Weird Medicine: The Podcast - 303 - Chronic Pain

Episode Date: March 14, 2018

In this "very special episode," Dr Steve and crew discuss the current opioid crisis and how it's affecting legitimate pain patients. Pseudoaddiction and other topics are discussed. STUFF.DOCTORSTEVE.COM simplyherbals.net Learn more about your ad choices. Visit podcastchoices.com/adchoices

Knock knock. Who's there? Oyster. Oyster who? Oyster the pot. The chowder is burning. I've got diphtheria crushing my esophagus. I've got Ebola vibes dripping from my nose. I've got the leprosy of the heartbound, exacerbating my incredible woes. I want to take my brain out, plastic with the wave, an ultrasonic, ecographic, and a pulsating shave. I want a magic pill. All my ailments, the health equivalent of citizen cane. And if I don't get it now in the tablet, I think I'm doomed, then I'll have to go insane.

I want a requiem for my disease. So I'm paging Dr. Steve. Dr. Steve. You're going to take a cowful. Yo-ho-ho-ho-ho-no-de-h. Yo-le-to-be. Yo-le-do. I need to touch it.

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You can sign up for one month, download everything if you want to, and then log off. And it's really easiest to use that using the Weird Medicine app that's available on Google Play and at the iTunes store. Anyway, and thank you for all of that, and thanks for indulging me talking about all this stuff. In this show, on the Sirius XM show, we had a very, I think, important conversation. It's nothing I do as important, but it was about, I think the topic is important. It's about chronic pain patients and what they're going through, given that we have this quote-unquote opioid crisis of prescription drugs. And it is a real problem. There's no question about that.

And there's too many pills on the streets. And the knuckleheads out there are ruining it, though, for the people who actually need these pain medications. And so now everybody's being seen as a drug seeker. And doctors are afraid to write it because they're afraid the FDA is going to come after them or somehow the CDC is going to come after them. And it's something I'd like to do a more in-depth show about sometime in the future. because this is something I actually know quite a bit about. But I just wanted to play for you. We're going to be on vacation for the next couple of weeks.

So it's my kid's spring break. So this week we'll play this segment from our Sirius XM show. Next week will be a best of, which I think I'm going to pull one of the older shows, maybe the oldest show that we ever did, and let you guys hear that from 2007, the very first serious XM show. It'll either be that or the three-hour turdacular that we did for Danny Ross when he was running the Saturday night virus thing on Saturday nights. Anyway, we'll see.

We'll worry about that next week. But this week is a phone call from one of our Twitter followers named Peppermint Patty and she wanted to call in and talk about chronic pain and chronic pain patients, and this is her call. Peppermint Patty, area code 303, you're on Weird Medicine. Hi, Dr. Steve. Hello. How are you? Hi, Dr. Scott.

Hi, Andy. Hey, how are you? Hi. So what's up? Well, I wanted to call and kind of talk about what's going on with the chronic pain patient people. Yeah, let's talk about that. I don't know if it. Yes.

I don't know how many people know what's really going on because I've been surprised in conversations with, like, even nurses and things. I want to where they are with the CDC guidelines, but for me, on a personal level, it's been devastating. And I know there has to be many other pain patients going through this. Sure. Well, let's let me give everybody some background. and then I want to hear about your case personally. And then we'll talk about sort of the greater issues that are involved. So back in the 70s and 80s, doctors were told that we were under prescribing pain or under prescribing for pain,

that people with chronic non-malignant pain should be treated with strong opioids. And we listened. So we said, okay, I guess we've been doing it wrong all this time. so we started writing a lot more long-acting, strong opioids for people with chronic non-cancer pain. And there were some people that found that there was a way they could make money off of it and took it to an extreme to the point where, you know, the market got flooded with pills. and now you've got the lunatics out there who are some of them started out as not being lunatics and some were lunatics from the get-go are ruining this situation for people who legitimately need

pain medication and the CDC guidelines we can talk about them I don't think they're that draconian there are some more guidelines that are significantly more draconian and including those at the Veterans Administration that I, you know, would be, I'm, I don't practice at the VA. I only know what I hear. So I can, but they're, look, all of these people, including the CDC, are trying to make a situation that seems out of control better. They really are trying to do that. Now, what's happening to me is that they're throwing the baby out with the bathwater, that there are people who, legitimately require pain medication, including my patients who are 100% cancer pain patients,

are having a hard time getting their medication, where they're having, you know, five-day trials, so they got to keep going back to the pharmacy to get their medication. Prior approval on 100% of all opioid prescriptions, stuff like that, things that are just making it difficult for people who actually need these medications. I don't know what the answer is, but Patty, tell us, go back and tell us a little bit about your situation and how you became a chronic pain patient, and now what's going on with you that prompted this call?

