Opioid Hysteria and Physician Credibility

The following is a true account of a recent illness experienced by my 28 year old daughter and how her condition worsened because of the treatment modality.  In summary, my daughter’s health became progressively worse because her very well regarded physician witheld opioid-based medicine.

It was not until my daughter, Isabella, went to the emergency room (after 8 days of “treatment” by her family physician) that her health improved markedly.  The ER physician administered Dilaudid for pain caused by broken ribs and an abdominal hernia, which had been caused originally by a severe cough.

Out of fear of the new opioid legislation and in general the fear of over-prescribing opioid-based medicine, my daughter’s primary care physician would not prescribe cough syrup with Codeine or Hydrocodone when she presented with symptoms of bronchitis, including a severe cough.

Here is her story.

Day 1:

Recently, my 28 year old daughter, Isabella, developed a severe cough with chills, fever, and headache.  Her cough was incessant, painful, and caused secondary maladies, such as inability to sleep.  She was also suffering from a fever between 101degF and 103degF and was having some difficulty breathing.

We all know that when we get sick, sleep is a priority for faster recovery.  We ALSO KNOW (via common sense) that without sleep, our health gets progressively worse.

Day 3: Isabella Relents and Goes to the Doctor

My daughter went to see her doctor, “Dr. Eglandina”, who is a family internist. In the past, Dr. “E” would prescribe whatever medicines and tests her patients needed based on their ailments and the BEST PRACTICES to treat those maladies.  She was and is a nationally recognized physician who does research in addition to her clinical practice; she often attends internationally recognized conferences, and she belongs to internationally recognized research groups.  She has presented her research at conferences, and she is often sought out by other physicians for clinical help/consultation in their own practices.

After doing a battery of tests, chest xrays, and performing a physical exam of my daughter, Dr. E prescribed some medicines, including a Prednisone pack to reduce overall inflammation, Albuterol to open up airways, Tessalon Perles for cough (little yellow non-narcotic pills), and advised her to use old-fashioned Vics vapor rub to help open up her breathing.  In addition to the pain reducing benefit of the anti-inflammatories, Dr. E also advised her to take Tylenol (Acetaminophen) for pain and fever mitigation.  At this point nothing unusual was observed so the cause of illness was thought to be a virus.

Day 4: Her Cough Continues

After a few days, my daughter’s condition was not improving.  In fact, her cough was getting progressively worse and her chest, ribs, and abdomen were now very painful.  Her throat was “red-raw” from the incessant hacking cough.  Her fever had reached 103deg.

Isabella called Dr. E’s office to move up her scheduled follow-up.  Still suspecting that my daughter’s condition was virus-driven, Dr. E was curious to see what her chest and lungs xray would show.  Fortunately, pneumonia was negative,  and Dr. E advised my daughter to “get more rest”.  No other anomolies were detected.

My daughter kept telling Dr. E that she could not sleep because of the cough, and she asked her if she could prescribe cough syrup with codeine or hydrocodone, as Dr. E had done with Isabella and other patients in the past.  Dr. E said that “because of new laws and guidelines from the government” it wasn’t “medically warranted” at this point.  Dr. E advised my daughter to take Robitussen DM Extended Release cough syrup, over the counter, and she sent my daughter home with a fever and a horrific cough.

Dr. E had said that rest, sleep, and cough control were the “keys to getting well” and that finishing the Prednisone Pack and taking the Abuterol would help her breath, enhancing her ability to sleep.  Taking the Robitussen ER with the Tessalon Perles would “definitely control the cough, enabling deep sleep.”

Day 7: Isabella’s Condition Worsens

By Day 7 my daughter was still very ill.  Since she lives alone in her own apartment, there were no family members or friends around to observe changes in her condition.  Her fever was fluctuatiing between 101 and 103, her chest felt heavy, her chest and ribs were increasingly painful, she was feeling significant pain in her abdomen, and she was not getting any sleep.  Her cough was getting worse and she had a severe headache.

