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April 14 Fibro is not in your head
And now let's hear what the experts have to say!
Information for your health care providers Information for Physician's sheetsThis gives information for everyone on your health care team. A PROFILE OF FIBROMYALGIA IN OCCUPATIONAL ENVIRONMENTS This is a definition of the physical capabilities of a person with FMS in the workplace from the American Journal of Physical & Rehabilitative Medicine. Fibromyalgia: The Muscle Pain Epidemic Is it ME by Another Name? Understanding and Treating Chronic Fatigue and Fibromyalgia Chronic Fatigue/Fibromyalgia: The Brain/Sleep Connection What Treatment Seems Most Effective in Treatment of Fibromyalgia This is a collection of 4 very informative articles written by Leon Chaitow N.D., D.O., MRO Senior Lecturer, University of Westminster Devin's Diagnostic: a brief guide to arriving at a likely diagnosis of Fibromyalgia and/or Chronic Myofascial Pain Syndrome April 12 Aches & Pains (weather)Aches and Pains Forecast Help This index forecasts the potential for weather-related aches and pains, especially in people with chronic health conditions (such as migraines or arthritis) that might make them sensitive to changes in weather conditions. "10" represents the highest risk of weather-related aches and pains. "1" represents the lowest risk. The Aches & Pains Index is calculated using barometric pressure, absolute humidity, chance of precipitation, temperature and wind. Areas of quiet, dry weather during warmer times of the year are generally associated with lower levels of aches and pains. Approaching areas of low pressure or strong frontal systems, both leading to stormy weather, may cause higher levels of aches and pains. The scale for the Aches & Pains Index is: Very High (9, 10), High (7, 8), Moderate (5, 6), Low (3, 4), Minimal (1, 2) For more information about the relationship between weather and well-being, see Aches & Pains 101. Chance of Precipitation Precipitation includes not only rain, but also snow, sleet, hail or any other form of water that reaches the ground. It is considered a factor in aches and pains because rainy weather accompanies changes in barometric pressure and humidity. For those who are sensitive to hot weather, rain can cool the atmosphere and may bring some relief. Humidity Change The four levels of the Humidity Change scale are: Steady, Slight, Moderate, Significant Temperature Change Rapidly rising or falling temperatures are a hallmark of big weather changes, indicating underlying shifts in barometric pressure. Extremes in temperature, not just changing temperatures, can also affect the potential for feeling aches and pains. Low temperatures may trigger migraine headaches, exacerbate circulatory conditions and contribute to arthritic joint stiffness. Cold weather has also been associated with an increase in asthma-related hospital admissions. The four levels of the Temperature Change scale are: Steady, Slight, Moderate, Significant For more about weather conditions and health, see Aches & Pains 101. Health Conditions And PainHealth Conditions
Addiction & DependenceDefinitions Related to theUse of Opioids for the Treatment of Pain
Consensus Document BACKGROUND Clear terminology is necessary for effective communication regarding medical issues. Scientists, clinicians, regulators and the lay public use disparate definitions of terms related to addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction, especially in situations in which opioids are used, or are being considered for use, to manage pain. Confusion regarding the treatment of pain results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals. Many medications, including opioids, play important roles in the treatment of pain. Opioids, however, often have their utilization limited by concerns regarding misuse, addiction and possible diversion for non-medical uses. Many medications used in medical practice produce dependence, and some may lead to addiction in vulnerable individuals. The latter medications appear to stimulate brain reward mechanisms; these include opioids, sedatives, stimulants, anxiolytics, some muscle relaxants, and cannabinoids. Physical dependence, tolerance and addiction are discrete and different phenomena that are often confused. Since their clinical implications and management differ markedly, it is important that uniform definitions, based on current scientific and clinical understanding, be established in order to promote better care of patients with pain and other conditions where the use of dependence-producing drugs is appropriate, and to encourage appropriate regulatory policies and enforcement strategies.
The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definitions and recommend their use: ADDICTION Addiction is a primary, chronic, neurobiologicneurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. PHYSICAL DEPENDENCE Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. In the case of sedative drugs, spontaneous withdrawal may occur with continued use. Tolerance Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.
