Pain Management as a Human Right

July 8, 2007 8:15 PM

Recognizing Pain Management as a Fundamental Human Right. These pieces from the journal of the International Anesthesia Research Society argue that under-treated chronic pain is becoming a public health crisis which must be addressed. But a warning to pain doctors in the U.S. who prescribe opioids in doses that seem high to narcotics agents and prosecutors: “Be afraid.” [Via Hit & Run and TalkLeft.]
posted by homunculus (69 comments total)

The DEA restrictions on opioid prescriptions are absolutely disgusting and inhuman. The government would rather legitimate pain sufferers continue to do so if it means a few people don't get a chance to "get high". It's absolutely sick.
posted by delmoi at 8:48 PM on July 8, 2007

Our current government/society will never recognize pain management as a fundamental human right -- because that would be (in their minds, anyway) one step away from legitimizing medically-assisted suicide.

Pain is a lesson from God, and any attempt to remove the pain is weakness, and so on.
posted by Avenger at 9:30 PM on July 8, 2007 [1 favorite]

The weird thing is they have all these crazy laws and you can still buy black market pills whenever you want.

It's almost as if prohibition doesn't work.
posted by furiousxgeorge at 10:26 PM on July 8, 2007 [2 favorites]

Hospital emergency rooms has a classification of patient they call "drug-seekers", who are frequent visitors (often on evenings or weekends when their doctors offices are closed and claiming to have run out of pain medications) claiming high level of pain but having no clinical symptoms. ER docs typically deny the narcotic type of pain-killers demanded by the patient. Then miraculously pain is somehow gone and replaced, instead, by anger and temper tantrum.

I'm sure some posters here will defend the rights of such patients to pain killers. However, isn't pain a psychological symptom of narcotics addiction? Should doctors be complicit in maintaining addictions? It's not an easy question to deal with. I'd tend to be on the side of the doctors when their frequent-flyer patients have no interest in obtaining treatment for addiction.
posted by PlanoTX at 10:40 PM on July 8, 2007

I'm sure some posters here will defend the rights of such patients to pain killers.

Huh? Which posters? And who are "such patients"? The subject of the links are people with chronic pain who can't get relief, not junkies like Rush Limbaugh.
posted by homunculus at 11:43 PM on July 8, 2007 [3 favorites]

Hospital emergency rooms has a classification of patient they call "drug-seekers"

The paranoia around this issue is such that people suffering from acute and debilitating pain that is under-medicated are being labelled as 'drug seekers' simply because they are trying to get adequate treatment for a medical problem that most pain experts and other civilized countries have long recognized and treat effectively.

The other issue is that the experience of pain is always subjective, so there really are no 'symptoms' that can tell a doctor whether somebody's pain is moderate, or whether it's life-ruining and traumatic. Fear of scrutiny and the concomitant legal problems that can cause for doctors means that many thousands of patients in severe pain are suffer under-medication for their condition in the US.

It's just another of the many, many ways in which a barbarous US government puts dogma and ideology over the health and wellbeing of its citizens.
posted by PeterMcDermott at 1:17 AM on July 9, 2007

Also:

Damn, I didn't know that they re-convicted Hurwitz. That's fucking outrageous. The *only* good thing about all of this has been Tierney's coverage of the story, both in the NYT and on his blog.

http://tierneylab.dblogs.nytimes.com/?s=Hurwitz&search.x=18&search.y=17&search=Search
posted by PeterMcDermott at 3:11 AM on July 9, 2007

I'm sure some posters here will defend the rights of such patients to pain killers.

Ok. I'll bite.

Yes, even people whom doctors suspect are opoid addicts should have access to proper pain management. Here's why: My father (true story here, grab the hanky) is terminally ill with renal failure, heart failure and very advanced diabetes. On top of those (quite painful) conditions, he also has unbelievable back pain due to multiple surgeries and fusions. As you can guess, though, he's been sick for a long time. Since I was just a little boy, as a matter of fact.

For many years, he really was a painkiller addict: even going so far as to falsely fill my grandmother's perscriptions in his name. Was he addicted to the pills by themselves or did he really need them to stay lucid? I don't know.

I do know, however, that he certainly needs them today, and shouldn't be denied proper drugs because of his drug-seeking past. The current regime creates an entire class of people ("drug-seekers") who will never be able to get proper pain management no matter how ill they are. My dad is still jumping through hoops, even near the end of his life, to relieve the pain somehow. It's not fair.

It really all boils down to values. As I pointed out above, as a society, we value pain. "Pain is weakness leaving the body". A "blessing in disguise". We look down on countries with progressive drug laws and medically assisted suicide as being weak, inferior or cowardly. This will all change once we start to value a person's choices regarding their quality of life more than what we have decided their quality of life should be. I'm not holding my breath, sadly.

Should doctors be complicit in maintaining addictions?

Criminally complicit or civilly complicit? I could see (and understand) a doctor being sued for malpractice and disbarred if he accepted bribes in exchange for perscriptions, or if his perscribed medications caused more harm than good for the patient ... but 25 years in prison for allegedly dispensing painkillers?

The fact that we aren't astonished by that verdict says volumes about how far down the rabbit hole we've gone.
posted by Avenger at 4:09 AM on July 9, 2007 [5 favorites]

I'd also like to point out (on re-readng my post) that the current regime makes it extremely hard for non-former-drug seekers to get pain relief too.

We are all casualties in society's endless war for moral purity...
posted by Avenger at 4:14 AM on July 9, 2007

There is something in the character--no, that's not a good word to apply to them--something in the psyche of a social conservative, that compels them to deny to a person whatever that person apparently wishes to have. Regardless of any reasons. They have trouble understanding that other people have other desires, different from their own, and view these desires with suspicion and hostility. Not being able to draw a line between rational and irrational disapproval, they disapprove blindly, and with malice.
posted by aeschenkarnos at 5:13 AM on July 9, 2007

It's important to bare in mind that prescription opioid paranoia and pain doctor persecution is an unfortunate overreaction to a scenario that did require some intervention, namely Purdue Pharma's profit driven campaign to get OxyContin prescribed for everything from back pain to arthritis. My opinion is that if Purdue had exercised ethical marketing and sales tactics (which they clearly did not, and a Virginia court justice punished them harshly for it) and left Oxy classified as for severe pain only there's a good chance that the "epidemic" would never have happened, nor the subsequent witch hunt.
posted by The Straightener at 5:24 AM on July 9, 2007

social conservatives... view these desires with suspicion and hostility....

