Impact of High-Dose Opioids on Overdoses

Zyp Czyk really outdid herself with this one…hard to imagine, but it’s true. Incredibly concise, clear statement of FACTS (remember those?).

EDS and Chronic Pain News & Info

Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality | Pain Medicine | Oxford AcademicJanuary 2016


Previous studies examining opioid dose and overdose risk provide limited granularity by milligram strength and instead rely on thresholds.

We quantify dose-dependent overdose.

Spoiler: there is no linear or incremental increase in overdose risk by dosage.  The 90MME limit proposed by the CDC Guideline isn’t based on science, but more like a consensus “best guess” by addiction doctors. 

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Switching Opioids for Better Pain Relief

Another excellent piece with insightful comments by my very good friend & amazing resource, Zyp Czyk

EDS and Chronic Pain News & Info

Could Switching Opioids in Cancer Patients Provide Relief? – Lori Smith, BSN, MSN, CRNP – Nov 12, 2018

I’m disappointed to see this limited only to cancer patients. Since we know that there’s NO DIFFERENCE between cancer and non-cancer pain, these findings would also apply to other kinds of chronic pain.

Side effects and inadequate pain relief with the use of opioids in cancer patients is a challenge for healthcare providers to manage and can cause considerable problems for these patients.

While the topic is still debated within the medical community, opioid switching in cancer patients may provide relief of pain and alleviation of opioid-related side effects, according to the results of a recent Italian study.  

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Study: Limiting opioid Rx won’t reduce overdose deaths

Another highly informative post by my good friend, Zyp Czyk

EDS and Chronic Pain News & Info

Limiting opioid prescriptions will do little to reduce overdose deaths, study says – by Felice J. Freyer Globe Staff  February 01, 2019

This article is about a very important, and for us very encouraging, new JAMA study that just came out showing that prescription limits barely reduce overdoses. We pain patients have known this all along, but when it’s officially researched and published it will be taken more seriously.

The anti-opioid zealots will try to explain away its findings, but it will be a piece of hard evidence that saner minds can use to push back against these ridiculously ineffective prescription opioid limits.

When the death toll from opioid overdoses began to soar a few years ago… Policy makers naturally sought to put a lid on opioid prescribing.

But a study published Friday in JAMA Network Open finds that reducing opioid prescriptions will have little effect on the death rate…

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Complications of Uncontrolled, Persistent Pain

EDS and Chronic Pain News & Info

Complications of Uncontrolled, Persistent Pain – By Forest Tennant, MD, DrPH – Jan 2018

To the unfortunate patient who is afflicted and the practitioner who treats it, incurable, persistent pain is truly its own disease regardless of its underlying cause.

Persistent pain, which is also often characterized as chronic or intractable, has all the ramifications of a disease in that it may have pre-clinical and overt phases.

I like that he calls it “persistent pain” instead of “chronic pain”, a term which has become synonymous in the public’s eye as a whining, complaining, catastrophizing, gonna-be addict.   

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HHS Report on Pain Mgmt Best Practices – part 3

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Draft Report on Pain Management Best Practices | – Dec 2018

This document is so long and so detailed that I spent hours working it over to add my own voluminous commentary.

I posted the second, most significant part yesterday, HHS Report on Pain Mgmt Best Practices – part 2, and the first part the day before: HHS Report on Pain Mgmt Best Practices – part 1.  

This is the third and final part of my series, and covers the middle of the document, starting where I left off in the second part detailing interventional procedures.

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HHS Report on Pain Mgmt Best Practices – part 1

EDS and Chronic Pain News & Info

This seems like the first good news in a while: a government agency admitting that most opioid overdoses are from illicit fentanyl. The report also documents the downsides of non-opioid medications and highlights the predicament of pain patients.

Draft Report on Pain Management Best Practices |

This document is so long and detailed that I spent hours picking it over to find the critical pieces and add my own commentary. It’s far from perfect, but still a welcome change from the usual PROPaganda – and I choose to celebrate.

Here’s the first part:  

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HHS Report on Pain Mgmt Best Practices – part 2

EDS and Chronic Pain News & Info

Draft Report on Pain Management Best Practices | – Dec 2018

This document is so long and so detailed that I spent hours working it over to add my own voluminous commentary. I posted the first part yesterday: HHS Report on Pain Mgmt Best Practices – part 1.

