States of Pain: Part II. The Influence of Regulations

States of Pain: Part II. The Influence of Regulations

By Terri Lewis, PhD.

Dr. Terri Lewis is a rehabilitation educator, clinician and researcher who specializes in chronic pain and is a frequent contributor to the National Pain Report. Dr. Lewis is writing a series of articles in September that address the big issues facing chronic pain and chronic illness patients. This is her is her second installment, her first installment can be found here.

Let’s Continue to Review the Experiences of Marlene and David-

Terri Lewis, PhD

As we have learned, Marlene, a single 42 year old woman who resides in Indiana, has lost her second leg to an amputation caused by an undetected blood clotting disorder. She has a history of substance abuse but has been free of its’ effects for four years. She presented to her local emergency room for pain related symptoms after experiencing a tearing sensation while lifting her wheelchair in her vehicle, followed by excruciating acute pain.  Her first presentation to a local ER resulted in ER personnel conducting an evaluation, then dismissing her to her home and self-care after her immediate injury was labeled as a hematoma with bruising, and after she was labeled as drug seeking based on her prior history. Pain and symptoms progressed however, so Marlene sought crisis care from her local mental health center which, after an assessment for SUDs and suicidal ideation, returned her to an ER in a second hospital.  ER number 2 conducted a CT scan but again dismissed her after noting that she had been admitted from the mental health center where she was assessed for suicidal ideal and substance abuse during the course of her brief stay. Moreover, Marlene who has documented pain generating disorders in her medical records, was developing blood clots that formed in her remaining leg from the undefined abdominal hematoma. Two ERs and one mental health assessment later, her health crisis was finally properly identified after a series of miscommunications, documentation errors, and mistakes in reading tests and imaging. Marlene was admitted into the ICU on an emergency basis, where her abdominal bleeding and clots were properly diagnosed, and where ultimately, her remaining leg was removed. After Marlene’s amputations and a brief hospital stay, she was discharged to her home with a 7 day prescription for opiates which her insurer, Humana, refused to authorize because opiates are no longer covered on her dual Medicare, Medicaid policy.  Recommended substitutions were contraindicated for her rare blood clotting disorder. Marlene borrowed $400.00 from her family members to obtain 7 days of minimum relief.  Her next appointment is on September 26 where she will be evaluated for possible changes to the medication that controls her blood clotting factors. Her aunt is providing close supervision and support.

David, 38, is a young father of three, a five year survivor of the fungal meningitis outbreak.  Still suffering from the effects of his exposure to contaminated epidural injections, he has been diagnosed with headaches, photophobia, tinnitus, adhesive arachnoiditis, fibromyalgia, and polyneuralgia.  David lives in West Virgina, a state that has agressivly battled opiate addiction.  David has been dropped from care by both his primary care physician and his pain management clinic as ‘too complex’ because of his high dose regimen of opiates.  Lacking support, he consulted with a neurosurgeon who recommended and installed a pain pump which resulted in 3 unsuccessful surgeries for pump reconfiguration and a blood patch.  The CSF leak remains. His daily morphine equivalent dose has been reduced to 40 MME of dilaudid, with no other medication assisted support – insufficient to reduce his pain levels.  He is not supported by any oral medications for breakthrough pain.  He spends 20 of 24 hours per day in a reclining position in a dark room. Parenting is difficult. Suicidal ideation is real.

The Influence of State Law, Regulation, Location

So we have two very different but similar cases to consider.  And as we consider how their intervention has developed, we begin with the basics – how do the definitions codified in state pain laws influence what has happened to the care they have received within their state?  State medical boards and legislatures considered a number of guidance documents in responding to the crises within their states – the Federation of State Medical Board (FSMB) recommendations, CDC Guidelines (March, 2016) and their own statistical analyses regarding overdoses, deaths, prevalence of illicit drugs on the streets of their cities, and the numbers of prescriptions for schedule 2 narcotics issued over a period of time.

The FSMB contains a number of definitions related to both pain and addiction.

How these influence the span of treatment design within each individual state is clear. For instance, the FSMB adopts the following definitions of pain –

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.  Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.”