There, fixed that for you. Seriously, though: it's not a particularly difficult thing to understand, since opioid addiciton is so very damaging to communities and relationships. The enforcement practices at present are simply too restrictive to be useful, and they could easily be changed if the public had a greater awareness of the problem. All that's required is a serious advertising and lobbying blitz by hospice policy groups to fix the current, over-restrictive regime. I think we're seeing the beginning of that now: I just saw an ad about this outside of Harrisburg, PA (the state capital.)
posted by anotherpanacea at 5:45 AM on July 9, 2007

opioid addiciton is so very damaging to communities and relationships

It is damaging because it is expensive, it is adulterated because it is expensive, and it is expensive because it is illegal. If addicts were to sit on their couches at home blissed out on Percodan or heroin or whatever, which they got free or nearly-so from the National Health Service, the crime rate would plummet to near-non-existence. Almost all property crime is driven by the illegality of drugs.
posted by aeschenkarnos at 6:16 AM on July 9, 2007

Almost all property crime is driven by the illegality of drugs.

Citation please.
posted by anotherpanacea at 6:39 AM on July 9, 2007

I think the counsel of the law should be a fundamental human right. So I'm going to walk into my attorney's office tommorow and tell him his services are my right and he is going to GIVE them to me, whether he likes that or not. Think that is going to fly? Heck no.

I think food is a human right. So I just walked into the grocery store and took whatever I wanted, and walked out. Did not pay. Hey, I have a right to this food!

If you thing it is your right to any type of professional or commercial service you are out or your mind. You are making slaves of those people that provide these services. They deserve to make a living just as you do. How would you feel if somebody came up to you and got your services because you were forced to give it to them because it is their "right"?

Regarding control of acute and chronic pain, I am all for it and much closer to the issue than you could believe. However, I would never consider it my "right." I do expect the medical system to have pathways for patients with pain to be treated if they can pay for it and it is medically appropriate.
posted by Ligament at 8:31 AM on July 9, 2007

Ligament: "I do expect... patients with pain to be treated if they can pay for it..."

I know that you can't really mean what you're saying here. You can't possibly mean that. Please reassure me this is a slip of the tongue?
posted by talitha_kumi at 8:49 AM on July 9, 2007

I'd also like to point out (on re-readng my post) that the current regime makes it extremely hard for non-former-drug seekers to get pain relief too.

Uh-huh. And then, you get the superfun stuff like a doctor who got busted by the state medical board for prescribing himself Vicodin -- something I didn't find out until he'd abused me multiple times and I brought it up to my physical therapist -- accusing me of being drug-seeking for asking him a question about why Vicodin didn't seem to work for me post-surgeries but Percocet did.

Color me crazy, but dude, you're the one with the medical degree, and therefore the logical one to ask this question as I am sitting in front of you 30 minutes post-surgery, crying in serious pain and wondering why the drugs you prescribed aren't working.

As for Ligament's comment, However, I would never consider it my "right." I do expect the medical system to have pathways for patients with pain to be treated if they can pay for it and it is medically appropriate. -- oh, fuck that.

Number one, the "if they can pay for it" is a red herring. Why don't you say what you really mean, which is "you know, assuming they're not a member of the underclass and have health insurance through their corporate job at Smith Barney"? (which, by the way, is who was paying for my shitty post-surgical abuse above, as I was a stockbroker at the time)

Number two, who determines "medically appropriate"? The asshole Vicodin addict chief-of-department who was treating me, the one my primary care guy said I was "lucky to have"? The one the state medical board busted but didn't remove from practice, the one on probation, the one making inappropriate accusations and recommendations based on HIS problems, not mine?

No one should have to suffer because some doctor's got his head up his ass or is worried that the feds (or the medical board) will bust him for prescribing something appropriate. Selling prescriptions to bored housewives? Sure, bust the jerk. Refusing to prescribe strong enough pain meds just in case he gets re-busted. Again, fuck that.

(Gee, you can't tell I'm bitter about this or anything, can you?)
posted by bitter-girl.com at 8:59 AM on July 9, 2007 [1 favorite]

Hey, if I want medical care I will pay for it. If I want a car, I will pay for it. If I want food, I will pay for it. Hey, I wanted to be on metafilter so I paid for it!

This is my view for all medical care, not just pain management. If your view is different, so be it. I'm cool with that. I simply don't think you should force people to give away their services or goods because you think you have a right to them.
posted by Ligament at 9:23 AM on July 9, 2007

On what planet is anyone forcing doctors to provide care and/or drugs for free? That's not the issue here at all, Ligament, and you know it. Did you even read the linked articles?

The issue is that doctors are chronically UNDERMEDICATING patients with pain problems because they don't want to run afoul of the DEA and other federal/state agencies looking for a showy drug bust. And this is wrong. It's yet another bullshit side effect of the so-called war on drugs. You're already paying for the others -- prisons and court systems chock-full of minor-league drug offenders, etc etc.

But to the point at hand: undermedicating a patient because you're afraid of the government busting you (NOT because the patient doesn't actually need the pain meds, or any other medically relevant reason) is sick, wrong, inhuman and morally unconscionable.

One of the truly sick examples, from the Hit and Run comment thread:

[M]y beloved paternal grandmother died in 1992 after about two years' illness. At one point the doctor at her nursing home refused to renew her Darvon prescription because, "she appears to be developing an addiction." My parents both lost it, culminating in my 6'5" father explaining, in his loudest voice, that "it doesn't fucking bloody goddamn matter if an 87 year old woman gets addicted. It does matter that she not be in pain."

So, you're cool with torturing 87-year-olds, is that it?

It has nothing to do with who can pay for care. It has nothing to do with health insurance. It has everything to do with doctors formulating their standard of care based on fear of the government instead of what's best for their patients, and if that isn't incredibly fucked up to you, then you're clearly not paying attention.
posted by bitter-girl.com at 9:36 AM on July 9, 2007 [3 favorites]

This is the most comical mixing of rhetorical attitudes I've seen in a bit. On the one hand this is familiar rhetoric:

If you thing [sic] it is your right to any type of professional or commercial service you are out or [sic] your mind [because in so doing] you [would be] making slaves of those people that provide these services.

