Welcome to the new world of abuse of citizens by the medical class elites: businessmen, lawyers &, most especially, Big Insurance, both private and public (federally funded).
From my view, a seeming commercial emphasis is being foisted on medical practices to save on medication expenses & not just opiates.
The pressure to save on medication expenses seems correlate with efforts to pay overlord CEO’s of medical Insurance companies millions/year in salaries in the private medical marketplace & generous but unknown amounts in the public/government marketplace.
I have been witness to this abuse. I told a similar story as below & a few years ago, but people did not seem interested at that time. With the full-throated wail of untreated chronic pain patients in the background these days, perhaps interest in this story might have shifted.
Can someone turn this into a threadreader?
For many years (~17; late 1990’s-2012), I had one of the largest single-doctor Work Comp practices in Humbolt County, northern CA. My patients were tough men & women from the lumber, timber, fishing & farming communities.
These patients taught me about pain and how to diagnose musculoskeletal pain disorders. They had lots of pain from acute and chronic trauma. In the late 90’s & early 2000’s, the public mandate was to effectively control pain, & opiates were the preferred method.
Years 2000-2010 were proclaimed, by US Congress, U.N., & WHO, to be the “Decade to Conquer Pain”. “30,000,000” Americans were determined to be experiencing “chronic pain”. These are all official statements.
During the “Decade to Conquer Pain”, pain was officially the, “fifth vital sign”. Doctors were being sued for inadequately treating pain. Doctors were literally running scared; afraid of predatory lawyers.
Within the ivy halls of medical academia, Professors of Anesthesiology, the “pain doctors”, were teaching student doctors & Medical Residents that large doses of opiates were ethical, appropriate, & humane treatments. Pain needed conquering.
Pharmaceutical reps espoused doses of opiate medications; new line of fancy opiates; constructed with consideration for much greater than 100mg of Morphine equivalent per daily dose; which has become the current official benchmark upper limit of opiate prescribing in the US.
During the era of “evil pain”, doctors were commonly prescribing 5-8x the 100mg Morphine equivalents per day. Oxycodone (OxyContin & Percodan) was proving to be effective for pain control.
Oxycodone is arguably the best oral pain medication within the analgesic pharmacopoeia: nice pain relief without mental confusion.
Oxycodone elicits warm & fuzzy feelings without deterioration of intellectual function. Also, unfortunately, with a Street value of about $1/mg!
As the Professors of Pain Medicine & Intervention were instructing newly minted doctors: “doses could be slowly scaled up until the patient’s pain were relieved. There was no upper limits as long as toleration was allowed to developed slowly”.
The use of Oxycodone did not generate social difficulties when used properly, and serious pain Syndromes were nicely ameliorated. Larger doses did not disinhibit people to become foolish, unpredictable, and unreliable.
As increasing amounts of opiates were used to control pain, patients commonly found a dosage at a certain level that provided comfort & they plateaued at that dose. Ideas that opiates create an escalating & insatiable hunger is a Hollywood myth.
About 15% of people have a propensity toward anti-social acts (addiction) in order to obtain altered reality via opiates, Cannabis, alcohol, or tobacco. Sometimes the feel-good drug is internally generated, e.g., Dopamine &
gambling.
gambling.
In the 1990s, I walked into this arena of generous opiate prescribing & helped a lot of people with chronic pain. No one overdosed or inflicted self-harm.
In the 1990’s, Work Comp patients were being successfully treated for their chronic pain; until a Canadian psychology researcher reported his unique rat study...
In the mid-2000’s, a rat study presented data & theorized that rats exposed to opiates developed a theoretical disorder called “hyperalgesia”; caused by the opiates.
The idea was that opiates all by themselves caused increasing subjective pain levels which the non-English-speaking rats somehow communicated to the researcher. It was a theory.
This information seems to have brought excited delight to Work Comp insurance companies; perhaps with images of dancing money trees in their heads.
Many Work Comp insurance companies sent letters throughout their physician systems announcing new pain treatment guidelines. The Work Comp Insurance company mandates to doctors as to use of opiates were devastating.
During his reign as CA Gov., Arnold Swartzenegger crafted a law whereby doctors in the trenches were forced to relinquish diagnostic & therapeutic decision making to Utilization Review (UR) doctors.
UR doctors are licensed medical doctors who are insurance company employees, & who have a desk somewhere in offices of towering Big Insurance buildings.
The purpose of UR doctors is to abide by medical ethical concerns that only licensed doctors can make medical decisions; irrespective of whether they have ever talked to or examined the patients.
With Swartzenegger’s sell-out decision, a new day had dawned in the medical arena. Data became king, & any licensed doctor could interpret any data for third party payers.
UR Doctors, who never even saw patients, now made decisions how to treat injured workers & from every angle. These mandates became CA law. The insurance companies were ecstatic. What was the Terminator thinking; beyond power & money?
Over the next years, Work Comp increasingly denigrated opiate prescribing & Utilization Reviewers (doctors employed by Work Comp Insurance companies) began to play a game of “hide & deny the opiates”!
By 2011, the Work Comp pain treatment model including persuading pharmacists to harass doctors who used over 100mg morphine equivalents per day.
Pharmacist who never saw the patient, except over the horizon of a cash register, were emboldened to tell doctors how to treat patients.
The noble practice of medicine has been reduced to a computer-assisted-money-laundering-physician slave-operation controlled by lawyers, businessmen, & governmental agents.
Nurse Practitioners with two years of part-time education actually say to patients, “Why see the doctor, I can do everything he does”.
In a world where the focus is on “prevention” (vaccinations, colonoscopies, & mammograms) diagnosis can be devalued; and it has.