Day 8: My Daughter’s Trip to the Emergency Room

On Day 7 Isabella called Dr. E’s office and asked to speak with her directly.  She begged Dr. E to prescribe something that would “make me feel better” and “control my cough”, but Dr. E said that they had “tried everything for the cough” and that cough syrup with codeine or hydrocodone was now only to be used for “extreme coughs”, such as in Whooping Cough, Tuberculosis, etc.  Further, Dr. E advised my daughter that this was based on new government orders/edicts, which indicated that cough and pain medicines made with narcotics were to be used only for the most dire of circumstances, such as use for patients with cancer.  Dr. E told my daughter that she would have to “tough it out”, echoing the words of Jeff Sessions and President Trump who had recently said this while touting the new opioid laws.

My daughter then decided to go to the ER out of desperation.  By now it was Day 8, and she felt miserable.  Her chest, rib cage, and abdomen were extremely painful, she was bleeding from a raw throat, and she had already missed several days of work.  I had advised her after Day 3 to consult a different doctor or go to the ER, but of course since when do children listen to parents.

The ER physician, “Dr. X”, took one look at my daughter’s chest imaging and admitted her to the hospital forthwith.  The images revealed two stress fractures of the ribs and pneumonia.

Dr. X immediately ordered a shot of Dilaudid for pain, which he said would also help reduce the urge to cough.  Guess what, my daughter, after 8 days from her initial doctor visit, finally felt significant pain relief and the reduction in frequency and intensity of the coughing was dramatic.  Elapsed time from the shot of Dilaudid (Hydromorphone) to a sensation of pain relief: 22 minutes.  Elapsed time spent in agony: 8 days.

Dr. X asked Isabella if she had experienced chest or abnominal pain prior to the start of her bronchitis, and Isabella was emphatic, replying “I had not.”  He also asked her if she had ever had a bump the size of a golf ball protruding from her lower abdomen, and Isabella was again emphatic, replying, “No”.

As it turns out, in addition to a bleeding throat, bronchitis, pneumonia, and fractured ribs, Isabella had an inguinal hernia, a rare type of hernia for a female.

Day 9: Significant Relief and Recovery

Isabella spent the night of Days 8 and 9 in the hospital being treated for a raw throat, pneumonia, bronchitis, cracked ribs, and a hernia.  Doctors had said that depending on her progress with pneumonia, it was possible that they would schedule hernia surgery on Day 11.  The hernia surgeon was emphatic that it had to be repaired since there was some risk that that the protruding intestine could itself be damaged.  On the other hand, hernia surgery was out of the question with active pneumonia.

The remarkable thing on Day 9 was the incredible pain relief and cough suppression that my daughter was experiencing.  It was a miracle.  I could not believe the difference in her appearence, in her disposition, and in her outlook.  I was overjoyed to see her feeling so much better.

When all was said and done, Isabella recovered nicely from the raw throat, bronchitis, pneumonia, and fractured ribs, and the hernia surgery was successful.  What is striking, but not unexpected, is that the recovery started almost immediately after receiving her first shot of Dilaudid.  By getting relief from coughing and  pain, my daughter was able to sleep, and as a result the healing process was able to begin and continue.  Existing injuries would no longer be aggravated and new injuries were prevented.  The speed at which she recovered was remarkable.

Day 12: Leaving the Hospital in High Spirits

As with the vast majority of patients who are given narcotic pain medicine in the hospital, my daughter left the hospital with her health back and almost no risk of addiction.  She was given scripts for antibiotics and a 3-day supply of Percocet 5/325 (5mg Oxycodone, 325mg Acetaminophen) for fractured rib pain and post-op pain, but she felt so good that she never filled it.