Indiana has adopted the following definition of chronic pain, omitting the terms pain, acute pain, and intractable pain, or any other definition of pain

“Chronic pain means a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.   (b) Notwithstanding subsection (a), this section and sections 4 through 10 of this rule shall not apply to the use of opioids for chronic pain management for the following: (1) Patients with a terminal condition. (2) Residents of a health facility licensed under IC 16-28. (3) Patients enrolled in a hospice program licensed under IC 16-25. (4) Patients enrolled in an inpatient or outpatient palliative care program of a hospital licensed under IC 16-21 or a hospice licensed under IC 16-25.”

West Virginia on the other hand, has adopted more inclusive definitions in their state pain regulations which distinguish the functions of pain care and read as follows –

Chronic pain” means pain that has persisted after reasonable medical efforts have been made to relieve the pain or cure its cause and that has continued, either continuously or episodically, for longer than three continuous months. For purposes of this article, “chronic pain” does not include pain directly associated with a terminal condition. And this, “intractable pain” means a state of pain having a cause that cannot be removed. Intractable pain exists if an effective relief or cure of the cause of the pain: (1) Is not possible; or (2) has not been found after reasonable efforts. Intractable pain may be temporary or chronic.”

To make these definitions usable means that we have to interpret them through information captured during medical interviews. Generally speaking the FSMB definition is somewhat nonspecific and tangled up in making sure that opioid users don’t become addicts, as is the Indiana definition. The West Virginia definition includes not only chronic pain but intractable pain and treatment. It also specifies these terms in relationship to care conditions related to chronicity versus death and dying.

Each of these definitions must be interpreted and applied through a review of medical records and the information gained through evaluation of the patient.  Regulations place an emphasis on physician evaluation activities within each state.  The FSMB defines evaluation of the patient as follows

A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. The medical record also should document the presence of one or more recognized medical indications for the use of a controlled substance.

Indiana’s code has adopted a consumer evaluation approach focused on chronic pain in relationship to discerning risk of abuse –

Sec. 4. (a) The physician shall do the physician’s own evaluation and risk stratification of the patient by doing the following in the initial evaluation of the patient: (1) Performing an appropriately focused history and physical exam and obtain or order appropriate tests, as indicated. (2) Making a diligent effort to obtain and review records from previous health care providers to supplement the physician’s under-standing of the patient’s chronic pain problem, including past treatments, and documenting this effort.

(3) Asking the patient to complete an objective pain assessment tool to document and better understand the patient’s specific pain concerns. (4) Assessing both the patient’s mental health status and risk for substance abuse using available validated screening tools.(5) After completing the initial evaluation, establishing a working diagnosis and tailoring a treatment plan to meaningful and func-tional goals with the patient reviewing them from time to time. (b) Where medically appropriate, the physician shall utilize nonopioid options instead of or in addition to prescribing opioids.

West Virginia’s code is focused on risk stratifications –

“Sec. 4. (a) The physician shall do the physician’s own evaluation and risk stratification of the patient by doing the following in the initial evaluation of the patient: (1) Performing an appropriately focused history and physical exam and obtain or order appropriate tests, as indicated. (2) Making a diligent effort to obtain and review records from previous health care providers to supplement the physician’s understanding of the patient’s chronic pain problem, including past treatments, and documenting this effort. (3) Asking the patient to complete an objective pain assessment tool to document and better understand the patient’s specific pain concerns. (4) Assessing both the patient’s mental health status and risk for substance abuse using available validated screening tools. (5) After completing the initial evaluation, establishing a working diagnosis and tailoring a treatment plan to meaningful and functional goals with the patient reviewing them from time to time.

The treatment plan is drawn from the patient evaluation. FSMB states that –

The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient. Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment.

