Opinion: The Power of Numbers: Stand Up and Be Counted

Opinion: The Power of Numbers: Stand Up and Be Counted

Kurt W.G. Matthies

Kurt W.G. Matthies

Denying chronic pain, and therefore minimizing the nation’s pain problem, has become a preoccupation of the Anti-Analgesia Cartel, which now includes the CDC.

It is time to Stand Up and Be Counted for those who live with daily intractable pain.

Many of our readers may know that in 2011 a prestigious medical think-tank, the Institute of Medicine (IOM), published Relieving Pain in America: A Blueprint for Transforming, Prevention, Care, Education, and Research.

It says about 100 million experience chronic pain, a condition that costs the nation between $560 billion and $635 billion every year.

This statement points out a medical problem without precedent. Never before have we dealt with a pandemic involving 100 Million adults. That number is almost unimaginable.

The U.S. is the third-most populous country in the world.  Look around you. One in every three of the people you see live with a daily pain that interferes with their quality of life. Maybe that person is you?

Americans spend as much as $635 billion annually seeking the treatment of pain which is more than the cost of treating heart disease, cancer, and diabetes, combined. Relieving Pain in America asks the questions – what can we do about this, and how will pain impact medical costs in the future?

Our national response to date has been to deny pain, to remove people from essential treatments, to persecute the physicians who dare to treat pain with effective medication, to shame those in pain by calling them “addicts”, and to ignore the human consequences of daily, disabling pain.

This story examines some of the factors behind our deplorable response to these facts, and asks all Americans who live with daily pain to speak up and be counted.

What is the Institute of Medicine?

Our number one medical treatment for pain involves the use of medications called opioid analgesics, known colloquially (and legally) as “narcotics.”

The IOM statement calls for more treatment of pain. It is unfortunate that to some, this makes them sound like a group of hyped-up narcotics addicts, calling for greater addiction rates, criminal behavior, and deaths.

Is calling for the use of more and better pain treatment inflammatory, dangerous, and destructive propaganda, hell-bent on destroying all we hold near and dear? Well then we need to get the children in the house and call the police. Our enemies are at the gate advocating the destruction of our American way of life.

I’ve identified this radical group, and it feel that it is my duty to out them here and now. I’ve discovered that:

“The Institute of Medicine (IOM) is a division of the National Academies of Sciences, Engineering, and Medicine. The Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions related to science, technology, and medicine. The Academies operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. <emphasis: author>

Now we know who is behind this radical faction of narcotic pushers – Abraham Lincoln.

Yet, there are groups of trained medical professionals and others who strongly disagree with the IOM conclusions.

The National Pain Report has followed the controversy over the numbers of people living in pain in America since our infancy. We’ve titled those stories: The Numbers Game. While you can search for them on our site, I’ve listed them at the bottom of this commentary for your convenience. Consult them later for your information. For now, please, I want your attention.

The Numbers Game – Redux

This group that denies the IOM numbers claim that they are inflated, and frankly, absurd. Included in that group is our nation’s stalwart edifice against the spread of disease, the Center for Disease Control, known as the CDC.

This group – I call them: The Anti-Analgesia Cartel – is led by addictionologists, in other words, doctors who treat addiction, pharmacists – those men and women who are the gatekeepers of our controlled substance inventory, parents of children who have died of drug overdose – as a parent, they have my sympathy, but not my empathy. Also included are some neurologists, some interventional pain doctors, some orthopedic surgeons, and others whose net profit is reduced by the medical treatment of pain, or who wish to control “drugs” and eradicate their influence from the face of the Earth.

Perhaps there are some counted among this group who simply do not understand the suffering and disability millions of Americans must face every day of their lives. I’d like to believe that.

Let me say this: anyone I’ve known who fears the use of opioid analgesics for the treatment of non-terminal chronic pain, and who has then experienced chronic pain personally, or in a loved one, has come to understand that these medications restore lives. This new understanding changes their attitudes about the use of these medications in the treatment of pain and suffering that does not end.

Why do I use the word, cartel – is it hyperbole?

There’s so much more money in treating pain. Americans spend a half-trillion dollars more seeking treatment for pain than they do seeking treatment for addiction each year. Any business person would understand that there is a tremendous potential for the addiction business here, and hey – isn’t it great to have money?

I suspect that the strategy behind the numbers game of minimizing the number of people who live with daily pain is ploy of this “Cartel” to gain a larger market share of the annual American medical expenditure. In other words:

They want a larger slice of the pie.

The riches at stake are enough to cause a grumpy addictionologist to break into song …

As I walk along the Bois de Boulogne

With an independent air

You can hear the girls declare

“He must be a Millionaire.”

You can hear them sigh and wish to die,

You can see them wink the other eye

At the man who broke the bank at Monte Carlo. ***

There’s money to be made in converting our pain population to anti-abuse formulations of inexpensive medications, like the conversion of oxycodone to OxyContin, hydromorphone to Exalgo, and now, the transfer of all people in pain from medications known as opioid agonists (like morphine, oxycodone, fentanyl), to the partial opioid agonists (like the active drug in Subutex and Suboxone), that treat addiction problems.

An agency of the federal government, the Drug Enforcement Agency, requires a special license to prescribe these partial agonists for addiction, and in general, addictionologists possess this license, while your PCP and pain doctor probably do not.

So, is the use of the word Cartel, unfair? Look it up.

That’s the numbers game – minimizing the number of people who live with daily pain.

An Example of Cartel Strategy

The Cartel is clever and there is much at stake. In 2014, they challenged the IOM numbers in the respected journal of the American Pain Society (APS), Journal of Pain. Their challenge attempted to obfuscate the medical evidence presented in the IOM document, and further supports their assertion – pain is overestimated and over treated in America.

Their argument goes something like this:

How can there be millions in pain? Where are they? Why don’t we see them in our treatment centers? Why aren’t more people writing letters to the New York Times about inadequate pain care?

You see how they do it?

While these are valid questions, they’re not being addressed. However, the Cartel is “busy, busy, busy.”

In their last effort, the Cartel brought the 100 million figure down to a mere 35 million – as if 35 million Americans in who suffer daily pain that’s severe enough to seek medical attention, is a trivial event hardly worthy of our attention.

The IOM defends its research, including its numbers. The vast majority of pain experts, and their professional organizations, the American Academy of Pain Medicine (AAPM), and the APS, also agree with the IOM.

