Tag Archives: death

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does chronic pain kill you?

Another writer sent me this story, saying that chronic pain killed Prince, not an overdose.

http://www.rawstory.com/2016/05/prince-did-not-die-from-pain-pills-he-died-from-chronic-pain/

My response is complex.

1. Is chronic pain an “illness” in it’s own right?

My answer is yes and no. It’s complicated and our understanding is evolving. Right now I think of chronic pain as a switch in the brain that gets thrown. It can be thrown by adverse childhood experiences, by infection, by trauma or war or abuse, by too much stress… or a combination of any of these.

2. Why a switch in the brain?

In fibromyalgia patients we can’t find much on physical exam, except that the pain seems out of proportion to the exam. Ditto with chronic fatigue, reflex sympathetic dystrophy, TMJ, etc. However, now we can image the brain with a functional MRI and watch which parts are lighting up and how much. A study of “normal” and fibromyalgia patients involved a standardized pain stimulus: a thumbscrew. (Kinky, right?) The normal patients said the pain stimulus was 3-4 out of 10 and their brains lit up a certain amount. The fibromyalgia patients said the same pain stimulus was 7-8 out of 10 and the pain parts of the brain lit up MORE corresponding to their pain level. So they are not lying… and it IS in their heads. Sort of. We aren’t sure whether the muscle is yelling more than normal or whether the brain is hypersensitive or both. My guess would be both.

And I think this is an adaptation. It is to get us to rest, heal, calm down, introspect, stop being type A, etc. Boy, do we suck at it. Though recently I had a person in clinic who said what their body wanted to do was nothing. They just wanted to lie around. I said, well, ok, so when can you do that? They did, for two weeks, at the holidays. And my patient said, “One day I had a cup of tea and a book and the cat on my lap and the dog at my feet. I realized that my adrenaline system was turning off and I felt calm and relaxed. Healed.” Back at work the person cannot always maintain it but is getting better at it.

3. What does this have to do with Prince?

The problem is that for 20 years we treated chronic pain with opiates. Unfortunately on continuous opiates, the brain cells change in many people and “down-regulate” the opiate receptors. Less receptors, the pain rises. The person needs more opiate. The brain removes more receptors. So two myths: one that if you have chronic pain and take medicine as directed, you can’t get addicted. Only dependent. Since that is a myth, the DSM-V has combined addiction and dependence into one diagnosis: opioid overuse syndrome. It is a spectrum, not two separate responses.

The second myth is that if you give enough opioid, it will help the pain. Well, no. UW Pain and Addiction Clinic says that on average pain is reduced about 30% by opiods, whatever the dose. And high doses start causing some weird  hyperalgesias. I’ve weaned two people from over 100mg methadone daily down to 20-30mg. It took two years. They felt better on the lower dose after they got through withdrawal symptoms and a short term increase in the pain receptors complaining at them. And they are much less likely to overdose and die.

Page two here http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf discusses current knowledge about opioids.

4. So like, Prince?

He may have died from a combination of fatigue and sedating drugs. If you get enough sedating drugs, then you stop breathing. Opioids are the biggest offenders combined with alcohol or sleep medicine like ambien or benzodiazepines like valium or ativan or alprazolam or muscle relaxants like methacarbomal or a combination of all of the above. I am a strict physician about urine drugs screens and I do the dip in clinic in front of the person. Way too often, the person does not tell me about the alprazolam or whatever until I am holding the dip over the cup…. and that’s when they tell me. They got it from the ER or a friend or two years ago or … took their dog’s. Really.

He may have died from influenza, if he had it, with sedating drugs. Bad influenza causes lung tissue swelling and can mess up your oxygenation. Your heart has to take up the slack and go faster. If you are trying to work and your heart rate is well above normal, it’s exhausting. It can kill you.

He may have died from overwork, another infection, sedating medicines…. but not directly from chronic pain. Chronic pain slows us but I do not think it kills us*. What kills us is trying to treat it with a pill instead of resting and doing gentle exercise and saying: What does my body want?