...some hyperbole excised for concision. On the other hand, I very seldom have seen such liberating rhetoric build to such a dissonantly regulatory final note:

Regarding control of acute and chronic pain, I am all for it and much closer to the issue than you could believe [ed: really? I'm not sure how "close to the issue" you'd have to be before it would be reasonable to expect your audience to be incapable of believing you to be that close]. However, I would never consider it my "right." I do expect the medical system to have pathways for patients with pain to be treated if they can pay for it and it is medically appropriate.

posted by little miss manners at 9:38 AM on July 9, 2007 [1 favorite]

anotherpanacea, aeschenkarnos's claim is somewhat hyperbolic but not off the mark. In 2003, the UK Prime Minister's Office prepared a strategy report on illegal drugs. This one slide touches on drug-related crime as proportion of all crime. The whole report, annotated and summarized, is available here.
posted by daksya at 9:44 AM on July 9, 2007

MetaFilter: Did you even read the linked articles?
posted by homunculus at 9:51 AM on July 9, 2007

Pain is a lesson from God, and any attempt to remove the pain is weakness, and so on

This argument was actually used to discourage women from getting chloroform for anesthesia during childbirth after Simpson began using it in the 1850's ("In pain shall you bear children..." from Genesis). That attitude was only changed when Queen Victoria insisted on the use of chlorform during her fifth delivery.

...isn't pain a psychological symptom of narcotics addiction?
No, it is not. Anyway, in typical doses and adminstered properly, opioids have relatively mild side effects and people can function quite well while taking them. It would be better to inadvertantly treat the occasional addict than to allow many other legitmate patients to either suffer or turn to the black market for relief.
posted by TedW at 10:20 AM on July 9, 2007

I'm somewhat surprised the Brennan, et al., were fairly comprehensive and yet failed, in my opinion, to cover what seems to be the issue's underlying cause (and, in a real sense, why the issue even exists): medicine as conceptualized by its practitioners derives from the notion that there are well-defined states of proper health and wellness, from which ill patients deviate and to which it is the physician's responsibility to return the patient; the general populace of physicians most certainly does not in any strong sense have the attitude that the proper role of the physician is essentially analogous to that of expert consultants assisting the "patient" in obtaining the particular kind of wellness that the "patient" desires.

Hence the problem: the person in pain has a particular conception of the pain-free state they are attempting to obtain, but even under the best of circumstances the patient is obligated to convince a third party that that conception is a correct and "appropriate" state to obtain; the consequent indignity should be apparent.

Thus when Brennan et al are discussing, eg, the role of social and cultural attitudes or the role of attitudes amongst physicians they in my opinion miss the mark a bit: those issues are a problem because physicians see their task as restoring "normal and proper health" -- which conceptualization will inherently acquire moral overtones from its cultural context -- rather than as directly assisting patients in their quest to obtain the sort of health they seek.
posted by little miss manners at 10:22 AM on July 9, 2007

So, you're cool with torturing 87-year-olds, is that it?

You got me pegged.
posted by Ligament at 10:23 AM on July 9, 2007

It has everything to do with doctors formulating their standard of care based on fear of the government instead of what's best for their patients, and if that isn't incredibly fucked up to you, then you're clearly not paying attention.

>This is messed up, I agree.

If you thing [sic] it is your right to any type of professional or commercial service you are out or [sic] your mind [because in so doing] you [would be] making slaves of those people that provide these services.

>I can't write today. Very bad! You got me. Seriously.

The issue is that doctors are chronically UNDERMEDICATING patients with pain problems because they don't want to run afoul of the DEA and other federal/state agencies looking for a showy drug bust. And this is wrong. It's yet another bullshit side effect of the so-called war on drugs. You're already paying for the others -- prisons and court systems chock-full of minor-league drug offenders, etc etc.

But to the point at hand: undermedicating a patient because you're afraid of the government busting you (NOT because the patient doesn't actually need the pain meds, or any other medically relevant reason) is sick, wrong, inhuman and morally unconscionable.

>This is very true and I agree.
posted by Ligament at 10:32 AM on July 9, 2007

Also from the same issue of A&A is this editorial taking a contrary, but well thought-out, view opposing increased opioid use for pain relief. That is not to say I agree with them, but they do a better job stating their case than do some of the posters in this thread.
posted by TedW at 10:32 AM on July 9, 2007

Clearly, Ligament. Clearly.

Seriously -- are you just being obtuse? How on earth does one get to

"You can't enslave people by forcing them to give you pain medication for free because you're not allowed to steal food from the grocery store if you're hungry."

from

"Doctors undermedicate chronically ill patients because they're afraid of getting their asses busted by the Feds thanks to political, not medical, policy."

???

We're not even discussing who's paying for the meds. We're discussing who's allowed to dispense them in what quantities under what circumstances, and the human rights implications of this. Torturing an 87-year-old on the rack at Gitmo and torturing her by withdrawing needed pain medication are pretty much the same damn thing if you ask me -- failed governmental policies screwing with an individual's right to not be forcibly harmed by someone with power over him or her.

Whether that person is a prison guard or a physician, they both have the responsibility to make sure they do their jobs in an ethical way, and to prevent abuse of the charges under their care whenever and however possible. And denying care based on political policy is sick. I'd go so far as to say it's even worse than the guards at Gitmo. How many dozen prisoners there versus how many thousands of undermedicated patients?
posted by bitter-girl.com at 10:32 AM on July 9, 2007

And on post I see that Ligature has responded above. My apologies for my rather strident rhetoric here, but I really do want to know how you got from point A to point B in terms of "chronic undermedication is a problem" to "people should only get drugs if they can pay for them"!
posted by bitter-girl.com at 10:35 AM on July 9, 2007

Egads, TedW -- did you see this in the alternate letter you linked?

The recommendation by Brennan et al. (1) that failure to alleviate pain "is negligent, a breach of human rights and professional misconduct" might well lead to increased morbidity and mortality, as well as more frequent medical legal conflicts for physicians and health care facilities.

(Bold mine)

Translation: "Heaven forfend our medical malpractice premiums go up or we risk the government busting us! I got a BMW out in the parking lot with 10 payments left..."
posted by bitter-girl.com at 10:38 AM on July 9, 2007

bitter-girl.com, unfortunately the fear of medical malpractice is all too real in the US and it is an easy button to push when you want to make a point to physicians. As I said, I don't agree with everything he says, but some of the other points are worth looking at.
posted by TedW at 10:50 AM on July 9, 2007

bitter-girl: some people only have a finite repertoire of conversations they know how to have, with the unfortunate side effect that they will attempt to replay one their stored conversational programs whenever they sniff something vaguely related; if the conversation doesn't trend in that reaction short bursts of sarcasm are a typical response.

