What is worse, the Opioid Epidemic or the Stupidity Epidemic?

What is worse, the Opioid Epidemic or the Stupidity Epidemic?

By Dr. Jay Joshi.

Editor: When the National Institutes of Health announced recently that it is launching a joint initiative with pharmaceutical companies to spur the development of drugs to address the opioid epidemic, we reached out to an occasional contributor to the National Pain Report, Dr. Jay Joshi.

Dr. Joshi is CEO/Medical Director – National Pain Centers in Chicago. We’ve been attracted to his patient-centered common-sense approach to dealing with current approaches to treating pain.

He provided the following thoughts:

The NIH outreach will start with a series of private workshops over the next six weeks and focus on three areas:

  1. Developing interventions for reversing overdoses, including medicines and wearable devices.
  2. New treatments for opioid addiction, including medications and even vaccines.
  3. Non-addictive treatments for chronic pain, including new compounds.

On a positive note, I am very happy that steps are being taken to ensure safety for patients nationwide.  There are many talented people at both the NIH and in the pharmaceutical industry and I sincerely hope the best and brightest find solutions quickly.  How can anyone dispute the altruistic goals of developing technologies that saves lives, medications that are safer, and non-addictive options for chronic pain?

Dr. Jay Joshi

On the other hand, substance abuse and overdose deaths are nothing new.  I have been cautioning about the dangers of opioids, and Oxycontin specifically, since the late 1990’s prior to my medical training.  Having worked at the World Health Organization’s Department of Substance Abuse in Geneva, Switzerland, I participated in the development of international substance abuse education while my professors and other physician in America thought that I was wasting my time!  When other physicians, especially in the university setting, were prescribing “opiates for everyone”, “there are no dose limits”, and “opiates are not addictive as long as you have pain”, I felt compelled to stand up for logic and common sense.  Those physicians are still considered “experts” and are interviewed by the media all the time.  What a joke!  The hypocrisy and bandwagon jumping is shameful.  Some of those experts are now the physicians who think that all opiates are the same and that they are all unnecessary regardless of pathology.  Opioids have been used responsibly for thousands of years for painful conditions (with the keyword being responsible).

Is the NIH outreach really going to address this epidemic that we are currently experiencing?  What are the realistic timelines for their fairly ambitious objectives?  Has anyone accurately defined this epidemic?  Many real pain physicians and pain patients do not think so because it is not an opioid epidemic, it is a Stupidity Epidemic.  Have you noticed that after all of these high-level meetings, recommendations, guidelines, and warnings, the following set of questions are never asked together?

  • Is the patient a legitimate pain patient?
  • Has the patient been prescribed legitimate molecules?
  • Does the medication have a legitimate formulation technology?
  • Is the medication prescribed by a legitimate pain physician?
  • Have the medications been legitimately manufactured (non-counterfeit and non-substandard)?
  • Is the treatment part of a legitimate multi-modal pain strategy?

The Stupidity Epidemic has caused more suicides because of inappropriate pain management than prescription opioid deaths, even from illegitimate patients and illegitimate medical care.  If that figure doesn’t put this epidemic into perspective, I don’t know what will.  Allowing chronic pain patients to suffer because of stereotypes, insurance denials, discrimination, and a fundamental lack of understanding of the complexities of pain is just plain ignorant, inhumane, and anti-American.  Chronic pain is torture and it terrorizes the patient’s brain.  That condition is called central sensitization.  For more information about central sensitization, please watch my lectures online.

We are still seeing illegitimate patients who are trying to get high.  We are still seeing prescriptions for “illegitimate” pain management molecules that are less safe, dangerous, and very addictive (here’s looking at you oxycodone, alprazolam, carisoprodol, zolpidem, etc).  We are absolutely seeing prescriptions with illegitimate formulation technologies, for example, the infamous 12-hour extended release medication that really releases over 4-6 hours.  The scourge of prescriptions by illegitimate pain physicians still exists as well, such as the prescription from “Doctor I-have-no-training-in-pain-management” or “Doctor I-prescribe-oxycodone-so-I-must-be-a-pain-doctor”.

Prescriptions that are manufactured illegitimately, such as counterfeit and substandard medications, is a major problem.  I have been the national pain management physician leader on both education and solutions to this “Silent Epidemic” of counterfeit and substandard medications.  Please watch my national presentations for more information.  Finally, many patients are still a part of an illegitimate pain strategies where a complete lack of a multimodal approach, a lack of basic and complex conceptual understanding of pain management, a lack of quality, and a lack of interventional skills exist.

So yes, we are witnessing the Stupidity Epidemic.

All of these NIH advances will be meaningless until we have a society of patients and physicians that recognize that they may be victims of the Stupidity Epidemic.  Swinging pendulums from one extreme to the other is useless and unintelligent.  I have held steadfast in my belief about the problem with substance abuse since the late 1990’s when it was not a sexy thing to do and, as it turns out, I was correct the entire time.  When I decided to never write a prescription for Oxycontin almost 2 decades ago, physicians and professors at universities and training programs thought I didn’t know how to manage pain because Oxycontin was all they knew.  When I said that medical cannabis in a pharmaceutical-like delivery format can help with pain, they looked at me as though I was being blasphemous.  When I discussed how properly administered ketamine infusions could reverse central sensitization, their heads short circuited like a bunch of Fembots from Austin Powers International Man of Mystery (one of the best documentaries about the human condition of all time).

The Stupidity Epidemic has caused the media and the so-called experts to lambaste safer medications all while promoting more dangerous medications. Case in point is Zohydro, which is a true 12 hour extended-release hydrocodone without acetaminophen.  Before this medication was released on the market in 2014, multiple physicians and media outlets said that it would cause more deaths than heroin and other opiates.  Even some of the major pain societies chastised it.  Ironically, these societies are filled with pain physicians that STILL prescribe high doses of oxycodone, alprazolam, zolpidem, etc!  In the last three years, to my knowledge, there have been no documented overdose deaths from Zohydro, but we do have about a 100,000 deaths from other opioids! Nice call, so-called experts.

The Stupidity Epidemic has caused insurance companies to force physicians to prescribe and pharmacies to dispense dangerous counterfeit, substandard, and generic medicines with variable bioavailability, efficacy, fillers, and pharmacokinetics.  These insurance companies have denied safer molecules in favor of highly addictive molecules like oxycodone and fentanyl.  They have also denied more stable extended release and abuse deterrent technologies.  They have also denied appropriate and safer treatments such as Interventional Pain Management options.

In order to curb the Stupidity Epidemic, we have to make sure the patient is legitimate through a variety of screening tools.  We have developed proprietary technologies that can help us identify illegitimate pain patient trends.  That is the kind of progress we need.  If the patient is truly addicted, they need to see an addictionologist.  We need to focus on more legitimate molecules.  The NIH outreach is trying to address that.  But for now, that means we need to stop using the more dangerous molecules.  We need to continue to encourage safer, legitimate formulation technology.  Some of these technologies are available now and can allow us to lower dosage, lower side effects, and maintain or improve efficacy.  We need to really start calling out illegitimate pain physicians and “Pain Practitioners”.  I met a nurse recently who recently started practicing independently as a “Pain Practitioner” because she “knows how to prescribe Oxycontin” since she gave it in the hospital as a floor nurse…no joke.

We will really start curbing the Opioid Epidemic and the Stupidity Epidemic if we start authenticating medications that can be counterfeited and diverted.  Unfortunately, pharmaceutical companies have been complacent in authenticating their products.  People die because of counterfeits and complacency.  If patients are part of a legitimate multi-modal pain strategy, you will see organic reduction of medications and improvements in function.

Chronic pain and substance abuse are completely different diseases but they sometimes overlap.  They are not politically correct discussions and therefore this article isn’t either. We need leaders that understand these important points and don’t just huddle up in a conference room handing out participation trophies to each other for showing up.  People are dying, both literally and figuratively, because of the Stupidity Epidemic.  If we want to start having real solutions, we need to start being honest and call out what the real problems are.


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Authored by: Jay Joshi, M.D.

There are 44 comments for this article
  1. Jay Joshi, MD at 5:59 pm

    @Richard,
    Thanks for your comments. A healthy discussion is always a good thing. I have no doubt that we are both on the same side in the sense that we are both advocates for patients. No disrespect taken and none intended with the following comments.

    You are correct that that the CDC Guideline has been distorted by the media and insurance companies for their own distorted agendas. But the CDC Guideline has been completely perverted by patients and physicians as well. It is unfortunate that you completely disagree with the CDC Guideline. Here is what you disagree with:

    1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred
    2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients
    3. Discuss known risks and benefits of opioid therapy and patient/clinician responsibilities for managing therapy
    4. When starting opioid therapy, clinicians should prescribe IR opioids instead of ER/LA opioid
    5. When starting opioid therapy, clinicians should prescribe lowest effective dosage
    6. Long-term opioid use often begins with treatment of acute pain
    7. Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or dose escalation
    8. Evaluate risk factors for opioid-related harm
    9. Review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data
    10. Use urine drug testing before starting opioid therapy
    11. Avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible
    12. Offer or arrange evidence-based treatment for patients with opioid use disorder

    Now that you have read the 12 recommendations in the CDC Guideline, I doubt you advocate against many of these common sense items. People seem so emotional about this topic that they end up making ridiculous and incorrect statements. The 90MMED is a small part of the recommendations and only meant for primary care providers. Primary care providers are not pain management experts and should not be prescribing high doses of opioids! Anyone who disagrees with all of these recommendations is not only perpetuating the opioid epidemic, but the stupidity epidemic as well.

    You stated: “There are published reports of successful pain management in at least a few patients maintained stably on doses exceeding 2500 MMED, and of many thousands on doses over 200 MMED. See the published work of Dr. Forest Tenant in “Practical Pain Management”.”