 

5. Overdose?

Also, are we talking about an accidental overdose? Are we talking about drug abuse? Are we talking about accidental death or suicide or do we as a society think that addiction deserves overdose death but a person taking medicine for chronic pain is a tragedy? Aren’t we a bit judgemental?

Prince may have taken a pain pill as directed but taken it with too many other controlled substances or with alcohol or while sick and exhausted. Overdose means too high a dose. If it was two percocets, alcohol, flu and xanax…. it could be an accidental poisoning.

6. Are you sure?

No. Medicine changes. Our understanding of the brain changes. Science is about change and deepening understanding. We are barely getting started on the brain and I would say that we are in preschool there.

 

http://www.doh.wa.gov/LicensesPermitsandCertificates/MedicalCommission/MedicalResources/PainManagement

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPatients

*And on the other hand: http://www.practicalpainmanagement.com/sudden-unexpected-death-chronic-pain-patients

 

*Stress alone can cause heart attacks and sudden death:    http://www.health.harvard.edu/blog/stress-cardiomyopathy-a-different-kind-of-heart-attack-201509038239

The photograph is from a week ago, part of my Maxfield Parish cloud series, zoomed way in to the mountains across the water.

 

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Advice to young people

My biggest piece of advice to young singles and young couples is: put half of each take home salary away. Married or not married, and I don’t care how committed you are.

I know people who lose their house when one half of a couple is sick, and the other can’t pay all the bills on one salary. We don’t want to think about illness or cancer, but it happens. Young parents, with one very ill and the other with a job, children and a sick spouse. Having a reserve is way more important than keeping up with the Joneses, unless you happen to inherit like Mr. Trump.

If you each put half of your take home salary away, then when life throws surprises at you, you will have a reserve. A big reserve if the surprises hold off for a while. Divide that half into retirement and half into money that you have access to in emergencies.

I listed the top ten causes of death in the US in 2012 here, but lets look by age: http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2012-a.pdf.

From age 1 to 44 the top cause of death is accidents, unintentional injuries.

Suicide is second from age 15 to 44.

Cancer takes over as number one, malignant neoplasms, at age 45 to 65.

After 65, the number one cause of death is the heart, and that is where the biggest numbers are. But if a younger cause of death affects your family, it feels unfair, wrong, as if we all expect to like to age 78 or beyond.

Untintentional injury, that is, accidents, are broken down here: http://www.cdc.gov/injury. When I do physicals on teens, I ask them what the number one cause of death is for teens. They all know the answer, even if they have to think for a moment: motor vehicle accidents.

But lets look at accidents in the age 25-65 age group: poisonings. What? Poisoning? And NOT intentional…. what is going on there? It is drugs, legal and illegal, but more legal. Sedating drugs in combination are effective at sedating people enough to stop breathing and die. Alcohol with benzodiazepines (valium, ativan, etc.), opiates and opioids, sleep medicines such as ambien and sonata, withdrawal from methamphetamines, cocaine, crack….people die. And supplements may be contributing as well.

75 years of US mortality data: http://www.cdc.gov/nchs/data/databriefs/db88.pdf#x2013;2010%20

At birth now in the US the life expectancy averages 78, but not everyone reaches that….some people still die younger and some live longer.

The age of death is rising, world wide. In the US, many of us have a world envied standard of living and yet we have a significant number of people who are anxious and depressed and way too high a rate of substance abuse, alcohol, opiates and opioids, benzodiazepines and yes, marijuana is addictive. How do I reconcile this? How do you reconcile this?

Keep your reserve, young singles and young couples…..

http://www.worldlifeexpectancy.com/usa-cause-of-death-by-age-and-gender
As of the day I am writing this on 5/2/16:

POPULATION
318,857,056

Numbers to be corrected, first set was wrong, wrong, wrong.

I took the photograph yesterday evening: there were the most amazing Maxfield Parish clouds…. life and death are a mystery.

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W is for wrath

W is for wrath, the seventh sin.

From Webster 1913:

Wrath

1. Violent anger; vehement exasperation; indignation; rage; fury; ire.
Wrath is a fire, and jealousy a weed. Spenser.
When the wrath of king Ahasuerus was appeased. Esther ii. 1.
Now smoking and frothing Its tumult and wrath in. Southey.

