An Ethical Paradox for Pain Practitioners: Objectivity vs. Subjectivity

An Ethical Paradox for Pain Practitioners: Objectivity vs. Subjectivity

…the ethical implications of trust and mistrust.Should doctors trust their patients? This was the dilemma posited in a keynote address by Peter A. Moskovitz, MD,

while an objective diagnosis can sometimes verify a patient’s account of symptoms, it cannot verify the patient’s experience of the condition

The mind is subjective and cannot be measured. It is fleeting and chaotic. It does not exist in a specific location. “An identity between a measureable objective state of the brain and a subjective experience of the mind remains elusive.” Yet, neuroscience respects the mind.

The health care system, however, does not respect the mind.

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Pharmacy Medicare Fraud Involving Opioids

Focus on Community Pharmacy Medicare Fraud

“Fraud and systematic overcharging are estimated at roughly $60 billion, or 10 percent, of Medicare’s costs every year… We know the government isn’t uncovering all of the Medicare Part D fraud, but let’s take a look at some recent stories about what has been found in various states.

While patients suffer monthly individual pill counts, those with access to hundreds of thousands of pills seem to be relatively lightly monitored. The rules I have to follow to get my individual pills seem stricter, or at least more strictly enforced, than those for suppliers handling massive amounts.

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Hormone Abnormalities in Uncontrolled Chronic Pain Patients

Hormone Abnormalities in Uncontrolled Chronic Pain Patients: Use of Hormone Profiles   July 1, 2014

Hormone profile testing is readily available and may be recommended for any chronic pain patient who is not achieving good pain control with their current medical regimen.

some specialty laboratories that offer body fluid toxicology and pharmacogenetic testing to pain practitioners are beginning to add hormone panel testing to their portfolio of services

Keep in mind that today’s standard pain control regimens are extremely effective in the vast majority of chronic pain patients, so non-responders are somewhat uncommon.

This statement could be misleading because by “extremely effective” he certainly doesn’t mean 100% pain control.  It is generally agreed that even optimum opiate pain management lowers pain by about 80%.

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Man sentenced to 25 years in prison for treating his own pain

Richard Paey Speaks – An interview with the paraplegic man sentenced to 25 years in prison for treating his own pain.

In October of this year, Florida Gov. Charlie Crist signed a pardon for Richard Paey, a paraplegic with multiple sclerosis who had served nearly four years of a 25-year prison sentence for drug trafficking

Paey, who requires high-dose opioid therapy to treat pain brought on by his MS, a car accident, and a botched back surgery, was convicted of trafficking despite concessions from prosecutors that there was no evidence the painkillers in his possession were for anything other than his own use.

When police came to arrest the wheel-chair bound Paey, they came with a full-on SWAT team, battering down the door and rushing into the home of the wheelchair-bound Paey, his optometrist wife, and their two schoolage children.

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Understanding the Microbiome and Its Impact on Human Health

Understanding the Microbiome and Its Impact on Human Health  September 20, 2014 | As presented by Donald C. Manning, MD, PhD, Chief Medical Officer of Adynxx Inc

The microbiome is all of the microbial genomes in or on the human body, differing slightly from microbiota, which refers to all microbial organisms in or on the human body.

the microbiome, which includes genomes of bacteria, archaea, virus, and fungi, is so large in comparison to the human genome, that we are actually part of a “Superorganism.”

In total, the microbiome contains around 150 times as many genes as the human genome. And amazingly, 90 percent of the microorganisms that were sequenced have been unculturable to date. In other words, the microorganisms found in or on the human body and studied through traditional culturing represent only 10 percent of the entire microbiota.

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Chronic Pain, Addiction, and Zohydro

Chronic Pain, Addiction, and Zohydro — New England Journal of Medicine 

The recent approval of the long-acting opioid Zohydro ER (hydrocodone bitartrate) by the Food and Drug Administration (FDA) has brought into sharp relief the tension between the twin challenges of chronic pain and addiction.

Chronic pain, which affects tens of millions of people in the United States, is associated with functional loss and disability, reduced quality of life, high health care costs, and premature death. U.S. physicians are now more likely to recognize and treat chronic pain than they have been historically

Enter Zohydro. A single-entity formulation of hydrocodone, Zohydro joins a category of extended-release and long-acting oral opioids that includes:

Alcohol Consumption Decreases Likelihood of Developing Pain

Alcohol Consumption Decreases Likelihood of Developing Pain – 9/24/14

Study participants who drank moderate amounts of alcohol each week experienced decreased chronic pain prevalence and lower levels of disability compared to non-drinkers.

Researchers from the Epidemiology Group at the University of Aberdeen in the United Kingdom studied 13,587 patients surveyed at general practices around the United Kingdom. Patients were about 55 years old, and were 56.8 percent female. The researchers wanted to conduct the study because recent literature suggested reduced symptoms among drinkers with fibromyalgia (FM) and chronic widespread pain (CWP) compared with non-drinkers.

Compared to the puritanical U.S., the U.K. has a much more relaxed view of drinking, and the study shows promising results for men drinking 35+ units per week, who would be considered alcoholics in the US.

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EDS 2014 Physicians Conference Slides Available

http://ednf.org/2014-physicians-conference

The slides are now available from the first EDNF Clinical Care and Research Center’s Physicians’ Conference

The conference was designed to increase overall knowledge of Ehlers-Danlos syndrome on the part of physicians and other medical professionals that currently work with EDS patients or are planning to in the future.

Topics Covered:

  • Gastrointestinal Complications of Ehlers-Danlos Syndrome
  • Physical Therapy in the Management of EDS
  • Ehlers-Danlos Syndrome: Molecular Analysis
  • Pain in Ehlers-Danlos Syndrome
  • Neurosurgical Management of Hereditary Hypermobility Connective Tissue Disorders
  • Ehlers-Danlos Syndromes in the Pediatric Population
  • Introduction to EDS
  • Clinical Autonomic Dysfunction in Ehlers-Danlos Syndrome

Toxic Insurance Plans

Editor’s Memo: Toxic Insurance Plans

As I write this memo, I have 2 patients who are hospitalized—the first, ostensibly, for seizures and the second for psychosis. Prior to hospitalization, both patients’ opioid prescriptions were only half-filled at the pharmacy because their insurance plans suddenly, without notice or warning, decided to limit drug coverage. In each case, some ancillary medications, in addition to opioids, were totally stopped.

One of my patients, who had 75% of her intestines and rectum removed due to an immunologic disorder, was denied injectable opioids because her plan only covered oral drugs.

When I’ve called insurance plans to advocate for my patients, I usually receive 1 of 2 basic responses:

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New drug for treatment of opioid-induced constipation

New drug approved by FDA for treatment of opioid-induced constipation | Formulary Journal

FDA has approved a new treatment option for opioid-induced constipation in adult patients with chronic noncancer pain. Naloxegol (Movantik, AstraZeneca) tablets C-II is the first once-daily, oral, peripherally acting µ-opioid receptor antagonist (PAMORA) to be approved for this condition.

Opioids help provide chronic pain relief by binding µ-opioid receptors in the brain, but as the drugs also bind µ-receptors in the gastrointestinal (GI) tract, the associated side effect of reduced motility in the GI tract can occur. This leads to infrequent bowel movements and difficulty passing stools or evacuating bowels. Naloxegol has been designed to block the binding of opioids to opioid receptors in the GI tract while not impacting the opioid receptors in the brain.

It is anticipated that naloxegol will be on the market in the first half of 2015. The drug is also under regulatory review by the European Medicines Agency and in Canada.