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Sat Jun 14, 2014, 12:51 PM

Poor, Sick…and in Pain

Recently, two very nice physicians that I know said essentially the same thing…

“People who are extremely poor are not good candidates for pain treatment with opiates. They will be tempted to sell their medication.”

Both doctors work with the uninsured and chronically ill. Neither is a monster. Both would be considered compassionate. Neither saw anything objectionable about the comment. To them, it was a simple fact. A person who is poor and needs money for rent or food will obviously consider selling drugs illegally. Obviously. And therefore, a prudent doctor will not give that person the chance to become a prescription drug dealer, no matter how severe the person’s pain. It is the doctor’s obligation to the public, to help fight the rising tide of prescription drug abuse. By assuming that every poor person is a drug dealer until that person proves herself worthy of the doctor’s trust.

I think I may have to ask my husband to build me a wall, so that I have something to bang my head against at times like these.

Before you tell me that our state needs a patient’s bill of rights guaranteeing them the right to pain relief, I must tell you that we already have one. However, doctors exercise their clinical judgment. If they believe that a patient is malingering, they do not treat their symptoms. If they believe that treatment will cause more harm than good, they do not treat. And while doctors are warned against being paternalist, paternalism is the middle name of many physicians—even the women.

By the way, “Trust” is one of the core values that most medical institutions (claim to) embrace. So is “Mutual Respect.” Usually those are right up there at the top. “I will protect you from becoming a criminal” is not typically one of the core values, though certainly no doctor wants to contribute to a patient’s incarceration. That’s why we warn them not to drive under the influence of certain sedating medications like antihistamines and pain pills.

A person who is too poor to eat will do a lot of things. He or she might, conceivably, pawn or sell their possessions, including their medication. But the Viagra that a man receives free of charge from the manufacturer as part of a patient assistance program of the uninsured can be sold just as easily as hydrocodone---and no one has ever said to me “The poor should not be on Viagra. They might sell it.” The albuterol inhalers that they get at the public health clinic pharmacy could probably fetch $15 or $20 on the streets since they cost about $45 at the pharmacy. Birth control pills, hormone replacement therapy, antibiotics, non-benzodiazepine psychiatric drugs---some of which cost up to $20 a pill---all have a “street value”. So, why the rush to deny the poor treatment for their pain? Why do some doctors seem so proud of the fact that they are protecting their poor patients from the temptation of having a bottle of hydrocodone at hand?

The doctors who are reading this will say “It’s the DEA’s fault. The docs are afraid of being audited and shut down.” But, at a public institution for the uninsured, practitioners seldom get in trouble for doing too much for their patients. They are much more likely to be censured for doing too little. Witness the VA scandal.

I have some theories. But I am still puzzled. After all the efforts in recent years to increase physicians awareness of patients right to pain treatment---it is actually on the list of most Patients Bill of Rights that you see posted---why would two seasoned doctors assume that every poor person is a potential drug dealer? I am sure that they have met a few drug dealers. I have a sneaking suspicion that they did not recognize the drug dealers who were white, middle class, conservatively dressed, polite, well educated. And that they may have harbored some false suspicions about others whose only crime was being Black or unkempt (it’s hard to stay groomed when you live in a car) or in need of mental health services that were not available. Because if you enter an examination room with a preconceived notion---like everyone in a “free” clinic is a malingerer who is here to feed his drug habit or get some product to sell—that is what you are going to see.

On the other hand, if you take a step back and consider how that person came to the “free” clinic, if you remember that he once had a job and once had insurance and once paid taxes, until a truck backed over him—on his job---fracturing his cervical vertebrae---and that his employer weaseled out of his Workman’s Comp obligation throwing the patient into bankruptcy and onto the mercy of the public health system, and that while he can walk, he has constant, disabling pain from the bone and joint injuries and from nerve injuries and is going to live with that pain---and the poverty and disability---for the rest of his life through no fault of his own---maybe you can remember that the so called “poor” are people just like you and me---and by “me” I mean the well dressed, well fed, well paid doctors who would be absolutely outraged were anyone ever to tell us “Sorry, but I can only give you Motrin for your pain. You might abuse hydrocodone. The stresses of being a physician in America right now are so high. I must protect you from yourself.”