2. The effects of anger or indignation; the just punishment of an offense or a crime.
“A revenger to execute wrath upon him that doeth evil.” Rom. xiii. 4.
Syn. — Anger; fury; rage; ire; vengeance; indignation; resentment; passion. See Anger.

 

Wrath is a sin, yet is it ever justified?

I am wrathful about this: http://www.npr.org/sections/health-shots/2016/03/23/471595323/drug-company-jacks-up-cost-of-aid-in-dying-medication

In my state a terminally ill patient may choose Death with Dignity: http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct

The person must be terminally ill, must not be suicidal and must go through a process. But one of the tablets prescribed, which only the person may administer to themselves, has had a price increase from $200.00 to over $3000.00.

I heard this from another physician, who has a patient who is going through the process.

I feel wrath and anger and hurt and rage that a corporation is choosing to make an enormous profit from terminally ill patients.

And so wrath may be a sin, but it is also an appropriate feeling at times.

In a sermon about forgiveness, hate is also discussed:

“Let me also say a word here about hatred, since I am speaking of forgiveness as being the release of hatred. Many  of us,  I suppose, like myself, have been taught not to hate.  We have been taught that hatred is always a bad thing and there is no place for it.  Thus, we feel uncomfortable in the face of this intense emotion and attitude.  Many times I have stumbled on the line from the biblical book of Ecclesiastes which reads, “There’s a time to love and a time to hate.”

Can there be  a time to hate?  Ironically, when  reflecting on the subject of forgiveness, I see that there is a place for hatred.
 
First,  your  hatred  lets  you  know  that  you  are  feeling  diminished  and  perhaps  being stepped on and treated as no human being ought to be treated.

Secondly,  your  hatred  lets  you  know  that  you’re  fighting  back  and  that  you  have something  to  fight  back  with.    It  lets  you  know  that  the  situation  is  intolerable  and  you will not put up with it.

And  so  hatred  can  be  a  natural  and  even  necessary  response  to  situations  that  threaten human dignity.  Says one author, “Not to feel resentment when resentment is called for is a sign of servility,… a lack of self-respect.”  (Forgiveness, Haber)”

From: November 15, 2009, here: http://www.quuf.org/index.php?page=2009—2010-sermons

p7
http://www.quuf.org/uploads/Sermons/Is%20Forgiveness%20Always%20Called%20For%20Part%20II%20Nov%2015%2009%20print.pdf

I took the picture in 2007. No wrath here, but three different expressions, and all complex….

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P is for pride

Pride is the fifth of the seven sins, in our seven sins and friends.

Which of the following is a sin?

1. a high or inordinate opinion of one’s own dignity, importance, merit, or superiority, whether as cherished in the mind or as displayed in bearing, conduct, etc.
2. the state or feeling of being proud.
3. a becoming or dignified sense of what is due to oneself or one’s position or character; self-respect; self-esteem.
4. pleasure or satisfaction taken in something done by or belonging to oneself or believed to reflect credit upon oneself:civic pride.
5. something that causes a person or persons to be proud: His art collection was the pride of the family.
6. the best of a group, class, society, etc.: This bull is the pride of the herd.
7. the most flourishing state or period: in the pride of adulthood.

Two quotations come to my mind:
Pride goes before a fall.
Death be not proud.

Pride goes before a fall: Proverbs 16:18, King James Version, Pride goeth before destruction, and an haughty spirit before a fall.

Here is the whole chapter: http://www.christianity.com/bible/bible.php?q=Proverbs+16&ver=kjv

Proverbs 16:5 is also relevant. Every one that is proud in heart is an abomination to the Lord: though hand join in hand, he shall not be unpunished.

And then Death be not proud is from John Donne: http://www.poetryfoundation.org/poems-and-poets/poems/detail/44107

Death, be not proud, though some have called thee
Mighty and dreadful, for thou art not so;
For those whom thou think’st thou dost overthrow
Die not, poor Death, nor yet canst thou kill me.
From rest and sleep, which but thy pictures be,
Much pleasure; then from thee much more must flow,
And soonest our best men with thee do go,
Rest of their bones, and soul’s delivery.
Thou art slave to fate, chance, kings, and desperate men,
And dost with poison, war, and sickness dwell,
And poppy or charms can make us sleep as well
And better than thy stroke; why swell’st thou then?
One short sleep past, we wake eternally
And death shall be no more; Death, thou shalt die.