Most specialists in pain medicine and addiction medicine agree that patients treated with prolonged opioid therapy usually do develop physical dependence and sometimes develop tolerance, but do not usually develop addictive disorders. However, the actual risk is not known and probably varies with genetic predisposition, among other factors. Addiction, unlike tolerance and physical dependence, is not a predictable drug effect, but represents an idiosyncratic adverse reaction in biologically and psychosocially vulnerable individuals. Most exposures to drugs that can stimulate the brain's reward center do not produce addiction. Addiction is a primary chronic disease and exposure to drugs is only one of the etiologic factors in its development. Addiction in the course of opioid therapy of pain can best be assessed after the pain has been brought under adequate control, though this is not always possible. Addiction is recognized by the observation of one or more of its characteristic features: impaired control, craving and compulsive use, and continued use despite negative physical, mental and/or social consequences. An individual's behaviors that may suggest addiction sometimes are simply a reflection of unrelieved pain or other problems unrelated to addiction. Therefore, good clinical judgment must be used in determining whether the pattern of behaviors signals the presence of addiction or reflects a different issue. Behaviors suggestive of addiction may include: inability to take medications according to an agreed upon schedule, taking multiple doses together, frequent reports of lost or stolen prescriptions, doctor shopping, isolation from family and friends and/or use of non-prescribed psychoactive drugs in addition to prescribed medications. Other behaviors which may raise concern are the use of analgesic medications for other than analgesic effects, such as sedation, an increase in energy, a decrease in anxiety, or intoxication; non-compliance with recommended non-opioid treatments or evaluations; insistence on rapid-onset formulations/routes of administration; or reports of no relief whatsoever by any non-opioid treatments. Adverse consequences of addictive use of medications may include persistent sedation or intoxication due to overuse; increasing functional impairment and other medical complications; psychological manifestations such as irritability, apathy, anxiety or depression; or adverse legal, economic or social consequences. Common and expected side effects of the medications, such as constipation or sedation due to use of prescribed doses, are not viewed as adverse consequences in this context. It should be emphasized that no single event is diagnostic of addictive disorder. Rather, the diagnosis is made in response to a pattern of behavior that usually becomes obvious over time. Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may "clock watch," and may otherwise seem inappropriately "drug seeking." Even such behaviors as illicit drug use and deception can occur in the patient's efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated. Physical dependence on and tolerance to prescribed drugs do not constitute sufficient evidence of psychoactive substance use disorder or addiction. They are normal responses that often occur with the persistent use of certain medications. Physical dependence may develop with chronic use of many classes of medications. These include beta blockers, alpha-2 adrenergic agents, corticosteroids, antidepressants and other medications that are not associated with addictive disorders. When drugs that induce physical dependence are no longer needed, they should be carefully tapered while monitoring clinical symptoms to avoid withdrawal phenomena and such effects as rebound hyperalgesia. Such tapering, or withdrawal, of medication should not be termed detoxification. At times, anxiety and sweating can be seen in patients who are dependent on sedative drugs, such as alcohol or benzodiazepines, and who continue taking these drugs. This is usually an indication of development of tolerance, though the symptoms may be due to a return of the symptoms of an underlying anxiety disorder, due to the development of a new anxiety disorder related to drug use, or due to true withdrawal symptoms. A patient who is physically dependent on opioids may sometimes continue to use these despite resolution of pain only to avoid withdrawal. Such use does not necessarily reflect addiction. Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects. For example, in the case of opioids, tolerance usually develops more slowly to analgesia than to respiratory depression, and tolerance to the constipating effects may not occur at all. Tolerance to the analgesic effects of opioids is variable in occurrence but is never absolute; thus, no upper limit to dosage of pure opioid agonists can be established. Universal agreement on definitions of addiction, physical dependence and tolerance is critical to the optimization of pain treatment and the management of addictive disorders. While the definitions offered here do not constitute formal diagnostic criteria, it is hoped that they may serve as a basis for the future development of more specific, universally accepted diagnostic guidelines. The definitions and concepts that are offered here have been developed through a consensus process of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine.
A Long JourneyThat I may know just what to say. 10 steps to overcome chronic pain
10 tips for communicating with person suffering pain
April 04 Talking about Check it OutHello cher, my name is Dr Patty V (psydchick) and I also have chronic/intractable pain. I would like to add you to my friends space on msn. I am new at msn so i dont know how to market. i guess i am doing it now..lol. I also have a group for pain patients and would love you to check it out also. I look forward to getting to know you!! March 28 About Me: Dr Patty V (psydchick)As you can see, my name is Dr Patty V (psydchick). I am 43 years old. I am married to a wonderful man that i have known since 1994. We have been married for almost 6 years (July 30, 2000). I was born in Freeport, NY and i lived on Long Island, NY for the first 11 years of my life (no, i don't have my accent still. I graduated high school in 1980 (Birmingham High School in Van Nuys, CA). Upom graduation, i went to college at UCSD. I went there for 1 year. Due to financial difficulties of my family at the time, i did not return to UCSD for a second year. I worked full-time and went to Jr College (LA Pierce College, Woodland Hills, CA). I saved money, applied for financial aid and then started