the unwashed masses

I don’t have any of THEM as patients. The unwashed masses. All of my patients are smart.

There aren’t any unwashed masses.

I have a gentleman who is overweight, obese, diabetes. He is not stupid. He is not unwashed. He is not exercising or controlling his blood sugar right now because the temperature is below freezing. He has a hole in his trailer floor and no heat. So he huddles under the electric blanket.

I have a gentlewoman, also diabetic. She too is not stupid. She is not unwashed. She lost her husband to cancer and then everything else and then was homeless for a period. She has a small house but she has no heat. She stays in bed to stay warm. Her contractor quit before he put in the furnace and he’s gone bankrupt. She is cold.

I have veterans. They are not stupid. They are not unwashed. One was homeless for a long period and pooled his resources with another to rent a section 8 house. I am so proud of them. They are having trouble living together, each would rather live alone. Only sometimes they would rather not be alone. It is hard.

I have a massage therapist. She started to train as a counselor. To be a counselor, she needs a certain number of supervised hours and was getting this through the county mental health. “I didn’t know.” she says. “It is taking twice as long as I thought because half the time they don’t show up. They don’t show up because they don’t have gas, they don’t have food, they have been evicted, their son is in jail, they are in jail. I had no idea. My massage clientele is so different, they pay. I thought poverty was in third world countries, but it is here, in my county. I didn’t know.”

I know the people who live in the woods. A schizophrenic who comes once a month for his shot. He was losing weight. “Why are you losing weight?” I demand. “I am only eating once a day.” he says. I nag him to go to the community meals. He is shy, he is afraid of people and he is hungry. He is not stupid. He is not unwashed.

I have opiate addicts. Six years ago one expressed concern. He is 6 foot 5 and big. “I am afraid of some of the other people. You shouldn’t be doing this! It’s too scary and dangerous!” My opiate addicts are not stupid. My opiate addicts are not unwashed. Sometimes they relapse. Sometimes they die, in their 50s, 40s, 30s, 20s.

One in six people in the US is below the poverty level. They are not stupid. They are not unwashed.

And when someone talks about the masses, the people, the stupid people, most people are stupid, the sheep….

….I am beyond angry….

….my heart hurts….

Poverty in the US: http://www.census.gov/newsroom/press-releases/2016/cb16-tps153.html.

More: http://www.census.gov/topics/income-poverty/poverty.html.

The examples are taken from 25 years of practice, details changed for hipaa, but I can list dozens at any one time. The photograph is during the sunset after clinic, when I walked down town, the view across the sound.

 

Weaning methadone

Weaning high dose methadone down to a lower, safer, less likely to stop breathing and die dose is difficult, but it can be done. It needs both a determined patient and a determined physician who are willing to work together.

In 2010 I took a class in buprenorphine treatment for opiate overuse syndrome from the University of WA Medical Center and got started with their telemedicine, once a week, on line with the Pain and Addiction Clinic. Each week there was a teaching half hour and then an hour where we could present patients anonymously on the telemedecine to a panel: a pain specialist, an addiction specialist, a psychiatrist, a physiatrist, and a guest physician. Five consults at once! And they would discuss the case and fax recommendations to me.

Three weeks after the course, police and Medicaid and the DEA shut down the pain clinic 5 blocks from me, taking the computers. I acquired 30 patients in 3 weeks. Trial by fire.

By 2012 Washington State passed a pain medicine law. This says that a primary care physician can only prescribe up to 120 morphine dose equivalents for chronic pain. Anything higher and the patient should be checked by a pain specialist and there were not that many in the state.

120 morphine dose equivalents is up to 20 mg of methadone or possibly 30mg. Methadone has a very long half life so it’s a bit weird. Hydrocodone is one to one with morphine and oxycodone is 1.5 to one, so 90 mg of oxycodone is 120 morphine dose equivalents.

The law requires urine drug screens, careful record keeping, screening for adverse childhood experiences and regular visits. If the pain medicine is not effective, it is to be weaned. I had a couple of patients with over 100mg of methadone daily. That is way over the 120 morphine does equivalents and UW helped me help the patients start weaning.

First, they recommended dropping the dose by about 1/3. Some patients left immediately. I would give patients links to the law on line and explain that the concern is that opioids in combination with other sedating drugs and alcohol are killing more people than either guns or car wrecks or illegal drugs in the United States and the CDC has declared it an epidemic. Honestly, doctors really take the “first, do no harm” seriously and we do not want to kill people. One angry patient said “Your first job is to keep me pain free.” I said, “No, my first job is to not kill you.”