___________________________________________

I am ambivalent about pride. I have mixed feelings. I find it easier to be proud of my children than myself. I am aware of my faults. Also, when I am really proud of something, I am more liable to mess up! To say something arrogant, to not pay attention, to lose my keys, to hurt someone’s feelings not on purpose! An analyst wrote that in their household, whoever has the best week, the most accolades, has gotten a prize or had a really good week: that person is in charge of the cat litter box for the next week. I think that is so sensible, to keep everyone grounded and connected to the daily tasks and remind us that even if we do something brilliant, the cat litter box still needs attention and the bathroom still needs to be cleaned. It is hard to keep a swelled head while scrubbing the toilet. I am proud that my children both did chores every weekend and my son still pitches in when he is home from college!

And now… the cat is reminding me….

I took the photograph in 2012 and came across it yesterday. Sometimes we get lost in a fog of pride or fantasy or emotion……. service to others and basic tasks like cleaning ground us again…..

 

 

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M is for mourn

M is for mourn. We mourn for losses. Mourning is part of being human and we have to give grief room and space. How can we love and feel intimacy without also feeling grief and mourning?

M

I wrote a poem the day my sister died. I had flown home four days before, after seeing her in hospice, 7 years of cancer. I flew home the day before her birthday. My birthday is three days after hers. She died the day after my birthday. It has now been four years.

An apology, a love note and a remembrance

I step outside into a fine mist rain.

I am enfolded in cloud.

The dog still wants to be walked.
The cats want their treats.
The bunny rattles her cage.
The fish will want feeding at the usual time.

My heart lies stunned in my chest.
The dog does not pull.
I walk measured.
He waits.

The rain comes harder.

I hope that where you are, is joy.

The crows harsh caws comfort me.
I answer.
They watch from the tree tops as we circle.

I am enshrouded in cloud.

We are back to the house.

I try to remember.
I have the birds.
I have the trees.

We go in.

first published on everything2.com with other poems for her here: http://everything2.com/title/An+apology%252C+a+love+note+and+a+remembrance

I don’t know who took the photograph. Probably my grandparents.

 

 

 

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Dear Mr. Donald Trump

Two weeks ago I sent this letter to Mr. Trump and all of the presidential candidates. To date I have gotten a form letter from Mrs. Hilary Clinton.

Dear Mr. Donald Trump and all Presidential candidates:

Mr. Trump, I am a rural family practice physician, a woman, who owns and runs my own medical clinic. I take care of patients from age zero to 104. Currently my oldest is 98. I take medicare and most insurances, but not medicaid.

I am running into legal immorality across the board from health insurance corporations that are maximizing profits at the expense of my health care dollar, our taxes and my patients. I would like your advice.

For example, the Veterans Hospital contacted me in May of 2015 and asked me to accept Veterans Choice patients, veterans who live more than 40 miles from the nearest VA Hospital. I accepted. I have 6 veteran patients, who are very complicated. To date I have not been paid for one visit. Now, before you say this is the fault of our government, it isn’t. It is the private for profit government contractor Triwest who is not paying me. They have my notes and we have followed their instructions on how to submit bills. Would you advise me to drop these patients?

For example, my father died in 2014. I called the oxygen company to pick up 6 tanks of oxygen. Then I found 8 more. I gently inquired why he had 14 tanks. The company said that his medical orders said that he should wear it continuously, so they delivered it. “Medicare paid for it.” they said. Ah. Well, I kept the other 8 tanks, because it is my and my father’s oxygen in those tanks: the company can have the tanks back when they are empty.

For example, the head of the sleep apnea supply company came to see me. He said, “You are getting in the way of your patients getting needed equipment.” I said, “Really? How?” “You only allowed a refill of one of the 8 necessary pieces of CPAP tubing instead of signing off on the whole group so we can fill as needed.” “Ah.” I said, “Actually my patients are tired of you mailing them 8 pieces of plastic that are filling up their closets and they don’t want extra plastic crap.” He mails it at the interval allowed by medicare, never mind whether the patient wants or needs it.

