Mysterious Pain Syndrome?

For immediate release: January 30, 2006

Study finds nerve damage in previously mysterious chronic pain syndrome

Reduction in small-fiber nerves may underlie complex regional pain syndrome-I (reflex sympathetic dystrophy)

BOSTON – Researchers at Massachusetts General Hospital (MGH) have found the first evidence of a physical abnormality underlying the chronic pain condition called reflex sympathetic dystrophy or complex regional pain syndrome-I (CRPS-I).

In the February issue of the journal Pain, they describe finding that skin affected by CRPS-I pain appears to have lost some small-fiber nerve endings, a change characteristic of other neuropathic pain syndromes. “This sort of small-fiber degeneration has been found in every nerve pain condition ever studied, including postherpetic neuralgia and neuropathies associated with diabetes and HIV infection,” says Anne Louise Oaklander, MD, PhD, director of the MGH Nerve Injury Unit, who led the study.

“The nerve damage in those conditions has been much more severe, which may be why it’s been so hard to detect CRPS-I-related nerve damage.” Complex regional pain syndrome is the current name for a baffling condition first described in the 19th century in which some patients are left with severe chronic pain and other symptoms – swelling, excess sweating, change in skin color and temperature – after what may be a fairly minor injury.

The fact that patients’ pain severity is out of proportion to the original injury is a hallmark of the syndrome, and has led many to doubt whether patients’ symptoms are caused by physical damage or by a psychological disorder.

Pain not associated with a known nerve injury has been called CRPS-I, while symptoms following damage to a major nerve has been called CRPS-II. Because small-fiber nerve endings transmit pain messages and control skin color and temperature and because damage to those fibers is associated with other painful disorders, the MGH research team hypothesized that those fibers might also be involved with CRPS-I.

To investigate their theory they studied 18 CRPS-I patients and 7 control patients with similar chronic symptoms known to be caused by arthritis.

Small skin biopsies were taken under anesthesia from the most painful area, from a pain-free area on the same limb and from a corresponding unaffected area on the other side of the body. The skin biopsies showed that, the density of small-fiber nerve endings in CRPS-I patients was reduced from 25 to 30 percent in the affected areas compared with unaffected areas.

No nerve losses were seen in samples from the control participants, suggesting that the damage was specific to CRPS-I, not to pain in general. Tests of sensory function performed in the same areas found that a light touch or slight heat was more likely to be perceived as painful in the affected areas of CRPS-I patients than in the unaffected areas, also indicating abnormal neural function.“The fact that CRPS-I now has an identified cause takes it out of the realm of so-called ‘psychosomatic illness.’ One of the great frustrations facing CRPS-I patients has been the lack of an explanation for their symptoms. Many people are skeptical of their motivations, and some physicians are reluctant to prescribe pain medications when the cause of pain is unknown,” says Oaklander.

“Our results suggest that CRPS-I patients should be evaluated by neurologists who specialize in nerve injury and be treated with medications or procedures that have proven effective for other nerve-injury pain syndromes.” She adds that the next research steps should investigate why some people are left with CRPS after injuries that do not cause long-term problems for most patients, determine the best way of diagnosing the syndrome and evaluate potential treatments.

“Investigations that identify the causes of disease are only possible if patients are willing to come to the lab and allow researchers to study them,” she adds. “We are tremendously grateful to these CRPS patients, whose willingness to let us study them – despite their chronic pain – allowed us to make an important step in helping those who suffer from this condition.” Oaklander is an assistant professor of Anaesthesia and Neurology at Harvard Medical School.The study was supported by grants from The Mayday Fund, the National Institute for Neurological Disorders and Stroke, and the American Federation for Aging Research. Coauthors are Julia Rissmiller, Lisa Gelman, Li Zheng, MD, PhD; Yuchiao Chang, PhD; and Ralph Gott, all of the MGH.

Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of nearly $500 million and major research centers in AIDS, cardiovascular research, cancer, cutaneous biology, medical imaging, neurodegenerative disorders, transplantation biology and photomedicine. In 1994, MGH and Brigham and Women’s Hospital joined to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups, and nonacute and home health services.

Contact: Sue McGreevey (617) 724-2764

Chronic Pain Article

Science Spots New Cause of Chronic Pain

WEDNESDAY, Jan. 25 (HealthDay News) -- In a finding that could alter pain treatment, British scientists have found that undamaged nerve fibers, not injured ones, cause ongoing spontaneous pain.

The unexpected finding that may help in the development of new treatments for back problems and other conditions that involve chronic pain. Previous research into chronic pain focused on nerve fibers damaged due to injury or illness, and largely overlooked intact nerve fibers.

"The cause of this ongoing pain and why it arises spontaneously was not understood before," Sally Lawson, of the University of Bristol, said in a prepared statement. "Now that we know the type of nerve fibers involved, and especially that it is the undamaged nerve fibers that cause this pain, we can examine them to find out what causes them to continually send impulses to the brain. This should help in the search for new analgesics that are effective for controlling ongoing pain."

The findings appear in the current issue of the Journal of Neuroscience.

Lawson and her colleagues identified nerve cells called nociceptors (damage detectors) that, when activated by disease or injury, send out electrical impulses that are sent to the brain. The faster these undamaged nociceptors fire electrical impulses, the stronger the ongoing pain.

The firing of these nociceptors seems to be caused by inflammation within the nerves or tissues, caused by dying or degeneration of the injured nerve fibers within the same nerve, the researchers said.

Yahoo News

Part D from Outer Space

Another viewpoint on Medicare Part D

Part D From Outer Space
by TRUDY LIEBERMAN
The Nation
January 30, 2006 issue

Despite the best efforts of the Bush Administration's public relations machine, Americans made it clear last year that they were in no mood to privatize Social Security. But the Administration had already won a quieter victory with an equally successful social insurance program, Medicare. Part D, the new prescription drug benefit that took effect January 1, looks like the first step on the way to destroying Medicare as a benefit for all senior Americans.

It's too early to tell whether Medicare Part D will be a flop like its predecessor, a drug discount card program that attracted only 15 percent of eligible seniors. But it may well be. So far only about 1 million have voluntarily signed up--fewer than 5 percent of the 21 million eligible seniors, most of whom have been without prescription coverage. At a carefully scripted press conference just before Christmas, Health and Human Services Secretary Michael Leavitt put a positive spin on the numbers, noting that another 21 million seniors were receiving coverage. But most of those enrollees were low-income people the government automatically enrolled, or those already receiving drug benefits elsewhere. The new plan is not yet reaching most of the people it's designed to help.

Unlike other Medicare benefits, Part D is modeled on the country's dysfunctional commercial health insurance system. With Medicare Parts A and B, which cover hospital services and doctor visits, the government pays providers directly. Under Part D, the government pays some 260 private insurers--including pharmacy benefit managers, HMOs and pharmacies--to provide the coverage. If seniors want the benefit, they must buy it from one of those private carriers. To force them to sign up, Congress imposed a financial penalty (growing more onerous over time) for those who don't get on board by May 15.

Medicare Part D represents the free market run amok. "You don't have to understand every detail and every option," Medicare administrator Dr. Mark McClellan told the Los Angeles Times. "People just need to focus on what they want." Easier said than done. In some counties, seniors have forty or fifty choices of plans--a jumble of insurance options with monthly premiums ranging from zero to more than $60. The government has allowed sellers to mold Part D coverage into hundreds of combinations of deductibles; co-insurance (a percentage of the drug cost consumers pay); drug utilization techniques (such as trying cheaper generic drugs first); and drug tiers, with their own dizzying array of co-payments (the flat amount consumers pay for each drug). Co-payments differ depending on whether people buy generics, preferred brand drugs, non-preferred brand drugs or specialty drugs--and depending on whether they buy from an in-network pharmacy where the insurer has negotiated good discounts or from an out-of-network pharmacy where it hasn't. Adding to the confusion is the fact that there's no standard nomenclature; sellers can use any fanciful name they think will lure buyers to their plan. They can also cover whatever drugs they want to; prescription formularies are not standardized either.