“A way has to be found to enable everyone to benefit from the fruits of the earth, and not simply to close the gap between the affluent and those who must be satisfied with the crumbs falling from the table, but above all to satisfy the demands of justice, fairness and respect for every human being.” (Pope Francis, Address to the Food and Agricultural Organization, 6/20/13)

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Response to McCamy Taylor (Original post)

Sat Jun 14, 2014, 01:01 PM

1. It's not the "street value", it's the addiction factor, and it's society being "protected".

And yes, doctors DO get investigated, and that fact DOES inhibit the prescription of narcotic pain relievers to some patients.

It sucks if the only pain relief choice for a patient is narcotic and the patient is a good candidate to be a pusher.

Myself, if I happen to come by a prescription for whatever-codone that is more than I need for that episode, I'm not likely to risk my lifestyle and freedom for the few bucks a pill I could get for it. I just hang onto it for the next time I have really bad back pain. But if I really, really needed money for rent? Probably a different story.

It's a tough situation for the doctor. Hopefully someday we can find a better way to deliver pain relief that avoids this dilemma.

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Response to MH1 (Reply #1)

Sat Jun 14, 2014, 03:34 PM

6. Not a good enough fucking excuse.

Being poor might indeed make a patient more likely to sell the drug for money. That fact is not a good enough reason to deny them effective pain relief. There are worse things than enabling someone to sell a few opiate pills. One of them is being a fucking torturer-by-denial. And basing it on their lack of affluence is as nasty as it gets.

A doctor that can be found to be prescribing opiates to affluent patients and denying them to poor patients should lose her fucking license. Pain relief is no fucking game, for people who truly need it.

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Response to enki23 (Reply #6)

Sat Jun 14, 2014, 04:05 PM

9. +1

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Response to enki23 (Reply #6)

Sat Jun 14, 2014, 04:06 PM

10. Where I live, they pretty much do exactly that

A doctor that can be found to be prescribing opiates to affluent patients and denying them to poor patients


I am currently on Medicaid and my primary (as with all us poor folk) is not a doctor but whatever student is in the clinic that day, PCP means "clinic" for poor people, and even though I do have a doctor listed under my insurance, I only met him once and even then he did not examine me, some very young person did. The doctor supervises them I am told. They also do not prescribe anything for pain relief at all, what they do is write you a referral and give you a list of pain management specialists, oddly however, none on the list take medicaid, nor do they take most bronze type insurance. If you are well to do, they will take cash, or your Cadillac plan.

The problem for me is that besides serious problems I have with pulmonary hypertension making simple tasks feel like running a marathon, I also have rather severe arthritis in my lower back, my neck, my knees, and my hands. Before I became to ill to work, I had a prescription for Percocet that enabled me to function physically and work as long as I did. The problem now is I am poor so it is decided I should be in constant pain (as a penance for being poor I suppose), they problem is not medical as the many doctors all admit that in my case pain management is appropriate, but no one that prescribes will take me as a patient. so it is already happening in Erie County exactly as you describe but rest assured no one will be losing their licence for the imposed torture.

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Response to Dragonfli (Reply #10)

Sat Jun 14, 2014, 07:18 PM

12. That is truly freaking awful. I'm sorry.

My father is currently on medicaid, but he's currently still on the hefty tramadol dose for very nasty arthritis that he had from before he went on medicaid. He has an opioid that he takes infrequently for severe pain when it occurs. There are times when tramadol isn't enough. He sounds suicidal sometimes. Real, serious pain can kill a person. And if it doesn't, it can wreck their life. Our priorities in this nation are fucking insane.

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Response to Dragonfli (Reply #10)

Sun Jun 15, 2014, 05:48 AM

16. I'm so sorry. My Medicaid story is different from yours

 

My doctor (she's retiring soon, but I've already found another) is wonderful. She's very conservative with pain medication and I am one of only five people that she prescribes oxycodone for. She was my doc for years before I was on Medicaid and she treats me in the same manner as she always has. I don't believe my soon-to-be doc will handle things any differently.

I'm very careful with my pain medication and don't take it when I don't need it, but when I do need it, I want it accessible.

You should have the same option.

I have Complex Regional Pain Syndrome, btw.

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Response to cali (Reply #16)

Sun Jun 15, 2014, 01:25 PM

21. I am not at all sorry your Medicaid story is different than mine, I am pleased it is.

I don't know if it is a state or county thing, perhaps the experience is quite diverse across the nation. I live in NYS in Erie county, here, my story is quite typical.

