Is Anybody Listening? The Failing Doctor/Patient Relationship: Part Two

Written by guest author Barry Ulmer

Physicians have been subjected to this campaign of official intimidation for years, but it has intensified over the past several years with the intentional efforts of a few anti-opiate crusaders who have effectively hijacked the whole area of pain medicine with debunked claims. Even more scurrilous there has developed an ethos of suspicion toward people in pain which now affects the patient/doctor relationship. Without so much as a peep from academic circles of medical ethics, the profession has adopted wholesale the imperatives that have been foisted upon it. This has led to a good number of physicians that will treat people with pain with an opiate to become more or less a compliance officer in a drug rehabilitation clinic, routinely forcing patients to perform random urine drug screens in order to prove they are worthy of receiving pain care. A significant number of patients don’t metabolize opiates as expected, a fact that isn’t widely known.

It is not unheard of for a physician to abruptly discontinue the use of opiates simply because he/she suspects “abuse”. If a patient’s family in any way objects to his or her use of the medication and just suspects the patient is addicted, many physicians will terminate care immediately, before incurring the wrath of their regulatory body. If a patient loses a prescription or has their pills stolen they are also likely out of luck of receiving any replacements. Many chronic pain patients are forced to sign what is euphemistically called a “pain contract” with their physician which gives the physician permission to terminate opiate treatment should any one of a litany of events occur. These “contracts” often have patients agreeing not to call him/her on weekends and skip visiting the local ER should they need more relief. If a patient is not happy with their care, they can attempt to find a new physician. However, then they become branded as a difficult patient, non-compliant or a malcontent and shut out of other practices that may prescribe opiates. With the standard of suspicion set firmly in place, the power relationship between doctor and the person in pain is tilted entirely on the side of the doctor. As a result the important patient/doctor relationship suffers even more.

To subject oneself to the ravages of modern pain practice is to put oneself at the mercy of people who are well versed in denying meaningful relief. Since the fall of 2016, when a group of anti-opiate crusaders obtained the ear of Health Canada, the field of pain medicine has been turned upside down. Much of this developed in secrecy to the exclusion of well qualified physicians who had years of experience in the field. It appears that every aspect of what is available now functions to profit off the suffering of the patient. Whereas medical management of pain is often the least expensive and most humane approach to serious intractable pain, the widespread denial of care functions to push out most vulnerable citizens into numerous surgeries, expensive poly-pharmaceutical regimens, tapering of medication, rounds of physical rehabilitation, repeated efforts at diagnosis, and interventional pain treatments that are exceedingly expensive and of little help to those suffering the disease of severe chronic pain. It would appear people with pain are slaves of the system, with many of those purporting to serve them profiting from their predictable decline.

Is Anybody Listening? The Failing Doctor/Patient Relationship: Part One

Written by guest author Barry Ulmer

One of the most disturbing consequences of the unwarranted attack on the use of opiates and the least talked about in polite company, is the steady failure in patient/doctor relationships within the pain community that has taken place over the past few years. In third world countries where opiates are generally unavailable, physicians speak truthfully to their patients when they tell them they have nothing to relieve their pain. In countries like Canada, where opiate pain medications are ostensibly legal, but where physicians have been intimidated and coerced into withholding pain treatment, doctors feign ignorance or as a colleague says, “sheer impotence”.

There is certainly ample evidence that a great deal of pain relief is found in opiate medications and they are readily available in pharmacies. But, physicians in Canada are disciplined, sanctioned for periods of time, losing their right to prescribe, blackballed by colleagues and even in one case that I am aware of have the police show up on their doorstep to intimidate them. Many lose their licenses to practice and are destroyed financially simply for treating pain that is inconsistent with the opinions of regulatory bodies and other government agencies. If you ask the physician who refuses to treat pain with opiates if his/her fear of official attention is the reason of their failure to serve their patient, you are often met with something quite different than such a humble confession. Instead, you will hear about the addictive nature of opiates, or that their use should be confined for the care of the terminally ill when addiction is not a concern, or they simply will not work on your condition. Your physician will extol the virtues of the anti-inflammatory or psychiatric drugs. He or she will talk about the miracle of physiotherapy, biofeedback, acupuncture and the importance of a positive outlook on life in treating your pain.