Indiana’s guidance states-

Sec. 3. (a) This section and sections 4 through 10 of this rule establish requirements concerning the use of opioids for chronic pain management for patients. (b) Notwithstanding subsection (a), this section and sections 4 through 10 of this rule shall not apply to the use of opioids for chronic pain management for the following: (1) Patients with a terminal condition. (2) Residents of a health facility licensed under IC 16-28. (3) Patients enrolled in a hospice program licensed under IC 16-25. (4) Patients enrolled in an inpatient or outpatient palliative care program of a hospital licensed under IC 16-21 or a hospice licensed under IC 16-25. However, a period of time that a patient who was, but is no longer, a resident or patient as described in subdivisions (2) through (4) shall be included in the calculations under subsection (c). (c) The requirements in the sections identified in subsection (a) only apply if a patient has been prescribed: (1) more than sixty (60) opioid-containing pills a month for more than three (3) consecutive months; (2) a morphine equivalent dose of more than fifteen (15) milligrams per day; for more than three (3) consecutive months; (3) a transdermal opioid patch for more than three (3) consecutive months; (4) at any time it is classified as a controlled substance under Indiana law, tramadol, but only if the patient’s tramadol dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day for more than three (3) consecutive months; or (5) a hydrocodone-only extended release medication that is not in an abuse deterrent form.

West Virginia’s guidance states-

  • 30-3A-2. Limitation on disciplinary sanctions or criminal punishment related to management of intractable pain (a) A physician shall not be subject to disciplinary sanctions by a licensing board or criminal punishment by the state for prescribing, administering or dispensing pain relieving controlled substances for the purpose of alleviating or controlling intractable pain when: (1) In a case of intractable pain involving a dying patient, the physician discharges his or her professional obligation to relieve the dying patient’s intractable pain and promote the dignity and autonomy of the dying patient, even though the dosage exceeds the average dosage of a pain-relieving controlled substance; or (2) In the case of intractable pain involving a patient who is not dying, the physician discharges his or her professional obligation to relieve the patient’s intractable pain, even though the dosage exceeds the average dosage of a pain relieving controlled substance, if the physician can demonstrate by reference to an accepted guideline that his or her practice substantially complied with that accepted guideline. Evidence of substantial compliance with an accepted guideline may be rebutted only by the testimony of a clinical expert. Evidence of noncompliance with an accepted guideline is not sufficient alone to support disciplinary or criminal action.

So, let’s review.  Legislatures define the laws and regulations for the dispensing of schedule II narcotics and pain management by licensed clinicians. Boards of Medicine regulate the practice of medicine within their states, not the federal government, and not federal guidance documents. State level regulations and activities are influenced by federal guidance documents, Medicare guidelines, insurance plans, and legislative initiatives.  FSMB guidance to state boards of medicine includes very nonspecific language that conflates opioid treatment with substance abuse treatment using terms like dependence, tolerance, and addiction as a basis for treatment evaluation and planning in addition to attention to chronic pain.  Indiana’s regulations are also nonspecific but allow for physicians to treat those who have chronic pain and palliative care needs so long as they thoroughly document the need for extensive measures.  And West Virginia, which leads the nation in opioid prescriptions, abuse, and overdose deaths, has adopted enabling language that distinguishes between the needs of the chronic care patient, the person who needs palliative care, and the physician’s right to provide treatment.

That said, let’s look at both Marlene and David to consider their needs. First, neither Marlene nor David have a primary care physician. That’s a problem. In both their cases, their primary physicians decided their care needs were too complex and they were red flagged, or discharged – code for high dose opiates make me fear for my practice license, and interference from DEA and CDC.  That means there is nobody to consistently coordinate their care.  That means their interaction with their systems of care is happenstance and both will rely on the emergency room where things are quite likely to fall apart.

Both Marlene and David receive Medicare and Medicaid – Marlene under an advantage plan (Part C, Humana) and David under Parts A,B, and D (Humana). Marlene should be receiving support from a case manager and coordinated benefits for her extensive needs as a dually eligible individual – but she’s not because the insurer has not met their obligation to follow through.  David’s plan requires him to coordinate his own benefits so he relies on his spouse.  Both have been denied the services of primary care and comprehensive pain management no matter which Humana administered plan they are on – again due to having been red flagged because of their complex needs and reliance on high dose opiates.  This lack of coordinated supports places both of these vulnerable individuals at great risk of error.  It also increases the likelihood that because they have neither  primary care or pain management physicians in place, they will be wrongfully characterized by ER personnel as drug seeking when they present to their respective hospital emergency facilities in a compromised state of pain.

In our next segment we will take a close look at what happens to both of these individuals with complex care needs when they present to their community providers – the emergency room, and specialists – without the support of primary care coordination or coordinated pain supports appropriate to their individual but complex needs.