For example, I called a patient’s insurance to get a prior authorization last week for a limited sinus CT. They no longer do prior authorizations. They will decide whether to cover the CT scan once they read my notes. I asked if there was ANY way to see if it would be approved. They offered to let me send a letter to a PO Box in Wisconsin. My patient was sick, Mr. Trump. What do you suggest the patient and I do?

This is all legal. But it is not moral. So, Mr. Trump, where do you stand? Is our country’s highest value free enterprise and profit at any cost, no matter how many of our seniors are legally ripped off? Or do we have morals that health care and our elderly are important and need to be protected from legal but predatory businesses.

Please let me know, Mr. Trump. I would rather stick with my small clinic in the United States. At this point I would be financially and emotionally better off working as a temporary doctor internationally. I am sure that there is immorality internationally, but I will be less ashamed when it is not MY country.

Thank you.

 

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DIY cat fud II

This is for Photrablogger’s Mundane Monday #50.

I crack the door in the early am and this is Boa Cat’s first spring mouse. She has a particular muffled call to tell me when she has a mouse. I love this picture because of the shadows and it’s not quite straight on and the light and silhouettes… This mouse was no longer cooperatively playful….

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Songs to raise girls: My name is Samuel Hall

The last time I visit my sister in hospice, my cousin is sitting by the bed when I arrive.

My sister looks terrible and like she is suffering. She is in renal failure and her eyes are slitted against the light. She is in a hospital bed and barely eating. It takes me three days to figure out how to make her comfortable.

But when I first arrive, I say hello and hug her. She laughs and it is dark.

She doesn’t want to talk. “Shall I sing to you?” I ask.

She nods.

I start singing a lullaby: I gave my love a cherry.

She shakes her head: no.

I study her. “How about Samuel Hall?”

She smiles and nods.

“My name is Samuel Hall,
Samuel Hall, Samuel Hall.
My name is Samuel Hall
And I hate you one and all
you’re a bunch of buggers all
damn your eyes, damn your eyes
you’re a bunch of buggers all
damn your eyes.”

Another song to raise girls. We adored it, because it is unrepentant, horrible and had swears.

I killed a man tis said
and I left him there for dead
with a bullet in his head
damn his eyes

My cousin’s eyes widen. “I haven’t thought of that song in years.” he says. He starts singing along, remembering.

They took me to the quod
They left me there by God
With a ball and chain and rod
Damn their eyes

My cousin has two children. I guess he is not raising them with the dark songs we were raised with….

The preacher he did come
And he looked so goddamn glum
As he talked of Kingdom Come
Damn his eyes

My sister is smiling, eyes slit against the light, angry.

The sheriff he came too
With his boys all dressed in blue
They’re a bunch of buggers too
Damn their eyes

To the gallows I must go
With my friends all down below
Saying “Sam, I told you so.”
Damn their eyes

I see Nellie in the crowd
I am shouting right out loud
I shout “Nellie, ain’t you proud!
Damn your eyes!”

“Let this be my parting Nell
Hope to see you all in Hell
Hope to Hell you sizzle well
Damn your eyes!”

And my sister laughs and then she sleeps for a while, angry, angry at death.

My name is Samuel Small: http://www.wtv-zone.com/phyrst/audio/nfld/02/sam.htm
My name is Samuel Hall: https://www.youtube.com/watch?v=iSpk1t4WYNY
My name is Samuel Hall: https://www.youtube.com/watch?v=pxiPCw21T-w
and Johnny Cash: https://www.youtube.com/watch?v=Ss_KyPfM1es

This is not the suffering photo. I can’t bear to post that….

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Crossing

This is the Staircase hike on Monday. It was not slick enough to make me turn back, but if the water had been higher or there had not been a railing, I would have turned back. I thought about rising water on that hike.

And the same day, I received a county email that an 18 year old slipped crossing a creek and was swept away.

Love to his friends and family and I am so sorry.