For those who stayed, dropping the dose by 1/4 or 1/3 worked. They had about two weeks of mild withdrawal symptoms and then gradually felt better. These were at doses of 120-150mg methadone daily. We started weaning then by 10mg or about 10% every couple of months. The UW Pain Clinic was doing this simultaneously.

In 2012 the WA PMP started as well. This is a central pharmacy reporting for all controlled substances. Controlled substances means addictive and monitored by the DEA. Even the head of the WA Pain Clinic found that he had 5-6 patients who were getting opioids from 4-5 different doctors. He said, “We do have to check because I thought I knew my patients and I would have none. I was wrong and I was surprised.” Those patients could be taking way more than any of their doctors knew or could be selling pills. Not a happy thing.

Once the methadone folks got down to about 1/3 of the high dose, we had to slow down. For my patients that meant at 40-50mg. The head of the pain clinic said wean by 5 mg or 2.5mg and do it every 6-8 weeks.

As people were weaned, their pain level stayed about the same. They would have an initial increase for the first two weeks. I describe it as follows: Think of it as if you are in a room listening to a stereo. The pain medicine is like noise protecting headphones. Once you are wearing the headphones, your brain says, uh, I can’t hear (feel pain). Hearing (feeling pain) is important information, so the brain turns up the volume. Way up if the dose is really high. Then you take the headphones off: OW!! IT’S TOO LOUD! THE SOUND (PAIN) IS BLOWING OUT YOUR EARDRUMS (HURTING LIKE HELL)!!!

Weaning slowly gives the brain a chance to turn the volume down on the receptors. UW said that at best chronic opiates lower pain an average of 30%. After a while, I said I had trouble telling the difference between withdrawal pain and increased chronic pain: they look the same. UW said, “Looks the same to us too.” But we had frequent visits and an ongoing discussion about pain. Pain is necessary for survival: you have to know if you are injured. Diabetics who can’t feel their feet are instructed to look all over their feet every day to check for injury and infection. I had one gentleman who couldn’t feel his feet and put them on a wood stove because they felt cold. He was needing skin grafts from the burns. So we need to feel pain and not numb it all the time. Also pain has three or more componants: the sharp cut/broken/bruised immediate pain. Second is nerve pain. Third is emotional pain, and we don’t yet have a meter that gives us what percentage each is contributing to the total sum. When I have a new chronic pain patient, I say that ALL THREE must be treated. We can argue about the details, but they can’t leave the emotional piece out…. or they have to find another doctor.

Also, at the higher doses, hyperalgesia is common, pain from the opioid itself. People felt better at lower doses. I gave people the links so they could read the law and the CDC information themselves. They were shocked and angry and threatened at first, but the “I don’t want you to die from too high a dose and it’s not safe and I am sorry.” message would get through eventually.

“Why do you have to do urine drug screens?” say some people. “You are treating me like an addict.”

My reply, “What do you think the addicts tell me?”

The person thinks about it. “The same thing?”

“Absolutely. So I can’t tell unless I check. Also, the boundary between chronic opiate use and opiate overuse is a lot thinner than we thought, so I have to check because all chronic opiate people are at risk for overuse.” The DSM-V combines opioid dependence and opiate addiction into opiate overuse syndrome, a spectrum from mild to moderate to severe.

We also talked about other ways of dealing with chronic pain. John Kabat Zinn’s mindfulness meditation classes drop pain levels by an average of 50%, so better than opioids. And way safer.

Meanwhile, since people could no longer get opioid pills from 4-5 doctors at once, the supply in Washington started drying up. Some people realized they had opiate overuse syndrome as well as chronic pain and turned to methadone clinics or buprenorphine clinics. Others went to heroin. The heroin overdose death rate has risen. I hope that as the stigma surrounding “addiction” changes into a better understanding of chronic pain and opiate overuse syndrome, more people will be able to get treatment and the death rate and heroin use will go back down.

https://depts.washington.edu/anesth/care/pain/pain-roosevelt.shtml

http://www.cdc.gov/cdcgrandrounds/archives/2011/01-february.htm

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

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP

http://www.uwmedicine.org/referrals/telehealth-services

https://www.drugabuse.gov/publications/research-reports/prescription-drugs/opioids/what-are-opioids

http://www.umassmed.edu/cfm/about-us/people/2-meet-our-faculty/kabat-zinn-profile/

 

 

Chronic pain update 2015

As a rural family practice physician, I am in an area with very few specialists. Our county has a 25 bed hospital and we have a urologist, three general surgeons, three orthopedists (except when we were down to none at one point), two part time hematologist oncologists and that’s it. We have a cardiologist who comes one day a week. We have a physicians assistant who worked with an excellent dermatologist for years: hooray! Local derm! Our neurologist retired and then died. We had two psychiatrists but one left. We had one working one half day a week.