I am curious about something, has Medicaid been taken over by private insurance where you live like it has here? Here you pick insurance companies from something like five options and very few places accept the plans, none in the case of pain management specialists (the clinics and most doctors don't prescribe pain killers here and instead refer you to the pain specialists). They are sort of sub-bronze plans, I jokingly refer to mine as the "tin plan". They are superior regarding copays as most medications are practically free with very little out of pocket but they also have the lowest reimbursement rates of all plans including Medicare which may explain why our primary care physicians tend not to be doctors but rather clinics established to help the poor (while educating the young).

In the last job I had that offered insurance I had a real doctor that actually called the specialist before referring me and sent my xrays and such as well as his recommendations so I was well taken care of, he does not take welfare insurance however so I can no longer see him, I am glad you still get to see the doctor you had previous he/she sounds like a good one.

Maybe the state here just makes it harder to get pain relief, it would be typical of NY to do that, but in the end it is as stated, "the well to do get help, the poor are expected to suffer" due to the catch 22 of needing a specialist for pain relief and having none of them take the poor people's tin plan insurance/Medicaid card.

When I had pain relief, I typically only used half the prescription because like you I was careful, a good side effect of that was I had extra put away that I used for a few months at the beginning of the transition to extreme poverty, now I am usually in pain and it has made me very grumpy and incredibly depressed and unable to sleep, I may just see how long I can take it before jumping off the Peace Bridge in the end, somethings gotta give.

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Response to enki23 (Reply #6)

Sun Jun 15, 2014, 01:15 AM

14. Damn straight. +1

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Response to enki23 (Reply #6)

Sun Jun 15, 2014, 01:25 PM

20. Ding, ding, ding, ding,! Right on the money

These drug-seeking welfare queens and kings need to be arrested and tried AND found guilty!!!!...But not the physicians who greatly increase their revenue by becoming a prescription-mill to rich and poor alike, assisting them in getting hooked. (First do no harm?) Pull their license and toss them in jail.

I've seen too many people in great pain for many years. They, as a whole, are not seeking opiates because they are hooked, they Fucking HURT for hours on end, day in, day out and need relief. When you attempt suicide because the doctor can't or won't help you...

Try it yourself and see what it is like. Pain, real pain. It can take a family member of mine an hour to get out of bed with help.
She sees doctors continually. Injured her back caring for a severely physical-mentally disabled young man for years...she used to fish, play baseball, horseback riding, loved going to auctions and shopping. Now? House-bound, can't nurse patients and in pain every fucking day...If she tells a physician this or that reliever doesn't work, she is now a "drug-seeker" and a loser.

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Response to McCamy Taylor (Original post)

Sat Jun 14, 2014, 01:17 PM

2. I've been enjoying your posts lately,

thank you. You're leaving us with a lot of food for thought.

You've hit the nail on the head, again - it is most certainly a side effect of our unspoken and to a degree unconscious conviction that the state of poverty is an indicator of character. That poverty never strikes those who deserve better, so when it does it must mean that they deserve it. Some character flaw, some moral failing that keeps them from striving in that Calvinist wet dream of the work ethic.

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Response to enlightenment (Reply #2)

Sat Jun 14, 2014, 01:27 PM

3. Max Weber "Protestant Ethic and Spirit of Capitalism", a great read.

The Christian Right does Calvin an injustice. He didn't think the poor should be scapegoated.

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Response to McCamy Taylor (Reply #3)

Sat Jun 14, 2014, 01:35 PM

5. It doesn't take long for

context to be lost, so all we're left with is the shell of what might have been a decent concept.

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Response to McCamy Taylor (Original post)

Sat Jun 14, 2014, 01:32 PM

4. There are alternative therapies

for many types of pain. Rehabilitation exercises, local injections, TENS units, etc can help reduce pain for many problems. Insurance companies are finally getting on board with this instead of paying for narcotics and then problems with addiction.

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Response to Ilsa (Reply #4)

Sun Jun 15, 2014, 01:05 AM

13. Yes and those sometimes work for some people some of the time.

Something like 50% of shots are misplaced according to an article on DU a while ago.
It is hard to do work hooked up to a tens machine, anything but simple exercise does nothing for spacicity except make it worse.