And what happens when seniors are understandably flummoxed by the overabundance of options? They're sent to a complicated web tool for answers--even though, according to one survey, three-quarters of seniors say they have never gone online.

This teeming marketplace, with its myriad sellers all offering their own versions of Part D, was no accident. The push for private market benefits began in earnest nearly a decade ago, when the right-wing Heritage Foundation proposed a bipartisan commission to look at "reforming" Medicare. In 1997 Heritage got its commission, chaired by then-Louisiana Senator John Breaux. A moderate, business-friendly Democrat, Breaux pushed a plan that would have given beneficiaries a set amount of money to buy health coverage in the private market. In the end it didn't fly. But in late 2003 moderate Democrats and Congressional Republicans, led by then-House majority leader Tom DeLay and Senator Breaux, saw their chance to move toward a privatized Medicare. Public outcry over escalating drug prices had caught the attention of Congress, and a drug benefit desperately needed by many seniors became the justification to pass legislation that took a big step toward privatization.

Think of Part D as Version 2.0 on the way to a Medicare system that relies completely on the private market. (The discount cards introduced in 2004, also provided by private insurers, were Version 1.0.) Congress appropriated $400 billion to finance Part D, a number that Richard Foster, chief actuary at the Centers for Medicare and Medicaid Services, later said was much too low. According to several news reports, Bush Administration officials prevented the agency from disclosing the real cost, then estimated at $550 billion, according to Foster.

While seniors are confronted with an overwhelming number of choices, insurers are benefiting from a massive Congressional giveaway. Insurers got generous payments to offer the coverage. And when the inevitable shakeout occurs among the 260 sellers, a cluster of mega-carriers like Aetna, WellPoint, UnitedHealthcare and CIGNA will reap the most from the Congressional largesse.

The size of these big insurers' marketing and operations budgets for Part D shows how important the new Medicare is to them. UnitedHealth Group is spending $75 million, Aetna $50 million and CIGNA $40 million. Humana, a large regional carrier looking to switch seniors to the company's other products, is spending $80 million. Steve Brueckner, Humana's vice president of senior products, says that Part D offers "an unprecedented opportunity to establish relationships."

Indeed it does. Drug companies are also eyeing new customers, especially among enrollees who could not in the past pay for drugs. They, too, are designing marketing strategies around Part D. Bob Dole, former senator turned Viagra pitchman, is selling the benefit on behalf of Pfizer. AstraZeneca is funneling $10 million to the National Council on the Aging (NCOA) to pay for vans and laptop computers that state insurance counselors can use to sign people up.

For politicians, of course, the goal was not just money but votes. Last summer at a meeting of some fifty healthcare lobbyists, a parade of Republicans, led by cheerleader DeLay, urged the lobbyists to help launch a national advocacy campaign to sell Part D, saying the effort would pay dividends in the 2006 midterm elections. That campaign is roaring across the country with the Medicare Rx Education Network, whose membership roster reads like a Who's Who of the business and medical establishment, leading the promotional charge. The network's star is none other than ex-Senator Breaux, who chairs the effort from his Washington law firm, Patton Boggs, one of the capital's premier lobbying outfits. Breaux has been placing op-eds and letters to the editor in newspapers urging seniors to sign up. The network has sent out six mailings to everyone eligible for Medicare, using the government's Medicare Rx Education logo. These mailings' return address is the US Chamber of Commerce. Seniors who also see the Medicare Rx Education logo on government publications can be forgiven if they are confused about who is sending the message.