The Science of Pain Management

My son-in-law is a Green Beret medic.  He has been on several dangerous deployments.  He cannot tell us about the missions, including where they are, how long they will be, what the purposes are, and so on.  However, he can tell us about his role as long as it is not tied to the particulars of a mission.  For example, he has told us how pain is treated in the field for categories of injuries, and he made one point in particular that is relevant to my daughter’s case:

”Pain relief is a significant determinative factor in the healing process for most situations.  Unless pain is mitigated, controlled, and managed, the patient’s disease state will either worsen, continue status-quo, or only marginally improve.  Therefore, we focus on pain mitigation as a priority following the acute or chronic experience of pain.  Narcotic-based pain medicine is the most effective agent for pain mitigation in most cases.  The superior pain relieving mechanisms of narcotics far outweigh the risk of addiction for most people.  If the patient is not allergic to NSAIDs and can tolerate Acetaminophen, we may administer them in combination with narcotics.”

The Impact of Government Opioid Restrictions

Dr. E is a very good physician indeed.  Like all doctors, she obviously must follow the law, and she follows Best Practices for a given modality, such as Pain Management.  When something is beyond her expertise or where she feels someone else would provide superior treatment, she refers the patient accordingly.

However, in my daughter’s case, Dr. E was acting contrary to her better clinical and academic judgement out of fear of the law.  She has colleagues, very good physicians, who are no longer practicing, not because they don’t want to, but because they were arrested and charged by the Drug Enforcement Administration (DEA) for “exceeding prescription targets for controlled substances.”  In some cases they were handcuffed and humiliated in public.

Let’s look at the cost of one physician applying a modality of treatment based on fear rather than based on sound training and experience as a licensed and practicing doctor:

1) In my daughter’s case, the Tessolan Perles were ineffective as a cough suppressant.  Robitussin DM Extended Release cough syrup was ineffective as a cough suppressant in my daughter’s case.  This was known within Day 3 of the onset of the cough.  In fact, it is well known within the medical community that the yellow pearles aren ineffective for many people.  By Day 3 this was becomimg evident and was certainly fully evident by Day 7.

2) Dr. E was FULLY AWARE that Isabella was in significant pain.  The Tylenol was recommended as a fever reducer and as a pain reliever.  Prednisone was also provided as an anti-inflammatory for the lungs (but there was no focused plan to address the significant pain from her cracked ribs and hernia).

3) Within only a few days of onset of Isabella’s cough, injury to her body was already underway:

a) Her cough was severe enough to cause the skin of the throat to tear, resulting in bleeding from the throat.

b) According to Dr. X, the hernia was caused by the coughing; these hernias are much more frequent in men than in women.

c) According to Dr. X, the rib fractures occurred as a result of the coughing.  This points to the severity of the cough.

d) Clearly, Isabella had serious pain brought on by cracked ribs and a hernia, each caused by a severe cough.  Clearly then, if adequate cough control had been implemented, the hernia & cracked ribs would have been avoided.

Lesson Learned

Use of opiate-based cough medicine would have prevented significant worsening of this patient’s condition.  Government intrusion in the form of opioid restrictions caused fear in the heart of Dr. E. who as a consequence, did not follow a known best practice to treat Isabella’s severe cough.  It follows by Modus Ponens logic that the government caused injury and pain by implementing opioid restrictions.

While attempting to “protect the public”, the government, as usual, has gone overboard.  Physicians are very hesitant to treat patients with medicine that contains opiates, even in the face of overwhelming evidence that such medicines will be of significant help in mitigating the patient’s symptoms.

Credibility of Physicians in Doubt

Many otherwise intelligent and well respected physicians are making justifications that have no scientific basis, such as “opioids are not effective in relieving pain”, and “We can use Tylenol and Advil (and other NSAIDs) for chronic pain.”

Physicians seem to have lost their ability to think clearly, likely out of fear of losing their license to practice, fear of liability because of mis-use, or fear of being arrested.  They have witnessed colleagues being arrested, well meaning doctors who were just trying to help patients.

The Nanny State Nullifies Best Practices

It is the new Nanny State that has had two major impacts in healthcare:

1) Doctors are afraid to prescribe and administer narcotic-based medicine, meaning that the “Best Practice” for a given situation may not be used (as in my daughter’s case).

2) Patients who have significant pain are being told to live with it, to “tough it out”.  As we have seen in my daughter’s case, “toughening it out” may lead to other serious maladies, such as hernias and fractured ribs.