These responses do have a place in the treatment of pain after the pain has been medically controlled. However, to recommend or proceed with them as if they replace the pain relief many receive from as opiate is like telling someone their house is burning and recommend throwing a glass of water on it to put the fire out, or making a diabetic exercise to earn their insulin. To a person in suicidal levels of pain, this kind of dissembling amounts to psychological and physical abuse. Yet this conversation between many physicians and patients is par for the course under the directions we are now in. It is a refrain patients hear over and over, until they stop searching for relief and give up living all together.

The fundamental truth that confronts anyone concerned with the quality of the doctor/patient relationship at present—namely, that most physicians have basically been turned against the interests of their patients—remains almost entirely unacknowledged by the profession as a whole. Resulting in a hodgepodge of an underworld of pain treatment—where there are still a few idealistic, caring physicians, and others who are taking advantage of what is perceived to be easy money—patients are essentially held captive in this system with their ability to function and provide for their families held hostage to the demands their physicians make on them in order to comply with what the physician believes is required by their regulatory body, provincial health departments and Health Canada (see the discredited 2017 pain guideline). It makes no difference that the demands might be utterly unreasonable, entirely degrading to the patient, or to the detriment of their health. The patient has no choice but to submit to the physician (see the results of forced tapering) or go to the street for medications—a prospect that brings with it even more onerous sanctions.

To be continued...

Do NSAIDs Really Work for Pain? Bias vs Objectivity

Since the highly flawed CDC guideline on opioid prescribing was introduced, followed by the “copycat” Canadian guideline, pain patients have lost rational treatment for their pain. Each patient is an individual and should be treated as such by his/her physicians. What works for one person may not work for another and finding the best treatment is often a trial and error process involving switching treatment modalities and titrating dosages. Unfortunately, since the advent of these guidelines and the opposition to using opiates, newly diagnosed pain patients have been forced into predetermined boxes, or, if previously treated successfully with opiate medicine, forced to forgo that treatment.

Examples abound. I fractured a knee cap recently and was told by the ER doc to take NSAIDs. Before the flawed guideline, I would have been given a script for Tylenol 3, but she told me that it would cause constipation and stronger pain drugs would cause me to fall down. Constipation is a very manageable side effect and causing me to fall down would be quite remote. These were poor excuses not to prescribe; plain and simple. Fortunately for me I did have Tylenol 3 left over from a tooth extraction.

We also see reports of how NSAIDs are sufficient for post-surgical pain. The fine print of course, is that the surgeries these studies report on are often laparoscopic which typically involve minimal pain. Try an NSAID for post-surgical bypass where the sternum is cracked open and the incision is lengthy and see how that works out. How about a mastectomy without opiates for recovery?

The research being done is often biased and conducted by those who start out with an attitude that NSAIDs and other non-opioid prescribing are good medicine for all that ails you. A case in point is a study that appeared in the Journal of American Medical Association by Jason Busse, a chiropractor and editor of the Canadian guideline. Busse found that in 42 high quality studies of 

opiates versus placebo, opiates resulted in reduced pain. However, he then reports that moderate quality data from 9 random controlled trials found no difference between NSAIDs and opiate pain medicine. This was the message picked up by the media and we were all told that NSAIDs are equal to opiates despite the fact that the studies were not high quality – which he admitted in the report.

Stephen Nadeau, a neurologist at the VA Medical Center in Gainesville, Florida, told the Pain

News Network that: 

“Because the study designs in all but a handful of studies did not remotely emulate clinical practice, it cannot be inferred that the results of this analysis are applicable to management of the general population of patients requiring opioid management of moderate to severe chronic non-malignant pain.”

The Pain News Network expressed that opiate critics were quick to focus on the Busse study as proof that opiates should rarely be prescribed for pain. Recently, we see a new study that did not involve researchers with biases and has entirely different results. This report was prepared for The Agency for Healthcare Research and Quality (AHRQ) by the Pacific Northwest Evidence-based Practice Center (EPC) at Oregon Health & Science University using objective researchers. This new study concluded that evidence was:

 “too limited to draw conclusions” on long-term use of non-opioid drugs, and “no treatment achieved a large improvement in pain or function.” They also cautioned that “careful consideration of patient characteristics is needed in selecting non-opioid drug treatments” because of the risk of side effects. This evaluation involved 200 studies of which 25 were of good quality.

