After five back surgeries, things are no better; after a knee replacement following a motorcycle wreck, the pain is now even worse and is accompanied by an unusual pain condition where even the slightest pressure from a garment causes burning and unbearable discomfort; the bullet wounds in a 20 year old's back, the result of a drive by shooting in which the bullets passed through the friend first killing him instantly, now cause permanent pain and weakness; the roofer that falls thirty feet, fractures his back and lives to tell about it after 60 days in a coma, or the rodeo cowboy that was kicked in the head by a horse after breaking his back at the same time. The list goes on and on. Everyone of them is real and each has a gripping story. Every one of these people is a prisoner to chronic unimaginable pain. Now put these vulnerable people in the "Oxycodone Game" where they are required to see a pain management doctor monthly for life, (yes for life) and there are constant shortages and price increases on a monthly basis, not to mention having to physically hunt five or six pharmacies monthly because of fear of being robbed, will not tell a patient over the phone whether they have the medication in stock.
Depression over their unfortunate accident, coupled with desperation of not finding the only medication that works, even at an outrageous price, makes people crazed about such unfairness. Why should these people be made to suffer over and above their physical problems more than any other medical condition? What political end game are these people caught up in? What sensational reporting of pill mill closures are they now victims of? Many have already lost their jobs and insurance because they are unable to work or because of the economic times. Many can't pay for their medications; many can't afford newer more expensive medications that we'd all prefer because their prescription plans won't cover them, and many are in between government assistance programs or the disability office and are subject to withdrawal symptoms that are horrific and potentially life threatening. Many live in high crime areas and suffer theft at a much higher rate to make matters all the more difficult. Thus begins the conversation about the potential for drug abuse with Oxycodone in our community. The stigma and shame many feel about being a "junky" plows into the psyche and we as a society make it mean something to the outside world that is less than honorable. And then again, pain is very subjective from one person to the next. What is real pain is sometime a very hard call. What is a therapeutic dose is equally difficult at times to determine even if it exceeds "normal." Many have abnormal MRI findings who do not require more than a Tylenol and yet others require Oxycodone. I write to discuss the scope of the problem and offer some solutions to what is one of the most serious problems of our times.
Having had the privilege of delivering many a child in our community I now find myself in an entirely new field. How I got here is immaterial but my recreation from OB-GYN to Family Practice with pain management skills throws me directly into the center of this controversy. So, wherein lies the real problem? The government seems confused with its good intentions on keeping the public safe from drug dealers who prey on our children and make physicians the focus of the problem. Let me offer some further insight.
Where would these people be if there was no such drug available? Should the government not just outlaw it outright? Would the disabled be confined to a bed in a back room of a relative's house or would they be put into a nursing facility at taxpayer expense? Without such drugs, people would be totally non productive at their trade, be it tile setter, policeman, or office manager. It is true that Oxycodone has pushed deaths from cocaine off the front page and is it true that deaths have increased in cities with multiple so-called pill mills which compounds the problem. Is it not true that the bad apples are at it again, causing havoc for the 98 percent that play by the rules? How many times have I heard "Thanks doc, I got my life back with the oxys!"
So, what are the alternatives? This medication and its derivatives been with us for nearly 100 years and, since oxycodone was introduced pharmaceutically in 1995, there have been multiple attempts to introduce less addicting, less tamperable medications. What other hope is out there that offers such amazing results? If Oxycodone was removed from the U.S. market, what would happen to the suicide rate? What would the consequence be to the "war on drugs"? What are the implications of tolerance to such a medication? Is there really no lethal dose to Oxycodone?
There isn't a month that goes by without some tragic new story that points to the "pill mill" in our community. Is it sensational journalism or is it politically motivated? Whether it be about an unintended tragic death of a young person from an overdose that usually goes unreported to the general population to honor the privacy of the families involved, pill mills are made the demons but who set them up in the first place to get these medications regulated? What about prescription drugs from each and every practitioner out there? Any physician regardless of specialty, can prescribe these potent narcotic pain medications. What happens to the unused quantities that end up in the medicine cabinet, ready for adolescent experimenters? Is that not a source for abuse as well? What makes that need for pain medications from one practitioner more legitimate than from any other practitioner? What are the chances these too will end up on the streets or be involved in an accidental overdose?