So in this case, I would assume Ligature is someone who has a pile of precalculated rhetoric about how establishing particular positive rights is de facto coercing someone, somewhere to provide the bundle of services associated with those rights...which topic is not at all related to the conversation in the content of the linked articles, but if you were someone who had a pile of stored rhetoric on that topic it's understandable that the headlines for this post might set you off on it
posted by little miss manners at 11:14 AM on July 9, 2007 [2 favorites]

and now I need to add my own [sic]s: the username is Ligament, not Ligature.
posted by little miss manners at 11:14 AM on July 9, 2007

Although, little miss manners, it's kinda funnier the other way 'round! ;)
posted by bitter-girl.com at 11:36 AM on July 9, 2007

From the contrarian editorial TedW linked:

In reviewing the critical outcomes related to the use of opioids in the management of chronic noncancer pain, Eriksen et al. (6) recently concluded that long-term use of these compounds in the treatment of noncancer pain failed to improve the patients pain relief, quality of life or functional capacity. A recent study by Chu et al. (7) suggested that opioid tolerance and hyperalgesia develop within one month of initiating therapy with oral morphine in patients with chronic pain. Even short-term use of potent opioid compounds for acute pain can produce clinically significant hyperalgesia (8–10).

While I am no doctor, there seem to be prominent medical reasons to avoid increased prescriptions of opioids in non-hospice settings. If you're not going to die soon, narcotics supply on a brief release from chronic pain, followed by a future where that same pain is mingled with the further suffering of physical and perhaps mental addiciton.

This problem is independent of costs, and tied to the nature of the drug that is being touted as a cure-all for pain when in fact it has finite efficacy. If medicine could transcend the human condition, we might be able to avoid the suffering that is apparently our lot. Until then, let's try to build pain-management regimes grounded in the medical realities rather than our fantasies of scientific omnipotence.
posted by anotherpanacea at 11:39 AM on July 9, 2007

typos and sics:

on[ly] a brief release
mental addi[cti]on
posted by anotherpanacea at 11:42 AM on July 9, 2007

Pain management is severely messed up in this country, and this sort of legal action will only make things worse. This doctor's "crime" was simple: he wanted his patients to get down to 2 on the pain scale ("can be ignored") rather than the 5 ("interferes with tasks") most doctors resort to out of fear of the DEA. In doing so, he wrote prescriptions that actually gave his patients enough opiates, a definite no-no under our current medical system. Can't have anything that challenges our sacred addiction model, after all, especially not people who live and work with opiates without turning into addicts.

Man, I really wish that the prosecutor in this case could have some idea -- really, even the faintest notion -- what the fuck a "5" actually means. Hell, I'll be nice and say he should feel it only for one day, as opposed to until he dies, like many pain patients have to live with. But of course, the problem with chronic pain is that you just don't get it... until one day, you do.
posted by vorfeed at 11:52 AM on July 9, 2007

The International Anesthesia Research Society has a particular angle on this issue. So does the DEA. So do people whose 87 year old grandmothers take Darvon.

I treat chronic pain as part of my medical practice and it is by far the most difficult, time-consuming part of my practice. If I could send every patient with chronic pain to an anesthesiologist who specializes in outpatient management of chronic pain, I would. These chronic pain patients include a 90 year old with debilitating osteoarthritis, a 60 year old former IV heroin addict who has multiple severe medical problems that leave him unable to do much but sit in a chair due to excruciating pain, and a 35 year old morbidly obese depressed single mother of three who simply doesn't have the time or will to do the physical therapy I prescribe. The approach to each of these people has to be individualized, multidisciplinary, and must be done with great care. Certainly, it takes much more work and liability than for which I am paid. I could inadvertantly cause an addiction that no one intended. I could overprescribe and kill someone. Of I could make the difference between disability and suffering or keeping someone functional and well.

I listen to what pain management groups say and I watch with great interest when a physician gets busted by the DEA but honestly, when I read things like this linked article, it doesn't seem to have much influence on how I handle the complexities of pain management. I am not sure if the intended audience for this article is primary care physicians. I think both the DEA and advocates for better pain management state the obvious but fail to provide any real guidance.
posted by Slarty Bartfast at 12:15 PM on July 9, 2007

"So in this case, I would assume Ligature is someone who has a pile of precalculated rhetoric about how establishing particular positive rights is de facto coercing someone, somewhere to provide the bundle of services associated with those rights...which topic is not at all related to the conversation in the content of the linked articles, but if you were someone who had a pile of stored rhetoric on that topic it's understandable that the headlines for this post might set you off on it"

miss manners, I think you have a pretty decent grasp on why I reacted the way I did. I was indeed set off by the headlines in this post. I admit it, I jumped the gun.

However, bitter-girl.com, accusing me of wanting to torture 87 year olds was mean spirited and uncalled for, hence my short and admittedly ineffective sarcastic reply. But how else to respond?

bitter-girl.com, I have personally helped many hundreds of elderly people in pain. I assume you have as well?

"it doesn't fucking bloody goddamn matter if an 87 year old woman gets addicted. It does matter that she not be in pain."

It DOES matter if she gets addicted, as opposed to developing pseudo-addiction or requiring escalating doses due to tolerance.

Hopefully the attending physician on this woman's case understood the difference. Possibly not. This is also part of the problem; most physicians are poorly educated on pain managment. If they try to help, they fear retribution from the feds...
posted by Ligament at 1:05 PM on July 9, 2007

If you're not going to die soon, narcotics supply only a brief release from chronic pain, followed by a future where that same pain is mingled with the further suffering of physical and perhaps mental addiction.

There are people in the world who, untreated, are going to have pain the rest of their lives. If they are lucky, they can find a long-term narcotics program that will enable them to function a little bit more like a human being. Long-term narcotics treatment is the best option until (if) something better comes along, and for some people it works quite well, if it is appropriately managed. A doctor I used to work with explained it: Saying that a chronic pain patient is addicted to narcotics is like saying a diabetic is addicted to insulin. The reason we attach the stigma to it is that we can't see it or objectively diagnose it.

Unfortunately, that's a big reason pain management will not get the respect it deserves. It's hard enough to get an insurance company to cover treatment for a diagnosis that will show up definitively on a test. Workers' compensation companies, especially, have a policy that if you can't see it, it doesn't exist, and they treat people with such pain like they are criminals. (Unfortunately, it is legal for them to hire private investigators, who like to do things like knock over trashcans or put tree limbs behind your car, to see if they can catch you bending over for the videotape.)