Well, for me, it started about 24 years ago. I was in a horrific auto accident on the highway. I was hit by a Mack truck at 70 miles an hour. Okay. And it just literally, for the medical term, is it smashed my back up. Sure. You know, and after five, oh, God, the specialist looked at it.

They said, you know, we just, we can't repair it. There was too many bones smashed together, and it was just unfixable. But they said at that point, we can make you comfortable enough. Then there were two other accidents. People flew through red lights. And, you know, as the years went by, they found a good dose that, worked for me pain-wise and I'd been on the same dose for the last 18 years and it worked great and never abused it and if I needed to have it filled early I had this great dog and I always

let him know here's what's going on and I have history with him so he knows there's no abuse going on suddenly it wasn't suddenly but it was sudden for me last August my doc said we are now going to slash your medicines from 120 milligrams a day. 90 for pain, 30 milligrams for breakthrough pain to 30 milligrams. And that happened within three months. Okay. And many people are facing this. Was there any indication for this other than the...

Oh, sorry. Was there any indication for doing this other than that people are starting to freak out about pain medication? Was there any medical indication for de-combing? increasing your pain medication. No, and the reason he told me, and he was very candid with me, because we have a very open relationship, was that these are the new CDC guidelines,

and we are being told from the DEA, if we do not do this, we are subject to being persecuted, prosecuted. Right, or both. And that's pretty much been this, yeah, that's pretty much been this story all along. I mean, there was no problem with my meds, and the CDC came in. And they used this word opiate crisis, but what they don't differentiate is that illicit fentanyl, heroin, those are opiates, too. So they were trying to make a drug war better, but instead the pain patients got slammed.

And now doctors, you guys are having to jump, do the monkey dance all day long with paperwork. And it's a bad situation all the way around for her. for many pain patients, I've heard from hundreds. This is what I've seen is the CDC guidelines don't say if you have someone on a stable chronic dose and there's no signs of diversion, take them off their medicine. There's nothing in the CDC guidelines say that. What's going on is these doctors are, and not all of them, but there are some that are getting scared because they think these things are going to happen.

I haven't heard the DEA ever say, we're going to prosecute you if you treat pain patients appropriately. Matter of fact, I had two DEA agents show up in my office one day. And I got a phone call from my office saying two giant men are in your office, and they want to see you right now. So I went running down there because knowing what I do for a living, I figured it's some. point, I would be on their radar screen. You know, I legitimately treat patients, but they're all, you know, it's very severe cancer pain. And I only see the ones that the regular oncologist can't handle.

So I went running in there, and yes, indeed, there are these two giant men mountain in my office. And they asked me my name. I said, yes, it's me. I said, this is a friendly visit, right, guys? And they handed me a subpoena. But they wanted me to testify against somebody else who was doing a pill mill. Unfortunately, our two subspecialties were different, so I really couldn't help them because, you know, I would have been, it's like apples testifying against oranges.

So, but while they were there, and it was a very friendly visit, I asked them, am I ever going to be on your radar screen? They said, what we're going after are people who are seeing 100 people a day, they're doing cash only, and every single person that comes in gets 90 oxycontin, you know, whatever, 40s, and 180 roxycodone 30s. And it's like they've got a rubber stamp, boom, boom, boom, boom. And that's what they're looking at. And they said, you who are individualizing your treatment, who are treating your patients appropriately,

will never be on our radar screen. Well, I wish every doctor who treats pain would hear what they had to say about that as long as we are treating and I'm knocking on wood when I'm saying this because sure is shit tomorrow they'll show up on my door step after I said this but um but uh I wish every doctor would hear this because they don't have to fear if they're treating people appropriately using the minimum dose of course the minimum dose required to do the trick and uh and documenting uh what they're treating the biggest thing that people get in trouble with is when they're documenting or when they're treating for an indication that they haven't documented for.

For example, the patient told me I had cancer pain or the patient told me they had arthritis and you haven't done a workup to prove that they do have arthritis. You know, Dr. Scott works at a pain clinic. Now, he does all the non-opioid stuff, you know. And why don't you talk for a second about what you do to alleviate this problem? because not everything has to be treated with opioids, that's for sure. Patty obviously does. But talk a little bit about what you're doing.