I see people from closed pill mill clinics often who are certainly legitimate, and it takes a keen eye, a staff that trusts no one, and a pharmacist who is well aware of his clientele and the prescribing habits of his doctors to keep opiate seekers out of the office. We have seen many an ingenious attempt to falsify information, from altered MRI results to even questioning the authenticity of the MRI facility where convincing reports may even be bought. Well-respected physicians have had their licenses revoked for what some bureaucrat believes is inappropriate without a hearing, warning or explanation and yet others do deserve revocation as they did not perform a real exam or did not review all the medical facts about each patient. What about those physicians who do not have any real relationship with the patient and deal with him as a number because of economic incentives provided by the non MD owner? These physicians are considered the new pushers, but is that really fair? Where does personal responsibility from the patient side enter the equation? Does he get a total pass and the physician takes the heat for someone else's indiscretion? This all contributes to the difficulties in this arena and marks a physician of a pain clinic as something less than legitimate because the state mandated such clinics. What irony here. The state makes patients seen monthly and, as a result the office visit, however brief, runs between $150-200 cash with no insurance accepted. Are we going to interfere with market forces in this arena and not then interfere with let's say, the dental fess or legal fees? Who gets to say what charges can be? Now add that to the cost of the medications, the hassle of finding them with the cost of gas, the inability to go on a vacation that is not planned around these monthly visits, as well as the chronic pain condition and one perhaps more clearly understands the plight of such desperate people. Never mind the physicians who practice defensively, write for a number rather than a number that works, and under medicate the patient. No wonder people buy them off the street at their peril.
Here are some solutions:
1. Get two physicians to certify the chronic intractable nature of a patient so that he may get a 6-month pass to receive his medications monthly at the pharmacy without a medical visit and employ random pills counts to insure they are in fact using their medications correctly.
2. Make pain clinics have consistency of care where the same physician must see the same patient every month.
3. Make that pharmacy responsible for having adequate amounts of medication available with the DEA blessing.
4. Hook up all pharmacy computers to a national drug base to avoid doctor shopping as now can and does happen in Florida.
5. Require (suggest) all disabled to participate in some sort of contribution to society, be it a volunteer at food programs or church related programs or be it a mentor for homework assistance at a local school. When people make a real contribution, they get a sense that they are no longer victims and that their lives matter. "Who you are" for the world speaks powerfully and opens up new possibility. In many poignant conversations in the office, it's amazing the amount of tears shed when the victimization of this all falls away and a new possibility is created about the meaning of their lives. After all, how does Steven Hawkins still make a contribution, is "happy" and yet be totally paralyzed ? Make a 3-day course at The Landmark Forum (landmarkeducation.com) part of the requirement for an additional disability subsidy so that people get clarity in a different powerful conversation about who they are for the world.
6. Support Adult Stem Cell research that is showing huge promise with certain types of back pain and intractable joint pain. Join and support groups like The Stem Cell Alliance that advances the prospect of indigents receiving this critical amazing therapy that reduces or eliminates pain.
7. Allow people to carry a day's worth of medication upon them and decriminalize it if they can show within 24 hours their actual prescription to the authorities. Stop this abuse of people just doing what most others do with their medications for travel.
8. Allow physicians an opportunity to respond to a government agency should there be a perceived violation and allow those infractions to be remedied prior to closing them down unless there is incontrovertible evidence the clinic is a source for traffickers.
The problem as you can see is extensive, exhaustive, and multifaceted. People are all wired differently and all have different physiologic circuitry that continues to be revealed in the neurosciences. It is an evolving field and as a result, newer drugs are sure to come that are less addicting. At what cost and who will pay for the research and development remains to be seen. The problem goes on and on and after it is solved, human nature will then create the next taboo to restore pleasure to an ever stressful world.
- KK Yankopolus, MD, Fort Myers