When I was first treated for my chronic pain, doctors first tried NSAIDs and Acetaminophen.  I discovered that NSAIDs caused significant gastrointestinal issues, such as severe cramping and diarrhea.  After taking Tylenol for some time, my skin and eye whites turned a shade of yellow (jaundice), and my doctors told me that based on blood work, I was going to experience liver failure if I did not stop the Acetaminophen. Neither the NSAIDs nor the Tylenol provided any significant pain relief in my case.

Data Conflation

We have all heard the legitimate concerns: 1) Deaths from opioids are increasing 2) Patients are “over-prescribed” with opiates after surgery, and those medicines are diverted.  However, what is not stated is how the data is conflated, and in fact, although there are ILLEGAL diversions of a very small percentage of LEGAL prescriptions, most of the opiate-related deaths are from ILLEGAL opiates, NOT PRESCRIPTIONS.  In addition, most of these deaths result from a combination of substances, for example, opioids taken in tamdem with antianxiety drugs:

Senate about to pass ‘opioid’ laws that are built on lies

The Party of Individual Liberty

Isn’t it ironic that the so-called “party of individual liberty” is really the party of intrusion, the Nanny State party.  Think about it, because of new laws passed by Republican-controlled local, state, and federal governments, we as pain sufferers are being forced to suffer when treatment is available to help mitigate the suffering.  That’s about as far away from “Individual Liberty” as one can get.

Unfortunately, the people we have elected to make government smaller have succeeded in doing just the opposite.  They have ensured a spot for themselves in the halls of power and they do whatever it takes to retain power.  Politicians in both major parties are satisfying the “whim of the moment”, that is, doing what is necessary to retain their seat individually, regardless of whether or not their party retains the majority.  We see politicians who have been in power for several decades, doing whatever it takes to retain and regain power, no matter what “We the People” have voted for.  As a consequence, we the people have lost our voice, we no longer have the ability to reduce the size of government so that it does what the founders had envisioned: limited federal powers, limited state powers, with the remaining “LIMITED” government powers designated as “The Enumerated Powers”.  The local government was supposed to be “the voice of the people”, but this voice has been successfully nullified. 

Gun Control IS Opioid Control

Unfortunately, limiting our use of opioids for legitimate medical practices has had the predicted side-effect: a surge in the black market for opioids.

The 2nd Amendment provides every US citizen the right to “keep and bear arms”, however, the wording of the amendment leaves a fair amount of room for regulation.  Hence, each state has interpreted the amendment differently, with some states favoring the individual’s right and others favoring a bigger role for government regulation.  

I have homes in a few USA states and in Europe.  In my Italian village, we actually make our own firearms and ammo and nobody bothers us, even though the laws are quite strict by USA standards (although quite lenient when compared to EU standards as a whole).  

In Florida, I was able to obtain a Conceal Carry Weapons (CCW) permit within 30 days after application, but in New Jersey, one cannot obtain a CCW unless a “need” is demonstrated.  Needs include 1) A weapon is needed by virtue of your job, such as a Private Investigator or 2) You have credible evidence that your life is being threatened.  For example, you are a politician who has received death threats.  In NJ, it is now also illegal to have magazines with a capacity greater than 10 rounds, and you cannot “stand your ground”; this means that you must make every attempt to flee when confronted with danger and that you do NOT have a God-given right to defend yourself until all escape paths are nullified.

In New Jersey, like Italy, the Black Market for guns is THRIVING.  This is a direct result of government regulation.

What does this have to do with opioids?

Ironically, the regulation of opioids in Florida is more pronounced in Florida than it is in New Jersey.  In FL, for example, one cannot leave a prescription for opioids with the pharmacist if the pharmacy does not have your medicine in stock, whereas in NJ, it is ok to leave the script.  In FL, you are technically not permitted as a customer to call around to pharmacies to see if they carry a particular medicine; one must drive around endlessly just to find a pharmacy that has your medicine in stock.  In NJ, you are able to call around.  Generally speaking, both states are over-regulated when it comes to legally prescribed opioids, but FL is stricter, thus the Black Market in FL is “very lively” and doing a great business.  For example, I have acquaintences in my gym who are able to obtain 30mg Oxycodone tablets in the Black Market without any issues whatsoever; physicians in Florida are very hesitant to prescribe 30mg OC because of the watchful eye of the DEA.

