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Living With Facial Pain

Does your country have an opioid crisis?


#21

Yers and No That report was published 2014 (which would be 2015 to the rest of us) The final year of a data report from the Drug Abuse Warning Network was 2011. Between 2011 and 2016 (which just ended), SAMHSA will continue to analyze and report using DAWN data. To replace DAWN, CBHSQ has been working with the National Center on Health Statistics on its new National Hospital Care Survey (NCHS). Through this new survey, SAMHSA will receive data on drug-related emergency department (ED) visits and will publish them as SAMHSA’s Emergency Department Surveillance System (SEDSS). The numbers have gotten worse if anything. but the data is based on the 2011 data base methodolgy. This report was the LAST time actual data was collected and anylyzed. Anything since is as has been suggested a wild guestimate.

One other legitimate study that involved just in-patient stays is even more disturbing. Between 2005 and 2014 (which would have bee oct 2015), the national rate of opioid-related inpatient stays increased 64.1 percent and the national rate of opioid-related emergency department (ED) visits increased 99.4 percent.

The rate of opioid-related ED visits increased in almost all States between 2009 and 2014, with the greatest increases in Ohio (106.4 percent), South Dakota (94.7 percent), and Georgia (85.2 percent). These numbers would have been reported mid 2016 (Fiscal year are significantly different - this is still early 2017 for government reporting) An old numbers argument doesn’t wash. ALL the numbers are “old”


#22

thanks
buy way too many numbers

What my brain is seeing it the report I asked about was for 2011.

And another report will be doe much later?
All so exciting.
I just do hope they are using the scientific method.


#23

They are scientific to the point that they don’t report a single year ever. Aside from the fact their years are ten months behind ours (they go October to October) they realize a single data point is worthless so they report in five year blocks. The next report is due anytime. Because reporting has improved due to EMR the numbers are not significant expect for the press. They will be higher and the press will have a field day. The decision making is based on slope of the trends, not sensational news reports and politics making points. It’s a very steep slope. ( It’s in the second two tabs) Steep enough in fact that the margin of error is essentially 0 within the first standard deviation. The increase no matter the raw numbers is concerning. Compared to rest of the world we are steep, and that’s going to make things difficult to get long term narcotics outside of managed program. But frankly for me when I. Need them and I do from time to time I would paint myself purple and dance naked on the court house steps to get them. Occasionally peeing in a cup or letting the doc’s office count my pills is just not a problem for me if it saves lives…


#24

I don’t think the issue is what we’re willing to do to get the meds, the issue is making the meds impossible to get.

I mentioned in an earlier post my mom’s doc is refusing to write prescriptions for just about anything, she spends the entire appt trying to refer out to other docs instead of taking responsibility for the immediate care of her patient. I just heard from a person with migraines who got a form letter from her neuro that the office is no longer providing any prescriptions for any controlled meds.

I’m terrified we’re slipping into witch hunting anyone who so much as utters the word narcotic! Common sense is becoming so far from common practice I don’t know what we’re going to do.


#25

Azurelle
That has been my experience.
Pain clinics that say NO NARCOTICS up front.I can understand-if you have
tried the rest then why prohibit narcotics?
Someone ,somewhere has convinced someone that we do not need the drugs.
All I can think is there is a medical takeover coming.I am that cynical.
So far,for me, the only thing that notches the pain back are those nasty
narcotics.
I guess I will be standing on a street corner soon.
And this is Canada
The land of 8 inches deep of slushy snow at the street corners.
Moderators please try and get out there and look what is actually happening
at pain clinics.Never once been asked to pee-and that was marijuana clinic.
Maybe different stateside.
Why is is different in US and Canada?
maybe we have operations that are somewhat successful-but still pain meds
needed
Or they don’t do operations and pain goes away through physio?
I would really like to know why there is not such a widespread panic in
other countries.