    Thank you for posting this. This one statement validates my entire article. For any physician to say that 2500MMED is safe and appropriate is just plain stupid. No legitimate pain physician, addictionologist, medical society, hospital, government agency, and media outlet, advocates this kind of lunacy. Any physician who advocates for this should be stripped of their medical license and probably be under investigation. The reason “pain management” has limited no credibility is because some physicians and patients regurgitate this idiocy. Some of these people even call themselves “pain specialists” and “addictionologists” even though they are neither!

    You stated: “If none of your patients are maintained on doses over 90 MMED, then I must suggest that many of those whom you serve are likely under-medicated and in severe pain despite the low levels they take. Have you done follow-up surveys? If you haven’t done genomic testing for enzymes involved in metabolism, then you won’t know who among them is unable to absorb he medications you’ve prescribed.”

    First, I never said none. Please read my post again. Second, my patients are well managed and safely managed with multimodal options. I’ve treated thousands of patients from all over the country successfully and SAFELY! The clinical practice of medicine is so much more complicated than any non-clinician could ever imagine. The easy (and stupid) thing to do is give high dose opioids and call it a day. The hard thing to do is diagnose and treat with a complex, individualized regimen, which is why I do. This is especially true when talking about interventional pain management, a key component to DIAGNOSIS and TREATMENT of pain. I am guessing you have unfortunately been exposed many bad “pain physicians” practicing bad pain management as many patients have.

    Genomic testing does not tell us anything about outcomes or even response to treatments. You have unfortunately been brainwashed by the false marketing from the genomic testing companies, one of which is under investigation by the FBI, HHS, and OIG! A good clinician knows how to prescribe responsibly.

    Thank you for being an advocate for patients. But please be an advocate for proper, safe pain management. Be an advocate for insurance coverage for multimodal options, not high dose opioids.

  2. Richard A. Lawhern, Ph.D. at 11:58 am

    Dr. Joshi: You wrote a follow-up comment as follows:

    3. The CDC Guideline has multiple recommendations. 10 out of the 12 are very accurate. 2 are open to debate. The Guideline was meant for primary care physicians, not pain specialists. The media has twisted the Guideline maybe because the Guideline was made without any fellowship trained pain specialists. That said, we have almost no patients over 90 MMED and none on benzos. Folks, it can be done in almost all chronic pain patients with proper multimodal pain management. There are reasons why 90MMED was chosen by the CDC. That also being said, there are exceptions, and I’m sure many of those exceptions are reading articles on sites like National Pain Report. Believe it or not, the CDC Guideline allows for exceptions! The Stupidity Epidemic caused the media and insurance companies to pervert the Guideline!

    ===================

    With no intention of discourtesy, sir, I must suggest that you have just about all of this narrative factually wrong.

    — The core consultants group which wrote the guidelines deliberately tried to stack the deck against the effectiveness and risks of opioids, from the get-go. And they got caught at it. To support their assertion that opioids are ineffective over the long term and pose a dangerous risk of addiction, they deliberately cherry picked from published work and imposed limitations on their analysis of opioid effectiveness that they did NOT apply to non-opioid medications or behavioral therapies. They also omitted the 2010 Cochrane Review of long-term effectiveness from their research, despite the fact that the leader of the consultants working group had included it in previous CDC reviews of the literature.

    — The media and insurance companies have indeed twisted the narrative on the so-called “opioid epidemic”. But to claim that the guidelines were intended to be voluntary ignores the facts. The US Veterans Administration was directed to make them mandatory in the December 2015 Congressional budget resolution bill — four months before CDC published, and WELL known to the authors and CDC bureaucrats.

    — Possibly the only reason 90 MMED popped up from the Guidelines is that the writers couldn’t find any studies of risks versus benefits that weren’t structured around that figure as one of four strata (zero control group, 0-20 MMED, 20-50 MMED, 50-90 MMED and above 90 MMED). While trends indicated a generally higher risk of opioid abuse disorder for higher doses of opioids, the populations of these studies appeared to be quite heterogeneous. Two of the studies addressed hospital admissions for opioid toxicity and two of them addressed deaths attributed to opioid overdose. The writers also ignored inconsistencies between the studies and omitted all of the confounds and reservations of the papers that they relied on to draw their pre-determined conclusions.

    http://nationalpainreport.com/tracking-down-the-research-behind-the-cdcs-opioid-prescribing-guidelines-8831122.html

    — The writers also ignored a well established body of medical literature which demonstrates that there are possibly hundreds of thousands of US chronic pain patients in whom opioid metabolism is highly variable due to polymorphism of genes which govern enzymes involved. This literature prompted FDA to ban codiene and Tramadol for children, out of concern for hypermetabolizers in whom these drugs might be dangerous because of elevated blood levels of morphine. Possibly more fundamentally, however, the literature demonstrates amply that there are possibly hundreds of thousands of poor metabolizers who might be helped by opioids — but only at much higher levels than the magical 90 MMED. There are published reports of successful pain management in at least a few patients maintained stably on doses exceeding 2500 MMED, and of many thousands on doses over 200 MMED. See the published work of Dr. Forest Tenant in “Practical Pain Management”.

    If none of your patients are maintained on doses over 90 MMED, then I must suggest that many of those whom you serve are likely under-medicated and in severe pain despite the low levels they take. Have you done follow-up surveys? If you haven’t done genomic testing for enzymes involved in metabolism, then you won’t know who among them is unable to absorb he medications you’ve prescribed.

    — The CDC guidelines are totally silent with regard to “exceptions” to the 90 MMED mythology. They are also silent with regard to any reason or logic for forcing hundreds of thousands of patients to taper down from levels over 90 MMED. But that silence has merely facilitated the epidemic of stupidity and a wave of arbitrary and destructive dose reduction. See the work of Dr Stefan Kertesz on the unlikelihood that pill counting will have any impact at all on deaths due to opioids — but may pose a risk of elevated rates of suicide.

    I strongly recommend that you read the introduction which PAIN Week offered for one of my articles here on National Pain Report: “What if Prescribing Guidelines Were Patient Centered?”

    https://www.painweek.org/news_posts/what-if-prescribing-guidelines-were-patient-centered.html

    The paper which this prominent publication introduced is “How Might Opiod Prescribing Guidelines Read if Pain Patients Wrote Them?” I invite your comments as a medical professional on this article.

    See http://nationalpainreport.com/how-would-opioid-prescription-guidelines-read-if-pain-patients-wrote-them-8833330.html

    Likewise as an independent and very well researched review of the CDC guidelines, I refer you to “Neat, Plausible, and Generally Wrong — A Response to the CDC Recommendations for Chronic Opioid Use” by Stephen A. Martin, MD, EdM; Ruth A. Potee, MD, DABAM; and Andrew Lazris, MD

    https://medium.com/@stmartin/neat-plausible-and-generally-wrong-a-response-to-the-cdc-recommendations-for-chronic-opioid-use-5c9d9d319f71

  3. Alessio Ventura at 12:57 pm

    In my view, the issues we are facing fall into these categories:

    1) Politicians, media, and a minority of physicians are conflating the addiction problem and crimes associated with improper use, with legitimate treatment and proper use of medicine. This is a difficult problem to counter, because the media give the majority of air time to opponents of opioids and fail to make distinctions between illnesses related to improper use and legitimate pain management.

    2) A minority of researchers and physicians have an anti-opioid agenda, hence, we see media again reporting on the research that reaches conclusions that are in fact are not consensus results. Many of the results are based on “extrapolation” of results, vs. definitive findings. Most media are incapable of delineating the difference between extrapolation and definitive cause and effect.

    3) The voice of the pain patient is not heard. The fact is, most of us in the pain community do not speak our minds because we are intimidated by the FDA, the US Congress, our state representatives, and our governors. It is true that the squeeky wheel gets the grease. If in fact our representatives were hearing from us en masse, things would start to change. Politicians just hear from the minority, hence, they tend to support the minority view.

    4) The minority view turns into policy and law, so a relatively small number of people ultimately dictate policy and law for the majority. Case in point, governor Christie of NJ convinced his legislature to limit opioid scripts after acute injury or surgery to 5 days. The FDA voted 18-8 to remove Opana ER from the market. The Ohio AG is suing opioid manufacturers for false marketing. So a few arrogant people wind up dictating how we are treated and what we can or cannot use, facts be damned. As I pointed out earlier, I developed sepsis after a recent shoulder replacement and was bed-ridden with a PICC line and broad spectrum antibiotics. If I had lived in NJ, I would have been forced to go to my physician after day 5, which was impossible. I also know several stage-4 cancer patients who depend on Opana ER (oxymorphone ER) but even though the FDA decision is “voluntary” right now, tbeir pharmacies have decided to stop providing it. 18 people decided the fate of millions of intractable pain patients.

    5) Flawed Research: Because of agendas, research is becoming agenda driven vs. based on solid science. I describe this in (1) to some extent, but I am further emphasizing here that the “scientific method” is being abandoned by government research groups and some private groups. The scientific method means proposing tbeories that are proven by either experimental data or field data, or both. Unfortunately, these minority of labs have the loudest voice, and their results are often based on flawed science and conflated data.

    6) Addiction is seen as equivalent to pain management. Although we know that the Locus Ceruleus in the brain phyically habituates to prolonged opioid use, that is distinct from a psychological addiction to opiates. When opioid restrictions are imposed by a minority of politicians and researchers, the addict seeks out the drugs in the illegal market. The legitimate pain patient does not do this. If they have been taking an opioid for an extended period, they will simply deal with the LC-induced withdrawal. They will not go the illegal route, and it is not an all consuming endeavor to find relief. So the patient with intractable pain will live with the pain and the withdrawal, and will consider suicide because the pain is so intense.

    7) The sins of the few always impact the innocent the hardest. Like gun control, the law abiding intractable pain patient is the only one impacted when politicians respond to the “opioid crisis”.

    8) Most politicians and researchers have not experienced intractable pain. Pain patients cannot be treated like addicts, because they are not. But politicians, media, and a minority of physicians treat it this way. Hence, we see the very misguided and frankly stupid policies to restrict medicines. As one researcher/pgysician put it, “more people die from sugar each year than from opiods”. In fact, many more substances create much more havoc than opioids, but the 184,000/yr who die from sugar will still die from sugar.