The bottom line: the Black Market in most US states is THRIVING, and it is a matter of gradients as to which black markets are more successful than others.

This is similar to gun control: the more guns are regulated, the easier it is to obtain a weapon on the black market.  The more opioid regulation that exists, the easier it is to obtain opioids in the black market.  For both guns and opioids, the black market increases the risk of bodily harm and death.  The guns sold have not been well maintained and the people who sell them are serious bad guys.  Likewise, the drugs sold are often stronger than the legal versions and are often laced with other drugs.  As a result, overdoses are much higher in the black market.

Since the new opioid laws were implemented on July 1, 2018, I know two stage 4 cancer patients who commited suicide because they could no longer legally obtain Oxymorphone ER, one of the strongest opiates.  Over a year ago, the FDA had recommended that manufacturers discontinue production of this medicine, and pharmacies were dispensing it as long as they had inventory.  Once either the inventory was exhausted or the the new laws were implemented, most pharmacies no longer dispensed this medicine in Florida.  These two persons tried other formulations, but because each formulation effects different opioid receptors, they could not find something to control their pain.  For them, suicide was the best option.  How sad.

I also know two other people who overdosed on street drugs after the July 1 law cut their allowable daily MME by over 50%.  When the cut happened, both were rushed to the ER approximately one day after the cuts.  In one case doctors were able to control the increased blood pressure through use of a drug called Lucemyra (lofexidine); when opiates are cut drastically, a person’s pain level increases dramatically, and the increased pain causes very high blood pressure.  The other patient suffered a stroke as a result of the drastically increased blood pressure.

Ultimately, both were released from the hospital, but in one case there was permanent physical damage from a stroke.

Several weeks later, one person died suddenly from an overdose of opiates he had obtained from the black market.  Soon thereafter, the second person overdosed on Oxycodone 30mg laced with another medicine.  He survived for a few weeks, but then passed away.  Both persons left a family behind, including children.

Please Leave us Alone!

As we learned from alcohol Prohibition, over-regulation by the government has very negative consequences.  Now, through systems like ISTOP/PMP, the government can see every medicine that you take, no matter where you go for treatment.  You can fill a script for Hydrocodone in NJ one day, fly to Seattle the next, go to an ER in Seattle and they will see that you filled Hydrocodone in NJ.  These systems were implemented to prevent “Doctor Shopping”, and that has been successful, but by staying quiet about it, we have given up our privacy COMPLETELY AND TOTALLY.

People die from many things every day:

  1. 15,000 people dies every year from NSAIDs like Ibuprofen, Naproxen, Endolac, and others.  100,000 go to the ER.
  2. 40,000 people die every year from anti-depressants.
  3. 88,000 people die every year from alcohol.
  4. 1.2million people die from sugar (diabetes) every year.
  5. ..and the list goes on..bath tub falls, falling on ice, falling down steps, car accidents, choking on food and candy, pushing too much weight in the gym, Salmonella poisoning from eggs and other foods, and so on.

Life is full of risks.  By allowing our governments to become our “Nannies”, we have given up our privacy and our individual rights.  We have relinquished our “Individual Liberty” for a false sense of safety.  Government beauracrats try to make “one size fits all” laws in the name of safety, yet, as we have seen in ALL CASES, the net result is suffering instead of safety.  

Gun laws make criminals out of good guys, and drug laws make drug addicts out of patients.  Like the innocent victim of a madman with a gun, that is, a person who cannot carry a firearm to protect himself because he obeys the law, the pain sufferer must “tough it out” rather than get the pain relief he so desperately needs.  

The government makes victims out of us by playing the role of Nanny State, and unfortunately, we suffer the consequences by allowing the government to get away with it.  We must step forward NOW to stop it before we lose all of our rights.

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