In its pro-Part D public relations efforts, Medicare Today--a creation of the Healthcare Leadership Council, an organization of hospitals, drug companies, device makers and academic medical centers--has enlisted more than 300 other organizations, ranging from the Blue Cross Blue Shield Association to Wal-Mart Pharmacies, which have contributed $6 million toward "outreach." Since July Medicare Today has held 1,000 events around the country promoting Part D to seniors, and it has stationed representatives in pharmacies and grocery stores to answer questions and help them use the web tool. "We believe this is the right fix for Medicare and it's the right evolution for the twenty-first century, and we're trying to get people to take advantage of it," explains Michael Freeman, executive vice president of the Healthcare Leadership Council.

the initial reluctance of seniors--despite the fevered push to sign up the 20 million older Americans still eligible but not yet enrolled--may reflect an intuitive wariness of a program that while helping them in the short run may doom Medicare in the long run. At the Christmas press conference, Secretary Leavitt said seniors would "never have to worry about high drug costs in the future." But they do. In the end, a drug benefit based on the free market may kill Medicare. It's bad enough that Congress underestimated the true cost of Part D by at least $150 billion. But in its most devastating concession to Big Pharma, Congress forbade the government to negotiate with pharmaceutical companies over drug prices--a deliberate and crucial omission. In essence, Congress bet on insurance carriers and competition to keep drug prices under control--something the market has done poorly.

With Part D causing a virtual epidemic of headaches and complaints, there will be plenty of pressure on Congress to fix the mess. Representative Jan Schakowsky, a progressive Illinois Democrat, has introduced a bill to standardize benefits and require the government to negotiate prices with pharmaceutical firms. Passing such needed reform will be difficult, if not impossible. But Part D will not work in the long run unless Congress mandates price negotiations and ends the formulary free-for-all. Without standardized formularies, sellers can change the drugs they cover at any time--forcing seniors to pay out of pocket, find another insurer, get their doctors to change their treatment plans or file for an exception.

Even with standardized formularies, runaway drug prices could cause Congress ultimately to conclude that Medicare is simply too expensive--and transform it into a means-tested welfare program that would make doctor, hospital and drug benefits available only to the very poorest seniors. That would end Medicare as we know it. Maybe that was the real goal of Part D all along.

The Part D Perfect Storm

The Part D Perfect storm:

What To Do If You Can’t Get MEDICATIONS You Need From Your Medicare Prescription Drug Plan

Introduction
The media, and advocates for people with Medicare, are focusing on the problems of dual eligibles who cannot get access to medically necessary drugs because drug plans are not honoring their obligation to provide a transition supply of prescribed medications. Despite statements by the Centers for Medicare & Medicaid Services (CMS), these issues will not go away even as drug plans get their computer and customer service systems up and running. As more people enroll and use their drug plans, problems will persist. They may change, but they will not go away.

Medicare's “Transition” policy only requires a drug plan to fill a prescription for a non-formulary drug or for a drug that requires prior authorization or other plan approval one time when the person first enrolls in a drug plan. After receiving the transitional first-fill, the beneficiary is expected to either go through the process to get the drug paid for by the plan or get a prescription for a different drug that is on the planes formulary from the treating physician. Unfortunately, advocates report that many people are leaving pharmacies without their medications. Even when beneficiaries are able to secure a transitional supply of medications, they are not being told that they must take further action to get their medications next month.

As a result, in February, we can expect people to be told once again by their pharmacy that their Part D plan will not pay for their medications. But next month, the plans will not be required to supply the medications, and most states will not fill in the gaps. This alert is designed to provide Medicare beneficiaries with information about the steps they need to take when they are told theirdrug plan will not pay for their medications.

What to Do When Your Drug Plan Won’t Pay for Your Medicine?
ANY TIME you can’t get your prescription filled, for ANY reason, you (or someone you authorize to act for you) must contact your Part D Prescription Drug Plan and ask for an official “coverage determination” to explain why you can’t get your prescription filled. You need this official explanation before you can take steps to get the drug you need, and it will tell you what to do next.