UCLA in 1983. I worked really hard to help my mom pay for school. I got 3 jobs at the beginning of my schooling at UCLA. I worked in a law office as a clerk, worked at a preschool as an assistant teacher and also worked in my dorm at UCLA food service. On may 15, 1983 while i was working in food service, i was helping another worker with the dishes (we worked on converyor belt at the time). This other person was getting behind so i gave him some help of moving a tray of silverware to another location. Unfortunately, they never taught proper body mechanics in those days. I felt a pull in my back. I continued with my shift and after i went to my dorm room to lay down. When i awoke i had severe pain in my back and could barely move. I was told by my roommate (who also worked in food service) to go to the hospital. I felt uncomfortable about making a fuss. I thank the Lord i did. I went to the E.R. that night and i was told i had to stay at bedrest for 2 weeks. I was given some pain medication that made me feel so ill. The first shot of narcotics in my life (Demerol). I told the nurse i was going to be sick. She didn't believe me..lol, so i vomited all over the place. Anyway, i was sent home to rest and employee health got ahold of me and sent me to an orthopedic surgeon 2 weeks after my injury. I had been given meds, went to a chiropractor (which made it hurt more), physical therapy, and then eventually an oil based mylogram. It turned out that what they thought i did (sprain), it was a disk herniation at L5-S1. Since then, i went through my first surgery in August, 1983. It was experimental and they no longer do it in the united states anymore. It was called chymopapain. I felt good for 2 years and then i started having horrible pain again. Then after more tests, going into pain management hospital, attempting to tough it out (also moved to Orange, CA to continue school), i had another surgery in 1986. It was a fusion from L5-S1. In 1987 i had a third surgery which was another fusion from L4-S1 (i had trouble fusing from the first one). After each of these surgeries i had to be at bedrest for 6 months. After the first fusion, i had very little pain for 6 months and only had to take aspirin for the pain. After the second fusion i did not get much relief. I was in a body cast for about 6 more months. I remember graduating from Chapman University with a cast under my cap and gown (cute pic huh? lol). After graduation from my bachelor's degree, i decided to apply for a master's in psychology. I wanted so bad to help others who were suffering from pain like i was. I remembered back several years when i was in pain management talking to the psychologist. She had been trying to tell me how to live my life in pain. I asked her "do you have pain" and she said "no". I said then "how can you tell me how to live my life in pain?" From that time on i realized that nobody could ever tell me that if i was a pain therapist. In 1989, i met an orthopedist who thought he would be able to help me. I was told that i had to lose weight (100 pounds) before he would attempt to do surgery. I had tried everything over the years. In 1989 i had a gastric stapling and a gastric intestinal bypass. I lost a lot of weight, to the point where i was vitamin deficient, and couldn't keep any food down. I also had dumping syndrome several times a day (this is where you have a really bad case of the runs). I lost over 100 pounds in 1 year and i had another back surgery in 1990. This was an anterior and posterior fusion (L3-S1). Here, hardware was placed. I had screws and isola rods. Again, i had trouble fusing. After this surgery, i didn't seem to do much better. Yet i continued to do things in my life. In 1994, after losing so much weight and being in so much pain, i had to go to the hospital because i was quite ill. It was recommended that i go through detox because the docs believed in those days that anyone who had to take narcotics every day was an addict (which is so far from the truth). In February, 1994 i entered the detox unit and live there for 1 month. I was horrible because i was cut off cold turkey. I couldn't sleep, eat, and lord i was in so much pain. The only drug i was given for pain was an anti inflammatory. It was called Dolobid. After leaving the hospital, i attempted to go home and deal with this horrible pain without medications. I felt so alone and frustrated because i was in severe pain and i was brainwashed to belive if i took any more narcotics i would explode. After leaving the detox program i decided i wanted to help others. I went back to the hospital to ask some questions and was asked to volunteer. I thought that it would be a great idea. I wanted to try to get my sitting tolerance up so that i could go back to school. I went to physical therapy in the early am's and went to volunteer in the detox unit right after exercising. I was doing great. Then, one day i got up and felt like i had the flu. I was dizzy, not hungry, just feeling horrid. Within a few days i went to my doc for a checkup and found out the i didn't have the flu and that i should not have been able to get up let alone drive. I had some sort of bleed and my hemoglobin went down to a 3. I was immediately put in the hospital for a transfusion and then went back home for the weekend. I returned back to my volunteer work on Monday and started to feel odd again. I decided it was too soon to come back to work, so I decided to go home. I went to say goodbye to one of the nurses and she wouldn't let me leave. Apparently, i was showing symptoms of bleeding inside. I was sent over to the emergency room and went in to shock pretty soon after getting there. It turns out that the Dolobid i was taking ate a hole through my little stomach pouch and i was bleeding to death. I was told that i would have to reverse the gastric stapling and bypass if i needed to stay on anti inflammatories. This was done soon after going in the hospital. I remember this guy visiting me in the hospital. He was chaiman of the volunteer organization that i was volunteering in. One night he bought this big stuffed bear in to me. He was very nice. When i was recovering with my family he used to call and check on me. We had so much in common, but he was 22 years older than I was. We eventually got really close over the years (Now he is my husband). Anyway, after the surgery i decided to go back to school. I went to a private school to finish my master of arts in psychology. In late 1994, i was on a trip with my friend in stateline nevada and my pain started up really bad again. It turned out that i needed another surgery on my back from L-S1. I had had some