    My bottom line view on the steps needed to address these categories include:

    a) Voiced must be heard, because they are not now. Write formal, well thought out letters to your reps and government bodies like the FDA.

    Write to the President’s Commission on Addiction and state your case.

    Write letters to the editor of major publications.

    Create a web site, as I recently have done, at http://www.47-Percentors.com

    b) Challenge those who would proport to know your pain, how you are feeling. Do not be intimidated by them. Use references to other opposing research.

    c) Get in touch with local pain advocacy groups. They can help you deal with the difficulty in getting treated and help you counter the false narrative based on bad research, and can help you seek out additional resources.

    d) Tell your pharmacist about your situation. Once I did that, they were much more amenable to providing the medicine. They need to know you are not an addictand that you have serious medical issues.

    e) DO NOT GIVE UP. Yes, suicide is often thought about by patients with intractable pain, but giving up the fight means we lose by default.

    Honestly, I think (a) will have the broadest impact. We need the numbers, they need to hear from us. If we all did this on a regular basis, we can start to turn the tide.

    c)

  4. Emily Raven at 5:20 pm

    Pushing to find cures and other treatments (that actually work) is great but they fail to realize that those things are 5 years out at the least; decades for someone like me with a rare condition that isnt mainstream and therefore not profitable (by this I mean probably not breaking even… Not as in greedy, just that it’s not in the companies interest if it wants to stay afloat). But noone wants to talk about what we’re​ supposed to do in the meantime. It’s as cruel and inhumane as people that say things like “it takes years to do yoga right” well should we really need to wait for years in agony for relief that isn’t guaranteed in the first place? I think not. Thanks for speaking up Dr Joshi.

  5. Owl at 9:31 am

    I think we can all agree on how stupid the current policy is. What we need is a doable plan to fix the mistakes these death squads are creating. We have been letter writing and calling and emailing but none of that is creating change. My question to all of you is “how do we effectively change the policy that is hurting us so badly?”

  6. Jay Joshi, MD at 4:50 pm

    @M, you didn’t misread, I am advocating safe and humane options for patients. That is why oxycodone is not prescribed in our office. We have one of the largest CRPS treatment practices in the state. We have been able to treat, and in many cases, reverse CRPS pain 100%. Of course, all without oxycodone.

    As a patient, when you start associating all opioids with oxycodone, you are no different than the media and the people who hate you. You have just affirmed their false point. When you say no oxycondone=without any relief at all, you sound like you really love your oxy. When you start insulting physicians who are trying to help, they stop listening.

  7. Jay Joshi, MD at 4:42 pm

    @Alessio, you misread my post again. I never said oxycodone doesn’t work. The risks outweight the benefits and there are many other safer options. It’s not a risk I would subject my patients to. I have found safer options for them.

  8. connie at 12:17 pm

    Dr. Josh I, just because you have given 600+ presentations doesn’t mean you are the all knowing one! Anyone can give presentations on a given subject without knowledge of what they are talking about!

  9. M at 11:26 am

    Doctor,
    I misread your paper at first. I thought you were advocating safe and humane medicine for those with chronic intractable pain. In fact, if I read your answers again and thoroughly, I read you are against pain medicine for even the most badly pain afflicted. You would leave them writhing in pain rather than administer oxycodone to relieve that pain.

    You are a monster. I say that because only a monster could leave a documented chronic pain patient without any relief at all.

    Each patient is different. Unfortunately an algorithm will not work on a case by case basis.

    I think it would help if you were afflicted by.. pseudogout, fibromyalgia, CRPS and put through spine surgery with 3 days of pain medicine. Only then could you understand what true pain is and if you had access to opioids to relieve the pain I bet you would take it. Not for long but to relieve the unendurable pain.

    I have been a patient since somersaulting down 3 flights of stairs some 30 years ago. I currently have an 8 level fusion/laminectomy, a 2 level laminectomy that has failed, fibromyalgia, CRPS, CFS, and an eroded esophagus. That is not something I am proud of. It is a fact of my life. I DISLIKE opioids but take them when I can’t take the pain. When I get tired of sleeping to avoid the pain. When I HAVE to shop or clean.

    I fear having these meds taken away. I have been depressed since this news started hitting the airways. I sleep even more.

    I shouldn’t have to fear having compassionate and humane treatment takin away. No one should.

    You and your friends are causing terrible pain and suffering to increase. Anytime a patient tenses up the pain increases. There are already suicides (documented) of pain patients who had their pain medicine taken away or lowered to a level the pain was intolerable.

    You really need to walk a mile in their shoes before continuing this.

  10. Pain patient mistaken for addict at 9:55 am

    Implementing black box programs to discern who is a pain patient and who is a drug addict is totally unethical and is a human rights and justice issue. This fact is standing perhaps in the way of healthcare provides finding simple solutions but it is absolutely critical that this not be institutionalized. Why?
    Because of what happened to me.
    I was disabled by a bad neurosurgery and I live with spinal cord injury, arachnoiditis, adjacent disk disease and post laminectomy syndrome and crps type 2 thanks to my neck surgery which was notched in 2011.
    In 2017 i went to the er to get an appendectomy because my pain doctor thought that I was in acute appendicitis so he told me to immediately get to the er.
    The hospital- unbeknownst to me- had a pilot program with their own proprietary way of discerning real pain patients between drug addicts and guess what happened?
    They got it DEAD WRONG.
    They pegged me as a drug addict because I have a marajuana card and because I had been seeing many doctors to find out how to fix my neck. I only got pain meds for one doctor office but 3 docs in that office wrote the scripts depending on who was there and I have 3 pharmacies I go to because I own 3 homes and travel a lot.
    So- they decided I was a drug addict faking belly pain so instead of sending me to the Ct scan they put me in a dark room while I was screaming in agony and passing in and out of consciousness from the pain because my appendix was in process of bursting. They left me there yelling and begging for help and refused to look at my MRI and brain scans I took 2 days before because their proprietary system to describe what kind of person I was old the, I was a degereate drug addict.
    I spent 7 hours in that dark room given nothing for pain until my pain doctor rescued me by calling them and threatening to sue. They finally took me to the Ct scan and immediately rushed me into surgery.
    I almost died. The crps went full body and attacked all my organs and I couldn’t walk. It has taken 4 months to get back to where I was before the surgery.
    This is what will happen to proprietary systems to discern who is lying and who is telling the truth which is why it is totally unconstitutional.
    So- how do you tell the difference?
    You need research and develop a way to askhe right questions. You need to develop systems which can truly gauge physiological state of human being without violating their rights as human beings!
    The stupidity is obviously contagious to think it is OK or right to pursue a black blog approach to assessing and discriminating between people. And that word- discriminate is a perfect word to use in this case which the ACLU would love to excercize their chops upon.

  11. Alessio Ventura at 9:29 am

    Dear Mr. Joshi,

    This is just arrogance, pure and simple.

    You completely ignored my point that I have in fact tried the modalities that you mentioned. NONE of them worked for me, and they don’t work for many others.

    I have tried “dose adjusted” oxymorphone, hydrmorphone, long acting hyfrocodone, in fact everything, even experimental medicined in research projects.

    This is the problem we in the pain management community face: arrogant people who want to tell us what works and what doesn’t, and they act as though we are lying, not telling the truth. Like so many politicians and media, this is the “nanny state” writ large.

    I go into detail with references at my web site, http://www.47-percentors.com. There you can read a number of references which show studies that in fact have a completely different perspective than yours. You will also read about personal experiences, where because medicines were limited, especially oxycodone-based, people suffered horribly.

    Although I am not a physician, I am in a scientific discipline and I am familiar with the scientific method. Unilaterally telling someone that a particular medicine doesn’t work when in fact we know it does from our own personal experiences is not the scientific method, it is extrapolation of results to unrelated elements (in this case, people with actual experience).

    It is really a shame that we have to fight these battles because of people who use flawed science and flawed application of limited results to everyone.

    Please take some time to step back and observe your arrogance. You are telling me to my face that what I know works and what my pain management physicians truly know works, “doesn’t work”. This is just outrageous.

    But, we will continue to fight people like you, who are so convinced othetwise that you would propose to take away our rights to the medicine that works for us, even though we have tried ALL of the alternatives.

  12. Pingback: What is worse, the Opioid Epidemic or the Stupidity Epidemic? | Dr. Jeffrey Fudin
  13. Jay Joshi, MD at 8:01 pm

    @ Alessio, you are correctly understanding my point and misunderstanding at the same time. You are correct that chronic pain management is not all about opioids. In fact, the minority of patients who have chronic pain need opioids. You are correct that the Stupidity Epidemic singularly focuses on all opioid treatments, not on the illegitimate items I have mentioned. The Stupidity Epidemic started with Oxycontin and again, there is no need for that medication for chronic pain. It’s like heroin…I’m sure it works, but there are safer options for chronic pain which I’ve outlined in the comments section and in the 600+ national presentation I have given.
    By the way, when you say other medications are “stronger” than Oxycontin (or oxycodone), it is not clinically accurate. All medications are supposed to be dose adjusted and converted to be equipotent. The real concerns are side effects, which are again dose dependent and patient dependent. However, looking at things like dopaminergic activity, drug high, drug liking, opioid induced hyperalgesia, etc, oxycodone is the best offender. In fact, it is the comparative drug that is used in drug studies because it is the worst legal opiate molecule when it comes to those criteria.
    Yes, there are far more deaths from alcohol, smoking, and even sugar. But that’s not what this article is about. The article was long enough as is and I cannot discuss every topic in pain management here.

  14. Alessio Ventura at 6:26 pm

    I honestly don’t know where this author is coming from. Is he for pain management for intractable chronic and acute pain, or is he recommending marijuana as a “safe” alternative?

    Is he saying that the data on deaths from opioids are conflated, meaning validly prescribed pain medicine from well respected pain management physicians is conflated with illigitimate use and use of street drugs, or opioids prescribed by doctors, like orthopedists, who are not “expert” in pain management?