Enter the Center for Disease Control

The CDC in Atlanta, GA is our stalwart defense against infectious disease in America. We call them the CDC, and that name is held in high esteem in medical circles. But Atlanta has a PR problem, and it’s been the cause of changes in leadership, recommitment, and I imagine, greater thought to improving public relations.

The CDC has missed some major events in the prevention of infectious disease in America during the past 30 years.

  • They stalled on effectively dealing with the AIDS crisis.
  • They thoroughly bungled the fungal meningitis outbreak.
  • They shipped live anthrax to Korea (oops).
  • They failed in instituting protocols for keeping Ebola from our shores.

Their job is to defend against disease, and they’ve been embarrassingly incompetent of late.

In the early 1980s, when other countries like Australia were heat-treating blood products to kill HIV and other blood-borne diseases like hepatitis C to protect their citizens from disease America’s stalwart defender against disease met in conference and traded memoranda – for years. We played political patty-cake while we lost one-third of our gay male population and one-half of our hemophiliacs to AIDS and other HIV-related mortality.

I take that personally. One friend and coworker, a compassionate dialysis nurse named Jeff, whose story is told in a 1980 back-issue of the San Francisco Chronicle, died of HIV.

Here’s the other reason CDC bureaucratic tomfoolery angers me: I am a hemophiliac.

Severe hemophiliacs need regular infusions of blood products called “clotting factors” because they are deficient in these essential proteins because of a genetic disorder.

My condition is mild – my body can make only 20% of the amount of one (of 13) clotting factors required in the “coagulation cascade.” While I am fortunate that I don’t require regular infusions that severe hemophiliacs require, had I needed a blood product in during the years 1979 to 1984 in America, the odds are that I too would have succumbed to HIV.

Sources of further information on the hemophiliac/AIDS connection are supplied at the end of this document.

The other CDC bungles listed above are from more recent history and you are invited to read about them in the back pages of major newspapers on your browser.

In the mid-1990s, the beginning of the period known as the Decade of Pain, physicians came to their senses and treated more people with daily intractable pain using our best weapon against moderate to severe pain, opioid analgesics.

At the beginning of this decade, the CDC began to notice an alarming rise in deaths due to “opioid-induced mortality.” They documented this trend in a paper titled Vital Reports, published in 2008, that noted a 400% rise in opioid-related mortality during the period 1999 to 2008. They have been publishing annually on this issue ever since, and have made it a major focus of their mission.

Last year over 16,000 Americans died with an opioid in their blood stream.

Increasing Death Rates

Another statistic the CDC noticed is that opioid prescriptions rose at a similar rate during this period. They came to understand that together, the rate of opioid prescribing and opioid-related deaths rose, in tandem, and came to a shocking conclusion:

The rise in opioid prescriptions is causing a subsequent rise in the death rate.

This conclusion became known as “the Opioid Epidemic.”

In a country committed to a “War on Drugs”, the CDC appeared to have been getting it right.  They found an effect, and discovered an associated cause. Doctors around the country were alarmed to this deadly result, and the Decade of Pain came to an abrupt conclusion.

Treatment of long-lasting pain, so-called “chronic pain” with opioids, has deadly consequences.

The medical world reacted, and as a result, people in pain began to receive less analgesic medications containing opioids. Doctors who treat pain with pain pills were blamed for addiction and death, and were stigmatized. Vicodin and Norco, a prescription medication containing acetaminophen and hydrocodone (a medication once labeled to treat mild to moderate pain), was branded as a “deadly” or “dangerous” drug by the media, and in 2014, the FDA rescheduled this medication in the same class as morphine, hydromorphone, and the most powerful opioid medications in our arsenal against pain.

But very few “investigative” journalists questioned the medical industry’s reactionary move away from the safe and effective treatment of pain, and hardly anyone questioned the CDC conclusions.

Epidemic or Logical Fallacy?

The CDC claims that the rise in opioid prescriptions written for the treatment of chronic pain conditions has caused an increase of opioid-related deaths.

In logical terms, they claim that a rise in rate A, associated with a corresponding rise in rate B, means that A causes B.

Claiming causality between these two statistical sets may seem logical to many, but this is not science.

There is no evidence that the two statistical sets are related. Their only close relation is the word “opioid”, and a particular window of time.

Given these two corresponding data sets and the graph labeled Figure 2 in the CDC’s Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999—2008, November 4, 2011, this conclusion appears, to many, to be conclusive evidence.

Again, you’ll find a link to all documents used to support my argument following this story, in the section labeled Notes.

My training is in engineering and computer science. In my way of thinking, the CDC’s conclusion is invalid. They’ve fallen victim to an error in reasoning known as a logical fallacy. This particular fallacy has a name – a post hoc fallacy.

The data presented by the CDC appear to be related, but on closer examination, one cannot make the conclusion that “a rise in rate A, associated with a corresponding rise in rate B, means that A causes B.”

This is not how one reaches a scientific conclusion. Perhaps this point requires scientific training to understand my point, but we must base our medicine, and our legislation around medicine, on science. The Henny Penny declaration that the sky is falling due to the increase in the compassionate and medically-proven, safe and effective treatment of chronic pain with opioid analgesics is irresponsible.

I’m not the one voice in the wilderness who says so.

In reference to a Twitter discussion of this fallacy, a clever (and formidable) medical journalist wrote:

Absence of evidence is not evidence of absence.

Simply put, there is little evidence that a rise in treating pain with opioid analgesics has caused a rise in opioid-related deaths. Yet, the CDC has sounded a warning bell, and medicine is listening. Government is listening. The American people, thanks to incomplete reports like the one on 60 Minutes last Sunday night, and biased sensationalism in papers like the New York Times, they are also listening.

If you are interested in logical fallacy, Google will provide you with a host of examples. The study of logic is a lost art in our technological society where we depend on “experts” to do our thinking for us. Perhaps it should again become part of a public education, as it was when we were a great nation?

A respected rehabilitation and mental health specialist familiar to readers of the National Pain Report, Dr. Terri A. Lewis, PhD., characterizes the CDC’s conclusion as “a systematic error.”

She reminds us that not all states and counties have laws in place regarding death statistics. For example, where I live and in many other places in America the office of coroner is a political position and election to coroner does not require a medical degree or special training as a pathologist. Medical examiner opinion and autopsy are not required to report death statistics. The circumstances surrounding each death are unknown.