#26

Ellen I honestly think we have it so good in North America we have the luxury of manufacturing “crisis” and I think needing to fill a 24 hour news cycle compounds the problem.


#27

I just wish there was a way of washing the spin out of the opioid
crisis(eg- who benefits the most,the least,and who really cares)There are
people dieing on the street for a reason.If the reason is their doctors
took them off drugs -then those doctors should be held accountable. An exit
plan should be a good place to start-but if no other drug works and no
surgery -is an exit plan really necessary?If because of this crisis-no
doctor feels comfortable prescribing narcotics people will be going to the
streets to get the pain treatment they cannot get from the medical system
anymore.And people are dieing over this.
From the inside-where you are a bit-what do you think this whole thing is
about?


#28

I am very much in the real world although I am retired except, boards, clerkship supervision etc and occasionally still peer review articles for publication (the stats are my specialty)

There is crises just not the on that Azurelle refereed to which has been manufactured. It goes a lot deeper than just the availability. Managing patients using narcotics is simply not economically feasible for most practices in the USA.
Its much easier in Universal health care countries (Canada is someplace in between) In universal health care countrie the doc gets paid whether he he is doing “intellectual time” or open heart surgery. There is just some areas where one shouldn’t be forced to compete in an open market Healthcare is one.

Standard of care now (and it always should have) requires that a patient using narcotic pain killers be seen every 30 days ACTUALLY SEEN and evaluated. The “law” attempted to put this in effect by requiring patients get a written script from their physician every 30 days. It of course didn’t work. Docs simply wrote out the prescription and left it at the front desk. A few even mailed it.

As became apparent this wasn’t working practice committees further define what should be happening. Patient notes were subject to review to make sure these patients were actually being seen. This simply was not practical for most PCP and definitly not practical for specialists such as the neuro who sent a form letter stating that the office is no longer providing any prescriptions for any controlled meds. he wasn’t afraid of the governmet (though he might have said so) he was afraid of not being able to pay his bills.

If a doc had a 100 patients using controlled meds (It takes about 4000 charts to operate a practice so 100 is conservative,) just meeting the standard of care would take 25 hours a month. Most of those patients because of chronic illness and age are on either medicare or medicaid and the rest on some kind of PPO. What this means is his cash rembursement would be less than $4000.00 (a med check remiburses about $40.00) You can’t operate a practice on that kind of money. Thats why they are getting out. Its simple economics.

So enter pain practice. They vary in what they do. The pill mills are gone, there are those that are “integrated” meaning they don’t want to manage meds but are more than willing to charge 100.00/hour for therapies of various kinds. There are actual Pain management practice (most are hospital based) that do the integrated approach (which is hghly succesful BTW) as well as mange meds. Med management can be done by non-physicians. APRN PA etc) The basis of the narcotic management is actually pretty sensible. Yup occasionally there is pee test to measure levels. Its important not only to make sure meds aren’t overused but to know how they are being used by the body. Pill counts serve a number of purposes are they selling the pills? Are they skipping doses (which raises all manner of trouble) and on goes the list.

So how does the pain Practice do this and the regular practice can not? Pain specualists are what we call Fellowship docs meaning they have completed a specialty and the completed and additional specialty in PM. Most are anesthesiologists so they support the practice with procedures (nerve block injections etc) While the PCP practice make 40.00 for a “short appointment” the PM doc makes $1200.00 for an injection. His assistants do the $40.00 job.

Medicine is becoming specialized in all areas as it should. There are no Jack of all trades anymore. My gripe with over specializing however is far too many docs no what they can’t or shouldn’t do but they fail to know who does. The lady with migraines who got a form letter from her neuro that the office is no longer providing any prescriptions for any controlled meds should have received a referral with that letter for someone who does.