When it came to the medications used for neuropathic pain, their results were markedly different from the conclusions presented by the CDC. Neuropathic pain is often treated with the anti-epilepsy gabapentinoid class of drugs. The EPC researchers found that:

“Large increases in risk of adverse events were seen with pregabalin (Lyrica: blurred vision, cognitive effects, dizziness, peripheral edema, sedation, and weight gain), gabapentin (Neurontin: blurred vision, cognitive effects, sedation, weight gain), and also cannabis (nausea, dizziness)....Dose reductions reduced the risk of some adverse events with SNRI antidepressants. In the short term small increases in risk of major coronary events and moderate increases in serious gastrointestinal events (both short and long term) were found with NSAIDs.”

The takeaway message from this research is that pain patients deserve to be treated with whatever works for them at effective doses and not medications which are pre-determined by flawed reports and can have devastating side effects. One-size-does-not-fit-all yet prescribers are being forced into a situation where they offer not what their patients require, but what is dictated by the misguided agenda of the day.

PAIN WARRIORS - The Wait is Over!

Toronto, Ontario filmmakers Tina Petrova and Eugene Weis are proud to debut their new documentary. This 80-minute film chronicles how patients and doctors have been blamed, shamed, and persecuted in a misguided attempt to fight the “opioid crisis.” It also addresses the very real issue of all hope lost and suicide - which had occurred during filming.

I have come to know Tina casually, through email correspondence over the past year or so and she has quite a story of her own. She suffers terribly from nerve damage and has often been bed-ridden. In 2014, she spearheaded a non-profit patient advocacy group with a desire to give a voice to intractable pain patients: Give Pain A Voice. She felt at that time that pain as an illness was not being given any news time. “As a filmmaker and chronic pain patient, I realized that having a visual representation of our stories was much more powerful than a news article because a film has such longevity and remains relevant for decades after it’s made. It also has the capacity to be very emotional and moving and create a lasting impression in the viewers mind.”

I wondered to myself if her project uncovered any surprises. Indeed it did. “While making the film I learned about dozens of chronic pain conditions I had never even heard of. All of these invisible people suffering, with almost no one to care about their illness and their well-being... it was a huge wake up call for me,” exclaims Tina. She would like to see the film screened at medical schools, for emergency room staff, universities, and of course pain groups all over the world. This would include patients with diverse illnesses and importantly, their families and caregivers who often do not believe the person is in pain. I’d like to add that there are far too many doctors out there who do not believe it either or, under today’s climate of hype, hysteria, and misinformation, believe that pain patients are simply drug-seeking or suffering from substance use disorder.

The filmmaker’s aim is for viewers to take away a deeper, more comprehensive and compassionate understanding of the complex issues faced by chronic pain patients. “I’d like the viewing audience to see the film as a wake-up call, as I did, and a call to action to better support this invisible community through funding for research and community initiatives to support both individuals and groups to be heard, seen and believed.”

This documentary is dedicated to Sherri Little, a California woman who tragically took her life at the age of 53 after a last desperate attempt to get treatment for severe and long-standing fibromyalgia and colitis pain. Sherri was a good friend of Tina, as both shared an understanding of the real challenges faced by chronic pain patients.

Pain Warriors was made available May 26th on DVD , iTunes, Google Play and Amazon Prime in the US.

The trailer to the film:

Welcome to our new blog!

As part of our mandate to keep chronic pain sufferers informed and united, we are starting this new blog and we hope you’ll join in the conversation! This blog will supplement our Facebook and Twitter feeds as well as our email campaigns to our supporters. We intend to use this as another platform to connect with pain patients throughout Canada.

You can also join our Facebook group at https://www.facebook.com/chronicpainca/ and our Twitter feed at https://twitter.com/canada_pain

If you have an idea or would like to be a guest author, please contact Barry at cpac@chronicpaincanada.com

Welcome to our new sharing space and stay tuned for postings!

The Chronic Pain Association of Canada is the only national registered charity of its kind. We are volunteers that do not rely on funding but your donation will help us to continue our work. Donating is easy and tax-deductible:

https://www.paypal.com/ca/fundraiser/charity/3474930