    He said he has NEVER, and NEVER WILL, prescribe oxycontin for pain, but how can that be if there are so many patients, like myself, who find it to be the only medicine that actually helps?

    Why doesn’t he mention the 100,000/yr who die from alcohol? What about the 15,000/yr who die from NSAIDs, and the 100,000/yr who wind up in the ER because of NSAIDs? Why doesn’t he mention the 40,000/yr who die from antidepressants? What about those who drop dead from pregabalin? The list goes on and on and on, but of course, “opioids” are the current target of so many.

    Look, I am a chronic pain patient with horrible pain from injuries and failed surguries. Like most people who are in legit pain management programs, I never overdosed, I don’t get “high” from the medicine, and the Extended Release oxycontin for me works a full 12 hours. This medicined allows me some semblance of a “normal” life, where I can actual work and contribute. My cognitive ability with the pain is essentially zero, whereas even though opioids reduce ones cognitive potential, by taking it to relieve my pain, I am actuall very productive in comparison.

    There are medicines that are far stronger than oxycontin, such as oppan (oxymorphone), fentanyl, and hydromorphone, but when legitimately used and monitored, there are very few overdoses when compared to deaths caused by “street opioids”, where addicts simply bypass pain management physicians and acquire stolen medicines.

    I have tried all pain modalities, and most of them either do not work, or they make me sick. NSAIDs cause severe cramping to the point where the cramp pain equals or exceeds the chronic pain I have. I have tries physical therapy, chiropractic, experimental “Real 12-hour” medicines that simply did not work, aspirin (again, severe stomach cramps), accupuncture, medical marijuana (which did make me REAL HIGH and made me REAL SICK, throwing up, diarrhea, very dizzy), injections of all kinds, steroids, and son on and so forth.

    The real epidemic is a “stupidity” epidemic, but it is the stupidity of politicians, the media, and certain physicians who don’t realize that every patient has a different reaction to the same medicine. Each opioid formulation effects different receptors, and everyone’s locus coeruleus is wired slightly differently.

    Tje real “stupidity” epidemic is a singular focus on opioids, the conflation of deaths from illigit use with professional treatment, the willfull disregard of the real crisis going on with so many other medicines, including medicines available over the counter that can destroy your liver, and the unwillingness of certain physicians and researches to actually LISTEN to patients like me who know what works for ME. If this doctor told me he could not prescribe oxycontin to me, I would consider it cruel, a malpractice, a violation of the oath to “do no harm”.

    But perhaps I am misunderstanding the good doctor.

  15. Heather v. Wolf at 9:09 am

    As a acute chronic pain patient since contracting reflex sympathetic dystrophy type 2 from a bad neck surgery where the doctor severed a sympathetic nerve trunk I find the title to your article amusing and catchy although much of your solutions flawed unfortunately and with all due respect.
    The problem with find solutions which protect the real pain patient population is that you are all looking to the wrong institutions for the solution. The solution is the patient. The human being. the ethics of healthcare have become mired in tidal waves of industrial evolution. An anestesiologist I spoke to yesterday called it “the medical industrial complex”. He watched neurosurgeons operate on otherwise healthy people who had pain because their pain doctor wouldn’t prescribe low dose narcotic to help them over the “healing hump”. The surgery turned them into chronic pain patients thanks to cutting sympathetic nerves.
    When a surgeon enter a humans body, they have no way of knowing where sympathetic nerves are located. But when they cut into them, especially in the case of even minimally invasive spinal surgery where the nerve roots are next to the operative site, the risk is incredibly high of essentially frying the body’s alarm system which transmits pain and amplifies it. Causalgia was discovered in the 1700’s and finally given its name in the 1880’s. Surgeons didn’t want the public to know about this risk factor so they changed its name 42 times. It is now called CRPS type 2. The pediatric anestesiologist I spoke to was nearing the end of his career so he felt free to talk about the epidemic of CRPS aka RSd aka Causalgia in patient populations and now his life work is set on urging non invasive medicine, he witnessed through his career spinal surgeons getting rich off “treating” pain only to have contributed to what the CDC calls the “opiod epidemic”
    IF we really want to find a solution to all the human beings needing pain pills, we need to address how physicians are treating pain.
    One epidural injection can cause arachnoiditis, or CRPs both chronic debilitating degenerative conditions. ANd yet pain patients are now being made to take these invaisive measures in order to quell the pain.
    In my new role as director of CURE CRPS Foundation I will be advocating for Patient-Based protocols for determining physiological state of the patient. while beaurocrats sit in rooms with sources of power who are positioned to get rich of of treating us, our role seems to be precariously remiss. Where is the patients seat at this roulette wheel of a bargaining table?
    Human beings who live with pain signals constantly firing in their brains and spinal cords must have representation. We MUST be in the room while these decisions are being made because we are not hypothetical actors we are human beings deserving of dignity and the most basic human right is the right to pursue happiness which cannot occur whilst living in a state of constant pain.
    Corporations like Aetna healthcare, Big pharmaceuticals, hospital networks and medical device manufacturers function for their taxpayers by law to pursue profits. That is their dual purpose and none of them interface directly with patients in the stage of considering how to address complex problems such as these.
    Patients need a seat at the bargaining table on this issue. This is the crux of the stupidity factor which has laid fecund ground for increasing pain and suffering across the spectrum of palliative care and complex disease.
    Pain patients want to function in society and contribute to society and many times opiod medicine is the only way to do that because for reasons unknown to neuroscientists, pain management professionals and pharamsceutical companies, there is as yet no cure.
    To find a cure for chronic pain we must be driving the research and not for-profit entities who are getting rich off of us being sick.

  16. Jay Joshi, MD at 2:30 pm

    Thank you everyone for the comments and real-life experiences. It is difficult to summarize almost 2 decades of experiencing the Stupidity Epidemic all around me daily. Sometimes I wonder if I’m in an episode of the Twilight Zone or I landed in a parallel universe of stupidity. If you haven’t seen the movie “Idiocracy”, I highly recommend it as it seems relevant to the Stupidity Epidemic.

    I’ll try to address as many comments and questions as possible:

    1. I know there are many people here on oxycodone/Oxycontin. Let me reiterate…I have never prescribed oxycodone, Oxycontin, percocet, roxicodone, etc, and my patients have done BETTER. The molecule is fundamentally flawed for chronic pain management. Oxycontin started the prescription opioid epidemic. One way to find out who is a pill mill is to find out who rx’s oxycontin. Oxycontin was formulated to be addictive and give people a high. Purdue pharma purposely mismarketed oxycontin and has been fined over $700 million with billions more in penalties pending. Read this article:

    http://www.latimes.com/projects/oxycontin-part1

    Of all the legal opioids, oxycodone is the most similar to heroin. It is high dopaminergic response and causes increased central sensitization. It literally makes pain worse in the long term. It is highly abused and has high street value. If you turn on the news, most opioid overdose deaths involve oxycodone. I could keep going on and on, but I think you get the point.

    So why would any “pain physician” prescribe Oxycontin today? Stupidity, plain and simple. Ignorance is not an excuse. If a prescriber is ignorant, then they are stupid for not educating themselves. Harsh, maybe, but we are dealing with life and death. I’ve taken care of thousands of incredibly complex patients from literally all over the world. They have failed at universities, pain practices, and even the big name places. They all became better without the use of oxycodone. In fact, they improved when I took them off it. I’m not saying oxycodone doesn’t work. I’m saying there are many better options. It takes a talented pain physician to know and explore ALL the different options. But again, I have almost 2 decades of experience and tens of thousands of patient interactions to back up my thoughts on this molecule. There are so many opioid options out there and even more non-opioid medication options and non-medication options out there!

    2. @Hazzy, it is absolutely appropriate to see a pain physician every month for reassessment and documentation for your controlled substances. As you know, the scripts can only be written for 30 day supplies. Now whether your physician is good and ethical is a separate issue! These are dangerous substances when not used responsibly. We need to make sure they are being prescribed and used responsibly. When that does not happen, I call it the Stupidity Epidemic. However, society calls all use of opioids the Opioid Epidemic.

    3. The CDC Guideline has multiple recommendations. 10 out of the 12 are very accurate. 2 are open to debate. The Guideline was meant for primary care physicians, not pain specialists. The media has twisted the Guideline maybe because the Guideline was made without any fellowship trained pain specialists. That said, we have almost no patients over 90 MMED and none on benzos. Folks, it can be done in almost all chronic pain patients with proper multimodal pain management. There are reasons why 90MMED was chosen by the CDC. That also being said, there are exceptions, and I’m sure many of those exceptions are reading articles on sites like National Pain Report. Believe it or not, the CDC Guideline allows for exceptions! The Stupidity Epidemic caused the media and insurance companies to pervert the Guideline!

    4. @Veronica, totally crazy (or stupid) that someone would bring up the “opioid epidemic” during Comey’s testimony. That’s the definition of the Stupidity Epidemic!

    5. @Zyp Czyk:
    This “Silent Epidemic” of counterfeit and substandard medications is a subject I’m highly interested in, so the lack of specific information is frustrating.
    https://www.youtube.com/watch?v=P_4Nud_uh-U

    “The Stupidity Epidemic has caused more suicides because of inappropriate pain management than prescription opioid deaths, even from illegitimate patients and illegitimate medical care.”
    https://afsp.org/about-suicide/suicide-statistics/
    >44K Suicides per year (mental and physical pain)
    >1.1 Million Suicide attempts
    http://www.militarytimes.com/story/veterans/2016/07/07/va-suicide-20-daily-research/86788332/
    7400 Military Suicides/year

    Could you explain what you mean by “illegitimate” molecules and how they differ from “legitimate” ones, perhaps with some examples?
    “Illegitimate” molecules are ones that are counterfeit, substandard, dangerous, risk>benefit, and those that perpetuate the disease that they are trying to treat.