 

You might be interested in these references –

This Federation of State Boards Model Policy for the Use of Controlled Substances for the Treatment of Pain is located at this link-

Model Policy for the Use of Controlled Substances for the Treatment of Pain https://www.ihs.gov/painmanagement/includes/themes/newihstheme/display_objects/documents/modelpolicytreatmentpain.pdf

A number of entities track laws associated with drug control policy and use of controlled substances for pain management legislation at the state level-

Database of Statutes, Regulations, & Other Policies for Pain Management

http://www.painpolicy.wisc.edu/database-statutes-regulations-other-policies-pain-management

National Alliance for Model State Drug Laws

http://www.namsdl.org/library/7C4DC653-1C23-D4F9-7411227356D4CFE3/

Academy of Integrative Pain Management

http://blog.aapainmanage.org/state-state-laws-regulations-guidelines-pain-management/

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Authored by: Terri A Lewis, PhD.

There are 14 comments for this article
  1. Cheri Furr at 3:21 am

    This is very scary for a chronic pain patient and downright criminal. They treat dogs better than this. Chronic pain patients like me who have had CRPS for 17 years, which no one understands anyway, are now subject to the arbitrary guidelines written by some state government commission doing its due diligence to “create guidelines to combat the opioid crisis” in their particular state. This is also, of course, designed to appease the CDC and FDA guidelines and the wrath of the Attorney General. In effect, it lets them say “they did something” to combat the opioid crisis. Chronic pain patients aren’t the ones who have created this crisis. They are in excruciating pain and have been for years, but no one cares. No effort is made to distinguish between a chronic pain patient who has always gone to the same specialist, always used their prescription as directed, not abused it, kept it in a safe place and never shared drugs with anyone, and a 20-year-old who became addicted to narcotics after receiving a prescription after shoulder surgery, then became addicted and eventually turned to the street when they could not obtain another orescription. Regular opioid addicts have addictive personalities, and often combine several drugs. They usually drink alcohol with them. They buy fentanyl or heroin off the street when they become desperate, which may be cut with bath salts or talcum powder and varies in strength from batch to batch. So you have to be dying, close to death, or in a licensed care fascility to legally obtain more than 7 days’ worth of opioids in one prescription? Are they kidding me? And even if you’re dying, you’re only allowed to have one pill a day??!! Like I said previously, they treat dogs better than this. I wonder what all the administrators and insurance companies will do once the suicide rate of chronic pain patients becomes higher than that of the overdose rate of opioid addicts???

  2. Pam Steele at 7:18 am

    This is such a major issue now for so many chronically ill patients. As I was saying in one of my tweets, my doctors (the majority) of them now understand that my chronic pain, is not from just one medical dilemma but “many” that cause the problems I have with pain. Yesterday, I went to “1” of my Orthopedic surgeons, that did my hip “fractures” fix last December. He “agreed” with me that I have some “bursitis” going on in BOTH hips. Now, I DO have “lumbar/sacral” back problems, but that pain is “different” than the pain that is more specific in the hips like bursitis. My other Orthopedic Surgeon, that did my shoulder replacement and both neck surgeries, tried to tell me that “ALL of my “hip” pain” WAS from my BACK! He would NOT even consider what I said “may be” correct. I “know” from all of the years of problems with most of my joints. So, he would not even consider trying to do a cortcosteroid injection. Yet, yesterday my other surgeon agreed with me and injected the “worst” hip and I go back next week for the other hip. Just ONE of the many issues we now face with pain problems. MUCH from the governmental bodies, that I am so extremely distraught over, I’ve posted on my blog and Facebook, as well as twitter and my Daily Newspaper, about all of the problems with our government and what they just don’t “get” about “true chronically pain patients”. If I were not in pain so badly, I would be “happy” to not have to have medications. But, I could not even “function” at all, many days if not for my pain medications. It’s a very horrible problem all of us face, and I feel unless we continue to be very “on top” of this situation, many of us will face “fighting” for our medications.