What happens at the drug store?
When your drug plan does not cover your medicine, your pharmacy should either give you a piece of paper telling you to contact your drug plan or have a sign posted that explains how to get more information. Even if your pharmacy tells you why the drug isn't covered, you still must contact your drug plan.

Your drug insurance card will have the drug plan’s phone number. If you don’t have a drug card, look in the Medicare & You Handbook you received in October or call 1-800-Medicare. (NOTE: Some plan phone numbers were listed incorrectly in the Medicare & You Handbook.)

How long do I have to call my drug plan?
You have up to 60 days to contact the drug plan for an explanation as to why it will not cover your medicine, but the longer you wait, the longer it may take for you to get your prescription. You can also send a written request to the drug plan. There is no special form to use, but you should say you want a “Coverage Determination” when making your request. (Some Coverage Determinations are called “Exceptions.” See below for details.)

What happens when I call my drug plan?
Ask why coverage has been denied for your medication and state that you want a written explanation. The drug plan must issue a written “Coverage Determination” that gives the reasons for the plan’s denial of payment for your prescription, and tells you what you need to do next to challenge the drug plan’s decision. If at all possible, get a letter from your doctor explaining why you need the medication. Submit it to the plan and keep a copy for your records.

The drug plan must issue the written Coverage Determination, within 72 hours of your request. It may have to issue the decision within 24 hours if you ask for, and are granted, “expedited” review. If an expedited decision is important, get a statement from your physician explaining that this is necessary, and why. The plan may have to issue the decision even sooner if your health condition requires a more immediate answer. If you have already paid for the drug yourself, the plan will issue a decision in 72 hours. If the drug plan doesn't issue a decision in time, it is required to send your claim to an outside, independent reviewer.

What can I do if the drug plan denies my request to pay for the drug?
You have 60 days to ask the plan for a “Redetermination” of its original decision. Your drug plan may require you to make a request for a “redetermination” in writing. The unfavorable coverage determination will tell you how to request a redetermination.

If you request a Redetermination, your drug plan must issue a written decision within 7 days or within 72 hours if you are entitled to expedited review. The drug plan may have to make a decision more quickly if your health condition requires a more immediate answer. The plan will issue a decision in 7 days if you have already paid for your drug. If the drug plan doesn't issue a decision in time, it is required to send your claim to an outside, independent reviewer. The written decision will explain the reasons for the drug plan’s decision and tell you what to do next.

What happens if the drug plan continues to say it won’t pay for the drug?
You have 60 days to file a written request for reconsideration with the Independent Review Entity (IRE). The request must be in writing; there is no option to call the IRE to request a Redetermination. The IRE is an independent company that contracts with Medicare to review prescription drug claims. Maximus is currently the company that has been hired by Medicare to perform this job.

The IRE will review the evidence and may contact you or your doctor. It will then issue a written decision that tells you the reasons for the decision and what you need to do next. The decision should be issued within 7 days or within 72 hours if you are entitled to expedited review.

What happens if the IRE denies my claim?
If the value of your claim is large enough, you may request a hearing before an Administrative Law Judge (ALJ). The hearing process for denied drug claims is the same as the process for appeals from denied hospital, nursing home, doctor, and other Medicare claims.

In 2006, your claim must be at least $110 to get an ALJ hearing. This amount may change each year. In determining this amount, Medicare will consider the cost of your drug over the course of the year. For example, if your drug costs $30, and you have 4 refills left, the value of your claim will be $120.

Can I appeal if the ALJ denies my claims?
Yes. You can ask for review by the Medicare Appeals Council (MAC) and even by federal court if the claim is large enough. Your claim must be worth $1090 to file an appeal in federal court in 2006. The written decision from the ALJ and then from the MAC will tell you how to proceed.