    This is the first time I’ve heard that even prescribed prescriptions from the pharmacy could be counterfeit and substandard – I find it truly terrifying – could you point me to where I can find more information about this?
    https://issuu.com/painweek/docs/pwj_16_q3_8.9a
    Page 65-69

    “When I discussed how properly administered ketamine infusions could reverse central sensitization” This is exciting news! I’ve read that ketamine can lift depression and might be effective for CRPS, but I didn’t know it could reverse central sensitization. Please let me know where I can find more information about this.
    https://www.youtube.com/watch?v=j-MgqDkKg4E
    https://www.youtube.com/watch?v=8QcwlE-tw1o
    https://www.youtube.com/watch?v=pPeY-BrIVz0

    “The Stupidity Epidemic has caused the media and the so-called experts to lambaste safer medications all while promoting more dangerous medications.” Which are the safer and more dangerous medications?
    Let’s start with getting rid of the “illegitimate medications first.

    “The Stupidity Epidemic has caused insurance companies to force physicians to prescribe and pharmacies to dispense dangerous counterfeit, substandard, and generic medicines with variable bioavailability, efficacy, fillers, and pharmacokinetics.” I’m angry that such a terrible scandal hasn’t made it into the mainstream media – or even the medical media I read!
    Don’t get angry, just follow the money. If you want to do something about it, education and awareness are key. That is what I am trying to do.

    “We have to make sure the patient is legitimate through a variety of screening tools. We have developed proprietary technologies that can help us identify illegitimate pain patient trends”. This is exactly what they say they’ve been waiting for: accurate, dependable, screening for addiction. Which company has developed these proprietary tools? They must be promoting them online somewhere – can you give me a link?
    Good pain practitioners know how to screen. Our proprietary tools are…proprietary.

    “We will really start curbing the Opioid Epidemic and the Stupidity Epidemic if we start authenticating medications that can be counterfeited and diverted.” It’s awful to think I may have been consuming adulterated medications for all these years. Some sort of authentication stamp on “legitimate” medications would be very reassuring for all patients. But I don’t understand how authentication of pharmacy-dispensed medications will ease the opioid epidemic.
    Again, please see my counterfeit lectures and articles. Authentication of products and services are key!

    6. @PaulC, “Damn it’s like banning guns. Guns don’t kill people do.” Exactly.

  17. Mark Ibsen at 10:20 am

    Zyp Czyk:
    I think no I see a proposal from Dr Joshi to place a marker on each pill to track in cases of od deaths.
    As you know, the deaths from pills are mostly counterfeit.
    We have never had good evidence about the source of the opiates that people are dying from, and there are unsubstantiated claims these come from Doctors Rx.
    A marker would clear than confusion up

  18. Alison at 9:17 am

    Dr. Joshi, in addition to relating to the horrible experience with certain medications that are being forced upon us, I echo the sentiments of EK Little in regards to requesting answers to the questions posed by Zyp Czyk. Please do respond.

  19. Hayden at 8:48 am

    Being a “functioning” pain patient for 20 plus years, I and my wife are watching and experiencing our world crumble. I realize that there are MILLIONS of more people in unmanageable but, can be, managed pain. When told of the coming “guideline” almost a year ago now, I was not too worried. The”experts” had the good of all at heart. I believed that maybe, with my personal health condition, I could tolerate less medication AND continue to be self sufficient. Self sufficiency in a one income family was and is a must as it was 20 years ago. I id not believe that an absolute “guideline” which IS 90 milligrams of morphine equivalent (90mme) to one and all would be enforced. According to my state medical board, the provider can not exceed 90mme without “justification”. I believe justification by the provider is either too difficult to “prove” or a flat out lie expressed with “words”.Now, six months into the new “guideline” for prescribing, any faith I had in the new agenda is gone. I”m not going to elaborate.

    I have contacted CDC by letter, e-mail and telephone, since this is where the mis-guided-line is proposed to have originated and have ran directly into a brick wall without ANY type positive result. Who am I anyway, to even consider making a difference in my personal life and advocating for others? I have also contacted my state medical board by the same methods and have actually had response with seemingly some, genuine, concern. Struck a nerve? I am thinking, can “individuals” on a state medical board be “responsible”, for an individuals or a collective of peoples manageable pain, be held responsible for unnecessary “pain and suffering” or worse? The “strategy” of the “guideline” and wording is great but, “someone” has to be held accountable for causing manageable pain and suffering. Where, exactly, does passing the “buck”, stop? I would be very pleased and value the information of anyone in the medical practice that may have an insight on this. What have I got to lose by making waves?

  20. Mona Twocats-Romero at 8:45 pm

    I am a patient in a pain management program which includes a pain specialist physician; a PhD psychologist specializing in pain management and cognitive behavioral therapy; and a physical therapist specializing in chronic pain patients. I have a number of spinal problems both genetic and acquired in addition to 3 spinal fusions, deformities in my feet that are both genetic and acquired, and fibromyalgia, and what my pain specialist lables, “chronic pain syndrome” which I assume is brain sensitization to my constant overwhelming and disabling pain. I take both methadone and Norco, (which is hydrocodone and Tylenol). When I entered the program, more than 10 years ago, my initial medication dosage was four 10 mg methadones per day and four 10/325 Norcos per day. This kept my pain well-controlled and I was able to function again after being on SSDI for many years. I even went back to work part-time teaching at our local University. About three years ago, and for no apparent reason, my doctor told me he was reducing my medication to three 10 mg methadones per day and two 10/325 Norcos per day. My pain was no longer well controlled and I lost quite a bit of my ability to function. Last month, he again reduced my medication to three 10 mg methadones, and two 5/325 Norcos per day. My functioning is now severely limited and I am in pain of about 7-9 on the pain scale twenty-four seven. I have a doctor’s recommendation for medical cannabis, which works fantastically, but I cannot afford to buy it, so it might as well not exist. Not only that, but my pain specialist is adamantly against cannabis use, and would DC ALL my meds if I used it.

    I have tried to explain to him that the CDC guidelines were just that and not demands or directives, and at any rate were for Primary Care Physicians and not Pain Specialists, but he won’t listen. He is always saying if I take more medication I will die, despite the fact that I took them for years and had no problems whatsoever. I am very disappointed in the level of care I get from him, though the psychologist and physical therapist are quite supporting and help a lot. I see them at minimum every three weeks. I use meditation, TENS, alternating heat and ice, and many other methods. They are not enough. Please help.

  21. Linette Woron at 11:37 am

    I have had severe to moderate pain on a daily basis for 6 years due to 3 back, knee surgeries and Fibromyalgia- I have never had a problem taking Oxycodone in a very low dose to manage pain. I am not an addict!! The only problem and fear I have is the worry when PT, Doctors, medical people who should know better start telling me how “bad” it is I’m taking it—

  22. HAZZY at 11:15 am

    DONT FEEL BAD, IVE BEEN ON OPIODS FOR ALONG TIME, NOW I HAVE TO SEE THE DOCTORS AT MY PAIN MANAGEMENT CENTER EVERY MONTH TO GET MY MEDS, SO THIS IS COSTING MORE MONEY THAN EVER BEFORE, IM A DISABLED VET AND CAN’T EVEN GET THE MEDS I TAKE FROM THE VETERANS ADMINISTRATION, WHERE IM RATED AT 70% DISABLED…………….ITS ALL A MONEY MAKING RACKET.

  23. EK Little at 10:55 am

    Dear Dr Joshi,
    THANK YOU for your time and effort! Your insights are so beneficial to my chronically pained soul.

    PLEASE do respond to the comments made by Zyp Czyk June 8, at 1:51PM. I too am anxiously awaiting any further information you’re able to provide on those which you touched upon.

    Also please take note that I had a HORRENDOUS experience while on ZOHYDRO a year ago. My CPP decided to take me off of the maximum recommended dosages of both IR Tramadol and hydrocodone, and replaced those with 30mg of Zohydro 2x/day. I suffered such severe effects from that switch, not only due to withdrawals from the Tramadol, ( I also take antidepressants due to treatment resistant and severe MDD and have since heard there is an antidepressant component inherent to Trams), but also the return of my pain since it took me 10 days of constant searching to find a pharmacy willing to get it in quickly to fill the script, (no OH pharmacy will stock it seemingly to deter getting held up), and it took a long time to build up in my system to be any kind of effective. Beyond that, my CPP knew that my sleep study (by a BC specialist) showed I’m a hypersomniac (idiopathic & severe exhaustion), and Zohydro took away my ability to regulate and time the side effects of it’s sedation thus causing me to suffer uncountable (30-50?) sleep attacks every day, despite getting a solid 12 hours of sleep. [Struggling to stay awake–day by day, minute by minute, second by second–while your life spins out of control is more agonizing than any continuous acute pain I’ve suffered, including infected abscessed teeth and the repeated passing of kidney stones.]

    Another problem was immense dizziness due to dehydration, and most disturbing: spontaneous macular (spell?) degeneration (seeing peripherally, but completely blind in central focus). I was unable to attend my own trial as a plaintiff and had to quickly provide documentation to prove to the judge the effects I was suffering from my recent start of Zohydro therapy, all of which were listed (in general terms) on the manufacturer’s insert. Then my ANE made me wait until my follow up appointment with to return to my old prescriptions without any apology. [So, please take heed when speaking on such a potentially deadly substance that one cannot control once it’s digested.]

    Even the specialists act like “mills,” nowadays. My prescriptions went from needing to go every two months down to every month, and receive only 14 day prescriptions including all of my non-narcotic scripts, like miralax, so all of my copays doubled, and I couldn’t make use of mail order on the non-narcotics. I sought treatment elsewhere, despite my 13 yr history with this doctor, only to get told I had no reason to be taking any hydrocodone since “it’s reserved for cancer pain” and yet this ANE said he wouldn’t wean me off of the 50mg/day I’d been on for 6 years because he said I would not suffer any negative effects from just stopping them. My cardiologist begged to differ, and prescribed me clonidine to stave off withdrawal symptoms caused by the flood of adrenaline to my system.