They for-profit competitive healthcare system is one of the things that creates an issue in the USA that no one else has


#29

Please be advised that really-even in Canada PAIN CLINICS will not
prescribe narcotics.(I have not gone around looking-just trying to find
someone that can treat facial pain)Although I live in one of the most
populous cities in Canada there does not seem to be anyone that treats
facial pain outside of the downtown hospitals-and appointments every 6
months.Maybe if my MRI’s showed something I would be happy with the
service-here you go Gamma Knife)
Canada is tied to the US
I just wish I could get treatment there.
maybe they could fix.
So what is the problem in Canada?
And the specialties thing has not got me ANYTHING
Persistent Idiopathic facial pain-how is that for a no nothing name.You
would think that they would look outside their gabapentin box-maybe do some
other tests.
I have no idea whether a cone beam CT scan is as good as a CT scan?Would
love for someone to give me a medical answer for that.
Not just a they are both CT scans.
I keep asking “are they the same”?
How does someone know what drug works for me.
I repeatedly tell them gabapentin puts me to sleep.
Take more they say.
Opiate help the pain-take less I am told-they are causing the pain.
But no one-not anyone has been able to tell me whether it is
nerve,muscle,bone or combination of a whole slew of things.
JUST TAKE GABAPENTIN and all will be wonderful.
I need to go to a neurologist.Maybe the ones I have seen count-but the only
ones I have seen are in pain clinics.
Maybe I have a bone problem-I do have osteoporosis
Maybe I have something wrong with my gums
Maybe I have something wrong that does not fall under the concerns of one
specialist.And the area is such a tiny area that multiple doctors looking
at it could not happen.
How about the pimple I had taken off from the side of my mouth last week-a
biopsy for cancer.
Could cancer be the cause?
As we overspecialize everything I think we de-specialize the patient.
Just a number to be taken off opiates.
And then do a brag dance.
When someone says they took EVERYONE off opioids except for 2,that person
is doing a brag dance.
What other possible explanation would there be for someone to make such a
statement to a patient.Who they had decided to keep on opioids-but then
forgot.
.
I almost think I could do a thesis on my last 2 appointments with this
doctor.
Or have a room waiting in the BIN(as my family endearingly call the mental
hospital)


#30

Wel I really don’t know what is going on with you. The diagnoses of IDIOPATHIC however is clue that thus far there is no known reason for your pain. That makes it difficult to treat. Even more difficult with opioids as they don’t know the effect they will have. For example if the source of your pain is actually a defect in the communication between your CNS and pituitary gland (which is the most common cause of idiopathic pain) opioids make the pain worse, permanent and more debilitating. pain management plans have traditionally been opioid based. Even single-shot nerve blocks are a challenge in this regard, because their limited duration leads to rebound pain and substantial opioid supplementation.This leads to complications that delay recoveries and affect outcomes. Down dosing is even worse.

One of the ways this has been demonstrated is with rats (who interestingly have the same endorphin system as Humans. They put the rats on an opiod prescription equivelent to 30mg of hydrocodone (a pretty mild dose) for 7 days. Then they use as series of very fine. “hairs” to irritate their foot. As expected they retract the foot. But what is surprising is the finer the hair the more violent the reaction. In short the opioids make the pain worse. Hyperalgesia (this miscommunication between CNS and Pituitary has become the most common cause of chronic pain period. The only thing worse is opioid induced Hyperalgesia.

Yup Canada is almost in lock step with the US who is the only country in the world that uses more opioids per capita than the USA. It also suffers from a similar problem in that the opioid standard of care procedures come down from Provincial Practice committees (the Docs themselves) The minimum standards are covered Here: http://www.cmaj.ca/content/189/18/E659

Ontarians have the strictest standards (if no other reason than 1 in 7 used opioids for non-cancer pain in the 2015 - 2016 reporting period Tha pendelum swing can be brutal. The pain Clinics CAN (and do) prescribe long term opioids but only after (and it is much the same in the USA) pain rehab and non narcotic treatment have failed.