One thing to keep an eye out for with a doctor or a hospital is whether they have a well-articulated pain management philosophy. While there are doctors who fear the DEA issues surrounding it, there are others (particularly of the pain management specialty) who would consider it far more unethical to allow someone to be in pain when it can be prevented.
posted by troybob at 2:13 PM on July 9, 2007

If you're not going to die soon, narcotics supply only a brief release from chronic pain, followed by a future where that same pain is mingled with the further suffering of physical and perhaps mental addiction.

Switch "narcotics" for "NSAIDs", and this sentence becomes "NSAIDs provide only a brief release from chronic pain, followed by a future where that same pain is mingled with the further suffering of intestinal bleeding and perhaps renal failure". So why is it that our medical system hands out heavy-duty NSAIDs like candy, but acts like narcotics are monstrous?

The truth is that there is NO cure for chronic pain -- "whatever works, for as long as it's gonna work" is as good as it gets. Denying access to an entire category of drugs that often work, based on nothing more than the fear of addiction, often means trading the possibility of future suffering for the certainty of it.
posted by vorfeed at 2:45 PM on July 9, 2007 [2 favorites]

It DOES matter if she gets addicted, as opposed to developing pseudo-addiction or requiring escalating doses due to tolerance.

Why? It only matters if someone gets addicted to medication they require for pain management if you believe that there's some kind of moral issue with addiction. Which there isn't. Why on earth should it matter if someone with chronic pain develops an addiction to their pain meds? If the choice is between having a relatively functional person and a bedridden lump, does it still matter? And why is it anyone's business but the person involved? This issue is entirely ridiculous, and the DEA should just go find something else to do, and stop pretending that the war on drugs matters to anyone but the delusional.
posted by biscotti at 2:55 PM on July 9, 2007 [1 favorite]

So you're a doctor, then, Ligament? Come on, put your dog in the fight. I've stated up front the conditions that bias my opinions here -- my pre- and post-surgical pain was very poorly managed by a doctor who was so afraid of getting in trouble with the med board again he accused me of being drugseeking instead of answering a simple question I'd asked about why one drug seemed to work when the other didn't.

The really funny part? Acupuncture ended up doing a better job than he did in getting me a better range of motion with two surgeries. Oh, and I had a great time being physically abused by him in front of my physical therapist, but that's another matter. Wait, no, it isn't. It's created some severe trust issues with doctors. Entering even my primary care guy's office -- someone I do trust and like -- causes my blood pressure to shoot up precipitously because I have an unconscious and semi-unreasonable fear of being abused by another doctor. In fact, it shoots up so fast and so high the entire time I'm there that he wants to put me on blood pressure meds. Measured outside a doctor's office, by my great-aunt the RN? Totally fine. Low, even.

There's my Fido. I have a real problem with doctors who treat patients who are not them as if they are, and who make their decisions according to irrelevant information. If you are a cranky, Vicodin-addicted jerk, that does not make me a drugseeking potential addict when I ask you what the difference is between Vicodin and Percocet. It does not entitle you to drop your diagnostic hat because you're afraid of the med board.

Reading some of the links in this thread brought me some interesting new info, that tolerance for pain meds might have a genetic component (which would explain why my dad's almost exactly like me, right down to the same migraine triggers -- any pain med lower than Tylenol 3 is as pointless as a sugar pill, so thank goodness for selective 5-hydroxytryptamine 1B/1D (5-HT1B/1D) receptor agonists!).

Troybob's got it: "Saying that a chronic pain patient is addicted to narcotics is like saying a diabetic is addicted to insulin." If you need it, you should get it. And if you're 87, in a nursing home and dying, well... I'm with that woman's son. Who gives a rat's ass if she meets some criteria for addiction? What's she going to do, go rob a convenience store? Turn into the new Rush Limbaugh? Why can't she be made comfortable? Biscotti's point that this anti-addiction mentality is morality- and not reality-based is dead on.
posted by bitter-girl.com at 3:02 PM on July 9, 2007 [1 favorite]

To continue the conversation I know how to have on this topic: the trouble is ultimately that there is a deeply nested sense that there is a single 'correct' treatment to provide, and that it is the doctor's duty is to provide that treatment; this contrasts with the desires of modern patients, who want to be in more direct control of their health (which desire, in my opinion, does much more to explain why americans buy so many vitamins and other alternative treatments: it is not because they are markedly more ignorant than comparable populations but because they feel limited and disenfranchised by the 'medical establishment', often for good reason).

And so the good doctor Ligament here notes that it does matter if an 87 year old gets addicted to painkillers, while sidestepping the question of "to whom does it matter?". It certainly matters to the woman and her family, but it's hard to make the case in good conscience that she and her family are the not the best judges as to whether a particular treatment's risk of inducing addiction is too high for the benefits it brings; it also matters to the physician, but for different reasons: it matters because another induced addiction is perhaps another lawsuit/DEA visit, and it matters because the physician is not only trying to advise but also, in a sense, attempting to decide as well (because without the physician's signature the law makes many treatments unavailable). The former reason it matters to the physician is potentially correctable by statute -- and is an understandable reason for any physician to refuse particular treatments, given the also-very-real pain of an investigation -- but the latter is only a matter of outlook, and part of an outlook I can only find repugnant and incompatible with the dignity of the patient.

By way of analogy: if I want to add monster wheels and a v12 to my vintage VW Beetle I want my ideal mechanic to not only tell me that the frame probably can't handle the added stress but also, having warned me, to then explain to me what additional precautions and modifications give it the best chance of not falling apart under the strain. I expect my doctor to be better-informed than I as to the likely effects of a particular action (after all, if I am better informed than my doctor on the matter at hand what value does the doctor have for me beyond being a state-mandated intermediary I would rather be rid of?), but I would not want that supposedly better-informed-ness to translate into a belief in being better able to decide for me.

At the end of the day I am already well-aged and can only anticipate aging further as time goes on, and I can say that I am filled with dread when I ponder the prospect of my having my options to ameliorate my golden years' almost-certainly-upcoming severe end of life pain mediated by some fresh-faced and straight-out-of-school thirty-five year old snot whom I must convince of the appropriateness of my requests; the scenario is sufficiently terrifying that there's to recommend it were there more attractive options available.

