We Should Not Add to the Problem by Pat Conrad MD
Accuse me of confirmation bias all you like, but this story corroborates what a lot of us have observed for years. In an age in which increasing numbers demand a pain-free existence, amidst widespread opioid and benzodiazepine addictions, where “disability” has become a profession so acceptable it should have its own university major, we are being trampled by an endemic of chronic pitifulness.
CP is a very real, very deadly condition to which anyone can succumb, which must be fought every day for the span of one’s (good-quality) years. So here is a statistical goody: a new study demonstrates a correlation between unemployment and increased pain medication usage. A conservative demographer quoted in the article said, “Time-use surveys suggest [these men] are almost entirely idle. Unlike in the past, the U.S. is now evidently rich enough to carry them, after a fashion.”
His liberal counterpart, a pro-Obama economist, concluded that “a lot of these men say they are in considerable pain…44 percent of male, prime-age labor force dropouts say they took pain medication the day prior — which is more than twice the rate reported by employed men.”
- 20 percent of these men say they have difficulty walking or climbing stairs
- 16 percent say they have memory or concentration problems
- a third say they have a disability of some kind
- 18 percent say they have multiple disabilities
The article states, “fully 6 percent of American men between the ages of 25-54 feel that their minds or their bodies are too broken for them to work. This rate has nearly quadrupled since 1968, when only 1.6 percent of men felt the same way.”
What does this have to do with authentic medicine? Physicians have an obligation, and ought to have the willingness to call things as they are. As it is, too many of us acquiesce too often to patients whining for some sort of disability status, and demanding pain or “nerve” medications. That is not compassionate, but just the opposite. The article states that, “Declining health is becoming a major reason prime-age men are working less and less”, and I think that is a boatload of crap. The government and much of medicine is colluding in a gluttonous, slovenly, growing disability industry that is giving the unemployed the poisoned excuses to remain exactly where they are, and quit. This has profound consequences first for the mental, and later the physical health of these individuals, and physicians ought to own their part in this disaster and work to reverse it.
I see a lot of patients who have 6 day weeks at 12 hours per day, pushed to the record productivity per employee levels business enjoys today. These folk are in their early 30’s and when they break, business often doesn’t accommodate their healing, but pursues them like bad little units of production, in accordance with the change from “Personnel” to “Human Resources,” like a cord of wood or bucket of coal. When they are well and truly broken, they get paper-trailed and replaced with someone cheaper, right out of school. They just aren’t given the choice of overtime, either. They have to work it. And when they are broke, what are they supposed to do? Most try finding jobs which won’t wear their remaining resilience down. I find your wholesale damnation of your patients more an indication of burnout. Yes, there are abusers out there, and depression, if you believe in depression. Maybe you should just walk off your pain?
I know all this…in 1981 I spent a lot of time taking care of disabled police and firemen at their wc clinic in Philly.
A lot of the same attitudes prevailed then… So I don’t need a lecture after 35 years as a pain specialist.
My best guess is that about 360.000 patients legitimately Ned’s moderate doses of opioids.
It won’t be any strain on our national fabric to just prescribe it to them instead of playing ‘I am the cop… You are the loser’
There’s no mystery here… Doctors hate chronic pain patients and welfare recipients… And legitimate pain patients are marginalized and disenfranchised by society and our profession
Wanna quibble?
I won’t quibble. You need to retire. If not from medicine, at least from this site. Oh, how many times did Purdue take you to dinner for Oxycontin again?
Actually…never
I think you are confused…be carrful about crossing personal lines of communication with false accusations,
If you are inferring that I was paid to prescribe opioids you are incorrect.
I advocate for opioid use in patients who have failed to improve from other treatments.
You can toss me off this website if you chose. I doubt that you would.
But do what you gotta do… That’s what I do. Best wishes to you either way.
Doc, I think we are both much more on the same page at Authentic Medicine than you think.
You stated the following: “Doctors hate chronic pain patients and welfare recipients… And legitimate pain patients are marginalized and disenfranchised by society and our profession”
Statement number two in that phrase is absolutely correct. That first group I spoke of, let us call them the REAL pain management patients. They are hindered by the abuses of the larger second group. I have legitimate pain management patients who are embarrassed to ask about medications. I will gladly treat them in a multi-disciplinary approach, involving necessary specialties. I explain to them the rigorous drug contracts and drug testing, much of it to counter the antics of the second group of patients.
Yes, we as a profession can do a better job, but many outside influences (Pain Scales, Purdue Pharmaceuticals, DEA, State Boards, the dreaded Narc-seekers (more in a moment), lousy EMRs,(redundant I know) and 15 minute or less time slots to do comprehensive care) make my job quite difficult to help the first group.