Instead, the system relies heavily on the OPINION of the certifying official or physician. If I were to die tomorrow of a lightning strike, I could be counted as an opioid-related death because I’m prescribed chronic opioid therapy for pain.

The system of reporting death in America lacks reliability and veracity. How can we rely on this method of reporting to make pronouncements on medical treatments, or pass legislation, Kentucky? ~~~

This is a tempest-in-a-teapot epidemic. The fact remains that more people die every year of NSAID poisoning. ^^^

The opioid-induced mortality figures need further investigation.

Dr. Bob Twillman, PhD, FAPM, and Executive Director of the American Academy of Pain Medicine (AAPM), in 2012 wrote a careful analysis and proposed a few reasoned arguments why the increase in mortality may not be related to the increase in compassionate treatment of pain and suffering. His paper is referenced at the end of this article for the scientifically inclined.

To date, further investigation has proven no connection between the two sets of statistics. In fact, there is additional evidence, some published as recently as the October 28, 2015 edition of the New England Journal of Medicine that demonstrates the recent five-year “crack down” on opioid prescribing has caused a large increase in the number of people using street Heroin.

Put that in your pipe and smoke it for sixty minutes.

Enter the Anti-Analgesic Cartel

The CDC has hired “experts” from the Anti-Analgesia Cartel to advise them on how to handle this “epidemic” of 16,000 deaths a year. Members of this Cartel belong to a group that believes opioid analgesics should be used for short-term care only. A few years ago, they tried to get the FDA to relabel opioids analgesics but failed. The Wayback Machine will give you an idea of the goals of this organization. If they had their way:

Poof – there went our strongest class of medication for treating chronic pain.

The legal prescription for the treatment of long-lasting pain with an opioid analgesic might become outlawed in the land of the free and the home of the brave, just like it is in today in state of Kentucky, by decree of a legislature of non-medical politicians. Their decision depended on the advice of “experts.”

How many of you are getting less “opioid-induced analgesia” today than you were five or ten years ago, and what has it done to the quality of your life?

Is there a hidden agenda here?

That’s a pretty cynical question?

But then I have had the unique pleasure of watching these people for many years. My perspective and experience with their message warns me to be skeptical of this group’s motives. They don’t give two hoots for the fact that I live with severe chronic pain.

So, imagine the transfer of wealth from the pain world’s $600 billion a year, to the addiction world’s $18 billion a year, more or less, if there were no opioid analgesic pain management medical treatments available in America.

Where would you be without your medication?

Just imagine the boom in treatment centers across this land. Where else would you go? Can you function without our pain medication? Is your opioid tolerance, like mine, so high that withdrawal would threaten your life?

Of course, if you’re an addiction mogul, like the non-profit Phoenix House, the concept can make your mouth water. Imagine the resources you’d control with a potential 35 million new patients.

Profits, not compassion for people in pain will drive standards of medical practice, backed up by the law of the land. Will Abe Lincoln rest more easily in his tomb, knowing that those “drug pushing doctors” are now out of business?

How can they do this?

If there are more addicts and less people with a legitimate need for pain medicine, they can and will take our medications away.

If they can insist that the rise in opioid prescriptions for people who live in daily pain causes the horrors of that psychological condition known as opiate addiction, in major media outlets like 60 Minutes and the New York Times, then America will believe that this is a fact.

The president will sign the End Heroin Addiction Act and go down in history as our greatest hero as a savior of all Americans from the ravages of addiction – prisons, institutions, and death.

Do we need this kind of savior?

Why it’s important to Stand Up and Be Counted – NOW!

Without my medication, I couldn’t sit here and write to you like this. I couldn’t shop for food, cook a meal for my family, or run the vacuum cleaner. I couldn’t play my piano, or play with my grandchildren. I would be in constant, unmitigated misery.

Hell, without my medication, I wouldn’t be here today – after 35 years of living with pain, and moderate to severe spinal stenosis in my cervical and lumbar regions that cause pain with every movement, an un-operable condition due to hemophilia, I’d be doomed to this life.

Do you think I’d want to hang around for much more of this torture?

Capisce?

Comprende?

You savvy?

Got it?

That’s why we need to be counted. It’s a numbers game.

How You Can Fight Back

Now, more than ever, America needs to hear from its tired, broken, suffering people who live with daily intractable pain and require strong pain medication to function.

We don’t need the meds because we’re addicts, but because we hurt.

We don’t need the meds because we crave the high, but because we need the analgesia.

We can’t let their new guidelines or their new initiative forget about us.

We are millions of Americans who need to speak with one voice.

That voice should echo a resounding NO across this land, while we are still free.

We are not lotus eaters. We are people who live with daily, overwhelming pain, and without our treatment modalities, we could not function.

Time to Stand Up and Be Counted, folks.

It’s Not A Hopeless Cause

So many of us are defeated before we’re started. You’ve lost your doctors, you’ve lost your medication. You’re already beaten.

It’s easy to click a link. I’ve provided the link to CBS news below. (Don’t forget to select the 60 Minutes show from the pulldown.)

You’re not going to be interviewed on 60 Minutes. Your email may be ignored. Your letter may go in the trash. No one will thank you, but me.

Do it. Keep doing it. Make noise, for crying out loud.

Make a nuisance of yourself and be heard.

Here’s an idea:

Persist to exist.

Can’t write?

Here’s a template:

I am an American who lives with severe daily intractable pain from a chronic illness. I need the pain medicines that my doctor prescribes to live my life. These are not “Heroin Pills” and do not contribute to any Heroin Epidemic. They are too few and too precious to sell or share, because they help me do the things in life that most people take for granted, like feed my family, bath my child, or fill in the blank…

How’s that? Can you copy, paste, add your own idea at the end about what your medicine lets you do, and mail it to CBS? How about to the other media outlets? Can you mail it to the White House? Your state representatives?

How much can you help yourself?

By the way, feedback to CBS news is: http://audienceservices.cbs.com/feedback/feedback.htm.

Don’t forget to select 60 Minutes as the show you watch above the comment box.

I think we can all do it. I believe that we must all do it.

Meet Your Ally — Social Media

Social media is a great equalizer. If you can, get on Twitter, and get on Facebook, and the other online places where people like us meet. The energy of fellow people in pain, whether their illness is obvious or invisible, is contagious. It fills me up. It lights my fire.

