ARC (ARACHNOIDITIS) NEWSLETTER

 

Volume6, No.2, Summer of 2006

 

Published by the Arachnoiditis Foundation, Inc.

A Non-Profit Organization created for the Study of the Causes, the Diagnosis and the Treatment of ARACHNOIDITIS.

 

 

FROM THE EDITOR’S DESK

 

Contrary to some of my colleagues who treat chronic pain, I am alarmed about the recent trend to implement drug testing in every patient that receives controlled substances by prescription.

 

Random urine drug testing has been adopted by the Federation of State Medical Boards (FSMB) of The United States as of May 2004 (Model Policy for the use of Controlled Substances for the Treatment of Pain  http://www.fsmb.org).

 

The FSMB expects physicians who prescribe controlled substances to include safeguards in their practices to minimize the potential for abuse and diversion of  controlled substances.  Along with early detection of signs of drug problems, physicians are afforded the opportunity to identify such problems pursuing any of the following:

  • Frequent follow-ups and re-evaluations
  • Review of old medical records
  • Drug utilization reviews (pharmacy records)
  • Communication with other physicians
  • Obtain information from family members or friends
  • Conduct “pill counts”
  • Urine or Blood testing

 

In the past, drug testing has been suspected to be an adversary way to find out if patients are “cheating” on their medications, taking more or taking something else not prescribed by their doctor.

 

Some religious groups, other self-appointed ethicists and even some relatives of the patients view the use of controlled substances for the treatment of pain unnecessary, an over-kill or a means to induce dependency. The connotation that patients are given narcotics to control their pain is considered wrong and improper. The main assumption is made that patients are not to be trusted and doctors are not astute or knowledgeable enough to identify when abuse of these medications, by the patient, occur.

 

However, a more tolerant approach has gradually advanced, both in the pain community, as well as, in medicine in general.  Still some feel that patient are given too early and too much narcotic drugs even before an accurate diagnosis is made.  As patients develop tolerance to the dose of narcotic first prescribed the  medication does not work as well as it initially did. So they feel more pain and they believe that their disease has gotten worse, they inform the doctor and the physician increases the dose.  This event is repeated, the dose is increased again and again.  The opiate is changed, but it is started at an equivalent (high) dose and the race starts again.  This is a battle that neither the patient nor the physician can win. We all loose, except the manufacturer of the medications.  

 

When we realize that the dose is too high, suddenly we start suspecting that the patient is abusing the medication. But we must remember that the patient can not prescribe for him or herself.  We are the ones that prescribe, we are the ones that have the control, but when we reach this point we cannot suddenly reduce the dosage or withdraw from the care of the patients. So what do we do?

 

Now we are going to drug test the patient’s urine, blood or saliva. This procedure is indicated when patients exhibit dysfunctional behavior. Insist on increasing the dosage, even when no apparent change in their clinical condition is evident or when they do not follow instructions on how many pills they are supposed to take. Patients usually feel resentment, as they seem to have been accused of wrongdoing.  So in stead of waiting for this to happen, random drug testing has been advised.

It has been said that it also increases and improves the physician-patient relationship setting the stage for communication and understanding between the two parities. It has also been suggested that by doing it at random, in all patients, it removes the stigma of drug testing including it as part of the treatment.

 

However, since there is no quantification of the amount of the drugs tested, it is not possible to determine if the patients are taken the medication as prescribed, nevertheless, the other objective, apparently, is to identify if the patients are taking medications, other than prescribed by their treating physicians (as it is common that chronic pain patient see several doctors for their ailment).

 

As alternative, we could ask them if they are taking other pain medications. It seems that we are going to treat all the patients as liars and abusers of medications.  It seems that a new industry is being created and someone is about to make a substantial amount of money. But why?

 I have treated most of my patients for years.  We use the same dose, never exceed 10mg of hydrocodone. We have them sign the enclosed contract the first day they walk into the office, we know their families.  Patients receive exactly the number of tablets, or patches until their next visit, which is scheduled and they know that regardless of whatever happens they will not receive a prescription, a refill, or a call in medication in between visits.  Medications are prescribed only when they are seen in the clinic and after they have been examined and have described their condition.  Every one in the office has a good personal relationship with all the patients.  Along with other physicians, I believe that DRUG TESTING OUGHT TO BE INDIVIDUALIZED AND USED WHEN NECESSARY.