Well, I'll tell you exactly what Dr. Steve just said. You know, the problem we have is working in a pain medicine clinic. We get a lot of the patients that none of the other doctors want to write medicines for it because they're afraid. Because they're on high doses just like you, Patty. And so what we try to do is. And by the way, most of my cancer patients would laugh at how much Patty was on before they reduced. Yeah, yeah. But anyway, go ahead.

Yeah, that's true. And so what we do, Patty, is we try to give the patients some alternatives and some comprehensive approaches. We do. Of course, I do the acupuncture and herbal medicines for pain. We have physical therapy. We have psychological help. We have every kind of modality you can ever use to help treat pain. And I'll give you a, for instance, last, and I'll just, I had an instance last night with a family member who broke his leg, okay?

He went to the emergency department. They're waiting for the swelling to come out of it. of it. Dr. Wrights him for pain medicine, you know. Right. So last night I go over and I'm like, well, how are you feeling? Okay, but I need my pain medicine. Why do you need your pain medicine? Because he told me I could take it every four hours.

And that's one thing. I corrected him on. I said, listen, this is where a lot of the trouble is when you read your prescription says, you know, take every four hours. It doesn't mean. It should say every four hours as needs. As needed. Right.

And so we work on that. But, you know, a chronic pain patient. that's been on well-controlled medicines for years. I've never seen any need to change. And this is, that's what we do. Hey, Patty, what do you think of Dr. John Sarno's book that says, are you familiar with that? And I wonder what the chronic pain patients feel about that.

You know, Howard Stern's always talking about him. It says chronic pain, back pain is just in everyone's head that you don't need anything. I know. Yes, I've been trying to perfect the method to think it away. I'm not quite there yet. I don't mean to be sarcastic. But, I mean, you know, most pain, chronic pain patients have kind of, we would like to incorporate the options with the pain medicine.

And if we could just do the options, we would love that because nobody, I mean, taking pain medication was not on my bucket list. Right. And anyone that's only prescribing that. And hold that thought just for a second, because if I don't say this now, I'll forget what I was going to say. Understand. If we never want to only prescribe opioids for chronic pain, and I'll tell you why, that's what got the Romans in trouble. The Romans would, when they were in battle, they would line up, and they would, you know, the other army would line up,

and they'd come to each other and start poking each other with swords and sticks and stuff, right? And then the vandals... That sounds right. The vandals said, well, this is fucking stupid. Let's just go around the side and flank these people. We could beat the shit out of them. And indeed, they did. And I'm vastly oversimplifying the fall of the Roman Empire.

But using a multifaceted, multi-front approach to battling anything is always preferable to a heads-on, you know, single-moder. approach. So I think the same thing is true. When we're treating chronic pain, it's like a battle. And we've got, you know, our frontline artillery, which may be chronic opioids. And then we've got all these other things that we can then flank the pain. And the more modalities we use, the less of each one that we can use. Exactly. So now what were you going to say, Patty? I interrupted you. I apologize. Oh, that's quite all right, because I love listening to you guys talk. So no worry either. I'm going to say, I don't know if you're aware of Dr. Forrest Tennant in California. I am not. He doesn't sound like what you do, Dr. Scott. He deals with a lot of pain patients

with complex pain issues, and he refused to slash their doses, and then the DEA came and investigated him and shut him down. Of course, I don't know how that trial is going, but it is gone from where they were guidelines to now their laws, and I think the big thing that's frightening. But they're not. They're being interpreted that way, but they're not laws. Even in the state of Tennessee, we have chronic pain guidelines that are truly guidelines. The guidelines even say we expect that these guidelines will be deviated from in certain cases.

I don't know this, Dr. Tennant, that it's all going to boil down to whether he documented what he was doing properly. Because that's the key to all of this is saying, what am I treating? what's the indication for treating with opioids? I tried A, I tried B, I tried C. Now we're doing chronic opioids. These people are not diverting. I'm doing urine drug screens. I'm doing pill counts.