  3. Alison at 11:04 am

    Alas, I found this site with high hopes of finding the key to unlocking the barred door to my impending end to successful management of my chronic coming this December. But I read stories just as compelling as mine and just as dire. I’ll spare you the whole story but I have been in pain management since 2001. When Medicaid informed me that they would no longer cover opioids for back pain I thought I could possibly manage to pay for the medication myself. Now I’m informed that my pain management clinic will not allow that due to “possible raised eyebrows” concerning their patients paying cash for medications. I just don’t get it. Why they would sentence us to unending hell over some raised eyebrows. It is not illegal. All this hoopla over opioids is just getting so paranoid and out of control, just like my soon to be life will be. Best to all here.

  4. Ibin at 9:40 pm

    It doesn’t really mater “how” each state medical regulators have written, amended, or flat out adpopted the CDC 90 mme max. DOT.GOV……..is in control. My wife is on medicare and has had no problems, since medictaion reduction. My provider, went to a mandatory meeting, with other physicians, and was told to under NO circumstances, prescribe over 90 mme. Regardless of documentation, of the patients beneficial use of a controlled substance, the inability to remain self sufficent, self providing, it does not matter. When health insurers refuse to “pay” for a prescription from a licensed physician, regardless of the medication, someone needs to be held accountable for “inflicting pain and suffering”. Pharmacies should NOT have the final say what scrip may be filled.Willful neglect comes into play with the CDC mis-guided-line. Pain is recognized as real, acute pain is evident with injury, “chronic” pain can be realized, documented through our providers examinations, tests, imaging, and frequent visits. Rescue treatment for pain, at an E.R. or Urgent Care, especially if you are a pain manaegement patent, is no existent.Health insurance is…….a problem. ALL citizens of this country deserve, have the right through paying our taxes, and I, personally, should be able to still “earn” my living…..and pay my taxes. The CDC mis-guided-line, and the fear of my state medical board to “amend” the CDC policy is non existent and IS causing monetary stress beyond my ability to satisfy even though with adequate medication I have remained employed for over 20 years, prior to the CDC mis-guided- line “policy”. If totally disabled the absolute right for treatment and appropriate prescription, must be available……to all Increase our tax money but, use it for the welfare, health wise, to all in need. .. . Pain, incurable, inretractible pain doesn’t go away or is relieved to tolerability by reducing opioid medication. Our opoviders, are very aware of the complexities that “can” become an extinuating circumstance and refusal of treatment is not…..the answer.There are millons of pain patients that are suffering, needlessly, without warrant,because of unsubstantiated evidence presented or arrived at by the CDC, HHS, and DEA that the prescribed patient is the “core” problem of drug overdose. As patient for over 20 years, I have had a good relationship with both my providers, my general MD and my specialist. The compexities of pain management can not be achieved by DOT.GOV full control with a set, maximum dosage of medication, for one and all. It is simply an asinine approach at a social reform, social conformity. Removal of the physicians judgement that has been relied on , for decades. Many patients, with the help of opioid medication, that have been injured, or may have a pain generating disease have been able to live, remain productive, socially interactive with adequate medication and only a few, relatives or friends even know the patient uses a controlled substance. The CDC “mis-guided-line” is another form of DOT.GOV creating a worse situation through an asinine policy. There is an answer, if any one in DOT.GOV gives a real dam$.The “commune-istic” approach of “this is all you get” associated with pain management in a futile attempt to lower drug overdose withou trecognizing the negative fallout from such “thinking” is alarming……..to say the least.

  5. Teresa Haney at 2:52 pm

    Thank you for addressing these issues. I have adhesive arachnoiditis. My pain meds have been reduced so dramatically. I don’t know how im going to survive. My daughter is a single mom of three and desperately needs my help. I can’t imagine what they would do without me. Its getting harder and harder to function. Yet the addicts are still getting high while those of us in pain suffer.

  6. Sandy Rintoul at 8:41 pm

    I am so grateful to be living in Australia, but we watch events in the States with mounting despair.

    Sad to say, there are now early signs of political rectitude taking hold here too, whereby the undoubted abuse of illegitimately-acquired opioids will lead inevitably to increasing difficulties for those suffering post-operative pain, CRPS and the like.

    Heaven help us all.