And, perhaps, by that point there may well be better, more responsive options: there has been brewing enough of a general dissatisfaction with how the doctors have been running things that the powers granted to, say, nurse practioners, have been only growing for the past decade; power to prescribe narcotics is probably a stretch for them in this country, but time will tell...look at what has happened in Oklahoma with regards to eye surgery.

And Ligament, I'm not intending to rag on you all that hard, but this whole tangle of issues is shocking from another sense: although clearly many questions remain as to the actual efficacy of opioids as long-term pain management tools, it is also clear that the legal issues hovering over their use are making it tremendously awkward for doctors to handle the chronic pain cases they run into. Given that
the class of "doctors" has all the makings of a powerful special interest -- large and reliable incomes, well-organized professional associations, etc. -- why has there been no effective, organized pushback on the DEA? Is there no sense of "first they came for the pain specialists" among the profession?
posted by little miss manners at 4:01 PM on July 9, 2007

And for snark purposes: I'm addicted to food! I can't live without it, and get the shakes if I go more than, say, ten hours between meals.
posted by little miss manners at 4:02 PM on July 9, 2007

There is a big difference between addiction, pseudo-addiction, tolerance, and dependence. Pain can be treated safely and treated well, WITHOUT addiction. Addiction is is no good for anybody.

"It only matters if someone gets addicted to medication they require for pain management if you believe that there's some kind of moral issue with addiction. Which there isn't. Why on earth should it matter if someone with chronic pain develops an addiction to their pain meds? If the choice is between having a relatively functional person and a bedridden lump, does it still matter?"

>Biscotti, I think you are confusing dependence with addiction. They are not the same thing.

There are three major components to addiction: loss of control, continued use despite harm, preoccupation with the substance, and craving. These qualities can range from very mild to catastrophic. More often than not the symptoms will progress to catastrophic (such as crime or bodily injury).

Clearly the qualities of addiction are very bad! I sure as heck would not want anybody I care about to be addicted to anything! Addiction to opioid medication does happen frequently and it can be very serious to the patient and society.

Dependence is a condition in which a patient goes through a drug specific withdrawal syndrome when the medication is no longer present. A person dependent upon opioid is not necessarily addicted to opioids.

Therefore there is a significant difference between the two. These words are not synonymous.

And this is also why the quote from your doctor is somewhat misleading. The diabetic is usually dependent upon insulin, but not (I dare say never) addicted to it. I don't see too many diabetics on the street selling their bodies to get their next fix of insulin...

The chronic pain patient is often dependent upon opioids, and is frequently (certainly not always or even most of the time) addicted to them. The literature is showing  an addiction prevalence of up to 50% in the chronic non-malignant pain population.  Interestingly, the addiction prevalence is only up to 7.7% in the malignant (cancer) pain population.

So the point is that people are using this label of addiction inappropriately. It confuses patients, doctors, families, the government, everybody.

In your example, perhaps dependent would be a better word to use.

Secondly, I would caution you to assume that people become more functional on opioids. Certainly many do! But many people show no improvement whatsoever. This issue is hotly debated in the medical community right now. I'll point you to a recent study:

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16842922&ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
posted by Ligament at 4:11 PM on July 9, 2007

Motherfuck the DEA*

I’ve got a friend who has diabetes. Has a serious form of it. She is a former addict who got her act together some time ago.
Recently was put through some serious life changes (ranging from suicide of her spouse to the loss of her child, just for starters). For some reason she’s a little depressed. But she doesn’t have much money so she went to see a psychologist provided through public funding. He would have prescribed anti-depressants for her, but she can only take a specific kind of anti-depressants due to her medical condition. The state won’t allow him to provide them. Why? Because it’s in a class of drug that can be abused. She’s broken down, lost her job, etc. (we, as her friends have tried to help, but there are a lot of factors, including distance, family elements, etc., that make this all difficult). And she’s been taking street drugs, and has been arrested for them. And jailed. Where she got an infection (a form of meningitis common to jail). Which she was treated for, but not given - yep, pain medication, because - it’s addictive.
The callousness built into the system is often appalling.

I’d argue, Slarty Bartfast, that ambiguity in terms of guidance and practice could, in some cases, be by design.
It is can be more useful to insinuate the undesirability of something rather than make it explicit (where it can be rationally questioned or opposed). I’m not asserting that such is the case, merely that this could be one of the facets of how this presents itself.
It is far easier to infer authority than take responsibility.

I’m curious about the practical position of the pharmaceutical companies (not their stated positions, what impact their actions have).
It occurs to me that pain can be very much a negative commodity. Something to trade in.

If one asserts pain management as a human right, it might be hard not to argue for a more socialized system of health care. I’d think.
(Not taking a position there, just ruminating on the theme)

*(and the DEA is full of pussies who don’t like doing PT)
posted by Smedleyman at 4:23 PM on July 9, 2007

/I expect the boomers to shatter the current system as soon as they start having ongoing real-world experiance with the medical system...whether this will be for good or ill I can’t say.

//I’m addicted to dihydrous oxide
posted by Smedleyman at 4:31 PM on July 9, 2007

I guess my take on it, is that the failure to treat pain adequately (in the outpatient setting) stems not from failure to recognize pain and not from threats of legal prosecution by the DEA, but rather the difficulty in doing so within the current system. Cognitive medicine, the kind where the doctor sits down and talks to the patient for a long time before coming up with a treatment plan, isn't paid very well. More and more, medicine is now the kind of thing where you have to move patients through quickly if you want to maintain your financial viability. I hate this fact: the best paid doctors are probably the least humane ones.

(Despite the comments about well paid doctors and guaranteed salary, after student loans, malpractice, rent, and employee salaries most doctors are taking home less money than ever for more work.)

I definitely think the movement to better understand and treat pain is a good thing and will result in more doctors willing and able to do so. I also think, if we as a society want to encourage this movement, the best thing at this point would be more structural change.
posted by Slarty Bartfast at 4:57 PM on July 9, 2007

I'm not familiar with the research, but I would think that the addiction rate could be considered higher for chronic pain patients as compared with malignant patients because they take the medications over a longer term, given the definition of malignancy.