If we can see you there – we’ll see you there.

Twitter uses index words, or key words called “hashtags.” These words start with the hash mark or pound sign that looks like this:

#

I use the hashtag #chronicpain in almost all of my posts to Twitter. If you want to learn about chronic pain, search for that hashtag.

Another hashtag invented by a woman in daily pain is #chroniclife. I believe that we all know what that means. If we live in chronic pain, then we have a chronic life.

In Twitter, hashtags bind us.

There’s a hashtag for us: #NatPainReport.

Online, you’ll develop friends and people that you admire, via addresses. A Twitter address begins with the “at sign”, @ and looks like this:

@kwgmatthies

That is my twitter address. Use it. Tell me – I’m here.

Hi @kwgmatthies. I have #chronicpain and I agree. We need to Stand Up and Be Counted. #NatPainReport

That Tweet contains my address, the hashtag #chronicpain, and the hashtag for the National Pain Report. Copy and Paste.

Ed Coghlan is the very good man who edits this publication. His address is @edCoghlan.

When you open a (free) Twitter account, open a new tweet and say:

Hi @edCoghlan –I live with #chronicpain and read the #NatPainReport. Thank you.

That’s a tweet. Ed would love to hear from you. So would I, and so would the other people who feel as you do.

You doctors out there:

Hi @kwgmatthies. I treat #chronicpain with #opioids. Cochrane says they are safe and effective when ppl take as directed. #NatPainReport

I would be honored if you “follow me.” That means you subscribe to my musings on Twitter.

View a Twitter tutorial video – You’ll quickly understand what I mean and how to get started.

Social Media can bind us together, and help us to speak with one voice.

Let us know you’re out here.

Say: I am a person in pain, and couldn’t function without my pain medication. Don’t take it away!

Right now, if you want to count, and if you want to keep your prescription pain medicine, or you want it back, Stand Up and Be Counted.

You have a right to adequate, effective, safe, and medically proven pain control.

But today, you have to fight for that right.

It’s a mean, ignorant, and greedy world out there for people who suffer with daily pain.

United we can defeat those who call us addicts and would take our medicine away.

Thank you.

@kwgmatthies

#NatPainReport

#chronicpain

#hemophilia

#opioids

#CDCTruth

#MedX

Notes:

The Numbers Game and The Numbers Game, II:

http://nationalpainreport.com/the-numbers-game-how-many-americans-have-chronic-pain-8814224.html

http://nationalpainreport.com/the-numbers-game-ii-how-many-americans-have-chronic-pain-8825066.html

 For the Story of Hemophilia, AIDS, and the CDC (1982-1985):

http://www.hemophiliafed.org/news-stories/2014/03/1980s-hemophilia-hivaids-hepatitis-c

http://www.hemophiliafed.org/news-stories/2014/03/1983-cdc-holds-summit-on-aids

Kuhn, Dana, PhD, The Trail of Aids in the Hemophilia Community, Committee of Ten Thousand.

Leveton, Lauren B. (Ed), Sox, Harold C. (Ed), Stoto, Michael A. (Ed), HIV and the Blood Supply, An Analysis of Crisis Decisionmaking, IOM, National Academy Press, Washington, D.C., 1995.
http://www.nap.edu/read/4989/chapter/1

http://www.nap.edu/read/4989/chapter/2

CDC Vital Reports

Figure 2: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm#fig2

http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/

 Dr. Bob Twillman’s:  What’s Really Driving Opioid-Related Death Rates? (2012):

http://updates.pain-topics.org/2012/01/whats-really-driving-opioid-related.html

From the New England Journal of Medicine: October 29, 2015

Shifting Patterns of Prescription Opioid and Heroin Abuse in the United States, N Engl J Med 2015; 373:1789-179 DOI: 10.1056/NEJMc1505541

http://www.nejm.org/doi/full/10.1056/NEJMc1505541?query=featured_home&

The Wayback Machine:

https://web.archive.org/web/20130126094558/http://www.supportprop.org/about/faqs.html

Medical Education in Pain

Our medical schools are negligent educating physicians in the most common complaint seen by primary care providers – the neurophysiology and treatment of pain. As Judy Forman described, in her excellent book A Nation In Pain (2014), the average veterinarian receive more training in pain treatment, about two weeks, than the average physicians, who receives eight hours of training in a four-year medical curriculum.

Footnotes:

*** From Gilbert (and Sullivan) – The Man who Broke the Bank and Monte Carlo.

~~~ From private correspondence with Dr. Terri A. Lewis, PhD. Thank you Terri, for generously sharing your special knowledge of mortality rates, specifications for standards of death, and other information essential to the facts presented in this story.

^^^ Data follows from the American Chiropractic Association website. http://www.acatoday.org/content_css.cfm?CID=2428

“A more recent study published in The New England Journal of Medicine estimated that at least 103,000 patients are hospitalized per year in the United States for serious gastrointestinal complications due to NSAID use. At an estimated cost of $15,000 to $20,000 per hospitalization, the annual direct costs of such complications exceed $2 billion. This study estimated that 16,500 NSAID-related deaths occur among patients with rheumatoid arthritis or osteoarthritis every year in the United States. This figure is similar to the annual number of deaths from AIDS and considerably greater than the number of deaths from asthma, cervical cancer or Hodgkin’s disease. If deaths from gastrointestinal toxic effects of NSAIDs were tabulated separately in the National Vital Statistics reports, these effects would constitute the 15th most common cause of death in the US.

Special thanks to all who reviewed and offered suggestions on this project. I couldn’t have done it without your careful attention to detail through multiple revisions. I am humbled by your generosity. You have my greatest respect and affection – Kurt.

The opinions expressed in this commentary are those of Kurt W.G. Matthies.

Copyright © 2015 by Kurt W.G. Matthies and National Pain Report

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Authored by: Kurt W.G. Matthies

There are 22 comments for this article
  1. Kristine (Krissy) at 8:47 am

    DMarie, there are thousands of us in your situation who are working very hard everyday, giving up our time and the little energy we have, to work on getting the word out that chronic pain patients, for whom opioids work, need their meds. We are against the CDC and any other government agency playing doctor, and we are in your shoes. When you read a news article, that’s just what it is, news. It doesn’t have anything to do with an individual’s opinion. Please look on Facebook and you will find hundreds of pages that deal with this issue…and that’s only Facebook. We’re out there and if you want to help you certainly can! There is a lot to be done. Write the presidential candidates, write senators and other members of congress, write to TV stations and newspapers. This is what we are doing as advocates for the fair treatment of pain.

  2. DMarie at 7:23 pm

    I am INFURIATED by your VERY BIASED, MISREPRSENTATION regarding “The Opioid Epidemic” airing! I am a disabled American who lives every single day of my life dealing with severe intractable pain from several chronic illnesses. The pain medicines that my doctor prescribes, is what enables me to live my life!! It enables me to do the laundry carrying the baskets up/down the stairs, to go to the grocery store & carry the bags in the house & to make dinner, to change the sheets on the beds.. it enables me to LIVE my life!! NOT being confined to my bedroom,in bed and in tears watching life pass me by, with nothing to look forward to accept, another day/night of debilitating pain to where you don’t even want to face the days anymore!! These opioid medications are NOT “Heroin Pills” and they do not contribute to ANY Heroin Epidemic. (The CDC has come under a great deal of fire due to their statements & secretive/biased report findings.) Secondly, there are chronic pain patients and then there are the drug addicts/abusers. I have some enlightening news for everyone: People who take opioid medications to help control their chronic intractable pain, ARE NEVER GOING TO SELL/GIVE their medication to ANYONE BECAUSE, THAT IS THEIR RELIEF, that medication is their LINK to being able to function and provide SOME “NORMALCY” to pain patients lives & provides patients with a Quality Of Life we otherwise would never have!!

    One of the many, infuriating aspects to all of this is that:

    •The Government should NOT BE THE ONES WHO IS DETERMINING what my medical treatment choices are!!
    •Unfortunately, the way the Government agencies like the CDC & DEA have handled this “Epidemic,” the ONLY THING they HAVE succeeded IN, is REMOVING ACCESS TO OPIOID MEDICATIONS THAT LEGITIMATE CHRONIC PAIN PATIENTS TRULY NEED!

    •If the Government Restrictions/Laws continue in this direction, REST ASSURED,THE Next 2 “REAL” EPIDEMICS the Government will be facing
    is: An overwhelming EPIDEMIC IN ALCOHOL & STREET DRUG USE, due to the millions of pain patients who have gone under-teated & leftuntreated, & are now DESPERATE for ANY FORM of pain relief. I can also ASSURE YOU of an ALARMING INCREASE IN THE SUICIDE RATE, especially, of long time chronic pain sufferer’s!!
    People who have NEVER SUFFERED CONSTANT, OVERWHELMING, DEBILITATING PAIN, HAVE ABSOLUTELY NO IDEA WHAT A TOLL IT TAKES, not only on your body but, your mind and your emotions as well. When you have severe pain that is not controlled properly, is DOES TAKE OVER EVERY ASPECT OF YOUR LIFE!

    In closing, I do not condone any illicit drug use & take no issues with combating illegal drugs which are sold/taken for no other reason than “to get high.” My issue, is with the new Laws, Regulations & Guidelines (being conducted behind closed doors, without disclosure) that has resulted in taking away life altering opiod treatment medications from the very people who need it most!! Finally, I would bet almost anything, that if any of these Doctors (ie. PROP), Pharmacists & other professionals on these Boards/Committees had to endure a Severe, Life Changing condition every day for the rest of their lives, or, watch a close loved one endure unrelenting pain every day unable to attain relief, their opinion of opioid medications & their use would change drastically in no time!

    Unfortunately, the OTHER SIDE of this story…”The Chronic Pain Patients Story” and this (60 Minute) email will probably never see any “air-time” or even a response. However, you NEED TO KNOW HOW DRASTICALLY THESE NEW LAWS & REGULATIONS ARE NEGATIVELY AFFECTING THE LIVES OF MILLIONS OF LEGITIMATE, CHRONIC PAIN SUFFERER’S AND THEIR ENTIRE FAMILIES!

    Case in point, refer to the article below on famous Nascar driver Dick Trickle, who committed SUICIDE because of insufficient pain relief. It is followed by numerous comments from pain patients who are also feeling hopeless, useless & suicidal due to uncontrolled chronic pain:

    NASCAR Legend’s Chronic Pain Led to Suicide
    Posted on May 18, 2013 in Diseases & Conditions
    The pain was so bad he killed himself.

    Its something that happens all too often, unrelenting chronic pain that causes someone to commit suicide.

    That’s what happened to retired NASCAR driver Dick Trickle this week. His brother Chuck told ESPN by phone from Las Vegas that Dick told him, “I don’t know how much longer I can put up with this.”

  3. Lauri at 3:00 pm

    New drug for abusers
    A now common medication that even my doctor is trying me on. Having bad side effects.
    I have said it befor and I will say it again. Abusers will abuse whatever may get them high! Again my first thoughts and words were are they going to take all of our meds away for because of the abusers ?
    http://www.medscape.com/viewarticle/855819

  4. Sara Batchelder at 4:46 am

