications are over prescribed and that the people who take them are looo...self-indulgent (she didn't exactly say, "losers", but the implication was clear).
- A patient's son complain because his mother was taking so much morphine for her cancer that she slept 18 hours a day. "She's going to die soon, I want her awake so she can talk to me. She's going to be gone soon!" Like, the cancer was about him.
- A nurse tell me on the basis of 2, that's exactly two, cases of patients she knows who misused narcotic pain medications; she believes no patient should ever get more than 30-60 oxycodone tablets per month for any reason - including cancer.
- A dentist tell me that she can see no reason to prescribe anything stronger than 800 mg ibuprofen. That includes removing wisdom teeth and root canals, bridge preparation - you name it.
- A doctor tell me that there's no reason to prescribe anything stronger than Tylenol or ibuprofen for bursitis as it normally heals within 10 days (of agony - believe me, I know).
- Countless numbers of doctors, nurses, health administrators including friends and family tell me that patients need to learn how to live with their pain without the "crutch" of pain meds.
That's what I call the "Pain is for Wussies" attitude. One incident is a tragedy that proves a point, a thousand people are a statistic to be ignored. People in pain are ignored in Florida ...and probably everywhere else in the United States - probably the world (actually).
When the idea that "Pain is For Wussie's" collapses
The concept that all chronic pain patients are charlatans or worse holds up until you experience intractable pain yourself. Then you find yourself to be a pariah. You have lost all credibility. You're an object of pity. Doctors look at you suspiciously and think you are selling the meds on the street. People think you're weak because you can't shake off the pain. Your family can't stand the side effects. You're losing your marbles due to the meds. They think you should man up and feel the pain.
Perceiving Florida's Opioid Problem
The Florida Medical Examiners regularly reports about opioid and other prescription drug deaths. The Report from June 2010 states:
The Office of Vital Statistics reported more than 171,300 deaths occurred in Florida during 2009. Of these, the medical examiners reported on 8,653 drug-related deaths (whether the cause of death or merely present) through toxicology reports submitted to the Medical Examiners Commission. In order for a death to be considered "drug-related" there needs to be at least one drug identified in the decedent, which is a drug occurrence. The vast majority of these 8,653 decedents (cases) had more than one drug occurrence.
One out of 20 deaths due to something preventable is a tempting target and I understand what the CDC wants to do. What I don't understand is the current strategy of dangerously putting thousands of patients in cold turkey withdrawal.
Local State Attorney Intimidation
Pasco and Pinellas counties have the highest drug related death rate in Florida. A local newspaper Creative Loafing accepts pain clinic advertising and that didn't sit well with Bernie McCabe, state attorney for Pinellas and Pasco Counties. Mr. McCabe wrote Creative Loafing a letter and asserted:
"We believe the physicians who prescribe these medications play a role in the prescription drug abuse and overdose epidemic that faces our community today," the letter, dated March 2, said in part. "While we understand the right to freedom of the press, we feel this type of advertisement is a blatant invitation to easy access to powerful narcotics by persons who are drug seeking."
snip,
But McCabe's letter had not said that any of the pain clinics on the back page were illegal. And editor David Warner didn't want to tar advertisers as unscrupulous pill mills without cause. So he decided CL needed to do some investigating on its own.
Creative Loafing wanted to be socially responsible, so they chose a former reporter, Eric Snider, to investigate (because he has a chronic pain medical history). Snider, wanted to do a fair story, so he went to see State Attorney McCabe and received the facts from the biased point of view of law enforcement. Basically, deaths due to opioid overdoses are way up nationwide and Florida's rate of 5% is significantly higher than the national average. Florida has decided vigilance and drug control is more important than compassion and has decided on a nanny state when it comes to overseeing legally obtained narcotic medications.
So many reporters have written stories that it's "too easy" to get pain medications from pain clinics, but I have only seen one article where a reporter tried to do it. Eric Snider did try and he failed to get narcotic pain meds. He failed 3 times.
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What's Missing
People who take narcotic pain medications make for easy political targets. The entire law enforcement and non-pain management medical apparatus views the chronic pain patient as criminal at worst and weak at best. A few people, usually mothers, but other family members who have loved ones die from overdoses want "something to be done". A politician can't say no and the specter of bad 30 spots screwing up their next campaign gets a lot of bad laws sponsored and passed. Bad laws based upon gut reactions, not science.
Personal Responsibility
People need to be responsible for the medications they take. If they drink and drug and die, it's their fault; not the fault of government or the doctor who prescribed the meds. Reducing unintentional opioid deaths is important, but not at the expense of the compliant pain patient. Humanely treating pain is just as important as preventing narcotic overdosing.
It's not About You
Pain is subjective and what is intolerable for one person is a mosquito bite to another. People who object to their adult family members medications often complain and promote the idea that 100% of chronic pain patients get more pain meds "than they need", which isn't true. If it's not your pain, then it's not your call; however, if you do see your loved one mixing alcohol, cocaine or whatever with the narcotics, that's the time to intervene.
Special Interest Influences
The Special Interest Groups like Florida Society of Anesthesiologists (FSA) and the Florida Society of Interventional Pain Physicians (FSIPP) influence how we view Chronic Pain Management with narcotic pain medications. FSA and FSIPP members would like to eliminate the competition. They don't want cardiologists, rheumatologists and internal medicine physicians raining on their parade. If you're a surgeon or pain injections, you want more business. Patients who take pills cost you business. What aggravates the interventional and invasive pain management specialist is the number of patients who return to opioid therapy because the injections and surgery didn't work (50-75%). One way to stop your patient's from leaving you is to lobby for a law that supports you and hurts the competition. Another consideration is that interventional pain management procedures like intrathecal opioid therapy can have a complication rate of 20% vs. long-term opioid therapy with a much lower rate of say, 3% for Roxicodone.
Pain Management Needs to Become More Important Than Drug Control
The under treatment of chronic pain must be addressed fairly and objectively. The special interests need to be curtailed. Drug Control needs to be more collaborative and less intimidating. Physicians and chronic pain patients need an environment in which physicians can treat their patients in a humane and ethical manner, in accordance with standards that arise from science, not politics.