    Please, does this sound like a legitimate cause for opiate pain relief? The majority of my nerve and muscular-skeletal pain stems from: a cervical bulging disc impinging on my spinal cord above two spinal fusions I had which causes nerve damage in my one arm/hand, 3 lumbar discs pinching nerve roots including sciatica and tailbone (can’t think of term right now for SI tailbone pain), as well as facet disease, spondylosis, stenosis, arthritis, neuropathy, etc. And, without ever being required, I attend 1-2x weekly Physical, Chiropractic, Acupuncture, Manipulation & Massage therapies, and yoga 2x/week–for years & years now. Oh, and I’ve suffered “the suicide disease,” TGN, for 28 years now, which is what my then NEU sent me to the ANE CPP 13 yrs ago, and I didn’t even receive traditional opiates from him (got Tramadol) for the first 7 years until the above accident to my spine 6 yrs ago. I’ve worked hard to remain slim and fit enough, but with reduced Tramadol and no hydrocodone treatment, atrophy is setting in, and I want to eat sugar & junk to self medicate. Other ways I self medicate is: since I’m unable to work & exercise, I distract myself by watching movies and History Channel, writing a journal, and trying to meditate which often doesn’t work any longer because I’m so distracted by my pain. Does that make sense?

    If you read this far, I thank you, and I so very much thank you for your empowering article. Again, please respond to your commentor, Zyp Czyk; I’d be much appreciative. All the best of luck to you in what you do!

  24. Charles at 2:52 am

    I’ve read some very good points here and it is great to see that some do understand “context”! I do have one point that I dispute here! The idea of abuse deterrent medications! The focus should be on which medications create the more intense withdrawals and not these worthless attempts at abuse deterrence! It’s the intensity of the withdrawals not whether it is harder to abuse! That’s where the focus should be! I’ve talked about this with quite a few people on recovery sites and they tend to agree with what I am saying! If it’s an opiaite, it can be abused. If it cannot be crushed and injected, they just take more of the pills. Which has a more intense withdrawal? (The abuse deterrent meds)! The older, less changed opiaites that have a lesser chance of creating an addiction. The withdrawals aren’t as severe! I won’t say an epidemic of stupidity, I’ll just say that these questions aren’t asked from the addicts point of view. Arrogance is in the way!

  25. Mark Ibsen MD at 9:23 pm

    Well said.
    Careful about throwing stones, however.
    I believe now, based on elimination of the competition,
    We have ‘way more “drill mills”
    Than pill mills.
    The patients I “inherited” were victims of the stupidity epidemic.
    They also were were victims of the “spinal exodus”
    Doctors have lost the independence to treat the individual patient with whT works, or
    Worse,
    Continue what has been working in a stable patient.
    I only treated these patients because
    No one Else Would.
    And
    In Montana,
    Most palliative care pain patients
    Have been harmed by the
    Stupidity Epidemic
    By receiving epidural steroid injections and
    Other invasive procedures
    As
    Prerequisite to
    Getting their Rx
    Really really stupid.

  26. PaulC at 9:06 pm

    Being a health care practioner for over 20 yrs and unfortunately a chronic pain patient for at least 15 yrs gives me an insight to both ends. I see the addict and the real pain. It is truly sad that the CDC and the rest of our
    government continually demonize opiods. If all prescription opiods were banned the addict and overdoses would still be high. Actually the Overdose deaths are much worse since doctors started sending their pain patients to pain specialist, which was around 2010. The only people affected by all these attempts at controlling doctors and pain meds are the chronic pain patient. The addicts while abusing prescription drugs knew what they were getting and now that they can’t get oxycodone they have turned to heroin, which in many cases is laced with fentanyl. I have never abused any medication i personally was on and weaned myself off of everything. The difficulty with being on medication that helps and keeps many people functioning is not worth the hassle plus you never see your pain doctor other than the initial visit. You see practioners just so they can document what is required. I myself followed all the rules and one scary eye opening experience caused me to take myself off of all opiods, which by the way now i don’t work. Want to guess why? Back to the eye opener. I had developed a bad case of epididymitis and following the rules i wouldn’t let the emergency room give me anymore pain medication. No i went to my pain doctor and said hey I’m off the pain scale here I need something else for 4, or 5 days. I was told. HOPE YOU FEEL BETTER SOON. I had to try and get one over on my brain. I had never felt as though i was going to pass out from pain like i did for the next 4 days. I used laughter to survive. Yes laughter. I watched funny movie after funny movie that my brain laughed at more easily in an attempt to deal with the distress. Do you know how bad pain has to be for you to resort to constant laughter. Thats when i said no more. We literally are now inhumane in our dealings with pain. Animals are better cared for. The only patient we haven’t punished yet is the terminal cancer patient, but i feel its coming. The CDC will not publish that 51% of overdose deaths are from heroin. Speaking of dealing with the addict. If you are stoped by the police and you are caught with any illegal drug what happens? Yep you are arrested. Now if you OD on Heroin and brought to the ER you are released with no penalty to go try again. Why is that. I mean hell. You are in Possession of an illegal substance. Its in your body. Hmm. You want to reduce drug use and deaths. Start puting every OD in a 12month rehab. Of course we will have to build many, many more facilities, but if the government is serious about reduction then quit demonizing medicine and start dealing with the addict.
    Damn its like banning guns. Guns dont kill people do

  27. Jillian Drexler at 8:30 pm

    Dr. Joshi,

    Thank you! You’ve made some excellent points. Very well written!

  28. TommyThis at 8:06 pm

    We have all described our individual cases of pain and suffering on this and many other pain sites, and have written until the pens go dry to the legislators and to the Government Agencies that have pegged all of our “stupid meters” and yet we watch while the concrete hardens by the day. I have heard many profound statements from CPP’s and from many enlightened Physicians yet the “Ministry of Truth” (A la “1984”) keeps showing us that we just need to “suck up the pain” as Doctors writing in the New England Medical Journal recently told us.
    On top of this I’m now told to expect that in a move ” to save money for the VA” my pension will lose $2000.00 which over time will save some money for the Government.
    When we decide to stop the talking among ourselves and start showing up in numbers to Government offices in Washington D.C. is the only time we will start to get the real coverage, the real discussions, and the change of mind that is needed. As a 67 year old Vietnam Vet, it pains me to see both old and young Veterans killing themselves in VA parking lots (One set himself on fire) and all of it being attributed to “mental illness”. The problem with going public with our needs is that most of us have found the anonymity of websites to tell our stories, or we hope for a “brave few” who are willing to speak for all of us.
    That was tried last October 22nd, and we all had our excuses for not showing up. But no one will listen to those considered too weak to be heard, and although I’m not a very political person, the only way we are going to change hardened or ignorant hearts is to show up and confront them, not with yelling or violence, but with the compassion of the pain coming through our voices. If we are unwilling to do this, then we will continue to be offered “Motrin” for a drunk who runs a red light and smashes into our vehicles, and we will continue to be snuffed out.
    My Theology teaches me to that I’m just a pilgrim passing through, but I have family and friends who are in terrible pain who are not as I am. I have listened to both friend and foe mutter for their mothers before they die and am watching legalized assisted suicide go up as a good alternative for CPP’s. May we start to grow a backbone as a unified voice to get our message across. We need to start planning to be heard.

  29. Carla Cheshire at 5:35 pm

    Thank you doctor Joshi– I’m hoping you will be able to talk some sense into the people at the FDA and CDC who are making the situation for legitimate chronic pain patients much worse. It’s hard enough to deal with our pain issues but to then take away the medications that bring relief is criminal in my opinion.

    You are a voice of reason, one of the few.

  30. Jean Price at 3:25 pm

    I think something besides stupidity MUST BE at play here! No it’s not an epidemic! But it’s much more than stupidity, too! Or maybe it’s that their stupidity is…stupid like a fox!! (At least that’s the way we used to say it when someone appeared dumb…just to be more cunning!!).

    How hard is it to understand the basics of multi modal pain therapy, including a wide range of various opioids which may give patients with sensitivities the ability to take at least one type?! And how hard is it to understand that marijuana has a legitimate place in medicine also…as do alternative therapies!? All of the efforts of the CDC regarding their manufactured epidemic are purely senseless…they don’t even have sound reasoning behind them! And they are also deceitful…so this isn’t about stupidity as much as it is about corruption, in my opinion!

    Corruption can’t be fought with common sense or smartening anyone up! It won’t work! That’s why all the efforts to date have yielded nothing to speak of for better pain care…and haven’t stifled all this “evil opioid” talk! Making sense and teaching them the truth isn’t going to fix this mess! We need a new tactic, or we just need to pray and wait it out! Without a nationally known spokesperson to champion appropriate pain care…in a manner aside from any addiction issues…and some actual legal backlash on all those who have perpetuated this myth that all opioids are evil and set up this witch hunt, we are wasting our efforts! We preach to the choir here and on a lot of the pain sites…and that’s only adding to the frustration and anger as I see it…because nothing has changed for the better! And few if any without pain have joined our ranks to help us! Sad! This is becoming one area where I think ignorance (mine) could actually be bliss!!

  31. Jose A. Jarimba at 1:56 pm

    Dear Dr. Jay, the truth hurts the feelings of a lot of people. The cause of pain in humans is when the human structure (bones( is asymmetric (misaligned) with the weight of the body (fluid) on top of the asymmetric (misaligned) structure (bones) causes friction (pain). Pain is a warning that the body needs balancing. When the body (fluid) is imbalanced, it presses on the veins and causes improper (poor) blood circulation, improper blood circulation results in organ malfunction, such: Heart failure, kidney, liver, pancreas, lungs, and possible brain cognitive complications, when these organs don’t function well, weakens the immune system, a weak immune system promotes infection, disease, even cancer in the human body. Poor blood circulation creates anxiety, and anxiety results in addiction. To help someone with their pain, we align, permanently their structure (bones) and the pain goes way for good, and balance their body (fluid), by balancing the body (fluid) the veins open, blood start circulating normal, the organs start functioning normal, the good Cells multiply and reach healing speed, the immune system rises, at this point, the body even reach auto-immunotherapy, and it heals itself for good. My office is located in McAllen, Texas. Just in case: (956)502-9668

  32. Zyp Czyk at 1:51 pm

    This “Silent Epidemic” of counterfeit and substandard medications is a subject I’m highly interested in, so the lack of specific information is frustrating.