Again I don’t know your situation where you have been or what has been done. But no clinic will prescribe unless you have established a relationship meaning if you have ever been to one, requested/demanded opioids and left the program when you didn’t get them, its going to be near impossible to get them anywhere without jumping through a lot of hoops.

However what I suggest you do in the meantime is contact: http://www.canadianpainsociety.ca/ and ask for a referal. Check out some of their resources at: http://www.canadianpainsociety.ca/page/CPSonOpioids which is really whats going on. There are additional resources at: http://www.canadianpainsociety.ca/page/OnlineResources

For sure I would connect with: https://actionontario.ca/

This is a source and advocacy group for Canadians with Neuropathic Pain. There is an Action Group covering every Province/Territory. Feel free to vent here not that it will change anything (and you may notice none have responded except azurelle and I) I’ll give you my 2 cents worth: keep it here or private vent all you want (we have limits here) but don’t take it anywhere else. PLEASE for your own good Even a doc who is handy with his script pad would be very hesitant to write if he heard you. a “what can I do” approach will work better. When he suggests XYZ you answe I tried XYZ from (date) to (date) and it didn’t help do you have a different approach from XYZ or better approach to XYZ? This reasoned approach will get you where you need to be including Opioids if thats where it needs to be. Call a guy who is trying to help an idiot or uncaring outright or subtley as you have me here and you will get nowhere. You will come off as a drug seeker even if it is not true.


#31

Thank you for information.
I am sorry that I caused you hurt in my e-mail.
I was just explaining my frustration-which is MY FRUSTRATION,not yours.
I am sorry if I have said something that abused you.
I want off of all these drugs faster than anyone.
Even an injection-get off the codeine and see where things are after that.
For your info-the buprevaine that was injected in my mental nerve has
taken away the sharp pain from my one tooth for 3 months.If I could get
something to take the pain out of the bad tooth(even temporarily) I can see
getting somewhere.
But that is a hope I have.
Happy Valentine’s Day


#32

No worries I have very thick skin. A lot providors don’t, I’m just telling you be careful when and to whom you vent and not to confuse it with “self advocacy”

TJ


#34

TJ, as for that rat study, it seems to me you left off the single most important part of the study info:

"In the meantime, the finding certainly shouldn’t be the basis for withholding opioids from people in pain, says Catherine Cahill, a neuroscientist at the University of California, Irvine. These drugs also work to block the emotional component of pain in the brain, she notes—a form of relief this study doesn’t account for. And opioids might not prolong pain in humans the way they did in these rats, she says, because the dosing of morphine and its quick cessation likely caused repeated withdrawal that can increase stress and inflammation. Humans usually don’t experience the same withdrawal because they take sustained-release formulations and taper off opioids gradually.

Last time I tried to do a link I didn’t do so well, I’ll try again with a link to the article about the study: http://www.sciencemag.org/news/2016/05/why-taking-morphine-oxycodone-can-sometimes-make-pain-worse

In more detailed article about that study which I can’t find right now there was also mention that the study was limited to male rats, which could be an issue as male and females often react very differently to things.

Also it seems to me there’s an issue with assuming the rats being poked were experiencing more pain. It could be that the rats that weren’t reacting as strongly had simply learned to live with a higher level of pain than the rats that were treated for pain. Which is no way for humans to live – I really don’t want to suffer enough that my body learns to live with higher levels of pain on a regular basis. Of course, there’s no way to ask the rats, it’s all conjecture.

In my opinion, at this point all the study really says is that if you poke rats hard enough they flinch. There is no empirical proof as to what’s really going on or how opiates are acting/reacting. And who cares how rats are reacting anyway? This study reminds me very strongly of the one in the 1970’s when we were all going to die from artificial sweetener because rats developed benign tumors from the stuff. Never happened, never heard any more about it.