I'm screening them for mental illness, all of this stuff. If you document all that stuff, I would be very surprised. And I would, if he did document all that stuff, I would be happy to volunteer as an expert witness to testify on his behalf. And I know there are lots of other pain people would as well Because that's just standard of care Now if he didn't do that He's going to be in a bit of a pickle

When it comes to defending himself If the DEA or whoever I don't know who it is that targeted him Has decided to come after him Yeah Well and I don't want to ramble on and chew up all your time No it's okay This is the most it comes down to this

That the most frightening thing is for people who were stable had provable pain were compliant pain patients across the nation they've either been abandoned by their doctors for fear of the DEA where they've had med slashed

and that's just as a pain patient you're like where do I go? What do I do? I mean the only option is to try to bite back I have... I think it's just scary to me that people are being left in pain you know? I give talks to

large medical groups and one of the things that I always tell them is that it upsets me when I hear doctors say to me and I have people who I respect to her colleagues well I just don't treat pain and that's like why don't you just say well I just don't treat diabetes or I just don't treat hypertension

and if you're not going to treat it that's your prerogative but send them to somebody who will develop a relationship with somebody who will because if I say I ain't going to treat no diabetes i gotta send those people to an endocrinologist and don't meet the person up for having pain or for having diabetes because that's what we get and then the patient feels like they're a bad person you know because here's the problem yes we don't have a blood test for pain if we did this would be a different story because it affects people's behavior and okay so

let's talk a little bit uh Andy I'm gonna I'm gonna put you on the spot on this I need you get pushed the microphone. If you had 10 out of 10 pain, let's say you had some tumor in your leg or something that was causing horrific pain. And I said, oh, shit, you know, it's all in your head. And I gave you Tylenol for it. How would you behave? What kind of things would you do to try to rectify this situation? Well, I mean, if you're talking about 10 out of 10 pain, I mean, 10 out of 10, right. Worst pain you can imagine. I mean, I feel like Tylenol only take you so far. then, you know, you would get to a point where you would be at a loss and, you know, maybe you would... So what would you do?

Consider looking at other alternatives. Like what? Well, I mean, the obvious thing would be, you know, I think you'd start talking about it with people and then you're going to talk, you're going to find somebody that knows somebody who knows somebody that's had similar issues. So you're going to go to another doctor? Perhaps. Okay, that's doctor shopping. Okay. Number two, what would you do?

Maybe that doesn't get you anywhere either. But, you know, maybe, hey, listen, I've got something for you that's going to maybe alleviate some of the pain that you're having. So you're talking about you get something on the street? Possibly. Okay, so you get something on the street. So now you're using street drugs. What else? What else would you do?

Self-medicate with alcohol. I mean, you know. So now you're a substance abuser. Exactly. How about anybody else throw some stuff in? I put Andy on the spot. You might raise hell in the doctor's office. You might slam the door.

You might yell in the lobby. We have people going out slamming doors, throwing shit down the hallway. Of course. So these are all. drug-seeking behaviors. These are all behaviors that we associate with addiction. But this is not an addicted person. This is someone that is simply seeking relief.

And it is almost impossible to determine who's an addict and who's a pseudo-addict, which is what we're describing here. So, you know what the answer is? And it's counterintuitive. You increase their pain medication. The pseudo-addict will go, oh, thank you. Finally. Thank you. I've got some relief, whereas the addict, there's no, they're a bottomless pit. There's no end to what they will.

So we hear these kind of vignettes all the time of people in these desperate positions. Are you seeing anything, and not to flip the subject, but are you seeing anything where people are hesitant to have procedures? Or go down the road of even being offered these pain medicines because they feel like, you know, they're two steps away from doing an intervention. And they're afraid of being addicted, that's exactly. Or being thought that they were addicted. I have people that say, I don't want to take that medicine because I don't want people thinking I'm a drug addict. I'm a drug seeker. Or they say, I don't want that stuff in my house because people are just going to break in my house and knock me over the head and take it from me.

And so there is this, there are people out there that are abusing the shit out of this stuff and they have ruined it for the patties of the world. Yep, yeah. And, you know, overprescribing, ruined it for the patties of the world. abusing the system where people were taking truckloads of people down to a certain state south of us and we're getting amorize and getting prescriptions for stuff and then getting a three-month supply of medication that they would then bring back up here and then distribute that ruined it for Patty. And, you know, so this knee-jerk reaction is, well, we got to do something, we got to do something. Well, let's just, let's make things more strict for everybody.

And the problem is Patty is suffering. Yeah, it's kind of a, we made it a one-size-fits-all, and that never works. Right. I agree. If the physicians out there and other providers that are prescribing would read the CDC guidelines, they really aren't that draconian. They really aren't. You've got to read them. they just basically say use the minimum amount required to do and do due diligence.