 

I agree that Urine Drug Testing may be indicated when

  • initiating therapy
  • patients insist to receive prescription  for a specific medication
  • they are unwilling to try other forms of therapy
  • aberrant behavior is noted

 

IS THE RANDOM TESTING REALLY NECESSARY?

 

Although this has not been my experience other colleagues feel that testing only patients that behave suspiciously would only identify about 50% of the patients abusing their medications it has been advised to do the testing “AT RANDOM”. To accomplish this selection fairly, several approaches have been suggested

a) pull names out of a hat

b) test only every fifth patient

d) invent a new computer program

e) roll the dice (test all patients that get  par numbers)

f) use a “roulette” table

 

BUT TESTING IS NO LAUGHING MATTER, WE SHOULD THINK THIS MEASURE THROUGH. THIS TOPIC IS TOO IMPORTANT TO RESOLVE IT ON ONE SINGLE DISCUSSION. 

I would like to hear some feed back from patients, please write how you  (patients) feel about this assumption that since “some patients abuse their medications”, we now are going to DRUG TEST THEM ALL.

 

FOR EXAMPLE, SOME QUESTIONS REMAIN:

-         Who is going to pay for these tests?

-         How often should they be tested?

-         What to do if the results are positive?

-         Can we get false positives?

-         Is it possible to fake the results?

-         Can we get false negatives?

 

Assuming that doctors do not trust their patients’ response to a simple, but important question.  The implications are numerous, but only few will be discussed here in this Newsletter.

It is assumed that doctors will obtain prior consent to procure the urine and to test it for drugs.

What if the patient refuses?

·        The doctor would refuse the consultation?

·        The doctor would refuse to write the prescriptions?

·        The doctor would dismiss the patient?

·        The doctor would abolish continuum of care?

·        The doctor would refer the patient and “mark” the patient as “refused testing”?

·        Should doctors denounce patients that abuse their drugs to the police?

·        If doctors do not, will they become accomplices?

 

Undoubtedly we are facing a difficult situation, one that further erodes the trust between patients and their doctors; how we resolve it, most likely, will determine what the doctor-patients relationship will be in the future.

 

Because this issues is far too important I plan to continue this discussion in the next issue of the newsletter.

 

REFERENCES:

Model policy for the use of control substances for the treatment of Pain. Federation of State Medical Boards of the United States. Adopted May 2004. Available at http://www.fsmb.org

Gourlay DL, et al: Universal precautions in pain medicine: a rational approach to the treatment of pain. Pain Med 2006:7:76-7.

Murphy JP: Tumblin’ dice- why does random matter. Practical Pain Management 2006:6:72-3.

Fornari FA, Siwiki DM, Bauer GB: Urine drug testing and monitoring in pain management. Practical Pain Management 2006:6:12-4.

 

Comments from patients and doctors are invited, please let us know what you think about this new regulation.

The Editor

 

 

 

 

                    “EVERY DAY A HEADACHE”

 

 

SOUNDS MORE LIKE A SONG

THAN A SYMPTOM DESCRIBED BY MANY PATIENTS. 

 

 

 

To define the type of headache it is necessary to identify the following

-         the location (neck, frontal, behind the eyes, temples etc)

-         relation to activities (work, exercise, computer use, etc)

-         mood changes (depression, anxiety, anger, etc)

-         foods (cheese, wines, beer, pasta)

-         medications (ergotamine, opiates, antihypertensives, etc).

 

Headaches can be provoked by coughing, sneezing, a Valsalva maneuver ( breath holding for long periods), or by assuming an upright or the supine position, certain garments like wearing a hat, a cap or using a girdle.

 

To qualify as a “daily headache” it should occur for at least 15 consecutive headaches, with the same characteristics and to be related to the same causative factors.

 The overuse of headache medications by patients that suffer a daily headache is not a rare occurrence; it is usually induced by the same or similar medication used to alleviate pain, appear to be more frequent in women over 50 years old. Peculiarly enough, these headaches may continue even when the culprit medication used is stopped.

 

Daily headaches in patient with arachnoiditis may occur form the disease itself such as cases of syringomyelia in the cervical spine or when the disease includes several levels of clumped nerve roots interfering with the normal circulatory, slow motion of the cerebrospinal fluid.  Not uncommonly, it may be  accompanied by changes in vision, hearing or equilibrium.  Rare cases of occult hydrocephalus may be reversed and become evident after a spinal anesthetic and incidental, but substantial loss of cerebrospinal fluid.