broken titanium screws and i had problems fusing again. I had the surgery and attempted to go back to my life. I graduated with my master of arts degree in clinical psychology in 1996 and was scholarshipped for my doctorate, in which i graduated 1 year after my master's because i had a lot of transfer credits. I became a Doctor of Psychology in 1997. I specialized in the assessment, diagnosis and treatment of chemical dependency (thought i may need that knowledge while dealing with pain patients) and pain management. While While i was working as a therapist, i learned that not everything is like what is in the books. In late 1997 i began having pain in my shoulder. I went through many many tests but the docs couldn't figure it out. Finally, during that time, i developed a problem with my left pinkie. It was a bone infection called osteomyelitis. I was in the hospital for a short time and was given high dose antibiotics. About 6 months after, i woke up one morning and could not get out of bed. I screamed for my boyfriend who was living with me at the time. I was taken to the hospital and was told that the infection from my shoulder and pinkie spread to my spine. I had gone through several biopsies and tests just to try to get rid of this infection. I was eventually told by my spinal specialist that there was nothing that could be done. What usually happens is that an individual gets the infection, clears if up with antibiotics and then they have surgery. For me, nothing else could be done. I was told that it was too dangerous to attempt to clean the infection out of my spine and the chances of me surviviing were not good. I was also told that i would fuse in a nonphysiological angle. I never listened to the docs because i felt only God knew what was going to happen. Unfortunately, the doc was right. I am now fused at a 90 degree angle, whereby my chin and brow line are parallel to the floor when i try to stand. I am unable to lay flat on my back or on my left side. I am also unable to sit for more than 10-15 minutes without causing my pain to go wild. I was told the only way to deal with the pain is by medications. I have gone to several pain docs. It turns out that my stomach surgery came up to bite me again. I now have a serious malabsorption problem so that my meds (antibiotics, pain meds) have to be administerd through other means such as intravenous. Since 1997, i married in July 2000. I am now bedbound. I figured out how to adapt to using a computer almost 2 years ago. Since i am unable to sit up straight when using the computer, i balance myself on my right elbow, have pillows between my knees, under my elbow, in back of me and i have a keyboard on my lap to type. I has a laptop, but it finally died. I am attempting to use a desktop because it is not possible to get another laptop right now. I am adjusting toward using a regular mouse. Since 1994 i have had multiple diagnoses or other medical problems that have resulted because of my posture. I was diagnosed with FMS, CFS, Epstein Barr, Rheumatoid Arthritis, Bursitis, Atalectasis (where my right lung doesn't expand well), vitamin deficient, lost weight on my own (over 100+ pounds) because after the reversal of the stapling and bypass i gained the weight and some. I now work in my bed as a pain patient advocate and help others suffering from severe pain. I am very happily married to a wonderful man who takes care of me because he says "it is a labor of love!" I am unable to cook, walk, etc. He brings me meals, cleans me up because it is too difficult to go in the shower, goes to the store, pharmacy, drives me to the docs when needed, and the list goes on. SOME OF YOU HAVE ASKED WHAT OUR SECRET IS TO STAYING SO HAPPILY MARRIED. WELL, IF SOMEONE CARED ABOUT YOU AS MY HUSBAND DOES FOR ME THAT IS ENOUGH. He also suffers from chronic pain and is disabled. So, this is my story, actually the short one. I hope this helps anyone get an idea of who i am and what i do...I will go out of my way to help another person in pain...because i never want anyone to have the feelings that i did and want to take their lives because they feel nobody understands!!!!! God is now bringing us together. Things are done in God's timing not ours!!! Theories Of PainTheories Of Pain: Researchers equate pain perception within the networks of free nerve endings in the skin. Pain appears to be generated through a variety of procedures. Intense mechanical stimulation activates a class of high threshold receptors that produce sensation of pain. The painful stimulus causes pain and tissue damage. Besson (1982) suggested that pain is also caused by the release of chemicals by injured cells. When cells are damaged in any way, they quickly synthesize what is called a prostaglandin. These are categories of hormones first discovered and seen in the prostate gland. This chemical sensitizes free nerve endings to another chemical known as histamine. The chemical sensitizes free nerve endings to another chemical known as histamine. Damaged cells also release histamine. An extremely interesting type of pain sensation happens after a limb has been amputated. Once the limb is gone, investigators state that approximately 70% of individuals who have lost lims report that they felt as though the missing limb still existed and hurt often. This phenomenon is referred to as phantom limb pain (Melzack, 1992). An important discovery made by Aberdeen, Scotland investigators lent weight to the general concept of the "gate control" theory of pain. These investigators found small members of proteins known as enkephalins (meaning "in the head"). In time, a larger group of proteins became isolated known as endorphins (meaning "morphine within"). Endorphins are released from nerve cells in the brain, which have been described to inhibit spinal cord cells through direct pathways decending from the brain to the spinal cord. Gate Control Theory Of PainA functional pain theory includes an explanation of all the possible ranges of pain phenomena. All of the present pain theories leave out a great amount of unknowns and are inadequate when dealing with the vast array of pain phenomena. The majority of contemporary theories have what Weisendberg (1977) referred to as "the neurophysiological structures related to pain". The gate control theory of pain was developed by Ronald Melzack and Patrick Wall in 1973 to account for some of the ways in which pain differs from other sensations. They were particularly interested in the mechanisms by which other cutaneous stimuli and emotional states alter the level of pain felt by a human being. Simply put, Melzack suggests that there is a control mechanism