Involving Your Doctor in Your Appeal
Your prescribing doctor plays a critical role if your drug claim is denied. In some cases, you cannot get the drug plan to pay for your drug without your doctor’s help.

When is help from my doctor required?
You must have a doctor’s statement when you are requesting a special type of Coverage Determination called an “Exception.” A plan will not grant your Exception request without a statement from your doctor.

When would I ask for an Exception?
You would ask for an Exception:
*When the drug you need is not on your drug plan’s list of covered drugs (formulary),
*When your drug plan requires you to get its approval (prior authorization) before it will pay for your drug,
*When the drug plan wants you to try a less expensive drug before paying for the prescribed drug (step therapy or fail first),
*When the drug plan limits the number of pills you may have (quantity limits), or
*To reduce the co-payment you have to pay to a lower, less expensive tier of co-payments.

How do I ask for an Exception?
You ask for an Exception the same way you would ask for any Coverage Determination. It is important to note that your doctor can ask for an Exception for you. Some drug plans may require your doctor to use a special form when asking for prior authorization or making a different exceptions request. Each drug plan may have its own form or forms. Even if the plan allows the doctor to request an Exception by telephone, the doctor should follow the telephone request with a written statement.

What does the doctor’s statement have to say?
Each drug plan sets its own requirements for the doctor’s statement. You or your doctor should check with the Evidence of Coverage from your drug plan, or directly with the plan itself, to find out its requirements. At a minimum, the doctor’s statement would have to show that you need to take the prescribed drug because taking any of the similar drugs on the plan’s formulary would cause adverse health consequences, would not be as effective, or both.

What happens if the exception request is denied?
As described above, you can ask your drug plan for a redetermination, just as you would if you got any other unfavorable coverage determination. The rest of the appeals process is also the same as that described above.

Are there other times when I should seek help from my doctor?
A drug plan and the Independent Review Entity must grant a request to expedite a coverage determination (including an Exception), a Redetermination, or a Reconsideration if a doctor asks for expedited review. They do not have to grant such a request if you make it yourself.

You should ask your doctor to request expedited consideration when making an Exceptions request. The doctor should indicate that waiting for a decision during the standard time period could seriously jeopardize your health or life or your ability to regain maximum function.

Conclusion
CMS has stated publicly that Medicare beneficiaries will have access to a wide array of drugs, though they may have to use the exceptions and appeals processes to get some of them. Only time will tell whether beneficiaries and doctors find these processes easier to use than the
transition and other processes CMS said would help all beneficiaries get their medicine when the new Part D drug benefit went into effect.

Relieve Chronic Pain!

New York Times

Let's Get Serious About Relieving Chronic Pain
By JANE E. BRODY

Patients with debilitating pain from chronic illness, accidents, surgery or advanced cancer have long had problems getting adequate medication to control their pain and make life worth living.

Now the federal government, and especially the Drug Enforcement Administration, is working overtime to make it even harder for doctors to manage serious pain, including that of dying patients trying to exit this world gracefully.

In an article in the current New England Journal of Medicine titled "The Big Chill: Inserting the D.E.A. into End-of-Life Care," two specialists in palliative care, Dr. Timothy E. Quill and Dr. Diane E. Meier, state that despite some physicians' commitment to treat pain and despite the effectiveness of opioid drugs like OxyContin and morphine, "abundant evidence suggests that patients' fears of undertreatment of distressing symptoms are justified."

They continue, "Although a lack of proper training and overblown fears of addiction contribute to such undertreatment, physicians' fears of regulatory oversight and disciplinary action remain a central stumbling block."

Obstacles to Relief
In addition to a case before the United States Supreme Court, Gonzales v. Oregon, that threatens to undermine Oregon's Death With Dignity Act, the D.E.A. has recently increased raids on doctors' offices, confiscating files and arresting doctors on charges of overprescribing narcotics to patients who are addicts or drug dealers.

