Letter to the Charleston Gazette: a physician explains how W.Va. became a wasteland of opioid addicts

[mountaineer]

A letter to the Charleston Gazette
Dec 21, 2016
link

I grew up in WV, graduated from Grafton high in 1979. The daughter of two high school dropouts, I got a full financial package to Yale and graduated from there in 1983. I returned to WV to get my medical school training at WVU and did my residency training there as well. I went off to teach at the University of Miami in Miami FL at the largest county hospital in the US. But in 2010 I went back to WV to help the hospital in Elkins WV get its anesthesia department back on track. What I found was a wasteland of people addicted to opiates, benzodiazepines, meth, and finally heroin.

But let me tell you how this whole mess got started. In 1999, the federal government decided that a paper written by a VA nurse regarding "pain is what the patient says it is" created a new mandate called "Pain is the 5th vital sign." Suddenly, a doctor was not allowed to decide if a patient's pain warranted cold compresses, Bengay, ibuprofen, or a few Percocet. Now we (I use this term loosely because as an anesthesiologist I don't ever write scripts for patients leaving the hospital) had to believe that 3 weeks after a simple knee scope that a patient still has 10/10 pain and needs 6 Percocet a day.

The pharmaceutical companies of course jumped on that band wagon: every patient with pain was more cha-ching in their bank accounts. Then more papers got published that showed that chronic pain was being under treated by family doctors and orthopedic surgeons and every other kind of physician. Medications that in the past had been the sole purview of those treating terminal cancer patients now wound up in the hands of obese patients with "bad backs" "bad knees" and "bad hips".

But the coup de grace was the Press-Ganey score. Now patients were armed with a means of cutting a physician's reimbursement. You see, if as a doctor you decide 67 year old Joe Smith doesn't need anything more than Naprosyn and physical therapy - and Joe Smith gives you a zero on your Press-Ganey while another doctor down the road who hands out Oxycontin like tic-tacs has a Press-Ganey of 99, under the ACA you will cut by 2% while the doctor down the road will get your 2% for having a better Press-Ganey score.

Now - you tell me - who ever thought that popularity was a good way to run medicine? Politicians and beauty queens get picked based on popularity. So does America's Got Talent. But we don't pick firemen, or policemen, or electricians or airline pilots based on popularity. So WHY would we apply that to physicians?

As far as I am concerned, the federal government made this mess. They pushed doctors into an untenable position. What followed was to be expected and many of us predicted exactly this scenario: you feed the addicts when you base pain management on the popularity of a physician.

The truth is that unless a patient becomes MORE functional - that is gets a job or goes back to work or has some tangible evidence of improvement like losing weight, then opiates have no role in chronic pain management. A patient sitting in a chair or lying in a bed stoned has no place in medicine. But until physician patient management is no longer a popularity contest, you will continue to have the killing fields in the poorest communities where the patients voting is most tied to physician reimbursement.

The minute the federal government steps out of the physician-patient relationship and allow doctors to take care of patients appropriately, then things will start to change for the better.

Joy Steadman, MD
Vice Chair Education and Research at University of Tennessee Memphis/ROH

[mountaineer]

No surprise, then, to read:

30 Percent Of W.Va. Families On Medicaid
Jan 7, 2017
Ian Hicks
Wheeling Intelligencer

WHEELING — Only six states have a higher percentage of residents on Medicaid than West Virginia, according to a national nonprofit health policy group.

More than 554,000 Mountain State residents — more than three of every 10 — are enrolled in the program, according to the Henry J. Kaiser Family Foundation. That’s well above the national average of 23.4 percent — meaning a potential repeal of the federal Affordable Care Act under which West Virginia’s Medicaid program was expanded could have a disproportionate impact on the state’s residents.

The percentage of West Virginians on Medicaid comes as little surprise to incoming state Senate Majority Leader Ryan Ferns, R-Ohio.

“What it says about our state is we have the lowest workforce participation rate in the country and the highest number of people on welfare,” Ferns said. “Over half our population is receiving financial assistance, and that is not sustainable.”  ...

[Suppressed]

Dr. Joy's God complex seems to ignore her economic ignorance. She thinks she's entitled to equal pay for unequal service. If she didn't have Medicaid protecting her, she'd find that "popularity" would make some doctors have more patients than others.

[Cripplecreek]

Apparently personal responsibility on the part of doctors or patients doesn't play a part and it has nothing to do with money.

I have a tendency toward abuse so I avoid hard drugs and haven't seen a doctor who encouraged me to accept them.

[Smokin Joe]

Apparently personal responsibility on the part of doctors or patients doesn't play a part and it has nothing to do with money.

I have a tendency toward abuse so I avoid hard drugs and haven't seen a doctor who encouraged me to accept them.