    Here is my note to 60 Minutes. I am contemplating starting a FB and Twitter group, “The 100 Million Pain Patient March on Washington”. What do you think? It’s probably already “too late” (propaganda can take 100 years to disseminate), but better late than never. And it feels good to speak out. EVERYONE needs to speak out. When the President’s office forwards your well-thought out, pissed off letter to a suicide prevention hotline (happened to me this week), get back on the computer and tell them that they were wrong to do that. Go to Washington. Call your Congresspeople. Demand a meeting with them. If they give you a meeting with their staff, great. Go to that. Email them every day. Pain patients are intelligent, ingenuitive, productive, hardy people. Let’s prove it. And let’s do it TOGETHER. We need a group, a lobby, a union, a whatever…. Let’s do it right – sit down together, figure out what we need, and go get it.

    To 60 Minutes:

    I am very dismayed by your coverage of opioid pain medication and the false “opioid epidemic”, I know that there are addicts out there who have taken advantage of prescription medicine. Pain patients, more than any other community, want addicts to stop abusing our meds and creating an “epidemic” where there is no epidemic. (BTW, these addicts will be dying in droves when they switch to heroin, which is illegally sold by drug dealers and cut with who knows what. And my understanding is that heroin doesn’t come in a bottle with standardized doses, but what do I know? I’m a pain patient who has never bought or used heroin. And doesn’t an increase in heroin usage support poppy growers in the Middle East, many of which we are trying to fight? Those we are not trying to fight have had their homes destroyed by our bombs and probably can only make a living growing poppies. Is heroin better than synthetic, regulated opioids with doctors and pharmacists as gatekeepers? I think not.)

    You are investigative journalists. Do your job. It doesn’t take a genius to realize that the heroin overdose epidemic is going to get so bad that the gov’t, media and American people may realize they made a mistake. If you don’t figure out what the actual problem is to begin with, then you use media outlets to propagandize your incorrect assumptions without asking the opinions of the stakeholders, then you are going to seriously make yet another mistake. But I guess that’s what the government does Remember the War on Drugs? This is the new War on Drugs. Period. I guess they realized that they lost the battle on marijuana, so what can we waste time, money and LIVES on next?

    Pain patients are pain patients. Addicts are addicts. We need thoughtful, creative solutions to these problems. And we need everyone at the table. You are propagandizing a very important issue. I would appreciate a follow-up to your story from the pain patient and pain doctor point of view. Start with the National Pain Report – they will know who you should contact. Call me. I’ll tell you my story. I graduated at the top of my class when I worked my butt of getting my MBA. All while on small doses of opioids for when I had a migraine. Then get the perspective from the 100 million pain patients in this country. Opioid medicines are safe. Pain patients don’t feel a high. Many of us, who don’t have non-opioid alternatives, cannot function without them. BTW, if we had an alternative that worked better than opioids, we’d use it. 100% of the time. Period. Please tell EVERYONE’S story.

  5. Lisa flahardy at 4:03 am

    Great article. People need to understand their is a difference between dependent on a drug to function and addiction. We need to stop punishing those who suffer from chronic pain because of drug addicts. The addicts will find something to get their high from they always do some use draino. Don’t take away my husbands quality of life because some have made bad choices and become a drug addict.

  6. Scott michaels at 7:17 pm

    We need to win this war waged against us. Although I am very concerned about my own future, I am more concerned with those that are unable to speakup.
    Our elderly population and our Vets. How many of our military personal come back from war disabled. How many elderly have been living quality lives because of opioid pain medication. It worries me that our military personnel will end up on the streets just like after Vietnam. They will need to look for pain relief ON THE STREETS because our own V.A. wont help them.
    The elderly on the other hand will give up, thats just sad. Its already happening in states like KY,WA and CT. suicides and heroin deaths have increased dramatically. Its no coincidence that these states have made it extremely hard to manage pain. People must leave the state to get the medication that works.
    Now back to me, having the spinal issues I have, caused so much pain i couldnt even get out of bed. About 9 years ago I was put on disability. I had a choice, 3 surgeries or live or live on pain medication the rest of my life. I would have taken the surgeries but after speaking with several doctors and recipients of the surgeries, all patients said they hurt more then ever and they still need the pain medicine. I went thru physical therapy, 3 epidurals, injections, electro something or other and a multitude of psychobabble. NOTHING WORKED!. I decided on the pain medication. That too wasnt working, my doctor continued to increase the dosages. Finally after about a year we found the right dose. I was able to work again, dress myself and have a blessed life. As time went on my Dr. Kept switching my medication so i would not become too tolerant to any one medication. After a couple of years the DEA started to give him a hard time because of my doses. He had me take a metabolism test. This verified what he knew. The medication goes right thru me. A high dose affected me the same as 4 low dose pills affested another patient. Unfortunately my spine is getting worse so I am not as good as I was. I live with pain 7 days a week. It usually measures 4 to 9 depending on the weather. I am unable to work, but i do get out of bed and dress myself. Best of all I dont feel like I am being stabbed in the spine most of the time. I am living proof that 1 dose doesnt fit all. We are all different and have different needs. I take my meds as directed, this prooves that I am not a person seeking to get high. Actually this medication never altered my mind. Once i was told to take muscle relaxers too. That messed me up. I never mixed again. That prooves that when a chronic pain patient takes only the opioid medication and does not mix with other medications AS DIRECTED, a normal life is to be had.
    The problem where i see it lies with people who start pain medication for ACUTE pain and like the way they feel. They take more and more, then they mix with anything searching for the original high. Doctors can not be to blame when a person says theyre in pain and they prescribe opioids. But if the doctor goes the extra step, like mine does and makes me take a urin sample and has a contract with the patient, Over prescribing will halt. If a patient has any other med in their system then its over they get 1 warning, then if it happens again, too bad. I also think that alcohol should also be avoided, that is the most dangerous drug, PERIOD!
    With all of the B.S..stats and reports i have read, and i have read ALOT, NOT 1 CHRONIC PAIN PATIENT THAT TAKES THEIR MEDICATION AS PRESCRIBED HAS ENDED UP OVERDOSING OR DYING.
    THE MILLIONS OF US THAT DO THE RIGHT THING WOULD APPRECIATE IT IF THE CDC,DEA,PROP,REHAB CLINICS AND INSURANCE COMPANIES LET US BE!.
    THE GREED OF THE INSURANCE COMPANIES AND REHAB CLINICS AND PROP SHALL NEVER INFLUENCE ANY GOVERNMENT OFFICE.