Below is the second part, covering more about opioid medication with all its “risk” and then the final, most significant section, covering the problems and errors of the CDC Opioid Prescribing Guidelines:

2.2.1 Risk Assessment 

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The civil war over prescription opioids

Another outstanding post with excellent analysis by Zyp! Should be required reading for everyone involved in prescribing policies, & especially for all the media morons who’ve spread the lies so effectively.

EDS and Chronic Pain News & Info

The civil war over prescription opioids – by Lynn Webster, MD – Dec 2018

The war is between science and fact versus PROPaganda and media hype.

Over the past 10 to 15 years, attitudes towards opioid use for pain have shifted dramatically. In the 1990s and early 2000s, pain relief was front and center on the newsstands and in medical literature.

During that time, compassion for people in pain increased and permeated our culture and opioids became standard therapy for chronic pain, because few affordable and effective treatment alternatives existed. 

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doctoral contempt

I had a visit recently with the most amazing diagnostician I’ve ever met. This pain doctor, who himself said that he doesn’t know much about migraines or their treatment, nevertheless knew all about & diagnosed mine on our first meeting, in less than 30 minutes! Amazing, eh? I went to a neurologist back in NC for almost as many years as I had minutes with the new guy, a neurologist who is a headache specialist & keeps up to the minute in the field of pain & migraines. That neuro saw & examined me hundreds of times, did all kinds of tests, tried literally dozens of medications, procedures, and treatments, had me keep HA & food & pain & all sorts of hour-by-hour diaries, consulted with fellow headache specialists, and in the end all he was able to do was to declare the migraines intractable and try to treat the symptoms as effectively as possible –we’ve tried every medicine anyone ever heard of that supposedly was prophylactic for migraines or reduced their frequency or severity, including some that were purely WAGs, some of them multiple times over the years.

So on one side I had this brilliant, thoughtful (in both meanings of the word), physician who specializes in migraines and spent decades trying to deal with mine. On the other there’s the pain ‘specialist’ who may not even really believe migraines even exist, but by golly he was able to pinpoint in moments the truth about mine: they’re not intractable, they’re not being treated appropriately, and they’re not really even that bad.

As galling as it is to have this cretin make this snap judgement –and it was very judgmental– about these nightmares that I’ve had to deal with my entire adult life, what really burns my buns is the fact that the jerk put down, as the official diagnosis, “migraines, not intractable.”

Now, NC Neuro first suggested I consider applying for disability in about 1989. I was missing six to twelve days of work per month. I spent those days huddled in bed in a dark room with ice bags on my head; as an added bonus, some of the time I would spend hours on end vomiting with such violence that I’d end up with black eyes because the  pressure caused all the blood vessels around my eyes to burst. It took days to recover, only partly because I always end up severely dehydrated because I can’t even suck on ice cubes when the nausea is bad (yes, I’ve switched tenses; it’s still going on, nearly thirty years later, except there’s some months when I lose more like twenty days a month to indescribable agony).

Anyway, the disability. I was utterly appalled and infuriated when NC Neuro brought it up; I was not a moocher or a sponger, I’m an independent & responsible adult who does not need to be taken care of. The very idea offended me on such a core level that I was rather surprised; I’m not generally judgmental about people who need assistance, it’s just that I wasn’t and would never be one of those people.

Well, the last time I worked, I spent nearly seven out of the last eight weeks of the job in bed, under ice, praying for death. It made for a kick-ass diet, and I probably should’ve been taken to the hospital at least for the dehydration, but I survived. Then I applied for disability. The day I sent in the application I spent most of the time throwing up from the incredible, grinding sense of shame I felt. Friends & my docs told me it wasn’t my fault, that I’d worked for many years around the blinding pain (& sometimes with it; I worked at my lab bench while wearing two pairs of sunglasses because the light was so painful). It was not a confession of weakness to admit that I wasn’t able to work because of the horrible headaches which I’d tried everything to stop –or even reduce.

It sure felt like an admission of weakness & worthlessness.