I have found that if I tell a doctor "I don't want any d@mned pain pills, I want the problem fixed." I get better service. I have a pretty high pain threshold, anyway.

[thackney]

I have found that if I tell a doctor "I don't want any d@mned pain pills, I want the problem fixed." I get better service. I have a pretty high pain threshold, anyway.

With a ruptured disk in my low back, significantly little cartilage remaining in my knee, I view pain as a reason to back off and allow the swelling due to more injury, inflammation, etc to recede.  I don't want to mask elevated pains, I want to respond to them.

[Smokin Joe]

With a ruptured disk in my low back, significantly little cartilage remaining in my knee, I view pain as a reason to back off and allow the swelling due to more injury, inflammation, etc to recede.  I don't want to mask elevated pains, I want to respond to them.

Exactly. I can deal with pain--after all it is just my body's way of telling me something isn't 'right'. If I dope it over, I risk doing more damage. To me, that makes as much sense as putting a sticky note over the oil pressure gauge in your car because it is reading really low. Just not a good idea.
If you know what's wrong, you had it fixed, and you are on the mend, something to take the edge off might be in order--as long as you aren't going full tilt, and don't forget you aren't up to snuff yet. Still, why risk tearing that apart?

[Cripplecreek]

I have found that if I tell a doctor "I don't want any d@mned pain pills, I want the problem fixed." I get better service. I have a pretty high pain threshold, anyway.

I think a decent doc prefers a patient who wants to know what's going on rather than the quick fix of a pain pill.

[mountaineer]

With a ruptured disk in my low back, significantly little cartilage remaining in my knee, I view pain as a reason to back off and allow the swelling due to more injury, inflammation, etc to recede.  I don't want to mask elevated pains, I want to respond to them.

I have similar issues and the last thing I want is a pill, especially a narcotic. If I can't manage the pain with ice and/or heat and some OTC anti-inflammatory, then it's just time for me to suck it up, buttercup.

[Wingnut]

I have found that if I tell a doctor "I don't want any d@mned pain pills, I want the problem fixed." I get better service. I have a pretty high pain threshold, anyway.

Since the age of 11 or 12 My brother and I never take novocaine when having cavity's filled.  This never created much of a problem except for the quizzical looks the DA's and dentist would occassionly give you.  A few years back after moving to DFW I started going to one of those chain store dentists places with the revolving batch of fresh faced graduates from god knows where.  Anyway this one white smock wearing nitrous oxide sniffing tooth driller said he wouldn't fill my cavity if I didn't take the "shots".  I told him where he could shove his needle and walked out.  I mean no one wants their teeth done by the Marquis De Sade but pain is relative. 

Pain Heals, Chicks dig scars, Glory lives forever.

[Weird Tolkienish Figure]

A surprising amount of red states have this problem.

[Smokin Joe]

Since the age of 11 or 12 My brother and I never take novocaine when having cavity's filled.  This never created much of a problem except for the quizzical looks the DA's and dentist would occassionly give you.  A few years back after moving to DFW I started going to one of those chain store dentists places with the revolving batch of fresh faced graduates from god knows where.  Anyway this one white smock wearing nitrous oxide sniffing tooth driller said he wouldn't fill my cavity if I didn't take the "shots".  I told him where he could shove his needle and walked out.  I mean no one wants their teeth done by the Marquis De Sade but pain is relative. 

Pain Heals, Chicks dig scars, Glory lives forever.

I will do novocaine, but at this point, It's usually a root canal. Years of wellsite work and not being able to get into a dentist have taken their toll, despite having most of the set.

I have a dentist I trust, though, and don't figure the feeling will come back with a disaster in my mouth.

[Wingnut]

I will do novocaine, but at this point, It's usually a root canal. Years of wellsite work and not being able to get into a dentist have taken their toll, despite having most of the set.

I have a dentist I trust, though, and don't figure the feeling will come back with a disaster in my mouth.

I root canal is a different kettle of fish.  Never had to have one... but I suspect I'd take the shot for that one!

[Cripplecreek]

I root canal is a different kettle of fish.  Never had to have one... but I suspect I'd take the shot for that one!

You gotta pluck the nerves.


http://www.youtube.com/watch?v=KqE14og1cQ8

[Sanguine]

I root canal is a different kettle of fish.  Never had to have one... but I suspect I'd take the shot for that one!

Oh, my, yes you would!  I had my first one last year, and it was a doozy.

[dfwgator]

I have similar issues and the last thing I want is a pill, especially a narcotic. If I can't manage the pain with ice and/or heat and some OTC anti-inflammatory, then it's just time for me to suck it up, buttercup.

Maybe Monty Python was onto something here....


http://www.youtube.com/watch?v=FsoUDP_6uyU