#35

No what the study proves is that with most forms of “chronic pain” there is a huge concern with various forms of hyperalgesia and that we can innocently CAUSE chronic pain within 7 days (there is a huge body of human evidence as well that this happens)

Humans usually do experience the same withdrawal especially with sustained-release formulations and tapering off opioids gradually does not work which is why methadone, and now Keppra is used to sustain the system when coming off opioids. The opioid receptor mecjhanism BTW in Rats is identical to humans.

Of course the first concern is pain control and NO ONE should be denied what helps. Which is something I can’t seem to get across. The pain is very real. What I am trying to get across is that in the USA and and Canada unlike the rest of the world, we have long used Opioids inappropriately and without regards to to some very serious and counterproductive side effects causing a real crisis (which has NOTHING to do with what you read in the news)

The fact is as you have noted a number of times, is that we are doing a very poor job of managing pain and what we have done in the past isn’t working and often has the exact opposite effect. We can and MUST do much better.

In the meantime we simply can do little else except more closely monitor and supervise with folks who have advanced training in the area the use of these meds. No one should be denied analgesia - ever.

The point of the study BTW is they flinch not by being poked hard which one would expect but rather a stimulus that should not cause a reaction in fact causes a very intense reaction which is identical to that in chronic pain patients. The fact that they were able to recreate the hyperanalgeisic reaction witin as little as 7 days of opioid exposure in otherwise normal animals with identical recpetor systems as humans is the concern. This is one of the reasons so many folks become dependent very quickly. There are other factors of course leading to the dependencey.


#36

Just on last note about that study, by definition chronic pain has to be around at least three months. The study talks about one, six, and twelve weeks, none of which meet the definition for chronic. So this study is really about acute use.


#37

I’m in the UK and I have no awareness of an “opioid crisis”, other than when I had gallstones and lived in 24/7 pain and wanted ‘strong’ codeine tablets and was told they “didn’t like to prescribe them as they were addictive”. I wanted to retort that so is chocolate but nobody gave me the third degree when I wanted to buy that.

What interests me is the why of this so-called ‘crisis’. Is this just people getting thrown into the middle of a piece of political propaganda so that the government of the day can be seen to be being tough and “cracking down on drugs”, or is somebody losing money? Those are the only two reasons Western governments get involved in things like this, so I would imagine the three questions to ask are is the US government somehow losing money, is big business somehow losing money or lastly, is a political party using this as a vote-getter (or trying to distract voters’ attention from a real problem occurring at the same time)?

If it is simply a matter of cracking down on illegal drug use then it is a piece of smoke-screening nonsense. What difference does it make if people use opioids recreationally? As I said before they already use everything from chocolate through to nicotine and alcohol and nobody gives a damn, other than to tax them for the pleasure. Prohibition proved beyond a shadow of a doubt that it is futile to try and come between people and their addictions, but apparently the US government hasn’t learned anything from that.


#38

Not when its induced. The defined study period the period was much longer than a month. the fact that opioid induced hyperalgesia is produced in less than three months (12 weeks) from initial exposure (only 7 days) and was almost universal at 12 weeks (3 months) would if applying your definitions would make the medication even more difficult to procure.


#39

In the interest of the forum and TN, post 3, years carbamazepine and any generic, is the only approved medication by my understanding, how many folk are still taking opiods, I don’t know, but surely a fair few prescription or otherwise.


#40

You’re correct, That is the only med with official use for facial pain. Amazing there’s only one, isn’t it.


#41

Funny thing about kidney stones… The newest protocol here specifically exclude s opioids. Found out when I went in with a 6mm stone and some babies 3-4mm. I was NOT a happy camper. I go through it every few years from amed reaction. 5mm used be surgical automatically. I was informed that now it was 7 unless a whole list of complications were met.

The protocol is a shot of torodol a big dose of flomax and 800 ibuprofen every 4 hours. They found the opiates slowed every thing down and increased inflammation. The protocol allows bigger stones to pass and the normal ones to pass with less pain and faster. The multi prong approach to antiflamitory therapy does the trick. Whuda thunk it. They were right. Best stone experience ever…