The second group is the challenge for the reasons I listed. If you are in Primary Care, as I am, I get to manage the Diabetes, Hypertension, Obesity, Depression, Hypothyroidism, and rashes often at the same time. Toss in a mixture of malingering, doctor shopping, narc-seekers, and diversion. It is this group that frustrates, exhausts, and demoralizes doctors.
Pain Management Specialists. Too few of the real ones exist, not the Pill Mills. By a real Specialist, I describe the ones who provide not only opiate and adjunctive therapy, but therapeutic injections and other interventions. Many of them will only see insured patients, not Medicaid or self pay. Many of my patients cannot afford the copay to see them every month or the gas to drive 30-45 minutes.
Doc, I do not believe anyone here is disparaging the REAL pain management patients. We are rather alarmed, and at time amused by the group of people giving them a bad name.
Now the first statement of your quote regarding hating them? No. Hate the disease, love the patient. Hating welfare recipients? No. Hate the fact they live in dependency, frustrated that too few seek to vigorously escape the vicious cycle of poverty (of body, mind, spirit, and savings), but love the patient.
As a Pain Management Specialist, help turn back this evil ogre launched upon Medicine 15 years ago: Treat all the pain but don’t treat all the pain. It is the Kobayashi Maru scenario: no win, damned if you do and damned if you don’t.
Peace out, bro.
I am a pain specialist trained with a
Al Winnie
I don’t like GP’ treating pain with opioids for conditions that are ostensibly of short duration- and it has created problems.
I had a gigantic argument with Purdue over their tactics and I am no friend of theirs- all due respect to Doug Farrago- who in fact is probably a good guy.
I was prosecuted and sent to prison in Pa. Because I refused to lower doses of opioids in five patients who had legit pain and had already been on these medications prior to seeing me.
I turned down an 11 month plea deal believing I was innocent. I got 20 years. Did nine and was paroled.
My gripes are with police and prosecutors who substitute the “knowledge” component
In specific intent with “medical practice standards” which even if violated do not rise to the level of a drug crime.
I never issued a prescription to a patient in whom I had reason to believe did not need the opioid.
Without any ill feelings; I will probably not comment again on this site.
I am poor these days- and living on SS retirement. I represent myself on appeal. I have nothing to hide and I put my case on the WWW starting in 2008 for the sake of complete disclosure.
I only came on board here because Andrea Trescott emailed the original article to me.
There is no need for me to use this venue.
I already have an extensive Internet presence with thousands of followers.
Best wishes
Bill Mangino MD
Bill, that is an interesting story, and underscores why I am intently libertarian, particularly in the realm of opioid prescribing and prosecutions thereof. That said, I think you have misunderstood or avoided the point of my piece: those with not enough to do, i.e the otherwise able-bodied who sit at home on some sort of flimsy disability status given them by an indulgent disability industry and lowered societal expectations, develop more pain and less pain tolerance than those of the declining numbers of us without excuses. That does not criticize those who are truly disabled or are rigorously evaluated and then deemed in need of actual chronic pain treatment. My point remains that physicians should not move patients into those categories that need not be there, and we harm them when we do so. Pat
I agree… But Andrea Trescott placed your article apparently as a rebuttal to my blog on LinkedIn- where I merely commented that the repeat cycles of referrals pain patients are subjected to serve no legitimate purpose: and at my trial these unproven treatment options were presented to jurors as options I failed to pursue — which prosecutors led jurors to believe was criminal prescribing.
We have over estimated the number of truly chronic pain patients who need upwards of 120- -60 MHz of pure opioid daily. My best guess is aRound 450,000 persons.
I do not believe that generalists should put anybody on opioids without first obtaining outside panel of pain specialist permission.
Nor do I believe – as prosecution told jurors at my trial – that the failure to measure pain objectively precludes any prescribing of opioids
If you all want to discus this with me then. Set up a video conference and stream it live around the country _ people need to see how easy it is to get convicted under any state drug act… Innocence means nothing to law enforcement.
It’s about stopping all opioid prescribing as much as we let them get away with it.
My case is still in the courts
I represent myself
Best wishes
Bill Mangino MD
Dr. Mangino, I Googled your name and obviously found information immediately.
No reason to doubt you’re who you say you are, so I’ll address you as such.
I’m afraid that your story simply confirms my resistance to prescribe opiods.
I’m a Family Practice doc, currently working in Urgent Care, and while I am happy to give a reasonable amount of a controlled med to patients who clearly have a good reason to be in pain, I refuse them to patients who do not have a clear need.