But along comes this little twerp of a physician who clearly had made up his mind about me before ever laying eyes on me. He saw that I was taking opioids, which are generally not considered the best option for migraines, and passed judgement on me and on my long-term doctor (who agreed to try opioids; he wsn’t a fan of them either, but he knew me, knew my conditions. They helped tremendously and gave me a few more years working). The fact that The Twerp obviously considered me a whiner or faker or whatever pisses me off enough, but it’s far from the first time that’s happened. But the fact that he basically declared that my NC Neurologist is incompetent seriously pisses me off. That poor man worked like a dog (a brilliant dog) for decades to try and help me, and I know I’m a frustrating patient. Not because I disobey directions or am not trying to get better, but because nothing he or I did worked to get me better. I’m firmly convinced that if anyone in the world could’ve come up with a way to do away with the headaches, NC Neuro and I would’ve found it. He’s a brilliant, kind, empathetic physician who treated me like a real human being, moreover like a human with a functional brain (& let me tell you, that’s an incredibly rare way for a physician to treat a patient). And here’s this schmuck dispensing condemnation of me and of NC Neuro; pah!!

Also, I can’t help but worry that The Twerp’s diagnosis –that insidious little “not” that he just had to put in front of “intractable”– will cause trouble with the disability payments. Because the migraines have not gotten much (if any) better since I’ve not been working. It is a relief not to be letting my employer down or feeling guilty &/or overwhelmed about missing work, but that relief hasn’t translated to a decrease in headaches.

We are in such a position of powerlessness to physicians. And many of them revel in being in the power position so much that they lose all compassion and humanity –assuming they had any to begin with. I spent most of my working years as a medical research technician, the person who does the laboratory work. After my first position I advanced to a point of being substantially responsible for designing the research plan; my PI (Principal Investigator) would tell me the kind of information they wanted to figure out, I’d go determine which procedures would best to get it. I worked for years at a lab attached to a teaching hospital, so I had the dubious honor of training newly minted MDs in laboratory techniques. Out of the dozens I trained in the lab, I recall only two who were willing to admit that a mere female, one with only many, many post-graduate courses (but not a Master’s –I was ABT– or Doctorate), could possibly have anything to teach them. These were people who didn’t know a beaker from a bean, but by God, they knew it all anyway.

MD arrogance is a stereotype for a reason; many MDs are arrogant. They firmly believe they are infallible, know everything there is to know, and can evaluate a patient’s mental, physical, and substance abuse status in one micro-second glance. After that, the patient is pigeonholed forever. I have contracted weird and rare health conditions throughout my life; rare indeed is the physician who will spend an instant listening to me say explain them. They are taught in Med School that “when you hear hoofbeats, think horses, not zebras.” In other words, a common condition that seems to fit presented symptoms is the more likely diagnosis. But here’s the thing: zebras do actually exist. Finding a physician who believes in zebras has gotten orders of magnitude more difficult over the last 2-3 decades.

Then there are physicians like The Twerp above, who refuse to even believe that horses exist. That patients are liars. Whiners. Fakers. Subhuman. Deserving not only not being listened to, but not even being treated politely. No, not all physicians are this appallingly narrow minded and bigoted, but given the current insane hysteria gripping the country, more and more are falling into snap judgement –even before attempting a diagnosis, if they even bother with that.

The Twerp could still come back to bite me metaphorically on the ass; I never went back to him, but that “not intractable” determination, based upon absolutely nothing other than his own arrogant prejudice, still lurks in my records somewhere. There is nothing I can do if it rears up, sea monster-like, to destroy my life. This is not hyperbole. We are even more prisoners of medicine than ever, even if we don’t get kidnapped and locked in a hospital like some have been. These doctors hold not only our physical lives in their arrogant, bigoted hands, but our very existence. Lab rats have greater protection against abuse.



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Book reviews: “Crimson Meniscus” & “Defragmenting Daniel” An intriguing & frenetic dystopian world from the delightfully twisted mind of Jason Werbeloff

It’s time for the semi-annual post. Just for grins, and because I’ve been promised a tweeted link (I’ve never been tweeted about before!), I decided to stop with the recipes already and combine two of my favorite activities (reading & writing) by posting a review of a couple of books by an up-and-coming writer I recently stumbled upon. (As a disclaimer, I’m not being paid, though I did get a free copy of the second book, Crimson Meniscus. I think I forked over a whopping $.99 for the first book in the series, Defragmenting Daniel. It was worth it.)  The inside of Jason Werbeloff’s head must be a fascinating & wee bit scary place….my favorite kind.

Defragmenting Daniel is the first book in the Bubble/Gutter world, and it would be a good idea to read DD before diving into the 7 shorter works of Crimson Meniscus. Otherwise CM is going to be very confusing, and it would be very difficult to not end up feeling fairly lost because the Bubble/Gutter world is unlike most any other in SF. I say this as someone who’s been reading SF since 1969 (including the SF Golden Age, back to Jules Verne & even earlier works, such as The Golem).  The good news is that DD is in this collection, tho’ at the end. So if you haven’t read that yet, you’ll probably want to start there.