    Below I’ve listed my questions about specific quotes from Dr. Joshi, and I hope he (or the editors or anyone else) can show me where I can find more information and hard numbers about this scourge.

    “The Stupidity Epidemic has caused more suicides because of inappropriate pain management than prescription opioid deaths, even from illegitimate patients and illegitimate medical care.”

    This is extremely important data to present as we fight to maintain access to opioids – I really want to blog about and publicize this. Can you give me a link to where you found the numbers?

    “We are still seeing illegitimate patients who are trying to get high. We are still seeing prescriptions for “illegitimate” pain management molecules that are less safe, dangerous, and very addictive (here’s looking at you oxycodone, alprazolam, carisoprodol, zolpidem, etc)”

    Could you explain what you mean by “illegitimate” molecules and how they differ from “legitimate” ones, perhaps with some examples?

    “Prescriptions that are manufactured illegitimately, such as counterfeit and substandard medications, is a major problem.”

    This is the first time I’ve heard that even prescribed prescriptions from the pharmacy could be counterfeit and substandard – I find it truly terrifying – could you point me to where I can find more information about this?

    “I have been the national pain management physician leader on both education and solutions to this “Silent Epidemic” of counterfeit and substandard medications.”

    I’ve long wondered about the month-to-month variability I notice in the daily medications I’ve taken for years, including opioids, and such a “silent epidemic” would explain a lot.

    The impact of this would reach far beyond just opioid medications. I really want to learn more about how this is happening and which parts of the supply chain are vulnerable, so could you point me to more information?

    “When I discussed how properly administered ketamine infusions could reverse central sensitization”

    This is exciting news! I’ve read that ketamine can lift depression and might be effective for CRPS, but I didn’t know it could reverse central sensitisation. Please let me know where I can find more information about this.

    “The Stupidity Epidemic has caused the media and the so-called experts to lambaste safer medications all while promoting more dangerous medications.”

    Which are the safer and more dangerous medications?

    “The Stupidity Epidemic has caused insurance companies to force physicians to prescribe and pharmacies to dispense dangerous counterfeit, substandard, and generic medicines with variable bioavailability, efficacy, fillers, and pharmacokinetics.”

    I’m angry that such a terrible scandal hasn’t made it into the mainstream media – or even the medical media I read!

    “we have to make sure the patient is legitimate through a variety of screening tools. We have developed proprietary technologies that can help us identify illegitimate pain patient trends”

    This is exactly what they say they’ve been waiting for: accurate, dependable, screening for addiction. Which company has developed these proprietary tools? They must be promoting them online somewhere – can you give me a link?

    “We will really start curbing the Opioid Epidemic and the Stupidity Epidemic if we start authenticating medications that can be counterfeited and diverted.”

    It’s awful to think I may have been consuming adulterated medications for all these years. Some sort of authentication stamp on “legitimate” medications would be very reassuring for all patients. But I don’t understand how authentication of pharmacy-dispensed medications will ease the opioid epidemic.

  33. Veronica at 1:01 pm

    Anyone watch the commentary after James Comey testified? David Urban said, on national television, that we shouldn’t be concerned about what Trump did or didn’t do – we should concern ourselves with the opioid epidemic in our country!! For real?? Since, after having been taking them for almost 20 years, then completely taken off them 4 months ago (because my clinic refuses to prescribe them), I can honestly say that I’ve never, ever, thought more about death than I do now! I actually pray to God to please just take me, as I cannot tolerate this pain. I’m a strong person, but even a strong person can take only so much.
    I an outraged that this man, who has all the meds he needs no doubt, is saying this while commenting on the Comey session!! Who the hell gave HIM that right to judge any of us chronic pain people?? I’m so angry, words cannot describe it.

  34. Ibin, again at 12:12 pm

    Thank You, Dr. Lawhern for a professional insight, into safe, possible, manageable pain practice, both truthful and objective The commingling of benzodiazepines and opioid medications do in fact encourage the “honest”, legitimate, patient to seek both medications for enhanced, pain relief. Top it off with alcohol use in an individual just, for pain relief, and this is being an irresponsible. chronic pain patient. If an individual has chronic pain, I would think that the primary goal would be pain relief to a tolerable level.

    If the patient has a psychological issue with chronic pain, which is probable, over the top prescribing is not using responsibility by the patient, nor the prescribing doctor(s) in the treatment of the most serious health condition of the patient which if, seeking pain relief should not include benzodiazipine medication in the majority of pain patients. I believe the medication HAS some use and value but, if being used to “enhance’ pain relief then this is dangerous use by the patient.

    At one point I was prescribed benzodiazipine ,(diazepam) for the relaxation of continuous muscle spasm with back surgeries. The medication IS described as use for, muscle relaxation but, the primary pain generating issue was not muscle spasm. My doctor, using his due diligence in prescribing, advised me that the combination of medications did not promote safe use. This was many years ago, before the published and enforced “guideline” of the CDC, swinging pendulum “studies” conducted by specialists and experts in the field of medication prescribing for pain reduction. I realized that I could deal with the muscle pain, which alone could be very bad but, the other pain causing issues could be better decreased with opiate medication. .If psychological medication IS needed for chronic pain issues, there are far more effective medications that truly have tremendous positive effect but, maybe unacknowledged for a short “burst” of feel good affect on the psyche. Non narcotic, good medication that can be used with opioid medications.

    I, personally do not use diazepam, nor alcohol;, do not smoke, and have never used illegal, illicit drugs. There ARE millions of patients that actually “use” medication to enhance life, not enhance life experiences. The real agenda by people can’t be that difficult to deduce by, our doctors. There are far more doctors that wish to treat their patients adequately and not over prescribe medication, than just make the patient, happy. It is not as if the patient will get angry and find another physician for treatment for chronic pain. It is not easy to be treated for pain and now it IS impossible to be sufficiently treated for chronic pain.

    Our doctors’, in the VAST majority, truly desire for their patient to have a “good” life while dealing with chronic pain. I believe it has been established that the mixture of drugs, different types, and alcohol is of a destructive nature and this needs be addressed firmly BY the prescribers and a reasonable pain prescriber medication guideline A “guideline” that is general in nature composed of “normal” dosages and different medication for the treatment of pain with a specific health condition.The objective with the current “guideline” is to reduce the mortality rate with deaths of people in the nation that had some sort of opioids and other drugs in their bodies at the unfortunate time of demise. However, the limitation of our doctors to prescribe sufficient medication for the published 50 million patients, published in the “policy for the use of opiates for the treatment of pain” is not beneficial to us. This situation of drug abuse and to make opioid medication safer for use by 50 million patients can not be made any safer by the denial of proven beneficially effective medication by lowering opioid medication for ALL people prescribed, opioid medication. The “guideline” attempt to eliminate “spare” medication prescribed to all pain patients is not addressing the abuse and misuse of “opioids” AND other drugs. Stripping the physicians ability to sufficiently help their patients manage chronic pain by a one, see all, know all, unilateral guideline is causing death by self destruction because consistent unmanageable pain is not humanly tolerable for a lifetime. Thank you, Dr. Lawhern for your professional insight.

  35. Bob Schubring at 11:51 am

    Pathological narcissism makes rational thinking impossible.

    Accordingly, the Stupidity Epidemic is most damaging when it reaches our law courts and the halls of Congress.

    Two sitting United States Senators seriously propose to relieve chronic pain by putting a tax on the medicines that relieve it.

    A colleague and supporter of theirs who raises money in support of the Pain Medicine Tax, sought election to the Presidency and can not seem to comprehend that she lost the election and has to wait four years for another election to take place.

    What nobody seems to have considered, in dealing with the “illegitimate” patient who seeks to feel pleasure from a medication, is simply asking these people why they think they need to “get high”, and then listening to the answers those patients give.

    The patient who “gets high”, because he or she experiences some very unpleasant symptoms of an underlying psychosis, and districts him/herself from that psychosis by “getting high” to ignore the problem, is not wholly choosing to “get high” out of some sort of moral weakness. That person has a mental health problem that could benefit from proper treatment, which treatment likely will include medications that are appropriate to the particular causes of the psychosis.

    The Drug War has so confounded the delivery of care to the mentally ill in our country, that the following form of Idiocracy nowadays passes for normal:
    1. People who have a psychotic break begin frightening the customers where they work, and get fired.
    2. Unable to pay rent on a room, they become homeless.
    3. As homeless people, they can get emergency care in an emergency room. But if they lack a permanent address to which the Postal Service can deliver letters, bills, summonses and the like, no physician will invite them into the office for routine care, and no pharmacy will fill their prescriptions, if they somehow happened to get one written.
    4. Because their symptoms are overwhelming, they seek relief at the local crack house, provided by a high school dropout who knows zilch about patient care, and knows only how to sell the drugs that the crack house proprietor has shipped in, bought from some Mexican organized-crime family whose tactics scare the hell out of most policemen in Mexico and the US, and who usually adulterate their opioid and cocaine-based drugs with synthetic Fentanyl, because it’s cheaper for them to make that drug right now.
    5. Either a) the patient ends up back at the Emergency Room because the Fentanyl almost killed him, or else
    b) the patient is now classified as an Addict, because he or she is habitually using drugs that we assume to be used only to “get high”.
    6. Because this patient now possesses illegal drugs, any house or building to which the patient brings those illegal drugs, can be seized on suspicion, auctioned off and sold, under the Asset Forfeiture laws now in place. Policemen who don’t want to be like the Mexican police chief who investigated one of those organized crime families a little too closely for their comfort, only for his colleagues to find a cardboard box in the police station’s mail one morning that contained the chief’s severed head, opt to use those asset forfeiture laws against non-violent people like landlords who own houses for rent. Landlords respond to that problem by refusing to rent a room to a former patient, who now uses illegal drugs.