I trained in treating opiate addiction with buprenorphine in 2010 and attended telemedicine with the University of Washington nearly weekly for a year and a half. Then life intervened. I attended last week again, but not the addiction medicine group. That is gone. Now there are two telemedicine pain groups.

And what have I learned since my Chronic pain update 2011?

Chronic opiates suck, and especially for “disorders of central pain processing” which includes fibromyalgia, reflex sympathetic dystrophy, TMJ, chronic fatigue, and all of the other pain disorders where the brain pain centers get sensitized. We don’t know what triggers the sensitization, though a high Adverse Childhood Experience score puts a person more at risk. Cumulative trauma? Tired mitochondria? Incorrect gut microbiome? All of them, I suspect.

Jon Kabot Zinn, PhD has been studying mindfulness meditation for over 30 years. He has books, CDs, classes. Opiates at best drop pain levels an average of 30%. His classes drop pain levels an average of 50%. I’ve read two of his books, Full Catastrophe Living and ….. and I used the CD that came with the former to help me sleep after my father and sister died. Worked. Though I used the program where he says, “This is to help you fall more awake, not fall asleep.” Being contrary, it put me to sleep 100% of the time.

Body work is being studied. Massage, physical therapy, accupuncture, touch therapy and so forth. It turns out that when you have new physical input, the brain says, “Hey, turn down the pain fibers, I have to pay attention to the feathers touching my left arm.” So, if you have a body part with screwed up pain fibers, touch it. Touch it a lot, gently, with cold, with hot, with feathers, a washcloth, a spoon, something knobby, plastic. Better yet, have someone else touch it with things with your eyes closed and guess what the things are: your brain may tell the pain centers “Shut up, I’m thinking.” Well, sensing. A study checking hormone blood levels every ten minutes during a massage showed the stress hormone cortisol dropping in half and pain medicating hormones dropping in half. So, massage works. Touch works. Hugs work. Go for it.

There are new medicines. I don’t like pills much. However, the tricyclic antidepressants, old and considered passe, are back. They especially help with the central pain processing disorders. I haven’t learned the current brain pathway theories. The selective serotonin uptake reinhibitors (prozac, paxil, celexa, etc) increase the amount of serotonin in the receptors: chronic pain folks and depressed folks have low serotonin there, so increasing it helps many. As an “old” doc, that is, over 50, I view new medicines with suspicion. They often get pulled off the market in 10 to 20 years. I can wait. I will use them cautiously.

We are less enthused about antiinflammatories. People bleed. The gut bleeds. Also, the body uses inflammation to heal an area. So, does an antiinflammatory help? Very questionable.

Diet can affect pain. When I had systemic strep, I would go into ketosis within a couple of hours of eating as the strep A in my muscles and lungs fed on the carbohydrates in my blood. This did not feel good. However, the instant I was ketotic, my burning strep infected muscles would stop hurting. Completely. I am using a trial diet in clinic for some of my chronic pain patients. I had a woman recently try it for two weeks. She came back and said that her osteoarthritis pain disappeared in her right hip entirely. She then noticed that the muscles ached around her left hip. She has been limping for a while. The muscles are pissed off. She ate a slice of bread after the two weeks and the right hip osteoarthritis pain was back the next day. “Hmmmm.” I said. She and I sat silent for a bit. It’s stunning if we can have major effects on chronic pain with switching from a carb based diet to a ketotic one.

I attended one of the chronic pain telemedicines last week and presented a patient. My question was not about opiates at all, but about ACE scores and PTSD in a veteran. The telemedicine specialists ignored my question. They told me to wean the opiate. He’s on a small dose and I said I would prefer to wean his ambien and his benzodiazepines first. They talked down to me. One told me that when I was “taking a medicine away” I could make the patient feel better by increasing another one. As I weaned the oxycodone, I should increase his gabapentin. I thought, yeah, like my patients don’t know the difference between oxycodone and gabapentin. No wonder patients are angry at allopaths. I didn’t express that. Instead, I said that he’d nearly died of urosepsis two weeks ago, so we were focused on that rather than his back pain at the third visit. All but one physician ignored everything I said: but the doctor from Madigan thanked me for taking on veterans and offered a telepsychiatry link. That may actually be helpful. Maybe.

And that is my chronic pain update for 2015. Blessings to all.

http://www.cdc.gov/violenceprevention/acestudy/

http://www.umassmed.edu/cfm/about-us/people/2-meet-our-faculty/kabat-zinn-profile/

I can’t think of a picture for this. I don’t think it should have a picture.