Werbeloff’s writerly mechanics are, thank the universe, strong. This alone puts him well ahead of many e-published authors these days. And he clearly proofreads well & has someone else do the same (it’s very hard to effectively proof your own work), so the plethora of typos & grammatical idiocies & random bits of earlier drafts that tend to clog other new authors’ ebooks is virtually non-existent. Dialogue nearly always sounds like actual people, another rarity in both new and ‘established’ authors. Cliches aren’t. Sly humor pops up in sometimes seriously unexpected places. This world he’s built is, like I mentioned, very fresh; it is a twisted twist on the whole dystopia idea.

The short works of Crimson Meniscus:
“Manufacturing Margaret” is a simultaneously hilarious & horrifying work, at least for those with a sufficiently dark sense of humor. Again, those unfamiliar with DD are probably not going to be able to figure out what’s going on; the narrator is an artificially intelligent taxi that’s addicted to soap operas & has a rather shaky grip on reality. As I read “MM” I couldn’t help thinking of James Thurber’s piece about radio soaps, where the actors & studios would receive hundreds of cards & gifts when characters got married, or the “other woman” actresses would get threats mailed to them for being despicable homewreckers from listeners who couldn’t distinguish entertainment from reality (that sort of thing didn’t stop with the advent of TV soaps). So, the taxi was no more screwed up than a lot of humans. What the taxi does, however, is a tad more extreme than sending some cards & letters.

“Investing Isobella” This is one that taxed even my very flexible suspension of disbelief, though not to the breaking point. Being a biologist & researcher, I just couldn’t shut up the internal critic that kept clearing its throat & asking how the scenario that drives the plot could work (I have similar problems with some of the VR-ish/”phase” issues that appear in many of the Bubble-verse, but step harder on the voice then because I’m not nearly as well versed in VR or physics). But for those who aren’t complete bio-nerds, or even for those who are, this is another arresting, scary scenario, one that carries risk-taking to drastic new levels. If you think it’s risky to gamble on the stock market now….! Heh heh.

“Oscillating Olaf” relies heavily on the “phase” concept mentioned above. The story is a neat idea if you can wrap your head around the whole phase shift concept. I also found myself repeatedly wondering if the Russian translations were accurate…I may have to adopt some of the phrases. At any rate, Olaf, the protagonist, is a guy you feel sympathy for while wanting to reach in & smack him (well, I did at times). He’s kind of a down-trodden worker who gets a big, though not necessarily great, idea for climbing out of his rut.

“Patenting Peter” Hoo-ee. The rules of the Tokyo Bubble society in this piece are extreme even for the extreme world of the Bubble. Werbeloff gives a reasonable explanation (within context) for them, though it would have helped me cruise along through the story more easily if the explanation had come a bit earlier; I was pulled from the story several times as I wondered why in the world those rules were made –then I got the story behind them, as it were, and they made more sense (in a bizarre sort of way). As in Werbeloff’s other works in the Bubble/Gutter society, the depths of human cruelty that can arise from indifference can make even me a bit queasy, & I don’t have a real high vision of the wonderfulness of the species anyway. On the other hand, if you’re feeling bad about your spouse, this could make things look great in comparison.

“Severing Sidney” Another extreme in the extremes. This story seemed more creeping horror within the SF context, though much of the “Bubble-verse” has strong horrific undertones anyway. And I (cynic that I am) had no trouble believing that tech could change marriage so drastically while religion kept divorce verboten; societies that try to wed science with religion have come up with some screwy ideas, but nothing like this. The story gives the whole concept of “separation” a savage new twist.

“Aborting Andromeda” It occurs to me that to keep saying this or that story is ‘extreme’ is fairly silly because there are extremes all over the place, frequently layered atop one another. I’m guessing this story will generate a lot a froth, given that the basic idea is “Post Natal Abortion,” i.e. “abortion” up to the age of 25. Can’t deal with an offspring/loved one? Scrub ’em from existence. Part of me loves the idea because I have a prime candidate or two. But it’s just one of the eye-popping/stomach churning options available in the world of the Bubble, where credit really can buy anything. The story is not exactly a ringing endorsement of the concept, just as reassurance for those who might be inclined to avoid the story altogether just on principle.