  7. Maureen at 6:21 pm

    Dr.Lews, again, I thank you for yet another well written, superbly researched and understandable writing. I’m loving connecting the dots with your posts and following the 2 patients stories now.
    I moved to Fla. almost 3 yrs ago after having had over 25 years of my pain management at UCSD, Ca., Morris Co, NJ and Stamford CT. only to be stunned at the huge difference in the level of care, that Ive so poorly received in this state. I’d love to know Florida’s rules! Maureen
    @Dr.Ibsen…keep up your good work for us also. We need you too!

  8. Rita KIMBEL at 9:45 am

    Who would have imagined this would be happening. Our government made this Opiate epidemic a real mess, addicts are still using and dieing right and left. The only people that have been affected by the new regulations are the law abiding chronic pain patients. Is this what they were trying to do? Erase everything and start over please, CDC should be ashamed of themselves for such an epic fail on the American citizens. Rewriting the regulations is needed and it’s taking way too long, what’s the hold up?

  9. MichaelL at 7:52 am

    Rick,
    This was going on long before Mr Trump came into office. Wake up and join us in the 21st century! It has been a problem since the 1980-s.

    Joanne,
    I would say it is attributable to ” too many cooks spoil the broth!” There are physician and pharmacy busybodies that know better how to treat the patients I had, without ever laying eyes on them or doing any history physical or other evaluations. I have not had a physical in the four years after I returned to the state, that told me everyone had to have a complete history and physical on the chart, with pain evaluation sheets and all the contracts signed. And, how common sense is it to ask if someone on chronic pain medication is it to ask if they have a history of addiction. The busybodies would think people are going to be honest about that when all they want is the pain they have to be treated with compassion. They deserve competent treatment for the chronic pain, as as well! They don’t need doctors hiding behind “the government” excuse, being afraid to treat their patients as they see fit. We need autonomous, thinking, physicians. We have enough pencil pushers out there!

  10. Mark Ibsen MD at 7:47 pm

    Thank you Doctor Lewis.
    As an ER doctor
    I could kick this can down the road.
    I became an “accidental pain Doc”
    When all in my community and state stepped away from care if anyone in pain.
    My Hippocratic duty presented no choice,
    As opiate refugees abound around me.
    Now
    The last pharmacy in my town has refused to fill the Rx I write for my patients.
    Not the occasional Rx
    But a policy to refuse to fill any Rx from a doctor that has a license
    A dea number
    And
    I am the top user of the prescription drug registry in our state.
    No patients harmed
    Until the refusals began, anyway.

    We need to treat pain.

  11. Rick at 11:04 am

    Mark this date in history where the controlling practice of ‘political correctness ‘ Trumps ‘common sense.’ Nothing more than Govt sanctioned ‘torture.’

    Rick
    Generalized refractory CRPS
    NO pain medicine. About to
    give up.

    Thank you for your help shinning light on our hell Ms. Lewis:)

  12. Joanna Pinne at 9:05 am

    I appreciate that these are complex situations, but it is so frustrating to wade through so much verbiage. What is wrong with us as a society that people cannot just be treated in a common sense fashion, for their pain?

  13. M.Billeaudeaux at 8:32 am

    Thank you for your research and interest in this fast approaching crisis. Now that our government has taken the initiative to tell physicians who to see, how to treat, and what to prescribe and has now decided insurance companies have the right to decide who they want to cover depending on what the patient is prescribed is beyond conceivable to me.
    The insurance companies who denied coverage for certain drugs seems to want their paying premium policyholder but only if they are not in pain. I want one of these decision makers to experience pain as did these patients, I want the congressmen in DC who are making our choices which are our rights to experience pain as did these patients, I want whoever is making these decisions for the patient, other than their physicians, to experience their pain just for one day, then tell me, who deserves to be pain free or relieved somewhat of pain. This is an outcry, this is unheard of in other countries, this is a crisis in the making!

  14. Rita KIMBEL at 5:57 am

    Thank you for all you are doing, this information is what we all need to understand. We’re going to be struggling to get the mg. we need, thank goodness I was under the care of my family and pain management doctors for 14 years. My medical records were available for all to see when the new CDC regulations hit us. It took 4 months of appeal process with United healthcare, I am approved now till December for extampza and nucynta. My neuro-stimulator is never turned off because the mgs. are not high enough to control the intractable neurogenic pain. After December I don’t know what is in store for me, I guess I will just stay informed for now.

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