    THE DEA NEEDS NOT ATTACK ITS COUNTRIES WEAKEST CITIZENS. BECAUSE THEY CANT FIX THE REAL PROBLEM, HEROIN AND COCAINE COMING OVER THE BOARDER THEY NEED TO LOOK LIKE THEY ARE CAPABLE OF SOMETHING. ITS LIKE A BULLY ON A PLAYGROUND. THE CDC SHOULD NOT BE SO NIAVE TO BELIEVE WHAT INSURANCE COMPANIES AND REBAB CLINICS SUGGEST, THEY ARE ONLY CONCERNED ABOUT THE MONEY THEYLL MAKE OR SAVE. THE FDA NEEDS TO STAND UP FOR THEMSELVES. THESE MEDICATIONS WERE PROVEN DECADES AGO, THEY WORK. THEY APPROVED DRUGS THAT HAVE HELPED MILLIONS AND MILLIONS OF PEOPLE. BECAUSE A FEW KNUCKLE HEADS ABUSED DRUGS IT IS NOT YOUR FAULT. HAVE STRENGTH AND FAITH IN YOUR CONVICTIONS. YOU MUST FIGHT WITH US. THE PEOPLE THAT OVERDOSED AND DIED IS THEIR FAULTS, THEY MADE THE CHOICE TO PUT ONE PILL IN THEIR MOUTH, NOT TO REDUCE PAIN, BUT TO GET HIGH. THOSE PEOPLE WOULD BE DRUG ADDICTS IF THESE PILLS WERE NEVER AVAILABLE. It starts with booze and pot. Ithey need more of an escape they try cocaine or heroin. All of the above were around long before oxycodone and vicodin AND BASED ON THE DEA’ S LACK LUSTER PERFORMANCE THEY WILL BE AROUND FOREVER.

  7. Sandy Auriene Sullivan at 11:27 am

    Oh I do know how current deaths are recorded – if I died right now? I have 2 controlled substances in my system. One for pain and one for anxiety.

    If it isn’t a heart attack or cancer et al they will record it as “multi-drug toxicity” and that’s that…

    Friend of mine died on the Fentanyl patch. She should never have been prescribed it. She had other issues besides. I suspect a leak as I suffered through a leak and survived *AND* it was the ‘new’ patches but during the high profile lawsuit which I couldn’t join as I was alive. Irony. I nearly died and the hospital did not know to give naltrexone for it. They did not know fentanyl [the only approved patch for chronic pain in the US] was a synthetic opiate and didn’t treat me for it.

    My ‘od’ from a bad patch – and it was a bad patch – 72hrs of med [just put it on!] dropped into me in 3hrs. To cover for their negligence [that’s another story] they put me on a geriatric ward [was 34 lol] and ‘observed’ me until the psychiatrist released me.

    In 2012 when my friend died [online she was in s. Florida] she too felt sleepy while visiting a relative [just as I was..] she laid down before she had to drive but in her case the relative didn’t check on her for several hours and she was long dead by then. In my case my then 2yr old was hitting me over the head with a metal toy truck and my sister said “NO WAY she could sleep through that…” came over to check on me and saw I was turning blue. Called 911 and EMT removed the patch. Woke once in ambulance and didn’t wake again for 8-10hrs. Had 7 seizures and ‘died’ 4 times.

    They were testing patches when *I* nearly died; not so in 2012 as they claim the new ones are safe. I’ve discussed this with my doctor and had to lay it out. 2 controlled substance = multi-drug toxicity. THAT is IT. Unles the family requests it.

    I’m a proponent of every CPP having the OD epipen for obvious reasons. Doc and i disagreed on it too YEARS ago. Then the state of FL started to tell physicians to offer it. He didn’t apologize to me; he didn’t tell me about it and he didn’t hand it to me. His nurse did with a smile.

    He’s my captive audience while Im on the table for injections just as I am his….45 min aprox good time to talk.

  8. g at 11:25 am

    Its amazing my insurance co dictates what i can have and how much for my pain, not a dr. They will allow meds that interfere with kidney function, liver function, and make me suicidal, meds used off label. They’ll give me opiates with acetaminophen (I’m allergic) but not without. While limiting how much pain control they will allow many states are now considering letting drs assist in suicide. A cheeper solution i guess.

  9. I.Hollis at 10:11 am

    Thank you Kurt W. G. Matthies this is amazing and you speak the truth for all of us in pain!
    I would add another issue ” the Epidural Epidemic” and $$$$ also adding to patient harm and further pain.
    Thank you Ed Coghlan our family lives with chronic pain and we read the National Pain Report!!

  10. Sandy Auriene Sullivan at 9:34 am

    Hello again! BL “If he is drug tested and there isn’t any of the drug in his system that will cause problems.”

    Yes it will. But it should only cause issues if it returns from the lab negative. The in office dipstick is not difinitive. FAR from it.

    2013-2014 [change in 12hr tablet is primary cause, body mostly dumps it!]

    was put through *pure hell* by my doctor [still my doc too!] for negative in office tests. I know I am taking my meds as prescribed and they should be there. I have been with him since early 2011.

    He finally gave up when he did a spit test on me [fast metaboliser] and I personally requested from a testing clinic with no connections to the testing co my doctor’s office used a blood test to check levels in my system, offering to pay cash right after leaving an appointment.

    In fact 1 time it came back from the lab negative; the doc’s called me in for another [mind you I was being tested up to 3-4 times a MONTH] random screen and it came back fine. But I cannot stress this enough – LAB results are the only ones worth their salt. In office tests are not definitive.

    To the editors please read this Fed court case Ameritox v Millennium RE booth backdrop test. Legally a doctor cannot label you as a med abuser by in office testing alone. Not anymore – the patient has recourse to have any reference to UAs scrubbed from records. Only returned lab results are admissible http://americannewsreport.com/wp-content/uploads/2012/06/Millennium-vs.-Ameritox.pdf

  11. Sandy Auriene Sullivan at 8:59 am

    Sadly the answer to the problems we face in the US quest to deny our existence lies in this sentence “$635 billion annually seeking the treatment of pain which is more than the cost of treating heart disease, cancer, and diabetes, combined.”

    Is it any wonder then as we have no large foundations like cancer, heart disease and diabetes behind us that they are trying to HIDE us? It is always about the $$$

    Of course 100 million people in CP doesn’t mean all are on or even seeking opiate therapy but that therapy should be there for those who need it. It is my humble belief that treated properly early saves people from CRPS.

    It’s depressing to think about. Australia is trying to improve how they treat pain while the US backed by private insurance cos who have to pay the bills can avoid caring for us they will. [if you are insured, even under state or Federal you use a private company which costs more.]

    There is a LAME statement going around chronic pain offices that state “pain won’t kill you” I corrected a doctor, nurse and PA about it. Told them no, it may not kill directly but indirectly? It’s more lethal than you’re acknowledging. You’re a pain clinic stop diminishing how people FEEL. [they took the pain doesn’t kill sign at their desks down!] Signs in office waiting room have gone up that say ‘No whining’ and I told my doc – we wouldn’t have to whine if you talked to us like humans with REAL problems and not approach each patient from the standpoint that they’re drug seekers.

    I can go on and will very soon send my story in. Just had some major tests so it’s better that I had waited. I see the pain specialist Thursday. Maybe Friday I can finally get my story out of me. Thursday I also plan on going to a townhall with my Fed Congressman [the large animal vet] and again speak up for ALL of us.

  12. Whitney at 8:34 am