in the spinal cord that acts as a gate. When the gate is open, pain messges will pass to the brain and theperson will feel pain. When the gate is closed, the messages will not pass from cell-to-cell and will not reach the brain. Thus the individual feels no pain. Physiologically described, pain messages are carried from the nerve endings through the nerve fibers (which are held together in bundles) to the spinal cord. If a non-pain stimulus is given to the nerve endings, the message is carried from the nerve endings to the spinal cord. If a non-pain stimulus is activated at the nerve endings that carry the different messages simulataneously as a non-pain message, the non-pain message moves up the the larger nerve bundles quicker than the pain message. Thus, the non-pain message reaches the spinal cord first and the pain message is unable to geet to the brain. The gate control theory also explains what occurs when the brain receives an excess amount of information passing through the gate. A neural mechanism is activated which is responsible for pain experience and control. At this time, a threshold is passed and another system is activated. This system controls reflex reactions such as swelling. This reflex reaction in turn activates the sympathetic nercous system. ***note: Please do not copy without permission from author*** By Dr. Patricia Verdugo, PsyD (1997) March 23 Intractable Pain Treatment Laws and Regulations (CA, Co, Fl, NJ, Tx,Va, WaIntractable Pain Treatment Laws and Regulations California Colorado Florida New Jersey Texas Virginia Washington As demand for better pain management grows in the United States, the public is taking an interest in policies that govern the medical use of opioid analgesics for people with chronic pain. Although the use of opioids in acute and cancer pain is well accepted, their use in chronic noncancer pain has been considered widely to be inappropriate due to concerns about efficacy, toxicity, and addiction (Portenoy, 1990; Turk & Brody, 1991). Indeed, some state medical boards have used their disciplinary authority to reject or discourage the prescribing of opioids for chronic noncancer pain (Oregon Board of Medical Examiners, 1991; Washington State Medical Disciplinary Board, 1987). However, the assumptions behind the belief that opioids should not be used for patients with chronic pain are undergoing a critical reappraisal in an effort to clarify patient selection and appropriate management strategies (Portenoy, 1994). At the same time, state governments have begun to adopt laws that specifically allow the use of opioids for the treatment of intractable pain. Definitions Intractable pain is a term that is used and defined in the federal controlled substances regulations and now in some state laws. The term generally refers to a pain state in which the cause cannot be removed or otherwise treated, and no relief or cure has been found after reasonable efforts (Code of Federal Regulations, 1988). It includes pain due to cancer as well as to other chronic diseases. Intractable pain treatment policy refers to laws, regulations, or other government-issued policies and guidelines that address the legitimacy of the medical use of opioid analgesics to treat patients with intractable pain. These policies vary in the degree to which opioid treatment for intractable pain is accepted or rejected, and they may include specific restrictions and conditions. The focus of this article is federal and state laws and regulations, including the Federal Intractable Pain Regulation (1974); the state laws of Virginia (1988), Texas (1989), California (1990), Colorado (1992), Washington (1993), and Florida (1994); and the state regulation of New Jersey (1984). Federal intractable pain policy Federal regulations established in the early 1970s govern the prescribing of controlled substances (Code of Federal Regulations, 1988, Part 1300). As a general principle, the federal government does not regulate medical practice as this is a function of the states (Joranson, 1990). In 1974, however, Congress adopted a law to prohibit physicians from prescribing opioids to detoxify or maintain opioid addiction (unless they are operating as part of a separately registered narcotic treatment program). Subsequently, to clarify the critical distinctions between the treatment of opioid addiction and the use of opioids to treat pain, the Drug Enforcement Administration (DEA) issued a regulation in 1974 stating that the law was not intended to interfere with physicians who used opioids to treat intractable pain: This section is not intended to impose any limitation on a physician or authorized hospital staff...to administer or dispense [including prescribe] narcotic drugs to persons with intractable pain in which no relief or cure is possible or none has been found after reasonable efforts. (Code of Federal Regulations, 1988, p. 72) The DEA has reiterated and communicated this policy to U.S. physicians through its Physician's Manual (Drug Enforcement Administration, 1990) and its Pharmacist's Manual (Drug Enforcement Administration, 1986). State intractable pain treatment policies In addition to federal regulations, physicians' prescribing is subject to the law and regulations of each state, which sometimes are more restrictive than federal law (Joranson & Gilson, 1994). A physician's prescribing of controlled substances may be reviewed by a number of agencies, including state justice departments, triplicate prescription programs, professional licensing boards, and local law enforcement agencies. Typically, these agencies want to identify physicians who are prescribing outside of legitimate medical practice. Legitimate and illegitimate medical practices are usually defined in state medical practice law and by the regulations and enforcement policies of state medical boards. There are no state laws or regulations that consider the use of opioids for intractable pain to be an illegitimate practice. Indeed, the model for state medical practice laws recommends that state legislatures define the practice of medicine to include the use of drugs to treat pain (Federation of State Medical Boards of the United States, 1988). Further, the model for state controlled substances laws specifically recommends that prescribing opioids for intractable pain be considered legal under state law (National Conference of Commissioners on Uniform State Laws, 1990). Physicians, however, have been investigated and prosecuted for prescribing opioids for chronic pain (Angarola & Joranson, 1993; Joranson & Gilson, 1994). According to a 1991 survey, most of the members of state medical boards of the United