If you have 4 hours of useable time and you are using it to get to and from therapy that leaves no time for work or family.

There comes a point when expensive therapy is done and the $20 prescription that keeps you working and from taking your life is well worth it.

Making Docs clairvoyant NARCS is a very, very bad idea. The more layers of bureaucracy and suspicion you require of doctors, totally breaks down the doctor patient relationship.

Short term recovery pain vs long term pain should not be hard to figure out and deal with. I almost broke their sensors when my OMG pain hit during a therapy session but at least I finally had some insurance company proof besides the BP spikes when my pain was not controlled.

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Response to kickysnana (Reply #13)

Sun Jun 15, 2014, 05:38 AM

15. I know it doesn't work for everyone,

Or 100% of the time. There are pros and cons to each of the options, and there can be down-time with opiate use as well as dosages are adjusted.

I'm surprised more therapists don't use ultrasound to assist with needle placement so the injection will be effective. Yes, it's an extra step, I think worth it.

And I didn't suggest that doctors narc on their patients. There is no reason to deny care to anyone by generalizing about the poor selling their pain medicine.

My point was to try to shift as many pain cases as possible away from narcotics use when it is feasible and the treatment works. Insurance has begun to recognize that option.

And lastly, I'm very sorry about your chronic pain.

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Response to Ilsa (Reply #15)

Sun Jun 15, 2014, 12:57 PM

19. Thanks, got it.

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Response to Ilsa (Reply #4)

Sun Jun 15, 2014, 05:53 AM

17. and then there are those of us who STILL need pain relief medication

 

Look, I think exercise- and I spend an hour+ a day doing aerobic and specific rehab exercises, has been more effective than anything else with the possible exception of meditation, but I still have uncontrollable breakout pain at times; particularly at night. I have a TENS unit. Useless for me despite much of my pain being of nerve origin. I've tried sympathetic nerve blocks, gabapentin, lyrica and many other drugs.

I'm good at distracting myself from pain during the day; at negotiating an uneasy alliance with my CRPS, but there are times when oxycodone is a real life saver.

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Response to cali (Reply #17)

Sun Jun 15, 2014, 05:53 AM

18. Absolutely! nt

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Response to McCamy Taylor (Original post)

Sat Jun 14, 2014, 03:39 PM

7. I'd hate to be a doctor nowadays.

Despite what's mentioned above, I know people who do exactly that. I know a woman on $600 a month disability, foodstamps & medicaid. Sells her oxy to pay bills. Besides that doctors are pressured by drug companies to push drugs while the DEA watches them to see they don't. The patient is considered by neither.

Like the old movie it's a mad, mad, mad, mad world.

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Response to McCamy Taylor (Original post)

Sat Jun 14, 2014, 04:05 PM

8. What a crock of shit--

the physicians, not your thread.

Most pills like hydrocodone are dispensed in relatively small quantities such as 10 pills per prescription. Comparing the cost of co-pays to the resale value the most anyone could raise by reselling those prescription is about $40. If someone is in severe enough pain to pay to see a doctor and get the prescription or even take the time to go to a free clinic they aren't going to sell those pills to someone else.

If someone is so poor that they would consider reselling their medication, then they are also possible candidates to commit suicide. I know because I've been there. I had 38 pills stocked up from over a six year period when I four separate prescriptions written. The biggest lot was when a doctor wrote me a prescription for 40 pills when I had severe back pain and still had a respectable job. The other prescriptions were filled either by my dentist or by oral surgeons as I had teeth extracted. Yes, I could have tried to sell those pills for a bit of money but I could see the necessity of keeping them available if my back pain flared back up in the future.

It's sad to believe that some people believe that they need to pass judgment upon others.

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Response to TexasTowelie (Reply #8)

Sat Jun 14, 2014, 04:15 PM

11. You are correct. Most poor people in pain will sell anything before they sell their pain meds

because it is very hard for them to pay to see a doctor, very hard for them to get a prescription (for the reasons I describe above) and they are always in pain and never know when it will flare up and they will not have the money to go to the ER. Poor people are much more likely to be the ones spending $5 or $10 to buy some middle class, insured person's Hydrocodone than they are to sell their own for the simple reason that they have no access to health care and they may need the medication so that they can stay on their feet for 8 hours at their minimum wage job so the kids don't get tossed into the street.

Hi, Towlie!

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