You know, make sure you're treating for a proper indication and you are not overprescribing it. You're that you're not dealing with aberrant behavior and that kind of stuff. And it doesn't, and don't worry in there. Does it say every doctor take all your patients off of their medication? So I think once. You know, it started out. Yeah, go ahead. Sorry.

Go ahead. No. It started out as guidelines, suggestions. But even before the full force of this had taken place, there was this rampant fear that the DEA had really kind of pushed on all these insurance people and the insurance doctors and the doctors had to go to seminars about these guidelines. But nobody was willing to do the guidelines that they did what was recommended by the MME, the CDC MME. And it's left atrocities. And I think next year so we're going to people are. general, we're really going to be shocked by the atrocities, but it's kind of laying out.

I think there will be a backlash. It's supposed to be a change. People like yourself will get your voice heard. The press loves this kind of story, and it will get out there, and people will realize that, you know, the guide, they will realize eventually things will settle down that the DEA isn't going to come after them just because they're treating appropriate pain. and that's really where the answer in this lies is with education. Now, I do the two-hour, in Tennessee, we have to do two hours of CME every two years on what's called safe opioid prescribing, and I give those talks. I'm the one who gives the talks, and nowhere do I ever say, take all your patients off their opioids. We're always talking about how to safely prescribe them, start loving.

and go slow, and monitor, give people naloxone, do urine drug screens, screen for mental illness, all these things so that you can safely describe. And I'm hoping that as this education spreads out there, that people will just start calming down a little bit, you know, it's a, it's a tough situation. I hope so, too. But I'm sorry that you're going through this, and, you know, yeah, if you turn around and and try to find another provider who may be more liberal in their prescribing than your prescriber who's decided that they're going to be afraid to prescribe anything, you're going to be labeled as a doctor shopper.

So there is a way to do this, though. You could ask your prescriber to refer you to somebody that might be more comfortable doing this. And they may be glad to do that, to be honest with you, just to not have to deal with. And you could still, if, I'm assuming that's your, is that your primary care provider? It is right now because I don't have a car in Denver, 60 miles from me. So, oh, you're in Colorado? Very good, you know. You're in Colorado?

Yes. So have you tried, I'm just asking, I'm not recommending this. Have you tried marijuana as medicine? And did it give you any benefit? You know, here's the double-edged sword. it violates my pain contract. I would like to try it. But it violates my pain contract.

Study after study has shown that people who use marijuana as medicine use less opioids. You know? I'd love to have it as an option. You know, they can say to me, sure, go ahead and try it. But if you don't put that in writing my pain contract, you can then drop me for violating my pain contract. Right, right, right, right. So it's a double-edged sword. That is not a double-edged sword.

That is what you call a catch-22. Okay, so this is what I... It's a dagger. Let's just call it what it is. This is what I'm going to recommend to you is that you go to your primary and say, look, I know you're uncomfortable writing this stuff because there's so much pressure being put on you. What do you think about referring me to a chronic pain clinic that might be a little more comfortable doing this stuff? And just see what they say.

because if you go on your own, of course, now you've got two pain contracts out there. That's not cool. But just to say, you know, to find somebody. And there's got to be somebody in the metropolitan Denver area or in your area that treats pain appropriately. And this isn't even to say that your primary care isn't operating in good faith. They think they're doing the right thing. They've been your provider for 18 years. They don't think they're doing the right.

wrong thing, you know, it's, so, but anyway, I, well, I hate that for you. Let me, try that and let me know how it goes. Thank you. And, you know, take heart. I do believe this will get better as the backlash kind of hits the press. And I know there's some of the people on Twitter are saying, oh, the press has been bought off. Bullshit, they love a great story. And they love a great story where the, you know, the little guy is going after the big guy and all that stuff. And I really, think. Going after the man. Yeah, that they're going to take this story up and you'll see a lot more interest in this as time goes on.

Well, they just haven't caught up with it yet. No, not yet, but they will. I'm looking forward to that. Okay. I really appreciate you calling. Thank you so very much, Dr. Steve and Dr. Scott and Andy. Take care. I have a great show and my kitties are all talking at once. Of course they are. Until all the other CPPs to leave me. alone. I'm doing the best I can. Jesus, I've been just one person. Good luck, Pat. Take care.

Have a good day, guys. Bye-bye. Bye-bye.