States said they would discourage a physician from prescribing opioids for chronic noncancer pain, and approximately one-third of state medical board members said they would investigate the practice as a potential violation of law (Joranson, Cleeland, Weissman, & Gilson, 1992). Although most state laws and regulations still do not specifically recognize the legality of opioids for intractable pain, this is changing. In the last several years, some legislatures have begun to adopt laws to affirm the use of controlled substances for intractable pain. Typically, legislators have been responding to (a) the undertreatment of patients with pain, (b) inappropriate medical board discipline of some physicians, and (c) proposed legalization of physician-assisted suicide. Media coverage of physician-assisted suicide and inadequate pain management as well as the efforts of patients and physicians who are advocating for legislative action to improve pain management are fueling state legislative interest in intractable pain treatment policy. Washington In the state of Washington, the use of opioids for intractable pain became an issue in 1987 when the Washington State Medical Disciplinary Board opposed prescribing opioids for chronic pain: Many cases reviewed by the Washington State Medical Disciplinary Board involve inappropriate prescribing of controlled substances. A significant number of these are related to the use of narcotics as a method to manage chronic pain. During fiscal year 1987 the Board experienced nearly a 100ncrease in disciplinary actions related to prescribing of controlled drugs for chronic pain. The Board does not recognize repeated prescribing of controlled drugs as appropriate therapy for chronic pain [italics added]. (p. 1) The subsequent outcry from physicians resulted in additional policy statements in 1989 and 1992 explaining that the board had not wanted "to interfere with a physician's exercise of appropriate clinical judgment" (State of Washington Department of Health, 1989, p. 1), and that chronic pain is "best not treated with opiates" (State of Washington Department of Health, 1992, p. 1). Concern about the board's position continued, and in 1993, the state legislature enacted a statute that borrowed a provision from a recently developed model for state drug laws developed by medical and legal experts (National Conference of Commissioners on Uniform State Laws, 1990): A practitioner may dispense or deliver a controlled substance to or for an individual or animal only for medical treatment or authorized research in the ordinary course of that practitioner's profession. Medical treatment includes dispensing or administering a narcotic drug for pain, including intractable pain. (Washington Uniform Controlled Substances Act, 1993) Colorado In 1992, the Colorado legislature adopted an intractable pain treatment policy as part of revisions to its controlled substances act. Colorado's approach is similar to that used in Washington state. Virginia In 1988, Virginia enacted a law allowing physicians to prescribe heroin for treatment of terminally ill cancer patients ("Virginia Enacts Law," 1988). (Note: This occurred despite the fact that legislation at the federal level was necessary to make heroin actually available and that Congress had already soundly defeated such a bill.) The Virginia legislature adopted an additional measure to allow prescription of pain medications "in excess of recommended dosage" for patients with intractable pain ("Relieving Intractable Pain," 1988, p. C5; Commonwealth of Virginia, 1988). Both laws exemplify how drug laws can reflect common misconceptions, that is, that heroin has significant analgesic advantages over currently available opioids, and that a physician's prescription cannot legally exceed the dosage recommended in FDA-approved product labeling (Angarola & Joranson, 1995). Texas: The first intractable pain treatment act The first intractable pain treatment act (IPTA) was approved by the Texas legislature in 1989 and has received considerable publicity (Hill, 1992). Physicians in Texas were concerned about board investigations of physicians and ambiguous language regarding opioid prescribing in the state's Medical Practice Act and went to the legislature for relief (Hill, 1992). The purposes of the new act were to clarify legal ambiguities, bring Texas law into conformity with the federal intractable pain regulation, and assure that no Texan requiring narcotics for pain relief, for whatever reason, was denied them because of a physician's real or perceived fear that the state regulatory agency would take disciplinary measures against the physician for prescribing narcotics to relieve pain. (Hill, 1992, p. 70) The Texas IPTA (a) provides a definition of intractable pain that is similar to that of the federal regulation, (b) autliorizes physicians to use controlled substances (not only opioids) for treatment of intractable pain, (c) prohibits healthcare facilities from restricting the use of such drugs for intractable pain, and (d) prohibits the Texas State Board of Medical Examiners from disciplining a physician for using such drugs in the legitimate treatment of intractable pain (Medical Practice Act of Texas, 1989). The Texas IPTA also contains important exclusions. For example, the act does not protect a physician if the pain patient is also being treated for chemical dependency or when the physician should have known that the patient was using drugs in a nontherapeutic manner. Several years after adoption of the IPTA, the Texas State Board of Medical Examiners issued a policy statement in its official newsletter that was drafted by a board member, C. Richard Stasney, MD, and by C. Stratton Hill, MD (1993). The statement endorsed the federal intractable pain regulation and the IPTA and stated that the board would use treatment outcome and not quantity or duration of prescribing as a standard for evaluating cases against doctors. In 1995, Hill, David Rallston, and colleagues are seeking further clarification of Texas policy and have submitted to the Board of Medical Examiners a proposed regulation for the treatment of intractable pain in Texas (C.S. Hill, personal communication). New Jersey The only state of which we are aware that currently has a regulation on intractable pain treatment is New Jersey. The regulation mirrors the federal intractable pain regulation in part. The New Jersey regulation, however, has several conditions that delimit the boundaries of intractable pain treatment: When protracted prescribing [of narcotic drugs] is utilized for the alleviation of intractable pain, practitioners shall remain alert to