Outpatient medical excellence can be easily accomplished by nurses trained to follow set formulas; medical recipes you might say. Diagnosis? Leave that to overworked Specialists & the ER. The system is broken.
In the era of Work Comp opiate bowdlerization in late 2000’s onward, certain doctors got wealthy setting up clinics where pain patients went to live for two weeks to “be rehabilitated” by doctors who had magical powers to teach patients how to think their pain away.
For $15,000/patient (about retail cost of one year of hyper-inflated costs of opiates) contracting doctors were paid by Work Comp insurance companies to withdraw patients from opiate analgesics.
These clinics, contracted to Work Comp insurance companies, used Psychiatrists, Psychologists, group therapy, Physical Therapy, counseling & other elements of Cognitive Behavioral Therapy (CBT) to “get the patient off all narcotics”.
My patients awarded these “therapy scholarships” were ecstatic; until they learned that CBT does not replace pharmaceutical pain control; & that they had signed a contract that by accepting the scholarship, they gave up all future rights to receive opiate analgesics!
Over the last several years, the bowdlerization of opiates has moved into the general medical services arenas. Now-a-days, it seems that Pharmacists’ powers have exceeded those of physicians’ re: prescribing of opiates.
What about Doctors? They’ve been branded as cause of the flood of opiates in the U.S. Federal Government proof that epidemic of overdose is caused by opiate Rx’s written by doctors is shoddy.
The statistics of overdose seems unable to separate out injuries caused by illegal fentanyl from China & Mexico. It appears that the Chinese have finally won the Opium wars.
In all of this conniving & opiate bowdlerization, the Federal Government has been complicit. It has benefitted governmental power enrichment to control Big Insurance & Big Medicine simultaneously; by playing one off the other.
Several years ago, one of two academic Professor Psychiatrists from a WA State medical school wrote some theoretical ideas that “exposed” an untidy physician use of opiates, & they jumped on the bowdlerization bandwagon.
Although Psychiatric doctors did not have background in prescribing opiates or treating pain patients, they wrote theoretical papers how doctors were directly responsible for opiate epidemic & became instant highly rewarded national consultant stars at federal hearings on issue.
As result of changed policy about pain control & supposed epidemic of overdoses that has been lain at the feet of doctors, doctors are now running scare, but in a different direction: away from prescribing any opiates to chronic pain patients. Why go to jail over vial of pills?
Next, I will examine how this shifted physician mindset about opiates is currently affecting humane treatment of chronic pain patients.
In the US, every county has been awarded an exclusive contract to provide care to those who meet standards of poverty. These contracts are taken up by grass roots non-profit organizations & several satellite clinics they sprinkle around each county. These are termed FQ clinics.
When you hear current politicians preaching “Medicare for All” it is exactly this country-wide FQ clinic system they are talking about as the place of service for the “All”. This system is already in place & is the nascent genesis of socialized medical care in the US.
Presently, in CA this system of FQ clinics provides free medical care to undocumented aliens. But I am not supposed to talk or write about that. Free speech only goes so far these days if you have an employer. Where is the first amendment to the US Constitution when you need it.
As to the broader function of these FQ clinics: some patients make too much money to be declared impoverished & they end up with a share of cost, but the majority of care provided at these clinics is free to the patient base.
There is a major dynamic at play in the area of pain management. Poor people are often poor because they can’t work. The reason they cannot work is because they are in chronic pain. Do you see what is happening?
The federal government has become, by default, the clinical go-to service for chronic pain management. There are two categories of federal clinics shouldering the burden of taking care of chronic pain patients: the VA & the FQ clinics.
The way these FQ clinics operate is to recruit patients & then receive about $200 in federal funds every time the patient comes in. There is no distinction between hangnail & an heat attack; $200 on the barrel head no matter what the problem.
Now that you have been provided insight, where do you think the majority of pain patients go for medical care? To FQ clinics, but there is a major paradox at play in this dynamic.
The way it works in FQ clinics is that chronic pain patients are laterally passed off to a handful of “pain management clinics”.
At these “Pain Management Clinics, Nurse Practitioners (APRN’s) write triplicate prescriptions for controlled opiate medications.
At these “Pain Management Clinics” poor people receive opiates & their care is funded by a mix of federal and state money. But there is a twist...
The pain patients at these clinics are coerced, as part of their care, to regularly receive injections of cortisone into body parts & joints that are painful.
I have talked to hundreds of patients of these “Pain Management Clinics” and the pain reduction benefits of these $100s/per injection don’t exist.
As to the operation of FQ clinics here is an example: One large non-profit corporation has the contract one county in the State of HI.
This HI FQ clinic controls a chain of three satellite clinics & might care for about 20,000. The county population is over 100,000. At one of these FQ satellite clinics there are only 28 patients receiving chronic pain management.
Considering county-wide statistics of HI county, these figures would extrapolate to about 90 patients receiving pain management out of the clinic patient population, i.e., ~0.5% What happened to the statistic that ~30% of the general population has chronic pain?
These figures might reflect that the 5,000 federally funded FQ clinics in the US, which might be taking care of over 100,000,000, one-third of the US population, are shirking their duty to provide pain management. I do not know! I am not privy to the global figures.
I do not even know if clinics nearly completely supported by federal funds have a duty to provide any pain management. Based upon the mandates of humane care, it would seem that they should. Based on the figures I have seen they actually don’t.
These 5,000 FQ clinics across the US probably have the same charter: to provide basic humane care to patients. It is time to study the charter of these clinics, & to find out what the federal mandate is for treating chronic pain at FQ clinics; if there even exists a mandate!
The seeming failure of these FQ clinics to provide basic pain management might be partial explanation for the escalating epidemic of people in the US who suffer uncontrolled chronic pain. I do not know.
Certainly, the few doctors who remain in private practice have lost interest in chronic pain management.