    That cycle of abandonment, in which everyone appears to follow the letter of the law and avoids malum prohibitum, makes everyone guilty of the malum in se of patient abandonment.

    Legislators who write words on paper, that have these kinds of evil effects, have a moral responsibility to correct the words written on the paper of our law books, so that the written law reflects accurately, the surrounding reality.

    But the problem with sending pathological narcissists to Congress, is that they are incapable of comprehending that they can make errors in their perception or judgment. So those corrections are never made, and instead, errors accumulate.

    Dr Joshi suggests a tiny step in the right direction: Tagging authentic medications in some verifiable way, so that counterfeit medication that’s been adulterated with Fentanyl or cyanide or any other substance that some psychopath introduces to medicine so that he can harm people who take it, can be sorted out from genuine drugs that were made in an ethical manner by professionals. Facially, that’s a solution that will assist police in discovering homicides that presently are mistaken for accidental overdoses. Whether our politicians will recognize this as a viable solution to the problem of adulterated drugs, remains to be seen. As of now, so many politicians want the bribes…ahem…political campaign contributions…that narcotrafficantes bestow on their favored officeholders, that when the crooks dig tunnels under the border fence and someone proposes to block the tunnels off, those politicians make an amazing jump back from reason and logic, and conflate a request that visitors coming to this country knock on our door instead of digging a tunnel into our basement, into imagined racial animus against all the people who live in other countries and come here to visit.

  36. M at 10:38 am

    Thankyou Thankyou Thankyou.

    Documented Chronic Pain patients need more like you on board.

  37. Richard A. Lawhern, Ph.D. at 9:33 am

    Dr Joshi, I invite you to read and comment upon another recent article here at National Pain Report: See http://nationalpainreport.com/warning-to-the-fda-beware-of-simple-solutions-in-chronic-pain-and-addiction-8833744.html

    I believe the facts are clear and in the public domain: complicating an epidemic of stupidity (your apt term) is a body of anti-opioid public policy which is grounded on hype, bad science, and deliberate distortions introduced by the writers of the March 2016 CDC guidelines on opioid prescription for chronic pain.

    Much of the statistical data offered by the CDC is corrupted by poor collection methods and bias on the part of both county medical examiners and CDC analysts. Reformulation of OxyContin in “abuse-resistant” form in 2010 resulted in immediate drops in prescribing, and directly contributed to the doubling of deaths due to street drugs. “About half of deaths now attributed to opioids also involve a co-prescribed anti-anxiety medication in the benzodiazepine class, and the majority of such deaths also involve alcohol. It is likewise a fundamental error to attribute these deaths as “accidental”. Many of them are in fact suicides on the part of patients who have been under-treated for their pain.

    The CDC guidelines are desperately mis-directed by unproven assumptions that opioid analgesics are ineffective over the long term, and that opioid prescribing is responsible for large numbers of addicted people. The Cochrane Review of 2010 estimated risk of addiction in long term opioid treatment at less than 1%. Recognizing (as the authors did) that there may be confounds and uncertainties in this review, it is still the best medical evidence we have.

    Most important of all, as you personally must surely know, there can be no convenient one-size-fits-all maximum acceptable dose of opioids or threshold dose of risk. This is true because of the major natural variations in opioid (also antidepressant and anti-seizure medication) metabolism between individuals, due to genetic polymorphism. Some patients are hyper-metabolizers and some are poor metabolizers — who need and benefit from doses far higher than the CDC fictional practice guideline of 90 MMED.

    Please join and comment on the discussion in the article referenced above.

  38. Kathy C at 9:26 am

    Thank You Doctor!
    Stupidity is a deadly disease too. We are currently seeing it run rampant across the u.S. When the new Death Toll, estimated of course, came out in the Mass Media the New York Times, again sensationalized it. Their Article was picked up by small town papers, and they even put a nice graph in there. Apparently the tactics they are using are not working, the death rate is climbing. A lot of us predicted this, the hysterical way the media portrayed this only fed the deaths. The Associated Press came our with suggestions for covering the “Opiate Epidemic” it is too little too late. They even mentioned the distinction between Addicted, and Dependent, and Chronic Pain Patients, most Journalists did not make these distinctions.

  39. GotNerve at 9:00 am

    When will medical researchers find a way to improve or repair a chronic nerve transection caused by a surgeon that’s causing unbearable constant pain? The only quality of life I have is when it comes to my pain meds. Nevertheless, I still do t sleep more than 3 hrs a night and that’s not even consecutive hours! I am NOT AN ADDICT. Stop torturing chronic pain patients who are already tortured.
    Since when does the CDC get to overrule the advice and recommendations of my trusted and quality trained pain management provider? My health is a private matter, and I have an innate human right to choose opioids to manage my pain when they have proven helpful and all alternative therapies have failed and cost me thousands out of pocket.

  40. Diane Succio at 8:19 am

    Well written and true.

  41. HAZZY at 8:01 am

    Ive been suffering with chronic pain for over 10 years, so now my Pain Management Doctors said i had to see them every month to get a Prescription for my Pain Meds !!!! So thats $30.00 copay plus between $ 30.00 to $ 60.00 a month. I was seeing the Doctor every other month, the month that i didn’t see the doctor i would have to call in to get my Prescriptions written. Like i said, now I have to see the Doctors even month. I think this is starting to become a money Racket !!!!!!………………..THANK

  42. Ibin at 7:52 am

    I agree with the statement from Dr. Joshi, ” chronic pain and substance abuse” are two totally different “diseases” or health conditions. Well said. The stupidity factor is the thinking that both “diseases” or conditions can be treated unilaterally with one prescribing, biased, “guideline”. My belief, realized, after 20 plus years of chronic pain is that each patient, legitimtate patient can be treated to achieve a plateau with dosage and medication for a better, pain tolerable life with the use of opiates, if that is what is medically necessary.

    20 year ago, after being subjected to the “least” treatment, including physical therapy, steroid injections, spinal infusions and non opiate oral medications it was determined that the corrective surgeries I have had did in fact”help” the underlying painful cause in my personal; health condition. The pain specialist that I was referred to, after several months released from the surgeon,was a compassionate provider. Many months of prescribing led to many years of different compounds, different delivery methods, and ‘trial and “see” just which method and compound made my persistent pain AND objective(s) in life, the best reasonable way to make life with continuous pain better for me without sentencing me to a declining overall health condition.

    Of course, oxycontin,was introduced to my personal prescription and after a very short time it was realized that I became very tolerant, very quickly, to the medication.Many different medications were prescribed to me and after a few years of different medications and delivery methods, the “right” medication and dosage was found for me. I am not advocating for any one medication. Each patient has different needs to reach a sustainable, reasonable level of pain relief and it may require a combination of medication and the realization by the patient that continuous pain at a zero level will not be achieved. Responsibility, by the patient, REAL communication, and honesty, between patient and health care provider is a must. The doctor can distinguish between the “legitimate” patient and the high seeker even though the patient may have real chronic pain and should prescribe accordingly.

    With the legitimate chronic pain patient, there are different variables, many variables, specific to the patients pain generating cause which can lead to a host of other “problems”.that require specific treatment of the individual. I was very fortunate to have realized the regiment of overall treatment that has helped me to manage the pain that I have personally had, and will have for life. Now, some 17 years or so later, I have been reduced on a medication by 80 percent that I have had not even one negative health condition caused by the medication. In the last 17 years. I even reduced my self from 160 milligrams of medication to 100 milligrams of medication, successfully. I had a few days a month that I felt I needed a little more medication but, they were tolerable and the reduction from 160 mgs to 100 mgs of medication was in the best interest of my persona overall health that I could have made. Currently, as prescribing by the asinine “guideline”, I am at 20 percent of prescribed med of the 100 mgs prescribed for the last five years. The same medication that I have been prescribed for over 17 years. Of course, medication adjustments will be necessary if the patient is legitimate. as continued use is required.

    I, personally, do not care if medication is an opiate based medication, a synthetic medication or totally non narcotic if unmanageable pain is reduced to a level that can be endured. In regard to extended relief medication, the level of relief as stated on ANY extended relief medication has never been realized by me with any medication prescribed, to me. The new “policy for the use of opiates for the treatment of pain”, which is the official policy published in my state, regardless of the published references of the experts and specialists is NOT fulfilling the chronic pain patients medically necessary needs. Lowering all dosages of the millions of patients that may have a higher tolerance level with the use of opiates is being totally disregarded, with new policy. Of course their is a dangerous level of dosage with any opioid medication. This is where patient RESPONSIBILITY, discretion, and docotrs due diligence in prescribing must be used. Is a heroin, cocaine user being “responsible”? One using heroin to get high? For the millions of people, in severe, continuous pain, opiate based medication may be the ONLY medication that gives life a level of tolerable pain relief, for now. Too “set” a maximum dosage, for one and all, of medication for the pain patient that has or may be responsible with use of opiate base medication is challenging the “medically necessary” clause in ALL health insurance policies. Until a medication is developed with the “bad” qualities of opiate based medication is achieved, to inflict worse pain and suffering on millions of unfortunate people having to live with unmanageable pain with ONE policy is…..asinine, in reasoning.To reach a specific, stated, targeted populous, through a revised policy, specifically the folks that are overdosing with the use of prescribed, illicit, or a combination of use of both, populous, within, a legitimate populous of unmanageable pain PATIENTS who have sought and benefited with opioid medication through a unilateral policy that is now realized to cause self destruction through illicit medication and suicide is an irresponsible action, enforced upon us..

    To cause pain and suffering, death, through declining health for chronic pain patients who may now choose the use of illicit drugs or choose suicide to curb the “reasoning” of those that have chose to use a substance which is known to cause self destruction and death by a unilateral “guideline” for patients “for the treatment of pain” is a totally irresponsible action that those who wield authority, in the name of the people, have adopted. If it,s not broke, then don’t fix it. If it is broke, then choose the proper tools and parts to do so.

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