Also, we are discussing in part how it can be difficult for chronic pain patients to get appropriate pain coverage for whatever reason, and this can lead them toward behavior that is more like what we would consider addictive: trying to get prescriptions from multiple doctors, buying drugs on the street, using alcohol excessively. It's not that these things would not occur anyway with some people, but the lack of appropriate pain management--under-medicating, for the reasons discussed; and issues of insurance coverage/authorization that can lead to abrupt discontinuation or delay in getting prescriptions--can play a role here for people who would otherwise not take on addictive behavior. Some people can become 'preoccupied with the substance' simply because it can be withdrawn arbitrarily, even if it is of benefit.

In any case, someone with a therapeutic need for narcotics, who is helped by them, and who has them administered under routine observation by a specialist (and DEA now requires physicians to maintain periodic appointments with patients using some medications), would not fall within the same category of addiction as the non-therapeutic addict and should not have treatment options limited as such.
posted by troybob at 5:09 PM on July 9, 2007

I don't see too many diabetics on the street selling their bodies to get their next fix of insulin...

My entire immediate family is diabetic, except me. I can tell you that I've seen things, more than once, that qualify as "continued use despite harm, preoccupation with the substance, [or] craving." Continued use despite harm: both my parents have put themselves in the hospital as a direct result of insulin therapy before. Diabetic hypoglycemia is a quite common side effect of insulin therapy, and can cause severe harm and even death. Diabetics (the ones who don't die from it, that is) generally continue using insulin afterwards. Preoccupation with the substance: this is something that diabetics think about all the time. Where's my insulin, is it in my purse, did I forget it, I need to make sure there's a fridge at the hotel so I can keep it cold, etc. And if you ever want to witness a classic junkie panic attack, just convince a diabetic that they've lost or left behind their insulin. Craving: when one of my parents' blood sugar is too high, they know it both physically and psychologically, and they certainly crave their shot. In short, if insulin were as hard to get as narcotics, I think you really would see diabetics out on the street trying to score it. Hell, at one point I seriously considered making a run down to Mexico to get it cheaper.

At any rate, if opioids help many patients without addicting them, as you've said, then it behooves us to find out which patients and why, rather than denying opioids to all patients for fear of addiction.
posted by vorfeed at 5:20 PM on July 9, 2007 [1 favorite]

A recent study by Chu et al. suggested that opioid tolerance and hyperalgesia develop within one month of initiating therapy with oral morphine in patients with chronic pain. Even short-term use of potent opioid compounds for acute pain can produce clinically significant hyperalgesia.

Dependence and addiction questions aside, incautiously rendering pain management impotent is a major concern, just as it is with overuse of antibiotics. Just do the math: turning a 5 to a 2 for six months may later create a situation where a 9 remains at 8 instead of being reduced to 4. Pain, like bacteria, can become immune to the available treatments.

troybob, vorfeed: As with most rights-claims, the righteous absoluteness of this issue is clouding your judgment regarding the nuances of self- and other-care. Take a step back: assume that I, like you, am a human being who detests suffering.
posted by anotherpanacea at 6:10 PM on July 9, 2007 [1 favorite]

anotherpanacea:

Opioid induced hyperalgesia is a major problem I agree. Poor monitoring, poor outcomes measurements, and poor physician and patient education on chronic pain have led to an entire group of humans whose pain experience may be "ramped up" forever. In other words, these people are living in a pain amplifier, just like in Dune. Yup, the gom jobbar. :)

This is the other side of the coin of liberally applied opioid pain management.

The answer lies somewhere in the middle most likely, where the "middle" is at is up for debate and the literature is starting to look at it.
posted by Ligament at 6:59 PM on July 9, 2007

troybob, vorfeed: As with most rights-claims, the righteous absoluteness of this issue is clouding your judgment regarding the nuances of self- and other-care. Take a step back: assume that I, like you, am a human being who detests suffering.

Oh, come on. First of all, I haven't actually made any "rights-claims" here. Second, the idea that we ought to find out what medicines work best for which patients, rather than declaring one-size-fits-all legislative limits from on high, is "righteous absoluteness"? I think maybe you should "take a step back" from the hyperbole. What I'm saying is that pain management shouldn't be a matter of absolutes. All available medications for chronic pain have their problems, including some as severe or more severe than addiction or hyperalgesia, yet only opioids are subject to this sort of legislative hoop-jumping, and only opioids are subject to over-strict dosage guidelines that purposefully stop short in managing pain. There's no scientific reason why doctors should be able to freely prescribe, say, TNF blockers, with their attendant serious side effects, but not opioids. If a doctor can decide that a greatly increased chance of serious infection is a valid risk to run in order to decrease a patient's pain, then he or she ought to be able to make the same decision about an increased chance of addiction or hyperalgesia.

All I ask is for doctors to be able to make informed decisions as best benefit their patients, without morality-based interference from the government. Until we make some kind of amazing breakthrough, the state of chronic pain management remains as it is -- "what works for you, works for you" -- and I will continue to naysay the government's insistence that what works for many people doesn't (or worse yet, shouldn't) work for them.
posted by vorfeed at 7:02 PM on July 9, 2007

You doctors and "not a doctor" s alike, should try some RSD - Reflex Sympathetic Dystrophy, a rare, incurable, ineurological pain syndrome - out for size some day and see how you feel about the possibility of the decreasing efficacy of and possible addiction to opiates. The pressure of WATER on my skin caused excruciating pain, let alone my surgical wound. And some people have it worse than I did.

I did eventually receive adequate pain management. My condition went into remission so I cut back on daily morphine and eventually stopped altogether, to the surprise of my asshole pain mgmt doctor (an anesthesologist who was applying to law school to go into malpractice).

Reading bitter-girl's posts has brought back the rage I felt over what I was put through, first and foremost by my primary care, morally and ethically bankrupt, college-at-15-Rhodes-Scholar-brilliant-diagnostician, who figured out what was wrong only to cut me off from meds three days before fucking Christmas (the good Catholic that he was) because my condition was going to require more and more pain relievers that he was unwilling to prescribe (nor was he willing to get me an emergency appt with a pain mgmt dr at the same hospital to tide me over).

Bitter-girl, I hope you're OK now.
posted by Marygwen at 7:39 PM on July 9, 2007 [1 favorite]

My mother has RSD in her arm following an injury and surgery. Thank god she has a dr. willing to prescribe pain medication.

I'm a chronic pain sufferer and I do not have a doctor who is helping me. She throws NSAIDS at me, I take them until my stomach starts up again, then go off them. And, they barely take the edge off any pain.