Most of these physicians are compassionate people trying to help suffering patients but are sometimes fooled by clever addicts, drug dealers or undercover agents who fake their pain.
Should the court rule against Oregon, the D.E.A. could turn to all physicians whose patients die while getting prescribed opioids or barbiturates, even if the drugs were administered only to relieve intractable pain, not to hasten death.

Yes, there are bad apples among members of the medical profession. There are some doctors who charge for medical exams that they never do and provide phony patients with prescriptions for narcotics to feed their habits or sell on the street.

But should all physicians be subject to intense scrutiny by the D.E.A. and risk arrest and prosecution, leaving legitimate patients to suffer intensely or scramble to find other doctors willing to risk taking them on?

Doctors have no certain way to measure patients' pain other than to ask them. Patients should be asked to rate their pain, say, on a scale of 1 to 10, with 10 being the most intense they can imagine.

"Model Guidelines for the Use of Controlled Substances for the Treatment of Pain" were established in 1998, and every physician who prescribes narcotics should know them by now. These guidelines emphasize that documentation is critical to proper pain management.
With patients who are prescribed strong painkillers, doctors first are supposed to obtain a medical history, perform a physical examination, ask about addictive behaviors and whether other treatment options have been tried, and fully record what they find.

Prescriptions for controlled substances like narcotics cannot be refilled automatically. When a patient asks for a new one, a well-documented follow-up visit is necessary. The doctor should ask about the kinds and amounts of painkillers being taking, side effects, performance of daily activities and aberrant drug-related behaviors.

Dr. Jennifer P. Schneider, a pain management and addiction medicine specialist in Tucson, gives this example: "Back pain today is 4/10, walks the dog 15 minutes daily, constipation is controlled with Senokot-S, patient is on schedule with his meds." She advises physicians, "If a patient lies about his medical problems and turns out to be a drug abuser, at least you've documented that you were acting in good faith."

A Fear of Prosecution
The growing number of arrests of pain management specialists is exacting high costs for patients, physicians and medical insurers. Some doctors order costly but unnecessary diagnostic tests so they can show the D.E.A. a reason for prescribing strong pain medication.

Many doctors are simply unwilling to prescribe narcotics, no matter how much a patient suffers. Ignorance, as well as a fear of the D.E.A., plays a role. For example, the surgeon who performed my double-knee replacement a year ago told me, in reference to OxyContin, a synthetic opioid: "I don't like to prescribe these drugs. Patients have too hard a time getting off them."
Well, sir, if you never prescribe them, then chances are you never learned how to help patients stop them. Many doctors and patients fail to understand the difference between physical dependence and addiction.

An addict uses a drug to get high, becomes tolerant and needs ever-increasing amounts to maintain that high. Patients taking narcotics for pain don't get high; they get relief from their pain, and when larger doses are needed, it is usually because their pain has become more intense, as often happens in patients with advanced cancer or degenerative diseases.

Physical dependence occurs in almost everyone who takes a narcotic for two weeks or more. The body becomes adapted to the presence of narcotics (that is, becomes physically dependent on them). A patient cannot go off them abruptly without suffering serious withdrawal.

A Gentle Weaning Process
I asked Dr. Schneider how to go off narcotics safely. She suggested cutting back 10 milligrams every three days (the exact amount would depend on the dose a patient is on). If at any point in the weaning process my pain became more intense, I was to go back to the last dose, wait a week, then try to resume the weaning.

As I neared the end, the cutback was five milligrams every three days. Then the dose was down to nothing, and no withdrawal symptoms, either.

Having heard only about those who, like Betty Ford, got hooked on painkillers, many patients are afraid of becoming addicted if narcotics are prescribed. But it is the rare patient who becomes addicted, and it is nearly always someone with a history of addiction, typically to alcohol.