And since Defragmenting Daniel is sort of a pre-req for fully appreciating Crimson Meniscus, here’s my review of DD:

I’m always excited to discover new authors, especially as I read so fast I’m constantly on the prowl for another book. I stumbled onto this one totally by chance, and was very happy as I read along. The writing was vivid & coherent and the idea well executed. Though I am a biologist & very long-term fan of hard SF, I was okay with the fact that some of the more extreme elements of Webeloff’s world didn’t have explanations and stood on rather shaky scientific underpinnings; this is more of a sociological SF than a hard biological SF (if you physics types will permit me to phrase it that way). The drastically futuristic tech (biological & computer-related) pretty much saturates the book, so if you’re not able to suspend disbelief on a society based on tech that borders on magic, beware. The tech ranges from organs switched as easily as our socks to programmable clothing that changes at the wearer’s whim (both in appearance and at the tactile level) to VR-type glasses that operate everything to flying/hovering taxis that are invisible unless you have the glasses, up to the entire Bubble, which operates on a certain ‘phase’ & virtually ceases to exist if you put yourself in a different ‘phase.’

There are very disturbing elements to the book; if you’re a reader who has trouble with blood or violence, or casual cruelty, you might want to give this one a pass. This world is a pitiless and vicious place. I wish I could say I couldn’t believe that people would be so depraved that they’d pay to hack up children for fun ‘n’ recreation if it were legal, but I’ve read too much history and seen too much reality to doubt it. Once one group of people views some other group as a subhuman “Them,” there’s no limit to the atrocities they can –and will– commit upon Them. And feel just fine & perfectly justified about doing it. I actually had more difficulty believing that Gepetto would so quickly & casually take in a total stranger off the street in this scary world.

Daniel is at first a very sympathetic character; orphaned, dumped out into a nearly totally unknown world on his 18th birthday, filled with crappy generic replacements for the body parts that’ve been taken from him to ‘pay’ for his room & board & the privilege work 12 hours a day, 7 days a week cleaning out organs yanked from other Gutter inhabitants. As he begins indulging in some cruelty of his own to regain his body parts, it is a little harder to love him, but given the world he inhabits, his behavior is not particularly surprising.

I loved Daniel’s cat, Odin, and the fact that Daniel sacrifices what little he has to share with Odin, and I don’t care if Odin only exists to provide more warm & fuzzy feelings for Daniel. Odin actually reminded me a lot of a real-life cat, Norman, the Scottish Fold who traveled the world with his human. Odin was a very nice touch, as well as being a cool cat.

I had some problems getting warmed up to Kage, the former Kassandra, but only because I couldn’t figure out who he was trying to impress (other than himself, and he clearly had some self-image issues). He says (well, he thinks) that he dislikes women, he gets really angry when people think he’s a gay man, but he really loves the way it feels when a man puts his hand on Kage’s back, and is thrilled when an impulsive dinner invite to a woman is accepted. I assume this contradictory behavior was supposed to be indicative of how conflicted Kage is, but I wished there was some better clarity; what does Kage really want, besides bigger muscles & a more manly voice? Ambivalence toward this character is sort of a problem since he’s the protagonist’s foil, or possibly nemesis.

General mechanics notes:
-Hallelujah for Werbeloff, because he proofreads & has professional proofreading done. This makes him a very rare bird these days. There are almost no typos or grammatical errors or dangling bits of sentences cluttering up the landscape like blown trash.
-Dialogue sounds like actual humans talking; another rarity & one of the harder aspects of writing to do well.


The round-up:

As my tagline Bradbury quote indicates, I am very much in favor of reading. When I was teaching I would sometimes get into arguments with other educators, the classic “They should read Quality Literature” vs “Let ’em read whatever grabs their fancy; it’ll spread” debate. I was firmly in the “whatever” camp; get kids interested in reading by letting them pick an interesting subject. Once the act of reading becomes easy for them they’re much more likely to expand their literary horizons, even unto Quality. And I have no patience for snobs who think SF (or “speculative” or SciFi or whatever the term is) is a waste of brain cells; there’s good SFm & SF that really is a waste of brain cells. Luckily, there comes along new writers who build onto the edifice of good, interesting, gripping SF. Though I don’t claim that Werbeloff is another Bradbury (nobody is), his writing is good, interesting, gripping hard/sociological/biological SF with a dash of horror that can keep you up nights, maybe even after you’ve put the book down. Dive into a new world…it may be even scarier than the real one, but it sure makes a good diversion from the real one.

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