I'm in constant 5-7 level pain. It never goes below a 5 unless I get rip roaring drunk, and that happens once a year, maybe. I wish that the doctors, and anyone who thinks that pain isn't that bad, should have to live like that for a month. They'd be marching on Washington, demanding the DEA to stop their bullshit.
posted by SuzySmith at 8:24 PM on July 9, 2007

SuzySmith, what part of the country are you in?
posted by Marygwen at 8:28 PM on July 9, 2007

Take a step back: assume that I, like you, am a human being who detests suffering.

Excellent advice.
posted by homunculus at 8:38 PM on July 9, 2007

In Pot We Trust
posted by homunculus at 8:49 PM on July 9, 2007

Ligament: The diabetic is usually dependent upon insulin, but not (I dare say never) addicted to it. I don't see too many diabetics on the street selling their bodies to get their next fix of insulin...

Neither do heroin addicts in Switzerland or Netherlands who receive pharmaceutical-grade heroin legally from the government. Stimulant dependence is one thing, but as far as opioids go, their illegality confers most of the trouble they lead to, such as varying & unknown dosage, very high cost, difficulty in acquisition, beholden to other people in the subculture, social stigma, mis- and disinformation about drug effects...etc

The other effect of the drug war ideology is the difficulty and delay in conducting research that makes drug-taking safer, as opposed to treating drug dependence.
posted by daksya at 11:10 PM on July 9, 2007

...RSD - Reflex Sympathetic Dystrophy, a rare, incurable, ineurological pain syndrome...

Actually RSD is not rare and there is an extensive body of literature on its treatment. You rightly state that it can be debilitating and very difficult to treat, especially if it has gone on for a long time. My brother-in-law has it but has been fortunate enough to get pretty good relief with a combination of nerve blocks and oral medications. As described above, like most chronic pain patients his pain never goes away completely, it is a matter of making it manageable.
posted by TedW at 5:28 AM on July 10, 2007

Ligament: The diabetic is usually dependent upon insulin, but not (I dare say never) addicted to it. I don't see too many diabetics on the street selling their bodies to get their next fix of insulin...

Neither do heroin addicts in Switzerland or Netherlands who receive pharmaceutical-grade heroin legally from the government. Stimulant dependence is one thing, but as far as opioids go, their illegality confers most of the trouble they lead to, such as varying & unknown dosage, very high cost, difficulty in acquisition, beholden to other people in the subculture, social stigma, mis- and disinformation about drug effects...etc

The other effect of the drug war ideology is the difficulty and delay in conducting research that makes drug-taking safer, as opposed to treating drug dependence.

>The topic of this thread is not pure recreational drug use. We have been talking, at most, about addiction to opioids in the context of chronic pain and chronic opioid use for medical purposes, and how this makes it difficult for people in chronic pain to access opioid medications.

Purely recreational drug use deserves an entirely different thread.
posted by Ligament at 8:25 AM on July 10, 2007

...righteous absoluteness of this issue is clouding your judgment...

Um, yeah...and the whole law enforcement issue with opioids is tied up in debates over which form of pain management is most effective, I'm sure.
posted by troybob at 9:07 AM on July 10, 2007

We have been talking, at most, about addiction to opioids in the context of chronic pain and chronic opioid use for medical purposes

Your statement was, "The chronic pain patient is often dependent upon opioids, and is frequently (certainly not always or even most of the time) addicted to them.

My point is that opioids, for even medical use, are treated lot more restrictively (the point of the FPP) than insulin , hence the dependence can trigger the addict's stereotyped behavior. Insulin is not subject to that. Put another way, make insulin (and equivalent treatments) as difficult and as cumbersome to obtain as opioids and then note the difference. Of course, it is likely it will be the caregiver exercising such behavior, especially if the diabetic has lapsed into a coma. Sorry for the hyperbole at the end.
posted by daksya at 9:07 AM on July 10, 2007

Ligament: Can you please improve your quoting style? Don't just c&p what you're citing directly into your comment, wrap it in "<cite>quote</cite>" or <blockquote>"quote"<blockquote>, or even just "quote"; it's rather confusing otherwise, I keep thinking I've lost my place in the thread. Thanks.
posted by Freaky at 9:37 AM on July 10, 2007 [1 favorite]

“More and more, medicine is now the kind of thing where you have to move patients through quickly if you want to maintain your financial viability.”

Very reasonable assessment. I’d have to agree. My focus is more on *why* that is the way it is.
Much in the same way I’m curious why, say, Tyson chicken workers would abet polluting their own drinking water. At some level someone is making - whether by design or not - profit off of someone else’s (typically someone ignorant of the situation) loss.
Certainly changes are needed. I suspect however it is easier to predict any opposition to change by discovering who is profiting from things the way they are.
Whether by conscious design, unconscious gaming of the system or diabolic master plan - whatever, systems don’t randomly assemble themselves. The apparent flaws therefore are, whether specifically designed to be exploited or to influence a given environment (in this case medical treatment) in a given way or merely taken advantage of by those in the field to shift profit to themselves, by design.
What that design is - profit, anti-drug ideology, sheer stupidity, whatever, is debatable of course.
posted by Smedleyman at 10:02 AM on July 10, 2007

Bitter-girl, I hope you're OK now.

Thank you, Marygwen. Yes. With the exception of a left arm that will never be able to fully straighten again and no recourse for it, I'm ok.

(Was it because I woke up during surgery? did someone make a mistake when that happened and I choked on my intubation tube? did the Vicodin addict doctor leave me in the cast too long to begin with? I'll never know!)

I'm fortunate that the newer migraine meds work on me, for example. After "growing out of" the crop of drugs available to migraineurs 10 years ago, I thought I'd never see another one that worked. A four-day (yes, you read that right) migraine, the longest I'd ever had, prompted current primary care doc to prescribe something new. Whew. I'm lucky. Seriously. Especially after reading some of the above... my thoughts are with all of you as you try to manage your pain.

Marygwen, I wonder if we had the same doc. Sheesh. Nothing like a little extra pain for the holidays. Here's a good one for you -- right after I asked the doctor about my medication after manipulation under anesthesia, he turned away from me and said to my boyfriend "Well, it's not like we opened her up again" before accusing me of being drugseeking. Cute, eh?
posted by bitter-girl.com at 11:49 PM on July 10, 2007

House Hearing on DEA's Regulation of Pain Medicine
posted by homunculus at 11:57 AM on July 12, 2007

The Accidental Drug Dealer: Hurwitz Sentenced
posted by homunculus at 1:01 PM on July 16, 2007