Even with dying patients, the families and physicians often shy away from narcotics for fear of addiction, as if it mattered whether someone near the end of life - in desperate pain or extreme agitation - became addicted to the morphine that could provide almost instant relief.

Proper pain management for dying patients can facilitate important communication between patients and their loved ones and provide what most people would call "a good death."
"Pain is a common symptom in patients nearing the end of life," with up to "77 percent of patients suffering unrelieved, pronounced pain during the last year of life," Dr. Timothy J. Moynihan wrote in The Mayo Clinic Proceedings in 2003.

In their current article, Dr. Quill of the University of Rochester School of Medicine and Dr. Meier of Mount Sinai School of Medicine stated, "Allowing D.E.A. agents, trained only to combat criminal substance abuse and diversion, to dictate to physicians what constitutes acceptable medical practice for seriously ill and dying persons" may make doctors increasingly reluctant to prescribe needed medications and "end up abandoning patients and their families in their moment of greatest need."

Free RSD Seminar!

FREE SEMINAR

Complex Regional Pain Syndrome
Formerly Known as RSD (Reflex Sympathetic Dystrophy)
CRPS is a chronic neurological disease.

Richard W. Lingenfelter, M.D., and Michael D. Papenfuse, D.O., board certified pain specialists at Matrix Pain Management, will discuss how CRPS impacts men, women, and children of all ages.

• Learn about CRPS: CRPS I and CRPS II
• Causes
• Symptoms
• Diagnosis and Treatment
• Prognosis

WHO SHOULD ATTEND: People affected by, or interested in CRPS

WHEN: Thursday, January 26, 2006 at 6:30PM

WHERE: Matrix Pain Management
4450 Fashion Square Blvd.
Saginaw, MI 48603
Call to 989.792.4090 to register.

Visit our website at www.matrixpain.com to learn more about Matrix Pain Management.

Chronic Multi-Symptom Illness

MYSTERIOUS CONDITION PLAGUES GULF WAR VETS

FRIDAY, Dec. 30 (HealthDay News) --

Veterans who served in the Persian Gulf War have nearly twice the prevalence of a chronic multi-symptom illness than soldiers who served elsewhere at the same time, a new study shows.

The condition, chronic multi-symptom illness (CMI), is similar to what is often called Gulf War Syndrome. Diagnosis requires at least two symptoms including fatigue, "mood symptoms" or difficulty thinking, and muscle or joint pain, for six months.

It appears that the risk of CMI is greater in those who had depression and anxiety disorders before military service, Dr. Melvin Blanchard, associate chief of medicine at the St. Louis Veterans Affairs Medical Center and an assistant professor of medicine at Washington University School of Medicine in St. Louis, said in a prepared statement.

"We're still not sure whether CMI is due to a single disease or pathological process," he said.
The study, which appears online in the Journal of Epidemiology, is part of a continuing analysis of data in a VA study called the National Health Survey of Gulf War Era Veterans and Their Families, conducted from 1999 to 2001.

The researchers also found that CMI doubles the risk of metabolic syndrome, which includes increased risk of coronary heart disease, diabetes and cirrhosis of the liver.

CMI continues to be much more prevalent in those who served in the war, although some of those veterans appeared to get better over the 10 years since. A study conducted soon after the war in 1995 by the U.S. Centers for Disease Control and Prevention found that nearly 45 percent of the war veterans were diagnosed with the disorder. The new study shows that number now to be 28.9 percent. However, the percentage of other soldiers with the disorder has held steady at about 15 percent.

"Physicians need to be aware of the potential manifestations of CMI and the need to treat them, and metabolic syndrome is a key example," Blanchard said. "There's quite a bit of literature on this condition, and there are steps physicians can encourage their patients to take, such as increased exercise, stress management and dieting to reduce abdominal fat, that can lessen its effects."

-- Meryl Harris
SOURCE: Washington University School of Medicine, news release, Dec. 27, 2005

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