 

Most commonly they may be related to cervical spine pathology such as bulging or herniated intervertebral discs, facet joint hypertrophy or long term muscle spasms that some patients may have, unrelated to ARC.  The latter may be ruled out by an MRI of the cervical spine, but the former may require a CAT scan or MRI of the brain. Consultation with ophthalmologists, or ENT specialists is advised.

 

However if they appear in clusters (cluster headache), behind one eye (migraines), during sleep (hypnic headache), short lasting accompanied by tearing and mostly in males, patient needs to be referred to a neurologist.

 

Other conditions such as intracranial tumors, hemicrania (ice pick pain), feochromocytoma, arterial hypertension, intracranial hypotension and other less common diseases need to be considered, also.

 

 

INSOMNIA, AMBIEN AND SLEEP-WALKING

 

Insomnia is a common symptom among patients that have spinal diseases. In my practice, the most current statistic in the patients that I have examined and confirmed radiologically as having arachnoiditis, over 60 % complained of  having INSOMNIA.

 

Lack of sleep is not unusual in adults, either caused by anxiety, certain foods, some medications, activities, worries and pain. In the case of ARACHNOIDITIS, in addition of self concern for the course of the disease, despair for the lack of improvement, financial concerns and interpersonal conflicts, there is pain. Patients are awakened often as they turn or move in their sleep because the spinal nerve roots that normally are free floating in the cerebrospinal fluid, within the dural sac, are clumped, adhered to each other or to the wall of the dural sac, so when the patients, turn or stretch their legs they experience pain.

 

The well publicized event involving one of the politicians who was found to “be driving under some kind of mind altering substance influence” and crashed in Washington DC has brought to light what appears to be a common side effect of Ambien.  

 

I must confess that I prescribed Ambien (ZOLPIDEM) for some of my patients; as a matter of fact Ambien has proven to be effective when other hypnotics had not rendered the expected effect. It is amazing that 26.6 million prescriptions of Ambien were filled in 2005 in the U.S.A., and despite all the testing and clinical trials required by the FDA, this side effect was not noted or reported? Again the FDA methodology to find important side effects of the medication it approves, has failed. It seems that we prescribe new drugs on our own risk and specially risking patients out there.

I suppose no answer will be given to this question by the FDA.

 

 

NEWS ON THE MEDICARE “D” PROGRAM

Has any one saved money on the new Medicare drug card? Just when we thought that we were not going to pay or that we were going to pay less for medications, the Drug Companies were allowed to raise the prices of their products.

First, the prices of all medications have gone up in the last six months, then, by shifting 6.4 million seniors to the Medicare drug program, plus the monthly payment required by all the other older citizens (taken out of our Social Security payment) resulted in a bonanza of over 2 billion dollars/year for the drug manufacturers. What I still do not understand is why those seniors who do not take medications were forced to sign in and start paying even if they do not need medications. The whole process and now the program has brought shame rather than credit to the authorities who allowed for this scam.

Congressman Henry A. Waxman has been the only voice who has requested an investigation on this matter. We should remember these facts when November elections come.

 

 

CALL FOR WRITTEN CONTRIBUTIONS

As in the past, we invite contributions by physicians, patients, relatives of patients, therapists on subject related to ARACHNOIDITIS, specially their impressions, experiences and sacrifices as they help or care for this patients.

 

CALL FOR LETTERS, ARTICLES, CONFESSIONS POEMS, DEBATES, etc.

Readers are invited to write short, but meaningful, articles on any subject related to Arachnoiditis.  They may be submitted with the author’s name or anonymously, however, with the understanding that:

a.       The Editorial Board reserves the right to modify them or alter them to conform with the style and the ”Objectives” of the ARC Newsletter.

b.      The copyrights will be waived with the assurances that the Editorial Board will not derive any profit from any of these publications.

c.       They are simple, constructive and civil. 

 

Thank you.

The Editorial Board

 

DISCLAIMER

Personal information (e-mail, location, etc) on the authors of reports will be made available upon request, as long as the authors authorize it.  The editors are entitled to modify the material so it can comply with the objectives of the Newsletter.

Neither the Arachnoiditis Foundation, Inc, nor the Editors of the Newsletter are responsible for the opinions or concepts herein expressed.  They represent the author’s point of view.

 

Arachnoiditis Foundation, Inc.

2213 Sterlingwood Drive, Birmingham, AL 35243

E-mail: aldrete@arachnoiditis.com

 

 

 

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