the availability of new or alternative types of treatment. The practitioner should attempt periodically to either cease the medication or taper down the dosage, or try other medication or treatment modalities in a regular and vigilant effort to reduce the addiction propensity for the patient. (New Jersey Board of Medical Examiners, 1993, p. 64) Regulations have the force of law, and compliance with specified conditions becomes the responsibility of the practicing physician. Indeed, failure to comply with such conditions might constitute a violation. Thus, a New Jersey physician who prescribes opioids for intractable pain should document compliance with the additional conditions in the patient's chart. California In 1990, California became the second state to adopt an IPTA due to the efforts of State Sen. Leroy Greene and Harvey Rose, MD. This legislation was the consequence of professional and public concerns about inadequate pain management, the harsh effects on patients, and physicians' concern about investigations by the state medical board. California's law is essentially identical to the Texas IPTA, although it requires evaluation of the patient by a specialist in addition to the attending physician (California Business and Professions Code, 1990). The adoption of the California IPTA has also served as a catalyst for a number of governmental and professional actions to identify and remove barriers to pain management. For example, other new legislation required examination of alternatives to the triplicate prescription program, distribution of information on pain management and the California intractable pain treatment policy to all physicians by the medical board, and a medical board survey of state medical schools' curricula on pain management. In March 1994, the governor sponsored the Summit on Effective Pain Management: Removing Impediments to Appropriate Prescribing to prepare a strategy for a statewide effort to improve pain management (Angarola & Joranson, 1994; State of California Department of Consumer Affairs, 1994). The licensing and disciplinary boards for medicine, pharmacy, and nursing developed positive guidelines for the appropriate use of opioids in intractable pain. The American Pain Society Board of Directors endorsed the medical board's guidelines (correspondence of APS President J. Campbell to D. Arnett, Executive Director, California Medical Board, January 11, 1995; see page 20 of this newsletter for details). The State of California's actions to make pain management a priority are exemplary. Florida In 1994, following an intense debate on euthanasia and physician-assisted suicide, the Florida legislature instead approved an intractable pain treatment provision. Intractable pain is defined as "pain for which, in the generally accepted course of medical practice, the cause cannot be removed and otherwise treated" (Florida Statutes, 1994, p. 2). A licensed and qualified physician must diagnose intractable pain. The new provision permits use of any controlled substance in Schedules II-V, not only opioids, to treat a person with intractable pain, provided the physician conforms to a standard of care that would be recognized by reasonably prudent physicians under similar circumstances [italics added] (Florida Statutes). (One might ask what this means, given the prevalence of inadequate pain management and the history of discouragement of extended use of strong opioids for chronic noncancer pain.) Florida's intractable pain provision also recognizes that the state does not condone euthanasia and bans the use of intractable pain treatment for such a purpose. Discussion The development of intractable pain treatment laws gives much-needed recognition to the necessity for better treatment of intractable pain and can help to correct past policy, which discouraged any use of opioids. However, the opportunity to develop new legislation merits our careful consideration of both benefits and risks. For example, could there be unintended consequences from making opioid therapy for intractable pain a "treatment of last resort"? Is it medically appropriate to require physicians to demonstrate that every chronic pain problem - whether due to terminal illness or any other chronic condition-is refractory to other therapies before prescribing opioid analgesics? How much time must elapse? How many therapies must be tried, and at what expense to the patient and the healthcare system? Although these questions should be answered by the physician and patient, they may also become legal questions once intractable pain treatment laws and regulations are enacted. Are state intractable pain treatment laws really needed? Although the states have the power to regulate medical practice, the results can be unpredictable when state legislators and other interest groups start writing new laws, especially when the subject is drugs and medical practice - witness, for example, Virginia's approval of heroin in an effort to treat cancer pain. Moreover, after a new law is passed, a state agency may adopt regulations to codify, and perhaps restrict, the treatment of intractable pain, potentially leading to new issues. For example, if intractable pain regulations include conditions and restrictions, as in New Jersey, these may expand recordkeeping requirements and, thus, increase instead of decrease the potential for violations when controlled substances are prescribed for pain. States do not now directly prohibit by law or regulation the use of opioids for intractable pain. If a state medical, pharmacy, or nursing board discourages the use of opioids for intractable pain, this is informal policy and it should be changed. Such a change can occur without legislation-for example, through a cooperative effort of regulatory boards and pain experts to develop and communicate new guidelines (Commonwealth of Massachusetts Board of Registration in Medicine, 1989; Medical Board of California, 1994). If the voluntary development of positive guidelines by a board proves unsuccessful, political action, including lobbying for intractable pain treatment legislation, merits consideration. In Idaho, an intractable pain treatment act was introduced to protect physicians who prescribed opioids for intractable pain from the medical board. Although the bill was not adopted, the medical board has undertaken a review of its policy on prescribing for intractable pain (Idaho State Board of Medicine, 1994). Which language should be used? The Texas and California IPTAs might be useful if the primary goal is to protect physicians from a medical board when, in fact, that threat exists or when the board is reluctant to