    Thank you for writing this. I’ve had a lot of trouble with my pain issues and trying to get treatment. I’ve had two surgeries to try to correct (really just limit) abdominal adhesions. Every doctor I’ve been to has treated me like a drug addict. Heck, seven days after my second surgery my doctor tried to switch me to ibuprofen! This is getting ridiculous, my primary care doctor is now sending me to a pain management specialist. Hopefully I can get some decent treatment there. Over the course of this year and last, I have been put on Gabapentin, Luria, Cymbalta, the list goes on. Each one has had awful side effects for me. Luria and Gabapentin both gave me paralysis problems in different areas. (This is seriously supposed to be better than vicodin?) Everything else caused severe mood swings with depression, resulting in me being put on anti-depressants as well. I do not understand why I keep having to play these loop the loop games with medications, when I had already found one that worked and didn’t cause me to vomit all day or cry myself to sleep. Thank you for being a voice and giving me some place to write my story.

  13. keith at 8:10 am

    Very well said!Thanks to all of you that work behind the scenes to give us a voice!an thanks for all the links,i added CBS in my favorites,along with the White House info.GL to you

  14. Mark Ibsen MD at 12:20 am

    Thank you again for a most cogent, in-depth summary of the so called problem of The Opiod OD epidemic that never was.
    We should also acknowledge that some of the anti opioid Ferver comes from the interventional pain doctors who claim to run “multidisciplinary” pain clinics.
    Except they are mono-disciplinary:
    Interventions only.
    They claim that they treat pain, then fail to treat it.
    What if cardiologists said ” no catch for you, keep your angina”
    You are doing great work.
    We are.
    Keep it up.

  15. Kristine at 5:32 pm

    Priscilla. What state do you live in? If it’s Florida or Minnesota I can help you. Otherwise, take BL’s comments to heart. He has good suggestions.

  16. BL at 5:01 pm

    Priscilla Reese, has your husband taken a copy of his medical records with him to give the pain management dr ? Maybe he could discuss taking extended release meds for his pain managment. Has he ever been dismissed from pain management ? Sometimes it just takes time to find the right dr. You have to usually stick with one for a while to see what they will and won’t prescribe. If he is drug tested and there isn’t any of the drug in his system that will cause problems.

  17. Priscilla Reese at 4:47 pm

    My husband is a chronic pain sufferer. He needs pain meds more than the normal person. He has: Rheumatoid Arthritis, Lupus, Chronic Pancreatitis, Fibromyalgia, and many more diagnosed conitions/health issues. To tru and get sufficient pain meds is like pulling teeth. He gets enough for 1 week, then, has to wait a whole month to get more. I see him suffer daily, needlessly. His daily activities are zilch. At least, when he has sufficient meds, he can do something. It’s not fair that he had to suffer so much, when there is pain medication available. He has gone to 3 pain mgt clinics, and was given a Butrans patch. It does nothing, but, give him severe back psi, (how ironic), rashes, constipation, and insomnia. What sense does that make? The stigma with the pain abusers has reached to all levels. The old adage apliez: one bad apple spoiled the whole bunch. This needs to be reversed. With all of the advances in science, and the medical field, NO one, with ALL of the documented illnesses that My husband has should have to suffer.

  18. Kristine at 3:25 pm

    BL, the data on death due to prescription medications are not available in one trusting source. There are no specialized nor mandatory reporting on causes of death. Not all bodies have autopsies done, as you know, and even then, reports are not well-documented. I find this very strange, but it’s the case. I believe there is another article recently published on NPR that goes into more, and very interesting detail. I don’t know much, but I want to look into this further also.

  19. Kristine at 1:20 pm

    Kurt, you are my hero. If we were in the same room, I believe I would do more than shake your hand, I would bow in your mere presence. Thank you for writing this — it has been, what I’m sure — an exhaustive effort while living in chronic pain. Thank you for dispelling the research that I have not trusted for so long. Thank you for highlighting the research that we all know to be true. Thank you for crying PARTICIPATE NOW to our fellow pain patients. Six months ago I said to a friend, why don’t we just create a huge national publicity effort so that we can be heard. Let’s call out the enemies and put them away. Let’s let our family and friends know how it really feels, and why we are afraid to come out and play. Let’s scream and holler so that they really hear us this time. Well here we go!

    And regarding pain clinics, the first one I was sent to was many years ago. I was mortified, but went through with it. The second pain clinic I was sent to, I had a loud, screaming outbursted argument with the doctor right where everyone in the whole building could hear me. Then I figured it out; pain clinics were popping up everywhere to get us off opioids! It was a new business, a new opportunity, to do what? MAKE MONEY. Yes, they were trying to cure us with talk therapy and PT. The next time a doctor tried to get me to go to a pain clinic, I absolutely refused and said I’d never go to one again. How may of them have gone out of business? I wonder, because it is just a matter of time that our fellow pain sufferers catch on and Just Say No.

    Now I will agree that pain clinic-types have a purpose for those who have a big surgery or injury and have never lived with more than a headache before. They may need to rehabilitate. But this can be done in the doctor’s office with maybe one referral to a specialist. We don’t need big, fancy buildings with waterfalls and glass ceilings to tell those of us who are on long-term opioids we are on the wrong path.

    I will read and re-read your article, and I will share it everywhere I can.

    Your new friend (and fellow writer),
    Krissy

  20. BL at 11:49 am

    Kurt W.G. Matthies, I often wonder how the number of deaths attributed to pain prescription overdose/misuse has come about. Is an autopsy done or do they just go by if the person has a prescription for narcotics ? If an autopsy was done, what were the results and the blood levels of all the drugs in that patients system ? Are illegal drugs and alcohol also in the person system ? Did they have a terminal illness with a short life expectancy given ? Were there other health condition such as cardiac problems that they were being treated for in addition to the chronic pain ? I do a lot of reading and I have only found one place where anything was said about there not being details regarding some of the deaths that were attributed to prescription pain meds and that was a government source that made that comment, but I only saw it made once in that report. I wonder what types of tangable evidence the powers that be had and have when they determine the number of deaths attributed to prescription pain meds.

    I also wonder about the number of Americans that have chronic pain. These numbers don’t distinguish between the ones that have chronic pain but don’t need anything more than an over the counter med, those that only need a prescription pain meds once to several times a week and someone that needs prescription pain meds 24/7 in order to do activites of daily living and those in between.