There was a time when I would have just thrown them a “good will prescription” and advised them to see their primary or a specialist, but not anymore.
Personally, I believe that the entire concept of “controlled substances” is absurd, and that they should all be over-the-counter (if you want to kill yourself, it’s really none of my business, and most people can take a Percocet once or twice a year with no problem), but that’s a different discussion.
So long as the threat of prosecution is hanging over my head every time I wiggle my pen, I’ll be stingy with the narcs. It’s just not worth it.
You are dead on target my friend.
If you read my entire body of blogs. Over especially the last eight months; you will see that if they want to get you then your risk of getting convicted is 95 percent.
You are not obliged to believe me. And some may say I am making excuses- but I swear on all that is sacred to me that at my trial the agent lied to jurors about a statement he claims. I made.
One of the jurors believed the agent lied- we only got input from one juror.
I never raised this as an issue on appeal until two months ago in one of my briefs- which all of you should read.
Had that lie not prevailed as unchallenged testimony… I probably would have been acquitted on all of the charges.
As it was… I was acquitted on over half of the charges.
So when people still accuse me of peddling prescriptions after I spent nine years in a hard core prison… My fangs come out and I can get very freakin nasty.
Other than that, I try to see everyone as deserving respect.
Read my case and-
“Mangino Verdict I: Is Treating Pain a Crime”? By Alexander Deluca MD on Google/yahoo search engines,
Thank you so much for your comments and tell Doug Farrago I was at TMC in Houston in 1985 as Clinical Instructor in Anesthesia at Baylor Medical College – lived on Post Oak Lane near the Galeria
Bill
Fantastic article.
SLS is a disease.
Perhaps it needs a Telethon.
A related condition: NGGB Syndrome.
“Never gonna get better”. I see this daily in my rural health clinic.
So what !
This is the typical garbage that The American Medical Profession foists on patients unable to defend against ‘the real message’ here that chronic pain sufferers are protoplasmically deficient undeserving of our compassion drains on our ( already corrupted ) society.
Some of these comments are border-line wise ass bullying on the adult level… Because we all know there are pain-fakers who infiltrate our practices— is no reason to put the screws to patients who benefit from opioids only: despite having been shuffled about for PT and worthless “sets” of injections never designed by nature to possibly effect cures for chronic back pain.
You should collectively be ashamed of yourselves.
William Mangino II MD
No shame here, Bill, just a compassion gauge that’s pointing to “E.”
I’m glad you’ve still got some optimism, but mine was used up years ago.
Please do not mistake humor for callousness.
A great number of patients I’ve seen the last two decades truly have painful conditions (be it neuropathic or orthopedic in nature). The greater number, however, tend to predominate. It is the task to tell the first group from the second.
The first group (by a large brushstroke) are motivated to get better, desire an improvement in function and return to work or productivity, rather than symptomatic relief. They do not want to be ill.
The second group (growing in number the last two decades) have less motivation, and perhaps prefer to purse the route of Disability. There are a multitude of factors for this. 1: There are at times no incentives to return to work (a life of Disability and Medicaid/Medicare and all the free time in the world). The perceived financial secondary gain of pain is rewarding. 2: Patients often have no marketable intellectual skills, thus a lumbar disc that many would work through do not let them return to their manual labor jobs. There are people to find this to be true and seek job retraining (they belong in the First group). Most do not and have little aspirations. 3. There is a great deal of psychological co-morbidities between the Axis I Anxiety-Depression-Bipolar disorders, and more importantly the Axis II Personality disorders. Some are simply dysfunctional human beings, unable to adapt to the inevitable injury and illness we all face at some times. Hence, they will never get better despite all the opium and valium in the world. 4. And yes there are a small minority who make more money than I do in secondary market drug sales or prefer to live each day in a drug induces haze.
As an aside, I find that the determination, wit, resilience, and fortitude of previous generations is becoming a rare commodity. We could wander into a discussion about the current economic circumstances of the USA, but we would be here beyond election day.
And yes, I try to save most of my compassion Dr. Mangino for that first group of patients.
And yes, gallows humor may offend some, but it has been the only way a great number of physicians can survive the day, in order to return again in the morning to see the same cadre of patients.
Employed or not (but usually not), I call the same syndrome Vivodynia (where it hurts just to live, Doc.).
Back when I was doing primary care internal medicine I used to call it SLS or “Shitty Life Syndrome” which, iirc, I stole from Doug and PJ. Although, I think I like CP better.
F-ing A.