clarify and communicate its policy. The Texas and California IPTAS, however, also appear to restrict prescribing of opioids to substance abusers, even if they have pain. The laws in Washington and Colorado do not exclude substance abusers and are consistent with the nationally approved model for drug control laws in the United States. On the other hand, they do not establish a legal protection for physicians from their medical boards. Can legislation be an opportunity to initiate action? A new intractable pain law, by itself, probably will do little directly to change practice patterns or improve the management of patients' pain. In California, however, the legislative sponsor and key supporters of the new IPTA have served as powerful catalysts for other positive actions to improve pain management in the state. In addition, either a legislature or a governor can establish a pain commission to study the problem and make recommendations for action. Study commissions can, however, also waste time and energy and actually delay real progress unless there is (a) strong support for implementation of the recommendations; (b) a clear mission focused on better and more cost-effective pain management; (c) willingness to identify and address common myths and barriers; (d) competent and adequate staff resources; and (e) a membership that is balanced, knowledgeable, and committed to the mission. Conclusions Long-held medical beliefs and regulatory traditions have rejected the use of opioids for chronic noncancer pain but are now undergoing reassessment in light of new knowledge, recent clinical experience, and the public attention being given to better pain management. The ultimate goal of a balanced public policy should be to harmonize medical and drug regulation with clinical practice so that physicians are free to use this treatment according to good medical judgment. This harmony can sometimes be promoted through laws and certainly through the development of medical, pharmacy, and nursing guidelines. Such guidelines should encourage pain management and help clinicians select and manage patients and avoid investigation. Guidelines should also continue sanctions against sloppy and unprofessional practices that can contribute to drug abuse. Such guidelines as those issued in Texas and California give medical boards unique opportunity to encourage quality care while at the same time allowing them to focus limited resources on cases in which there is harm to public health. (Note: The second article in this series will discuss state medical boards' development of intractable pain guidelines.) As the development of intractable pain policy proceeds in the United States, we should take care not to oversimplify the complexity of chronic pain and its treatment. We should avoid creating the impression that all prescribing of opioids is appropriate or that any person with chronic pain has a right to opioids. We should also avoid creating the impression that new policies will correct deficits in practitioners' knowledge and attitudes. The appropriate use of a range of therapeutic options, including nonpharmacologic treatments, opioids, and other drugs, depends on careful evaluation and monitoring of results by knowledgeable professionals supported by regulatory policy and practice. Opioids and other individual therapeutic modalities should neither be prescribed nor proscribed by laws, regulations, or policies. Do the differences in today's state intractable pain laws and regulations suggest we are moving toward a balkanized approach to the use of opioids for chronic pain? How can we uniformly raise the quality of pain care if policies differ from state to state? The quality of intractable pain treatment policy at the state level would benefit from a dialogue aimed at acheiving consensus among healthcare professional, regulatory, and patient interests in the United States. One aim of such a dialogue should be to achieve reasonable uniformity of policy among the states; another would be to address the needs of individual patients who have fallen through the cracks. The author would appreciate having readers' perspectives and any additional information about state policies Different Types Of PainWhat is pain? Pain is a psychological as well as a physiological phenomenon or process. It is an event that involves the entire nervous system, brain, spinal cord and nerves. When an individual experiences pain, the stimulus is carried from the nerve endings of the site of the painful experience to the brain. The brain registers the experience as being painful and quickly sends messages back to the area that causes the individual to react. Reactions are determined by many factors that are incorporated into us as human beings. The experience and _expression of pain is a purley subjective event that is unique to each person. It is universal, complex and no two people feel pain in the same way. The word pain describes everything from a stubbed toe to malignant cancer pain. Weisenberg (1977) defines pain as "a reaction related to actual or impending tissue damage on the basis of the responses measured to indicate the evidence of its presence". The Agency for Health Care Policy and and Research (1993) defines pain as an "uncomfortable feeling that tells you something may be wrong in your body." Pain is the body's way of sending a warning to the brain. The spinal cord and nerves provide pathways for messages to travel to and from the brain as well as to other parts of the body. Pain is one of the many reasons why indibiduals seek help from the medical profession. Throughout our lives human beings experience many different types of painful stimuli. However, due to the uniqueness of each person's pain, it is extremely difficult to adequately explain to others as well as understand ourselves. One reason why pain is hard to convey to another person is that the description of the pain that is felt is combined with personal emotions that human beings possess. The description a person gives is not the actual sensations of the painful experience, but rather the person's perceptions of the discomfort while experiencing the pain. ***Note this comes from owners dissertation. If you wish to copy, please ask permission. Patricia Verugo, PsyD (1997) Hello msn, I am new to msn messenger and msn my space. I have done 2 other pages on yahoo and myspace. The url's are http://www.360.yahoo.com/psydchick http://www.myspace.com/psydchick I also started a group on yahoo for intractable pain. I am very happy to be acquainted with msn and hope that i will meet some wonderful individuals
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